Increasing coverage in mass drug administration for lymphatic filariasis elimination in an urban setting: a study of Malindi Town, Kenya

Adolescents' Perspective Regarding a Community-Wide Mass Drug Administration Program for Soil-Transmitted Helminths in India

This study was undertaken to understand the perspective of adolescents in endemic communities of India regarding soil-transmitted helminth (STH) infections and community-wide mass drug administration (cMDA). A multicountry community-based cluster-randomized trial, the Deworm3 trial, tested the feasibility of interrupting STH transmission with cMDA, where all individuals aged 1-99 are treated empirically with albendazole. Using a guideline based on the Consolidated Framework for Implementation Research, eight focus group discussions were conducted among 57 adolescents from the trial site in India and analyzed on ATLAS.ti 8.0 software using an a priori thematic codebook. Adolescents believed that adults could be a source of STH infection because they were not routinely dewormed like the children through the national deworming program. Perceived benefits of cMDA for all were better health and increased work efficiency. Perceived barriers to adults' participation in cMDA was their mistrust about the program, fear of side effects, perceived low risk of infection, and absence during drug distribution. To encourage adult participation in cMDAs, adolescents suggested community outreach activities, engaging village influencers and health workers, and tailoring drug distribution to when adults would be available. Adolescents were confident in their ability to be change agents within their households for treatment compliance. Adolescents provided insights into potential barriers and solutions to improve adult participation in cMDA, identified best practices of cMDA delivery, and suggested that they have unique roles as change agents to increase their household participation in cMDA.

Exploring the Impact of Mining on Community Health and Health Service Delivery: Perceptions of Key Informants Involved in Gold Mining Communities in Burkina Faso

Sub-Saharan Africa is rich in natural resources but also faces widespread poverty. The United Nations' Sustainable Development Goals brought increased attention to resource extraction projects, emphasizing their development potential in extraction regions. While mining companies are required to conduct environmental impact assessments, their effect on the project-affected communities' health mostly lacks systematic management, and their consideration of community perspectives is insufficient. Between March and May 2019, qualitative research was conducted at three industrial gold mines in Burkina Faso. Thirty-six participants, including community leaders, healthcare providers, and mining officials, were interviewed through key informant interviews about their perceptions on the impacts of mining operations on health, health determinants, and health service delivery. Disparities in perceptions were a key focus of the analysis. Mining officials reported mainly positive effects, while healthcare providers and community leaders described enhancing and adverse health impacts without clear trends observed regarding the extent of the impacts on health determinants. The perception of predominantly positive health impacts by mining officials represents a potential risk for insufficient acknowledgement of stakeholders' concerns and mining-related effects on community health in affected populations. Overall, this study enhances comprehension of the complex interplay between mining operations and health, emphasizing the need for comprehensive assessments, stakeholder involvement, and sustainable practices to mitigate negative impacts and promote the well-being of mining communities.

Challenges and strategies for the uptake of mass drug administration among pastoralist communities in South Sudan

Preventive chemotherapy through mass drug administration (MDA) to control and eliminate neglected tropical diseases (NTDs) requires the active participation of communities living with NTDs, or at risk of NTD infections. Despite considerable progress by national control and elimination programs, achieving consistent and sustainable treatment campaigns that reach pastoralist communities remains challenging, which in turn delays the achievement of global disease elimination goals. The challenges of accessing pastoralist communities for treatment also hinder the achievement of the UN’s Sustainable Development Goals’ (SDGs) pledge to “leave no one behind“. Elimination targets cannot be achieved if significant proportions of endemic populations, such as pastoralists, are missed out during treatment campaigns. In South Sudan, close to 70% of the population is categorized as pastoralist, with previous data on MDA showing low access to and acceptance of MDA among the pastoralist community, as well as inconsistent treatment coverage. To address this challenge, a cross-sectional study design was conducted in five counties, with 239 pastoralist community respondents participating in in-depth interviews (IDIs), key informant interviews (KIIs), and focus group discussions (FGDs). Our findings show that, in the pastoralist community, high mobility, lay perceptions about the causes of NTDs and methods of treating them, limited awareness of MDA, and suboptimal health-seeking behaviors are the major factors that limit accessibility and participation. Our results suggest that improved uptake of MDA in these communities may be achieved by timing treatment campaigns to take account of pastoralists’ seasonal migration patterns, by involving pastoralist leaders in planning and social mobilization activities, by engaging community members as community drug distributors (CDDs), by using participatory behavior change approaches to design NTD interventions, and by addressing negative perceptions around the medicines involved, including those related to drug expiry and drugs causing impotence or other side effects. The results from this study could enable national programs to address the challenges of implementing treatment campaigns through the enhanced involvement and representation of pastoralist communities.

Towards elimination of Lymphatic Filariasis in Kenya: improving advocacy, communication and social mobilization activities for mass drug administration, a qualitative study

Introduction

The Kenya Breaking Transmission Strategy for Neglected Tropical Diseases (NTD) from 2019 to 2023 intensifies advocacy, coordination, and partnerships. The purpose of this study was to explore views and experiences of stakeholders and health workers on ways of improving the Advocacy, Communication and Social Mobilization (ACSM) activities of Mass Drug Administration (MDA) for Lymphatic Filariasis (LF) programs through participatory approaches in Kilifi County, Kenya.

Methods

Two wards were purposely selected in the Kaloleni sub-county, Kilifi County, where there was an average treatment coverage of 56% in 2015, 50.5% in 2016. Qualitative data collection methods were employed, which included participatory meetings with county stakeholders to understand their views, experiences, and suggestions on how ACSM strategies can be improved in MDA for LF. Twelve In-Depth Interviews (IDIs) were conducted (six with opinion leaders and six with Community Health Extension Workers (CHEWs) and two semi-structured interviews (SSIs) were held with county and sub-county coordinators involved in MDA administration. The aim was to better to understand their perceptions of the NTD program about ACSM, challenges to ACSM strategies, and ways to improve the strategies for ACSM in MDA for LF. The Data was organized and classified into codes and themes using QSR NVIVO version 12.

Results

The study observed the low participation of stakeholders in the ACSM activities of MDA for LF and identified potential areas for stakeholders’ involvement to strengthen the activities. Challenges hindering effective implementation of ACSM activities include late delivery of Information, Educational and Communication (IEC) and few IEC materials, insufficient funding, inadequate time allocated to reach the assigned households with messages, messaging, and packaging of information for dissemination due to the vastness of the area. The stakeholders recommended innovative strategies and techniques to improve ACSM activities.

Discussion and conclusion

The results of this study show key challenges to ACSM implementation of MDA for LF. Implementers need to pay attention to these challenges to enhance the effectiveness of MDA per the Kenya NTD Breaking Transmission Strategy. ACSM efforts in MDA for LF control and elimination should be linked with overarching efforts to mainstream partnerships and coordination in control and elimination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-022-00172-8.

Defining optimal implementation packages for delivering community-wide mass drug administration for soil-transmitted helminths with high coverage

Background

Recent evidence suggests that community-wide mass drug administration (MDA) may interrupt the transmission of soil-transmitted helminths (STH), a group of intestinal worms that infect 1.5 billion individuals globally. Although current operational guidelines provide best practices for effective MDA delivery, they do not describe which activities are most essential for achieving high coverage or how they work together to produce effective intervention delivery. We aimed to identify the various packages of influential intervention delivery activities that result in high coverage of community-wide MDA for STH in Benin, India, and Malawi.

Methods

We applied coincidence analysis (CNA), a novel cross-case analytical method, to process mapping data as part of the implementation science research of the DeWorm3 Project, a Hybrid Type 1 cluster randomized controlled trial assessing the feasibility of interrupting the transmission of STH using bi-annual community-wide MDA in Benin, India, and Malawi. Our analysis aimed to identify any necessary and/or sufficient combinations of intervention delivery activities (i.e., implementation pathways) that resulted in high MDA coverage. Activities were related to drug supply chain, implementer training, community sensitization strategy, intervention duration, and implementation context. We used pooled implementation data from three sites and six intervention rounds, with study clusters serving as analytical cases (N = 360). Secondary analyses assessed differences in pathways across sites and over intervention rounds.

Results

Across all three sites and six intervention rounds, efficient duration of MDA delivery (within ten days) singularly emerged as a common and fundamental component for achieving high MDA coverage when combined with other particular activities, including a conducive implementation context, early arrival of albendazole before the planned start of MDA, or a flexible community sensitization strategy. No individual activity proved sufficient by itself for producing high MDA coverage. We observed four possible overall models that could explain effective MDA delivery strategies, all which included efficient duration of MDA delivery as an integral component.

Conclusion

Efficient duration of MDA delivery uniquely stood out as a highly influential implementation activity for producing high coverage of community-wide MDA for STH. Effective MDA delivery can be achieved with flexible implementation strategies that include various combinations of influential intervention components.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08080-5.

Community views on mass drug administration for filariasis: a qualitative evidence synthesis

BACKGROUND

The World Health Organization (WHO) recommends mass drug administration (MDA), giving a drug at regular intervals to a whole population, as part of the strategy for several disease control programmes in low- and middle-income countries. MDA is currently WHO policy for areas endemic with lymphatic filariasis, which is a parasitic disease that can result in swollen limbs and disability. The success depends on communities adhering to the drugs given, and this will be influenced by the perception of the drug, the programme, and those delivering it.  OBJECTIVES: To synthesize qualitative research evidence about community experience with, and understanding and perception of, MDA programmes for lymphatic filariasis. To explore whether programme design and delivery influence the community experience identified in the analysis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases up to 8 April 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

This review synthesized qualitative research and mixed-methods studies when it was possible to extract qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards MDA programmes for lymphatic filariasis in any country, conducted between 2000 and 2019.  DATA COLLECTION AND ANALYSIS: We extracted data on study design including: authors, aims, participants, methods, and qualitative data collection methods. We also described programme delivery factors including: country, urban or rural setting, endemicity, drug regimen, rounds of MDA received at the time of the study, who delivered the drugs, how the drugs were delivered, use of health education, and sensitization and adherence monitoring. We conducted a thematic analysis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display our findings.  MAIN RESULTS: From 902 results identified in the search, 29 studies met our inclusion criteria. The studies covered a broad range of countries in Africa, South-East Asia, and South America, and explored the views and experiences of community members and community drug distributors in low-income countries endemic for lymphatic filariasis. Four themes emerged. People weigh up benefits and harms before participating. People understand the potential benefits in terms of relief of suffering, stigma, and avoiding costs (high confidence); however, these theoretical benefits do not always mesh with their experiences (high confidence). In particular, adverse effects are frightening and unwelcome (high confidence); and these effects are amplified through rumour and social media (moderate confidence). Many people are suspicious of MDA programmes. When people lack a scientific explanation for the programme and their experiences of it, they often develop social explanations instead. These are largely shaped on the historical backdrop and level of trust people have in relevant authority figures (high confidence), although some have unwavering faith in their government and, by extension, the programme (moderate confidence). Programmes expect compliance, and this can become coercive and blaming. Health workers and community members stigmatize non-compliance, which can become coercive (moderate confidence), so communities may appear to comply publicly, but privately reject treatment (moderate confidence). Community distributors are often not respected or valued. They have little authority (moderate confidence), and the behaviour of some distributors damages the MDA programme's reputation (high confidence). Communities want information about programmes to help make decisions about participation, but drug distributors are not sufficiently informed, or skilled in this communication (high confidence). We intended to assess whether programme designs influenced communities' perceptions of the programme and decision to adhere but were unable to do so as few studies adequately reported the design and implementation of the local programme. We have moderate to high confidence in the evidence contributing to the review themes and subthemes.

AUTHORS' CONCLUSIONS

Adherence with MDA for filariasis is influenced by individual direct experience of benefit and harm; social influences in the community; political influences and their relationship to government; and historical influences. Fear of adverse effects was frequently described and this appears to be particularly important for communities. When views were negative, we were surprised by the strength of feeling expressed. Enthusiasm for these schemes as a strategy in global policy needs debate in the light of these findings.

Mass drug administration targeting Onchocerca volvulus in Owabi catchment area in Ashanti Region, Ghana: Determinants of drug coverage and drug uptake

Introduction

Achieving high Mass Drug Administration (MDA) coverage and drug uptake are pivotal in the efforts to eradicate onchocerciasis. The present study investigated the extent and predictors of ivermectin MDA coverage and uptake from the individual and healthcare providers' perspectives. The extent of ivermectin distribution and uptake, and the predictors of distribution and uptake were investigated in endemic communities in the Ashanti Region of Ghana.

Methods

A cross-sectional survey was conducted from August to October 2019 in communities within the Atwima Nwabiagya North District. A total of 2008 respondents were interviewed. Data was collected with REDCap mobile App which had an electronic version of the structured questionnaire. Descriptive data was presented in frequency tables, and bivariate and multivariate logistics regression analysis were performed to measure the associations between exposure variables and outcome variables which were received and uptake of MDA drugs.

Results

A total of 1284 (63.9%) respondents did not receive ivermectin during the 2019 MDA programme and more than half of them were not aware of the drug distribution (53.3%). The most common reasons for not ingesting the drug were fear of side effects (47.7%) and not trusting the drug distributors (20.0%). Respondents in the age group 48–57 years (AOR = 1.37; 95%CI: 1.01–2.67), Persons in the high wealth index (AOR = 1.40; 95%CI: 1.11–1.77), Being aware of the MDA programme (AOR = 6.67: 95%CI: 4.76–9.35), MDA being beneficial (AOR = 2.12; 95%CI: 1.54–2.92) participating in previous MDA (AOR = 5.44; 95%CI: 4.25–6.98) and having stayed in the communities for 10 years and above significantly increased the odds of receiving MDA drugs. Previous uptake of MDA drugs (AOR = 10.58; 95%CI: 5.78–19.38) and perception of the MDA drug as beneficial (AOR = 5.25; 95%CI: 2.55–10.82) increased the likelihood of ingesting drugs when received.

Conclusion

The main health system challenge was limited awareness creation regarding MDA. This seems to affect the optimal utilization of the ivermectin MDA intervention. MDA programmes against onchocerciasis eradication should be designed taking into account specific contextual factors to improve implementation outcomes.

Factors influencing mass drug administration adherence and community drug distributor opportunity costs in Liberia: a mixed-methods approach

Background

Preventive chemotherapy delivered via mass drug administration (MDA) is essential for the control of neglected tropical diseases (NTDs), including lymphatic filariasis (LF), schistosomiasis and onchocerciasis. Successful MDA relies heavily on community drug distributor (CDD) volunteers as the interface between households and the health system. This study sought to document and analyse demand-side (households) and supply-side (health system) factors that affect MDA delivery in Liberia.

Methods

Working in two purposively selected counties, we conducted a household MDA access and adherence survey; a CDD survey to obtain information on direct and opportunity costs associated with MDA work; an observational survey of CDDs; and key informant surveys (KIS) with community-level health workers. Data from the CDD survey and Liberian minimum wage rates were used to calculate the opportunity cost of CDD participation per MDA round. The observational data were used to calculate the time spent on individual household-level tasks and CDD time costs per house visited. KIS data on the organisation and management of the MDA in the communities, and researcher reflections of open-ended survey responses were thematically analysed to identify key demand- and supply-side challenges.

Results

More respondents were aware of MDA than NTD in both counties. In Bong, 39% (103/261) of respondents reported taking the MDA tablet in the last round, with “not being informed” as the most important reason for non-adherence. In Maryland, 56% (147/263) reported taking MDA with “being absent” at the time of distribution being important for non-adherence. The mean cost per CDD of participating in the MDA round was −$11.90 (median $5.04, range −$169.62 to $30.00), and the mean time per household visited was 17.14 min which equates to a mean opportunity cost of $0.03 to $0.05 per household visited. Thematic analysis identified challenges, including shortages of and delays in medicine availability; CDD frustration over costs; reporting challenges; and household concerns about drug side effects.

Conclusions

Improved adherence to MDA and subsequent elimination of NTDs in Liberia would be supported by an improved medicine supply chain, financial compensation for CDDs, improved training, healthcare workforce strengthening, greater community involvement, capacity building, and community awareness.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-05058-w.

Assessing factors influencing communities' acceptability of mass drug administration for the elimination of lymphatic filariasis in Guyana

BACKGROUND

Guyana is one of four countries in the Latin American Region where lymphatic filariasis (LF) remains endemic. In preparation for the introduction of a new triple drug therapy regimen (ivermectin, diethylcarbamazine, and albendazole (IDA)) in 2019, an acceptability study was embedded within sentinel site mapping in four regions to assess mass drug administration (MDA) coverage and compliance, acceptability, and perceptions about treatment and disease. The results from this survey would inform the rollout of IDA in Guyana in 2019.

METHODS

Data collection for the study occurred in August 2019, using a validated questionnaire administered by trained enumerators. Across all regions, a total of 1,248 participants were sampled by the Filarial Mapping team. Four-hundred and fifty-one participants aged over 18 years were randomly selected for participation in an expanded acceptability questionnaire. All data were captured in Secure Data Kit (SDK).

RESULTS

Acceptability was measured using a mean acceptability score. Unadjusted mean scores ranged from 24.6 to 29.3, with 22.5 as the threshold of acceptability. Regional variation occurred across many indicators of interest: self-rated understanding about LF, mechanisms of LF transmission, LF drug safety and history of treatment during MDA. Region IV (Georgetown) recorded higher knowledge about LF, but lower compliance and acceptability. Number of pills was not perceived as a concern.

CONCLUSION

Acceptability of MDA was good across all four regions under study. Results from this study set a baseline level for key indicators and acceptability, from which the acceptability of IDA can be measured. Regional variations across indicators suggest that localized approaches should be considered for social mobilization and MDA delivery to capture these contextual differences.

Use of lay vaccinators in animal vaccination programmes: A scoping review

Background

The human resource gap in veterinary sectors, particularly in low-income countries, imposes limitations on the delivery of animal healthcare in hard-to-reach populations. Lay animal health workers have been deployed in these settings to fill the gap though there are mixed views about the benefits of doing this and whether they can deliver services safely. We mapped evidence on the nature and extent of roles assigned to lay animal vaccinators, and identified lessons useful for their future deployment.

Methodology/Principal findings

Following the PRISMA Extension for Scoping Reviews guidelines, we searched seven bibliographic databases for articles published between 1980 and 2021, with the search terms lay OR community-based OR volunteer AND "animal health worker" OR vaccinator*, and applied an a priori exclusion criteria to select studies. From 30 identified studies, lay vaccinators were used by non-government developmental (n = 12, 40%), research (n = 10, 33%) and government (n = 5, 17%) programmes to vaccinate domestic animals. The main reason for using lay vaccinators was to provide access to animal vaccination in the absence of professional veterinarians (n = 12, 40%). Reported positive outcomes of programmes included increased flock and herd sizes and farmer knowledge of best practice (n = 13, 43%); decreased disease transmission, outbreaks and mortality (n = 11, 37%); higher vaccination coverage (10, 33%); non-inferior seroconversion and birth rates among vaccinated herds (n = 3, 10%). The most frequently reported facilitating factor of lay vaccinator programmes was community participation (n = 14, 47%), whilst opposition from professional veterinarians (n = 8, 27%), stakeholders seeking financial gains to detriment of programmes goals (n = 8, 27%) and programming issues (n = 8, 27%) were the most frequently reported barriers. No study reported on cost-effectiveness and we found no record from a low and middle-income country of lay vaccinator programmes being integrated into national veterinary services.

Conclusion

Although the majority of included studies reported more benefits and positive perceptions of lay vaccinator programmes than problems and challenges, regularization will ensure the programmes can be designed and implemented to meet the needs of all stakeholders.

In the absence of professional animal healthcare workers in hard-to-reach settings, lay persons, with limited, non-formal training, have been used to provide animal healthcare services, including vaccination. In spite of the perceived crucial roles lay persons play in the animal health sector, their services are largely unrecognized within official animal healthcare systems. We compiled evidence on how lay persons have been used in animal vaccination programmes and make recommendations regarding how they can be used in more effective ways. We found they were used by both government and non-government institutions to vaccinate different domestic animals and provide regular animal healthcare services. They were mainly used where professional animal healthcare workers are not available or are limited in number. The programmes were more successful where they had the support of the public and institutions, and their outcomes were largely similar to those delivered by professionals. We also found that community participation was an important facilitating factor, whilst the main challenges they faced were opposition from professional veterinarians, financial interests of stakeholders and planning issues. We concluded that lay animal vaccinator programmes could be more beneficial if better regulated.

Community acceptability to antimalarial mass drug administrations in Magude district, Southern Mozambique: A mixed methods study

Background

This study aimed to capture the acceptability prior to, during and after the implementation of the first year of MDA rounds conducted under the Magude project, a malaria elimination project in southern Mozambique.

Methods

This was a mixed-methods study, consisting of focus group discussions (FGDs) prior to the implementation of MDA rounds (September 2015), non-participant observations (NPOs) conducted during the MDA rounds (November 2015 –beginning of February 2016), and semi-structured interviews (SSIs) after the second round (end of February 2016). Community leaders, women in reproductive age, general members of the community, traditional healers and health professionals were recruited to capture the opinions of all representing key members of the community. A generic outline of nodes and codes was designed to analyze FGDs and SSI separately. Qualitative and quantitative NPO information was analyzed following a content analysis approach.

Findings

222 participants took part in the FGDs (n = 154), and SSIs (n = 68); and 318 household visits during the MDA underwent NPOs. The community engagement campaign emerged throughout the study stages as a crucial factor for the acceptability of MDAs. Acceptability was also fostered by the community’s general will to cooperate in any government-led activity that would reduce malaria burden, the appropriate behavior and knowledge of field workers, or the fact that the intervention was available free of charge to all. Absenteeism of heads of households was identified as the main barrier for the success of the campaign. The most commonly reported factors that negatively affected acceptability were the fear of adverse events, rumors of deaths, being unable to drink alcohol while taking DHAp, or the fear to take DHAp while in anti-retroviral treatment. Pregnancy testing and malaria testing were generally well accepted by the community.

Conclusion

Magude’s community generally accepted the first and second antimalarial MDA rounds, and the procedures associated to the intervention. Future implementation of antimalarial MDAs in southern Mozambique should focus on locally adapted strategies that engage the community to minimize absenteeism and refusals to the intervention.

Evaluating context-specific evidence-based quality improvement intervention on lymphatic filariasis mass drug administration in Northern Ghana using the RE-AIM framework

Background

Over a decade of implementing a global strategy to eliminate lymphatic filariasis in Ghana through mass drug administration, the disease is still being transmitted in 11 districts out of an initial 98 endemic districts identified in 2000. A context-specific evidence-based quality improvement intervention was implemented in the Bole District of Northern Ghana after an initial needs assessment to improve the lymphatic filariasis mass drug administration towards eliminating the disease. Therefore, this study aimed to evaluate the process and impact of the lymphatic filariasis context-specific evidence-based quality improvement intervention in the Bole District of Northern Ghana.

Method

A cross-sectional mixed methods study using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate the context-specific evidence-based quality improvement intervention was employed. Quantitative secondary data was extracted from the neglected tropical diseases database. A community survey was conducted with 446 randomly selected participants. Qualitative data were collected from 42 purposively selected health workers, chiefs/opinion leaders and community drug distributors in the study area.

Results

The evaluation findings showed an improvement in social mobilisation and sensitisation, knowledge about lymphatic filariasis and mass drug administration process, willingness to ingest the medication and adherence to the direct observation treatment strategy. We observed an increase in coverage ranging from 0.1 to 12.3% after implementing the intervention at the sub-district level and reducing self-reported adverse drug reaction. The level of reach, effectiveness and adoption at the district, sub-district and individual participants’ level suggest that the context-specific evidence-based quality improvement intervention is feasible to implement in lymphatic filariasis hotspot districts based on initial context-specific needs assessment.

Conclusion

The study provided the groundwork for future application of the RE-AIM framework to evaluate the implementation of context-specific evidence-based quality improvement intervention to improve lymphatic filariasis mass drug administration towards eliminating the disease as a public health problem.

Implementation challenges and opportunities for improved mass treatment uptake for lymphatic filariasis elimination: Perceptions and experiences of community drug distributors of coastal Kenya

Community drug distributors (CDDs) who are volunteers have the responsibility of awareness creation, household census, drug distribution and record-keeping and are thus key stakeholders in the campaign for Lymphatic Filariasis (LF) elimination. Taking into account their experiences and perceptions is important for a successful elimination campaign. We conducted a qualitative study in 2018 to identify implementation challenges and opportunities for improved mass drug administration (MDA) uptake based on the CDDs perceptions and experiences. Within a larger study that used mixed methods quasi-experimental design, we collected qualitative data from two wards in Kaloleni Sub-County of Kilifi County which was purposively selected owing to its low, 56% and 50.5% treatment coverage in 2015 and 2016 respectively. Focus group discussions (FGDs) (n = 8) and in-depth interviews (IDIs) (n = 8) with CDDs, IDIs (n = 22) with opinion leaders and IDIs (n = 8) with health workers were conducted and the data analyzed by QSR NVIVO version 10 according to thematic areas. The results showed that based on the perceptions and experiences of the CDDs, several challenges: communities’ refusal to take the drugs; absenteeism during MDA; non-adherence to CDDs selection criteria; inadequacy in number of CDDs engaged during the campaign and training provided; insufficiency of drugs issued to CDDs; lack of CDDs supervision and low motivation negatively impact on MDA uptake. Opportunities to address the challenges included: awareness creation on MDA, health education on LF and observation of hygiene during drug administration, increased duration of awareness creation and drug administration, adherence to CDDs selection criteria and putting into consideration the vastness of an area and population density while deploying CDDs. Other opportunities include: improved CDDs training and scheduling; issuing of enough drugs to CDDs to meet the communities’ demand and improved supervision and motivation of CDDs. Addressing the challenges highlighted is an important step of maximizing MDA uptake. The opportunities presented need to be considered by the NTD program personnel, the county health personnel and the community while planning the implementation of MDA campaigns.

Elephantiasis infection which is common in tropical areas is targeted for elimination globally through delivery of drugs to all populations living in areas where infections occur. Community Drug Distributors (CDDs) are persons who live in the affected communities and who volunteer themselves to distribute drugs after receiving training from the health care workers. Understanding the challenges and opportunities for improved community drug uptake from the perspectives and experiences of the CDDs is important for a successful elimination campaign.

As part of a larger study to address barriers of drug uptake in Kenya, we collected qualitative data to explore the challenges and opportunities for improved drug uptake in two wards of Kilifi County. The data was collected through focus group discussions and in-depth interviews and analyzed.

For drug uptake to be improved, the CDDs’ mentioned challenges related to how their selection is done, number of CDDs engaged, quality of their training, quantities of drugs issued to them, supervision and motivation that need to be addressed. The communities targeted for treatment need well scheduled health education activities on elephantiasis, awareness creation on drug distribution and drug reaction for them to understand the importance of receiving the treatment. These findings suggest the need for strong collaborations between NTD program, county health personnel and the community that are useful in the planning the implementation of successful national programs.

Lot quality assurance sampling to assess coverage and compliance following mass drug administration to eliminate lymphatic filariasis in Fiji: A methodological approach

Background

Assessing the quality of mass drug administration (MDA) rounds is a key component of lymphatic filariasis (LF) elimination programs. Routine collection of administrative coverage is unreliable, especially when pockets with low program coverage exist. To address this gap, we used lot quality assurance sampling (LQAS) following the 10th annual LF-MDA round in Fiji to explore whether there was any area in which target coverage was not reached. We also assessed the level of drug compliance and satisfaction with the LF-MDA implementation strategy.

Methodology/principal findings

We conducted a cross-sectional household survey in 3 divisions of Fiji. For LQAS, we defined 19 lots in 7 medical areas of the Suva sub-division and another 12 sub-divisions in the Central, Northern, and Eastern Divisions. A sample of 16 randomly selected household members was taken un each lot. We defined our decision rule as follows: if more than 1 person in a given lot did not swallow the medication, coverage was considered inadequate, i.e. less than 80%.

Of the 7 lots in Suva sub-division and 12 lots in the 3 divisions, five and two lots, respectively, were identified as having inadequate coverage. The overall program coverage estimated from 304 samples was 92%, which was higher than the reported administrative coverage of 82%. About 98% of interviewees were offered the medication and 96% swallowed it. Non-participation arose from insufficient information on how to obtain the drugs. At least 92% were satisfied with the LF-MDA implementation strategy.

Conclusions

Areas of low program coverage with results discordant with the reported administrative coverage existed in both urban and rural settings. Drug compliance and satisfaction were high, even after repeated rounds. We recommend increasing efforts to deliver the service in those areas with inadequate program coverage, as well as conducting timely coverage assessment through LQAS for corrective action.

Addressing barriers of community participation and access to mass drug administration for lymphatic filariasis elimination in Coastal Kenya using a participatory approach

Since the prioritization of Lymphatic Filariasis (LF) elimination in 1997, progress has been made in reducing disease transmission and burden. Validation of elimination through Transmission Assessment Surveys (TAS) in implementation units (IUs) that have received at least 5 rounds of mass drug administration (MDA) and achieved minimum threshold of 65% treatment coverage is required. There are IUs that do not qualify for TAS due to achievement of low treatment coverage. This study sought to identify barriers of community participation and access to MDA, develop and test strategies to be recommended for improved uptake. Two wards in Kaloleni sub-county, Kilifi county with an average treatment coverage of 56% in 2015, 50.5% in 2016 were purposively sampled and a quasi-experimental study conducted. Through systematic random sampling, 350 (pre-intervention) and 338 (post-intervention) household heads were selected and interviewed for quantitative data. For qualitative data, 16 Focus Group Discussions (FGDs) with purposively selected community groups were conducted. Participatory meetings were held with county stakeholders to agree on strategies for improved community participation in MDA. The quantitative data were analyzed using STATA version 14.1, statistical significance assessed by chi square test and qualitative data by QSR NVIVO version 10. The identified strategies were tested in experimental sites during the 2018 MDA and the usual MDA strategies applied in control sites. The results showed an increase in community participation and access to MDA in both sites 80.6% (pre-intervention), 82.9% (post-intervention). The proportion of participants who considered the treatment as necessary significantly (p = 0.001) increased to 96.2% from 88.3% and significantly dropped for those with drug swallowing problems associated with: size (p<0.001), number (p<0.027) and taste (p = 0.001). The implemented strategies may have contributed to increased participation and access to MDA and should be applied for improved treatment uptake. Health education on disease aetiology and importance of drug uptake in all rounds is key to program's success.

The roles of stakeholder experience and organizational learning in declining mass drug administration coverage for lymphatic filariasis in Port-au-Prince, Haiti: A case study

The World Health Organization (WHO) defines an effective round of mass drug administration (MDA) for lymphatic filariasis (LF) as one that reaches at least 65% of the target population. In its first round of MDA in 2011–2012, the National Program to Eliminate LF in Haiti achieved a 79% epidemiological coverage in urban Port-au-Prince. In 2013, coverage dropped below the WHO threshold and has declined year-over-year to a low of 41% in 2017. We conducted a retrospective qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. Our findings suggest that the main contributors to the decline in MDA coverage appear to be the absence of effective documentation of practices, reporting, analysis, and program quality improvement—i.e., learning mechanisms—within the program’s MDA design and implementation strategy. In addition to their contribution to the program’s failure to meet its coverage targets, these deficits have resulted in a high cost for the MDA campaign in both lost momentum and depleted morale. Through a proposed operating logic model, we explore how the pathway from program inputs to outcomes is influenced by a wide array of mediating factors, which shape potential participants’ experience of MDA and, in turn, influence their reasoning and decisions to take, or not take, the pills. Our model suggests that the decisions and behavior of individuals are a reflection of their overall experience of the program itself, mediated through a host of contextual factors, and not simply the expression of a fixed choice or preference. This holistic approach offers a novel and potentially valuable framing for the planning and evaluation of MDA strategies for LF and other diseases, and may be applicable in a variety of global health programs.

In order to eliminate lymphatic filariasis from a region, the World Health Organization recommends a strategy of preventative drugs delivered annually to the population. At least 65% of the population must participate for four to six consecutive years for this approach to be effective. In urban Port-au-Prince, Haiti, the number of people taking the drugs has been declining progressively below the 65% benchmark since 2012. We used a qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. We found that the lymphatic filariasis elimination program lacks the necessary design and program infrastructure to ensure reliable learning about problems faced by pill distribution teams on the ground, and the improvisations they introduced to address these challenges. The inability to incorporate these lessons into program improvements and refinements resulted in under-performance and contributed to the decline in coverage. Furthermore, the way that people experience the program is strongly influenced by a host of contextual factors, which shape potential participants’ experience of the program and, in turn, influence their reasoning and decisions to take, or not take, the pills.

Implementer and recipient perspectives of community-wide mass drug administration for soil-transmitted helminths in Kwale County, Kenya

Soil-transmitted helminthiases (STH) are one of 17 neglected tropical diseases (NTDs) earmarked for control or elimination by 2020 in the WHO’s Roadmap on NTDs. Deworming programs for STH have thus far been focused on treating pre-school and school-aged children; however, there is a growing consensus that to achieve elimination of STH transmission, programs must also target adults, potentially through community-wide mass drug administration (MDA). There is currently a gap in the literature on what components are required to deliver community-wide MDA for STH in order to achieve high intervention reach and uptake. Nested within the TUMIKIA Project, a cluster randomized trial in Kenya evaluating the effectiveness of school-based deworming versus community-wide MDA, we collected qualitative data from program implementers and recipients in eight clusters where community-wide MDA was delivered. Data collection included semi-structured in-depth interviews (n = 72) and focus group discussions (n = 32). A conceptual framework for drug distribution was constructed to help build an analysis codebook. Case memos were developed for each top-level theme. Community-wide MDA for STH was perceived as a complex intervention with key administrative and social mobilization domains. Key actionable themes included: (1) developing an efficient strategy to allocate reasonable workload for implementers to cover all targeted households; (2) maximizing community drug distributors’ motivation through promoting belief in the effectiveness of the intervention and providing sufficient financial incentives; (3) developing effective capacity building strategies for implementers; and (4) implementing a context-adapted community engagement strategy that leverages existing community structures and takes into consideration past community experiences of MDAs. Transitioning from STH control to elimination goals requires significant planning and action to ensure community-wide MDA is delivered with sufficient reach and uptake. We present findings that can inform national deworming programs to increase intervention delivery capacity.

Infections by soil-transmitted worms are common in tropical and subtropical areas. Control strategies usually involve distributing deworming drugs to children, who are most affected. However, recent evidence suggests that distributing these drugs to whole communities, including adults, might help to achieve the elimination of these worms as a public health problem. As part of a large trial in Kenya evaluating the distribution of deworming drugs to communities, we conducted a qualitative study to explore the perspectives of drug delivery among drug distributors and recipient communities. We conducted and analyzed in-depth interviews and focus group discussions. For community deworming to be implemented well, it requires distributors to be highly motivated and follow a plan that fits well with the characteristics of the target community. In order to accept the deworming drugs, communities need to know about the health problem and the intervention, and trust the delivery system. These findings should prove useful to national deworming programs planning to distribute drugs to whole communities when developing their delivery strategies.

The fight against lymphatic filariasis: perceptions of community drug distributors during mass drug administration in coastal Kenya

Background

Lymphatic filariasis (LF), a neglected tropical disease (NTD) and leading cause of global disability, is endemic in 32 countries in Africa with almost 350 million people requiring regular drug administration, and only 16 countries achieving target coverage. Community Drug Distributors (CDDs) are critical for the success of NTD programs, and the distribution of medicines during mass drug administration (MDA) in Africa; however they could also be a weak link. The primary aim of this study is to explore and describe perceptions of CDDs during MDA for LF in Mvita sub-county in Mombasa county and Kaloleni sub-county in Kilifi county, Kenya; and provide recommendations for the effective engagement of communities and CDDs in low-resource settings.

Methods

In September 2018, we conducted six focus group discussions with community members in each sub-county, three with men aged 18–30, 31–50, and 51 years and above and three with women stratified into the same age groups. In each sub-county, we also conducted semi-structured interviews with nine community health extension workers (CHEWs), the national LF focal point, the county NTD focal points, and seven community leaders. Content analysis of the data was conducted, involving a process of reading, coding, and displaying data in order to develop a codebook.

Results

We found that several barriers and facilitators impact the engagement between CDDs and community members during MDA. These barriers include poor communication and trust between CDDs and communities; community distrust of the federal government; low community knowledge and perceived risk of LF, poor timing of MDA, fragmented supervision of CDDs during MDA; and CDD bias when distributing medicines. We also found that CDD motivation was a critical factor in their ability to successfully meet MDA targets. It was acknowledged that directly observed treatment and adequate health education were often not executed by CDDs. The involvement of community leaders as informal supervisors of CDDs and community members improves MDA.

Conclusions

In order to achieve global targets around the elimination of LF, CDDs and communities must be effectively engaged by improving planning and implementation of MDA.

How lymphatic filariasis was eliminated from an urban poor setting in Santo Domingo, Dominican Republic

BACKGROUND

While progress has been made in the elimination of lymphatic filariasis, challenges that call for innovative approaches remain. Program challenges are increasingly observed in 'hard-to-reach' populations: urban dwellers, migrant populations, those living in insecurity, children who are out of school and areas where infrastructure is weak and education levels are low. 'Business-as-usual' approaches are unlikely to work. Tailored solutions are needed if elimination goals are to be reached. This article focuses on mass drug administrations (MDAs) in urban settings.

METHODS

We selected the urban poor area of Santo Domingo, Dominican Republic. With three rounds of MDA and with good coverage, elimination was achieved. We wanted to understand contributing factors to achieving good coverage. A qualitative study analyzed context, barriers and facilitators using a predefined framework based on review of the literature.

RESULTS

Results show that barriers commonly reported in urban settings were present (population density, lack of organization in household layout, population mobility, violence, shortage of human resources and challenges in monitoring treatment coverage). Tactics used included strong visibility in the community leading to high levels of awareness, the use of laminated photo sheets during house-to-house visits and a 1:4 supervision strategy. The importance of working through community leadership structures and building relationships with the community was evident.

DISCUSSION

The approach developed here has applications for large-scale treatment programs for lymphatic filariasis and other diseases in urban settings.

Eliminating Neglected Tropical Diseases in Urban Areas: A Review of Challenges, Strategies and Research Directions for Successful Mass Drug Administration

Since 1950, the global urban population grew from 746 million to almost 4 billion and is expected to reach 6.4 billion by mid-century. Almost 90% of this increase will take place in Asia and Africa and disproportionately in urban slums. In this context, concerns about the amplification of several neglected tropical diseases (NTDs) are warranted and efforts towards achieving effective mass drug administration (MDA) coverage become even more important. This narrative review considers the published literature on MDA implementation for specific NTDs and in-country experiences under the ENVISION and END in Africa projects to surface features of urban settings that challenge delivery strategies known to work in rural areas. Discussed under the thematics of governance, population heterogeneity, mobility and community trust in MDA, these features include weak public health infrastructure and programs, challenges related to engaging diverse and dynamic populations and the limited accessibility of certain urban settings such as slums. Although the core components of MDA programs for NTDs in urban settings are similar to those in rural areas, their delivery may need adjustment. Effective coverage of MDA in diverse urban populations can be supported by tailored approaches informed by mapping studies, research that identifies context-specific methods to increase MDA coverage and rigorous monitoring and evaluation.

Community and Drug Distributor Perceptions and Experiences of Mass Drug Administration for the Elimination of Lymphatic Filariasis: A Rapid Review of Qualitative Research

STUDY OBJECTIVES

This article presents findings from a rapid review of qualitative research conducted to inform decision makers about community and drug distributor perceptions and experiences of mass drug administration campaigns for the elimination of lymphatic filariasis. We focused on questions related to acceptability of the mass drug administration campaigns within these groups and their thoughts around the feasibility of planning and carrying out the campaigns.

METHODS

We carried out a systematic search in five databases to identify potential studies. We included studies that focused on community members and drug distributors and used qualitative methods for data collection and analysis. We conducted a thematic framework analysis using the Supporting the Use of Research Evidence framework. Due to time constraints, one author conducted the screening, extraction and data analysis.

FINDINGS

Studies found that communities lack knowledge and information about lymphatic filariasis and the mass drug administration campaigns and that this can have an impact on how many community members choose to take medication. Health workers often had a good understanding that lymphatic filariasis was a problem in their setting, of its cause and mode of transmission and that hydrocele and elephantiasis had the same cause. However, this knowledge was not as prevalent amongst community drug distributors who often had misconceptions surrounding the topic. Furthermore, studies found that the length, timing, level of community and health system involvement, access to care for side effects, inadequate numbers of drug distributors and supervisors and motivation of drug distributors influenced participation in mass drug administration campaigns. Finally, the inadequate training of drug distributors could influence community trust in the mass drug administration program and the drug distributor themselves if there was a perception that the person was uninformed or not trained to carry out their tasks.

Assessing knowledge about lymphatic filariasis and the implementation of mass drug administration amongst drug deliverers in three districts/cities of Indonesia

Background

This research assesses knowledge amongst drug deliverers about the implementation of mass drug administration (MDA) for lymphatic filariasis (LF) in Agam District (West Sumatera Province), the City of Depok (West Java Province) and the City of Batam (Kepulauan Riau Province), Indonesia.

Methods

A cross-sectional survey was conducted from January to March 2015 at these three sites. Respondents were identified using purposive sampling (i.e. cadre, health worker or community representatives). A total of 318 questionnaires were accepted for analysis. Three outcomes were assessed: knowledge about LF; knowledge about MDA implementation; and was informed about MDA coverage. Logistic regression analyses were employed to examine factors associated with these three outcomes.

Results

Less than half of respondents were charactersised as having a high level of LF knowledge and less than half a high level of knowledge about MDA. The odds of having a high level of knowledge of LF was significantly lower in Batam City than Agam District, yet higher amongst health workers than cadres. Deliverers living in urban areas reported more feedback on MDA outcomes than in the rural district. Health workers received more feedback than cadres (P < 0.001). Deliverers perceived the difference between coverage (drug receipt) and compliance (drug ingestion) in the community.

Conclusions

There are variations in knowledge about LF and MDA as well as feedback across drug deliverers in MDA across geographical areas. Adaptation of the MDA guidelines, supportive supervision, increasing the availability of supporting materials and directly-observed therapy might be beneficial to improve coverage and compliance in all areas.

Elimination of lymphatic filariasis: current perspectives on mass drug administration

Following the London declaration on neglected tropical diseases (NTDs) in 2012 and inspired by the WHO 2020 roadmap to control or eliminate NTDs, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) intensified preventive chemotherapy and management of morbidity as the two main strategies to enhance progress towards the elimination of lymphatic filariasis (LF). This paper focuses on current perspectives of mass drug administration (MDA) towards the elimination of LF. The goal of MDA is to reduce the density of parasites circulating in the blood of infected persons and the intensity of infection in communities to levels where transmission is no longer sustainable by the mosquito vector. Three drugs, diethylcarbamazine, albendazole, and ivermectin are currently available for LF treatment, and their effectiveness and relative safety have opened the possibility of treating the entire population at risk. Currently, almost all LF endemic countries rely on the single-dose two-drug regimen recommended by the GPELF to achieve elimination. The 4th WHO report on NTDs has indicated that considerable progress has been made towards elimination of LF in some countries while acknowledging some challenges. In this review, we conclude that the 2020 elimination goal can be achieved if issues pertaining to the drug distribution, health system and implementation challenges are addressed.

Strategies to improve treatment coverage in community-based public health programs: A systematic review of the literature

Background

Community-based public health campaigns, such as those used in mass deworming, vitamin A supplementation and child immunization programs, provide key healthcare interventions to targeted populations at scale. However, these programs often fall short of established coverage targets. The purpose of this systematic review was to evaluate the impact of strategies used to increase treatment coverage in community-based public health campaigns.

Methodology/ principal findings

We systematically searched CAB Direct, Embase, and PubMed archives for studies utilizing specific interventions to increase coverage of community-based distribution of drugs, vaccines, or other public health services. We identified 5,637 articles, from which 79 full texts were evaluated according to pre-defined inclusion and exclusion criteria. Twenty-eight articles met inclusion criteria and data were abstracted regarding strategy-specific changes in coverage from these sources. Strategies used to increase coverage included community-directed treatment (n = 6, pooled percent change in coverage: +26.2%), distributor incentives (n = 2, +25.3%), distribution along kinship networks (n = 1, +24.5%), intensified information, education, and communication activities (n = 8, +21.6%), fixed-point delivery (n = 1, +21.4%), door-to-door delivery (n = 1, +14.0%), integrated service distribution (n = 9, +12.7%), conversion from school- to community-based delivery (n = 3, +11.9%), and management by a non-governmental organization (n = 1, +5.8%).

Conclusions/significance

Strategies that target improving community member ownership of distribution appear to have a large impact on increasing treatment coverage. However, all strategies used to increase coverage successfully did so. These results may be useful to National Ministries, programs, and implementing partners in optimizing treatment coverage in community-based public health programs.

Many public health platforms provide decentralized interventions outside of health facilities, including mass drug administration for neglected tropical diseases, immunizations, vitamin supplementation, and others. The purpose of these community-based public health platforms is to reach large proportions of populations in need with important preventative healthcare. However the platforms require high treatment coverage of targeted populations in order to achieve health impact. And, in many cases, targeted populations are low-income, rural, and hard to reach with large health campaigns. The purpose of this systematic review is to evaluate strategies for achieving high treatment coverage in public health service distribution programs. We identified nine different strategies used to increase coverage of distribution programs. Community-directed distribution was associated with the largest increase in treatment coverage. Similarly, incentivizing distributors also had a strong influence on increasing treatment coverage. These findings have important implications for governments, implementers, and funders who aim to provide health services at scale.

Elimination of lymphatic filariasis in west African urban areas: is implementation of mass drug administration necessary?

Lymphatic filariasis in Africa is caused by the parasite Wuchereria bancrofti and remains a major cause of morbidity and disability in 74 countries globally. A key strategy of the Global Programme for the Elimination of Lymphatic Filariasis, which has a target elimination date of 2020, is the treatment of entire endemic communities through mass drug administration of albendazole in combination with either ivermectin or diethylcarbamazine. Although the strategy of mass drug administration in combination with other interventions, such as vector control, has led to elimination of the infection and its transmission in many rural communities, urban areas in west Africa present specific challenges to achieving the 2020 targets. In this Personal View, we examine these challenges and the relevance of mass drug administration in urban areas, exploring the rationale for a reassessment of policy in these settings. The community-based mass treatment approach is best suited to rural areas, is challenging and costly in urban areas, and cannot easily achieve the 65% consistent coverage required for elimination of transmission. In our view, the implementation of mass drug administration might not be essential to interrupt transmission of lymphatic filariasis in urban areas in west Africa. Evidence shows that transmission levels are low and that effective mass drug distribution is difficult to implement, with assessments suggesting that specific control measures against filariasis in such dynamic settings is not an effective use of limited resources. Instead, we recommend that individuals who have clinical disease or who test positive for W bancrofti infection in surveillance activities should be offered antifilarial drugs through a passive surveillance approach, as well as morbidity management for their needs. We also recommend that more precise studies are done, so that mass drug administration in urban areas is considered if sustainable transmission is found to be ongoing. Otherwise, the limited resources should be directed towards other elements of the lymphatic filariasis programme.

Local stakeholders' perceptions of community sensitization for school-based deworming programme in Kenya

Background

In Kenya, the National School-Based Deworming Programme (NSBDP) for soil-transmitted helminthes and schistosomiasis in prioritized areas has been going on since the year 2012. By the year 2013 over 6 million School Age Children (SAC) had been treated. A community sensitization supplement containing key messages and answers to frequently asked questions was developed as a guiding tool. Awareness creation methods used include county sensitization meetings, stakeholder forums, town criers and posters. To assess the local stakeholders’ perceptions of community sensitization for programme implementation, a qualitative cross-sectional survey was conducted in four-sub-counties of coastal region.

Methods

In-depth interviews (IDIs) were administered to 40 purposively selected opinion leaders so as to explore their perceptions of awareness creation sources, adequacy of information given, length of period of awareness creation and period between which information is given and drugs are administered. Separate IDIs were administered to pre-school teachers (41), community health extension workers (34) and primary school teachers (38). To elicit more information, 20 focus group discussions (FGDs) categorized by gender and age were conducted among parents of school-age children. Data was audio recorded, transcribed, coded and analyzed manually by study themes.

Results

The most commonly reported source of information was school pupils. Due to low literacy levels, use of posters was regarded as ineffective and religious institutions, town criers and vernacular radio stations considered more effective. The information given during programme implementation was considered inadequate and use of complementary methods to reach all targeted children including the non-enrolled, and relay adequate information reported as important. Use of school and chief’s meetings with health personnel being present was mentioned as a useful method that would allow for interaction with participants indicating that they did not understand why adults were not being treated. Repeated awareness creation before deworming day to serve as a reminder and to reach those missing initial messages was also mentioned as important. Furthermore, the awareness creation period needed to be extended as 85% of the participants indicated that they learnt of deworming a day before it took place or after their children had received the drugs.

Conclusion

Awareness creation is a key factor in the success of NSBDP implementation. For programme sustainability, preferences of local stakeholders need to be considered as control of worms can only be achieved through an integrated approach of deworming, health education and use of safe water and sanitation facilities which require collaboration with local stakeholders.

Lymphatic filariasis patient identification in a large urban area of Tanzania: An application of a community-led mHealth system

BACKGROUND

Lymphatic filariasis (LF) is best known for the disabling and disfiguring clinical conditions that infected patients can develop; providing care for these individuals is a major goal of the Global Programme to Eliminate LF. Methods of locating these patients, knowing their true number and thus providing care for them, remains a challenge for national medical systems, particularly when the endemic zone is a large urban area.

METHODOLOGY/PRINCIPLE FINDINGS

A health community-led door-to-door survey approach using the SMS reporting tool MeasureSMS-Morbidity was used to rapidly collate and monitor data on LF patients in real-time (location, sex, age, clinical condition) in Dar es Salaam, Tanzania. Each stage of the phased study carried out in the three urban districts of city consisted of a training period, a patient identification and reporting period, and a data verification period, with refinements to the system being made after each phase. A total of 6889 patients were reported (133.6 per 100,000 population), of which 4169 were reported to have hydrocoele (80.9 per 100,000), 2251 lymphoedema-elephantiasis (LE) (43.7 per 100,000) and 469 with both conditions (9.1 per 100,000). Kinondoni had the highest number of reported patients in absolute terms (2846, 138.9 per 100,000), followed by Temeke (2550, 157.3 per 100,000) and Ilala (1493, 100.5 per 100,000). The number of hydrocoele patients was almost twice that of LE in all three districts. Severe LE patients accounted for approximately a quarter (26.9%) of those reported, with the number of acute attacks increasing with reported LE severity (1.34 in mild cases, 1.78 in moderate cases, 2.52 in severe). Verification checks supported these findings.

CONCLUSIONS/SIGNIFICANCE

This system of identifying, recording and mapping patients affected by LF greatly assists in planning, locating and prioritising, as well as initiating, appropriate morbidity management and disability prevention (MMDP) activities. The approach is a feasible framework that could be used in other large urban environments in the LF endemic areas.

A systematic review of factors that shape implementation of mass drug administration for lymphatic filariasis in sub-Saharan Africa

BACKGROUND

Understanding factors surrounding the implementation process of mass drug administration for lymphatic filariasis (MDA for LF) elimination programmes is critical for successful implementation of similar interventions. The sub-Saharan Africa (SSA) region records the second highest prevalence of the disease and subsequently several countries have initiated and implemented MDA for LF. Systematic reviews have largely focused on factors that affect coverage and compliance, with less attention on the implementation of MDA for LF activities. This review therefore seeks to document facilitators and barriers to implementation of MDA for LF in sub-Saharan Africa.

METHODS

A systematic search of databases PubMed, Science Direct and Google Scholar was conducted. English peer-reviewed publications focusing on implementation of MDA for LF from 2000 to 2016 were considered for analysis. Using thematic analysis, we synthesized the final 18 articles to identify key facilitators and barriers to MDA for LF programme implementation.

RESULTS

The main factors facilitating implementation of MDA for LF programmes were awareness creation through innovative community health education programmes, creation of partnerships and collaborations, integration with existing programmes, creation of morbidity management programmes, motivation of community drug distributors (CDDs) through incentives and training, and management of adverse effects. Barriers to implementation included the lack of geographical demarcations and unregistered migrations into rapidly urbanizing areas, major disease outbreaks like the Ebola virus disease in West Africa, delayed drug deliveries at both country and community levels, inappropriate drug delivery strategies, limited number of drug distributors and the large number of households allocated for drug distribution.

CONCLUSION

Mass drug administration for lymphatic filariasis elimination programmes should design their implementation strategies differently based on specific contextual factors to improve implementation outcomes. Successfully achieving this requires undertaking formative research on the possible constraining and inhibiting factors, and incorporating the findings in the design and implementation of MDA for LF.

Improving drug delivery strategies for lymphatic filariasis elimination in urban areas in Ghana

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas.

The control of lymphatic filariasis depends on the treatment of entire endemic communities, ensuring that a greater proportion of the population is treated. In urban areas, this can be very difficult to achieve. In Ghana, parts of the Greater Accra Region, where the capital city is located, are also endemic for lymphatic filariasis. Treatment in these areas started in 2006, but the proportion of people treated has continuously been below the required programmatic coverage levels. To understand the reasons behind this, a study was undertaken in three endemic districts. The study was carried out in three stages; pre-treatment, treatment and post-treatment. Individuals and groups of people were interviewed in the pre-treatment phase, following which their concerns were used to plan and execute treatment activities. After treatment, some individuals were again interviewed to assess the effectiveness of the interventions. The results showed that the knowledge and behavior of community members towards the disease and treatment activities improved from the pre-treatment to the post-treatment reviews. Many factors were identified including, financial, management and leadership issues that should be considered when planning treatment activities in urban areas.

Community engagement and the social context of targeted malaria treatment: a qualitative study in Kayin (Karen) State, Myanmar

Background

The spread of artemisinin-resistance in Plasmodium falciparum is a threat to current global malaria control initiatives. Targeted malaria treatment (TMT), which combines mass anti-malarial administration with conventional malaria prevention and control measures, has been proposed as a strategy to tackle this problem. The effectiveness of TMT depends on high levels of population coverage and is influenced by accompanying community engagement activities and the local social context. The article explores how these factors influenced attitudes and behaviours towards TMT in Kayin (Karen) State, Myanmar.

Methods

Semi-structured interviews were conducted with villagers from study villages (N = 31) and TMT project staff (N = 14) between March and July 2015.

Results

Community engagement consisted of a range of activities to communicate the local malaria situation (including anti-malarial drug resistance and asymptomatic malaria), the aims of the TMT project, and its potential benefits. Community engagement was seen by staff as integral to the TMT project as a whole and not a sub-set of activities. Attitudes towards TMT (including towards community engagement) showed that developing trusting relationships helped foster participation. After initial wariness, staff received hospitality and acceptance among villagers. Offering healthcare alongside TMT proved mutually beneficial for the study and villagers. A handful of more socially-mobile and wealthy community members were reluctant to participate. The challenges of community engagement included time constraints and the isolation of the community with its limited infrastructure and a history of conflict.

Conclusions

Community engagement had to be responsive to the local community even though staff faced time constraints. Understanding the social context of engagement helped TMT to foster respectful and trusting relationships. The complex relationship between the local context and community engagement complicated evaluation of the community strategy. Nonetheless, the project did record high levels of population coverage.

The acceptability of mass administrations of anti-malarial drugs as part of targeted malaria elimination in villages along the Thai-Myanmar border

Background

A targeted malaria elimination project, including mass drug administrations (MDA) of dihydroartemisinin/piperaquine plus a single low dose primaquine is underway in villages along the Thailand Myanmar border. The intervention has multiple components but the success of the project will depend on the participation of the entire communities. Quantitative surveys were conducted to study reasons for participation or non-participation in the campaign with the aim to identify factors associated with the acceptance and participation in the mass drug administrations.

Methods

The household heads in four study villages in which MDAs had taken place previously were interviewed between January 2014 and July 2015.

Results

174/378 respondents (46 %) completed three rounds of three drug doses each, 313/378 (83 %) took at least three consecutive doses and 56/378 (15 %) did not participate at all in the MDA. The respondents from the two villages (KNH and TPN) were much more likely to participate in the MDA than respondents from the other two villages (HKT and TOT). The more compliant villages KNH and TPN had both an appearance of cohesive communities with similar demographic and ethnic backgrounds. By contrast the villages with low participation were unique. One village was fragmented following years of armed conflict and many respondents gave little inclination to cooperate with outsiders. The other village with low MDA coverage was characterised by a high percentage of short-term residents with little interest in community interventions. A universal reason for non-participation in the MDA applicable to all villages was an inadequate understanding of the intervention.

Conclusions

It is unlikely that community engagement can unite fragmented communities in participating in an intervention, which benefits the community. Understanding the purpose and the reasons underlying the intervention is an important pre-condition for participation. In the absence of direct benefits and a complete understanding of the indirect benefits trust in the investigators is critical for participation.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa. Similar to other developing areas throughout the world, this region's dearth of skilled health providers renders Western-style primary care efforts to address such diseases unrealistic. Consequently, many countries rely on their corps of nurses and community health workers to engage with underserved and hard-to-reach populations in order provide interventions against these maladies. This article attempts to cull together recent literature on the impact that nurses and community health workers have had on neglected tropical diseases.

METHODS

A review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses' and community health workers' responsibilities for neglected tropical disease control within their respective countries' health systems.

RESULTS

A total of 59 articles were identified that fit all inclusion criteria.

CONCLUSIONS

Successful disease control requires deep and meaningful engagement with local communities. Expanding the role of nurses and community health workers will be required if sub-Saharan African countries are to meet neglected tropical disease treatment goals and eliminate the possibility future disease transmission. Horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies-benefits that vertical programs are not able to attain.

Assessing Lymphatic Filariasis Data Quality in Endemic Communities in Ghana, Using the Neglected Tropical Diseases Data Quality Assessment Tool for Preventive Chemotherapy

Background

The activities of the Global Programme for the Elimination of Lymphatic Filariasis have been in operation since the year 2000, with Mass Drug Administration (MDA) undertaken yearly in disease endemic communities. Information collected during MDA–such as population demographics, age, sex, drugs used and remaining, and therapeutic and geographic coverage–can be used to assess the quality of the data reported. To assist country programmes in evaluating the information reported, the WHO, in collaboration with NTD partners, including ENVISION/RTI, developed an NTD Data Quality Assessment (DQA) tool, for use by programmes. This study was undertaken to evaluate the tool and assess the quality of data reported in some endemic communities in Ghana.

Methods

A cross sectional study, involving review of data registers and interview of drug distributors, disease control officers, and health information officers using the NTD DQA tool, was carried out in selected communities in three LF endemic Districts in Ghana. Data registers for service delivery points were obtained from District health office for assessment. The assessment verified reported results in comparison with recounted values for five indicators: number of tablets received, number of tablets used, number of tablets remaining, MDA coverage, and population treated. Furthermore, drug distributors, disease control officers, and health information officers (at the first data aggregation level), were interviewed, using the DQA tool, to determine the performance of the functional areas of the data management system.

Findings

The results showed that over 60% of the data reported were inaccurate, and exposed the challenges and limitations of the data management system. The DQA tool is a very useful monitoring and evaluation (M&E) tool that can be used to elucidate and address data quality issues in various NTD control programmes.

The Global Programme for the Elimination of Lymphatic Filariasis has been conducting yearly treatment of entire communities in endemic countries since the year 2000. During the treatments various information is collected on the populations, number of medicine tablets distributed and remaining, the number of people treated, etc. that can be used to evaluate the performance of the lymphatic filariasis control programme. For example, information on the number of people treated in a District gives an indication of the success of the programme. In line with this, the World Health Organization in collaboration with other agencies developed a tool for Neglected Tropical Diseases (NTD) to help national control programmes assemble and analyse their data. This study was undertaken to evaluate this tool and the information collected from some endemic communities in Ghana. Community registers were reviewed and personnel involved in drug distribution in the communities were interviewed to collect the necessary information. The results showed that more than half of the data reported in the endemic communities surveyed were inaccurate. It also revealed some weaknesses in the data management and reporting system. The tool, however, is good for identifying and quantifying the magnitude of the challenges encountered in the information management for NTD programmes, especially at peripheral levels.

Interrupting transmission of soil-transmitted helminths: a study protocol for cluster randomised trials evaluating alternative treatment strategies and delivery systems in Kenya

INTRODUCTION

In recent years, an unprecedented emphasis has been given to the control of neglected tropical diseases, including soil-transmitted helminths (STHs). The mainstay of STH control is school-based deworming (SBD), but mathematical modelling has shown that in all but very low transmission settings, SBD is unlikely to interrupt transmission, and that new treatment strategies are required. This study seeks to answer the question: is it possible to interrupt the transmission of STH, and, if so, what is the most cost-effective treatment strategy and delivery system to achieve this goal?

METHODS AND ANALYSIS

Two cluster randomised trials are being implemented in contrasting settings in Kenya. The interventions are annual mass anthelmintic treatment delivered to preschool- and school-aged children, as part of a national SBD programme, or to entire communities, delivered by community health workers. Allocation to study group is by cluster, using predefined units used in public health provision-termed community units (CUs). CUs are randomised to one of three groups: receiving either (1) annual SBD; (2) annual community-based deworming (CBD); or (3) biannual CBD. The primary outcome measure is the prevalence of hookworm infection, assessed by four cross-sectional surveys. Secondary outcomes are prevalence of Ascaris lumbricoides and Trichuris trichiura, intensity of species infections and treatment coverage. Costs and cost-effectiveness will be evaluated. Among a random subsample of participants, worm burden and proportion of unfertilised eggs will be assessed longitudinally. A nested process evaluation, using semistructured interviews, focus group discussions and a stakeholder analysis, will investigate the community acceptability, feasibility and scale-up of each delivery system.

ETHICS AND DISSEMINATION

Study protocols have been reviewed and approved by the ethics committees of the Kenya Medical Research Institute and National Ethics Review Committee, and London School of Hygiene and Tropical Medicine. The study has a dedicated web site.

TRIAL REGISTRATION NUMBER

NCT02397772.

Profiling Nonrecipients of Mass Drug Administration for Schistosomiasis and Hookworm Infections: A Comprehensive Analysis of Praziquantel and Albendazole Coverage in Community-Directed Treatment in Uganda

BACKGROUND

Repeated mass drug administration (MDA) with preventive chemotherapies is the mainstay of morbidity control for schistosomiasis and soil-transmitted helminths, yet the World Health Organization recently reported that less than one-third of individuals who required preventive chemotherapies received treatment.

METHODS

Coverage of community-directed treatment with praziquantel (PZQ) and albendazole (ALB) was analyzed in 17 villages of Mayuge District, Uganda. National drug registers, household questionnaires, and parasitological surveys were collected to track 935 individuals before and after MDA. Multilevel logistic regressions, including household and village effects, were specified with a comprehensive set of socioeconomic and parasitological variables. The factors predicting who did not receive PZQ and ALB from community medicine distributors were identified.

RESULTS

Drug receipt was correlated among members within a household, and nonrecipients of PZQ or ALB were profiled by household-level socioeconomic factors. Individuals were less likely to receive either PZQ or ALB if they had a Muslim household head or low home quality, belonged to the minority tribe, or had settled for more years in their village. Untreated individuals were also more likely to belong to households that did not purify drinking water, had no home latrine, and had no members who were part of the village government.

CONCLUSIONS

The findings demonstrate how to locate and target individuals who are not treated in MDA. Infection risk factors were not informative. In particular, age, gender, and occupation were unable to identify non-recipients, although World Health Organization guidelines rely on these factors. Individuals of low socioeconomic status, minority religions, and minority tribes can be targeted to expand MDA coverage.

The impact of residual infections on Anopheles-transmitted Wuchereria bancrofti after multiple rounds of mass drug administration

BACKGROUND

Many countries have made significant progress in the implementation of World Health Organization recommended preventive chemotherapy strategy, to eliminate lymphatic filariasis (LF). However, pertinent challenges such as the existence of areas of residual infections in disease endemic districts pose potential threats to the achievements made. Thus, this study was undertaken to assess the importance of these areas in implementation units (districts) where microfilaria (MF) positive individuals could not be found during the mid-term assessment after three rounds of mass drug administration.

METHODS

This study was undertaken in Bo and Pujehun, two LF endemic districts of Sierra Leone, with baseline MF prevalence of 2 % and 0 % respectively in sentinel sites for monitoring impact of the national programme. Study communities in the districts were purposefully selected and an assessment of LF infection prevalence was conducted together with entomological investigations undertaken to determine the existence of areas with residual MF that could enable transmission by local vectors. The transmission Assessment Survey (TAS) protocol described by WHO was applied in the two districts to determine infection of LF in 6-7 year old children who were born before MDA against LF started.

RESULTS

The results indicated the presence of MF infected children in Pujehun district. An. gambiae collected in the district were also positive for W. bancrofti, even though the prevalence of infection was below the threshold associated with active transmission.

CONCLUSIONS

Residual infection was detected after three rounds of MDA in Pujehun--a district of 0 % Mf prevalence at the sentinel site. Nevertheless, our results showed that the transmission was contained in a small area. With the scale up of vector control in Anopheles transmission zones, some areas of residual infection may not pose a serious threat for the resurgence of LF if the prevalence of infections observed during TAS are below the threshold required for active transmission of the parasite. However, robust surveillance strategies capable of detecting residual infections must be implemented, together with entomological assessments to determine if ongoing vector control activities, biting rates and infection rates of the vectors can support the transmission of the disease. Furthermore, in areas where mid-term assessments reveal MF prevalence below 1 % or 2 % antigen level, in Anopheles transmission areas with active and effective malaria vector control efforts, the minimum 5 rounds of MDA may not be required before implementing TAS. Thus, we propose a modification of the WHO recommendation for the timing of sentinel and spot-check site assessments in national programs.

Fighting fire with fire: mass antimalarial drug administrations in an era of antimalarial resistance

The emergence and spread of antimalarial resistance has been a major liability for malaria control. The spread of chloroquine-resistant Plasmodium falciparum strains had catastrophic consequences for people in malaria-endemic regions, particularly in sub-Saharan Africa. The recent emergence of artemisinin-resistant P. falciparum strains is of highest concern. Current efforts to contain artemisinin resistance have yet to show success. In the absence of more promising plans, it has been suggested to eliminate falciparum malaria from foci of artemisinin resistance using a multipronged approach, including mass drug administrations. The use of mass drug administrations is controversial as it increases drug pressure. Based on current knowledge it is difficult to conceptualize how targeted malaria elimination could contribute to artemisinin resistance, provided a full treatment course is ensured.

Coverage of, and compliance with, mass drug administration under the programme to eliminate lymphatic filariasis in India: a systematic review

India's mass drug administration (MDA) programme to eliminate lymphatic filariasis (PELF) covers all 250 endemic districts, but compliance with treatment is not adequate for the programme to succeed in eradicating this neglected tropical disease. The objective of our study was to systematically review published studies on the coverage of and compliance with MDA under the PELF in India. We searched several databases-PubMed/Medline, Google Scholar, CINAHL/EBSCO, Web of Knowledge (including Web of Science) and OVID-and by applying selection criteria identified a total of 36 papers to include in the review. Overall MDA coverage rates varied between 48.8% and 98.8%, while compliance rates ranged from 20.8% to 93.7%. The coverage-compliance gap is large in many MDA programmes. The effective level of compliance, ≥65%, was reported in only 10 of a total of 31 MDAs (5 of 20 MDAs in rural areas and 2 of 12 MDAs in urban areas). The review has identified a gap between coverage and compliance, and potentially correctable causes of this gap. These causes need to be addressed if the Indian programme is to advance towards elimination of lymphatic filariasis.