Gender and access to DOTS program (Directly Observed Treatment, Short-course) in a poor, rural and minority area of Gansu Province, China

Background. China has the second highest tuberculosis (TB) caseload in the world and in response, has been rapidly expanding DOTS (Directly Observed Treatment, Short-course) Program to control TB. However, access to TB services in poor, rural areas remains a major difficulty.Design and methods. The study described the care seeking and treatment experiences of TB patients in the DOTS program in Dongxiang County of Gansu Province, China. A cross-sectional study using semi-structured in-depth interviews was conducted with 22 male and 22 female TB patients. The influence of poverty and gender in the care seeking experiences, and factors related to treatment completion and post-treatment medication behaviors were explored. Physical access of all the 1,508 registered TB patients to DOTS services was determined by using the criteria of 1-hour traveling time to reach the TB Dispensary.Results. Key barriers to prompt care seeking and entering DOTS program include lack of knowledge about TB symptoms, the ability of health providers to detect TB and their willingness to refer. Poverty mediated a circuitous cycle of care seeking, while traditional gender roles placed additional constraints on women in terms of their lack of access to finances for medical care, information about TB care, and restrictions on their mobility. All participants reported self-administration of medication without explicit direct observation being done. Yet, they reported high level of adherence to treatment. But after completing treatment, participants generally did not believe they were cured and continued self-medication in pursuance of a "cure", potentially due in part to their cultural perceptions of cure and the persistence of symptoms. Of all the 1,508 registered TB patients, only 17% could reasonably access the clinic-based DOTS services in one hour's time. Experiences of the 44 participants further revealed the potential of utilizing family members, past TB patients, women's networks and community leaders as DOT supporters.Conclusions. The results indicate an urgent need to develop short-term strategies to improve the quality of TB services and develop innovative community-based DOT to improve access in rural areas. Long-term policies are also needed to address structural constraints to accessing TB care such as poverty and gender.