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TÀI LIỆU TRẮC NGHIỆM, BÀI GIẢNG PPT CÁC MÔN CHUYÊN NGÀNH Y DƯỢC HAY NHẤT CÓ TẠI “TÀI LIỆU NGÀNH Y DƯỢC HAY NHẤT” ;https://123doc.net/users/home/user_home.php?use_id=7046916. TÀI LIỆU LUẬN VĂN – BÁO CÁO – TIỂU LUẬN (NGÀNH Y DƯỢC). DÀNH CHO SINH VIÊN CÁC TRƯỜNG ĐẠI HỌC CHUYÊN NGÀNH Y DƯỢC VÀ CÁC NGÀNH KHÁC, GIÚP SINH VIÊN HỆ THỐNG, ÔN TẬP VÀ HỌC TỐT KHI HỌC TÀI LIỆU LUẬN VĂN – BÁO CÁO – TIỂU LUẬN (NGÀNH Y DƯỢC)
1 BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH DEPARTMENT OF INTERNATIONAL HEALTH CONCENTRATION PAPER COVER PAGE Name: Concentration Paper Title: MANAGEMENT OF PULMONARY TUBERCULOSIS IN THE PRIVATE HEALTH SECTOR OF PAKISTAN Abstract: WHO ranks Pakistan 6th among the 23 high burden TB countries Based on a total population of 152 million, estimated incidence rate of all TB cases in Pakistan is 177/100,000-population Tuberculosis control in Pakistan is primarily the responsibility of the government sector, which has been neglected for years Due to flaws in the governmental health infrastructure in Pakistan, a large number of tuberculosis (TB) patients in both rural and urban areas visit private clinics run by general practitioners and consultants Due to a personal interest in how TB is treated, I undertook a study of knowledge, attitude, and practices (KAP) of private medical practitioners, along with TB patients and pharmacists selling TB drugs in the Federal Capital of Pakistan and its neighboring city (i.e Islamabad and Rawalpindi) The study reflects the tip of an iceberg of weaknesses in the private health sector in controlling and treating tuberculosis by examining the linkages between private physicians, pharmacies and TB patients This paper is intended to help policy makers in health systems, health officials, faculty in medical institutes, non-governmental organizations and health care providers in developing countries to understand the reasons for the poor private sector treatment of TB Donor agencies dealing with TB control and high level officials of the WHO TB Control program in Geneva will find this paper beneficial for promoting similar studies on a bigger level TABLE OF CONTENTS Introduction Literature Review Survey Methodology Survey Results a Survey of Private Medical Practitioners b Survey of Pharmacies c Survey of Patients Discussion Recommendations Conclusion References Survey Result Tables 10 Annex (A/B/C) INTRODUCTION TB is the leading infectious cause of death worldwide Almost two billion people are infected around the globe (1), with 49% of the TB cases in Southeast Asia Approximately 2.5 million people die each year of TB, while 95 % of deaths occur in developing countries (2) WHO ranks Pakistan 6th among the 23 high burden TB countries Based on a total population of 152 million, estimated incidence rate of all TB cases in Pakistan is 177/100,000-population (3) The majority of 74,229 registered doctors in Pakistan tend to practice in the urban areas (4, 5) Due to a poorly managed government health infrastructure in Pakistan, a large number of TB patients in both rural and urban areas visit private clinics run by general practitioners and consultants Among the handful of studies done in Pakistan, 36 patients were interviewed in depth who were attending TB clinics in rural areas of Islamabad to determine the effects of TB on their private lives (6) One of the findings showed that patients’ knowledge about their disease was minimal, and these patients initially went to private practitioners, who gave incorrect or limited health education and prescribed faulty treatment regimens Another study done in the Indian State of Maharashtra found that many private doctors prescribe wrong TB drugs (7) Due to a personal interest in how TB is treated in Pakistan, I undertook a similar study of knowledge, attitude, and practices (KAP) of private medical practitioners, along with TB patients and pharmacists selling TB drugs in the Federal Capital of Pakistan and its neighboring city (i.e Islamabad and Rawalpindi) The study reflects the tip of an iceberg of weaknesses in the private health sector in controlling and treating tuberculosis by examining the linkages between private physicians, pharmacies and TB patients Tuberculosis control in Pakistan is primarily the responsibility of the government sector, which has been neglected for years Treatment completion is low as patients are burdened with poverty and come from all walks of life (8), the majority being unmarried women, housewives, and daily wage laborers The National TB Programme has adopted DOTS as their main course of action, but requires guidance on types of treatment according to the local conditions (8) A randomized clinical trial at three sites in Pakistan to assess effectiveness of different packages for TB treatment under the operational conditions proposed by the National TB Control Programme showed that the cure rates for various treatment strategies were between 62% to 67% as compared to the WHO guidelines (8) The pharmaceutical industry plays an important role regarding choice of medicines by doctors in the private and public health sectors through the use of various incentives These pharmaceutical giants also arrange educational seminars for doctors to update them about various treatment strategies This paper is intended to help policy makers in health systems, health officials, faculty in medical institutes, non-governmental organizations and health care providers in developing countries to understand the reasons for the poor private sector treatment of TB Donor agencies dealing with TB control and high level officials of the WHO TB Control program in Geneva will find this paper beneficial for promoting similar studies on a bigger level LITERATURE REVIEW The purpose of the literature review was to find a correlation between poor private sector treatment of TB in developing countries Prevalence: TB infects almost one-third of the world population (1) Of those aged over years, TB kills more people than AIDS and all other tropical diseases combined (9) Ninety million new cases of TB were expected to occur worldwide during 1990-1999 The incidence of TB is likely to increase to 11.9 million cases annually by 2005 (2) Due to inadequacy of disease surveillance in the majority of countries the exact data on incidence and mortality of TB cannot be projected accurately (2) In 1993, WHO declared TB a global emergency (9) From 1994-1997 the global surveillance for anti-tuberculosis drug resistance by WHO found drug resistance in 35 countries During the current age of air travel, this problem could threaten the US as well (1) The developing world hosts 95% of the eight million cases of TB reported annually Of these, million receive some treatment, while only 0.5 million receive curative DOTS (10) WHO has warned that the annual number of deaths by 2004 could go up to million a year (9) Economic Impact: Even though an effective cure has been available for 40 years, the number of people dying each year keeps on increasing The economic impact affects both the developed and the developing countries The budget of the Bureau of TB Control of New York City Department of Health increased from $4 million to $ 40 million between 1988 and 1994 (11) In a study done in India to assess the socioeconomic impact of TB, over 300 patients were interviewed (12) It was seen that mean total cost of treatment projected for a six-month course was $171, while the average period of loss of wages was months This shows the extent of burden TB patients and their families face in developing nations Treatment Strategies: Two strategies proposed by different clinicians for improving TB treatment are DOTS and re-education of private physicians for prescribing proper treatment for TB patients (1) The importance of DOTS in the US and U.K is clear as it can be enforced by a court order for non-compliant patients in both countries Incentives of free food, clothes, transportation tokens and even financial assistance have been used to implement DOTS (11) It should be noted that the main cause of failure of TB control is the fault of the health practitioner, therefore WHO strongly emphasizes use of DOTS (9) It has been documented that fixed dose combinations (FDC) of TB drugs led to simplified treatment, better compliance, limited prescription mistakes and reduced chances of monotherapy The combined effect can in theory limit the risk of multi-drug resistant TB (13) Diagnostic Tools for TB include clinical examination, sputum microscopy (specific/limited sensitivity), chest radiology (sensitive/nonspecific) and culture (sensitive/long term) WHO has recommended that data collection for TB cases should be backed by laboratory confirmed pulmonary cases (3) Low Treatment Knowledge & Faulty Prescription Practices of Doctors: It was kept in mind during the review that the health care and medical education system in India and Pakistan are similar to each other i.e., British based Reviewing studies for evaluating TB treatment in the private health sector in India indicated a similar scenario of faulty prescription practices Five hundred thousand Indians die from TB every year A 50% default rate in treatment points towards the non-effectiveness of the National TB Control Program (14) The Indian Health Ministry TB Control program reports 1.5 million cases of TB every year with a mortality of 1200 patients per day (15) A study done in Maharashtra revealed 71 faulty prescriptions among 100 doctors who had a post-graduate degree Over three-quarters of the million registered doctors in India are working in private practice Studies indicate gaps and weaknesses in the private doctors’ practice of managing TB (15) A knowledge, attitude and practice (KAP) study comprised of 40 residents and faculty members from various departments prescribing TB treatment was done in a medical institution in India (16) Only 50% of doctors gave correct doses in prescriptions and < 50% knew what DOTS was The authors of the paper suggested that the faculty members should be re-educated regarding recent guidelines and trends if knowledge was to percolate to the periphery (16) In a study done in Mumbai (India), it was found that 100 private practitioners prescribed 80 different regimens of anti-tuberculosis treatment, most of which were inappropriate and expensive (17) A study in Maharashtra tried to look at TB management among 122 private practitioners and the treatment behavior of 173 patients The results indicated that 79 different prescriptions were given out (18) The treatment of TB is not possible without re-educating prospective and practicing clinicians around the world (1) One effective method to fight discrepancies in prescription practices by private practitioners would be to remove all single formulations of TB drugs from the open market and permit only fixed dose combinations to be sold (19) Patient Behavior: Private medical practitioners play a vital role in TB control in Southeast Asia In Hong Kong, 159 patients with smear positive and 187 with smear negative TB, attending Government chest clinics were interviewed, of them 86% initially went to a private practitioner (20) Another study in Hong Kong included 201 smear positive and 199 smear negative TB patients The results of the study showed that a private practitioner was the initial choice for 53% of these patients (21) In Vietnam, a retrospective survey of 801 TB patients in District TB Units was carried out to assess utilization of private and public health care providers for TB symptoms Half of the patients initially went to a private practitioner (22) Most TB patients in urban and rural parts of India initially go to doctors in the private sector (15) It is estimated that there are 10 million TB patients in India who prefer to visit a private health practitioner after working hours and pay them as little as 10 rupees for a checkup (23) A study done in Maharashtra indicated that 86% of TB patients go to private doctors for their first source of treatment, while the treatment adherence rate among these patients was 59% (18) A NGO in Mumbai studied the healthseeking behavior of poor male and female TB patients Results indicated that during the first two months of symptoms the patients took home remedies and then proceeded to visit private practitioners who were generally unable to diagnose the disease (24) Role of Pharmacies: In most parts of the world it is very common for TB treatment to be self- administered (19) Untrained healers and patients often misuse TB medications, as they are available for sale over the counter (19) At the onset of initial symptoms, people tend to self prescribe drugs, rather than go to a doctor (19) A study pointing towards anti TB treatment in 50 private pharmacies in Nepal suggested that 65% of pharmacies had sold anti TB drugs during the last month Eighty eight percent said that only 16% patients returned to buy the full course of drugs Thirty percent of pharmacies had no doctors attached to them (25) A study conducted by a Government Medical College in India showed that 31% of the people interviewed practiced self-medication for their illness (26) A cross sectional study done in Karachi, Pakistan involving 158 households showed that medicines were self prescribed by 51.3% of the sample population for various ailments (27) Based on this literature review, a study was undertaken in Pakistan to investigate the KAP of private medical practitioners, pharmacists and TB patients to assess the reasons for poor private sector treatment of TB 10 Survey Methodology Three different types of surveys were designed These consisted of an equal number of private doctors, private pharmacies and TB patients who at one time visited a private health practitioner for their checkup a Survey of Private Medical Practitioners (Annex 1- A): Thirty private practitioners were randomly selected by convenience in two adjoining cities An equal number of general practitioners (GP) and specialists were selected Each survey had 26 questions, which contained observations combined with qualitative and quantitative responses These questions range from characteristics of practitioners, patient interaction, knowledge of diagnostic criteria and diagnostic procedures followed, prescription practices, knowledge of causes of TB and information/advice provided to patients In certain cases the doctors filled in the answers to the questions themselves rather than replying to the questions verbally b Survey of Pharmacies (Annex – B): Thirty private pharmacies were randomly selected by convenience Each survey had 20 questions involving qualitative and quantitative responses Questions asked included characteristics of pharmacies, turnover of TB medicines and their cost, knowledge held by pharmacy owners about TB, willingness to provide TB treatment on their own, knowledge about DOTS and supervising treatment of a TB patient c Survey of Patients (Annex – C): Thirty TB patients were randomly selected by convenience from medical clinics and government hospitals around two adjoining cities These patients at one time of their TB disease had visited a private medical practitioner Thirty questions were asked which included patient characteristics, duration of symptoms, time interval between onset of symptoms and visit to doctor, followed by diagnosis time Further questions revolved around cost of treatment, name/number and duration of drugs 26 21.Allan WG, Girling DJ, Fayers PM, Fox W The symptoms of newly diagnosed pulmonary tuberculosis and patients’ attitudes to the disease and to its treatment in Hong Kong Tubercle 1979; 60(4): 211-223 22.Lonroth K, Thuong LM, Linh PD, Diwan VK Utilization of private and public health-care providers for tuberculosis symptoms in Ho Chi Minh City, Vietnam Health Policy & Planning 2001; 16(1): 47-54 23.Kumar M, Kumar S Tuberculosis control in India: role of private doctors The Lancet 1997; 350(9087): 1329-1330 24.Nair DM, George A, Chacko KT Tuberculosis in Mumbai: new insights from poor urban patients Health Policy & Planning 1997; 12(1): 77-85 25.Hurtig AK, Pande SB, Baral SC, Porter JD, Bam DS Anti-tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal International Journal of Tuberculosis & Lung Disease 2000; 4(8): 730-736 26.Deshpande SG, Tiwari R Self medication – a growing concern Indian Journal of Medical Sciences 1997; 51(3): 93-6 27.Haider S, Thaver IH Self-medication or self-care: implication for primary health care strategies Journal of the Pakistan Medical Association 1995; 45(11): 297-298 28.Madden J, Kafle K, Shrestha A Can licensed drug sellers contribute to safe motherhood? A survey of the treatment of pregnancy related anemia in Nepal Social Science & Medicine 1996; 42(11); 1577-1588 27 SURVEY RESULT TABLES Qualification of Doctors Highest Degree Held Number of Doctors MBBS 12 FCPS 12 MRCP MD MCPS FRCP FRCS Total 30 Location of Clinic Where 1= Poorest areas and 5= Affluent/Rich areas Location of Clinic Number of Doctors 3 5 11 Total 30 Facilities Offered at Clinic Facilities Offered 1= Only consultation given with minimal medical equipment, e.g B.P apparatus, thermometer, Number of Doctors 28 weighing scale, etc., 2= + minimal laboratory facilities 3= + advanced lab Facilities, x-ray plant, endoscope, etc 12 4= + pharmacy in the compound 5= + inpatient admission facilities (private hospital) Total 30 Diagnostic Criteria Followed Symptoms Number of Doctors Responded Chronic Cough 25 Fever 23 Weight Loss 13 Night Sweats Malaise Productive Cough Other Responses (Including Haemoptysis, History/Clinical Examination, Weakness, Loose Motions, and Chest Pain) Diagnostic Criteria Followed Signs Number of Doctors Responded Crepts on Auscultation 10 Toxic Look/ Ill Looking 29 Cervical Lymph Node Enlargement Weakness Congestion Other Responses (Including Bronchial Breathing, Effusion, Pallor, Pigmentation, Weight loss, Productive Cough, Consolidation, Fever, Haemoptysis, and Red Eyes) 25 Diagnostic Criteria Followed Lab Tests Number of Doctors Responded Chest X-Ray 26 Blood Complete Picture (CP) 21 Sputum Culture/Sensitivity 14 Mantoux Test Erythrocyte Sedimentation Rate (ESR) Diagnostic Criteria Followed Special Tests Number of Doctors Responded Micro Dot/ Anti Dot 14 Acid Fast Bacilli (AFB) 11 Sputum Culture/Sensitivity Other Responses (Including Mantoux Test, Pulmonary Function Test, and DNA Analysis) 30 Method of Confirmation of TB Elimination Method Used Number of Doctors Responded Chest X-Ray 27 Sputum Culture/Sensitivity 17 Blood Complete Picture (CP) 12 Other Responses (Including Erythrocyte Sedimentation Rate (ESR), Mantoux Test, Acid Fast Bacilli, Lymph Node Biopsy, Weight Gain, Fever Settlement, and Appetite Return) 31 Information Provided to Patients by Doctor Method of Taking Drugs Number of Doctors Responded Before Breakfast 21 Other Responses (Including After Breakfast, Oral Treatment, Empty Stomach, As Written per Drug, Regularly Take Medicine, and Not Known) 10.Information Provided to Patients by Doctor Adverse Effects Number of Doctors Responded Orange Urine 11 Jaundice/Hepatitis Other Responses (Including Nausea/Vomiting, Orange Sweat/Stools, Remove Contact Lenses, Red Yes, Hearing Defects, Liver Disease, Visual Loss, Weight Loss, No Clear Response and Did Not Know) 22 32 11.Information Provided to Patients by Doctor Precautions Number of Doctors Responded Avoid Physical Contact Gastrointestinal Discomfort/Problem Yellow Eyes Open Environment Other Responses (Including High Fever, Gout, Vision Loss, Jaundice, Vomiting, Complete Course, Regular Checkup, Avoid Fried Meat, Separate Utensils, Did Not Respond and Not Known) 21 12.Preference of TB Patients Cost of TB Treatment Length of Treatment Low/Short 23 21 No Preference 13.Level of Knowledge Held by TB Patients None Low Medium High TB as a Disease 16 Treatment 15 Outcome 15 14.Reason for Referral of TB Patients to a TB Specialist Reasons Number of Doctors 33 Responded Non-Affording Patient End Stage None Yet Other Responses (Including No Response to Treatment, Low Compliance, Complications, MDRTB, and Not Responded) 12 15.Correctness of Treatment No Replie s Intensive Phase Over Treated Under Treate d General Practition ers Total Continuation Phase Perfect Over Unde Treatm Treat r ent ed Treat ed 4 Perfect Treatm ent 34 No Replie s Intensive Phase Over Treated Under Treate d Local Qualified Consultan ts Total Continuation Phase Perfect Over Unde Treatm Treat r ent ed Treat ed Perfect Treatm ent No Replie s Intensive Phase Over Treated Under Treate d Foreign Qualified Consultan ts Total Continuation Phase Perfect Over Unde Treatm Treat r ent ed Treat ed Perfect Treatm ent 35 16.Location of Pharmacy Where 1= Poorest locality and 5= Upper Class areas Location of Pharmacy Number of Respondents 6 5 Total 30 17.TB Treatment Provided to Patients if asked by TB Patients Poor Patients Rich Patients Resistant Cases Pharmacy Myrin P, Pyrazinamide, Rifampacin Myrin P, Pyrazinamide, Rifampacin No Idea Pharmacy Myrin P Myrin P No Treatment Given Pharmacy Myrin P Myrin P Myrin P Pharmacy Myrin P Myrin P No Treatment Given Pharmacy Myrin P, Vitamins Myrin P, Vitamins No Idea Pharmacy Myrin P, Ethambutol Myrin P, + Isoniazid Ethambutol + Isoniazid, Antibiotic No Idea 18.Name of Drugs Prescribed for TB Patients 36 Name of Drug Number Prescribed Isoniazid 26 Rifampacin 19 Myambutol (Ethambutol) 16 Myrin P 16 Other Drugs Prescribed (Including Vitamin B6, Steroid Tablets, Streptomycin, Pyrazinamide, and Paracetamol) 19.Type of Investigations done at Follow Up Lab Tests Number of Patients Responded Chest X-Ray 29 Blood Complete Picture (CP) 20 Sputum Culture/Sensitivity 15 Other Investigations ( Including Erythrocyte Sedimentation Rate (ESR), Widal Test, and Urine Test) ANNEX SURVEY OF DOCTORS (ANNEX - A) 1) I.D Number: 2) Last Position/Post Held In The Govt Sector: 3) Highest Degree/ P.G.D Held: 4) Number 0f Years In The Private Sector: 5) Location Of Clinic: 37 6) Facilities Offered By Doctor's Clinic: 7) Time Spent Each Day In Clinic: 8)Average Consultation Fee: 9) Approx Number Of New T.B Patients Seen In One Month: 10) Usual Diagnostic Criteria followed For T.B: Symptoms: Signs: Lab Investigations: Special Tests: 11) Consultation Time: 12) Treatment Methodology: New Cost Relapse Rich Int Rich Contd Poor Int Poor Contd Cost 13) Follow Up Guidelines: No Of Follow Ups Advised: Method Of Confirmation Of Disease Elimination: 14) Information Given To Patients: Method/Way Of Taking Treatment: Adverse Effects: Precautionary Steps: Diet: 15) Have You Seen A Rise Of T.B Cases In The Community You Practice, If Yes, Why? 16) Which Population Groups Are More Susceptible And Why? 17) What Do You think Are The Preferences Of Patients Regarding Cost Of Treatment Regimen, Treatment Time, etc.? 18) What Is The Level Of Knowledge Held By The Patients Regarding T.B As A Disease, Its Treatment And Outcome? 19) What Do You Think Of DOTS As An Approach? 20) Do You Think FDC Tablets Or Individual Tablets Are Better? Survey Of Pharmacies & Drug Sellers (ANNEX – B) 1) I.D Number: 2) Number Of Years In The Business: 3) Location: 4) Approx Number Of Medicines Kept: 5) Association With Any Health Plan/ Pension System/ Zakat System: 6) Number Of T.B Drugs Kept: 7) Which Brand & Company Are More Popular: Is It Due To Price Or The Prescription Patterns: 8) Average Number Of T.B Drugs Sold In One Month: Approx Value Of These Drugs Sold: (Y) (N) 38 ) Mode Of Drug Procurement: Self Prescribed: Private Practitioners: Hospitals: Traditional Healers: 10) Are People Comfortable With The Price Of Drugs: 11) Knowledge Of Disease: Mode Of Transmission: Congenital: (Y) (N) Without Treatment Outcome: With Treatment Outcome: Outcome If Treatment Not Completed: 12) What Would You Give If Some One Asks You For A T.B Regimen: Poor Patients: Rich Patients: Resistant Cases: 13) What Information Will You Give To The Patient While Giving These Medicines: 14) How Will You Manage A Patient Of Chronic Cough: 15) What Do You Think Is The Knowledge Of General Public About T.B: 16) Do You See Breaks In The Course Of Treatment In Various Cases: (Y) (N) If Yes, Give Reasons: SURVEY OF PATIENTS (ANNEX - C) 1) I.D Number: 2) Age: 3) Sex: 4) Marital Status: 5) Number Of Dependents: 6) Average Monthly Family Income: 7) Health Plan: (Y) (N) 8) Type Of Employment: (Govt.) (Private Sector) (Self) 9) Smoking History: (Y) (N) Intensity: Duration: 10) Initial Symptoms: Cough: (Y) (N) Duration: Sputum: (Y) (N) Duration: Haemoptysis: (Y) (N) Duration: Fever: (Y) (N) Duration: Night Sweats: (Y) (N) Duration: 11) Time Interval Between Onset Of Symptoms & First Visit To A Doctor: 12) Time Interval Between First Visit To Doctor & Diagnosis: 13) Nature Of Health Facility First Visited: Private Medical Practitioner: (G.P) (Consultant) Govt Chest Clinic (T.B Centers): 39 40 ... Islamabad and Rawalpindi) The study reflects the tip of an iceberg of weaknesses in the private health sector in controlling and treating tuberculosis by examining the linkages between private physicians,... on the findings of the surveys the following recommendations might help to improve the treatment of TB in the private health sector of Pakistan First of all, the government should take more interest... selling TB drugs in the Federal Capital of Pakistan and its neighboring city (i.e Islamabad and Rawalpindi) The study reflects the tip of an iceberg of weaknesses in the private health sector in