**5.4 Drug side effects**

*Healthcare Access - Regional Overviews*

ment completion.

Uzbekistan found that joblessness contributes toward LTFU [18]. This is confirmed by a study from China which found that pre-school children, unemployed laborers, and retirees have a higher rate of LTFU [76]. Patients with low income have financial constraints to complete treatment leading to LTFU as seen in India [77], a lower middle-income country. A similar phenomenon has been observed in South Korea, a high-income country [78]. Even in the USA, it was found that homelessness is associated with LTFU [79, 80], which might be due to low income. Therefore, regardless of the country, patients with low income still have barriers against treat-

LTFU is also associated with alcohol abuse, tobacco use, smoking, and illicit drug use. Association between alcoholism and LTFU was observed in India [77], Philippines [5], and Congo [74], tobacco use in Georgia [41], smoking in Brazil [75], and illicit drug use in Norway [30], Georgia [41], and the UK [81]. Therefore, before initiating treatment, personal history should be carefully taken to find out

The treatment providers should give support to the patients since a perceived lack of provider support is a barrier to regular follow-up [77], and receiving any type of assistance and support from the providers can protect against LTFU [5]. They need to build up trust [5] from the patients. An intervention program targeting these factors will be described later in the chapter. Lastly, the timing of the treatment services should be flexible according to the needs of the patients [77], but

The timing of the treatment is important since those who initiate the treatment late (beyond and within 30 days of onset) are more likely to be LTFU [85]. Those who initiate it late may not have enough motivation, will, or knowledge to continue taking treatment until they are cured. Moreover, the timing of treatment interruption is found to be the most important during the intensive phase [7]. This stage should be particularly targeted while conducting interventions against LTFU. Different providers have different abilities to retain the patients. In Korea, patients treated by a non-pulmonologist were found to be more likely to default from TB treatment [78]. In Myanmar, patients treated by private practitioners were more likely to be LTFU [86]. An interesting situation was observed in Nigeria where patients treated at private, not-for-profit (PNFP) DOT facilities were more likely to be LTFU [87]. The researchers concluded that "Patients managed at PFP [private, for-profit] DOT facilities were probably richer, had better education, nutrition, and knowledge of TB than patients managed at PNFP

these risk factors, and special attention should be given to such patients. There are also certain disease-specific factors that are associated with LTFU. Those who were previously LTFU tend to be LTFU again. This was confirmed by studies conducted in Brazil [4], Kenya [7], Uzbekistan [18], and Korea [78]. Caution should be taken while planning treatment for such patients. Studies from Nigeria and Ethiopia both point out that smear-negative TB patients were more likely to be LTFU [72, 82]. However, the opposite was observed in the UK where smear-positive pulmonary TB patients were more likely to be LTFU [11]. Researchers also found that patients with extrapulmonary TB were more likely to be LTFU [71, 83]. Co-morbid diseases such as diabetes mellitus and human immunodeficiency virus (HIV) infection also cause hin-

drance against TB treatment conditions [7, 71, 84].

**5.2 Treatment support services**

**5.3 Diagnosis and treatment**

this may not be an easy task to implement.

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Studies from the USA and India have found that drug side effects are associated with LTFU [49, 77]. The researchers from the Philippines take one step further regarding this concept, stating 'patients' self-rating of the severity' as an associated factor [5]. Indeed, some side effects, such as hepatitis, of the anti-tuberculosis drugs are already severe. However, some side effects, such as vomiting, might need self-rating since different patients may perceive differently. It would be interesting to research which kind of patient rates which side effect as severe.
