Implementation Challenges of Community Directed Treatment with Ivermectin Program for Control of Onchocerciasis in Ulanga, Tanzania

Background: Community drug distributors (CDDs) have a crucial role in distributing ivermectin for onchocerciasis control and prevention. Their roles, experiences and challenges faced in the implementation of community-directed treatment with ivermectin (CDTI) programme could potentially affect coverage, consequently leading to persistent transmission. Therefore, this study aimed to explore the experience and the roles which CDDs plays in implementation of community directed treatment with ivermectin program for onchocerciasis control in Ulanga, Tanzania. Methods: A cross-sectional study design was used to collect qualitative data in 2018 in Ulanga district, Tanzania. Five community drug distributors were purposively selected for in-depth interviews. Thematic framework approach for qualitative data analysis was used to generate codes, categories and themes. Results: Out of the five community drug distributors interviewed, two had experience of 15 to 20 years on implementation of the community directed treatment with ivermectin programme while the remaining community drug distributors had experience of less than 10 years. The main challenges faced by CDDs in the implementation of the CDTI programme include; the geographical location of the hamlets (hard to reach hamlets), long distances between houses, low compliance of community members to medication due to fear of side effects experienced before and mistrust of methods of dose calculation, short time of drug distribution and absence of people from their households as the exercise was conducted when community members were involved in agricultural activities. Conclusions: The challenges faced in the implementation of the CDTI programme could negatively affect the distribution and coverage of ivermectin treatment in the Ulanga district. It’s now an opportune time to address the challenges that CDDs are facing in the implementation of the CDTI programme to ensure effective control of onchocerciasis in the district.

Co-implementing Vitamin A supplementation with Seasonal Malaria Chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study

Background Bi-annual high dose vitamin A supplements administered to children aged 6-59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. Methods A mixed methods study design was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one local government area of Sokoto state in northern Nigeria. Existing SMC implementation tools and job aids were revised and community drug distributors, experienced in SMC delivery, were trained on the determination of VAS eligibility, administration of the correct doses and identification of adverse drug reactions. SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were calculated and the outcome of the integration was assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The Bowen framework was used to assess feasibility through focus group discussions and key informant interviews; thematic analysis was carried out on the qualitative data. Results At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2–59% (p<0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p=0.412) at endline. There was no significant change (p=0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at endline (68%) compared to baseline (54%). Study findings demonstrated acceptability among caregivers, community drug distributors, State and National healthcare officials. Conclusion This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaign can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Co-implementing Vitamin A supplementation with Seasonal Malaria Chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study

BackgroundBi-annual high dose vitamin A supplements administered to children aged 6-59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes.MethodsA mixed methods study design was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one local government area of Sokoto state in northern Nigeria. Existing SMC implementation tools and job aids were revised and community drug distributors, experienced in SMC delivery, were trained on the determination of VAS eligibility, administration of the correct doses and identification of adverse drug reactions. SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were calculated and the outcome of the integration was assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The Bowen framework was used to assess feasibility through focus group discussions and key informant interviews; thematic analysis was carried out on the qualitative data. ResultsAt endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2% to 59% (p<0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p=0.412) at endline. There was no significant change (p=0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at endline (68%) compared to baseline (54%). Study findings demonstrated acceptability among caregivers, community drug distributors, State and National healthcare officials. ConclusionThis study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaign can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Understanding the Role of Health Workers in the LF Elimination Program in Kenya: Challenges Faced and Suggestions for Improved Program Performance

The Kenyan Ministry of Health and its partners through the Division of Vector-Borne and Neglected Tropical Diseases, is in charge of the Lymphatic Filariasis Mass Drug Administration programme. This is implemented through the national, county, and sub-county neglected tropical diseases coordinators. The current study sought to understand the roles, challenges faced and suggestions of how program performance can be improved by the community health extension workers, county and sub-county neglected tropical diseases coordinators. Two wards of the Kaloleni sub-county; Kilifi County were purposively selected. In 2015, Kaloleni and Kayafungo wards had a treatment coverage of 58% and 54% respectively; 62% and 39% respectively in 2016, all below the recommended minimum treatment coverage of 65%. Qualitative data was collected through sixteen in-depth interviews with community health extension workers and two semi-structured interviews with the county and sub-county neglected tropical diseases coordinators. Data were analysed by QSR NVIVO version 10 according to identified themes. The study results show the various roles in planning and implementation of the program include; supply chain management; health information education communication and records management; health workforce training and management, leadership and governance, and service delivery. Challenges faced included insufficiency of drugs supplied and information education communication materials, the inadequacy of community drug distributors selected and trained, poor facilitation for training and supervision of community drug distributors, limited duration of the mass drug administration, and delayed reporting due to poor network coverage. The results of this study show that the community health extension workers, county and sub-county neglected tropical diseases coordinators are not fully involved in program leadership and governance, a role that is taken up at the national level. They should be involved in all the stages of the mass drug administration program to create ownership to improve the program performance

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.

Keeping communities at the centre of efforts to eliminate lymphatic filariasis: learning from the past to reach a future free of lymphatic filariasis

Since the launch of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000, more than 910 million people have received preventive chemotherapy for lymphatic filariasis (LF) and many thousands have received care for chronic manifestations of the disease. To achieve this, millions of community drug distributors (CDDs), community members and health personnel have worked together each year to ensure that at-risk communities receive preventive chemotherapy through mass drug administration (MDA). The successes of 20 y of partnership with communities is celebrated, including the application of community-directed treatment, the use of CDDs and integration with other platforms to improve community access to healthcare. Important challenges facing the GPELF moving forward towards 2030 relate to global demographic, financing and programmatic changes. New innovations in research and practice present opportunities to encourage further community partnership to achieve the elimination of LF as a public health problem. We stress the critical need for community ownership in the current Covid-19 pandemic, to counter concerns in relaunching MDA programmes for LF.

Community drug distributors’ experiences and challenges faced in the implementation of community-directed treatment with ivermectin programme for onchocerciasis control in Ulanga, Tanzania

Background: Community drug distributors (CDDs) have a crucial role in distributing ivermectin for onchocerciasis control and prevention. Their experiences and challenges faced in the implementation of the community-directed treatment with ivermectin (CDTI) programme could potentially affect coverage, consequently leading to persistent transmission. Therefore, this study aimed to explore CDDs experiences and challenges faced in the implementation of the CDTI programme in Ulanga, Tanzania.Methods: A qualitative study was conducted in Ulanga, Tanzania, in 2018. An in-depth interview guide was used to collect data from 5 CDDs above 18 years who were selected purposively. The analysis was performed using a thematic framework approach to generate codes, categories and themes.Results: Out of the five CDDs interviewed, two had 15 to 20 years of experience in the implementation of the CDTI programme, while the remaining CDDs had less than 10 years of experience. The main challenges faced by CDDs in the implementation of the CDTI programme include the geographical location of the hamlets (hard to reach hamlets), long distances between houses, low compliance of community members to medication due to fear of side effects experienced before and mistrust of methods of dose calculation, short time of drug distribution and absence of people from their households as the exercise was conducted when community members were involved in agricultural activities.Conclusions: The use of CDDs in the implementation of the CDTI programme has been successful despite the challenges mentioned. It is now opportune time to address the challenges that CDDs are facing in the implementation of the CDTI programme to ensure effective control of onchocerciasis in the district.