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Table 2 Overview of implementation strategies deployed in the intervention commune

From: Rapid ethnography and participatory techniques increase onchocerciasis mass drug administration treatment coverage in Benin: a difference-in-differences analysis

Implementation strategy

Targeted barrier

Actor

Action

Action target

Dose and temporality

Redesign of community drug distributor (CDD) job aids

MDA drugs were perceived to be associated with side effects

Socio-cultural beliefs of some community members led to refusals to participate

PACT study team in collaboration with the MOH

The PACT study team accessed existing training manuals and worked with the MOH to redesign job aids with supportive messages that directly address community member concerns and knowledge gaps identified in the rapid ethnography. The job aids were shared with the MOH for approval and iteratively revised based upon feedback

CDDs: The strategy aimed to increase CDD knowledge and skills necessary to respond to specific points of community resistance to treatment

One redesign period took place, prior to CDD training (planning stage)

Make CDD training more dynamic

Compromised trust in CDDs and perceived lack of professionalism is a barrier to community member participation

PACT study team in collaboration with the MOH

Nearly 150 CDDs were trained in December 2020. The revised training included hands-on practice negotiating with community members about key issues that arose in the rapid ethnography. The training also highlighted topics of professionalism, including role play of ideal conduct when visiting households. We conducted pre-post tests to evaluate the improved training format, and the effects on CDD knowledge

CDDs: The strategy aimed to provide CDDs opportunity to increase knowledge and practice managing real life scenarios of treatment and community resistance to treatment in a safe training-based setting, and with peer feedback

One dynamic two-day training took place December 2020, prior to implementation (engaging stage)

Improve CDD supervision during MDA

Compromised trust in CDDs and perceived lack of professionalism

Respondents reported that drugs did not reach all areas of the communes, and many individuals were never offered treatment

CDD and NTD staff burnout was high, leading to work force challenges

MOH

CDDs were trained to mark the doorposts of houses with chalk during MDA, and supervisors (primarily commune-level head nurses) were trained on how to review household markings during MDA to guide feedback for CDDs. During trainings, CDD supervisors were also supported in developing new distribution maps (building on the social maps developed during rapid ethnography), to ensure entire geographic areas were not systematically excluded from MDA

CDDs: The strategy aimed to provide structured supervision necessary to ensure houses and neighborhoods were not systematically missed and build a culture of support for CDDs in their field work

CDD supervisors: The strategy aimed to provide structured supervision tools with which supervisors were empowered to support and provide feedback to CDDs in specific, mutually agreed upon ways

Daily throughout 10 days of MDA implementation (executing stage)

Tailor community-level communication and sensitization

Pre-MDA communication does not reach all neighborhoods in the catchment area

Socio-cultural beliefs of some community members led to refusals to participate in MDA

PACT study team in collaboration with the MOH

New sensitization messages were created for public criers and radio announcements that built upon community feedback and specific concerns noted during rapid ethnography. Public criers were trained to deliver the messages in December 2020

Community members: The strategy aimed to increase the reach of community sensitization messages and directly address community member concerns with tailored message content

In total, 61 public criers were trained on the new messages. The public criers delivered messages to the community for 5 days prior to MDA. Additionally, 30 radio spots ran daily during the two weeks prior to MDA (engaging stage)

Prepare local champions by increasing engagement with local leaders

In some areas, MDA was viewed as lacking legitimacy

PACT study team in collaboration with the MOH

Educational flyers were created for local leaders with updated guidance on how to engage community members and specific educational messages to reinforce. The flyers were shared with community leaders during a series of neighborhood-level informational meetings

Community leaders, including political, religious, and traditional leaders (ex. village chiefs): The strategy aimed to increase community leader knowledge of MDA and provide tools for leaders to support MDA implementation, increasing MDA programs legitimacy

Ten meetings with local leaders were conducted in December 2020 to distribute and discuss the educational flyers. 100 local leaders were trained within one week of the first day of MDA (engaging phase)

  1. CDD community drug distributors, MDA mass drug administration, MOH Ministry of Health