Exploring Factors Affecting Coverage of Mass Drug Administration against Schistosomiasis Post COVID-19 in the Municipality of Talibon, Bohol: a mixed method study
Kenneth Costillas Samaco, Prof. dr. E. Elsa Herdiana Murhandarwati,M.Kes,Ph.D ;Prof. Dr. Yodi Mahendradhata, M.Sc, PhD,FRSPH
2024 | Tesis | S2 Ilmu Kesehatan Masyarakat
Introduction: Schistosomiasis (SCH) is transmitted by direct contact with freshwater containing parasites that penetrate the human epidermis (Mari et al., 2017). Schistosomiasis can be an acute and chronic disease caused by parasitic worms - trematodes (Colley et al., 1998). An estimated 240 million people are affected by schistosomiasis worldwide and about 700 million people live in endemic areas (WHO, 2020). In many areas of the Philippines, schistosomiasis japonica is still a public health problem despite efforts to disseminate accurate and up-to-date information (Belizario et al., 2022). The disease is endemic in the Philippines, where it affects 1,599 villages, 189 municipalities, 15 cities, 28 provinces and 12 regions. To strengthen the Department of Health's (DOH) Schistosomiasis Control and Elimination Program, a multi-stakeholder approach was identified to support the expansion of preventive chemotherapy with 40mg/kg single dose orally administered Praziquantel (PZQ) as the drug of choice (DOH, 2007 ) and is an essential component in the community-based schistosomiasis control program, intensified case management, integrated approach with Water, Sanitation, and Hygiene (WASH) program, One Health approach, and robust host control and surveillance program. The Bohol Health Office conducts SCH MDA every July with a target coverage of ?85% in endemic areas for individuals aged 5-65 years using a school and community-based approach (DOH, 2018). The schistosomiasis control and elimination program is still an ongoing program in Bohol Province, aiming to achieve a schistosomiasis-free province since 1996. While the current program implemented by the Provincial Health Office of Bohol includes Mass Drug Administration in endemic areas, the local government faces challenges to achieve coverage targets before and after the COVID-19 pandemic
Problem Statement and Relevance of the Study: Since 1996, the Province of Bohol has been implementing strategies in line with national guidelines to eliminate SCH including annual MDAs. To date, the province has not achieved its goal. Mass Drug Administration coverage has not reached the target due to low community participation. Due to low participation, the Provincial Health Office in coordination with the District Health Office agreed to only target school-aged children to participate in MDA in 2018. However, adults can still participate but on a voluntary basis. Based on available data, MDA coverage for 2019 was 78% (DOH, 2019) and no data was available for out-of-school children and adults. Despite the implementation of important strategies to eradicate SCH in the province, cases continue to be reported. This study will help identify barriers to one of the most important strategies, namely MDA against SCH. The results will inform health programs about gaps or barriers to MDA implementation that may contribute to the non-elimination of the disease and should be addressed to achieve elimination of SCH in Talibon, Bohol.
General objective: To explore important factors affecting the coverage of Preventive Mass Drug Administration (MDA) against schistosomiasis in Talibon, Bohol Province post COVID-19.
Specific objectives:
a. Explore the uptake of MDA against schistosomiasis in the last 5 years in Talibon, Bohol
b. Learn the factors that hinder the individuals living in SCH endemic areas from participating in the MDA
c. Explore the challenges of the service providers in implementing MDA against schistosomiasis
d. Identify challenges for the MDA against schistosomiasis policy to be fully implemented
Research Questions: In exploring the critical factors affecting the coverage of MDA against schistosomiasis in the Talibon, Province of Bohol in relation to the research problem as well as the study objectives, the study is going to address the following research questions:
a. What is the trend of MDA against schistosomiasis coverage in the barangays of Talibon, Province of Bohol over the past 5 years where SCH is endemic?
b. Is the level of awareness regarding schistosomiasis, knowledge, attitude, practices and perceived drug safety and effectiveness a factor that hinders individuals who are living in high-risk areas where schistosomiasis is endemic in participating in the MDA?
c. What are the challenges of the health service providers in implementing MDA against schistosomiasis to targeted populations during and post COVID-19?
d. What are the challenges of the community leaders in supporting the MDA against schistosomiasis policy in the endemic area?
Method: A sequential explanatory mixed methods study was conducted in the municipality of Talibon, Bohol, Philippines from June to August 2024. The study employed a cross-sectional survey for the quantitative component and focus group discussions (FGDs) and key informant interviews (KIIs ) for the qualitative component. The study was conducted in four barangays (villages) where schistosomiasis is endemic: San Agustin, San Carlos, San Jose, and San Roque. The study population included parents or primary caregivers of individuals who received mass drug administration (MDA) for schistosomiasis, program implementers, technical staff, and community leaders. The inclusion criteria were: (1) residing in the selected barangays, (2) aged 18 years and above, and (3) willing to participate in the study. Individuals with active schistosomiasis infection and those living outside the study area were excluded. For the quantitative component, the Lot Quality Assurance Sampling (LQAS) technique was used to determine the sample size. A total of 105 respondents were randomly selected, with 21 respondents from each of the five supervision areas (SAs) in the four barangays. For the qualitative component, purposive sampling was employed to identify participants for the FGDs and KIIs. A total of 10 MDA recipients/primary caregivers, 6 program implementers, 1 technical staff, and 4 community leaders participated in the FGDs and KIIs. Quantitative data were collected using a structured survey questionnaire adapted from published literature. The questionnaire was translated into the local language (Cebuano) and administered verbally by trained interviewers. Qualitative data were gathered through FGDs and KIIs using semi-structured interview guides developed based on the study objectives and literature review. The FGDs and KIIs were conducted in Cebuano, audio-recorded, and transcribed verbatim. Quantitative data were analyzed using descriptive statistics. Frequencies and percentages were calculated for categorical variables, while means and standard deviations were calculated for continuous variables. Qualitative data were analyzed thematically using Open Code 4 software. The transcripts were read repeatedly, and codes were assigned to meaningful segments. Similar codes were grouped into categories, and themes were generated based on the study objectives.
Results: The survey involved a diverse group of respondents from different barangays (villages) and ecological settings. The breakdown of respondents by barangay was as follows: 20% from San Agustin, 20% from San Carlos, 20% from San Jose, 20% from San Roque A and 20% from San Roque B. In terms of ecological settings, respondents were almost evenly split, with 47% remaining in highland areas and 53% in lowland areas. The gender distribution revealed that 63% of the respondents were female, while 37% were male. Regarding marital status, 66% of respondents were married, 10% were in cohabitation, 10% were single, and 14% were widowed. Educational attainment varied among respondents: 12% had completed college, 49% had a high school education, and 39% had completed elementary school. Occupational data showed that a majority, 51%, were farmers. Other occupations included business (6%), employees (10%), students (3%), unemployed individuals (25%), and a small percentage (5%) classified as others. The survey results 5 showed that 56% of respondents had participated in mass treatment for schistosomiasis, while 44% had not. Among those who had participated, the timing of their last participation varied: 23% participated in 2015 or earlier, 10% in 2018, 7% in 2019, 10% in 2021, 5% in 2022, and 2% in 2023. The remaining 44% did not participate in any of these years. In terms of contact with local bodies of water, 24% of respondents reported regular contact, while the majority, 76%, did not. Regarding access to functional toilets, 90% of respondents reported having access to such facilities, whereas 10% did not. The survey shows the awareness, knowledge, and experience of schistosomiasis among respondents. It shows that about 95% of the respondents had heard about schistosomiasis, indicating effective health communication efforts in the community. Of those aware, 67% have participated in health education campaigns, showing active engagement with health promotion initiatives. About 86% of the respondents knew what schistosomiasis is, but only 66% were aware of its source. Similarly, 76% knew the signs and symptoms, and 69% knew how healthy people get infected. 76% knew how to prevent contracting the disease. The majority, 91%, were aware that schistosomiasis was treatable by drugs, and only 5% reported having contracted the disease. Most sought treatment from health facilities. 61% had received drugs for schistosomiasis prevention, with health facilities being the primary source (38%). Health facility workers were the main dispensers of these drugs. Lastly, about 72% of the respondents affirmed the availability of drugs in the village. The survey results showed that 62% of respondents were willing to participate in the next MDA, while 38% expressed reluctance. Among those unwilling to participate, the primary reasons cited were fear of side effects (67%), distance from the health facility (7%), and the belief that schistosomiasis no longer exists in the community (16%). Additionally, a small percentage (9%) cited other reasons for their reluctance.
Critical factors that facilitate or hinder the service provider in providing MDA against schistosomiasis
Aside from the quantitative data, key informant interviews and focus group discussions were also used to identify the possible factors that facilitate or hinder the service provider in providing MDA against schistosomiasis.
Facilitators
The findings emphasize the important role of Community Health Workers (CHWs) and midwives in providing essential medical services within the community. Participants emphasized the significance of activities such as deworming campaigns in preventing schistosomiasis. Health education sessions, often combined with deworming activities, were found to be effective in raising awareness about schistosomiasis transmission and prevention methods. The presence of strategic local health facilities was noted as crucial in providing access to medical services, including deworming and diagnostic procedures. This is because CHWs are being deployed by the Department of Health to facilitate the MDA through the deployment of community health workers in conducting house-to-house distribution of PZQ in targeted areas within the local government units based on the master list of clients. Moreover, it was highlighted that health education or health initiatives should be a requirement before implementing MDA to address existing misunderstandings about transmission, prevention, treatment, and potential side effects of the drugs.
Hindrances
The study findings highlight numerous challenges in preventing and controlling schistosomiasis within the study community, encompassing various aspects of healthcare delivery and community engagement.
Manpower and Resources: The study shows that manpower shortages, worsened by the COVID-19 pandemic, significantly hindered the implementation of Mass Drug Administration (MDA) activities. Participants noted a lack of personnel available for MDA campaigns as healthcare workers were mainly focused on responding to the demands of the COVID-19 crisis. However, there is a shortage of such personnel, which may limit the reach of health education campaigns. This shortage of manpower posed significant barriers to the effective implementation of schistosomiasis prevention and control efforts.
COVID-19 Pandemic : The COVID-19 pandemic emerged as a significant disruptor of schistosomiasis control activities within the study community. Participants highlighted the suspension of MDA activities in 2020 due to safety concerns and logistical challenges associated with the pandemic. The prioritization of COVID-19 response efforts led to the reallocation of manpower and resources away from schistosomiasis control activities, further exacerbating existing challenges in the healthcare system. The previous SCH coordinator noted, “ during the pandemic, I act as the COVID-19 vaccination coordinator which oversees the daily operations including the monitoring and reporting of adverse events following immunization . We have no activity regarding schistosomiasis that time due to the prioritization of COVID-19 ”. A midwife shared, “ we didn't have any MDA in 2020 and 2021, we just resumed in 2022 but we didn't have any school-based MDA. We practice community-based MDA which is more difficult to organize ”.
Mass Drug Administration Accomplishment Reporting: Although reports are required to be submitted every after any activity. It has been observed that some reports on the MDA are not well documented or other reports are missing. The previous SCH coordinator has endorsed reports however, some documents including the attendance sheets of participants were missing. As the current SCH coordinator noted, “ some of our MDA documentation was damaged during the Typhoon Odette in December 2021. The typhoon was so strong that it damaged our health facilities significantly ”. There were also more recent MDA activity conducted in 2022 in some villages however, the attendance of participants was missing. The activity report was retrieved however, it lacks the necessary information relating to the number of attendees and the feedback from the participants. One midwife noted, “ after our activity we submit the attendance sheets and the reports to the RHU but we do not have a copy of the reports in our facility ”.
Geographical Challenges: Geographical factors such as distance from health centers, difficult terrain, and the presence of water bodies pose significant challenges in accessing medical services and controlling schistosomiasis. Participants emphasized the logistical barriers faced by communities in remote or rural areas, where access to healthcare facilities and preventive interventions is limited. One of the participants verbalizes “ we have to walk at least 45 minutes to reach the health facility especially during the rainy season because traveling by motorbike is difficult. Sometimes, we also walk so we can save money for from transportation ”. Participants also pointed out cases where infrastructure projects initiated for schistosomiasis control efforts were left incomplete, despite initial budget allocations.
Fear of Medication Side Effects: Concerns about medication side effects, particularly related to previous experiences with Praziquantel were prevalent among community members. Participants mentioned that individuals who had previously experienced adverse reactions to medication were hesitant to undergo treatment again, citing fears of recurring side effects. One of the community participants shared, “ whenever I join the MDA, I have to skip working the entire day because the side effects are hard to tolerate, I need to have bed rest the entire day. This has led to a loss of my income for that day ”. Some respondents became hesitant to join the MDA against SCH due to the stories they heard from those who previously joined that experienced side effects. One of the participants noted, “ I won't be joining the MDA anymore because the side effects make me sick, with my age, it is even harder to tolerate ”. Another participant noted, “ I heard about the side effects that my fellow farmers went through, after hearing their stories of how bad the drug made them feel, it scared me that is why I won't join in the MDA ”. This fear of medication side effects contributed to reluctance among community members to participate in schistosomiasis control programs, highlighting the importance of addressing misconceptions and ensuring the safety and efficacy of treatment regimens.
Challenges for the Mass Drug Administration (MDA) against schistosomiasis policy to be fully implemented.
The implementation of Mass Drug Administration (MDA) programs to combat schistosomiasis encounters several significant challenges. These barriers hinder the effectiveness and reach of MDA policies, impacting public health efforts to control this parasitic disease.
Community Resistance and Lack of Participation: One of the primary challenges is community resistance and lack of participation to MDA for SCH initiatives. Despite extensive awareness campaigns and educational efforts highlighting the importance of MDA, many individuals remain reluctant to participate. This resistance often stems from fears of potential side effects and entrenched misinformation about the necessity and safety of deworming treatments. As the midwife noted, " there are still stubborn people who refuse to participate " even when materials are provided. Moreover, achieving full participation in MDA programs is a persistent issue. Adults may decline deworming due to concerns about side effects, a lack of perceived personal risk of contracting schistosomiasis or do not believe that schistosomiasis is still present in their community. A participant noted, “ it has been many years that we didn't see any person with schistosomiasis here. I don't believe that it is still present in our community ”. The midwife observed that " we don't always get a 100%, we just get a few percent ," indicating that convincingly the entire target population remains a significant hurdle.
Misinformation and Lack of Awareness: Misinformation and a lack of awareness about schistosomiasis and the benefits of deworming are prevalent. Some community members do not fully understand how the disease is transmitted or its potential health consequences. This gap in knowledge leads to hesitancy and refusal to participate in MDA programs. The midwife mentioned, " there are lots of people who refuse to be dewormed since they are afraid that there's a worm that will come out ". These initiatives should not only deliver disease-specific information but also address existing misunderstandings about transmission, prevention, treatment, and potential side effects of the drugs.
Budgetary Constraints: Budget constraints emerged as a significant barrier to effective schistosomiasis prevention and control efforts. Participants noted that the Local Government Unit's (LGU) budget allocation for health programs, including schistosomiasis control, was often unstable and inconsistent. While funds were allocated at times, they were not always sufficient or sustained, leading to uncertainties in resource availability and hindering the implementation of comprehensive control measures. Limited financial and human resources are also critical barriers to the successful implementation of MDA programs. The provincial SCH coordinator noted, “ although the SCH-related activities including MDA are reflected in our annual plans, the budget is not enough to cover the needed funding. We often also seek financial support from the Regional Department of Health ”. The SCH coordinator also noted that their usual budget is not enough to cover the required municipal amount to implement MDA. The SCH coordinator noted, " we cannot implement MDA on our own budget, we often seek support from the provincial and regional Department of Health so we can fully implement MDA ". Village leaders also verbalize that they do not have budget allocation for MDA-related activities. A village leader verbalizes, “ we are heavily reliant on the budget from the municipality for our MDA activities. When it comes to MDA, it is only the rural health unit and community health unit staff that are involved. When it comes to schistosomiasis-related activities, we are involved during snail clearing operations in areas where the snails are known ”. Adequate funding, staffing, and training are essential for conducting effective outreach, monitoring side effects, and ensuring compliance with deworming protocols. The midwife highlighted the need for more detailed explanations and resources to improve community understanding and participation in MDA activities.
Conclusions: This study has explored several factors that have become barriers for the community participation and coverage of mass drug administration for schistosomiasis. It was found that mass drug administration for schistosomiasis failed to reach the target population. There is the need to re-strategize and recalibrate drug distribution strategies and develop evidence-based policies at the local level to include a client-centered and targeted approach while ensuring adequate program funding. The utilization of local channels for community sensitization and exploring other platforms will be beneficial to maximize information dissemination. In addition to strategic distribution points, regular program monitoring through an integrated approach, community follow up activities and age-appropriate participatory health education campaigns can possibly enhance both treatment coverage supported by an agile program infrastructure.
Recommendations : Based on the findings of this study, the following recommendations are proposed to enhance the effectiveness of schistosomiasis control programs in the surveyed barangays:
Addressing personal-related factors: Misconceptions and misinformation about schistosomiasis
A. Enhanced Health Education Programs: Implement comprehensive health education campaigns to raise awareness about schistosomiasis, focusing on its transmission, prevention, and treatment. This can also be a platform to discuss issues relating to the current status of schistosomiasis in the area. Showing the community sample of the snail may help in facilitating better understanding.
B. Targeted Education: Develop educational materials that address common misconceptions and provide clear, accurate information about the disease and the benefits of MDA. An age-appropriate and culturally sensitive material may facilitate health literacy and optimize understanding on the concepts.
Addressing drug-related factors: Fear of side effects
A. Addressing Fears and Misconceptions of the Side Effects of Drugs: Conduct focused groups or one-on-one counseling sessions to address fears and misconceptions about the side effects of the medication used in MDA. Print out materials that can be taken home by the participants be developed to maximize the delivery of messages including the hotline that they can contact should there be clarifications or report adverse side effects. This may help in assuring a follow-up of care to the community.
B. Targeted Approaches: Prioritize individuals who have high risk of acquiring SCH. Due to the limitation of resources, a more targeted approach can provide focused intervention. An updated mapping of high risk areas provides information in prioritizing the conduct of MDA. This will also ensure that these pockets of community are monitored well.
Addressing health information-related factors: Monitoring and Evaluation and Community Engagement
A. Regular Assessments and Complete Documentation: Conduct regular assessments of the MDA program to identify areas of improvement and ensure that objectives are being met. Implement periodic community follow up through surveys to gauge the effectiveness of health education campaigns. Proper documentation should be practice to facilitate analysis on the status of implementation. Activity reporting forms should be improved so it can provide the essential information needed in the review and analysis of the program implementation such as complete attachments of attendance sheet to activity reports along with the budget line items and its sources including keeping a digital copy of the reports .
B. Community Involvement: Encourage greater community involvement in health initiatives by training local volunteers to assist health workers. Community consultations are also essential during the planning stage to foster participation and ownership. This can also provide crucial information to have a better understanding on the current status of the community. Establish regular feedback mechanisms where community members can voice their concerns and suggestions regarding the MDA program and other health initiatives. Both verbal and written feedback should be properly documented as this can be used during the program implementation reviews.
Addressing MDA policy-related factors: Funding Sources for MDA
A. Resource allocation: Ensure adequate resources, including protective equipment and transportation, are available for health workers, especially in remote and geographically challenging areas. Provision of food and a token in the form of grocery items during MDA may also help in encouraging the community to participate. Explore other means of potential funding streams such as the Gender and Development Fund (GAD Funds) from the municipality or village level. Complementing resources or pooling of funds of the municipality with the Department of Health from the regional and provincial levels can help in ensuring adequate resources to implement MDA.
B. One Health Approach: A stronger collaboration with a multi-sectoral approach along with its members, the Department of Health (DOH), Department of Education (DEPED), Department of Agriculture (DA), and Department of Environment and Natural Resources ( DENR) to ensure sustained policy support, and adequate funding for effective prevention, control and elimination of schistosomiasis.
C. Expansion of the study: The respondents from the community were limited to heads of households or primary care givers who described their personal experiences and what they observed from their children who participated in the MDA for SCH. Engaging school-aged children who participate in the activity in future studies can provide further information on the critical factors that affect the participation and the coverage of MDA for SCH.
Bibliography
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Mari, L. et al . (2017). Heterogeneity in schistosomiasis transmission dynamics. Journal of theoretical biology, 432, 87–99. https://doi.org/10.1016/j.jtbi.2017.08.015
ABSTRACT
Introduction: The schistosomiasis control and elimination program remains an ongoing program in the Province of Bohol, aiming for a schistosomiasis free province since 1996. Current programs implemented by the Provincial Health of Bohol including Mass Drug Administration in endemic areas, the local government is facing challenges to achieve the target coverage both pre and post COVID-19 pandemic.
Objective: The primary objective of this study is to explore the critical factors influencing coverage of the Mass Drug Administration against Schistosomiasis in the Municipality of Talibon, Province of Bohol.
Method: This research is a sequential explanatory mixed method sequential study. The quantitative component collected data using a structured survey and the qualitative component of this study was explored through in-depth interviews and focus group discussions. One hundred and five participants were identified using Lot Quality Assurance Sampling and homogenous purposive sampling technique for quantitative and qualitative were utilized respectively. Descriptive analysis was applied for the quantitative data while thematic analysis using the deductive approach was used to analyze the qualitative data. One focus group discussion among community members living in the affected area. Ten in-depth interviews were conducted with the municipal and provincial schistosomiasis coordinator while eight were midwives and village leaders from the respective areas.
Results: It was revealed that sixty two percent of survey respondents were willing to participate in the mass drug administration while thirty eight percent had pointed out reasons for declining their participation. The level of knowledge was found to be significantly high on schistosomiasis at ninety five percent and seventy six percent knew the prevention of schistosomiasis. The thematic analysis showed that the barriers that affected the coverage of mass drug administration found in this study were fear of side effects, belief that schistosomiasis is non-existent in their areas, accessibility to facilities, lack of community engagement, unsystematic documentation, lack of funding, and information dissemination gap. These factors adversely affected the participation and compliance of the intervention.
Conclusions: This study has explored several factors that have become barriers to coverage of mass drug administration for schistosomiasis. It was found that mass drug administration for schistosomiasis failed to reach the target population. The COVID-19 pandemic impacted the program through suspension of activities, reallocation of resources and shifting of mass drug administration strategies. There is a need to update distribution strategies and develop policies at the local level to include targeted approaches while ensuring adequate funding. Exploring other platforms in community sensitization will maximize information dissemination. Additional strategic distribution points, regular program monitoring through an integrated approach and age-appropriate participatory health education campaigns can possibly enhance coverage supported by an agile program infrastructure.
Kata Kunci : Keywords: coverage; mass drug administration; schistosomiasis; participation
