Perceptions of tuberculosis patients about private providers before and after implementation of revised national tuberculosis control programme.

Background: Most of the persons with chest symptoms in India approach private providers (PPs) for health care. It has been observed that patients who start treatment with PPs for tuberculosis (TB) frequently switch over subsequently to the public sector. The reasons for this discontinuation and their perceptions of the TB care provided by the PPs are unknown. Objective: To document the perceptions about PPs India’s Revised National TB Control Programme (RNTCP) and the reasons for discontinuation of treatment with PPs and subsequent attendance at a public provider. Methods: This was a cross sectional study on patients registered under TB programme during 1997 and 2005in rural and urban areas. During this period patients who were initially diagnosed and treated for TB in a private clinic and subsequently shifted to public health facility were considered for the study. A semi-structured interview schedule was used to collect the factors related to patient’s perceptions on PPs, the factors responsible for initiating treatment with PPs, reasons for discontinuing treatment with PPs, and their willingness to continue treatment from government health facilities were collected. This data was compared with data collected in 1997 before implementation of the RNTCP. Results: A total of 1000 and 1311 TB patients were registered during 1997 and 2005 respectively. Among them, 203 (20%) and 104 (8%) patients were identified as having been initially diagnosed and started on TB treatment by PPs and subsequently shifted to government health facilities. There were significant changes in reasons for selecting PPs between the two periods: being convenient (47% vs 10%; p<0.001), quality care (41% vs 19%; p<0.001), motivated by others (49% vs 19%; p<0.001), confidentiality (19% vs 9%; p<0.05) and known doctor (6% vs 28%; p<0.001) respectively. Financial problems were the most common reason for discontinuation of treatment in both periods. The use of sputum test for diagnosing TB by PPs was significantly increased after RNTCP implementation. Conclusion: This study suggests that slowly perceptions of patients have changed towards PPs, and RNTCP has begun to gain acceptance amongst patients in terms of convenience, confidentiality and personal care.

Psycho-social dysfunction: perceived and enacted stigma among tuberculosis patients registered under revised national tuberculosis control programme.

OBJECTIVE: To examine the perceived and enacted stigma experienced by TB patients and the community. METHODS: We interviewed 276 TB patients registered for treatment during January-March 2004 in government health facilities of two Tuberculosis Units of south India. Data on perceived and enacted stigma were collected after two months of starting treatment, using a semi-structured interview schedule. In addition, four Focus Group Discussions were conducted among Directly Observed Treatment (DOT) providers and community members. Narrative summaries were also taken down to collect additional qualitative information. RESULTS: Of the 276 patients, 190 (69%) were males. There was no significant difference between the genders in relation to social stigma. Perceived stigma was higher than enacted stigma in both genders and significantly higher among males (Low self esteem p < 0.05), change of behavior of community (p < 0.05), ashamed to cough in front of others (p < 0.05). CONCLUSION: Considering the social and emotional impact of the disease, it is essential to adopt support strategies to enhance acceptance and for a successful health programme.

Reasons for non-compliance among patients treated under Revised National Tuberculosis Control Programme (RNTCP), Tiruvallur district, south India.

OBJECTIVES: To elicit reasons for treatment default from a cohort of TB patients under RNTCP and their DOT providers. METHODS: A total of 186 defaulters among the 938 patients registered during 3rd and 4th quarters of 1999 and 2001 in one Tuberculosis Unit (TU) of Tiruvallur district, Tamil Nadu and their DOT providers were included in the study. They were interviewed using a semi-structured interview schedule. RESULTS: Sixteen (9%) had completed treatment, 25 (13%) died after defaulting, and 4 (2%) could not be traced. Main reasons given by the remaining 141 patients and their DOT providers were: drug related problems (42%, 34%), migration (29%, 31%), relief from symptoms (20%, 16%), work related (15%, 10%), alcohol consumption (15%, 21%), treatment from other centers (13%, 4%), respectively. Risk factors for default were alcoholism (P<0.001), category of treatment (P<0.001), smear status (P<0.001), type of disease (P<0.001) and inconvenience for DOT (P<0.01). CONCLUSION: This study has identified group of patients vulnerable to default such as males, alcoholics, smear positive cases, and DOT being inconvenient. Intensifying motivation and counselling of this group of cases are likely to improve patient compliance and reduce default.

Management of multi drug resistance tuberculosis in the field: Tuberculosis Research Centre experience.

SETTING: Multi-drug TB resistant (resistant to isoniazid and rifampicin) patients identified from a rural and urban area. OBJECTIVE: To study the feasibility of managing MDR TB patients under field conditions where DOTS programme has been implemented. METHODS: MDR TB Patients identified among patients treated under DOTS in the rural area and from cases referred by the NGO when MDR TB was suspected form the study population. Culture and drug susceptibility testing were done at Tuberculosis Research Centre (TRC). Treatment regimen was decided on individual basis. After a period of initial hospitalization, treatment was continued in the respective peripheral health facility or with the NGO after identifying a DOT provider in the field. Patients attended TRC at monthly intervals for clinical, sociological and bacteriological evaluations. Drugs for the month were pre-packed and handed over to the respective center. RESULTS: A total of 66 MDR TB patients (46 from the rural and 20 from the NGO) started on treatment form the study population and among them 20 (30%) were resistant to one or more second line drugs (Eto, Ofx, Km) including a case of "XDR TB". Less than half the patients stayed in the hospital for more than 10 days. The treatment was provided partially under supervision. Providing injection was identified to be a major problem. Response to treatment could be correctly predicted based on the 6-month smear results in 40 of 42 regular patients. Successful treatment outcome was observed only in 37% of cases with a high default of 24%. Adverse reactions necessitating modification of treatment was required only for three patients. IMPLICATIONS: Despite having reliable DST and drug logistics, the main challenge was to maintain patients on such prolonged treatment by identifying a provider closer to the patient who can also give injection, have social skills and manage of minor adverse reactions.

Identifying effective communication channels in a rural community: A field report from south India.

Background: There is scarcity of information on communication channels in rural areas where about 38% of people are illiterate. Objective: To identify the channels of communication available in rural areas by interviewing key informants. Method: This study was conducted in 51 villages of Ellapuram block, Tiruvallur district, Tamil Nadu in the year 2004. Key informants selected from the villages were interviewed by a Medical Social Worker. The questionnaire included information on modes of communication channels, availability of markets, public facilities, and local associations. Result: The study block included 9893 households covering a population of 39255. Their main occupation was agriculture (86%). Electricity was available in all the villages. More than 80% of the villagers had community TV/cable connections, >50% of the villages had cinema star fan associations, mahila mandals, youth clubs, self-help groups, anganwadi centres and ration shops. The main source of communication as per interview was television (100%), wallposters (55%); publicity through panchayat office meetings (53%) and dandora or beat of drums(43%). Conclusion: Main communication channels, commonly used to disseminate information were TV and wall posters. More than 50% of villages had local associations which can be used for effective communication. This information is vital for disseminating important information on public health programmes and educating the rural community.

Is migration a factor leading to default under RNTCP.

Objective: To study the contribution of migration to treatment default among tuberculosis patients treated under RNTCP Methods: Retrospective study by interviewing the defaulters using semi-structured interview schedule to elicit the reasons for default including migration. Results: Of the 531 patients registered under TB programme in 3rd and 4th quarters of 2001, 104 (20%) had defaulted for treatment. Among defaulters, 24% had migrated. The reasons for migration were: occupational (48%), returning to the native place (28%), domestic problems (12%) and other illnesses (12%). Conclusion: After initiation of treatment, patients should be encouraged to report to the provider, if they are leaving the area, to transfer treatment to the nearest centre to ensure continuity of treatment. These measures will help to reduce default on account of migration and achieve the desired outcome in RNTCP. Availability of treatment under the DOTS strategy should be popularized among patients, providers and community.

Course of action taken by smear negative chestsymptomatics a report from a rural area in south India.

Objective: To evaluate adherence to diagnostic algorithm of Revised National Tuberculosis Control Programme (RNTCP) and course of action taken by smear-negative chest symptomatics (CSs). Method: Interviewing smear-negative chest symptomatics. Results: Of the 423 smear-negative CSs interviewed, 85 (20%) were not prescribed antibiotics and only 133 (39%) received it for more than seven days. Of the 148 patients with persistence of symptoms, 83 (56%) returned for further investigations and only 39% were X-rayed. Main reasons for not returning were: ‘not aware’ or ‘consulted another health provider.’ Conclusion: Strict adherence to diagnostic algorithm and proper counselling of patients are important for diagnosing smear-negative pulmonary tuberculosis (PTB) cases.

Default during the intensive phase of treatment under DOTS programme.

Objective: To study default and its associated risk factors during the intensive phase of treatment among new sputum smear positive patients registered under a Directly Observed Treatment- Short Course (DOTS) programme in Tiruvallur district, Tamil Nadu. Design: Analysis of data collected from the Tuberculosis Register, treatment cards and interview schedules during May 1999 to December 2002. Results: Of the 1463 patients registered, drug regularity results were available for 1406 patients. The cure rate was 76% with an overall default rate of 15%, of which nearly three-fourth occurred during the intensive phase. The potential risk factors were identified by multivariate analysis. A higher likelihood of default was associated with age > 45 years (AOR=1.9; 95% CI=1.2-3.0), illiteracy (1.6; 1.0-2.4), alcoholism (2.7; 1.8-4.2), DOTS inconvenience (1.9; 1.1-3.4) and cases identified and referred by the community survey (1.8; 1.1-3.0). Of the 75 defaulters from two cohort periods visited separately, 53 defaulted during the intensive phase. Among these, only 31 patients were interviewed since 17 (32%) migrated, three died, one was untraceable at the address provided while another had treatment elsewhere. Drug related (84%) and work related (32%) problems were the other reasons for default reported by the patients interviewed. Conclusion: The majority of defaults occurred during intensive phase of treatment. All efforts should be made to retrieve these patients and return them to treatment to achieve the expected goal of the RNTCP.

Evaluation of Directly Observed Treatment Providers in the Revised National Tuberculosis Control Programme.

Background: Non-governmental personnel such as Anganwadi workers and community volunteers have been used as directly observed treatment (DOT) providers in the Revised National Tuberculosis Control Programme (RNTCP), but their effectiveness has not been documented. Aim: To assess the treatment outcome and problems encountered by patients managed by different DOT providers in the RNTCP. Material and Methods: Patients diagnosed with tuberculosis at 17 Primary Health Institutions (PHIs) in Tiruvallur District during a 3-year period received DOT from one of the four types of trained DOT providers (PHI staff, governmental outreach workers, Anganwadi workers, community volunteers), and their treatment outcomes were compared. Of the 1131 new smear-positive patients treated between May 1999 through June 2002, 199 (18%) received DOT from PHI staff, 238(21%) from outreach workers, 496 (44%) from Anganwadi workers, and 170 (15%) from community volunteers. Twenty-eight patients (2%) collected drugs for self-administration. Results: Treatment success rates among patients treated by different DOT providers, Anganwadi workers (80%), governmental outreach workers (81%), community volunteers (76%) and PHI staff (76%), were statistically similar. Patients who received drugs for self-administration were significantly more likely to fail to treatment or die than patients who were treated by a DOT provider (5/28 versus 84/1103; odds ratio=4.1; 95% confidence interval=1.2-12.6; p=0.02). Conclusion: In addition to governmental staff, Anganwadi workers and community volunteers can be effectively utilized as DOT providers.

Status of long absentees among multibacillary leprosy patients admitted to a controlled clinical study.

Of 210 multibacillary leprosy patients who were admitted to a trial of two drug regimens, fifty-seven were excluded from efficacy analysis at 120 months for various reasons. Thirty-three of these patients were identified as long absentees. Efforts were made to contact these patients through letters and home visits to assess their clinical and bacteriological status and to find out the reasons for default. Twenty-one patients were thus retrieved. Only one patient was found to be having active disease requiring treatment; the rest were clinically inactive and bacteriologically negative.