Gender differences in the perceived need for community-wide deworming: Formative qualitative research from the DeWorm3 study, India.

Current soil-transmitted helminth (STH) programs target morbidity control with school-based deworming. Increasing interest in steering neglected tropical disease (NTD) programmes from morbidity control towards disease elimination has prompted evaluation of strategies that may interrupt transmission. The feasibility of interrupting transmission of STH with community-wide deworming is being tested in the ongoing DeWorm3 cluster randomized trial. Gender-based perspectives about susceptibility to infection and need for treatment have been shown to influence both health-seeking behaviour and health outcomes. We carried out a qualitative study among men and women in the community to understand their knowledge, beliefs, and attitudes about STH infections and community-wide mass drug administration (cMDA). Eight semi-structured focus group discussions were conducted among men and women residing in the DeWorm3 study site in India-Vellore and Tiruvannamalai districts of Tamil Nadu. Thematic coding was used to analyse the transcripts in ATLAS.ti 8.0. Both men and women in this study demonstrated a high level of STH knowledge but some men had misconceptions that intestinal worms were beneficial. Men and women shared several similar beliefs and attitudes regarding STH treatment. Both believed that adults were likely to have STH infections and both reported that stigma prevented them from seeking treatment. Influenced by gender norms, women were more likely to associate STH infections with inadequate sanitation and hygiene, while men were more likely to believe that those engaged in agricultural work were at risk. Both genders reported a positive attitude towards cMDA for STH. Barriers to cMDA implementation differed by gender; women expressed concern regarding side-effects and drug quality while men were concerned that treatment coverage may be affected due to the absence of people during the day when the drug is distributed. Both men and women perceived the treatment of adults for STH infections to be important, however, the perceived barriers to participating in cMDA differed by gender in this community. The study identified key messages to be incorporated in communication and outreach strategies for cMDA programmes. Author summary In this qualitative study, we conducted focus group discussions with men and women residing in communities participating in a cluster-randomized trial of community-wide deworming for soil-transmitted helminth (STH) in order to understand how knowledge, beliefs, and attitudes are influenced by gender. Men and women shared similar beliefs and attitudes, although there were differences in knowledge about STH infection and its treatment. While both genders understood that STH transmission is associated with poor sanitation and hygiene, women voiced a greater appreciation of these risk factors, perhaps because of the STH knowledge gained from the frontline health workers during school MDA and anaemia programs. Men and women both believed that adults may be re-infecting children in the community and both articulated acceptance of deworming medications. However, both men and women also noted that stigma associated with an adult having STH infection prevented them from actively seeking treatment. The cMDA for STH, may provide important socio-behavioural benefits to communities, as it provides an opportunity to treat all community members over one year of age without discrimination by infection status or age. However, compliance with treatment may be affected by community beliefs; women expressed concerns regarding treatment safety while men specifically expressed concerns about achieving treatment coverage due to the absence of some individuals during cMDA due to migration and people being absent for work. Findings from this study suggest that communication and dissemination messages should include a rationale for cMDA and stress the safety and benefits of the drug. In addition, these results highlight the importance of carefully timing the delivery of cMDA to ensure that working adults and migratory populations have access.