A total of 53 decision-makers participated in 30 semi-structured interviews (Table 1) and 6 focus group discussions (Table 2). Of these, 27 were cis male individuals and one was a trans female individual. Twenty-seven informants were based in Jakarta, and the rest were based in Banten and North Sulawesi. The majority (n=39) had completed undergraduate university studies.
Knowledge of COVID-19 detection and testing
Vaccination and vitamin intake were mentioned by all study groups as means to prevent COVID-19 disease. No informant mentioned routine screening or testing as a means to impede further transmission of the virus that causes COVID-19. However, it was made clear that many Indonesian people seek a COVID-19 diagnosis when they travel; when they start to experience COVID-19-related symptoms or when they know that they have been in close contact with a case.
When individuals need to obtain a test, the most accessible diagnostics for them would be facility based test available in public or private hospitals, laboratories and clinics; train stations; and in the Puskesmas (i.e., a network of government-funded primary-level healthcare centers).
Multiple deterrents to the uptake of health professional-provided testing were identified. The fear of having to isolate which could limit their ability to earn their daily income was described as a major deterrent for testing. As one male PI from Jakarta noted, there are some people who “are grateful just being able to buy rice” and who may not want to test and risk isolation, because to them “it’s better to eat”.
In some instances, poverty may intersect with the belief that COVID-19 “does not exist” as a reason to refuse testing; this was described as not frequent, although also as “not uncommon”. No informant in this study was able to elaborate on which rumors, events, or misunderstandings could be the origins of this belief.
Another deterrent to testing that might be common to those who do not have the resources to use private testing services relates to the various health system-related inconveniences (e.g., long queues and turnaround times of results, limited testing hours and tests-per-day quotas in some facilities, and the risk involved in encountering people infected with COVID-19 in the clinic), which were described as possible reasons not to seek a test in public health facilities. Some RCSs in North Sulawesi remarked that the distance to testing sites, be they private or public, especially for those living on the islands, was a difficult impediment to overcome.
Finally, fears around stigma, “disgrace and shame”, and, as one Banten nurse explained, of “dying alone in the hospital during self-isolation”, were mentioned as deterrents that might have played a major role at the start of the pandemic. From the informants’ perspective, nowadays, fears around stigma and death are less prevalent than they were during the early part of 2020, when having COVID-19 was perceived as being like suffering “leprosy in the days of the Prophets”.
Values around COVID-19 self-testing
Although some informants, including a few HCWs, thought that “COVID-19 self-testing” was a term that referred to people voluntarily seeking professional testing services and paying for them, the majority of informants were aware of the existence and availability of self-testing in Indonesia. The internet, social messaging groups, and the mass media were mentioned as common sources of information about self-testing.
Some informants reported having already used self-testing. One male PI, a branch manager in Jakarta, showed the interviewer the saliva self-tests that he stocked at home for the “fifteen relatives” who were living in his compound. Another informant, a midwife from Jakarta, explained how she herself used professional RATs for home administration:
“My boy had symptoms like coughing at night, having a cold, and he said ‘Please examine me’. And we used Lungene®. I checked, and it was positive.” Female, midwife, Jakarta
Self-testing is a screening approach that is seemingly endorsed by some professionals in the healthcare sector. As explained by a female nurse from Banten, self-testing was also promoted by Puskesmas in some rural areas. Reportedly, some neighborhood officials (e.g., youth groups, village advisory officers) received training by Puskesmas on how to teach villagers to self-test and to ensure that their results were reported to the local healthcare facility. Another HCW, a male physician from Jakarta, expressed that self-tests are easy to use and can be rapidly interpreted by lay people without having to rely on health services. This opinion was shared by the majority of the sample surveyed.
It was emphasized that self-testing would be beneficial for early treatment and to prevent transmission. Self-testing would enable non-infected people to test in private without needing to go to a facility where they could be exposed to people who were infected. A male RCS valued how self-testing is “the” solution to overcoming barriers to testing, as in the medium-term it will inevitably be integrated in people’s daily lives, because he perceived that society is moving toward accepting that everybody will need to live “side by side” with COVID-19.
“I don’t believe this pandemic will end. This will continue. Finally, it will become endemic. Yes, we have to live side by side with the coronavirus.” Male, Patient Group leader, Jakarta
Nevertheless, not all HCWs supported self-testing, mainly because of the possibility of invalid results due to user error. Other disadvantages identified by the HCWs included the challenges in reporting, recording, and monitoring of COVID-19 cases detected via self-testing. Difficulties for case tracing and the risk of false results were also mentioned by some PIs and RCSs, who also expressed doubts about the healthcare system’s preparedness to manage the increase in the number of cases that might occur if communities began to undertake widespread self-testing.
If clear pathways for reporting, tracing, and accessing care were to be provided to the target end-users of self-testing, the main beneficiaries of this strategy could be the general population (i.e., if previously sensitized) and specific groups of people who are at increased risk of COVID-19 due to their personal vulnerabilities (e.g., comorbidities, being elderly) or to the nature of their occupation (e.g., students and teachers who are exposed to many different people on a daily basis).
For the HCW informants to recommend self-testing to their communities, it was emphasized that certain prerequisites should be met, such as: the self-test kits must be used for screening and not to confirm a diagnosis; they must have high accuracy, be easy to use, and be packaged with user instructions in Bahasa Indonesia; they must be recognized by the Ministry of Health; and they must be delivered alongside training for their target end-users. It was also noted by some PIs and RCSs that, for them to recommend self-testing to their employees and neighboring communities, the kits should be accurate, user-friendly, and health authority-endorsed.
Preferences for service delivery
The Indonesian public might prefer saliva self-tests, as these are perceived as being easier, more comfortable, and less painful devices than self-tests that use other specimen types. Nasal swab or finger-prick self-tests were described as “scary”, “traumatizing”, and complicated. Due to the discomfort associated with the insertion of a swab into the nasopharyngeal cavity, some PIs suggested that these self-tests may increase the risk of user errors.
“There are people whose swab tools have just touched the front of the nose and they won’t continue…I’m afraid they haven’t finished reading the instructions and the interpretation might be wrong, painful, and more uncomfortable to the user.” Male, Head of Hospital Division, Jakarta
Despite these perceptions, a few RCSs and PIs expressed a preference for swab or blood-based self-tests, as they were perceived to be more accurate. Some HCWs reflected that any choice around which self-tests to use should be based on the devices’ sensitivity and specificity rather than on the specimen required.
“If the accuracy is the same with currently available antigen swab, and the price is cheaper, I highly recommend it.” Male, physician, North Sulawesi
There was agreement that self-tests could be made widely available at pharmacies, drug or medical equipment stores, and at Puskesmas sites. Also, a few informants suggested that self-tests could be made available at schools, offices, or companies. Many RCSs from the rural areas suggested that self-tests should be made available at neighborhood associations in any Rukun Warga (i.e., division of regions under the villages) or Rukun Tetangga (i.e., division of villages under Rukun Warga). A few PIs indicated that self-tests should be made available at any public place, such as transport terminals, stations, airports, malls, and markets. One male PI opined that the distribution could follow the distribution line of consumer goods such as “Coca-Cola and cigarettes” which was, according to him, “the widest and best-proven distribution chain”. When discussing who the distributors could be and where the distribution points should be, a concern about “counterfeit products” was raised by a few PIs, who thought that the risk of fake self-tests being made available to the public needed to be considered. To prevent acquisition of “counterfeited” kits, these PIs would not recommend buying self-tests in websites other than known “flagship stores” and those websites that receive official government permission to sell self-tests.
“People are very creative with counterfeiting. Fake products. What needs to be anticipated is how to guarantee that the product in circulation is the original product.” Female, Vice Principal, Banten
Irrespective of where self-tests could be accessed, it was emphasized that they should be affordable, especially for low- to middle-income groups. There was no consensus on how much a device should cost. HCWs’ responses varied from IDR 25,000 (1.76 USD) to IDR 150,000 (10.57 USD), RCSs’ responses ranged from IDR 15,000 (1.05 USD) to IDR 500,000 (35.05 USD), and PIs’ responses ranged from IDR 10,000 (0.7 USD) to IDR 200,000 (14.02 USD).
The public’s preferred location for self-testing might be their own home. Some RCSs from Jakarta suggested that some individuals might prefer to self-test at their workplace, at public transportation stations, or even at markets. Nevertheless, some HCWs were clear that they would discourage self-testing in any public space, as the procedure would require an individual to remove their mask.
“If done in groups, in the end, instead of keeping the health protocol, we carry out risk behavior for transmission. Also, don’t do it in a narrow place. And, when there are roommates, for example. Or at the office, don’t hold it in meeting places. It’s better to stay in your own place.” Male, family physician, Jakarta
Even if performed in their own homes, some end-users may need assistance from a third person to self-test. As explained by one trans-woman RCS from Jakarta, many transgender individuals may be illiterate and would need assistance. Some RCSs and PIs thought that supervised use of self-tests in the home could be achieved with the aid of family members, partners, or even healthcare workers. Nevertheless, like their refusal to accept that people should self-test in public spaces, some HCWs disagreed that self-testing should require any aid from a third person who might then be unnecessarily exposed to the virus (i.e., in the event that the self-tester was infected with SARS-CoV-2).
Supporting the safe use of self-testing
As the risk of invalid results was voiced as a likely impediment for the HCW informants to recommend self-testing, it was suggested that staff from either private pharmacies or Puskesmas clinics could teach end-users how to use them. Correct usage could also be ensured, as per all groups’ suggestions, through education provided by village officers at the Rukun Tetangga-level and by other population-recognized experts, using a wide range of formats, including video tutorials which could be uploaded to YouTube-like platforms.
User instructions should be written in non-complicated vocabulary, in a legible font size, and be accompanied by easy-to-interpret pictorials. User instructions must be inserted in each self-testing kit, and they could include QR-code links to online tutorials. User instructions should be clear about the kit’s accuracy, how to use it, how to read the result, and what its expiry date and government license number is. Some RCSs also expressed that the instructions should indicate the risks involved in self-testing, in reference to the possibility of invalid results if the instructions are not properly followed. There was consensus that an explanation on what to do following the reading of the results should be a key component of the user instructions.
Reporting of a positive result could be done by going to any Puskesmas clinic, contacting the local COVID-19 Task Force, or using available reporting technology (e.g, hotlines, telemedicine, and tracing apps). A transgender RCS suggested that transgender individuals might report their results via trained community members, while some PIs suggested that some people might choose to report a result to their employer.
“Maybe you can use an application from the government that has been used, such as Peduli Lindungi. Report the results directly in the application. So, everyone who accesses the place can also be notified for the test.” Female, patient group leader, Jakarta
Despite their preference for facility-based post-test counseling only, a few HCWs discussed the role that the community-based Tim Reaksi Cepat (quick response teams) could play in ensuring linkage to care for those self-testing positive. Although technological aids such as telemedicine apps were suggested, a few urban RCSs expressed that some of these already available aids are not always user-friendly.
“Sometimes we get ping‑ponged at hotlines. Ee call but the person talking is not the person but the machine says: ‘Thank you for calling the hotline center. If you want to consult, please press 1.’ Then, asked to continue: ‘Press 6.’ [You] press 6 and later,: ‘Operator is busy, please wait.’” Male, trade union leader, Jakarta
To ensure linkage to care, some HCWs emphasized the importance of the self-test users’ “honesty”, while some RCSs mentioned the users’ “conscience”. However, there were also informants in all groups who recognized that fear of isolating, hunger, and poverty might be a more compelling factor than “honesty” and “conscience” for some asymptomatic individuals who receive a positive self-test result and who might feel that they could manage the infection on their own.
Taking action upon receiving a reactive self-test result for COVID-19
The psychosocial impact of a positive result may depend on the users’ understanding and awareness of both COVID-19 disease and the use of self-testing as a screening (not diagnostic, as per some HCWs’ opinions) tool. It was indicated that people could be either angry, in denial, worried about the result being false, afraid of being ostracized, or think that they will die soon. The HCWs thought that pre-test counseling on what to do in the event of receiving a positive result would be crucial to mitigate any such potentially harmful effects. Some PIs, emphasized that self-test users might be very concerned about how their neighbors and workmates would react. One female PI from Banten insisted that the impact may be dependent on the level of education and awareness among people in the users’ environment. This view was shared by one male PI from Jakarta, a trade union leader, who expressed that the impact in the workplace might be mitigated if there are no punitive measures in place against SARS-CoV-2-infected employees.
On the other hand, the same PI stated that users who receive a positive result may also “think positively” and immediately self-isolate, try to “evacuate” their family, and inform their neighbors and co-workers. Many RCSs also supported the idea that, if the level of awareness were high, many users would choose to self-isolate by themselves and try to obtain support from their nearest facility or via the COVID-19 hotline. One HCW stated that a factor that might encourage people to report a positive result might be the need to obtain medical clearance letter from their community leader:
“If you want to go back to work, you must have a certificate of completion of isolation issued by the government. If you don’t have that letter, you are not being allowed to work. And, if they don’t report at the beginning, for example, and suddenly they get healthy and ask for the letter, the health center won’t be issuing the letter: ‘We didn’t monitor you, why do you ask for an isolation completion letter?’” Male, occupational medicine specialist, Jakarta
Although the notion that positive actions following a positive result would depend on the awareness of the user and those in their environment was commonplace, this notion was not shared by all informants. There were voices in all groups who doubted that users would report a positive result due to them having financial worries. Even if users did not react badly to a positive result, concerns about the costs of healthcare or fear of losing their job might be an impediment to some reporting the result.
The informants indicated that reporting of a positive result could be done directly, by going to any Puskesmas clinic, contacting the local COVID-19 Task Force or designated village officers, or using available reporting technology (e.g, a website, a hotline, telemedicine, or tracing app). Alternatively, a transgender RCS from Jakarta suggested that transgender individuals might want to report a positive self-test result via trained, senior peer community members, while some PIs suggested that, if self-testing ever occurred in working environments, some people might choose to report a positive result with the aid of their employer.
“Maybe you can use an application from the government that has been used, such as Peduli Lindungi. Report the results directly in the application. So, everyone who accesses the place can also be notified for the test.” Female, tuberculosis youth group leader, Jakarta
For most HCWs, self-testing users who receive a positive result should go to their nearest testing site to receive a confirmatory diagnosis. Despite their preference for facility-based post-test counseling only, a few HCWs discussed the important role that community leaders who are members of community-based Tim Reaksi Cepat (quick response teams) could play in monitoring self-test users and in ensuring linkage to care for those self-testing positive. Although technological aids such as telemedicine apps or call centers were suggested as resources to assist with seeking linkage to care, a few urban RCSs expressed that some of these aids are already available and that they are not always user-friendly.
“Sometimes we get ping‑ponged at hotlines. Say, for example, we call but the person talking is not the person but the machine says: ‘Thank you for calling the hotline center. If you want to consult, please press 1.’ Then, asked to continue: ‘Press 6.’ [You] press 6 and later, there is an answer: ‘Operator is busy, please wait.’” Male, trade union leader, Jakarta
Irrespective of personal reactions to a positive result, a lack of awareness could also lead some individuals, especially those who feel healthy, to forgo preventive measures such as self-isolation, mask wearing, and social distancing. As with reporting the result, there were informants across all groups who mentioned that some individuals may not self-isolate due to economic concerns. As one informant put it: “They will die not because of COVID, but because they were hungry”. In some specific groups, such as the transgender community, self-isolation could be difficult due to the living conditions of some transgender individuals. There could be, allegedly, transgender individuals who would simply prefer to be isolated in a healthcare facility following a positive self-test:
“For transgender friends whose home environment is not adequate, it is better not to stay at home for self-isolation. A mechanism must also be considered so that they can do self-isolation in a health facility if there are no severe symptoms.” Trans-woman RCS, Jakarta
Challenges for self-isolation were anticipated, even for self-test users who would be willing to self-isolate. There was consensus that community support (e.g., providing three meals a day, contacting them via messaging apps, using telemedicine systems) may increase uptake and adherence to isolation.
In general, it was believed that people who received a positive result would warn their contacts. Informants explained that it was not uncommon for people in Indonesia to either announce their positive result through social media (e.g., Instagram) or inform village officials via WhatsApp about any infected household member. While there is a possibility that people using self-tests would use social media to let their close ones know that they should take a test, the fear of stigma, as per HCW and RCS narratives, would prevent many people from disclosing their infection.
“It’s because of stigma. If, for example, they found out one house is positive in the neighborhood… the treatment they get from their neighbor... especially if they sell something, maybe food. They tend to shut their mouth, because they are worried people won’t buy their food anymore.” Female, psychologist, Jakarta
Fear of pain from the procedure and a fear of shame when requesting self-tests were mentioned as potential barriers to demand for self-testing. Financial barriers, concerns about the kits’ authenticity and accuracy, and distribution issues (where to access the kits, especially for those in rural areas and islands) were mentioned as important barriers to demand that could be eliminated with good planning. It was suggested that HCWs be trained to teach people about self-tests; that self-tests be subsidized and made available at all Puskesmas sites; that the kits be packaged with proof of authenticity; and that 24-hour hotline be established. It was suggested that new government and Badan Pengawas Obat dan Makanan (i.e., National Agency of Drug and Food Control of Indonesia) regulations should be issued and communicated to healthcare workers at all levels, to enforce any actions needed to mitigate any barriers to demand.
The RCSs insisted that self-testing should be available in all pharmacies and that regulations on stockpiling, on distribution permits, and on medical waste management would be necessary. The PIs suggested that, to ensure wide distribution of self-tests, it could be helpful to capitalize on structures such as local women’s and neighborhoods’ associations, and COVID-19 Task Forces.
Demand barriers must be tackled if Indonesia is to encourage the general population to serially self-test. To facilitate serial self-testing, some HCWs suggested that self-tests be incorporated into screening programs at Rukun Tetangga and Rukun Warga-levels, and be provided in schools and workplaces. Most PIs supported self-testing in the workplace. However, for at-work serial self-testing to be feasible, a few PIs indicated that regulations would be needed to guide their use by small-scale private companies. It was also noted that companies will need to enforce policies to protect people from being fired if they self-test positive.