Implementing WHO DOTS strategy in the Russian Federation: stakeholder attitudes.

Russia has the ninth highest tuberculosis burden in the world. After a period of decline starting in the 1960s, the case notification rate tripled during the 1990s. Historically, case-finding, treatment and reporting practices in Russia have differed from those advocated by WHO and the international community: Directly Observed Therapy--short course (DOTS). By 2003, approximately 26% of the population in Russia was covered by the DOTS strategy. By contrast, the average coverage in the 22 high-burden countries is 61%. The reasons for this low rate in Russia have not been systematically examined. Using qualitative research methods we explored, in depth, the attitudes of key stakeholders involved in tuberculosis control to introduction of DOTS in a region of Russia. Six focus groups and 128 in depth interviews were held with clinicians, managers, policy-makers and patients. The results show negative attitude to change due to inadequate understanding of DOTS; perceived 'directiveness' of the 'externally developed' DOTS strategy and the standardized nature of the treatment regimen. The doctors, managers and patients saw that prolonged periods of hospitalisation (the traditional way of managing TB in Russia) was advantageous because treatment routines could be ensured, medical expertise was readily available, and other needs such as shelter and food were provided. Respondents felt that the patients were unlikely to adhere to treatment in the community. Cultural issues and capacity constraints, especially in laboratory equipment and personnel, would impede introduction and sustainability of the DOTS strategy.