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

The results are presented with the relevant verbatim quotes according to the four thematic areas that emerged from the data. These four thematic areas are summarised in Table 1. They were challenges affecting the effective implementation of ACSM activities of MDA for LF; Potential of stakeholders’ involvement and participation in resource mobilization for MDA delivery with a focus on ACSM activities and; the need for innovative strategies and techniques to improve ACSM preparation, development, and dissemination and finally challenges with morbidity management and disability prevention services. Whilst data were collected across various participant categories, no major differences in the discussions were noted. Each of the themes is discussed below.

Table 1 Themes, challenges and opportunities identifiedChallenges affecting effective implementation of ACSM activities of MDA for LF

Stakeholders discussed the progress made by the Ministry of Health Kilifi County towards ACSM activities of MDA for LF elimination. The stakeholders shared life experiences. It was agreed that the county had made good progress noting that there was a significant increase in knowledge on LF over the last decade, since 2002 when the program was launched in the county. It was noted that despite efforts made by the national NTD division in soliciting funds and materials to support ACSM activities, the level of awareness was still low. The stakeholders discussed and identified the following reasons for low awareness. This included inadequate information on the transmission cycle which lead to myths and misconceptions, individual decisions not to take drugs, pressure to meet targets, and vastness of the area compounded by poor terrain and houses being far apart. Nonetheless, CDDs who are expected to walk to the assigned household were not able to reach out to all the households with MDA messages. Failure to address these issues could affect the uptake of drugs by the target communities. Each of these issues is elaborated below with selected quotes.

Insufficient knowledge on the transmission cycle thus perpetuating myths and misconceptions Participants in IDIs and stakeholders’ meetings reported that inadequate knowledge on the LF transmission cycle and drugs administered during MDA for LF had perpetuated myths and misconceptions. Below are some extracts from participants:

… information is not adequate; simply because, mostly we call people in meetings for awareness creation in social halls, but not all people come to these meetings and forums, maybe they are employed somewhere or maybe are struggling for their daily bread, so they do not come to the places where awareness is done, so that is the problem (IDI-KLN-OL-003)

… LF is a silent disease. You only see the manifestation. The symptoms are not related to LF e.g. fever. The community is not aware. For us to convince them to take drugs, some do not relate it with the transmission cycle. They relate it to witchcraft (SSI_NTDC_01)

… several people in the community still say the drugs are for family planning. And family planning you know it's a choice, so people were saying you were told to do family planning you refused that is why the government has come with these drugs so that when you take them you will not bear children anyone. Men will not be able to produce children. Now, those things came up because they didn't get enough awareness, they were just told these drugs are for swollen limbs and swollen genitals so they thought they were being told that so that they could take them (IDI-KYF-OL-001)

Individual decision not to take drugs

Several issues were cited as influencing individual decisions to comply with taking the drugs. Participants in IDIs indicated that some residents would accept to be left with the drugs and promise to take them later which in most cases they did not. Reasons cited included literacy levels, low perceived benefits of the drugs, perceived beliefs and attitudes towards the drugs. Other reasons included making one sleepy, being afraid of the drugs, they make them feel hungry, the taste remains in the mouth for 2 days, they are very strong, the tablets are too many, those who have swollen libs think that the drug will heal them and they get disappointed when they do not see any change, they make one feel weak and fatigue. Below are selected comments from the participants interviewed:

… during mobilization and sensitization, they will assure you that they will have understood and that they will take the drugs but refuse to take the drugs during the MDA day. Others will receive the drugs but fail to consume in your presence saying they will take the drugs after a meal and you know you will not be there to witness and confirm they have taken. It is hard because you know you cannot force an adult person or even know their intention (IDI-KLN-HW-002)

… .. there was one person I asked, despite the rest taking the drugs, why are you not willing he replied that because he does not know what the drugs are for, then he could not accept but promised to take them next time (IDI-KLN-OL-004)

… . many people are illiterate, they have their own beliefs concerning the drugs (IDI-KYF_HW_001)

Pressure to meet set targets

The CDDs were assigned to every 500 households to provide awareness sessions before and during the MDA campaign. The MDA exercise takes 5 days (2 days’ awareness and 3 days for drug administration. Opinion leaders who sometimes accompany CDDs during the campaign confessed that CDDs lack time to create awareness and to persuade residents to take drugs owing to the high target during the campaign and vastness of the area.

… if you probe for reasons why a person does not want to take drugs, you will not cover the assigned households … You see such people if you probe they say it’s just within themselves. And if you probe more we delay and we shall not cover the assigned households (IDI-KLN-OL-004)

The information given to the household is not enough because the speed the CDDs had was only to enter a household and give drugs according to the instruction there was not enough time to talk and explain more about the drugs to make the household owners understand. They were in a hurry to finish the target of the day (IDI-KLN-OL-005)

… It was like it did not reach all the people .... the area is so vast. If you have visited Kayafungo, the area is so vast therefore it did not reach everyone (IDI-KYF-HW-001)

The IEC materials are few, not in the native language and they are delivered late

The IEC materials are important aids in creating awareness for MDA campaigns. During the interviews with county and sub-county NTD coordinators and CHEWs, it was reported that the materials were delivered late, were few, and were usually in Swahili and English instead of the native language, Giriama. Additionally, the materials are delivered during the time drugs are delivered to the counties a few days before the drug distribution exercise which gave CHEWs and CDDs limited time to conduct awareness and sensitization sessions. Examples of extracts from the transcripts are given below.

We receive the materials late. They are delivered to the county and we should organize to collect them. Sometimes, they do not arrive at the sub-county (SSI-SCNTD-01)

The main challenge is that those IEC materials arrive late. They are delivered at the county headquarters a week before the exercise and they must be transported to the sub-county before they are distributed to CDDs (IDI-KLN-HW-001)

Posters are good because when the community see pictures they understand, but the problem is posters are always very few like we receive 3 posters and you are allocated about 12 villages (IDI-KLN-HW-002)

Again, those that cannot read will just pass by unless they decide to ask what the poster is about. What if they decide to not ask? He/she will not know (IDI-KLN-OL-004)

The IEC materials are usually in Swahili and CDD passes the messages in the local dialect. This means they translate them to their understanding causing delays in mobilization activities (SSI_NTDC_01)

The one day allocated for the training is not enough to cover the content. We focus mostly on how drugs are dispensed and reporting tools. We usually do not cover the content in the IEC but we ask the CDDS if they have issues during mobilization to inform us (IDI-KYF-HW-003)

MDA Planning, implementation, and follow-up

Although the development of IEC materials was executed by the National NTD office, the county and sub-county officers recommended that if given the responsibility, they could help on messaging and development of IEC materials as they understand their communities better. The county NTD program depends on the national NTD program for support.

The MDA activities are perceived as national government activities and therefore most planning and other related activities are done at the national level. The county and sub-county levels usually feel left out. We could be allowed to organize the MDA activity, messaging, and development of IEC materials that are appropriate to our communities (SSI – CNTD_01)).

Both the county and sub-county coordinators as well as health workers interviewed acknowledged that supervision and follow-up of ACSM of MDA for LF were not sufficiently carried out due to low funding.

We plan for MDA activities and even include them in the Annual Work Plans (AWP) for the county (Kilifi). Consequently, this is included in the budget. But funds are never allocated for the activity (SSI_NTDC_01)

Potential of stakeholders’ involvement and participation in resource mobilization for MDA delivery with a focus on ACSM activities

The participants observed that Kilifi County had many stakeholders but most were never utilized or minimally involved to champion access of MDA medicines and ACSM to communities they serve. The meeting participants recognized and appreciated the importance of each stakeholder and partner, as shown in the size of the circle in Fig. 2. They also identified their level of involvement in ACSM as shown in Table 2. They agreed that apart from the identification of stakeholders, they needed to be actively involved in joint planning, directed messaging, communication, and sensitization to enhance uptake of medicines in the communities. Strengthening the role of stakeholder participation was therefore identified as crucial in resource mobilization thus improving awareness and information about MDA and LF. Below are some extracts from stakeholders’ meetings:

You see there are many stakeholders and partners here. The problem is that we are not involved in this activity (referring to the MDA program). If we can be informed early, we can always support with whatever one has (Participant in the stakeholders’ meeting - Kilifi County)

There is a lot that the stakeholders and partners can participate in if they are involved early. We can chip in providing resources. Letters can be sent to us requesting assistance and I am sure most of us here will be willing to support the MDA with fuel, umbrellas, gumboots, airtime, and other things that officers and CDDs might require improving coverage of MDA (Stakeholders’ meeting – Kilifi)

In addition, we can participate in creating awareness to our congregations and informing them of the importance of taking the medicines (Religious leader – Representative- Stakeholders’ meeting - Kaloleni)

However, it was noted that a few stakeholders including schools through the Ministry of Education, State Department of Social Protection, and State Department of InteriorServices and Co-ordination of National Government were involved mainly in social mobilization activities such as informing the residents about the dates of MDA activity.

… the county has pledged support. We have had increased advocacy and many sectors, departments and ministries have been involved. They include the State Department of Social Protection, in advocacy and Ministry of Education through schools (SSI-NTDC-01)

Fig. 2figure 2

Example of Venn diagram showing the level of involvement in ACSM activities of MDA for LF at the county level. The big outer circle represents ACSM activities for MDA for LF. The middle of the outer circle is represented by a circle written ACSM activities. Circles close to the middle depict closeness to ACSM activities. The stakeholders that were identified as actively participating in ACSM activities are close to the middle while those that are far off from the middle were minimally engaged. The size of the circle depicts perceived importance of a stakeholder or partner in ACSM activities. All stakeholders and partners were identified as important. Their importance was based on expected roles in ACSM activities

Table 2 shows the stakeholders & partners identified and their level of involvement in ACSM activitiesPreferred mode of awareness and ways to improve ACSM preparation, development, and dissemination processes

During the stakeholders meeting, FGDs and IDIs discussed the preferred modes of awareness and gave suggestions for the need to provide more information about the MDA and health education through a variety of channels for improved community mobilization and compliance as shown in Table 3. Stakeholders suggested channels such as the media through radio talk shows; public address systems and roadshows; focused meetings with women groups, youth groups, churches, and mosques. They also suggested that messages should be simple, easy to understand, and translated/disseminated in the local language to enable community members better to understand the importance of MDA for LF. Roadshows involve crisscrossing the whole village, announcing the MDA from a truck equipped with loudspeakers, and stopping where there were gatherings to distribute information brochures/leaflets and answer questions about the treatment.

Health education is very important in this exercise. We have used focused meetings, roadshows and the media like Lulu FM in other programs and the reception has been very good. (Stakeholder attendee - Kilifi County).

Table 3 Preferred mode of awareness and innovative ways improve ACSM preparation, development and dissemination processesEnhanced community meetings (barazas) with awareness attended by health officers

Community meetings, Baraza, were used to create awareness. These were called by community leaders such as the chiefs and assistant chiefs. In these meetings, community members were informed about MDA for LF exercise and encouraged to participate as well as inform others about the program. The community meetings were however stated not to be among the best awareness creation platforms because some community members absconded them for lack of incentives.

Community members do not attend these meetings the way they attend when we are providing them with free food (Stakeholder attendee - Kilifi County).

Importantly, the community meetings could be enhanced by the attendance of health officials to educate residents about MDA for LF including why it is important to take the drugs, demystifying myths and misconceptions concerning the disease and the drugs, side effects, and answering technical questions from residents.

The Chief should call a meeting and the health workers are invited to create awareness in the meetings. In schools, we can have parents meeting and health officers can create awareness in such meetings too (FGD-KLN-CM-AW-003 –P4)

The Barazas are important and residents can be encouraged to attend when they hear there are health officials in attendance to give them more information about the disease and the drug distribution exercise (IDI-KYF-OL-002)

Let CDDs be accompanied by health workers so that they can explain the side effects to the community members (FGD-KLN-CM-AW-003- P6)

Some participants especially the opinion leaders felt that door to door awareness creation strategy was still the best. This was preferred as it allowed a face to face communication with the household members. But sensitization about the MDA activity was only assigned 1 day during the implementation process. This, therefore, made it tedious, time-consuming and only a few households could be reached.

.. door to door is the best strategy because if you schedule a meeting not all people shall come for the meeting and it allows a face to face interaction (IDI-KLN-OL-004)

Mobile phones using WhatsApp and radio programs

Stakeholders suggested the need to use innovative awareness creation strategies and techniques to reach as many people as possible. They proposed the use of mobile phones to send messages about MDA for LF in areas with a local network through social media platforms such as WhatsApp groups. Additionally, they suggested that the use of local radio stations such as Kaya FM and Lulu FM would help inform people in the local language about the program, especially in rural areas. Once the community is made aware of the program, they could easily plan their activities and avoid missing the awareness teams. It was further suggested that engaging health officials knowledgeable with LF to discuss with community members on radio programs would also help create understanding and combat any negative beliefs and myths regarding the drugs and the disease.

“. . .we could also use mobile phones like a WhatsApp group. Most of us have WhatsApp groups with many members from churches and mosques. If we could get simplified messages from the health officials, we could send them to our members for quick dissemination. [Stakeholders – chairman Faith-Based Organization representative).

Challenges with morbidity management and disability prevention services

Most of the stakeholders recounted the suffering that LF patients had to go through in their daily lives within the communities. They suggested that whilst MDA was meant for prevention, there was a need to hasten prevention services such as surgeries to those with chronic manifestations of hydrocele. It was reported that the MMDP program was started and identification of the patients was carried out. But, challenges were reported that hampered its effective implementation.

… at the planning stage, about 550 operations were intended to have been done. Currently, over 100 are conducted. But, several challenges were encountered. Among them, functional theatre to execute the surgeries, wards to admit patients after surgeries, and personnel (Kilifi Stakeholders’ meeting attendee)

Again, patients refuse to be registered when approached fearing surgical procedures saying that they are old and the procedure may lead them to early death.

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