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1
1Microplanning improves stakeholders’ perceived capacity and engagement to implement
2lymphatic filariasis mass drug administration
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4Authors: Caitlin M. Worrell1,2,3*, Tara A. Brant1, Alain Javel4, Eurica Denis4, Carl Fayette4, Franck
5Monestime4, Ellen Knowles5, Cudjoe Bennett5, Jürg Utzinger2,3, Peter Odermatt2,3, Jean-Frantz
6Lemoine6
7
81U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
92Swiss Tropical and Public Health Institute, Allschwil, Switzerland;
10 3 University of Basel, Basel, Switzerland;
11 4IMA World Health, Port-au-Prince, Haiti;
12 5IMA World Health, Washington, DC, USA;
13 6National Program to Eliminate Lymphatic Filariasis, Ministry of Public Health and Population, Port-au-
14 Prince, Haiti
15
16 *Corresponding author: Caitlin M. Worrell - uvz2@cdc.gov
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27 Disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official
28 position of the Centers for Disease Control and Prevention.
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2
29 Abstract
30 Background: Achieving adequate mass drug administration (MDA) coverage for lymphatic
31 filariasis is challenging. We sought to improve stakeholder engagement in MDA planning and improve
32 subsequent MDA coverage through a series of microplanning workshops.
33 Methodology/Principal Findings: Prior to the 2018 MDA, Haiti’s Ministry of Public Health and
34 Population (MSPP) and partners conducted 10 stakeholder microplanning workshops in metropolitan
35 Port-au-Prince. The objectives of the workshops were to identify and address gaps in geographic
36 coverage of supervision areas (SAs); review past MDA performance and propose strategies to improve
37 access to MDA; and review roles and responsibilities of MDA personnel, through increased stakeholder
38 engagement. Retrospective pre-testing was used to assess the effectiveness of the workshops.
39 Participants used a 5-point scale to rank their understanding of past performance, SA boundaries, roles
40 and responsibilities, and their perceived engagement by MSPP. Participants simultaneously ranked their
41 previous year’s attitudes and their attitudes following the 2-day microplanning workshop. Changes in
42 pre- and post-scores were analyzed using Wilcoxon-signed rank tests. A total of 356 stakeholders across
43 five communes participated in the workshops. Participants conducted various planning activities
44 including revising SA boundaries to ensure full geographic reach of MDA, proposing or validating social
45 mobilization strategies, and proposing other MDA improvements. Compared with previous year
46 rankings, the workshops increased participant understanding of past performance by 1.34 points
47 (standard deviation [SD]=1.05, p<0.001); SA boundaries by 1.14 points (SD=1.30; p<0.001); their roles
48 and responsibilities by 0.71 points (SD=0.95, p-<0.001); and sense of engagement by 1.03 points
49 (SD=1.08, p<0.001). Additionally, drug coverage increased in all five communes during the 2018 MDA.
50 Conclusions/Significance: Participatory stakeholder workshops during MDA planning can
51 increase self-reported engagement of key personnel and may improve personnel performance and
52 contribute to achievement of drug coverage targets. Microplanning success was supported by MDA
53 results, with all communes achieving preset MDA coverage targets.
54
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55 Author summary
56 Lymphatic filariasis is a neglected tropical disease that can be eliminated by treating entire at-risk
57 communities with safe and efficacious medicines, a strategy known as mass drug administration (MDA).
58 MDA campaigns require intense planning to ensure that every eligible person within the community can
59 receive the medicines if they desire. We aimed to improve the campaign by better involving key MDA
60 stakeholders such as volunteers and other important community members in the planning process,
61 through microplanning. The participants suggested many strategies to help the campaign reach more
62 community members, including better ways to prepare and inform that community that the campaign is
63 happening. We invited the microplanning participants to give feedback on how this new strategy
64 worked compared with their experiences during past campaigns. Participants reported that they felt
65 better engaged by health authorities, and in particular, that they had more information about the
66 results of past campaigns, where they should be distributing medicines, and their specific tasks and
67 responsibilities during the campaign. We found that more people received medicines during the
68 campaign that followed the microplanning workshops compared with the previous campaigns. We
69 conclude that microplanning helped to increase the number of people who received MDA medicines.
70
71
72
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73 Introduction
74 Lymphatic filariasis (LF) programs in some countries have met global program targets for
75 elimination. However, many programs continue to face challenges in achieving high levels of community
76 participation in mass drug administration (MDA) [1]. Triple drug regimen MDA [2] may accelerate
77 national and global progress toward LF elimination [3], but the benefits of such novel approaches can
78 only be realized if a high proportion of at-risk community members have access to the intervention and
79 are receptive to taking the drugs [3]. Numerous factors can impact community drug coverage and
80 compliance [4, 5], and the factors that influence an individual’s willingness and ability to participate in
81 MDA are multi-factorial and subject to change through multiple rounds of MDA [5]. These factors are
82 often related to the broader social-ecological context, as well as provider or recipient community
83 characteristics.
84 While many studies have highlighted the recipient community characteristics that drive non-
85 adherence to MDA [6-8], increasing focus has been placed on understanding and addressing provider-
86 related issues that are important drivers of drug uptake [9]. In Tanzania, for example, the majority of
87 community members who did not receive the medication reported program-related issues, such as
88 community drug distributors (CDDs) not visiting all eligible households, inopportune timing of the MDA,
89 and not knowing that MDA was occurring [10]. Other reported program issues associated with poor
90 MDA compliance include drug shortages, insufficient time and human resources, inadequate training of
91 drug distributors, inappropriate selection of drug distributors, poor adverse event management, and
92 limited community engagement or coordination in MDA planning [5]. Failure to adequately engage
93 members of the health system and the community during MDA planning can adversely impact the
94 quality of MDA implementation and, therefore, lead to low levels of community participation [11, 12].
95 Conversely, strong community participation in the planning and implementation of MDAs has been seen
96 as key to the success of some campaigns, particularly in urban areas [13-15]. In India, the involvement of
97 mid-level health authorities, especially at the district level, was identified as a key element in carrying
98 out a successful MDA [6].
99 Microplanning is an approach that may improve access to and acceptability of MDA programs by
100 addressing the various issues faced by providers and recipients [16]. While the specific implementation
101 varies by location, microplanning generally encompasses a ‘bottom-up’ approach that engages local
102 stakeholders in health program planning by leveraging local data and knowledge to both identify site-
103 specific problems and design solutions [17]. This iterative and multi-stage process engages local
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104 representatives to define the target populations in a delineated area that are eligible for an intervention
105 [18]. During this process, stakeholders define the location of the target population and the catchment
106 areas for each program delivery actor. Stakeholders design service delivery strategies to reach targeted
107 sub-populations, often with an emphasis on hard-to-reach populations (e.g., mobile and remote
108 populations). They create a realistic operational plan based on local circumstance and available
109 resources, as well as determine the material, financial, and human resources needed to accomplish
110 program targets. Microplans are typically gathered and compiled across various administrative levels
111 and, ideally, inform the allocation of program resources.
112 Microplanning has been shown to improve public health program coverage [19], and is a key
113 component of the Reaching Every District strategy [18, 20] for improving immunization systems and
114 vaccination coverage [19, 21, 22]. Outside immunization programs, microplanning has been used in
115 planning and delivering other health interventions, including HIV care and prevention [23, 24], malaria
116 prevention [25, 26], and reproductive and child health programs [27, 28]. Neglected tropical disease
117 (NTD) programs such as LF MDA have applied microplanning less frequently than other programs due to
118 financial constraints. However, as national NTD programs approach LF elimination targets and identify
119 areas of LF foci of transmission that appear to be particularly intractable, new tools and strategies are
120 needed. Increasingly, digital tools are being used during microplanning for health program planning and
121 implementation [25, 29] as they have been shown to be a cost-effective strategy [25, 30] that can
122 increase program coverage [23, 31], identify mobile and displaced populations [21, 29, 31], and promote
123 an efficient allocation of resources [32].
124 Haiti has been implementing large scale MDA campaigns for LF since 2000 and reached full scale in
125 2012 once MDA began in the metropolitan region of Port-au-Prince [33]. Despite most of the communes
126 in Port-au-Prince achieving globally recommended targets of at least 65% population coverage of MDA
127 for LF during initial rounds [34], the Port-au-Prince communes struggled to achieve coverage targets
128 during subsequent rounds of MDA [35]. In 2016, sentinel site assessments identified that five of six Port-
129 au-Prince communes required additional rounds of MDA that achieved coverage targets prior to
130 qualifying to undergo the transmission assessment survey (TAS). After the 2017 MDA, in which coverage
131 targets were again not met, the Ministry of Public Health and Population (MSPP) convened a meeting
132 with implementing partners in order to create a plan for improving coverage in subsequent MDAs.
133 During these meetings, the partners identified a series of strategies for improving coverage based on
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134 literature of best MDA practices in urban areas and lessons learned by MSPP staff and partners during
135 years of MDA implementation. Microplanning was one of several proposed activities.
136 The study reported here details the results of a microplanning activity aimed to improve 2018 MDA
137 coverage in the five communes of Port-au-Prince that had experienced declining MDA coverage. Our
138 specific objectives were to evaluate the effect of using established microplanning techniques on (i)
139 identifying program gaps and key solutions; (ii) the perceived performance and engagement of key
140 stakeholders (both community leaders and program staff) who attended a microplanning workshop; and
141 (iii) MDA coverage in the subsequent 2018 MDAs conducted in five communes of Port-au-Prince.
142 Methods
143 Ethics statement
144 This project took place as an evaluation of a routine LF elimination program and was considered
145 by Haiti’s MSPP to be a program evaluation. The project is covered by a non-research determination
146 granted by the Center for Global Health (CGH) Human Subjects Protection Office at the U.S. Centers for
147 Disease Control and Prevention (CDC) in Atlanta, Georgia, USA.
148 Project area
149 This evaluation took place from January through March 2018 in five of the six communes (i.e.,
150 Carrefour, Cité-Soleil, Delmas, Port-au-Prince, and Tabarre) comprising metropolitan Port-au-Prince. This
151 area, which represents a population of approximately 2.3 million people, was the last area in Haiti to
152 initiate LF MDA in 2012 [33].
153 In Port-au-Prince, MDA is delivered through distribution posts located in the community and at
154 schools. One post, staffed by three CDDs, is allocated to treat approximately 1,000 people over a 4-day
155 MDA. Community promoters (CPs) manage approximately three health posts and are in turn managed
156 by community leaders (CLs). CLs, with assistance from CPs, are responsible for conducting social
157 mobilization activities within a supervision area (SA) in the months prior to the MDA, selecting and
158 supervising distribution sites, and training CPs and CDDs.
159 Overall design
160 To improve stakeholder engagement and MDA implementation, we conducted a 2-phase
161 microplanning exercise in the five target communes. In phase one, LF program staff, in collaboration
162 with CLs, conducted an inventory of the 2017 MDA distribution posts using ODK Collect (Open Data Kit
163 Inc., v2.0) [36] loaded onto mobile devices. Historic distribution post sites were overlaid onto a Google
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164 satellite base layer (Google Inc, n.d.), using open-source QGIS (Open Source Geospatial Foundation
165 Project, v2.14.21). To identify possible access gaps, we applied a 300 m buffer around each distribution
166 post to identify areas within approximately a 500 m maximum walking distance. These maps were
167 prepared to inform the discussion during microplanning workshops in phase two.
168 During phase two, all CLs as well as a selection of CPs, and other community stakeholders were
169 invited to participate in microplanning workshops. In close consultation with communal and
170 departmental focal points from MSPP, the program staff identified key community stakeholders who
171 would be critical for community- and school-based with distribution. These individuals included school
172 directors, Ministry of Education inspectors at the district and sub-district level. For community-based
173 MDA this included representatives from local authorities such as mayors and CAESECs, church-leaders
174 and pastors, voodoo temple, and local youth associations. The microplanning workshops included
175 several key activities. Initially, the project staff provided an overview of the LF elimination program
176 objectives, reviewed the historical results from the 2012 to 2017 MDAs, summarized the results of
177 several key MDA evaluations, and engaged the participants in a discussion of the challenges to and
178 opportunities for improving MDA coverage. To clarify stakeholder roles and responsibilities, program
179 staff presented and validated the terms of references for key MDA staff (i.e., CLs, CPs, and CDDs), and
180 drafted a document detailing expectations from opinion leaders and other stakeholders. Further,
181 program staff presented several specific strategies that were proposed by implementing partners to
182 improve the 2018 MDA. These strategies included but were not limited to extending the number of
183 MDA days, modifying MDA distribution times, enhancing schools’ participation in MDA, improving
184 visibility and credibility of CDDs, and expanding mop-up activities. Participants were invited to propose
185 revisions including defining and validating key strategies for community drug distribution (e.g., optimal
186 timing and location).
187 Finally, SA boundaries were delineated for each community leader in QGIS (Open Source
188 Geospatial Foundation Project, v2.14.21). GPS coordinates of distribution posts collected during phase
189 one were overlayed onto an Open Street Maps layer that included various landmarks (e.g., streets,
190 places of business, etc.). Google Maps and satellite base layers (Google Inc., n.d.) were used as
191 additional references for identifying landmarks and delimiting boundaries. Through an iterative process,
192 microplanning participants used the 2017 distribution post maps as a basis to discuss and agree upon
193 the supervision area boundaries for each CL, ensuring no overlapping or omission of areas within the
194 targeted communes.
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195 Impact measures
196 We used retrospective pre-testing to evaluate the microplanning workshops against the stated
197 objectives [37-39]. This method involves asking participants in a single data collection event to rate their
198 attitudes before and after the workshop. Following the microplanning workshops, participants were
199 invited to complete a questionnaire simultaneously rating their previous year’s perceptions and their
200 perceptions following the 2-day microplanning workshop. This strategy aimed to reduce the
201 confounding factor of response shift bias [40], a phenomena where the respondents’ internal frame of
202 reference is altered due to the influence of the intervention itself. In this context, the participants
203 perceptions of their previous knowledge and engagement may be altered by participating in the
204 workshop, as has been seen in evaluations using traditional self-reported pre-post-test evaluation
205 frameworks[41]. Participants were asked to evaluate four measures: (i) understanding your past
206 performance; (ii) understanding the boundaries of your coverage zones or area of influence; (iii)
207 understanding your roles and responsibilities in the MDA; and (iv) engagement by MSPP in the MDA
208 planning process. Participant commune and role in the MDA were also recorded. Each measure was
209 evaluated using a 5-point scale where 1=poor; 2=fair; 3=good; 4=very good; and 5=excellent; N/A=not
210 applicable. We also assessed changes in coverage between the 2017 and 2018 MDAs as an indirect
211 measure of impact. MDA coverage was calculated using the total number of MDA doses delivered by
212 each commune’s MDA distribution teams divided by the estimated population of the commune.
213 Statistical analysis
214 Data were compiled using spreadsheet software (Microsoft Excel 2010, Microsoft, Seattle, WA,
215 USA) and data management and statistical analyses were completed using SAS v9.4 (SAS Institute, Cary,
216 NC, USA). For pre-workshop and post-workshop summary analyses, all responses were considered,
217 however results were filtered to include only complete pre-post pairs to measure changes as a result of
218 the workshop. Within pair differences between the pre- and post- workshop ratings were analyzed using
219 a Wilcoxon signed-rank test to determine whether microplanning had impacted perceived capacity to
220 deliver quality MDA as well as key engagement metrics. Alluvial plots describing changes in participant
221 ratings were created in R v1.1.463 (RStudio, Free Software Foundation Inc., Boston, MA, USA).
222 Results
223 Microplanning outputs
224 During phase one, project staff and CLs collected 8,034 GPS coordinates representing the 2017
225 distribution points. In advance of the microplanning workshop, the GPS coordinates were plotted in
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226 QGIS overlayed on satellite images of Port-au-Prince to create a detailed distribution post map for all
227 five communes. Program staff used these distribution post inventory maps to assess coverage gaps that
228 were presented to MDA stakeholders.
229 During phase two, 10 2-day microplanning workshops were held for 356 participants, including
230 73 CLs, 240 CPs, and 43 other key MDA stakeholders selected from the five targeted communes. Several
231 activities were conducted as part of the workshops. First, LF program staff presented workshop
232 participants with the maps showing the location of the 2017 distribution posts. Staff then worked with
233 CLs to delineate the 2017 SA boundaries as they were understood by each CL. Supplemental Figure 1
234 shows the resulting SA maps following the iterative process by which LF program staff and workshop
235 participants modified the MDA maps to ensure no overlapping or omitted areas within the targeted
236 communes. As part of this process, certain leaders’ distribution posts that fell outside their updated SA
237 boundaries were flagged to be prioritized for relocation.
238
239 Supplemental Fig 1. Final supervision area (SA) boundaries for 2018 mass drug administration
240 (MDA) for community leaders (CLs) by commune in Port-au-Prince, Haiti
241 A map generated by LF program staff in consultation with community leaders during microplanning
242 workshops detailing supervision areas for each community leader for five communes in Port-au-Prince,
243 Haiti. Areas are color coded by commune with shades of blue representing Carrefour, red representing
244 Port-au-Prince, yellow representing Delmas, purple representing Tabarre, and green representing Cité-
245 Soleil.
246
247 To support the optimal deployment of posts, each CL received a printed map following the
248 workshop that contained detailed information about their supervision area, including roads and points
249 of interest such as churches, businesses, and schools (Figure 1). Each CL’s supervision area was clearly
250 outlined, and neighboring CLs were listed. Maps were printed in Haitian Creole to improve the ease of
251 use by stakeholders and listed the CL’s name to foster a sense of ownership over the activities in that
252 area.
253
254 Figure 1 shows an illustrative CL’s supervision map.
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255
256 Fig. 1. Illustrative supervision area (SA) maps, 2018 mass drug administration (MDA) in Port-
257 au-Prince, Haiti Illustrative supervision area (SA) map displaying the SA for a community leader in the commune of
258 Tabarre for the 2018 mass drug administration for lymphatic filariasis (in Haitian Creole). The map includes the
259 boundaries of the SA (in red) including infrastructure and key points of interest obtained from OpenStreetMaps.
260 Additionally, it shows the community leaders working in adjacent SAs. For privacy reasons, this figure has been lightly
261 edited to anonymize the names of community leaders.
262
263 Another key activity included reviewing past MDA performance, identifying local challenges to
264 achieving high coverage, and proposing updated strategies to improve program coverage. As part of this
265 process, participants discussed and finalized distribution strategy modifications including some
266 modifications proposed by LF program staff, as well as drafts of new social mobilization strategies and
267 tools that were developed by LF program staff and partners. Table 1 describes a selection of key
268 discussion points and associated solutions based on these discussions. Participants identified key actions
269 to improve partnerships, planning and logistics associated with MDA planning; strategies to improve
270 support for CLs, CPs, and CDDs; new social mobilization strategies; as well as modifications to improve
271 distribution strategies.
272
273 Table 1: Selected feedback and outcomes from microplanning workshops conducted in Port-au Prince,
274 Haiti in 2018.
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Theme
Identified issues / key suggestions
Decisions or actions taken1
Some school authorities refuse to participate in MDA
activities due to lack of timely official correspondence
from Ministry officials.
Departmental authorities will prepare official correspondence detailing the
specifics of the MDA distribution. This correspondence will be available to
MDA staff within one week of the microplanning workshops.
Local authorities should accompany leaders during
mobilization and promotion events at schools,
churches, and other settings.
Local authorities are involved in the microplanning workshops to ensure that
they are informed of the MDA activities and may coordinate with MDA staff to
mobilize and sensitize their populations.
Partnerships,
planning, and
logistics
Boundaries of supervision areas are poorly understood
by leaders and other authorities.
Supervision area boundaries are defined during the microplanning workshops.
Detailed maps of the newly defined supervision areas, including boundaries,
infrastructures, and key points of interest, will be distributed to leaders to
facilitate efficient MDA planning.
Working conditions should be improved for the
leaders to achieve better results.
Leaders and promoters will be provided official badges to facilitate their
identification and perceived legitimacy, particularly at institutions such as
schools.
Supporting
leaders,
promoters,
and CDDs
Existing social mobilization tools are outdated and
insufficient for adequate social mobilization of the
community.
New social mobilization tools will be created as part of broader MDA
strengthening activities. Training sessions will be held for the main MDA actors
orienting them on the use of new social mobilization tools.
The program should create testimonials or
documentaries featuring persons affected by LF
disease.
Radio spots will be released promoting the MDA that include testimonials of
persons affected by LF disease.
Local celebrities and community leaders should be
better engaged in social mobilization campaigns.
A local comedian will be engaged to create social mobilization messages that
will be disseminated on social media platforms.2
High level officials and medical professionals should
take medications in public to improve public
confidence in the reliability of the medicines.
A public launch of the MDA will be held and local authorities and partners will
swallow the MDA medicines in public.
Social
mobilization
strategies
The program should publicize the location of sites that
can manage adverse events during the MDA.
The program will make adverse event management information available
through a toll-free hotline.
Schools are a key population that should be
emphasized during MDA, however limited school
information is available to staff, including lists and
enrollment numbers of schools in the treatment zone.
Schools will be prioritized during MDA. Data on school population will be
collected in collaboration with the Ministry of National Education and
Vocational Training (MENFP).
Distribution
strategies
MDA distribution hours should be shifted to include
Several communes will shift daily distribution times from 09:00 – 17:00 to
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1 Some actions described in this table were devised by partners based on feedback from the microplanning process or other MDA improvement activities in response to stakeholder feedback and suggestions
2 Link to social media https://www.instagram.com/p/BifOhCVBfFM/?utm_source=ig_web_copy_link
early evening hours to capture populations who are
working or unavailable during working hours.
10:00 – 18:00 hours; however, other communes will maintain the original
distribution hours due to security concerns.
Leaders and drug distributors have difficulty reaching
populations who live/work in restricted access zones
(e.g., industrial areas or gated communities).
For leaders affected in restricted access zones, a specific distribution strategy
will be developed with the list of key partners in support.
Some zones have insufficient personnel to adequately
serve the targeted populations.
Two additional promoters will be assigned to support MDA activities in the
Grand Ravine and Tibwa area of Port-au-Prince commune.
Upon harmonization of supervision area boundaries,
stakeholders recognized that several MDA distribution
posts were located in neighboring supervision areas or
communes.
Several leaders’ posts were identified for re-location to access. A Cité-Soleil
leader will supervise posts in bordering Port-au-Prince, due to hesitation of
Port-au-Prince leaders to work there due to insecurity. However, these posts
will be counted as part of the Port-au-Prince coverage figures.
Several areas had insufficient distribution post
coverage (e.g., mountainous areas within Carrefour
commune).
Distribution posts will be reorganized to provide better coverage of the
supervision areas, particularly in the mountainous areas of Carrefour
commune.
Mop-up should be conducted after the initial MDA
campaign to maximum coverage.
Both passive and active mop-up strategies will be implemented after the 5-day
MDA campaign.
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275 Several challenges were identified that were unable to be addressed fully by the LF program at
276 the time of the activity (e.g., participants from multiple communes noted a need to improve working
277 conditions for the leaders to achieve better results, noting a particular need for umbrellas at distribution
278 posts and increasing MDA stipends). Participants from Carrefour noted that lack of health facilities in
279 rural sections of communes pose a challenge for adverse events management. Participants from Cité-
280 Soleil noted the need to combat LF at different stages in the transmission cycle, especially as effluence
281 from factories creates sanitation concerns within the commune. Finally, the LF program staff presented
282 and validated the roles and responsibilities of CLs, CPs, and CDDs.
283
284 Respondent evaluation
285 Following the workshop, participants simultaneously evaluated their perceptions of their
286 capacity and engagement prior to and following the microplanning workshops using a retrospective pre-
287 test model. Evaluation questionnaires were completed by 339 (95.2%) workshop participants across all
288 five targeted communes, including two (0.6%) national-level MSPP staff, two (0.6%) departmental-level
289 MSPP staff, 68 (20.1%) community leaders, 227 (67.0%) community promoters, and 40 (11.8%)
290 community members (Table 2). Participant counts were approximately proportional to the underlying
291 commune population.
292 Table 2: Demographic characteristics of microplanning workshop participants (n=339)
Characteristics
No. (%) of respondents
Commune*
Carrefour
72 (21.2%)
Cité-Soleil
70 (20.7%)
Delmas
73 (21.5%)
Port-au-Prince
96 (28.3%)
Tabarre
28 (8.3%)
Role
National MSPP
2 (0.6%)
Departmental MSPP
2 (0.6%)
Community leader
68 (20.1%)
Community promoter
227 (67.0%)
Community member
40 (11.8%)
293 *Estimated population by commune in 2018: Carrefour=534,702; Cite-Soleil=277,180; Delmas=413,315; Port-au-
294 Prince=1,032,409; Tabarre=136,234.
295
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296 At baseline, understanding roles and responsibilities had the highest score 3.91 ± 0.91 (mean ±
297 standard deviation, SD), followed by perceived engagement 3.41 ± 1.07, SAs 3.29 ± 1.12, and past
298 performance 3.05 ± 1.00 (Table 3). The highest proportion of individuals providing a “poor” assessment
299 was seen within respondents’ understanding of the boundaries of supervision areas (n=8, 21%), while
300 the highest proportion of individuals reporting “excellent” was seen with understanding roles and
301 responsibilities (n=73, 28%).
302
303 Table 3: Retrospective pre-testing results collected following microplanning workshops held in
304 Port-au-Prince, Haiti in 2018
Pre-workshop
Post-workshop
Difference (post-pre)
n
Mean (SD)
n
Mean (SD)
n*
Mean (SD)
p-value
Past performance
303
3.05 (1.00)
302
4.37 (0.72)
283
1.34 (1.05)
<0.001
Roles/responsibilities
277
3.91 (0.91)
283
4.61 (0.60)
262
0.71 (0.95)
<0.001
Supervision areas
277
3.29 (1.12)
286
4.39 (0.82)
266
1.14 (1.30)
<0.001
Perceived engagement
281
3.41 (1.07)
286
4.45 (0.79)
268
1.03 (1.08)
<0.001
305 *Only individuals with complete pre- and post-workshop data were considered for a difference in pre- and post-
306 workshop scores.
307
308
309 When assessing the participants’ scores after the microplanning session, the elements
310 maintained the same rank order as in in the pre-workshop for the mean score for each metric, which
311 were in descending order (post-test mean ± SD): roles and responsibilities (4.61 ± 0.72), perceived
312 engagement (4.45 ± 0.79), SAs (4.61 ± 0.60), and past performance (4.37 ± 0.72).
313 Figure 2 shows the evolution of pre-post responses for each respondent, among complete pairs.
314 When comparing pre- and post-workshop scores, statistically significant improvements were seen in
315 scores across all four evaluation metrics (p<0.001). The smallest improvement was seen among
316 respondents’ understanding of their roles and responsibilities with 0.71 ± 0.95, while the greatest
317 improvement was seen in understanding of past performance with a mean improvement of 1.34 ± 1.05
318 (Table 3).
319
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320 Fig 2. Changes in participant understanding and perceptions before and after microplanning
321 workshops, Port-au-Prince, Haiti, 2018.
322 The alluvial charts track the individual-level dynamics in ratings before and after the microplanning workshops for
323 four indicators: (a) understanding of past performance; (b) understanding of SAs/zones of influence; (c) understand
324 respective roles/responsibilities in the MDA; and (d) perception of engagement by MSPP in the MDA planning
325 process. The left of each chart displays the distribution of participants’ ratings before the workshop, while the right
326 indicates the participant responses from after the workshop. Participants ranked their perception on a 5-point scale
327 where: 1=poor; 2=fair; 3=good; 4=very good; and 5=excellent. The width of the band corresponds to the relative
328 weight of persons with a particular before-after combination. The color of the band corresponds to the score at the
329 before timepoint, with red/orange colors representing lower before workshop responses.
330
331 The following alluvial charts show the individual-level dynamics in rating before and after the
332 stakeholder workshop. On the left of each chart, you see the distribution of rating before the workshop
333 with 1 representing “Poor” and 5 representing “Excellent,” while the numbers on the right of the chart
334 indicate the responses after the workshop. The thickness of the band represents the number of people
335 giving a particular response combination. The color of the band indicates the response at the time point
336 before the workshop; with orange/red colors representing lower before workshop responses. For
337 example, this band shows the 25 individuals who reported having a “Fair” understanding of their past
338 performance prior to the workshop, but an “Excellent” understanding of past performance following the
339 workshop.
340 MDA coverage
341 Based on results of the microplanning meeting, the 2018 MDA campaigns in all five communes
342 were extended from 4 to 5 days. MDAs were held from April 26 to June 4, 2018, sequentially in Tabarre,
343 Cité-Soleil, Port-au-Prince, Carrefour, and Delmas. Reported MDA coverage increased in all five
344 communes between 2017 and 2018 respectively with an increase from 50% to 120% in Tabarre, 50% to
345 93% in Cité-Soleil, 38% to 81% in Port-au-Prince, 37% to 72% in Carrefour, and 45% to 70% in Delmas.
346 Discussion
347 Microplanning outcomes
348 These evaluation results suggest that microplanning led to several important outcomes. First, the
349 lack of clearly defined and communicated supervision area boundaries was a central challenge to
350 ensuring broad access to the MDA in previous years. Using microplanning, program staff were able to
351 collaboratively define SA boundaries with all key stakeholders, thus minimizing likelihood of missing
352 underserved areas, efficiently allocating scare MDA resources, and avoiding duplication of efforts of a
353 limited workforce across the Port-au-Prince region. With this knowledge, stakeholders were able to
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354 collaboratively realign SA boundaries and commit to deploying posts within their respective SAs. The use
355 of digital mapping tools was critical for helping MDA stakeholders to visualize the targeted MDA area
356 and harmonize boundaries of their SA, without which harmonizing SA borders would have been
357 extremely challenging in this dense urban setting. Zonal maps provided needed documentation that
358 allowed CLs and CPs to plan and execute activities in their assigned areas, as well as more effectively
359 coordinate with staff in neighboring areas. The presence of numerous landmarks in urban settings and
360 orienting microplanning participants to their individual zone helped with the uptake and use of the
361 maps by CLs and CPs.
362 Second, the participatory workshops provided a forum for engaging various stakeholders in
363 identifying key MDA challenges and collectively designing locally appropriate, feasible and acceptable
364 solutions. For example, MDA staff from Port-au-Prince commune revealed that they did not cover
365 certain areas within the commune due to safety concerns. One such area was an economically
366 disadvantaged and underdeveloped area. In light of this, a CL from Cité-Soleil volunteered to cover these
367 areas to ensure that no service gaps existed. Furthermore, volunteers from the Delmas commune
368 expressed frustrations of being scheduled as the final commune to undergo MDA in the area as well as
369 concern that CLs from neighboring communes placed posts within their commune boundaries. They
370 feared that these factors artificially reduced their coverage figures, as members of the population were
371 already treated by neighboring communes. These concerns were supported by coverage data showing
372 progressively decreasing coverage figures as the MDA progressed sequentially across communes. The
373 refinement of SA boundaries and creation of zonal maps reduced the risk of cross-commune post
374 deployment.
375 Third, the microplanning activities provided previously unknown data and information that was
376 helpful in supporting other MDA strengthening initiatives. For instance, the distribution post census
377 allowed for the generation of unique identification codes for each distribution post. These codes were
378 then used to track post-based distribution data through real-time data collection, which permitted MDA
379 staff to track the daily progress of MDA in near real time and adapt MDA procedures to achieve
380 adequate coverage.
381 Finally, one of the most successful outcomes of the microplanning was an increase in community
382 engagement, program ownership, and motivation of MDA volunteers and stakeholders. By working with
383 CLs and other stakeholders to review distribution post distribution and refine SA boundaries, program
384 staff sense that stakeholders felt they were involved with the “highly technical work” of MDA planning,
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385 rather than passive actors. For example, several leaders took an initiative to conduct informal,
386 uncompensated mop-up activities beyond their allocated MDA days. Increased motivation was
387 corroborated by the results of the pre- and post-workshop surveys from participants attending the
388 microplanning workshop. The survey data provided additional insights into the perceived utility of such
389 participatory planning efforts from the perspective of MDA stakeholders. For example, although LF
390 program staff perceived themselves to be generally successful in conveying the MDA roles and
391 responsibilities to the various MDA actors, they reported further improvements after the microplanning
392 exercise when roles and responsibilities were reviewed and validated collectively.
393 The workshop evaluation supported research by Wodnik et al. with CLs, CPs, and CDDs in Tabarre
394 and Carrefour communes [35]. Their evaluation suggested that the LF program needed to improve
395 communication and feedback of the outcomes of the MDA rounds with the stakeholders, as well as
396 provide opportunities for collectively identifying and implementing strategies to improve MDA [35].
397 Further, their evaluation revealed that SAs were poorly understood by CLs, likely leading to missed
398 populations during previous MDA activities. Finally, they suggested that strategies such as
399 microplanning can be a successful approach for engaging MDA staff and can contribute to increased
400 program ownership and improved MDA outcomes.
401 We believe the experience in Port-au-Prince highlights several considerations that programs seeking
402 to increase MDA coverage though microplanning in other settings, particularly complex urban locations,
403 should consider. The strategy employed in this project was tailored to Port-au-Prince and based on
404 known challenges in the area and considered available local resources and needs. We trust the ability to
405 follow up the microplanning exercises with modified program strategies, such as developing new social
406 mobilization tools or distribution methods, in response to the results of the exercise was essential.
407 However, this requires sufficient time is available between the microplanning exercise and the MDA in
408 order to implement these changes.
409 The exercise also highlighted the importance of programs’ challenging their assumptions about
410 the reasons for low MDA coverage. The microplanning strategy uncovered barriers to MDA compliance
411 that were unexpected and previously unknown challenges. This allowed stakeholders to leverage local
412 knowledge to identify solutions that were acceptable to MDA volunteers and targeted communities.
413 This is consistent with findings from other studies that have suggested that such grassroots engagement
414 can yield a better understanding of the MDA, lead to a shared management of resources, and
415 responsibilities, and can ultimately lead to higher treatment coverage [13, 42].
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416 This evaluation had some limitations. Since Port-au-Prince is a large and complex urban setting,
417 it was not possible to engage all relevant actors in the microplanning workshops (e.g., private medical
418 sector who are influential on many individuals’ health decisions making and management of gated
419 communities who determine the ability to access these communities). The microplanning evaluation
420 surveys were limited by self-reporting of performance and engagement indicators, and hence, we
421 cannot assert that microplanning led to increases in specific knowledge or performance metrics as
422 microplanning was included as a broader MDA improvement initiative. Thus, it is not possible to
423 attribute improvements in 2018 MDA coverage to any one improvement strategy. However, the
424 increase in MDA coverage in all five communes in 2018 after years of gradual decline and the use of
425 microplanning results in other MDA improvement strategies supports our belief that microplanning
426 played a key role in improving MDA drug coverage in Port-au-Prince in 2018. Coverage was highest in
427 the earliest treating communes and decreased sequentially, which we hypothesize was due to
428 individuals from neighboring communes being treated and highlights the challenges of assessing
429 coverage during post-based MDA in complex urban settings.
430 We believe the results of this evaluation support that microplanning should be considered in
431 areas that are undergoing MDA for NTDs, particularly areas that have had historic challenges in
432 achieving adequate MDA coverage. Microplanning may be particularly useful in areas where it is
433 challenging to define the boundaries of work areas, and where the program has faced challenges in
434 providing feedback to MDA volunteers and staff. Finally, it is important to note that microplanning is an
435 iterative process and is ideally employed over successive rounds of MDA.
436
437 Acknowledgments
438 We would like to give special thanks to the community drug distributors, community promoters,
439 community leaders, and other stakeholders who enthusiastically participated in the microplanning
440 sessions and for their everyday efforts to eliminate LF in Haiti. We would also like to thank our partners,
441 namely the Ministry of Public Health and Population (MSPP) staff, RTI International, the Carter Center,
442 U.S. Agency for International Development (USAID), the Pan-American Health Organization (PAHO), and
443 the University of Notre Dame for their collaborative efforts to improve MDA coverage in Port-au-Prince.
444 We would like to thank Dr. Ryan Wiegand and Dr. Andrew Hill for their assistance in generating the
445 alluvial diagrams.
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19
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