Article Text
Abstract
Background Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges.
Methods We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics.
Findings 80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively).
Interpretation Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
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Footnotes
Handling editor Seye Abimbola.
Contributors MM, JDG-F and MV-H contributed to study design. MM, JDG-F and MV-H contributed to instrument development. MM, SG, JDG-F and MV-H contributed to data collection, cleaning and analysis. All coauthors contributed to data interpretation and manuscript writing and revision.
Funding This study was funded by the Bill and Melinda Gates Foundation (Grant number OPP1025880).
Disclaimer The funders had no role in study design, data collection, analysis, interpretation, writing of the manuscript or decision to submit the paper for publication.
Competing interests None declared.
Ethics approval This study, as part of the BEST study protocol, was approved by Duke University (29755) and India's Health Ministry Steering Committee (number 12/2008/30-HMSC/4).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All our protocols and instruments are made available publicly at http://cohesiveindia.org/publications-downloads.html. We also plan to submit our complete data set with documentation to the Harvard Dataverse data depository for public access.