Community views on mass drug administration for soil-transmitted helminths: a qualitative evidence synthesis

Background: 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 methods: 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.