Mohanan Manoj, Goldhaber-Fiebert Jeremy D, Giardili Soledad, Vera-Hernández Marcos
Sanford School of Public Policy, Duke Global Health Institute, and Department of Economics, Duke University, Durham, North Carolina, USA.
Centers for Health Policy and Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA.
BMJ Glob Health. 2016 Dec 16;1(4):e000155. doi: 10.1136/bmjgh-2016-000155. eCollection 2016.
Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges.
We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics.
80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively).
Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.
全球近25%的新增结核病病例发生在印度，耐药性和医疗服务质量低下仍是主要挑战。
2012年6月至9月，我们在印度比哈尔邦农村地区对医疗服务提供者关于结核病诊断和治疗的知识进行了一项观察性横断面研究。利用对研究区域内395名最常就诊的医疗服务提供者进行的基于病例的访谈数据，我们对提供者的知识进行评分，并使用多变量回归模型来检验其与提供者特征的关系。
395名提供者中80%没有正规医学资格。总体而言，提供者的知识水平较低：64.9%（95%可信区间59.8%至69.8%）诊断正确，21.7%（可信区间16.8%至27.1%）推荐正确治疗方案。提供者很少询问诸如发热（31.4%，可信区间26.8%至36.2%）和咯血（11.1%，可信区间8.2%至14.7%）等诊断问题，或痰涂片显微镜检查结果（20.0%，可信区间16.2%至24.3%）。在控制了提供者是否治疗结核病之后，医学学士提供者在知识评分或提供正确治疗方面与不合格提供者或具有替代医学资格的提供者没有显著差异。然而，相对于补充医学提供者和不合格提供者，医学学士提供者更有可能推荐转诊（分别高出23.2和37.7个百分点）。
印度比哈尔邦农村地区的医疗服务提供者对结核病诊断和治疗的知识水平较低。我们的研究结果强调需要制定政策来改善培训、激励措施、任务转移和监管，以提高现有提供者的知识水平和表现。此外，需要进一步研究提供者面临何种激励措施以及质量信息的作用，以帮助患者选择提供更高质量医疗服务的提供者。
