CHAPTER I - SOCIOLOGICAL APPROACH TO HEALTH CARE & TB CONTROL <<Back
 
a) Sociological considerations
 
030
AU : Uplekar MW & Sheela Rangan
TI : Tackling TB – the search for solutions
SO : Tackling TB – the search for solutions; Bombay Foundation for Research in Community Health, Bombay, 1996
DT : M
AB :

The present study attempts to understand the nature of the social and operational constraints affecting TB control and identify ways to remedy them. Such constraints, which are by their very nature intricate, demand prolonged, in-depth, field-based, qualitative and quantitative investigation, for their appreciation. The design of the present study allowed such an exhaustive inquiry and the composition of the study team facilitated it. The study had a ‘rural’ and an ‘urban’ component, and ‘users of health services’ and ‘providers of health services’ as sub-components. Distinctively, the investigation encompassed the lay people, the patients of TB, the public health care providers and the private health sector – all within the set-up of a district which is the peripheral administrative unit of the NTP. The study was conducted between 1991 and 1994 in Pune district of Maharashtra, at the time when TB was being rediscovered as a problem requiring urgent attention and action. Pune is one of the better developed districts of the most progressive state of Maharashtra in India. While this limits the generalizability of the study findings, there is little reason to believe that the constraints faced by the programme and its beneficiaries in areas with lower levels of development and poorer infrastructure, will be less.

KEY WORDS: SOCIAL INQUIRY; HEALTH SERVICES; HEALTH PROVIDER; SOCIAL ASPECTS; INDIA
 

  b) Socio-Cultural, Socio-Economic & Demographic Aspects  
 
054
AU : Juvekar SK, Morankar SN, Dalal DB, Sheela Rangan, Khanvilkar SS, Vadair AS, Uplekar MW & Deshpande A
TI : Social and operational determinants of patient behaviour in lung tuberculosis.
SO : INDIAN J TB 1995, 42, 87-93.
DT : Per
AB :

Two hundred and ninety nine patients registered for treatment with the public health services-103 with rural PHC`s and 196 with urban TB clinics in Pune district were interviewed in order to understand social and operational determinants that influence treatment behaviour in lung TB. Detailed quantitative as well as qualitative information was elicited. The study showed that despite weak, if not missing, health educational inputs, patients' understanding of TB was satisfactory. Their preference for private doctors over public health services for TB, their frequent change of health providers for diagnosis as well as treatment, their poor treatment adherence despite knowledge of its ill-effects and their related actions perceived clearly as deleterious to their own good were influenced more by social, economic, and operational factors than by their self-destructive attitude and behaviour. The study concluded that it was the availability, affordability and acceptability of health facilities for TB-factors related primarily to the provider behaviour- that deserved greater and priority attention. Attempts at rectifying provider behaviour were likely to be more productive than those at disciplining patients.

KEYWORDS: SOCIAL BEHAVIOUR, SOCIO-ECONOMICS, HEALTH PROVIDER; INDIA.
 

 
  CHAPTER II - HEALTH SERVICES  
 
a) Health Policy, Delivery of Health Services & Health Care
 
107
AU : Uplekar MW
TI : Tuberculosis control in India: the urban viewpoint - Guest Editorial.
SO : INDIAN J TB 1993, 40, 59-60.
DT : Per
AB :

The guest editorial considers that the NTP, while a well-designed one, has been deficient in implementation of the programme, that the blame for this deficiency should go to the general conditions under which the programme has to function and not the programme itself. Therefore, those who wish to improve the functioning of the NTP should direct their attention to improving the GHS. Regarding the TB control programme in urban areas of India, three trends that have emerged are described. Given these trends, it is considered that only a consensual approach based on mutual understanding towards achieving a common goal could bring about the desired change in the programme. A set of interventions to improve the programme are included.

KEYWORDS: HEALTH SERVICES; HEALTH SYSTEM; HEALTH CARE; INDIA.
 

 
  CHAPTER II - HEALTH SERVICES  
 
c) Involvement of Private Practitioners
 
157
AU : Uplekar MW, Juvekar SK & Shepard DS
TI : Treatment of tuberculosis by private general practitioners in India
SO : TUBERCLE 1991, 72, 284-290
DT : Per
AB :

Early detection and optimal treatment constitute the most important measures in the control of TB. A study of doctors practicing in a large low income settlement of Bombay was carried out to find out the prescribing pattern for treatment of TB. The doctors selected by simple random were a mixture of those qualified in western medicine (allopaths) and those qualified in indigenous systems such as Ayurveda, Homeopathy and Unani (non-allopaths). From the list of total 287 doctors, 143 were selected. The sample included 79 allopaths and 64 non-allopaths.

All the doctors were requested to write a prescription for a previously untreated adult case of sputum positive pulmonary TB indicating drug used, dosages and duration. The slips were collected by the Investigator on the spot and later analysed by EPI-INFO software. Of the 143 doctors, 31 (22%) refused participation in the study. The final analysis included 102 doctors (48 allopaths and 54 non-allopaths). Hundred doctors using two or more of the five anti-TB drugs (S, H, R, Z & E) prescribed 80 different regimens non-confirmed with standard recommended regimen except for two doctors who wrote indigenous drugs. None of them employed thioacetazone as the anti-TB drug or recommended intermittent regimen.

This study highlights that irrespective of their background and training, most of the doctors use modern chemotherapeutic agents in the treatment of TB. Most of the regimens were inappropriate, expensive and of long duration of 12-24 months.

This inefficient use of scarce resources may be avoided through Continuing Medical Education of private doctors by experts. Effective media and other possible modes of communication could be used to educate lay people about the disease, the importance of regularity of treatment. Ways need to be considered to make private doctors participate in effective implementation of programme, for which their curative functions could contribute significantly to control the disease.

KEY WORDS: PRIVATE DOCTORS; GENERAL PRACTITIONER; DOCTORS’ AWARENESS; INDIA

158
AU : Uplekar MW & Sheela Rangan
TI : Private doctors and tuberculosis control in India
SO : TUBERCLE AND LUNG DIS 1993, 74, 332-337
DT : Per
AB :

Over three quarters of the 8 million registered doctors in India are engaged in private medical practice. In urban and rural areas alike people prefer private doctors to public health services for their health care needs. A majority of patients and those with suspected TB also report first to private doctors. A study on ‘private doctors and TB control in India’ was conducted in Dharavi a shanty settlement of Bombay metropolis to assess their knowledge and practice as regards the diagnosis and treatment of pulmonary TB, their awareness of the NTP and their impression of public health services. A population of 200,000 people was randomly selected. Among a total of 207 private allopathic and non-allopathic doctors serving the population, 143 were interviewed on a semistructured interview schedule on various aspects of TB, its diagnosis and treatment; 31 doctors refused and 10 could not give time. The completed schedules were obtained from 102 (70%) of doctors (48 allopaths and 54 non-allopaths). All of them stated to have come across TB patients in their practice and 25 stated correctly that it is not a notifiable disease. All the doctors were aware of the symptoms of early manifestation of TB, about 20% replied that they would first investigate the patient before starting treatment, 60% would give antibiotic, 10% with cough mixture and 10% treat for eosinophilia. In response to confirm clinical diagnosis of TB all the doctors would subject the patients to X-ray, ESR & CBC, and 38% of them said they relied on sputum examination. All except 2 doctors employed 80 types of regimens containing SCC drugs, most of them were expensive, inappropriate and non-standard. Cost of drug treatment ranged from Rs.1500/- to Rs.5000/-, cost of diagnosis from Rs.50/- to Rs.200/-. Compliance by patients was reported to be in the range of 25% to 50%. The private doctors’ perceptions for treatment default by TB patients were illiteracy, lack of funds, carelessness, relief of symptoms and ignorance.

The nearest government facility providing free diagnosis and treatment to TB patients with all the facilities was a Municipal Clinic with an OPA of 35 per day. About 500 TB patients were under treatment at that point of time. All anti-TB drugs were available in the clinic. A large majority of the private doctors referred those patients who could not afford treatment, to this clinic. Their opinion about public health service was as follows: half of them found unsatisfactory, 40% average, 10% would never refer their patients due to bad treatment. About 70% of private doctors were aware about NTP but could not elaborate on the activities of NTP. About updating their knowledge on TB, 65% mentioned medical representatives of drug companies, 25% through books, 5% through CMEs and 5% did not reply.

Although private practitioners are the first points of contact by the patients, few attempts have been made to involve them in the important national disease control programmes. As a result, although they treat the TB patients in their clinics, but poorly. The importance of notification is well known, yet none of the private doctors ever reported a case of TB. As a result, private doctors seem to be alienated from national efforts towards control of TB, there being no well-defined role for them in the NTP. It is evident from this study that private doctors cannot be wished away, as the people opt for their services, but at the same time they must not be granted total freedom to act as they see fit without caring for the consequences. There is a need for better communication between the private doctors and those implementing disease control programmes so as to enable them to follow appropriate clinical and public health practices.

KEY WORDS: PRIVATE DOCTORS; GENERAL PRACTITIONER; DOCTORS’ AWARENESS; INDIA.

159
AU : Uplekar MW, Juvekar SK, Parande SD, Dalal DB, Khanvilkar SS, & Sheela Rangan
TI : Tuberculosis management in private practice and its implications
SO : INDIAN J TB 1996, 43, 19-22
DT : Per
AB :

This study of 81 rural and 96 urban private medical practitioners, which included 67 allopaths and 110 nonallopaths, was conducted to understand how patients of lung TB are diagnosed and treated in their clinics as well as their interactions with and perceptions regarding the public health services available for TB control. A majority of private doctors gave little importance to sputum examination and considered X-ray of the chest as the single most important diagnostic test for lung TB. They were neither aware of nor employed inexpensive standard regimens for treating their patients. While all private doctors used SCC in the treatment of lung TB, few regimens used by them conformed to the ones recommended under the NTP. Private doctors were aware of but sceptical about TB treatment available at public health facilities.

KEY WORDS: PRIVATE PRACTITIONER; INDIA

160
AU : Uplekar MW
TI : The private medical sector and tuberculosis control in India
SO : Proceedings of International CME on TB, 27th & 28th Sep. 1996, p.159-160
DT : CP
AB :

This paper presents the findings of some of the first studies on the private sector in TB control in India, undertaken by the Foundation for Research in Community Health, in the rural and urban parts of Maharashtra. Two studies examined the management practices of private medical practitioners. One prospective study documented the treatment behaviour of TB patients under care of private medical practitioners and the third one evaluated two city-based TB projects undertaken by groups of private medical practitioners.

KEY WORDS: PRIVATE SECTOR; INDIA.

162
AU : Uplekar MW, Juvekar S, Morankar S, Sheela Rangan & Nunn P
TI : Tuberculosis patients and practitioners in private clinics in India
SO : INT J TB & LUNG DIS 1998, 2, 324-29
DT : Per
AB :

This study is conducted in Rural and urban areas of Maharashtra, a large state in Western India. to understand TB management practices among private medical practitioners (PPs) and the treatment behaviour of the patients they manage.

Prospective study of help-seeking patterns and treatment behaviour among 173 pulmonary TB patients diagnosed in private clinics, and the TB management practices of 122 PPs treating these patients.

The first source of help for 86% of patients was a PP. The diagnostic and treatment practices of PPs were inadequate; 15% did not consider sputum examination to be necessary, and 79 different treatment regimens were prescribed by 105 reporting PPs. Sixty seven percent of the patients diagnosed in private clinics remained with the private sector, and the rest shifted to public health services within six months of treatment. The treatment adherence rate among the patients in private clinics was 59%. There were discrepancies between the reported management practices of the PPs and what their patients actually followed.

The study identifies and highlights the need to educate PPs and their TB patients, and indicates ways in which PPs could be meaningfully involved in efforts to revitalize the NTCP.

KEY WORDS: PRIVATE PRACTITIONER; MANAGEMENT PRACTICES; INDIA.
 

 
     CHAPTER IV - TREATMENT BEHAVIOUR OF TB PATIENTS  
 
b) Measures to Improve Treatment Adherence
 
257
AU : Uplekar MW & Sheela Rangan
TI : Alternative approaches to improve treatment adherence in tuberculosis control programme.
SO : INDIAN J TB 1995, 42, 67-74.
DT : Per
AB :

Non-adherence to treatment by patients is a major impediment, worldwide, in controlling TB. Failure of approaches attempted so far, in effectively tackling the problem of non-adherence, has led to the inclusion of directly observed or supervised chemotherapy as an essential element of the WHO's revised strategy for global TB control. Supervise chemotherapy has also been made the most important component of India's NTP being revitalized with the help of a loan from the World Bank and technical assistance from WHO. The reason for advocating supervised chemotherapy in India is the failure to ever achieve desirable cure rates, under a well designed NTP in operation for ever 3 decades. The demonstration projects of several NGO's, claiming success in achieving high cure rates, rarely provide hard data as evidence and their results are often considered anecdotal and unsuitable for wider application. This paper presents alternative approaches adopted by two NGO‘s providing services to large populations in different settings, one a most backward area of rural Gujarat and the other in the slums of Bombay. Both organizations could ensure reasonably high levels of treatment completion and cure rates under field conditions. While the urban NGO used pre-registration screening and motivation as tools to ensure treatment completion and cure, the rural NGO successfully employed the services of the female anganwadi workers of the Integrated Child Development Services(ICDS) scheme. The reproducibility and wider applicability of some important elements of these approaches are discussed.

KEYWORDS: COMPLIANCE; CASE HOLDING; ADHERENCE; INDIA.
 
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