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Join us for our next Journal Club session happening on August 12, 2026 at 8am ET /2pm SAST/7pm WIB-Indonesia (*note earlier time for August session only).

We will be discussing the following article below:

Fuady A, Haya MAN,  Anindhita M, Haniifah M, Hardy FR, Haq DFA, Aliska I,  Febriani ER, Rifky AF, Karnasih A, Agiananda F, Yani FF,  Pakasi TA, Menaldi A, Hermawan B, Wingfield T (2026).  Community-based, peer-led psychosocial support to address stigma and reduce depression among adults with tuberculosis in Indonesia: a prospective interventional cohort study. Preprint available here https://papers.ssrn.com/sol3/papers.cfm?abstract_id=6068307
 

Email nancy.bedingfield@ucalgary.ca for more information

Indonesia SSHIFTB
Publication

In an ideal scenario, someone with chronic cough, fever, and weight loss would promptly seek care at a public tuberculosis clinic, be tested immediately for tuberculosis with a rapid molecular test and receive appropriate short-course tuberculosis therapy. They would receive social support to complete therapy without missing any doses and recover completely with no residual symptoms or post-tuberculosis lung syndrome. However, people with symptoms of tuberculosis typically delay seeking care for weeks due to factors such as low disease awareness, distance to facilities, self-medication, or age. When they do seek care, they are likely to first visit local primary care providers in their neighbourhoods, including pharmacies and private practitioners, or informal providers, such as drug sellers and traditional healers. Tuberculosis is rarely diagnosed on that first visit. What health systems typically record as “delayed care-seeking” often reflects initial symptom misattribution rather than patient inaction. Studies in India, Indonesia, Kenya, and Nigeria done before and after the COVID-19 pandemic show patients have between two and eight visits before tuberculosis diagnosis, with extremes reaching 21 visits in highly fragmented systems.

Behavioural research India
Publication

The COVID-19 pandemic had significant widespread financial impacts, resulting in decreased household income, increased unemployment, and disrupted health services. Despite the higher prevalence of infections of tuberculosis (TB) and human immunodeficiency virus (HIV) in poorer populations, research on the financial challenges faced by these populations during the pandemic is still limited. Indonesia recorded the highest COVID-19 cases in Southeast Asia (6,815,156) while contending with the dual burden of HIV and TB. This study investigates the factors influencing out-of-pocket (OOP) payments and catastrophic health spending during the pandemic, alongside patients' challenges and coping mechanisms in Bandung and Yogyakarta, Indonesia. We employed a parallel convergent mixed-methods approach, combining quantitative analysis of OOP costs with qualitative interviews. The determinants of OOP payments were analysed using a two-part cluster-robust regression model. Catastrophic health spending was defined as OOP payments exceeding 10% of a household's annual income. Data on OOP spending were recorded via diaries, while qualitative data were gathered from in-depth interviews with TB and HIV patients and healthcare workers from January to October 2022. The findings indicated that 5.13% (95% CI: 2.99 to 7.28) of households incurred catastrophically. The median household spent USD 8.48 OOP, with non-medical expenses comprising the largest share (median USD 5.93). Key predictors of higher costs included facility location in Yogyakarta (OOP costs difference USD 23.84, 95% CI: 9.90 to 37.77, P<0.001); seeking care from public hospitals (USD 17.37, 8.83 to 25.90, P<0.001); and absence of health insurance (USD 10.49, 2.40 to 18.58, P = 0.011). Patients reported that job losses during lockdowns exacerbated financial strain, while coping strategies documented included borrowing, family contributions, and selling assets. This is the first study to focus on OOP spending and the financial hardships experienced by TB and HIV patients in Indonesia during the pandemic, providing insights for targeted policy and preparedness efforts to alleviate the financial burden during large-scale public health crises.

Keywords: COVID-19; Financial Hardship; HIV; Indonesia; Mixed-Methods; Tuberculosis.

Comorbidities COVID-19 Indonesia
Publication

Background: Indonesia faces a dual burden of high tuberculosis (TB) burden and rising diabetes mellitus (DM) prevalence. Given that DM is a significant risk factor for TB, screening people with TB for DM comorbidity is important for early management to mitigate adverse outcomes.

Objectives: This study aimed to measure the degree of implementation fidelity, moderating factors, and barriers to implementing DM screening among TB patients in Indonesia's Primary Healthcare setting.

Methods: A sequential explanatory mixed method was used. A cross-sectional survey was conducted with 42 Directly Observed Treatment, Short-course providers to assess adherence to DM screening guidelines. Screening coverage was evaluated through the TB information system. In-depth interviews with providers, managers, and patients identified key barriers and enablers.

Results: Screening coverage ranges from 36.3% to 97.6% between 2020 and 2024. High fidelity was reported among providers, with 95% screening for DM at the time of TB diagnosis. Facilitators included TB-DM policy availability, screening affordability, provision of equipment, and patients' responsiveness. However, delays in data reporting and insufficient cross-sector collaboration posed challenges to the implementation.

Conclusion: Despite positive progress in integrating TB-DM care, addressing barriers is essential to optimize the programme's impact. Strengthening reporting mechanisms and fostering collaboration could enhance programme outcomes.

Keywords: diabetes; screening; tuberculosis.

Comorbidities Diabetes Indonesia
Publication

Stigma often accompanies people with multidrug-resistant tuberculosis (MDR-TB) and potentially affects their health-related quality of life (HRQoL). The aim of this study was to investigate the stigma faced by patients with MDR-TB, both from the patients' and community's perspective, and its relationship with HRQoL. Data was gathered at the provincial hospital in Makassar, South Sulawesi, Indonesia. The instrument employed in this research was the Indonesian version of the tuberculosis (TB) stigma instrument to assess MDR-TB stigma from the patient and community perspectives. The patient perspective represents how individuals with TB perceive and experience stigma, including the fear of disclosure, isolation, and guilt (feeling responsible for the burden on their family or their own risky behaviors). Meanwhile, the community perspective reflects how individuals with TB perceive societal attitudes towards them, such as social distancing, avoidance, and reluctance to interact. HRQoL was measured using the European quality of life-5 dimensions-5 level version (EQ-5D-5L) instrument. Notably, the evaluation of anxiety and depression is centered on the fifth dimension of the EQ-5D-5L instrument. A total of 210 patients with MDR-TB were included in the study, all of whom reported experiencing stigma. Most participants perceived stigma at a moderate level, with 76% from the patient perspective and 71% from the community perspective. The average EQ-5D-5L index score was 0.72 (95% confidence interval (95%CI): 0.68-0.76). Measurements from both perspectives show similar scores. There is a substantial negative association between the level of stigma and HRQoL, both from the patient's perspective (R2=-0.33; F=102.52; p<0.001) and the community's (R 2=-0.32; F=96.76; p<0.001). The study highlights that the stigma of MDR-TB significantly affects the HRQoL from the patient and community perspective.

Keywords: EQ-5D-5L index scores; HRQoL; Indonesia; MDR-TB; stigma.

Community Engagement Drug-resistant TB Indonesia
Publication

Background

Indonesia remains one of the highest tuberculosis (TB) burden countries globally. Despite national efforts to expand TB care, disparities in treatment outcomes persist across regions and population subgroups. This study aimed to evaluate TB treatment outcomes and identify their determinants using national surveillance data from 2020 to 2022.

Methods

We conducted a retrospective cohort study using data from the national SITB TB registry. A total of 1,022,351 drug-sensitive TB patients with complete treatment outcome records were included. Multivariable logistic regression models were used to identify factors associated with treatment success. ROC curves were generated to evaluate model performance across Western, Central, and Eastern Indonesia. Stratified analyses were conducted by year and region.

Results

The overall treatment success rate was 92.1 %. Female sex (aOR: 1.20; 95 % CI: 1.19–1.22), younger age, and new treatment status were associated with higher odds of success, while HIV positivity (aOR: 0.22; 95 % CI: 0.21–0.23), diabetes (aOR: 0.79; 95 % CI: 0.77–0.81), and retreatment cases predicted poorer outcomes. Regional analysis showed that treatment success was highest in Western Indonesia (93.2 %), followed by Central (91.5 %) and Eastern Indonesia (89.8 %). Predictive model performance was modest, with AUCs ranging from 0.59 in Eastern Indonesia (2021) to 0.65 in Central Indonesia (2020).

Conclusions

Although Indonesia has achieved high national TB treatment success rates, disparities remain across regions and patient subgroups. Tailored strategies are needed to improve outcomes in Eastern Indonesia and among high-risk populations. Strengthening integrated, region-specific TB care is critical to achieving national TB elimination targets.
Indonesia
Publication

Globally, Indonesia has the second-highest tuberculosis burden and the second-largest gap between estimated incidence and reported cases. Achieving the WHO End Tuberculosis Strategy milestones, and 2027 targets set at the 2023 UN High-Level Meeting remains challenging. Between 2015 and 2023, the estimated tuberculosis incidence increased by 19%, and deaths increased by 26% in Indonesia. In 2020, 38% of affected households faced catastrophic costs (ie, direct medical costs [eg, for medical visits, diagnostic tests, medication], direct non-medical costs [eg, transportation, food, and accommodation], and indirect costs [eg, due to job loss and reduced productivity]), contrary to the WHO target of 0% by 2020. In 2023, 61% of patients with tuberculosis were initially tested with WHO-recommended rapid tests, which is below the 100% target for 2027. Although treatment coverage improved (77% in 2023 vs 90% target by 2027), tuberculosis preventive therapy coverage remains low (2·6% in 2023), which is markedly lower than the 90% target set by WHO for 2027.

Advocacy Indonesia
Publication

The tuberculosis (TB) program was massively disrupted due to the COVID-19 pandemic, which may have impacted on an increase in costs for people with TB (PWTB) and their households. We aimed to quantify the pre-treatment out-of-pocket costs and the factors associated with these costs from patients' perspective during the COVID-19 pandemic in Bandung, Indonesia. Adults with pulmonary TB were interviewed using a structured questionnaire for this cross-sectional study recruiting from 7 hospitals, 59 private practitioners, and 10 community health centers (CHCs) between July 2021 to February 2022. Costs in rupiah were converted into US dollars and presented as a median and interquartile range (IQR). Factors associated with costs were identified using quantile regression. A total of 252 participants were recruited. The median total pre-treatment cost was $35.45 (IQR 17.69-67.62). The highest median cost was experienced by participants from private hospitals ($54.51, IQR 29.48-98.47). The rapid antigen and PCR for SARS-CoV-2 emerged as additional medical costs among 26% of participants recruited in private hospitals. Visiting ≥ 6 providers before diagnosis ($38.40 versus $26.20, p < 0.001), presenting first at a private hospital ($50.68, p < 0.05) and private practitioners ($34.97, p < 0.05), and being diagnosed in the private health sector ($39.98 versus $20.30, p < 0.05) were significantly associated with higher pre-treatment costs. PWTB experienced substantial out-of-pocket costs in the process of diagnosis during the COVID-19 pandemic despite free TB diagnosis and treatment. Early detection and identification play an important role in reducing pre-diagnostic TB costs.

Access Comorbidities Indonesia

Onti Erlina has officially launched! This new platform or Chatbot is designed to provide a safe and supportive space for people with TB to share their experiences, ask questions, and access reliable information about tuberculosis. Initially conceived as “Aunty Erlina,” the name has been adapted to "Onti Erlina" to better resonate with the Indonesian community.

Explore the platform and be part of this initiative to raise TB awareness:
 Website: https://ontierlina.id/
 WhatsApp Chatbot: (+62) 812-1469-1128

Indonesia
Publication

In Indonesia, primary health centres (PHCs) are mandated to provide essential medicines to ensure equal access to medication for all Indonesians, as stated in the national medicine policy. However, limited information is available regarding the actual practices of health workers within the context of decentralized governance. This paper investigates the discrepancies between national policies and local practices in two Indonesian districts, shedding light on coping mechanisms employed in each phase of medicine management within PHCs. The mixed-method study began by identifying pertinent policies addressing medicine management in PHCs. Subsequently, panel data on patient visits to tuberculosis, maternal and neonatal health (MNH), and noncommunicable disease (NCD) services were collected from 2019 to 2022. After analysing the panel data, interviews were conducted with 56 health workers including physicians, nurses, pharmacists, midwives, and public health programme managers regarding their views on fluctuations in medicine stocks and the patient visit data. These participants included pharmacists and programme managers specializing in tuberculosis, MNH, and NCD care and were affiliated with PHCs and district health offices. Our findings highlight the occasional unavailability of essential medicines in PHCs, with stockouts being attributed to supplier shortages at provincial and national levels and to variations in the capacity of the local health system. Low-skilled pharmaceutical staff are a contributing factor in each phase of medicine management. Additionally, health workers employ coping mechanisms, such as deviating from policy on the use of capitation funds to purchase medicines, to manage temporary stockouts. To tackle systemic stockouts, central government should prioritize capacity-building among health workers, by establishing a continuous and easily accessible local learning system.

Keywords: access to medicine; decentralization; local system; managing medicines; primary health centre.

Access Health care workers Indonesia
Publication

Evidence relating to peer support and community-based psychological and social (psychosocial) interventions to reduce stigma and depression among people with tuberculosis (TB) and their households is limited. This study aimed to engage with multisectoral stakeholders in Indonesia to co-develop a peer-led, community-based psychosocial intervention that is replicable, acceptable, and sustainable. We used a participatory action design and engaged key national, multisectoral stakeholders to ensure that the intervention co-design was relevant and appropriate to the TB health system and the sociocultural context of Indonesia. The co-design of the intervention evolved through four phases: (1) a scoping review to identify a long list of potential TB stigma reduction interventions; (2) a modified Delphi survey to define a shortlist of the potential interventions; (3) a national multisectoral participatory workshop to identify and pre-finalize the most viable elements of psychosocial support to distill into a single multi-faceted intervention; and (4) finalization of the intervention activities. The scoping review identified 12 potential intervention activities. These were then reduced to a shortlist of six potential intervention activities through a modified Delphi Survey completed by 22 multisectoral stakeholder representatives. At the national participatory workshop, the suitability, acceptability, and feasibility of the six potential intervention activities were discussed by the key stakeholders, and consensus reached on the final four activities to be integrated into the psychosocial support intervention. These activities consisted of: individual psychological assessment and counselling; monthly peer-led group counselling; peer-led individual support; and community-based TB Talks. In Indonesia, meaningful participation of multisectoral stakeholders facilitated co-design of a community-based, peer-led intervention to reduce TB stigma and depression amongst people with TB and their households. The intervention was considered to be locally appropriate and viable, and is being implemented and evaluated as part of the TB-CAPS intervention study.

Community Engagement Mental Health Indonesia

Irma Prasetyowati is a lecturer and researcher at the Faculty of Public Health, Universitas Jember. She obtained her Bachelor's degree (S.KM) and Master's degree in Epidemiology (M.Kes) from the Faculty of Public Health, Universitas Airlangga in 2003 and 2008, respectively. She then pursued a doctoral program at Universitas Sebelas Maret, successfully defending her thesis on the Model of External Community District Public Private Mix for presumptive TB in 2024. Since joining Universitas Jember in 2003, Irma has been actively engaged in teaching and research, with a focus on epidemiology and public health. Her research interests include TB, surveillance, and public health, with a particular emphasis on improving health outcomes through education and community engagement. She received a short course scholarship from Australia Awards Indonesia for the Eradication TB program in 2018, and another in TB epidemiology from Prince of Songkla University, Thailand in 2022. She is also a member of The Indonesian Tuberculosis Research Network. Irma has served as a consultant in various regions to develop regional action plans for TB control. Additionally, she regularly contributes to public health conferences and journals, sharing her insights and findings with the academic community.

IndonesiaContributor
Publication

Background: Operational research is currently one of the pillars of the global strategy to control tuberculosis. Indonesia initiated capacity building for operational research on tuberculosis over the last decade. Although publication of the research in peer-reviewed journals is an important indicator for measuring the success of this endeavor, the influence of operational research on policy and practices is considered even more important. However, little is known about the process by which operational research influences tuberculosis control policy and practices.

Objective: We aimed to investigate the influence of operational research on tuberculosis control policy and practice in Indonesia between 2004 and 2014.

Design: Using a qualitative study design, we conducted in-depth interviews of 50 researchers and 30 policy makers/program managers and performed document reviews. Transcripts of these interviews were evaluated while applying content analysis.

Results: Operational research contributed to tuberculosis control policy and practice improvements, including development of new policies, introduction of new practices, and reinforcement of current program policies and practices. However, most of these developments had limited sustainability. The path from the dissemination of research results and recommendations to policy and practice changes was long and complex. The skills, interests, and political power of researchers and policy makers, as well as health system response, could influence the process.

Conclusions: Operational research contributed to improving tuberculosis control policy and practices. A systematic approach to improve the sustainability of the impact of operational research should be explored.

Keywords: Indonesia; knowledge translation; operational research; qualitative study; research; tuberculosis.

Qualitative Methods Indonesia
Publication

Background: Even though conceptually, Tuberculosis (TB) is almost always curable, it is currently the world's leading infectious killer. Patients with pulmonary TB are the source of transmission. Approximately 23% of the world's population is believed to be latently infected with TB bacteria, and 5-15% of them will progress at any point in time to develop the disease. There was a global diagnostic gap of 2.9 million between notifications of new cases and the estimated number of incident cases, and Indonesia carries the third-highest of this gap. Therefore, screening TB among the community is of great importance to prevent further transmission and infection. The electronic nose for screening TB (eNose-TB) project is initiated in Yogyakarta, Indonesia, to screen TB by breath test with an electronic-nose that is easy-to-use, point-of-care, does not expose patients to radiation, and can be produced at low cost.

Methods/design: The objectives of the two-phase planned project are to: 1) investigate the potential of an eNose-TB as a screening tool in Indonesia, in comparison with screening with clinical symptoms and chest radiology, which are currently used as a standard, and 2) analyze the time and cost of a screening algorithm with eNose-TB to obtain additional case detection. A cross-sectional study will be conducted in the first phase to validate the eNose-TB. The validation phase will involve 395 presumptive TB patients in the Surakarta General Hospital, Central Java. In the second phase, a cross-sectional research will be conducted, involving 1,383 adults and children in the municipality of Yogyakarta and Kulon Progo district of Yogyakarta Province.

Discussion: The findings will provide data concerning the sensitivity and specificity of the eNose-TB as a screening tool for tuberculosis, and the time and cost analysis of a screening algorithm with the eNose.

Digital health Intervention / trial Indonesia
Publication

Incarcerated people have been reported to have higher rates of tuberculosis (TB) than the general population. However, TB is rarely reported among incarcerated people in correctional facilities in Mimika District, in Central Papua Province of Indonesia. This study aims to describe the outcomes of comprehensive screening and treatment of TB disease and latent TB infection (LTBI) within a prison in Mimika. In response to a newly reported case of TB within a prison, a facility-wide comprehensive screening and treatment program was carried out for both TB disease and LTBI between September 2021 and June 2022. We evaluated the outcomes of the screening intervention, including the number of people found to have TB and LTBI and the number and proportion of people who started and completed TB-preventive treatment at the facility. A total of 403 incarcerated people and facility staff participated in the comprehensive screening program. Ten participants were found to have TB disease, all of whom commenced treatment. LTBI was detected in 256 (64%) participants, 251 (98%) of whom completed TB-preventive treatment. Comprehensive screening revealed a high prevalence of TB disease and LTBI in this prison. Completion of treatment for TB disease and latent TB infection was high. These outcomes suggest a role for routine search-treat-prevent strategies for TB in this setting.

Keywords: Indonesia; latent tuberculosis; prevention; prison; screening; tuberculosis.

Behavioural research Treatment Indonesia
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