OJHAS Vol. 11 Issue 1:
|DOTS Awareness and the Myths and Misconceptions about DOTS among Medical Practitioners in Mysore
Vinayak Nagaraja, Research Assistant, Dept. of Community Medicine Mysore Medical College & Research Institute, Mysore, Karnataka, India,,
Ganraj Bhat Sankapithilu, Research
Assistant, Dept. of Community Medicine Mysore Medical College & Research Institute, Mysore, Karnataka, India,
Mudassir Azeez Khan, Professor & Head, Dept of Community
Medicine, Mysore Medical College & Research Institute, Mysore, Karnataka, India.
Dr. Mudassir Azeez Khan,
Address for Correspondence
Professor & Head,
Dept of Community
Mysore Medical College & Research Institute,
Mysore, Karnataka, India.
Nagaraja V, Sankapithilu GB, Khan MA. DOTS Awareness and the Myths and Misconceptions about DOTS among Medical Practitioners in Mysore. Online J Health Allied Scs.
Submitted: Feb 12,
Accepted: Mar 30, 2012; Published: Apr 15, 2012
Background: Annually 2 million people in India develop Tuberculosis
and 330,000 die. WHO-recommended DOTS strategy was pilot-tested in 1993 and launched as Revised National Tuberculosis Control Program
(RNTCP) in 1997. Awareness of DOTS among the doctors in the private sector was appalling although nationwide coverage was attained by
2006. OBJECTIVE: To study awareness of DOTS among Medical Practitioners of urban and rural Mysore. Methodology:
practitioners in hospitals and nursing homes of urban and rural areas of Mysore who treated Tuberculosis patients (private and public
sector) were approached. They were grouped under different specialties as per the year of graduation (before or after introduction of DOTS). Results:
38 % doctors who graduated before the introduction of DOTS didn’t follow DOTS compared to 14.9% doctors who graduated
later. 100% doctors working in Government sector felt that DOTS was better than daily regimen while 85% from the private sector felt so.
Only 47.9% of the doctors in the private sector practiced DOTS compared to 95.1 % in the Govt. Sector. Hence, the number of doctors
practicing DOTS in Private Sector was less than 50 % of that in the Govt. Sector. Both of these comparisons were found to be
statistically highly significant (p<0.001). Awareness of DOTS was alarmingly low among Orthopedic Surgeons, Gynecologists and
Pediatricians when compared to Physicians and General Practitioners. Conclusions:
DOTS awareness is still low among doctors
who graduated before the introduction of DOTS. Private practitioners harbored myths and misconceptions about DOTS.
DOTS Awareness; Tuberculosis; Medical Practitioners
Globally 9.2 million new cases were reported and 1.7 million deaths occurred due to
tuberculosis (TB) in 2006. Reported incidence of TB in India, as per WHO, is 168/1,00,000 and there are about 28 deaths/lac population.
TB has become global epidemic with emergence of HIV/AIDS and multidrug resistant strains of the microbes. Tuberculosis (TB) is one of
India’s most important public health problems. India accounts for nearly one fifth of the global TB burden. Every day in India more than
20,000 people develop the disease, and more than 1000 die from TB. Many of these deaths can be prevented with timely care and treatment.
They can be cured and the battle against TB can be won. As the treatment is of such a long duration, Indian patients feel the pressures of
poverty and unemployment. Treatment is often interrupted as the awareness of compliance leaves a lot to be desired both among the
care-providers as well as the care-seekers. Therefore, just providing anti-TB medication is not sufficient to ensure that patients are cured.
Today, for the first time since the discovery of the first anti-TB medicines in 1944, there is hope of stopping TB. The RNTCP-DOTS (Revised
National Tuberculosis Control Program- Directly Observed Treatment, Short-course) was formally launched in 1997, following a pilot test
phase from 1993-96, and by March 2006 the entire country was covered under the programme.
In the period prior to implementation of the Government of India’s
Directly Observed Treatment Short course (DOTS) based RNTCP, studies on health care seeking behavior revealed that patients approached
private facilities more frequently than government health facilities for the treatment of acute ailments irrespective of socio-economic
class.[5,6] The private sector accounts for 82 per cent of all out patient visits at the all India level, with no significant variations by
income group. Suspected TB patients also first approach private sector. Private practitioners in India treat over half of the TB cases.
But there seems to be a missing link between the Medical practitioners and DOTS. The Practitioners have their own misconceptions regarding its efficacy and the mode of functioning. These inhibitions among the doctors and reluctance to adopt (or refer patients to take) DOTS have been quite astonishing as staggering. Available research data suggests that the basic knowledge about DOTS is lacking among the doctors practicing in the private sector. Tuberculosis is a disease encountered by doctors across various disciplines of medicine. Hence studying the awareness about DOTS among them will reveal the picture of how different specialists perceive DOTS and treat TB patients. 100% DOTS coverage was achieved throughout the country by RNTCP in March 2006. Not many studies were conducted to know DOTS awareness among medical practitioners after this achievement.
Aims and Objectives
To study the extent of awareness of ‘DOTS – Directly Observed
Treatment-Short course’ among Medical practitioners who practice in Mysore Urban and Rural.
To Compare DOTS awareness and usage among
Doctors who have graduated before and after the inclusion of
DOTS in the medical school curriculum.
Doctors working in different types of health centers (Govt. Hospitals, Private hospitals, Nursing Homes & Private clinics) and area of practice (rural and urban).
Doctors across different specialties of medicine.
To know and understand the myths, misconceptions and
apprehensions that thwart DOTS from being accepted as an effective weapon to combat TB.
It is a cross-sectional comparative study which was done in Mysore.
401 medical practitioners, belonging to both govt. and Private sector were approached to participate in the study. Only 311
practitioners in Mysore urban and rural from all possible specialties who confronted tuberculosis responded. Questionnaire consisted of
3 parts. In Part – 1, all the practitioners were grouped under different specialties; type of healthcare setup; year of graduation -
before or after DOTS was introduced and so on. In Part – 2, experience/opinion of doctors who were practicing DOTS was analyzed.
In Part – 3, the various myths which deterred some practitioners from practicing DOTS were obtained. The data thus gathered was
systematically tabulated, compared, graphically analyzed and interpreted. A report was prepared including suggestions for improving
the awareness of DOTS among Medical Practitioners.
Inclusion criteria: Registered Medical Practitioners in Mysore
(Urban & Rural) who encountered TB patients.
Exclusion criteria: Registered Medical Practitioners in Mysore District
who did not come across TB patients.
Basic Information about DOTS
Out of 401 subjects only 311 individuals responded. Based on the
area of practice, 87% of medical practitioners belonged to Mysore urban and 13% were from rural areas. 30% of the doctors
saw more than 5 new TB patients in a month. It included some TB and chest diseases specialists who saw up to 200 new TB patients in
a month. The rest of them came across 1 to 5 new TB patients per month. Only 21 of the doctors who encountered TB patients had not
heard of DOTS and 6 of them thought that drugs were given daily in DOTS. All of them were from private sector and graduated before the
introduction of DOTS. The basic knowledge about DOTS was considerably low among the doctors who graduated before the introduction
of DOTS in medical curriculum. Of them, 26.9% did not know the correct expansion of DOTS and 38.0% of doctors did not follow DOTS.
Comparing it with the doctors who graduated in the DOTS era, 98.6% of them knew the basic difference between DOTS and NTCP regimen
whereas 85.1% of doctors followed DOTS. (p<0.001 and hence statistically highly significant). This significant disparity reveals
that many doctors have not made an attempt to know about DOTS even if they are encountering and treating TB patients. The paradox
is that some of the doctors who practice DOTS themselves don’t know the correct expansion of the acronym DOTS! The basic awareness
of DOTS expansion and the number of people following it was alarmingly low among orthopedic surgeons, Gynecologists and Pediatricians
when compared to Physicians and General Practitioners in the present study. This can probably be attributed to not only lesser number
of TB patients seen by orthopedic surgeons, Gynecologists and Pediatricians but also lesser emphasis on DOTS in their respective
curriculum. Only 47.9% of the doctors in the private sector practiced DOTS compared to 95.1% in the Govt. Sector. Hence
the number of doctors practicing DOTS in Private Sector was less than 50 % of that in the Govt. Among the doctors in the private
sector, the number of people who followed DOTS was considerably less in the doctors working in Private Hospitals compared to Private
Clinics. Doctors working in rural areas had more knowledge regarding DOTS compared to those who practiced in urban areas.
Opinion about DOTS
The doctors who followed (referred the patients to take) DOTS were asked
about their opinion/ experience in treating TB patients with DOTS. 94% of the 197 doctors felt that DOTS was better than NTCP this
suggested clearly that doctors who practiced DOTS thought that it was better than the earlier mode of therapy. 100% of the doctors
working in Government sector felt that DOTS was better than NTCP; whereas only 85% of the respondents from the private sector felt so.
Of the private hospital doctors, 33.75% felt that DOTS was not reaching all sections of society. This was because they were unaware of
the 100% coverage of DOTS in India under RNTCP and that it is provided free of cost. Only 4.1% of doctors who practiced DOTS felt that the
efficacy of treatment with DOTS was not satisfactory to them only 8.75% of the doctors from private sectors said that adherence to full
course of therapy was not better with DOTS. These 2 points suggest that doctors practicing DOTS felt that it was highly effective in
Though following DOTS, 57.5% of the doctors working in private
sector, 66.7% anesthetists,
27.3% of orthopedic surgeons and 16.7% of physicians did not know the nearest DOTS center! This suggests
that there is a communication gap among the policy makers and the health care professionals working in
private sector. Of
the doctors who practiced DOTS, 65.5% felt that all TB patients could be put on DOTS, while 23.9% of doctors said that daily treatment was
better in some cases. And 9.6% doctors (mostly private practitioners) felt that some patients were apprehensive to go to DOTS centers.
They substantiated their stand by saying that when some patients were apprehensive of going to DOTS centers and could afford daily
treatment regimes, there was no need to unnecessarily force all patients to take DOTS.
Opinion/Experience of doctors who didn’t practice DOTS
Majority of the
doctors felt that compliance to treatment; adherence to long course of therapy
and the cost of daily therapy were not acceptable. Among the doctors from the private
sector, 15.2% said that the
cost of daily treatment was acceptable for their patients. They thought that some of their patients could afford daily treatment.
A total of 64.9% of the doctors felt that if the drugs are provided free of cost, people have doubts regarding its potency. Most of the doctors who said so were
private practitioners. This was a startling
observation because it reflects very badly on the Govt. supply of drugs and that doctors and people don’t have confidence about its
Among those who didn’t practice DOTS, 66.7% of the
physicians and 100% pediatricians had a myth that DOTS was ineffective because drugs
were not given daily. The fact is that drugs given thrice a week are as effective as drugs given daily. This reflects the lack of basic
knowledge of Pharmacology about the half life of anti TB drugs among these doctors.
Fifty nine percent of the doctors said that the cost of full course of treatment of TB
with daily regimen was between Rs 500 to Rs 1000, which in fact easily exceeds Rs. 1000. This suggested that the doctors who are unaware
of the financial burden on the patients, while purchasing drugs for their daily treatment of TB.
It was astonishing to observe that 64.9% of these doctors said that they
would not practice DOTS even after coming to know that it is given free of cost, under supervision and equally efficacious. The most
prominent reason given was, they had a fear that the patient would not come back for follow up if prescribed DOTS. This indirectly
suggested that these doctors did not keep patients’ concerns as a priority, which was disheartening.
After studying the DOTS awareness among medical
practitioners in the urban areas of Mysore in 2010, the following points could be concluded. Most of the doctors who
participated in the study had heard about DOTS and knew that drugs were given thrice a week. The basic knowledge about
DOTS was considerably low among doctors who graduated before the introduction of DOTS into the medical curriculum. 38% of
them did not follow it (p<0.001). An interesting fact is that some of the doctors who follow DOTS don’t know what the
acronym DOTS stands for. Comparing DOTS awareness among various specialists, it was found to be low among the orthopedic Surgeons,
Gynecologists and Pediatricians. The number of doctors practicing DOTS in the private sector was less than 50% of that when compared
to the Govt. sector (p<0.001). All (100%) the doctors working in Government sector felt that DOTS was better than NTCP; whereas only
85% of the respondents from the private sector felt so.
Doctors working in Private hospitals had the least knowledge
about DOTS among the different types of health centers in the private sector. Most of the doctors who practiced DOTS felt that
it was highly effective in treating TB. Among the doctors working in the private
sector who prescribed DOTS, 57.5% did not know the nearest DOTS center. About
24% of the Doctors who practiced DOTS felt that daily treatment was required in
some cases of TB. The most common reason given was that some of their patients
were apprehensive to go to DOTS centers. Of the doctors from the private sector,
15% did not practice DOTS because they said that their patients could afford
daily treatment regimen. About 2/3rd of the doctors who did not practice DOTS
felt that if drugs were provided free of cost, people will have doubts regarding
its potency. Two thirds of the Physicians and all the Pediatricians who did not
practice DOTS had a misconception that DOTS was ineffective because drugs were
not given daily. Of those who did not practice DOTS. 64.9% doctors did not want
to do so in the future, majority of them stating that if they did so, their
patients would not come back to them for follow up.
The RNTCP is being primarily implemented through the Government
network of institutions and health providers. Several studies have suggested that roughly 50% of the population sought medical care
from the Private Sector in India.[8,10] This aspect needs further research as to why patients prefer to go to private practitioners
first. The RNTCP, therefore, cannot hope to achieve major successes unless public-private mix is a success. Majority of private
practitioners are not aware of or not prescribing the treatment regimen recommended by the RNTCP and the majority of patients are
being improperly treated or over-treated. There is a lack of emphasis on proper supervised treatment provision. They need periodic
training, and more collaborative efforts are required between public health facilities and practicing doctors for control of tuberculosis.
We would like to thank Dr Lance D'Souza for assisting us with the statistical analysis of the paper.
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