Utilization of and barriers to public sector tuberculosis services in India.
BACKGROUND
Tuberculosis control in India still faces many challenges related to the provision of services under the Directly Observed Treatment, Short-course (DOTS) strategy. We assessed the utilization of and barriers to the Revised National Tuberculosis Control Programme (RNTCP) services based on DOTS in 4 states of India, and recommend actions to optimize utilization of the RNTCP services.


METHODS
Two districts each in 4 states with more than 50% of the population covered under the RNTCP in 2002, representing diverse levels of general health indicators, were selected. Sex-disaggregated data on patients who reported to the RNTCP facilities for the diagnosis and treatment of tuberculosis in 2002 were reviewed from the laboratory and tuberculosis registers to assess the utilization of these services. Data on barriers to utilization of the RNTCP services were collected through interviews of 4310 patients with tuberculosis who were 16 years of age or older.


RESULTS
A total of 83,099 patients had reported for the diagnosis of tuberculosis in the study areas, of whom 29,279 were women (35.2%). The proportion of sputum-positive diagnosis was lower in women (10.8% [95% CI 10.5%-11.1%]) than men (17% [95% CI 16.7%-17.3%]). For the treatment of tuberculosis, 21592 patients were registered in the study areas; 6789 were women (31.4%). Among new smear-positive tuberculosis patients, 79.9% of women (95% CI 78.4%-81.4%) and 74.4% of men (95% CI 73.4%-75.4%) were cured. Multivariate analysis revealed that the odds of not completing the process of diagnosis of tuberculosis were significantly higher for patients > 50 years of age, those who were never married or married currently, those with symptoms for < or = 15 days, those who had gone alone for diagnosis, and those who were not informed about a suspicion of tuberculosis by the health personnel at the time of diagnosis. Among the reasons for not completing the process of diagnosis of tuberculosis, health provider-related barriers were cited most frequently (45.9%), followed by improvement in symptoms. Health provider-related barriers were also cited most frequently (40.4%) by those who had completed the process of diagnosis but did not start treatment in the RNTCP facility. On multivariate analysis, the odds of not completing the treatment of tuberculosis were significantly higher for men, those who were ever married, those who were not informed that tuberculosis was curable, those who were not informed of the duration of treatment at the time of starting treatment, those who were dissatisfied with the DOTS provider, and those who had health facility staff as the DOTS provider compared with those who had an anganwadi/health worker. Medicine-related barriers were cited most frequently by patients who had defaulted in the intensive (37.1%) or continuation (23.1%) phase of treatment.


CONCLUSIONS
Of the persons utilizing the RNTCP services, about one-third are women. The health services-related factors indicated in the multivariate analysis for less than optimal utilization of the RNTCP services, and the health provider-related and treatment-related barriers to utilization of the RNTCP services at various levels cited by the patients suggest the need to adopt a patient-centred approach to improve utilization of the RNTCP services.
Dandona
Rakhi
R
Administrative Staff College of India, Hyderabad, Andhra Pradesh 500082, India. rakhi@asci.org.in
Dandona
Lalit
L
Mishra
Ashish
A
Dhingra
Saroj
S
Venkatagopalakrishna
K
K
Chauhan
L S
LS
D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000008:administration & dosage; D003140:Communicable Disease Control / Q000458:organization & administration*; D003153:Community Health Services / Q000706:statistics & numerical data*; D023801:Directly Observed Therapy; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009313:National Health Programs; D017150:Public Sector; D014376:Tuberculosis / Q000453:epidemiology / Q000517:prevention & control*
D000995:Antitubercular Agents