Assessment of knowledge, attitudes and practices regarding NTD and MDA
The survey on knowledge, attitudes and practices levels regarding NTD and MDA reached a total of 379 respondents comprising 268 (70.7%) female and 111 (29.3%) male drawn from the three districts of Chiradzulu, Mangochi and Zomba (Figure 1). The mean age of the respondents was 40.7 years ranged between 16 and 89 years and majority (93.9%) of them resided in rural areas. Table 3 summarizes distribution of the socio-economic characteristics of respondents across the study districts.
Table 3
Socio-economic characteristics of survey respondents
Characteristic
|
Number (%) of respondents who participated in the survey
|
Chiradzulu
|
Mangochi
|
Zomba
|
Totals
|
1. No. of respondents
|
126 (33.3)
|
129 (34%)
|
124 (32.7%)
|
379 (100)
|
2. Sex
Female
Male
|
91 (72.2)
35 (27.8)
|
92 (71.3)
37 (28.7)
|
85 (68.5)
39 (31.5)
|
268 (70.7)
111 (29.3)
|
3. Age (in years)
Mean
Range
|
42.5
18-89
|
36.9
18-87
|
42.6
16-81
|
40.7
16-89
|
4. Location
Urban
Rural
|
21 (16.7)
105 (83.3)
|
-
129 (100)
|
1 (0.8)
123 (99.2)
|
23 (6.1)
356 (93.9)
|
5. Marital status
Single
Married
Divorced
Widowed
Separated
|
5 (4)
86 (68.3)
18 (14.3)
13 (10.3)
4 (3.2)
|
11 (8.6)
104 (80.6)
8 (6.2)
3 (2.3)
3 (2.3)
|
4 (3.2)
101 (81.5)
5 (4)
13 (10.5)
1 (0.8)
|
20 (5.3)
291 (76.8)
31 (8.2)
29 (7.6)
8 (2.1)
|
6. Education level
None
Primary
Secondary
Tertiary
|
13 (10.3)
82 (65.1)
30 (23.8)
1 (0.8)
|
41 (31.8)
67 (51.9)
20 (15.5)
1 (0.8)
|
20 (16.1)
80 (64.5)
22 (17.8)
2 (1.6)
|
74 (19.5)
229 (60.4)
72 (19)
4 (1.1)
|
7. Occupation
Business
Farmer
Fisher
Employed
Unemployed
Other
|
34 (27)
72 (57.1)
-
6 (4.8)
14 (11.1)
-
|
19 (14.7)
92 (71.3)
2 (1.6)
-
11 (8.5)
5 (3.9)
|
29 (23.4)
72 (58.1)
7 (5.6)
5 (4)
10 (8.1)
1 (0.8)
|
82 (21.6)
236 (62.3)
9 (2.4)
11 (2.9)
35 (9.2)
6 (1.6)
|
Knowledge levels about schistosomiasis varied among respondents according to aspects asked about and district. The survey revealed that a majority of the respondents is highly knowledgeable about what schistosomiasis is (78%). However, respondents’ knowledge levels declined when asked to mention what causes schistosomiasis (41%), intermediate organism for schistosomiasis (18%) and the types of schistosomiasis (11%). Among the participating districts Chiradzulu generally fared better in terms of knowledge levels followed by Zomba and Mangochi (Figure 2).
With regards to knowledge of STH, the survey results (Figure 3) revealed that knowledge levels of STH varied across the study districts depending on the question that was asked. Majority of the respondents were highly knowledgeable about whether STH are treatable with drugs (97%) and what STH are (50%). However, respondents had low knowledge levels when asked to mention what causes STH (20%). Among the districts, Zomba (range: 21%-99%) and Chiradzulu (range: 7%-99%) scored better in terms of STH knowledge levels than Mangochi (range: 9%-91%).
The survey delved to inquire attitudes of respondents towards community based health service delivery process in relation to MDA. The majority expressed positive views as evidenced when 89.4% agreed that there very were few health services in the communities, which they said necessitates community members to take some of the health care responsibilities in health services delivery. They were of the view that involvement of community members in health activities will enhance health for people in their community (96.3%). As regards to community involvement in drug distribution, 93.9% opined that it helps in saving the time of the health worker to do other things, and that it is a good way to make drugs available to the people (95.2%). However, 65.2% were of the view that the distribution of drugs like praziquantel and albendazole is best done by health workers, and that communities are not capable of organizing and monitoring treatment of schistosomiasis and intestinal worms on their own (46.4%). About 68.1% of the respondents thought that community members should not handle drugs for schistosomiasis and intestinal worms because they are not trained as health workers. Only 8.4% said that community involvement in schistosomiasis and intestinal worms’ treatment is a take-over of the duties of the health worker while majority (85.5%) agreed that community members are capable of supervising the treatments of schistosomiasis and intestinal worms during MDA.
The survey sought to elucidate the issues surrounding practices related to NTD and MDA by the respondents (Table 4). About a quarter (23.5%) of the respondents revealed that they had ever suffered from schistosomiasis for which 88.8% were able to receive treatment. In general about 51.4% of the respondents had recently received schistosomiasis drugs where Chiradzulu got more (58.7%) followed by Zomba (53.2%) and Mangochi (42.6%). Majority of those who received schistosomiasis drugs got them within their communities (69.7%) followed by from health facilities (18.5%) and schools (11.8%). The drugs were mainly dispensed by HSA (49.7%), facility-based health workers (45.7%) and community-based volunteers (4.6%). Asked if the respondents had experienced any problem after taking the schistosomiasis drugs, 23.6% answered affirmatively. Majority reported feelings of drowsiness or dizziness (65.2%), followed by abdominal pains (13%) and nausea or vomiting (10.9%). Less than half of the respondents (41.2%) reported that schistosomiasis drugs are readily accessible by people in villages.
Table 4
Practices related to NTD and MDA of respondents by districts
Practice issues asked
|
Number of respondents who agreed (%)
|
Chiradzulu
|
Mangochi
|
Zomba
|
Totals
|
a) Have you ever suffered from schistosomiasis?
|
N=126
23 (18.2)
|
N=129
36 (27.9)
|
N=124
30 (24.2)
|
N=379
89 (23.5)
|
b) If yes, did you get drugs for treatment of schistosomiasis?
|
N=23
20 (87)
|
N=36
34 (94.4)
|
N=30
25 (83.3)
|
N=89
79 (88.8)
|
c) Have you recently received drugs for schistosomiasis?
|
N=126
74 (58.7)
|
N=129
55 (42.6)
|
N=124
66 (53.2)
|
N=379
195 (51.4)
|
d) Where did you get the drugs from?
• Community
• Health facility
• School
|
N=74
58 (78.4)
14 (18.9)
2 (2.7)
|
N=55
27 (49.1)
16 (29.1)
12 (21.8)
|
N=66
51 (77.3)
6 (4.1)
9 (13.6)
|
N=195
136 (69.7)
36 (18.5)
23 (11.8)
|
e) Who dispensed the schistosomiasis drugs to you?
• Facility health worker
• Community health worker
• Community health volunteer
|
N=74
33 (44.6)
36 (48.6)
5 (6.8)
|
N=55
26 (47.3)
27 (49.1)
2 (3.6)
|
N=66
30 (45.4)
34 (51.5)
2 (3)
|
N=195
89 (45.7)
97 (49.7)
9 (4.6)
|
f) Did you experience any problem(s) after taking schistosomiasis drugs?
|
N=74
11 (14.9)
|
N=55
17 (30.9)
|
N=66
18 (27.3)
|
N=195
46 (23.6)
|
g) If yes, what problem did you experience after taking schistosomiasis drugs?
• Drowsiness/dizziness
• Abdominal pain
• Nausea/vomiting
• Other
|
N=11
4 (36.3)
3 (27.3)
2 (18.2)
2 (18.2)
|
N=17
11 (64.6)
2 (11.8)
2 (11.8)
2 (11.8)
|
N=18
15 (83.2)
1 (5.6)
1 (5.6)
1 (5.6)
|
N=46
30 (65.2)
6 (13)
5 (10.9)
5 (10.9)
|
h) Are schistosomiasis drugs readily accessible in this village?
|
N=126
48 (38.1)
|
N=129
61 (47.3)
|
N=124
47 (37.9)
|
N=379
156 (41.2)
|
Assessment of MDA coverage
The study assessed MDA coverage targeting delivery of praziquantel and albendazole for schistosomiasis and STH respectively. MDA coverage data for these two NTD for the consecutive years of 2018 and 2019 were obtained from the three study districts. The MDA deliveries in 2018 and 2019 were done by HSA both in schools and communities in all the districts. A comparison of the coverage across the districts during the two years revealed that all the districts registered high coverage rates for praziquantel using community-based MDA (range: 73%-100%) and using school-based MDA (range: 75%-91%). For community MDA for praziquantel, Chiradzulu district scored highly above the national coverage rates in the two years. As for school-based MDA, Zomba and Chiradzulu districts were the highest scoring above the national rates both in 2018 and 2019 (Figure 4).
Similarly, high coverage trends for community (range: 73%-90%) and for schools (range: 75%-92%) were observed in albendazole MDA in all the districts for 2018 and 2019. In 2018 and 2019, Chiradzulu and Zomba respectively had highest albendazole coverage using the community MDA delivery approach. As for school coverage, Zomba and Chiradzulu were highest for 2018 and 2019, respectively (Figure 5).
A comparison between albendazole MDA coverage rates for 2018 and 2019 revealed that there were no differences among the districts with regards to praziquantel and albendazole distribution. No differences were also observed for both praziquantel and albendazole between community and school modes of MDA deliveries.
Health authorities and community perceptions on priority health issues and MDA
The study sought to understand the perceptions on priority health issues and MDA by health authorities as providers and community members as beneficiaries of health services in the three districts. On health issues, both groups agreed on Covid-19, malaria, schistosomiasis, human immunodeficiency virus (HIV) and diarrhoea as health issues requiring priority attention. Some differences between perceptions of health providers and beneficiaries regarding priority health interventions were observed. In addition, the health authorities mentioned acute respiratory infections (ARI), sexually transmitted infections (STI) and tuberculosis (TB) as priority issues. However, communities went further by mentioning inadequate health workers, natural disasters, unclean water, poor sanitation, and lack of amenities such as clinics, ambulances, bicycles, protective wear, drugs, mosquito nets and health education materials as deserving priority attention. These are some of the health determinants or risk factors for the mentioned diseases.
On the community-based delivery of MDA, health authorities perceived the approach as good because it brings treatment closer to people. These sentiments were also shared by community members who exalted the role they play during MDA delivery:
“This is a welcome idea to us communities since we are experiencing shortage of health workers in the area to deliver health services. If a community takes part in the delivery of health services the development of the area will likely to improve.” - FGD young male, Chiradzulu
While most community members applauded delivery of MDA, some expressed misgivings because the health system prioritizes children over adults although both schistosomiasis and STH are prevalent in both groups of people in endemic areas.
“[…] it is good but they give more to children ignoring the rest of us.” - FGD adult male, Mangochi
Availability of partners and resources for MDA
According to key informant interviews, it was learned that although MDA delivery is primarily a responsibility of the MOH through the NSCP, there are a number of partners who assist by providing various support towards implementation of MDA. The support is mostly in form of technical advisory, research, financial, personnel, logistics and supplies which are provided at various levels of health care system. At national level, the partnership for MDA comprise the two Government Ministries for Health and Education, Youth and Sports and various non-governmental organizations who play several roles. At district level there was a presence of partners such as GIZ through the Nutrition and Access to Primary Education (NAPE) project in Chiradzulu, Save the Children in Zomba and the Blantyre Institute of Community Outreach (BICO) in Mangochi who assist the districts by providing various resources such as transport and feeding pupils during implementation of MDA. However, in the study districts, the presence of partner organisations at facility and community levels was scarce (Table 5).
Table 5
Implementation partnerships, resources and roles in MDA
No.
|
Name of partner
|
Type
|
Resources and role played
|
1.
|
Ministry of Health
|
Government
|
Personnel, logistics and overall implementation
|
2.
|
Ministry of Education, Youth and Sports
|
Government
|
Personnel and logistics
|
3.
|
World Health Organization
|
UN agency
|
Technical advisory and supplies
|
4.
|
Schistosomiasis Control Initiative Foundation
|
NGO
|
Financial and logistics
|
5.
|
World Vision International
|
NGO
|
Financial and logistics
|
6.
|
The German Agency for International Cooperation (GIZ)
|
NGO
|
Financial and logistics
|
7.
|
Save the Children
|
NGO
|
Financial and logistics
|
8.
|
Centre for Health, Agriculture Development Research and Consulting (CHAD)
|
NGO
|
Financial, research and logistics
|
9.
|
Blantyre Institute of Community Outreach (BICO)
|
NGO
|
Financial, research and logistics
|
10.
|
Research for Health Environment and Development (RHED)
|
NGO
|
Research
|
Community participation in MDA delivery
Although MDA delivery is inherently a community and school based service, it is mostly the health professionals from national and district levels who are responsible for the planning and implementation. At the grassroots level, it is generally the HSA assisted by the teachers and community health volunteers who are involved in MDA delivery in schools and communities respectively. During interviews held with various health authorities and community members it was learned that community involvement and participation are restricted to community sensitization and actual drug distribution. Both health authorities and community members share positive perceptions on the use of community-based modes of delivering health services during MDA delivery. These community-based approaches enhance accessibility of the services and furthermore, allow community participation in solving their own health problem which will bring a sense of ownership and sustainability of MDA services.
“[…] community participation in health delivery is good, it reduces workload” - Medical Assistant, Chiradzulu
“Community participation makes the work of health workers easier by supporting in some cases like emergency conditions. It helps to improve the quality of health services like immunization and to promote good hygiene practices.” – A community leader, Zomba
Challenges associated with MDA delivery
The study identified challenges associated with MDA delivery from both the NSCP and involved study districts perspectives. According to the interview with the NSCP manager, the following were some of the challenges at the national level:
- Existence of research gaps leading to limited information on available current efforts regarding effective options for prevention and control of NTD.
- Non-existent vector control activities as one of the five integrated public health interventions recommended by WHO for prevention and control of NTD specifically through transmission control.
- Inadequate linkages with the national WASH programme also in the MOH despite existence of evidence that joint efforts between NTD and WASH can lead to simpler, more cost-effective and streamlined interventions.
- Inadequate support by private sector and other partners in prevention and control of NTD where it is mostly a few non-governmental organizations who are involved as implementation partners.
- Disproportionate level of knowledge of schistosomiasis and STH diseases which retards efforts towards implementation of effective MDA delivery for long term prevention, control and elimination of NTD.
Similarly, during interviews held with NTD coordinators and health workers the following were identified as challenges incurred during delivery of MDA in the study districts:
- Lack of partners to support MDA delivery at district and facility levels for prevention and control of NTD.
- Apart from health education, no other complementary interventions such as WASH and vector control are implemented during MDA campaigns.
- Scheduling of annual MDA campaigns by the NSCP mostly coincide with the rainy season when people are busy with agricultural activities.
- In some instances poor community engagement strategies have led to people not embracing MDA services.