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Danis Pertiwi,1 Muchlis Achsan Udji Sofro,2 Tri Indah Winarni,3 Ari Natalia Probandari4 1Department of Clinical Pathology, Faculty of Medicine, Universitas Islam Sultan Agung, Semarang, Indonesia; 2Department of Tropical and Infectious Disease, Dr. Kariadi Hospital, Semarang, Indonesia; 3Department of Anatomy, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia; 4Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, IndonesiaCorrespondence: Danis Pertiwi, Department of Clinical Pathology, Faculty of Medicine, Universitas Islam Sultan Agung, Semarang, 50112, Indonesia, Tel +628122910269, Email danispertiwi@unissula.ac.idBackground: Macrocytic anemia is the most common anemia in HIV-infected patients receiving zidovudine, and is closely related to folate and vitamin B12 deficiencies. Homocysteine > 10 μmol/L and increased MMA (methylmalonic acid) levels > 24.8 ng/mL indicate high/low folate and vitamin B12 deficiencies. Furthermore, MTHFR (Methylene-tetrahydrofolate-reductase) plays an essential role in the transmethylation of homocysteine to methionine and is related to DNA synthesis. The MTHFR C665T gene polymorphism decreases the activity of MTHFR, which culminates in homocysteinemia. Therefore, this case-control aims to assess the role of the MTHFR C665T gene polymorphism on the risk of macrocytic anemia among HIV-infected individuals receiving zidovudine.Methods: This study was conducted using an unmatched case-control design and the participants were HIV-infected adults aged 20 to 59 years old, receiving zidovudine for four weeks and above. A sample of 232 patients was divided into case group with macrocytic anemia and the control having no anemia. Multivariate logistic regression analysis was then implemented to determine the risk factors.Results: The results showed that there was a significant difference in the number of female and male patients namely 51.3% and 48.7%, respectively, with p< 0.001. Moreover, the mean age of the cases and control group was 41.9 ± 9.4 and 36.2 ± 8.3. Regarding education, there were significant differences between subjects with low and high education 47.8% vs 52.2% with p< 0.001. The majority of patients or 90.95% had taken AZT for more than 6 months. The logistic regression analysis test results showed that sex, age, education level, duration of AZT use, and homocysteine levels were predictors of macrocytic anemia with p< 0.05, while MTHFR C665T gene polymorphism and MMA levels were not risk factors.Conclusion: MTHFR C665T gene polymorphism does not contribute to the incidence of macrocytic anemia among HIV-infected individuals receiving zidovudine.Keywords: polymorphism, MTHFR C665T, macrocytic anemia, HIV, zidovudine

The prevalence of multimorbidity, the coexistence of two or more chronic diseases, is expected to increase, including in Indonesia. This phenomenon is associated with increased life expectancy and incidence of non-communicable diseases. Therefore, this study assesses the burden of multimorbidity in Indonesia by sociodemographic factors. The researchers analyzed cross-sectional data from the latest wave of IFLS conducted in 2014, the IFLS wave 5. The researchers included individuals aged 15 and above with blood pressure measurements (n= 32.256) from 13,536 households. Meanwhile, the researchers excluded individuals with missing data on BMI (183 individuals) or who had biologically implausible or extreme values (n=6). The analyses were then conducted on 32,067 individuals. The analyses comprised the ten most common self-reported chronic diseases diagnosis in IFLS-5. The findings revealed that the prevalence of self-reported multimorbidity in Indonesia was relatively high, at 9.32% (n= 2.989), with the highest proportion of multimorbidity reported among the elderly. Approximately 2.76% of the respondents (n- 885) reported having three or more chronic diseases. The most common combinations were hypertension and digestive problem (2.15%, n= 689), followed by hypertension and arthritis (1.79%, n= 574), and hypertension and high cholesterol (1.68%, n= 539). When stratified by sociodemographic factors, the researchers found a higher proportion of multimorbidity among females (11.01%, n= 3,530) compared to males (7.41%, n= 2.376), elderly (21.54%, n= 3.530) compared to younger adults, and previous smokers (20.90%, n= 6.072). People who were obese and overweight also reported a higher prevalence of multimorbidity (13.73%, n= 4.403 and 9.3%, n= 2.998, respectively). In addition, those living in urban areas had a higher proportion of multimorbidity (10.33%, n= 3.313) compared to rural areas (7.2%, n= 2.527). In conclusion, this study uncovered a relatively high prevalence of multimorbidity. People living in urban areas were overweight/obese and those who had low SES had a higher proportion of multimorbidity. With the nature of self-reported data and previously reported underdiagnosis of chronic diseases, screening to examine multimorbidity is needed.

Introduction Non-prescription antibiotic dispensing is prevalent among community pharmacies in several low- and middle-income countries. We evaluated the impact of a multi-faceted intervention to address this challenge in urban community pharmacies in Indonesia.Methods A pre-post quasi-experimental study was carried out in Semarang city from January to August 2022 to evaluate a 7-month long intervention comprising: (1) online educational sessions for pharmacists; (2) awareness campaign targeting customers; (3) peer visits; and (4) pharmacy branding and pharmacist certification. All community pharmacies were invited to take part with consenting pharmacies assigned to the participating group and all remaining pharmacies to the non-participating group. The primary outcome (rate of non-prescription antibiotic dispensing) was measured by standardised patients displaying symptoms of upper respiratory tract infection, urinary tract infection (UTI) and seeking care for diarrhoea in a child. χ2 tests and multivariate random-effects logistic regression models were conducted. Thirty in-depth interviews were conducted with pharmacists, staff and owners as well as other relevant stakeholders to understand any persistent barriers to prescription-based dispensing of antibiotics.Findings Eighty pharmacies participated in the study. Postintervention, non-prescription antibiotics were dispensed in 133/240 (55.4%) consultations in the participating group compared with 469/570 (82.3%) in the non-participating group (p value

# Background Indonesia has the second-highest burden of tuberculosis (TB) globally and is experiencing one of the fastest-growing HIV epidemics worldwide. The COVID-19 pandemic disrupted access to essential health services, including those for TB and HIV, due to health system overload, social distancing measures, and negative economic repercussions on the health sector and the population. An in-depth understanding of these challenges and the health system responses to mitigate the negative impact of the pandemic on TB and HIV services is crucial to building health system resilience and preparing for future emergencies. # Methods This qualitative study, conducted in two cities in Indonesia, explored the impact of the COVID-19 pandemic on TB and HIV services including mitigation strategies to sustain the provision of testing and treatment in the midst of the pandemic. Between February and June 2022, semi-structured interviews were conducted with 16 healthcare workers and 16 clients at nine health centers (puskesmas), three hospitals, and one Community Center for Lung Health in Bandung and Yogyakarta. Themes were identified from transcripts using open and selective coding and then refined. # Results Extraordinary measures were implemented in health facilities to sustain TB and HIV service delivery, and prevent the spread of COVID-19, including testing of clients for COVID-19 before receiving medical care, physical distancing when visiting healthcare facilities, revised schedules for medicine dispensing, involvement of community health workers and peers in community outreach activities such as the home delivery of medicines, and the use of telemedicine. Challenges encountered during the implementation of these strategies included medicine stock-outs, health worker overload, lack of sufficient client-provider interaction and technical difficulties when implementing telemedicine, and the risk or fear of exposure to COVID-19 among the community health workers and peers. # Conclusions Significant efforts were made to mitigate disruptions to TB and HIV services during the COVID-19 pandemic. However, some challenges were encountered. Key policy recommendations to strengthen pandemic preparedness include investing in local manufacturing and robust drug supply networks to prevent medicine shortages, and supporting community health workers to alleviate workload issues, reduce the risk of disease exposure, and explore the potential for a financial incentive system. Equally vital is the need to invest in staff training and education, as well as implementing user-friendly telemedicine technologies.

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.

Lack of participation of household contacts is the main problem of early detection of tuberculosis (TB) in Indonesia. A comprehensive health education (CHE) program has been developed to encourage the participation of household contacts. This study aimed to assess the implementation of the CHE to improve participation of household contacts in early detection of TB. This was a quasi-experimental study conducted between November 2018 and June 2019 in Badung District, Bali, Indonesia. Twelve public health centers (PHCs) were randomly allocated to six PHCs implementing the CHE and six PHCs implementing standard health education (SHE). The CHE was developed through a pilot study using the health belief model supplemented with perceived stigma and social support to identify the factors that influence participation. The participation was measured using a TB register with a cross-check to the health care officer until 2 months after health education was provided. Four hundred and twenty-eight household contacts enrolled in this study--216 in the CHE group and 212 in the SHE group. The CHE group's participation was 28.2%, with 10 new TB cases found; in the SHE group, the participation was 15.6%, with 3 new TB cases found. The CHE increased the household contact participation by 1.83-fold (95% confidence interval [1.19, 2.81]) and case findings by 3.13-fold (95% confidence interval [0.85, 11.56]). The CHE implementation should be scaled up to other areas with a high level of TB transmission. The content and technique of the CHE could also be incorporated in contact investigation guidelines and materials for the TB campaign.

Introduction Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution.Methods In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam.Results In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13–0.45), Viet Nam: +0.17 SD (0.03–0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15–0.51), vegetable consumption +0.27 SD (0.04–0.50)), body mass index (BMI) (Viet Nam: BMI −0.07 SD (−0.13 to −0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: −0.13 SD (−0.26 to −0.00)).Conclusion Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem.Trial registration number NCT05239572.

Introduction In Indonesia, a country with around 280 million people and the second-highest tuberculosis (TB) incidence rate in the world, the impact of the COVID-19 pandemic on TB care needs careful assessment so that future response strategies can be strengthened. We conducted a study comparing TB testing and treatment rates before and during the first 2 years of the COVID-19 pandemic in Indonesia, and the reasons for any disruptions to care.Methods We conducted retrospective secondary data analysis and qualitative interviews in Yogyakarta and Bandung, Indonesia. Routine data on TB testing and treatment were sourced from the national TB information system operated by the Indonesian Ministry of Health. TB testing and treatment outcomes were compared between two time periods: pre-COVID (2018–19); and during COVID-19 (2020–21). In-depth interviews were conducted with patients and health workers to explore their experiences in accessing and providing TB services during the pandemic.Results There was a 45% (21 937/39 962) reduction in the number of patients tested for TB during the pandemic compared with pre-COVID-19, while the proportion of TB tests returning a positive result increased from 12% (4733/39 962) to 50% (10 945/21 937). The proportion of TB patients completing treatment increased by 2.6% during the pandemic, yet the proportion cured and the number of patients successfully treated both decreased (by 7% and 4.4%, respectively). Our qualitative interviews highlighted several factors influencing TB service access and delivery, including fear of being diagnosed with COVID-19 during TB-related clinic visits, fear of COVID-19 exposure among patients and health workers, healthcare facilities prioritising COVID-19 over other services, and mandatory mobility restrictions affecting both patients and health workers.Conclusion The COVID-19 pandemic impacted TB testing and treatment outcomes in Bandung and Yogyakarta. Policymakers should consider these findings in designing strategies to ensure TB services are maintained and supported during future health crises.

Introduction Scaling up interventions targeting non-communicable diseases (NCDs) is a global health priority, and implementation research can contribute to that effort. In 2019, the Global Alliance for Chronic Diseases funded 27 implementation research studies to improve evidence for scaling up interventions targeting prevention and/or control of hypertension and/or diabetes in low-resource settings. We examined these studies to improve the understanding of the implementation factors, including challenges and facilitators, that influence the early implementation phase of scale-up research projects targeting NCDs.Methods This qualitative study was undertaken between August 2020 and July 2021. 43 semi-structured interviews were conducted with project investigators, implementers and policymakers, across 19 diverse scale-up projects, being implemented in 20 countries. The transcripts were inductively, open-coded using thematic analysis. Generated themes were mapped systematically to four out of five domain categorisations of the Consolidated Framework for Implementation Research (CFIR); the innovation domain fell outside the scope of this study.Results Highlighted findings using CFIR are: (i) outer setting: influence of politics, lack of coordination between government departments and differing agendas towards NCDs hindered implementation while reliable and trustworthy government connections proved useful; (ii) inner setting: commitment of resources for implementation was a challenge while research capacity, work culture and trustworthy networks facilitated implementation; (iii) individuals: high-level stakeholder support and leadership was essential; (iv) process: extensive time and efforts required for stakeholder engagement towards local contextualisation was challenging, while collaborating, joint reflection, effective communication and adaptation facilitated. COVID-19 provided both challenges and opportunities and these varied depending on the intervention characteristics and study objectives.Conclusion Researchers supporting the scale-up of complex interventions targeting NCDs need to leverage on existing trusting relationships and foster equitable stakeholder partnerships through research. Interpersonal skills and good communication are essential complements to research expertise and must be considered during capacity building.

BackgroundWorking memory is a crucial element of cognitive function. Previous cross-sectional studies have identified various determinants of working memory in children and adolescents. Nonetheless, no study has yet demonstrated the causal relationship of social determinants with working memory in adolescents.ObjectiveThis study explores the causal link between the level of education, smoking, and other factors with adolescent’s working memory.MethodsThis study analyzed secondary data from waves 4 and 5 of the Indonesia Family Life Survey (IFLS), utilizing cross-lagged analysis in Jamovi version 2.4.8. The variables included working memory score, maternal education, household income, stress, educational level, smoking, urbanicity, and physical activity. These variables were extracted from IFLS waves 4 and 5, and each dependent variable in IFLS wave four was controlled by the same dependent variables in IFLS 5. Then, we used cross-lagged analysis to assess the causality between each dependent variable and a working memory score in IFLS wave 5.ResultThe findings indicate that level of education had a positive impact on working memory in adolescents aged 15–18 years, with a Beta value of 0.18 (95% CI 0.81–0.2; p

Summary: Background: Indonesia is making significant strides toward achieving universal health coverage, which involves providing free access to essential medicines. This study examines the availability of essential medicine in primary health centres (PHCs) across Indonesia, the reasons why medicines are unavailable, and the extent to which communities have access to alternative dispensing points. Methods: Enumerators visited each of the 9831 PHCs in all 514 districts to assess the availability of 60 essential medicines and identify reasons for any absent medicines. We correlated the results with the national village census to assess the relationship between availability, poverty, and access to alternative dispensing points. Findings: Medicine availability varied greatly. The median availability for 17 priority medicines was 82%, while 58% of the broader selection of 60 essential medicines was present. The availability of maternal and childcare medicines was highest (73%) and lowest for mental health (42%). The main reasons for absence were that medicines were deemed unnecessary (46%) or not supplied (38%). The Java/Bali region had the highest medicines availability, and rural areas in Eastern Indonesia had the lowest. In these districts, the population is financially struggling, most dependent on free medicines from public providers, and had the least access to alternative dispensing points. Interpretation: The availability of priority medicines in PHCs is relatively high, while public-paid prices are low by international standards. To improve availability of all essential medicines, the government should prioritize areas with the highest need, increase funding for PHCs in remote areas, and implement transparent monitoring of medicines availability. Funding: Indonesian Government.

BackgroundA high prevalence of hypertension is found in Low- and Middle-income Countries (LMICs) including in Indonesia. However, hypertension awareness, treatment, and control are relativity poor. A community-based program to screen and educate people on non-communicable disease prevention (POSBINDU) was launched by the Indonesian government. However, the association between participation in the POSBINDU program with increasing knowledge, attitude, and practice of hypertension has not been widely assessed. In this study, we compared the knowledge, attitudes, and practices among people who accessed the POSBINDU and those who did not access the POSBINDU program. Subsequently, factors associated with the knowledge, attitudes, and practices among people who accessed the POSBINDU and those who did not access the POSBINDU were explored.MethodsThis was an observational study with a cross-sectional design measuring the knowledge, attitudes, and practices for hypertension control in four districts in Indonesia from October 2019 to January 2020. A total of 1,988 respondents were included in this study. A questionnaire was used to assess the knowledge, attitudes, and practices of hypertension. Simple logistic regression was used to investigate the correlation between the characteristics of respondents and knowledge, attitudes, and practice status. Multiple logistic regression tests were conducted to investigate factors associated with knowledge, attitudes, and practice status.ResultsWe found that people who accessed POSBINDU had higher odds of having better knowledge (aOR:1.4; 95%CI:1.2-1.8), however, accessed to POSBINDU was associated with lower attitudes (aOR:0.6; 85%CI: 0.5-0.7) and had no association with hypertension-related practice.ConclusionPeople who accessed POSBINDU have an association with good knowledge, but the association with good attitude and practice was less clear. Therefore, an improvement in the POSBINDU program is needed to increase the attitudes and practices of hypertension.

Abstract Background Childhood tuberculosis (TB) has been neglected in the fight against TB. Despite implementation of Directly Observed Treatment Shortcourse (DOTS) program in public and private hospitals in Indonesia since 2000, the burden of childhood TB in hospitals was largely unknown. The goals of this study were to document the caseload and types of childhood TB in the 0-4 and 5-14 year age groups diagnosed in DOTS hospitals on Java Island, Indonesia. Methods Cross-sectional study of TB cases recorded in inpatient and outpatient registers of 32 hospitals. Cases were analyzed by hospital characteristics, age groups, and types of TB. The number of cases reported in the outpatient unit was compared with that recorded in the TB register. Results Of 5,877 TB cases in the inpatient unit and 15,694 in the outpatient unit, 11% (648) and 27% (4,173) respectively were children. Most of the childhood TB cases were under five years old (56% and 53% in the inpatient and outpatient clinics respectively). The proportion of smear positive TB was twice as high in the inpatient compared to the outpatient units (15.6% vs 8.1%). Extra-pulmonary TB accounted for 15% and 6% of TB cases in inpatient and outpatient clinics respectively. Among children recorded in hospitals only 1.6% were reported to the National TB Program. Conclusion In response to the high caseload and gross under-reporting of childhood TB cases, the National TB Program should give higher priority for childhood TB case management in designated DOTS hospitals. In addition, an international guidance on childhood TB recording and reporting and improved diagnostics and standardized classification is required

Abstract Background The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment Short-Course (DOTS) strategy has increased rapidly internationally - including in Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed to estimate the proportion of outpatient adult Tuberculosis patients who received standardized diagnosis and treatment at outpatients units of hospitals involved in the PPM-DOTS strategy. Methods A cross-sectional study using morbidity reports for outpatients, laboratory registers and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota sampling, 62 hospitals were selected. Post-stratification analysis was conducted to estimate the proportion of Tuberculosis cases receiving standardized management according to the DOTS strategy. Result Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis cases in hospitals that participated in the PPM-DOTS strategy were not treated with standardized diagnosis and treatment as in DOTS. Conclusion This study found that a substantial proportion of TB patients cared for at PPM-DOTS hospitals are not managed under the DOTS strategy. This represents a missed opportunity for standardized diagnoses and treatment. A combination of strong individual commitment of health professionals, organizational supports, leadership, and relevant policy in hospital and National Tuberculosis Programme may be required to strengthen DOTS implementation in hospitals.

Increasing cases of emerging and re-emerging infectious diseases, requires healthcare systems to provide essential palliative care for critically ill patients and their families. With the rapid onset and often accelerated deterioration in patients with acute conditions, palliative and supportive care for these patients have different characteristics compared to those for chronic diseases. Furthermore, providing end-of life services for critically ill patients with acute diseases and their families to ensure good death for the patients, will also have its own challenges. This scoping review aims to explore the concept of palliative care and good death for acute diseases. This scoping review will be conducted using the Arksey and O’Malley's framework for scoping reviews: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarizing, reporting results, and conducting consultation. All original research with a focus on palliative care and good death due to acute diseases will be included. This review will include all original research designs published between the period of 2000–2021 that describe a measure of palliative care management for and good death due to acute diseases. Quantitative, qualitative and mixed-method studies will be included in order to consider different aspects of healthcare services. This review will also include guidelines and gray literature on palliative care and good deaths. The search will be conducted through PubMed, Scopus Database, and ScienceDirect using the key terms related to acute disease palliative care and the concept of good death due to acute diseases. Two authors will screen the titles and abstracts of the studies. Two authors will review the full text of selected studies independently and extract the data. All selected studies will be synthesized qualitatively, and the results will be consulted with experts through discussion and depict the current concept of palliative care and good death in acute diseases.

Background and Objectives: The virtual community plays a crucial role in increasing health literacy. A successful and empowered woman demands an adequate level of health literacy. Knowing the determinants affecting e-health literacy in the virtual community was hoped to optimize efforts to increase ehealth literacy. This research is aimed to assess the determinants that affect e-health literacy in virtual communities for empowering women. Materials and Methods: A study with a cross-sectional approach was used to assess the determinants of e-health literacy. A total of 117 samples were taken using the total sampling technique. Data was collected using demographic variables checklist, social support, community participation, ehealth literacy, and information process paradigms questionnaire. Data was analyzed for path analysis using Stata 13 software. Results: The path analysis showed that social support and community participation in women had a significant positive direct effect (p<0.05) on health literacy. The community participation, information processing paradigm, ethnicity, number of social media owned, age, education, distance from home to healthcare facilities, and number of healthcare places significantly indirectly affect health literacy (p <0.05). Conclusion: To empower woman's health literacy in online communities, we should pay attention to increase social support, community participation, processing information paradigm, ethnicity, number of social media owned, age, education, distance from home to healthcare facilities, and number of healthcare places. [ABSTRACT FROM AUTHOR]

Background: Community health centers (CHCs) are a backbone healthcare facility for tuberculosis (TB) services. Identifying barriers amongst TB service providers at the CHC level is required to help them deliver successful TB treatment.Aims: The current study aimed to analyze barriers to successful TB treatment from the perspective of TB service providers at the CHC level in a high prevalent TB country.Methods: A qualitative study was conducted using in-depth interviews and focus group discussions in a province of Indonesia with a high TB prevalence. Two districts representing rural and urban areas were selected to obtain information from TB service providers (i.e., physicians and nurses) at the CHC level. In addition, key informant interviews with TB patients, hospital TB specialists, pharmacists, and activists were conducted. The trustworthiness and credibility of the information were established using information saturation, participant validation, and triangulation approaches. The interviews were also transcribed for the inductive analysis using Atlas.ti 8.4 software.Results: We identified 210 meaning units from 48 participants and classified them into two main themes: organizational capacity and TB program activities. We identified the inadequacy of human resources, facility, and external coordination as the main barriers to organizational capacity. Furthermore, the barriers were identified regarding TB program activities, that is, inadequate TB case finding, diagnosis, drug supply chain and dispensing management, treatment and monitoring, case recording and reporting, and public-private collaboration.Conclusion: Strengthening CHCs in the management of TB is critical to reaching the national and global goals of TB eradication by 2035. These findings can be considered to develop evaluation strategies to improve the successful TB treatment in high prevalent TB countries, especially Indonesia.

In many low- and middle-income countries (LMICs), the epidemiological transition is characterized by an increased burden of non-communicable diseases (NCDs) and the persistent challenge of infectious diseases. The transmission of tuberculosis, one of the leading infectious diseases, can be halted through active screening of risk groups and early case findings. Studies have reported comorbidities between tuberculosis (TB) and NCDs, which necessitates the development of an integrated disease management model. This scoping review discusses the possibilities and problems of integration in managing TB and NCDs, with a particular emphasis on diabetic mellitus (DM) and hypertension screening and control. We will conduct this review following Arksey and O’Malley’s framework for scoping review. We will use key terms related to integrated management, i.e., screening, diagnosis, treatment, and care, of TB, DM, and hypertension in PubMed, Scopus Database, and ScienceDirect for research published from January 2005 to July 2021. This review will also consider grey literature, including unpublished literature and international disease management guidelines on TB, DM, and hypertension from WHO or other health professional organization. We will export the search results to citation manager software (EndNote). We will remove duplicates and apply the inclusion and exclusion criteria to identify the set of papers for the review. After screening the titles and abstract, two authors will independently review the full text of selected studies and extract the data. We will synthesize all selected studies qualitatively and the results will be discussed with the experts. The results will be used as the basis of the development of a guideline for integrated TB, DM, and hypertension management.

Increasing cases of emerging and re-emerging infectious diseases, requires healthcare systems to provide essential palliative care for critically ill patients and their families. With the rapid onset and often accelerated deterioration in patients with acute conditions, palliative and supportive care for these patients have different characteristics compared to those for chronic diseases. Furthermore, providing end-of life services for critically ill patients with acute diseases and their families to ensure good death for the patients, will also have its own challenges. This scoping review aims to explore the concept of palliative care and good death for acute diseases. This scoping review will be conducted using the Arksey and O’Malley's framework for scoping reviews: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarizing, reporting results, and conducting consultation. All original research with a focus on palliative care and good death due to acute diseases will be included. This review will include all original research designs published between the period of 2000–2021 that describe a measure of palliative care management for and good death due to acute diseases. Quantitative, qualitative and mixed-method studies will be included in order to consider different aspects of healthcare services. This review will also include guidelines and gray literature on palliative care and good deaths. The search will be conducted through PubMed, Scopus Database, and ScienceDirect using the key terms related to acute disease palliative care and the concept of good death due to acute diseases. Two authors will screen the titles and abstracts of the studies. Two authors will review the full text of selected studies independently and extract the data. All selected studies will be synthesized qualitatively, and the results will be consulted with experts through discussion and depict the current concept of palliative care and good death in acute diseases.

Background: Drug resistance and multi drugs tuberculosis (DR/MDR-TB) are associated with patients' low adherence to undergoing complex treatment. Driven by the increasing use and penetration of a smartphone and the End of TB Strategy that seeks for digital health solution, Center for Tropical Medicine Universitas Gadjah Mada has developed TOMO, an Android-based app for improving medication adherence in MDR-TB. Objective: This paper aims to present the sequential steps to develop the app, its general architecture, and its functionalities. Methods: It is a design thinking process involving two MDR-TB referral centers, district health offices, primary health centers, and MDR-TB patients in Central Java and Yogyakarta, Indonesia. We adopted the Principles for Digital Development to develop and design the app. MDR-TB treatment guideline from the Indonesian Ministry of Health was used to develop functionalities of the app for improving adherence. Results: TOMO app could be used by patients, primary health centers, clinical teams, and case managers. The app prototype features include adverse event records and reports, medication-taking reminders, and communication between the patient and the TB-MDR case manager. We have successfully tested the functionalities based on four use cases: patients with high adherence, patients with low adherence, patients with adverse events, and patients following treatment in the primary health center without any visit to the MDR-TB center. Conclusion: TOMO app has contributed to the limited body of literature on improving TB-MDR adherence with digital health intervention, especially using a health app. The app has been tested using four scenarios. We will follow up with usability testing before implementing the app in a real setting.

Background: Drug resistance and multi drugs tuberculosis (DR/MDR-TB) are associated with patients' low adherence to undergoing complex treatment. Driven by the increasing use and penetration of a smartphone and the End of TB Strategy that seeks for digital health solution, Center for Tropical Medicine Universitas Gadjah Mada has developed TOMO, an Android-based app for improving medication adherence in MDR-TB. Objective: This paper aims to present the sequential steps to develop the app, its general architecture, and its functionalities. Methods: It is a design thinking process involving two MDR-TB referral centers, district health offices, primary health centers, and MDR-TB patients in Central Java and Yogyakarta, Indonesia. We adopted the Principles for Digital Development to develop and design the app. MDR-TB treatment guideline from the Indonesian Ministry of Health was used to develop functionalities of the app for improving adherence. Results: TOMO app could be used by patients, primary health centers, clinical teams, and case managers. The app prototype features include adverse event records and reports, medication-taking reminders, and communication between the patient and the TB-MDR case manager. We have successfully tested the functionalities based on four use cases: patients with high adherence, patients with low adherence, patients with adverse events, and patients following treatment in the primary health center without any visit to the MDR-TB center. Conclusion: TOMO app has contributed to the limited body of literature on improving TB-MDR adherence with digital health intervention, especially using a health app. The app has been tested using four scenarios. We will follow up with usability testing before implementing the app in a real setting.

Abstract Background There exists low uptake of Human Immunodeficiency Virus (HIV) testing among Tuberculosis (TB) patients through Provider-Initiated HIV Testing and Counseling (PITC) under the national TB control program in Nepal. The degree and quality of program delivery were explored through determining whether the PITC program is currently implemented as intended. This study aimed to assess three major components of the program’s implementation fidelity: adherence to PITC service, exposure, and quality of program delivery in order to optimize and standardize PITC implementation by exploring its barriers and enablers. Methods This research used a sequential explanatory mixed method design. Retrospective cross-sectional study of TB patients enrolled in five TB treatment centers of the Kathmandu district from July 1, 2016, to June 30, 2017 was done to assess PITC adherence to Direct Observed Treatment-Short Course (DOTS) protocols. The centers’ TB-DOTS readiness was assessed using the WHO Service Availability and Readiness Assessment checklist. A qualitative study was conducted to explore the barriers and enablers of PITC service implementation. Results From a total of 643 TB patients registered, 591 (92.1%) patients were offered HIV test counseling. Amongst those, 571 (96.6%) accepted and 523 (91.5%) were tested. Service providers’ HIV knowledge was found to be good although only 2/5 (40%) had participated in PITC training. The key barriers experienced by service providers were: patients feeling offended, stigmatization and lack of human resources in DOTS centers. The main enablers for PITC were national TB program commitment, health workers’ motivation, collaboration between stakeholders and external development partners’ promotion of program implementation. Conclusion In the selected study sites, PITC services are well integrated into the routine TB control program with a high uptake of HIV testing among registered TB patients. This achievement should be sustained by addressing the identified barriers mainly in the quality of the PITC program delivery.

Background: Jaminan Kesehatan Nasional (JKN) is Indonesia's health policy to achieve universal health coverage (UHC). Towards 2019, not all regions have succeeded in achieving UHC. One of the reasons is the uneven distribution of information regarding JKN policies. Socialization is needed so that the JKN policy is understood by the people of Indonesia. Objective: This research was design to describe the importance of JKN policy socialization to reach UHC. Methods: Qualitative research was conducted in September 2018- February 2019 in two districts in Central Java, that were the district that had reached UHC and districts that had not yet reached UHC. The informants consisted of leaders of regional organizations and also the community. The researcher conducted an interactive model analysis on the interview transcript. Results: In districts that had reached UHC, socialization was conducted directly and indirectly through the government, community cadres and BPJS cadres. The district government provided support by issuing circulars letters. The district socialization effectively increases JKN participants. Meanwhile, in districts that had not yet reached UHC, there was found differences between community and the government. The government said that they had conducted effective socialization. But the community said that the information provided has not been effective and there is no detailed information about JKN. Conclusion: An effective socialization of JKN policies is needed to increase the understanding and awareness of the community to achieve UHC.