Social Factors Affecting Community Participation in Mass Drug Administration Programs to Eliminate Lymphatic Filariasis in Zimbabwe. A Case Study of Muzarabani District, Zimbabwe.

Social Factors Affecting Community Participation in Mass Drug Administration Programs to Eliminate Lymphatic Filariasis in Zimbabwe. A Case Study of Muzarabani District, Zimbabwe.

Vincent Tafara Rusike^1*, Rejoice Murisi², Craig Kanaveti³, Maxwell Tawanda Mutukwa⁴

^1,4Department of Development Studies, Midlands State University, Zimbabwe.

²Department of Community and Social Development, University of Zimbabwe.

³Department of Psychology, Midlands State University, Zimbabwe.

^*Corresponding author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.905000259

Received: 07 May 2025; Accepted: 13 May 2025; Published: 10 June 2025

ABSTRACT

Neglected Tropical Diseases (NTDs) continue to be common in Sub-Saharan Africa, with the region contributing to about 40% of the global burden. In Zimbabwe, Lymphatic Filariasis (LF) is one of the most common NTDs and the government and its health sector partners has committed to eliminate the disease and other NTDs. However, the Zimbabwe NTDs Master Plan (2023-2027) reports that transmission of LF in Zimbabwe is challenging to stop because elimination programs often fail to reach full community coverage. These elimination programs are implemented through Mass Drug Administrations (MDAs) where preventive chemotherapy is performed through administration of Albendazole and Ivermectin. The failure of MDA programs to reach everyone in affected areas is partly because of community members who deliberately not participate in the program. Therefore, this study aimed to investigate the social factors affecting community participation in MDA programs to eliminate LF in Zimbabwe. The study used a qualitative case study approach and was conducted in Muzarabani district, one of the areas most affected by LF. Using non-probability convenience sampling, fifteen participants were selected and engaged using semi-structured interviews and five key health personnel working in the district were purposively selected as key informants relevant for the study. Document analysis also complemented the study and the triangulated with interviews to ensure findings credibility. Thematic analysis was used to analyze data and findings were systematically presented in form of most emerging themes. The study found that community participation in MDA programs is affected by several social factors including myths surrounding drugs and vaccine, lack of comprehensive health information and education, history with previous MDA and other vaccination programs and religious beliefs. The study concluded that most of the identified factors stemmed significant gaps in comprehensive health information and education. It recommends that awareness raising, capacity building in health literacy and community engagement stand as the miracle medicine to counter the social factors imbedded in historical colonial prejudice, cultural norms and values presided by socio-religious contexts.

Keywords; Social Factors, Community Participation, Health Information

INTRODUCTION AND BACKGROUND

Neglected Tropical Diseases (NTDs) remain widespread in Sub-Saharan Africa (SSA) contributing the most towards the global burden with approximately 40%. According to Niles et al., (2021) and the ZIMVACC (2022), at least 600 million people still require preventive chemotherapy. Over the years, the World Health Organization (WHO) along with its partner organizations has coordinated efforts to eliminate NTDs as part of the efforts towards meeting the Sustainable Development Goal 3 Target 3.8, which focuses on elimination of infectious diseases by 2030. To ensure preventive chemotherapy affordable for everyone, it is usually conducted through administration during nationwide mass drug administration were in most cases, these drugs are funded.

Significant progress has been recorded in SSA towards the elimination of NTDs, with 19 countries in the WHO Africa region reportedly having eliminated at least one of the eleven NTDs (WHO, 2022) up from just six countries in 2010. This significant progress has rippled far-reaching positive impact with notable improvements towards the reduction of morbidity and mortality rates. A considerable number of countries in Africa such as Gambia, Togo, Malawi, Guinea and Benin have recorded significant progress. This reflects the commitment that governments and partner organizations have put into the work, but such successes need to be replicated across other SSA countries in realization of SDG Target 3.8 to be a lived reality.

In Zimbabwe, Lymphatic Filariasis (LF) has been a key target of donor-funded programs. Caused by a several parasites   LF is a second leading cause of disability around the globe (Krentel et al., 2013). In Zimbabwe, where most of the population resides in rural areas, the major cause of LF is the existence of anopheles species. According to the Zimbabwe National Health Strategy 2016-2020, the target was to eliminate LF by 50% in 2020 (MoHCC 2016): However, progress towards the goal was hindered by a multiplicity of factors, including Covid-19 pandemic that affected the health landscape and the country’s economy where the government was already cash strapped.

MoHCC’s (2022) annual report, highlighted that LF remains a disease of public health significance in Zimbabwe, and it will take multi-partner efforts to eliminate it. Data from the Zimbabwe Country NTD Masterplan 2023-2027 reflects that LF is a high priority and the progress towards its elimination has fallen short of expectations. Organizations committed to public health such as WHO, Higherlife Foundation, World Vision, Global Fund and the End Fund have become key partners to the MOHCC as they continue to fund efforts of MDAs to eliminate LF and other NTDs. In 2024, the prevalence of LF was very high in Mashonaland Central, Mashonaland West, Matebeleland North, Masvingo and Midlands provinces in Zimbabwe and these have become a target of MDAs interventions as efforts continue to intensify to eliminate the disease. The country is following the footsteps of Gambia, Mali and Malawi who have at least been able to eliminate one of the many NTDs faced.

However, despite the far-reaching consequences of infection by NTDs, uptake of drugs during MDAs has continued to face resistance in communities, not only in Zimbabwe but also in SSA region. Community participation in MDAs has been shaped by a plethora of factors, which can largely be classified as socio-economic (Sangare et al., 2024). In their study in Mali, Sangare et al., (2024) concluded that misconceptions, religious beliefs and low levels of education were key factors influencing community participation in MDA programs. John et al., (2021) reported similar findings in Tanzania noting that poor attitude, lack of knowledge and inappropriate practices had a negative impact on community participation in MDA programs. Another study in Tanzania by Ngunyali et al., (2023) concluded that communities had average to low knowledge about LF and this had a strong impact on their decision to participate in LF-MDAs. They recommended that community sensitization was a necessary tool if maximum participation was to be expected from the communities. According to desk research conducted by Silumbwe et al., (2017) there were a multiplicity of factors affecting the implementation of MDA in SSA. They concluded that community participation is largely hindered by lack of knowledge, religious beliefs which then shaped attitudes, perceptions, and other factors including families not having been reached by outreach teams that were responsible for the administration of the drugs.

In Zimbabwe, MDAs have become increasingly common because the government has committed to intensify efforts to eliminate NTDs, with specific provinces hard hit by LF. Partner organizations have shown unwavering support to the government by providing resources to ensure that the six rounds of MDA as recommended by WHO are implemented. LF continues to be a leading cause of limb elephantiasis in rural Zimbabwe, despite all this knowledge and efforts. Low-turnout of community members in these programs remains one of the persistent issues raising concerns among health professionals, development practitioners and the academia. Hence, understanding the social factors influencing community participation in MDA programs in Zimbabwe forms the core premise for this study.

Overview Of Lymphatic Filariasis (Lf) As A Public Health Problem

Lymphatic filariasis (LF) is a debilitating parasitic disease that impairs the lymphatic system, potentially leading to abnormal enlargement of body parts, chronic pain, severe disability, and profound social stigma (WHO 2013). Globally, LF continues to pose a significant public health threat, with over 657 million people in 39 countries requiring preventive chemotherapy to halt its spread (WHO 2013). In 2018, an estimated 51 million individuals were infected, representing a substantial 74% decrease since the World Health Organization (WHO) launched the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000 (WHO 2013). The predominant causative agent, responsible for approximately 90% of cases, is the filarial worm Wuchereria bancrofti (WHO 2013). LF is recognized as a leading cause of long-term disability worldwide, imposing not only physical suffering but also considerable mental, social, and financial losses, which contribute to stigma and poverty.

The consequences of LF extend beyond individual health, creating complex societal challenges. The visible disfigurement and disability associated with conditions like lymphedema and hydrocele can lead to social exclusion and isolation (WHO 2013). This isolation can, in turn, limit an individual’s access to information, health services, and community support systems, including mass drug administration (MDA) campaigns. Furthermore, physical disability may impede an individual’s ability to reach drug distribution points. Thus, the very manifestations of the disease can become social determinants that influence the effectiveness of programs designed to eliminate it, creating a challenging cycle that public health interventions must navigate.

Problem Statement

Understanding these factors means that there is a growing need to unearth the specific reasons and factors affecting community participation. Although many studies have provided rich literature on this topic in SSA, there is a dearth of literature on the Zimbabwean context, there are very few to no studies that have tried to explore this issue in depth in Zimbabwe hence presenting a gap in empirical evidence and research. This study addresses these gaps by investigating the social factors affecting community participation in LF-MDA programs as outlined below by the study objective.

Aim And Objectives

The main aim of the study is to investigate the social factors affecting community participation in LF-MDA programs.

RESEARCH METHODOLOGY

The study was guided by a social-interpretivist research philosophy which emphasizes on the need for understanding the  social world through the lenses the research participants. Pervin & Mokhtar, (2022) reiterate that interpretivism is a school of thought that presents a sharp contrast with positivism, focusing on subjective reality and   existence of multiple realities rather than a single objective reality. The founding assumption of the interpretivist paradigm is that individual perceptions, thinking, ideas and the meaning they attach to things can be understood through studying their culture, therefore the methods that can be used to understand human interaction cannot be the same with the methods that can be used to understand human interaction (Hammersley, 2013).

The study utilized the case study research design which Bryman (2012) in his book social research methods states is an intensive analysis of a single case or unit to develop knowledge about a certain subject matter that can only be provided by that specific unit. The study was conducted in Muzarabani Rural District, in Mashonaland Central Province in Zimbabwe during the 2024 LF-MDA campaign. The study was conducted in Wards 23, 24 and 27 that is Kaerezi Ward, Chionde Ward and Chiwenga Ward respectively and where the MOHCC implemented the LF MDA campaigns with support of its partners. The campaign targeted children from the age of two and all adults.

Muzarabani, as a case study, is a rural district situated along the Mozambique-Zimbabwe border. The district covers a total area of 4,266km of land and according to the 2022 population census; the district had a total population of around 134,076. The district is one of the most economically marginalized in the country due to its low production potential (Mavhura, 2018). Ninety seven percent of the economically active population are smallholder farmers. The district is generally a flat terrain, with generally hot temperatures, which makes it tsetse infested, and the prevalence of mosquitos is very high in that area.

Since the study was conducted during the LF-MDA campaigns, the target population were individuals who refused the preventive treatment and the health professionals at different stations who were responsible for administering the drugs. Participants were using convenience sampling; focusing on those who refused to take the drugs to participate in the interviews and share their reasons why they had decided not to participate in the mass drug administration program despite the well-known existence of LF in the area. The researcher, having been part of the mobile outreach team had direct access to interviewees who had refused to participate, allowing them to state the reasons for their actions and this was done until saturation ensuring in-depth data gathering. Fifteen (15) participants from the general population in the respective wards were selected for the study including both men and women. Five (5) health professionals were purposively selected based on experience in the field of implementing MDA and their prior experiences and insights into community resistance to taking the drugs. It is this experience that they deemed knowledgeable of the factors affecting community participation in mass drug administrations.

The study used both primary and secondary data. For primary data, a combination of semi-structured interviews and key-informant interviews with open-ended questions. This combination allowed the researcher to gather in-depth knowledge about the research questions, by allowing the participants to express themselves without any limits or confined to a set of responses and to speak their mind therefore allowing for insights that might have not crossed the mind of the researcher to surface during the study. The fifteen (15) participants who had refused to participate during the campaigns were interviewed using the semi-structured interviews, with the semi-structured interview guide being used to probe the participants. During the interviews, the researcher developed follow-up questions based on the revelations of the participants and the insights being brought to light by the participants.

The study also conducted five (5) key-informant interviews with nurses, including a community health nurse, a nurse in charge at one of the health facilities and five of them were taken from the mobile teams meaning that in total 20 interviewees participated in the study. The researcher probed with questions from the key-informant interview guide, allowing the participants to express their views on the subject matter. Both the semi-structured interviews and the key informant interviews were recorded using a voice recorder on a mobile phone to ensure capturing all the   and supplementary notes were taken to also capture non-verbal cues as part of the data collection process.

To complement the interviews, the study also used document analysis to enhance the depth and findings credibility. The study systematically reviewed country policy documents including the Zimbabwe National Health Strategy (2016–2020), the Zimbabwe NTD Master Plan (2023–2027), and reports from the Ministry of Health and Child Care (MoHCC). In addition to these documents, the study also complemented the findings with literature on the social barriers to community participation, such as limited health literacy and education and socio-cultural resistance. This methodological triangulation of interviews and document analysis reinforced data credibility strengthened the validity of the study’s conclusions and ensured a more comprehensive understanding of the social dynamics influencing MDA uptake in rural Muzarabani.

Thematic analysis was used to analyze data in consistent with the research design adopted for the study. Thematic analysis ensured identification of recurring themes and patterns across the dataset fostering a structured interpretation of social issues and factors influencing community participation in the MDA interventions.

RESULTS AND DISCUSSION

Myths surrounding vaccines and drugs

The study found that myths and misconceptions surrounding vaccines and drugs was one of the factors determining or influencing people’s participation in LF-MDA programs. Interviewees who had refused to take the drugs expressed mistrust towards the initiative stating there was a sinister agenda behind the drug administrations. Other community members perceived donor funded intervention as an attempt by Western actors to harm African populations that help them with colonial ideology hangover that such programs were not acts of goodwill but hidden efforts to depopulate African communities and reclaim land and resources. The study shows that these sentiments developed partly because of colonial period memories where African communities suffered harsh treatment at the hands of colonial oppression and exploitation.

Some participants even went further to attribute past declines in sexual performance to previous MDA drugs, interpreting this as the Western actors’ intentional attempt to suppress African reproduction processes. Parker and Allen (2013) also underscored that myths can shape perceptions about the intentions of MDA programs. Their study in Tanzania and Uganda illustrated that community members associated MDA drugs with infertility, poison and population control beliefs, these beliefs were rooted in historical mistrust of biomedical interventions. The current study therefore notes that through socialization, these perceptions and myths continued to trickle down to newer generation thereby affecting the reach of MDA programs.

Below are some of the statements that were shared by the participants during the data collection process:

“The donors funding this program are white men who have motives; to kill us so that they can reclaim our wealth as such we are not going to take these drugs.”

“My man, there is no way that these white people will care for us to the extent of giving us medications and drugs for free, the last time I took these drugs during an MDA, I then realized that my sexual performance at home decreased. This means that their agenda is to wipe us out since we will not be able to bear children.”

From the above, it is clear that these beliefs shaped by historical trauma and misinformation, contributed to fear and resistance, ultimately undermining participation for not only adults but also infants and children in the MDA campaign and other vaccination programs.

Religious beliefs

Religious beliefs also influenced community participation in MDA programs. The study highlighted this in two parts. In the first instance, communities expressed that LF and elephantiasis were not natural illnesses but a result of witchcraft.  Such superstitious beliefs led individuals and communities to underestimate the value of participating in the MDA programs. Participants felt witchcraft was rampant in their communities and conditions like LF and its symptoms were attributed to witchcraft activities. Using this reasoning and belief system, individuals felt that the best way to cure such a sickness was through traditional healers, to cure diseases.

Below is a quote from one of the participants highlighting how individuals in the community perceived LF and its symptoms and why they did not participate in MDAs:

“My friend this place has a lot of people practicing witchcraft, this sickness that you say you want to prevent using medicinal drugs will not work because the cause is witchcraft nothing else. If we want someone to be cured from this sickness, consult a traditional healer because they can cure this.”

A second interpretation rooted in religious beliefs as shown by participants from the African Apostolic Sects who expressed that taking medicinal drugs did not align with their religious doctrine. They also highlighted that if any natural illness by a natural (God-given) forces should have and be addressed with natural and spiritual solution as per their church doctrine maintaining that divine healing, not medicine, was the only legitimate form of prevention and cure. Some participants perceived the MDA programs as a proclamation that science gained superiority in the world over divine authority and taking drugs was perceived as deviant behavior. Whilst most semi-structured interviewees were religiously affiliated, with the African Apostolic Sects, key informants also indicated that this group was well-known for non-participation in MDA programs. Participation in the MDA program was proclaimed to one as having chosen to be living in the ways of the world rather than the ways of God. Further religious connotations also perceived that participation would dilute religious purity hence the only option was to stay away from the programs. These are similar views channeled by the study of Koroma et al., (2012) in Sierra Leone where Pentecostal and Charismatic Christian groups perceived compliance with MDA programs as a form of spiritual contamination resorting to the belief that healing could only be done through divine intervention. In addition, the study supports the findings by Gyapong et al., (2018) stating that religious beliefs around purity and bodily sanctity often conflicted with the idea of mass treatment especially in instances where medication must be administered without prior diagnosis.

Lack of comprehensive health information

The study found that limited access to comprehensive health information made it difficult for community members to participate in the MDA program and the disease. This caused low turnout on village points. Upon arriving at a village point, community members raised concerns that they were not aware of the program’s purpose and its value to their health; schedules and some of the members chose to continue with daily routines working in their gardens unaware that the program was underway. Upon interviewing key-informants, the researcher gathered that the views within the communities and those of the key informants were in harmony, showing lack of awareness; inequitable access to relevant information; particularly social mobilization efforts had not adequately addressed the various community informational gaps and needs resulting in community members low turnouts at village points.

The lack of comprehensive health information cannot be simply explained by the above; the study also observed that participants lacked a clear perception of why such a program was happening. There were even participants who denied participating indicating that they could not just take drugs that they were not aware of why they were taking those drugs.

One of the semi-structured interviewees said:

“My brother, would you just take drugs because you have been instructed to do so but without an understanding of the purpose and value of why you have to take the drugs?”

This shows that participants were not ready to participate in the program due to the lack of health information and health education. Other participants even indicated that they were not aware of the existence of such an illness in their area hence they were not ready to participate in the MDA program. In addition, the study found that there were participants who felt that the existence of LF was just a lie and fiction therefore they could not participate in the MDA program. When follow up interviews were done with key-informants, it was understood that such statements showed a lack of health education among the communities and this highly exposed insufficient pre-implementation sensitization thatlacked intensity. Still on community sensitization, other participants even expressed that they did not know anything about LF, the causes, and why it was such a big issue demanding such a program.

The findings above corroborate with the findings of Kumah et al., (2023) who alludes that limited knowledge of LF has a significant impact on community participation in MDA programs in Asante Akim South Municipal, Ghana. In addition, Kisoka et al., (2014) noted that in Tanzania, several individuals who exhibited little knowledge about the essence of MDA programs resorted not to participate in the programs. Furthermore, (John et al., 2021) found that in Tanzania, low levels of health knowledge had a negative impact on individuals’ decisions to participate in the MDA programs. Sangare et al., (2024) study in Mali found that limited health information was among the main factors resulting in non-participation of communities in MDA programs. Therefore, this shows that lack of comprehensive knowledge among communities can be a stumbling block inhibiting communities and individuals from participating in MDA programs as alluded by this study.

Prior experiences with vaccines and drugs

The study took note that participants who had negative experiences with prior MDA or vaccination campaigns were hesitant to participate in future programs. Participants expressed that sometimes, instead of preventing illness, they appeared to trigger health complications and community members desisted from any further drug uptake.

Several participants reported testing positive to Covid-19 after taking the first vaccine dose and were hesitant to take second dose and the booster. After such experiences, participant chose not to engage in other drug administration and vaccination programs hence shaping their attitudes, and leading to reluctance towards participating in the LF-MDA program.

“When Covid-19 came I was never infected by it, when Vaccines came we were instructed to go and be

vaccinated, after being vaccinated that is when I fell sick. When I went to seek medical attention, I tested positive for Covid-19. So if you were me would you want to continue taking drugs that cause sickness?”

From the above quote, participants perceived drugs and vaccinations as causative agents of the disease rather than offering preventive chemotherapy. It is within the context of such experiences that have shaped the attitudes and perceptions of communities and as a result discouraging participation in MDA programs.

Other participants also expressed dislike for the drugs due to previous adverse effects experienced with MDA and vaccination programs. Key informant interviews, revealed that drugs administered before a meal led to side effects. These included nausea, drowsiness, headache and fatigue. The study shows that these side effects had been experienced in the past MDA programs by some participants therefore there was hesitation to repeat the same cycle. Key-informant health workers further concurred that several members of their target population lacked health education with many community members unaware of the importance of taking medication with food. Many times, rather than being understood as temporary or manageable, key informants noted, the side effects were often interpreted as harmful consequences of the drugs themselves. Mistrust, misinformation and limited health information reinforced decisions to avoid any future participation in MDA programs.

Prior experiences with vaccination programs has been found to be a factor negatively affecting community participation in Mass Drug Administration campaigns as raised by this study. These findings are in alignment with the findings of Kumah et al., (2023) who found that prior experiences related to side effects of Ivermatin drugs had a negative impact of individuals’ decision to participate in future MDA programs. John et al., (2021) in their study also alluded that individuals with negative experiences of MDA programs were more likely to develop attitudes and negative perceptions about the programs thereby shaping their decision to participate which is in most cases non-participation. Sangare et al., (2024) states that in Mali, individuals developed fear of side effects of drugs due to prior experiences and these then influence their decisions resulting in non-participation in the MDA programs.

CONCLUSION

Given the weight of the above evidence, this study concludes that there is a plethora of social factors collectively contributing to Muzarabani low community turnout and participation in MDA programs. The most critical barrier being the absence of tailored context sensitive health education approach. Whist the study identified myths, religious beliefs, prior experiences to vaccines and related medication administration, it leaves a lot to be desired especially with significant gaps in awareness raising, capacity building and broader gaps in health literacy and community engagement.

As the factors discussed are deeply rooted in historical colonial prejudice, cultural norms and values presided by socio-religious contexts, the study also highlighted that misinformation, limited awareness to informed decisions continue to affect rural communities and populations where unequal access to health education and outreach is limited and inadequate. A more urgent tailored approach is needed to identify these context specific barriers that ensure health communication strategies that address local beliefs and involvement of trusted community figures, including religious and traditional leaders. This study thus contributes to the scientific knowledge by providing a foundation for designing more responsive oriented and culturally sensitive public health strategies that enhance participation and improve the effectiveness of interventions targeted at the elimination of LF disease.

RECOMMENDATIONS

Based on the findings and conclusions of the study, the study recommends the following actions to address the identified deterrents and ensure success of MDA programs in rural Zimbabwe:

1. Improve community engagement through equality of access to health literacy education aimed at raising awareness and providing capacity building about the MDA program. These efforts should be part of the Ministry of Health and Child Care strategy in the respective provincial and district offices and should target strategic community leaders such as religious leaders, traditional leaders and local authorities who can influence and promote social behavior change in communities they lead.
2. Awareness campaigns should be designedand communicated in a comparative and culturally relevant manner to help reshape community perceptions, address misinformation, and motivate informed decision-making. They should also clearly communicate the purpose, benefits and significance of participation in MDA programs and outline the potential risks associated with non-compliance.
3. Education related to NTDs should be incorporated into mainstream education curriculum in both primary and secondary education to allow for positive socialization and sensitization which can have a wider reach and shape choices of future generations into participating in the MDA and other related programs.
4. Through strategic partnerships with donor organizations and corporates, the Ministry of Health can secure funding to procure foodstuffs, in case of community members who would have not consumed any food before administration of drugs. This reduces incidences of community members suffering from the side effects of the drugs hence reducing the risk of negative experience with MDA programs.

REFERENCE

1. Bryman, A. (2012). Social research methods (4th ed.). Oxford University Press Gyapong, J. O., Owusu, I. O., da-Costa Vroom, F. B., Mensah, E. O., & Gyapong, M. (2018). Elimination of lymphatic filariasis: current perspectives on mass drug administration. Research and reports in tropical medicine, 9, 25–33. https://doi.org/10.2147/RRTM.S125204
2. Hammersley, M. (2013). What is qualitative research? Bloomsbury Academic.John, W., Mushi, V., Tarimo, D., & Mwingira, U. (2021). Community Participation in the Mass Drug ‎Administration and their Knowledge, ‎Attitudes, and Practices on Management of Filarial Lymphoedema in Lindi District, ‎Tanzania: A Cross-Sectional Study‎. Afro-Egyptian Journal of Infectious and Endemic Diseases, 0(0), 0–0. https://doi.org/10.21608/aeji.2021.91409.1169
3. Kisoka, W. J., Simonsen, P. E., Malecela, M. N., Tersbøl, B. P., Mushi, D. L., & Meyrowitsch, D. W. (2014). Factors influencing drug uptake during mass drug administration for control of lymphatic filariasis in rural and urban Tanzania. PLoS ONE, 9(10). https://doi.org/10.1371/journal.pone.0109316
4. Krentel, A., Fischer, P. U., & Weil, G. J. (2013). A Review of Factors That Influence Individual Compliance with Mass Drug Administration for Elimination of Lymphatic Filariasis. PLoS Neglected Tropical Diseases, 7(11). https://doi.org/10.1371/journal.pntd.0002447
5. Koroma, J. B., Bangura, M. M., Hodges, M. H., Bah, M. S., Zhang, Y., Bockarie, M. J., & MacCarthy, P. (2012). Lymphatic filariasis mapping by Immunochromatographic Test cards and baseline microfilaria survey prior to mass drug administration in Sierra Leone. Parasites & Vectors, 5, 10. https://doi.org/10.1186/1756-3305-5-10
6. Kumah, E., Owusu, P., Otchere, G., Ankomah, S. E., Fusheini, A., Kokuro, C., Mensah-Acheampong, F., Atta, J. A., & Agyei, S. K. (2023). Factors influencing community acceptability of mass drug administration for the elimination of onchocerciasis in the asante akim south municipal, Ghana. PLoS Neglected Tropical Diseases, 17(3), 1–14. https://doi.org/10.1371/journal.pntd.0011251
7. Mavhura, E. (2018). Vulnerability to drought and food insecurity: A case study of rural households in Muzarabani District, Zimbabwe. Jàmbá. Journal of Disaster Risk Studies, 10(1), 1–9.
8. Ministry of Health and Child Care. (2016). The National Health Strategy for Zimbabwe 2016 – 2020. Government of Zimbabwe.
9. Ministry of Health and Child Care. (2023). Zimbabwe NTD Master Plan 2023 -2027. Government of Zimbabwe
10. Ngunyali, D. A., Mpomele, S. S., Kilonzi, M., Mutagonda, R. F., Mikomangwa, W. P., Mlyuka, H. J., Kibanga, W., & Marealle, A. I. (2023). Knowledge and participation in mass drug administration against lymphatic filariasis and soil-transmitted helminth infections among the community members in Dar es Salaam, Tanzania. Transactions of the Royal Society of Tropical Medicine and Hygiene, 117(5), 358–364. https://doi.org/10.1093/trstmh/trac119
11. Niles, R. A., Thickstun, C. R., Cox, H., Dilliott, D., Burgert-Brucker, C. R., Harding-Esch, E. M., Clementson, N., Sampson, A., Alexandre, J. S., Morice Trejos, A. C., Carvalho Scholte, R. G., & Krentel, A. (2021). Assessing factors influencing communities’ acceptability of mass drug administration for the elimination of lymphatic filariasis in guyana. PLoS Neglected Tropical Diseases, 15(9), 1–27. https://doi.org/10.1371/journal.pntd.0009596
12. Parker, M., & Allen, T. (2013). Will mass drug administration eliminate lymphatic filariasis? Evidence from northern coastal Tanzania. Journal of biosocial science, 45(4), 517–545. https://doi.org/10.1017/S0021932012000466
13. Pervin, N., & Mokhtar, M. (2022). The Interpretivist Research Paradigm: A Subjective Notion of a Social Context. International Journal of Academic Research in Progressive Education and Development, 11(2), 419–428. https://doi.org/10.6007/ijarped/v11-i2/12938
14. Sangare, M., Diabate, A. F., Coulibaly, Y. I., Tanapo, D., Thera, S. O., Dolo, H., Dicko, I., Coulibaly, O., Sall, B., Traore, F., Doumbia, S., Kulkarni, M. A., Nutman, T. B., & Krentel, A. (2024). Understanding the barriers and facilitators related to never treatment during mass drug administration among mobile and migrant populations in Mali: a qualitative exploratory study. BMJ Global Health, 9(10), 1–15. https://doi.org/10.1136/bmjgh-2024-015671
15. Silumbwe, A., Zulu, J. M., Halwindi, H., Jacobs, C., Zgambo, J., Dambe, R., Chola, M., Chongwe, G., & Michelo, C. (2017). A systematic review of factors that shape implementation of mass drug administration for lymphatic filariasis in sub-Saharan Africa. BMC Public Health, 17(1), 1–15. https://doi.org/10.1186/s12889-017-4414-5
16. World Health Organization. (2013). Sustaining the drive to overcome the global impact of neglected tropical diseases: Second WHO report on neglected tropical diseases. World Health Organization.
    https://apps.who.int/iris/handle/10665/77950
17. World Health Organization. (2023). Global report on neglected tropical diseases 2023. World Health Organization.https://www.who.int/publications/i/item/9789240065061
18. Zimbabwe Vulnerability Report. (2022). https://fscluster.org/sites/default/files/documents/zimvac_2022_rural_livelihoods_assessment_report.pdf.