|
OJHAS Vol. 10, Issue 4:
(Oct-Dec 2011) |
|
|
| Assessment
of Knowledge and Practices of Referring Private Practitioners Regarding
Revised National Tuberculosis Control Programme in Nagpur City - A
Cross Sectional Study |
|
Jyoti Khadse, Medical Officer, Amravati,
Sumit
Dutt Bhardwaj, Assistant Professor, Department of Preventive
and social Medicine, Chirayu Medical College, Bhopal,
Manisha
Ruikar, Associate Professor, Department of Community Medicine, VN Medical College,
Yavatmal. |
|
|
| |
|
|
|
|
|
|
Address for Correspondence |
3070/26, Shyambagh,
Mandir wali Gali, Near Everest Plaza,
Bhadawas
gate, Rewari - 123401
Haryana, India.
E-mail:
drsumit.bhardwaj@yahoo.co.in |
|
|
|
|
|
Khadse J, Bhardwaj SD, Ruikar M. Assessment
of Knowledge and Practices of Referring Private Practitioners Regarding
Revised National Tuberculosis Control Programme in Nagpur City - A
Cross Sectional Study. Online J Health Allied Scs.
2011;10(4):2 |
|
|
|
|
Submitted: Oct 20,
2011; Accepted: Jan 4, 2012; Published: Jan 15, 2012 |
|
|
|
|
|
|
|
| |
|
| Abstract: |
|
Objectives:
To assess knowledge, diagnostic and treatment practices of the referring
private practitioners of Nagpur city regarding Revised National Tuberculosis
Control Programme (RNTCP). Methods:
The study involved interview of 103 Private Practitioners (PPs) of Nagpur
city. Knowledge of private practitioners was assessed based on questions
related to diagnosis, categorization, treatment regimens & follow
up. Practices of private practitioners were assessed based on which
investigations and treatment regimen they advise & whether they
offer supervised treatment. Their willingness to get involved in the
programme was also recorded. Results:
Only 49 (47.6%) private practitioners knew sputum smear examination
as primary tool of diagnosis of TB. Only half, 52 (50.5%) of the private
practitioners knew number of categories of tuberculosis correctly and
64 (62.1%) private practitioners did know how to categorize TB patients.
Chest X-ray and Mantoux test (38.5%) was mainly used by the PPs for
TB diagnosis. 42.7% of PPs were prescribing treatment for TB and among
them only 8 were prescribing as per RNTCP guidelines and just one provided
treatment under direct observation. Different combination of HRZE and
HRZES was prescribed for variable period ranges from 2-8 months. And
only 12 (11.6%) private practitioners expressed their willingness to
get involved in RNTCP for TB control. Conclusion:
There is lack of adequate knowledge, diagnostic and treatment practice
among PPs as per RNTCP guidelines and further encouragement is required
for their participation in the programme.
Key Words:
Private Practitioner; Tuberculosis; Knowledge; Practices; India
|
|
Tuberculosis
(TB) is the cause of 1.8 million deaths annually; 98% of these occurs
in developing countries and among the poorest people of these countries.1
In 2008, there were estimated 9.4 million new cases equivalents to 139
cases per 100,000 population of TB globally.2
Multi drug resistance occurring primarily as a consequence of poor treatment
services, could lead to emergence of XDR TB if MDR TB is not managed
properly. There were an estimated 0.5 million cases of MDR-TB in 2007.
The country that ranked first in terms of total number of MDR-TB cases
in 2007 was India (131 000).3
The Indian Revised National Tuberculosis Control Programme began large
scale nationwide implementation of the World Health Organization’s
global tuberculosis control strategy (DOTS) in 1998 and has since expanded
rapidly. Today, almost half of patients with tuberculosis in India may
initially seek help from the private healthcare sectors, where diagnosis,
treatment, and reporting practices often do not meet national or international
standards for tuberculosis.4–6 Subsequent delays in diagnosis
and inadequate treatment may result in extended infectiousness, acquired
drug resistance, treatment failure, and high rates of relapse—all
of which may impair efforts for tuberculosis control in India. Collaborations
between the public and private health sectors, or public-private mix,
may be an important solution. Public-private mix has been defined
by WHO as strategies that link all healthcare entities within the private
and public sectors (including health providers in other governmental
ministries) to national tuberculosis programmes for expansion of DOTS
activities.7 And thus private practitioner has a important
role play to reach the Millennium Development Goal (MDG) related
to TB by 2015.
The
present cross-sectional study was carried out in OPD of TB & Chest
Diseases of Government Medical College & Hospital (GMCH), Nagpur
and at clinics of private practitioners in Nagpur city. RNTCP in Nagpur
city is under City TB Control Society of Nagpur Municipal Corporation
and City TB Officer is accountable for quality implementation of the
programme in all four Tuberculosis Units of Nagpur city. The department
of TB and Chest Diseases of GMCH, Nagpur is the head-quarter of one
of the four Tuberculosis Units of Nagpur city.
Total
452 newly registered Tuberculosis (TB) patients at OPD of TB & Chest
Diseases in the month of May and June 2008 and out of total 155 referring
private practitioners; 105 (67.8%) were from Nagpur city and 50 (32.2%)
were from outside Nagpur city. Only private practitioners from Nagpur
city were included in the study. Out of 105 private practitioners of
Nagpur city, 2 (1.9%) refused to participate in the study. Thus data
from 103 private practitioners was analysed finally. Out of 103 private
practitioners, 99 (96.1%) were interviewed using pretested proforma
to collect information about their knowledge and practices regarding
RNTCP. Only 4 (3.9%) private practitioners insisted on filling up the
same proforma on their own. Knowledge of private practitioners was assessed
based on questions related to diagnosis, categorization, treatment regimens
& follow up. Practices of private practitioners were assessed based
on which investigations and treatment regimen they advise & whether
they offer supervised treatment. Their willingness to get involved in
the programme was also recorded. Knowledge and diagnostic practices
of private practitioners were analysed against diagnostic algorithm,
treatment categories & regimens and case definitions in RNTCP. Data
thus collected was analysed using Microsoft Excel to obtain Percentages
& proportions.
Table 1 shows the distribution
of private practitioners. Out of 47 Allopaths, 17 were graduate doctors
and 30 were postgraduate doctors. Among 30 postgraduate doctors 21 were
physicians, 2 were surgeons, 3 had diploma in child health and 1 had
diploma in TB & Chest diseases. Among 34 Ayurved doctors, 10 were
postgraduate doctors. Out of 22 Homeopaths, 17 had degree and 5 had
diploma in Homeopathy.
Table 1:
Distributions of Private Practitioners According to their
Systems
|
Systems |
Private Practitioners |
|
No. (%) |
|
Allopathic |
47(45.6) |
|
Ayurvedic |
34(33) |
|
Homeopathy |
22(21.4) |
|
Total |
103(100) |
Private practitioner’s
Knowledge
Maximum,
72 (68.9%) private practitioners (PPs) had heard of RNTCP but only 37
(35.9%) of them knew full form of the same. Only 49 (47.6%) PPs knew
primary tool of diagnosis of TB (sputum smear examination). Time of
sputum collection remained un-answered by 65 (63.1%) PPs and only 27
(26.1%) knew it correctly. Almost one third, 34 (33.0%) PPs had incorrect
knowledge while 32 (31.0%) did not knew about action to be taken if
all sputum samples for diagnosis are negative. Only half, 52 (50.5%)
of the PPs knew number of categories of tuberculosis correctly while
46 (44.7%) did not answer. Maximum, 64 (62.1%) PPs did know how to categorize
TB patients and only 8 (7.8%) PPs knew categorization correctly for
each category. Treatment regimens of category I, II and III were not
known to 75(72.8%), 87 (84.4%) and 92 (89.3%) PPs respectively. Only
8 (7.8%) PPs knew treatment regimens correctly for each category.
Private practitioner’s
Practice
Only
38 (36.9%) private practitioners were using sputum microscopy as primary
tool of diagnosis and the remaining 65 PPs used different combinations
of investigations for diagnosis of TB were mainly chest X-ray and Mantoux
test (38.5%), followed by chest X-ray & sputum microscopy (23.1%)
and sputum microscopy, Mantoux test and CBC-ESR (13.8%).( Table 2)
Table 2:
Distribution of Private Practitioners according to their practices when
not following RNTCP guidelines for diagnosis
|
Practices of diagnosis TB |
Private Practitioners
(n=65) |
|
No. |
% |
| Chest X-ray
& Mantoux test |
25 |
38.5 |
| Chest X-ray
& sputum microscopy |
15 |
23.1 |
| Sputum
microscopy, Mantoux test and CBC-ESR |
9 |
13.8 |
| Sputum
microscopy & CBC-ESR |
7 |
10.8 |
| Chest X-ray,
sputum microscopy & Mantoux test |
6 |
9.2 |
| Chest X-ray,
sputum microscopy and CBC-ESR |
2 |
3.1 |
| Mantoux
test and CBC-ESR |
1 |
1.5 |
Out
of total 103 PPs, 59 (57.3%) were referring the patients
for treatment and only 44 (42.7%) were treating them. Out of 44 PPs
treating TB, only 17 were giving anti-TB medicines in two phases, intensive
and continuation. Out of these 17 PPs, 8 were prescribing treatment
regimens recommended by RNTCP & 9 PPs were prescribing daily regimens
(HRZE+HR), continuation phase of which varied from 6 to 8 months. Out
of remaining 27 PPs, 20 were prescribing HRZE & 7 were prescribing
HRZES, duration of which varied from 2 to 8 months. Anti-TB treatment
under direct observation was provided by just one, 1 (0.9%) private
practitioner. And sputum microscopy for follow up during anti-TB treatment
was advised by only 24 (23.3%). Very few only 12 (11.6%) private practitioners
expressed their willingness to get involved in RNTCP for TB control.
In our survey
of private practitioner in Nagpur city, we identified several knowledge
gaps, this includes gaps regarding diagnosis, categorization, regime
and treatment. PPs relied more on Chest X-ray and Mantoux test for confirmation
of clinical diagnosis and only 36.9% relied on sputum examination. A
study conducted by Uplekar MW in Bombay (1993) reported that only 38%
GPs relied on sputum examination.8 Similar findings were
reported from other studies.9-11 So diagnosis of tuberculosis
patient by PPs on the basis of X-ray, Mantoux and CBC/ESR subjects the
patients to unnecessary toxic medication and expense. Nearly half, 44
(42.7%) of the PPs were treating the patients, out of them only 8 PPs
were treating as per RNTCP guidelines ( but not under direct observation),
only 1 on direct observation and rest giving treatment either as daily
regime or not giving TB-medication in two phases. Different combination
of HRZE and HRZES were prescribed for variable duration ranging from
2 – 8 months and this variable treatment and duration might potentiate
the development of drug resistance. 57.7% of PPs were referring the
patient either to some private hospital or to TU. Thus some of the TB
patients are lost with out notification. Our findings are similar to
those of surveys done elsewhere in different part of the country by
by Thakur JS et al (2006)12 in Chandigarh and Baxi RK in
Vadodara (2006)13. Majority of the private practitioner did
not gave emphasis on screening the family member for TB, as contacts
of the tuberculosis patients are 10-60 times more likely to have disease
than the general population.13,14 However active case
finding is not a part of RNTCP but this strategy can help in diagnosis
of hidden burden of disease. Our study finding also revealed that only
11.6% of PPs were willing to be involved in RNTCP, this give us an insight
to find out various operational difficulties for involvement of PPs
in RNTCP and require further study to clearly know the reasons for their
non-involvement. RNTCP itself has a component of training and involvement
of PPs, but present study revealed this area need strengthening. There
is a need for better communication between the private doctors and those
implementing disease control programme, so as to enable them to follow
appropriate clinical and public health practice.
PPs have a
lot of scope for improvement in the management of tuberculosis as per
the RNTCP guidelines; they should also be encouraged to participate
in the programme and there should be better advocacy of the scheme to
ensure participation of private practitioner in to the programme.
We express
our sincere gratitude to the Department of TB and Chest medicine, Government
Medical College, Nagpur for their logistic support to carry out the
project. We also acknowledge the support and cooperation of the Medical
officer of the TU, Government Medical College, Nagpur.
-
World Health Organization.
Reaching the poor: challenges for the TB programmes in the Western Pacific
Region. Manila: WHO Regional Office for the Western Pacific; 2004.
- Global Tuberculosis Control:
Epidemiology, Strategy, Financing. Geneva, Switzerland: World Health
Organization. WHO/HTM/TB/2009.411 WHO/ HTM/TB/2009.411
- World Health Organization.
The Global MDR-TB and XDR-TB response plan. WHO, Geneva: 2007-08.
- Prasad R, Nautiyal RG, Mukherji
PK, Jain A, Singh K, Ahuja RC. Treatment of new pulmonary tuberculosis
patients: what do allopathic doctors do in India? Int J Tuberc Lung
Dis 2002;6:895-902.
- 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;2:324-329.
- World Health Organization.
The behaviour and interaction of TB patients and private for profit
health care providers in India: a review. Geneva: WHO, 1997. Report
No WHO/TB/ 97.223. Available at
http://whqlibdoc.who.int/hq/1997/WHO_TB_97.223.pdf
(Accessed 11 Oct 2011).
- World Health Organization.
Public-private mix for DOTS: report of the second meeting of the PPM
subgroup for DOTS expansion. Geneva: WHO; 2004. Report No WHO/HTM/TB/
2004.338. Available at
http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.338.pdf (Accessed 11
Oct 2011).
- Uplekar MW, Ranjan S. Private
doctors and tuberculosis control in India. Tubercle and Lung Dis
1993;74:332-337
- Prasad R, Nautiyal RG, Mukherji PK,
Jain A, Ahuja RC. Diagnostic evaluation of pulmonary TB: what do doctors
of modern medicine do in India? Int J Tuberc Lung Dis 2003;7(1):52-57.
- Suryakantha AH, Mendonca V, Tejaswini
HJ. A study of knowledge, attitude and practices of allopathic medical
practitioners regarding TB and its control in Davangere city. NTI
Bulletin 2006;42(1):5-8.
- Uplekar MW, Juvekar SK,
Parande SD, Dalal DB, Khanvilkar SS, Vadair AS, Ragan SD. TB in private
practice and its implication. Ind J Tub 1996;43:19-22.
- Thakur JS, Sekharkar S,
Behgal A, Kumar R. Private sector involvement in TB control in Chandigarh. Ind J Tub 2006;53:149-153.
- Baxi RK, Shah AR. Management
of TB by the general practitioners of Vadodara city. Indian J Commun
Med 2006;31(4):10-12.
- Schiling W. Epidemiology
and surveillance of tuberculosis in the German Democratic Republic.
Bull Int Tuburc Lung Dis 1989;65(2-3):73-74.
|
