|Year : 2021 | Volume
| Issue : 2 | Page : 81-85
Tuberculosis notification: Facilitators and barriers among private practitioners in Trichy, South India
Prabha Thangaraj, Kumarasamy Hemalatha
Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Trichy, Tamil Nadu, India
|Date of Submission||01-May-2021|
|Date of Acceptance||19-Dec-2021|
|Date of Web Publication||10-Feb-2022|
Dr. Kumarasamy Hemalatha
Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Trichy - 621 105, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Context: The framework for tuberculosis (TB) notification is one of the components of the World Health Organization's End TB strategy. Notification is essential for estimating the true burden of TB and its control in community which is currently lacking in the private health sector. Aims: The objectives are to identify awareness, willingness, barriers, and preferred methods of TB notification among private practitioners (PPs) in Trichy, South India. Methods: A descriptive cross-sectional study was conducted among 152 doctors working in the private sector and having at least 1 year of clinical experience using nonprobability sampling. A semi-structured, pretested questionnaire was used to obtain details about the general profile, awareness, and willingness regarding TB notification, as well as factors that facilitate and hinder it. Results: Among PPs, 90.7% referred TB cases/suspects to other health facilities and 71.7% were aware that TB notification is mandatory. Only 52.6% and 38.2% were ready to provide the patients' Aadhaar number and bank account details respectively during notification. The most common barriers for notification were: not being aware about the notification procedure (50.7%), lack of time (32.2%), process being tedious (29.6%) and difficulties in getting information from patients (25.7%). Mobile SMS/App/call (74.3%) were preferred by PPs over notification through online (32.2%) and government health staff (26.3%). Conclusions: Although three-fourth of the practitioners were aware and willing to notify TB, more than half of them were not aware about the notification procedure. Improving the awareness on the techniques for notification could motivate PPs to notify TB.
Keywords: Awareness, barriers, notification, private practitioner, tuberculosis
|How to cite this article:|
Thangaraj P, Hemalatha K. Tuberculosis notification: Facilitators and barriers among private practitioners in Trichy, South India. J Mahatma Gandhi Inst Med Sci 2021;26:81-5
|How to cite this URL:|
Thangaraj P, Hemalatha K. Tuberculosis notification: Facilitators and barriers among private practitioners in Trichy, South India. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Jul 1];26:81-5. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/81/337435
| Introduction|| |
In 2018, the incidence of tuberculosis (TB) in India was estimated to be 204 per 100,000 population, contributing to 26% of worldwide burden. India continues to account for about one-fourth of world TB cases in spite of various control activities implemented in the country for more than 50 years. The first major change in the National TB Programme took place in 1997 with the launch of the Directly Observed Treatment-Short course under the Revised National TB Control Programme (RNTCP). Despite the improved quality of services provided by RNTCP, there continued to be a TB epidemic which eventually led to significant initiatives that were introduced during the National Strategic Plan (NSP) 2012–2017 in terms of mandatory TB notification of all cases, integration of the programme under the National Health Mission, expansion of diagnostic services, programmatic management of drug-resistant TB etc.
TB has been declared a notifiable disease by the Government of India since 2012. The main objective of doing so is to support the private sector to follow standardized practices in terms of TB Care and help patients get the right diagnosis, treatment, follow-up, contact tracing, chemoprophylaxis and facilitate social support systems. The total TB case notification in Tamil Nadu for the year 2016 was 122 cases per 100,000, an overall increase of 17 per 100,000 from 2015. In spite of this increase, there is a gross disparity of TB notification by the public and private sector for the year 2017 which are 75,561 and 20,856 respectively. A few studies, done to assess the burden of TB based on sales of TB drugs, have found a huge sale of these drugs in private sector and need to re-estimate the real burden of TB.
TB notification is one of the key factors to aid in control of TB by providing essential data for evaluating the trend of the disease. There are only a few studies,,, done in India on TB notification among private practitioners (PPs). Mandatory TB notification has been recommended by the World Health Organization in such countries to provide effective health care services to achieve the goals of the End TB strategy. To assess the true estimate of TB cases and take action for control of TB in the community, notification, and surveillance need to be done. Earlier TB was notified only by the public sector. India has implemented mandatory TB notification since 2018 by both public and private sectors. This decision is essential because almost 50-80% of the health care services for TB are provided by the private sector. Hence, the present study was done to assess the awareness, willingness, motivating, hindering factors, and preferred methods of notification among PPs in Trichy, Tamil Nadu. This operational research provides information that might help public health planners to take necessary action for improving TB notification among PPs.
| Methods|| |
This cross-sectional descriptive study was conducted among the registered PPs who were practicing in and around Trichy district of Tamil Nadu. For the purpose of this study, PPs are “doctors those who are working as practitioners in private health care facilities including hospitals, nursing homes, clinics and teaching institutions and not employed in public health sector.” PPs of all specialties with a minimum of 1 year clinical experience were included in the study. Doctors working in the government sector and those practitioners who were engaged in both private and government sector were excluded. PPs who were not willing to participate and those who did not give consent were also excluded. In a study done in Chennai, Tamil Nadu, the proportion of practitioners aware about the notification process was 73%. Using prevalence as 73%, with an allowable error of 10% and level of significance as 95%, the sample size was calculated as 142 using the formula (1.96)2 pq/d2 and including nonresponse rate of 10%, the sample size was calculated to be 156.
A semi-structured, self-administered, anonymous questionnaire was prepared. Content validity of the questionnaire was determined by subject experts from the Departments of Community Medicine and Respiratory Medicine. Pilot testing was done among 10 PPs and necessary modifications were made. The questionnaire consisted of 3 sections. The first part included general information of practitioners (such as age, sex, and specialty). The second part had 2 sections. Section I included awareness and practice of TB notification process (such as awareness on whether TB has to be notified, if yes then the source of information, methods of notification, number of case confirmed and notified, etc.); Section II included perceived barriers and preferred method for TB notification (such as perceived factors that motivate and hinder TB notification process, and preferred method to notify). Nonprobability purposive sampling method was used and 162 PPs were approached. Of these 6 were not willing to participate in the study and 4 practitioners did not return the filled questionnaire in spite of 2 visits by the investigators. The total PPs included for data analysis was 152. The nonresponse rate was 6.2%. Ethics approval was obtained from the Institutional Ethics Committee of Trichy SRM Medical College Hospital and Research Centre, Tiruchirappalli. Informed, written consent was obtained from all PPs those who participated in the study. The data were entered into Microsoft Excel and data analysis was done using SPSS Version 21 (IBM Corp., Armonk, NY, USA). Descriptive statistical analysis was performed and the results have been presented in the form of proportions and means with standard deviations.
| Results|| |
A total of 152 practitioners participated in the study. Among them, 55.9% were males and 44.1% were females. The mean age was 38.34 ± 9.7 years ranging from 25 to 63 years. Median years of clinical experience among the practitioners was 10 years with interquartile range (IQR) of 12.75. Median number of TB cases suspected during the last 1 year by an individual practitioner was 6 (IQR = 15.5), while those diagnosed was 3 (IQR = 8). Median number of TB patients notified by PPs who treated TB patients themselves was 2 (IQR = 7). [Table 1] describes the general profile of all PPs who participated in the study.
Most of the PPs (90.8%) always/sometimes referred TB cases/suspects to other health facilities rather than treating it themselves. Of these 99 (71.7%) were referred to the government health facility. Majority (50.7%) of PPs stated availability of free drugs as a reason to refer TB patients to government health facilities, followed by high cost of treatment in the private sector (46.4%), 42.9% of PPs were not confident about treating TB patients, and therefore referred them [Table 2].
|Table 2: Reasons* for referral of tuberculosis suspects/cases by private practitioners (n=98)|
Click here to view
Among the participants, 77% were aware that TB is a notifiable disease and 71.7% knew that it is mandatory to notify the same. The most common source of information regarding mandatory notification of TB cases was through academic gatherings (55%) such as CMEs, workshops, and conferences. Only 31.6% were aware about the legal implications of failing to notify TB patients [Table 3].
|Table 3: Awareness about tuberculosis notification among study participants (n=152)|
Click here to view
More than 90% of PPs were willing to provide patient's name, age, gender, and treatment details during the notification process. Only 52.6% and 38.2% were ready to provide patients' Aadhaar number and bank account details, respectively [Table 4].
|Table 4: Proportion of private practitioners willing to provide personal and treatment details of tuberculosis patients during notification|
Click here to view
Most (63.8%) of the PPs felt that TB notification will help to control the disease. About 50% of PPs were unaware of the notification process. Other reasons stated for hindering notification were lack of time (32.2%) and the process being tedious (29.6%) [Table 5].
|Table 5: Factors motivating and hindering tuberculosis notification among private practitioners* (n=152)|
Click here to view
[Table 6] shows the preferred method for notifying TB. The use of mobile phones by sending SMS/App (57.2%) and direct phone call (34.9%) was the most preferred method by PPs.
| Discussion|| |
The present study was conducted among PPs to assess their awareness on TB notification process, perceived barriers, and their preferred method of notification. Of the 152 PPs, 90.8% referred TB cases/suspects to other health facilities, and of them almost 72% referred the cases to government sector. This is almost similar to a study done in Chennai where 78% referred TB patients to government health facility. The common reasons stated were availability of free drugs in government health facilities (50.7%), inability to afford care in the private sector (46.4%), and not being an expert in treating TB (43%). In a study conducted in Chennai, free drugs in government health sector and inability to afford treatment in private health facilities were the reasons for referral by 48% and 74% of PPs respectively. These findings suggest that PPs prefer to refer TB suspects and cases directly to the public health sector to decrease the cost of treatment. Moreover, they are also not confident about managing TB patients. Therefore there is a need to increase the availability of free drugs available to the private sector by public–private partnership through RNTCP and to train the PPs on TB management. In the present study, 77% of the PPs were aware that TB has to be notified which is similar to the awareness level reported by studies done in Chennai (73%) and Karnataka (79%)., Among the PPs, 71.7% knew that TB notification is mandatory which is less than the proportion of PPs who were aware (88%) about mandatory notification in a study by Thomas et al. In a qualitative study done in Pune, the participants were aware that TB has to be notified but not aware about the rationale, patient benefits, and details of notification. In the present study, about 30% were not aware about recent mandatory TB notification which implies that Continuing Medical Education programmes have to be conducted for PPs. The most common sources of information were academic gatherings (55%) and hence conducting frequent academic meetings specific for TB whenever a modification is done in the RNTCP would be a better method to communicate this information to all the practitioners. This could result in improvement in the patient care, follow-up, notification and other activities related to the programme. Almost 42% knew about mandatory notification since it is a routine procedure in their working institution. Hence, having institutional-level protocols to notify TB cases could be an additional measure to improve the notification rate among PPs. Our study found that almost 90% of the PPs were willing to provide personal details like name, age, gender, residential address, and treatment details of the patients during the notification process. However, only 52% of PPs were willing to provide patient details regarding Aadhaar card and bank account respectively. Thomas et al. reported that 23% PPs were comfortable about providing Aadhaar details during notification which is much less compared to the present study. In a study conducted in Kerala, 60% of the general practitioners felt it to be difficult to obtain details on government-issued identity number from the patients. With regards to providing bank account details of the patients, only 38% of the PPs in this study were willing to do so. This could probably be due to lack of awareness about the cash transfer scheme for treatment completion under RNTCP.
Almost 64% of the PPs in the present study felt that notification helps in controlling the disease which motivates them to notify TB cases which is similar to another report by Patil and Bathija. Not being aware about the process of notification (50.7%), lack of time (32.2%), notification process being tedious (29.6%), patient unwilling to provide details (25.7%), fear about loss of confidentiality (21.1%), and stigma for the patients (19.7%) were the common reasons stated by the PPs which hinders them from notifying TB. Few other studies done in India,, have also reported similar findings as barriers to notify TB. In a qualitative study done by Nair et al., loss of patient confidentiality was the most important reason stated as a barrier for linkage with the RNTCP by the practitioners. PPs who participated in a qualitative study by Satpati et al. suggested training and workshops on notification to disseminate the information on the process of notification which will make notification easier. We found that in spite of 75% of practitioners being willing to notify TB cases, more than half of them were not aware about the process and they also felt the process was tedious and time-consuming. In a study by Siddaiah et al. using focus group discussion and interviews, practitioners felt that they need to be trained about notification and how to use NIKSHAY app to notify TB. The results of these studies indicate that there is a need to simplify the notification process and provide training on the same.
There are several mechanisms for TB notification in India which includes submitting the details to nodal officer via hard copy (post/courier/hand), E-mail, phone calls, Interactive Voice Response System, SMS, online through NIKSHAY, and local public health authority with the permission of nodal officer. Mobile SMS/App (57.2%) was the most common method of notification preferred by PPs who participated in this study. This is more than the proportion of practitioners preferring to notify through mobile SMS in studies done by Thomas et al. (18%) and Philip et al. (24%)., One-fourth of PPs in the present study preferred notification through health staff from the government sector. On the other hand, a study done in Kerala showed that 54% of the PPs preferred notification through health workers. Almost all PPs are willing to notify TB cases and they had an inclination towards using mobile SMS/App/Call over any other available methods probably because of its ease of usage. Thus, there is a scope of linking mobile numbers of the PPs with the RNTCP which would have the dual benefit of increasing the notification rate by PPs and also serve as a means to disseminate the information related to RNTCP.
| Conclusions|| |
We found that three-fourths of the PPs were aware that TB notification is mandatory. This study provides an insight into factors which facilitate and hinder TB notification. Lack of awareness about the notification process, lack of time, and procedure being tedious were the common barriers for notification among PPs. There is a need to increase the awareness about various notification processes and it should be simplified and communicated to them through academic gatherings for a better understanding of the notification process.
Authors sincerely thank the practitioners for their participation in the study and are also grateful to late Dr. S. Elango for his motivation during the initial phase of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Revised National Tuberculosis Control Program. Guidelines for TB Notification in India. Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; July, 2012. Available from: https://tbcindia.gov.in/showfile.php?lid=3139
. [Last accessed on 2018 Mar 03].
Arinaminpathy N, Batra D, Khaparde S, Vualnam T, Maheshwari N, Sharma L, et al
. The number of privately treated tuberculosis cases in India: An estimation from drug sales data. Lancet Infect Dis 2016;16:1255-60.
Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME. Size and usage patterns of private TB drug markets in the high burden countries. PLoS One 2011;6:e18964.
Satpati M, Burugina Nagaraja S, Shewade HD, Aslesh PO, Samuel B, Khanna A, et al
. TB notification from private health sector in Delhi, India: Challenges encountered by programme personnel and private health care providers. Tuberc Res Treat 2017;2017:6346892.
Thomas BE, Velayutham B, Thiruvengadam K, Nair D, Barman SB, Jayabal L, et al
. Perceptions of private medical practitioners on tuberculosis notification: A study from Chennai, South India. PLoS One 2016;11:e0147579.
Philip S, Isaakidis P, Sagili KD, Meharunnisa A, Mrithyunjayan S, Kumar AM. “They know, they agree, but they don't do”-the paradox of tuberculosis case notification by private practitioners in Alappuzha district, Kerala, India. PLoS One 2015;10:e0123286.
Yeole RD, Khillare K, Chadha VK, Lo T, Kumar AM. Tuberculosis case notification by private practitioners in Pune, India: How well are we doing? Public Health Action 2015;5:173-9.
Uplekar M, Atre S, Wells WA, Weil D, Lopez R, Migliori GB, et al
. Mandatory tuberculosis case notification in high tuberculosis-incidence countries: Policy and practice. Eur Respir J 2016;48:1571-81.
Samal J. Ways and means to utilize private practitioners for tuberculosis care in India. J Clin Diagn Res 2017;11:LA01-4.
Patil SK, Bathija GV. Perception of private practitioners towards diagnosis and treatment of tuberculosis in Hubballi city, India. Int J Community Med Public Health 2018;5:2076-80.
Nair S, Philip S, Varma RP, Rakesh PS. Barriers for involvement of private doctors in RNTCP – Qualitative study from Kerala, India. J Family Med Prim Care 2019;8:160-5.
] [Full text]
Siddaiah A, Ahmed MN, Kumar AM, D'Souza G, Wilkinson E, Maung TM, et al
. Tuberculosis notification in a private tertiary care teaching hospital in South India: A mixed-methods study. BMJ Open 2019;9:e023910.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]