Key messages
People consider several personal, social, and historical factors before deciding to take medicine. Within one community, different individuals will experience benefits and harms associated with treatment, which shape their decision to participate. The decision to adhere depends on the perceived benefits compared to harms, the trust built between communities and the programme, the competency of people delivering the drugs to provide reassurance to the community members, and the perceived organisation of the delivery programme.
Our findings are largely consistent with those of a 2022 Cochrane review exploring people's views and experiences of mass drug administration (MDA) programmes for lymphatic filariasis. This evidence overlap suggests that there are key challenges in the design of MDA programmes in general that need to be addressed to increase adherence.
What was studied in this synthesis?
Mass drug administration (MDA) involves the periodic delivery of drugs to treat entire communities or groups, regardless of whether an individual has a particular disease. This method aims to prevent onward transmission of infection within the population. MDA is currently recommended for some disease-control programmes in low- and middle-income countries, including for soil-transmitted helminth (STH) infections. STHs are a group of parasitic worms, including roundworm, hookworm, whipworm, and threadworm. These MDA programmes are usually delivered within a community or as a school-based programme. Successfully stopping STH infections through MDA depends on community members being willing and able to participate.
In this review, we looked for studies that explored how people view and experience mass drug administration programmes for STHs. We identified 17 studies relevant to this synthesis.
What was the aim of this synthesis?
In this synthesis of qualitative research, we searched for studies that explored people's views on MDA programmes for treating STHs in low- and middle-income countries. We wanted to understand how people view and experience mass drug administration programmes for soil-transmitted helminths. We were also interested in whether our findings would support, extend, or conflict with findings from a 2022 Cochrane review which looked at MDA programmes for lymphatic filariasis, another infectious disease caused by worms.
What were the main findings?
We included 17 studies in our analysis. The studies covered several countries in Africa and South‐East Asia, and one country in the Eastern Mediterranean region. The included studies explored the views and experiences of community members and those distributing the medicines in low-income countries where STH infection is a considerable problem. From the data, four themes emerged. The 2022 Cochrane review of MDA for lymphatic filariasis identified three of these themes, highlighting the similarities between these programmes. One new theme emerged.
1. People weigh up benefits and harms in their decision to participate in MDA, though some may not have a choice. There are many outcomes to participating in the MDA programme, both positive and negative. For community members, several of these may exist at once, and the decision to partake is a careful balance of risk, benefit, and feasibility (we have high confidence in the evidence). Unpleasant experiences can quickly spread through the community (moderate confidence). Physical and social barriers (e.g. travel distance or not attending school, respectively) prevent some people from accessing treatment through the MDA programme (moderate confidence).
2. Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical experiences, rumours, and mistrust of people involved in the programme affect overall trust in the programme. Past experiences can have a strong effect on people; negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence).
3. The drug distributor's status in the community is often low, and they are not well-equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background, and in-depth training around the drug or the disease itself (moderate confidence). Whilst some community members prefer distribution from people who they know or trust (high confidence), others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors cannot answer their questions related to the programme (moderate confidence).
4. (New theme) Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign which includes improved sanitation is necessary to tackle STH burden (moderate confidence).
How current is this evidence?
The evidence is current to November 2024.
Read the full abstract
Soil-transmitted helminth (STH) infections are amongst the most common infectious diseases worldwide, with an estimated 24% of the world’s population currently infected. Mass drug administration (MDA) is the periodic medicinal treatment, without prior individual diagnosis, of at-risk people living in endemic areas. The World Health Organization currently recommends MDA for STHs. MDA programmes are complex health interventions; achieving adherence is important to their success. Adherence is influenced by the target population's perceptions of the drug, the programme, and those delivering it.
Objectives
To synthesize qualitative research evidence about community experiences and perceptions of mass drug administration programmes for soil-transmitted helminths.
To assess whether our findings confirm, extend, enrich, or conflict with those of a 2022 Cochrane qualitative evidence review of mass drug administration programmes for lymphatic filariasis.
Search strategy
We searched CENTRAL, MEDLINE, Embase, and four other databases up to 11 November 2024, together with reference checking, and citation searching.
Selection criteria
We synthesized qualitative and mixed-methods studies. We included studies exploring community experiences and perceptions of MDA programmes for STHs in any country, conducted between 2001 and 2024.
We included all participants of MDA programmes, regardless of disease status, individual participation, or other demographic information. We also included lay healthcare workers and formally qualified healthcare workers, if their perspectives were clearly separated from those of the general population.
Data collection and analysis
We collected data on study characteristics and programme delivery, including country, endemicity, drug regimen, how the drugs were delivered, use of health education and sensitization, and adherence monitoring.
We conducted thematic analysis using a 'best-fit' framework synthesis based on a framework developed in a 2022 Cochrane review exploring community views on mass drug administration for filariasis (a parasitic infection caused by filarial worms). We conducted a deductive phase, accommodating our data within the existing model, followed by an inductive phase, during which we explored data not accommodated by the framework. We used the GRADE-CERQual approach to assess our confidence in the findings, and updated the filariasis review's conceptual model to display our findings.
Main results
We included 17 studies, conducted in Bangladesh, Benin, India, Kenya, Malawi, Nigeria, the Philippines, and Turkey. Four themes emerged, three of which were identified in the review of MDA for lymphatic filariasis.
People weigh up the benefits and harms in their decision to participate in MDA, though some may not have a choice. Outcomes of individual participation in MDA may be positive, negative, or both. The decision to partake is a careful balance of risk, benefit, and feasibility (high confidence). Unpleasant associations become part of the narrative and spread rapidly through the community (moderate confidence). Physical and social barriers prevent some people from being able to access MDA even if they want to participate (moderate confidence).
Many people are suspicious of MDA programmes, although trust may be built over time. Factors such as historical legacies, rumours, and mistrust of people involved in the programme affect overall trust in drug distribution and influence whether people choose to participate. Past experiences can have a profound effect on people, and negative experiences are likely to deter people from future participation (high confidence). Careful management of the relationships between people implementing the programme and people receiving the programme is important to building trust over time (moderate confidence).
The drug distributor's status in the community is often low, and they are not well-equipped to answer the communities' questions. People employed to distribute the drugs during STH treatment campaigns often lack a healthcare background and in-depth training around the drug or the disease itself (moderate confidence). Some community members prefer distribution from people they know or trust (high confidence). However, others place value on the knowledge or status of the drug distributors, and may not participate if the community drug distributors (CDDs) cannot answer their programme-related questions (moderate confidence).
Many community members have ideas to improve delivery and want more involvement in the programme. Although some programmes conduct education and sensitization activities prior to drug distribution, many community members still lack awareness of the timing and purpose of the distribution (high confidence). People value distribution strategies that make it easy for everyone to participate, and express a desire for adults in the community to be included in the programme (moderate confidence). Many community members believe a more comprehensive health campaign, which includes improved sanitation, is necessary to tackle STH burden (moderate confidence).
One theme that the filariasis review identified was not substantiated by the findings in this review (Programmes expect compliance: this can result in coercion and blame).
Authors' conclusions
Despite the prevalence and undoubted impact of MDA programmes over the past 10 years, endemic hotspots and continued transmission are common, due in part to poor community adherence. The 2022 Cochrane review outlined several key community concerns and doubts that hinder the effective implementation of MDA for lymphatic filariasis. This review shows that most of these concerns and doubts are shared by communities targeted for MDA for STHs, indicating that there are fundamental challenges in the overall conceptualization and design of MDA programmes that need to be addressed.
Funding
TF, MT, RK, and the Cochrane Infectious Diseases Group editorial base were funded by UK aid from the UK Government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK Government’s official policies.
Registration
The protocol for this review was published in January 2024 on the Cochrane Database of Systematic Reviews. Available at doi.org/10.1002/14651858.CD015794.