The Role of Community Drug Distributors In The Fight Against Lymphatic Filariasis: A Mixed-Methods Study in Coastal Kenya

The Declaration of Alma Ata in 1978 defined community health workers as one of the important providers of primary healthcare. Following the Declaration, two critical agendas emerged for community health programs. The first focused on the provision of preventive and curative services within the existing health system, and the second focused on the engagement of communities in the process of taking responsibility for their health. Between the 1980s and 1990s, several post-colonial African countries adopted the community-based approach for delivering primary healthcare to individuals. However, several community-based health programs experienced challenges around training, remuneration and incentives, supervision, integration within the health system, drug supply and storage, and the biased selection and training of individuals who lacked motivation. With the adoption of the Resolution by the World Health Assembly (WHA) in 1997 calling for the elimination of lymphatic filariasis (LF) as a public health problem, and the availability of free medicines, namely albendazole (ALB) and ivermectin in countries co-endemic for onchocerciasis and diethylcarbamazine citrate (DEC) and ALB are used for treatment in countries not co-endemic for onchocerciasis to facilitate elimination, there was a need for a cost-effective and efficient approach for delivering treatment to at-risk groups. Following commissioned studies to identify and implement a delivery strategy, the World Health Organization (WHO) adopted the community-directed treatment approach for the mass delivery of medicines for the elimination of LF. This approach included the distribution of medicines by community-selected volunteers or community drug distributors (CDDs) that were often health volunteers for other health programs or did not have any experience with being a volunteer. In Africa, volunteers receive material incentives, remuneration, training, supervision, drugs and social mobilization materials. However, research over the past decade has revealed that low motivation and performance among volunteers, as a result of various program and community level factors, negatively impact coverage and compliance. As a result, countries have to repeat mass drug administration (MDA) for a minimum of 5-6 years until the transmission of LF is interrupted. Kenya adopted the community-directed treatment approach in 2002; however, the national neglected tropical diseases (NTD) program experienced challenges with implementation due to financial constraints and limited capacity. This resulted in fragmented MDA, and low coverage and compliance, delaying the achievement of elimination goals. Despite efforts in 2016 to renew its commitment to achieving global and national targets, community volunteers’ poor motivation and low retention and performance were identified as significant predictors of coverage and compliance. The following stakeholder groups and their unique challenges play a role in the ineffective engagement of volunteers during MDA: • National program: Poor leadership, financial constraints, and limited capacity impede the program from effectively meeting the needs of volunteers. • County program and health facilities: Limited supportive supervision of volunteers and resources, low drug supply, inadequate training, lack of positive engagement of communities before MDA, and high workload for volunteers affect compliance and coverage. • Community level: The lack of involvement of communities in the selection of volunteers, low community knowledge of LF and MDA, and community distrust of the government lead to resistance towards volunteers. This dissertation critically examines the role and engagement of CDDs in the fight against LF in Kenya, as well as the role of globalization in shaping the engagement between CDDs and the NTD program. Using the professional quality of life (PQoL) framework and the socio-ecological model, we sought to extract information from all levels of the health system in Kenya in order to better understand the contribution of CDDs, their challenges, and areas in which interventions are needed. First, we used qualitative methodology to examine perceptions of CDDs from the perspectives of their supervisors, community leaders, community members, and program officials. Secondly, we used the PQoL measures and employed a mixed methods approach to quantify the relationship between the measures and CDD performance and retention. In order to triangulate these findings, we conducted in-depth interviews with CDDs. Lastly, we used the healthy policy triangle framework to conduct a retrospective policy analysis to asses the interactions between context, actors, process, and content in the adoption of the community-directed treatment approach for the delivery of mass treatment to those at-risk for LF. Given the challenges with getting in touch with the original policy makers and the availability of detailed reports at the global and national levels, a document review was determined to be the most appropriate method. From the qualitative study, the findings indicated that communities do not trust CDDs; and as a result, they resist CDDs. Furthermore, CDDs desire additional material and financial incentives, supportive supervision, and resources to effectively do their jobs. Also, CDDs do not always directly observe drug ingestion; they are biased in their selection of households for the delivery of drugs; and ineffectively conduct social mobilization during MDA. In addition, low community knowledge of LF and MDA, poor timing of MDA campaigns, and poor communication between CDDs and communities affect MDA targets. The NTD program acknowledged that financial constraints impede their ability to effectively motivate and engage CDDs and communities. Next, the mixed-methods study focused on the on-the-job quality of life (also known as PQoL) of CDDs revealed that higher household income and lower burnout scores were positively associated with their performance. Also, CDDs perform well when they have higher income and low secondary traumatic stress; and burnout negatively affects the retention of CDDs. In-depth interviews with CDDs revealed that various work conditions negatively affect their performance, motivation and MDA targets. These challenges include emotional and physical exhaustion from distributing medicines, verbal and physical abuse from community members, out of pocket expenditure on things related to MDA, high workload and limited time, and inadequate incentives. Third, the health policy analysis showed that the need to deliver donated medicines to endemic communities-using cost-effective and feasible approaches without burdening the local health system-was the catalyst for the commission of a multi-country study to determine the effectiveness, efficiency, and sustainability of the community-directed treatment approach. However, after the approach was adopted and shared with national programs to implement, countries like Kenya lacked the financial and human resources required to fully implement, monitor, evaluate, and scale-up the approach as required. This resulted in low community acceptance of MDA and medicines, affecting the target date to eliminate LF as a public health problem. This dissertation project revealed the need for additional research on the contribution of CDDs, the opportunity costs they incur during MDA and the sustainability of the community-directed treatment approach. Using evidence from this project, it is critical to identify and test specific indicators that are needed to support CDDs as they deliver medicines to at-risk groups. In addition, new and innovative approaches are needed to integrate MDA and CDDs into the health system, and properly recognize the critical contribution of CDDs in reaching public health goals such as LF elimination. In order to achieve its elimination targets, the NTD program in Kenya will require resources and scientific evidence to implement changes at all levels of the health system. This dissertation not only provides evidence that can inform the development and implementation of interventions, but also recommendations for improving MDA. In delivering medicines to at-risk groups, evidence-based strategies at all levels of the health system are needed. At the global and national levels, an evidence-based review and adaptation of the community-directed treatment strategy and CDD stipends is needed to ensure that it reflects the current and changing needs of Kenyans. Secondly, national NTD staff can benefit from capacity building around advocacy, resource mobilization, effective cascade training, equity, gender, and human rights in NTDs, evidence-based decision-making, program monitoring and evaluation, integration of public health programs into the country health system, human resource management, and effective and efficient planning of MDA. In addition, the national NTD staff can collaborate with other disease programs (e.g. Malaria, Polio) to share resources and integrate activities where possible. At the global level, partners in NTDs and other disease programs can foster stronger collaborations, and share limited resources to achieve maximum impact and efficiency. Given that MDA is implemented through counties in Kenya, greater accountability and transparency among health leaders may foster trust between communities and the NTD program. Furthermore, county and sub-county health teams can also benefit from capacity building around community engagement, supply-chain and logistics, MDA supervision, and rapid responses to real-time MDA challenges. Post-MDA review meetings should provide county and sub-county health teams the opportunity to request for additional funds and resources to improve the next MDA. Healthcare workers can benefit from additional resources and trainings in order to better supervise and support CDDs during MDA activities. Next, CDDs should receive adequate training on social mobilization, reporting, managing severe adverse effects, coping with stressful MDA events, supportive supervision, incentives, resources, and time to effectively engage communities. The selection of CDDs by communities is critical, even when there might be shortages and CDDs have to distribute to unfamiliar communities. Finally, in order to reduce burnout and traumatic stress among CDDs, extra days for mop-up, distribution, and social mobilization may be needed, as well as informal supervision of communities by their leaders.