From informed consent to adherence: factors influencing involvement in mass drug administration with ivermectin for malaria elimination in The Gambia

Abstract

Background The World Health Organization (WHO) recommends consideration of mass drug administration (MDA) for malaria control in low-endemic settings approaching elimination. However, MDA remains a controversial strategy, as multiple individual, social, and operational factors have shown to affect its acceptability at local levels. This is further complicated by inconsistent definitions of key indicators derived from individual and community involvement—coverage, adherence, and compliance—that cast doubts about the actual and potential epidemiological impact of MDA on disease control and elimination. This study aimed to identify limitations and enabling factors impacting involvement at different stages of a large cluster-randomized trial assessing the effect of combining dihydroartemisinin-piperaquine (DP) and ivermectin (IVM) in malaria transmission in The Gambia. Methods This social science study used a mixed-methods approach. Qualitative data were collected in intervention and control villages through ethnographic methods, including in-depth interviews (IDIs), focus group discussions (FGDs), and participant observation conducted with trial participants and decliners, community leaders, and field staff. A cross-sectional survey was conducted in the intervention villages after the first year of MDA. Both strands of the study explored malaria knowledge and opinions, social dynamics influencing decision-making, as well as perceived risks, burdens, and benefits associated with this MDA. Results 157 IDIs and 11 FGDs were conducted, and 864 respondents were included in the survey. Barriers and enabling factors to involvement were differentially influential at the various stages of the MDA. Issues of social influence, concerns regarding secondary effects of the medication, costs associated with malaria, and acceptability of the implementing organization, among other factors, differently affected the decision-making processes throughout the trial. Rather than a linear trajectory, involvement in this MDA trial was subjected to multiple revaluations from enrolment and consent to medicine intake and adherence to treatment. Conclusions This study went beyond the individual factors often associated with coverage and adherence, and found that nuanced social dynamics greatly influence the decision-making process at all phases of the trial. These issues need to be consider for MDA implementation strategies and inform discussions about more accurate ways of reporting on critical effectiveness indicators.

Acceptability and perceived barriers to reactive focal mass drug administration in the context of a malaria elimination program in Magude district, Southern Mozambique: A qualitative study

“…Moreover, participants had experience of previous antimalarial pills, and they were concerned about drug adverse reactions, and others were reluctant to take drugs without malaria symptoms. These barriers have also been documented in previous studies [18,[21][22][23][24]. Furthermore, like previous studies [25] have reported, lack of access to accurate information, spread of misinformation about malaria intervention, being unable to drink alcohol while taking DHAp [7], lack of PLOS ONE trust of fieldworkers, and the demand of food as precondition to take DHAp are potentials barriers to rfMDA.…”

Mass Drug Administration: Contextual Factor Considerations

“…One study required women of reproductive age to undergo pregnancy testing; both the production of the urine specimen for testing in places where a private toilet was not available and reading of the test result in a public place created privacy concerns, leading to decreased participation among this group. 36 Ethnicity was related to willingness to participate in MDA. 40 One study noted that ethnic minorities were potentially underrepresented because of geographic distribution rather than direct discrimination and also found that some portions of the population relied on traditional medicine because of affordability more so than any other reason, which led to less familiarity with MDA and thus to lower participation.…”

Risk factors for non-participation in ivermectin and dihydroartemisinin-piperaquine mass drug administration for malaria control in the MASSIV trial

“…It might be anticipated that exclusion criteria related to pregnancy or breastfeeding would affect the uptake of ivermectin, however a similar phenomenon would not be expected for DHP. Previous studies have highlighted that not receiving ivermectin during previous pregnancies can encourage women not to participate to the MDA even if not pregnant [ 20 , 21 ], alternatively some women may have not wanted to complete a pregnancy test due to a lack of privacy [ 22 ]. Men have also been reported to be more likely to receive MDA for soil transmitted helminths in Kenya but no difference between sexes was seen amongst children in a previous study examining participation in trachoma MDA in the Gambia or in adults for soil-transmitted helminths in Uganda [ 3 , 6 , 23 ].…”