Psychosocial and health system factors associated with tuberculosis treatment adherence in Kota Kinabalu, Sabah

Treatment adherence remains a major challenge in tuberculosis (TB) control and may be influenced by psychosocial and health system factors that remain underexplored in many settings. This study aimed to examine the association between psychosocial and health system factors and treatment adherence among TB patients in Kota Kinabalu, Sabah.

A cross-sectional study was conducted among 351 TB patients registered in the National TB Registry between 2023 and 2024. Data were collected using structured, validated, and translated questionnaires, including the TB Stigma Scale and the Patient Health Questionnaire-9 (PHQ-9). Variables included sociodemographic characteristics, TB knowledge, treatment-related factors, and healthcare system factors. Simple and multivariable logistic regression analyses were performed to identify factors of treatment adherence.

Stigma was negatively associated with treatment adherence (AOR=0.90; 95% CI: 0.86-0.95; p<0.001), whereas higher TB knowledge was associated with higher treatment adherence (AOR=1.20; 95% CI: 1.06-1.35; p=0.004). Compared with video directly observed therapy (VDOT), healthcare worker (HCW)-supervised direct observed treatment short-course (DOTS) was associated with lower treatment adherence (AOR=0.23; 95% CI: 0.06-0.90; p=0.030). Longer clinic waiting time was associated with higher treatment adherence (AOR=1.09; 95% CI: 1.05-1.13; p<0.001). Depression was negatively associated with adherence in univariate analysis but was not statistically significant in the multivariable model (AOR=0.58; 95% CI: 0.21-1.58; p=0.285).

Stigma, TB knowledge, DOTS modality, and clinic waiting time were independently associated with TB treatment adherence in this setting. These findings highlight the importance of integrated, patient-centered TB care that addresses stigma, strengthens patient education, and incorporates digital approaches such as VDOT. Strengthening multifaceted interventions targeting both psychosocial and health system factors may improve TB treatment outcomes in Malaysia and similar high-burden settings.