Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

BACKGROUND

Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19.

RESULTS

Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic.

CONCLUSIONS

Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

A public health intervention package for increasing tuberculosis notifications from private practitioners in Bandung, Indonesia (INSTEP2): A cluster-randomised controlled trial protocol

Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public–private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public–private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.

OR8. Appropriateness of percutaneous coronary intervention procedure in Indonesia

Background and Aims

There is a possibility of the high variability of the appropriateness of PCI performed in Indonesia. It is assumed that appropriate PCI tends to have clinical outcomes than other categories. This study aimed to evaluate the appropriateness of the percutaneous coronary intervention (PCI) procedure in Indonesia.

Method and Results

We assigned appropriateness ratings to 214 acute coronary syndromes (ACS) and 191 stable ischemic heart disease (SIHD) records that underwent PCI in four hospitals from 2017 - 2018. The included hospitals consist of one public and three private hospitals, two cardiovascular centers, and two general hospitals with the most performed PCI procedures on 2016 - 2018 and accessible to the researchers. The PCI appropriateness was adjudicated using 2016/2017 ACC/AHA guidelines of the Appropriate Use of Care (AUC) for coronary revascularization in ACS and SIHD. The results were categorized into “appropriate”, “maybe appropriate”, and “rarely appropriate”.  

The result from this study demonstrated that in ACS patients, 76.0% and 24.0% of PCI were appropriate” and “maybe appropriate”. While, in SHID patients, 68.7%, 28.7%, and 2.6% of PCI were “appropriate”, “maybe appropriate”, and “rarely appropriate”. In ACS patients, “appropriate” PCI is more commonly found in ST-elevation myocardial infarction (STEMI) cases (62.6%). In SIHD patients, 54.0% and 46.0% of left-main diseases patients underwent “maybe appropriate” and “rarely appropriate” PCI. 

Conclusion

The majority of PCI performed in ACS and SIHD patients from the studied hospitals are “appropriate”. 

Are neighbourhoods of tuberculosis cases a high-risk population for active intervention? A protocol for tuberculosis active case finding

BACKGROUND

Indonesia has the second largest tuberculosis (TB) burden globally. Attempts to scale-up TB control efforts have focused on TB households. However, in most high burden settings, considerable Mycobacterium tuberculosis (Mtb) transmission occurs outside TB households. A better understanding of transmission dynamics in an urban setting in Indonesia will be crucial for the TB Control Program in scaling up efforts towards elimination of TB in a more targeted way. Therefore, the study aims to measure TB prevalence and incidence in household contacts and neighbourhoods in the vicinity of known TB cases and to assess their genomic and epidemiological relatedness.

METHODS AND ANALYSIS

Individuals (~1000) living in the same household as a case diagnosed with pulmonary TB (n = 250) or in a neighbouring household (~4500 individuals) will be screened for TB symptoms and by chest x-ray. Two sputum samples will be collected for microbiological analysis from anyone with a productive cough. Any person found to have TB will be treated by the National TB Control Program. All those with no evidence of TB disease will have a repeat screen at 12 months. Whole-genome sequencing (WGS) and social network analysis (SNA) will be conducted on Index cases and contacts diagnosed with TB.

A public health intervention package for increasing tuberculosis notifications from private practitioners in Bandung, Indonesia (INSTEP2): A cluster-randomised controlled trial protocol

Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public-private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public-private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.

Faktor yang Memengaruhi Dukungan Suami terhadap Pemberian ASI Eksklusif Berdasarkan Theory of Planned Behavior (TPB)

The coverage of exclusive breastfeeding has not yet reached the target both in Indonesia and other countries. One of the factors that influence husband’s support. Husband’s support for exclusive breastfeeding will be influenced by his intention. A person’s planned behavior or intentions can be predicted through their attitudes as described in Theory of Planned Behavior (TPB), which states that a person’s intention is influenced by behavior belief, outcome evaluation and perceived power. The research aims was to analyze which factors most influenced husband’s support for exclusive breastfeeding based on TPB. The study is a quantitative research using survey method. The sampling technique used multistage sampling to get respondents as many as 90 husbands who have babies aged 0-6 months in Bandung. The instrument used the Partner Breastfeeding Influence Scale (PBIS) and the TPB questionnaire, while the statistical analysis used the Multiple Linear Regression Test. The results of the analysis showed that the husband’s support for exclusive breastfeeding can be categorized as sufficient. Whereas the factors that most influenced the husband’s support for exclusive breastfeeding based on TPB were behavior beliefs (β = 1.8; p = 0.01). These results provide information that a health promotion program design is needed to improve attitudes and support for husband in exclusive breastfeeding. Abstrak Cakupan pemberian Air Susu Ibu (ASI) eksklusif masih belum mencapai target baik di Indonesia maupun di negara lain. Salah satu faktor yang memengaruhinya adalah dukungan suami. Dukungan suami terhadap pemberian ASI eksklusif akan dipengaruhi oleh intensinya. Perilaku terencana atau intensi seseorang dapat diprediksi melalui sikap yang dimilikinya seperti yang dijelaskan dalam Theory of Planned Behavior (TPB) bahwa intensi seseorang dipengaruhi oleh behavior belief, outcome evaluation dan perceive power. Tujuan penelitian yaitu untuk menganalisis faktor mana yang paling memengaruhi dukungan suami terhadap pemberian ASI eksklusif berdasarkan TPB. Penelitian ini merupakan penelitian kuantitatif dengan metode survei. Teknis pengambilan sampel menggunakan multistage sampling untuk mendapatkan responden sebanyak 90 orang suami yang memiliki bayi usia 0-6 bulan di Kota Bandung. Instrumen penelitian menggunakan Partner Breastfeeding Influence Scale (PBIS) dan kuesioner TPB sedangkan analisis statistik menggunakan uji regresi linear berganda. Hasil analisis diperoleh besar dukungan suami terhadap pemberian ASI eksklusif dapat dikategorikan cukup, sedangkan faktor yang paling memengaruhi dukungan suami terhadap pemberian ASI eksklusif berdasarkan TPB adalah behavior beliefs (β=1,8; p=0,01). Hasil ini memberikan informasi bahwa diperlukan suatu rancangan program promosi kesehatan untuk meningkatkan sikap serta dukungan suami dalam pemberian ASI eksklusif.  

Out-of-Pocket Costs for Patients Diagnosed with Tuberculosis in Different Healthcare Settings in Bandung, Indonesia

Costs related to tuberculosis (TB) can impose a significant burden on patients and their families and create barriers to diagnosis and treatment. Our study aimed to quantify out-of-pocket costs expended by TB patients in Bandung, Indonesia. This cross-sectional study recruited adults with TB from community health centers (CHCs), public and private hospitals, and private practitioners (PPs). An interview was completed at the time of diagnosis or at their return for 2- or 6-month treatment. Costs were converted to U.S. dollars (US$)-presented as median and interquartile range (IQR). Of 469 TB patients recruited, the mean age was 38 years and 57% were male. The median pretreatment direct cost per person was $37.51 (IQR 20.79-71.24). Hospitalization, diagnostic tests, and travel costs were predominant. Higher pretreatment costs were associated with no health insurance ($41.88 versus $27.41, P < 0.001), ≥ 6 visits to a healthcare provider ($39.91 versus $24.32, P < 0.001), ≥ 60 days pretreatment ($36.35 versus $26.25, P = 0.02), and presenting first to a PP ($40.71) or informal provider ($32.72) compared with private hospital ($21.26), public hospital ($19.63), or CHC ($13.52) (P = 0.01). For a subsample of 106 patients with total pre- and posttreatment costs available, the median total cost was $243.66 (IQR 128.46-550.71). For 26.5% of these patients, total costs were ≥ 20% of their annual household income. Despite having a good network of free TB diagnostic and treatment services throughout Bandung, patients experienced significant out-of-pocket costs. Increased uptake of the National Health Insurance, and systems for early recognition and diagnosis of TB, will contribute toward reducing costs.

Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia

How countries, particularly low- and middle-income economies, should pay the coronavirus disease 2019 (COVID-19) vaccine is an important and understudied issue. We undertook an online survey to measure the willingness-to-pay (WTP) for a COVID-19 vaccine and its determinants in Indonesia. The WTP was assessed using a simple dichotomous contingent valuation approach and a linear regression model was used to assess its associated determinants. There were 1,359 respondents who completed the survey. In total, 78.3% (1,065) were willing to pay for the COVID-19 vaccine with a mean and median WTP of US$ 57.20 (95%CI: US$ 54.56, US$ 59.85) and US$ 30.94 (95%CI: US$ 30.94, US$ 30.94), respectively. Being a health-care worker, having a high income, and having high perceived risk were associated with higher WTP. These findings suggest that the WTP for a COVID-19 vaccine is relatively high in Indonesia. This WTP information can be used to construct a payment model for a COVID-19 vaccine in the country. Nevertheless, to attain higher vaccine coverage, it may be necessary to partially subsidize the vaccine for those who are less wealthy and to design health promotion materials to increase the perceived risk for COVID-19 in the country.

Hubungan Persepsi tentang Penularan HIV/AIDS dari Ibu ke Anak terhadap Praktik Penggunaan Kontrasepsi pada Wanita Usia Subur Penerima Obat Antiretroviral di Kota Bandung

Abstract    More than 90% of cases of Human Immunodeficiency Virus (HIV) / Acquired Immune Deficiency Syndrom (AIDS) in children, occur due to transmission from mother to child. Prevention of unwanted pregnancies with contraception in HIV positive women is important strategy to reduce the rate of mother to child HIV/AIDS transmission. The practice of contraceptive use in HIV positive women is strongly influenced by individual beliefs regarding the benefits and effectiveness of contraception for the prevention of mother to child HIV/AIDS transmission. This study aims to determine the relationship of perceptions based on the construct of the Health Belief Model (HBM) wich consists of perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self efficacy, and cues to action and based on pluralistic ignorance on the practice of contraceptive use among woman of childbearing age recipients of antiretroviral in Bandung. The design of this study was quantitative non-experimental with survey methods. Data were collected for one month, using questionnaire from 188 women of childbearing age  receiving  antiretroviral drughs taken by consecutive sampling (non-probability) technique. Data were analyzed by logistic regression. The results revealed perceived susceptibility is an HBM construct that affects contraceptive use (Adjusted Odds Ratio (AOR):4.5). While knowledge (AOR:7.3) and age (AOR:0.801), emerged as other factors that influence contraceptive use among WUS recipients of antiretroviral in Bandung. The HBM is used to predict contraceptive behavior in women. HIV positive women who believe themselves to be at high risk of infecting HIV/AIDS from mother to child will tend to use contraception, besides that knowledge is the basis for HIV positive women taking action to use contraception. Abstrak Lebih dari 90% kasus Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrom (AIDS) pada anak, terjadi akibat penularan dari ibu ke anak. Pencegahan kehamilan yang tidak direncanakan dengan kontrasepsi pada wanita HIV positif merupakan strategi penting untuk menurunkan angka penularan HIV/AIDS dari ibu ke anak. Praktik penggunaan kontrasepsi oleh wanita HIV positif sangat dipengaruhi oleh keyakinan individu terkait manfaat dan efektivitas kontrasepsi terhadap pencegahan penularan HIV/AIDS dari ibu ke anak. Penelitian ini bertujuan untuk mengetahui hubungan persepsi berdasarkan konstruk Health Belief Model (HBM) yang terdiri dari perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self efficacy, dan cues to action serta berdasarkan ketidaktahuan majemuk terhadap praktik penggunaan kontrasepsi pada Wanita Usia Subur (WUS) penerima obat antiretroviral di Kota Bandung. Desain penelitian ini adalah kuantitatif non-experimental dengan metode survei. Data dikumpulkan selama satu bulan, menggunakan kuesioner dari 188 WUS penerima obat antiretroviral yang diambil dengan teknik consecutive sampling (non-probability). Data dianalisis dengan regresi logistik. Hasil penelitian mengungkapkan perceived susceptibility adalah konstruk HBM yang berpengaruh terhadap penggunaan kontrasepsi (Adjusted Odds Ratio (AOR):4,5). Sementara pengetahuan (AOR:7,3) dan usia (AOR:0,801) muncul sebagai faktor-faktor lain yang berpengaruh terhadap praktik penggunaan kontrasepsi pada WUS penerima obat antiretroviral di Kota Bandung. HBM digunakan untuk memprediksi perilaku kontrasepsi pada wanita. Wanita HIV positif yang meyakini dirinya berisiko tinggi dapat menularkan HIV/AIDS ke anak, akan cenderung menggunakan kontrasepsi, disamping itu pengetahuan menjadi dasar bagi wanita HIV positif dalam mengambil tindakan untuk menggunakan kontrasepsi.

Community acceptance and willingness-to-pay for a hypothetical Zika vaccine: A cross-sectional study in Indonesia

BACKGROUND

Understanding people's perceptions of the economic benefits of a potential Zika vaccine (ZV) is critical to accelerating its introduction into either public sector programs or private market. The aim of this study was to assess the acceptance and willingness-to-pay (WTP) for a hypothetical ZV and the associated explanatory variables in Indonesia.

METHODS

We conducted a health facility-based cross-sectional study in Aceh and West Sumatra province from 1 February to 13 June 2018. Patients who visited outpatient departments, have had children or were expecting their first child, were approached and interviewed to collect information on acceptance, WTP, demographic and socio-economic variables and attitudes towards childhood vaccines. Associations of explanatory variables influencing acceptance and WTP were assessed using logistic regression and linear regression analysis, respectively.

RESULTS

In total, 956 respondents were included in the final analysis of acceptance, of whom 338 (35.3%) expressed their WTP. We found that 757 (79.1%) of the respondents were likely to be vaccinated and to recommend their partner to be vaccinated. Higher educational attainment, having a job, having heard about Zika and a good attitude towards childhood vaccination were associated with ZV acceptance in the univariate analyses. In the multivariate analysis, attitude towards childhood vaccination was the strongest predictor for ZV vaccination. We found the geometric mean and median of WTP was US$ 13.1 (95% CI: 11.37-15.09) and US$ 7.0 (95% CI: 4.47-10.98), respectively. In the final model, having heard about Zika, having a job, and higher income were associated with a higher WTP.

CONCLUSION

Although the acceptance rate of the ZV is relatively high in Indonesia, less than 40% of respondents are willing to pay, underscoring the need for a low-cost, high-quality vaccine and public sector subsidies for Zika vaccinations in the country.

Flatfoot decreases school functioning among children < 11 years of age

Background Flatfoot is a musculoskeletal abnormality commonly found in children that could result in a reduction of quality of life because of its related symptoms and functional abnormalities. This study aimed to determine the association between flatfoot and the quality of life among children 5-18 years of age. Methods A cross sectional design was used in this study of children aged 5-18 years. The diagnosis of flatfoot was made in accordance with the Chippaux-Smirak Index classification, whereas general and domain-specific quality of life were measured using the Indonesian version of PedsQL™ that has been previously validated. Mann Whitney test was used to compare quality of life between children with flatfoot and normal feet, along with other variables that potentially may influence a child’s quality of life. Results A total of 79 out of 120 subjects was used to analyze the data. There was a statistically significant difference in the quality of life score in the school functioning domain between children with flatfoot (64.46 ±18.22) and those with normal feet (75.90 ±17.29) in children <11 years of age (p=0.029). Apart from this, the study did not find any statistically significant differences in the total quality of life score or in other quality of life domains between the two groups. Conclusions Flatfoot significantly decreases children’s quality of life in the school functioning domain. Early detection and correction of flatfoot may be necessary to improve the educational attainment of children suffering from this condition.

Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study

BACKGROUND

The Indonesian region of Aceh was the area most severely affected by the earthquake and tsunami of 26 December 2004. Department of Health data reveal an upward trend of dengue cases in Aceh since the events of the tsunami. Despite the increasing incidence of dengue in the region, there is limited understanding of dengue among the general population of Aceh. The aim of this study was to assess the knowledge, attitude, and practice (KAP) regarding dengue among the people of Aceh, Indonesia in order to design intervention strategies for an effective dengue prevention program.

METHODS

A community-based cross-sectional study was conducted in Aceh between November 2014 and March 2015 with a total of 609 participants living in seven regencies and two municipalities. Information on the socio-demographic characteristics of participants and their KAP regarding dengue was collected using a pre-tested structured questionnaire. The KAP status (good vs. poor) of participants with different socio-demographic characteristics was compared using Chi Square-test, ANOVA or Fisher's exact test as appropriate. Logistic regression analysis was used to determine the predictors of each KAP domain.

RESULTS

We found that 45% of participants had good knowledge regarding dengue and only 32% had good attitudes and good dengue preventive practices. There was a significant positive correlation between knowledge and attitudes, knowledge and practice, and attitudes and practice. In addition, people who had good knowledge were 2.7 times more likely to have good attitudes, and people who had good attitudes were 2.2 times more likely to have good practices regarding dengue. The level of education, occupation, marital status, monthly income, socioeconomic status (SES) and living in the city were associated with the knowledge level. Occupation, SES, and having experienced dengue fever were associated with attitudes. Education, occupation, SES and type of residence were associated with preventive practices.

CONCLUSION

Our study suggests that dengue prevention programs are required to increase KAP levels regarding dengue in the communities of Aceh.