Applying The Neuman Systems Model to Examine Intrapersonal, Interpersonal, and Extrapersonal Influences on Tuberculosis Treatment Adherence: A Mixed-methods Study

Introduction Treatment adherence remains a major challenge in tuberculosis (TB) control, particularly in low- and middle-income countries like Indonesia. Although TB ​​treatment is provided free of charge, many patients still experience non-adherence due to various factors. This study examined the intrapersonal, interpersonal, and extra personal factors influencing TB treatment adherence using an integrated mixed-methods approach guided by Neuman's systems model. Methods We employed a simultaneous mixed-methods design. Quantitative data were collected from 185 TB patients using a structured questionnaire assessing cognitive, psychosocial, and health system-related variables. Bivariate correlations and multivariate regression analyses were conducted to analyze factors influencing adherence across Neuman's domains. Qualitative data were generated through in-depth interviews with six purposively selected patients and were analyzed thematically. Findings from both approaches were integrated through joint interpretation to identify convergent and complementary patterns within the theoretical framework. Results In the multivariate analysis, shame was a significant negative intrapersonal predictor of adherence, while knowledge showed a significant trend. Family and social support served as protective interpersonal factors. Extrapersonal variables, such as healthcare support, had limited effects in the regression models. Qualitative findings highlighted emotional exhaustion, stigma, family support, and systemic barriers such as long wait times and limited follow-up as key influences. Integrated analysis showed that internal emotional struggles were the most prominent barrier. Supportive relationships and responsive healthcare services were important buffers. Discussion TB treatment adherence is shaped by cognitive and emotional processes at the intrapersonal level, reinforced by interpersonal support, and constrained by extrapersonal conditions. Integrating quantitative and qualitative evidence through Neuman's systems model clarifies how shame and forgetfulness undermine adherence, and how motivation and social support strengthen patients' adherence to treatment. Structural challenges are less evident in the statistical models but are articulated in patient narratives, highlighting the responsiveness of the system. Conclusion TB treatment adherence is an interaction between individual, relational, and systemic stressors. Neuman's systems model provides a useful framework for understanding these dynamics. Interventions that strengthen emotional resilience, increase caregiver engagement, and incorporate digital health strategies may improve adherence in similar settings.