A Mixed-Methods Investigation of Community Acceptability and Structural Drivers of Mass Drug Administration Non-Compliance in Northeast Nigeria

Community-level non-compliance with mass drug administration for neglected tropical diseases remains the primary obstacle to achieving elimination targets in Nigeria's Northeast zone, yet the structural and cultural determinants of non-compliance are poorly understood beyond the level of individual risk factors. This doctoral study used an embedded mixed-methods design to investigate community acceptability and the structural drivers of mass drug administration non-compliance for lymphatic filariasis, onchocerciasis, and soil-transmitted helminthiases across six communities in Gombe and Adamawa states. Quantitative data from structured household surveys (n = 480) measured compliance rates, disaggregated by age, sex, religion, and occupation. Qualitative data from 18 focus group discussions and 36 in-depth interviews with community members, religious leaders, community drug distributors, and programme officers were analysed thematically. Community drug distributor interviews provided implementation quality data. Non-compliance ranged from 27 to 46 percent across communities. Thematic analysis identified five structural drivers: historical mistrust rooted in vaccine rumour narratives, perceived drug side effects inadequately addressed by health workers, exclusion of pregnant and lactating women creating household-level hesitancy, religious authority opposition in three communities, and community drug distributor social capital gaps. Quantitative modelling confirmed religious opposition and prior side effect experience as independent non-compliance predictors (p less than 0.001). The study presents an evidence-based community engagement framework addressing identified structural barriers. Keywords: mass drug administration, non-compliance, neglected tropical diseases, community engagement, Northeast Nigeria.