Strengths of this research included the multi-faceted research team that provided a good level of validity and allowed data triangulation. The FGDs allowed wide scope for understanding the meaning of tuberculosis diagnostic delay because informants facilitated each other during communication . We reached saturation after the fifth FGD, allowing us to create a model to explain the phenomenon of diagnostic delay among patients in the Arkhangelsk region . Limitations of the study included the need to wear facemasks and respirators, which introduced limitations to the face-to-face communication.
The theoretical model of diagnostic delay of tuberculosis diagnosis in Arkhangelsk identified the dominant role of the patients’ “being overpowered by hopelessness”.
This core category of “being overpowered by hopelessness” reflects the passive position of persons in this situation, including the patients’ feelings of inability to change anything in their lives, to get a job, or to receive disability benefits. They blamed the administrative system and the doctors for their problems. “Being overpowered by hopelessness” affected their self-esteem and influenced their entire lives, including family, work and social relations. Therefore, health-seeking behaviour could in this sense be seen as contributing to avoidance of diagnosis and treatment. According to the Illness Behaviour Model , the biological, psychological, and sociocultural dimensions interact to explain why and how people respond to somatic changes and seek help. In this model, concepts of the disease-illness distinction, psychological mediation of affect, and sociocultural variables are used . Based on this, we can say that “being overpowered by hopelessness” explains how people see themselves as victims rather than active agents for their own health.
People were aware of the conflict between treatment and work. They described how they were unable to carry out their work or could not get a job. They did not trust doctors partly because doctors were perceived to only help in difficult cases, or because the treatment process was expensive for various reasons. Although the treatment was free, patients were often asked to take tests, for which they had to pay. A similar situation was described in Vietnam, where patients were required to pay for travel, drugs, etc. .
We cannot say that “being overpowered by hopelessness” is specific to tuberculosis, but it may be common for specific groups of people in Russia who are at particular risk of tuberculosis. The reasons for it are complex. The most obvious are cultural traditions (such as the Orthodox religion), which promotes determinism with both positive and negative values. The destruction of the religious system in the beginning of the twentieth century led people to a sense of victimization that brought negative images into the life philosophy of ordinary people . This appears in the passive behaviour in many parts of their lives. A faith in a leader is typical for underprivileged people; they are accustomed to shifting the responsibility for their lives to a leader. This shift might be aimed at any kind of leader (political, religious, local, or manager at work), depending on the context. Such people remain passive in everyday behaviour by blaming the leader.
The trajectory model provides new dimensions to several types of tuberculosis diagnostic and therapeutic delay described by other authors, including both patient and health system factors. For example, patient delay, doctor delay, health provider delay, diagnostic delay, and treatment delay [3, 36, 37]. Socioeconomic development is one of the key features in our study as in many other studies, but these studies do not account for the individual position of patients . The model can encompass all types of diagnostic delay .
Contrary to the study of Mfinanga et al.,  we did not identify women as vulnerable. E. Johansson , for example, found that women in Vietnam had a TB diagnostic delay two weeks longer than men and had other treatment because of the patient-doctor encounter. Our results are similar to studies from China that identified risk factors of poverty, low educational level, low awareness and knowledge about tuberculosis, and not having any insurance . Flemming et al.  and Shin et al.  described alcohol problems as a risk factor for tuberculosis. This is in line with our findings. Similar to Thomas et al. , who performed a qualitative study of TB patients with alcohol problems, we found alcohol abuse to be a risk factor for delayed tuberculosis diagnosis. Further, alcohol is often related to a low level of social position and peer pressure plays a huge role in alcohol intake.
Our model can be used as a framework for further FGDs and as an interview guide in further research. It would be interesting to find out from in-depth interviews how the passive position has implications in private life. Such phenomena as patient self-esteem and motivation should be studied as influencing the entire life, including family, work and social relations. It is necessary to understand the ways in which treatment and work are incompatible to develop improved management of tuberculosis. Distrust for doctors needs to be clarified by interviews with doctors.
An important finding of our study is that this model might be suitable in similar cultural contexts and other cultural traditions and could lead to a demand for change.
These findings show that it is important to involve people in early medical examination by explaining that tuberculosis can be cured if they ask for medical care in time. It is possible for a patient to avoid passive behaviour if the patient knows what and how to manage the situation with early symptoms.