Co-designing the ‘LEAD’ strategy: A theory-informed stakeholder-led behavioural intervention to improve mass drug administration compliance for lymphatic filariasis elimination in an urban block of Odisha, India

Introduction Sustained compliance with Mass Drug Administration (MDA) is essential for interrupting transmission of Lymphatic filariasis (LF). However, behavioural and system-level barriers persist to hinder its uptake. We aimed to explore determinants of MDA participation using behavioural frameworks and to co-design a theory-informed, stakeholder-led intervention to enhance MDA compliance. Methods A mixed-methods formative study was conducted between January and June 2025 in an LF-endemic block of Odisha, India. The quantitative component comprised a community-based KAP survey(n = 400) assessing knowledge, MDA coverage, and compliance. The qualitative component involved two focus group discussions and three key informant interviews with frontline health workers, community members, and programme supervisors to explore perceptions, barriers, and delivery challenges. Findings were mapped to the Theoretical Domains Framework (TDF) and the Capability–Opportunity–Motivation–Behaviour (COM-B) model to identify behavioural determinants and inform intervention design. Two stakeholder workshops were subsequently held to co-develop a contextually relevant implementation package. Results Among 400 survey respondents (mean age 46 years; 52% female), MDA coverage was 81% (n = 322), while MDA compliance was 57% (n = 229). The main reasons for non-compliance included fear of side effects (40%), misconceptions about the disease, and mistrust of government medicines. Qualitative findings revealed barriers in C apability (limited awareness, inadequate communication skills), O pportunity (weak supervision, irregular supply, competing workloads), and M otivation (low risk perception, fear, misinformation). Stakeholders jointly developed the ‘LEAD’ strategy ( L everaging existing community platforms, E ducation in schools, A wareness via digital media, and D elivery through Frontline Health Workers). LEAD integrates interpersonal communication by health workers, school-based education using children as health messengers, community mobilisation through self-help groups, and message reinforcement via digital media. Conclusion/Significance The study identified multi-level behavioural and operational determinants influencing MDA uptake in an endemic Indian setting. The LEAD package will be evaluated in the next phase of our study for feasibility, acceptability, and effectiveness in strengthening India’s LF elimination efforts.