Policy stakeholder perspectives on barriers and facilitators to launching a community-wide mass drug administration program for soil-transmitted helminths

BACKGROUND

Recent evidence suggests that soil-transmitted helminth (STH) transmission interruption may be feasible through community-wide mass drug administration (cMDA) that deworms community members of all ages. A change from school-based deworming to cMDA will require reconfiguring of STH programs in endemic countries. We conducted formative qualitative research in Benin, India, and Malawi to identify barriers and facilitators to successfully launching a cMDA program from the policy-stakeholder perspective.

METHODS

We conducted 40 key informant interviews with policy stakeholders identified as critical change agents at national, state/district, and sub-district levels. Participants included World Health Organization country office staff, implementing partners, and national and sub-national government officials. We used the Consolidated Framework for Implementation Research to guide data collection, coding, and analysis. Heat maps were used to organize coded data and differentiate perceived facilitators and barriers to launching cMDA by stakeholder.

RESULTS

Key facilitators to launching a cMDA program included availability of high-quality, tailored sensitization materials, and human and material resources that could be leveraged from previous MDA campaigns. Key barriers included the potential to overburden existing health workers, uncertainty of external funding to sustain a cMDA program, and concerns about weak intragovernmental coordination to implement cMDA. Cross-cutting themes included the need for rigorous trial evidence on STH transmission interruption to gain confidence in cMDA, and implementation evidence to effectively operationalize cMDA. Importantly, if policy stakeholders anticipate a cMDA program cannot be sustained due to cost and human resource barriers in the long term they may be less likely to support the launch of a program in the short term.

CONCLUSIONS

Overall, policy stakeholders were optimistic about implementing cMDA primarily because they believe that the tools necessary to successfully implement cMDA are already available. Policy stakeholders in this study were cautiously optimistic about launching cMDA to achieve STH transmission interruption and believe that it is feasible to implement. However, launching cMDA as an alternative policy to school-based deworming will require addressing key resource and evidence barriers. Trial registration This study was registered in the U.S. National Library of Medicine Clinical Trials registry (NCT03014167).

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.

Tuberculosis control in rural India: lessons from public-private collaboration

SETTING

A rural tuberculosis (TB) Unit (population 350 794) in Pune district, Maharashtra State, India.

OBJECTIVE

To develop a 'model' partnership between rural private medical practitioners (PMPs) and the Revised National Tuberculosis Control Programme (RNTCP).

DESIGN

A partnership was developed between 100 PMPs in the study area and the district health and tuberculosis staff through facilitation by a non-governmental organisation (NGO). Participatory research methods were used to plan and implement the partnership. The process of creation and implementation of the partnership was analysed using quantitative and qualitative research methods.

RESULTS

The partnership contributed to 30% of the cases detected in the TB Unit over a 5-month period. Six months after withdrawal of the NGO, referrals from the private sector to the RNTCP were continuing to a lesser extent, but there was a breakdown of the communication and documentation systems.

CONCLUSION

The project highlights the importance of organisational and individual commitment to these partnerships, the key roles of the District Health Officer and the District Tuberculosis Officer in guiding and supporting these initiatives from the public sector, the potential role of process and outcome 'indicators' in monitoring partnerships and the important role of NGOs as intermediaries and facilitators.

Kaleidoscope: a 5-year action research project to develop nursing confidence in caring for patients with HIV disease in west India

As the national epidemic of human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome (AIDS) epidemic rapidly unfolds in India, nurses have to acquire new competencies in order to provide appropriate care to an increasing number of affected persons. In response, an Indo-British action research collaboration was initiated to build clinical confidence and facilitate relevant changes in nursing practice. During a 10-day educational programme, a change intervention was applied, culminating in the development of individual and partnership action plans focused on bringing about changes in nursing practice within well-defined fields of action. Following implementation of their action plans, participants were reassembled 12 months later for a follow-up workshop to discuss their progress and describe those factors that either helped or hindered them in achieving their objectives. They then developed new action plans for the next 12-month period. This article reports on the results from six cohorts (n = 160) in India who participated in this project between 1995 and 1999. Action plans were frequently focused on infection control, primary prevention, curriculum development in preregistration nursing programmes and in-service nursing education. The majority of participants reported significant achievements in realizing their action-plan objectives. Data analysis revealed that the change intervention itself, together with multidisciplinary support from colleagues, the senior status of the participant, and anticipating and attending the follow-up workshop, were all positively correlated with achievement. The lack of personal authority and resistance from managers were the two major factors negatively correlated with achievement. This method for facilitating changes in nursing practice has been successfully adapted and replicated by our group in other countries.