tuberculosis ( tb ) is one of the oldest diseases known to humankind , and it is the second leading cause of death from an infection worldwide today . the world health organization ( who ) estimates that the global incidence of tb in 2012 was 8.6 million cases , with 1.3 million deaths , predominantly occurring in developing countries ( 1 - 6 ) . the stop tb program , developed by the who and its partners , aims to reduce the burden of disease in accordance with the global targets set for 2015 ( 2 , 7 , 8) . tuberculosis is the second cause of death from infectious diseases after hiv in the world ( 9 ) . the initial optimism that dots would have a dramatic effect on tb incidence rates in developing countries has not been supported by the evidence accumulated so far ( 10 ) . the who recommended treatment strategy for detection and cure of tb is dots , which is the most effective strategy available for controlling the tb epidemic today ( 11 , 12 ) . the dots regimen has higher cure rates and a lower incidence of adverse reactions compared , with the non - dots regimen ( 13 ) . the tb is an important health problem in iran and the issue has become even more and therefore , as a result of increasing drug - resistant strains , drug resistance complicates efforts to control tb . moreover , the problem of extensively drug - resistant strains has recently been introduced ( 14 , 15 ) . despite effective drugs and diagnostic methods , tb is one of the main killers of humanity throughout history and is still growing ( 16 , 17 ) . patient adherence and appropriate monitoring systems in healthcare can lead to the prevention of outbreak of multidrug - resistant tb . this qualitative study aims to investigate experience of tb treatment in patients , who were treated according to dots , in iran . the goal of a directed content analysis approach is to validate or extend conceptually a theoretical framework or theory . existing theory or research can support the research question , to begin identifying key concepts or variables , as initial coding categories ( 18 ) . the data were collected through semi - structured in - depth interviews , with 40 participants from december 2013 to april 2014 . after transcription and analysis of each interview , in case of ambiguity and for probing into participants experience , the interview question was repeated to clarify different aspects of the subject , if needed . each interview lasted between 40 to 60 minutes and all the interviews were conducted in a private room . during interviews , memos and reflections were written by the interviewers . the interview guide consisted of open - ended questions , allowing respondents to fully explain their own experiences . the study was approved by the ethics committee of lorestan university of medical sciences , lorestan , iran . the authors of this manuscript have certified that they comply with the principles of ethical publishing . all interviews were conducted , recorded , transcribed verbatim , then reviewed , coded and immediately analyzed . a directed content analysis approach was used for data analysis . according to the directed content analysis process , at first , each interview was read carefully several times to gain deep understanding of the data . if the goal of the research is to identify and categorize all instances of a particular phenomenon , such as emotional reactions , then it might be helpful to read the transcript and highlight all text that , on first impression , appears to represent an emotional reaction . the next step in analysis would be to code all highlighted passages using the predetermined codes ( 18 ) . then , important statements were underlined to identify the initial codes or meaning units that exist in the interview text . in the next phase , these similar meaning units ( codes ) were placed initially in subcategories of the precede planning model and then into its three main categories of predisposing , enabling and reinforcing . any text that could not be categorized , with the initial coding scheme , would be given a new code . framework  are : familiarization : authors listened to recorded interviews several times to become familiar , read the transcripts , reviewed the field notes and so on , in order to find key ideas and recurrent themes .   identifying a thematic framework : the stage of identifying all the key issues , concepts , and themes by which the data can be examined and referenced . drawing on a priori issues and questions derived from the aims and objectives of the study , as well as issues raised by the respondents themselves and views or experiences that recur in the data . the end product of this stage is a detailed index of the data , which labels the data into manageable chunks for subsequent retrieval and exploration . indexing : index systematically to all the data in textual form by annotating the transcripts with numerical codes from the index , usually supported by short text descriptors to elaborate the index heading . charting : rearranging the data according to the appropriate part of the thematic framework to which they relate , and forming charts . mapping and interpretation : using the charts to define concepts , map the range and nature of phenomena , create typologies and find associations between themes , with a view to providing explanations for the findings . prolonged engagement in the field , from september to december 2013 , helped to establish a certain degree of trust and rapport with participants , providing an opportunity to collect the data . to make sure that the analysis reveals the patients experience , member checking was performed during the data collection , and where needed , several changes were done . to confirm dependability and conformability of the data , the interviews and results of the analyses , the initial codes , subcategories and the categories determined were audited by several experts , the external check method using the co - author ( masoud mirzaei and masoud behzadifar ) expertise in health education sampling strategies allowed for maximum variation to occur and a vast range of views and perspectives to be considered . the data were collected through semi - structured in - depth interviews , with 40 participants from december 2013 to april 2014 . after transcription and analysis of each interview , in case of ambiguity and for probing into participants experience , the interview question was repeated to clarify different aspects of the subject , if needed . each interview lasted between 40 to 60 minutes and all the interviews were conducted in a private room . during interviews , memos and reflections were written by the interviewers . the interview guide consisted of open - ended questions , allowing respondents to fully explain their own experiences . the study was approved by the ethics committee of lorestan university of medical sciences , lorestan , iran . the authors of this manuscript have certified that they comply with the principles of ethical publishing . all interviews were conducted , recorded , transcribed verbatim , then reviewed , coded and immediately analyzed . a directed content analysis approach was used for data analysis . according to the directed content analysis process , at first , each interview was read carefully several times to gain deep understanding of the data . if the goal of the research is to identify and categorize all instances of a particular phenomenon , such as emotional reactions , then it might be helpful to read the transcript and highlight all text that , on first impression , appears to represent an emotional reaction . the next step in analysis would be to code all highlighted passages using the predetermined codes ( 18 ) . then , important statements were underlined to identify the initial codes or meaning units that exist in the interview text . in the next phase , these similar meaning units ( codes ) were placed initially in subcategories of the precede planning model and then into its three main categories of predisposing , enabling and reinforcing . any text that could not be categorized , with the initial coding scheme , would be given a new code . framework  are : familiarization : authors listened to recorded interviews several times to become familiar , read the transcripts , reviewed the field notes and so on , in order to find key ideas and recurrent themes .   identifying a thematic framework : the stage of identifying all the key issues , concepts , and themes by which the data can be examined and referenced . drawing on a priori issues and questions derived from the aims and objectives of the study , as well as issues raised by the respondents themselves and views or experiences that recur in the data . the end product of this stage is a detailed index of the data , which labels the data into manageable chunks for subsequent retrieval and exploration . indexing : index systematically to all the data in textual form by annotating the transcripts with numerical codes from the index , usually supported by short text descriptors to elaborate the index heading . charting : rearranging the data according to the appropriate part of the thematic framework to which they relate , and forming charts . mapping and interpretation : using the charts to define concepts , map the range and nature of phenomena , create typologies and find associations between themes , with a view to providing explanations for the findings . prolonged engagement in the field , from september to december 2013 , helped to establish a certain degree of trust and rapport with participants , providing an opportunity to collect the data . to make sure that the analysis reveals the patients experience , member checking was performed during the data collection , and where needed , several changes were done . to confirm dependability and conformability of the data , the interviews and results of the analyses , the initial codes , subcategories and the categories determined were audited by several experts , the external check method using the co - author ( masoud mirzaei and masoud behzadifar ) expertise in health education sampling strategies allowed for maximum variation to occur and a vast range of views and perspectives to be considered . mean age for the studied patients was 40  17 years ( mean  standard deviation ( sd ) ) , age range ( 16 - 81 ) years . in terms of gender , the majority of individuals , in terms of marital status , were married ( 57.5% ) , secondary and tertiary graduates ( 55% ) , had pulmonary tuberculosis ( 65% ) , and were under 25 years of age 25% of patients . we identified six major issues , under three subcategories of individual factors , related to patients experience of tuberculosis treatment using dots , which included changing attitudes and beliefs about the treatment of tuberculosis patients , protecting patients privacy role of health care , professionals and system , social factors , and the financial cost of treatment . abbreviations : dots , directly observed treatment short - course ; tb , tuberculosis . patients expressed the following individual factors : acceptance by the illness , awareness of its treatment , lack of knowledge of the dangerous side effects of drugs used to treat , non - compliance , knowing that the treatment of the disease is free and not be scared of failure , fear of stigma , no use of tobacco , alcohol , and drugs , which may lead to treatment failure , abstain from drug use because of the lack of employment problems and social tensions , failure to stop medication due to side effects , such as redness , taste , urine changes , itching , etc . , no fear of illness and worries that he is not married , select the medications provided by health centers and not another drug , taking care of the family ( wife and children ) with their adherence . patients expressed the need to change the attitudes and beliefs of patients about tb treatment using dots . this included acceptance of the disease , trust on dots health professionals , be convinced of the improvements of their health , to be ensured that effective and correct use of regular medication would recover them after treatment , according to dots . when they ( healthcare professionals ) said that i have tb , i did not believe it . ( female , 23 years ) .  before administering the treatment , healthcare professionals warned me about the consequence of withdrawal or irregular use of my medications , according to dots patients should be ensured that their confidentiality is a priority for healthcare professionals , as one patient declared :  now , that i am diagnosed with tb , and people are informed about it , no one talks to me and others leave me . ( female , 19 years old ) patients expressed their needs for better education about tb treatment , in general , and dots , in particular . they requested more attention from the healthcare professionals , while their privacy was considered : when i went to the health center to get my medication and test results , i preferred nobody would see me and to receive my education privately  ( female , 22 years old ) ;  at the beginning of treatment , they ( healthcare practitioners ) told me that i have to take 6 months the treatment regularly and according to the protocol . they emphasized that non - compliance to treatment will reduce the chance of successful treatment  ( female , 22 years ) . several inappropriate encounters were mentioned by patients :  at the beginning of my tb , i had used mask to avoid transmission of the disease . ( male , 49 years old ) . patients on tb treatment concerned about the cost of tb treatment , including medications and various tests . one said :  my economic situation is not good and i can not afford the cost of treatment i have concerned that i will die from tb if i can not afford the cost of treatment several also mentioned that they have to follow dots accountably to avoid extra cost for the health care system and the country . my disease has cost for the country , i have to follow the protocol carefully to avoid extra cost on family s budget and the country i am happy that i did not lose my job due to my disease ( tb ) . i look carefully for dots to be respected as on protocol and get back to work patients and carers were asked if they felt involved in making decisions about their condition . seven patients and family cares reported that healthcare personnel did not readily trust or act on their knowledge of their signs , symptoms and beliefs about their illness . this limited the capacity of patients and carers to participate in their care , because there was a perception that healthcare professionals were dismissive and failed to take the views of patients into consideration . the healthcare professionals agreed that the inclusion of patients in planning and decision making about their health could be very helpful in achieving a better health outcome . patients expressed the following individual factors : acceptance by the illness , awareness of its treatment , lack of knowledge of the dangerous side effects of drugs used to treat , non - compliance , knowing that the treatment of the disease is free and not be scared of failure , fear of stigma , no use of tobacco , alcohol , and drugs , which may lead to treatment failure , abstain from drug use because of the lack of employment problems and social tensions , failure to stop medication due to side effects , such as redness , taste , urine changes , itching , etc . , no fear of illness and worries that he is not married , select the medications provided by health centers and not another drug , taking care of the family ( wife and children ) with their adherence . patients expressed the need to change the attitudes and beliefs of patients about tb treatment using dots . this included acceptance of the disease , trust on dots health professionals , be convinced of the improvements of their health , to be ensured that effective and correct use of regular medication would recover them after treatment , according to dots .  when they ( healthcare professionals ) said that i have tb ( female , 23 years ) .  before administering the treatment , healthcare professionals warned me about the consequence of withdrawal or irregular use of my medications , according to dots patients should be ensured that their confidentiality is a priority for healthcare professionals , as one patient declared :  now , that i am diagnosed with tb , and people are informed about it , no one talks to me and others leave me . patients expressed their needs for better education about tb treatment , in general , and dots , in particular . they requested more attention from the healthcare professionals , while their privacy was considered :  when i went to the health center to get my medication and test results , i preferred nobody would see me and to receive my education privately  ( female , 22 years old ) ;  at the beginning of treatment , they ( healthcare practitioners ) told me that i have to take 6 months the treatment regularly and according to the protocol . they emphasized that non - compliance to treatment will reduce the chance of successful treatment  ( female , 22 years ) . several inappropriate encounters were mentioned by patients :  at the beginning of my tb , i had used mask to avoid transmission of the disease . however , several people showed signs of being uncomfortable and avoided me patients on tb treatment concerned about the cost of tb treatment , including medications and various tests . one said :  my economic situation is not good and i can not afford the cost of treatment i have concerned that i will die from tb if i can not afford the cost of treatment several also mentioned that they have to follow dots accountably to avoid extra cost for the health care system and the country . my disease has cost for the country , i have to follow the protocol carefully to avoid extra cost on family s budget and the country  ( female , 24 years old ) . i am happy that i did not lose my job due to my disease ( tb ) . i look carefully for dots to be respected as on protocol and get back to work patients and carers were asked if they felt involved in making decisions about their condition . seven patients and family cares reported that healthcare personnel did not readily trust or act on their knowledge of their signs , symptoms and beliefs about their illness . this limited the capacity of patients and carers to participate in their care , because there was a perception that healthcare professionals were dismissive and failed to take the views of patients into consideration . the healthcare professionals agreed that the inclusion of patients in planning and decision making about their health could be very helpful in achieving a better health outcome . limited time and human resources were seen , as significant barriers . this study has demonstrated that patients with tb , who received treatment according to dots , faced a range of challenges in completing the treatment . these include attitudes and beliefs about the treatment of tb , protecting patients privacy , the role of health care professionals and system , social factors and the financial cost of treatment . other studies mention patient perceptions of disease in high - prevalence areas , reducing the transmission of disease through early detection and immediate treatment of patients with tb ( 19 ) . these involve patients understanding of their illness , beliefs , attitudes toward treatment , as such factors affect the individual treatment . lack of attention to factors , such as poverty and gender discrimination , may lead to treatment failure ( 21 ) . when someone is identified as a patient , he needs to be motivated to treat according to his desire and make their adherence to the treatment the highest possible ( 21 - 24 ) . the role of community , family services and health systems , is essential in counteracting the feelings of stigma of the disease , and help patients to overcome wrong thinking and attitudes and follow the protocol more cautiously ( 25 ) . factors related to health care professional and system includes flexibility in patients demands , depending on the type of services provided to patients , reducing the waiting time , creating a convenient location for the completion of the treatment and improving patients satisfaction ( 26 - 28 ) . providing financial support will help to complete their treatment according to dots . when people with low incomes are faced with the costs of tb , they suffer from distress and are aware that therapies are expensive ( 30 , 31 ) . it is essential to ensure the preservation of their jobs , because in the absence of disease , the patient will have more confidence to continue his treatment , whereas neglecting these issues makes the patients not willing to treat themselves ( 32 ) . to achieve the main goal in the early treatment of patients with tb , it is mandatory to manage prevention of infection and reduce the social and economic costs . considering this is essential if we want patients to adhere to their treatment of tb , we should strive to learn effectively and interconnected factors should continuously be assayed . successful completion of tb treatment requires an effective collaboration between the healthcare professional and the patient . the cultural context , the attitude of the patient , patient and family education and information , supported by the appropriate legislation are key factors to be considered to aid in reducing the livelihood concerns of patients and lack of patient adherence to treatment and health care costs .
background : despite effective diagnosis and treatment , prevalence of tuberculosis ( tb ) is still growing . 
 the directly observed treatment , short - course ( dots ) strategy to treat tb was introduced by the world health organization more than a decade ago . 
 little is known about patients experience of tb treatment , according to dots , in iran.objectives:this study aimed to understand the patients experience of tuberculosis treatment according to dots in iran.patients and methods : this study is a qualitative study , using content analysis to examine patients experience of tb treatment and to understand their compliance during dots . in this study , a semi - structured interview with open questions was answered by 40 patients , who had a diagnosis of pulmonary and extrapulmonary tuberculosis , and improved during the course of their treatment . 
 the method of sampling was purposive sample and the interview process lasted until data saturation.results:data analysis resulted in the extraction of six themes , which reflect the experiences of the study participants . 
 the themes are : 1 ) individual factors ; 2 ) change of the attitudes and beliefs of patients on tb treatment ; 3 ) support terms of patients with tuberculosis ; 4 ) the role of health care professionals ; 5 ) social factors and 6 ) the financial burden.conclusions:successful completion of tb treatment requires an effective partnership between the patient and health care professionals , and a harmony between the cultural context , attitude of the patient , family support and health literacy . 
 future health policies should address these issues to improve patients adherence to dots .