Evaluation of implementation determinants shaping the appropriateness of a trachoma mass drug administration program in Livingstone district, Zambia

Abstract

Mass Drug Administration (MDA) is the most effective way of interrupting disease transmission in trachoma endemic countries including Zambia. Active community participation is necessary coverage goals and global trachoma elimination targets are to be met. This study was a retrospective assessment of the appropriateness of a MDA program conducted in Livingstone, Zambia and the multilevel factors affecting it. To better understand the suitability of the program to the local context and gauge the adequacy of the resources set aside for the implementation process. This was a concurrent mixed methods study. Key informant interviews with district officials were conducted (n=4). Two cross-sectional surveys using structured questionnaires were done amongst community drug distributors (n=38) and community members (n=171). Interview guides and structured questionnaires were adopted from the 14 domain version of the Theoretical Domains Framework (TDF), Bowen et al, Orsmond and Cohn’s guide to conducting feasibility studies. Quantitative data was analyzed to obtain means and proportions and general data trends with further analysis using regression equations. Whereas qualitative data was analyzed using thematic analysis. Acceptability of the program at the community level was low due to exposure to similar programs MDA, prevailing political conditions and differing religious beliefs. There was an increased demand for the MDA at the organisational level to reduce the active infection rates in the district. Participation over the two year period was low; 32% in Nakatindi and 33% in Simoonga. Logistical issues, human wildlife conflict and inaccessibility of some parts of the districts affected the reach of the program. Eleven domains of the TDF were found to be determinants of feasibility of the MDA. Four were thought to be the most dominant: Knowledge, Environmental Context and Resources, Social Influences and Belief about consequences. The creation of appropriate implementation conditions at higher levels of the health system affects how feasible and acceptable programs are at lower levels as shown by low participation rates. The TDF provided a useful framework for exploring how community and environmentally driven determinants could be used to explain the poor feasibility being observed. Keywords : Implementation, Feasibility, Mass Drug Administration, Theoretical Domains Framework, Trachoma