Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13571 Correlation of self-efficacy and medication adherence with treatment continuity among tuberculosis patients in East Java, Indonesia Karyo Karyo,1,2 Ah Yusuf,1 Ilya Krisnana,1 Nursalam Nursalam,1 Miftahul Munir,2 Tri Yunita Fitria Damayanti,2 Kusno Ferianto,2 Ahmad Daniel2 1Faculty of Nursing, Airlangga University, Surabaya; 2Faculty of Nursing and Midwifery, Ilmu Kesehatan Nahdlatul Ulama Tuban Institute, Indonesia Abstract Tuberculosis (TB) remains a significant global health chal- lenge, and treatment adherence is crucial for successful outcomes. This study aimed to investigate the correlation between self-effi- cacy, medication adherence, and treatment continuity among patients with TB in East Java, Indonesia. This cross-sectional, cor- relational study was conducted in four randomly selected districts of East Java in 2024. The study employed probability sampling with a simple random sampling technique. Data were collected using the Guide for Constructing Self-Efficacy Scale and Morisky Medication Adherence Scale (MMAS-8). A total of 6,792 TB patients participated in this study. Statistical analysis was per- formed using SPSS version 25, including frequency distribution, percentage calculation, and Spearman’s rank correlation test, with a significance level of 0.05. Among the participants, 70.3% (n=4,775) demonstrated high self-efficacy, whereas 29.7% (n=2,017) showed low self-efficacy. Regarding medication adher- ence, 60% (n=4,075) exhibited high adherence, and 40% (n=2,719) reported low adherence. Spearman’s rank correlation test revealed a strong positive correlation between self-efficacy and medication adherence (r=0.936, p<0.001). The study findings indicated a significant relationship between self-efficacy, medica- tion adherence, and treatment continuity in patients with TB. These results underscore the importance of addressing psycholog- ical factors in TB management programs. Interventions aimed at enhancing patients’ self-efficacy could potentially improve medi- cation adherence and, consequently, treatment outcomes. These results provide a strong rationale for developing comprehensive care models that incorporate medical and psychological interven- tions to enhance treatment continuity and improve patient out- comes. Introduction Tuberculosis (TB) remains one of the leading causes of death worldwide. Pulmonary tuberculosis has an estimated annual mor- tality rate of 27 per 100,000 individuals. Contributing factors include low self-efficacy and non-adherence to anti-tuberculosis treatment, both of which adversely impact recovery rates. Tuberculosis patients undergo treatment for approximately 6 to 9 months, resulting in prolonged exposure to the treatment regimen. One of the psychological factors that affects adherence to taking medication is self-efficacy. A high level of self-efficacy in an indi- vidual positively influences their confidence and belief in their capacity to address challenges.1-3 Self-efficacy, or an individual’s belief in their ability to successfully complete a task, is a crucial factor in promoting adherence to TB treatment. Self-care perfor- mance mediates the relationship between self-efficacy and health- related quality of life among patients undergoing primary treat- ment for pulmonary TB. This suggests that self-efficacy plays a vital role in enabling patients to engage in their treatment and improve their health outcomes actively.4,5 Tuberculosis patients often exhibit diminished self-efficacy, hindering their capacity for self-care and adversely affecting their adherence to prescribed Correspondence: Karyo Karyo, Faculty of Nursing, Universitas Airlangga, Surabaya; Faculty of Nursing and Midwifery, Institut Ilmu Kesehatan Nahdlatul Ulama Tuban, Indonesia. E-mail: karyo.iiknu@gmail.com Key words: self-efficacy; medication adherence; tuberculosis; treatment continuity; East Java. Contributions: KK, conceptualization, investigation, data curation, for- mal analysis, methodology, validation, visualization, writing – original draft & review; AY, conceptualization, methodology, validation, writing – original draft & review; IK, conceptualization, methodology, formal analysis, validation, writing – original draft & review; HH, methodology, visualization, writing – review & editing; NN: resources, investigation, writing – review; MM, formal analysis, validation, writing – review; TYFD, resources, supervision, writing – review; KF, resources, investi- gation, writing – review; AD, writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the study was approved by the Health Research Ethics Commission of the Nahdlatul Ulama Institute of Health Tuban (approval number: 55/0084223523/LEPK. IIKNU/III/ 2024). Consent for publication: patients’ written informed consent was obtained for anonymized information to be published in this article. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Acknowledgments: I extend my gratitude to my supervisor for his guid- ance in preparing this manuscript as a requirement for the Doctor of Nursing degree at the Faculty of Nursing, Airlangga University. I also thank my colleagues for their assistance in writing this article and my family for their unwavering support and encouragement. Received: 1 January 2025. Accepted: 11 March 2025. Early view: 12 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13571 doi:10.4081/hls.2025.13571 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s2):13571] [page 29] medication, thereby impeding their recovery due to a lack of con- fidence in their abilities and commitment to treatment.5-7 Pulmonary tuberculosis is a chronic condition, necessitating that patients adhere to a treatment regimen of no fewer than four medications daily during the initial or intensive phase, followed by two medications daily in the subsequent phase, with a minimum treatment duration of six months.8-10 Treatment over a long period, if not supported by good self-efficacy and regular medication adherence, can significantly affect the recovery rate in pulmonary TB patients. Non-adherence to medication in cases of tuberculosis represents a complex healthcare issue, frequently occurring and involving numerous dimensions related to patients, their care, and/or healthcare providers. In long-term treatment, patient adher- ence is crucial for understanding patient behavior and attitudes toward the treatment program provided by doctors or healthcare workers. For patients who do not follow the recommended treat- ment, adverse side effects may occur.3,8,11,12 Tuberculosis ranks second among infectious diseases in terms of mortality worldwide. Indonesia is the third highest country globally in tuberculosis cases, with a total of 809,000 individuals affected.13 In 2023, the number of pulmonary tuberculosis cases in Indonesia rose to 809,000, marking an increase compared to two years earlier. According to the 2023 data, approximately 509,000 pulmonary TB patients were reported as non-compliant with treat- ment. Similarly, the WHO reported a treatment dropout rate of 535,000 individuals in the same year. In East Java specifically, the regional health profile indicates that 2,073 patients discontinued their TB treatment.14 Furthermore, a survey conducted on September 21, 2024, gathered data through interviews in several randomly selected representative districts. The findings revealed treatment dropout figures of 1,809 in Pacitan, 1,600 in Lumajang, 1,653 in Tuban, and 1,730 in Mojokerto. Many pulmonary TB patients fail to complete the full six- month course of anti-TB treatment and are often unaware of the importance of follow-up sputum examinations. This lack of adher- ence increases their risk of developing drug-resistant forms of tuberculosis and experiencing relapses. Key factors influencing recovery include patients’ self-efficacy and medication adherence, both of which are strengthened by support from family or close contacts. Patients who do not consistently follow their treatment regimen frequently face the need to restart therapy from the begin- ning.15-17 Tuberculosis patients become non-compliant with treat- ment due to side effects from the treatment and self-efficacy issues because they suffer from tuberculosis. Another factor contributing to non-compliance in treatment is the lack of motivation and knowledge among tuberculosis patients. Pulmonary TB patients require mental support from both their families and those around them, as this can aid in their recovery.15,16 Materials and Methods Design This study utilized an analytical research design with a corre- lational approach. The researchers explored the relationships between the variables without intervention. A cross-sectional time design was employed, highlighting that the measurement and observation of both independent and dependent variable data occur only once at a specific point in time. However, employing a cross- sectional design has limitations; specifically, it cannot establish a causal relationship. Study participants The study population consisted of tuberculosis patients from four districts in East Java in 2024. The sample size encompassed these four districts. This study employs probability sampling using a simple random sampling technique. The inclusion criteria includ- ed patients with tuberculosis undergoing treatment for a minimum of 6 months in East Java in 2024, aged 18 years or older, and will- ing to participate in the study. Exclusion criteria included inability to respond to the questionnaire due to physical or mental limita- tions. To enhance the representativeness, the sample distribution was proportionally drawn from each selected district. Variables, instrument, and data collection This study examined two primary variables, namely self-effi- cacy and medication adherence among patients with tuberculosis. Two instruments were used for data collection: a questionnaire based on the Guide for Constructing Self-Efficacy Scale, compris- ing 15 questions to assess self-efficacy, and the Morisky Medication Adherence Scale (MMAS-8), which consists of 8 ques- tions to evaluate medication adherence. Additionally, secondary data from medical records were used to examine the continuity of tuberculosis treatment. The researchers distributed questionnaires to participants in the selected districts. After the data collection and editing process was conducted, the obtained data and answers were selected and checked. Validity and reliability tests were conducted, with the Self-Efficacy Scale demonstrating good internal consis- tency with a Cronbach’s alpha of 0.85 and the MMAS-8 with a Cronbach’s alpha of 0.82. Data analysis Data analysis was performed using SPSS software version 25 for Windows. The analysis included frequency distribution, per- centage calculation, and Spearman’s rank correlation test with a significance level of 0.05. Spearman’s rank correlation test was used to measure the relationship between self-efficacy, medication adherence, and continuity of care. This test was chosen because the research variables were ordinal and non-normally distributed. Another justification for selecting this test is its ability to capture the strength and direction of the relationship between independent and dependent variables. Results This study included 6,792 patients with tuberculosis. The results showed that 4,775 (70.3%) patients had high self-efficacy, while 2,017 had low self-efficacy. Regarding medication adher- ence, 4,075 (60%) patients demonstrated high adherence, whereas 2,719 (40%) showed low adherence. The Spearman’s rank correla- tion test yielded an Asymp Sig. (2-tailed) value of 0.000 and a cor- relation coefficient of 0.936, indicating a very strong correlation between the variables. A correlation coefficient of 0.936 empha- sizes a strong relationship between self-efficacy and medication adherence (Table 1). This highlights the potential of interventions designed to enhance self-efficacy, thereby improving treatment adherence and outcomes. The high percentage of patients with high self-efficacy (70.3%) was a positive finding, indicating that many patients had confidence in their ability to manage their condition. However, most patients with low medication adherence (40%) highlighted the need for interventions to address this problem. The demographic profile of patients with TB reveals notable Pathways of Change, Part II [page 30] [Healthcare in Low-resource Settings 2025;13(s2):13571] trends based on recent data from East Java, Indonesia. The major- ity of tuberculosis cases were found in the productive age group of 19-59 years (70.3%), followed by a smaller percentage in individ- uals aged 60 years and older (22.5%), and a minor proportion in those under 19 years (7.2%). The gender distribution showed a higher prevalence in males, with the majority of cases occurring in this group (53.77%) than in females (46.3%). Nearly half of the respondents possessed primary school education (42.7%), approx- imately one-third had junior high school education (28.3%), a minor percentage completed senior high school (22.5%), and a small fraction (6.5%) attained a university degree (Table 2). Discussion Self-efficacy plays a crucial role in treatment adherence and overall management of tuberculosis (TB). Recent studies have shown that patients with TB who have higher levels of self-effica- cy tend to have better treatment outcomes and a higher quality of life.1,8,18 The concept of self-efficacy in TB patients encompasses their belief in their ability to follow treatment protocols, manage symptoms, and prevent disease transmission.1,16,19,20 This psycho- logical construct is particularly important given the long duration of TB treatment, which typically lasts 6-9 months. Patients with strong self-efficacy are better equipped to overcome the challenges associated with prolonged treatment, including potential side effects and the need for lifestyle improvements.1,21,22 Self-efficacy in TB patients is not static but can be enhanced through targeted interventions. Health education programs, counseling sessions, and peer sup- port groups have been shown to improve self-efficacy levels among TB patients.23,24 These interventions help patients develop a more positive outlook on their treatment journey and increase their confidence in managing their condition. However, it is important to note that self-efficacy can be influenced by various factors, including socioeconomic status, education level, and cultural beliefs. A comprehensive approach that addresses these underlying factors is necessary to effectively boost self-efficacy in TB patients. Future research should focus on developing tailored inter- ventions that consider these diverse influences on self-efficacy.7,25 Medication adherence is a critical factor in the successful treat- ment of tuberculosis. Recent evidence indicates that adherence strongly influences therapy outcomes and the risk of developing drug-resistant TB. A meta-analysis of three Phase III trials found that non-adherence was the single most potent factor associated with unfavorable treatment outcomes, with adjusted hazard ratios of 5.7 for patients who missed 10% or more of prescribed doses. The challenges of maintaining high levels of medication adherence in TB treatment are complex. Factors such as the long duration of treatment, potential side effects, and socioeconomic barriers can all contribute to non-adherence. Recent technological advancements have introduced new methods for monitoring and improving medication adherence.7,26 Electronic monitoring devices, mobile health applications, and directly observed therapy (DOT) using video technology are being increasingly utilized to support patients in maintaining adherence. These tools not only help in tracking adherence but also provide real-time support and reminders to patients. Despite these advance- ments, there is a growing recognition that a one-size-fits-all approach to medication adherence is insufficient.19,27 Tailored interventions that consider individual patient needs, cultural con- texts, and social support systems are necessary to achieve optimal adherence rates. Future research should focus on developing and evaluating personalized adherence interventions that can be inte- grated into routine TB care.28,29 The results show that the majority of tuberculosis patients have high self-efficacy, while a significant portion experiences low self- efficacy. Similarly, most patients exhibit high medication adher- ence, but a notable percentage struggles with low adherence. This low adherence is associated with treatment failure and poor quality of life. Low self-efficacy and poor medication adherence are close- ly linked to a person’s physiological condition and mental state. When physical health deteriorates or when an individual experi- ences stress, emotional disturbances, or misconceptions about their medical condition, self-efficacy can decline. Negative and pes- simistic self-evaluations also contribute to reduced self-efficacy. For tuberculosis patients, having a strong sense of self-efficacy is essential, as it fosters the self-confidence needed to stay motivated and committed to completing the treatment. Self-efficacy reflects an individual’s belief in their ability to overcome challenges, which significantly influences both their thought processes and behaviors.1,30,31 The continuity of treatment is essential for achieving a cure and preventing the development of drug-resistant TB. Recent stud- ies have emphasized the importance of uninterrupted therapy in Pathways of Change, Part II Table 1. Crosstabulation of self-efficacy, medication adherence, and continuity of tuberculosis treatment. Characteristic Continuity treatment Total Yes No Self-efficacy Low 1432 585 2017 High 3769 1006 4775 Medication adherence Low 1870 849 2719 High 2472 1601 4073 Spearman’s test result: 0.000 Table 2. Characteristics of participants. Characteristic Number % Age 18 years 489 7.2 19-44 years 2038 30 45-59 years 2738 40.3 ≥60 years 1529 22.5 Gender Male 3653 53.7 Female 3139 46.3 Education Elementary school 2899 42.7 Junior high school 1920 28.3 Senior high school 1523 22.5 Undergraduate 442 6.5 Self-efficacy Low 2017 30 High 4775 70 Medication adherence Low 2717 40 High 4075 60 Continuity treatment Yes 4822 71 No 1970 29 [Healthcare in Low-resource Settings 2025;13(s2):13571] [page 31] improving patient outcomes and reducing the risk of disease trans- mission. The treatment interruptions, even if brief, can significant- ly impact the effectiveness of TB therapy. Factors affecting treat- ment continuity are complex and often interrelated. These may include healthcare system factors (such as drug availability and accessibility of healthcare services), patient-related factors (including side effects and competing life priorities), and social determinants of health. Addressing these multifaceted challenges requires a comprehensive approach that goes beyond simply focus- ing on individual patient behavior. Innovative approaches to ensure treatment continuity have emerged in recent years. These include the use of community-based DOT, patient support groups, and integrated care models that address both TB and other health needs. Such approaches have shown promise in improving treat- ment continuity, particularly in resource-limited settings.32,33 This study revealed a strong positive correlation between self- efficacy and medication adherence among patients with TB in East Java, Indonesia. However, it is crucial to consider potential con- founding variables and biases that might have influenced these findings among other socioeconomic, educational, cultural, and health-service systems. Conclusions This study confirms a significant relationship between self- efficacy, medication adherence, and TB treatment continuity in East Java. Despite high self-efficacy, low adherence highlights the need for integrated medical and psychological interventions. A holistic approach can enhance patient confidence, improve out- comes, and reduce the risk of infections. Policymakers and health- care providers should prioritize strategies that strengthen adher- ence and treatment success. References 1. Marselina S, Kusmiran E, Sutisna I. The relationship between self efficacy and medication compliance in tuberculosis patient-S at Garuda Health Center in Bandung City in 2023. Indones J Community Heal Nurs 2024;9:67-72. 2. Marin PM, Munyeme M, Kankya C, et al. 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