Several neglected tropical diseases (NTDs) employ mass drug administration (MDA) as part of their control or elimination strategies. This has historically required multiple distinct campaigns, each targeting one or more NTDs, representing a strain on both the recipient communities and the local health workforce implementing the distribution. We explored perceptions and attitudes surrounding combined MDA among these two groups of stakeholders. Our qualitative study was nested within a cluster randomized non-inferiority safety trial of combined ivermectin, albendazole and azithromycin MDA. Using semi-structured question guides, we conducted 16 key informant interviews with selected individuals involved in implementing MDA within the participating district. To better understand the perceptions of recipient communities, we also conducted four focus group discussions with key community groups. Individuals were selected from both the trial arm (integrated MDA) and the control arm (standard MDA) to provide a means of comparison and discussion. All interviews and focus group discussions were led by fluent Afaan oromo speakers. Interviewers transcribed and later translated all discussions into English. The study team synthesized and analyzed the results via a coding framework and software. Most respondents appreciated the time and effort saved via the co-administered MDA strategy but there were some misgivings amongst community beneficiaries surrounding pill burden. Both the implementing health work force members and beneficiaries reported refusals stemming from lack of understanding around the need for the new drug regimen as well as some mistrust of government officials among the youth. The house-to-house distribution method, adopted as a COVID-19 prevention strategy, was by far preferred by all beneficiaries over central-point MDA, and may have led to greater acceptability of co-administration. Our data demonstrate that a co-administration strategy for NTDs is acceptable to both communities and health staff.

The strategy for several neglected tropical diseases is treatment of the whole community, referred to as mass drug administration. Normally these are delivered as separate rounds of treatment for each disease. This creates a burden for both the health workforce and the communities. As part of a larger study conducted in Ethiopia we used interviews and focus groups to explore perceptions and attitudes towards combined mass drug administration among both communities and health workers.

Both community members and health workers appreciated the time and effort saved via combined treatment although some community members were worried about the number of pills that had to be taken. Both health workers and community members said some people declined to take part due to a lack of understanding around the need for a combined drug regimen. Delivery of the drugs house-to-house, which had been adopted as a COVID-19 prevention strategy, was preferred over delivering the treatment at a central point in the community. Overall, our study showed that combined treatment of multiple neglected tropical diseases was acceptable to both communities and health workers.

Citation: McPherson S, Geleta D, Tafese G, Tafese T, Behaksira S, Solomon H, et al. (2023) Perceptions and acceptability of co-administered albendazole, ivermectin and azithromycin mass drug administration, among the health workforce and recipient communities in Ethiopia. PLoS Negl Trop Dis 17(10): e0011332. https://doi.org/10.1371/journal.pntd.0011332

Editor: Peter U. Fischer, Washington University School of Medicine, UNITED STATES

Received: April 24, 2023; Accepted: August 30, 2023; Published: October 2, 2023

Currently, mass drug administration (MDA) for neglected tropical disease (NTD) control and elimination takes place through several distinct campaigns, with the number of such campaigns depending on the number of diseases being targeted. If trachoma, lymphatic filariasis (LF), and onchocerciasis are all in frame, the first MDA round that takes place addresses onchocerciasis and LF through a height-dependent dosage of up to four pills of ivermectin and, regardless of height or age, one pill of albendazole; in some populations, diethylcarbamazine is also added. The second round of MDA takes place for trachoma at least two weeks later, involving a height-dependent dosage of up to four pills of azithromycin, a height-dependent dose of azithromycin oral suspension, or (for children aged <6 months or those unable or unwilling to take macrolides) tetracycline eye ointment (TEO).

While the workload of the health work force is an important consideration, it’s also important to consider its acceptability to those receiving the intervention. Co-administration may present an opportunity to significantly lessen the time investment required for beneficiaries to participate in MDA and reduce the indirect costs of participation. Ideally, this reduction in indirect costs would subsequently improve MDA coverage as participants would not have to choose between participating in multiple MDA rounds and their other obligations. Co-administration might alternatively result in decreased coverage if enough individuals decline to swallow the larger number of tablets offered as part of a combined MDA approach or have other safety concerns.

To assess the acceptability of the co-administration strategy from both provider and recipient perspectives, we nested a qualitative study within our recently conducted RCT in Ethiopia.

The study was nested within the larger co-administration RCT. The study received ethical approval from the National Research Ethics Review Committee (NRERC) of Ethiopia (reference 3-10/195/2018) and the London School of Hygiene & Tropical Medicine (reference 11985). Based on low levels of literacy in the study population, permission to use verbal consent was specifically provided by the ethics committees. Study teams read the study consent form to all prospective participants and obtained verbal permission to participate in the study.

Interviewers used a digital audio recorder during the interviews. They uploaded the audio files to the RedCap account created for the study which had a specific passcode. Once uploaded, the files were deleted from the digital recorder. The two interviewers then completed transcription and translation on the computer and also uploaded these to RedCap. Each individual interviewed was anonymized via a specific code during transcription.

For individual participant selection, the study team engaged with the local leadership and health workforce with some specific criteria. The study team stressed that those selected should have lived in the community for at least a year and should be open to engaging in discussion. The study team further stressed that participants should live in different gotes (sub-districts) where the study took place.

The kebele leader recommended the religious and community leaders interviewed as well as all of the males in the focus groups. The most senior Health Extension Worker, a position predominantly held by a woman, made the recommendations for the members of the Health Development Army and for the females in the focus groups.

The study team conducted semi-structured in-depth interviews with health care workers and focus group discussions (FGD) with members of the community using a semi-structured question guide. This interview guide was created specifically for this study and had not been previously tested. A native Afaan oromoo speaker conducted all key informant interviews (KII) and led the focus group discussions. The study team had some concern regarding the social desirability bias in which participants would be influenced by the expectations of their communities to give specific responses regarding MDA. To avoid this, the study team prefaced each interview with the goals of the research including reassurance that the participant’s honest feedback would help to improve their community’s health programs. The study team also conducted the interviews either in a closed office space or out in a field away from non-participants to allow for privacy and open discourse. The interviews took place immediately after the drugs were administered in both the trial and control arms.

Interviewers recorded and transcribed verbatim into Afaan oromoo. The same interviewers that conducted the interviews translated them into English. The study team reviewed the transcribed interview data and flagged statements from participants that were significant, insightful, or frequently repeated. As Ethiopia has an established history of MDA but not of co-administration, certain codes surrounding MDA were previously identified while emerging codes were also important. Using NVIVO 12, the study team assigned deductive codes based on key themes, identified from both published literature and practical experience in Ethiopia, and added new codes based on insights that occurred during the review of the transcripts themselves. We used descriptive codes relating to the participant demographics (age, gender, etc.) and thematic codes relating to what was said by the participants. We then explored patterns in responses, linkages between the thematic and descriptive codes, and often repeated statements which required follow-up to avoid generalizations.

As is standard, the trial study team carried out community awareness campaigns prior to the MDA for both intervention and control groups. Dissemination of information took place through public gatherings, community leaders, health extension personnel, development armies, and other community members. The cooperation between health workers, village leaders, and community volunteers was cited as an excellent example of how to administer drugs successfully compared to previous MDAs. Participants stated that with previous MDAs this coordination was not common resulting in less than adequate social mobilization and preparation:

“…There was a big meeting conducted; they provided us the information on that meeting. The health professionals had identified the pregnant women and given special care. Those who were not available at the time the tablets were given… are eager to get them. It was not like this in the previous times. They are serving us properly. People had benefited from that. I was feeling a disturbance in my stomach (nervousness); I got relief after I took it. When they give a tablet today, they recheck it the next day. To see whether there is a side effect or not. Because they were serving us just like this, the community is very happy”- (Female youths FGD)

All participants mentioned the value of these community awareness events in ensuring village residents were aware of the MDA.

During the study, we employed a house-to-house MDA strategy. Volunteers informed each village of the day and time that the study team would conduct the distribution. This differed from the previous MDA approach in this population, in which MDA was conducted at a central point in the village and community members had to attend within a given window to be treated.

The majority of participants said that the house-to-house MDA strategy used in the trial was preferable to the central point distribution strategy and enabled the majority of the community to receive the drugs. Participants were appreciative of the house-to-house delivery method. The early morning timing of drug delivery, team makeup, counseling and advice provided, and post-MDA follow-up that formed part of the RCT were all appreciated.

“The drug administration was done in a good manner. It was not common for the district, health professionals, and the kebele leaders to collaborate in the way they are doing it now. They were serving each household in time. People are eagerly waiting for them [drug distributors]. They give the tablets/drugs today and revisit them the next day. It was not common before”. [FGD, Adult man, 48yrs]

Using the previous central point strategy, it was reported that many members of the community had missed the MDA for a variety of reasons, including distance, being busy, a lack of available information and limited availability of health care staff.

Within the RCT, anyone who missed treatment had the chance to take it the next day thanks to the study follow-up visit.

“Previously….there was no follow-up. Follow-up [re-visit] and house-to-house service is done for the first time. In the current distribution, they are telling us that there will be no problem because we are following you closely. They never move to the next group, without checking up on the one already provided to. People are very happy about this and received the drug very well” [FGD, Female Youth]

However, some study participants mentioned that the community members were unsure of the need for the follow-up. One health extension worker (HEW) stated:

“They [community] are not familiar with the revisit [follow-up] after providing the drugs. They are suspicious of our revisit [follow-up]. They think that the drugs are harmful. We tell them that we are watching them if there is a side effect from the tablets. We tell them that we can give them assistance and take them to a health facility if there is any harm” [KII, HEW].

Health workers also mentioned the effectiveness of the current MDA approach and its role in expanding coverage and reach as strengths:

“The current MDA is very suitable. Because we are providing it by going to their residence. They are not willing to come to the place we want them to come…. Because we go to them early in the morning, we get everyone at home. At the time we used to gather them at one place in the previous MDA, only a few old men are coming. The majority of them are mothers and their children. This time we get everyone at home” [KII, HEW]

The majority of study participants did not feel that taking a larger number of pills was more difficult compared to the previous separate MDAs. Many reported that they initially felt apprehensive but that the presence of supervisors at the time of drug administration, as well as provision of adequate information, advice, and counseling, made people feel comfortable taking the drugs.

“It was very nice. Many people came together and gave us the tablet. Health extension workers, health professionals, those from district and zone were together in a team while providing the tablets. We got to know each other and then they told us the details of each tablet. That is how they provided it to us. The presence of many people (study team) while providing the tablet increases the acceptance. I wouldn’t even receive if I wasn’t convinced and understood the benefit to each drugs” [FGD, Adult woman, 30 yrs]

Some community members, particularly young women, expressed concerns that the taking so much of the drug at one time might lead to infertility. These concerns were allayed by a majority of community members receiving counseling and assistance from the staff responsible for administering drugs. An elder highlighted the absence of any issue related to the burden of pills in his village’s communities.

“The number of pills did not affect anyone. People may be afraid of it but because the health professional know the way, there are no worries…… Because it is safe, the community is taking it. It has been more than 20 days since [drug distribution] began, I saw no single challenge so far” [KII, Elder man, 60 yrs]

“Nine tablets are not harder. I was afraid when taking it, but because I took it gradually in two rounds, it is not that hard. They were patient giving it to us. That is why we didn’t feel anything” [FGD, Youth female]

The district NTD focal point stated that, in comparison to previous MDAs, more community members took part with the notable exception of some youth:

“Some youth refused. Some of them politicized it. Some of them argue how and why to take drugs without getting sick and get diagnosed.”. [KII, Health Worker, 37 yrs]

This hesitancy may have been linked with the recent introduction of the COVID-19 vaccine program which health workers noted had been met with hesitancy and suspicion among the youth in the communities. The introduction of a novel, multiple drug distribution strategy among the community stirred rumors that it was a replacement to COVID-19 vaccine for those who refused the injection. As the study continued and more community members received the drug, including religious and kebele leaders, the majority of youth eventually accepted the co-administered NTD medicine regimen.

Interviewees emphasized the importance of co-administration for saving time and preventing people being ‘missed’ during MDA:

“I choose the nine tablets taken at once. Because re-visit (second MDA) can create a miss, as well a burden for a person delivering the drugs” [KII, Aba Gada, 45 yrs]

“Coming twice (for different MDAs) is just wasting time. If the nine tablets did not have any harm, it is better to give them at once. It solves the problems of drop out and missing”. [KII, HDA, 45yrs]

As well as using a central point method, previous MDAs had relied heavily on community drug distributors rather than health care workers to conduct MDA. Some study participants reported that this strategy had resulted in concerns from the community that drugs were provided by volunteers.

“…the volunteer did not get payment, but they need to get some money. It was difficult to identify who took drugs and not in previous MDA. In addition, there is a complaint on the side of the community. They complain about the MDA provided by farmers selected from the community. There are community members who say, how you dare you allow a farmer to deliver us a medicine in the previous MDA”. [KII, Health Worker, 37 yrs]

Previously, MDA was carried out at various times of the year, such as during harvest, sowing, or cultivation depending on the timing that drugs were available. Even though our co-administered MDA occurred during harvest, the time [early morning distribution] and method [house-to-house distribution] were chosen to maximize participation. Communities in the area have a custom of staying at home until 10:00 AM before leaving for fieldwork, which made it easier to contact household members after breakfast.

Study participants advised administering MDA before or after harvest, when people are less busy, and during the dry season because transportation is also difficult during the rainy months. Participants in the study said that, with the exception of a small number of individuals who first displayed opposition, all community members, regardless of their gender, age, or religion, took part in the current MDA. Overall, all study participants acknowledged the MDA’s primary strategies, such as community awareness and sensitization, house-to-house distribution, early morning distribution, a second visit the next day, the team composition, and collaboration with local leaders as major factors in the high level of acceptance.

Our respondents indicated that, even outside of the specific question of co-administration, a house-to-house approach is preferable. This model reduced barriers to participation, such as aligning work schedules with central point MDA schedules. In terms of co-administration, it also allowed for a more direct health education exchange with individual families to address any concerns related to this new MDA approach.

There were some limitations to the study. The design of the randomized control trial in which this study was nested took place in a sub-set of a woreda and required intensive social mobilization, community sensitization, increased supervision and mandatory active and passive follow-up mechanisms. Standard mass drug administration campaigns may require the treatment of hundreds of districts and millions of people so the intensified supervisory parameters of the study may have created acceptability perceptions among the community which would not have occurred normally. It is also important to note that these districts have already received several rounds of MDA for both trachoma and LF and that a community which is new to MDA may have very different idea surrounding co-administration.

For the larger co-administration trial in which this study is nested, Ivermectin was donated by the Mectizan Donation Program, the albendazole was donated by the Glaxosmithkline Corporation, and the azithromycin was donated by Pfizer via the International Coalition of Trachoma Control.