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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 66
| Issue : 4 | Page : 480-486 |
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A survey of the training and working arrangements of general practitioners providing asthma and chronic obstructive pulmonary disease care in a rural area of Maharashtra State
Dhiraj Agarwal1, Makrand Ghorpade2, Pam Smith3, Sanjay Juvekar4, Hilary Pinnock5
1 Research Scientist, Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India
2 Study Physician, Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India
3 Professorial Fellow in Nursing Studies, NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland
4 Professor and Head, Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India
5 Professor, Centre for Global Health, NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| Date of Submission | 22-Jan-2022 |
| Date of Decision | 25-Oct-2022 |
| Date of Acceptance | 25-Oct-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Dhiraj Agarwal
Sardar Moodliar Road, Rasta Peth, Pune - 411 011, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.ijph_102_22
 Abstract | | |
Background: Chronic respiratory diseases (CRD), especially asthma and chronic obstructive pulmonary disease (COPD), are common public health problems resulting in a substantial burden of disease for individuals. There is a need to understand the perceptions and practices of primary care physicians (“general practitioners [GPs]”) who provide most of the health care in rural India. We surveyed all private and public practitioners listed as practising in a rural area of Western India with the aim of identifying GPs (GPs: graduates, registered and allowed to practice in India) to understand their training, working arrangements, and asthma/COPD workload. Methodology: We administered a short questionnaire at educational meetings or via e-mail to all private and public practitioners listed as providing community-based services in the Junnar block, Pune district, Maharashtra. The survey asked about qualifications, experience, and working arrangements, and about current asthma and COPD workload. A descriptive analysis was performed. Results: We approached 474 practitioners (434 from private sector and 40 from public sector). Eighty-eight were no longer practising in the study area. The response rate was 330/354 (93.2%) of private and 28/32 (87.5%) of public sector practitioners. We excluded 135 nonrespiratory hospital specialists and 23 private practitioners whose highest qualification was a diploma. Our final sample of 200 GPs (70% males) was 177 from private sector and 23 from public sector. The private GPs had more experience in clinical practice in comparison to public GPs (18.6 vs. 12.8 years). Eighty-four percent of GPs from the private sector only had Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) qualifications, though >90% provided “modern medicine” services. In the public sector, 43.5% GPs only had AYUSH qualifications, though all provided “modern medicine” services. A minority (9% of private GPs and 16% of public GPs) provided both services. Nearly two-thirds (62%) of private GPs had inpatient facilities compared to only 9% of public sector GPs. In both sectors, more GPs stated that they managed people with asthma than treated COPD (Private: 97% vs. 75%; Public 87% vs. 57%). Conclusion: Many GPs practising “modern medicine” only had qualifications in Ayurveda/Homeopathy and fewer GPs are involved in the management of COPD as compared to asthma. These are important factors that form the context for initiatives seeking to improve the quality of community-based care for people with CRD in Maharashtra state in India.
Keywords: Asthma, chronic obstructive pulmonary disease, diagnosis, management, perception, practices
How to cite this article:
Agarwal D, Ghorpade M, Smith P, Juvekar S, Pinnock H. A survey of the training and working arrangements of general practitioners providing asthma and chronic obstructive pulmonary disease care in a rural area of Maharashtra State. Indian J Public Health 2022;66:480-6 |
How to cite this URL:
Agarwal D, Ghorpade M, Smith P, Juvekar S, Pinnock H. A survey of the training and working arrangements of general practitioners providing asthma and chronic obstructive pulmonary disease care in a rural area of Maharashtra State. Indian J Public Health [serial online] 2022 [cited 2023 Apr 1];66:480-6. Available from: https://www.ijph.in/text.asp?2022/66/4/480/366560 |
| Introduction | |  |
Chronic respiratory diseases (CRDs), especially asthma and chronic obstructive pulmonary disease (COPD), are common public health problems with high prevalence and mortality rates across the world.[1],[2],[3],[4] In India, the population prevalence of asthma is estimated to be 5%–10%[5],[6],[7] and that of COPD around 5%–7%.[6],[8],[9],[10] Despite respiratory symptoms being the most common reason for consulting general practitioners (GPs) in India,[11] diagnosis and management of the underlying condition[1],[12],[13],[14],[15] requires clinical knowledge and skills as well as access to diagnostic tests which may not be available in resource-poor rural areas of low- and middle-income countries.
India has a mixed health-care system with private and public sectors providing both alternative Medicine Encompassing Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) and “modern medicine” services [Figure 1]a.[16],[17] In rural areas, where 60% of the Indian population live, the majority of respiratory health care is provided by GPs and other community-based practitioners (from both private and public sectors) as most respiratory physicians' practise in urban areas.[18] GPs are graduates and registered with the medical authority in India.[19] In India, training and qualifications may be in either modern medicine or AYUSH, so that their knowledge and skills related to diagnosis and management of CRD varies. In addition, some community-based practitioners may not be graduates. People tend to “shop around” for treatment (exploring treatment options available), and this “shopping” for treatment means that people will go to both private and public GPs. | Figure 1: (a) Indian Health System; (b) Questionnaire filling status, reasons for not filling questionnaire and reasons for not including them in the analysis both from private and public sectors.
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There is concern that noncommunicable causes of chronic respiratory symptoms in developing countries are poorly managed.[20] The high prevalence of chronic respiratory symptoms[11] coupled with limited recorded diagnoses[1] suggests that asthma and COPD (and other CRDs) are under-recognized and represent an unmet health need. Understanding context is crucial to developing strategies to implement improved quality of care. There is a need to work with public health systems and their different stakeholders to inform quality improvement initiatives. We, therefore, surveyed all private and public practitioners listed as practising in Junnar block (a rural area of Western India) with the aim of identifying GPs to understand their training, working arrangements, and asthma/COPD workload.
| Methodology | | |
Study area
The Junnar block is one of the 14 blocks in Pune district in Maharashtra state of India. It comprises 179 villages with a total population of 400,000,[21] encompassing rural, urban, and tribal populations. Of total 12 Primary Health Centres (PHCs); three are in tribal and nine are in nontribal areas. There are two rural hospitals, one at Junnar and other at Ghodegaon. Junnar has been an important trading and political center for the last two millennia as it is situated on the border of three districts (Ahmednagar, Nashik, and Thane). The marketplaces (Narayangaon, Otur, and Junnar) in all three regions of Junnar have many private medical practitioners. The state and national highways cross in this block.
Study population and sample size
We approached all private and public practitioners listed as practising in Junnar (n = 474) between March 2021 and September 2021. Lists of private sector practitioners were obtained from their local professional associations (n = 434) which include formally registered practitioners of modern medicine and AYUSH systems and public GPs from the PHCs/RHCs (n = 40). We aimed to identify “GPs” who we defined as graduated (in modern medicine or AYUSH) registered with their respective medical authorities in India and allowed to practice in India by the Indian Law. Practitioners (n = 158) who did not meet our definition of GPs were noted but excluded from the analysis.
Study questionnaire development
The study questionnaire was developed based on tools used in previous studies[19],[20],[21],[22],[23] and developed in consultation with local pulmonologists and study investigators. We collected demographics, trainings, service arrangements, and workload related to asthma/COPD care. [Supplementary Table 1] shows the questionnaire. Before data collection, we piloted the questionnaire among GPs practising in Shirur block of Maharashtra state.
Participant recruitment and study questionnaire administration
We used two modes of data collection. We distributed questionnaires to all attendees at a continuing medical education (CME) activity regularly provided by the King Edward Memorial Hospital Research Centre, Vadu Rural Health Program (KEMHRC, VRHP) for private and public GPs in the study area. Those GPs who did not attend the CME and others who we could not reach due to the COVID-19 pandemic were invited by e-mail or text to complete an online version of the survey (Google Form). Before sending the invitation, they were contacted by telephone, and verbal consent was obtained to participate in the study.
Data entry, quality check, and analysis
Questionnaires were checked for the completeness and accuracy of data entry (e.g. by checking for values outside the plausible range). Missing values were treated as discrete missing values. A descriptive analysis was performed using Stata software (version 15) StataCorp LLC, City: College Station, State: Texas, Country: United States.
Stakeholder engagement
GPs and other stakeholders (e.g., local chest physicians, researchers, public and private health practitioner representatives) were actively engaged in developing the NIHR Global Health Unit (RESPIRE) research agenda (including this study), reviewing proposals, and are now involved in disseminating the findings of projects.
| Results | | |
Survey and response rate
We approached 474 community-based practitioners. After excluding 88 practitioners who were no longer practicing in the area, 358 of the remaining 386 (92.7%) completed the questionnaire: 93.2% (330/354) of private and 87.5% (28/32) of public sector practitioners. Reasons for nonresponse are given in [Figure 1]b. Most nonresponders were from the public sector and were too busy treating and managing COVID-19 patients to complete questionnaires.
We excluded 130/330 (39.4%) practitioners from the private sector and 5/28 (17.9%) from the public sector who had community-based specialist practices and (apart from pediatricians) were not involved in providing care for people with CRD. Of these, 74 had post-graduate specialist qualifications, and 61 were graduate trained. We further excluded 23/200 (11.5%) private sector practitioners as their highest qualification was a diploma and thus not meeting the definition of a GP. Analysis was therefore performed on 200 GPs (177 GPs from the private sector and 23 GPs from the public sector) [Figure 1]b.
General practitioners demography, qualifications, and medical practice
The demographic characteristics of GPs with their experience and qualifications are given in [Table 1]. Almost 70% of GPs were male, both in private and public sectors. The private GPs had more experience (Mean 18.6 years, standard deviation [SD] 8.9 years) in clinical practice compared to public GPs (Mean 12.8 years, SD 9.1 years). | Table 1: Demographic characteristics of general practitioners with their experience and qualification and number of asthma and chronic obstructive pulmonary disease cases with them
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Of the 177 GPs from the private sector, 148 (83.6%) only had qualifications in AYUSH medicine, although 135 (76.2%) of the AYUSH-trained GPs provided modern medicine services. All 23 of the GPs in the public sector provided modern medicine services, though 10 (43.5%) only had AYUSH qualifications. A minority in both sectors provided both AYUSH and modern medicine services. Nearly two-thirds (61.6%) of private sector GPs had inpatient facilities compared to only 8.7% of public sector GPs. All others managed patients at the clinic level only. Inpatient facility helps for better treatments.
Asthma and chronic obstructive pulmonary disease caseload
Of the 177 GPs from the private sector, almost all (172 [97.2%]) treat/manage asthma, but only 133 (75.1%) treat/manage COPD. Similarly, from the public sector, more GPs treat/manage asthma (n = 20, 87.0%) than treat/manage COPD (n = 13 [56.5%]). [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d shows cases currently in treatment with GPs and cases in the past 3 months with GPs. | Figure 2: Number of cases for asthma and COPD currently and in the past 3 months (a-d): (a) Cases currently in private sector, (b) cases in the past 3 months in private sector, (c) cases currently in public sector, (d) cases in the past 3 months in public sector; Number of cases for asthma and COPD currently and in the past 3 months according to GP training (e and f)- (e) -cases currently, (f) cases in the 3 months. COPD: Chronic obstructive pulmonary disease.
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We also looked at CRD caseload by the GP's training (AYUSH or Modern Medicine) as given in [Table 2]. Similar patterns emerged across both groups with more asthma than COPD cases, though two-thirds 60/158 (37.9%) of AYUSH-trained GPs were not involved in asthma management compared to only 2/42 (4.7%) of GPs trained in modern medicine [Figure 2]e and [Figure 2]f. | Table 2: Chronic respiratory diseases workload by general practitioners training
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| Discussion | | |
Our survey reveals that many GPs in Junnar block of Maharashtra state are practising modern medicine despite only having qualifications in Ayurveda or homeopathy. This was particularly evident not only among private GPs, but also applied to nearly half the GPs in the public sector. Although almost all GPs looked after patients with asthma, only three quarters provided COPD care.
Interpretation and implications
There may be several reasons for the mismatch between qualifications and practice. Health care is a state responsibility, and cross-practice is allowed legally in Maharashtra. Second, most of the doctors trained in modern medicine prefer to practice in urban areas, while rural areas in centuries-old traditions are served by Ayurveda and other AYUSH practitioners. Maharashtra state has almost 60 homeopathy and 70 ayurvedic colleges compared to only 48 modern medicine colleges so that the number of ayurvedic and homeopathic practitioners trained far exceeds the number of modern medicine doctors in the state. Every year, of the 10,000 medical graduates in India, only 2,800 are from government medical colleges where medical education is heavily subsidized on condition that the doctor serves at least 1 year in one of the 1814 government-run PHCs. Having served their 12-month mandatory postings, few continue in rural practice.[19]
Both asthma and COPD are both common causes of chronic respiratory symptoms in LMICs like India,[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] yet there was a marked discrepancy in the proportion of GPs who cared for patients with these two conditions suggesting that COPD may be under-recognized and under-treated compared to asthma. Reasons for this are likely to be multifactorial, including poor community awareness so that people with insidious onset of breathlessness may not present to their GP in a timely manner,[22] and both GPs and patients may be unfamiliar with the terminology asthma and COPD. A further problem is that there is no specific word for COPD in the local dialect, and the word “dama” which means asthma in the local dialect, is commonly also used for COPD. Underrecognition of COPD by GPs could be the result of inappropriate training and misdiagnosis though modern medicine-trained GPs had similarly low-COPD caseloads.[23] In addition, as COPD requires some special diagnostic equipment (e.g., spirometry) which may be difficult to access, it may be a diagnosis that GPs feel unable to make.
Strategies to improve the quality of care for respiratory disease in rural India will need to understand the perception and practice of GPs (both public and private) involved in diagnosis and management of asthma and COPD. In-depth qualitative interviews could explore the challenges of diagnosing and managing asthma and COPD and identify strategies that could facilitate better care. COVID-19 has raised the profile of respiratory disease both for GPs and the community which may be an incentive for developing care. More broadly, there is a need to understand the health-care context, in particular, the infrastructure at government facilities enabling diagnostic services and specialist support for GPs. The perception and needs of patients are equally important.
Understanding context represents the first stage of developing and evaluating a complex initiative to improve the quality of CRD care in our locality.[24] The findings of this study highlight the need to provide training for GPs with a background in Ayurveda or homeopathy as well as offering advanced training on asthma and COPD diagnosis and management for modern medicine practitioners. It raises policy questions about eligibility to practice modern medicine and the training that should be required before a practitioner is licensed to prescribe modern medicines.
Strengths and limitations
As this study was conducted only in one block of Maharashtra state, the findings may not be applicable to other blocks within the state or more widely in India. We achieved a good response rate (92.7%) but to do this, we kept the questionnaire short which limits the inferences we can make. Several joint husband and wife practices responded but only completed one questionnaire limiting the information that we have about the individual GPs workload. Our assumption that practitioners with specialist training were providing specialist services in the community and not practicing as GPs may not always be correct, but we have no further information on this group.
| Conclusion | | |
Many GPs practising modern medicine only had AYUSH qualifications. Fewer GPs are involved in the management of COPD as compared to asthma. About half of the GPs who treat/manage these common respiratory symptoms have in-patient facilities. To develop strategies to improve respiratory care, it will be necessary to recognize the diverse backgrounds of the practitioners providing general medical services in the community and to understand the challenges, they face in diagnosing and managing people with asthma and COPD.
Ethical approval and consent to participate
Ethics approval was obtained from the KEM Hospital Research Centre Ethics Committee, and the study was sponsored by the University of Edinburgh (ACCORD: Reference number: AC18111). Written informed consent was provided by all study participants. Permissions were obtained from the relevant health officers at district and block level, and the private GPs' association. The study was implemented following the National Ethical Guidelines for Biomedical and Health Research involving Human Participants issued by the Indian Council of Medical Research in 2017 and the recent National Guidelines for Ethics Committees Reviewing Biomedical and Health Research during the COVID-19 Pandemic issued in 2020.
Availability of data and materials
Data analyzed during the current study are not publicly available as data collection for qualitative aspect of the study is still ongoing. The corresponding author will upload data on the Edinburgh DATASHARE data-sharing repository (https://datashare.ed.ac.uk/) after completion of data collection for the current study. However, data used for the current publication will be available from the corresponding author on reasonable request.
The RESPIRE collaboration
The University of Edinburgh, Edinburgh, UK; The Allergy and Asthma Institute, Islamabad, Pakistan; Maternal Neonatal and Child Health Research Network, Islamabad, Pakistan; University of Malaya, Malaysia; KEM Hospital Research Centre, Pune, India; Aga Khan University, Karachi, Pakistan; Christian Medical College, Vellore, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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