"Our desire is to make this village intestinal worm free": Identifying determinants of high coverage of community-wide mass drug administration for soil transmitted helminths in Benin, India, and Malawi

Abstract

Background: Soil-transmitted helminth infections (STH) are associated with substantial morbidity in low-and-middle-income countries, accounting for 2.7 million disability-adjusted life years annually. Current World Health Organization guidelines recommend controlling STH-associated morbidity through periodic deworming of at-risk populations, including children and women of reproductive age (15-49 years). However, there is increasing interest in community-wide mass drug administration (cMDA) which includes deworming adults who serve as infection reservoirs as a method to improve coverage and possibly to interrupt STH transmission. We investigated determinants of cMDA coverage by comparing high-coverage clusters (HCCs) and low-coverage clusters (LCCs) receiving STH cMDA in three countries.

Methods: A convergent mixed-methods design was used to analyze data from HCCs and LCCs in DeWorm3 trial sites in Benin, India, and Malawi following three rounds of cMDA. Qualitative data were collected via 48 community-level focus group discussions. Quantitative data were collected via routine activities nested within the DeWorm3 trial, including annual censuses and coverage surveys. The Consolidated Framework for Implementation Research (CFIR) guided coding, theme development and a rating process to determine the influence of each CFIR construct on cMDA coverage.

Results: Of 23 CFIR constructs evaluated, we identified 11 constructs that differentiated between HCCs and LCCs, indicating they are potential drivers of coverage. Determinants differentiating HCC and LCC include participant experiences with previous community-wide programs, communities' perceptions of directly observed therapy (DOT), perceptions about the treatment uptake behaviors of neighbors, and women's agency to make household-level treatment decisions.

Conclusion: The convergent mixed-methods study identified barriers and facilitators that may be useful to NTD programs to improve cMDA implementation for STH, increase treatment coverage, and contribute to the successful control or elimination of STH.

Trial registration: The parent trial was registered at clinicaltrials.gov (NCT03014167).

Fig 1. Schematic of qualitative analysis.

Process used by the DeWorm3 team to collect, code, and analyze qualitative data.

Fig 2. Benin CFIR strength and valence rating.

Summary of strength and valence scores applied to CFIR constructs and non-CFIR codes in Benin FGDs. Excluded are constructs with limited discussion or minimal data (e.g., referenced in only one FGD by one individual). Strength and valence scores are presented as averages (dot) and ranges from the minimum to maximum (line). A dot without a line indicates consistent scores across FGDs.

Fig 3. India CFIR strength and valence rating.

Summary of strength and valence scores applied to CFIR constructs and non-CFIR codes in India FGDs. Excluded are constructs with limited discussion or minimal data (e.g., referenced in only one FGD by one individual). Strength and valence scores are presented as averages (dot) and ranges from the minimum to maximum (line). A dot without a line indicates consistent scores across FGDs.

Fig 4. Malawi CFIR strength and valence rating.

Summary of strength and valence scores applied to CFIR constructs and non-CFIR codes in Malawi FGDs. Excluded are constructs with limited discussion or minimal data (e.g., referenced in only one FGD by one individual). Strength and valence scores are presented as averages (dot) and ranges from the minimum to maximum (line). A dot without a line indicates consistent scores across FGDs.