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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 15
| Issue : 5 | Page : 713-721 |
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Extent of involvement of private practitioners in public-private mix-directly observed treatment short course (PPM-DOTS) for tuberculosis management in South Coastal India: A mixed-method study
Mathiyalagen Prakash1, Anandaraj Rajagopal1, Kavita Vasudevan1, Senthil Kumar Subramani2, Mausumi Basu3
1 Department of Community Medicine, Indira Gandhi Medical College and Research Institute(IGMCRI), Puducherry, India
2 Department of Biochemistry, School of Studies in Biochemistry, Jiwaji University, Gwalior, Madhya Pradesh, India
3 Department of Community Medicine, IPGMER & SSKM Hospital, Kolkata, India
| Date of Submission | 05-Jan-2021 |
| Date of Decision | 31-Jul-2021 |
| Date of Acceptance | 07-Aug-2021 |
| Date of Web Publication | 04-Oct-2022 |
Correspondence Address:
Mausumi Basu
Department of Community Medicine, IPGME and R and SSKM Hospital, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.mjdrdypu_7_21
Background: Ensuring the effective participation of both public and private healthcare providers is essential to fulfill the goals of universal access to tuberculosis (TB) care. Objectives: The objective was to assess the knowledge, attitude, and practice about TB, Directly Observed Treatment Short (DOTS) program and Public-Private Mix-DOTS course (PPM-DOTS) strategy among allopathic private practitioners (PP) and to explore their extent of involvement in PPM-DOTS strategy in the diagnosis, notification, and management of TB in Puducherry, India. Materials and Methods: A sequential explanatory mixed-method study was conducted from November 2017 to February 2018 with quantitative survey using a pretested semistructured questionnaire followed by in-depth interview (IDI) using field guide. Descriptive manual content analysis was performed after verbatim transcription of the manuscripts from IDIs. Results: Qualitative data based on survey revealed that 97.66% of PPs were aware of subjecting patients with cough for more than 2 weeks for sputum examination and 93.75% were aware of mandatory TB notification. About 88.28% preferred to get the investigation done for presumptive TB cases from nearby DOTS centers. About 89.06% preferred to refer TB cases to nearby primary health centers whereas only 20.31% preferred to notify TB cases. IDIs revealed that PPM-DOTS was not utilized optimally due to the following reasons: minimal TB caseload to collaborate and function with DOTS centers, fear of losing the patient, distrust in PP, busy schedule, availability of Anti-tubercular treatment (ATT) in the nearby pharmacy, breach of confidentiality while notification and finally the easy referral mechanism due to nearby DOTS centers. Conclusions: Involvement of PPs in PPM-DOTS remains sub-optimal. Strategies such as conducting regular workshops, providing timely information about policy changes, and constructive communications individually with PPs to dispel any misconceptions might enhance PPM-DOTS.
Keywords: Mixed method study, public-private mix-directly observed treatment short, private practitioner, tuberculosis
How to cite this article:
Prakash M, Rajagopal A, Vasudevan K, Subramani SK, Basu M. Extent of involvement of private practitioners in public-private mix-directly observed treatment short course (PPM-DOTS) for tuberculosis management in South Coastal India: A mixed-method study. Med J DY Patil Vidyapeeth 2022;15:713-21 |
How to cite this URL:
Prakash M, Rajagopal A, Vasudevan K, Subramani SK, Basu M. Extent of involvement of private practitioners in public-private mix-directly observed treatment short course (PPM-DOTS) for tuberculosis management in South Coastal India: A mixed-method study. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 26];15:713-21. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/713/357774 |
| Introduction | |  |
Involving all relevant healthcare providers in tuberculosis (TB) prevention, management, and control through public-private mix (PPM) policy is a crucial component in the World Health Organization's (WHO) end TB strategy.[1] Roughly, 2500 nongovernment organizations, 19,000 private practitioners (PP), 150 corporate hospitals, and 267 medical colleges are implementing the Revised National TB Control Program (RNTCP).[2] In India, over 80% of TB patients initially care-seek in the private sector.[3] Realizing this, the Government of India engaged PPs via the WHO recommended PPM-Directly Observed Treatment Short (PPM-DOTS) partnership strategy which permits PPs to refer patients to the RNTCP for free diagnosis and treatment, following which the patient can continue treatment with RNTCP or as an alternative PPs themselves can provide DOTS.[4] PPM policy means all the actions that bridge healthcare facilities of public and private sectors to RNTCP for the expansion of DOTS course strategies. PPM-DOTS initiated in 1998 in Pimpri Chinchwad, a city in Maharashtra is one of the few Indian models implemented as envisaged by global and national policymakers.[5]
This PPM-DOTS strategy could facilitate reaching the unreached as well as to reach patients even if they are accessing private/other sectors where RNTCP would act as an enabler and not provider of services.[6] PPM-DOTS strategy is a vital component for implementing International Standards for TB Care to achieve national as well as international TB targets.[7]
The private health sector's notification rates of smear-positive pulmonary TB varies from 10% to 60%.[8] Notification of all TB patients from all health care providers is made mandatory by the Ministry of Health and Family Welfare, Government of India since 2012.[9] A study conducted in Gujarat by Damore et al. during 2010–2011 showed that only 5% of new sputum positive cases were referred by PPs through the PPM model.[10] Another study by Salve et al. in a Southern Indian State revealed that PPM-TB policy's lack of malleability allows PPs to advocate TB treatment on their own, or using their own.[11] Overall in India, the private sector providing TB treatment was roughly twice as much as provided in the public sector.[12]
Good coordination between RNTCP and PP generally improves the notification rates, but it was also noticed that consulting the private healthcare provider with TB-related symptoms and signs might delay the commencement of the TB diagnosis and treatment.[13],[14] Vandan et al. at Lucknow demonstrated that 49% of doctors working in the public sector and 53% working in the private sector correctly reported all TB symptoms as per the RNTCP guidelines whereas 66% of doctors in the public sector and 39% in the private sector reported the correct technique for sputum sampling.[15]
There is the dearth of information on the private sector regarding the utilization of PPM-DOTS strategy to investigate and notify a presumptive TB case to appropriate authorities. In this context, this study was carried out to assess the knowledge, attitude, and practice about TB, DOTS program, PPM-DOTS and to explore the extent of involvement of allopathic private healthcare providers in PPM-DOTS strategy in the diagnosis and treatment of TB.
| Materials and Methods | | |
Study design, study timing
A cross-sectional mixed-method study (sequential explanatory design) was conducted between November 2017 and February 2018.
Study setting
Puducherry, one of the four districts of The Union Territory of Puducherry, lies in the Southern Part of the Indian Peninsula. The population density of this district is 3232 persons/km2 as per census 2011.[16]
Study population
The registered allopathic PPs of Puducherry district.
Inclusion criteria
Those practicing in clinics, nursing homes, or private hospitals of Puducherry district and gave informed written consent.
Exclusion criteria
PPs of other systems of medicines were excluded (AYUSH).
Sample size
The sample size was calculated using the following manner.
Quantitative part
Was calculated using the formula, N = Z2pq/l2, where Z = 1.96, P = proportion of PPs have adequate knowledge about RNTCP DOTS, q = 1 − p, l = 0.05. With an absolute precision of 10% and 95% level of confidence, the sample size was calculated as 97. After adding a nonresponse rate of 30%, the final sample size was 127 and 128 data were collected.
For qualitative part
Fourteen PPs were chosen purposively (had seen presumptive TB cases in the last 1 year) and interviewed till the point of saturation.
Sampling technique
Simple random sampling technique was followed.
Study tools
A predesigned pretested semi-structured questionnaire. It was designed by a research team, including a physician, a professor of community medicine, and a chest specialist. The questionnaire was piloted among 30 randomly selected study population of the same setting to assess its clarity, reliability, and validity. After some minor modifications, it was re-evaluated by the same panel of experts. The participants who were included in the pilot study were not included in the final study sample. The content and construct validity of the schedule were investigated by a research team and its reliability was confirmed by Cronbach's alpha test. Based on this test; all questions' reliability was higher than 78% and validity was higher than 80%.
Methods of data collection
Quantitative part
Hospitals or clinics were identified from a list of known private health care institutions. PPs were also approached either through friends who work in the survey area or through personal contacts. The prior appointments were made for each doctor at their convenient time. Self-administered questionnaire was to collect quantitative data regarding their knowledge, attitude, and practice about TB and RNTCP DOTS program.
Qualitative part
In-depth interviews (IDIs) of 20–30 min duration were conducted at a time based on the prior appointment given by the PPs. The principal investigator who had undergone training in qualitative research conducted the IDI's and recorded the audio using audio-recorder. Verbatim transcription of the audio recording was done on the same day after the IDI. Since some PPs expressed unwillingness for audio-recording the IDI, the principal investigator took field notes to record the interview. The field notes were read to confirm the meaning and clarity from the interviewee. The topic guide was prepared including questions related to the awareness and involvement in PPM-DOTS, criteria to suspect for TB, diagnosis, notification, treatment, and the perceived reasons for sub-optimal involvement in PPM-DOTS.
Data management and analysis
Quantitative part
Data entry was done using EpiData Version 3.1 (The EpiData Association, Odense, Denmark, 2004). Analysis of the data was performed using EpiData Analysis Version 2.2.2.183. Frequencies and percentages were used to summarize the categorical data and mean (standard deviation [SD]) was used to express the quantitative data.
Qualitative part
Transcription of the field notes was done and coded manually. Content analysis and thematic analysis were done from the verbatim transcript. Thematic analysis [Figure 1] helped to understand those aspects that participants talk in-depth, whereas content analysis helped count instances of codes, appropriate for analyzing visual imagines like pictures and was useful for determining how words and word patterns were used in context. A coding scheme was developed and refined progressively over time. Five categories and ten codes emerged during the analysis of the transcripts. We systematically checked across the transcripts for the consistency of these emerging categories. To increase the internal validity of the analysis, the coding scheme [Figure 2] was discussed with a sociologist, and a public health expert also who was not involved in data collection. | Figure 1: Thematic analysis regarding the sub-optional involvement of private practitioners in public private mix directly observed treatment short
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 | Figure 2: Manual content analysis of qualitative data with categories and codes (n = 14) regarding the private practitioners involvement in public private mix directly observed treatment short
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Ethics
Ethical approval was obtained from the Institute Ethics Committee of Indira Gandhi Medical College and Research Institute, Puducherry. Before data collection, informed written consent was obtained from all the study participants.
| Results | | |
Quantitative component (Phase I)
Mean (SD) age of the PPs was 41.8 (±14) years. About 60% of the PPs were males. Almost 40% of the PPs studied up to MBBS, 55% had master degrees (MD/DNB) and 5% were diploma holders.
Knowledge about tuberculosis and Revised National Tuberculosis Control Program among study participants
[Table 1] showed the knowledge about TB and RNTCP among the PPs. Almost 97.66% of the PPs answered correctly that cough of 2 weeks duration should be subjected to sputum examination. 93.75% answered correctly that TB notification is mandatory. About 88.28% of the PPs answered correctly about the duration of treatment for a new case of pulmonary TB. Only 22.66% of them responded that X-ray findings of pulmonary TB do not persist for many years. 92.97% answered the case definition of MDR TB correctly. 67.97% told that ATT treatment should be stopped if a patient develops signs of hepatitis during treatment. | Table 1: Knowledge about tuberculosis and Revised National Tuberculosis Control Program among study population (n=128)
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Attitude of study participants towards tuberculosis patients and Revised National Tuberculosis Control Program
About 97.66% of the study participants felt that RNTCP training should be given to all practitioners. About 71.88% of the PPs were of the opinion that sputum of suspected TB patients should be examined only at RNTCP accredited laboratories. All the PPs agreed that there is a need for continuous up-gradation of practitioners on recent advances in the field of TB [Table 2]. | Table 2: Attitude of study participants toward tuberculosis patients and Revised National Tuberculosis Control Program (n=128)
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[Table 3] revealed the common practices in the diagnosis and management of TB patients by PPs. Regarding the modality for diagnosis, smear microscopy and chest radiography were mentioned by 85.94% and 45.31% of the PPs respectively. Most of them (96.09%) told that they would follow the RNTCP regime while prescribing TB patients. Regarding laboratories preferred for investigating suspected TB cases, 88.28% preferred public laboratories while 9% preferred private laboratories. 89.06% preferred to refer the TB cases to nearby primary health centers, whereas only 20.31% preferred to notify the TB cases. Investigation, notification, treatment, follow up and incentive related possible suggestions were demonstrated in [Table 4] to improve the involvement of Private practitioner's in PPM DOTS. | Table 4: Possible suggestions to improve the involvement of private practitioner's in public-private mix directly observed treatment short
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Qualitative component (Phase II)
IDIs were conducted among 14 PPs including eight specialists and six general practitioners. They were from varied specialties (general practitioners (6), pulmonologist (3), pediatrician (3), family medicine specialist (1), and general medicine specialist (1) and were treating the TB patients in their private practice. Their age group was between 28 and 65 years.
Private practitioner's involvement in public-private mix-directly observed treatment short
Five categories and ten codes emerged during the analysis of the transcripts from 14 PPs [Figure 2].
Awareness of public-private mix component of the Directly Observed Treatment Short Program
Most of the PPs were aware of the PPM-DOTS but they have not utilized it.
“Yes… I'm having idea about PPM DOTS. I know about free drugs given under PPM but I have not availed it” (pulmonologist, 43 years, male).
When the patient can't be followed up in private practice, there is no benefit for anyone.
“When we give incentives we should make sure that patient is compliant right throughout the treatment, only then the private practitioner will get that incentive. Just you make diagnosis and start treatment, later there is no follow-up, you don't know what happen to the patient; then no incentives” (general practitioner, 38 years, female).
Attribute to suspect for tuberculosis and mode of diagnosis
All the PPs mentioned at least one or more of the criteria listed in the RNTCP program for presumptive TB but none answered “chest radiography abnormality” as attribute for suspecting TB. Other criteria as listed by participants for suspecting TB include anorexia, sleeplessness, chronic Lower respiratory tract infection (LRI), asthmatic bronchitis, and raised erythrocyte sedimentation rate.
“…if it is pulmonary tuberculosis, mainly it is by X-ray and history. If sputum is positive, go ahead with the sputum. If sputum is negative, patient brings sputum, I will send for CBNAAT through one of the TB officer. And for extra pulmonary again I am sending for CBNAAT” (physician, 47 years, male).
“X-ray and tuberculin test will be done. I will consider the child to be having TB when there is tuberculin positive and X-ray positive or tuberculin negative but X-ray positive. If both are negative but still symptomatic, then two weeks antibiotic course followed by CT scan or expert opinion” (pediatrician, 28 years, male).
Involvement of private practitioner's in public-private mix directly observed treatment short
Some practitioners get the investigation done from DMC's considering the quality of results.
“For sputum, I will not send the patient to outside labs since sputum reports from private labs are not valid for DOTS” (general practitioner, 65 years, male).
“But some patients who say I can't come in morning hours I need to go to work, X-ray alone I will give as an outside investigation, sputum for AFB examination I am not writing to outside labs. Because I know the quality of sputum results from outside labs” (family medicine, 39 years, male).
Based on patient's affordability, compliance and literacy, anti-tubercular treatment was started in their clinic.
“If the patient is category two, I will refer. Because I am not much comfortable in managing category two. And regarding category one, if the patient cannot afford for the drugs, I will refer. And second thing is, if I feel that compliance is poor, again I will refer. Because there is at least somebody there who will follow. If I feel that patient is uneducated, may not come for regular follow-up, I will refer to GH” (pediatrician, 38 years, female).
Notification and treatment practices
Many a time's presumptive TB cases were referred to nearby DOTS centers. Some directly inform the State TB office either by themselves or through their supporting staff.
“It is the job of my staff. Sometimes patient does not want to get notified and this is a barrier to this notification” (pulmonologist, 43 years, male).
“For extra pulmonary I gave for nine months. Otherwise I do only for six months” (pediatrician, 45 years, male).
Reasons for sub-optimal involvement in public private mix directly observed treatment short
The perceived reasons for sub-optimal involvement for utilizing PPM-DOTS is summarized in [Figure 1] with a global theme and four subthemes. Majority of the PPs referred, instead of notifying and treating TB cases to the nearby DOTS course center.
Investigation
Some PPs felt that investigation done from DMC's would result in distrust in doctors and switching of doctors.
“…they switch the doctor. They don't trust when someone is sent to government lab at the first visit. They don't come back also” (general practitioner, 56 years, male).
“I lose the patient when I send them for investigation outside especially to government side” (pulmonologist, 30 years, Male).
“Tuberculosis case load is too low in my practice. Some known (TB) cases, probably investigated from primary health center (PHC), keep coming to me for treatment purpose alone”(family medicine, 39 years, male).
Notification
Some TB cases were not notified due to confidentiality issues.
“I knew the family for a long time. They feel the news could spread to outsiders. They don't want to get notified. I counseled them about the importance of completion of treatment” (general practitioner, 60 years, male).
TB cases were referred and not notified to the government due to easy accessibility to nearby DOTS centers.
“Government centers are nearby in this city. I refer my cases when i suspect them of having tuberculosis. I have worked there and their set up is good. This will save lot of patient's money” (physician, 47 years, male).
TB cases were not notified by the supporting staff in the hospital.
“When we get cases, weassumeour staffs would notify the case due to my busy practice. I never checked whether they notify or not” (pediatrician, 45 years, male).
Many of the practitioners had opined that there were not approached from the program managers regarding the notification process.
“I'm not aware of this (notification) process. No one had contacted me to explain how it can be done. Some (TB patient's) could be infective to others waiting for me here (clinic). I used to refer instead of doing this (notification)” (general practitioner, 56 years, male).
Drugs
Some physicians consider procuring free ATT drugs from government and giving patient's regularly as cumbersome.
“Some are not affordable. They get benefitted from the free drug supply. But I have not utilized till date as it is an extra workload to maintain the logistics” (general practitioner, 60 years, male).
(Some physicians utilize the ATT drugs available in the pharmacy)
“Some patient's come from upper socioeconomic class. They don't prefer getting the drugs from government prescribe AKT4 and send them to nearby medicals wherever drug is available” (general practitioner, 50 years, male).
Follow-up
Some physicians mentioned that they can't do regular follow-up citing busy schedule, manpower shortage. Some physicians mentioned that the existing DOTS facility has good mechanism for regular follow-up.
“Once they feel better, they don't come back. Some might come after a few months with the same complaint. They (DOTS center) have manpower for regular follow-up “ (general practitioner, 65 years, male).
“It is difficult to follow on a regular basis due to my busy schedule. Moreover we don't get proper contact details of the patient. It would be better if the government does this” (pediatrician, 45 years, male).
| Discussion | | |
PPs are the first line of contact with presumptive TB patients in most cases; thus their involvement becomes important in TB case detection and treatment. The findings of the present study indicate that majority of PP's have answered correctly in the knowledge part. In the present study, 93.75% of the study population were aware about the duration of cough in presumptive TB cases, which was similar to a study conducted by Sawase et al. at Mumbai among PPs (97%),[17] a current study by Naik et al. among Interns at Goa (98.8%)[18] and a very recent study by Samarasinghe et al. among PPs at Sri Lanka (91%).[19] However it was much higher than a study by Basu et al. at Kolkata among PP (56.7%),[20] and another recent study by Hemavarneshwari et al. at Bengaluru, Karnataka (50%).[21]
Sputum smear examination as the most reliable investigation of choice under RNTCP was known by 85.9% of PPs in our study, whereas it was 67.2% by Sawase et al.;[17] 97.4% by Samarasinghe et al.;[19] 66.7%by Basu et al.;[20] 56% by Hemavarneshwari et al.;[21] 36% by Srivastava et al.;[22] and 94.1% by Patil and Bathija at Hubballi City Karnataka.[23] About 75.8% preferred both sputum examination and chest X-ray for diagnosis of TB in Karnataka.[23] However, in Mumbai (85.1%) and Gwalior X-ray was the most preferred modality for diagnosis and follow-up among PPs.[17],[22] In contrast, 75% of HCWs were not aware of the current diagnostic technique under RNTCP in a study by Gadde and Chandra at Andhrapradesh.[24]
About 93.75% of PPs in this study were aware of mandatory notification regarding TB cases which was similar to Goa (94.4%),[18] a very recent in Udupi District, Karnataka (99%) by Dey et al.[25] and Mysore City by Singh Chadha et al.(91%)[26] but higher than Hubbali City (79%),[23] Alappuzha (88%) by Philip et al.[27] and Chennai by Thomas et al.(73%).[28] In Hubbali City 97.5% of PPs agreed that TB case notification to the government should be made mandatory.[23]
Srivastava et al.[22] in 2011 at Gwalior observed that a new case of pulmonary TB require 6 months of treatment was answered correctly by 84% and 24% of government and PPs respectively where the government practitioner's response was corroborative with our study finding of 88% and 90% in Goa.[18]
Regarding attitude, almost all the (100%) PP's have opined that there is a need for continuous up gradation of PPs on recent advancements in the TB field which was in line with the study by Srivastava et al.[22] and a current study by Qadri and Andrabi at Kashmir.[29]
About 50% of the study population believed that DOTs is a viable method to control TB in contrast to 88% in Kashmir.[29]
When practice is concerned, almost all (100%) PPs of the present study refer patients suffering from TB to the nearest DOTS center in contrast to very low in Gwalior,[22] 42.5% in the Hubballi city,[23] 78% in Chennai,[28] and 80% in Kashmir.[29]
In the present study, only 20.31% of the study population had ever notified a TB case which was consistent with Thomas et al. at Chennai and Mysore (29%).[26],[28]
The strengths of our study were
(a) Qualitative study design was incorporated, (b) PPs from varied disciplines were included, and (c) Interviews conducted by a trained investigator to minimize interviewer bias, (d) The practitioners were not provided any incentives, (e) written informed consent were obtained before the interview of practitioners.
The authors followed STROBE and COREQ guidelines in the study reporting format.[30],[31]
The limitations of the study were
- Only allopathic practitioners were selected
- Social desirability bias
- Relatively smaller sample size.
| Conclusions | | |
PPM model is a key tool that facilitates reaching the unreached through the private sector to accomplish national as well as global TB targets. There is a sub-optimal utilization of PPM-DOTS by PPs in Puducherry. Though the majority of PPs having answered correctly in the knowledge part, many preferred to refer the TB case to nearby DOTS centers instead of notifying and treating on their own. There is a need for regular update on TB control activities among PPs and a dedicated liaison officer for public-private coordination and motivating to optimally utilize PPM-DOTS.
| Acknowledgment | | |
We express our gratitude to the private practitioners (PPs) for their support and co-operation. We thank our medico-social workers for their liaison activity with the PPs.
Financial support and sponsorship
Financial assistance was received from The Tuberculosis Association of India.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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