"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 Apr 24;10(4):e0123286. doi: 10.1371/journal.pone.0123286. eCollection 2015.

Abstract

Background: Despite being a recognized standard of tuberculosis (TB) care internationally, mandatory TB case notification brings forth challenges from the private sector. Only three TB cases were notified in 2013 by private practitioners compared to 2000 TB cases notified yearly from the public sector in Alappuzha district. The study objective was to explore the knowledge, opinion and barriers regarding TB Notification among private practitioners offering TB services in Alappuzha, Kerala state, India.

Methods & findings: This was a mixed-methods study with quantitative (survey) and qualitative components conducted between December 2013 and July 2014. The survey, using a structured questionnaire, among 169 private practitioners revealed that 88% were aware of mandatory notification. All patient-related details requested in the notification form (except government-issued identification number) were perceived to be important and easy to provide by more than 80% of practitioners. While more than 95% felt that notification should be mandatory, punitive action in case of failure to notify was considered unnecessary by almost two third. General practitioners (98%) were more likely to be aware of notification than specialists (84 %). (P<0.01). Qualitative purposive personal interviews (n=34) were carried out among private practitioners and public health providers. On thematic framework analysis of the responses, barriers to TB notification were grouped into three themes: 'private provider misconceptions about notification', 'patient confidentiality, and stigma and discrimination 'and 'lack of cohesion and coordination between public and private sector'. Private practitioners did not consider it necessary to notify TB cases treated with daily regimen.

Conclusion: Communication strategies like training, timely dissemination of information of policy changes and one-to-one dialogue with private practitioners to dispel misconceptions may enhance TB notification. Trust building strategies like providing feedback about referred cases from private sector, health personnel visit or a liaison private doctor may ensure compliance to public health activities.

MeSH terms

  • Adult
  • Aged
  • Cross-Sectional Studies
  • Disease Notification / statistics & numerical data*
  • Female
  • General Practitioners / statistics & numerical data*
  • Humans
  • India
  • Male
  • Middle Aged
  • Private Practice / statistics & numerical data*
  • Professional Competence
  • Qualitative Research
  • Surveys and Questionnaires
  • Tuberculosis / epidemiology*
  • Young Adult

Grants and funding

Funding for the operational research course was made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this paper do not necessarily reflect the views of USAID, the United States Government, or International Union Against Tuberculosis and Lung Disease (The Union). The training for research methodology was received in National Operations Research Course from the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières. The support for this publication is from a specific SORT IT programme which was jointly developed and implemented by: The Union South-East Asia Regional Office, New Delhi, India, and the Centre for Operational Research, The Union, Paris, France and Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Center, India. The funds required to conduct the study in Alappuzha was provided by the State Board of Medical Research (SBMR) Unit of Government T.D. Medical College, Alappuzha. SBMR funds are utilised to promote research activities among faculty of the institution. The funders had no role in study design, data collection, analysis and interpretation of data, decision to publish or preparation of the manuscript.