Research projects in Indonesia

Background

The National TB Control Program (NTP) of Indonesia started the implementation of the DOTS strategy in 1995. The strategy has now been rolled out to all provinces. To support the implementation and improvement of the DOTS strategy and the new Stop TB strategy, KNCV Tuberculosis Foundation provides Indonesia with technical support for research. The support consists of organizing and facilitating training programs in which TB program workers and university employees are trained in operational research. Support is also given to local universities in designing research projects, data analysis and reporting of results. Furthermore, KNCV Tuberculosis Foundation supports the NTP in developing and implementing a research agenda.

Epidemiological studies

The university in Yogyakarta was the first to perform a TB-HIV co-infection study in Indonesia. In 2006, KNCV Tuberculosis Foundation assisted with protocol development and data collection. In 2007, we worked on the data analysis and reporting of the results. The prevalence of HIV among TB patients is higher than current estimates. There was high uptake of unlinked anonymous testing but low interest in knowing HIV status.

In Yogyakarta province, an intervention was tested which aimed at involving private practitioners in TB control. The intervention was implemented in 2003-2005 and evaluated in 2007. Private practitioners were interested in referring TB suspects to the public health system for diagnosis. They were less interested in treating themselves their TB patients according to National TB Program guidelines. In a well functioning public DOTS program, the tested strategy to involve private practitioners was cost-effective.

In Central Java, Semarang, we have worked on a study to examine the reasons for non adherence of TB patients that are treated in hospitals using qualitative research techniques. The most frequently mentioned reason for non adherence to treatment was feeling better. Although the drugs were given free of charge, many patients were non adherent (also) because of lack of money. Treatment adherence of TB patients receiving treatment in hospitals in Central Java might be improved by providing health education about treatment duration and side effects, facilitating procedures for receiving treatment free of charge and reducing costs of transportation and consultation.

A study in Bandung focused on assessing the long term effects of TB. A cohort of TB patients that was treated 2-4 years ago was followed up and examined by questionnaire and physical examination. The results of these examinations were compared with the findings in a control group. The study showed that TB-patients remain at increased risk for recurrent TB and impaired pulmonary function. Follow-up of TB patients after treatment seems warranted and possible interventions to limit lung damage during TB-treatment should be examined.

Operational research and capacity building

KNCV Tuberculosis Foundation has been supporting the NTP of Indonesia in building capacity for operational research since 2003. After a needs assessment it was decided to organize operational research courses in which TB program workers and university employees are trained in operational research. We use a method developed by the International Development Research Centre (IDRC) ‘Designing and conducting health system research projects’. It deals step-by-step with the development of an operational research proposal, field data collection, data analysis and report writing. 

By now three courses have started. In each course 4 groups of 5 individuals participate. A course consists of a two week workshop in which a protocol is developed by each group. Thereafter, there is a period of 6-12 months in which the group members collect the data according to the protocol. In this period the groups are visit by national facilitators and by KNCV Tuberculosis Foundation to monitor the quality of the data collection and to assist in solving problems. Finally there is a two week workshop in which the data are analyzed and a report is written. The first group has completed the whole course and KNCV Tuberculosis Foundation has assisted in 2007 in the development of manuscript for scientific publication. The data collection of the second group was monitored by KNCV Tuberculosis Foundation in 2007 and the third group developed a protocol with assistance of KNCV Tuberculosis Foundation in 2007. In 2008, the second group will perform the data analysis and write the report and the third group will start data collection.

Examples of operational research projects:

Sputum smear microscopy is the standard diagnostic method for detection of smear positive pulmonary tuberculosis (TB) in Indonesia. Insufficient quality of sputum might result in missing cases. We assessed the quality of sputum in Central Java and tried to identify patient and health worker factors associated with submission of three good quality sputum samples. Very few patients provided three samples of good quality. We did not identify factors related to sputum quality. Training of health workers in providing health education to the TB suspect about the reason for sputum examination and how to produce a good quality sputum sample should be a priority of the TB program.

Many tuberculosis (TB) patients in Indonesia are diagnosed late. We documented patient journeys toward TB diagnosis and treatment and factors that influence health care seeking behavior. Factors that influenced care seeking behavior include income and advice from household members or friends. Family members based their recommendation on previous experience and affordability. Many community members from the rural area doubted whether TB treatment would be available free of charge.

Besides research projects KNCV Tuberculosis Foundation is also involved in other assisting activities to control tuberculosis in Indonesia. Click here for more information on these activities, and for further country information.