Brief Communication
 
Lack of awareness, and attitude towards tuberculosis of health providers outside the ambit of DOTS centres
 
Surya P Bhatt*, Anant Mohan**, Charu Mohan**, Sudip Nanda#, Randeep Guleria**
*Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital, Iowa City, IA, USA
**Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
#Division of Cardiovascular Medicine, Lehigh Valley Hospital, Allentown, PA, USA.


Corresponding Author
: Dr. Surya Prakash Bhatt,
Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242
Email- surya-bhatt@uiowa.edu, Fax: 319-353-6406


Abstract

Efforts are being made to involve the private sector in caring for patients of tuberculosis (TB) in India, including attempts to implement private-public mixture in Directly Observed Therapy Short-course (PPMDOTS). A cross-sectional survey of physicians working in places outside the ambit of DOTS centres showed that there is poor awareness of diagnostic methods, therapy and attitudes toward patients with tuberculosis. The frequency of inappropriate therapy by private practitioners is high. There is an over-reliance on chest radiography for diagnosis and data maintenance is inadequate. There is a need for periodic update of knowledge for health care providers in the private sector.

The global burden of tuberculosis remains alarming despite the World Health Organization (WHO) and various national programmes’ efforts. Despite good Directly Observed Treatment-Short Course (DOTS) coverage, India still accounts for about one-third of the world’s TB burden and is one of the 22 high burden countries identified by WHO [1]. Even in areas with good DOTS coverage, many patients of tuberculosis continue to seek alternative sources of care.

Previous studies have shown use of inappropriate therapy by private practitioners, inadequate data maintenance, over-reliance on chest radiography for diagnosis, and inadequate mechanisms to ensure compliance and adherence to therapy [2]. Despite an awareness of the importance of involving the private sector in the ambit of national programmes, there have been few attempts in this direction. There has been some effort in the recent past to involve the private sector in caring for tuberculosis patients, including attempts to implement privatepublic mixture DOTS (PPM-DOTS). However, in the absence of stringent auditing, how effective the awareness drive has been, remains a matter of conjecture. This is especially so in places without DOTS centres, and data about health providers’ knowledge regarding standard practice remains scarce. We attempted to determine awareness and attitude towards tuberculosis of health providers in places without DOTS centres by performing a  crosssectional study of allopathic qualified physicians practicing in the private sector outside the ambit of DOTS centres.

Methods

This was a questionnaire-based survey of allopathic qualified physicians practicing in the private sector outside the ambit of DOTS centres. This included practitioners working in clinics, nursing homes and hospitals. Other non-qualified providers including traditional healers and providers of non-allopathic forms of medicine were not included. The questionnaire was distributed over a two-month period. The questionnaire assessed the awareness, knowledge and attitude of practitioners towards tuberculosis. The entire study was conducted in Gurgaon, an urban town in North India. The list of private health care providers was obtained from the yellow pages. In order to include unlisted practitioners, we also randomly included all practitioners within a 200 metre radius from the listed ones visited. All doctors were handed the questionnaire and were asked to fill them to the best of their knowledge. Filled questionnaires were collected back within a maximum of six hours. All data were tabulated on excel sheets and analysed using SPSS version 11.5 (SPSS Inc., Chicago, IL).

Results

Thirty six of the forty two practitioners approached responded. Average age of the physicians was 44.5 ± 12.2 years; 21 (58%) had postgraduate degrees. The median duration of practice was 14 years (range- 2 to 40). The break-up of responses provided is shown in Table 1. Six (17%) were afraid of contracting tuberculosis from patients though it affected treatment practice in only one of them. Twenty-eight (78%) preferred to treat the patients themselves and the most common reason for referral to DOTS centres were availability of free drugs (81%) and better drug compliance (22%). Fifteen (42%) used chest radiography alone for diagnosis of suspected pulmonary tuberculosis. Twenty (56%) started therapy if only one sputum sample was positive for acid fast bacilli; 42% failed to identify all first line drugs correctly while 14% misclassified second line drugs as first line ones. Fifteen (42%) treated newly detected pulmonary tuberculosis for 9 months or more as policy. Six (17%) advised pregnant patients to stop breastfeeding while 17 (47%) modified drugs in pregnancy. Only 21 (58%) had heard of the Revised National Tuberculosis Control Programme (RNTCP). While 30 (83%) had heard of DOTS, only three (8%) knew what it stood for. Only 6 to 17% could correctly identify appropriate DOTS categories for representative examples. Only one knew what DOTS plus stood for. Fifteen (42%) maintained records of the patients they treated.

Discussion

The present study shows that there is a very high rate of inappropriate therapy for tuberculosis in an urban centre amongst practices close to but outside the ambit of DOTS centres. This is due to lack of awareness of diagnostic and therapeutic options, and despite vigorous and protracted efforts by the WHO and various national programmes. The WHO estimates that 89% of the global population and 91% of the Indian population lives in areas covered by DOTS [2]. The good DOTS coverage has not translated into tangible improvements in the ground situation. Even in areas with good DOTS coverage, many TB patients continue to seek alternative sources of care.

India has one of the largest private health care sectors in the world, and private expenditure forms an estimated 87% of the total health care expenditure [3]. 50 to 86% of tuberculosis patients in India seek care from private practitioners [4-7]. This translates into about a fourth of the world’s TB burden as being managed by India’s private sector. There has been an increasing thrust to involve private practitioners in the management of tuberculosis in partnership with the government agencies working under the ambit of national programmes. One such programme is private-public mixture DOTS  (PPMDOTS). Roughly 3000 private practitioners and 750 non-government organisations are estimated to
be providing RNTCP services [2]. The impact and quality of these services remains unknown. In the absence of a determined standard of care, there is large variation in practitioners’ ability to deliver quality care.

Previous studies have individually reflected the findings of this study: use of inappropriate therapy by private practitioners, inadequate data maintenance, over-reliance on chest radiography for diagnosis, and inadequate mechanisms to ensure compliance and adherence to therapy [3]. Further, there is a lack of knowledge regarding optimal duration of therapy and management of pregnant women with the disease. There was a proportion of  doctors who misclassified anti-tubercular drugs as first line. This could have important ramifications with regard to emergence of resistance to second line drugs. The source of knowledge was diverse. The association of tuberculosis with HIV and the implications thereof seemed to be lost on a vast majority of those interviewed.

For convenience of logistics and time, the assessment focussed on urban areas. Also, the private practitioners tend to congregate in urban areas. Many of the high-burden countries have a large number  of tuberculosis patients among the urban poor. Since tuberculosis patients as well as practitioners in rural areas share many common characteristics with their urban counterparts, the findings will have relevance for a large number of patients of tuberculosis. Though the current study is small, in terms of number of doctors interviewed, it has highlighted the lack of awareness of various issues related to diagnosis and treatment of tuberculosis. Clearly, we have a long way to go before the seventeen standards for quality in TB care are met [7]. We suggest that private practitioners should receive periodic updates either through seminars and continuing medical education programmes or more practically, through dissemination of fact sheets with guidelines for treatment.



Key points
  • The present study highlights lack of awareness among private practitioners on various diagnostic and therapeutic aspects of tuberculosis.
  • The frequency of inappropriate therapy by private practitioners is high.
  • There is an over-reliance on chest radiography for diagnosis and data maintenance is inadequate.
  • There is a need for periodic update of knowledge for health care providers in the private sector.
References
  1. WHO, Global Tuberculosis Control -- Surveillance, Planning, Financing, 2011. Available at: http://www.who.int/tb/publications/global_report/en/. Accessed on Dec 17, 2011.
  2. Uplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak links intuberculosis control. Lancet 2001;358:912-6.[%PMID11567729%]
  3. Uplekar MW, Rangan S. Private doctors and tuberculosis control in India. Tubercle Lung Dis 1993;74:332-7.[%PMID8260666%]
  4. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private clinics in India. Int J Tuberc Lung Dis 1998;2:324-9.[%PMID9559404%]
  5. Ramana GNV, Naidu BMCS, Murthy KJR. Mapping of TB treatment providers in selected sites in Andhra Pradesh state, India. 1997. World Health Organization, Geneva.
  6. Nair DM, George A, Chacko KT. Tuberculosis in Bombay: new insights from poor urban patients. Health Policy Plan 1997;12:77-85.[%PMID10166105%]
  7. Pai M, Sharma SK. Are we providing quality care to our patients with tuberculosis? Indian J Med Res 2007;125:491-7.[%PMID17598932%]

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