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Nair M, Engel N, Zeegers MP, Burza S. Perceptions of effective policy interventions and strategies to address antibiotic misuse within primary healthcare in India: A qualitative study. J Infect Prev 2023; 24:113-118. [PMID: 37065277 PMCID: PMC10090571 DOI: 10.1177/17571774231158778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
Objectives Antimicrobial resistance poses a major public health threat. Despite Indian retail sector antibiotic consumption per capita increasing by approximately 22% between 2008 and 2016, empirical studies that examine policy or behavioural interventions addressing antibiotic misuse in primary healthcare are scarce. Our study aimed to assess perceptions of interventions and gaps in policy and practice with respect to outpatient antibiotic misuse in India. Methods We conducted 23 semi-structured, in-depth interviews with a variety of key informants with diverse backgrounds in academia, non-government organisations, policy, advocacy, pharmacy, medicine and others. Data were charted into a framework matrix and analysed using a hybrid, inductive and deductive thematic analysis. Themes were analysed and organised according to the socio-ecological model at various levels ranging from the individual to the enabling environment. Results Key informants largely focused on the importance of adopting a structural perspective to addressing socio-ecological drivers of antibiotic misuse. There was a recognition that educational interventions targeting individual or interpersonal interactions were largely ineffective, and policy interventions should incorporate behavioural nudge interventions, improve the healthcare infrastructure and embrace task shifting to rectify staffing disparities in rural areas. Conclusions Prescription behaviour is perceived to be governed by structural issues of access and limitations in public health infrastructure that create an enabling environment for antibiotic overuse. Interventions should move beyond a clinical and individual focus on behaviour change with respect to antimicrobial resistance and aim for structural alignment between existing disease specific programs and between the informal and formal sector of healthcare delivery in India.
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Affiliation(s)
- Mohit Nair
- Maastricht University, Maastricht, Netherlands
| | - Nora Engel
- Maastricht University, Maastricht, Netherlands
| | | | - Sakib Burza
- London School of Hygiene & Tropical Medicine, London, UK
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Haldane V, Zhang Z, Ma Q, Yin T, Zhang B, Li Y, Pan Q, Dainty KN, Rea E, Pasang P, Wei X, Hu J. A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infect Dis Poverty 2021; 10:120. [PMID: 34544492 PMCID: PMC8451167 DOI: 10.1186/s40249-021-00906-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB. Methods We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al. Results Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment. Conclusions We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00906-4.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Qi Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Tingting Yin
- Weifang Medical College, Weifang, Shandong, China
| | - Bei Zhang
- Weifang Medical College, Weifang, Shandong, China
| | - Yinlong Li
- Jining Medical University, Jining, Shandong, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Elizabeth Rea
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Pande Pasang
- Xigaze Centre for Disease Control and Prevention, 7 Keji Road, Sangzhuzi District, Xigaze, Xizang, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada.
| | - Jun Hu
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China.
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Deo S, Jindal P, Sabharwal M, Parulkar A, Singh R, Kadam R, Dabas H, Dewan P. Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India. BMJ Glob Health 2020; 5:bmjgh-2020-003600. [PMID: 33376100 PMCID: PMC7778745 DOI: 10.1136/bmjgh-2020-003600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. Methods We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013–September 2014) to after intervention (October 2014–December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. Results The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3–US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. Conclusions Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.
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Affiliation(s)
- Sarang Deo
- Max Institute of Healthcare Management, Indian School of Business, Mohali, Punjab, India .,Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | - Pankaj Jindal
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | | | | | - Ritu Singh
- Clinton Health Access Initiative, New Delhi, India
| | | | | | - Puneet Dewan
- Bill and Melinda Gates Foundation, New Delhi, India
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Ananthakrishnan R, Thiagesan R, Auguesteen S, Karunakaran N, Jayabal L, M J, Stevens R, Codlin A, Creswell J. The impact of chest radiography and Xpert MTB/RIF testing among household contacts in Chennai, India. PLoS One 2020; 15:e0241203. [PMID: 33147240 PMCID: PMC7641361 DOI: 10.1371/journal.pone.0241203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 10/10/2020] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis prevalence surveys have demonstrated the benefit of screening with chest x-ray (CXR) and sensitive diagnostic tests compared to symptoms and smear microscopy. However, in programmatic practice there is little evidence on the yield of different algorithms. We implemented contact tracing in Chennai, India for adult sputum-positive TB patients registered from January 2015 to March 2016. Patients with symptoms or abnormal X-ray findings further underwent testing using Xpert MTB/RIF (Xpert) and smear microscopy. A retrospective cohort study was done to summarize the key findings. We verbally screened 5553 contacts for symptoms, CXR through private sector collaboration, Xpert, and smear microscopy. Overall, 1312 (23.6%) contacts screened positive. CXR alone identified 531 (40.5%) of them, 679 (51.8%) were symptom-positive only, while 102 (7.8%) were positive on both the symptom and CXR screen. Overall, 35 bacteriologically positive cases were identified (0.7%). A standard approach of symptoms screening followed by microscopy identified only 9 (25.7%) of the total number of bacteriologically positive cases, whereas the combination of a CRX screening followed by microscopy identified 13 (37.1%) of the cases. The algorithm of symptoms screening followed by Xpert testing, detected 20 cases, whereas the combination of symptoms and CXR followed by Xpert increased this number to 35 (75% increase compared to symptoms and Xpert). Optimal use of more sensitive screening tests, better diagnostic tests, and novel private sector engagement can improve diagnostic yield in a programmatic setting.
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Affiliation(s)
- Ramya Ananthakrishnan
- REACH – Resource Group for Education and Advocacy for Community Health, Chennai, Tamil Nadu, India
- * E-mail:
| | - Rajeswaran Thiagesan
- REACH – Resource Group for Education and Advocacy for Community Health, Chennai, Tamil Nadu, India
| | - Sheela Auguesteen
- REACH – Resource Group for Education and Advocacy for Community Health, Chennai, Tamil Nadu, India
| | - Nalini Karunakaran
- REACH – Resource Group for Education and Advocacy for Community Health, Chennai, Tamil Nadu, India
| | - Lavanya Jayabal
- GCC RNTCP – Greater Chennai Corporation Revised National Tuberculosis Control Programme Chennai, Tamil Nadu, India
| | - Jagadeesan M
- GCC RNTCP – Greater Chennai Corporation Revised National Tuberculosis Control Programme Chennai, Tamil Nadu, India
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Subbaraman R, Jhaveri T, Nathavitharana RR. Closing gaps in the tuberculosis care cascade: an action-oriented research agenda. J Clin Tuberc Other Mycobact Dis 2020; 19:100144. [PMID: 32072022 PMCID: PMC7015982 DOI: 10.1016/j.jctube.2020.100144] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The care cascade-which evaluates outcomes across stages of patient engagement in a health system-is an important framework for assessing quality of tuberculosis (TB) care. In recent years, there has been progress in measuring care cascades in high TB burden countries; however, there are still shortcomings in our knowledge of how to reduce poor patient outcomes. In this paper, we outline a research agenda for understanding why patients fall through the cracks in the care cascade. The pathway for evidence generation will require new systematic reviews, observational cohort studies, intervention development and testing, and continuous quality improvement initiatives embedded within national TB programs. Certain gaps, such as pretreatment loss to follow-up and post-treatment disease recurrence, should be a priority given a relative paucity of high-quality research to understand and address poor outcomes. Research on interventions to reduce death and loss to follow-up during treatment should move beyond a focus on monitoring (or observation) strategies, to address patient needs including psychosocial and nutritional support. While key research questions vary for each gap, some patient populations may experience disparities across multiple stages of care and should be a priority for research, including men, individuals with a prior treatment history, and individuals with drug-resistant TB. Closing gaps in the care cascade will require investments in a bold and innovative action-oriented research agenda.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Tulip Jhaveri
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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Deo S, Singh S, Jha N, Arinaminpathy N, Dewan P. Predicting the impact of patient and private provider behavior on diagnostic delay for pulmonary tuberculosis patients in India: A simulation modeling study. PLoS Med 2020; 17:e1003039. [PMID: 32407407 PMCID: PMC7224455 DOI: 10.1371/journal.pmed.1003039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 04/20/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) incidence in India continues to be high due, in large part, to long delays experienced by patients before successful diagnosis and treatment initiation, especially in the private sector. This diagnostic delay is driven by patients' inclination to switch between different types of providers and providers' inclination to delay ordering of accurate diagnostic tests relevant to TB. Our objective is to quantify the impact of changes in these behavioral characteristics of providers and patients on diagnostic delay experienced by pulmonary TB patients. METHODS AND FINDINGS We developed a discrete event simulation model of patients' diagnostic pathways that captures key behavioral characteristics of providers (time to order a test) and patients (time to switch to another provider). We used an expectation-maximization algorithm to estimate the parameters underlying these behavioral characteristics, with quantitative data encoded from detailed interviews of 76 and 64 pulmonary TB patients in the 2 Indian cities of Mumbai and Patna, respectively, which were conducted between April and August 2014. We employed the estimated model to simulate different counterfactual scenarios of diagnostic pathways under altered behavioral characteristics of providers and patients to predict their potential impact on the diagnostic delay. Private healthcare providers including chemists were the first point of contact for the majority of TB patients in Mumbai (70%) and Patna (94%). In Mumbai, 45% of TB patients first approached less-than-fully-qualified providers (LTFQs), who take 28.71 days on average for diagnosis. About 61% of these patients switched to other providers without a diagnosis. Our model estimates that immediate testing for TB by LTFQs at the first visit (at the current level of diagnostic accuracy) could reduce the average diagnostic delay from 35.53 days (95% CI: 34.60, 36.46) to 18.72 days (95% CI: 18.01, 19.43). In Patna, 61% of TB patients first approached fully qualified providers (FQs), who take 9.74 days on average for diagnosis. Similarly, immediate testing by FQs at the first visit (at the current level of diagnostic accuracy) could reduce the average diagnostic delay from 23.39 days (95% CI: 22.77, 24.02) to 11.16 days (95% CI: 10.52, 11.81). Improving the diagnostic accuracy of providers per se, without reducing the time to testing, was not predicted to lead to any reduction in diagnostic delay. Our study was limited because of its restricted geographic scope, small sample size, and possible recall bias, which are typically associated with studies of patient pathways using patient interviews. CONCLUSIONS In this study, we found that encouraging private providers to order definitive TB diagnostic tests earlier during patient consultation may have substantial impact on reducing diagnostic delay in these urban Indian settings. These results should be combined with disease transmission models to predict the impact of changes in provider behavior on TB incidence.
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Affiliation(s)
- Sarang Deo
- Indian School of Business, Hyderabad, India
| | - Simrita Singh
- Indian School of Business, Hyderabad, India
- Kellogg School of Management, Northwestern University, Evanston, Illinois, United States of America
| | - Neha Jha
- Indian School of Business, Hyderabad, India
- Kenan-Flagler Business School, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | | | - Puneet Dewan
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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Affiliation(s)
- Sougat Ray
- Asvini Hospital, Colaba, Mumbai 400005, India.
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Kwan A, Daniels B, Bergkvist S, Das V, Pai M, Das J. Use of standardised patients for healthcare quality research in low- and middle-income countries. BMJ Glob Health 2019; 4:e001669. [PMID: 31565413 PMCID: PMC6747906 DOI: 10.1136/bmjgh-2019-001669] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/28/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
The use of standardised patients (SPs)-people recruited from the local community to present the same case to multiple providers in a blinded fashion-is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement.
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Affiliation(s)
- Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Benjamin Daniels
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
| | - Sofi Bergkvist
- ACCESS Health International, New York City, New York, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Madhukar Pai
- Department of Epidemiology & Biostatistics, and McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Jishnu Das
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
- Center for Policy Research, Delhi, India
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Daftary A, Satyanarayana S, Jha N, Singh M, Mondal S, Vadnais C, Pai M. Can community pharmacists improve tuberculosis case finding? A mixed methods intervention study in India. BMJ Glob Health 2019; 4:e001417. [PMID: 31179037 PMCID: PMC6528751 DOI: 10.1136/bmjgh-2019-001417] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/13/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction India has the world’s highest burden of tuberculosis (TB). Private retail pharmacies are the preferred provider for 40% of patients with TB symptoms and up to 25% of diagnosed patients. Engaging pharmacies in TB screening services could improve case detection. Methods A novel TB screening and referral intervention was piloted over 18 months, under the pragmatic staggered recruitment of 105 pharmacies in Patna, India. The intervention was integrated into an ongoing public–private mix (PPM) programme, with five added components: pharmacy training in TB screening, referral of patients with TB symptoms for a chest radiograph (CXR) followed by a doctor consultation, incentives for referral completion and TB diagnosis, short message service (SMS) reminders and field support. The intervention was evaluated using mixed methods. Results 81% of pharmacies actively participated in the intervention. Over 132.49 pharmacy person-years of observation in the intervention group, 1674 referrals were made and 255 cases of TB were diagnosed. The rate of registration of symptomatic patients was 62 times higher in the intervention group compared with the control group (95% CI: 54 to 72). TB diagnosis was 25 times higher (95% CI: 20 to 32). Microbiological testing and test confirmation were also significantly higher among patients diagnosed in the intervention group (p<0.001). Perceived professional credibility, patient trust, symptom severity and providing access to a free screening test were seen to improve pharmacists’ engagement in the intervention. Workload, patient demand for over-the-counter medicines, doctor consultation fees and programme documentation impeded engagement. An additional 240 cases of TB were attributed to the intervention, and the approximate cost incurred per case detected due to the intervention was US$100. Conclusions It is feasible and impactful to engage pharmacies in TB screening and referral activities, especially if working within existing public-private mix (PPM) programmes, appealing to pharmacies’ business mindset and among pharmacies with strong community ties.
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Affiliation(s)
- Amrita Daftary
- McGill International TB Centre and Department of Epidemiology & Biostatistics, McGill University, Montreal, Québec, Canada.,Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Srinath Satyanarayana
- The International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Nita Jha
- World Health Partners, Patna, Bihar, India
| | | | - Shinjini Mondal
- Department of Family Medicine, McGill University, Montreal, Québec, Canada
| | - Caroline Vadnais
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology & Biostatistics, McGill University, Montreal, Québec, Canada.,Manipal McGill Centre for Infectious Diseases, Manipal, Karnataka, India
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Daniels B, Kwan A, Satyanarayana S, Subbaraman R, Das RK, Das V, Das J, Pai M. Use of standardised patients to assess gender differences in quality of tuberculosis care in urban India: a two-city, cross-sectional study. Lancet Glob Health 2019; 7:e633-e643. [PMID: 30928341 PMCID: PMC6465957 DOI: 10.1016/s2214-109x(19)30031-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice. METHODS We sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender. FINDINGS Between Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76-1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification. INTERPRETATION Systematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India. FUNDING Grand Challenges Canada, Bill & Melinda Gates Foundation, World Bank Knowledge for Change Program.
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Affiliation(s)
| | - Ada Kwan
- Development Research Group, The World Bank, Washington, DC, USA; University of California at Berkeley, Berkeley, CA, USA
| | - Srinath Satyanarayana
- Center for Operational Research, International Union Against TB and Lung Diseases, Paris, France
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ranendra K Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, MD, USA
| | - Jishnu Das
- Development Research Group, The World Bank, Washington, DC, USA; Center for Policy Research, New Delhi, India
| | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India.
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Bhattacharya Chakravarty A, Rangan S, Dholakia Y, Rai S, Kamble S, Raste T, Shah S, Shah S, Mistry N. Such a long journey: What health seeking pathways of patients with drug resistant tuberculosis in Mumbai tell us. PLoS One 2019; 14:e0209924. [PMID: 30653523 PMCID: PMC6336307 DOI: 10.1371/journal.pone.0209924] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/13/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The Indian Tuberculosis (TB) Programme currently faces the dual challenges of tackling increasing numbers of drug resistant (DR) TB cases and regulating practices of a pluralistic private sector catering to TB patients. A study of health seeking behaviour of DR-TB patients in such a situation, offers an opportunity to understand the problems patients face while interacting with health systems. METHODOLOGY Forty-six DR-TB patients drawn from 15 high TB burden wards in Mumbai were interviewed using an open ended interview tool. Interviews were audio recorded and transcribed. Pathway schematics developed from analysis of patient records, were linked to transcripts. Open coding was used to analyse these units and themes were derived after collating the codes. RESULTS AND DISCUSSION The paper presents themes interwoven with narratives in the discussions. These include awareness-action gap among patients, role of neighbourhood providers, responsiveness of health systems, the not-such a 'merry go round' that patients go/are made to go on while seeking care, costs of diagnostics and treatment, and how DR-TB is viewed as the 'big TB'. CONCLUSION The recommendations are based on a preventative ethos which is sustainable, compared to interventions with top-down approaches, which get piloted, but fail to sustain impact when scaled up.
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Affiliation(s)
| | - Sheela Rangan
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Yatin Dholakia
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Sonu Rai
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Swaran Kamble
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Tejaswi Raste
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Sanchi Shah
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Shimoni Shah
- The Foundation for Medical Research, Worli, Mumbai, India
| | - Nerges Mistry
- The Foundation for Medical Research, Worli, Mumbai, India
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Mistry N, Lobo E, Shah S, Rangan S, Dholakia Y. Pulmonary tuberculosis in Patna, India: Durations, delays, and health care seeking behaviour among patients identified through household surveys. J Epidemiol Glob Health 2017; 7:241-248. [PMID: 29110864 PMCID: PMC7384577 DOI: 10.1016/j.jegh.2017.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 11/26/2022] Open
Abstract
Background: Delays in accessing effective health care plays a pivotal role in increasing Tuberculosis (TB) transmission within the community. Patna, North India, with high levels of poverty and weak public health system, faces huge challenges for achieving effective TB control. The study aims to determine delays that occur from onset of TB symptoms until initiation of pulmonary TB (PTB) treatment among patients in Patna. Methods: Of the 109 self-reporting TB patients identified through an active household survey, 64 PTB patients were interviewed. First care seeking, TB diagnostic and treatment initiation durations were calculated and delays defined for new and retreatment patients and minors and adults. Outliers exhibiting extreme delays were additionally identified. Results: A cross sMean total pathway duration for TB care was 40 days, with diagnostic duration contributing to 58% of the duration. No significant differences were noted between new and retreatment patients. Minors, comprising of 30% of total PTB patients accessed care faster than adults, but showed significantly higher diagnostic duration (38 days vs. 17 days). Preference for private sector, chemists and allopaths was seen throughout the pathway. Discussion: Patna requires a more effective harnessing of the private sector augmented with reliable diagnostic investigations and a focus on quality.
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Affiliation(s)
- Nerges Mistry
- The Foundation for Medical Research, 84A, R.G. Thadani Marg, Worli, Mumbai 400018, India.
| | - Eunice Lobo
- The Foundation for Medical Research, 84A, R.G. Thadani Marg, Worli, Mumbai 400018, India
| | - Shimoni Shah
- The Foundation for Medical Research, 84A, R.G. Thadani Marg, Worli, Mumbai 400018, India
| | - Sheela Rangan
- The Foundation for Medical Research, 84A, R.G. Thadani Marg, Worli, Mumbai 400018, India
| | - Yatin Dholakia
- The Foundation for Medical Research, 84A, R.G. Thadani Marg, Worli, Mumbai 400018, India
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14
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Fitchett JR, MacPherson P, Corbett EL. Implementing the End TB Strategy and the intersection with the Sustainable Development Goals, 2016-2030. Trans R Soc Trop Med Hyg 2016; 110:145-7. [PMID: 26884489 DOI: 10.1093/trstmh/trw010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joseph R Fitchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Peter MacPherson
- Department of Public Health and Policy, University of Liverpool, UK Department of Clinical Sciences, Liverpool School of Tropical Medicine, UK
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi Department of Clinical Research, London School of Hygiene & Tropical Medicine, UK
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15
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The Tuberculosis Cascade of Care in India's Public Sector: A Systematic Review and Meta-analysis. PLoS Med 2016; 13:e1002149. [PMID: 27780217 PMCID: PMC5079571 DOI: 10.1371/journal.pmed.1002149] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 09/09/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND India has 23% of the global burden of active tuberculosis (TB) patients and 27% of the world's "missing" patients, which includes those who may not have received effective TB care and could potentially spread TB to others. The "cascade of care" is a useful model for visualizing deficiencies in case detection and retention in care, in order to prioritize interventions. METHODS AND FINDINGS The care cascade constructed in this paper focuses on the Revised National TB Control Programme (RNTCP), which treats about half of India's TB patients. We define the TB cascade as including the following patient populations: total prevalent active TB patients in India, TB patients who reach and undergo evaluation at RNTCP diagnostic facilities, patients successfully diagnosed with TB, patients who start treatment, patients retained to treatment completion, and patients who achieve 1-y recurrence-free survival. We estimate each step of the cascade for 2013 using data from two World Health Organization (WHO) reports (2014-2015), one WHO dataset (2015), and three RNTCP reports (2014-2016). In addition, we conduct three targeted systematic reviews of the scientific literature to identify 39 unique articles published from 2000-2015 that provide additional data on five indicators that help estimate different steps of the TB cascade. We construct separate care cascades for the overall population of patients with active TB and for patients with specific forms of TB-including new smear-positive, new smear-negative, retreatment smear-positive, and multidrug-resistant (MDR) TB. The WHO estimated that there were 2,700,000 (95%CI: 1,800,000-3,800,000) prevalent TB patients in India in 2013. Of these patients, we estimate that 1,938,027 (72%) TB patients were evaluated at RNTCP facilities; 1,629,906 (60%) were successfully diagnosed; 1,417,838 (53%) got registered for treatment; 1,221,764 (45%) completed treatment; and 1,049,237 (95%CI: 1,008,775-1,083,243), or 39%, of 2,700,000 TB patients achieved the optimal outcome of 1-y recurrence-free survival. The separate cascades for different forms of TB highlight different patterns of patient attrition. Pretreatment loss to follow-up of diagnosed patients and post-treatment TB recurrence were major points of attrition in the new smear-positive TB cascade. In the new smear-negative and MDR TB cascades, a substantial proportion of patients who were evaluated at RNTCP diagnostic facilities were not successfully diagnosed. Retreatment smear-positive and MDR TB patients had poorer treatment outcomes than the general TB population. Limitations of our analysis include the lack of available data on the cascade of care in the private sector and substantial uncertainty regarding the 1-y period prevalence of TB in India. CONCLUSIONS Increasing case detection is critical to improving outcomes in India's TB cascade of care, especially for smear-negative and MDR TB patients. For new smear-positive patients, pretreatment loss to follow-up and post-treatment TB recurrence are considerable points of attrition that may contribute to ongoing TB transmission. Future multisite studies providing more accurate information on key steps in the public sector TB cascade and extension of this analysis to private sector patients may help to better target interventions and resources for TB control in India.
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