Determinants of adherence towards tuberculosis guidelines among Indonesian private practitioners: a qualitative study

In high tuberculosis (TB) burden countries, the private sector manages a large proportion of initial visits by presumptive patients with TB. In Indonesia, the second largest contributor of TB cases globally, private practitioners (PPs) often do not adhere to national TB guidelines. A district public-private mix programme to mitigate this issue was started in 2019, yet engagement remains low. This study examines what affects the decisions of Indonesian PPs regarding TB management.

We performed semistructured in-depth interviews and focus group discussions (FGDs) with 24 PPs and 6 relevant stakeholders. Data collection and analysis were based on Flottorp's comprehensive and generic checklist on determinants of healthcare professional practice, including seven domains: guideline factors; individual professional barriers; patient factors; professional interactions; incentives and resources; organisational changes capacity and social, legal and political factors. The interviews and FGDs were recorded and transcribed verbatim. Coding and analysis were conducted by using NVivo software.

Barriers that influenced PPs adherence to following the national TB guideline were found in all seven domains, including incoherence between national and international TB management guidelines, the complex referral and financing system, limited access to appropriate diagnostics tools and drugs, and patient preferences. This was further exacerbated by perceived lack of trust between PPs and local governmental stakeholders. In this study, in addition to seventh Flottorp's domain, we also found the complex nature of TB disease, which also complicates the decision-making process of PPs in TB management.

PPs face several challenges in complying with TB guidelines to enable optimal clinical decision-making.