Poor personal protective equipment practices were associated with heat-related symptoms among Asian healthcare workers: a large-scale multi-national questionnaire survey

BACKGROUND

It is pertinent to understand the perceptions of healthcare workers (HCWs) with their associated personal protective equipment (PPE) usage and heat strain symptoms experienced to effectively combat the negative effects of heat stress during treatment and care activities.

METHODS

We evaluated the associated heat stress perceived by HCWs across Asia and validated a questionnaire on perceptions of heat stress, associated PPE usage, and heat strain symptoms experienced. The questionnaire was administered to 3,082 HCWs in six Asian regions. Factor analyses, including Cronbach's alpha, assessed the questionnaire's validity and reliability. Structural equation modelling analysed the effects of knowledge, attitudes and practices, and heat strain symptoms.

RESULTS

The questionnaire was found to be reliable in assessing HCWs' knowledge, and attitudes and practices towards heat stress and PPE usage (both Cronbach's alpha = 0.9), but not heat strain symptoms (Cronbach's alpha = 0.6). Despite knowledge of heat stress, HCWs had negative attitudes and practices regarding PPE usage (β1 = 0.6, p < 0.001). Knowledge (path coefficient = 0.2, p < 0.001), and negative attitudes and practices (path coefficient = 0.2, p < 0.001) of HCWs towards heat stress and PPE usage adversely affected symptoms experienced.

CONCLUSIONS

The questionnaire was not reliable in assessing symptoms. HCWs should, nevertheless, still self-assess their symptoms for early detection of heat strain. To effectively attenuate heat strain, understanding HCWs' attitudes and practices towards PPE usage should guide policymakers in implementing targeted heat management strategies.

Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries

BACKGROUND

The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC).

METHODS

In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing.

FINDINGS

Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement.

INTERPRETATION

Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC.

FUNDING

Bill & Melinda Gates Foundation.

Family Involvement to Stop the Conversion of Prediabetes to Diabetes

Prediabetes is a condition associated with an increased risk of developing diabetes, in which blood glucose levels are high but not high enough to be diagnosed as diabetes. The rapid increase in the prevalence of prediabetes is a major global health challenge. The incidence of prediabetes has increased to pandemic levels and can lead to serious consequences. Unfortunately, nearly 90% of prediabetic individuals are unaware of their ailment. A quarter of prediabetic individuals develop type 2 diabetes mellitus (T2DM) within 3-5 years. Although prediabetes is a reversible condition, the prevention of diabetes has received little attention. It is essential for prediabetic individuals to implement new health-improvement techniques. Focusing on family systems is one strategy to promote health, which is determined by health patterns that are often taught, established, and adjusted within family contexts. For disease prevention, a family-based approach may be beneficial. Family support is essential for the metabolic control of the disease. This study aimed to show several strategies for involving the patient's family members in preventing the conversion of prediabetes to T2DM and to emphasize that the patient's family members are a valuable resource to reduce the incidence of diabetes.

Acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics in Yogyakarta, Indonesia: a qualitative study

BACKGROUND

The relationship between Tuberculosis (TB) and Diabetes Mellitus (DM) is intricate and intertwined, posing significant global health challenges. In addition, the increasing prevalence of DM worldwide raises concerns regarding the potential resurgence of tuberculosis. The implementation of tuberculosis prevention strategies is of the utmost importance, especially in countries like Indonesia that encounter a dual burden of TB and DM. The significance of TB screening in private primary care settings for patients with diabetes cannot be overstated. Implementing TB screening protocols in private primary care settings can assist in identifying diabetic patients with tuberculosis. Therefore, this study aims to explore the acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics.

METHODS

We conducted implementation research with an exploratory qualitative design. Fifteen healthcare professionals from five private primary health care clinics in Yogyakarta, Indonesia, participated in five focus groups. The discussions were audio recorded, transcribed verbatim, and thematically analyzed. As part of the feasibility assessment, surveys were conducted in each clinic. We conducted a thematic analysis in accordance with the theoretical framework of acceptability and the feasibility assessment.

RESULTS

We identified that most private primary care clinics deemed the implementation of TB screening in DM patients acceptable and practicable. We revealed that the majority of diabetes patients enthusiastically accepted TB-DM screening services. In addition, we found that the healthcare professionals at the clinic are aware of the nature of the intervention and demonstrates a positive attitude despite a subtle burden. The stigma associated with COVID-19 has emerged as a new implementation barrier, joining TB stigma, lack of resources, and regulatory issues. We identify concealed and tiered screening as a potential method for enhancing the implementation of TB-DM screening.

CONCLUSIONS

The implementation of TB screening in DM patients in private primary care clinics had the potential to be acceptable and feasible. To achieve a successful implementation, consideration should be given to supporting factors, hindering factors, and strategies to improve TB screening in DM patients.

Health-related Quality of Life of Patients With Diabetes Mellitus Measured With the Bahasa Indonesia Version of EQ-5D in Primary Care Settings in Indonesia

OBJECTIVES

Diabetes mellitus (DM) is a serious public health issue that places a heavy financial, social, and health-related burden on individuals, families, and healthcare systems. Self-reported health-related quality of life (HRQoL) is extensively used for monitoring the general population's health conditions and measuring the effectiveness of interventions. Therefore, this study investigated HRQoL and associated factors among patients with type 2 DM at a primary healthcare center in Indonesia.

METHODS

A cross-sectional study was conducted in Klaten District, Central Java, Indonesia, from May 2019 to July 2019. In total, 260 patients with DM registered with National Health Insurance were interviewed. HRQoL was measured with the EuroQol Group's validated Bahasa Indonesia version of the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) with the Indonesian value set. Multivariate regression models were used to identify factors influencing HRQoL.

RESULTS

Data from 24 patients were excluded due to incomplete information. Most participants were men (60.6%), were aged above 50 years (91.5%), had less than a senior high school education (75.0%), and were unemployed (85.6%). The most frequent health problems were reported for the pain/discomfort dimension (64.0%) followed by anxiety (28.4%), mobility (17.8%), usual activities (10.6%), and self-care (6.8%). The average EuroQoL 5-Dimension (EQ-5D) index score was 0.86 (95% confidence interval [CI], 0.83 to 0.88). In the multivariate ordinal regression model, a higher education level (coefficient, 0.08; 95% CI, 0.02 to 0.14) was a significant predictor of the EQ-5D-5L utility score.

CONCLUSIONS

Patients with diabetes had poorer EQ-5D-5L utility values than the general population. DM patients experienced pain/discomfort and anxiety. There was a substantial positive relationship between education level and HRQoL.

Seroprevalence of SARS-CoV-2 and risk factors in Bantul Regency in March-April 2021, Yogyakarta, Indonesia

COVID-19 case counts in Indonesia inevitably underestimate the true cumulative incidence of infection due to limited diagnostic test availability, barriers to testing accessibility and asymptomatic infections. Therefore, community-based serological data is essential for understanding the true prevalence of infections. This study aims to estimate the seroprevalence of SARS-CoV-2 infection and factors related to the seropositivity in Bantul Regency, Yogyakarta, Indonesia. A cross-sectional study involving 425 individuals in 40 clusters was conducted between March and April 2021. Participants were interviewed using an e-questionnaire developed in the Kobo toolbox to collect information on socio-demographic, COVID-19 suggestive symptoms, history of COVID-19 diagnosis and COVID-19 vaccination status. A venous blood sample was collected from each participant and tested for immunoglobulin G (Ig-G) SARS-CoV-2 antibody titers using the enzyme-linked immunosorbent assay (ELISA). Seroprevalence was 31.1% in the Bantul Regency: 34.2% in semi-urban and 29.9% in urban villages. Participants in the 55-64 age group demonstrated the highest seroprevalence (43.7%; p = 0.00), with a higher risk compared to the other age group (aOR = 3.79; 95% CI, 1.46-9.85, p<0.05). Seroprevalence in the unvaccinated participants was 29.9%. Family clusters accounted for 10.6% of the total seropositive cases. No significant difference was observed between seropositivity status, preventive actions, and mobility. Higher seroprevalence in semi-urban rather than urban areas indicates a gap in health services access. Surveillance improvement through testing, tracing, and treatment, particularly in areas with lower access to health services, and more robust implementation of health protocols are necessary.

Mitigating the impacts of the COVID-19 pandemic on vulnerable populations: Lessons for improving health and social equity

The COVID-19 pandemic had an inequitable and disproportionate impact on vulnerable populations, reversing decades of progress toward healthy populations and poverty alleviation. This study examines various programmatic tools and policy measures used by governments to support vulnerable populations during the pandemic. A comparative case study of 15 countries representing all World Health Organization's regions offers a comprehensive picture of countries with varying income statuses, health system arrangements and COVID-19 public health measures. Through a systematic desk review and key informant interviews, we report a spectrum of mitigation strategies deployed in these countries to address five major types of vulnerabilities (health, economic, social, institutional and communicative). We found a multitude of strategies that supported vulnerable populations such as migrant workers, sex workers, prisoners, older persons and school-going children. Prioritising vulnerable populations during the early phase of COVID-19 vaccination campaigns, direct financial subsidies and food assistance programmes were the most common measures reported. Additionally, framing public health information and implementing culturally sensitive health promotion interventions helped bridge the communication barriers in certain instances. However, these measures remain insufficient to protect vulnerable populations comprehensively. Our findings point to the need to expand fiscal space for health, enlarge healthcare coverage, incorporate equity principles in all policies, leverage technology, multi-stakeholder co-production of policies and tailored community engagement mechanisms.

Early diagnostic indicators of dengue versus other febrile illnesses in Asia and Latin America (IDAMS study): a multicentre, prospective, observational study

BACKGROUND

Improvements in the early diagnosis of dengue are urgently needed, especially in resource-limited settings where the distinction between dengue and other febrile illnesses is crucial for patient management.

METHODS

In this prospective, observational study (IDAMS), we included patients aged 5 years and older with undifferentiated fever at presentation from 26 outpatient facilities in eight countries (Bangladesh, Brazil, Cambodia, El Salvador, Indonesia, Malaysia, Venezuela, and Viet Nam). We used multivariable logistic regression to investigate the association between clinical symptoms and laboratory tests with dengue versus other febrile illnesses between day 2 and day 5 after onset of fever (ie, illness days). We built a set of candidate regression models including clinical and laboratory variables to reflect the need of a comprehensive versus parsimonious approach. We assessed performance of these models via standard measures of diagnostic values.

FINDINGS

Between Oct 18, 2011, and Aug 4, 2016, we recruited 7428 patients, of whom 2694 (36%) were diagnosed with laboratory-confirmed dengue and 2495 (34%) with (non-dengue) other febrile illnesses and met inclusion criteria, and were included in the analysis. 2703 (52%) of 5189 included patients were younger than 15 years, 2486 (48%) were aged 15 years or older, 2179 (42%) were female and 3010 (58%) were male. Platelet count, white blood cell count, and the change in these variables from the previous day of illness had a strong association with dengue. Cough and rhinitis had strong associations with other febrile illnesses, whereas bleeding, anorexia, and skin flush were generally associated with dengue. Model performance increased between day 2 and 5 of illness. The comprehensive model (18 clinical and laboratory predictors) had sensitivities of 0·80 to 0·87 and specificities of 0·80 to 0·91, whereas the parsimonious model (eight clinical and laboratory predictors) had sensitivities of 0·80 to 0·88 and specificities of 0·81 to 0·89. A model that includes laboratory markers that are easy to measure (eg, platelet count or white blood cell count) outperformed the models based on clinical variables only.

INTERPRETATION

Our results confirm the important role of platelet and white blood cell counts in diagnosing dengue, and the importance of serial measurements over subsequent days. We successfully quantified the performance of clinical and laboratory markers covering the early period of dengue. Resulting algorithms performed better than published schemes for distinction of dengue from other febrile illnesses, and take into account the dynamic changes over time. Our results provide crucial information needed for the update of guidelines, including the Integrated Management of Childhood Illness handbook.

FUNDING

EU's Seventh Framework Programme.

TRANSLATIONS

For the Bangla, Bahasa Indonesia, Portuguese, Khmer, Spanish and Vietnamese translations of the abstract see Supplementary Materials section.

COVID-19 public health and social measures: a comprehensive picture of six Asian countries

The COVID-19 pandemic will not be the last of its kind. As the world charts a way towards an equitable and resilient recovery, Public Health and Social Measures (PHSMs) that were implemented since the beginning of the pandemic need to be made a permanent feature of health systems that can be activated and readily deployed to tackle sudden surges in infections going forward. Although PHSMs aim to blunt the spread of the virus, and in turn protect lives and preserve health system capacity, there are also unintended consequences attributed to them. Importantly, the interactions between PHSMs and their accompanying key indicators that influence the strength and duration of PHSMs are elements that require in-depth exploration. This research employs case studies from six Asian countries, namely Indonesia, Singapore, South Korea, Thailand, the Philippines and Vietnam, to paint a comprehensive picture of PHSMs that protect the lives and livelihoods of populations. Nine typologies of PHSMs that emerged are as follows: (1) physical distancing, (2) border controls, (3) personal protective equipment requirements, (4) transmission monitoring, (5) surge health infrastructure capacity, (6) surge medical supplies, (7) surge human resources, (8) vaccine availability and roll-out and (9) social and economic support measures. The key indicators that influence the strength and duration of PHSMs are as follows: (1) size of community transmission, (2) number of severe cases and mortality, (3) health system capacity, (4) vaccine coverage, (5) fiscal space and (6) technology. Interactions between PHSMs can be synergistic or inhibiting, depending on various contextual factors. Fundamentally, PHSMs do not operate in silos, and a suite of PHSMs that are complementary is required to ensure that lives and livelihoods are safeguarded with an equity lens. For that to be achieved, strong governance structures and community engagement are also required at all levels of the health system.

Strengthening government’s response to COVID-19 in Indonesia: A modified Delphi study of medical and health academics

The Indonesian government has issued various policies to control COVID-19. However, COVID-19 new cases continued to increase, and there remain uncertainties as to the future trajectory. We aimed to investigate how medical and health academics view the Indonesian government’s handling of COVID-19 and which areas of health systems need to be prioritized to improve the government’s response to COVID-19. We conducted a modified Delphi study adapting the COVID-19 assessment scorecard (COVID-SCORE) as the measurement criteria. We invited medical and health academics from ten universities across Indonesia to take part in the two-round Delphi study. In the first round, participants were presented with 20 statements of COVID-SCORE and asked to rate their agreement with each statement using a five-point Likert scale. All participants who completed the first cycle were invited to participate in the second cycle. They had the opportunity to revise their answers based on the previous cycle’s results and ranked a list of actions to improve government response. We achieved a moderate consensus level for five statements, a low consensus level for 13 statements and no consensus for two statements. The prioritization suggested that top priorities for improving the government’s response to COVID-19 in Indonesia encompass: (1) strengthening capacity to ensure consistent, credible and targeted communication while adopting a more inclusive and empathic communication style to address public concerns; (2) ensuring universal access to reliable COVID-19 testing by expanding lab infrastructure, facilitating operational readiness, and scaling up implementation of proven alternative/complementary tests to RT-PCR; and (3) boosting contact tracing implementation capacity and facilitating contact tracing for all positive cases, involving key stakeholders in further development of the existing contact tracing system (i.e. PeduliLindungi) as well as its evaluation and quality assurance. Ultimately, our study highlights the importance of strengthening health system functions during the pandemic and improving health system resilience for dealing with future public health emergencies.

Maintaining Polio-Free Status in Indonesia During the COVID-19 Pandemic

Despite the negative impact that the COVID-19 pandemic has had on polio eradication efforts, ensuring the high coverage of polio immunization and high performance of surveillance are essential to maintaining Indonesia’s polio-free status and the reaching the 2023 global polio eradication target.

Implementation fidelity of tuberculosis preventive therapy for under five children exposed to sputum smear positive pulmonary tuberculosis in Kaski district, Nepal: An implementation research

Introduction

In line with the WHO recommendation, Nepal has started implementing Tuberculosis prevention therapy (TBPT) for under five children exposed to Sputum Smear Positive Pulmonary Tuberculosis, as one of the strategies for prevention, care and control of TB. Implementation fidelity study is important to assess on what extent preventive program is being implemented. The objective of the study measured the implementation fidelity of TBPT program Kaski district, Nepal.

Methods

We used a mixed-method explanatory sequential design study. Quantitative data were collected through retrospective review of records from April 2018 to May 2019 and level of adherence was established. Moderating factors influencing the implementation of TBPT were TBPT were assessed qualitatively. Sixteen in-depth interviews and a focus group discussion was conducted purposively with responsible stakeholders. The study was guided by the Conceptual Framework for Implementation Fidelity (CFIR) developed by Carroll.

Results

The majority of the components of the TBPT program were found to be implemented with a moderate level of fidelity. The proportion of under five years children initiate and complete the full course of TBPT was 72.5% and 75.86% respectively. The proportion of index cases traced for household contact, contact tracing within two months and timely initiation of therapy within two months were 54.19%, 82.73% and 86.20%. Moderating factors identified in the implementation of the program were contact tracing and enrollment, partnership and ownership, training resources, medication, awareness and information dissemination.

Conclusion

The TBPT program is being moderately implemented in Kaski districts. Addressing the key challenges identified in contact tracing, partnership/ownership, incentives, training and knowledge of health workers results in more identification of children eligible for TBPT.

Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research

Introduction

Tuberculosis is one of the leading causes of death worldwide. Diagnosing TB in an early stage and initiating effective treatment is one of the best ways to reduce the burden of tuberculosis. Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) Strategy helps to improve the early diagnosis of tuberculosis cases among inpatient settings as well as out patient department patients and prevent TB transmission in hospital. This study aimed to assess the feasibility of the FAST strategy, organizational factors, technical factors, barriers and enablers for the proper implementation of the FAST strategy in Nepal.

Methods

A qualitative study was conducted from April 2019 to August 2019. Data was collected by using focus group discussion, key informant interviews, and client exit interviews. A retrospective research was conducted in different hospitals in Nepal where FAST strategy was implemented. The patients, health care workers, province, district, and National level stakeholders were interviewed. Thematic analysis was used to assess the feasibility as well as barriers and enablers of the FAST strategy.

Results

Study identified that the ‘current setting’ of implementation and service delivery arrangement at hospitals were not well arranged as per requirements. The research findings showed hospital ownership is crucial for mobilizing staff and proper space management inside hospitals. Study identified that unavailability of a separate room, limited capacity of GeneXpert machine, irregular supply of GeneXpert cartridge, and insufficient human resources for screening and counseling are the major barriers of FAST implementation in Nepal.

Conclusion

FAST strategy is feasible to implement in healthcare settings in Nepal although the technical and organizational factors should be managed to ensure effective function of the strategy as per the approach. Hospital ownership is essential to mobilize health workers, improve client flow system and proper space management for FAST services.

Ensuring sustainability of polio immunization in health system transition: lessons from the polio eradication initiative in Indonesia

BACKGROUND

Sustaining an effective evidence-based health intervention will maximize its impact on public health. Political and governmental reforms impacted on immunization program sustainability both positively and negatively. This study aims to explore the sustainability of polio immunization in a decentralized health system taking lessons learned from a polio eradication initiative in Indonesia.

METHODS

We collected qualitative data through in-depth interviews with 27 key informants from various backgrounds at district, provincial, and national levels, consisting of frontline workers, managers, and Non-government Organizations (NGOs). We conducted thematic analysis and triangulated using document reviews. We also conducted member checking and peer debriefing to ensure trustworthiness.

RESULTS

Competing priority was identified as the significant challenge to sustain government commitment for polio immunization and AFP surveillance during the transition toward a decentralized health system. Variation of local government capacities has also affected immunization delivery and commitment at the sub-national level government. The government reform has led to a more democratic society, facilitating vaccine rejection and hesitancy. The multi-sector partnership played a significant role in maintaining polio immunization coverage. Strong and continuous advocacy and campaign were essential to raising awareness of the community and policymakers to keep polio in the agenda and to maintain the high polio immunization coverage.

CONCLUSION

Competing priority was the major factor affecting high polio immunization coverage during the decentralization transition. Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized.

Understanding the Spatial Predictors of Malnutrition Among 0-2 Years Children in India Using Path Analysis

Background: Despite several programs and policies to turn down the burden of malnutrition in the country, the rank of India in the Global Hunger Index (GHI) is 102 among 117 countries, which indicates a serious hunger situation. It is essential to design more specific interventions by focusing on the key determinants that may directly or indirectly influence malnutrition in India. Methods: Utilizing data from the National Family and Health Survey-4 (NFHS) (2015-16), we developed a structural equation model to find the direct, indirect, and total effect of various determinants on stunting, wasting, and underweight. We used spatial analysis to identify local occurrences of factors that are critical in controlling malnutrition. A p-value of 0.05 was considered to be significant throughout the study. Analysis was performed using STATA (version 15.1MP) and GeoDa software (version 1.14). Results: A final sample of 90, 842 children of 0-24 months of age was selected for the analysis. The CFI and TLI values of 0.98 and 0.93, respectively, are indicative of a good fit model. Moran's I value of global spatial autocorrelation for the widespread presence of diarrhea, poor drinking water source, exclusive breastfeeding, low birth weight, no prenatal visits, poor toilet facility was observed to be 0.446, 0.638, 0.345, 0.439, 0.620, and 0.727, respectively. Conclusion: A robust direct relation was observed for diarrhea, exclusive breastfeeding, and children born with stunting, underweight, and wasting. The variables associated indirectly with the outcome variables were the education of the mother, residence, and desired pregnancy. The identification of hotspots through spatial analysis would help revive control strategies in the affected area according to geographical needs. It is extensively addressed that interventions related to health and nutrition during the first 1, 000 days of life is crucial to seize the upshoot of growth floundering among children.

The effects of polio eradication efforts on health systems: a cross-country analysis using the Develop-Distort Dilemma

Vertical disease control programmes have enormous potential to benefit or weaken health systems, and it is critical to understand how programmes' design and implementation impact the health systems and communities in which they operate. We use the Develop-Distort Dilemma (DDD) framework to understand how the Global Polio Eradication Initiative (GPEI) distorted or developed local health systems. We include document review and 176 interviews with respondents at the global level and across seven focus countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We use DDD domains, contextual factors and transition planning to analyse interactions between the broader context, local health systems and the GPEI to identify changes. Our analysis confirms earlier research including improved health worker, laboratory and surveillance capacity, monitoring and accountability, and efforts to reach vulnerable populations, whereas distortions include shifting attention from routine health services and distorting local payment and incentives structures. New findings highlight how global-level governance structures evolved and affected national actors; issues of country ownership, including for data systems, where the polio programme is not indigenously financed; how expectations of success have affected implementation at programme and community level; and unresolved tensions around transition planning. The decoupling of polio eradication from routine immunization, in particular, plays an outsize role in these issues as it removed attention from system strengthening. In addition to drawing lessons from the GPEI experience for other efforts, we also reflect on the use of the DDD framework for assessing programmes and their system-level impacts. Future eradication efforts should be approached carefully, and new initiatives of any kind should leverage the existing health system while considering equity, inclusion and transition from the start.

Barriers and facilitators to knowledge translation activities within academic institutions in low- and middle-income countries

The barriers and facilitators of conducting knowledge translation (KT) activities are well-established but less is known about the institutional forces that drive these barriers, particularly in low resource settings. Understanding organizational readiness has been used to assess and address such barriers but the employment of readiness assessments has largely been done in high-income countries. We conducted a qualitative study to describe the institutional needs and barriers in KT specific to academic institutions in low- and middle-income countries. We conducted a review of the grey and published literature to identify country health priorities and established barriers and facilitators for KT. Key-informant interviews (KII) were conducted to elicit perceptions of institutional readiness to conduct KT, including experiences with KT, and views on motivation and capacity building. Participants included representatives from academic institutions and Ministries of Health in six countries (Bangladesh, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria). We conducted 18 KIIs, 11 with members of academic institutions and 7 with policymakers. KIIs were analysed using a deductive and inductive coding approach. Our findings support many well-documented barriers including lack of time, skills and institutional support to conduct KT. Three additional institutional drivers emerged around soft skills and the complexity of the policy process, alignment of incentives and institutional missions, and the role of networks. Participants reflected on often-lacking soft-skills needed by researchers to engage policy makers. Continuous engagement was viewed as a challenge given competing demands for time (both researchers and policy makers) and lack of institutional incentives to conduct KT. Strong networks, both within the institution and between institutions, were described as important for conducting KT but difficult to establish and maintain. Attention to the cross-cutting themes representing barriers and facilitators for both individuals and institutions can inform the development of capacity building strategies that meet readiness needs.

The Capacity of the Indonesian Healthcare System to Respond to COVID-19

The Indonesian Government has issued various policies to fight Coronavirus Disease (COVID-19). However, cases have continued to fluctuate over a year into the pandemic. There is a need to assess the country's healthcare system's capacity to absorb and accommodate the varying healthcare demands. We reviewed the current capacity of Indonesia's healthcare system to respond to COVID-19 based on the four essential elements of surge capacity: staff, stuff, structure, and system. Currently available medical staffs are insufficient to deal with potentially increasing demands as the pandemic highlighted the human resources challenges the healthcare system has been struggling with. The pandemic has exposed the fragility of medical supply chains. Surges in the number of patients requiring hospitalization have led to depleted medical supplies. The existing healthcare infrastructure is still inadequate to deal with the rise of COVID-19 cases, which has also exposed the limited capacity of the healthcare infrastructure to manage medical waste. The COVID-19 pandemic has further exposed the weakness of the patient referral system and the limited capacity of the healthcare system to deliver essential health services under prolonged emergencies. The Indonesian Government needs to ramp up the country's healthcare capacity. A wide range of strategies has been proposed to address those mounting challenges. Notwithstanding, the challenges of increasing healthcare capacity highlight that such efforts could represent only one part of the pandemic response equation. Effective pandemic response ultimately requires governments' commitment to increase healthcare capacity and flatten the curve concurrently.

eNose-TB: A trial study protocol of electronic nose for tuberculosis screening in Indonesia

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.

TRIAL REGISTRATION

NCT04567498; https://clinicaltrials.gov/.

Scaling up public health interventions: case study of the polio immunization program in Indonesia

BACKGROUND

The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018.

METHODS

A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data.

RESULTS

The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization.

CONCLUSION

Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

Prioritizing knowledge translation in low- and middle-income countries to support pandemic response and preparedness

The COVID-19 pandemic has created urgent demand around the world for knowledge generation about a novel coronavirus, its transmission, and control, putting academic institutions at the frontline of politics. While many academic institutions are well poised to conduct research, there are well-documented barriers for these institutions, particularly in low- and middle-income countries (LMICs), to further conduct strategic synthesis and dissemination to promote knowledge utilization among policy-makers. These systemic barriers to knowledge translation (KT) pose significant challenges for academic institutions seeking to take advantage of unprecedented policy windows to inform evidence-based decision-making. Global health funding organizations should prioritize the support of academic institutions' activities along the KT pathway, including both knowledge generation and strategic dissemination, to improve knowledge uptake for decision-making to improve health. Institutional capacity-building initiatives for KT have the potential to profoundly impact responses to this and future pandemics.

COVID-19 and ASEAN responses: Comparative policy analysis

Scholars and policy-makers agree that cross-border and multi-sector cooperation are essential components of coordinated efforts to contain the spread of COVID-19 infections. This paper examines the responses of ASEAN (Association of Southeast Asian Nation) member countries to the COVID-19 pandemic, including the limits of regional cooperation. ASEAN has pre-existing cooperative frameworks in place, including regional health security measures, which, at least theoretically, could assist the region's efforts to formulate cooperative responses to containing a global pandemic. With its overarching "One Vision, One Identity, One Community", ASEAN cooperation has extended to include region-wide disaster responses, framed as "One Asean, One Response". Using content analysis, this paper examines media statements and policies from ASEAN member states and the ASEAN Secretariat to assess the collective response to COVID-19 during the period from January to August 2020. By identifying gaps and opportunities in government responses to COVID-19 as the virus spread throughout Southeast Asia, this paper provides new insights as well as recommendations for the future.

Epidemiology and risk factors of Strongyloides stercoralis infection in Papua, Indonesia: a molecular diagnostic study

Strongyloides stercoralis is a parasitic worm that is of considerable clinical relevance. Indeed, it may persist asymptomatically for many years, but can lead to potentially fatal dissemination when the host's immune status is impaired. As commonly employed stool microscopy techniques (e.g. Kato-Katz thick smear) fail to detect S. stercoralis, the epidemiology is poorly understood. In 2013, we conducted a cross-sectional household survey in the district of Mimika in Papua, Indonesia. A total of 331 individuals, aged 1 month to 44 years, had a single stool sample subjected to real-time polymerase chain reaction (PCR) for S. stercoralis diagnosis. The prevalence of S. stercoralis infection was 32.0% (106/331 individuals); higher than any of the three main soil-transmitted helminths (Ascaris lumbricoides, 23.9%; Trichuris trichiura, 18.4%; and hookworm, 17.2%). Amongst the S. stercoralis-infected individuals, 73.6% were concurrently infected with another helminth, with hookworm being the most frequent co-infection (27.4%). Fourteen percent of the S. stercoralis infections had low cycle threshold values on real-time PCR, which may indicate a higher infection intensity. Multivariate logistic regression analysis revealed that age ≥5 years (adjusted odds ratio (OR) 5.8, 95% confidence interval (CI): 3.1-10.8) was significantly associated with S. stercoralis infection. There is a need for in-depth clinical and diagnostic studies to elucidate the public health impact of S. stercoralis infection in Indonesia.

Synthesis and translation of research and innovations from polio eradication (STRIPE): initial findings from a global mixed methods study

BACKGROUND

Lessons from polio eradication efforts and the Global Polio Eradication Initiative (GPEI) are useful for improving health service delivery and outcomes globally. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a multi-phase project which aims to map, package and disseminate knowledge from polio eradication initiatives as academic and training programs. This paper discusses initial findings from the knowledge mapping around polio eradication activities across a multi-country context.

METHODS

The knowledge mapping phase (January 2018 - December 2019) encompassed four research activities (scoping review, survey, key informant interviews (KIIs), health system analyses). This paper utilized a sequential mixed method design combining data from the survey and KIIs. The survey included individuals involved in polio eradication between 1988 and 2019, and described the contexts, implementation strategies, intended and unintended outcomes of polio eradication activities across levels. KIIs were conducted among a nested sample in seven countries (Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria) and at the global level to further explore these domains.

RESULTS

The survey generated 3955 unique responses, mainly sub-national actors representing experience in over 74 countries; 194 KIIs were conducted. External factors including social, political, and economic factors were the most frequently cited barriers to eradication, followed by the process of implementing activities, including program execution, planning, monitoring, and stakeholder engagement. Key informants described common strategies for addressing these barriers, e.g. generating political will, engaging communities, capacity-building in planning and measurement, and adapting delivery strategies. The polio program positively affected health systems by investing in system structures and governance, however, long-term effects have been mixed as some countries have struggled to institutionalize program assets.

CONCLUSION

Understanding the implementing context is critical for identifying threats and opportunities to global health programs. Common implementation strategies emerged across countries; however, these strategies were only effective where organizational and individual capacity were sufficient, and where strategies were appropriately tailored to the sociopolitical context. To maximize gains, readiness assessments at different levels should predate future global health programs and initiatives should consider system integration earlier to ensure program institutionalization and minimize system distortions.

Evaluating the process of partnership and research in global health: reflections from the STRIPE project

Background

Thoughtful and equitable engagement with international partners is key to successful research. STRIPE, a consortium of 8 academic and research institutions across the globe whose objective is to map, synthesize, and disseminate lessons learned from polio eradication, conducted a process evaluation of this partnership during the project’s first year which focused on knowledge mapping activities.

Methods

The STRIPE consortium is led by Johns Hopkins University (JHU) in partnership with 6 universities and 1 research consultancy organization in polio free, at-risk, and endemic countries. In December 2018 JHU team members submitted written reflections on their experiences (n = 9). We held calls with each consortium member to solicit additional feedback (n = 7). To establish the partnership evaluation criteria we conducted preliminary analyses based on Blackstock’s framework evaluating participatory research. In April 2019, an in-person consortium meeting was held; one member from each institution was asked to join a process evaluation working group. This group reviewed the preliminary criteria, adding, subtracting, and combining as needed; the final evaluation criteria were applied to STRIPE’s research process and partnership and illustrative examples were provided.

Results

Twelve evaluation criteria were defined and applied by each member of the consortium to their experience in the project. These included access to resources, expectation setting, organizational context, external context, quality of information, relationship building, transparency, motivation, scheduling, adaptation, communication and engagement, and capacity building. For each criteria members of the working group reflected on general and context-specific challenges and potential strategies to overcome them. Teams suggested providing more time for recruitment, training, reflection, pre-testing. and financing to alleviate resource constraints. Given the large scope of the project, competing priorities, and shifting demands the working group also suggested a minimum of one full-time project coordinator in each setting to manage resources.

Conclusion

Successful management of multi-country, multicentered implementation research requires comprehensive communication tools (which to our knowledge do not exist yet or are not readily available), expectation setting, and institutional support. Capacity building activities that address human resource needs for both individuals and their institutions should be incorporated into early project planning.

Implementation fidelity of hospital based directly observed therapy for tuberculosis treatment in Bhutan: mixed-method study

Background

Direct observed treatment (DOT) has been implemented in Bhutan since 1997 and currently, it is offered in various model of delivery including a combination of hospital based, home based DOT and ambulatory DOT. Overall, treatment success rate for tuberculosis cases is higher than the global target; however, it is still need to be improved. Evaluation to the implementation fidelity of DOT is important to identify potential rooms for improvement. This study aimed to assess two major components of the program’s implementation fidelity: to assess patient’s adherence to DOT and explore factors for adherence; to assess provider’s compliance with DOT guideline and explore factors for compliance.

Methods

This research used a sequential explanatory mixed method. The conceptual framework of implementation fidelity was adopted to guide this study design. The cross-sectional study of TB patients was enrolled in two hospitals with highest TB load, between September to November 2017 in Bhutan. Interviewer assisted survey was conducted with 139 TB patients who visited the hospital in continuation phase. In-depth interview was then conducted with nine TB patients and four health staffs to explore the barriers and enablers of DOT.

Results

Total of 61.9% (86/139) of patients has received DOT at intensive phase. Proportion was higher among MDR-TB cases (100%), and smear sputum positive TB cases (84.7%). In the continuation phase, 5.8% of patients took medicine at hospital, 48.9% at home and the rest 45.3% no longer practiced DOT. More than 90% of patient received correct dosage and standard regimen of anti-TB drugs according to the guideline. The key factors affecting poor adherence to DOT as perceived by patients were; lack of willingness to visit the clinic on daily basis due to long distance, financial implications and family support. However, patient’s satisfaction to the quality of TB treatment service delivery was high (98.6%). Providing incentives to the patient was most agreed enabler felt by both health workers and patients.

Conclusion

In the selected hospital sites, the patient’s adherence to DOT and provider’s compliance with DOT guideline is partially implemented; the coverage and the duration of DOT is very low, therefore, need to revise and improve DOT model and structure.

Can a National Health Insurance Policy Increase Equity in the Utilization of Skilled Birth Attendants in Indonesia? A Secondary Analysis of the 2012 to 2016 National Socio-Economic Survey of Indonesia

The Indonesian government has been implementing the National Health Insurance (Jaminan Kesehatan Nasional [JKN]) policy since 2014. This study aimed to evaluate JKN based on equity indicators, especially in skilled birth attendants (SBAs) use. The data were obtained from National Socio-Economic Survey of Indonesia during 2012 to 2016. To analyze the data, χ² and logistic regression tests were applied. The respondents were married mothers from 15 to 49 years who had delivered a baby. Deliveries by SBAs increased at the national level, but this achievement showed significant variation according to geographical location. The coverage of deliveries by SBAs in the eastern areas of Indonesia was still much lower than those in the western areas. All factors determining SBAs utilization (health insurance ownership, education, household economic status, and geography factor) indicated the positive correlation (P < .05). The inequity of SBA use in differences in geographical location and socioeconomic status continues to occur after the implementation of JKN.

Can a National Health Insurance Policy Increase Equity in the Utilization of Skilled Birth Attendants in Indonesia? A Secondary Analysis of the 2012 to 2016 National Socio-Economic Survey of Indonesia

The Indonesian government has been implementing the National Health Insurance (Jaminan Kesehatan Nasional [JKN]) policy since 2014. This study aimed to evaluate JKN based on equity indicators, especially in skilled birth attendants (SBAs) use. The data were obtained from National Socio-Economic Survey of Indonesia during 2012 to 2016. To analyze the data, χ² and logistic regression tests were applied. The respondents were married mothers from 15 to 49 years who had delivered a baby. Deliveries by SBAs increased at the national level, but this achievement showed significant variation according to geographical location. The coverage of deliveries by SBAs in the eastern areas of Indonesia was still much lower than those in the western areas. All factors determining SBAs utilization (health insurance ownership, education, household economic status, and geography factor) indicated the positive correlation (P < .05). The inequity of SBA use in differences in geographical location and socioeconomic status continues to occur after the implementation of JKN.

Developing a framework of core competencies in implementation research for low/middle-income countries

The field of implementation research (IR) is growing. However, there are no recognised IR core competencies in low/middle-income countries (LMICs), nor consistent curriculum across IR training programs globally. The goal of this effort is to develop a framework of IR core competencies for training programs in LMICs. The framework was developed using a mixed-methods approach consisting of two online surveys with IR training coordinators (n = 16) and academics (n = 89) affiliated with seven LMIC institutions, and a modified-Delphi process to evaluate the domains, competencies and proficiency levels included in the framework. The final framework comprised of 11 domains, 59 competencies and 52 sub-competencies, and emphasised competencies for modifying contexts, strengthening health systems, addressing ethical concerns, engaging stakeholders and communication especially for LMIC settings, in addition to competencies on IR theories, methods and designs. The framework highlights the interconnectedness of domains and competencies for IR and practice, and training in IR following the outlined competencies is not a linear process but circular and iterative, and starting points for training may vary widely by the project, institution and challenge being addressed. The framework established the need for a theory-based approach to identifying proficiency levels for IR competencies (ie, to determine proficiency levels for IR based on generalisable educational theories for competency-based education), and the relevance of various IR competencies for LMICs compared with high-income settings. This framework is useful for identifying and evaluating competencies and trainings, and providing direction and support for professional development in IR.

Acceptability of mandatory tuberculosis notification among private practitioners in Yogyakarta, Indonesia

Objective

Indonesia ranks second globally in the number of cases not reported to the National Tuberculosis Control Program, accounting for 11% of the total cases lost worldwide. In 2016, the Ministry of Health has issued Regulation Number 67 on tuberculosis control, which requires mandatory tuberculosis notification. We aimed to assess the prospective acceptability of mandatory tuberculosis notification among solo private practitioners and private primary care clinics in Yogyakarta.

Results

Our study highlighted critical issues which need to be addressed in ensuring acceptability of mandatory tuberculosis case notification. We found that that private practitioners do not notify tuberculosis cases due to a lack of policy knowledge. Mandatory tuberculosis notification and its potential penalties were also felt as burdensome by private practitioners. There were ethical concerns among the private practitioners in our study about patient’s privacy and patients potentially lost to other healthcare facility. Private practitioners emphasized the need for intervention coherence and cooperation. We also observed pattern variations of these constructs across characteristics of private practitioners.

Diagnosis of tuberculosis through breath test: A systematic review

Background

Breath tests may diagnose tuberculosis (TB) through detecting specific volatile organic compounds produced by Mycobacterium tuberculosis or the infected host.

Methods

To estimate the diagnostic accuracy of breath test with electronic-nose and other devices against culture or other tests for TB, we screened multiple databases until January 6, 2019.

Findings

We included fourteen studies, with 1715 subjects in the analysis. The pooled sensitivity and specificity of electronic-nose were 0.93 (95% CI 0.82–0.97) and 0.93 (95% CI 0.82–0.97), respectively, and no heterogeneity was found. The sensitivity and specificity of other breath test devices ranged from 0.62 to 1.00, and 0.11 to 0.84, respectively.

Interpretation

The low to moderate evidence of these studies shows that breath tests can diagnose TB accurately, however, to give a real-time test result, additional development is needed. Research should also focus on sputum smear negative TB, children, and the positioning of breath testing in the diagnostic work flow.

Funding

The authors received no specific funding for this work.

Predicting transmission of pulmonary tuberculosis in Daerah Istimewa Yogyakarta Province, Indonesia

This study aims to explain the current dispersion of tuberculosis (TB) and provide evidence that could help predicting its future transmission in Daerah Istimewa Yogyakarta (DIY) Province, Java Island, Indonesia. One hundred thirty-two adult (>14 years old) individuals, with TB diagnosed by health professionals using the Directly Observed Treatment, Short Course strategy, were identified Their residential addresses and geographical patterns of movement were investigated by global positioning systems and descriptive spatial analysis using standard deviation ellipse analysis and kernel estimation. The dispersion of TB cases was studied by ellipse regression, which showed a pattern extending in a direction oriented from north-west to south-east centred on Kasihan District, Bantul Regency, DIY Province, located near Yogyakarta City. Levels of TB risk in the study area varied from non-existent to high as calculated by kernel estimation. We conclude that suburban communities, followed by densely populated residential areas, enabled by socio-economic factors, are more likely to see increased TB transmission in the future.

Bridging the knowledge-practice gap in tuberculosis contact management in a high-burden setting: a mixed-methods protocol for a multicenter health system strengthening study

Background

People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome.

Methods

This methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework.

Discussion

Use of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period.

Study registration

Australian New Zealand Clinical Trials Register 375803.

Diagnostic comparison of Baermann funnel, Koga agar plate culture and polymerase chain reaction for detection of human Strongyloides stercoralis infection in Maluku, Indonesia

Human infection with the nematode Strongyloides stercoralis, which may have a life-threatening course, primarily occurs in tropical settings. Epidemiological data on the occurrence of strongyloidiasis are scarce, and microscopic stool-based detection methods are insensitive. Polymerase chain reaction (PCR) assays have been developed, yet conflicting results have been reported. Our goal was to determine whether there was diagnostic agreement between an in-house PCR and two microscopic techniques, the Baermann funnel (BM) and the Koga agar plate culture (KAP) for the detection of S. stercoralis in stool samples. Eighty ethanol-fixed stool samples stemming from a cross-sectional survey in Maluku, Indonesia, were purposefully selected for PCR analysis. The final sample size comprised four groups, each with 20 samples: group 1, positive for S. stercoralis on both BM and KAP; group 2, positive only by BM; group 3, positive only by KAP; and group 4, negative on both BM and KAP. A Strongyloides-specific PCR targeting the internal transcribed spacer 2 (ITS2) region was carried out in an Indonesian reference laboratory. The overall agreement between PCR and microscopy was 61% (49/80 samples), being highest in group 1 (15/20, 75%) and lowest in group 3 (9/20, 45%). PCR revealed eight additional S. stercoralis infections in group 4. Future studies should elucidate the 'true' infection status of samples that are negative by PCR, but positive upon microscopy. Taken together, there is a lack of agreement between microscopy and PCR results for the diagnosis of human S. stercoralis infection in Indonesia. ClinicalTrials.gov (identifier: NCT02105714).

Proceed with caution: Potential challenges and risks of developing healthcare tourism in Indonesia

The Indonesian government is set to take part in the region's growing healthcare tourism industry. However, Indonesia would need to do much more than just develop world-class hospitals at major tourist destinations to provide a thriving healthcare tourism industry that could attract patients from abroad. Moreover, the amount of resources needed to ensure the success of a healthcare tourism industry attracting foreign patients also raises the question of potential resource allocation diversion, as the country still has a long list of public health issues to address. There is also the potential of intensifying the migration of healthcare professionals from the public to the private sector or from rural to urban areas. Policymakers in Indonesia, and other resource-constrained countries, contemplating the development of healthcare tourism have an ethical obligation to weigh the evidence on potential positive and negative impacts before moving forward.

Development of the Good Health Research Practice course: ensuring quality across all health research in humans

Quality and ethics need to be embedded into all areas of research with human participants. Good Clinical Practice (GCP) guidelines are international ethical and scientific quality standards for designing, conducting, recording and reporting trials involving human participants. Compliance with GCP is expected to provide public assurance that the rights, safety and wellbeing of participants are protected and that the clinical research data are credible. However, whilst GCP guidelines, particularly their principles, are recommended across all research types, it is difficult for non-clinical trial research to fit in with the exacting requirements of GCP. There is therefore a need for guidance that allows health researchers to adhere to the principles of GCP, which will improve the quality and ethical conduct of all research involving human participants. These concerns have led to the development of the Good Health Research Practice (GHRP) course. Its goal is to ensure that research is conducted to the highest possible standards, similar to the conduct of trials to GCP. The GHRP course provides training and guidance to ensure quality and ethical conduct across all health-related research. The GHRP course has been run so far on eight occasions. Feedback from delegates has been overwhelmingly positive, with most delegates stating that the course was useful in developing their research protocols and documents. Whilst most training in research starts with a guideline, GHRP has started with a course and the experience gained over running the courses will be used to write a standardised guideline for the conduct of health-related research outside the realm of clinical trials, so that researchers, funders and ethics committees do not try to fit non-trials into clinical trials standards.

Social multiplier effects: academics' and practitioners' perspective on the benefits of a tuberculosis operational research capacity-building program in Indonesia

BACKGROUND

The Tuberculosis Operational Research Group (TORG) implemented a capacity-building model involving academics and practitioners (i.e. clinicians or program staff) in an operational research (OR) team in Indonesia.

OBJECTIVE

This study explored academics' and practitioners' perspectives regarding the benefits of participating in a tuberculosis (TB) OR capacity-building program in Indonesia.

METHODS

We conducted a qualitative study involving in-depth interviews with 36 academics and 23 practitioners undertaking the TORG capacity-building program. We asked open-ended questions about their experience of the program. Data were analyzed via content analysis.

RESULTS

The findings demonstrated the social multiplier effects of the OR capacity-building program. Both academics and practitioners reported perceived improvements in research knowledge, skills, and experience, and described additional individual- and institutional-level benefits. The individual-level benefits level included improvements in understanding of the TB program, motivation for research and self-satisfaction, the development/enhancement of individual networking, receipt of recognition, and new opportunities. The additional benefits reported at an institutional level included improvement in research curricula, in-house training, and program management and the development/enhancement of institutional partnerships.

CONCLUSIONS

The program improved not only individuals' capacity for conducting OR but also the quality of the TB program management and public health education. OR should be included in research methodology curricula for postgraduate public health/disease control programs. The capacity-building model, in which academics and program staff collaborated within an OR team, should be promoted.

It is time to revise the international Good Clinical Practices guidelines: recommendations from non-commercial North-South collaborative trials

The Good Clinical Practices (GCP) codes of the WHO and the International Conference of Harmonization set international standards for clinical research. But critics argue that they were written without consideration for the challenges faced in low and middle income countries (LMICs). Based on our field experience in LMICs, we developed a non-exhaustive set of recommendations for the improvement of GCP. These cover 3 domains: ethical, legal and operational, and 8 specific issues: the double ethical review of 'externally sponsored' trials; the informed consent procedure in minors and in illiterate people; post-trial access to newly-developed products for the trial communities; the role of communities as key research actors; the definition of sponsor; and the guidance for contractual agreements, laboratory quality management systems, and quality assurance of investigational medicinal products. Issues not covered in our analysis include among others biobanking, standard of care, and study designs. The international GCP codes de facto guide national legislators and funding agencies, so the current shortcomings may weaken the regulatory oversight of international research. In addition, activities neglected by GCP are less likely to be implemented or funded. If GCP are meant to serve the interests of global society, a comprehensive revision is needed. The revised guidelines should be strongly rooted in ethics, sensitive to different sociocultural perspectives, and allow consideration for trial-specific and context-specific challenges. This can be only achieved if all stakeholders, including researchers, sponsors, regulators, ethical reviewers and patients' representatives from LMICs, as well as non-commercial researchers and sponsors from affluent countries, are transparently involved in the revision process. We hope that our limited analysis would foster advocacy for a broad and inclusive revision of the international GCP codes, to make them at the same time 'global', 'context centred' and 'patient centred'.

Promoting good health research practice in low- and middle-income countries

Background

Good clinical practice (GCP) guidelines have been the source of improvement in the quality of clinical trials; however, there are limitations to the application of GCP in the conduct of health research beyond industry-sponsored clinical trials. The UNICEF/UNDP/World Bank/WHO Special Program for Research and Training in Tropical Disease is promoting good practice in all health research involving human through the Good Health Research Practice (GHRP) training program initiative.

Objective

To report the results of piloting the GHRP training program and formulate further steps to harness GHRP for promoting good practices in all health research involving human, particularly in low- and middle-income countries (LMICs).

Design

The objective of this training is to impart knowledge and skills for the application of ethical and quality principles to the design, conduct, recording, and reporting of health research involving human participants based on the level of risk, to ensure a fit-for-purpose quality system. This has been formulated into five sequential modules to be delivered in a 4-day course. Four courses have been organized in the pilot phase (2014–2015). The courses have been evaluated and assessed based on course feedback (quantitative and qualitative data) collected during course implementation and qualitative email-based pre- and post-course evaluation.

Results

Participants were highly satisfied with the course content and its organization. The relevance and applicability of the course content resulted in positive feedback and an articulated willingness to adapt and disseminate the course. Action points to strengthen the training program have been identified, and showed the imminent need to develop a consensus with a broader range of key stakeholders on the final set of GHRP standards and means for implementation.

Conclusions

There is an urgent need to harness the momentum to promote high-quality and ethical health research in LMICs through scaling up GHRP training and further development of GHRP principles into international standards.

Clinical evaluation of dengue and identification of risk factors for severe disease: protocol for a multicentre study in 8 countries

BACKGROUND

The burden of dengue continues to increase globally, with an estimated 100 million clinically apparent infections occurring each year. Although most dengue infections are asymptomatic, patients can present with a wide spectrum of clinical symptoms ranging from mild febrile illness through to severe manifestations of bleeding, organ impairment, and hypovolaemic shock due to a systemic vascular leak syndrome. Clinical diagnosis of dengue and identification of which patients are likely to develop severe disease remain challenging. This study aims to improve diagnosis and clinical management through approaches designed a) to differentiate between dengue and other common febrile illness within 72 h of fever onset, and b) among patients with dengue to identify markers that are predictive of the likelihood of evolving to a more severe disease course.

METHOD/DESIGN

This is a prospective multi-centre observational study aiming to enrol 7-8000 participants aged ≥ 5 years presenting with a febrile illness consistent with dengue to outpatient health facilities in 8 countries across Asia and Latin America. Patients presenting within 72 h of fever onset who do not exhibit signs of severe disease are eligible for the study. A broad range of clinical and laboratory parameters are assessed daily for up to 6 days during the acute illness, and also at a follow up visit 1 week later.

DISCUSSION

Data from this large cohort of patients, enrolled early with undifferentiated fever, will be used to develop a practical diagnostic algorithm and a robust clinical case definition for dengue. Additionally, among patients with confirmed dengue we aim to identify simple clinical and laboratory parameters associated with progression to a more severe disease course. We will also investigate early virological and serological correlates of severe disease, and examine genetic associations in this large heterogeneous cohort. In addition the results will be used to assess the new World Health Organization classification scheme for dengue in practice, and to update the guidelines for "Integrated Management of Childhood Illness" used in dengue-endemic countries.

TRIAL REGISTRATION

NCT01550016. Registration Date: March 7, 2012.

The path to impact of operational research on tuberculosis control policies and practices in Indonesia

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.