Results are presented in three main categories (barriers, facilitators, and solutions) and themes with relevant verbatim quotes regarding equitable access and use of PC by taking four dimensions (availability, accessibility, acceptability, and effective coverage) into consideration. This study explored the perspectives and experiences of stakeholders who participated in the MDA process. In cases where views are specific to particular participants, these are noted within the manuscript.
The emerged barriers to equitable access and use of PC were lack of resources (financial, human, communication and vehicle), low community drug distributor’s motivation; inadequate information, mobilization and community engagement, lack of awareness, inappropriate scheduling of MDA, mobile nature of nomadic communities, security challenge, low school attendance, drugs distribution at central point, scatter pattern of households, misconception, misbelief, distrust of government, lack of PC program ownership; rumor and drugs’ side-effects; and weak planning, leadership, supportive system, and coordination (Table 3).
On the other hand, the emerged facilitators to equitable access and use of PC were the presence of community structure (health development army), provision of drugs free of charge, availability of community volunteers, the presence of community health workers, partners support to train drug distributor, the presence of the religious and cultural organization, and decentralization of government structure to smallest point (kebele) (Table 3)
Barriers to equitable access and use to PC
Challenges related to the availability of drugs, such as lack of leadership, resources and infrastructures (financial, communication, roads, and vehicle) could affect access and use of PC in the communities affected by NTDs, as revealed with the following quotes.
“…Although drugs were provided for STH and SCH to Hamer district from supplier, it was not distributed to SAC due to lack of leadership. Besides, at districts where drugs were available, CDDs were unable to get around communities due to lack of resource and infrastructure...” [Key informant, NTDs focal point]
“…Even CDDs move on foot to reach their communities. Moreover, lack of vehicles affects to conduct supervision...” [Key informant, NTDs program manager]
Shortage of syrups or eye ointments for trachoma
“…Sometimes lack of convenient drugs formulation for children, for example, zithromax syrups and eye ointments for trachoma affect the uptake of drugs…” [Key informant, primary health care unit-in charge]
“…Lack of CDDs and supporting professionals adversely affect the MDA process. For example, a single HEW visited our school to distribute drugs, and in some kebeles there are no HEWs…” [Key informant, school director]
“..High turnover of trained health professionals adversely affect the implementation of MDA…] [Key informant, NTD program manager]
Difference in partners support
“…Difference in partners support to train CDDs for different PC-NTDs affects the implementation of MDA through creating perception difference. For instance, partners for trachoma, oncho and LF paid much periderm compared to SCH-STH programs…” [Key informant, NTDs focal point]
Study participants stated that access to PC could affect the reach of PC in different ways, as illustrated below.
Inadequate information, mobilization, and community engagement
Most participants (≥ 75%) repeatedly mentioned that lack of access to information, mobilization, and community engagement as the main barriers to the equitable access of PC. These barriers include a lack of sufficient and relevant information about PC drugs, their purpose, and possible side-effects.
“…Usually community people did not receive adequate information and not well communicated on purpose, benefits, and side-effects of drugs ahead of the MDA campaign...” [Key informant, head of health centre]
“…Lack of community mobilization was main barrier for equitable access to use of PC...” [Key informant, NTDs focal points]
“…Low coverage of PC could be associated with students’ absenteeism associated with drugs side-effects on the deworming day, and school dropout of female students...” [Key informant, primary health care unit-in charge]
“…In our setting, parents did not get well engaged into PC program in an active manner; which resulted in lack of awareness and ownership of PC programme…” [CDD, HEW]
“…Even CDDs do not explain why they distribute drugs being distributed…” [Community member]
“…Some kebeles were left to be reached due to security challenges; which resulted in interruption of MDA due to ethnic clashes …” [Key informant, NTDs focal point]
Lack of treatment round schedule out of working hours affect communities to access PC.
“…Most importantly, the health system did not give adequate time to perform community mobilization about MDA; it was done just after orientation given to deworming team at zone level. The main reason was due to limited funding to conduct mobilization and community engagement adequately especially for SCH-STH programs…” [Key informant, NTD program director]
“…The MDA day should be longer than the usual days (3 days) to include some individual who are absent during the MDA day…” [Community member, SAC]
“…Since MDA campaign was done during specific periods, this resulted in overlapping with busy working hours of communities…” [Key informant, health center head]
“..The adequacy and duration of mobilization and community engagement was inadequate for creating awareness …” [Key informant, primary health care unit-in charge]
Mobile nature of community and scatter pattern of households
CDDs had to travel long-distance within their respective kebeles to reach out to all segments of the communities due to the mobile nature of the community and scatter pattern of households. Also, a significant number of participants stated that distributing drugs at a central point in a nomadic setting could not bring the required coverage in this setting.
. “…Due to the movement of people from place-to-place and scatter pattern of household’s settlement, CDDs should move long distance to reach out to their community. This situation is aggravated by lack of transport facilities in the area…” [Key informant, health center head]
“…Often we distribute drugs at a central point, this does work in the nomadic setting since people move from place-to-place…” [CDD, HEW]
Lack of infrastructure and resource
Access of PC to communities has been affected due to a lack of resources, as illustrated below.
“…Lack of infrastructure and resources (road and money) were barriers to equitable access to PC…” [CDD, HEW]
“…Even we paid out from our pocket for mobile costs even for the motor bicycle to get around the points of distribution …” [CDD, community member]
Significant number of participants mentioned that in areas where low school attendance exists, especially in nomadic and remote settings, with exclusive school-based deworming all children could not access to PC.
“…Children out of school did not access to albendazole but they took zithromax drug at health post level…” [CDD, Community member]
Study participants mentioned different barriers related to the acceptability of PC, as stated with the following utterances.
Living in a semi-urban area
“…Most students who refused drugs were individuals living in semi-urban areas. This could be due to people in these areas considered they knowledgeable about health issue…” [Key informant, NTDs focal point]
Rumor and drugs’ side-effects
A substantial number of participants revealed that rumor and fears of drugs’ side-effects are often associated with praziquantel was mentioned as a potential barrier for drug uptake.
“…Sometimes conflicts happened between drug distributors and recipients during MDA campaign due to side-effect of praziquantel. This often resulted in interruption of MDA as well as injury…” [CDD, HEW]
“…Even though teachers and health workers informed students to take food for MDA before one day, most of them would be absent at school on MDA campaign day due to fear of drug’s side-effects…” [SAC, Jinka town]
“…MDA was delayed and interrupted in four districts of South Omo zone related to rumor and fears of drugs’ side-effects…” [Key informant, NTDs focal point]
“…Some parents came to MDA sites to stop the process and fight with CDDs, especially when side-effects occurred in children...” [CDD, HEW]
“…Many students had feared to take drugs; some think drugs may harm or kill them...” [SAC, Jinka]
“….Most of my colleagues refused to take the drug due to fear of drugs’ side-effects...” [School-age children]
“..Many students did not take drugs if they observe drugs’ side-effect while their colleagues took drugs…” [Key informant, teacher]
“..Drug distributor didn’t start the MDA early in the morning; this aggravated the side-effect of drugs due to hungry...” [KII, school director]
“…Many individuals may take drugs without having food. Food should be available on the deworming day or MDA should be done in January and February…” [Key informant, women and child issues department head]
Participants mentioned that some individuals refuse to receive drugs.
“…Usually adolescent males and elders (≥ 60) individuals refuse to take drugs…” [CDD, HEW]
Different misconceptions were revealed by the study participants, as quoted below.
“…Few people think that the drugs are delivered for trial purpose, especially when side-effect of drugs appeared...” [CDD, community member]
“…People perceived as drugs should not be distributed to the community without a diagnosis of the diseases ─ community members thaink as taking drugs without the disease being diagnosed may get them sick …” [Key informant, NTDs program manager]
“…People said that drugs have an adverse effect on sexuality desire …” [Community drug distributor, community member]
“…Some people felt as they are healthy and disease may appear if they took PC drugs, and also they think drug may harm them...” [Key informant, NTDs manager]
“…Students think that drugs may not meet quality standard so that thought as it harm them...” [Community member, SAC]
Study participants stated potential misbeliefs that could affect the uptake of PC. Communities relate MDA with religious issue mainly with the number “666”.
“…Although a significant number of people realized the importance of drugs, substantial numbers of people relate MDA with religious aspects such as “666” ─ relating the number with evil purpose [illuminate]…” [Key informant, primary health care unit-in charge]
“…Many individuals mentioned religious issues as a reason for not taking drugs. They believe that God can save us, and no need to take drugs...” [CDD, community member]
“…There are some extremist religious leaders who promote people not to take drugs…” [CDD community member]
“…There are some private pharmacy owners who discourage people from not take drugs…” [CDD, HEW]
Distributing drugs without the consent of parents adversely affect the acceptance of PC.
“…Members of the community ask why drugs distributed without permission of parents…” [Drug distributor, teacher]
“…Parents usually command their children not to take drugs without their permission...” [Drug distributor, HEW]
Lack of community awareness potentially affect drug uptake.
“…The main problem-related acceptability of PC was lack of community awareness due to lack of financial funding to conduct community mobilization…” [Key informant, NTD program manager]
“…Some people thought that why drugs were given without diagnosis of disease. Many people even did not know the purpose of drugs. Besides, lack of media coverage on NTDs and MDA also affected the implementation of MDA…” [Key informant, kebele leader]
“…Misunderstanding due to lack of community mobilization and awareness towards side-effects of drugs was the possible main reason for the interruption of drugs…” [CDD, HEW]
“…My child was a victim of drugs’ side-effects ─ my neighbor informed me that your child may die due to side-effects of drugs…” [CDD, community member]
“…For me, I noticed the advantage and disadvantage of PC ─ when I see side-effects, I feel as bad, and if not, I feel as good…” [SAC]
“…Students spilled out drugs after given by the CDDs. I heard that one child passed on due to drugs’ side-effects…” [Community member]
“… a substantial number of parents thought they can treat their children at a health facility when they get sick, no need for mass drug administration. And children and parents did know the about purpose, side-effect of drugs and benefit of drugs…” [Key informant, primary school head]
“…I took drugs, and in fact, I like to take drugs, but some individuals oppose to take the drugs due to lack of awareness among parents and children on the purpose of the MDA…” [Community member]
“…The CDD did not educate us about the benefit of drugs…” [SAC]
“….Many of my colleagues doesn’t know the benefit of PC, but I’m still taking the drugs...” [SAC]
“…Sometimes teacher forced students to swallow drugs instead of providing health education regarding the purpose of swallowing drugs; this resulted in student to escape from the school…” [SAC]
“…Even teachers do not get well informed about PC ─ do not participate in MDA training…” [School director]
Gender and cultural issues
Focus group participants pointed out that gender and cultural norms that could affect acceptance and use of PC.
“..Some women need permission from their husband to take drugs due to cultural reason...” [Community member]
“…In nomadic and remote settings, there is a cultural norm that could make children keep cattle in a nomadic setting so that SAC does not attend school when a treatment round scheduled...” [Key informant, NTDs focal point]
“…Usually males CDDs are selected in some districts due to husbands’ influences…” [Key informant, health centre head]
Distrust of government and health services could potentially affect equitable use of PC.
“…People thought as drug drugs are provided for political purpose, and they did not take drugs due to distrust of the health system and government…” [Community member, SAC]
Low attention is given to NTDs and PC
“…PC intervention has been implemented for many years, however people are saying other interventions, such as WASH and vector control should be implemented. For example, 50% of the community did not have clean water; many people are taking water from river…” [Community member]
Lack of ownership of the PC program
“…Since NTDs programs depend on donors, lack of ownership of PC program among implementers and community members affect the implementation of MDA…” [NTDs focal point]
“…Some CDDs consider MDA as a source of income…” [Key informant, NTDs focal point]
Effective coverage of drugs adversely affected by different factors, as revealed below.
Planning, coordination, and supportive system
Study participants mentioned that access and uptake of PCT were affected by planning, coordination and supportive system.
“…Very tight time has been given to conduct MDA to minimize periderm cost. This resulted in community members and teachers not to be well informed about the MDA …” [Key informant, primary health care unit-in charge]
“…Lack of coordination remained as a challenge for the community to be not informed due to inadequate times to educate the community...” [Drug distributor, HEW]
“…I would say that the main problem exists within the health system ─ the health system did not give adequate time to aware the community…” [CDD, HEW]
“..The vertical nature of MDA programs adversely affects our planning to conduct it timely. It resulted in an overlapping of different programs…” [Key informant, primary health care unit-in charge]
“…The per-diem we have been paid was inadequate ─ we are working in hardship setting, even we did not have money to move from pace-to-place. We only received a small per-diem during training. So, this does not motivate us to reach all segments of our community…” [CDD, community member]
“…CDDs leave out from the MDA role mainly due to lack of per-diem, which resulted in CDDs not get motivated…” [Key informant, health center head]
“…In the school-based deworming, teachers were not collaborative as they seek incentive…” [Drug distributor, HEW]
“…We are not motivated by leadership of the health system; the per-diem payment was unfair, not paid equally for equal work. We worked hard but those who were not on work more paid than us...” [CDDs, HEW]
“…CDDs usually leave the program due to lack of incentive…” [Key informant, NTDs focal point].