title: "They know, they agree, but they don't do"--the paradox of tuberculosis case notification by private practitioners in Alappuzha district, Kerala, India.
abstract: BACKGROUND
  Despite being a recognized standard of tuberculosis (TB) care internationally, mandatory TB case notification brings forth challenges from the private sector. Only three TB cases were notified in 2013 by private practitioners compared to 2000 TB cases notified yearly from the public sector in Alappuzha district. The study objective was to explore the knowledge, opinion and barriers regarding TB Notification among private practitioners offering TB services in Alappuzha, Kerala state, India.
  
  
  RESULTS
  This was a mixed-methods study with quantitative (survey) and qualitative components conducted between December 2013 and July 2014. The survey, using a structured questionnaire, among 169 private practitioners revealed that 88% were aware of mandatory notification. All patient-related details requested in the notification form (except government-issued identification number) were perceived to be important and easy to provide by more than 80% of practitioners. While more than 95% felt that notification should be mandatory, punitive action in case of failure to notify was considered unnecessary by almost two third. General practitioners (98%) were more likely to be aware of notification than specialists (84 %). (P<0.01). Qualitative purposive personal interviews (n=34) were carried out among private practitioners and public health providers. On thematic framework analysis of the responses, barriers to TB notification were grouped into three themes: 'private provider misconceptions about notification', 'patient confidentiality, and stigma and discrimination 'and 'lack of cohesion and coordination between public and private sector'. Private practitioners did not consider it necessary to notify TB cases treated with daily regimen.
  
  
  CONCLUSIONS
  Communication strategies like training, timely dissemination of information of policy changes and one-to-one dialogue with private practitioners to dispel misconceptions may enhance TB notification. Trust building strategies like providing feedback about referred cases from private sector, health personnel visit or a liaison private doctor may ensure compliance to public health activities.
authors.affiliation: Government T.D. Medical College, Alappuzha, Kerala State, India.
authors.forename: Sairu
authors.initials: S
authors.lastname: Philip
authors.affiliation: Operational Research Unit, Médecins Sans Frontières, India.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
authors.affiliation: International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.
authors.forename: Karuna D
authors.initials: KD
authors.lastname: Sagili
authors.affiliation: Government T.D. Medical College, Alappuzha, Kerala State, India.
authors.forename: Asanarupillai
authors.initials: A
authors.lastname: Meharunnisa
authors.affiliation: State TB Training and Demonstration Centre, State TB Cell, Directorate of Health Services, Thiruvananthapuram, Kerala, India.
authors.forename: Sunilkumar
authors.initials: S
authors.lastname: Mrithyunjayan
authors.affiliation: International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.
authors.forename: Ajay M V
authors.initials: AM
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D018563:Disease Notification / Q000706:statistics & numerical data*; D005260:Female; D058005:General Practitioners / Q000706:statistics & numerical data*; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D011331:Private Practice / Q000706:statistics & numerical data*; D011361:Professional Competence; D036301:Qualitative Research; D011795:Surveys and Questionnaires; D014376:Tuberculosis / Q000453:epidemiology*; D055815:Young Adult