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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 12-16

Preferred Healthcare Destination for Tuberculosis Care among the Slum Dwellers in Chhattisgarh: An Exploratory Study


Medical Consultant, Catholic Health Association of India (CHAI), Chhattisgarh, India

Date of Web Publication3-Jan-2018

Correspondence Address:
Janmejaya Samal
C/O Bijaya Ketan Samal, Panasapalli, Bangarada, Gangapur, Ganjam, 761123, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.217316

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  Abstract 


Background: Health seeking behavior for tuberculosis (TB) among Indian population varies greatly with different indicators like habitation, gender, socioeconomic status, and literacy. Studies reveal that a substantial portion of Indian population seeks medical care at private health facilities, despite TB being a centrally sponsored program. Objective: The main objective of this study was to assess the health seeking behavior for TB among the slum dwellers in Chhattisgarh, India. Materials and Methods: A cross-sectional study was carried out using a structured questionnaire to collect information regarding the preference of health facilities and reasons for not approaching government health facility for TB care among 100 households in a slum area in Chhattisgarh. Results: Of the 100 families, 25, 69, 01, and 05% of the families reported to approach private practitioners, government health facilities, traditional practitioners, and adopt self-medication, respectively, for common health problems. Similarly, of 100 families, 44, 54, 01, and 01% families reported to approach private practitioners, government health facilities, traditional practitioners, and adopt self-medication, respectively, for TB care. In addition, several factors were identified for not approaching the government health facilities for TB care. Of 100 households, 13, 01, 20, 19, and 25% households, respectively, reported the following factors “there is long queue in govt. hospital, the Govt. medicines are not of good quality, in Govt. hospital nobody takes care of us, there is no communication facility, my home is far away from Govt. health facility.” In addition, 21% households reported to accept government health facility for TB care. Conclusion: As a centrally sponsored program, TB care in India is free of cost and quality in diagnosis, and treatment is assured. Thus, communities should be mobilized to access TB care at public health facilities to prevent poverty trap, and other problems owing to private sector TB care.

Keywords: Government health facility, health seeking behavior, private health facility, slum dwellers


How to cite this article:
Samal J. Preferred Healthcare Destination for Tuberculosis Care among the Slum Dwellers in Chhattisgarh: An Exploratory Study. J Assoc Chest Physicians 2018;6:12-6

How to cite this URL:
Samal J. Preferred Healthcare Destination for Tuberculosis Care among the Slum Dwellers in Chhattisgarh: An Exploratory Study. J Assoc Chest Physicians [serial online] 2018 [cited 2018 Jun 22];6:12-6. Available from: http://www.jacpjournal.org/text.asp?2018/6/1/12/217316




  Introduction Top


The scourge of tuberculosis (TB) is a global public health crisis. It was ranked at seventh position by the WHO’s 1990 global disease burden report which is further expected to continue till 2020 in terms of morbidity.[1] TB continues to be a distressing health crisis with more than 0.3 million deaths and 2.2 million new cases in India. The economic damage due to TB in India is enormous which is around $23 bn (£14.9 bn; €20.3 bn) each year.[2] Revised National TB Control Program (RNTCP) is the Government of India’s flagship TB control program to control TB at community level. The main objective of this program is 85% cure rate and 70% case detection rate. India has already achieved this global target of cure rate and case detection rate since 2007. Furthermore, RNTCP has 100% coverage rate under Directly Observed Treatment Short course (DOTS). Despite this, the scourge of TB continues as it is owing to multiple factors.[3] One of the major bottlenecks of RNTCP is its passive case finding approach,[4] which is strongly linked with health seeking behavior and related delays in TB treatment.[5] Health seeking behavior refers to the help seeking attitude of the patients to choose a healthcare destination and the time of seeking help as per their own wish. The health seeking behavior of patients is strongly linked with the knowledge of the patients and their family members regarding a particular health problem, as in this case TB. Studies carried out in India regarding the awareness of TB control program shows poor knowledge among the families.[6],[7],[8],[9] Of 200 patients interviewed regarding their awareness about TB control program at P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India revealed that only 30 (15%) of the study participants are aware of TB control program.[6] Moreover, a significant delay in seeking help is observed among TB patients in India. Studies reveal that the mean patient delay in seeking care ranges from 25 to 120 days[7] and that the patients meet several healthcare providers before getting diagnosed and initiated with TB treatment.[8],[9] Given this context a cross-sectional study was conducted among the slum dwellers (families) in Chhattisgarh to assess their preferred health facilities for TB care along with the factors for not seeking TB care at public health facilities.


  Objective Top


The main objective of this study was to assess the health seeking behavior along with the factors for not approaching the public health facilities for TB care among the slum dwellers in Chhattisgarh, India.


  Materials and methods Top


A cross-sectional study was carried out by using a structured questionnaire to collect the information regarding the preference of health facilities and health seeking behavior among the slum dwellers in Chhattisgarh. The Hindi version of this questionnaire was used for the purpose of the study as the same is the vernacular language in the study area. The data analysis was carried out in Statistical Package of Social Sciences (SPSS), version 16 (SPSS Inc., Chicago, IL), for windows. Verbal informed consent was obtained from the study participants for the purpose of this study. In this study, for the purpose of analysis, one household/family is treated as one unit, and one response was accepted to a particular question. As the entire family was treated as one unit, the response was captured from all the family members (whoever voluntarily responded) present at the time of data collection.

Sampling frame and technique

Simple random sampling technique was used to obtain the desired number of 100 households in two different slums in Durg district of Chhattisgarh. The selected area was initially looked in to for the feasibility of the study in terms of number of households, and then a list of 100 households was obtained as per serial numbers from one end to the other from each of these two sites; Bajranganagar and Khursipar. These numbers were written in small pieces of papers and kept in two different bowls and named as Bajranganagar and Ghasidasnagar. From each of these two bowls, 50 chits were picked up and kept separately for each of these two sites which finally formed the sample of this study. [Figure 1] describes the sampling technique used in this study.
Figure 1: Sampling technique

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Study implementation strategy

The first question was asked to assess the health seeking behavior and choice of health facilities among the slum dwellers for general illness. The question used to assess this behavior was − where do you seek treatment when you fall sick? The question contained four multiple options: private practitioner, government health facility, traditional healer, and self-medication, or over-the-counter purchase of medicine. [Figure 2] describes the health seeking behavior and preference of health facilities among slum dwellers for common health problems.
Figure 2: Health seeking behavior/health facility preference for common health problems

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The second question assessed the health seeking behavior and the health facility preference of slum dwellers for TB. [Figure 3] describes the preference of health facilities (%) among the slum dwellers in Chhattisgarh. The question used to assess this behavior was – What will you do if someone in your family/neighborhood develops TB symptoms? The question contained following multiple options: private practitioner, government health facility, traditional healer, and self-medication, or over-the-counter purchase of medicine.
Figure 3: Health seeking behavior/health facility preference for TB

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The third question was asked to understand the factors behind not approaching government health facilities for TB care despite the free availability of services at government health facilities. The question used to assess this behavior was – Why should you not visit government health facility as TB treatment is free of cost? The question contained following options: my home is far away from government health facility, there is no communication facility, in government, hospital nobody takes care of us, the government medicines are not of good quality, there is long queue in government hospitals, government staff ask money for treatment, the treatment duration is long in government hospital, and any other reason and ready to accept government health services.


  Results Top


Three different questions were asked to assess the health seeking behavior and preference of health facilities along with the factors for not approaching public health facilities for TB care among the slum dwellers in Chhattisgarh. [Figure 2] explains the health facility preference for common health problems, [Figure 3] explains the health facility preference for TB, and [Figure 4] explains the factors for not approaching government health facility for TB care.
Figure 4: Factors for not approaching government health facility for TB care

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  Discussion Top


The study identified the preferred health facility options in case of general illness and TB as depicted in [Figure 3]. In addition, the study also identified the factors behind not accessing the government health facility for TB care despite TB services being freely available in public health facilities. In case of general illnesses, the slum dwellers preferred to opt for a public health facility to seek help which is around 69%, whereas the help seeking for TB care did not really make a great difference as the public and private options are 54% and 44%, respectively, among the slum dwellers. Similar results were obtained in a study conducted among 73,249 households spanning 30 districts in India. The study found that of 371,174 household members 761 TB patients were identified and data on 609 TB patients were obtained. Of these 609 TB patients, 331 (54%) are in DOTS/RNTCP regimen and the rest 278 (46%) were taking treatment from non-RNTCP sources.[10] Similarly, a study conducted in the tribal pockets of Thane district reported that TB patients were more likely to seek care from private practitioners and traditional providers as compared with government health facilities. The same study compared the health seeking behavior for TB and Leprosy, and observed that three-fourth and one-third of patients, respectively, preferred public health facility.[11] The study conducted in the urban slums of Aurangabad city among 105 chest symptomatic reported that 51.4% (n = 105) visited private health facilities, and 23.8% preferred government health facilities. Moreover, 24.76% did not visit any health facility of which 12.4% had indulged in self-medication which was higher among the age group of 35 to 54.[12] The study conducted among 156 TB patients in the E-ward of Mumbai Municipal Corporation reported to prefer private practitioners and self-medication.[13] The cross-sectional study conducted among 601 TB patients in Tamil Nadu revealed that the first point of contact was a government provider for 47% and a private provider for 43% of the respondents. Faith in the provider (87/262, 33%) and proximity to the practitioner (63/262, 24%) was the main reason offered by the participants when asked about preferring private health facilities in place of government health facilities. Similarly, community advice (72/280, 26%) was the main reason for approaching the government health facility among the study participants.[14] The cross-sectional study conducted in Wardha among 189 TB patients revealed that 85% of all patients were treated at government health facilities and the remainder by nongovernmental organizations.[15] The hospital-based cross-sectional study conducted among 656 chest symptomatic at RIMS, Ranchi revealed that 52.29, 23.47, and 24.24% of study participants approached government health facilities, qualified, and unqualified private practitioners, respectively.[16] In the current study, both these questions also tried to understand the self-medication or over-the-counter purchase of medicine habit and help seeking behavior at traditional practitioners among the slum dwellers. The results obtained in both these instances are substantially low and in case of general illness it accounted to 5% for self-medication. This is true in Indian communities that for a common ailment everybody initially tries to behave as a self-doctor and buy medicines over-the-counter with or without the advice of the drug store keeper.

It is clearly evident from the current study and the above studies that a substantial portion of TB symptomatic preferred private health facilities for seeking care for TB. In some instances, the preference for private health facilities for TB care is more compared to public health facilities. There are two important facets emerging out of this situation; the people are not aware of freely available TB services in government health facility or have an over reliance on private health facilities owing to several reasons.

In the third question, an effort was made to unravel the factors behind not approaching a government health facility for TB care. It was found that 21% of the households were ready to accept the public health facility for TB care, whereas other families reported several factors for not approaching public health facility as depicted in [Figure 4]. Several studies have also identified similar factors for not approaching or delaying seeking help at the government health facilities. The factors such as dissatisfaction with government health facility,[12],[17] lack of transport,[12],[14] long distance,[18] difficulty in accessing health facility,[14],[16] and fear of government tertiary care health facility[19] are the common factors for not availing public health facilities for TB care in India. Some of these problems can be resolved with proper health education; however, others need strong persuasion on the part of a beneficiary as long distance can be covered by taking some public transport system. However, people do not do that as they feel they can avail similar services in a nearby private health facility. Similarly, inaccessibility and other factors like “long queue, nobody takes care of at Govt. health facility and Govt. medicines are of not good quality” require health education at both the provider and receivers’ end.


  Conclusion Top


Despite the freely available health services at public health facilities for TB care, people do seek medical care at private health facilities as per different studies. People definitely exhibit a strong preference for private health facilities owing to several of the factors. Studies also reveal that the TB treatment and diagnostic services provided at private health facilities remain substandard which ultimately lead to Multi Drug Resistant/Extremely Drug Resistant Tuberculosis (MDR/XDR-TB). It is further evident that the consumption of anti-TB drugs is more in private sector as compared with public health facilities which pushes a major section of the community to impoverishment. Thus, it is important that the people should be aware of freely available public health facilities for TB and should avail the quality diagnostic and treatment services free of cost, and thereby creating a TB free society in their own vicinity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lopez AD, Murray CJ, editors. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Boston: Harvard School of Public Health; 1996.  Back to cited text no. 1
    
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Udwadia ZF, Mehra C. Tuberculosis in India. BMJ 2015;350:h1080.  Back to cited text no. 2
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TBC India. Directorate General of Health Services, Ministry of Health and Family Welfare. New Delhi: Govt. of India; 2014. Retrieved from: http://www.tbcindia.nic.in. (Last accessed on 25 September 2016)  Back to cited text no. 3
    
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Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: A systematic review. Int J Tuberc Lung Dis 2014;18:255-66.  Back to cited text no. 4
    
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Pinto LM, Udwadia ZF. Private patient perceptions about a public programme; what do private Indian tuberculosis patients really feel about directly observed treatment?. BMC Public Health 2010;10:357.  Back to cited text no. 6
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Selvam JM, Wares F, Perumal M, Gopi PG, Sudha G, Chandrasekaran V et al. Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003. Int J Tuberc Lung Dis 2007;11:161-7.  Back to cited text no. 9
    
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Satyanarayana S, Nair SA, Chadha SS, Shivashankar R, Sharma G, Yadav S et al. From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts. PLoS One 2011;6:e24160.  Back to cited text no. 10
    
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Maske AP, Sawant PA, Joseph S, Mahajan US, Kudale AM. Socio-cultural features and help-seeking preferences for leprosy and TB: A cultural epidemiological study in a tribal district of Maharashtra, India. Infect Dis Poverty 2015;4:1-14.  Back to cited text no. 11
    
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Karanjekar VD, Gujarathi VV, Lokare PO. Socio demographic factors associated with health seeking behavior of chest symptomatics in urban slums of Aurangabad city, India. Int J App Basic Med Res 2014;4:173-9.  Back to cited text no. 12
    
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Kulkarni PY, Kulkarni AD, Akarte SV, Bhawalkar JS, Khedkar DT. Treatment seeking behavior and related delays by pulmonary TB patients in E-ward of Mumbai Municipal Corporation, India. Int J Med Public Health 2013;3:286-92.  Back to cited text no. 13
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Selvam JM, Wares F, Perumal M, Gopi PG, Sudha G, Chandrasekaran V et al. Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003. Int J Tuberc Lung Dis 2007;11:161-7.  Back to cited text no. 14
    
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Nimbarte SB, Wagh V, Selokar D. Health seeking behaviour among pulmonary TB patients in rural part of central India. Int J Biol Med Res 2011;2:394-7.  Back to cited text no. 15
    
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Jayachandran V. A case study on TB treatment defaulters in Delhi: Weak health links of the community with the public sector, unsupported migrants and some misconceptions. Ann Trop Med Public Health 2014;7:124-29.  Back to cited text no. 19
  [Full text]  


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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