Two vicious circles contributing to a diagnostic delay for tuberculosis patients in Arkhangelsk

Figures & data

Table 1 Table indicating the coding procedure from citations to core categories

Citation	Code	Subcategories	Category	Core category
You freeze, you sweat, and the whole day is like that. Plus I did not sleep for 24 hours. I could have caught a cold. The cold is not a reason to seek medical help. Moreover, I had so much work that time!	Symptoms of cold No awareness of danger Work as an obstacle for seeking medical help		These symptoms are not serious	Limited awareness of importance of contacting the health system
Well, I thought I had caught a cold … fever and cough. I thought I would treat myself. Then it went further and further … it made me ask for help.	Symptoms of cold Self-treatment Failure of self-treatment		Self-treatment
I had fever, 38°; I treated it by some pills, and I got relief and came down. Then fever became 39°, then 40°. I came to my daughter; she called for an ambulance.	Fever as a symptom of cold Self-treatment Failure of self-treatment		Failure of self-treatment
They said that I have to go for fluorography, but I did not pay attention to it. I thought: later on, later on …. I have to work … the more I work the more money I will get	Low attitude to own health Work as an obstacle for seeking medical help	Work/housing:	Factors influencing the health-seeking behaviour of patients
I have had a cough for more than one month. Well, such cough, like a normal one. I thought it was a cold …. not tuberculosis, but something else.	Symptoms of cold Cough is normal thing Lack of knowledge about TB	Lack of knowledge about TB
I was in prison. I know these symptoms. I started coughing, but I thought that it was “a joke.”	Prison as a special environment Informed about TB symptoms Low attitude to own health
I don't pay attention to my health, because I have to work from early morning till night. If I feel bad I drink to forget this.	Low attitude to own health Work as an obstacle for seeking medical help Alcohol as a treatment	Low attitude to own health
When I drink, nothing is bad for me! Illness flies out with alcohol. You don't feel it. Alcohol softens everything, all diseases. When you drink you do not pay attention to illness. Well, today you sneeze, cough, but it will pass! In the morning you wake up, something squeaks, whistles; you groan but go anyway, then you forget about it during work.	Alcohol as a treatment Alcohol as a life style	Alcohol use
This is the best prevention! (He showed the sign of drinking). Usually, I come from a shift, get drunk and it does not matter, if you have it or not [tuberculosis].	Alcohol as a treatment Alcohol as a life style
My wife cried that I should have gone to the doctor earlier. I was to blame that if I had gone to the doctor earlier our daughter would be OK. I'm guilty for the delay and I have infected my daughter.	Wife blaming Child was infected Guilt for infection	Family support
I have got a daughter, 39 years. She told me: ‘Mama, go to the doctor, cure yourself!’ My mother said: ‘Go immediately, go to Arkhangelsk, get examined and cured’.	Daughter's initiative to enter mama to hospital Fever is not a motivator
They support me, call very often and are interested in how I feel.	Family support
I applied for the 2nd time. I lived in Moscow, so I came only in March, even though X-ray results were in the district in December. Doctors did not see it there, but in Arkhangelsk they did. I was sent to Arkhangelsk, when I was examined for the tenth time! They took sputum. I made fluorography in March and took pills for pneumonia till May.	The second trial to get medical help Lived far from Arkhangelsk Doctor could discover disease Wrong diagnosis		Breach of diagnostic standards	Limited resources of the health system
I visited a doctor three times! I had a fever 37,2 ^0 , and headache. One doctor said: ‘Headache?’ ‘Yes!’ ‘Let it be’. ‘I can take sick leave for a month only, then my salary will be taken away’. He discharged me. Then I came again. There was another doctor. He sent me to a hospital, where I got injections. But the hospital was closed for reconstruction and I was discharged.	Several attempts to contact the doctor Doctor's low attention to symptoms’ Doctor under strict administrative control Change of the doctor Infection in hospital		Treatment of wrong disease
They took sputum. I made fluorography in March and took pills for pneumonia till May.	Failure of treatment		Failure of treatment
Our administration talks all the time about how we should complete treatment of all TB cases and how we should recognize new cases as soon as possible. But how can I do it, if they don't want to go to the doctor? A majority of patients are alcohol dependants. Very often we do not have enough doctors or nurses in the medical sites.	Administration demands completed treatment Diagnosis in time is a criteria of effective work Alcohol is widespread among patients Lack of personnel		Factors influencing the health system delay
The patients are very hard, we have to visit their living places up to ten times to catch them and to convince them to take a test and treatment!	Hard to find patients Hard to convince patient to take treatment	Knowledge of the health personnel
For sure, we prescribe two antibiotics if necessary. Patients don't want to be cured very often! How can we control them! It is hard to even catch them at home!	Knowledge about right treatment Patients don't want to be treated Hard to find patients No tools to perceive patients
Our doctor is absent very often. Then we go to another one. But she might not know my situation and prescribes something at random. So, I don't like to go to other doctors and instead I try to wait for my doctor.	Lack of doctors Doctors changed Wish to contact one doctor	Organisational problems
I came to the doctor, but did not enter the doctor's room because of a queue. There were 10 persons before me in the end of working hours.	Long queue in policlinic Failed attempt to contact doctor
Fluorography works till 4 p.m. How shall a working person be able to do it?	X-ray working time is inconvenient Patient have to work
Our work is not easy at all. Not everybody can work here. Much experience is necessary to work effectively. The system does not work by itself.	Hard work in policlinic Special work People are the main factor in the policlinic	Experience of personnel
There are different patients in a medical district. Some make fluorography test regularly; others don't come for several years. There are alcohol dependants; they do not care at all.	Patients are different Some patients don't follow prescriptions Alcohol-dependent patients are a problem

Fig. 1 Model of the sickness trajectory, including categories influencing the process of TB diagnosis and treatment.