Understanding men's participation in mass drug administration: evidence from a cluster-randomised trial of community-based deworming in Malawi

1.BackgroundMass drug administration (MDA) is a key strategy in the response to neglected tropical diseases (NTDs). Operational research indicates that treatment of adult men during MDA is frequently lower than that of adult women, but this remains poorly understood and obscured by a lack of routine sex-disaggregated reporting. Such differences may represent a potential threat to NTD strategies that require high MDA treatment coverage to achieve control or elimination objectives. MethodsUsing detailed treatment data from a cluster-randomised trial of community-based MDA for soil-transmitted helminths (STH) conducted in southern Malawi, this secondary analysis describes sex-specific trends in coverage over six consecutive rounds of MDA delivered biannually at household level. We report community-level coverage by both a per-protocol (trial) definition, and a pragmatic operational definition to simulate routine implementation. We used multilevel mixed-effects logistic regression to investigate individual, household and programme factors associated with non-treatment by both coverage definitions amongst adult men. ResultsAdult mens participation in MDA was substantially and consistently lower than adult women. Median difference (women minus men) in community-level protocol coverage was 15.7% (IQR 10.4-21.3%), increasing to 23.2% (IQR 17.5-30.2%) by operational coverage. Factors associated with increased odds of non-treatment were similar by coverage definition and included younger age, lower levels of education, and previous reported absenteeism; and were reduced by modifiable programmatic factors such as the day or time of household visit. ConclusionsThis analysis highlights the persistence of inequity for adult men in participation in MDA, despite a well-resourced context that achieved high coverage of adult women. More nuanced MDA strategies that respond to the needs of adult men will be required to achieve equitable coverage, accompanied by robust monitoring and evaluation to evaluate their effectiveness at reaching this under-served population. What is already known on this topicO_LIAchieving high coverage of mass drug administration (MDA) across population groups is key to targets for control and elimination of many neglected tropical diseases (NTDs) and achieving global health equity. C_LIO_LIMens lower participation in MDA has been recognised by routine programmes but has received limited research and policy attention, compounded by a lack of sex-disaggregated monitoring and evaluation. C_LI What this study addsO_LIWe show that high overall levels of MDA coverage masked substantial inequity, with adult mens coverage in MDA substantially and consistently lower than women. C_LIO_LIWe identify specific factors associated with non-treatment of adult men - including modifiable programmatic characteristics - that could be targeted by programmes seeking to address this disparity. C_LI How this study might affect research, practice or policyO_LIThese findings underscore the need for MDA strategies to comprehensively assess and address coverage gaps among adult men, and should encourage policymakers to ensure that the design and implementation of community-based NTD strategies reflect the needs of both men and women. C_LI