Evaluation of Revised National Tuberculosis Control Program among Ten Designated Microscopy Centers of West Tripura: A Cross-Sectional Study

Introduction

Pulmonary tuberculosis (PTB) is a worldwide, chronic communicable bacterial disease. It is very ancient disease and its description has also been found in the ancient Buddhist and Chinese writings. Even the Egyptian mummies as old as 500 BC show the evidence of man suffering from TB. TB in India is also known as “Kshyya Rog,”, “Tapedic,” and “Rajayaakhsma,” whereas in western world as phthisis, in Romans as tabes, and in Greek as consumption.¹

In 2015, incidence of estimated 10.4 million cases was reported worldwide, in which 3.5 million (34%) were women, 1.0 million (10%) were children, and 5.9 million (56%) were men, respectively. The 2020 End TB Strategy, 35% reduction in TB deaths and a 20% reduction in incidence rate, compared with levels in 2015. There should be no TB-affected households facing catastrophic costs.²

The 12th Five Year Plan (2012–2017) aimed to achieve universal access to quality assured TB diagnosis and treatment. This required broad efforts and support from stakeholders with enhancement of commitment and financing at all levels.³

India account for 2.2 million out of 9.6 million new TB cases annually worldwide. To support TB notification and strengthen the surveillance of TB, web-based system of NIKSHAY is established for notification from public and private sector and increases the use of information for betterment of care delivery of services at local level.⁴

To provide easy access for population, designated microscopy center (DMC) for PTB smear microscopy services with competency in acid-fast sputum smear microscopy has been established.⁵

In West Tripura, as per 2016 to 2017 achievements, the sputum examination per lakh per year was 620 (800), new smear case detection rate was 48 lakh per year (100), and total case detection rate was 68 (217) per lakhs per year. As per the TB-HIV collaborative activities of 2017, total 621 patients were registered, in which 477 PTB patients were known to be tested for HIV, and out of total tested patients, eight were known to be tested HIV positive.⁶

Although there were studies regarding adherence of directly observed treatment short course (DOTS) regimen among PTB patient in West Tripura district,⁷ research with respect to evaluation of PTB program was not done explicitly in past; therefore, this study was done for the evaluation of PTB program in West Tripura in ten DMC. The objective was to assess the performance in terms of knowledge and practice of Revised National Tuberculosis Control Program among DOTS provider, lab technician, senior treatment supervisor (STS), senior tuberculosis laboratory supervisor (STLS), factors affecting knowledge and practice of PTB program, rate of detection, cure rate and to identify the gaps and underlying contributing factors in terms of supply, manpower, and infrastructure.

Materials and Methods

A cross-sectional study was conducted in TB unit and DMC of West Tripura for 1 year duration from May 2018 to April 2019. DOTS providers, STS, STLS, and lab technician were included in the study. Sadar Tuberculosis Unit of West Tripura and DMCs of Agartala Government Medical College (AGMC), Tripura Medical College (TMC), district TB centers (west), Narshinghar primary health center (PHC), Anandanagar PHC, Mohanpur community health centers (CHCs), Katlamara PHC, Mandai PHC, Jirania PHC, and Ranirbazar PHC were the study unit. Predesigned, pretested, semistructured interview schedule was used for data collection. Kaur et al conducted a study on knowledge and attitude of DOTS providers in TB unit of Patiala in which adequate knowledge of DOTS provider among PTB patient was 90% (P).⁸ The sample size calculated based on the formula (N) = (Z_α/2)² p x q/L ² where “p” was 90% (P) and an allowable error (L) 10% of prevalence (P) at 5% level of significance and considering 10% nonresponse rate, so 50 DOTS provider were taken for the study. Statistical data analysis was done by the software SPSS 22.0 version. In this study, frequency and percentages were expressed using descriptive statistics. Association between different variables was applied using chi-squared test. In thus study, p-value of less than 0.05 was taken as significant for the study. Institutional ethics committee has granted ethical clearance for clinical studies, AGMC, Agartala, Tripura, having Ref. No. F.4(5-192).

Sample Size Calculation

Sample size for assessing knowledge of DOTS provider: Considering the adequate knowledge of DOT provider among PTB patient to be 90% (P)⁸ and allowable error (l) of 10% with 5% level of significance (type I error), the minimum required sample size was as follows: To calculate sample size, Prevalence (P) of 90% and allowable error (L) of 10% of Prevalence was taken. Calculation of sample size (N) = (Z_α/2)² p x q/L ². Considering 10% nonresponse rate, the total sample size taken was 50. During visit, there were 10 lab technicians from each DMC, and 1 STS, 2 STLS were available for interview and all of them were interviewed for the present study.

Sampling method: Simple random sampling method using lottery method was followed for collection of data from DOTS provider. Purposive sampling method was followed for STS, STLS, and lab technician for data collection.

Results

Sociodemographic profile of the DOTS provider: Majority of the participants (40%) of the DOTS providers belonged to age group of 31 to 40 years followed by 30% of patients who were in 41 to 50 years. The mean age of the participants was 40.98 ± 10.13 years. Female were 68.0% and 32.0% of the patients were male. Regarding service experience, 66.0% of the DOTS provider had served for more than 5 years followed by 24.0% who had served for 3 to 5 years and 10.0% were in service for the last 3 years. Among the DOTS provider, 36.0% were multipurpose worker followed by 24.0% who were ASHA workers. An equal share of 12.0% was shared by pharmacist and nurses as per the occupation. Regarding education, 48.0% of the DOTS provider had studied up to secondary school followed by 30.0% up to higher secondary and 22.0% were graduates and above (►Table 1).

Knowledge of PTB program among DOTS provider: Majority (80%) of providers had undergone RNTCP training, while 20.0% had not. Regarding category I, 86% of them had given correct answer, while 14.0% had given wrong answer and in category II treatment duration, majority (84.0%) gave the correct response, while 16.0% providers were unable to do so. Majority (82.0%) of the DOTS provider had noticed side effect of ATT in the patients, while 18.0% did not notice any such. Regarding side effects, 34.0% had nausea and vomiting followed by multiple symptoms (28.0%), itching (20.0%), and giddiness (2.0%). About 34.0% of patients discontinued treatment due to the toxicity of the drugs. Change in address became the second most common reason for the denial in 30.0% of the patients and 12% discontinued due to the negligence. Regarding latest information, 54.0% providers received from the health officials followed by 20.0% in the form of seminars and 12% contribution was made by the books (►Table 2).

Practices followed on PTB program by DOTS provider: Among DOTS provider, 84.0% of them had verified address of the beneficiaries before starting the treatment, while 16.0% did not verify it. Majority (60.0%) of the patients were referred to the higher center for further management, 24.0% were referred to the district hospital, and 16.0% were asked to continue the treatment on noticing the side effect of ATT drugs. Majority (80.0%) of the DOTS provider had tallied patient's treatment card of patient while providing the drugs, whereas 16.0% were unable to do the same. All the DOTS providers were in practice of arranging information, education, and communication (IEC) activities in which 44.0% of them used to health camp followed by 20.0% each on displaying of banners and verbal communication (►Table 3).

Association of sociodemographic profile with knowledge of DOTS provider: Association of RNTCP training of DOTS provider with the sociodemographic profile—it was significantly associated with age group (p < 0.004), service duration (p < 0.001). Association of knowledge regarding side effect of ATT drug of DOTS provider with the sociodemographic profile—it was significantly associated with age group (p < 0.004), sex (p < 0.015), and service duration (p < 0.002; ►Table 4).

Discussion

The mean age among DOTS provider was 40.98 ± 10.13 years. Kaur⁸ et al conducted similar study in Patiala in which the mean age of DOTS provider was 39.98 + 6.09 years. Bhawnani⁹ et al conducted a study on DOTS providers regarding TB in Raipur in which 20.6% were in age group of 40 to 50 years. Males and females in this study were 32 and 68%, respectively. Kaur et al conducted similar study in Patiala in which 26% were males and 74% were females. Jain¹⁰ et al conducted a study on Knowledge, Attitude, and Practices (KAP) of DOTS in Ujjain in which 71.6% were females. Jain et al conducted a study on KAP of DOTS provider under RNTCP in Ujjain in which 76.5% of the DOTS provider belonged to health-related occupation, whereas 24% were others. Study showed 48% of the DOTS provider had studied up to secondary school, 30% had higher secondary, and 11% had graduation degree. Bhawnani⁹ et al conducted a study on the assessment of knowledge of DOTS providers regarding TB in Raipur in which 36% were higher secondary and 12% were graduates. Sarpal¹¹ et al conducted a study on DOTS providers perceptions of barriers to TB care in Chandigarh, North India, in which females and males were 52.2 and 47.8%, respectively. Kaur et al conducted similar study in Patiala in which 84% of the DOTS provider received training under PTB program. The duration of treatment for category I and category II (86% and 84%) of the DOTS provider was 6 and 8 months, respectively. Kaur et al conducted similar study in Patiala in which 92% of the DOTS provider knew the treatment schedule. Reasons of defaulter for drugs were as follows: 34% of the DOTS provider said it was due to toxicity of drugs, 24% said it was due improvement in symptoms, 30% said it was due to change in address, and 12% said it was due to negligence of the patient. Kaur et al conducted similar study in Patiala which found that reason for default was 24% due to change in address. Regarding latest information on PTB Program, 54% of the respondents information was obtained from health officials, 20% from health camps, 12% from books, followed by 14% from media. Kaur et al conducted similar study in Patiala in which 10% of the latest TB information was collected from media. Jain¹⁰ et al conducted a study on Knowledge, Attitude, and Practices (KAP) of DOTS provider under RNTCP in Ujjain in which 56.9% of the DOTS provider had good knowledge about TB as only 21.6% of the DOTS provider had completed more than 5 years, whereas in this study it is 74% because 66% of the DOTS provider had completed service of more than 5 years. Ajay et al¹² conducted study on to assess the TB treatment providers in the mid hills of India in which a large number of DOTS provider (86.8%) had the experience of more than 5 years of service.

However, our study has some limitation in conducting research. The concept of evaluation in PTB program is broad term; as a result we had to limit to certain extent, so that it could be manageable within stipulated period. Due to shortage of time and resources, the sample size of DOTS provider was less than the registered DOTS provider in 1 year in 10 DMC area of West Tripura.

Conclusion

Majority of the DOTS provider had satisfactory knowledge and practice about PTB program. Regarding association of training status among DOTS provider with the sociodemographic profile, it was significantly associated with age group and service duration. In all ten TB units or DMC, proportion of the medical officers attending DOTS training was inadequate and had significant gap with the standard guidelines from central TB division. There were no gaps found in proportion of the cases receiving the supervised treatment. There was adequate number of the health care workers who had attended DOTS training.

Hence, this study may help PTB program in planning and implementation of TB control measures by addressing the factors associated with evaluation in West Tripura and overcoming the barriers regarding treatment completion and knowledge of PTB program.