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Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 736-742

Directly observed therapy and repeat house-to-house visit: pincer movement for mass drug administration in West Bengal, India

1 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Forensic Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India

Date of Web Publication23-Jan-2017

Correspondence Address:
Dibakar Haldar
Anandapally, Sitko Road, Duttapara, Baruipur, Kolkata 700144, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.198792

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The aim of this study was to assess the effect of directly observed therapy (DOT) on coverage, the compliance of mass drug administration (MDA), and to find out correlates of noncompliance.
MDA for the elimination of lymphatic filariasis (LF) by 2015 in West Bengal (WB) has been criticized for undercoverage and mere distribution of antifilarial medicines for unsupervised consumption. To overcome these shortcomings, the government of WB adopted DOT for MDA.
Participants and methods
A cross-sectional survey was conducted in three villages of three blocks and two wards of one municipality of Bankura district, WB, India, selected randomly. Information was collected by interviewing inhabitants of randomly selected households.
Overall, appropriate medicine distribution and consumption were 71.31 and 53.21%, respectively. Multivariate analysis revealed that medicine consumption was higher among the following: participants who belonged to the Hindu religion; people of poor socioeconomic status; those who were distributed medicine by a routine health worker acting as drug administrators;; those whose consumption was supervised and those who had complied to MDA previously. Almost three-fourth consumptions were unsupervised. 58.73% respondents knew about LF and 42% knew about transmission; 50.79% had heard about MDA and 39.68% stated that MDA is to avoid LF. Noncompliance to the distributed medicines might be due to lack of awareness about LF and MDA. The reasons for noncompliance were as follows: 'fear of adverse reaction' (63.72%), 'didn't know why to consume' (23.89%), and 'healthy' (20.35%) were causes of noncompliance.
Despite DOT and repeat house visit coverage of MDA, we fell short of target. Mass mobilization with effective supervision is the need of hour for universal coverage of MDA with supervised consumption of tablets.

Keywords: compliance, directly observed therapy, elimination, lymphatic filariasis, mass drug administration

How to cite this article:
Haldar D, Sarkar AP, Saren AB, Mitra S, Samanta S, De A, Sarkar GN, Chakraborty P. Directly observed therapy and repeat house-to-house visit: pincer movement for mass drug administration in West Bengal, India. Menoufia Med J 2016;29:736-42

How to cite this URL:
Haldar D, Sarkar AP, Saren AB, Mitra S, Samanta S, De A, Sarkar GN, Chakraborty P. Directly observed therapy and repeat house-to-house visit: pincer movement for mass drug administration in West Bengal, India. Menoufia Med J [serial online] 2016 [cited 2020 Feb 16];29:736-42. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/736/198792

  Introduction Top

It has been estimated that 1254 million people in 83 endemic countries of the world are at risk for lymphatic filariasis (LF), 64% of which is contributed by the Southeast Asia region alone [1] . In India, it is 554.2 million in 243 districts [2] . India launched its National Filariasis Control Program in 1955. In 1998, the WHO had targeted the elimination of this disease and formulated a Global Program on Elimination of lymphatic filariasis. India's National Health Policy (2002) goal is to eliminate LF by the year 2015 [3] . The basic features of Global Program on Elimination of lymphatic filariasis are mass drug administration (MDA) with appropriate antifilarial drugs and morbidity management [4],[5] . Under this program, a National Filaria Day is being observed once a year, usually in the month of November, for MDA. On that day a single dose of antifilarial drug diethylcarbamazine (DEC) along with albendazole (400 mg) is distributed to inhabitants of all age and sex in filariasis endemic areas, excluding children below 2 years of age, pregnant women and severely ill patients [6] . The recommended DEC single dose (at the rate of 6 mg/kg of body weight) as follows: is one tablet (100 mg) for children of age 2-5 years; two tablets for those 6-14 years of age group; and three tablets for those greater than and equal to 15 years of age, along with a fixed single dose of albendazole one tablet of 400 mg [7] . It aims at cessation of transmission of filariasis by curbing the microfilaria (Mf) load in the community to less than 1%. To increase the participation in MDA, the existing chronic cases are line-listed during the MDA implementation and referred for management. MDA in combination with other techniques has already eliminated filariasis from Japan, South Korea, and 16 other countries, as well as markedly reduced the transmission in China [8] . MDA has been implemented since 2004 in India and all its LF endemic states including West Bengal (WB). However, different post-MDA coverage evaluation surveys (CESs) highlighted low coverage and consumption of antifilarial medicines. Moreover, independent appraisal carried out by vector control research center, Pondicherry, in the district of Birbhum and Bankura of WB in July 2014, revealed an Mf rate well over 1% (contrary to the target of <1%) in most of the sites of Night Blood Survey. Being strickened by abysmally high Mf rate and to achieve the target of LF elimination by 2015 the vector-borne disease control division of the Department of Health and Family Welfare, Government of WB, first placed emphasis on directly observed therapy (DOT) and repeat house-to-house visit, a paradigm shift in the strategy of MDA implementation. In previous rounds, DOT - that is swallowing of antifilarial medicines under supervision - has not been emphasized.

Research question

The research question of the study was to investigate the effect of new strategy (DOT and repeat house visit) in the implementation of MDA program in terms of coverage of drug administration and influencing factors of noncompliance, if any, in Bankura district, WB, India.


The aims of the study were to:

  1. Estimate the coverage rate of antifilarial medicine administration, as well as correlates of noncompliance in the last round of MDA.

    Assess the effect of DOT and repeat house visits with respect to antifilarial medicine administration in the last round of MDA, and to find out correlates of noncompliance if any.

  Participants and methods Top

A descriptive evaluation study was conducted in the form of community based cross-sectional survey carried out for a period of 1 week within 2 weeks after implementation MDA in the district of Bankura from 11 April 2015 to 13 April 15. For this purpose, the multistage random sampling method was adopted. First, the district Bankura of WB, India, was chosen purposively. Baseline details such as number of block primary health centers and subcenters (SC) under their jurisdiction, municipalities and wards, total eligible population, reported recoverage rates of last round of MDA in these blocks and the district, etc., were collected from the office of Deputy Chief Medical Officer of Health-II, Bankura. Of the 22 blocks of the district, 4, 14, and 4 blocks were in the arbitrary categories of low, medium, and high performing, with less than 80, 80-90, and greater than 90% MDA coverage rate in last round, respectively. All four municipalities had coverage rate between 80 and 90%. One block from each of low, medium, and high category and one municipality were selected by simple random sampling for post-MDA CES. Thus, the block Kanchanpur (low coverage, i.e. 67.6%), Khatra (medium coverage, i.e. 85.17%), and Taldangra (high coverage, i.e. 91.52%) along with the Bankura municipality (medium coverage, i.e. 87.15%) were selected for the purpose of survey. In the next stage, one SC was selected by simple random sampling out of the 23, 24, and 26 subcenters of Kanchanpur (Kesiakole SC), Khatra (Kashipur SC), and Taldangra (Saltore SC) blocks, respectively. Thereafter, from each selected SC, one village was chosen by simple random sampling. Likewise, out of 22 two wards (nos 5 and 17) of Bankura municipality were selected randomly. A household (H-H) list of the selected villages/wards was prepared. Subsequently, H-H was included following a systematic random sampling technique in such a manner that the criteria of both 30 H-Hs and 150 individuals from each village/ward were fulfilled. Thus, total 644 individuals were surveyed from 126 selected H-Hs with a breakup of 169, 167, 154, and 154 individuals from 30, 32, 30, and 34 H-Hs of villages from SC Saltore, Kashipur, Kesiakole, and ward nos5 and 17 of Bankura municipality, respectively.

Inclusion criteria

All individuals who were 2 years of age or older were included in the study.

Exclusion criteria

Pregnant women, lactating mothers, and seriously ill individuals were excluded from the study.

Information pertaining to type of family, age, sex, religion, caste, residence, education, occupation, per capita monthly income, category of drug administrator (DA) and their house-to-house visits before the implementation of MDA, information education and communication (IEC) for this round of MDA, receipt of DEC and albendazole tablets as well as status of consumption, reasons for nonconsumption, adverse events (AEs) and seeking care after AEs, awareness about LF and MDA, etc., by collected interviewing the responsible member (s) of the H-Hs using a predesigned structured questionnaire after obtaining informed consent. Relevant records/left out medicines, if any, were also scrutinized. Interviewees were shown flash cards and enquired about the presence of LF case in their villages, and whether the flash card was shown by DA. Socioeconomic status (SES) of respondents was determined using modified B.G. Prasad's scale updated in 2014. Approval from the Institutional Ethics Committee was obtained before study.

Limitation of the study

Limitation of recall was present. There was little scope for verification of information on tablet consumption as the survey was carried out after a couple of days since MDA implementation, and people failed to show empty strips of MDA medicines, which were disposed by that time. Moreover, all beneficiaries in sampled H-Hs could not be interviewed and the respondents might fail to recall the exact number of tablets given for and consumed by all members of family.

The data were described using proportion, mean, SD, and median and using statistical methods such as tables and diagrams for display. The statistical tests such as χ2 test and odds ratio with 95% confidence interval were used for drawing statistical inferences. Multiple logistic regressions were carried out for finding inter-relationship between variables. Microsoft Excel (Micro-soft Corporation Pvt. Ltd., Kolkata, India) and IBM SPSS statistics, 22 version, were utilized for analysis.

  Results Top

Overall 96.89% surveyed people were eligible for MDA, being 26.12, 25.32, 23.04, and 24.52% from the cluster Saltore, Kashipur, Kesiakole, and Municipality, respectively.

Baseline characteristics of study participants

There was slight male predominance (51.28%) among the study participants. Overall, 6.57, 18.43, and 75.0% were in the age group of 2-5, 6-14, and greater than 15 years, respectively ([Figure 1]), with average, median, and range of age 29.41 ± 17.93 (mean ± SD), 28 and 88 years, respectively. The majority (61.06%) of participants belonged to nuclear family and Hindu (90.06) religion; 37, 29, 18, and 16% were of general caste, scheduled caste, schedule tribe, and other backward classes (considering Muslims as other backward classes), respectively. Around one-third of the participants were illiterate or yet to schooling, one-tenth had education up to madhyamik pariksha and above. Overall, one-fourth of the study participant were reportedly student and home maker each. More than three-fourths (84%) of participants belonged to lower SES (classes IV and V).
Figure 1: Distribution of study participants as per age group.

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More than half (58.73%) of the respondents were aware about LF, of whom 87.84% reported swelling of the leg/foot/hand and 36.49% fever as symptoms of LF; 41.89 and 51.35% had awareness on transmission and ways of prevention. Overall 50.79% had heard about MDA before this round predominantly (71.88% of them) from health workers (HWs) and 28.12% from other sources such as miking/relatives. At the time of survey 52.38% of respondents knew the purpose of MDA and most of them (75.76%) reported avoidance of LF as the purpose.

Mass drug administration coverage and compliance

A substantial proportion (41%) of participants were distributed medicines through DAs other than routine HWs (mentioned as 'other') and many of them were not known to beneficiaries, especially in urban cluster ([Table 1]). However, in some cases, even routine HWs acted as DAs in areas other than their area of usual activity and were not known to beneficiaries. Overall 37.30% participants reported H-H MDA campaign by HWs before last round.
Table 1 Distribution of study participants as per few attributes and medicine distribution

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As a whole, 71.31, 90.38, and 71.31% of the beneficiaries were distributed DEC, albendazole, and both of them correctly. Overall 61.22 and 66.83% of study participants consumed DEC and albendazole tablets and 21.47 and 20.14% of the consumptions were supervised, respectively. It was found that 57.21, 66.51, and 53.21% of surveyed people consumed DEC, albendazole, and both tablets appropriately with a compliance rate of 332/445 × 100 = 74.61%. Altogether 5.45% individuals reported AEs, of whom 61.76, 35.29 and 14.71% complained of drowsiness, nausea, and dizziness, respectively. The median time for occurrence of AEs was estimated to be 1.5 h after consumption. However, only 11.76% consulted with concerned DAs.

Correlates of medicine distribution and consumption

Multiple logistic regressions revealed that consumption was higher among the following: participants who belonged to Hindu religion; people who belonged to low SES, such as laborers; those who were supplied medicines by the routine HWs; those who had consumed MDA in previous round; participants whose consumption was supervised; and of course those who had been supplied both medicines appropriately ([Table 2]).
Table 2 Multivariable analysis of correct consumption of both medicines and few attributes

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The noncompliance rate was 25.39% - that is individuals did not consume medicines even after having been distributed both of them correctly. The majority (63.72%) of individuals stated 'fear of side effects' as the reason of noncompliance. Other noteworthy causes were 'didn't know why to consume' these medicines (23.89%), 'inspite of remaining healthy' why should they consume (20.35%), and 'not at home' during MDA implementation (14.16%) ([Figure 2]).
Figure 2: Distribution of participants according to their awareness about the symptoms of lymphatic filariasis.

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  Discussion Top

As per WHO, DEC coverage in India was recorded as 54.5% during MDA program in 2006 [1] . MDA CES conducted by Sinha et al. [9] observed that the coverage, compliance, and effective coverage in Pashchim Medinipur district of WB were 84.1,70.5, and 59.3% in the year 2009, and with a declining trend of 78.5, 66.9, and 52.52% in 2010. Chattopadhyay et al. [10] in their MDA CES in 2010 in the district of Purba Medinipur, WB, reported an effective coverage rate of 73.7%. Raykarmakar et al. [11] showed coverage, compliance, and effective compliance rate of 72.87, 70.47, and 51.35%, respectively, in the district of North 24 Parganas (NPG), WB, in 2010. Roy et al. [12] documented an effective coverage of 41.18% in the district of Bardhaman, WB, in 2010. Ghosh et al. [13] estimated an effective coverage of 93.7% in the district of Bankura, WB, in 2012. Haldar et al. [14] revealed coverage, compliance, and effective coverage rates of 83.4, 61.28, and 48.01%, respectively, in district NPG, WB in 2012. As per the unpublished report (A. Gupta, S. Ghosh, A.P. Sarkar, and A. De) of similar CES conducted in the district of Bankura in 2014 reported coverage, compliance, and effective coverage rates of 97, 87.3, and 84.7% in 2013 and 97.23, 78.55, and 76.55%, respectively, for 2014. Unpublished CES report for the district of NPG, WB, in 2014 by R. Basu, S. Banerjee, D. Ghosh, and S.K. Lahiri (unpublished report) showed the estimated coverage to be 81.2%. All these reports are government sponsored post-MDA CESs and most of them have been published. The difference in their results for evaluating same program conducted in the same state of India following same standard methodological guidelines might be partly due to the variation in the efficiency of program implementing system in different districts, as well as the perception and motivation of local people. It is noteworthy that most of the studies reported coverage rates of below the desired cut-off (that is 85% or more). Similar trend was also noted in the present study, with an effective coverage rate of 53.21% even below the minimum of at least 65% for LF elimination [15] .

Universal unsupervised consumption in both 2009 and 2010 in the district of Purba Medinipur and in 2010 in NPG, WB, was reported by Sinha et al. [9] and Raykarmakar et al. [11]. Ghosh et al. [13] and Haldar et al. [14] also found 66.9 and 97.52% unsupervised drug consumption in 2012 in NPG and Bankura district, WB, respectively. A. Gupta, S. Ghosh, A.P. Sarkar, and A. De (unpublished report) stated that most of the consumption was unsupervised in Bankura district, WB in 2014. Unsupervised medicine consumption was alleged for suboptimal coverage in previous rounds, and DOT was emphasized in this round. Ironically, the DOT was found to be neglected in this round, with three-fourths (75.31%) of drug consumption unsupervised. Shifting priority on DOT seemed to be failed in making any dent on the problem. However, it was the first time DOT was emphasized and the hangover of mere distribution of medicines in MDA might yet to be overcome.

Clients' attributes for noncompliance to distributed medicines were revealed to be unaltered with respect to previous rounds. As per current study, 'fear of side effects' was the most common (63.72%) cause of noncompliance, followed by 'didn't know why to consume' (23.89%), and 'no drug required for a healthy person' (20.35%). This is in agreement with the findings of Haldar et al. [14] , who found that 'fear of side effects' was the most common (63.02%) cause of noncompliance, followed by 'not aware/counselled' (24.48%), and 'no drug required for a healthy person' (13.54%) in NPG in 2012. Chattopadhyay et al. [10] also revealed 'fear of side effects' as the most common cause (41.5%) of noncompliance in Purba Medinipur district, WB, in 2010.

'Fear of side effects' was found to be the most common cause, but ironically AEs were reported only in 10.24%, and that too minor in nature developed within 24 h; no care was sought by most of the victims. This was observed by Haldar et al. [14] as well as, who reported an incidence of only in 5.08% in NPG. Aswathy et al. [16] also reported that only 2.7% of interviewees who had ingested the distributed tablets reported AEs and these were mild (fever, drowsiness, swelling/edema, and/or vomiting) and only occurred within 24 h of tablet ingestion. Chattopadhyay et al. [10] reported that only 2.0% complained of minor AEs.

Other less contributing factors behind noncompliance were forgetfulness, not at home, mixing of tablets for all members of family, etc.; however, lack of awareness of beneficiaries as regards LF was one of the important reasons for their demotivation.

Current study revealed that around six out of every 10 respondents were aware of LF, of whom about 42.0% had correct knowledge about the transmission of LF, and around 51.0% had heard about MDA before last round. Pre-MDA house visit for this round was paid by HWs only in 37.30% of H-Hs. Haldar et al. [14] observed that almost two-thirds of respondents had awareness about LF, about 47.0% had correct knowledge about transmission of LF, and 60% had heard about MDA predominantly (47.68%) from HWs. Pre-MDA visit for this round was paid by HW only in one-tenth of H-Hs. Chattopadhyay et al. [10] explored that 85.1% of respondents were aware of filariasis and 38% knew its mode of transmission. Low awareness level was reported by Ghosh et al. [13] (about 60%) [13] , Raykarmakar et al. [11] (55.42%), Roy et al. [12] (41.4%), and Sinha et al. [9] (55.42%) as well. Suboptimal IEC might be responsible for this dismally poor awareness.

Muslims were found to be less compliant, as Njomo et al. [17] reported from Keniya that religion was significantly associated with compliance - for example, about one-half (49.1%) from the high compared with 34.3% from the low compliance villages were Christians, and 40.6% from the low compared with 29% from the high compliance villages were Muslims (P < 0.001; χ2 = 24.021; d.f.=3). However, Amarillo et al. [18] from Philippines observed 60% overall compliance but no influence of religion. Religious difference as revealed in present study might be attributed to the feeling of untrustworthiness/unfaithfulness of beneficiary on the upstart, nonmedical DAs belonging to other religion, similar to what happened during intensified pulse polio-immunization. There might be other misconceptions or religious beliefs which could not be explored from this study with a cross-sectional quantitative approach.

The present study observed that the incidence of improper medicine distribution and lack of compliance were higher among the participants who were distributed medicines by DAs other than routine HWs, and it was corroborated with the observation made by Haldar et al. [14] from NPG and Mahalakshmy et al. [19] , who also reported lower compliance rate among participants who were distributed medicines by volunteers.

Careful selection, rigorous training/reorientation, and strict supervision cannot be overemphasized in case of deployment of DAs other than routine HWs as it was rightly suggested by investigators for the sake of better program performance.

With due apprehension about the consequence of dismal undercoverage and noncompliance, Joseph et al. [20] concluded from their study in Samoa that persistent transmission in residual areas, despite many years of MDA, might be in part due to systematic noncompliance of infected individuals who maintained the chain of transmission serving as reservoirs, thus impeding successful elimination of LF.

Take home message

  1. In its inception DOT seemingly could not break the trend of the program system toward mere distribution of antifilarial medicines for unsupervised consumption.
  2. Undercoverage/noncompliance could be resulted from low awareness and interest of people about LF and MDA due to suboptimal IEC components of program.
  3. Casual mindset of providers and beneficiaries might be partly due to the fatigue of prolonged program implementation as well as to the apparent benign nature of LF - for example, lack of epidemic potentiality, long incubation period and gradual onset and progression to serious stage, etc., - which are enough to confuse lay people to correlate the disease with mosquito bite.

  Conclusion Top

Unsupervised reported short of target consumption is to be considered seriously to achieve LF elimination, as well as to prevent resistance to MDA. Rethinking on program implementation utilizing only the HWs as DAs for few more days for drug administration and mop-up may be tried in the next round to ensure universal DOT. After the first round of pincer strategy it can be said that mixed strategies of DOT and repeat house visit would turn the wheel turn in reverse direction. Intensive social mobilization through powerful advocacy, behavior change communication for motivating the systematically noncomplaints for participating in MDA, effective microplanning, supportive supervision of all levels of workers are highly required for the success.


The authors sincerely thank the Deputy Director of Health Services (P.H. and C.D.), Government of West Bengal, India, for giving financial and technical support.

The authors received the financial aid (INR 15 000/only) and technical quide from Deputy Director of Health Services (P.H. and C.D.), Government of West Bengal, India.

Dibakar Haldar contributed to concept, design, and sampling of the study. Dibakar Haldar, Aditya Prasad Sarkar, Satabdi Mitra, Sumana Samanta, Arindam De carried out data collection. Dibakar Haldar, Satabdi Mitra, Sumana Samanta, Prabir Chakraborty carried out data compilation and analysis. Dibakar Haldar, Satabdi Mitra, Sumana Samanta, Arindam De, Prabir Chakraborty contributed to drafting of the results. Aditya Prasad Sarkar, Asit Baran Saren, and Gautam Narayan Sarkar contributed to critical review of the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]


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