Table 1 Perceptions of CDDs

Communication between CDDs and the community

CDDs hurriedly distribute drugs, resulting in little to no health education.

Adequate health education enables community members to understand LF as a disease with devastating outcomes. Once this is understood from CDDs, they are more likely to participate in MDA and ingest medicines.

Qualities of good CDDs

Trust is established between CDDs and communities when CDDs are nominated and selected by their community.

CDDs that are perceived to behave well and have a good image are desirable.

When trust is established, CDD interactions with community members are positive. As a result, community members are able to trust information from CDDs about the importance of MDA and ingesting medicines. Conversely, when CDDs are not trusted, community members are hostile and refuse medicines. CDDs must be known and selected by their community in order to achieve their goals during MDA.

CDDs that are not only selected by community members, but are also well mannered and respectful are embraced and trusted.

Community resistance toward CDDs

Community members’ distrust of CDDs often led to sharp resistance and negative treatment of CDDs.

Drug misconceptions stemming from cultural beliefs, political propaganda, and lack of awareness fuel resistance to MDA and CDDs in the community.

Community distrust of the federal government

Community members perceive that the government is motivated by a political agenda, and that MDA is the platform used to advance their harmful agenda.

Community members perceive MDA to be a way for the government of Kenya to enforce family planning. This misinformation results in a lack of participation in MDA.

CDD motivation

Community members perceive that CDDs are motivated when they feel appreciated by them.

When communities are receptive to the health information, look for CDDs to obtain the drugs, encourage their neighbors to accept the drugs, and provide water, airtime and food, CDDs often feel appreciated. Monetary incentives also serve as motivation for some CDDs to perform well, especially those who are unemployed. Nonetheless, the primary motivator for volunteering among CDDs is their commitment to serve the community.

Perception of MDA as a distribution strategy

Community members that perceive that drugs should be distributed in private facilities or hospitals often don’t participate in MDA and belong the higher income groups. On the other hand, those in the lower income groups embrace MDA.

CDDs find it challenging to reach those in higher income levels because they perceive that access to medicines should be from private doctors and hospitals in the event that they do fall sick. This perception may suggest that LF is a disease associated with poverty and that CDDs are not qualified to offer them medicines.

Timing of MDA

The period during which CDDs distributed medicines has an impact on coverage.

Some community members are frequently absent during MDA because of work, travel or school.

Community accountability during MDA

Community elders often help achieve treatment coverage through indirect supervision of community members and CDDs during MDA.

Community leaders serve as informal supervisors by addressing troublesome community members and by encouraging them to accept and ingest medicines.

CDD bias

CDDs purposively decide which individuals and groups would receive medicines, which impacts treatment coverage.

Community members believe that CDDs should offer drugs to everyone and not those they like.

Community understanding of CDD job responsibilities

CDDs are expected to engage in a variety of activities before, during and after MDA.

Directly observed treatment, health education prior to MDA, dosage assessment, and mop-up are all responsibilities of CDDs. Community members report forgetting to take the drugs when CDDs left the drugs, without implementing directly observed treatment.