|Year : 2022 | Volume
| Issue : 5 | Page : 45-50
Tuberculosis case notification by registered private medical practitioners in Kolkata: A mixed-methods study
Vineeta Shukla1, Sanghamitra Maulik2, Mausumi Basu3, Meghna Mukherjee4
1 Senior Resident, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Assistant Professor, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
3 Professor and Head of Department, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
4 Statistician-Cum-Tutor, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
|Date of Submission||09-Aug-2022|
|Date of Decision||18-Aug-2022|
|Date of Acceptance||19-Aug-2022|
|Date of Web Publication||11-Nov-2022|
Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Under-notification of tuberculosis (TB) cases remains a persistent problem that impedes accurate estimation of the disease burden. India's private health sector contributes to only one-fourth of the total TB notifications. Objectives: The present study was conducted among registered private practitioners in Kolkata to assess their knowledge, attitude and practice on TB notification, to find the socio-demographic and work-related factors associated with it, to identify the barriers faced by them in notifying TB cases and to elicit suggested solutions in overcoming these barriers. Materials and Methods: It was an observational study, cross-sectional in design following explanatory sequential mixed-methods approach conducted among 426 private practitioners in Kolkata Municipal Corporation area over 2 years (July 2019–October 2021). Quantitative data were analyzed using SPSS 25.0 with suitable descriptive and inferential statistics. Qualitative data were analyzed using Atlas.ti 7.1 and data were represented in the form of themes, codes, and verbatims. Results: Out of 426, 295 (69.2%) of the study population had adequate knowledge, 385 (90.4%) had positive attitude and only 115 (27.0%) had satisfactory practice. Lack of awareness, inadequate communication, and breaching patient confidentiality were the main barriers identified. Suggested solutions to improve engagement of private sector were organizing more continuing medical educations, active case finding, and acknowledgement to private practitioners on notification. Conclusion: Private practitioners had adequate knowledge on TB notification, their attitude was very positive but practice was poor. Training and sensitization of private practitioners on notification are recommended with feedback from both ends.
Keywords: India, Nikshay, private practitioners, private sector, tuberculosis notification
|How to cite this article:|
Shukla V, Maulik S, Basu M, Mukherjee M. Tuberculosis case notification by registered private medical practitioners in Kolkata: A mixed-methods study. Indian J Public Health 2022;66, Suppl S1:45-50
|How to cite this URL:|
Shukla V, Maulik S, Basu M, Mukherjee M. Tuberculosis case notification by registered private medical practitioners in Kolkata: A mixed-methods study. Indian J Public Health [serial online] 2022 [cited 2022 Dec 4];66, Suppl S1:45-50. Available from: https://www.ijph.in/text.asp?2022/66/5/45/360643
| Introduction|| |
India accounts for the highest burden of tuberculosis (TB) and drug-resistant TB cases worldwide. India contributed to 27% of the total 10 million TB cases globally in 2019. Of these, only 7.1 million (71%) were notified to various national programs, leaving a gap of 2.9 million people. This is the “missing cases” gap which also included unreported cases from the private sector who were not diagnosed and ultimately left inadequately treated. Out of 2.69 million new cases which occurred in 2019 in India, only 2.16 million were notified, showing a striking 0.53 million (20%) missing cases.
The Government of India declared TB notification mandatory on May 7, 2012, and the online notification portal “Nikshay” was launched to serve as the database for the notified cases.
India has a vast private health sector and majority of people seek health care in private facilities. It is estimated that nearly half of TB patients are diagnosed and treated in private institutions. The private sector contributed to only 28% of total number of notifications in 2019, out of which only 1.06% were notified from the private sector of West Bengal.
Over past few decades most of these studies involve patients' perspectives such as quality of life and social stigma and the public health-care system. There are very few studies pertaining to the private sector. The area of notification is relatively new and there is a dearth of studies on this topic, especially from West Bengal. Kolkata is a hub of private practitioners and there is a paucity of studies on TB notification among them. With this background, this study was conducted among private practitioners in Kolkata with objectives to assess their knowledge, attitude, and practice on TB notification, to find the socio-demographic and work-related factors associated with it, to identify the barriers encountered by them in notifying TB cases and to elicit suggested solutions in overcoming these barriers.
| Materials and Methods|| |
Study type, design, area, and duration
It was an observational study, cross-sectional in design following explanatory sequential mixed-methods approach conducted in Kolkata Municipal Corporation area over 2 years (July 2019–October 2021).
Study population and selection criteria
- Registered private medical practitioners having minimum MBBS degree
- Currently practicing in Kolkata since last 3 months or more
- If previously attached to government health facilities, then retired or resigned before 2012.
- AYUSH Doctors
- Private practitioners currently attached to government health facilities
- Pulmonology/Chest Medicine specialists.
Private practitioners who had inadequate knowledge on TB notification and who gave informed electronic consent were included.
According to a study conducted by Siddaiah et al. in a private hospital in Bengaluru, in 2018, the proportion of TB notification was 23%.
Thus taking, P = 0.23, q = 1 - P = 0.77, confidence interval (CI) = 95%, Standard normal deviate (Zα) at 95% CI = 1.96 and absolute error (d) = 5%, sample size was calculated using Cochran formula,
= [(1.96)2 × 0.23 × 0.77]/(0.05)2 ≈273
Multiplying by a design effect of 1.5 for stratified random sampling technique and adding a nonresponse of 20%, final sample size was 492.
Twelve (10% of the private practitioners who had inadequate knowledge were included.).
Study participants were selected by stratified random sampling technique [Figure 1].
|Figure 1: The process of sampling technique (n = 426). IMA: Indian Medical Association|
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Participants were selected by purposive sampling.
The study tool was a predesigned, pretested, and structured questionnaire having components of socio-demographic and work profile, knowledge (24 items), attitude (10 items on a 5-point Likert scale), and practice (6 items) which was validated by three experts-two professors from Community Medicine and one Public Health expert working as District TB Officer.
In-depth interview guide was used which was validated by experts.
For data collection, questionnaire was self-administered to the participants by E-mail. The first page was designed for consent. Only one response per participant was allowed.
In-depth interviews were conducted face-to-face through an online meeting platform due to the ongoing COVID-19 pandemic. Each interview lasted for about 15 min.
Quantitative: Dependent variables
- Knowledge of TB notification
- Attitude toward TB notification
- Practice of TB notification.
Socio-demographic and work-related characteristics.
Qualitative: Two domains were focused on
- Barriers faced in notifying TB cases
- Possible solutions for the identified barriers.
Out of 492 forms, a total of 426 responses were received and included in analysis. Thus, there was a nonresponse of 13.4%. Data were analyzed using Statistical Package for the Social Sciences (SPSS for Windows, version 25.0, SPSS Inc., Chicago, Illinois, USA).
Knowledge was evaluated on 21 questions and responses were scored. Knowledge was categorized as adequate knowledge: ≥50% of total score (≥25) and inadequate knowledge: <50% of total score (<25)
Each response under attitude domain (5-point Likert scale) was scored. Attitude was categorized as positive attitude: ≥50% of total score (≥30) and negative attitude: <50% of total score (<30).
Practice was evaluated on 3 items, scored and categorized as satisfactory practice: ≥50% of total score (≥3) and unsatisfactory practice: <50% of total score (<3).
To find the factors associated with inadequate knowledge, negative attitude, and unsatisfactory practice, multivariable binary logistic regression was performed. All independent variables having P < 0.20 in the univariate regression model was considered biologically plausible to be included in the multivariable model. Data were checked for multicollinearity (VIF <10) and variables with P < 0.05 were considered statistically significant.
Atlas.ti version 7.1 (Atlas.ti for Windows, ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used for coding. Final representation of data was tabulated as themes, codes and verbatims.
i. Registered Medical Practitioner: A doctor having minimum MBBS degree and registered with National Medical Commission or State Medical Council.
Approval from the Institutional Ethics Committee was obtained (Institute name/IEC/2020/016 dated January 28, 2020). Informed electronic consent was obtained prior to data collection both for quantitative and qualitative strands.
| Results|| |
Out 426 study participants, 344 (80.8%) were male. The mean age of the study participants was 46.07 ± 13.31 years with a range of 52 years. Nearly three-fourth, i.e., 305 (72.5%) were residing in Kolkata, 171 (40.1%) had completed their MBBS, 173 (40.6%) held postgraduate degrees. 174 (40.8%) were general practitioners and 69 (16.3%) specialized in Medicine. Two hundred and forty-six doctors practiced at private hospital followed by private clinic (209), 129 (30.3%) had <10 years of practice experience, 113 (26.5%) reported seeing more than 60 patients weekly, 290 (68.1%) treated TB patients and among these more than 90% followed national tuberculosis elimination program (NTEP) protocol. More than 95% of the study population referred TB patients to other facilities for treatment, most commonly to government institutions. The most common reason was referral was availability of free drugs. Majority, 365 (85.7%) had received some form of training or sensitization on TB notification, most commonly being Continuing Medical Education followed by information from social media.
Of 426 study participants, 295 (69.2%) of the study population had adequate knowledge, 385 (90.4%) had positive attitude and only 115 (27.0%) had satisfactory practice.
Higher age group (>50 years) (Adjusted odds ratio [aOR] 8.46 [C. I: 1.45–21.73]), practice at private clinic (aOR 1.76 [C. I: 1.01–3.08]), practice at nursing home (aOR 2.86 [C. I: 1.41–5.82]), duration of practice between 11 and 20 years (aOR 3.75 [C. I: 1.26–11.12]), seeing a smaller number of patients weekly (up to 20 patients) (aOR 6.10 [C. I: 2.45–15.17]) and no sensitization/training on TB notification (aOR 2.59 [C. I: 1.29–5.21]) was significantly associated with higher odds of inadequate knowledge. Seeing 21–30 patients seen weekly (aOR 14.74 [C. I: 1.70–27.75]) was significantly associated with higher odds of negative attitude and practice at private hospital (aOR 2.10 [C. I: 1.12–3.96]) was significantly associated with higher odds of unsatisfactory practice.
Thematic analysis of in-depth interviews on barriers and solutions are presented in [Table 1] and [Table 2], respectively.
|Table 1: Thematic analysis from in-depth interviews on barriers in notifying tuberculosis cases (n=12)|
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|Table 2: Thematic analysis from in-depth interviews on solutions for identified barriers (n=12)|
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| Discussion|| |
About 69.2% of the study population had adequate knowledge on TB notification which corroborated with Rupani et al. in Bhavnagar, Gujarat (69%). It was lesser than findings by Dey et al. in Udipi, Karnataka (99%), Sahasrabudhe et al. in Pune (97%), Singh Chadha et al. in Mysore (91%), Philip et al. in Alapuzzha, Kerala (88%), and Thomas et al. in Chennai (73%).,,,,,
It was observed that even though the private practitioners knew that TB was a notifiable disease, awareness on Nikshay was low. This clearly presented the picture of public-private gap in the management of TB.
About 71% of the private practitioners had received some form of training or sensitization from programme personnel. This was in contrast to findings by Bharaswadkar et al. in Pune and Hemavarneshwari et al. in Bengaluru where 55% and 17.6% of the private practitioners had received training from the NTEP, respectively.,
About 69% of the study participants preferred to be neutral when asked if they would want to be associated with the programme. In the Bengaluru study, 82.4% of the private practitioners were unwilling to join the programme whereas in a study by Vaibhav et al. in Uttar Pradesh, 82% of private practitioners agreed to be partners with the government sector for implementation of the national program.,
A little over one-fourth (25.4%) of the private practitioners in the present study were registered on Nikshay. Only 10.9% of the study participants had their registered profiles on Nikshay in Udipi, Karnataka study by Dey et al. and 16.6% were registered in Mysore study as reported by Singh Chadha et al.,
About 33.8% of the study participants reported notifying at least one case which corroborated with Thomas et al. in Chennai (33%). It was greater than findings by Lal et al. in 14 urban districts of India (18%), Yeole et al. in Pune (20%) and Chadha et al. (29%). However, studies by Karthikeyan et al. in Chennai (65%), Shibu et al. in Mumbai (62.8%), Bhalla et al. in Bengaluru (54%) and Dey et al. (48%) reported higher proportions of notification.,,,,,
Findings from the in-depth interviews showed that some private practitioners perceived that notification of TB is not enough to bring about change in the road towards TB elimination.
In Kerala, private practitioners assumed that only patients attending government institutions and receiving nationally recommended treatments needed to be notified. Private providers had concerns about the workload involved in notification procedures, breaching patient confidentiality about a stigmatizing disease and the absence of incentives. This was similar to the present study.
In Korea, inadequate knowledge was a likely barrier to notification. A study from Pakistan mentioned that private practitioners reported lack of time as the major reason for not reporting, followed by confidentiality and poor knowledge of the notification procedure. Similarly, in the studies from Kerala and Pune, the main reasons for not notifying were lack of time, confidentiality concerns, fear of offending patients, lack of awareness, complex notification mechanism, and lack of trust and coordination with the government.,
The study participants in the present study wanted acknowledgement by the government to increase their participation in the program. Similar recommendations were reported by Dey et al., Singh Chadha et al. and Datta et al.,,
Some participants in the current study pointed out that they were uncomfortable sharing personal details of patients as it would make their information public and create more stigma. This corroborated with other studies., Further, perceived stigma makes healthcare providers feel awkward in obtaining personal identifiers from patients.
Doctors who were not enlisted in Kolkata Indian Medical Association branches but practice in Kolkata could not be included. The responses received would not have been free of social desirability bias. The information on notification was self-reported and may not be a true representation of the practice.
| Conclusion|| |
Private practitioners had adequate knowledge on TB notification, their attitude was very positive but practice was poor. Training and sensitization of private practitioners for notification is recommended. In order to increase the notification rates, it is essential to address the barriers faced by them. It is also essential to provide feedback to them on number of notifications and their progress. In addition, obtaining feedback from private practitioners is also important. Last but not the least, it is of utmost importance to bridge the public-private gap.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Satyanarayana S, Subbaraman R, Shete P, Gore G, Das J, Cattamanchi A, et al.
Quality of tuberculosis care in India: A systematic review. Int J Tuberc Lung Dis 2015;19:751-63.
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.
Rupani MP, Shah CJ, Dave JD, Trivedi AV, Mehta KG. 'We are not aware of notification of tuberculosis': A mixed-methods study among private practitioners from western India. Int J Health Plann Manage 2021;36:1052-68.
Dey S, Rao AP, Kumar A, Narayanan P. Awareness & utilization of NIKSHAY and perceived barriers for tuberculosis case notification among the private practitioners in Udupi district, Karnataka. Indian J Tuberc. 2020;67:15-9.
Sahasrabudhe T, Barthwal M, Sawant T, Ambike S, Jagtap J, Hande S, et al.
Tuberculosis notification: An inquiry among private practitioners in Pimpri-Chinchwad municipal corporation area of Maharashtra, India. Indian J Tuberc 2022;69:73-8.
Singh Chadha S, Burugina Nagaraja S, Trivedi A, Satapathy S, Devendrappa NM, Devi Sagili K. Mandatory TB notification in Mysore city, India: Have we heard the private practitioner's plea? BMC Health Serv Res 2017;17:1.
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.
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.
Bharaswadkar S, Kanchar A, Thakur N, Shah S, Patnaik B, Click ES, et al.
Tuberculosis management practices of private practitioners in Pune municipal corporation, India. PLoS One 2014;9:e97993.
Hemavarneshwari S, Shaikh RB, Naik PR, Nagaraja SB. Strategy to sensitize private practitioners on RNTCP through medico-social workers in urban field practice area of a Medical College in Bengaluru, Karnataka. Indian J Tuberc 2019;66:253-8.
Vaibhav G, Zia H, Singhal S. Awareness of revised national tuberculosis control program among medical practitioners. Indian J Sci Res 2013;4:85-6.
Lal SS, Sahu S, Wares F, Lönnroth K, Chauhan LS, Uplekar M. Intensified scale-up of public-private mix: A systems approach to tuberculosis care and control in India. Int J Tuberc Lung Dis 2011;15:97-104.
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.
Karthikeyan M, Logaraj M, Kalpana MS. Adherence to international standards of tuberculosis care guidelines among private practitioners, Chennai, Tamil Nadu, India, 2016–2017. Int J Infect Dis 2020;101 Suppl 1:461.
Shibu V, Daksha S, Rishabh C, Sunil K, Devesh G, Lal S, et al.
Tapping private health sector for public health program? Findings of a novel intervention to tackle TB in Mumbai, India. Indian J Tuberc 2020;67:189-201.
Bhalla BB, Chadha VK, Gupta J, Nagendra N, Praseeja P, Anjinappa SM, et al.
Knowledge of private practitioners of Bangalore city in diagnosis, treatment of pulmonary tuberculosis and compliance with case notification. Indian J Tuberc 2018;65:124-9.
Park YS, Hong SJ, Boo YK, Hwang ES, Kim HJ, Cho SH, et al.
The national status of tuberculosis using nationwide medical records survey of patients with tuberculosis in Korea. Tuberc Respir Dis (Seoul) 2012;73:48-55.
Mansuri FA, Borhany T, Kalar M. Factors responsible for under reporting of notifiable infectious diseases by general practitioners: A veiled reality 2014;30:126-9.
Datta K, Bhatnagar T, Murhekar M. Private practitioners' knowledge, attitude and practices about tuberculosis, Hooghly district, India. Indian J Tuberc 2010;57:199-206.
[Table 1], [Table 2]