Awareness and Participation of Lymphatic Filariasis Patients in Mass Drug Administration of a Gram Panchayat Area of West Bengal

INTRODUCTION WITH OBJECTIVES

Lymphatic filariasis (LF) is classified as a neglected tropical disease, affecting 863 million people across 47 countries. Preventive chemotherapy is crucial to halt the spread of this parasitic infection.¹ The National Health Policy (2002) aimed initially to eliminate LF in India by 2015, but this target was later postponed to 2021.² The global objective was established to eliminate LF by 2020, which was later revised to 2030.³ Annual mass drug administration (MDA) is a vital component in eliminating LF. MDA now entails administering a single dose of diethylcarbamazine citrate (DEC) along with albendazole. This MDA program should continue for at least 5 years, targeting a minimum of 85% actual drug compliance to eliminate the disease from a geographic region effectively. Therefore, it is crucial to evaluate the acceptance and compliance of MDA among the target population beneficiaries.⁴

Diethylcarbamazine effectively targets parasites. By conducting mass annual single-dose drug administration and selective vector control, we can potentially eliminate the infection by disrupting the transmission cycle. This MDA should be performed annually for five consecutive years.⁴Even though MDA began in our country in 2004, we have yet to reach our desired outcomes. Therefore, it is crucial to evaluate how drugs are distributed and utilized by the intended beneficiaries at the community level. Numerous community-based studies have already reported the same,^5-11but coverage and subsequent compliance among affected LF patients are scarce in Indian Settings. Only one study in the Southeast Asian region has documented the coverage and compliance of MDA among LF-affected patients.¹² With this background, the present study was conducted to assess the awareness and participation of patients suffering from LF about MDA.

MATERIAL AND METHODS

This community-based, cross-sectional study was conducted in the Gourbazar Gram Panchayat area between 2019 and 2020. The region encompasses seven villages: Gourbazar, Guthuliya, Madhaiganj, Baidyanathpur, Bhabanandapur, Srikrishnapur, and Aamdahi. This area serves as the rural field practice site for IQ City Medical College located in Durgapur, Paschim Burdwan District, West Bengal. Around 2707 households are found across these villages, with a total population of 11661.

All these households were visited, and any one responsible member of these households was shown the Flash card.¹ They were asked to identify whether any family member was suffering or not with the picture shown on the flash card. A flash card included the pictures of lymphoedema, hydrocele, painful swelling in groin/axilla, with a history of frequent attacks of fever and chills. This was in accordance with the erstwhile “National Vector Borne Disease Control Program” guideline presently known as “National Center for Vector Borne Diseases Control Program.”¹ In this way, 115 LF-affected patients were identified, and all were recruited for the present study. Study participants were interviewed face-to-face regarding awareness and participation in the last MDA campaign. The Institutional Ethics Committee approval was obtained, and the study was conducted after prior consent from study participants.

The variables considered for awareness and participation in MDA included: Having heard about MDA, sources of information regarding MDA, the most effective source in order of priority, any reservations about the drug distributor, receipt of drugs in the last MDA, receipt of counseling from drug distributors, being asked to consume drugs in front of drug distributors, consumption of the drugs, reasons for non-consumption, experiences of side effects after taking MDA, receipt of a remedial drug if side effects occurred, and encouragement from neighbors, relatives, and friends to consume the drugs during the campaign.² An “eligible population” for MDA coverage includes individuals aged 2 years and older, excluding pregnant women and severely ill individuals. “Coverage” refers to the percentage of eligible individuals who received both drugs, DEC and albendazole, during the MDA round. “Compliance” denotes the percentage of individuals who reported having taken both drugs among those who received the drugs.²

The proportion was calculated from categorical data. Pearson’s Chi-square test was performed to determine the association between gender and different outcomes. Yates’ corrected Chi-square and Fisher’s exact Chi-square tests were employed to find the association in a 2 × 2 contingency table, where the expected cell value in one of the cells was between 5 and 10, and <5, respectively.¹³ Statistical analysis was done by Statistical Package for the Social Sciences software (version 20.0), and p ≤ 0.05 was considered statistically significant.

RESULTS

A total of 115 patients were identified, with an average age of 50.08 years. Of these, approximately 49.6% were male, and the majority of the study participants (52.3%) belonged to a lower-middle class, as defined by the modified Bal Gobind Prasad socio-economic status scale. Most filariasis patients (91.3%) were aware of MDA related to filariasis in their locality, and the distribution was nearly equal between males and females. The majority of filariasis patients (77.1%) learned about MDA from accredited social health activists (ASHA) workers, followed by anganwadi workers (21%) from the Integrated Child Development Services Scheme (ICDS) center. Only two patients (one male and one female) heard about MDA from the rural health unit and training center. No significant difference was observed when comparing ASHA to the combined (ICDS + Rural Health Training Centre [RHTC]) in both genders. Regarding the priority of receiving MDA drugs, all of them (100%) expressed a preference for ASHA workers and Anganwadi workers. Except for two male patients, none of them had any reservations about the drug distributor. He had the opinion that somebody else could have been better at distributing drugs, though he could not suggest any alternatives [Table 1].

About 88.7% (102 out of 115) of patients received medication in the recent MDA campaign. The percentage of female patients was slightly greater than that of male patients, yet the difference was not statistically significant. Approximately four-fifths (78.4%) of those who received medication in the last MDA campaign also received counseling in the preceding campaign. The distribution between males and females was nearly equal, although there was a marginally higher proportion of females. Among the patients who received drugs in the last MDA campaign, 39.2% were advised to consume drugs in front of the drug distributors. Males were significantly more likely than females who were advised to consume drugs in front of drug distributors. Out of the 102 patients who received drugs in the last MDA campaign, 18.6% of them did not consume the drugs, and the distribution was more or less similar in the two groups, with a higher proportion among males (22.4% vs. 15.1%). Thus, the overall effective compliance rate was found to be 81.4% (83/102). The reasons of non-compliance were cited as fear of side effects (36.7%), not satisfied with MDA (26.2%), refused by family member (5.3%), not present at home (5.3%), did not meet healthcare workers (5.3%), lack of awareness (5.3%), suffering from other disease (5.3%), fear (5.3%), and did not receive counseling to consume the drugs (5.3%). Out of the 83 patients, 77.1% did not experience any side effects of the drugs in the last MDA campaign. A higher proportion of female patients experienced side effects, and the association between side effects and gender was found to be statistically significant (ρ = 0.02). Except for one male patient, none of the other 19 patients received any remedial drugs after experiencing side effects [Table 2].

Out of the total 108 patients, 63% encouraged their neighbors to take MDA drugs in the last campaign, while the rest 37% did not encourage their fellow neighbors, with almost equal gender distribution in the two groups without any significant difference (χ² = 0.02, df = 1, ρ= 0.88). Side effects of the drugs (52.5%) and non-satisfaction (27.5%) were the main reasons behind the non-encouragement of the neighbors.

DISCUSSION

Most of the filariasis patients (91.3%) were aware of MDA related to filariasis in their locality, with a median duration of awareness of 3 years. Approximately three-fourths of them learned about MDA from ASHA workers, followed by anganwadi workers from the ICDS center. Cabral et al. also noted that about 80% knew about MDA, and the main source of information was healthcare workers (68.3%),⁵ similar to the present study. In contrast, Dharukaswami et al. and Roy et al. found that only 45.4% and 58.0%, respectively, had knowledge regarding the MDA programme.^6,7 Ghosh et al. found leaflets (20.3%) and posters (9.8%) as major sources of information for the surveyed families.⁸ Mukhopadhyay et al. documented that 77.87% of respondents came to know about MDA from health personnel and 20.87% through media (Television [TV], radio, and miking), whereas nongovernmental organizations had very little involvement (1.24%).⁹ The Female Community Health volunteers, health workers, and radio/TV were the chief sources of MDA-related information in a study conducted by Adhikari et al. in Nepal.¹⁰ Awasthi et al. found TV, radio, and newspaper to be the major source (62.5%) for awareness about MDA in Kerala.¹¹

Research on MDA awareness has focused on a community approach within the eligible general population. In contrast, the present study evaluated awareness solely among LF patients, making the proportions not directly comparable to those found in general population studies. Only one study, conducted by Ipa et al., closely mirrors the present research, as it examined LF-affected individual patients.¹² About 88.7% of patients received drugs, and 78.4% of them also received counseling in the MDA campaign in the present study. Ipa et al., in Indonesia, found coverage and compliance of 100% and 70.1% among LF patients.¹² Ghosh et al. showed that 98.8% received both the drugs in MDA;⁸ but only 17% of them were advised to consume drugs in front of the drug distributors. Furthermore, among the 102 patients who received medication during the last MDA campaign, 18.6% did not take the drugs at all. Consistent with the current findings, Hussain et al. (2014) reported that in the endemic districts of Odisha, 99% of the study participants were given DEC and albendazole tablets during MDA; however, only slightly over a quarter actually consumed the drugs.¹⁴ Ghosh et al. also revealed that about 5% of the recipients took none of the drugs, and more than two-thirds of the families took unsupervised doses.⁸ Adhikari et al. in Nepal in 2015 found the coverage of MDA as 95.5%, though the actual consumption was less.¹⁰ Dharukaswami et al., in their study in Bidar district, Karnataka, found that overall coverage of MDA was 62.3%. Compliance among those who had received the tablets was only 60.4%.⁶ Mukhopadhyay et al. reported that out of 5015 who received DEC tablets only, 3242 (64.64%) actually consumed the tablets.⁹ The main reasons of non-compliance in the present study came out to be fear of side effects, not satisfied with MDA (26.2%), refused by family member (5.3%), lack of awareness (5.3%) etc., which was also supported by Ghosh et al.,⁸ Adhikari et al.,¹⁰ Dharukaswami et al.,⁶ and Hussain et al.¹⁴ In most of the situations, MDA was restricted to tablet distribution only, which was attributed to improper training of service providers and a lack of community awareness. In the present study, 22.9% of patients experienced side effects after receiving the drugs, and except for one male patient, none of the other 19 patients received any remedial drugs. In line with the current study, Adhikari et al. found that approximately 20% of participants experienced side effects following DEC administration, with just 3.9% reporting a specific issue treated.¹⁰ The occurrence of adverse events was found to be 0.2% by Dharukaswami et al.⁶ In a study conducted by Sunish et al. in Andaman, 4.2% of people who received drugs developed side effects, which were mild and managed by paramedic staff and medical officers.¹⁵ About 37% of participants did not encourage their fellow neighbors to consume drugs in MDA. Lack of knowledge (57.7%) and side effects of the drugs (42.3%) ought to be the main reasons behind the non-encouragement of the neighbors, as also found out by different researchers across the world.^{5,6,8,10,14,16}

CONCLUSION

The healthcare workers distribute drugs in a timely manner. However, not all eligible individuals are consuming. Fear of side effects, dissatisfaction, ignorance, lack of initial counseling, and lack of direct observation were reasons behind non-consumption. Moreover, side effects of the drugs and dissatisfaction were major barriers to encourage fellow neighbors for taking MDA. MDA efforts would extend beyond simply distributing the drugs. Health education, counseling about side effects, ensuring direct observation of consumption, monitoring for side effects among recipients, and providing remedial drugs when side effects occur are the need of the hour. Only then will we be able to eliminate LF by 2027, as envisaged in the National Symposium on India’s Roadmap to Eliminate LF.