記住我
ORIGINAL ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 136-140
A mixed method study to assess notification of tuberculosis patients by private practitioners in New Delhi, India
Rashmi Agarwalla1, Rambha Pathak2, Faheem Ahmed3, Farzana Islam4, Varun Kashyap5, Himashree Bhattacharyya6
1 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
2 Professor and Head, Department of Community Medicine, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
3 Associate Professor, Department of Public Health, King Khalid University Abha, Kingdom of Saudi Arabia
4 Professor and Head, Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi, India
5 Assistant Professor, Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi, India
6 Associate Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
Correspondence Address:
Rambha Pathak
Department of Community Medicine, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_1275_22
Abstract
Background: A staggering one million tuberculosis (TB) cases are missing from notification, most of them being diagnosed and treated in the private sector. To curb this issue, the Government of India declared TB as a notifiable disease and NIKSHAY was launched in 2012. However, even after years of implementation, as per the report published by TB India 2020, the proportion of private case notification of total TB cases is very low. Objectives: The objectives of the study were to assess the current practices related to TB Notification being followed by private practitioners of Delhi and to explore the enablers and barriers to TB notification among private-sector treatment providers. Methods: This cross-sectional study was done from January 2019 to January 2020. Six hundred doctors were line listed under the chosen TB unit, 375 gave consent and in depth interview was conducted among them. Data were collected on the reporting status and facilitators and barrier toward NIKSHAY reporting were assessed. For the qualitative component, focused group discussions were done. Results: Out of 375 private practitioners, over two-third (68%) practitioners reported that they were not treating TB patients. Out of 108 doctors treating patients only 50% were reporting the cases. Major reason cited for not reporting was “don't know how to” and major barrier considered was “lack of training.” Conclusion: Strategies such as training and retraining, and one-to-one sensitization of private practitioners to address barriers may enhance TB notification.
Keywords: Notification, private practitioners, tuberculosis
Introduction 
As per the latest global tuberculosis (TB) report 2020, an estimated 10 million new cases were reported in 2018 but out of these only 7.1 million were detected and officially notified in 2019, leaving a gap of 2.9 million cases that are “missing” globally. These cases are either undiagnosed or managed in the large unregulated private sector and not notified to TB programs.[1] Five countries accounted for more than half of the global gap: India (17%), Nigeria (11%), Indonesia (10%), Pakistan (8%), and the Philippines (7%).[1] As India target's elimination of TB by 2025, such gaps will pose as big hindrances in reaching the target.
India is estimated to have one of the highest missing cases of TB in the world.[2] If a large number of patients are put on anti-TB drugs without notification to the authorities, the benefits of the robust program shall not be available to such patients which leads to issues such as unabated spread in the community, inadequate contact tracing, nonadherence to treatment, incomplete and inadequate treatment leading to multi- and extensive-drug-resistant TB, mitigating all efforts of the program to impede further emergence and spread of drug resistance.
To curb this issue, TB was declared as notifiable disease on May 7, 2012, and a web-based, case-based notification system called NIKSHAY was launched.[3] The notification made it mandatory for all public and private health providers to notify TB. This was an attempt toward providing an opportunity to support the patients with right diagnosis, treatment, follow-up, contact tracing, linkages to social support systems, and monitoring the disease trends.[4] However, even after years of implementation, as per the report published by TB India 2017, the proportion of private case notification of total cases from Delhi was only 10%–20%.[5] Although increase in the percentage of reporting has been noticed in subsequent years; however, the percentage growth is minimal.[6]
Only a few studies have evaluated the status of TB reporting and some have tried to explore the reasons and barriers of notification in the private sector since the legal requirement was put in place.[7],[8],[9]
As India starts moving toward the elimination goal, the private sector will play a mammoth role in contributing toward it. Keeping this in mind the study was planned with the following objectives of line listing the private practitioners under the area of study, to assess the current practices related to TB Notification being followed by private practitioners of Delhi and to explore the enablers and barriers to TB notification among private sector treatment providers. Our study also assisted private practitioners for enrolling in NIKSHAY and reporting TB cases.
Materials and Methods The study was a mixed method study where a survey was done for the quantitative assessment and qualitative part included grounded theory design to provide an explanation behind the current notification practice. Out of all chest clinics in New Delhi, one chest clinic was selected by simple random sampling. The study was conducted in the vast area under Nehru Nagar Chest Clinic, New Delhi.
The sample size included all private practitioners' line listed under the Nehru Nagar Chest Clinics. All allopathic practitioners (MBBS, Medicine, Surgery, Pediatrics, Orthopaedics, Gynaecology, and Pulmonologist) and nursing homes and hospitals falling under the area who gave consent to participate were included.
The study was done from January 2019 to January 2020. For baseline data collection, the investigators visited each of the practitioners after a prior appointment and consent were taken. A semi-structured questionnaire-based interview was conducted, this included data on status of registration under NTEP, number of TB cases diagnosed and/or treated in the last 1 year, and the number notified through NIKSHAY. Furthermore, data on awareness and attitude about notification system were collected.
For the qualitative component, focused-group discussions (FGD) were conducted to explore the barriers in case notification among the group not notifying the cases. The FGD was conducted by a team trained in performing it, which comprised a moderator (investigator), and two assistants one for taking down notes and other for running tape recorder.
One to one sensitization of the physicians was done regarding use of NIKSHAY software by trained staff from district and various options regarding TB notification modalities was explained. An attempt was also made to generate NIKSHAY ID of the private practitioners and they were informed and motivated to report in NIKSHAY.
The institutional ethics committee clearance was obtained before the study and written informed consent was obtained from each of the study participants. The information collected was kept strictly confidential and the result of the study has been used for academic purposes and for framing recommendations for the improvement in services and for no other purpose.
Results A total of 600 private practitioners, hospitals, and nursing homes practicing/located under the area of Nehru Nagar Chest Clinic in South East district of Delhi were contacted out of which 375 consented to participate. A line list of these practitioners was prepared and their contact details were also collected.
Out of the total 375 practitioners, 80% of them belonged to the age group of 36–65 years. Males (58%) were in slight preponderance compared to female doctors (42%) in the study. Slightly over a third of the practitioners were having only the basic qualification required for independent medical practices while rest of them were having one or other additional specialty qualifications. The most common specialist practitioners belonged to the medicine specialty (16%) followed by obstetrics and gynecology and pediatrics specialty [Table 1].
About a quarter of practitioners had been practicing for over 30 years (23.7%), whereas another 6th (16.8%) were practicing for about 6–10 years. About an 8th (12.3%) of practitioners was practicing for ≤5 years only. The distribution of duration of practice ranged from 9.3% to 13.6% for duration categories of 11–15 years, 16–20 years, 21–25 years, and 26–30 years. Two-fifth (40.3%) of the practitioners were seeing 10 or less cases per day, whereas over two-third (71.5%) were seeing 20 or less cases in a day. Almost 90% of practitioners were seeing 30 or less patients a day. However, about 5% of practitioners were seeing over 50 cases in a day.
Over two-third (68%) of practitioners did not report treating any TB patient in their practice, whereas a small but significant number of them (3.2%) said that they were refusing TB patients. Only 108 practitioners included in our study were treating TB patients and only about a half of them (53) were reporting these patients. Almost all of nonreporting practitioners who were seeing and treating TB cases (50/55) were willing to do the reporting [Figure 1].
Figure 1: Status of TB patients treated and NIKSHAY reporting (%). TB: TuberculosisThe major reasons for not reporting included a lack of knowledge about the mechanism to report (72.7%) and not feeling the need to report by about a third of practitioners (34.5%). A quarter of practitioners (25.4%) felt that the process of reporting was too time-consuming. However, about 40%–50% of the practitioners believed that notification would help in patients receiving the right diagnosis and treatment, in tracing contacts of the patient and to follow the patient. Only a minuscule number of practitioners thought that notifications of TB patients should be done because it was a legal requirement [Table 2].
The major barrier identified included lack of training of practitioners in notification (45.3%), difficulty of notification process (27.7%), consumption of too much time (27.7%), nonavailability of technical infrastructures such as laptop or internet connection (22.2%), lack of technical (10.2.%), or financial support from the program side (9%) [Table 3].
We conducted six focus group discussions among 6–8 practitioners and prepared a thematic network organizing the basic and organizing themes around the global theme “Barriers to notification.”
As per the responses received the barriers and challenges in notification were assessed under four themes. The themes were – logistic problems faced, issues related to patient confidentiality, and affective attitude of the provider.
Logistic problems
Many of the private practitioners complained of a lack of human resources or untrained human resources. The notification was burdensome for them as it consumed time also. The following excerpts were made by the practitioners:
“We are already having shortage of staff, I cannot spare my staff for reporting of TB cases. If government is interested in getting it done they should make arrangements” (GP, Private clinic).
“Reporting should be made hassle free and easy so that it does not too much time and extra manpower is not required” (GP, Private clinic).
Patient confidentiality
Some of the practitioners discussed that they felt it to unethical to share information about a disease which is a social stigma. They feel that it is against the principles of physician–patient confidential relationships. Practitioners also had fear regarding sharing of patient data as they felt some patients might feel that privacy is being breached. The following responses reflect the ethical considerations felt by the practitioners.
“If we report the patient might be followed up and sometimes patient feel that their privacy is being breached” (GP, Solo private practice).
“The patients will go to doctors who do not report and it helps in maintaining their privacy” (GP, Solo private practice).
”People feel if identity is revealed the health workers will come and follow-up at home and it will cause stigma” (Physician, 65 year, Male).
Affective attitude of the provider
Many of the private practitioners were involved actively in managing the cases; however, due to ignorance about the notification system and its importance many of them did not report the cases. The following responses were received from the health-care providers:
“The hospital I visit reports the cases. As I see less TB cases at clinic, I do not report from clinic (Specialist, Solo private practice).“
“I am not well acquainted with the reporting procedure” (GP, Private clinic).
Discussion In our effort to support the program with evidence, our study found that among 28% of private practitioners attending to TB patients, only half of them (14.1%) were reporting the same in the NIKSHAY portal. Our findings are almost similar, although slightly better compared to those found by Siddaiah et al. in which of the 3820 patients with TB, 885 (23.2%, 95% CI 21.9–24.5) were notified to the NTEP and of those notified, only 82 (9%) were also recorded in the NIKSHAY portal.[10]
About two-thirds (63%) of the private practitioners interviewed did have the knowledge about reporting on the NIKSHAY portal and roughly about half of them were also aware of the Gazette notification. Despite having the knowledge and being aware of the gazette mandate for notification of TB patients, majority of practitioners were not reporting as approximately 70% did not know how to report and about 25% found it time-consuming. These reasons are similar to those found in the study conducted by Philip et al. in Kerala where a qualitative study found three major themes for barriers to notification. The study also found similar reasons and theories as to why reporting was not done during their qualitative research.[11]
Similar results were also noted by Uplekar et al., who undertook a literature search for selected high-incidence countries, they found that incomplete compliance to notification law by private practitioners was one of the major contributors to undernotification. Furthermore, the simplified easy notification system is lacking which needs to less time taking for an average private provider to put into routine practice. They also proposed that government-supported agencies are critical to strengthening the public health functions of adherence and reporting, which otherwise individual private providers would be poorly placed to carry out reporting.[12] Among the private practitioners, there were several perspectives found toward reporting. About 40% said it was useful for following up with patients, 36.1% felt it would help in tracing contacts, whereas 42% and 46% of them felt it would aid in facilitating the right diagnosis and right treatment, respectively. A mere 2.7% reported because of the legal repercussions. While majority of the practitioners did start reporting after the notification, about one-fifth of them felt that legal action should be taken against those not notifying. This figure was found to be lower than that seen in the study conducted by Philip et al. (approximately one-third).[11]
Our extensive literature review found several studies exploring the reasons for low rates of notification from the private sector. About half of the practitioners felt that there was a lack of training for them on part of the program and one-third of the participants found the process of notification difficult. Other reasons included increased time consumption, lack of incentives for notifying, and lack of technical support from the program. These findings mirror those of the study conducted by Satpati et al. which revealed the operational issues in implementation of notification at various levels among private practitioners/providers (PP) starting from registration in the notification system, the actual process of notification, and the perceptions associated with it among PPs.[13]
This study tried to explore the perception of the private sector in identifying barriers to reporting. It has been felt that the entire private sector is willing for TB control in the state and that needs to be used optimally. Many of the issues emerging from the FGDs have been documented previously also.[14],[15] A mixed method study done by Philip et al. in 2015 in Kerala found the particular theme of relevance in qualitative data analysis – “private provider misconceptions about notification,” “patient confidentiality, stigma, and discrimination,” and “lack of cohesion and coordination between public and private sector.”[11] A qualitative study done by Nair et al. in Kerala also found that building locally customized partnership schemes, behavior change for public–private partnership (PPP), building managerial capacity of public sector to deal with private sector, the presence of an interphase agency, and quality control through a participatory body could be important solutions for improvement of PPP.[16]
In addition to data collection by the interviewer (one on one), group sensitization sessions were also conducted for the private practitioners, where trained experts from the field imparted their knowledge and experiences to the audience.
Limitations
The study had certain limitations since the data were collected by self-administered questionnaire, the reliability of the data is subjective as a number of private practitioners could have denied treating TB patients and there is chance of response bias.
Conclusion and Recommendations The study is the first of its kind to assess the current status of TB notification being followed by private practitioners in South Delhi. It has helped in exploring barriers and reasons for not notifying at a larger level. The study has helped in identification of perspective and will help in development of intervention models for improving notification. Listing of PP's and one-to-one sensitization of the PP's has helped in accelerating TB notification. List of practitioners willing to report was submitted to district office for generation of NIKSHAY ID's.
We recommend that timely training and retraining and providing information on reporting, treatment guidelines, and any change in policies will be helpful in enhancing reporting. Supportive supervision and providing adequate support will help in building partnership with the private sector health-care provider. Offering nonfinancial incentives such as appreciations and recognitions would be helpful. Providing all technical inputs and support wherever needed will help in going a long way in decreasing the percentage of missing cases and in reaching the elimination goal.
Acknowledgment
We would like to acknowledge our health workers - Mr. Khursheed Alam, Mr. Dhiraj, Miss. Kimi, Mr. Haseen and Mr. Sonu who have helped in collecting data. We would also like to acknowledge Dr Farishta and Dr Tazean for helping in report writing.
Financial support and sponsorship
State TB Office, New Delhi, India.
Conflicts of interest
There are no conflicts of interest.
References 
留言 (0)