Soil-transmitted helminth (STH) infections remain a global health concern with 600-800 million persons infected worldwide.1 The World Health Organization (WHO) recommends preventive chemotherapy through periodic mass drug administration (MDA) of anthelmintics for at-risk populations in endemic areas even without previous individual diagnosis.2 In the Philippines, preventive chemotherapy through MDA of anthelmintics is provided through the Integrated Helminth Control Program of the Department of Health since 2007.3 Since 2015, biannual MDA in school-age children (SAC) is done nationwide through a school-based, teacher-assisted approach.3
In 2013, the Philippines was devastated by the deadliest typhoon to hit the Philippines and 1 of the strongest tropical storms ever recorded, Typhoon Haiyan.4 Natural disasters, such as Typhoon Haiyan, led to several public health concerns in the disaster aftermath, including ensuring potable water supply, the establishment of adequate hygiene measures, control of the outbreak of endemic diseases, and the re-establishment of routine health programs.5 Loss of hygiene infrastructure is particularly concerning for its effect on STH infections, as increased open defecation and the loss of handwashing facilities promotes STH transmission, thereby increasing STH infections.
As the school-based MDA relies on social mobilization and health-care delivery services within a community,2 we aimed to understand how the deterioration of health infrastructure could have an impact on the MDA program for SAC. In particular, we wished to understand the posttyphoon concerns, experiences, challenges, and needs of the local health and education officials responsible for the MDA program. Learning from the perspectives of these officials is a first step in understanding the posttyphoon state of the MDA program in Capiz and Iloilo (Region VI) and the impact of this natural disaster on the MDA program.
METHODS
Study Site and Population
The study was conducted in the municipalities of Panay and Pilar in the Province of Capiz and the municipalities of Estancia and Sara in the Province of Iloilo. Capiz and Iloilo are on the Island of Panay in the Western Visayas Region. The study sites were selected due to the impact of Typhoon Haiyan, which reached Category 5 level, and the existence of the War on Worms Campaign.
Key Informant Interviews
We spent several weeks from June to July 2015 interviewing and collecting data from key informants (regional coordinators, provincial health officers, district supervisors) using semi-structured qualitative interviews. A qualitative approach was chosen to better understand the true experiences of community members and those overseeing health programs during this difficult time. Qualitative analysis allows for an empirically based insight into the personal experiences of key informants that would not otherwise be achieved through traditional survey methodology.Reference Giacomini and Cook6
Interview questions were designed and written both with considerations of being open-ended and explorative, and with consideration of cultural differences in language. As such, they were fully reviewed and edited by our collaborative partners at the University of Philippines Manila, before completion of interviews.
Participants were selected due to their experience, knowledge, and expertise through involvement with the MDA program and its processes. Additionally, these participants were serving as community leaders of the government health-care and school systems during the time of Typhoon Haiyan, so they shared the typhoon experience and posttyphoon circumstances of the communities they served.
All interviews were completed in English. Interviews were recorded using an audio recorder. All interviews were transcribed verbatim. As outlined per coding methodology in Patton’s Qualitative Research & Evaluation Methods, once the transcriptions were complete, each transcript was coded independently by 2 coders (authors E. Chernoff and G. Silverstein) in an open, editing manner.Reference Patton7 After each set of 3 interviews were coded, coders met and discussed their codes, assessed agreement in interpretation, and created the codebook in an iterative manner.Reference Patton7 The coding team reviewed the patterns among and relationships between codes to identify major themes.Reference Patton7 This analysis focused on themes related to participants’ perceptions regarding how the MDA implementation had been affected posttyphoon, as well as perceived additional factors that had a positive or negative impact on the MDA implementation.
Ethical Considerations
This study has been approved for exempt review through the University of Pittsburgh Institutional Review Board (PRO15030661) and has also been approved by the University of the Philippines Manila - Research Ethics Board (UPMREB 2015-267-01).
RESULTS
A total of 16 key informants participated in the interviews (Refer to Figure 1 for key informant roles). Overall, all participants spoke about many posttyphoon challenges that brought great distress to their communities.
FIGURE 1 Key Informants and Their Positions With the Department of Health (DOH), Department of Education (DepEd), and the Local Government Units or Municipal Level
Our participants described the following major themes: (1) the typhoon had little to no effect on the MDA program or on the resources necessary to complete the program; (2) the program’s simple design allowed for a 1-time administration to a pre-assembled population; (3) the program allowed a sense of community cohesiveness and return to normalcy; and (4) the program served as a vehicle for altruism, particularly regarding helping needy children, in this time of calamity. Table 1 provides examples of each theme with illustrative quotes from the key informant interviews.
TABLE 1 Themes Identified in Key Informant Interviews With Illustrative Quotes
DISCUSSION
Our study objective was to understand the posttyphoon state of the school-based MDA implementation in Capiz and Iloilo (Region VI) and the impact of this natural disaster on the MDA implementation from the perspectives of local health and education officials. The destruction due to natural disasters is a critical global health issue; however, very little data concerning the state of health programs after natural disaster devastation exists within the current literature. This study’s goal was to add to the literature regarding the state of the MDA implementation after Typhoon Haiyan and hoped to provide important knowledge regarding how a government established program in poverty-stricken regions can adapt after disaster.
The reasons for the continuation of MDA coverage were explored in the key informant interviews with regional and provincial coordinators. Based on these interviews, the MDA implementation was thought to be still effective posttyphoon. All participants stated that the strategy was able to be implemented after the typhoon and said this despite stating the pervasive damage that occurred after the super typhoon.
The MDA strategy had many key characteristics that led it to be successful in such a situation. The simple and school-based design of its implementation allowed for the ease of coordination amongst multiple organizations involved with the effort, including the schools, local government, and national government. The implementation of this strategy was also well established within the communities before the typhoon occurred and had been accepted as a necessary component of each child’s health within the community by the parents, teachers, and children themselves. Due to the system the program has established, the community responded to destruction caused by the typhoon with overwhelming mobilization for rehabilitation. This community mobilization was grounded in a focus on caring for each child in the community as a sense of altruism. This pervaded the beliefs of all participants and the descriptions of their community members as a means to combat typhoon devastation.
Despite the damage from the typhoon, all key informants indicated that school-based MDA was able to continue with SAC receiving anthelmintics to control STH infections. In an evaluation of pre-Haiyan MDA coverage rates in Capiz in January and July 2011, coverage rates ranged from 52.9% to 85.4%.Reference Sanza, Totanes and Chua8 In examining post-Haiyan rates of MDA administration, some participants spoke of a delay in the deworming process from the regularly scheduled time in January to February or March. Despite this delay in administration, all participants indicated that the medications were eventually administered between 3 and 6 months following Haiyan. Post-Haiyan MDA coverage in July 2014 was 90% in Capiz and 87% in Iloilo.Reference Belizario, Totañes and de Leon9 Post-Haiyan cumulative prevalence of STH infections in the municipality of Panay (within the province of Capiz) in December 2015, was found to be as low as 8.9% (V. Y. Belizario, Final surveillance report “War on Worms –Western Visayas,” Manila, 2015).
Our key informants spoke about the push to continue classes after the typhoon, even though 90% of the schools had been damaged in the highly affected areas.10 Region VI was 1 of those highly affected areas, which also included regions IV-B, VII, and VIII.10 Of the 1853 schools damaged, 7448 classrooms were reported to have sustained partial damage, while 3879 classrooms were destroyed.10 A total of 45% of these highly damaged schools referred to the Capiz and Iloilo regions affected.10 Based on the Typhoon Haiyan Strategic Response Plan prepared by the Philippines Humanitarian Country Team, school rebuilding and continuation was a high priority during the aftermath of the typhoon,10 which likely allowed for the MDA program to continue with a physical space and trained teachers to conduct the deworming.
Although we conducted only 16 interviews, we were able to reach thematic saturation: a point in our data collection when themes were continually maintained by participants as indicated by data replication or redundancy, indicating a sufficient number of interviews completed. In terms of project limitations, we did not explore potential differences in opinions between our key informants based on their differing roles in the health versus education sectors or in the local versus regional appointments. Additionally, these interviews were conducted 1 year and several months after Typhoon Haiyan, which could have led to potential recall bias when key informants were speaking of the time directly after the typhoon.
All interviews took place in English, and interview questions were updated to the Filipino cultural and language practices by the staff of the University of Philippines Manila research team. However, there may have been potential translation barriers based on local language and cultural difference by region that could have influenced comprehension for certain interviews. It is also important to note that those interviewed in English were all government officials of a higher level of educational attainment, and in turn, a higher socio-economic status (SES). In doing so, we would be potentially excluding the opinions of a broader SES population within our interviews.
Our study objective purposely focused on the perspectives of government officials. Interviews with other types of key informants (eg, general citizens, families, health-care providers) would likely generate different findings and themes. However, we chose to understand the perspective of these officials as they were the ones with the responsibility of implementing the MDA strategy and, thus, had relevant insights on the public health system’s challenges and resilience in efforts to control tropical diseases. Future studies are needed to examine the experiences, perceptions, and concerns of these other important populations.
CONCLUSIONS
Our study findings suggest components of the Philippine MDA Program that contributed to its resilience, such as its straightforward design, integration within the school system, community support, and its future-focus representing a return to normalcy.
Based on its effectiveness, the program with its MDA strategy may be useful as a model for other developing countries that are prone to natural disasters. More quantitative data surrounding the MDA coverage surveillance and current STH infection rates and intensities after Typhoon Haiyan could be beneficial in the future. Future studies should also include additional factors affecting MDA implementation (ie, sanitation, parent education, politics), the future of MDA strategy, measures to improve efficacy, and other public health programs that may have been affected by Typhoon Haiyan.
Funding
This study was funded by the University of Pittsburgh School of Medicine: Dean’s Summer Research Scholarship; the University Center for International Studies – International Studies Fund: https://www.ucis.pitt.edu/main/isf; and the Clinical & Translational Science Institute, University of Pittsburgh; http://www.ctsi.pitt.edu/; Grant Number UL1-TR-001857.
