It sounds simple – we ask entire communities to take medications periodically, provided free of charge, to protect themselves and their community from neglected tropical diseases (NTDs). However, the motivations and influences that drive community compliance in these mass drug administration (MDA) programs are diverse, complex, and constantly changing.
Many NTD programs emphasize directly observed therapy (DOT). However, in some locations, tablets are left with people, allowing them to take them at their own discretion. This practice has led to a “coverage – compliance gap”, that is, a difference between the proportion of the population receiving tablets and the proportion of the population swallowing tablets. There are many reasons for this shift from the gold standard of directly observed therapy, including fear of adverse events, desire to take the tablets after a meal, or overburdened distribution teams. Typically, social mobilization approaches and messages may not be specifically adapted to the local context, based on timely formative research, or tailored to ensure access to knowledge and treatment.
These challenges led to a collaboration between researchers from Pattimura University (Indonesia), the Bruyère Research Institute (Canada) and the Centers for Disease Control and Prevention (U.S.A) to develop tools to help close the coverage-compliance gap. Our aim was to create a simple, field-applicable tool to identify factors influencing MDA compliance and provide guidance on tailoring locally-relevant social mobilization messages. We used the Risks, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) behavioural framework to identify behavioural factors influencing MDA compliance for lymphatic filariasis (LF) in Ambon, Indonesia. RANAS promotes a systematic approach to assess the influence of five primary behavioural blocks on a specific behaviour. The results guide the design of effective social mobilization tools and messages that address specific factors affecting behaviours in a community.
Starting in August 2018, we used existing data and qualitative research to create and refine a RANAS behavioural model addressing MDA compliance. Next, we used the model to test how the behavioural factors differed between those who swallowed the drug in the last MDA and those who didn’t in two sites in Ambon - Waihaong and Air Salobar.
We found that important drivers of MDA compliance included community and family norms, with individuals more likely to comply if they perceived that many people in their family or community also complied, and self-regulation, with individuals more likely to comply if they perceived that MDA compliance was a matter of personal commitment or habit. In addition, non-compliant individuals reported limited confidence in understanding the instructions on taking the tablets, higher levels of difficulty in swallowing all tablets at once, and greater difficulty swallowing tablets consistently for several years.
We used these findings to develop new social mobilization messages for the 2018 MDA in Ambon. We applied the RANAS framework to identify key messages and, along with local staff, reviewed these messages to design data-driven messages on how to consume the MDA pills (abilities). We involved community stakeholders in the planning and promotion of key MDA messages (norms), and re-enforced commitment of various MDA staff members to improve MDA delivery and compliance (self-regulation).
The results of this body of work showed an improvement in MDA compliance among individuals in Air Salboar in 2018 (57.5%) compared to 2017 (35.0%). In contrast, in Waihaong, where the local uptake of new social mobilization strategies was more limited – we saw a more modest improvement in compliance, 41.2% in 2018 compared to 38.4% in 2017. These increases were achieved with a very limited social mobilization budget. Additional resources to expand social mobilization with the tailored messages may yield greater increases in MDA compliance.
The RANAS technique is a novel and promising strategy for empowering NTD programs to identify the predominant drivers of MDA compliance for their setting. It can be deployed and analysed without specialized knowledge. We look forward to sharing this tool with other LF program managers in a variety of LF-endemic settings. With wider use, this framework will be refined and perhaps extended for use with other NTD treatment programs.