This study delves into the effectiveness of Mass Drug Administration (MDA) programs for onchocerciasis in Benin, utilizing rapid ethnography to compare intervention and control communes. The research highlights critical barriers and facilitators influencing MDA coverage, offering valuable insights for program optimization in Benin and similar contexts.
Rapid ethnography, a qualitative research approach, was employed to gather in-depth understanding of community perceptions and experiences related to onchocerciasis MDA programs. A total of 1595 data collection activities were conducted across Bembèrèkè (intervention commune) and Kandi (control commune) in Benin (Fig. 3). Short surveys revealed that only 44% in the intervention and 73% in the control commune reported being offered MDA previously. Furthermore, of those offered, only 34% and 30% respectively chose to ingest the medication. These initial findings pointed to significant challenges in both MDA delivery and community uptake, which were further explored through detailed ethnographic research.
Fig. 3
Fig. 3: Distribution of data collection activities across intervention (Bembèrèkè) and control (Kandi) communes in Benin, highlighting the scope of the rapid ethnography study.
Key Themes Emerging from Rapid Ethnography in Benin
The rapid ethnography identified nine overarching themes representing key barriers to achieving high coverage in onchocerciasis MDA programs in Benin. These themes were consistently observed across both the intervention and control communes, indicating systemic challenges within the program implementation.
1. Onchocerciasis Awareness is Present, but Misinformation Persists
While participants in both Bembèrèkè and Kandi demonstrated general awareness of onchocerciasis and its treatment, misconceptions about the disease’s causes were prevalent. Beliefs attributing onchocerciasis to factors like hunger, poor diet, lack of hygiene, aging, or even witchcraft were common. Notably, there was no significant difference in the level of community knowledge between the two communes in Benin. Despite these misunderstandings, a lack of basic awareness was not identified as a primary barrier to MDA participation.
“I am willing to take the drug because I don’t want to go blind. However, no distributor has ever come to my home” – Intervention, Case interview
2. Positive Perception of MDA Program Effectiveness
A strong consensus emerged from respondents in both communes in Benin: MDA programs are widely perceived as effective in curbing the spread of onchocerciasis and preventing blindness. Participants frequently cited MDA as the primary reason for the observed decline in eye conditions over the years, fostering considerable community trust and positive sentiment towards the program. The accessibility (free of charge) and perceived effectiveness of MDA drugs were the most frequently cited reasons for acceptance. Furthermore, MDA was often associated with additional perceived health benefits, including enhanced sexual vitality, scabies control, insect bite prevention, and increased longevity. This positive perception contributes to a generally receptive community environment for MDA programs in Benin.
“I used to have problems with my eyes but since I started drinking the medication, all these problems have disappeared, the medication has been very effective” – Intervention, Case interview
3. Side Effects of MDA Drugs Deter Some Individuals
The perceived side effects of MDA drugs emerged as a significant deterrent to treatment acceptance in both communes of Benin. Reported side effects included skin reactions (allergies, itching) and vomiting. Some individuals interpreted these side effects as the drugs “awakening” dormant illnesses within the body, leading to concerns about potential harm. Conversely, others viewed side effects as a positive indication of the drug’s efficacy against onchocerciasis. The interpretation of side effects significantly influenced an individual’s and household’s willingness to participate in MDA. Community Drug Distributors (CDDs) acknowledged their responsibility to support individuals experiencing side effects but often felt inadequately prepared to do so. These findings underscore the need for improved community education regarding potential adverse events and enhanced support for CDDs in addressing drug safety concerns in Benin.
“When some take these drugs, they become weak, vomit and sometimes go to the hospital for treatment. I think this is normal because what comes out is the diseases in their bodies” – Intervention, Focus group
4. Trust in CDDs and Perceived Professionalism Gaps
While many participants reported accepting MDA drugs when offered, compromised trust in CDDs and perceptions of unprofessional conduct presented barriers. Factors contributing to distrust included CDDs not being ethnically representative of the community, language barriers, general mistrust of government initiatives, lack of confidence in the distributors themselves, and insufficient communication regarding MDA. Specific behaviors observed, such as CDDs smoking, speaking disrespectfully, or acting inappropriately during campaigns, further eroded trust. Respondents also noted instances of CDDs not dedicating sufficient time to households or visiting during working hours when residents were away. Alarmingly, some CDDs were reported to have refused to take the MDA drugs themselves due to fear of side effects, contributing to the perception of a lack of professionalism among CDDs in Benin.
“Refusal of the drugs is sometimes linked to the behavior of distributing agents who are often in a hurry and do not explain to beneficiaries why they are distributing the drugs” – Kandi, Focus group
“We encounter a few cases of refusal and this is because communication is not getting through. [CDDs] do not explain the consequences of this disease and the benefits of this drug.” – Kandi, KII
5. Socio-cultural Beliefs Impact MDA Participation
Community distributors encountered various socio-cultural challenges impacting MDA program participation in Benin. These included myths surrounding the origins of the drugs (e.g., linked to nefarious intentions of foreign entities), cultural norms related to height measurement for drug dosing, and cultural sensitivities around administering drugs across different age groups. For example, the practice of measuring height, necessary for ivermectin dosage, was culturally sensitive as measuring sticks are associated with measuring corpses for funeral preparations, especially when a younger person measures an elder. These insights highlight the importance of incorporating cultural sensitivity training for CDDs to enhance program acceptance within Benin communities.
“A lady friend came to my office one day and told me that she received a product but didn’t take it because the [CDDs] didn’t say why they were giving her. For them white people are looking for ways to destroy us” – Intervention, Case interview
6. Inadequate Pre-MDA Communication Reach
Pre-MDA communication in both communes of Benin primarily relies on “town criers” to inform communities about upcoming treatment campaigns. However, participants reported that these messages often fail to reach remote areas, leaving residents feeling excluded. Furthermore, the typical mobilization period of 1-2 days prior to distribution was deemed insufficient advance notice by many. Participants suggested increased engagement with community leaders, including ethnic and religious figures, to enhance campaign publicity. These findings emphasize the need to diversify and expand pre-MDA communication strategies to ensure comprehensive reach, particularly in peri-urban and rural areas of Benin.
“I have never heard of the disease. My wife is always at home, has never been visited by a distributor” – Intervention, Mini interview
“Last year distributors were not able to cover all the hamlets because the town crier didn’t do his job well. He passed on the information just in center. He did not to hamlets” – Intervention, Focus group
7. Gaps in Drug Distribution Coverage
Participants across various neighborhoods in both Bembèrèkè and Kandi reported instances of not being offered treatment in past MDA rounds. In the control commune, nomadic Hausa populations were often missed. Similarly, peri-urban areas experienced sporadic treatment coverage. Overall, access to MDA appeared somewhat random based on residence, suggesting the absence of a systematic distribution plan to ensure all households in Benin are reached.
“I am not satisfied because distributors did not come to my house even though it was a door-to-door” – Intervention, Case interview
“Here in [neighborhood], we don’t have any information on MDA. Inhabitants of the village do not benefit from MDA” – Control, mini interview
CDDs corroborated these reports, citing challenges with door-to-door distribution and the likelihood of missing households due to a lack of structured plans. Drug stockouts were also frequently reported by both community members and CDDs in both communes. Local leaders indicated that drug stock estimations were based on outdated demographic data, potentially excluding neighborhoods not reached in previous campaigns, creating a cycle of inequitable access within Benin.
“As a supervisor, we don’t do anything to monitor distribution. If we are told that the drugs have run out of stock, we just accept” – Control, KII
8. Perceived Lack of Legitimacy in MDA Delivery
While MDA drug administration should occur under CDD supervision, instances of medication being given to individuals for distribution to others were reported, complicating coverage tracking. In some areas, local political delegates collaborated with CDDs, but in others, engagement with religious, political, and administrative leaders was minimal. A strong consensus emerged regarding the need for greater involvement of social officials to enhance the perceived legitimacy and community endorsement of MDA programs in Benin.
“Distributing agents do the distribution in one day at the most. The rest of the time they sit under sheds or somewhere in the village and when someone comes by, they [call out] and give them the tablets” – Kandi, Mini interview
9. CDD Burnout and Workforce Challenges
CDDs reported issues of non-payment for previous MDA campaigns, leading to demotivation and burnout. Many felt the provided incentives were inadequate considering the time commitment required. Outdated training and a lack of necessary skills development were also reported by CDDs and supervisors. Insufficient supervisory support during distribution further compounded these challenges. Both community members and CDDs perceived that these training and supervision gaps negatively impacted community trust in MDA programs in Benin.
“Distributors do not go to every home…I wonder if it is because the money they are given is not enough or if it is just unwillingness to serve the village” – Control, Case interview
Time Investment in Rapid Ethnography
The rapid ethnography in Bembèrèkè (intervention) involved 186 hours of data collection, averaging 17 activities per team per day over 14 days. In Kandi (control), 203 hours were spent, with an average of 21 activities per team per day (Fig. 4). Transect walks constituted approximately half of the data collection time in both communes (50% and 45% respectively). While time-intensive, transect walks are crucial for ethnographic data collection, as they facilitate various data collection activities like mini-interviews.
Fig. 4
Fig. 4: Comparison of time allocated for rapid ethnographic data collection in Bembèrèkè and Kandi communes, highlighting the resource investment in this qualitative approach.
Strategy Development and Implementation in Benin
Based on the rapid ethnography findings, five key implementation strategies were developed and implemented in the intervention commune of Bembèrèkè. These strategies, formulated during a strategy design meeting, aimed to address the identified barriers:
- Redesigning CDD job aids: To address concerns about drug side effects and socio-cultural beliefs.
- Dynamic CDD training: To enhance CDD professionalism and address trust issues.
- Improved CDD supervision: To strengthen trust, improve coverage, and mitigate CDD burnout.
- Tailored community sensitization: To improve pre-MDA communication and address socio-cultural beliefs.
- Local champion engagement: To increase community legitimacy through engagement with local leaders.
These strategies, detailed in Table 2, were specifically designed to target identified barriers, actors, and actions to improve MDA program effectiveness in Benin.
Table 2 Overview of implementation strategies deployed in the intervention commune
The dynamic CDD training strategy was evaluated using pre- and post-training tests. Prior to the revised training, 72% of CDDs failed a knowledge test on onchocerciasis, ivermectin, and adverse event management. Following the dynamic training, the failure rate decreased to 39%, demonstrating a 32% improvement in CDD knowledge.
Impact on Treatment Coverage in Benin
Ministry of Health registers indicated an 87% treatment coverage in both Bembèrèkè and Kandi during the 2020 MDA, representing a 1% coverage increase in the intervention commune. A coverage survey was conducted to validate these figures and evaluate the intervention’s impact. The survey, encompassing 2,437 households and 14,575 individuals, revealed that 83% of households in the intervention commune were visited by CDDs, compared to only 59% in the control commune (Table 3). Furthermore, 82% of individuals in the intervention commune had pre-campaign MDA awareness, compared to 54% in the control commune. The primary reason for not receiving ivermectin was the lack of CDD visits, particularly pronounced in the control commune (67% vs. 38% in intervention). Radio emerged as the most effective awareness channel in the intervention commune (70%), while word-of-mouth was dominant in the control commune (46%). Treatment acceptance among those offered was equally high in both communes (96%). Directly observed swallowing (DOTS) rates were also higher in the intervention commune (84% vs. 74%).
Fig. 5
Fig. 5: Comparative analysis of MDA coverage data sources and the impact of the implementation strategy package on coverage rates in Benin.
Table 3 Coverage survey results
The coverage survey indicated similar ivermectin uptake rates in 2019 (pre-intervention) between intervention and control communes (approximately 51% overall, and 58% vs 55% among eligible individuals). However, in 2020 (post-intervention), coverage among eligible individuals (over age 5) significantly increased in the intervention commune (77%) compared to the control commune (55%). Difference-in-differences (DID) analysis confirmed a significant 13.4% (95% CI: 11.0–15.9%) increase in coverage attributable to the intervention (p < 0.001) (Fig. 5).
Feasibility of Rapid Ethnography in Benin’s Health Programs
A project dissemination meeting with 17 participants assessed the feasibility of integrating rapid ethnography into routine Ministry of Health activities in Benin. Participants rated the acceptability, appropriateness, and feasibility of this approach, along with their intentions to incorporate findings into future programs (Fig. 6). Acceptability received the highest mean score (4.2), indicating strong appeal for rapid ethnography in enhancing MDA coverage in Benin. However, feasibility and intention to incorporate measures received lower scores (≤ 3.5), suggesting areas needing further consideration for successful integration.
Fig. 6
Fig. 6: Assessment of acceptability, appropriateness, and feasibility of rapid ethnography implementation within Benin’s Ministry of Health activities, as rated by project dissemination meeting participants.
Conclusion
This rapid ethnography study in Benin provides valuable comparative insights into the barriers and facilitators of onchocerciasis MDA programs. The findings demonstrate the feasibility and effectiveness of using rapid ethnography to inform targeted intervention strategies, leading to improved treatment coverage. While highly acceptable, realizing the full potential of rapid ethnography within routine health programs in Benin requires addressing perceived feasibility challenges and strengthening intentions for programmatic integration. The study underscores the importance of context-specific, qualitative research methodologies in optimizing public health interventions and achieving better health outcomes in Benin and similar settings.
