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RESEARCH ARTICLE
Indonesian healthcare professionals’
experiences in rural and urban settings during
the first wave of COVID-19: A qualitative study
Ida Ayu Sutrisni
1
, Aria Kekalih
2
, Dewi Friska
2
, Diana Timoria
3
, Ralalicia LimatoID
1,4
,
Ragil Dien
1
, Claus Bogh
2
, Mary ChambersID
4,5
, Sonia LewyckaID
5,6
, Jennifer Ilo Van
NuilID
4,5☯
*, Raph L Hamers
1,4☯
, on behalf of the OUCRU COVID-19 Research Group
¶
1Faculty of Medicine Universitas Indonesia, Oxford University Clinical Research Unit Indonesia, Jakarta,
Indonesia, 2Faculty of Medicine Universitas Indonesia, Department of Community Medicine, Jakarta,
Indonesia, 3Sumba Foundation, Sumba, Indonesia, 4Nuffield Department of Medicine, Centre for Tropical
Medicine and Global Health, University of Oxford, Oxford, United Kingdom, 5Oxford University Clinical
Research Unit, Ho Chi Minh City, Vietnam, 6Oxford University Clinical Research Unit, Hanoi, Vietnam
☯These authors contributed equally to this work.
¶ Membership of the OUCRU COVID-19 Research Group is listed in the Acknowledgments
*jvannuil@oucru.org
Abstract
Introduction
During the COVID-19 pandemic, healthcare workers (HCWs) faced unprecedented chal-
lenges, increased workload, and often struggled to provide healthcare services. We
explored the experiences faced by HCWs working at primary healthcare centers (PHCs)
and hospitals across urban and rural settings in Indonesia.
Methods
As part of a larger multi-country study, we conducted semi-structured in-depth interviews
with a purposive sample of Indonesian HCWs. We used thematic analysis to identify the
main challenges described by the participants.
Results
We interviewed 40 HCWs between December 2020 and March 2021. We identified that
challenges varied depending on their role. i) For those in clinical roles, challenges included
maintaining trust with communities, and patient referral issues; ii) for those in non-clinical
roles, sub-optimal laboratory capacity and logistics, and lack of training were the main chal-
lenges; iii) for managerial roles, challenges included access to budget and supplies, and
staff shortages due to isolation and overwork. There were also several cross-cutting chal-
lenges across all the roles including limited or rapidly changing information (in urban set-
tings), and culture and communication (in rural settings). All of these challenges contributed
to mental health issues among all HCW cadres.
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Citation: Sutrisni IA, Kekalih A, Friska D, Timoria D,
Limato R, Dien R, et al. (2023) Indonesian
healthcare professionals’ experiences in rural and
urban settings during the first wave of COVID-19: A
qualitative study. PLoS ONE 18(7): e0288256.
https://doi.org/10.1371/journal.pone.0288256
Editor: Muhammad Arsyad Subu, School of Health
Binawan: Universitas Binawan, INDONESIA
Received: December 15, 2022
Accepted: June 22, 2023
Published: July 11, 2023
Copyright: ©2023 Sutrisni et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Data cannot be
shared publicly because it is qualitative data. Data
are available from the OUCRU Institutional Data
Access Committee (contact via info@oucru.org)
for researchers who meet the criteria for access.
Funding: This work was supported by Wellcome
[106680 https://doi.org/10.35802/106680,
Wellcome Programme core award; 106680 https://
doi.org/10.35802/106680, Wellcome Provisions
for Public Engagement award; 096527 https://doi.
org/10.35802/096527, Wellcome Strategic Award].
Conclusions
HCWs across roles and settings were confronted with unprecedented challenges. Under-
standing the various challenges across different healthcare cadres and within different set-
tings is crucial for supporting HCWs during pandemic times. In rural areas, in particular,
HCWs should be more sensitive to cultural and linguistic differences to enhance the effec-
tiveness and awareness of public health messages.
Introduction
Low and middle-income countries (LMICs) have been disproportionately impacted by severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19. Dur-
ing the early stages of the pandemic, diverse challenges faced by healthcare workers (HCWs)
included a lack of accurate information regarding disease management [1], limited availability
of adequate personal protective equipment (PPE) [2], limited access to diagnostic tests [2], and
psychosocial factors such as unsupportive work environments, excessive workload, and a lack
of time to rest for frontline HCWs [2–4].
As of October 10th, 2022, there have been an estimated total of 6.4 million confirmed cases
and 158 thousand deaths [5], ranking Indonesia as the second worst affected country in the
Asian region. Since March 2020, Indonesia experienced an extended first wave that steadily
trended upward through January 2021, a Delta-driven second wave in July 2021, and an Omi-
cron-driven third wave in January 2022. The highest number of reported cases occurred in the
major cities on Java Island, although COVID-19 also spread widely among remote, rural com-
munities across the vast Indonesian archipelago. During the pandemic, the health system
struggled to manage the number of patients as the virus kept spreading and frontline HCWs
with direct contact with COVID-19 patients were at a higher risk of infection [6]. The health
system appeared ill-prepared to deal with the pandemic, making HCWs a vulnerable target for
nosocomial infection, with a five-fold risk of dying from COVID-19 compared to the general
population [7]. Since the start of the pandemic, approximately 2,087 HCWs died due to
COVID-19, with the highest reported deaths among doctors, midwives, and nurses between
March 2020 and October 2022 [8]. A small study early in the pandemic among medical hospi-
tal staff in the city of Surabaya, reported feelings of physical and psychological exhaustion dur-
ing COVID-19 for a variety of reasons (e.g. limited staff, length of diagnostic procedures,
limited skills, and shortage of beds) [9]. However, little is known about the specific challenges
faced by HCWS employed in different professional roles (e.g. clinical, non-clinical, managerial
roles), settings (e.g. rural, urban), and healthcare system levels (e.g. hospital, primary care lev-
els). As part of a multi-country social science and public engagement action research (SPEAR)
project [10], we conducted a qualitative study, based on in-depth interviews (IDIs) with a
range of HCWs, to explore challenges faced by HCWs working in clinical, non-clinical and
managerial roles, and across different healthcare levels and geographic settings in Indonesia.
Materials and methods
Study design
SPEAR is mixed-methods social science and community engagement study using quantitative
surveys, key informant discussions (KIDs), IDIs, and participant-led digital diaries across 13
sites in Indonesia, Nepal, and Vietnam. SPEAR is divided into two main phases, which is fully
described in a protocol paper [10]. The overarching aim of SPEAR Phase 1 was to explore the
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This publication arises from activities funded by the
Higher Education Innovation Fund and ESRC
Impact Acceleration Account through the
University of Oxford’s COVID-19: Economic,
Social, Cultural, & Environmental Impacts – Urgent
Response Fund. The funding bodies had no role in
the design of the study. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
lived experiences and impact of COVID-19 on HCWs, health-related staff, and vulnerable
communities in 13 sites, while the aim of Phase 2 was to explore themes surrounding accep-
tance and accessibility of COVID-19 vaccines within the same settings. SPEAR data collection
for Phases 1 and 2 took place from December 2020 to Jun 2022. In this paper, we describe data
that were drawn from the Phase 1 qualitative IDIs and KIDs conducted with HCWs and
related staff within the three sites in Indonesia.
Study setting
Indonesia is a lower-middle income country in Southeast Asia with the world’s fourth largest
population (estimated to be 275 million), with a wide range of socio-economic conditions and
health indicators across the archipelago [11]. Indonesia has a decentralised public healthcare
system in which provincial or district-level governments have authority over most public hos-
pitals and primary healthcare centres (PHCs), and there is also a substantial private healthcare
sector [12]. To achieve the goal of universal healthcare coverage, in 2014 the government intro-
duced national health insurance (Jaminan Kesehatan Nasional), which had reached 84% of the
population by 2021 [13]. The SPEAR study sites in Indonesia included both urban and rural
settings: i) Jakarta city (urban), the national capital, a megacity of 10.6 million inhabitants with
a total of 122 hospitals and 252 PHCs [14]; ii) Bandung city (urban), the capital city of West
Java province, with a population of 2.4 million and total of 26 hospitals and 70 PHCs [15]; iii)
and West Sumba (145,097 population, 2 hospitals and 10 PHCs) [16] and Southwest Sumba
(303,650 population, 2 hospitals and 16 PHCs) districts (both rural), on the remote island of
Sumba in East Nusa Tenggara province [17].
Participant sampling and recruitment
We recruited key informants from study sites in order to gain perspectives on the situation at
each site, as well as to identify potential participants for the subsequent data collection. Key
informants were interviewed prior the IDIs to obtain contextual information and to gain
advice regarding data collection and potential interviewees at each site. For the IDIs that are
presented in this analysis, we used purposive sampling to recruit 40 participants who were
working in hospitals and PHCs during the data collection period of SPEAR 1. We used partici-
pant mapping based on information from the survey including demographic characteristics
(e.g., age, gender), job related specifics (e.g., position or role), and responses to specific ques-
tions of interest. Most participants (75%) were recruited from the mapping [10] while the
remaining participants (25%) were recruited from leaders within the study sites based on the
key informants’ advice. Participants were selected from five hospitals (three hospitals in
Sumba and one hospital in Jakarta and Bandung each) and 15 PHCs (four in Jakarta, five in
Bandung, and six in Sumba).
Data collection
The data collection for Phase 1 qualitative component with HCWs and related staff in Indone-
sia took place between December 2020 and March 2021, which corresponded with the first
wave of COVID-19 in Indonesia. Three Indonesian researchers conducted the interviews in
the local language, either face-to-face, and following the COVID-19 guidelines, or virtually via
video or voice calls. For the study tool for the IDI, we used an interview guide which covered
topics related to perspectives and experiences working during the COVID-19 pandemic, the
impact of COVID-19 to careers and work responsibilities, impacts of HCWs’ work on their
relationships with family and community, and stigma and community responses around
COVID-19 (S3 & S4). Prior to the interview, prospective participants were contacted and
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asked for their willingness and availability to be interviewed. Upon agreement, the interviewer
arranged the time and venue/media of the interview. The interviewer provided information
regarding the study, confidentiality, and how the data would be handled, disseminated, and
used in the future before the interview. We then obtained written or oral informed consent
from all the participants for the interview to take place and for it to be audio recorded. The
interviewers supplemented the audio with handwritten field notes. We expected the interview
duration to be between 60 and 90 minutes.
Data analysis
The interviews were transcribed in the language spoken and translated into English. We
removed identifying information during the transcription process to preserve the confidential-
ity of the participants [18]. We managed the transcripts in NVivo 12 software. For this analysis,
we used an iterative process that included both deductive and inductive coding techniques.
The SPEAR Indonesia team conducted multiple cycles of coding (IAS, DT, RD), with input
and discussion from study investigators (JIVN, DF, AK, HRL, LS, CM). To start, we created a
coding framework with deductive codes (i.e. topics that inform the study objectives, driven by
the researchers) and inductive topics from the regular debrief sessions conducted with the full
international SPEAR team during the data collection period [19–21]. During provisional cod-
ing, we also integrated additional categories and topics into the codebook and discussed dur-
ing the debrief meetings with other sites. For the second cycle coding for this analysis, we used
the ‘relevant text’ as coded from the first cycle of coding [22]. We then conducted pattern cod-
ing to explore the larger patterns and themes in the data [21]. We discussed the patterns and
themes using an iterative process of discussion and refinement of the core themes over multi-
ple meetings and compared between rural and urban sites, as well as between roles within the
health centers. We then contrasted data between urban and rural sites as well as between hos-
pitals and PHCs.
Ethical approvals
The SPEAR study in Indonesia was reviewed and approved by Ethics Committee of the Faculty
of Medicine, University of Indonesia (1283/UN2.F1/ETIK/PPM.00.02/2020) and Oxford
Tropical Research Ethics Committee (547–20).
Results
Participant characteristics
A total of 40 participants between the ages of 20 and 59 years participated in the study includ-
ing 26 females and 14 males, 25 from urban settings and 15 from rural settings, 7 working in
hospitals and 33 working in the PHCs. 18 participants were working in clinical roles, 17 in
non-clinical roles, and 5 in managerial roles (Table 1).
We grouped the findings into four main categories based on primary job role including
challenges in clinical roles, non-clinical roles, managerial roles, and cross-cutting challenges
across all roles. We also noted if specific challenges related to both rural and urban settings or
if the challenges were unique to either setting (Table 2).
Reported challenges
1. Clinical roles. For clinical roles, the main challenges reported included maintaining
trust with communities and patient referral issues. The participants’ narratives often included
feelings of frustration, fear, and stress.
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Maintaining community trust. Building and maintaining community trust was a challenge
in both urban and rural healthcare settings. HCWs reported a lack of openness from the com-
munity in some instances (e.g. dishonesty regarding travel history). This caused difficulties for
HCWs to carry out their duties related to the pandemic, for example contact tracing. A nurse
at the rural hospital described challenges related to people not sharing information about
travel. From her point of view, the silence meant dishonesty.
“A woman,she just arrived from Bali two days ago.She is originally from West Sumba.I
asked them,do you have any family members who traveled outside the area these days?She
didn’t say anything."
(13SUM1814, Female, Nurse, Rural Hospital).
Table 1. Participant demographics.
Remarks n (%)
n = 40
Sex
Female 26 (65)
Male 14 (35)
Settings
Urban 25 (62.5)
Rural 15 (37.5)
Workplace
PHC (Puskesmas) 33 (82.5)
Hospital 7 (17.5)
Age group
20–29 7 (17.5)
30–39 16 (40)
40–49 5 (12.5)
�50 3 (7.5)
Not stated 9 (22.5)
Participant professions roles
Managerial roles 5 (12.5)
Hospital director 1 (2.5)
Head of PHC 2 (5)
Management staff 2 (5)
Medical roles 18 (45)
Doctors 5 (12.5)
Psychiatrist 1 (2.5)
Nurse 9 (22.5)
Midwife 3 (7.5)
Non-medical roles 17 (42.5)
Health promotion officer 4 (10)
Administrative staff 3 (7.5)
Laboratory staff 3 (7.5)
Nutritionist 1 (2.5)
Pharmacist 2 (5)
Spiritual officer 1 (2.5)
Tracing officer 1 (2.5)
Cleaners 2 (5)
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In urban settings, lack of trust caused the quarantine process to be complicated and it often
took time to urge individuals to go to an isolation facility. One HCW described a struggle
when they picked up a pregnant woman, who contracted COVID-19, from her home to be
transferred to the quarantine facility. Her family did not give consent for her release as she
stated that she felt fine and did not believe the COVID-19 test result. In this case, the local lead-
ers became involved with the family to help facilitate the process. This was a common occur-
rence across sites.
“Many of them [patients] and their families refused to give birth in the referral hospitals,and
they did not believe the COVID-19 test results.When the Puskesmas team went to her house
to pick her up,she did not want to go out.”
(26JKT1798, Female, Midwife, Urban PHC)
Table 2. Summary of key elements/challenges faced by HCWs by roles.
Main themes Key narrative elements/challenges
Challenges in clinical role
Obtaining public trust • Challenges in performing duty of care, contact tracing as an example, is
influenced by lack of trust among community (dishonest with travel
history, quarantine refusal and distrust with COVID-19 test result)
Patient referral system • Overburdening of COVID-19 referral hospitals in urban sites led to stress
and conflict between staff at PHCs, hospital level, and patient’s families.
Challenges in non-clinical role
Limited trainings related to
COVID-19 measures
• Lack of communication training and limited time to transfer knowledge to
other colleagues confronted during the pandemic
• Lack of training and mixed messages led to difficulty working
collaboratively to perform contact tracing with local cross-sectors.
Sub-optimal laboratory and logistic
capacity
• Limited lab capacity and surge COVID-19 cases created a delay in PCR
results for several days. In addition to rural sites, the sample needs to be
sent to other islands, where have PCR laboratory.
Challenges in managerial roles
Budget and supplies • Budget management, especially for PPE and medical waste disposal, was
complex and often led to budget deficits.
Staff shortage due to isolation and
overwork
• Engaging and motivating health staff, with high numbers of staff having to
isolate and die due to COVID-19
Cross-cutting challenges across roles
Increasing mental health issues • Contributing factors on HCWs mental health include having infection,
work overload, death among HCWs, shortage staff and fear to transmit
COVID-19 to others, payment delays, and complex situations in
coordinating contact tracing
Rapidly changing or lack of
information
• Health staff had difficulties providing updates and accurate information to
the community because the information changed rapidly
• Frequent COVID-19 policy revisions influenced practice
• Staff need extra attention for rapid information on hospital space allocation
for COVID-19 case management
Culture and communication
barriers
• Communication and explanation in local languages was more effective and
understandable
• Dilemmas between cultural practices (such as nose kissing in Sumba) and
COVID-19 prevention methods
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Similarly, HCWs based in rural sites mentioned that it was challenging when people did
not believe the results of the COVID-19 tests or advice from the HCWs. It was not easy to
inform people with positive COVID-19 results, particularly those who were asymptomatic.
“A traveler was back from Jambi,he confirmed as a positive patient,but at first,his parents
did not accept that their son was positive for COVID-19.”
(20SUM953, Female, Midwife, Rural PHC)
Patient referral issues. Another challenge in the urban settings was related to referring
COVID-19 patients to COVID-19 designated hospitals during first wave. The referral process
was complicated because most referral hospitals were full at that time. HCWs at PHCs level
were forced to contact many hospitals to refer each COVID-19 patient, which caused stress
and conflicts between staff at PHCs, hospitals, and patients’ families.
"We [PHC staff] cannot handle a pregnant mother with breech presentation at PHC.It was
an extreme emergency situation.We called a hospital only telling them we are on the way
to the hospital although they said the hospital capacity was full with many reasons.How-
ever,we kept going and had no choices.It was extremely challenging to find a hospital,even
we have got a scolding from the hospital staff,so what I can say it was an emergency
situation.”
(26JKT1798, Female, Midwife, Urban PHC)
HCWs were facing a crisis situation in which it was extremely challenging to refer patients
and find available hospital beds. The usual referral protocols were not followed, and HCWs
had to improvise to help the patients.
2. Non-clinical roles. For those working in non-clinical roles, the main challenges dis-
cussed in both settings were lack of training and sub-optimal laboratory and other logistic
capacities.
Lack of training related to the COVID-19 response. Across all settings, participants
described how there was minimal training given in response to the pandemic. This related to
a combination of limited staff to provide the trainings and not enough time to conduct for-
mal trainings.
“. . . the challenging part was when doing the swab on the nose and the throat.We must learn
a lot about it through training.Indeed,we had our seniors who had received some training
but that was only 2 people.We are still novices,learning a little bit from them,and we haven’t
received training.”
(22SUM1727, Male, Laboratory staff, Rural Hospital)
Participants also mentioned that they received no training on good communication
practices.
“When we were assigned as a tracer,we try our best to do it ourselves.Like in terms of com-
munication,how to deliver information to the patient’s family and the patient himself. . . I
learned it by myself.Because there hasn’t been any training about it [communication].”
(29JKT1743, Male, Administrative staff, Urban PHC)
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Importantly, communication breakdowns impacted the collaborative work between the
COVID-19 task force and the HCWs. For example, the management of the isolation process
for individuals with asymptomatic COVID-19 was exceptionally challenging. One participant
reported that a task force member ignored the guidelines that those with asymptomatic
COVID-19 should also be isolated.
"The patient did not report to us [one of covid-19 taskforce members],he is still walking
around normally.Then if you report to me,what should I do?" [participant was repeating the
local team response].”
(16BDG2870, Female, Tracer, 24)
Limited laboratory and other logistics capacity. Early into the pandemic, staff in non-clini-
cal roles in both settings were overwhelmed with rising numbers of cases but were receiving
little guidance on the COVID-19 swab procedures and were struggling with limited COVID-
19 testing lab facilities. During the first wave, participants from the urban sites mentioned
how the limited lab capacity for testing was linked to low number of COVID-19 cases
detected.
“From March to August,we only added 8 more COVID-19 patients,nothing more.Why?
Because month per month starting March up to Mid-August there was one lab. . . an addi-
tional lab didn’t exist yet.We were still doing COVID-19 test with the provincial health office.
Too complicated. . .”
(10BDG2921, Male, Nurse, Urban PHC)
Similarly, in the rural health settings the laboratory facilities were not strengthened. Partici-
pants said they needed to wait more than one week to get the swab test results released because
the samples were sent to another island with more laboratory facilities.
“[COVID-19 test sample] need to be sent to Kupang [another island].”
(22SUM1727, Male, Laboratory staff, Urban PHC)
3. Managerial roles. The pandemic challenges faced by those working at managerial levels
included budget and supply challenges, medical waste management, and recruiting and retain-
ing staff.
Budget and supplies. Challenges in securing and managing budgets (including audits) dur-
ing the pandemic was a common concern in all the study sites. Managers struggled to purchase
sufficient amounts of protective equipment (PPE) within their budgets.
“If we order tens of thousands of PPE,the standards are not the same,some are good,many
are not.What is not good,this cannot be used by health workers.”
(39JKT, Male, Director, Urban Hospital)
“We didn’t have a stock of KN95 masks.It’s a standard mask for health workers who are
assigned in the isolation room.It happened for around 2 weeks,it’s not available anywhere.I
asked the hospital to purchase it,but the hospital said don’t have budget.”
(12SUM1258, Female, Pharmacist, Rural Hospital)
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In the early stages of the pandemic, staff in the urban settings reported shortages of PPE,
including face masks. Many participants discussed how they would use raincoats or make
their own PPE. Some sites received donations of PPE.
Medical waste management. Apart from dealing with the huge budget on infectious waste,
participants also commented that medical waste management quickly became a challenge in
both rural and urban settings. The increasing number of disposable PPE meant increases in
medical waste from health facilities. Participants from the rural setting mentioned that
although medical waste management was handled through a third party, the waste transporta-
tion was affected during the pandemic. As a result, the storage of medical waste onsite at the
clinic became an issue, and managers needed extra space to store it before transporting it to
the third-party company.
“The waste became a problem because it was not directly thrown away.At that time,we still
kept it near the toilet rear.It means it’s not safe,it should be directly destroyed.”
(07SUM1975, Female, Pharmacist, Rural PHC)
“Our medical waste is greatly increased.Those ingredients increase by tons in a year,uhm. . .
a month.To burn them take a lot of money,it’s really extraordinary.”
(39JKT, Male, Director, Urban Hospital)
Staff sortage due to isolation and overwork. Staff in management levels, primarily in urban
sites, relayed challenges related to staff shortages and keeping staff engaged and motivated.
Additional health staff often needed to be secured during the pandemic. Although the staff
were equipped with PPE, many of them still contracted COVID-19 and the remaining staff
had to cover for them during their absence. Participants equated dealing with COVID-19 with
fighting on the battlefield, with no days off. In their minds, exposure to COVID-19 was
unavoidable.
“We share the load,the PHCs do not stop in giving care.At the moment I have 15 staff mem-
bers suffering from COVID-19.”
(23BDG2902, Head of PHC, Urban PHC)
“Although we are already equipped with adequate PPE. . . There are still some friends,col-
leagues who contracted the virus.”
(17JKT1869, Male, Doctor, Urban PHC)
Eventually, some wards or health units were closed due to staff shortages. One participant
expressed the opinion that it was likely that these staff were infected with COVID-19 from out-
side the health facilities.
“We closed several rooms. . . Because at that time more than half of the midwives and nurses
were tested positive.But after being traced,the transmission was not from the patients.They
got the transmission from friends,neighbors.”
(36BDG3241, Male, Research and Training Unit, Urban Hospital)
Indeed, those in management roles felt fear and stress but also struggled as to how to keep
their staff motivated and supported.
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“The challenging thing is that COVID cases have been increasing,and we have to make right
decisions.The concern is how to tackle COVID-19 properly,securing [protecting HCWs from
transmission and keep them motivated facing high cases] the workers is hard. . ..And last,the
thing we are most afraid of is that our employees will burn-out.So,when they got fed up with
the job,I can’t do anything else.Sometimes ago,the Health Office issued a rule that at this
time of COVID-19 surge,no employees take on leave.“
(39JKT, Male, Director, Urban Hospital)
4. Common challenges across roles. Many of the challenges that health care workers
faced were the same regardless of their role or setting. These cross-cutting challenges included
mental health challenges, limited or rapid changes in information related to COVID-19 proto-
cols, and language and cultural dilemmas in regard to communicating COVID-19
information.
Increasing mental health issues. Participants expressed fear, confusion, exhaustion, guilt,
feeling overwhelmed, struggles, and at times felt unmotivated in their job roles. Often these
descriptions were in the context of increased workload and limited human resources. In the
urban settings, where incidence and mortality rates were higher, participants expressed fear
over death of their colleagues, feeling overwhelmed due to increased workload and shortage of
HCWs therefore time off was not always guaranteed. Further, participants spoke of feeling
demotivated due to delayed incentives or extra remuneration as a financial aid given by
government.
“. . .currently,there are a lot of health workers who have been confirmed to have COVID-19,
and lost their life.”
(15JKT1852, Female, Doctor, Urban PHC)
“We cannot relax,there is no day off,no leave,no sick leave.We continue to carry out the
roles.”
(02BDG2777, Male, Nurse, Urban PHC)
In the rural settings, participants described concerns over disease transmission to their fam-
ily members or being infected by co-workers who had just arrived back from travelling. The
fear was heightened because COVID-19 tests were not routinely performed in the rural areas.
“The fear among fellow health professionals is,for example,there is a colleague who just came
home from a trip,we were worried whether the person was infected or not.After self-isolation,
the swab procedure was not performed.”
(07SUM1975, Female, Pharmacist, Rural PHC)
In addition, participants reported feeling restless and overwhelmed when faced with com-
plex situations in coordinating contact tracing. For instance, the manager was often contacted
in the middle of the night to solve COVID-19 related cases and had to respond quickly as part
of contact tracing. Then, due to the extra work, those in non-clinical roles (e.g. nutritionist)
were also involved in aspects of COVID-19 coordination on tracing.
"At midnight [outside working hours],I got a call asking me to check [on] someone [who]
passed away [at home] whether they have COVID-19 or not!. . ."
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(23BDG,Female,Head of Puskesmas,Urban PHC)
"My responsibilities are actually getting heavier. . . I have a lot of work,. . .coordination for
getting COVID-19 patients’ data and isolation process."
(06SUM1951, Male, Nutritionist, Rural Hospital)
Rapidly changing or lack of information. Participants both in rural and urban settings
expressed confusion regarding the rapidly changing information, guidelines, and procedures
during the pandemic. Clinical staff mentioned the rapid changes in clinical guidelines while
laboratory staff stated how the protocols to collect and handle COVID-19 specimens changed.
“This puzzled us continuously why we only had 8 patients in all those months.This link to
COVID-19 SOP 1
st
,2
nd
,and 3
rd
revision about limited swab test at PHC [performed].Then,
after 5
th
COVID-19 protocol revision used,more the COVID-19 cases are found since more
testing was applied at PHC.”
(10BDG2921,Male,Nurse,Urban PHC)
Further, all these rapid changes created difficulties for the HCWs to communicate the most
up to date and accurate COVID-19 information to the community.
"Technical instructions also change very quickly.For example a registration link for the
COVID -19 vaccine provided for the elderly changed within a day—so that makes it difficult
for us to send information regarding the registration link.So people ended up doing vaccine
registration on the spot,which make staff work hastily."
(11JKT, Female, Doctor, Urban PHC)
"We are confused,a few days ago we were given a policy update. . . oh now it has changed
again. . .we need confirmation because sometimes we don’t understand a thing,suddenly
there is a new policy that we need time to understand again."
(21BDG2773, Female, Health Promotion Staff, Urban PHC)
Beyond the rapid changes in information, there were also other rapid changes, such as the
transformation of hospital spaces into designated COVID-19 spaces, which required addi-
tional management.
“This is a new hospital,there is no system available yet.When I joined this hospital,it just
had its inauguration.So,I was the one who established the system here by creating workflow
and set up the job description for each staff in this unit.I also deal with new staff,some of
them are fresh graduates and lack experience. . .That’s the challenge.”
(12_SUM_1258, Female, Pharmacist, Rural Hospital)
Participants informed us that there were many reports that had to be filled in during the
pandemic, both for the health system and for the COVID-19 task force at the sub-district level.
"The data was a mess,it was a total headache.For example,some reports are screenshots of
images!"
(10BDG2921, Male, Nurse, Urban PHC)
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Culture and communication. Communication and cultural barriers were reported in rural
settings. In Sumba, there are numerous different local languages used in the communities
(e.g., Laura, Wewewa, Kodi). Typically, communities had a better understanding when infor-
mation was delivered in their local languages, rather than Bahasa Indonesia, the national lan-
guage. Therefore, basic communication was often a challenge for HCWs who were not local,
when communicating with the communities and/or providing health education related to the
pandemic.
“If we have to explain something long enough,we ask someone who understands Bahasa
Indonesia quite well to translate it into the Kodi language. . ..Yes,it’s very different,except for
the villages that are located near here,like Bukambero [a region] to Wewela,they have mixed
languages.Also,for the people who live in Wejewa,they can understand the Wejewa language
only.”
(18SUM913, Female, Health Promotion, Rural PHC)
Another dilemma was regarding the culture of "nose kissing", a form of greeting, and other
common greetings, such as hugging. HCWs spoke about the dilemmas they faced between
respecting the local culture while also trying to remain a role model and comply with physical
distancing for COVID-19 prevention. At times, the HCWs had to decide whether or not to use
these greeting forms with their acquaintances. In other instances, the HCWs would tell the
community members to withhold the cultural greetings during the pandemic to reduce the
likelihood of COVID-19 transmission.
“Sometimes we told them not to do that [nose kissing],especially among friends and col-
leagues.But it is difficult when we meet our family,although we already wear a mask,they
keep pushing us to nose kiss and hug.”
(13SUM1814, Female, Nurse, Rural PHC)
Discussion
Based on interview data from a variety of HCWs and related staff at PHCs and hospitals across
a range of settings in Indonesia, we established that HCWs were confronted with unprece-
dented challenges during the first COVID-19 wave. We identified several COVID-19-related
role-specific challenges, as well as several cross-cutting challenges. Main findings included
challenges in public trust, patient referral issues, lack of training, sub-optimal laboratory
capacity, budget and supplies issues, recruiting and retaining staff, and culture and communi-
cation. Issues related to trust and mental health were prominent themes across all participant
groups from both urban and rural sites and were intertwined with many of the other chal-
lenges described. In this study, we highlighted the range of challenges to note the gaps in the
system but also to better understand how to support HCWs in the future.
Importance of trust
In our study, we found trust to be an underlying factor for several challenges faced by HCWs.
The public trust (or lack thereof) impacted contact tracing processes, in addition to issues sur-
rounding COVID-19 related stigma. In other contexts, social stigma [9], self and structural
stigma perceived by community influenced the contact tracing process, for instance avoiding
testing, hiding illness [23], and “marking” people differently [24]. In our findings, some people
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with COVID-19 infection and their families reacted with resistance when HCWs arrived to
their homes in hazmat suits and in an ambulance accompanied by local leader/government to
investigate potential COVID-19 cases. Trust further deteriorated when people had asymptom-
atic COVID-19 and/or did not believe their COVID-19 test results but HCWs were asking
them to adhere to social distancing and other public health measures. These findings resonate
with studies in the UK and Nigeria that linked lack of trust with government guidelines;
although in UK, participants reported high self-adherence to social distancing, they also men-
tioned how others did not adhere to these measures [25,26], which created confusion and frus-
tration with the public health response [27]. Public trust challenges have been previously noted
as a concern in other outbreaks, for example in Ebola where rumors were circulating that the
outbreak was not real and was produced for monetary purposes [28]. In our context, we found
that the lower levels of public trust reported by HCWs were possibly caused by factors such as
frequently changing information, lack of clarity, and varying messages on social media by pub-
lic figures, experts, government, etc. We also noted low community trust towards the contact
tracing policy in Indonesia become the challenge for the HCWs. Our assumption is that the
difficulty to gain public trust may not be because of the contact tracing itself but for the fear of
subsequent adverse economic and social consequences of the process. Enhancing public trust
and providing sustained social capital support for communities could enhance HCWs’ pro-
ductivity and management of contact tracing and public health measures in general and in
future pandemic times. Lessons learned from Ebola included the importance of considering
social issues rather than the health issues alone, highlighting that genuine, context-specific
public engagement with the community is an essential strategy during a crisis situation to gain
public trust. The engagement has to be flexible, adaptable, well-coordinated, and guided by
evidence [29].
Mental health challenges
Another prominent theme across all HCW groups and settings was surrounding mental
health. We found that one reason for the mental health challenges, which is in line with recent
COVID-19 studies conducted globally [18,30,31], was the constant and rapidly changing infor-
mation and guidelines. Other studies also found that confusion or misinterpretation and
unclear protocols often led to staff stress and weakened self-efficacy [18,32]. As noted else-
where and within our data, lack of information, unqualified trainings, and increased workload
also contributed to confusion regarding changing guidelines [33]. As mentioned above, the
gaining of public trust in the community possibly contributed to frustration and stress for
HCWs across our sites. Prolonged stress could be a cause of burnout syndrome [34] and our
findings support this view. To support the mental health of HCWs, in 2020, the Ministry of
Health in Indonesia released detailed mental health guidelines for HCWs [35]. However, in
our interviews, we found that some HCWs felt stressed when the support did not meet their
expectations, for example access to mental health services or access to basic needs, such as staff
incentives and leave time. In order to provide continued support for HCWs, mental health
support is mentioned in national guidelines [35] but should be provided at more accessible lev-
els to all HCWs across health center levels, particularly at PHCs, as they are responsible for
individual and community-level health.
Communication and culture
Finally, cultural and communication aspects in rural settings was an important barrier to
delivering health education and pandemic-related information. For example, when HCWs
provided education to avoid the nose kissing culture [36], it took time for communities to
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acknowledge that this practice could result in COVID-19 exposure. In fact, the COVID-19
cases in rural settings were relatively low [37], therefore our findings resonate with another
study in West Sumba that stated that there were minimal changes in funeral rituals, including
the large crowds who gather for the ritual, during COVID-19 [38]. We know from other stud-
ies, and our own findings, that different types of healthcare providers and local leaders (e.g.
traditional healers, spiritual leaders) are trusted to greater or lesser extents [39]. In order to
promote positive education and prevention messages, coordination by trusted individuals and
context specific communication would provide better and more trusted information to
communities.
Limitations
Due to mobility restrictions, many interviews were conducted online resulting in connection
issues and shorter interview durations for some of the participants. Some interviewees
requested that interviews were conducted within the workplace, which may have made them
reluctant to speak openly. Additionally, the interviews were only conducted in a limited num-
ber of provinces and health care facilities; although the study has made an effort to ensure
include diversity in professional roles, health facilities and geographical and socio-economic
settings, we cannot rule out the possibility that HCWs in other settings may have had different
lived experience and challenges.
Conclusion and recommendations
Findings of this study outline the various challenges faced by HCWs in the health care system
that occurred during the first wave of the COVID-19 pandemic. Supporting HCWs with addi-
tional training in soft skills could help with problem solving during complex situations but
these trainings should be implemented routinely (i.e. in advance of uncertain situations and
on a more regular basis). Based on the cross-cutting challenges across the HCW roles, policy-
makers should continue the mental health support that is available in national guidelines and
make it more accessible for HCWs, particularly at PHCs level. However, we feel that providing
mental health services alone is not be enough. Integration of additional organizational support
(e.g. mandatory leave time, effective communication of changing information and revised pro-
tocols) would also provide security during crisis and in the face of uncertainty. Lastly, a better
understanding of local cultures and integration of multiple languages into public health com-
munications would promote inclusion of all communities. Further studies on exploring behav-
iors on willingness/unwillingness of societies to trust with public health measures, are likely
beneficial to deliver better public health messages and prepare for future outbreak prepared-
ness [40].
Supporting information
S1 File. HCW In-depth Interview guide SPEAR Phase 1 Indonesia.
(PDF)
S2 File. HCW In-depth Interview guide SPEAR Phase 1 English.
(PDF)
Acknowledgments
We would like to acknowledge the Ministry of Health Indonesia and the healthcare workers
who participated in the study and provided valuable input and time. We would like to
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acknowledge the SPEAR research team members for their contribution to this study and the
OUCRU COVID-19 research group: OUCRU VN COVID-19 research group Chambers
Mary, Choisy Marc, Day Jeremy, Dong Huu Khanh Trinh, Dong Thi Hoai Tam, Donovan
Joseph, Du Hong Duc, Dung Vu Tien Viet, Fisher Jaom, Geskus Ronald, Ho Quang Chanh,
Ho Thi Bich Hai, Ho Van Hien, Hung Vu Bao, Huong Dang Thao, Huynh le Anh Huy,
Huynh Ngan Ha, Huynh Trung Trieu, Huynh Xuan Yen, Kestelyn Evelyne, Kesteman
Thomas, Lam Anh Nguyet, Lawson Katrina, Leigh Jones, Le Kim Thanh, Le Dinh Van Khoa,
Le Thanh Hoang Nhat, Le Van Tan, Lewycka Sonia Odette, Lam Minh Yen, Le Nguyen Truc
Nhu, Le Thi Hoang Lan, Nam Vinh Nguyen, Ngo Thi Hoa, Nguyen Bao Tran, Nguyen Duc
Manh, Nguyen Hoang Yen, Nguyen Le Thao My, Nguyen Minh Nguyet, Nguyen Thanh Ha,
Nguyen Than Ha Quyen, Nguyen Thanh Ngoc, Nguyen Thanh Thuy Nhien, Nguyen Thi Han
Ny, Nguyen Thi Hong Thuong, Nguyen Thi Hong Yen, Nguyen Thi Huyen Trang, Nguyen
Thi Kim Ngoc, Nguyen Thi Kim Tuyen, Nguyen Thi Ngoc Diep, Nguyen Thi Phuong Dung,
Nguyen Thi Tam, Nguyen Thi Thu Hong, Nguyen Thu Trang, Nguyen Thuy Thuong Thuong,
Nguyen Van Vinh Chau, Nguyen Xuan Truong, Nhung Doan Phuong, Ninh Thi Thanh Van,
Ong Phuc Thinh, Pham Ngoc Thanh, Phan Nguyen Quoc Khanh, Phung Le Kim Yen, Phung
Khanh Lam, Phung Tran Huy Nhat, Rabaa Maia, Rahman Motiur, Thuong Nguyen Thi
Huyen, Thwaites Guy, Thwaites Louise, Tran Dong Thai Han, Tran Kim Van Anh, Tran
Minh Hien, Tran Phuong Thao, Tran Tan Thanh, Tran Thi Bich Ngoc, Tran Thi Hang, Tran
Tinh Hien, Trinh Son Tung, van Doorn H Rogier, Van Nuil Jennifer Ilo, Vidaillac Celine Pas-
cale, Vu Thi Ngoc Bich, Vu Thi Ty Hang, Yacoub Sophie; OCRU ID COVID-19 research
group Raph Hamers, Soraya Weldina Ragil Dien, Livia Nathania Kurniawan, Mutia Rahard-
jani, Ida Ayu Sutrisni, Ralalicia Limato, Diana Timori, Fahmi Ramadhan; OCRU NP COVID-
19 research group Abhilasha Karkey, Summita Udas, Samita Rijal, Amit Gautum, Aakriti
Pandey, Pratibha Thapa, Niharika Kharel, Manish Duwal; SPEAR PARTNERS Dewi Friska,
Aria Kekalih, Claus Bogh, Dinesh Deokota, Rabi Shakya, Pawan Sharma, Anup Rajbhandari,
Nguyen Thanh Phong, Nguyen Thanh Truong, Bui Thi Hong Ngoc, Mai Thi Phuoc Loan.
Author Contributions
Conceptualization: Ida Ayu Sutrisni, Aria Kekalih, Dewi Friska, Mary Chambers, Sonia
Lewycka, Jennifer Ilo Van Nuil, Raph L Hamers.
Funding acquisition: Mary Chambers, Sonia Lewycka, Jennifer Ilo Van Nuil, Raph L Hamers.
Project administration: Ragil Dien.
Supervision: Aria Kekalih, Dewi Friska, Claus Bogh, Sonia Lewycka, Jennifer Ilo Van Nuil,
Raph L Hamers.
Writing – original draft: Ida Ayu Sutrisni, Jennifer Ilo Van Nuil.
Writing – review & editing: Ida Ayu Sutrisni, Aria Kekalih, Dewi Friska, Diana Timoria, Rala-
licia Limato, Ragil Dien, Claus Bogh, Mary Chambers, Sonia Lewycka, Raph L Hamers.
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