Challenges and strategies of implementing active case finding for tuberculosis: A qualitative study at a high-burden primary healthcare center, Yogyakarta, Indonesia

Abstract

Tuberculosis (TB) remains a major public health problem in Indonesia, and strengthening active case finding (ACF) is essential to improve early detection and interrupt transmission in high-burden settings. This study aimed to analyze the implementation of TB ACF at Depok II Primary Health Center, Sleman, Indonesia, using the Donabedian framework consisting of input, process and output components, with a focus on implementation processes, challenges, and strategies from a health promotion perspective. A qualitative case study design was employed. Data were collected through in-depth interviews, field observations, and document reviews involving 14 informants, including primary health center staff, district health office representatives, community health cadres, TB patients, a community leader, and a representative from a non-governmental organization. Data were analyzed thematically using the Miles and Huberman framework with support from NVivo version 12. The findings showed that the input component was generally well established, supported by policy commitment, multidisciplinary human resources, adequate basic logistics, program financing, and strong multisectoral partnerships, although challenges remained in village-level budget execution, limited cadre incentives, and dependence on external diagnostic services such as mobile chest X-ray. The process component was generally effective, characterized by structured service delivery, adaptive outreach strategies, strong health education, and patient-centered implementation. However, variation in community responsiveness, internalized stigma, and referral delays remained important barriers. The outcome component was reflected not only in case detection, but also in improved community awareness, acceptance of diagnosis, treatment adherence, and recognition of TB symptoms. Overall, TB ACF at Depok II Primary Health Center was generally effective and supported by strong system readiness and community engagement; however, its sustainability requires strengthened financing, referral access, and health promotion capacity to address remaining operational, behavioral, and social challenges.