Publications by authors named "Yodi Mahendradhata"

56 Publications

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

Health Policy Plan 2021 Apr 21. Epub 2021 Apr 21.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/heapol/czab044DOI Listing
April 2021

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

PLoS One 2021 21;16(4):e0249689. Epub 2021 Apr 21.

Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, 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/.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249689PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059810PMC
April 2021

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

BMC Public Health 2021 Mar 29;21(1):614. Epub 2021 Mar 29.

Center for Tropical Medicine, Faculty Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-021-10647-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008664PMC
March 2021

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

Health Policy Plan 2021 Mar 1. Epub 2021 Mar 1.

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/heapol/czaa188DOI Listing
March 2021

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

Health Res Policy Syst 2021 Jan 18;19(1). Epub 2021 Jan 18.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, United States of America.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12961-020-00670-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812976PMC
January 2021

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

BMC Public Health 2020 Aug 12;20(Suppl 2):1176. Epub 2020 Aug 12.

Indian Institute of Health Management Research, Jaipur, India.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-020-09156-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7421832PMC
August 2020

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

BMC Public Health 2020 Aug 12;20(Suppl 2):1058. Epub 2020 Aug 12.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-020-08591-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7421813PMC
August 2020

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

Acta Trop 2020 Sep 4;209:105575. Epub 2020 Jun 4.

Postgraduate Programme in Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of Parasitology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia. Electronic address:

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.actatropica.2020.105575DOI Listing
September 2020

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

BMC Public Health 2020 Apr 19;20(1):533. Epub 2020 Apr 19.

Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-020-08666-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7168849PMC
April 2020

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.

Asia Pac J Public Health 2020 01 6;32(1):19-26. Epub 2019 Dec 6.

Universitas Gadjah Mada, Yogyakarta, Indonesia.

The Indonesian government has been implementing the National Health Insurance ( [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, χ 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 ( .05). The inequity of SBA use in differences in geographical location and socioeconomic status continues to occur after the implementation of JKN.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1010539519892394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7066478PMC
January 2020

Can General Practitioners manage mental disorders in primary care? A partially randomised, pragmatic, cluster trial.

PLoS One 2019 7;14(11):e0224724. Epub 2019 Nov 7.

Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.

Background: For a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care.

Methods: In this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment. All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ-5D-3L, and resource use and costs evaluated from a health services perspective, at six months.

Results: 153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY.

Conclusion: General Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap.

Trial Registration: ClinicalTrials.gov NCT02700490.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224724PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837310PMC
March 2020

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

BMJ Glob Health 2019 3;4(5):e001747. Epub 2019 Sep 3.

Research Capacity Building and Knowledge Management, Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjgh-2019-001747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6730585PMC
September 2019

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

BMC Res Notes 2019 Aug 27;12(1):543. Epub 2019 Aug 27.

Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13104-019-4581-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712591PMC
August 2019

Diagnosis of tuberculosis through breath test: A systematic review.

EBioMedicine 2019 Aug 8;46:202-214. Epub 2019 Aug 8.

University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, Department of Internal Medicine-Infectious Diseases, Groningen, the Netherlands. Electronic address:

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ebiom.2019.07.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712009PMC
August 2019

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

Geospat Health 2019 05 14;14(1). Epub 2019 May 14.

Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Depok.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4081/gh.2019.673DOI Listing
May 2019

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.

Implement Sci 2019 03 19;14(1):31. Epub 2019 Mar 19.

Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

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 .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13012-019-0870-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425655PMC
March 2019

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

Parasitol Res 2018 Oct 3;117(10):3229-3235. Epub 2018 Aug 3.

Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, 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).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00436-018-6021-5DOI Listing
October 2018

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

Glob Public Health 2019 03 26;14(3):340-350. Epub 2018 Jul 26.

Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/17441692.2018.1504224DOI Listing
March 2019

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

Glob Health Action 2017 ;10(1):1381442

e Department of Internal Medicine, Faculty of Medicine , Padjajaran University , Bandung , 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/16549716.2017.1381442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800739PMC
September 2018

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

BMJ Glob Health 2016 16;1(3):e000122. Epub 2016 Nov 16.

Public Health Department, Institute Tropical Medicine, Antwerp, Belgium.

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 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'.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjgh-2016-000122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321366PMC
November 2016

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

Health Res Policy Syst 2017 Mar 31;15(1):28. Epub 2017 Mar 31.

Center for Tropical Medicine, Faculty of Medicine, Universitas Gadjah Mada, Gedung PAU, Jl, Teknika Utara, Barek, Yogyakarta, 55281, Indonesia.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12961-017-0193-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374655PMC
March 2017

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

Glob Health Action 2016;9:32474. Epub 2016 Aug 5.

Freelance Consultant, Chennai, India.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976305PMC
http://dx.doi.org/10.3402/gha.v9.32474DOI Listing
August 2016

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

BMC Infect Dis 2016 Mar 11;16:120. Epub 2016 Mar 11.

Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12879-016-1440-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4788847PMC
March 2016

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

Glob Health Action 2016 25;9:29866. Epub 2016 Feb 25.

Department of Internal Medicine, Faculty of Medicine, Universitas Padjajaran, Bandung, 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4770863PMC
http://dx.doi.org/10.3402/gha.v9.29866DOI Listing
August 2016

The case for stronger regulation of private practitioners to control tuberculosis in low- and middle-income countries.

BMC Res Notes 2015 Oct 23;8:600. Epub 2015 Oct 23.

Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta, 55281, Indonesia.

Tuberculosis case management practices of private practitioners in low- and middle-income countries are commonly not in compliance with treatment guidelines, thus increasing the risk of drug resistance. National Tuberculosis control programs have long been encouraged to collaborate with private providers to improve compliance, but there is no example yet of a sustained, large scale collaborations with private practitioners in these settings. Regulations have long been realized as a potential response to poor quality care, however there has been a lack of interest from the international actors to invest in stronger regulation of private providers in these countries due to limited evidence and many implementation challenges. Regulatory strategies have now evolved beyond the costly conventional form of command and control. These new strategies need to be tested for addressing the challenge of poor quality care among private providers. Multilateral and bilateral funding agencies committed to tuberculosis control need to invest in facilitating strengthening government's capacity to effectively regulate private providers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13104-015-1586-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619435PMC
October 2015

How do private general practitioners manage tuberculosis cases? A survey in eight cities in Indonesia.

BMC Res Notes 2015 Oct 14;8:564. Epub 2015 Oct 14.

Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University, Sekip Utara, Yogyakarta, 55281, Indonesia.

Background: Private practitioners (PPs) in high-burden countries often provide substandard tuberculosis (TB) treatment, leading to increased risk of drug resistance and continued transmission. TB case management among PPs in Indonesia has not been investigated in recent years, despite longstanding recognition of inadequate care and substantial investment in several initiatives. This study aimed to assess case management practices of private general practitioners (GPs) in eight major cities across Indonesia.

Methods: A cross-sectional survey of private GPs was carried out simultaneously in eight cities by trained researchers between August and December 2011. We aimed for a sample size of 627 in total, and took a simple random sample of GPs from the validated local registers of GPs. Informed consent was obtained from participants prior to interview. Diagnostic and treatment practices were evaluated based on compliance with national guidelines. Descriptive statistics are presented.

Results: Of 608 eligible GPs invited to participate during the study period, 547 (89.9%) consented and completed the interview. A low proportion of GPs (24.6-74.3%) had heard of the International Standards for TB care (ISTC) and only 41.2-68.9% of these GPs had participated in ISTC training. As few as 47.3% (90% CI: 37.6-57.0%) of GPs reported having seen presumptive TB. The median number of cases of presumptive TB seen per month was low (0-5). The proportion of GPs who utilized smear microscopy for diagnosing presumptive adult TB ranged from 62.3 to 84.6%. In all cities, a substantial proportion of GPs (12.0-45.5%) prescribed second-line anti-TB drugs for treating new adult TB cases. In nearly all cities, less than half of GPs appointed a treatment observer (13.8-52.0%).

Conclusions: The pattern of TB case management practices among private GPs in Indonesia is still not in line with the guidelines, despite longstanding awareness of the issue and considerable trialing of various interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13104-015-1560-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607095PMC
October 2015