Soedarsono et al.

BMC Pulm Med (2021) 21:360

https://doi.org/10.1186/s12890-021-01735-9

RESEARCH Open Access

Determinant factors for loss to follow‑up

in drug‑resistant tuberculosis patients:
the importance of psycho‑social and economic
aspects
Soedarsono Soedarsono1,5* , Ni Made Mertaniasih2,5* , Tutik Kusmiati1,5, Ariani Permatasari1,5,
Ni Njoman Juliasih3,5, Cholichul Hadi4,5 and Ilham Nur Alfian4,5

Abstract
Background: Drug-resistant tuberculosis (DR-TB) is the barrier for global TB elimination efforts with a lower treat-
ment success rate. Loss to follow-up (LTFU) in DR-TB is a serious problem, causes mortality and morbidity for patients,
and leads to wide spreading of DR-TB to their family and the wider community, as well as wasting health resources.
Prevention and management of LTFU is crucial to reduce mortality, prevent further spread of DR-TB, and inhibit the
development and transmission of more extensively drug-resistant strains of bacteria. A study about the factors associ-
ated with loss to follow-up is needed to develop appropriate strategies to prevent DR-TB patients become loss to
follow-up. This study was conducted to identify the factors correlated with loss to follow-up in DR-TB patients, using
questionnaires from the point of view of patients.
Methods: An observational study with a cross-sectional design was conducted. Study subjects were all DR-TB
patients who have declared as treatment success and loss to follow-up from DR-TB treatment. A structured question-
naire was used to collect information by interviewing the subjects as respondents. Obtained data were analyzed
potential factors correlated with loss to follow-up in DR-TB patients.
Results: A total of 280 subjects were included in this study. Sex, working status, income, and body mass index
showed a significant difference between treatment success and loss to follow-up DR-TB patients with p-value of
0.013, 0.010, 0.007, and 0.006, respectively. In regression analysis, factors correlated with increased LTFU were nega-
tive attitude towards treatment (OR = 1.2; 95% CI = 1.1–1.3), limitation of social support (OR = 1.1; 95% CI = 1.0–1.2),
dissatisfaction with health service (OR = 2.1; 95% CI = 1.5–3.0)), and limitation of economic status (OR = 1.1; 95%
CI = 1.0–1.2)).
Conclusions: Male patients, jobless, non-regular employee, lower income, and underweight BMI were found in
higher proportion in LTFU patients. Negative attitude towards treatment, limitation of social support, dissatisfaction
with health service, and limitation of economic status are factors correlated with increased LTFU in DR-TB patients.

*Correspondence: [email protected]; [email protected]

1
Department of Pulmonology and Respiratory Medicine, Faculty
of Medicine, Universitas Airlangga, Surabaya, Indonesia
2
Department of Clinical Microbiology, Faculty of Medicine, Universitas
Airlangga, Surabaya, Indonesia
Full list of author information is available at the end of the article

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Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 2 of 8

Non-compliance to treatment is complex, we suggest that the involvement and support from the combination of
health ministry, labor and employment ministry, and social ministry may help to resolve the complex problems of
LTFU in DR-TB patients.
Keywords: Drug-resistant tuberculosis, Loss to follow-up, Psycho-social support, Economic support

Introduction mortality, prevent further spread of DR-TB, and inhibit

Tuberculosis (TB) remains a global health problem the development and transmission of more extensively
caused 10 million people fell ill with TB and 1.2 mil- drug-resistant strains of bacteria [10]. This present study
lion deaths. Drug-resistant TB (DR-TB) continues to be was conducted to identify the factors correlated with
a public health threat. There were an estimated 465,000 LTFU in DR-TB patients, using questionnaires in the
DR-TB cases. Indonesia ranks 5th for high DR-TB bur- point of view of patients in aspects of treatment, psycho-
den with 24,000 DR-TB cases. DR-TB is the barrier for social and economic.
global TB elimination efforts with a global treatment suc-
cess rate of 57% for DR-TB. Loss to follow-up (LTFU) Methods
is one of the main factors affecting low success rate of This was an observational study with a cross-sectional
DR-TB treatment. In Indonesia, treatment success rate design. The samples were all DR-TB patients who have
was below 50% due to high rates of LTFU (26%) [1]. been declared as treatment success and LTFU from
Non-adherence to treatment is important concern for DR-TB treatment and received long regimen with inject-
clinicians when managing infectious diseases, especially able drug from 2017 to March 2021. Treatment success
for the governments when making the public health poli- was defined as the sum of cured and treatment com-
cies as a strategy to end TB [1]. LTFU is a serious prob- pleted. Cured was defined as treatment completed as
lem, causes mortality and morbidity for patients, and recommended by the national policy without evidence
leads to wide spreading of DR-TB to their family and the of failure and three or more consecutive cultures taken
wider community, as well as wasting health resources at least 30 days apart are negative after the intensive
[3]. DR-TB requires treatment with second-line drugs, phase. Treatment completed was defined as treatment
which have many more adverse effects than first-line completed as recommended by the national policy with-
anti-TB drugs. The treatment duration ranged from 9 to out evidence of failure but no record that three or more
11 months for shorter regimen and 18 to 24 months for consecutive cultures taken at least 30 days apart are
longer regimen, depending on the treatment regimen. negative after the intensive phase. LTFU was defined as
Therefore, compliance and motivation of patients during a patient whose treatment was interrupted for 2 consecu-
treatment should be maintained to complete treatment tive months or more [11]. Respondents included DR-TB
and achieve cure [1, 4]. patients who come from residents in the area of Surabaya
Previous studies reported adverse drug reactions and surrounding areas of East Java, Indonesia.
(ADRs) as the most important factors associated with A structured questionnaire was used to collect infor-
LTFU, as DR-TB treatment was longer and greater inci- mation by interviewing the subjects as respondents who
dence of ADRs compared to drug-susceptible TB [5–9]. have signed the informed consent. The questionnaire was
A long duration, greater incidence of ADRs, and unfa- developed from any validated and previously published
vorable social conditions (unemployment and home- articles, and some questions were added from the experi-
lessness) are considered to be correlated with LTFU in ences of clinicians when providing medical services and
DR-TB treatment [5, 6]. The adverse effects of treatment hearing the complaints of DR-TB patients. The question-
and history of previous DR-TB treatment were also asso- naire was administered when the treatment outcomes of
ciated with non-adherence to anti-TB treatment [7–9]. DR-TB patients have been reported. The questionnaire
However, non-treatment factors such as psycho-social was administered to DR-TB patients in a home visit by
and economic may also played role in LTFU. The prob- peer educators or patients’ supporters.
lem of LTFU in DR-TB treatment also may be more com- The questionnaire contained four aspects: negative
plex in Indonesia, as one of the countries with a high attitude towards treatment, limitation of social sup-
DR-TB burden. port, health service, and limitation of economic status.
Prevention and management of LTFU is crucial [1]. Negative attitude towards treatment consisted of 30
Knowing the factors associated with LTFU could be questions, limitation of social support with 7 questions,
used to develop appropriate strategies to prevent DR-TB dissatisfaction of health service with 1 question, and
patients become LTFU. This was important to reduce limitation of economic status consisted of 3 questions.
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 3 of 8

A 2-point (yes and no) was used for negative attitude approved by the ethics committee with ethical clearance
towards treatment. Every patient who answered yes number 103/EC/KEPK/FKUA/2021.
(has a negative attitude towards treatment) for each
question has a score of 1 (maximum score: 30), while Results
every patient who answered no (has no negative atti- Of the 350 DR-TB patients with treatment outcomes
tude towards treatment) for each question has a score of treatment success and LTFU, a total of 280 subjects
of 0 (minimum score: 0). While a 5-point scale (strongly agreed to be interviewed and included in this study.
disagree, disagree, neutral, agree, and strongly agree) 280 subjects consisted of 115 treatment success and 165
was used for limitation of social support, dissatisfac- LTFU. Sex, working status, income, and body mass index
tion with health service, and limitation of economic showed significant differences between treatment suc-
status. Each question has a score of 1 for strongly disa- cess and loss to follow-up DR-TB patients with p = 0.013,
gree, 2 for disagree, 3 for neutral, 4 for agree, and 5 for 0.010, 0.007, and 0.006, respectively. While age, educa-
strongly agree. tion level, marital status, and family history of TB disease
Negative attitude towards treatment in the question- between treatment success and LTFU DR-TB patients
naire is the negative attitude and perception of subjects showed no significant difference. Socio-demographic of
about DR-TB treatment. Questionnaire of limitation of study subjects are presented in Table 2.
social support described support from family, friends, Table 2 above also showed that LTFU patients have
co-workers, and other people when the subjects were a significantly higher mean value of negative attitude
diagnosed and treated for DR-TB. Questionnaire of towards treatment, compared to treatment success
health service described the view of subjects about the patients, with median (IQR) of 20 (14–22) versus 14 (10–
health services by the health-care worker in provid- 16), p < 0.001. Limitation of social support was also found
ing DR-TB treatment. Questionnaire of limitation of higher significantly in LTFU patients than in treatment
economic status comprised the questions of economic success patients with median (IQR) of 19 (16–23) versus
conditions while being treated with DR-TB treatment, 15 (11–16), p < 0.001. LTFU patients also have a higher
including job, income, transport fee, and enablers from dissatisfaction with health service than those treatment
the government. Table 1 below is themes of questions in success patients with median (IQR) of 4 (2–4) versus 2
the questionnaire. (1–2), p < 0.001. While limitation of economic status in
Completed questionnaires are input by the research LTFU and treatment success patients have median (IQR)
assistant and double checked by the investigators. Data of 6 (5–11) versus 7 (5–9), p = 0.310.
was entered and analyzed using SPSS 21.0 (SPSS 21.0 by Regression analysis in Table 3 showed that factors
IBM Corporation, New York, United States) for all sta- increased of being LTFU were negative attitude towards
tistical analyses. Socio-demographic data were summa- treatment (OR 1.2, 95% CI 1.1–1.3), limitation of social
rized as frequencies & percentages and were analyzed for support (OR 1.1, 95% CI 1.0–1.2), health service (OR
significance test using Chi-square test. Logistic regres- 2.1, 95% CI 1.5–3.0), and limitation of economic status
sion analysis was performed to determine potential fac- (OR 1.1, 95% CI 1.0–1.2). This result also showed that
tors correlated with LTFU in DR-TB patients. A p < 0.05 although limitation in economic status was not signifi-
was considered statistically significant. This study was cantly higher in LTFU patients, it has a significant impact

Table 1 Variables and themes of questions in the questionnaire

Variables Themes of questions

Negative attitude towards treatment Lack of awareness

Myths and misbeliefs regarding disease
Adverse drug and treatment effects
Duration and schedule of medication conflict-
ing with daily activities
Limitation of social support Stigma and discrimination
Lack of family and social support
Dissatisfaction with health service Behavior of service provider
Limitation of economic status Conflicting timing of job and treatment
Unemployment and financial constraints
Late of enablers payment from the government
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 4 of 8

Table 2 Socio-demographic of study subjects

Variables Treatment success LTFU Total (n = 280) P-value
N (%) or mean ± SD or median (IQR, 1st–3rd quartile)

Sex 0.013
Male 65 (35.7%) 117 (64.3%) 182
Female 50 (51%) 48 (49%) 98
Age 0.367
47.5 ± 11.4 44.4 ± 12.1 45.7 ± 11.9
(19–73)* (16–75)* (16–75)*
Education level 0.635
Elementary school 29 (40.3%) 43 (59.7%) 72
Junior high school 21 (38.9%) 33 (61.1%) 54
Senior high school 55 (40.4%) 81 (59.6%) 136
Diploma and above 10 (55.6%) 8 (44.4%) 18
Working status 0.010
Jobless 55 (33.7%) 108 (66.3%) 163
Non-regular Employee 35 (48.6%) 37 (51.4%) 72
Regular employee 25 (55.6%) 20 (44.4%) 45
Income 0.007
< 1 million rupiah 61 (34.7%) 115 (65.3%) 176
> 1–3 million rupiah 37 (48.1%) 40 (51.9%) 77
> 3 million rupiah 17 (63%) 10 (37%) 27
Marital status 0.140
Single 11 (27.5%) 29 (72.5%) 40
Married 89 (42.6%) 120 (57.4%) 209
Divorced 15 (48.4%) 16 (51.6%) 31
Family history of TB disease 0.148
Yes 9 (29%) 22 (71%) 31
No 106 (42.6%) 143 (57.4%) 249
Body mass index 0.006
Underweight 22 (30.6%) 50 (69.4%) 72
Normal 72 (41.1%) 103 (58.9%) 175
Overweight and obese 21 (63.7%) 12 (36.3%) 33
Negative attitude towards treatment 14 (10–16)** 20 (14–22)** 280 < 0.001
Limitation of social support 15 (11–16)** 19 (16–23)** 280 < 0.001
Dissatisfaction with health service 2 (1–2)** 4 (2–4)** 280 < 0.001
Limitation of economic status 7 (5–9)** 6 (5–11)** 280 0.310
*Mean ± standard deviation (minimum–maximum)
**Median (IQR, 1st–3rd quartile)

Table 3 Binary logistic regression analysis between complaints on the prevalence of LTFU when analyzed in a logistic
of patients and LTFU regression.
Variables OR (95% CI)

Negative attitude towards treatment 1.2 (1.1–1.3) Discussion

Limitation of social support 1.1 (1.0–1.2) Socio-demographic of study subjects in Table 2 showed
Dissatisfaction with health service 2.1 (1.5–3.0) that sex, working status, income, and BMI between
Limitation of economic status 1.1 (1.0–1.2)
treatment success and LTFU patients were significantly
different (p-value of 0.013, 0.010, 0.007, and 0.006,
respectively). While age, education level, marital status,
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 5 of 8

and family history of TB between treatment success Our study found that income between treatment
and LTFU patients were not significant differences with success and LTFU patients was significantly different
p = 0.367, 0.635, 0.140, and 0.148, respectively. LTFU (p = 0.007). Most of subjects in this study have income
was found higher in males than females (64.3% vs. 49%, below 1 million rupiah (rate of 65.3%), showing poor
p = 0.013). A previous study reported that older age and condition. Cost of transport and other needs during
male sex were risk factors for LTFU, whereas patients treatment are also problems for patients who are in poor
with higher initial body weight were less likely to be condition, and LTFU became their final option [3]. The
LTFU [12]. A significant association of LTFU with occu- correlation between poverty and LTFU could be reduced
pation, marital status, and socio-economic status in by a strategy in programs, the supply of financial incen-
newly diagnosed pulmonary TB and extra pulmonary TB tives may improve the adherence to treatment [17].
patients was also reported in a multi stratified study in Using structured questionnaires, logistic regression
India [3]. analysis found that negative attitude towards treatment
Loss to follow-up patients in our study were found (OR 1.2, 95% CI 1.1–1.3), limitation of social support
higher in males, compared to females (64.3% vs. 49%, (OR 1.1, 95% CI 1.0–1.2), dissatisfaction with health ser-
p = 0.013). Working status between treatment suc- vice (OR 2.1, 95% CI 1.5–3.0), and limitation of economic
cess and LTFU was also found significantly different status (OR 1.1, 95% CI 1.0–1.2) were significantly posi-
(p = 0.010). A high rate of LTFU was found in patients tively correlated with LTFU from treatment (Table 3).
who were unemployed and non-regular employees Our findings suggested that a strategy to improve treat-
(66.3% and 51.4%). Male sex and working status affected ment adherence needs to combine the aspect of psycho-
LTFU probably because male patients often work to pro- logical, social, health service, and economic support.
vide the needs of their families, while patients of regular The aspect of negative attitude towards treatment com-
employees have a lower rate of LTFU (44.4%) perhaps prised lack of awareness, myths and misbeliefs regarding
because they already have permanent jobs and no need the disease, adverse drug and treatment effects, duration
to be worried when dividing their times between work- and schedule of medication conflicting with daily activi-
ing and taking DR-TB treatment. Another study also ties. Education and counseling for DR-TB patients are
reported that most of non-adherents were males patients, very important to break the myths and misbeliefs among
most of them were day-laborers and main earning mem- patients regarding disease, also to inform the patients
bers [13]. Going to a healthcare facility for DR-TB treat- about the benefits of medication over the adverse effects.
ment for an employed patient means an absent time from A previous study also reported drug side effects and con-
work, and it may pose huge problems, especially for non- flicts with the timing of treatment services as the barri-
regular employees. Working and treatment may also put ers to treatment adherence [19]. Another study found
them in a stress condition, that as soon as they begin to that poor adherence to DR-TB treatment is associated
feel better, they will choose to return to work to continue with negative side effects from the treatment, busy work
to earn for their families. While female patients, espe- schedules, and financial difficulties [8]. In patients with
cially who were housewife may have more available time multidrug-resistant tuberculosis (MDR-TB), both patient
to take their drugs on proper time [3]. and regimen were related factors associated with LTFU
Patients with education levels of elementary school, [20]. A case–control study in Tajikistan reported that
junior high school, and senior high school have higher patients who have been previously treated need extra
rates of LTFU, compared to patients with education levels care to ensure treatment completion [21].
of diploma and above, but the statistical analysis showed Treatment adherence is influenced by many factors,
no significant difference (p = 0.635). Patients with educa- including socio-economic factors and drug toxicity, per-
tion level of diploma and above have a lower rate of LTFU ceived health benefits, and subjective experience of ill-
(44.4%), although it was not significant statistically. A ness [3]. Independent factors associated with LTFU
study in China in Ethiopia found that anti-TB treatment included patients’ higher self-rating of the severity of
non-adherence was associated with poor TB knowledge adverse drug reaction, while protective factors included
[14, 15]. In this study, the lower rate of LTFU in patients receiving any type of assistance from the TB program,
with higher education levels may be due to higher aware- better TB knowledge, and higher levels of trust in and
ness and better knowledge of their disease, thus increase support from physicians and nurses [22]. Treatment out-
their compliance for treatment. A higher education level comes were mainly affected by patient individual factors
affected the way of thinking, including the ability to over- [23].
come problems [16], associated with better adherence to Limitation of social support in this study included
treatment since it increases awareness of the disease [17, stigma, discrimination, and lack of family and social
18]. support had a significant correlation with LTFU (OR
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 6 of 8

1.1, 95% CI 1.0–1.2) (Table 3). Non-adherence to treat- factors such as employment status and the need to bor-
ment correlated with lack of provider support and social row money when seeking treatment may also influence
stigma. Resolving medical problems like adverse drug LTFU [10]. Helping patients to achieve full adherence to
effects, motivational counseling, flexible timings for TB medication is a complex problem as it is influenced
health-care services, social, family support for patients by interplay between many factors. Healthcare managers,
& improving awareness about disease were required to providers, and researchers need to consider and address
be enhanced [19]. In certain patients, motivation to con- multiple underlying factors when designing adherence
tinue treatment decreases over time, and when they feel interventions [26].
their conditions have improved, they may LTFU from Loss to follow-up from DR-TB treatment is a barrier
treatment [3]. Patients will need support to overcome the to cure and control the disease [28]. LTFU patients are
hardships associated with TB and its treatment, includ- a threat to the spread of DR-TB disease in the commu-
ing daily adherence, adverse drug reactions, indirect nity. Identified factors correlated with LTFU can be used
costs, and stigma [4]. Counseling based on behavioral to make a strategy to resolve this urgent problem [29], it
activation theory, information/education materials, and is also essential to prevent the community from primary
group interactions with other patients showed acceptable DR-TB infection and to reduce further drug resistance
to patients to resolve their depression during treatment, developments [30]. Non-compliance to treatment is com-
suggested the need for counselors in TB clinics [24]. plex [3], the role and efforts from all parties are essen-
Dissatisfaction with health service (from the physi- tial. The involvement and support from the combination
cians and nurses) such as poor communication between of health ministry, labor and employment ministry, and
patients and healthcare workers was associated with social ministry may help to resolve the complex problems
LTFU [25]. A good communication between health care of LTFU in DR-TB patients.
providers, patients, and their families, and strong social
support networks could reduce the stigma [17]. Eco-
nomic status, including conflicting timing of job and Strength and limitations
treatment, financial constraints, and late payment of The strength of this study was that it was the first in this
enablers from government also play role in LTFU in our kind reported from Indonesia, especially when adverse
study. Although medicines are provided free, but family drug reaction of DR-TB treatment was considered as
liabilities and burden of losing income from work were the most important factor for LTFU. Thus, the authori-
possible to cause LTFU [3]. ties should evaluate psycho-social and economic factors
Enablers for transportation may minimize the finan- of patients. The results of this study were also as a policy
cial barrier to adherence. However, the delay of payment intake to strengthen the collaboration between health
is a problem. The amount of assistance from enablers is ministry, labor and employment ministry, and social min-
limited and transportation cost may exceeds the finan- istry as a strategy to prevent LTFU in DR-TB patients.
cial ability of patients, and loss of income when under- The limitation of this study was that the respondents
going treatment at health-care facility which is not open were possible to have a tendency to report an answer in
for full-day [10]. The World Health Organization (WHO) a way they deem more acceptable and more appropriate
also reported that DR-TB patients and their households instead of their true thoughts and experiences.
faced higher catastrophic costs than drug-susceptible
TB (DS-TB) patients, including the combined cost of
transportation, food, nutritional supplements, and other Conclusions
non-medical expenditures [1]. Improving treatment Male patients, unemployment, non-regular employee,
adherence is needed, including providing material sup- lower income, and underweight BMI were found higher
port (e.g. food, financial incentives, and reimbursement in LTFU patients. Negative attitude towards treatment,
of transport fees) and psychological support [4]. Factors limitation of social support, dissatisfaction with health
influencing patient adherence to TB treatment are fac- service, and limitation of economic status are factors cor-
tors of patient-centered, social, economic, health system, related with increased LTFU in DR-TB patients. Non-
therapy, lifestyle, and geographic access [26]. Psycho- compliance to treatment is complex, we suggest that the
emotional and socio-economic interventions provided involvement and support from the combination of health
to TB patients showed beneficial effects on TB treatment ministry, labor and employment ministry, and social
outcomes [27]. ministry may help to resolve the complex problems of
Certain LTFU patients may lose their jobs due to LTFU in DR-TB patients.
undergoing treatment at a healthcare facility. Economic
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 7 of 8

Abbreviations 4. World Health Organization. WHO operational handbook on tuberculosis:

ADRs: Adverse drug reactions; Anti-TB: Anti-tuberculosis; BMI: Body mass drug resistant tuberculosis treatment. Geneva: WHO; 2020.
index; CI: Confidence interval; DR-TB: Drug-resistant tuberculosis; DS-TB: Drug- 5. Soedarsono S, Kusmiati T, Wulaningrum PA, Permatasari A, Indrawanto
susceptible TB; LTFU: Loss to follow-up; OR: Odds ratio; TB: Tuberculosis; WHO: DW. Factors cause of switching shorter regimen to longer regimen in
World Health Organization. multidrug-resistant/rifampicin-resistant tuberculosis treated patients in
Dr. Soetomo Hospital Surabaya, Indonesia. Indian J Forens Med Toxicol.
Acknowledgements 2021;15(1): 1589–95.
The authors would like to thank all peer educators (Rekat Surabaya) and 6. Gualano G, Mencarini P, Musso M, Mosti S, Santangelo L, Murachelli
patients’ supporters (TB Aisyiyah) who helped in data collection by interview- S, et al. Putting in harm to cure: drug related adverse events do not
ing all study subjects. affect outcome of patients receiving treatment for multidrug-resistant
Tuberculosis. Experience from a tertiary hospital in Italy. PLoS ONE. 14(2):
Authors’ contributions e0212948.
SS, NMM, TK, NMJ, AP, CH, INA: concepts, design, definition of intellectual 7. Ajema D, Shibru T, Endalew T, Gebeyehu S. Level of and associated factors
content. ATA: data collection and literature search. SS, NMM: data analysis, for non-adherence to anti-tuberculosis treatment among tubercu-
prepared tables, manuscript preparation. All authors: manuscript editing and losis patients in Gamo Gofazone, southern Ethiopia: cross-sectional
review. SS and NMM contribute equally. All authors read and approved the study. BMC Public Health. 2020;20:1705. https://​doi.​org/​10.​1186/​
final manuscript. s12889-​020-​09827-7.
8. Xing W, Zhang R, Jiang W, Zhang T, Pender M, Zhou J, et al. Adherence
Funding to multidrug resistant tuberculosis treatment and case management in
This study was supported by a grant from Universitas Airlangga. Chongqing, China—a mixed method research study. Infect Drug Resist.
2021;14:999–1012.
Availability of data and materials 9. Batte C, Namusobya MS, Kirabo R, Mukisa J, Adakun S, Katamba A. Preva-
The datasets analyzed during the current study are available from the cor- lence and factors associated with non-adherence to multi-drug resistant
responding author on reasonable request. tuberculosis (MDR-TB) treatment at Mulago National Referral Hospital,
Kampala. Uganda Afri Health Sci. 2021;21(1):238–47.
10. Mangan JM, Tupasi TE, Garfin AM, Lofranco V, Orillaza-Chi R, Basilio R, et al.
Declarations Multidrug-resistant tuberculosis patients lost to follow-up: self-reported
readiness to restart treatment. Int J Tuberc Lung Dis. 2016;20(9):1205–11.
Ethics approval and consent to participate 11. World Health Organization. Meeting report of the WHO expert consulta-
This study was approved by the ethics committee with ethical clearance tion on drug-resistant tuberculosis treatment outcome definitions: 17–19
Number 103/EC/KEPK/FKUA/2021. The study was a non-intervention research, November 2020. Geneva: WHO; 2021.
data were obtained by interviewing DR-TB patients as respondents. Before the 12. Aung YK, Swe PP, Kyaw Z, Thein ST. Differential loss to follow-up
interview, the respondents were explained about the research and publica- rates among adult tuberculosis patients—Findings from the largest
tions to be carried out. All respondents’ information is kept confidential and private sector tuberculosis clinic database in Myanmar. PLoS ONE.
only used for research purposes. After getting an explanation, the respondent 2019;14(6):e0218450. https://​doi.​org/​10.​1371/​journ​al.​pone.​02184​50.
is allowed to refuse the interview or resign in the middle of the interview. The 13. Hossain MM, Flora MS, Shahidullah M, Amin MN, Mosharref M, Wahab MA.
respondents gave their written consent and permission for publication of Socio-demographic and economic factors associated with adherence to
the letters and to participate in the research. We confirm that all the research anti-tuberculosis treatment. JAFMC Bangladesh. 2019;15(1):39–41.
meets the ethical guidelines and has been submitted to the ethics committee. 14. Fang XH, Shen HH, Hu WQ, Xu QQ, Jun L, Zhang ZP, et al. Prevalence
of and factors influencing anti-tuberculosis treatment non-adherence
Consent for publication among patients with pulmonary tuberculosis: a cross-sectional study in
The respondents in this study have given their written consent for publication Anhui Province. Eastern China Med Sci Monit. 2019;25:1928–35.
of the research. 15. Woimo T, Yimer WK, Bati T, Gesesew HA. The prevalence and factors asso-
ciated for anti-tuberculosis treatment non-adherence among pulmonary
Competing interests tuberculosis patients in public health care facilities in South Ethiopia: a
The authors declare that they have no competing interests. cross-sectional study. BMC Public Health. 2017;17:269. https://​doi.​org/​10.​
1186/​s12889-​017-​4188-9.
Author details 16. Juliasih NN, Mertaniasih NM, Hadi C, Soedarsono, Sari RM, Alfian IN. Fac-
1
Department of Pulmonology and Respiratory Medicine, Faculty of Medi- tors affecting tuberculosis patients’ quality of life in Surabaya, Indonesia. J
cine, Universitas Airlangga, Surabaya, Indonesia. 2 Department of Clinical Multidiscip Health. 2020;13: 1475–1480.
Microbiology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. 17. Viana PV, Redner P, Ramos JP. Factors associated with loss to follow-up
3
Laboratory of Tuberculosis, Institute of Tropical Disease, Universitas Airlangga, and death in cases of drug-resistant tuberculosis (DR-TB) treated at
Surabaya, Indonesia. 4 Department of Psychology, Faculty of Psychology, Uni- a reference center in Rio de Janeiro, Brazil. Cad. Saúde Pública 2018;
versitas Airlangga, Surabaya, Indonesia. 5 Tuberculosis Study Group, Universitas 34(5):e00048217.
Airlangga, Surabaya, Indonesia. 18. Ruru Y, Matasik M, Oktavian A, Senyorita R, Mirino Y, Tarigan LH, et al.
Factors associated with non-adherence during tuberculosis treatment
Received: 5 August 2021 Accepted: 4 November 2021 among patients treated with DOTS strategy in Jayapura, Papua Province,
Indonesia. Glob Health Action. 2018; 11. https://​doi.​org/​10.​1080/​16549​
716.​2018.​15105​92.
19. Deshmukh RD, Dhande DJ, Sachdeva KS, Sreenivas A, Kumar AMV,
Satyanarayana S, et al. Patient and provider reported reasons for lost to
References follow up in MDRTB treatment: a qualitative study from a drug resistant
1. World Health Organization. Global Tuberculosis Report 2020. Geneva: TB Centre in India. PLoS ONE. 2015;10(8):e0135802. https://​doi.​org/​10.​
WHO; 2020. 1371/​journ​al.​pone.​01358​02.
2. Bea S, Lee H, Kim JH, Jang SH, Son H, Kwon JW, et al. Adherence and 20. Walker IF, Shi O, Hicks JP, et al. Analysis of loss to follow-up in 4099
associated factors of treatment regimen in drug-susceptible tuberculosis multidrugresistant pulmonary tuberculosis patients. Eur Respir J.
patients. Front Pharmacol. 2021;12:625078. https://​doi.​org/​10.​3389/​fphar.​ 2019;54:1800353. https://​doi.​org/​10.​1183/​13993​003.​00353-​2018.
2021.​625078. 21. Wohlleben J, Makhmudova M, Saidova F, Aamova S, Mergenthaler C,
3. Heemanshu A, Satwanti K. Determinants of lost to follow up during Verver S. Risk factors associated with loss to follow-up from tuberculosis
treatment among tuberculosis patients in Delhi. Int J Med Res Health Sci. treatment in Tajikistan: a case-control study. BMC Infect Dis. 2017;17:543.
2016;5(1):145–52. https://​doi.​org/​10.​1186/​s12879-​017-​2655-7.
Soedarsono et al. BMC Pulm Med (2021) 21:360 Page 8 of 8

22. Tupasi TE, Garfin AM, Kurbatova EV, Mangan JM, Orillaza-Chi R, Naval patients on treatment adherence and treatment outcomes—a system-
LC, et al. Factors associated with loss to follow-up during treatment for atic review and meta-analysis. PLoS ONE 11(4): e0154095. https://​doi.​org/​
multidrug-resistant tuberculosis, the Philippines, 2012–2014. Emerg 10.​1371/​journ​al.​pone.​01540​95.
Infect Dis. 2016;22(3):491–502. 28. Kendall EA, Theron D, Franke MF, Helden P, Victor TC, Murray MB. Alcohol,
23. Ali MK, Karanja S, Karama M. Factors associated with tuberculosis treat- hospital discharge, and socioeconomic risk factors for default from mul-
ment outcomes among tuberculosis patients attending tuberculosis tidrug resistant tuberculosis treatment in Rural South Africa: a retrospec-
treatment centres in 2016–2017 in Mogadishu. Somalia Pan African Med tive cohort study. PLoS ONE. 2013; 8(12): e83480.
J. 2017;28:197. https://​doi.​org/​10.​11604/​pamj.​2017.​28.​197.​13439. 29. Kuchukhidze G, Kumar AMV, Colombani P, Khogali M, Nanava U, Blum-
24. Walker IF, Khanal S, Hicks JP, Lamichhane B, Thapa A, Elsey H, et al. berg HM, et al. Risk factors associated with loss to follow-up among
Implementation of a psychosocial support package for people receiving multidrug-resistant tuberculosis patients in Georgia. Public Health Action.
treatment for multidrug-resistant tuberculosis in Nepal: a feasibility and 2014;4(3):S41–6.
acceptability study. PLoS ONE. 2018;13(7):e0201163. https://​doi.​org/​10.​ 30. Kassa GM, Teferra AS, Wolde HF, Muluneh AG, Merid MW. Incidence and
1371/​journ​al.​pone.​02011​63. predictors of lost to follow-up among drug-resistant tuberculosis patients
25. Tola HH, Tol A, Shojaeizadeh D, Garmaroudi G. Tuberculosis treatment at University of Gondar Comprehensive Specialized Hospital, Northwest
non-adherence and lost to follow up among TB patients with or without Ethiopia: a retrospective follow-up study. BMC Infect Dis. 2019;19:817.
HIV in developing countries: a systematic review. Iran J Public Health. https://​doi.​org/​10.​1186/​s12879-​019-​4447-8.
2015;44(1):1–11.
26. Nezenega ZS, Perimal-Lewis L, Maeder AJ. Factors influencing patient
adherence to tuberculosis treatment in Ethiopia: a literature review. Int Publisher’s Note
J Environ Res Public Health. 2020;17:5626. https://​doi.​org/​10.​3390/​ijerp​ Springer Nature remains neutral with regard to jurisdictional claims in pub-
h1715​5626. lished maps and institutional affiliations.
27. Van Hoom R, Jaramillo E, Collins D, Gebhard A, van den Hof S. The effects
of psycho-emotional and socio-economic support for tuberculosis

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