“They Know, They Agree, but They Don’t Do”- The Paradox of Tuberculosis Case Notification by Private Practitioners in Alappuzha District, Kerala, India

Abstract

BackgroundDespite being a recognized standard of tuberculosis (TB) care internationally, mandatory TB case notification brings forth challenges from the private sector. Only three TB cases were notified in 2013 by private practitioners compared to 2000 TB cases notified yearly from the public sector in Alappuzha district. The study objective was to explore the knowledge, opinion and barriers regarding TB Notification among private practitioners offering TB services in Alappuzha, Kerala state, India.Methods & FindingsThis was a mixed-methods study with quantitative (survey) and qualitative components conducted between December 2013 and July 2014. The survey, using a structured questionnaire, among 169 private practitioners revealed that 88% were aware of mandatory notification. All patient-related details requested in the notification form (except government-issued identification number) were perceived to be important and easy to provide by more than 80% of practitioners. While more than 95% felt that notification should be mandatory, punitive action in case of failure to notify was considered unnecessary by almost two third. General practitioners (98%) were more likely to be aware of notification than specialists (84 %). (P<0.01). Qualitative purposive personal interviews (n=34) were carried out among private practitioners and public health providers. On thematic framework analysis of the responses, barriers to TB notification were grouped into three themes: ‘private provider misconceptions about notification’, ‘patient confidentiality, and stigma and discrimination ’and ‘lack of cohesion and coordination between public and private sector’. Private practitioners did not consider it necessary to notify TB cases treated with daily regimen.ConclusionCommunication strategies like training, timely dissemination of information of policy changes and one-to-one dialogue with private practitioners to dispel misconceptions may enhance TB notification. Trust building strategies like providing feedback about referred cases from private sector, health personnel visit or a liaison private doctor may ensure compliance to public health activities.

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“…Our findings are indicative of an urgent need to educate PPs systematically about TB notification and to improve the TB notification system, as has also been recommended by Philip et al 16 In our study, issues regarding ethics, confidentiality and the notification process itself emerged from PP interviews. These areas could all be addressed by training PPs in TB notification by RNTCP staff.…”

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“…Raising awareness, collection of notification forms right at PP clinics and constant dialogue between RNTCP staff and PPs had no effect on notification in our study. Studies trying to understand the barriers to notification in India reported that not all PPs have fully understood the notification's rationale and that, although aware, many do not notify, the main reasons being lack of time, concerns regarding patients’ confidentiality and lack of trust in the government health system . Ensuring notification without legal backup seems difficult.…”

“…Furthermore, the evidence base of PPM effectiveness is considered rather weak and several unknowns remain regarding initiatives to effectively and sustainably engage PPs . In India, since 2012 it is mandatory for PPs to notify TB cases diagnosed outside RNTCP but notifications remain low .…”

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“…Such an effort is expected to increase the overall number of notified cases to the RNTCP, thereby presenting a correct picture of the actual TB burden in the community. Sairu Philip and colleagues have recognized that notification of TB as a public health measure for control of TB needs to be showcased to the private practitioners in India [19]. …”