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Ssemasaazi JA, Bongomin F, Akunzirwe R, Bayowa JR, Ssendikwanawa E, Adolphus C, Kivumbi RM, Kalyango JN, Mupere E, Ekyaruhanga P, Katamba A. Private practitioners' practices for tuberculosis management in a city largely served by the private health sector in Uganda. PLoS One 2024; 19:e0296422. [PMID: 38261594 PMCID: PMC10805318 DOI: 10.1371/journal.pone.0296422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/13/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Globally, tuberculosis (TB) remains a significant cause of morbidity and mortality having caused 1.6 million deaths in 2021. Uganda is a high TB burden country with a large private sector that serves close to 60% of the urban population. However, private for-profit health facilities' involvement with the National TB and Leprosy Program (NTLP) activities remains poor. This study evaluated the practices of diagnosis and treatment of pulmonary tuberculosis (PTB) and associated factors among practitioners in private for-profit (PFP) healthcare facilities in Kampala, Uganda. METHODS We conducted a cross-sectional study among randomly selected private practitioners in Uganda's largest city, Kampala. A structured questionnaire was used for data collection. Descriptive statistics and generalized linear models with log Poisson link were used to analyze data. Practices were graded as standard or substandard. RESULTS Of the 630 private practitioners studied, 46.2% (95% confidence interval (CI): 26.6 to 67.1) had overall standard practices. Being a laboratory technician (prevalence ratio (PR) = 2.7, p< 0.001) or doctor (PR = 1.2, p< 0.001), a bachelor's degree level of qualification (PR = 1.1, p = 0.021), quarterly supervision by the national TB program (PR = 1.3, p = 0.023), and acceptable knowledge of the practitioner about TB (PR = 1.8, p<0.001) were significantly associated with standard practices. CONCLUSIONS The practices of TB management for practitioners from the PFP facilities in Kampala are suboptimal and this poses a challenge for the fight against TB given that these practitioners are a major source of primary health care in the city.
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Affiliation(s)
- Judith Amutuhaire Ssemasaazi
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Faculty of Medicine, Department of Medical Microbiology and Immunology, Gulu University, Gulu, Uganda
| | - Rebecca Akunzirwe
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan Rokani Bayowa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Ssendikwanawa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Cherop Adolphus
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Muganga Kivumbi
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ezekiel Mupere
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Pediatrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Phiona Ekyaruhanga
- Department of Pediatrics, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere University Lung Institute, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere University Lung Institute, Kampala, Uganda
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Adepoju VA, Adelekan A, Etuk V, Onoh M, Olofinbiyi B. How Do Private Providers Unaffiliated With the Nigeria National TB Program Diagnose and Treat Drug-Susceptible TB Patients? A Cross-Sectional Study. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200210. [PMID: 36951286 PMCID: PMC9771464 DOI: 10.9745/ghsp-d-22-00210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION TB diagnosis and treatment practices among private providers not affiliated with the Nigeria National TB Program (NTP) have implications for TB control efforts. Studies evaluating these practices among non-NTP providers are scarce. We aimed to investigate TB diagnosis and treatment practices among non-NTP private providers in urban Lagos State, Nigeria. METHODS We conducted a cross-sectional study among doctors and nurses operating private facilities not formally affiliated with the NTP for TB case notification. Between May 2018 and January 2019, we implemented a survey using a pretested questionnaire among 152 doctors and nurses attending TB sensitization seminars in Lagos, Nigeria. We used descriptive statistics to summarize the sociodemographic information and proportion of non-NTP providers with different self-reported TB diagnostic, prescription, and monitoring practices. RESULTS Private non-NTP doctors and nurses self-reported diagnosing TB using 8 different types of tests. Acid-fast bacilli was the most common (39.8%) means of diagnosing TB. Private non-NTP providers also self-reported prescribing 23 different TB regimens, including streptomycin, to treat TB. Only 32.4% of providers self-reported using the correct combinations of anti-TB drugs to treat TB. Additionally, 58.3% of providers prescribed the standard 6-month treatment duration for pulmonary TB patients, and the remaining 41.7% either undertreated or overtreated TB. CONCLUSION A large proportion of private doctors and nurses not formally affiliated with the NTP in Nigeria were not following the NTP guidelines in the diagnosis and treatment of TB. Overtreatment and undertreatment were common. Engagement of these practitioners by the NTP in the form of supervision, on-the-job mentorship, and other strategies can mitigate the negative effects of their current practices on TB case notification and the spread of drug-resistant strains in Nigeria.
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Affiliation(s)
| | | | - Victoria Etuk
- International Research Center of Excellence, Institute of Human Virology of Nigeria, Abuja, Nigeria
| | - Moses Onoh
- Communicable and Noncommunicable Diseases Cluster, World Health Organization, Abuja, Nigeria
| | - Babatunde Olofinbiyi
- Department of Obstetrics and Gynecology, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
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Adepoju VA, Oladimeji KE, Adejumo OA, Adepoju OE, Adelekan A, Oladimeji O. Knowledge of International Standards for Tuberculosis Care among Private Non-NTP Providers in Lagos, Nigeria: A Cross-Sectional Study. Trop Med Infect Dis 2022; 7:tropicalmed7080192. [PMID: 36006284 PMCID: PMC9414366 DOI: 10.3390/tropicalmed7080192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Studies specifically evaluating tuberculosis knowledge among private non-NTP providers using the International Standards for Tuberculosis Care (ISTC) framework are scarce. We evaluated the knowledge of ISTC among private non-NTP providers and associated factors in urban Lagos, Nigeria. We performed a cross-sectional descriptive study using a self-administered questionnaire to assess different aspects of tuberculosis management among 152 non-NTP providers in Lagos, Nigeria. The association between the dependent variable (knowledge) and independent variables (age, sex, qualifications, training and years of experience) was determined using multivariate logistic regression. Overall, the median knowledge score was 12 (52%, SD 3.8) and achieved by 47% of the participants. The highest knowledge score was in TB/HIV standards (67%) and the lowest was in the treatment standards (44%). On multivariate analysis, being female (OR 0.3, CI: 0.1−0.6, p < 0.0001) and being a nurse (OR 0.2, CI: 0.1−0.4, p < 0.0001) reduced the odds of having good TB knowledge score, while having previously managed ≥100 TB patients (OR 2.8, CI: 1.1−7.2, p = 0.028) increased the odds of having good TB knowledge. Gaps in the knowledge of ISTC among private non-NTP providers may result in substandard TB patient care. Specifically, gaps in knowledge of standard TB regimen combinations and Xpert MTB/RIF testing stood out. The present study provides evidence for tailored mentorship and TB education among nurses and female private non-NTP providers.
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Affiliation(s)
- Victor Abiola Adepoju
- Department of HIV and Infectious Diseases, Jhpiego (An Affiliate of John Hopkins University), Abuja 900108, Nigeria
| | - Kelechi Elizabeth Oladimeji
- Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5099, South Africa
| | | | | | | | - Olanrewaju Oladimeji
- Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5099, South Africa
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Thapa P, Hall JJ, Jayasuriya R, Mukherjee PS, Beek K, Das DK, Mandal T, Narasimhan P. What are the Tuberculosis Care Practices of Informal Healthcare Providers? A Cross-Sectional Study from Eastern India. Health Policy Plan 2022; 37:1158-1166. [PMID: 35920775 DOI: 10.1093/heapol/czac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/23/2022] [Accepted: 08/02/2022] [Indexed: 11/14/2022] Open
Abstract
India is the highest Tuberculosis (TB) burden country, accounting for an estimated 26 % of the global burden of disease. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan (NSP) for TB elimination (2017-2025). However, Informal Healthcare Providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilised in the National TB Elimination Program (NTEP) of India. Non-prioritisation of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment, and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilising the retrospective case study method. A total 203 IPs participated who reported seeing at least one confirmed TB patient in six months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices which have consequences for achieving India's National Goal of TB elimination.
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Affiliation(s)
- Poshan Thapa
- School of Population Health, University of New South Wales, Sydney, Australia.,Department of Public Health and Community Programs - Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - John J Hall
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Rohan Jayasuriya
- School of Population Health, University of New South Wales, Sydney, Australia
| | | | - Kristen Beek
- School of Population Health, University of New South Wales, Sydney, Australia
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Nirmal A, Kuzmik A, Sznajder K, Lengerich E, Fredrick NB, Chen M, Hwang W, Patil R, Shaikh B. 'If not for this support, I would have left the treatment!': Qualitative study exploring the role of social support on medication adherence among pulmonary tuberculosis patients in Western India. Glob Public Health 2021; 17:1945-1957. [PMID: 34459366 DOI: 10.1080/17441692.2021.1965182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Social support has been identified as a significant factor in addressing treatment barriers and facilitating treatment adherence. Using a descriptive design, this qualitative study aims at sharing personal feelings and social support-related experiences among pulmonary tuberculosis (TB) patients in Western India. A semi-structured interview guide was designed, and thirty-seven in-depth interviews were conducted. Descriptive thematic analysis was employed for reporting the themes and the results. The participants highlighted diverse social support experiences like empathy, compassion, trust, neglect, tangible aid, strained relationships with in-laws, health provider's support, strength, and motivation which influences their treatment adherent behaviour. Contrasting differences of social support experiences among adherent and non-adherent TB patients were also reported. The study has important ramifications for developing patient-centric social support intervention strategies, TB policy, and practice. The study has shown, 'if not for this support', patients would have left the treatment, and it is mainly because this debilitating disease robs people of their physical, social, economic, psychological, and emotional well-being far beyond the period when treatment is being administered. However, we resonate that addressing social support is not the only way, and TB elimination overall will require an optimal mix of enhanced biomedical, social, economic, and policy interventions.
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Affiliation(s)
- Ahuja Nirmal
- Population Health Sciences Department, Harrisburg University of Science and Technology, Harrisburg, USA
| | - Ashley Kuzmik
- Department of Nursing, Penn State College of Nursing, University Park, USA
| | - Kristin Sznajder
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Eugene Lengerich
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - N Benjamin Fredrick
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, USA
| | - Michael Chen
- Global Health Center and Department of Opthalmology, Penn State College of Medicine, Hershey, USA
| | - Wenke Hwang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | | | - Bushra Shaikh
- Revised National Tuberculosis Control Program of India, Indira Gandhi Memorial Hospital, Bhiwandi, India
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DeBaun MR, Lai C, Sanchez M, Chen MJ, Goodnough LH, Chang A, Bishop JA, Gardner MJ. Antibiotic resistance: still a cause of concern? OTA Int 2021; 4:e104(1-4). [PMID: 37609480 PMCID: PMC10441676 DOI: 10.1097/oi9.0000000000000104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Antibiotic resistance remains a global public health concern with significant patient morbidity and tremendous associated health care costs. Drivers of antibiotic resistance are multifaceted and differ between developing and developed countries. Under evolutionary pressure, microbes acquire antibiotic tolerance through a variety of mechanisms at the cellular level. Patients after orthopaedic trauma are vulnerable to drug-resistant pathogens, particularly after open fractures. Traumatologists practicing appropriate antibiotic prophylaxis and treatment regimens mitigate infection and propagation of antibiotic resistance.
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Affiliation(s)
- Malcolm R DeBaun
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA
- Department of Orthopaedic Surgery
| | - Cara Lai
- Stanford University School of Medicine
| | | | | | - L Henry Goodnough
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA
- Department of Orthopaedic Surgery
| | - Amy Chang
- Department of Medicine-Infectious Disease, Stanford University School of Medicine, Stanford, CA
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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; 36:1052-1068. [PMID: 33735506 DOI: 10.1002/hpm.3151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Implementing the Standards for tuberculosis care in India (STCI) guidelines in the private sector is vital. This study attempted to estimate the knowledge and practices regarding STCI guidelines among private practitioners and to explore the reasons and solutions for low tuberculosis (TB) notification rates. METHODS We conducted a cross-sectional study for assessing the knowledge and practices of the STCI guidelines among 100 full-time allopathic private practitioners in Bhavnagar (in western part of India) from September 2018 to January 2019. Knowledge and practice were categorised as good or poor by assigning scores to the responses to a questionnaire based on the STCI guidelines. It was followed by two focus group discussions to explore the reasons and solutions for low notification rates of TB as perceived by private practitioners. RESULTS Among the 100 private practitioners, 55% had good knowledge, and 41% had good practice regarding the STCI guidelines; 69% knew about the gazette notification of mandatory notification of TB, and 58% were notifying TB cases to the government. Lack of awareness about the process as well as incentives for notification, time constraints and infrequent visits by health workers were the main reasons perceived by private practitioners for not notifying TB cases to the government. The critical solutions suggested by them were creating awareness regarding the notification process as well as incentives, increasing health worker visits and use of social media for notification. CONCLUSION Only about half of private practitioners follow the STCI guidelines for TB care, and the notification rates are low in our setting. Regular sensitisation programs need to be arranged for private practitioners to create awareness on TB notification.
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Affiliation(s)
- Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
| | - Chinmay J Shah
- Department of Physiology, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
| | - Jigna D Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
| | - Atul V Trivedi
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Bhavnagar, Gujarat, India
| | - Kedar G Mehta
- Department of Community Medicine, GMERS Medical College Gotri (Maharaja Sayajirao University of Baroda), Vadodara, Gujarat, India
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Saria V. New Machine, Old Cough: Technology and Tuberculosis in Patna. FRONTIERS IN SOCIOLOGY 2020; 5:18. [PMID: 33869427 PMCID: PMC8022787 DOI: 10.3389/fsoc.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/27/2020] [Indexed: 06/12/2023]
Abstract
In 2013, a new technology, GeneXpert, was introduced in India, which, in addition to testing for TB, could also diagnose whether the detected strain was drug resistant. By detecting the bacterium more effectively than other available tests and simultaneously testing for resistance, GeneXpert promised to reduce the delay in diagnosis and hence ineffective treatments. The new test was introduced to multiple cities via a coalition that included global health funding bodies, the government of India, the World Health Organization, and non-governmental organizations. Despite the concerted effort of the coalition, among formal providers (those trained in biomedicine) in the private sector, the new technology was not adopted as quickly as had been hoped. Examining formal providers' initial responses to the technology's introduction in the city of Patna reveals how the adoption of new technology can be influenced by the particularities of the local medical market such as the availability of diagnostic tests, presence of informal providers, and reputation of formal providers. While protocols and operations might seem standardized across implementation plans, the work that is required to ensure success must take into account the particular role that the market plays from site to site.
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Affiliation(s)
- Vaibhav Saria
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, BC, Canada
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McDowell A, Engel N, Daftary A. In the eye of the multiple beholders: Qualitative research perspectives on studying and encouraging quality of TB care in India. J Clin Tuberc Other Mycobact Dis 2019; 16:100111. [PMID: 31497654 PMCID: PMC6716552 DOI: 10.1016/j.jctube.2019.100111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This paper outlines insights qualitative research brings to the study of quality of care. It advocates understanding care as sequential, interpersonal action aimed at improving health and documenting the networks in which care occurs. It assesses the strengths and weakness of contemporary quantitative and qualitative approaches to examining quality of care for tuberculosis (TB) before outlining three qualitative research programs aimed at understanding quality of TB in India. Three case studies focus on the diagnosis level in the cascade of TB care and use qualitative research to examine the clinical use of pharmaceuticals as diagnostics, the development of diagnostic tests, and the role of care providers in the utilization of diagnostic services. They show that 1) care must be understood as part of relationships over time, 2) the presence or absence of technologies does not always imply their expected use in care, 3) physicians' provision of care is often inflected by their perceptions of patient desires, and 4) effective care is not always perfectly aligned with global health priorities. Qualitative methods with a networked perspective on care provide novel findings that can and have been used when developing quality of care improvement interventions for TB.
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Affiliation(s)
- Andrew McDowell
- Department of Anthropology, Tulane University, New Orleans, USA
- CERMES3, Institute National de la Santé et la Recherché Médicale, Paris, France
| | - Nora Engel
- Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Amrita Daftary
- McGill International TB Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Centre for the AIDS Programme of Research (CAPRISA), University of KwaZulu Natal, Durban, South Africa
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Abstract
Introduction: Antibiotic-resistant infections have become increasingly prevalent nowadays. As a result, it is essential to examine the key socioeconomic and political factors which contribute to the rise in the prevalence of antibiotic resistance in developing and developed nations. This study aims to identify the various contributors to the development of antibiotic resistance in each type of nation. Methods: PUBMED was used to identify primary research, systematic reviews, and narrative reviews published before Jan 2017. Search terms included antibiotic resistance, antimicrobial resistance, superbugs, multidrug-resistant organisms, developing countries, developed countries. Publications from different countries were included to ensure generalizability. Publications were excluded if they didn't mention factors causing resistance, focused on the molecular basis of resistance, or if they were case reports. Publicly available reports from national and international health agencies were used. Results: In developing countries, key contributors identified included: (1) Lack of surveillance of resistance development, (2) poor quality of available antibiotics, (3) clinical misuse, and (4) ease of availability of antibiotics. In developed countries, poor hospital-level regulation and excessive antibiotic use in food-producing animals play a major role in leading to antibiotic resistance. Finally, research on novel antibiotics is slow ing down due to the lack of economic incentives for antibiotic research. Conclusion: Overall, multiple factors, which are distinct for developing and developed countries, contribute to the increase in the prevalence of antibiotic resistance globally. The results highlight the need to improve the regulatory framework for antibiotic use and research globally.
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Affiliation(s)
- Aastha Chokshi
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Ziad Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - David Cennimo
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Helen Horng
- Department of Pharmacy, University Hospital, Newark, New Jersey, USA
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Sagili KD, Satyanarayana S, Chadha SS, Wilson NC, Kumar AMV, Moonan PK, Oeltmann JE, Chadha VK, Nagaraja SB, Ghosh S, Q Lo T, Volkmann T, Willis M, Shringarpure K, Reddy RC, Kumar P, Nair SA, Rao R, Yassin M, Mwangala P, Zachariah R, Tonsing J, Harries AD, Khaparde S. Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice. Glob Health Action 2018; 11:1445467. [PMID: 29553308 PMCID: PMC5912428 DOI: 10.1080/16549716.2018.1445467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. OBJECTIVES To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. METHODS From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes. RESULTS In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. CONCLUSIONS OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.
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Affiliation(s)
- Karuna D Sagili
- a Department of Tuberculosis and Communicable Diseases , International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office , New Delhi , India
| | - Srinath Satyanarayana
- b Centre for Operational Research , International Union Against Tuberculosis and Lung Disease , Paris , France
| | - Sarabjit S Chadha
- a Department of Tuberculosis and Communicable Diseases , International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office , New Delhi , India
| | - Nevin C Wilson
- c Independent Senior Public Health Consultant , Nilgiris , Tamil Nadu , India
| | - Ajay M V Kumar
- b Centre for Operational Research , International Union Against Tuberculosis and Lung Disease , Paris , France
| | - Patrick K Moonan
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - John E Oeltmann
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - Vineet K Chadha
- e Epidemiology and Research Division , National Tuberculosis Institute , Bangalore , India
| | | | - Smita Ghosh
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - Terrence Q Lo
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - Tyson Volkmann
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - Matthew Willis
- d Division of Global HIV and Tuberculosis , US Centers for Disease Control , Atlanta , GA , USA
| | - Kalpita Shringarpure
- g Department of Community Medicine , Government Medical College and SSG Hospital , Vadodara , India
| | | | - Prahlad Kumar
- h National Tuberculosis Institute , Bangalore , India
| | - Sreenivas A Nair
- i World Health Organisation India Country Office , New Delhi , India
| | - Raghuram Rao
- j Central Tuberculosis Division , Ministry of Health and Family Welfare, Government of India
| | - Mohammed Yassin
- k The Global Fund to fight AIDS , Tuberculosis and Malaria , Geneva , Switzerland
| | - Perry Mwangala
- k The Global Fund to fight AIDS , Tuberculosis and Malaria , Geneva , Switzerland
| | - Rony Zachariah
- l Médecins sans Frontières , Brussels Operational Center (LuxoR) , Luxembourg City , Luxembourg
| | - Jamhoih Tonsing
- m International Union Against Tuberculosis and Lung Disease , South-East Asia Regional Office , New Delhi , India
| | - Anthony D Harries
- b Centre for Operational Research , International Union Against Tuberculosis and Lung Disease , Paris , France
| | - Sunil Khaparde
- j Central Tuberculosis Division , Ministry of Health and Family Welfare, Government of India
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Tuberculosis diagnostic and treatment practices in private sector: Implementation study in an Indian city. ACTA ACUST UNITED AC 2018; 65:315-321. [DOI: 10.1016/j.ijtb.2018.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 06/02/2018] [Accepted: 06/22/2018] [Indexed: 11/23/2022]
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K.S. S, Saldanha PR, Kushwah S, Prabhu AS. Management practices of tuberculosis in children among pediatric practitioners in Mangalore, South India. ACTA ACUST UNITED AC 2018; 65:195-199. [DOI: 10.1016/j.ijtb.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 09/05/2017] [Accepted: 02/05/2018] [Indexed: 10/18/2022]
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15
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Bhalla BB, Chadha V, Gupta J, Nagendra N, Praseeja P, Anjinappa S, Ahmed J, Srivastava R, Kumar P. Knowledge of private practitioners of Bangalore city in diagnosis, treatment of pulmonary tuberculosis and compliance with case notification. ACTA ACUST UNITED AC 2018; 65:124-129. [DOI: 10.1016/j.ijtb.2018.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/28/2017] [Accepted: 01/05/2018] [Indexed: 12/01/2022]
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16
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17
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Verguet S, Riumallo-Herl C, Gomez GB, Menzies NA, Houben RMGJ, Sumner T, Lalli M, White RG, Salomon JA, Cohen T, Foster N, Chatterjee S, Sweeney S, Baena IG, Lönnroth K, Weil DE, Vassall A. Catastrophic costs potentially averted by tuberculosis control in India and South Africa: a modelling study. Lancet Glob Health 2017; 5:e1123-e1132. [PMID: 29025634 PMCID: PMC5640802 DOI: 10.1016/s2214-109x(17)30341-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 06/25/2017] [Accepted: 08/08/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The economic burden on households affected by tuberculosis through costs to patients can be catastrophic. WHO's End TB Strategy recognises and aims to eliminate these potentially devastating economic effects. We assessed whether aggressive expansion of tuberculosis services might reduce catastrophic costs. METHODS We estimated the reduction in tuberculosis-related catastrophic costs with an aggressive expansion of tuberculosis services in India and South Africa from 2016 to 2035, in line with the End TB Strategy. Using modelled incidence and mortality for tuberculosis and patient-incurred cost estimates, we investigated three intervention scenarios: improved treatment of drug-sensitive tuberculosis; improved treatment of multidrug-resistant tuberculosis; and expansion of access to tuberculosis care through intensified case finding (South Africa only). We defined tuberculosis-related catastrophic costs as the sum of direct medical, direct non-medical, and indirect costs to patients exceeding 20% of total annual household income. Intervention effects were quantified as changes in the number of households incurring catastrophic costs and were assessed by quintiles of household income. FINDINGS In India and South Africa, improvements in treatment for drug-sensitive and multidrug-resistant tuberculosis could reduce the number of households incurring tuberculosis-related catastrophic costs by 6-19%. The benefits would be greatest for the poorest households. In South Africa, expanded access to care could decrease household tuberculosis-related catastrophic costs by 5-20%, but gains would be seen largely after 5-10 years. INTERPRETATION Aggressive expansion of tuberculosis services in India and South Africa could lessen, although not eliminate, the catastrophic financial burden on affected households. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Carlos Riumallo-Herl
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Gabriela B Gomez
- Department of Global Health, Amsterdam Institute for Global Health and Development, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Tom Sumner
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Marek Lalli
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard G White
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua A Salomon
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Knut Lönnroth
- Global TB Programme, WHO, Geneva, Switzerland; Department of Public Health Science, Karolinska Institutet, Stockholm, Sweden
| | | | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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18
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Yellappa V, Lefèvre P, Battaglioli T, Devadasan N, Van der Stuyft P. Patients pathways to tuberculosis diagnosis and treatment in a fragmented health system: a qualitative study from a south Indian district. BMC Public Health 2017; 17:635. [PMID: 28778192 PMCID: PMC5544986 DOI: 10.1186/s12889-017-4627-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP. METHODS We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. RESULTS Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP. CONCLUSIONS India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.
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Affiliation(s)
- Vijayashree Yellappa
- Institute of Public Health, #250, 2nd C Main, 2nd 'C' Cross-, Girinagar I Phase, Bangalore, Karnataka, 560 085, India. .,Institute of Tropical Medicine, Nationalestraat, 155, 2000, Antwerp, Belgium.
| | - Pierre Lefèvre
- Institute of Tropical Medicine, Nationalestraat, 155, 2000, Antwerp, Belgium
| | - Tullia Battaglioli
- Institute of Tropical Medicine, Nationalestraat, 155, 2000, Antwerp, Belgium
| | - Narayanan Devadasan
- Institute of Public Health, #250, 2nd C Main, 2nd 'C' Cross-, Girinagar I Phase, Bangalore, Karnataka, 560 085, India
| | - Patrick Van der Stuyft
- Institute of Tropical Medicine, Nationalestraat, 155, 2000, Antwerp, Belgium.,Public Health Department, Faculty of Medicine, Ghent University, Ghent, Belgium
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19
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Akachi Y, Kruk ME. Quality of care: measuring a neglected driver of improved health. Bull World Health Organ 2017; 95:465-472. [PMID: 28603313 PMCID: PMC5463815 DOI: 10.2471/blt.16.180190] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 11/27/2022] Open
Abstract
The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. We propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalize civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.
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Affiliation(s)
- Yoko Akachi
- United Nations University World Institute for Development, Katajanokanlaituri 6B, FI-00160, Helsinki, Finland
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, United States of America
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20
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Law S, Piatek AS, Vincent C, Oxlade O, Menzies D. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. LANCET PUBLIC HEALTH 2017; 2:e47-e55. [DOI: 10.1016/s2468-2667(16)30035-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 12/01/2022]
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21
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Anand T, Babu R, Jacob AG, Sagili K, Chadha SS. Enhancing the role of private practitioners in tuberculosis prevention and care activities in India. Lung India 2017; 34:538-544. [PMID: 29099000 PMCID: PMC5684812 DOI: 10.4103/0970-2113.217577] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
India accounts for the highest number of incident tuberculosis (TB) cases globally. Hence, to impact the TB incidence world over, there is an urgent need to address and accelerate TB control activities in the country. Nearly, half of the TB patients first seek TB care in private sector. However, the participation of private practitioners (PPs) has been patchy in TB prevention and care and distrust exists between public and private sector. PPs usually have varied diagnostic and treatment practices that are inadequate and amplify the risk of drug resistance. Hence, their regulation and involvement as key stakeholders are important in TB prevention and care in India if we are to achieve TB control at global level. However, there remain certain barriers and gaps, which are preventing their upscaling. The current paper aims to discuss the status of private sector involvement in TB prevention and care in India. The paper also discusses the strategies and initiatives taken by the government in this regard as evidence shows that the involvement of private sector in co-opting directly observed treatment short-course (DOTS) helps to enhance case finding and treatment outcomes; it improves the accessibility of quality TB care with greater geographic coverage. Besides public-private mix, DOTS has been found more cost-effective and reduces financial burden of patients. The paper also offers to present some more solutions both at policy and program level for upscaling the engagement of PPs in the national TB control program.
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Affiliation(s)
- Tanu Anand
- North Delhi Municipal Corporation Medical College, Hindu Rao Hospital, New Delhi, India
| | - Ranjith Babu
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Anil G Jacob
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Karuna Sagili
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Sarabjit S Chadha
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
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22
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McLaren ZM, Sharp AR, Zhou J, Wasserman S, Nanoo A. Assessing healthcare quality using routine data: evaluating the performance of the national tuberculosis programme in South Africa. Trop Med Int Health 2016; 22:171-179. [PMID: 27886429 DOI: 10.1111/tmi.12819] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the performance of healthcare facilities by means of indicators based on guidelines for clinical care of TB, which is likely a good measure of overall facility quality. METHODS We assessed quality of care in all public health facilities in South Africa using graphical, correlation and locally weighted kernel regression analysis of routine TB test data. RESULTS Facility performance falls short of national standards of care. Only 74% of patients with TB provided a second specimen for testing, 18% received follow-up testing and 14% received drug resistance testing. Only resistance testing rates improved over time, tripling between 2004 and 2011. National awareness campaigns and changes in clinical guidelines had only a transient impact on testing rates. The poorest performing facilities remained at the bottom of the rankings over the period of study. CONCLUSION The optimal policy strategy requires both broad-based policies and targeted resources to poor performers. This approach to assessing facility quality of care can be adapted to other contexts and also provides a low-cost method for evaluating the effectiveness of proposed interventions. Devising targeted policies based on routine data is a cost-effective way to improve the quality of public health care provided.
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Affiliation(s)
- Zoë M McLaren
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alana R Sharp
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Jifang Zhou
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sean Wasserman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ananta Nanoo
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
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23
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McDowell A, Pai M. Alternative medicine: an ethnographic study of how practitioners of Indian medical systems manage TB in Mumbai. Trans R Soc Trop Med Hyg 2016; 110:192-8. [PMID: 26884500 DOI: 10.1093/trstmh/trw009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Mumbai is a hot spot for drug-resistant TB, and private practitioners trained in AYUSH systems (Ayurveda, yoga, Unani, Siddha and homeopathy) are major healthcare providers. It is important to understand how AYUSH practitioners manage patients with TB or presumptive TB. METHODS We conducted semi-structured interviews of 175 Mumbai slum-based practitioners holding degrees in Ayurveda, homeopathy and Unani. Most providers gave multiple interviews. We observed 10 providers in clinical interactions, documenting: clinical examinations, symptoms, history taking, prescriptions and diagnostic tests. RESULTS No practitioners exclusively used his or her system of training. The practice of biomedicine is frequent, with practitioners often using biomedical disease categories and diagnostics. The use of homeopathy was rare (only 4% of consultations with homeopaths resulted in homeopathic remedies) and Ayurveda rarer (3% of consultations). For TB, all mentioned chest x-ray while 31 (17.7%) mentioned sputum smear as a TB test. One hundred and sixty-four practitioners (93.7%) reported referring TB patients to a public hospital or chest physician. Eleven practitioners (6.3%) reported treating patients with TB. Nine (5.1%) reported treating patients with drug-susceptible TB with at least one second-line drug. CONCLUSIONS Important sources of health care in Mumbai's slums, AYUSH physicians frequently use biomedical therapies and most refer patients with TB to chest physicians or the public sector. They are integral to TB care and control.
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Affiliation(s)
- Andrew McDowell
- McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, Canada H3A 1A2
| | - Madhukar Pai
- McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, Canada H3A 1A2
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24
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Salve S, Sheikh K, Porter JDH. Private Practitioners' Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State. Int J Health Policy Manag 2016; 5:631-642. [PMID: 27801358 PMCID: PMC5088723 DOI: 10.15171/ijhpm.2016.52] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 05/01/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Public and private health sectors both play a crucial role in the health systems of low- and middle-income countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India. METHODS The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis. RESULTS PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector's dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as 'partners with the TB programme.' CONCLUSION Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supported.
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Affiliation(s)
- Solomon Salve
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- The Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development (MAAS-CHRD), Savitribai Phule Pune University, Pune, India
| | - Kabir Sheikh
- Public Health Foundation of India, New Delhi, India
| | - John DH Porter
- Departments of Clinical Research and Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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25
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Houben RMGJ, Menzies NA, Sumner T, Huynh GH, Arinaminpathy N, Goldhaber-Fiebert JD, Lin HH, Wu CY, Mandal S, Pandey S, Suen SC, Bendavid E, Azman AS, Dowdy DW, Bacaër N, Rhines AS, Feldman MW, Handel A, Whalen CC, Chang ST, Wagner BG, Eckhoff PA, Trauer JM, Denholm JT, McBryde ES, Cohen T, Salomon JA, Pretorius C, Lalli M, Eaton JW, Boccia D, Hosseini M, Gomez GB, Sahu S, Daniels C, Ditiu L, Chin DP, Wang L, Chadha VK, Rade K, Dewan P, Hippner P, Charalambous S, Grant AD, Churchyard G, Pillay Y, Mametja LD, Kimerling ME, Vassall A, White RG. Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models. LANCET GLOBAL HEALTH 2016; 4:e806-e815. [PMID: 27720688 PMCID: PMC6375908 DOI: 10.1016/s2214-109x(16)30199-1] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 04/06/2016] [Accepted: 08/01/2016] [Indexed: 12/30/2022]
Abstract
Background The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. Methods 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. Findings Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. Interpretation Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. Funding Bill and Melinda Gates Foundation
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Affiliation(s)
- Rein M G J Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Tom Sumner
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK; Public Health Foundation of India, Delhi NCR, India
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Chieh-Yin Wu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | | | | | - Sze-Chuan Suen
- Management Science and Engineering Dept, Stanford University, Stanford, CA, USA
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Allison S Rhines
- Department of Biology, Stanford University, Stanford, CA, USA; Johnson & Johnson Global Public Health, Raritan, NJ, USA
| | | | - Andreas Handel
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | | | | | | | - James M Trauer
- The Burnet Institute, Melbourne, Australia; The Victorian Infectious Diseases Service, at the Peter Doherty Institute, Melbourne, Australia; Department of Microbiology and Immunology, the University of Melbourne at the Peter Doherty Institute, Melbourne, Australia
| | - Justin T Denholm
- The Victorian Infectious Diseases Service, at the Peter Doherty Institute, Melbourne, Australia; Department of Microbiology and Immunology, the University of Melbourne at the Peter Doherty Institute, Melbourne, Australia
| | - Emma S McBryde
- The Burnet Institute, Melbourne, Australia; The Victorian Infectious Diseases Service, at the Peter Doherty Institute, Melbourne, Australia; Department of Microbiology and Immunology, the University of Melbourne at the Peter Doherty Institute, Melbourne, Australia
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Joshua A Salomon
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Marek Lalli
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Delia Boccia
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mehran Hosseini
- Strategic Information Department, The Global Fund, Geneva, Switzerland
| | - Gabriela B Gomez
- Department of Global Health, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | | | | | - Daniel P Chin
- Bill and Melinda Gates Foundation, China Office, Beijing, China
| | - Lixia Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Vineet K Chadha
- Epidemiology and Research Division, National Tuberculosis Institute, Bangalore, India
| | - Kiran Rade
- World Health Organization, Country Office for India, New Delhi, India
| | - Puneet Dewan
- The Bill & Melinda Gates Foundation, New Delhi, India
| | | | | | - Alison D Grant
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Gavin Churchyard
- Aurum Institute. Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | | | - Michael E Kimerling
- Bill and Melinda Gates foundation, Seattle, WA, USA (currently KNCV Tuberculosisn Foundation, The Hague, Netherlands)
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard G White
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
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26
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Satyanarayana S, Subbaraman R, Shete P, Gore G, Das J, Cattamanchi A, Mayer K, Menzies D, Harries AD, Hopewell P, Pai M. Quality of tuberculosis care in India: a systematic review. Int J Tuberc Lung Dis 2016; 19:751-63. [PMID: 26056098 DOI: 10.5588/ijtld.15.0186] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While Indian studies have assessed care providers' knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care. METHODS We searched multiple sources to identify studies (2000-2014) on providers' knowledge and practices. We used the International Standards for TB Care to benchmark quality of care. RESULTS Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector. CONCLUSIONS Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India.
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Affiliation(s)
- S Satyanarayana
- Department of Epidemiology, Biostatistics and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada; Center for Operations Research, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - R Subbaraman
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Partners for Urban Knowledge, Action and Research, Mumbai, India
| | - P Shete
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA; Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, California, USA
| | - G Gore
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, California, USA
| | - J Das
- Life Sciences Library, McGill University, Montreal, Canada
| | - A Cattamanchi
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA; Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, California, USA
| | - K Mayer
- Development Economics Research Group, World Bank, Washington DC, USA
| | - D Menzies
- The Fenway Institute and Beth Israel Deaconess Medical Center, Boston Massachusetts, USA
| | - A D Harries
- Center for Operations Research, International Union Against Tuberculosis and Lung Disease, Paris, France; Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Canada
| | - P Hopewell
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA; Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, California, USA
| | - M Pai
- Department of Epidemiology, Biostatistics and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
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Bronner Murrison L, Ananthakrishnan R, Sukumar S, Augustine S, Krishnan N, Pai M, Dowdy DW. How Do Urban Indian Private Practitioners Diagnose and Treat Tuberculosis? A Cross-Sectional Study in Chennai. PLoS One 2016; 11:e0149862. [PMID: 26901165 PMCID: PMC4762612 DOI: 10.1371/journal.pone.0149862] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 02/05/2016] [Indexed: 12/04/2022] Open
Abstract
Setting Private practitioners are frequently the first point of healthcare contact for patients with tuberculosis (TB) in India. Inappropriate TB management practices among private practitioners may contribute to delayed TB diagnosis and generate drug resistance. However, these practices are not well understood. We evaluated diagnostic and treatment practices for active TB and benchmarked practices against International Standards for TB Care (ISTC) among private medical practitioners in Chennai. Design A cross-sectional survey of 228 practitioners practicing in the private sector from January 2014 to February 2015 in Chennai city who saw at least one TB patient in the previous year. Practitioners were randomly selected from both the general community and a list of practitioners who referred patients to a public-private mix program for TB treatment in Chennai. Practitioners were interviewed using standardized questionnaires. Results Among 228 private practitioners, a median of 12 (IQR 4–28) patients with TB were seen per year. Of 10 ISTC standards evaluated, the median of standards adhered to was 4.0 (IQR 3.0–6.0). Chest physicians reported greater median ISTC adherence than other MD and MS practitioners (score 7.0 vs. 4.0, P<0.001), or MBBS practitioners (score 7.0 vs. 4.0, P<0.001). Only 52% of all practitioners sent >5% of patients with cough for TB testing, 83% used smear microscopy for diagnosis, 33% monitored treatment response, and 22% notified TB cases to authorities. Of 228 practitioners, 68 reported referring all patients with new pulmonary TB for treatment, while 160 listed 27 different regimens; 78% (125/160) prescribed a regimen classified as consistent with ISTC. Appropriate treatment practices differed significantly between chest physicians and other MD and MS practitioners (54% vs. 87%, P<0.001). Conclusion TB management practices in India’s urban private sector are heterogeneous and often suboptimal. Private providers must be better engaged to improve diagnostic capacity and decrease TB transmission in the community.
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Affiliation(s)
- Liza Bronner Murrison
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | | | | | | | - Madhukar Pai
- McGill International TB Centre & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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Sharma S, Sharma S, Whig J, Satija M, Chaudhary A. Factors Related to Non-Referral of Patients with Presumptive Pulmonary TB to Designated Microscopy Centers (DMCs) by Registered Private Practitioners in Urban Areas of Punjab, India. J Clin Diagn Res 2015; 9:LC05-8. [PMID: 26674553 DOI: 10.7860/jcdr/2014/14944.6777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Early diagnosis and proper treatment under RNTCP guidelines, forms the mainstay of management of a TB patient. A large proportion of patients with presumptive tuberculosis (TB) visit a Private Practitioner (PP) in the first place. Studies have shown that PPs rely more on X-rays and other diagnostic tools rather than referring the patient to the nearest Designated Microscopy Centre (DMC) for sputum microscopy. AIM The present study was planned to look in to factors responsible for non-referral of patients with presumptive pulmonary TB to the DMCs for diagnosis by PPs. MATERIALS AND METHODS Present study was a case-control study conducted over a period of one year among registered PPs in urban areas of Punjab. The study was carried out in five major cities which have approximately half of the urban population of Punjab. Forty three Private Practitioners per city for referral group and 43 matched PPs for non-referral group were selected. RESULTS Knowledge regarding RNTCP was low in both the referral (38.1%) as well as non-referral (25.6%) group of PPs. Allopathic doctors had significantly higher knowledge regarding TB as compared to ayurvedic and homeopathy doctors, and Registered Medical Practitioners (RMP). Both the knowledge of PPs regarding nearest DMC as well as perception about accessibility of the nearest DMC for the patients were found to be significantly higher in the referral group. Only 15.3% of practitioners in the non-referral group said that they had been contacted by RNTCP staff. CONCLUSION The main factors responsible for non-referral of pulmonary TB suspects to DMCs for diagnosis in the present study included low knowledge regarding RNTCP, lack of awareness regarding place and accessibility of nearest DMC, and inadequate sensitization of PPs by the RNTCP staff.
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Affiliation(s)
- Sarit Sharma
- Professor, Department of Community Medicine, Dayanand Medical College & Hospital , Ludhiana, Punjab, India
| | - Shruti Sharma
- Intensivist, Department of Critical Care Medicine, Dayanand Medical College & Hospital , Ludhiana, Punjab, India
| | - Jagdeep Whig
- Ex. Professor and Head, Department of Pulmonary Medicine, Dayanand Medical College & Hospital , Ludhiana, Punjab, India
| | - Mahesh Satija
- Associate Professor, Department of Community Medicine, Dayanand Medical College & Hospital , Ludhiana, Punjab, India
| | - Anurag Chaudhary
- Professor and Head, Department of Community Medicine, Dayanand Medical College & Hospital , Ludhiana, Punjab, India
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Mahendradhata Y. The case for stronger regulation of private practitioners to control tuberculosis in low- and middle-income countries. BMC Res Notes 2015; 8:600. [PMID: 26499482 PMCID: PMC4619435 DOI: 10.1186/s13104-015-1586-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/14/2015] [Indexed: 11/30/2022] Open
Abstract
Tuberculosis case management practices of private practitioners in low- and middle-income countries are commonly not in compliance with treatment guidelines, thus increasing the risk of drug resistance. National Tuberculosis control programs have long been encouraged to collaborate with private providers to improve compliance, but there is no example yet of a sustained, large scale collaborations with private practitioners in these settings. Regulations have long been realized as a potential response to poor quality care, however there has been a lack of interest from the international actors to invest in stronger regulation of private providers in these countries due to limited evidence and many implementation challenges. Regulatory strategies have now evolved beyond the costly conventional form of command and control. These new strategies need to be tested for addressing the challenge of poor quality care among private providers. Multilateral and bilateral funding agencies committed to tuberculosis control need to invest in facilitating strengthening government’s capacity to effectively regulate private providers.
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Affiliation(s)
- Yodi Mahendradhata
- Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta, 55281, Indonesia. .,Faculty of Medicine, Institute of Public Health, University of Heidelberg, Heidelberg, Germany.
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How do private general practitioners manage tuberculosis cases? A survey in eight cities in Indonesia. BMC Res Notes 2015; 8:564. [PMID: 26468010 PMCID: PMC4607095 DOI: 10.1186/s13104-015-1560-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/05/2015] [Indexed: 12/02/2022] Open
Abstract
Background Private practitioners (PPs) in high-burden countries often provide substandard tuberculosis (TB) treatment, leading to increased risk of drug resistance and continued transmission. TB case management among PPs in Indonesia has not been investigated in recent years, despite longstanding recognition of inadequate care and substantial investment in several initiatives. This study aimed to assess case management practices of private general practitioners (GPs) in eight major cities across Indonesia. Methods A cross-sectional survey of private GPs was carried out simultaneously in eight cities by trained researchers between August and December 2011. We aimed for a sample size of 627 in total, and took a simple random sample of GPs from the validated local registers of GPs. Informed consent was obtained from participants prior to interview. Diagnostic and treatment practices were evaluated based on compliance with national guidelines. Descriptive statistics are presented. Results Of 608 eligible GPs invited to participate during the study period, 547 (89.9 %) consented and completed the interview. A low proportion of GPs (24.6–74.3 %) had heard of the International Standards
for TB care (ISTC) and only 41.2–68.9 % of these GPs had participated in ISTC training. As few as 47.3 % (90 % CI: 37.6–57.0 %) of GPs reported having seen presumptive TB. The median number of cases of presumptive TB seen per month was low (0–5). The proportion of GPs who utilized smear microscopy for diagnosing presumptive adult TB ranged from 62.3 to 84.6 %. In all cities, a substantial proportion of GPs (12.0–45.5 %) prescribed second-line anti-TB drugs for treating new adult TB cases. In nearly all cities, less than half of GPs appointed a treatment observer (13.8–52.0 %). Conclusions The pattern of TB case management practices among private GPs in Indonesia is still not in line with the guidelines, despite longstanding awareness of the issue and considerable trialing of various interventions.
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Diagnosis and Treatment of Childhood Pulmonary Tuberculosis: A Cross-Sectional Study of Practices among Paediatricians in Private Sector, Mumbai. Interdiscip Perspect Infect Dis 2015; 2015:960131. [PMID: 26379705 PMCID: PMC4563113 DOI: 10.1155/2015/960131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/04/2015] [Indexed: 11/18/2022] Open
Abstract
Majority of children with tuberculosis are treated in private sector in India with no available data on management practices. The study assessed diagnostic and treatment practices related to childhood pulmonary tuberculosis among paediatricians in Mumbai's private sector in comparison with International Standards for Tuberculosis Care (ISTC) 2009. In this cross-sectional study, 64 paediatricians from private sector filled self-administered questionnaires. Cough was reported as a symptom of childhood TB by 77.8% of respondents. 38.1% request sputum smear or culture for diagnosis and fewer (32.8%) use it for patients positive on chest radiographs and 32.8% induce sputum for those unable to produce it. Sputum negative TB suspect is always tested with X-ray or tuberculin skin test. 61.4% prescribe regimen as recommended in ISTC and all monitor progress to treatment clinically. Drug-resistance at beginning of treatment is suspected for child in contact with a drug-resistant patient (67.7%) and with prior history of antitubercular treatment (12.9%). About half of them (48%) request drug-resistance test for rifampicin in case of nonresponse after two to three months of therapy and regimen prescribed by 41.7% for multidrug-resistant TB was as per ISTC. The study highlights inappropriate diagnostic and treatment practices for managing childhood pulmonary TB among paediatricians in private sector.
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Majumdar A, Sujiv A, Palanivel C. Video Directly Observed Treatment: How Effective Will it be in Indian Setting? J Family Med Prim Care 2015; 4:152-3. [PMID: 25811013 PMCID: PMC4366994 DOI: 10.4103/2249-4863.152279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Anindo Majumdar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Akkilagunta Sujiv
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Chinnakali Palanivel
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Kumar AMV, Satyanarayana S, Berger SD, Chadha SS, Singh RJ, Lal P, Tonsing J, Harries AD. Promoting operational research through fellowships: a case study from the South-East Asia Union Office. Public Health Action 2015; 5:6-16. [PMID: 26400596 PMCID: PMC4525361 DOI: 10.5588/pha.14.0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/27/2015] [Indexed: 11/10/2022] Open
Abstract
In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.
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Affiliation(s)
- A. M. V. Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | - S. Satyanarayana
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | | | - S. S. Chadha
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | - R. J. Singh
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | - P. Lal
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | - J. Tonsing
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
| | - A. D. Harries
- The Union, Paris, France
- London School of Hygiene & Tropical Medicine, London, UK
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Salje H, Andrews JR, Deo S, Satyanarayana S, Sun AY, Pai M, Dowdy DW. The importance of implementation strategy in scaling up Xpert MTB/RIF for diagnosis of tuberculosis in the Indian health-care system: a transmission model. PLoS Med 2014; 11:e1001674. [PMID: 25025235 PMCID: PMC4098913 DOI: 10.1371/journal.pmed.1001674] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 06/05/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND India has announced a goal of universal access to quality tuberculosis (TB) diagnosis and treatment. A number of novel diagnostics could help meet this important goal. The rollout of one such diagnostic, Xpert MTB/RIF (Xpert) is being considered, but if Xpert is used mainly for people with HIV or high risk of multidrug-resistant TB (MDR-TB) in the public sector, population-level impact may be limited. METHODS AND FINDINGS We developed a model of TB transmission, care-seeking behavior, and diagnostic/treatment practices in India and explored the impact of six different rollout strategies. Providing Xpert to 40% of public-sector patients with HIV or prior TB treatment (similar to current national strategy) reduced TB incidence by 0.2% (95% uncertainty range [UR]: -1.4%, 1.7%) and MDR-TB incidence by 2.4% (95% UR: -5.2%, 9.1%) relative to existing practice but required 2,500 additional MDR-TB treatments and 60 four-module GeneXpert systems at maximum capacity. Further including 20% of unselected symptomatic individuals in the public sector required 700 systems and reduced incidence by 2.1% (95% UR: 0.5%, 3.9%); a similar approach involving qualified private providers (providers who have received at least some training in allopathic or non-allopathic medicine) reduced incidence by 6.0% (95% UR: 3.9%, 7.9%) with similar resource outlay, but only if high treatment success was assured. Engaging 20% of all private-sector providers (qualified and informal [providers with no formal medical training]) had the greatest impact (14.1% reduction, 95% UR: 10.6%, 16.9%), but required >2,200 systems and reliable treatment referral. Improving referrals from informal providers for smear-based diagnosis in the public sector (without Xpert rollout) had substantially greater impact (6.3% reduction) than Xpert scale-up within the public sector. These findings are subject to substantial uncertainty regarding private-sector treatment patterns, patient care-seeking behavior, symptoms, and infectiousness over time; these uncertainties should be addressed by future research. CONCLUSIONS The impact of new diagnostics for TB control in India depends on implementation within the complex, fragmented health-care system. Transformative strategies will require private/informal-sector engagement, adequate referral systems, improved treatment quality, and substantial resources. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Henrik Salje
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jason R. Andrews
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sarang Deo
- Indian School of Business, Hyderabad, India
| | - Srinath Satyanarayana
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Amanda Y. Sun
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Madhukar Pai
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University Health Centre, Montreal, Quebec, Canada
- Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada
- * (DWD); (MP)
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America
- * (DWD); (MP)
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Pai M, Yadav P, Anupindi R. Tuberculosis control needs a complete and patient-centric solution. LANCET GLOBAL HEALTH 2014; 2:e189-90. [PMID: 25103049 DOI: 10.1016/s2214-109x(14)70198-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Madhukar Pai
- McGill International TB Centre and Department of Epidemiology & Biostatistics, McGill University, Montreal, Quebec H3A 1A2, Canada.
| | - Prashant Yadav
- Stephen M Ross School of Business, University of Michigan, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ravi Anupindi
- Stephen M Ross School of Business, University of Michigan, Ann Arbor, MI, USA
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