Dimitrova B, Balabanova D, Atun R, Drobniewski F, Levicheva V, Coker R
Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
Health Policy Plan. 2006 Jul;21(4):265-74. doi: 10.1093/heapol/czl014. Epub 2006 May 25.
The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.
在过去十年中，俄罗斯联邦的结核病发病率显著上升。尽管在实施世界卫生组织的“直接观察治疗短程疗法”（DOTS）战略方面进行了大量投资和宣传，但公共卫生结核病控制机构的模式大致仍沿袭1990年前的模式。2002年，我们开展了一项定性研究，以探究俄罗斯萨马拉州医疗服务提供者对获取结核病服务现有障碍的看法。我们与城乡地区医疗机构的医生和护士进行了六次焦点小组讨论。使用应用政策研究的框架方法对数据进行了分析。在相互关联的领域发现了获取医疗服务的障碍：与医疗保健系统相关的障碍、护理过程障碍、与更广泛背景问题相关的障碍以及与患者个人特征和行为相关的障碍。在医疗保健系统中，资金不足被确定为一个根本问题，导致筛查覆盖率下降、工资低、人员短缺、药品供应不规范以及基础设施陈旧。与一般医疗服务和社会服务的协作不佳限制了为患者提供护理和社会支持的机会。社会经济状况的恶化既被视为结核病的一个原因，也是获取医疗服务的一个主要障碍。行为特征被确定为有效护理和治疗的一个重要障碍，医护人员赞成对“不依从”患者进行强制治疗，并让警方参与追踪违约者。结核病与耻辱感密切相关，这导致就医延迟以及确保治疗成功的障碍。
