Approaching and Engaging Private Practitioners: Strategic Lessons from Two Tuberculosis Related Field Studies in India

Dear Editor, India carries a fourth of the global burden of tuberculosis (TB). Private practitioners (PPs) manage around 50% of TB cases in India.[1,2] They are the first source of help-seeking for more than two-thirds of the patients who get diagnosed with TB.[3] Studies reported that the private sector is weakly regulated, and some PPs may deviate from the standard TB treatment guidelines.[4,5] Such practices can fuel the emergence of anti-TB drug resistance, which is a global concern. Involving the private sector in TB control has been a topic of long debate in India due to its indispensable role, yet inconsistent practices. Enhancing collaboration between the National TB Programs (NTPs) and the private health providers for TB care in different settings is a main objective of the Stop TB Working Group on Public-Private Mix (PPM Working Group).[6] In this context, understanding PPs' perspective would be the first crucial step to guide efforts toward their successful involvement in TB control. Through this letter, we aim to share our team's first-hand experiences in approaching and involving PPs in TB research studies. We hope that these experiences can benefit upcoming researchers who plan to conduct research studies with PPs and policymakers in designing strategies for TB control. We conducted two studies among PPs within Pune and Pimpri-Chinchwad Municipal Corporation areas in Maharashtra state of India. The first study was related to PPs' experiences related to TB notification policy, which involved 200 PPs,[7] and the second study, involving 100 PPs, was focused on awareness about management of TB/MDR-TB cases (under review). It aimed at providing inputs for designing an educational tool for PPs. Our staff used simple, respectful language with confidence in explaining the study while introducing themselves with PPs. Sharing printed summaries of the study objectives and carrying visible ID cards of the institute also reassured PPs about the team's authenticity. Furthermore, the team collected information about other PPs in nearby areas by applying snowball sampling and interviewed them. Some PPs agreed to the interview after learning that other clinicians also participated in the study, reflecting the influence of professional trust and peer validation. The prospect of learning about updated TB/MDR-TB management protocols motivated some PPs to participate in these studies. The team also collected PPs' visiting cards and contact numbers to invite them to the dissemination meeting, which was held after finishing the data analysis process. While conducting research among PPs, one of the main challenges was that the team could not enroll 40 PPs (~12% of PPs approached) because they had no time or were not interested in participating. At some clinics, the study team waited for up to 2 hours due to heavy load in the outpatient departments (OPD), and despite that the PPs did not offer to meet them. The team identified timings when the patient load was generally low and managed to visit them during those hours. A few PPs (n = 4) mentioned also that they stopped examining TB cases and prefer referring symptomatic individuals to the government facilities. Some PPs (n = 5) asked to leave the interview schedule with them and collect it after 2-3 hours. In a few places, our team of social workers faced direct rejections by the PPs as they experienced some sense of superiority complex among PPs due to their higher educational qualifications. Nevertheless, they handled the situation by remaining calm. Furthermore, a couple of PPs refused to sign the consent, but they were ready to participate and provide information. Recognizing the value of their inputs, the team sought their oral consents after seeking permission from the institutional ethics committee. Some PPs had expectations about nonfinancial incentives such as a certificate toward their participation in the study or Continuing Medical Education (CME) credit points as all practicing doctors under 65 years of age are required to accumulate 30 CME credits every 5 years to renew their licenses.[8] This letter provides insights into strategies for engaging PPs in TB research and control activities. Experiences from these field studies are important from different vantage points. These highlight the importance of having soft skills and an approach among the researchers or NTEP staff when dealing with PPs. Since PPs have busy practices, their prior appointments are necessary. In case PPs are not available or unwilling to participate in research/activities, their decision should be respected. When written consents are not possible, counselling on its importance should be emphasized, and oral consent can be considered as an alternative. Nonmonetary incentives, such as CME credit points and updates on management guidelines, can be considered as motivating factors for their involvement in the NTEP activities. These points can be credited by inviting them to study dissemination meetings by providing them with a sense that they are an indispensable part of the TB management and control. We hope that our experiences would find suitable applications for strengthening public-private partnerships not just in the area of TB but also for other health issues. Data availability statement The data from both studies are available with the lead author Sachin Atre. Author contribution Sachin Atre: conceptualization, data analysis and writing of the draft manuscript. Tushar Sahasrabudhe: Input for revisions. Trupti Sawant: Data entry and analysis. Sunil Ambike, Hanumant Chaugule, Dharmenrda Padalkar and Jayashri Jagtap: Data collection and comments. All authors provided input for revisions and approved final version. Financial support and sponsorship We gratefully acknowledge funding support from Dr. D. Y. Patil Vidyapeeth, Pune, for two small intramural grants (Ref. DPU/960/2019 and DPU/49/2022). Conflicts of interest Nil.