Effect of Educational Intervention on Knowledge and Attitude Regarding Tuberculosis among Uncertified Rural Practitioners in Singur, West Bengal

Introduction:

Uncertified Rural Practitioners (URPs) occupy an important position in healthcare system in India. URPs also known as Quacks or Rural medical Practitioners are individuals who practice modern medicine without any formal training or legal sanction ^(1-4). West Bengal have roughly 2 lakh URPs practicing currently.⁽⁵⁾

URPs often receive some training on modern medicine from several institutes without any credibility or they learn by handling patients while working under any registered doctor. They usually provide medical services on outpatient basis in their chambers or during domiciliary visits. Some of them even perform minor surgeries. URPs often prescribe antibiotics despite their lack of knowledge regarding antibiotic use and thus provide quick relief to their clients^(1,3,4,6,7). It is a well known fact that incorrect usage of antibiotics lead to antimicrobial resistance. On the other hands, India has the highest burden of Drug Resistant TB (DR- TB) with a high rate of treatment failure and death.

Additional fluroquinolone resistance was observed in 21.8% DRTB patients.⁽⁸⁾

Nearly 70% of all primary health care are provided by URPS and despite all the perilous practices observed among, they continue to remain an important part of health system especially in rural India. ^(9-11). Rural healthcare severely lack doctors while registered private practitioners are available but often not accessible in odd hours and not affordable by economically weaker sections of society. Several studies have shown URPs covered nearly 58% to 76% of total rural healthcare professionals and become an unavoidable part of rural healthcare system. ^{(2,3,7,10-13)}.

There is paucity of studies regarding knowledge and attitude regarding Tuberculosis among URPs.In this context current study was aimed to assess knowledge and attitude regarding Tuberculosis management among URPs and to evaluate the improvement of this knowledge and attitude following an educational intervention.

Results:

Majority were Flindus (92.9%).All of them practiced Allopathic system of medicine. Most received training in healthcare from private institute (39.3%) or as an apprentice of registered doctor (39.3%). Nearly two-third (60.7%) received training on TB in the past. Most of them were practising for ≥ 20 years (79.5%) and they attend to ≥ 10 patients/day (89.3%). Majority also responded that they did nottreatTB patients on their own (96.4%).

negative. Most of them also denied for stoppage of treatment with improvement of symptoms (92.9%). Only 42.9% believed that ATD can be given to pregnant women. Similar number of participants responded that ATD can be given to children. Correct attitude improved for all the above mentioned items after the intervention; however this change was not statistically significant.

Discussion:

Mukherjee et al found that most of the URPs practised allopathic system (85.6%) and provided antibiotic to their patients (95%). Half of them knew correct dosing of antibiotics.⁽¹⁾ Poor knowledge regarding antibiotic use in current study was comparable with the findings of Mukherjee et al.

Dasgupta et al. studied on 233 urban private practitioners, comprising both registered and unregistered practitioners, in Kolkata in 2008 and found that only 9.9% urban private practitioners notified TB cases. Nearly one-fourth had knowledge about cough more than 3 week as a symptom of TB (21%) and about all five first line ATDs (29.2%).Good knowledge and proper practice were present in 24% and 19.7% of the practitioners, respectively.⁽¹⁴⁾ Poor knowledge of tuberculosis among private practitioners in the study by Dasgupta et al corresponds to this study.

Mangal et al studies on knowledge of TB among grass root level practitioners in Jaipur in 2015 show that 64% did not notify TB cases. Only 25.5% believed that cough for more than 2 week could be a symptom of TB. Majority diagnosed TB by sputum microscopy (78%) and X-ray(80%).More than two- thirds (70%) referred the suspected TB cases to other centres, mostly government (86%).. ⁽¹⁵⁾. Current study found slightly better knowledge among the participants.

Table 2 reveals that more than half (57.1%) disagreed that sputum negative patients should be considered tuberculosis Das et al conducted an open label randomized controlled trial among 304 informal health care providers in Birbhum to find a positive impact of training on proper case management with significant improvement in history taking and correct case management. No significant improvement in behaviour of antibiotic misuse or unnecessary use of harmful medicine was observed ⁽¹⁶⁾. However, current study showed significant improvement in knowledge regarding correct antibiotic use among the URPs.

In spite of intensive search the researchers could not find any such similar studies where knowledge and attitude of URPs have been assessed following an educational intervention.. One of the major drawbacks of this study was low sample size which disabled the researchers to conduct any stratified analysis. The questionnaire was not pretested. However content and face validity were ascertained by experts from AIIH&PH. Moreover this study was not free from biases like recall bias and social desirability bias.

Conclusion:

Improvement of correct knowledge and attitude regarding tuberculosis is essential for correct practice. The study highlighted that educational intervention can promptly improve knowledge gap regarding TB management and notification. After the intervention improvement of attitude was seen but the change was not statistically significant. Thus such repeated interventions are very much needed for marked improvement of attitude which in turn will lead to improvement of their practice. Further studies with larger sample size are also needed.