Table 2 Solutions to improve MDA

Communication between CDDs and the community

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

• CDDs can be given an extra day for distribution or sensitization in order to provide adequate health education for communities.

• CDD trainings can include modules that emphasize the importance of and justification for providing health education to households before administering 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.

• Prior to the implementation of MDA, community leaders should be provided with a roster that lists all CDDs assigned to their community, and ensure that CDDs are known to and accepted by the community. This can be done during standing community meetings.

• CDD trainings can include modules on expectations of community members for good behavior and image, and how to achieve that.

Community resistance toward CDDs

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

• Prior to MDA implementation, community leaders can hold a meeting or forum introducing CDDs and explaining their roles. During this meeting leaders can emphasize the importance of accepting MDA and medicines

• Increase CDDs’ knowledge of LF through adequate training before MDA

• Provide CDDs with the job resources, aids and time they need to adequately conduct social mobilization activities before MDA

• Community leaders and key popular figures can show community members that they have ingested medicines.

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.

• Government leaders at all levels can join community meetings and record videos for various social media platforms to promote MDA and the importance of ingesting medicines.

• Government leaders can collaborate with celebrities to use digital media to build trust and assure the public that MDA and medicines are safe and important.

CDD motivation

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

• Communities can pool resources like water and food, and provide it to CDDs during MDA.

• During meetings with community members, leaders can encourage them to embrace CDDs, show them appreciation and help them where they can

• The NTD program can ensure that program staff and supervisors are always within walking distance of CDDs to reduce out of pocket expenses on airtime and transport.

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.

• The NTD program can offer those in higher income groups the option of obtaining their medicines from health centers or their own doctors.

Timing of MDA

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

• The NTD program can explore alternative dates for MDA, and ensure that CDDs have adequate time and resources to conduct mop-up.

• The NTD program can explore distribution of drugs in workplaces, health centers and other fixed posts.

Community accountability during MDA

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

• Community leaders can serve as informal supervisors during MDA by conducting random checks on households and CDDs.

CDD bias

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

• CDD trainings can include modules that emphasize the negative impact and consequences of overlooking certain individuals.

• Supervisors can closely monitor the progress of CDDs during MDA, and ensure that daily targets are being met. Supervisor trainings should include modules of effective and supportive supervision of CDDs to reduce bias.

Community understanding of CDD job responsibilities

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

• CDD trainings should emphasize the importance of directly observed treatment.

• Community meetings held prior to MDA should include discussions around the responsibilities of CDDs.