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Practitioners Perspectives On National Tuberculosis

ABSTRACT

Background; Tuberculosis constitutes a growing threat to the survival of mankind. Its high rate of mortality has been attributed to inadequate control programs, poor compliance with anti-tuberculosis regimes for various reasons, increasing prevalence of HIV infection, and overpopulation.

Tuberculosis management practices of private practitioners have recently come under scrutiny worldwide; it has been observed that private practitioners tend to deviate from recommended tuberculosis management practices. Of particular concern are those of private practitioners in poor countries with a high burden of tuberculosis. Treatment regimen used by private practitioners has been noted to be inconsistent and non-standardised thus highlighting the physicians’ lack of familiarity with the recommended anti-tuberculosis guidelines. The gap in knowledge on treatment regimens is mainly a reflection of the lack of proper channels of communication between the National Tuberculosis Programs (NTPs) and the private practitioners. The improper use of chemotherapy with incorrect regimens for TB treatment could be one of the causes for the emergence of multi-drug resistant tuberculosis (MDR-TB),

The aim of this research is to explore the perception of private medical practitioners around the National tuberculosis control program in Developing Countries.

Design: A literature review was undertaken of both qualitative and quantitative research studies reporting data relevant to the research question: What are the perceptions of private practitioners around NTP in developing countries? 8 primary research articles were critically appraised.

Findings: It was discovered that the awareness level amongst private practitioners was quite poor; this was blamed on poor outreach by the control program coordinators. This also affected the level of knowledge update by the practitioners. Several private practitioners felt that the control program was not as effective as it should be; this was blamed mainly on the poor outreach level by the program coordinators. It was also established that the collaboration level was appalling and several recommendations were propagated to help move the National TB control program forward one of which was to incorporate the private practitioners into the program as they were open to collaboration.

TABLE OF CONTENTS

ABSTRACT………………………………………………………………………… ii

TABLE OF CONTENT…………………………………………………………….. iv

LIST OF FIGURES…………………………………..……………….…………….vii

LIST OF APPENDICES…………………………………………..…….………….viii

ACKNOWLEDGEMENT……………………………………………………………ix

ALPHABETICAL LIST OF ABBREVIATIONS……………………………………x

CHAPTER 1 BACKGROUND OF THE STUDY……………………………………1

1.0 Introduction………………………………………………………………………..1

1.1 Statement of problem……………………………………………………………...1

1.2 Justification of the study…………………………………………………………..3

1.3 Research aim………………………………………………………………………7

1.4 Research objectives ………………………………………………………………8

1.5 Research question………………………………………………………………....8

CHAPTER 2 METHODOLOGY………………………………….…………..........10

2.1 Literature search strategy………………………………………………………...10

LIST OF FIGURES

Figure 1- Emergent themes from the reviewed literature

Figure 2- Themes from findings

LIST OF APPENDICES

ALPHABETICAL LIST OF ABBREVIATIONS

2HRZ/4HR- 2 months of H-Isoniazid, R-rifampicin, Z-pyrazinamide and 4months

of Isoniazid and rifampicin

AGPMPN- Association of General and Private Medical Practitioners of Nigeria.

DOTS- Directly Observed Therapy Short-course

FMOH- Federal Ministry of Health

HIV- Human Immune deficiency Virus

IDH- Infectious Diseases Hospitals

LTI- Leprosy and TB Inspectors

MDR-TB- Multi Drug Resistant Tuberculosis

NGOs- Non-Governmental Organizations

NTBLCP-National TB and Leprosy Control Program

NTP- National Tuberculosis control Program

PPs – Private Practitioners

PPM- Public-Private Mix

RNTCP- Revised National TB Control Program

TB- Tuberculosis

USA- United States of America

USAID- United States Agency for International Development

WHO- World Health Organisation

CHAPTER 1:

BACKGROUND TO THE STUDY

Introduction

Tuberculosis (TB) constitutes a growing threat to the survival of humankind. Its high rate of mortality has been attributed to inadequate control programs, poor compliance with anti-tuberculosis regimes for various reasons, increasing prevalence of Human Immunodeficiency Virus (HIV) infection, and overpopulation. Tuberculosis management practices of private practitioners have recently come under scrutiny worldwide; it has been observed that private practitioners tend to deviate from recommended tuberculosis management practices. Of particular concern are those of private practitioners in poor countries with a high burden of tuberculosis. Treatment regimen used by private practitioners has been noted to be inconsistent and non-standardised thus highlighting the physicians’ lack of familiarity with the recommended anti-tuberculosis guidelines, (Philip et al, 2008). The gap in knowledge on treatment regimens is mainly a reflection of the lack of proper channels of communication between the National Tuberculosis Programs (NTPs) and the private practitioners. The improper use of chemotherapy with incorrect regimens for TB treatment could be one of the causes for the emergence of multi-drug resistant tuberculosis (MDR-TB), (Uplekar, Pathania and Raviglion, 2001).

It was discovered that the awareness level amongst private practitioners was quite poor; this was blamed on poor outreach by the control program coordinators. This also affected the level of knowledge update by the practitioners, (Donaldson et al 2004). Several private practitioners felt that the control program was not as effective as it should be; this was blamed mainly on the poor outreach level by the program coordinators, (Lewis et al, 2006). Collaboration level was appalling and several recommendations were propagated to help move the NTP program forward one of which was to incorporate the private practitioners into the program as they were open to collaboration, (Dye et al, 2006). This review will concentrate on private practitioners in developing countries: Themes developed from recurrent arguments and issues from the articles obtained for further discussion include; the national tuberculosis control programme, diagnosis of tuberculosis, treatment of tuberculosis, private practitioner’s involvement, collaboration between the NTP and private practitioners and private practitioner’s perceptions will be discussed.

Communicable diseases dominate the disease burden in developing countries. Tuberculosis is a leading cause of death of young people and adults. Despite much worldwide attention and implementation of the World Health Organisation (WHO) recommended Directly Observed Treatment, Short-course (DOTS) strategy by 119 countries, only 40% of estimated tuberculosis cases are notified worldwide (Uplekar, Pathania and Raviglion, 2001). Tuberculosis constitutes a growing threat to the survival of humankind. Every year, about 8 million people develop this disease, and about 3 million die of it, over 95% of these in developing nations (Khan et al., 2006). This high rate of mortality has been attributed to inadequate control programmes, poor compliance with anti-tuberculosis regimes for various reasons, increasing prevalence of HIV infection, and overpopulation. Tuberculosis is among the top ten causes of death worldwide and holds a prominent place in public-health statistics, in part because it is listed among the top ten causes of death worldwide (Davidson, 2005).

Nearly one-third of the global population, i.e. two billion people, are infected with Mycobacterium tuberculosis and at risk of developing the disease tuberculosis. More than eight million people develop active tuberculosis every year, and about two million die (WHO, 2003). More than 90% of global TB cases and deaths occur in the developing world, where 75% of cases are in the most economically productive age group (15-54 years). There, an adult with TB loses on average three to four months of work time. This results in the loss of 20-30% of annual household income and, if the patient dies of TB, an average of 15 years of lost income. In addition to the devastating economic costs, TB imposes indirect negative consequences - children leave school because of their parents' tuberculosis, and women are abandoned by their families as a result of their disease (WHO, 2003).

Tuberculosis management practices of private practitioners have recently come under scrutiny worldwide, in places as different as the Indian subcontinent, South-East Asia, Africa, some European countries, and USA. Banerjee et al. (2005) observed that private practitioners tend to deviate from recommended tuberculosis management practices. Of particular concern are those of practitioners in poor countries with a high burden of tuberculosis. For example, private practitioners in such countries relied on chest radiography for diagnosis and rarely referred patients for sputum microscopy or monitored their treatment. In addition, some prescribed inappropriate drug regimens, often with incorrect combinations and inaccurate doses for the wrong duration. Few paid attention to maintenance of records, case notification was uncommon, treatment defaulters are never followed-up, and treatment outcomes were not known (Okeke and Aguwa, 2006).

Treatment regimen used by private practitioners has been noted to be inconsistent and non-standardised thus highlighting the physicians’ lack of familiarity with the recommended anti-tuberculosis guidelines (Shimeles et al, 2006). Where diagnosis, treatment, and reporting practices often do not meet national or international standards for tuberculosis, the patients tend not to get evidence based practice treatment, (Dejio et al, 2003). Subsequent delays in diagnosis and inadequate treatment may result in extended infectiousness, acquired drug resistance, treatment failure, and high rates of relapse—all of which may impair efforts for tuberculosis control The improper use of chemotherapy with incorrect regimens for TB treatment could be one of the causes for the emergence of multi-drug resistant tuberculosis (MDR-TB), moreover, patients can be unnecessarily exposed to drug side effects (Carrin et al., 2007). The gap in knowledge on treatment regimens is mainly a reflection of the lack of proper channels of communication between the National Tuberculosis Programmes (NTPs) and the private practitioners (Jaramillo, 2006). Norman (2005) suggest that by ignoring private practitioners in the involvement of TB management programmes had been an omission on the part of national tuberculosis programme leaders, particularly in places where a substantial proportion of tuberculosis patients visit private practitioners whose management practices are suspect. Such doctors seem to pose both threats to and opportunities for improved tuberculosis control. If the private medical sector grows into an alternative unregulated source of care, the goals of national tuberculosis programmes will be hampered. However, private practitioners offer major opportunities to improve tuberculosis control. A private practitioner is a valuable resource, located close to, and often trusted by the community. National tuberculosis programmes could increase case detection and notification by the inclusion of private practitioners (Uplekar, Pathania and Raviglion, 2001).

Needham et al (2004) illustrated the significant role of the private health care system in Zambia for patients with tuberculosis. Many patients seek private health care before ultimately receiving tuberculosis care through the public health care system. Integration of these two separate systems may result in many benefits to patients through reduced barriers for diagnosis and treatment and decreased delay before diagnosis. For example, by allowing local private practitioners access to public sector sputum smear microscopy services, private practitioners could more easily and accurately diagnose tuberculosis within their own practice. Through integration of these health systems, sputum smear positive patients could then have appropriate tuberculosis notification, contact tracing and free treatment within the existing public tuberculosis programme.

In India, private physicians believe that patients will more readily remain in their practice if they provide access to free anti-tuberculosis medication through the tuberculosis programme. This may be the necessary incentive for private physicians’ cooperation. Free continuing education for private practitioners by the tuberculosis programme may raise awareness of tuberculosis and the public health programme and open lines of communication for subsequent cooperation and integration (Needham et al, 2004).

In support of the above, evidence suggests that all sections of the population in developing countries seek care from private practitioners (Uplekar, Pathania and Raviglion, 2002; Uplekar, 2003). A large proportion of tuberculosis patients in high prevalence countries such as India, Pakistan, Philippines, Vietnam, and Uganda, first approach a private practitioner. For example, a household survey in India found that 60% individuals with a longstanding cough first went to a private practitioner. Another study noted that 88% of rural and 85% of urban patients with tuberculosis first went to a private practitioner (Uplekar, Pathania and Raviglion, 2002; Uplekar, 2003).

Managers of tuberculosis programmes believe that in many countries only a small proportion of tuberculosis patients—mainly the well off—seek care from private practitioners. The basis for this assumption is that tuberculosis mainly affects the poor who cannot afford private doctors’ fees and expensive drugs. However, a recent survey in a Mexican state showed that about a third of patients who died from tuberculosis were treated in the private sector (Uplekar, 2003).

As a part of global efforts to control tuberculosis through effective DOTS implementation, the World Health Organization has recently begun addressing the issue of private providers in TB control through an evolving global strategy (WHO, 2001). As a first step, a global assessment of private providers’ participation in tuberculosis programmes was undertaken in 1999. Twenty-three countries in the 6 WHO regions were visited as part of the assessment, including 10 of the 22 high-burden countries identified as priorities for global TB control. The assessment focused on private for-profit practitioners. Particular attention was also given to ongoing and proposed Private-Public Mix (PPM) approaches in TB care (WHO, 2001).

The assessment confirmed earlier findings of both a substantial TB caseload and unsatisfactory management practices in the private health sector. The consequences include high morbidity and mortality, a heavy socio-economic burden and the serious risk of drug resistance (WHO, 2001). The findings of the assessment were discussed and debated in a consultation involving private practitioners, TB programme managers and policy makers. Their recommendations have contributed to the evolving global strategy called Public–Private Mix for DOTS implementation (PPM DOTS) (Uplekar, 2003; WHO, 2006).

Options available to National Tuberculosis control Programmes (NTPs) range from an exclusively public delivery system through parallel and independent public and private systems to a coordinated public-private mix. In practice, most NTPs have ignored the private health sector and opted to deliver services through government channels. The wisdom of such an approach is questionable, particularly in many high-burden countries with large private health sectors. In these countries, there is a compelling case for collaboration with private practitioners in the delivery of TB care (WHO, 2001).

The private health sector in developing countries tends to be a relatively amorphous, unorganised and dynamic entity comprising various provider types of different sizes and characteristics. In contrast, government health services are structured – well suited to the specialised nature of the typical DOTS programme (WHO, 2001).

The basic medical education in most poor countries is of uneven quality and there is inadequate attention to public health education. Continuing education is usually missing. Regulations are often non-existent or archaic, and where they do exist, they are rarely conveyed to professionals or enforced. Furthermore, there is a major communication void between TB programmes and Private Practitioners (WHO, 2006).

The aim of this literature review is to explore the perception of private medical practitioners around the National tuberculosis control programme in developing countries.

Objectives

To collect and analyse the information on private medical practitioners with regards to their perception of the National Tuberculosis Control programme in developing countries.

Knowledge obtained from this study may in time assist in the formulation of policies necessary for the integration of private practitioners into the national tuberculosis control programme. It will also make a contribution to the knowledge base and help in the understanding of the problems facing the national tuberculosis control programme in developing countries by highlighting the important issues militating against the collaboration of private medical doctors and the national programme co-ordinators from the view point of the private doctors themselves.

I intend to pursue these prospects by presentation and dissemination of this piece of research to relevant bodies concerned with Tuberculosis control in developing countries. Efforts will also be made to publish it in health journals especially those concerned with Tuberculosis and other tropical diseases in Africa.

Research question

What are the perceptions of private medical practitioners around the National Tuberculosis Control programme in Developing Countries?

CHAPTER 2

2.1 Methodology

A research literature review is a systematic, explicit and reproducible method for identifying, evaluating and synthesizing the existing body of completed and recorded work produced by researchers, scholars and practitioners (Fink, 2005). The literature review helps to lay the foundation for a study, and can inspire new research ideas. It also plays a role at the end of the study, when researchers are trying to make sense of their findings (Polit and Beck, 2004). It may identify gaps in the previous literature that the new research can address, or may suggest research to be replicated (Cormack, 2000). A systematic search was made of both qualitative and quantitative studies, which is also known as a mixed method was used in this research. Researchers such as Creswell (2003) verify that both qualitative and quantitative approaches explore the behaviour, perspectives, feelings and experiences of people and what lies at the core of their lives, they do not just focus primarily upon the identification and explanation on the facts, but upon the illumination of people’s interpretations of those facts and often to explain why something happens.

The mixed method review (qualitative and quantitative) was conducted, based on the guidance of the United Kingdom Centre for Reviews and Dissemination guidelines (2001). Qualitative is a form of social inquiry which tends to focus on how people see and makes sense of the world, (Hollaway and Wheeler, 2001). Qualitative research is described as a form of social enquiry that focuses on the way people interpret and make sense of their experiences and the world in which they live, (Bryman, 2008). Researchers use qualitative approaches to explore the behaviour, perspectives, feelings and experiences of people and what lies at the core of their lives. The basis of this type of research lies in the interpretive approach to social reality and the description of the lived experience of human beings. Qualitative approaches are typically used where very little is known about a topic and the researcher’s intention is to construct theory (Crookes and Davies, 2004) or where the researcher is trying to understand a phenomenon from the perspective of the actors in the situation (Brink and Wood 2004, Polit and Hungler 2006).

Approaches to social enquiry consists not only of the procedures of sampling, data collection and analysis, but they are based on particular ideas about the world and the nature of the knowledge which sometimes reflect conflicting and competing views about social reality. Some of these positions towards the social world are concerned with the very nature of reality and existence (ontology). Epistemology is the theory of knowledge and is concerned with the question of what counts as valid knowledge. Methodology refers to the principles and ideas on which researchers base their procedures and strategies (methods) (Holloway and Wheeler, 2002).

Strauss and Corbin (2002), researchers use qualitative approaches to explore the behaviour, perceptive, feelings and experiences of people and what lies at the core of their lives and, it is also useful in the exploration of change or conflict. Consequently it could be argued that the quantitative research is more precise but the response would be that with people it is not possible to be so precise, people change and the social situation is too complex for numerical description. Qualitative research is believed to possess a special value for investigating complex and sensitive issues. The in-depth, probing nature of qualitative research is well suited to the task of answering such questions as, ‘what is this phenomenon?’ and ‘what is its name?’ Whereas in quantitative research by contrast, the researcher begins with a phenomenon that has been studied or defined previously, sometimes in a qualitative study, thus, in quantitative research, identification typically precedes the inquiry, Saunders and Thornhill (2003). The traditional, positivist (scientific method) paradigm is a general set of orderly, disciplined procedures used to acquire information. Positivism is rooted in the 19th-century thought, guided by such philosophers as Comte, Newton and Locke (Polit and Beck, 2006).

Quantitative researchers typically move in a systematic fashion from the definition of a problem and the selection of concepts on which to focus, to the solution of the problem. By systematic, it is meant that the investigator progresses logically through a series of steps, according to a pre-specified plan of action. Quantitative researchers gather empirical evidence- evidence that is rooted in objective reality and gathered directly or indirectly through the senses rather than through personal beliefs or hunches. Evidence for a study in the positivist paradigm is gathered systematically, using formal instruments to collect needed information. Usually (but not always) the information gathered is quantitative, that is, numeric information that results from formal measurement and that is analysed with statistical procedures. Quantitative research conducted in the positivist paradigm has sometimes been accused of narrowness and inflexibility of vision, a problem that has been called a sedimented view of the world that does not fully capture the reality of experiences (Polit and Beck, 2006).

2.2 Search strategy

2.2.1 Inclusion and exclusion criteria.

Inclusion and exclusion criteria enable the literature reviewer to identify the literature that addresses the research question and that which does not, (Hart, 2003). In addition the rationale for setting an inclusion and exclusion criteria is to focus the literature searching and to ensure not to get sidetracked with literature that is not strictly relevant, (Greenhalgh and Peacock, 2005). Therefore, assisting to keep the study focused, inclusion and exclusion criteria were set. Inclusion - information entered since 2002 to date articles dealing with humans, written in English and with abstract and keywords, only primary studies. The date is of importance because the literature will be recent and not outdated, however, Aveyard, (2007) argues that limiting your search to time restrictions you will miss some seminal documents even at times they could be found being referred to in other papers. The exclusion:  and at this point studies were excluded if there was insufficient information on Private Practitioners and National Tuberculosis therefore, the study did not contribute important information to this review, Non English articles, unpublished research and pre-2002 articles.  Eastely et al 2001) argue that by reviewing published literature can bias the review, because it is understood that journals tend to publish research that shows the positive effect of an intervention rather than a negative effect or no effect. Unpublished literature which shows results of no effect can balance the review if used in conjunction, (Law, 2004), this literature is known as the grey literature. However this review will not be able to access the grey literature due to lack of time and resources.

An extensive search of the electronic databases; Science Direct, British Nursing Index, World Health Organisation (WHO), Cochrane Library, Department of Health (DOH), Health Protection Agency (HPA) and Central Diseases Centre (CDC) and public health website.

A broad range of search key words were used: tuberculosis, involvement, management, decision making, perception, perspectives, experiences and role. Each of these terms was combined with every term in the following list; tuberculosis management, private practitioners perspectives, private practitioners perspectives, private practitioners role in tuberculosis management. All of these two – three term combinations were subsequently linked with the wildcard Tuberculosis Programme.

The initial search in all the databases yielded 11676. The combination of tuberculosis management and private practitioners in CIHNAL and Medline yield 2676, (3) search included private practitioners and tuberculosis programme 1400, (4) search private practitioner’s perspectives in tuberculosis programme, 200, (5) private practitioners and collaboration with tuberculosis programme 38. These were reviewed and appraised a total of 8 articles relevant to this study were selected. 

It should be emphasised that, despite the advances in electronic searching, computerised searching tools are not 100% comprehensive and will fail to identify relevant literature on the topic. This is because some relevant literature might have been categorised using different keywords and therefore would not be identified by one particular searching strategy. Further strategies including reference list searching, hand searching through reference lists and author searching add thoroughness to the search strategy (Aveyard, 2007). Therefore for this review, reference list searching, author searching, and keywords was used.

Greenhalgh and Peacock (2005) emphasise the importance of using many approaches to identifying appropriate literature when undertaking a literature search and argue that systematic reviewers cannot rely on computerised databases to yield all the information needed for a study. Given the limitations of using electronic searching alone, the wider searching strategy, can be part of a comprehensive systematic approach. Greenhalgh and Peacock refer to this process as snowball sampling- where the sampling strategy develops according to the requirements of the study and is responsive to the literature already obtained.  These support what was done in this study in order to obtain more relevant papers required for the review.

Search results Table 1

DATABASE

NUMBER OF REFERENCES

NUMBER OF EXCLUDED REFERENCES

NUMBER OF RELEVANT REFERENCES

Science Direct

32

20

12

Cochrane Library

249

241

20

British Nursing Index

50

48

2

CDC

159

155

4

Medline

200

19

1

Health Protection Agency

10

8

2

Pubmed

-

-

-

Cinahl

433

350

43

Public Health

10

9

1

WHO

16

12

4

Reference from retrieved references

48

4

50

Reference list

456

406

5

Duplications

22

Total reference list

38

The 38 articles chosen included both qualitative and quantitative, and all focused on developing countries, 55% were from Asia, and 45% covered Africa. The articles focused on the themes identified in the discussion and findings. A total of 8 articles were primary studies, with inclusive of review and discussion articles from the rest. CINAHL and the Cochrane Library returned the most articles this could be due to the fact that they are evidence based sources for primary studies.

Time Scale: 2.4

I submitted my research proposal to the supervisors, prior to seeing them.

April 27 – Met with supervisors we discussed the first draft of the proposal, will review after the feedback on the structure and the methodology.

May 12 – Run a search, refined proposal after feedback and search strategy.

May 17 – continue with the search strategy, methodology, prior to meet with the supervisors.

June 9 - continued with the methodology literature search.

June 22 – Discussed methodology, search strategy, critical appraisal review articles.

June 30 – Discussed critical analysis of articles and findings.

Ethical Issues 2.5

Codes of ethics are formulated to regulate the relations of researchers to the people and field they intend to study (Flick, 2006). Polit and Beck (2006) describes ethics as a system of moral values that is concerned with the degree to which research procedures adhere to professional, legal, and social obligations to the study participant.

Three major ethical principles are incorporated into most ethical guidelines; these include beneficence, respect for human dignity and justice. In addition, informed consent is also included (Polit and Beck, 2004).

Beneficence involves the protection of participants from physical and psychological harm, exploitation and performance of some good. Respect for human dignity involves the participants’ right to self determination, which means participants have the freedom to control their own activities, including study participation. It also encompasses the right to full disclosure, which means that researchers have fully described to prospective participants their rights and the full nature of the study. Justice includes the right to fair treatment and the right to privacy. This can be maintained through anonymity or through formal confidentiality procedures that safeguard the information participants provide. Informed consent procedures are involved with providing participants with information needed to make a reasoned decision about participation and normally involve signing a consent form (Polit and Beck, 2004; Gomm, 2004).

2.3 Critical appraisal

Critical appraisal is the structured process of examining a piece of research in order to determine its strengths and limitations, and therefore the weight it should have in literature review, (Aveyard, 2007). In order to facilitate the process of critical appraisal, there are many critical appraisal tools available to guide the evaluation of research, (Crombie, 2006). Therefore one is advised to use a critical appraisal tool to assist in the critique of the research. There are different types of these critique tools depending on the type of research. A review complex and use of an appraisal tool will assist in the development of a systematic approach and ensure that all papers are reviewed with equal rigour, (Fink, 2005). One set of critical appraisal tools are produced by the Critical Appraisal Skills Programme, (CASP), developed by the Oxford University Public Health Resources Unit.

The advantage of the CASP critical appraisal tool is that there is a specific critical appraisal tool for qualitative studies, Random Control Trails, cohort and case control studies, (Greenhalgh and Peacock, 2005). The tools were designed to address the epidemiological principles behind the study types with particular attention to assessing study validity.  All the study tools are divided into three sections relating to internal validity, the results and the relevance to practice.  Each section contains several questions with supporting hints to explain the relevance of the question or to expand on a principle (Aveyard, 2007). For this review the CASP tool used will be for the Qualitative and Quantitative articles selected. The study appraisal will be undertaken in order to achieve an understanding of each study on its own terms (Sandelowiski et al 2007) and to enable consideration of the ways in which the methodologies used shaped understandings about the subject of interest (in this case the perceptions of private practitioners around NTP management in developing countries.), Paterson et al. 2001). The latter went on to suggest that it is not possible to exclude all methodologically flawed studies, both because standards change over time and because researchers judgements as to what is flawed vary according to their own disciplines, methodological training and preferences.

2.5 The Appraised Studies

The papers were first reviewed first by title, then abstract and finally by full text, excluding at each step those which did not satisfy the inclusion and exclusion criteria (Meade and Richardson 2007). However the process was more time consuming than anticipated. Evans (2002) has observed that the relevance of a qualitative study is often not clear from its title alone. The experience of undertaking the current review highlighted that, furthermore the title frequently fails to indicate whether an article reports a qualitative research study, non qualitative research study, or news item, opinion piece, or other item. As a result relatively few papers could be excluded at the title sifting state. Out of the 38 studies yielded from the literature review, 8 studies were chosen for appraisal, these were all primary research, and were peer reviewed. The articles included 4 of qualitative and 4 of quantitative, thereby providing a fair representation of the literature reducing the bias of overlapping different methods. The articles were all analysed for, Quantitative research: validity and reliability. Quantitative researchers use several criteria to assess the quality of a study, and two of the most important criteria are reliability and validity. Reliability refers to the accuracy and consistency of information obtained in a study (Polit and Beck, 2004) or the stability of a research design (DePoy and Gitlin, 2005). The term is most often associated with the methods used to measure research variables. Validity on the other hand is the degree to which an instrument measures what it is supposed to measure (Polit and Beck, 2004) or according to Silverman (2005) validity is another word for truth.

Qualitative research: Credibility and Trustworthiness. Qualitative researchers use somewhat different criteria (and different terminology) in evaluating a study’s quality. In general qualitative researchers discuss methods of enhancing the trustworthiness of the study’s data. Trustworthiness in qualitative research means methodological soundness and adequacy (Holloway and Wheeler, 2002) and encompasses several different dimension- credibility, transferability, conformability and dependability (Polit and Beck, 2004). Lincoln and Guba (1985 in Holloway and Wheeler, 2002) use the term dependability instead of reliability. For the findings of a study to be dependable, it should be consistent and accurate. This therefore means that there should be clear reasons for any decisions taken in the study and although the study cannot be replicated, in similar circumstances with similar participants, it might be repeated. Credibility this refers to confidence in truth of data and interpretation. It corresponds to the notion of internal validity (Holloway and Wheeler, 2002). Parahoo (2006) describes credibility as the extent to which the findings of a study reflect the experience and perceptions of those who provided the data. or the truth, value or believability of the findings.

While the credibility in quantitative research depends on instrument construction, in qualitative research, “the researcher is the instrument". Thus the credibility of the researcher is dependent on training, experience, track record, status and presentation of self (Patton, 2002). Thus, it seems when quantitative researchers speak of research validity and reliability, they are usually referring to a research that is credible, while the credibility of a qualitative research depends on the ability and effort of the researcher. Credibility also asks question about how qualified the researcher is, and to how long the researcher was engaged with the data. The author felt that use of the CASP tools enabled her to appraise the articles confidently, but she lacked the experience and track record. However, these deficiencies were made up by her competent and experienced supervisors who gave her the necessary direction and advice regularly.

Auer et al (2006) in their study- “diagnosis and management of tuberculosis by private practitioners in Manila, Philippines, the study used interview survey method, private practitioners chosen randomly throughout the country to a total of forty five. Interviewing is a data collection method that is often used by researchers to ascertain individual experiences of events and would therefore be appropriate, Bryman 2008. The inclusion and exclusion criterion was clearly identified with the inclusive of private practitioners who treated or treating adult TB patients, however data collection stages were not clearly stated or the discussion of research design. The authors did not mention whether ethical approval was given or sought. The results were clearly presented and they produced evidence which clearly correlated with the research question. The authors mentioned that they did not attempt to verify the answers of the private practitioners with observations or by consulting patients. Barnes (2004) emphasise that research might find it worthwhile to combine several methods of checking, including some form of triangulation.

Greaves et al, 2007 in their study titled “Compliance with DOTS diagnosis and treatment recommendations by Private practitioners in Kerala, India”, presented a clear statement of the stage of data collection. A formal discussion of the research design was presented as well as the sampling approach which showed the involvement of private practitioners. They did a random sampling in different parts of the country urban and rural, with the inclusion of all private practitioners’ specialities; however all should have treated an adult TB patient. Given the aim of the study it would seem appropriate to use this sample group. There is no clear discussion on how data was collected however the data analysis is clearly presented including measures taken to validate entry. As with any participant reported survey it is heavily exposed to information biases, (Freeman, 2009), it is likely that the private practitioners will answer with a response that they consider to be correct, rather than with what they would do in practice. The study does not discuss whether ethical approval was granted or applied for.

Suleiman et al (2003) in their study titled “Do doctors in north-western Somalia follow the national guidelines for tuberculosis management?” used the cross sectional approach to assess the knowledge and practices of registered medical practitioners in the management of tuberculosis. The results revealed that knowledge on treatment was grossly inadequate and that doctors working exclusively in private settings had worse knowledge about the diagnostic procedures of tuberculosis. Cross-sectional studies involve data collected at a defined time. They are often used to assess the prevalence of acute or chronic conditions, or to answer questions about the causes of disease or the results of medical intervention. They involve the collection of data at one point in time (Polit and Beck, 2004). This method proved to be appropriate for the research question. The sampling method was clearly explained with the inclusion and exclusion criteria stated. The data was collected by direct contact with the responders. The disadvantage is that researchers may inadvertently influence or even stifle responses during direct contact (Ajetunmobi, 2002). The ethical approval was granted from the Ministry of health as well as the private practitioners before the interviews and confidentiality was maintained.

In a study by Shah et al (2003) entitled “Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan?” The study design was a descriptive cross sectional survey of 245 practitioners from a total population of 884. This sample size was estimated at a confidence level of 92% at 20% expected confidence of consistency with NTP guidelines, and a power of 80%. A standardized questionnaire on the relevant themes and issues was used in this study. Questions were mostly dichotomous knowledge about symptoms suggestive of TB. Data from the study were analysed using Epi-info, version 6.04c and SPSS version 10.0, frequency tables were prepared for most of the variables. These soft-wares are recognised for use in data analysis in social sciences (Polit and Beck, 2004). (Shah et al, 2003). The weaknesses in this study were namely, details of selection of participants was not mentioned, this can invariably introduce volunteer bias, there was no mention of how the questionnaire was generated and if it was piloted to iron out any potential or unforeseen problems that may affect the performance of the instrument (Ajetunmobi, 2002). The major strength of the study is in result presentation and adequate explanation of the statistical procedures done.

“Involvement of private practitioners in tuberculosis control in Ballabgarh, Northern India” by Krishnan and Kapoor (2006), Private practitioners were identified and invited for training in RNTCP guidelines; they were then interviewed at the end of the project to assess their perceptions. A major pitfall of the study is the unclear nature of the research design, as the researchers did not state or elaborate on the approach used (Polit and Beck, 2006). In addition, details of recruitment strategy applied, response rate and details of the sample size used for the study is unclear. There was no clear discussion about the data collection, or how the data was analysed including measures taken to validate data entry. There is no evidence of statisticians input to the research, although there is no reference to any computer method package used. The study claims of meeting with the private practitioners however they do not elaborate how these were ran and what they included to the input of the practitioners training.

Lonnroth and Arora (2003) in their work “Hard gains through soft contracts - productive engagement of private providers in tuberculosis control”. This study failed to state the research method used. Such failure to provide specific details of qualitative methodologies could pose problems for reviewers wishing to undertake a meta-synthesis of studies using a specific methodology, (Evans, 2002). It is not stated how the sample was identified or the selection process. Data collection was clearly identified and the results clearly presented using graphs and tables. The results of this study may have been influenced by several types of bias. There may be information bias in the study if the participants gave information which in reality they do not practice. They may prepare themselves for the interview, giving information in line with guidelines, not reflecting their true (prior) practices.

Watkins et al (2006), “Joining DOTS in Bali: Private Practitioner’s Perceptions on Tuberculosis Control”. Using a qualitative approach, they purposively sampled private practitioners to obtain a broad range of information rich respondents. A semi-structured interview format was used to encourage participants to discuss issues freely and interviews were tape recorded. This technique according to Polit and Beck (2004) ensures that the researcher obtains all the information required. The analyses were performed independently by the researchers to ensure descriptive validity and consistency. This yielded no significant differences from the themes derived from these analyses. This investigator triangulation lends credibility to the study (Polit and Beck, 2004). 22 private practitioners participated in the study and 10 of them were females. The mean age of the participants was 47 years and all were born in Bali. All interviews completed their undergraduate medical training in Bali, and all participated in some form of for-profit, fee-for-service private practice.

Vyas et al (2003) in their study “The private-public divide: impact of conflicting perceptions between the private and public health care sectors in India” provided a very clear and detailed account of the research design and the methods of data collection. The detail provided on the purposeful selection of the sample allows us to follow their decision trail and replicate the study if we so wish in terms of private practitioners interviewed, (Parahoo 2005). Data was collected by audio taping interviews and transcription, the word processed files then being analysed using NUDIST software. This software structures the data in terms of hierarchical relationships which may have an effect on the form of the analysis (Freeman, 2009). The authors do not comment on whether this was a positive or negative element to the analysis. The person who conducted the interviews did not carry out the analysis of the texts. This may have had an impact on the richness of the analysis performed, but steps were taken to maintain the rigour of the interpretation by including another researcher in the process Strauss and Corbin, 2008). While ethical approval was obtained to carry out the work, the authors did not comment on the associated ethical issues of autonomy, preventing harm and benefit.

CHAPTER 3

3.1 FINDINGS (Structured analysis)

THEMES FROM FINDINGS

PPs KNOWLEDGE/AWARENESS OF NTP

EFFECTIVENESS OF THE NTP

UPDATING KNOWLEDGE

RECOMMENDATIONS OF THE PPs ON THE WAY FORWARD

ISSUES OF COLLABORATION

Figure 2: Themes from the findings

Themes were developed from recurrent arguments and issues from the articles obtained and were fit together major themes.

The National Tuberculosis Control Programme

The most cost-effective public health measure for the control of tuberculosis is the identification and cure of infectious TB cases, i.e. patients with smear-positive pulmonary TB (WHO, 2001). Treatment of TB is the cornerstone of any National Tuberculosis Programme. Organised efforts to control TB led to the design and launch of National Tuberculosis Programmes (NTPs) in high burden countries over half a century ago. The focus was on the use of government machinery to implement public health initiatives (WHO, 2001).

The objectives of an NTP are to reduce TB mortality, morbidity and disease transmission, while preventing the development of drug resistance. The NTP and Leprosy Control Programme (NTBLCP) co-ordinates and provides strategic direction for TB control activities in developing. The Federal Ministry of Health (FMOH) declared TB a national emergency in April 2006 and inaugurated the National TB-HIV Working Group in June 2006 (USAID, 2006).

Nshuti et al (2001), observed that majority of private practitioners in Uganda knew about the existence of the National Tuberculosis and Leprosy Control Programme (the major control body), but only half of them knew that it issued national guidelines for diagnosis and treatment of tuberculosis and leprosy. This sharply contrasts with the findings by Shah et al (2003) in the study “Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan?” where 96% of private medical practitioners in Rawalpindi and 99% in Lahore admitted that they did not know about the guidelines. This study was a descriptive cross-sectional survey; Private practitioners believed that there were a number of specific barriers to successful TB control associated with the existing public health services. The lack of systematic health promotion efforts aimed at increasing community awareness of TB was widely identified as a major problem (Watkins et al, 2006).

As a measure to ensure proper Tuberculosis control Harper et al (2003) observed that in Gambia, control of TB relied on passive detection of smear-positive cases through general and primary health care services. All TB cases detected in the country are referred to the National Tuberculosis and Leprosy Control Programme (NTBLCP). Suspect TB cases are seen by Leprosy and TB Inspectors (LTI), who are responsible for microscopically diagnosis and treatment of TB, and are based in major health centres throughout the country. The policy to be followed by health staff dealing with TB in The Gambia is detailed in a manual published by the Department of State for Health, which is made available to all medical staff throughout the country. This ensures improved knowledge on the control programme amongst medical staff.

Diagnosis of Tuberculosis

The diagnosis of tuberculosis refers to the recognition of an active case, i.e. a patient with symptomatic disease due to Mycobacterium tuberculosis (WHO, 2008). The standard method of diagnosis according to WHO (2008) is through sputum microscopy (sputum smear), however as highlighted below, the practice by several private practitioners does not conform to this. Auer et al (2006) in their study- “diagnosis and management of tuberculosis by private practitioners in Manila, Philippines” observed that contrary to DOTS principles, almost all respondents (private practitioners) in their study (93%) relied on the clinical presentation and result of an X-ray to decide whether or not to start anti-TB treatment. Only six respondents (13%) said they routinely also asked for sputum examination (microscopy). Nineteen respondents (42%) said that in some cases they would ask for a sputum examination in addition to an X-ray. Of the 11 respondents (24%) who did not always use X-ray, only one reported ‘often’ using sputum examination, and three reported to ‘sometimes’ use sputum examination. The remaining seven (16%) relied on the signs and symptoms. In addition, one of the seven also ‘always’ considered the response of the TB suspect to antibiotic treatment for chest infection. Most respondents thought chest X-ray was a tool with high specificity, i.e. the reliability of X-ray findings was believed to be high.

There are several reasons why X-ray was preferred to sputum examination by the respondents, these include: (i) easier process and faster result when opting for X-ray; (ii) sputum microscopy – if not undergone in a public TB programme – generally entails higher expenditures for the patients than X-ray; (iii) due to the low sensitivity of sputum microscopy, the value of sputum microscopy is questioned; (iv) poor reputation of sputum microscopy, also because giving sputum is strongly associated with having TB; (v) overestimation of the reliability of chest X-ray; (vi) a substantial proportion of private practitioners has their own X-ray facility (38% in this setting) (Auer et al, 2006).

Similarly, Greaves et al, 2007 in their study titled “Compliance with DOTS diagnosis and treatment recommendations by Private practitioners in Kerala, India”, discovered that 80% of the practitioners interviewed used sputum microscopy as a first-line test, but a variety of other tests were also employed, including purified protein derivative, chest radiograph, and various blood tests. Only 14% used sputum microscopy alone as an initial test as recommended by WHO guidelines. In agreement with the above findings, Watkins et al (2006) observed that the non-adherence to accepted clinical guidelines for diagnosis was attributed to difficulties with finding positive sputum specimens and their confidence in their ability to clinically diagnose TB without the need for positive test results.

Khan et al (2003) noted that far more respondents recommended using sputum microscopy for diagnosing pulmonary TB but few used this test when general practitioners were provided this facility free of charge at a nearby centre. This according to them showed that these physicians often do not practise what they know is medically correct. A probable reason for this could be that X-rays are financially more viable to the referring doctor than the cheaper sputum examination, especially in cases where there is some financial arrangement between the doctor and the diagnostic centre.

Treatment of Tuberculosis

The aims of treatment of tuberculosis are to cure the patient of TB, prevent death from active TB or its late effects, prevent relapse of TB, decrease transmission to others and prevent the development of acquired drug resistance (WHO, 2003). WHO introduced the standardised treatment schedule is to prevent the proliferation of drug resistant strains of the bacteria causing TB which will pose a huge public health problem. It is widely agreed that treatment in the private health sector is usually of poor quality with low cure rates (Newell 2002).

Greaves et al (2007) conducted a study to assess the compliance of private physicians with Revised National Tuberculosis Control Programme (RNTCP)-standardized diagnostic and treatment guidelines, as recommended in the DOTS strategy, to evaluate the effectiveness of the PPM model introduced Trivandrum, the capital of Kerala state in Southern India. Of the doctors interviewed, 43% treated all their patients in a DOTS-compliant way, administering medications according to the DOTS protocols and requiring directly observed therapy. This study showed that the quality of management of TB by private practitioners in the Trivandrum region did not strictly adhere to the guidelines recommended in the DOTS strategy, despite the introduction of a new PPM project. There was, however, improvement in the quality of treatment compared to previous studies, which suggests that the PPM scheme has had an important beneficial effect.

In the study by Auer et al (2006), only 6 out of 45 (ie 13%) private practitioners prescribed 2HRZ/4HR (meaning H-Isoniazid, R-rifampicin, Z-pyrazinamide for the first two months and then H and R for another four months), the regimen endorsed by the Philippine National Tuberculosis Control Programme (NTP). It was also observed that there was a tendency to over-medicate new patients, and TB patients with previous treatment of TB were almost always under-medicated.

Similarly, Hussain et al (2005) discovered that only 2 (3.7%) of prescriptions out of 53 met the required standard for TB patients as laid down by NTP in their survey.

Private Medical Practitioners’ involvement

WHO (2001) discovered that in the Indian City of Pune, of households reporting chest symptomatic individuals, over 60% of the symptomatic individuals first went to a private health provider. Rangan et al (2004) highlighted that for tuberculosis (TB) patients, the comparative advantages of attending a private medical practitioner could be easily recognised: easier accessibility, shorter waiting times, availability of doctors and drugs, considerate staff attitudes and sometimes credit or payment in instalments.

Shah et al (2003) entitled “Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan?” aimed to determine the knowledge and practices of private general medical practitioners towards diagnosis, treatment and follow up of pulmonary TB patients in 2 cities of Pakistan and to collect baseline information to plan future interventions to involve the private sector in the National TB programme, they used a descriptive cross sectional survey as the approach. The basic inclusion criteria for the study were that the private medical practitioner should have managed at least 1 pulmonary TB patient during the previous year. The results from the study amongst many showed that only 1 out of the 245 participants was aware that cough for more than 3weeks alone is the main symptom suggesting pulmonary TB, also none of the participants followed the National TB Control programme guidelines for prescribing treatment (Shah et al, 2003). When asked if they were aware of the National TB Control guidelines, an amazing 96% and 99% for the 2 different cities admitted that they did not know about the guidelines. In defence of private practitioners, Watkins et al (2006) are of the opinion that the lack of communication and necessary update is the major cause of the ignorance and poor management procedures that usually characterise private practice with respect to TB control.

Collaboration between the NTP and Private Practitioners.

Public-private mix has been defined by WHO as strategies that link all healthcare entities within the private and public sectors (including health providers in other governmental ministries) to national tuberculosis programmes for expansion of DOTS activities (WHO, 2004).

In most developing countries, there is very little interaction between the public and the private health sectors. Given this communication void, it is important to understand how either side views the other particularly in terms of potential collaboration. For collaborative arrangements to have a realistic chance to succeed, the gap in perceptions has to be recognised and bridged. The NTP staff always viewed collaboration with Private practitioners with a mix of pragmatism and scepticism (WHO, 2001). In the study “Involvement of private practitioners in tuberculosis control in Ballabgarh, Northern India” by Krishnan and Kapoor (2006), they aimed to test the feasibility of involving private practitioners in the Revised National Tuberculosis Control Programme (RNTCP) for identification and management of cases. Private practitioners were identified and invited for training in RNTCP guidelines; they were then interviewed at the end of the project to assess their perceptions. The results showed that private practitioners wanted to contribute to the social cause and desired more of a professional association and social recognition.

They postulated that it was feasible to involve private practitioners in the tuberculosis control programme especially for case identification for subsequent treatment under the programme rather than as DOTS providers. The three stakeholders stood to gain from the collaboration- the patient gains by a more definitive diagnosis, receiving correct treatment, free drugs at a place of their choice and better follow up. The private practitioners gain by improving their knowledge and skills, not only in TB control but possibly in other diseases as well. The government’s main gain is an increase in case detection under the DOTS strategy, enhancing the possibility of achieving the target set under the National TB Control Programme (Krishnan and Kapoor, 2006).

The issue of collaboration (Public-Private Mix: 55PPM) has been so widely recognised that it is now one of the components of the WHO STOP TB STRATEGY campaign (WHO, 2007). This has been associated with an increase in case notification, with maintained treatment success (Ambe et al, 2005; Maung et al, 2006).

Given the common initial distrust between private practitioners and NTPs, involvement of private practitioners needs communication to build trust. The public sector must be able to demonstrate high technical and service quality to attract the interest of both private practitioners and their patients. Likewise, the private practitioners must demonstrate that they are capable of managing TB according to DOTS principles to gain trust among public sector staff. These challenges were encountered in Mumbai, and considerable time and resources were invested in building trust between the NTP and private practitioners, facilitated by NGOs acting as intermediaries (Ambe et al, 2005).

Lönnroth et al (2006) in their work “Hard gains through soft contracts - productive engagement of private providers in tuberculosis control”, reviewed 18 initiatives involving private health care providers in National TB control efforts and results suggest that different types of for-profit private providers can be effectively involved in TB control. In all but two initiatives, the treatment success rates were above 80%, which were as good or better than the treatment success rates in the NTP facilities in the same settings. Also, in 13 initiatives, free drugs were distributed from the NTPs to private providers on the conditions that they: followed recommended diagnostic procedures and disease classification; followed recommended treatment regimen; dispensed the drugs free of charge to patients; supervised treatment; and followed standards for referral, recording and reporting.

In one of the initiative used by Lönnroth et al (2006), drugs were provided through an NGO at a subsidized rate to for-profit providers based on similar conditions. These “drugs-for-performance contracts” were verbal in relation to for-profit providers in most initiatives, though certificates and /or signposts stating that the provider had been “accredited” by the NTP were used by some.

Lönnroth et al (2006) acknowledged that the overall positive results across the studies reviewed should be interpreted with caution due to the possibility of publication bias. It is expected that unsuccessful initiatives are less likely to be evaluated and reported. Also, a factor limiting the generalizability was that seven of the eight countries covered in this review were Asian and all but one of the initiatives was in an urban setting. Published experiences from other regions and rural areas are still scarce.

The review focused on involvement of for-profit providers, mainly individual practitioners, and thus results should not be generalized to not-for-profit organizations and institutions, many of which are delivering TB care to defined catchment populations under various types of agreements with NTPs (Lönnroth et al, 2006).

Caminero (2003) is of the view that NTP managements are often unconcerned with including private medical practitioners/specialists in their activities; this is a frequent reason for their non-integration into National TB Programmes.

The success of a NTP depends mainly on the action of nurses and technical personnel, and therefore a physician’s participation is not thought of as essential. Due to professional hierarchies, physicians frequently under-estimate the work done by nurses and technical personnel, it is important to educate medical specialists and private physicians to change this view. It is also frequent for an NTP to underestimate what specialists and private physicians can do, and thus they are frequently excluded from their training courses, the transmission of information and basic activity guidelines, and from the development of the NTP guides. Many doctors are not even familiar with the NTP guides, usually because NTP management has not contacted them. As private physicians are a difficult group to bring together or approach, the NTPs tend to ignore them as well (Caminero, 2003).

Thus, two different attitudes are encountered, that of the specialists and private physicians, and that of the NTP. These are frequently divergent and it can be very difficult to make them meet. This is why it is necessary to carry out specific training courses for these groups, planned by the NTP management with two objectives in mind: appeasing their scientific curiosity while bringing them up-to-date, and making them aware of ways in which they can be more useful both for the NTP and the community.

Private physicians working in the private sector have also been known to look down on the NTP, which they consider could affect their income and their influence on their patients (Caminero, 2003). However, private practitioners have consistently indicated their willingness to work with the NTP in several studies (Chakaya et al, 2005; Shah et al, 2003; Khan et al, 2005) and many researchers point out that this area has to be pursued in order to harness the potentials.

Private Practitioners Perceptions

The study of Watkins et al (2006) “Joining the DOTS in Bali: Private practitioner’s perception of tuberculosis control. The study investigated the private practitioners’ perceptions of barriers to TB control efforts in Bali, Indonesia. The main barriers to improved TB control that were identified reflected difficulties encountered within the following four areas namely patients non-adherence to treatment, limitations to public services, public-private integration and limitations of private services (Watkins et al, 2006).

Private practitioners believed that the lack of systematic health promotion efforts aimed at increasing community awareness of TB was a major problem. Some practitioners were of the view that a patient having treatment provided by a single doctor tended to increase patients’ confidence in their care and led to improved adherence to treatment. This view however is contradicted by several studies that have demonstrated that the issue of adherence and follow-up by private practitioners is deficient and needs to be seriously addressed to reduce the scourge of treatment failure leading to multidrug resistant tuberculosis (MDR) (Uplekar and Rangan, 2003, Greaves et al, 2007, Auer et al, 2006).

The level of integration of the private and public sectors was found to be mixed. Interviewees who had some experience within the public health service were better informed about current government initiatives and the resources available, and were able to successfully integrate their private patients with public programmes and make use of resources such as free medication when necessary. Some private practitioners who worked within a mixed private-public practice recognised the advantages offered by the public services with respect to promoting adherence to treatment, and would diagnose patients within their private practice and then refer them to public services to receive free supervised treatment. Private practitioners with more limited exposure to the public system generally described less integration with the public system and had poorer knowledge about what the public system offered and how it might be utilised within their practice. Private practitioners who had little interaction with the public sector would not routinely offer their patients free medications or other services from the public programmes, and often had a lower level of trust in the level of service provided by the public programme.

These private practitioners also reported difficulties with accessing continuing medical education (Watkins et al, 2006). The study was very clear and detailed to understand. The research design and method collection was of highest standard description and detailed. Ethical approval was obtained to carry out this research on participants were aware and consented. The authors commented on the associated ethical issues of autonomy, beneficence, malificence (preventing hard and benefit).

The findings allowed the writer to hear the voices of the participants by including extracts of text from the interviews to illustrate analytical points. This is a very powerful way of maintaining credibility, believability and trustfulness and allows the reader to gain richer understanding of the issues being discussed, (Morse, 1996). Watkins et al acknowledged that the purposeful sampling strategy may have had an effect, on their findings. They make very useful recommendations for practice for health care practitioner working with TB patients that are based on the findings. Vyas et al (2003) in their study “The private-public divide: impact of conflicting perceptions between the private and public health care sectors in India”, examined the social perceptions in public and private physicians to examine whether differences in behaviour and lack of cooperation are fundamentally rooted in differing views about the social impact of DOTS. They discovered significant conflicting perceptions between the two health care sectors concerning the role of DOTS in TB stigma and patient discrimination: public physicians were more likely than private physicians to believe that DOTS works to reduce stigma through each of four distinct mechanisms: conveying TB as a treatable disease, exposing TB patients to others undergoing TB treatment, spreading communal information about TB, and social support for TB patients and their families. Furthermore, 27.2% of private physicians but 0% of public physicians believed DOTS might actually increase TB stigma by institutionally publicizing diseased individuals. This study found out that private physicians have many reservations about both the fundamental tenets and practical implementation of the DOTS strategy. These include the effectiveness of intermittent treatment, use of sputum examinations for monitoring TB treatment, discrimination towards sputum smear-negative patients, and the creation of social stigma.

Such uncertainties and perceptions that conflict with those of public physicians undoubtedly influence the willingness of private physicians to follow the DOTS strategy. Additionally, they found that public physicians perceive private physicians as irresponsible and selfish. Examples include the beliefs held by public physicians that the private sector over utilizes second-line drugs and refuses to refer poorer patients to the public sector for free treatment. The literature supports the belief of many public physicians that private patients are more likely to prematurely terminate treatment because of costly private sector drugs, including unnecessary second-line drugs given to first-time TB patients. They found that not only do such conflicting perceptions affect behaviour and cooperation, but they also create conflicting views on reform initiatives (Vyas et al, 2003).

Summary

In summary, TB has been and is still a major public health issue especially in developing countries. The current scourge of HIV has worsened the TB picture in poor countries. Several studies have been done in different parts of the world with respect to National Tuberculosis programmes and private medical practitioner but very few in Southern Africa. Considering that Southern Africa is amongst the highest burden countries, a lot of work still has to be done on the said topic. Like in other developing countries, it is extremely difficult to ban private TB care for a number of reasons, including limited capacity to enforce such legislation and the mal-administration and lack of qualified personnel in public hospitals. Moreover health sector reforms in many countries tend to promote private health care, which makes collaboration essential. What often holds NTPs back are negative perceptions about the private sector rather than negative evidence of any serious attempt at collaboration?

When the private practitioners in most of the studies where asked what they know about the National TB control programme, varied answerers were presented such as not much, except that they knew that the government instituted it but presently did not know how far the implementation has gone. Some of the PP stated that they know that the national TB control programme is a kind of programme that they have based on trying to reduce the incidence, prevalence and prognosis of TB patients. In one study some PP claimed that the awareness for private practitioners about the National TB programme is very poor. They are not properly informed, government did not include them in the implementation therefore some when they come cross tuberculosis patients, they usually refer to government centres, with the notion that the doctors that work there are more aware of the government policies regarding tuberculosis management.

When the discussion of the effectiveness of the programme, brought out the knowledge that even when a limited number had some knowledge about the programme the majority knew how effective it is on TB management. They suggested that there is always room for improvement: The programme at least sets ahead of what is better care for the patients, in the first instance because the drugs are free it makes it affordable rather available. But the monitoring has proved not to be effective. In such that at times when a patient requires admission, the cost of the admission is borne by the patient-hospital bed fees, feeding and a lot of other conveniences about admissions and of course TB is common among the lower socio-economic group so financing is a problem. If it were possible to take more care of the patients, the assistance is significant but when one consider where the patient is coming from that is the financial background, one discovers that more needs to be done. A need to involve more finances if it were possible to take total care of the patient so that the patient comes into the hospital and come out of hospital without spending. One study showed that most of the patients have a relapse based on the fact that they did not complete the treatment or take the treatment for a period of time and then go away, and do not come back to continue with the treatment. In one study the PP claimed that the programme is not effective because they are supposed give them adequate information, organise training and symposia so that they can start the initial management of the simple cases and refer only complicated cases to the TB centres.

TABLE SUMMARY OF FINDINGS

REFERENCE

METHODOLOY

AUTHORS MAIN

FINDINGS

COMMENTS

1)Auer et al (2006)

Qualitative

93% relied the clinical presentation of an x-ray to decide to short or not anti-TB treatment

13% routinely asked for sputum sample.

The quality of care among the PP needs improvement, innovative strategies is required.

2)Greaves et at (2007)

Quantitative (survey)

80% PP used sputum as a first line test and a variety of other tests.

14% used microscopy alone as an initial test as recommends by WHO guidelines.

The management of TB patients was not according to the NTP however some PP expressed the need to be included into the programme.

3)Krishnan and Kapoor (2006)

Qualitative

PP wanted to contribute to the social cause and desired more of a professional and association and social recognition

The involvement of PP in the programme will not only benefit the patients but the country as a whole. With the PP expressing the desire to learn more.

4)Lonnroth et al (2006)

Qualitative

Different types of for profit providers can be effectively involved in TB control

The PP were aware of the programme but did not have the facts or the information on the guidelines of how to manage TB patients, hence they felt left out and not regarded as important in the health care.

5)Shah et al (2003)

Quantitative (survey)

Showed only 1 out of the 245 participants was aware that cough for more 3 weeks alone is the main symptom suggesting pulmonary TB

-none of the participants followed the NTP guidelines for prescribing treatment.

Awareness of the programme was lacking among the most senior PP in the region which proved to be worrying for the TB patients and a wonder how the NTP introduced it.

6)Suleiman et al (2003)

Quantitative (survey)

Showed that knowledge on treatment was grossly inadequate.

PP had worse knowledge about

Training in diagnosis and case management is needed to improve TB.

7)Watkins et al (2006)

Qualitative

PP reflects difficulties encountered within the following: patient non-adherence to treatment, limitations of public services, public-private integration and limitations of private services.

There is a need for education of the PP, the perceptions of the PP varied among them some feeling let down by the government not including them in the programme.

8)Vyas et al (2003)

Quantitative (survey)

-Private practitioners had many reservations about both the fundamental tenets and practical implementations of DOTS

The PP did have the knowledge of the programme but felt that they were not included in the implementation and this has led to drug resisted for most of their patients because they did not know the guideline.

3.2 Discussion and Synthesis

EMERGENT THEMES

NATIONAL TB CONTROL PROGRAM

DIAGNOSIS OF TUBERCULOSIS

TREATMENT OF TUBERCULOSIS

COLLABORATION BETWEEN NTP AND PRIVATE PRACTITIONER

PRIVATE PRACTITIONERS INVOLVEMENT

PRIVATE PRACTITION-ERS PERCEPTIONS

Figure 1: Emergent themes from the reviewed literature

Private practitioners’ knowledge/awareness of the National TB Control Programme.

The review indicate very poor awareness level of the private practitioners of the TB control programme with majority of the participants unaware of the control programme and its’ functioning. This finding is in line with that by Shah et al (2003), which showed that an amazing 96% of private medical practitioners in Rawalpindi and 99% in Lahore admitted that they did not know about the guidelines. In contrast, a study in Uganda, a similar third world African country, Nshuti et al (2001), observed that majority of private practitioners in Uganda knew about the existence of the National Tuberculosis and Leprosy Control Programme (the major control body), but only half of them knew that it issued national guidelines for diagnosis and treatment of tuberculosis and leprosy. Similarly, the awareness level was improved in Gambia according to Harper et al (2003) by the Department of State for Health making available to all medical staff throughout the country the policy to be followed by health staff in dealing with tuberculosis. This measure ensured that the awareness of TB and its management was there.

With the established poor awareness level of the National TB control programme amongst the private practitioners in this study, there will be a lot of doubt on the use of the correct WHO recommended treatment regimen by the private practitioners. Evidence show that the WHO Public-Private Mix (PPM) initiative (WHO, 2006) has made grounds in this area is

private practitioners in the Trivandrum region improved when compared to previous studies, which suggests that the PPM scheme had an important beneficial effect.

Effectiveness of the National TB Control Programme

The WHO (2003) recommended DOTS strategy internationally for effective tuberculosis control and DOTS has been noted to be the most effective means of combating non-adherence to treatment ( Chan and Iseman, 2002).

From the review, the effectiveness of the National Tuberculosis control programme was assessed by the private practitioners based on current incidence and prevalence rates of tuberculosis in the country, the integration of private practitioners into the control programme, the poverty scourge in the country, programme awareness amongst the populace and the medical personnel at different levels and accessibility to the programme.

Most of the private practitioners were of the view that if the awareness level was poor then the programme would not be as effective as it should be. This makes some sense considering that the private practitioners are usually the first port of call by TB patients, this therefore means that if the doctors are not aware of the programme, there cannot be effective DOTS implementation. The consequence of the improper tuberculosis case management cannot be over emphasized.

However, some authors did acknowledge that the programme was effective. Yes the programme is effective, at least the drugs are available, that’s one thing they are doing right and the DOTS procedure is followed to the letter, and the incidence of resistance has really dropped too, (Freeman, 2009).

Issues of collaboration

This study indicates that there has been no collaboration between the private medical practitioners and the National TB Control programme.

Khan et al (2003) observed that private medical practitioners can have a positive impact on TB control if properly engaged and are often the first point of contact of many TB patients; however, this is not the case.

In the study “Involvement of private practitioners in tuberculosis control in Ballabgarh, Northern India” by Krishnan and Kapoor (2006) the results showed that private practitioners wanted to contribute to the social cause and desired more of a professional association and social recognition. These findings are similar to a couple of studies in the review.

The issue of collaboration (Public-Private Mix: PPM) has been so widely recognised that it is now one of the components of the WHO STOP TB STRATEGY campaign (WHO, 2007) and has been associated with an increase in case notification, with maintained treatment success (Ambe et al, 2005; Maung et al, 2006). Practitioners in their activities; this is a frequent reason for their non-integration into National TB Programmes. Caminero (2003) also stated that private physicians working in the private sector have also been known to look down on the NTP, which they consider could affect their income and their influence on their patients.

Updating knowledge

Majority of the private practitioners updated their knowledge personally by reading textbooks or journals and using the internet. Several participants expressed dismay at the programme coordinators for not inviting them to seminars and conferences to update them on current issues in tuberculosis management. In addition, there is no law enforcing continued medical education amongst practicing doctors in developing countries.

This finding agrees with the observation of the World Health Organisation (WHO, 2006) that the basic medical education in most poor countries is of uneven quality and there is inadequate attention to public health education. Continuing education is usually missing, regulations are often non-existent or archaic, and where they do exist, they are rarely conveyed to professionals or enforced. Furthermore, there is a major communication void between TB programmes and Private Practitioners.

Similarly, Watkins et al (2006) in their study “Joining the DOTS in Bali: private practitioners' perceptions of tuberculosis control” reported that private practitioners with more limited exposure to the public system generally described less integration with the public system and had poorer knowledge about what the public system offered and how it might be utilised within their practice. Private practitioners who had little interaction with the public sector would not routinely offer their patients free medications or other services from the public programmes, and often had a lower level of trust in the level of service provided by the public programme. These private practitioners also reported difficulties with accessing continuing medical education.

This lack of communication and necessary update is the major cause of the ignorance and poor management procedures that usually characterise private practice with respect to TB control.

Caminero (2003) is of the view that NTP managements underestimate what private physicians can do, and thus they are frequently excluded from their training courses, the transmission of information and basic activity guidelines, and from the development of the NTP guides. Many doctors are not familiar with the NTP guides, usually because NTP management has not contacted them.

HOW THE ABOVE LITERATURE ANWSER MY QUESTION

This review has attempted to acknowledge the fact that private practitioners are valuable resources, located close to, and often trusted by the community. They are usually the first point of contact for many patients especially in the developing world. This therefore would suggest that their views count and cannot be over-looked. The aim of this review has been to explore the perception of private medical practitioners around the National tuberculosis control programme in developing countries and the research question that has been raised is “What are the perceptions of private medical practitioners around the National Tuberculosis Control programme in Developing Countries?”

Literature was critically appraised using allocated CASP tools to address the research question. It is clear from this study that the awareness level amongst private practitioners was quite poor, this was blamed on poor outreach by the control programme coordinators. This also affected the level of knowledge update by the practitioners. Several private practitioners felt that the control programme was not as effective as it should be; this was blamed mainly on the poor outreach level by the programme coordinators. It has also been established that the collaboration level was appalling and several recommendations were propagated to help move the National TB control programme forward one of which is to incorporate the private practitioners into the programme as they were open to collaboration. However, the review did not just answer the intended question it brought out a lot more which is needed if any improvement in patient care can be done in the developing countries.

CHAPTER 6: Limitations

The most important limitation to this study is that I am not an experienced in literature review and this piece of work is my first exposure in the field. The first module of the course PBR1 should have concentrated more on literature review with the inclusion of both qualitative and quantitative and the assessment should have included if by choice to do one in literature review, this could have prepared the writer for the dissertation.

Studies in the review consisted of both qualitative and quantitative methodology covering developing countries. They all but one article covered the Asian region and the single one only covered Ghana. The limitation in the review is the lack of studies covering most of Africa where it is reported to have high prevalence’s of TB, HIV induced patients. Therefore, this brings to mind that the information gained in this review can only be applied to third world countries in Asia. The single study from Africa cannot be generalised across Africa, it is too small a sample to represent Africa. The WHO reports high levels of drug resistance in Africa southern region, therefore there is no literature which can cover or make it clear the causes of drug resistance in TB patients, and however the lack of education of private practitioners could be other cause. The methodologies are not consistent across the reviewed paper which makes it difficult to compare and generalise the findings.

The cultures where the studies were carried out are different and that makes it difficult to compare and generalise the results from one geographic area to another. Most of the third world countries are in Asia, South America and Africa. According to the literature search the writer did not find literature from South America.

6.1 Recommendations and Implication for practice

The results from this study suggest that a lot of ground needs to be covered by the coordinators of the national tuberculosis control programme in Developing Countries in promoting the WHO PPM initiative. It also highlights the importance of enforcing Continued Medical Education (CME) amongst private medical practitioners because it is logical that uninformed personnel could spell danger to the war against tuberculosis and above all aid the proliferation of Multi-Drug Resistant Tuberculosis (MDR-TB).

It is universally accepted that a partially treated TB patient is worse than an untreated one as the chronic cases are the ones who excrete multi drug resistant organisms and increase the community burden of TB. Partial treatment with inappropriate regimens in terms of dosage and duration is probably the most important factor leading to rise in multi-drug resistant (MDR) TB (Khan and Malik, 2003). The findings of this survey call for remedial actions. What can easily be implemented and logically follows from the findings is to provide the private practitioners with appropriate health education materials. However, health education materials alone normally do not increase adherence to treatment, Haynes et al (2002). To change the private practitioners’ practices, simple dissemination of information, e.g. through seminars, is not expected to be effective, Oxman, 2005). More promising are multifaceted approaches, combining, e.g. practice visits, using local opinion leaders, (O’Brien, 2002), and patient-mediated interventions to reduce the pressure on the private practitioners that comes from the patient demands, (Kamit 2001, Schwartz et al, 2003). Assisting the private practitioners to optimise their prescription practices should be relatively easy, especially if participation of the influential pharmaceutical companies and a commitment to evidence-based medicine can be brought about.

A challenge is to see effective case holding mechanisms established for TB patients treated in the private sector. Operational research that explores the role of incentives and disincentives, including legislation and regulation is needed. The option of re-certification (i.e. renewal of the license to practice depends on fulfilling certain standards) should be discussed. Measures to promote case holding should be evaluated and refined continuously. Processes that enable and encourage private practitioners to meet as peers in order to find effective case holding mechanisms suitable to them and their patients need to be found. However, efforts among the private sector alone will be of limited value. Communication as well as collaboration between the private and public health sector is crucial in the search for effective TB control.

Although this study cannot provide a sound basis for change in the National Tuberculosis Control in Developing Countries, it does however suggest a very disappointing state of affairs. Based on the findings of this study, it can be suggested that a multi faceted approach could be adopted to improve the current situation.

The following recommendations are therefore put forward;

Anti-Tuberculosis drugs should be regulated by the government to compel private practitioners to refer all TB patients to the National Tuberculosis Control Programme as is done in Gambia (Harper et al, 2003).

Continued Medical Education of private doctors is important and should be enforced possibly as a prerequisite for practice licence renewal.

National resources of expertise, NTPs should be strengthened to advise, contribute and monitor undergraduate, post-graduate and continuing medical education in TB treatment. Radical modification in medical school curriculum which stresses on National TB guidelines, its implementation and adherence to DOTS is required.

A simple booklet should be devised and distributed to all concerned health care providers to provide clear information on TB treatment and prevention.

NTPs should help educate the public through electronic and print media about TB, its treatment and where to receive it.

Better collaborative efforts between private practitioners and public health services should include inviting representatives of private doctors to participate in the planning process of TB control activities, involving them in case-finding activities within their areas of practice, providing them with free or subsidized but reliable laboratory services, making drugs available for the patient referred by the private doctor to the TB centre or supplying drugs to individual doctors on submission of reports and records.

6.2 Future research

Future research should be directed towards viewing the perceptions of the National TB Programme coordinators especially in Africa as this will aid the identification of all/most of the issues militating against proper collaboration and foster the WHO PPM initiative.