Identifying opportunities to optimize mass drug administration for soil-transmitted helminths: A visualization and descriptive analysis using process mapping.

BACKGROUND: The control of soil-transmitted helminths (STH) is achieved through mass drug administration (MDA) with deworming medications targeting children and other high-risk groups. Recent evidence suggests that it may be possible to interrupt STH transmission by deworming individuals of all ages via community-wide MDA (cMDA). However, a change in delivery platforms will require altering implementation processes. METHODS: We used process mapping, an operational research methodology, to describe the activities required for effective implementation of school-based and cMDA in 18 heterogenous areas and over three years in Benin, India, and Malawi. Planned activities were identified during workshops prior to initiation of a large cMDA trial (the DeWorm3 trial). The process maps were updated annually post-implementation, including adding or removing activities (e.g., adaptations) and determining whether activities occurred according to plan. Descriptive analyses were performed to quantify differences and similarities at baseline and over three implementation years. Comparative analyses were also conducted between study sites and areas implementing school-based vs. cMDA. Digitized process maps were developed to provide a visualization of MDA processes and inspected to identify implementation bottlenecks and inefficient activity flows. RESULTS: Across three years and all clusters, implementation of cMDA required an average of 13 additional distinct activities and was adapted more often (5.2 adaptations per year) than school-based MDA. An average of 41% of activities across both MDA platforms did not occur according to planned timelines; however, deviations were often purposeful to improve implementation efficiency or effectiveness. Visualized process maps demonstrated that receipt of drugs at the local level may be an implementation bottleneck. Many activities rely on the effective setting of MDA dates and estimating quantity of drugs, suggesting that the timing of these activities is important to meet planned programmatic outcomes. CONCLUSION: Implementation processes were heterogenous across settings, suggesting that MDA is highly context and resource dependent and that there are many viable ways to implement MDA. Process mapping could be deployed to support a transition from a school-based control program to community-wide STH transmission interruption program and potentially to enable integration with other community-based campaigns. TRIAL REGISTRATION: NCT03014167.

It depends on how you tell: a qualitative diagnostic analysis of the implementation climate for community-wide mass drug administration for soil-transmitted helminth.

OBJECTIVES: Current soil-transmitted helminth (STH) morbidity control guidelines primarily target deworming of preschool and school-age children. Emerging evidence suggests that community-wide mass drug administration (cMDA) may interrupt STH transmission. However, the success of such programmes depends on achieving high treatment coverage and uptake. This formative analysis was conducted to evaluate the implementation climate for cMDA and to determine barriers and facilitators to launch. SETTINGS: Prior to the launch of a cMDA trial in Benin, India and Malawi. PARTICIPANTS: Community members (adult women and men, children, and local leaders), community drug distributors (CDDs) and health facility workers. DESIGN: We conducted 48 focus group discussions (FGDs) with community members, 13 FGDs with CDDs and 5 FGDs with health facility workers in twelve randomly selected clusters across the three study countries. We used the Consolidated Framework for Implementation Research to guide the design of the interview guide and thematic analysis. RESULTS: Across all three sites, aspects of the implementation climate that were facilitators to cMDA launch included: high community member demand for cMDA, integration of cMDA into existing vaccination campaigns and/or health services, and engagement with familiar health workers. Barriers to launching cMDA included mistrust towards medical interventions, fear of side effects and limited perceived need for interrupting STH transmission. We include specific recommendations from community members regarding cMDA distribution sites, personnel requirements, delivery timing and incentives, leaders to engage and methods for mobilising participants. CONCLUSIONS: Prior to launching the cMDA programme as an alternative to school-based MDA, cMDA was found to be generally acceptable across diverse geographical and demographic settings. Community members, CDDs and health workers felt that engaging communities and tailoring programmes to the local context are critical for success. Potential barriers may be mitigated by identifying local concerns and addressing them via targeted community sensitisation prior to implementation. TRIAL REGISTRATION NUMBER: NCT03014167; Pre-results.

Gender differences in the perceived need for community-wide deworming: Formative qualitative research from the DeWorm3 study, India.

Current soil-transmitted helminth (STH) programs target morbidity control with school-based deworming. Increasing interest in steering neglected tropical disease (NTD) programmes from morbidity control towards disease elimination has prompted evaluation of strategies that may interrupt transmission. The feasibility of interrupting transmission of STH with community-wide deworming is being tested in the ongoing DeWorm3 cluster randomized trial. Gender-based perspectives about susceptibility to infection and need for treatment have been shown to influence both health-seeking behaviour and health outcomes. We carried out a qualitative study among men and women in the community to understand their knowledge, beliefs, and attitudes about STH infections and community-wide mass drug administration (cMDA). Eight semi-structured focus group discussions were conducted among men and women residing in the DeWorm3 study site in India-Vellore and Tiruvannamalai districts of Tamil Nadu. Thematic coding was used to analyse the transcripts in ATLAS.ti 8.0. Both men and women in this study demonstrated a high level of STH knowledge but some men had misconceptions that intestinal worms were beneficial. Men and women shared several similar beliefs and attitudes regarding STH treatment. Both believed that adults were likely to have STH infections and both reported that stigma prevented them from seeking treatment. Influenced by gender norms, women were more likely to associate STH infections with inadequate sanitation and hygiene, while men were more likely to believe that those engaged in agricultural work were at risk. Both genders reported a positive attitude towards cMDA for STH. Barriers to cMDA implementation differed by gender; women expressed concern regarding side-effects and drug quality while men were concerned that treatment coverage may be affected due to the absence of people during the day when the drug is distributed. Both men and women perceived the treatment of adults for STH infections to be important, however, the perceived barriers to participating in cMDA differed by gender in this community. The study identified key messages to be incorporated in communication and outreach strategies for cMDA programmes.