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BRIEF RESEARCH REPORT
published: 06 October 2020
doi: 10.3389/fpubh.2020.531514
Frontiers in Public Health | www.frontiersin.org 1October 2020 | Volume 8 | Article 531514
Edited by:
Anders Nordahl-Hansen,
Østfold University College, Norway
Reviewed by:
Elia Gabarron,
University Hospital of North
Norway, Norway
Benjamin James Knox,
Norwegian Defence University
College, Norway
*Correspondence:
Zisis Kozlakidis
kozlakidisz@iarc.fr
Specialty section:
This article was submitted to
Digital Public Health,
a section of the journal
Frontiers in Public Health
Received: 31 January 2020
Accepted: 27 August 2020
Published: 06 October 2020
Citation:
Aisyah DN, Ahmad RA, Artama WT,
Adisasmito W, Diva H, Hayward AC
and Kozlakidis Z (2020) Knowledge,
Attitudes, and Behaviors on Utilizing
Mobile Health Technology for TB in
Indonesia: A Qualitative Pilot Study.
Front. Public Health 8:531514.
doi: 10.3389/fpubh.2020.531514
Knowledge, Attitudes, and Behaviors
on Utilizing Mobile Health
Technology for TB in Indonesia: A
Qualitative Pilot Study
Dewi Nur Aisyah 1,2 , Riris Andono Ahmad 3, Wayan Tunas Artama 3,4 , Wiku Adisasmito 1,5 ,
Haniena Diva 1, Andrew C. Hayward 2,6 and Zisis Kozlakidis 7
*
1Indonesia One Health University Network (INDOHUN), Depok, Indonesia, 2Infectious Disease Informatics, Institute of Health
Informatics, University College London, London, United Kingdom, 3Center for Tropical Medicine, Gadjah Mada University,
Yogyakarta, Indonesia, 4One Health Collaborating Center (OHCC), Faculty of Veterinary Medicine Gadjah Mada University,
Yogyakarta, Indonesia, 5Faculty of Public Health, Universitas Indonesia, Depok, Indonesia, 6Institute of Epidemiology and
Health Care, University College London, London, United Kingdom, 7International Agency for Research on Cancer, World
Health Organization, Lyon, France
Tuberculosis (TB) infections remain a global health burden with a high incidence rate
in South-East Asia, including Indonesia. TB control strategy is founded on early case
detection and complete treatment to minimize transmission and prevent the emergence
of drug resistance. However, many patients face challenges to comply with daily
medication, causing many to adhere inconsistently or stop prematurely. Technological
solutions could enhance adherence to treatment and support national screening and
follow-up policies. These include telephone video communication, enabling health
professionals to watch patients take their medication, address patients’ concerns, and
provide advice and support. This manuscript describes the outcome of a qualitative pilot
study, based on a series of focus group discussions to assess the knowledge, attitudes,
and behaviors, on the potential utilization of mobile technology for health purposes
with a particular focus on TB treatment follow-up. The findings illustrate that general
knowledge of mobile health technologies, of their legal framework of operations, and of
their exact potential within the healthcare system is incomplete or poor. The novel findings
are as follows: (a) the willingness of participants to learn about these technologies,
(b) the open and welcoming attitude toward receiving such information even within
frontline community settings, and (c) the willingness to back a government-supported,
healthcare-driven set of such initiatives. Potential implementation barriers have also been
highlighted. This study is an important first step toward understanding the attitudes and
behaviors on utilizing mobile health technology for TB in Indonesia.
Keywords: tuberculosis, Indonesia, mobile health, community based research, qualitative study
INTRODUCTION
Tuberculosis (TB) is one of the infectious diseases caused by Mycobacterium tuberculosis with
millions of new infections reported globally and a significant number of deaths. In 2014, 1.4 million
people globally died from TB, reducing slightly to 1.2 million in 2018; with an estimated 10 million
new infections reported per year over the last few years (1,2). TB affects people in both sexes of all
Aisyah et al. mHealth Technology Knowledge in Indonesia
age groups. It infects the lungs and other organs such as the
glands, skin, bones, and brain. Thus, TB can potentially infect
anyone but predominantly affects the poor. Globally, 98% of TB
deaths are in the poorest countries (3), while most TB cases in
2018 were in the WHO regions of South-East Asia (44%), Africa
(24%), and the Western Pacific (18%). Eight countries accounted
for two-thirds of the global total, with India (27%), China (9%),
and Indonesia (8%) being the top three countries on that list (2),
Specifically, in Indonesia, there were 566,623 TB cases in 2018;
44% of the total cases were found in the most populated areas
such as East Java, West Java, and Central Java (4).
Most TB patients are curable by a course of treatment,
which is globally affordable, although this treatment takes a
minimum of 6 months to complete and 2 years or longer for
multidrug-resistant tuberculosis (MDR-TB) (5). The current TB
control strategy is founded on early case detection and complete
treatment to minimize transmission and prevent the emergence
of drug resistance. However, even though many patients initiate
TB treatment each year, they still face challenges complying with
daily medication, causing many to adhere inconsistently or to
stop prematurely. Treatment interruption increases the risk for
acquired drug resistance, treatment failure, disease progression,
relapse, and death; it also prolongs transmissibility (6).
In Indonesia, in particular, the incidence, and by consequence,
the human and financial cost of TB infections remains extremely
high (7). Some of the factors that cause loss to medical
follow-up have been described in previous studies (8–11).
Besides that, adherence to treatment completion is lower when
patients have a negative treatment experience, e.g., when access
to care involves substantial travel time, lost earnings, and
other patient expenditures; when adverse drug reactions are
frequent or consequential; or conversely, when patients feel
better, and their motivation to finish treatment declines (12).
Furthermore, in Indonesia, the role of community education
has been described as low and impacting adversely on the
effectiveness of TB treatment in the population, though these
studies are still few and over short periods of time, for
example, in Surakarta and Flores, and cannot necessarily be
generalized over the entire Indonesian geographical and cultural
complexity (13,14).
Psychosocial support for Indonesian TB patients is a
significant component in the management of TB drug side effects.
Drugs supervisors (Pengawas Menelan Obat) are the people
tasked to provide education and encouragement to the patients to
maintain their treatment, organizing, when possible, individual
meetings, community meetings, as well as support group
meetings. The drug supervisors must be people who are already
trained and accepted by the TB patients (15). The need for close,
regular contact between caregivers and TB patients receiving
treatment has been long recognized and remains topical (16).
However, supervision by health workers is costly and requires
a large number of health workers available in the field who are
also appropriately trained. In the case of Indonesia, with a large
population, dispersed over a geographically challenging terrain,
this is not a realistic option. Therefore, novel technological
solutions have to be deployed to enhance the national screening,
treatment, and follow-up policies.
One of these novel technological solutions to TB treatment
monitoring is telephone video communication, enabling
health professionals to watch patients take their medication,
address patients’ concerns, and provide advice and support
(17–19). Video (or virtually)-observed therapy (VOT)
was piloted originally by using videophones connected to
telephone landlines. This has now evolved toward using mobile
telephones with video applications (smartphones) and even
tablet computers. All these devices are becoming increasingly
affordable and reliable in high- and low-income settings, such as
Indonesia, while the coverage of cellular and internet networks is
increasingly available in places where telephone landline services
had never existed or are facing obsolescence.
This manuscript describes the outcome of a qualitative
pilot study, based on a series of focus groups, to assess the
knowledge—attitudes toward and behaviors on the potential
utilization—of mobile technology for health purposes with a
particular focus on TB treatment follow-up. Similar studies have
taken place previously in other countries, though the global
picture on the subject and, in particular, in the areas addressed
by the current manuscript, remains incomplete (20–23). The
focus groups were organized through the collaboration of UCL,
the INDOHUN (Indonesia One Health University Network)
consisting of 34 faculties from 20 universities across Indonesia
(24) and Gadjah Mada University and took place in Yogyakarta,
Indonesia, in the late 2018, and included various stakeholders
[academic researchers, policy-makers, frontline healthcare staff
from primary healthcare centers (Puskesmas), and patients] so
that a deeper and more inclusive understanding can be pursued.
Focus groups were not a mix of all the above stakeholders, but
were focusing on one of the stakeholder groups at any one time.
The four stakeholder groups were identified as critical, as such
topics in Indonesia are still mostly within the academic sphere,
with occasional pilot applications. At the same time, healthcare
provision for the majority of the population is public through
a recently introduced universal health coverage scheme (25).
Therefore, policy-makers play a crucial role in the potential
adoption process. Furthermore, the frontline staff and patients
are providing a viewpoint from the potential implementation
perspective, as evidence regarding optimal patient engagement is
scarce globally (26). It was envisaged that in this way, top–down
as well as bottom–up views will be captured.
This is the first time to our knowledge that this topic is
discussed in this manner in Indonesia—outside of a narrow
academic or political context and with a direct link to potential
clinical utility, so that it can provide pilot data for the
eventual development of a community-engaged intervention.
Furthermore, the focus groups aimed to identify locally relevant
priority areas where the participants felt that the implementation
of mobile health technology would have the highest impact and
reduce the burden of disease in the community.
METHODS
A community-based participatory research (CBPR) team
comprising of active academic researchers in public health
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Aisyah et al. mHealth Technology Knowledge in Indonesia
TABLE 1 | The list of questions used in all Focus Group Discussions following a
short introduction on mobile-enabled health technologies for a potential
implementation in TB remote observation and treatment monitoring in Indonesia.
1) Have you previously used or had experience with digital health technology?
2) What constraints do you experience when following the TB treatment process
over a long time?
3) Is the monitoring from clinical staff needed during the long treatment
process? Why is it needed?
4) Has the monitoring of treatment by clinical staff been done for the entire
treatment process?
5) What kind of health technology have you known so far especially in
monitoring treatment of TB for the patients?
6) If the health system in Indonesia implements technology as in the video (Video
Directly Observed Therapy for TB), will you accept or refuse?
7) After hearing about the V-DOT in the video, do you think digital technology
can help in monitoring the treatment process, especially the disease with a
long duration treatment process?
8) Do you think that such technology is effective to be implemented in
Indonesia; how and how would it be regulated?
9) What possible constraints that will arise if the technology is implemented
in Indonesia?
10) Any suggestions given for application development and implementation?
from the local university [Gadjah Mada University (UGM),
Yogyakarta] and the INDOHUN network with projects active
in community one-health engagement (Universitas Indonesia,
Jakarta) sought to gain insight on person knowledge, attitudes,
and behaviors related to mobile-technology utilization for TB
treatment monitoring and follow-up, by conducting a qualitative
research study. The UGM Institutional Review Board approved
this study. The team jointly designed the study and selected
a qualitative research approach using focus groups to address
the specific aims. The CBPR team developed a focus group
moderator’s guide with semistructured questions related to the
use of mobile health technology (the list of questions is available
in Table 1).
Participants’ Recruitment
The INDOHUN and UGM designed the recruitment
process with the UCL research team providing additional
input. Purposive sampling was used and planned with the
goal of collecting data until we reached saturation (27).
Recruitment focused on the four key stakeholder communities:
academic researchers, frontline clinical staff, policymakers,
and patients (28). The community-engaged recruitment
included flyers and word-of-mouth (snowball sampling)
to the local University (UGM), the local Department of
Health, community-based primary healthcare centers, and
clinics. Eligibility criteria were individuals who self-identified
as belonging to the four stakeholder categories and being
≥18 years old.
Focus Group Procedures
Focus groups, arranged per stakeholder group, allowed for
observations of nonverbal behaviors and interactions as well
as group dynamics and to elicit shared cultural meanings (29).
The focus group moderator guide, containing semistructured
questions and probes, was adapted from a study conducted
in Pakistan by academic and community members (30).
In that case, the community members and leaders were
interested in increasing health and wellness by using biomedical
research to increase health awareness in the community.
Bicultural and bilingual moderators and note-takers were
recruited and trained to complete the data collection. The
INDOHUN team members had prior expertise with conducting
community-based qualitative research and had appropriate
training. The training aims to ensure understanding of the
purpose and objective and to maintain effective community-
based participatory relationship (31). The groups were not
separated by gender as it was thought from a cultural
perspective that participants would be sharing in mixed-gender
groups, as well as the use of such technology is generally
gender agnostic; hence, a participant separation might create
false assumptions.
Focus Group Data Collection
We conducted four focus groups (FGs) using bilingual, bicultural
moderators with participants from local communities from April
to October 2018. Several study participants had low levels of
English proficiency. To ensure that participants understood
the aims and purpose of the study, a short description was
provided as introduction in Indonesian. The semistructured
questions were stated in both English and Indonesian, while
most of the discussion took place in Indonesian. The participants
received a light meal for their time. The structure of the focus
group was repeated over the different events; it included two
short keynote presentations providing (i) the definitions of
mobile health and a few short examples of potential public
health use from other resource-restricted settings globally and
(ii) the framework for the regulation and implementation of
mobile health solutions within Indonesia. The aim of these
short presentations was to provide a common starting point,
as well as to delineate the area of interest across the different
focus groups.
Prior to starting the focus group discussions, facilitators (a)
introduced themselves, (b) outlined the structure of the focus
group, (c) instructed in the importance of confidentiality, and
(d) collected selected sociodemographic information (sex, age,
TB status, and professional occupation) through a brief survey.
Focus groups facilitated in Indonesian were transcribed
verbatim and translated into English by the UGM and
INDOHUN teams. Data were de-identified and unique IDs
given to each participant and moderator. Participants were
asked general questions pertaining to beliefs of health, which
progressed to the specific list of questions (Table 1) leading
the subsequent discussions. The moderators were familiar with
the questioning route and experienced enough to know which
questions were the most important and which could be dropped
momentarily and return to those later. Following this method,
the discussion had a better flow than being stifled by strictly
following the order of questions. The focus groups were
audio recorded. Audio files of the interviews were transcribed
into English.
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Aisyah et al. mHealth Technology Knowledge in Indonesia
TABLE 2 | Summary of the participants’ characteristics in the Focus Groups.
Total Number 46
Male/female 22(48%)/24(52%)
Front-line clinical staff 16 (34%)
Academic public health researchers 11 (23%)
Public health practitioners 12 (26%)
Ex TB-patients 7 (17%)
Qualitative Analysis
Members from the research team independently conducted
an initial review and coded transcripts. Preliminary thematic
groups were generated and were linked to interview texts using
traditional content analysis. Emerging themes were discussed and
presented at team meetings. During these meetings, discordant
codes were discussed until consensus was reached.
There are advantages and challenges in conducting qualitative
research via focus groups. For example, focus groups, not
individual interviews, were chosen as the preferred method
because data are obtained from the communication between
participants, as they share experiences and comment on different
perspectives. This would be suppressed during a more formal
interview setting. Also, sometimes, participants are more open
when less inhibited members explore difficult topics and more
open in a group format (32). The flow of the discussion was
facilitated by using Indonesian throughout, so it is not stifled by
any potential translation requirements. On the other hand, the
process of analyzing the data was found to be time consuming.
Factors such as the dynamics within the groups, between-group
variations, and the need for translation, all contributed to the
complexity of data and analysis.
Validation of Findings
Uncertainties or disagreements were resolved by consensus
discussion among the moderators and participants during the
focus group. The identified themes are expected to be presented
at an annual meeting of public health and research stakeholders
by the INDOHUN colleagues (including some of the focus
group participants) to confirm that interpretation of results was
consistent with the intended meaning.
RESULTS
The CBPR team recruited 46 participants with a slight majority
identifying as female (female 24, 52%; male 22, 48%). Sixteen
participants were frontline clinical staff from primary healthcare
centers (34%: 13 from the public sector, 3 from the private
sector; FG1); 11 participants were academic researchers in
public health (23%; FG2); 12 were public health practitioners
(26%: 9 from public health offices of the local government,
3 from nongovernmental organizations; FG3), and 7 were ex-
TB patients who have completed their respective treatments
and are being followed-up actively (17%; FG4) (Table 2). The
FGs were ∼90 min in duration (range 80–110 min). FGs1–3
participants had completed tertiary education, FG4 participants
had completed primary education.
Three major themes emerged from the analysis of the
data: (a) the increasing knowledge at all levels of healthcare
activity in terms of the potential of mobile-enabled health
technologies; (b) the structural and societal barriers associated
with implementing potential mobile-based solutions; and
(c) the need for government-driven, community-engaged
implementations complemented by educational initiatives. There
were no differences noted between communities or by gender,
thus the results are consistent for the FGs.
Theme 1: Increasing Understanding of
Mobile Health Technologies Potential in
Indonesia
Regarding overall knowledge, most FG participants agreed that
there is a gradual implementation of mobile health technology
in Indonesia through several applications known to them, which
are approved by the Data Centre and Information Department
of the Ministry of Health (Pusdatin, Kementerian Kesehatan).
Such examples include the Integrated Referral Information
System (Sistem Informasi Rujukan Terpadu, Sisrute) used in
tertiary referral hospitals, the Integrated Nutrition Information
System (Sistem Informasi Gizi Terpadu, SIGIZI Terpadu) used
in primary healthcare centers (Puskesmas), the Integrated
Emergency Response System (Sistem Penanggulangan
Gawat Darurat Terpadu, SPGDT) used by the general public.
Interestingly, while the professionals in the FGs were familiar
at a minimum with the names of these systems and their
basic aims, the patient FG was not fully aware of all of these
systems or of their functions, though they were aware that some
such systems exist. Specifically, both the patient and frontline
staff FGs mentioned the current extensive use of automated
messaging services and Whatsapp-based messaging as blanket
reminder services for the adherence to the TB treatment between
doctors’ visits.
There was an overall positive attitude toward potential mobile
health implementations. In particular, it was clear, especially
by public health practitioners, that mobile health technology is
considered vital in providing different solutions potentially to
be implemented in almost every sector in Indonesian healthcare,
from the general public, to frontline staff needs. However, from
the outset of the discussions, several problems were identified
relating to such a deployment. These can be summarized as lack
of a planned integration between initiatives already taking place
in different sectors. Therefore, it was considered critical that as
part of the future deployment of mobile health technologies, the
plans for their integration to existing healthcare functions (and
complementarity with existing ones) should become a critical
deciding factor.
Nomenclature and Health Literacy should also be mentioned
here as a subtheme. From the FG discussions, participants
mentioned that they lacked awareness of the scientific terms
associated with mobile health. This lack of awareness hampers
the understanding of the full potential of using such technologies
and can create inconsistencies in terms of the expectations and
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Aisyah et al. mHealth Technology Knowledge in Indonesia
influence a distant or less-less welcoming behavior toward mobile
health. Across the different FGs, it was advised that if full-
scale adoption by the public and the wider healthcare sector in
Indonesia is the eventual aim, then the descriptive terms should
exist in very simple language (in Bahasa Indonesia), accompanied
by a number of explanatory pictures/depictions.
Theme 2: Structural and Societal Barriers
Assessing the knowledge in terms of structural barriers, the
lack of a specific legal framework was mentioned by healthcare
professionals in the FGs. In Indonesia there exists a basic
regulation and policies related to the application of technology
[Law no. 19/2016, on Amendment to Law no. 11/2008
on Information and Electronic Transactions, Government
Regulation (PP) No. 46/2014 on Health Information Systems].
Nevertheless, the latter law provisions do not specifically
regulate the implementation of Mobile Health Technology.
The Yogyakarta region specifically serves as a provincial
model in Indonesia for community-oriented services utilizing
communication technologies (“Jogja Cyber Province,” Governor
Regulation No.42/2006). This might explain the heightened sense
and general consensus observed in healthcare professionals, for
the need of developing a legal framework to specifically address
and regulate the implementation of mobile health technologies.
There was a general concern expressed as many FG
participants spoke about several barriers to accessing healthcare.
Such barriers contribute toward a more cautious attitude when it
comes to the potential adoption on mobile health technology. For
example, the language barrier was mentioned often, and in quite
a similar manner, across the different groups, as language barriers
can compromise the patient navigation. Participants mentioned
they need someone who understands both the medical and
technical languages and is able to translate the information
“speak[ing] the dialect of the same community,” as frontline
staff added. This allows the translation of information effectively
from English into Indonesian and then into local, regional
dialect(s). Numerous participants mentioned that the drugs
supervisors (Pengawas Menelan Obat) might fulfill this role
within the local context. Another possible barrier is the lack of
confidence in western medical approaches, which needs to be
taken into account when providing information about mobile
health technologies originating from outside of Indonesia.
One constant subtheme across the different groups was the
notion of “workload creep” as a barrier to eventual adoption of
such technologies in the field. Participants felt people would tend
to emphasize the potential benefit of mobile health technologies,
without balancing appropriately potential pressures elsewhere in
the system (from healthcare staff to administrative public health
staff). For example, some participants mentioned that even when
a video directly observed therapy for TB is implemented, while
the potential patient benefits are clear, the potential workload
implications on frontline healthcare staff are yet to be defined.
FG participants were also concerned about practical aspects:
for example, the cost in accessing enough data quotes for
video-based applications, and second, the quality of existing
connections on mobile networks. While most of Indonesia is
covered by mobile networks, and most Indonesians are owners
of mobile phones, the quality of these networks is not uniform
across all areas depending on population density and geography,
nor is access to newer smartphones equally distributed in the
population, allowing for video-based applications, which will
affect the end-user behavior during a potential nationwide
implementation of such initiatives, especially in remote and
poorer areas of the country.
Theme 3: Governmentally-Supported,
Community-Driven Implementation,
Complemented by Education
FG participants expressed a wide range of responses and
opinions regarding the potential models of introduction and
implementation of such mobile health technologies. The overall
knowledge consensus was that an initiative, such as a potential
one relating to TB treatment monitoring and follow-up, should
be nationwide and supported by the central government, in
line with other such recent initiatives [e.g., Antimicrobial
Resistance Control National Action Plan (NAP/2016), Universal
Health Coverage through the National Health System (Badan
Penyelenggara Jaminan Sosial/2014), etc.].
Several examples participants mentioned were of
implementation models driven by primary or tertiary healthcare
structures. In the particular case of existing TB pathways in
Indonesia, the current national healthcare system expects most
TB patients to be treated by primary healthcare centers, with
referrals to specialist tertiary centers be limited only to MDR-
TB patients. Navigating through this tiered system is already
challenging for individuals who are of the lowest income and/or
educational levels, often resulting to a delay or interruption
of patients’ treatments. Additionally, there is limited data
linkage/transfer between the different healthcare tiers; thus, any
mobile-driven technology would need to bridge and converse
with the different healthcare tiers, as well as be resilient to
limitations in terms of healthcare data availability.
Therefore, in some FGs, the favorable position was that mobile
healthcare technologies focusing on TB should be supported by
the central government/public health departments through the
central framework and overseeing mechanisms, and be driven
in terms of implementation by the primary healthcare centers.
This allows a close support of the initiative by drugs supervisors
and an easy/ier information flow to patients. Across each FG,
participants mentioned the importance of involving influential
community leaders like civic leaders in helping to provide
awareness of such a potential initiative.
The potential of such mobile health technologies for a
number of overlapping healthcare aspects (e.g., TB and other
infectious diseases) was currently not promoted in public health
efforts. A number of FG participants stated that there is a
paucity of pilot studies to support the introduction of such
technologies. A participant in a frontline medical unit stated she
did not know anything about mobile-driven technologies until
she did her final year of training. When asked, “If there is an
official approval process for allowing the introduction of such
technologies?,” several members mentioned they did not know
what such a process might be and needed more information.
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Aisyah et al. mHealth Technology Knowledge in Indonesia
For instance, one participant mentioned, “[the] need for specific
regulation to allow potential implementation.” There was also
a lack of awareness of the breadth of such mobile-driven
health technologies. One participant maintained that “there are
different types of these applications” but “didn’t have access to
information about the different kinds.” However, participants
were aware that they are not utilized for clinical purposes in
Indonesia; some (six participants; 13%) have used applications
for personal fitness/well-being requirements, and a very low
number (three participants; 6%) for managerial purposes within
their healthcare organization.
Continuing with the overall positive attitude toward mobile
health, participants in all FGs expressed interest in learning more
about mobile health technologies. For example, the need to learn
about the implementation in other countries/communities of
similar societal challenges, and not from more advanced nations,
which is applicable only to upper-class levels of society and
not the majority of the Indonesian population. Others discussed
that partnerships for health education and promotion were
most appropriate with academic institutions and community-
based organizations, to pilot test such implementation attempts
and provide the first evidence from within Indonesia before
embarking on a nationwide initiative. Participants indicated the
importance of having someone explain the nature of mobile
health technologies (as was provided during the opening of the
FG sessions). Last, several participants felt that it is important for
individuals to start discussing such technologies within academic
institutions so as to increase awareness of the potential to
eventually save lives. More importantly, participants recognized
the need for Indonesia to move forward with the rest of the world
in this developing healthcare field.
DISCUSSION
To our knowledge, this is the first qualitative research study
examining knowledge, attitudes, and behaviors toward
mobile health technologies in Indonesia and, in particular,
for the treatment and follow-up of TB patients. Findings
from this pilot study provide insight on areas of research
focus. Having a moderator team consisting of members
with demonstrated community-based engagements, from
the INDOHUN network, helped to increase trust and
foster an understanding of shared community values.
Information from this study provides evidence to support
the creation, testing, and eventual development of professionally
and culturally appropriate strategies in Indonesia to
introduce mobile health technologies, eventually for a wider
public use.
The findings illustrate that general knowledge of mobile
health technologies, of their legal framework of operations, and
of their exact potential within the healthcare system can be
characterized as incomplete or poor. There is general knowledge
that such technologies exist, but not a detailed operational
exposure to them and their potential applications. There was
a general positive attitude throughout the FGs toward mobile
health technologies and their potential applications, especially as
the benefits to the population and potential reach and immediacy
of applying this technology was evident to participants from
the outset. At the same time, there was also concern on the
number of challenges that lay ahead for such technologies to be
applied on a larger scale or even nationwide. These challenges
can be at the individual level (accessibility to mobile phones
and/or networks, language/comprehension challenges), to the
local level (local healthcare facility capacity and integration
to other ongoing tasks and activities) to the national level
(improved national framework for mobile health technologies).
Last, the behavior toward the mobile health technologies can be
characterized as cautious and distant overall. There have been
previous successful as well as unsuccessful attempts in Indonesia
in rolling out nationwide healthcare initiatives, and as such, a
general cautious behavior has ensued. However, this does not
seem to be specific to mobile health technologies, but rather
relating to the magnitude and operational complexity of such
a task.
The novel findings of this study were: (A) the willingness
of participants to learn about these technologies, as during
the FGs there were repeated questions to the moderators
and other participants to provide examples and online points
of reference for further investigation. (B) The open and
welcoming attitude of the participants toward receiving such
information even within frontline community settings. This
was perhaps surprising, as frontline staff are under constant
pressure and often under resourced; hence, a discussion on
a potential new initiatives might have not been welcome,
expected to be greeted with heightened concern. However,
there is clear acceptance that the benefits of mobile health
technology are likely to outweigh potential disadvantages
stemming from any complexity of implementation. (C) The
willingness of participants to back a government-supported,
primary healthcare-driven set of such initiatives. Various
barriers to the implementation, operation, and eventual
adoption, were described. In other parts of the world,
studies have reported poor uptake of such technologies
when the communication between various sections of the
healthcare system was suboptimal, as well as within different
units; this was supported from the opinions shared in our
study (33,34).
A previous work showed an agreement by healthcare
providers and public health professionals that mobile health
technologies can improve patient care, as this technology is
perceived as able to reach most patients, when needed (35,36).
While this constitutes a benefit for the patient population, in
general, the same ability can be seen as a potential barrier due
to increased workload (34,37,38) and distributed workflow by
frontline healthcare staff (39,40). Our study has demonstrated
general alignment with these previous findings. In addition,
our study indicates that participants do not have a good
understanding of the different types, or of the range, of existing
mobile health technologies. Culturally, participants did not view
the introduction of new technology as a serious barrier in itself,
but had to be well-supported through community engagement.
Our results indicate that participants had some level of
understanding of the various models of implementing such
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Aisyah et al. mHealth Technology Knowledge in Indonesia
healthcare initiatives, based on recent nationwide campaigns
within Indonesia. However, further research and education are
needed to enhance the understanding of the potential barriers
and facilitators before aiming to adopt such technologies widely.
This was evident as several participants mentioned that access
to reliable networks, data packages, and appropriate devices,
would become immediate stumbling blocks in implementing
such initiatives. This has been demonstrated previously in other
resource-limited settings (41,42).
Another subtheme emerging as a barrier is language and
understanding. This notion is quite consistent with previous
research in low-resource settings, and geographies where
multiple languages coexist (43,44). Ways that were suggested to
empower and enable the community were to utilize community-
based organizations, such as primary healthcare centers as a
source of health education. Finally, it is worth mentioning
a potential friction point, where there is a willingness to
progress by adopting and embracing technological advances,
while there still remains, in some part of the population,
a mistrust of western medicine and medical approaches.
The latter are likely to be entirely incorporated into mobile
health technology solutions and, thus, would be interesting to
observe how such beliefs can impact any potential adoption by
the community.
LIMITATIONS
The limitation of our study is that it might not be generalizable
to the populations of South-East Asia, indeed, even Indonesia
itself. Recruitment for the focus groups was limited by the
sample size, as this was a pilot study with insufficient resources
to conduct additional focus group sessions to allow for a
more comprehensive comparison between groups (i.e., age,
gender, education, etc.). Moreover, the focus group participants
were self-selected and may not represent the majority of the
population or the majority of opinion within their respective
population groups. Another limitation is the need for having
these observations validated through their presentation to
the stakeholders as well as to the Indonesian healthcare
community to ensure that the presented views are, indeed,
widely representative. Furthermore, we acknowledge that the
academic medical centers included in this study do not represent
all types of facilities in which people are hospitalized and
that any potential implementation might differ according to
local needs and requirements. Nonetheless, we acknowledge
the early nature of our findings in this rapidly evolving field.
Finally, despite our efforts, our findings may not be exhaustive;
they more than likely underscore considerable challenges and
barriers to implementation and adoption as perceived by
stakeholder participants.
CONCLUSION
The entire issue of mobile health technologies, especially
for remote patient monitoring, is attracting a great deal of
attention worldwide because it presents a unique way to provide
information and resources to healthcare professionals and
patients alike, and may be a promising tool to support healthcare
(45). The findings from the current pilot qualitative study focus
on Indonesia due to the paucity of available data and the high
healthcare need in terms of TB burden. The current work has
identified challenges of implementation, integration, and health
literacy that need to be addressed prior or during the future
deployment of mobile health technologies. Additionally, it has
identified the need for legal regulations and policies to allow for
implementation and integration of mobile health technologies as
well as their integration to existing healthcare functions. Further
issues such as workload creep for frontline health workers
and the literacy concerning both medical and technological
languages were identified. Finally, there were concerns raised
around the issue of accessibility of such technologies across
the population, as well as governance and regulating of
such technologies.
The themes expressed through the FGs provide a common
ground, making it possible to better understand the challenges
and opportunities related to mobile health technology utilization.
While some of the aspects to the potential adoption are
similar to those identified in systematic reviews about other
technological applications (ease of use, access, etc.), this
study has enabled us to identify factors that are specific to
mobile health in one of the most populous nations of the
world, Indonesia.
Based on these early findings, our most notable
recommendation is that the findings described in the current
manuscript would need to be further validated by a wider
participation from the existing focus group stakeholder
categories and expanded, through additional focus groups with
other key stakeholders (e.g., health app developers, mobile
industry representatives). This should allow the development
of a core set of understanding regarding the knowledge,
attitudes, and behaviors of Indonesians toward mobile health
technologies and advance safe, coordinated, and effective
dialogue and implementation of such technologies for patient-
centered care. Further qualitative and quantitative research
should build upon these concepts, enhance the themes we
identified, test design assumptions, and measure the impact
on outcomes.
DISCLAIMER
Where authors are identified as personnel of the International
Agency for Research on Cancer /WHO, the authors alone
are responsible for the views expressed in this article,
and they do not necessarily represent the decisions,
policy, or views of the International Agency for Research
on Cancer/WHO.
DATA AVAILABILITY STATEMENT
The datasets generated for this study are available on request to
the corresponding author.
Frontiers in Public Health | www.frontiersin.org 7October 2020 | Volume 8 | Article 531514
Aisyah et al. mHealth Technology Knowledge in Indonesia
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by UGM Institutional Review Board. The
patients/participants provided their written informed consent to
participate in this study.
AUTHOR CONTRIBUTIONS
DA, ZK, and WTA contributed to study concept and design.
WTA, RA, HD contributed on acquisition of data, data
analysis, interpretation of data, and drafting of the manuscript.
ZK, DN, WA, and AH contributed in interpretation of
data, and critical revision of the manuscript and final
approval of the manuscript. All authors contributed to
manuscript revision, read, and approved the submitted version.
All authors contributed to the article and approved the
submitted version.
FUNDING
This work has been supported by UCL Global Engagement
Funds to Prof. AH and Dr. ZK in 2018; and by own-funds by
INDOHUN for Indonesian staff.
ACKNOWLEDGMENTS
The authors would like to thank the study participants and
the recovered TB patients from Bethesda Hospital Yogyakarta
and Yayasan Vesta Indonesia. We also thank INDOHUN as an
umbrella organization supporting this collaboration research.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpubh.
2020.531514/full#supplementary-material
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Aisyah, Ahmad, Artama, Adisasmito, Diva, Hayward and
Kozlakidis. This is an open-access article distributed under the terms of the Creative
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