Mass drug administration means giving every person living in a village or region a drug, irrespective of whether they have the disease or not. It’s an approach used in some disease control programmes in Africa, Asia, and South America since the 1930s. They are often steeped in controversy: some specialists believing they are effective, whilst others seeing them as being imperialistic and imposed.
Lymphatic filariasis is one such programme, where the WHO recommends mass drug administration. The LSTM-hosted Cochrane infectious Diseases Group (CIDG) has carried out a qualitative systematic Cochrane Review to synthesize available literature on community responses to such programmes. This is important as their experiences are likely to influence whether they decide to take the drugs or not.
Looking specifically at drugs given for lymphatic filariasis, the author team identified 29 studies for inclusion in Africa, South-East Asia, and South America published since 2000. The studies described some fundamental community concerns, which are missing from policy documents, to understand some of the failings of MDA programmes and to help with better programme design in the future.
Lead author and LSTM researcher, Melissa Taylor, notes, “Whilst global policy makers are enthusiastic about these programmes, this research gives a voice to intended beneficiaries. Rather than blindly following programme expectations, we found communities make up their own minds about programmes, weighing up the benefits and harms before participating. Mistrust and fear of adverse effects are common and probably mean there are far more people not complying than policy specialists think”.
This Cochrane Review synthesized qualitative research and mixed-methods studies when it was possible to extract qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards MDA programmes for lymphatic filariasis in low-income countries endemic for lymphatic filariasis.
Four themes emerged:
• People weigh up benefits and harms before participating. People understand the potential benefits in terms of relief of suffering, stigma, and financial burden of the illness, but side effects in infected people are frightening and unwelcome. These effects are often amplified through rumour and social media.
• Many people are suspicious of Mass Drug Administration Programmes. When people lack a scientific explanation for the programme and their experiences of it, they often develop social explanations instead, shaped on the historical backdrop that may include foreign imperialism and level of trust people have in relevant authority figures.
• Programmes expect compliance, and this can become coercive and blaming. Health workers and community members stigmatize non-compliance, which can become coercive, so communities may appear to comply publicly, and privately reject treatment.
• Community distributors are often not respected or valued. They have little authority and the behaviour of some distributors damages the MDA programme's reputation. If distributers are not sufficiently informed or skilled, they cannot help communities make informed decisions about participation.
The review authors found a few positive opinions about the benefits of the programme and about attributes they appreciate in distributors. However, negative views about mistrust, coercion or insufficient information were often far more common or expressed more strongly. This may be because those satisfied with the programme do not have strong objections.
Nevertheless, co-author Professor Sandy Oliver, based at University College London (UCL), was surprised: “Given the huge amount of money spent on these programmes, we believe a robust debate is needed as to the appropriateness of centrally mandated mass drug administration and the style of the delivery in global health”.
Taylor M, Thomas R, Oliver S, Garner P. Community views on mass drug administration for filariasis: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews 2022, Issue 2. Art. No.: CD013638. DOI: 10.1002/14651858.CD013638.pub2
The CIDG editorial base and the author team (Melissa Taylor, Rebecca Thomas, Sandy Oliver, and Paul Garner) are 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.