***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: To test the hypothesis that widespread treatment with artemisinin derivatives can reduce malaria transmission , a mass drug administration ( MDA ) campaign was undertaken in an area of The Gambia in 1999 . Coverage of 85 % of the target population was achieved , but the intervention did not reduce overall malaria transmission . We studied the perceptions , knowledge and attitudes of the community to the MDA campaign . A vali date d question naire was administered to r and omly selected MDA participants ( n = 90 ) and MDA refusers ( n = 71 ) . Individuals who believed in the importance of the MDA ( adjusted OR 58.3 % ; 95 % CI 17.4 - 195.8 ) and those who were aware that a high level of participation was needed for the MDA to be successful ( adjusted OR 28.1 ; 95 % CI 10.3 - 75.9 ) were more likely to participate . Underst and ing that the purpose of the MDA was to reduce malaria ( adjusted OR 13.9 ; 95 % CI 5.5 - 35.1 ) and knowledge of the fact that malaria is transmitted by mosquitoes and of the clinical signs of malaria ( adjusted OR 3.4 ; 95 % CI 3.1 - 9.0 ) were associated with participation . Individuals who discussed the MDA with other villagers ( adjusted OR 5.5 ; 95 % CI 2.2 - 13.5 ) and those who attended the sensitization meeting ( adjusted OR 2.6 ; 95 % CI 1.1 - 6.0 ) were also more likely to participate . Women were significantly more likely to participate in the  MDA  than men ( adjusted OR 3.1 ; 95 % CI 1.5 - 6.2 ) . Individuals who refused to participate were unlikely to plan participation in future MDAs . One of the most difficult challenges in the implementation of a malaria control strategy such as an MDA is to convince villagers to participate and to make them aware that a high level of participation by the community is needed for success . We found that our sensitization meetings could be improved by giving more information on how the MDA works and finding means to generate small group discussion s after the meeting Background Effective mass drug administration ( MDA ) with anti-malarial drugs can clear the human infectious reservoir for malaria and thereby interrupt malaria transmission . The likelihood of success of MDA depends on the intensity and seasonality of malaria transmission , the efficacy of the intervention in rapidly clearing all malaria parasite stages and the degree to which symptomatic and asymptomatic parasite carriers participate in the intervention . The impact of MDA with the gametocytocidal drug combination sulphadoxine-pyrimethamine ( SP ) plus artesunate ( AS ) plus primaquine ( PQ , single dose 0.75 mg/kg ) on malaria transmission was determined in an area of very low and seasonal malaria transmission in northern Tanzania . Methods In a cluster-r and omized trial in four villages in Lower Moshi , Tanzania , eight clusters ( 1,110 individuals ; cluster size 47- 209 ) were r and omized to observed treatment with SP+AS+PQ and eight clusters ( 2,347 individuals , cluster size 55- 737 ) to treatment with placebo over three days . Intervention and control clusters were 1 km apart ; households that were located between clusters were treated as buffer zones where all individuals received SP+AS+PQ but were not selected for the evaluation . Passive case detection was done for the entire cohort and active case detection in 149 children aged 1 - 10 year from the intervention arm and 143 from the control arm . Four cross-sectional surveys assessed parasite carriage by microscopy and molecular methods during a five-month follow-up period . Results The coverage rate in the intervention arm was 93.0 % ( 1,117/1,201 ) . Parasite prevalence by molecular detection methods was 2.2 - 2.7 % prior to the intervention and undetectable during follow-up in both the control and intervention clusters . None of the slides collected during cross-sectional surveys had microscopically detectable parasite densities . Three clinical malaria episodes occurred in the intervention ( n = 1 ) and control clusters ( n = 2 ) . Conclusions This study illustrates the possibility to achieve high coverage with a three-day intervention but also the difficulty in defining suitable outcome measures to evaluate interventions in areas of very low malaria transmission intensity . The decline in transmission intensity prior to the intervention made it impossible to assess the impact of MDA in the chosen study setting .Trial Registration Clinical Trials.gov : Background Nearly 45 % of people living at risk for lymphatic filariasis ( LF ) worldwide live in India . India has faced challenges obtaining the needed levels of compliance with its mass drug administration ( MDA ) program to interrupt LF transmission , which utilizes diethylcarbamazine ( DEC ) or DEC plus albendazole . Previously identified predictors of and barriers to compliance with the MDA program were used to refine a pre-MDA educational campaign . The objectives of this study were to assess the impact of these refinements and of a lymphedema morbidity management program on MDA compliance . Methods /Principal Findings A r and omized , 30-cluster survey was performed in each of 3 areas : the community-based pre-MDA education plus community-based lymphedema management education ( Com-MDA+LM ) area , the community-based pre-MDA education ( Com-MDA ) area , and the Indian st and ard pre-MDA education ( MDA-only ) area . Compliance with the MDA program was 90.2 % in Com-MDA+LM , 75.0 % in Com-MDA , and 52.9 % in the MDA-only areas ( p<0.0001 ) . Identified barriers to adherence included : 1 ) fear of side effects and 2 ) lack of recognition of one 's personal benefit from adherence . Multivariable predictors of adherence amenable to educational intervention were : 1 ) knowing about the MDA in advance of its occurrence , 2 ) knowing everyone is at risk for LF , 3 ) knowing that the MDA was for LF , and 4 ) knowing at least one component of the lymphedema management techniques taught in the lymphedema management program . Conclusions / Significance This study confirmed previously identified predictors of and barriers to compliance with India 's MDA program for LF . More importantly , it showed that targeting these predictors and barriers in a timely and clear pre-MDA educational campaign can increase compliance with MDA programs , and it demonstrated , for the first time , that lymphedema management programs may also increase compliance with MDA programs A double-blind , community-r and omized , placebo-controlled trial was conducted in a rural area of The Gambia between June and December 1999 to test whether a reduction in the infectious reservoir can reduce malaria transmission . Overall 14,017 ( 85 % ) individuals living in the study area were treated with either placebo or sulfadoxine-pyrimethamine ( SP ) combined with a single dose of artesunate ( AS ) . Following the mass drug administration ( MDA ) 1375 children aged 6 months to 10 years were kept under surveillance for clinical malaria in 18 villages throughout the 1999 malaria transmission season . During a 20-week surveillance period 637 episodes of malaria were detected . The mean incidence rate was 2.5/100 child-weeks in the placebo villages , and 2.3/100 child-weeks in villages that received SP + AS . The mean rate ratio , adjusted for individual and village-level covariates , was 0.91 ( 95 % CI 0.68 - 1.22 , P = 0.49 ) . During the first 2 months of surveillance , the malaria incidence was lower in treated villages . After 2 months the incidence was slightly higher in the MDA group but this was not statistically significant . Overall , no benefit of the MDA could be detected . The reason for the absence of an impact on malaria transmission is probably the very high basic reproductive number of malaria , and the persistence of mature gametocytes , which are not affected by AS treatment OBJECTIVE To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions . METHODS A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon , Nigeria and Ug and a. Four trial districts and one comparison district were r and omly selected in each site . All districts had established ivermectin treatment programmes , and in the trial districts four other established interventions - vitamin A supplementation , use of insecticide-treated nets , home management of malaria and short-course , directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention ( CDI ) process . At the end of each of the three study years , we performed quantitative evaluations of intervention coverage and provider costs , as well as qualitative assessment s of the CDI process . FINDINGS With the CDI strategy , significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course , directly-observed treatment . The coverage of malaria interventions more than doubled . The district-level costs of delivering all five interventions were lower in the CDI districts , but no cost difference was found at the first-line health facility level . Process evaluation showed that : ( i ) participatory processes were important ; ( ii ) recurrent problems with the supply of intervention material s were a major constraint to implementation ; ( iii ) the communities and community implementers were deeply committed to the CDI process ; ( iv ) community implementers were more motivated by intangible incentives than by external financial incentives . CONCLUSION The CDI strategy , which builds upon the core principles of primary health care , is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa 
    Output:
    
Community engagement was often a process involving various activities throughout the duration of the intervention .