Introduction Optimal pharmacological treatment of tuberculosis (TB) requires a multidisciplinary team, yet the hospital pharmacist’s role is unclear. We aimed to analyse hospital pharmacist-provided clinical pharmacy services (CPS) implementation in TB care.
Method A nationwide survey-based online cross-sectional study was conducted on hospital pharmacists in Indonesia from 1 November 2022 to 22 November 2022. Outcomes were the extent of pharmacists’ involvement in multidisciplinary TB care, TB-related CPS provided and views on TB-related CPS. The probability of pharmacists’ involvement in multidisciplinary TB teams was assessed using logistic regression.
Results In total, 439 pharmacists (mean age 31.2±6.22 years, 78% female) completed the survey. Thirty-six per cent were part of multidisciplinary TB care, and 23% had TB-related tasks. Adherence monitoring (90%) and drug use evaluation (86%) were the most conducted TB-related CPS. Pharmacists’ views on TB-related CPS implementation were generally positive, except for financial incentives. Work experience (OR 1.99, 95% CI 1.09 to 3.61), ever received TB-related training (OR 3.51, 95% CI 2.03 to 6.14) and specific assignments to provide TB-related CPS (OR 8.42, 95% CI 4.99 to 14.59) significantly increased pharmacist involvement in multidisciplinary TB care.
Conclusion Around one-third of hospital pharmacists are part of multidisciplinary TB care, with medication adherence and drug use monitoring as primary tasks. Pharmacists’ experience, training, assignment to provide TB-related CPS and financial incentives are key elements for further implementation in multidisciplinary TB care. Pharmacists should proactively support current TB care and conduct operational research, sharing data with healthcare peers and fostering a collaborative multidisciplinary TB care team.
- Surveys and Questionnaires
Data availability statement
Data are available on reasonable request. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to security and privacy concerns.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Patient-centred tuberculosis (TB) care is the first pillar of the End TB strategy, yet its implementation requires further improvement, especially in TB-related clinical pharmacy services. Despite its potential benefit in TB care, we do not yet have a comprehensive description of TB-related clinical pharmacy services’ implementation in Indonesia.
WHAT THIS STUDY ADDS
This study provides structured evidence of the pharmacist’s role and involvement in TB care through clinical pharmacy services by using a standardised framework to capture current TB-related clinical pharmacy services and factors related to their implementation.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study underlines the need for clinical pharmacy services in multidisciplinary TB care, specifically medication safety and adherence related activities. However, their impact remains limited, with currently only one-third of pharmacists involved and lack of adequate financial incentives. Further studies should explore clinical pharmacy service’s role in TB care through randomised trials. In addition, pharmacists should proactively support TB care and conduct operational research, sharing data with healthcare peers and fostering a collaborative multidisciplinary TB care team.
Tuberculosis (TB) is a disease of global concern, affecting about 10.6 million people. Despite the pandemic, in 2020, the global treatment success rate of those who started using first-line anti-TB was unchanged compared with 2019, at 86%.1 However, it was still below the End TB strategy target of a minimum 90% success rate,2 which is also the case in Indonesia.3
In improving TB treatment success rates, patient-centred pharmacological TB care is one of the key prerequisites.2 Clinical pharmacy services (CPS) encompass patient-focused and direct engagement activities with patients to achieve optimal drug outcomes within a multidisciplinary healthcare team.4 Notably, proper use of anti-TB drugs is a significant predictor of successful treatment outcomes.5 Potentially, CPS could result in better adherence, improved quality of life and less therapeutic failure.6
When delivering patient-centred TB care through CPS, understanding patients’ needs is vital to building engagement between patients and healthcare providers.7 8 In addition, public–private healthcare providers’ partnerships within the National Tuberculosis Programme are crucial for improving service capacity in diagnosing, treating and monitoring TB patients across the different continuums of care.9
Time, people, organisational/structural conditions, pharmacist competence and communication are related to CPS implementation.10 Moreover, external factors such as policy, regulations, resources to implement CPS, and expectations towards and attitudes of pharmacists affect service uptake.11
In Indonesia, TB care is formally institutionalised with additional specific guidelines highlighting the pharmacist’s role in screening, medication adherence and drug-related problem monitoring.12 13 However, amidst the increasing uptake of CPS in Indonesia, the extent of its implementation in multidisciplinary TB care is still unclear since it requires both behaviour changes of pharmacists and organisational changes. This study aims to identify current TB-related CPS in Indonesia and factors related to its implementation in multidisciplinary TB care from a hospital pharmacist’s point of view.
Materials and methods
A nationwide cross-sectional online survey targeting pharmacists in a hospital across Indonesia was reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist (online supplemental appendix table 1).14 Of the total 10 505 hospital pharmacists in Indonesia by July 2022 (www.apoteker.or.id), based on the Yamane equation15 to calculate the minimum sample size, with a 95% confidence level and a 5% error margin, at least 388 hospital pharmacists as respondents were required (online supplemental appendix section 2).
Hospitals in Indonesia are categorised from A to D based on the number of beds and the accreditation level of their services. Within the accreditation scheme, Paripurna has the highest accreditation level for quality of service, of which pharmaceutical services are a part.16
The survey was conducted using a questionnaire that was divided into four sections: (1) hospital characteristics, (2) pharmacist characteristics, (3) CPS characteristics and (4) pharmacists’ views on the barriers or facilitators of TB-related CPS implementation. Both English and Indonesian versions of the questionnaire were available for the respondents. A literature study on implementation research and its related factors resulted in two relevant frameworks for questionnaire development: the Consolidated Framework for Implementation Research (CFIR)17 and the Attitudinal, Political, Technical and Administrative (APOTECA) framework.18 CFIR is a general framework to identify and understand key elements of implementing an intervention, including constructs and domains related to the intervention, while APOTECA is specific to CPS implementation.
The outer setting, inner setting, intervention and individual characteristics from CFIR were used as the main domains. Outer setting is where the inner setting exists, for example, country or province. Inner setting is where the CPS is implemented, for example, hospital. Intervention characteristic is related to the CPS being implemented. Individual characteristic is the role and characteristic of the individual implementing the CPS.17 19
The CFIR domain was further explained by the corresponding domain and factors from APOTECA, providing details of common barriers or facilitators regarding CPS implementation. Operationalised statements in the questionnaire inquiring about pharmacists’ perspectives on the identification and availability of factors contributing to CPS implementation were developed based on the guiding questions from CFIR (www.cfirguide.org).
First, face validity, which refers to the questionnaire’s appropriateness, sensibility and relevance, was assessed.20 A committee of hospital pharmacists conducted a face validity assessment to ensure questionnaire items sufficiently represented CPS implementation factors in the hospital, with minor adjustments on the readability. Subsequently, pilot testing of the revised questionnaire was done by 21 hospital pharmacists, complemented by reliability testing. The reliability test of the questionnaire resulted in an adequate internal consistency in each domain with Cronbach’s α of 0.722, 0.742, 0.903 and 0.775 for outer setting, inner setting, intervention and individual characteristics, respectively (online supplemental table 2).
The final questionnaire consisted of 55 items divided into four sections (online supplemental appendix section 4). Section 1 included hospital characteristics: type, ownership, class, accreditation status and location. Section 2 covered pharmacist characteristics: gender, birth year, academic degree, work experience and TB training. Section 3 specified the CPS: TB specialty polyclinic, specific assignment to TB-related CPS and CPS characteristics (recipient, clinical data source, focus and activities). Section four covered pharmacists’ views on the outer setting, inner setting, intervention and individual characteristics affecting CPS implementation in multidisciplinary TB care.
The open survey was initiated via the Indonesian Pharmacist Information System (SIAP) (www.apoteker.or.id). SIAP is a system that facilitates Indonesian pharmacists’ administrative and continuing development management. While the website and the survey link were publicly visible, the visitors and targets were mainly pharmacists who could log in to the system using their accounts to record their participation in the survey.
The open survey link was also distributed through social media, for example, WhatsApp and Instagram (https://www.instagram.com/p/Ck0W8G_p1Px/). In increasing the response rate, periodic reminders through social media, direct mail, or personal contact and communication were conducted.
The survey was conducted from 1 November 2022 to 22 November 2022, using Qualtrics (www.qualtrics.com). To protect the privacy of respondents, the survey was distributed using anonymised link without tracking, either by using cookies or IP address. After 24 hours, the link expired, and the device initially used to access it was restricted to avoid duplicated filling. Further, conditional questions were provided to ensure only hospital pharmacists completed the survey. Pharmacists submitted their survey completion proof through their SIAP account, and then the researcher manually verified the pharmacists’ survey completion in the system based on the submitted survey data. Based on the Indonesian Pharmacist Association (www.iai.id) regulations, pharmacists’ participation in research contributes to knowledge development, and therefore, they could earn credit points as part of professional development. Credit points were attributed on successful validation. Specific credit point designation related to this study is stated in online supplemental appendix section 5.
The primary study outcomes were (1) hospital pharmacists’ involvement in multidisciplinary TB care, (2) TB-related CPS provided, (3) hospital pharmacists’ views on TB-related CPS and (4) facilitators for the involvement of hospital pharmacists in multidisciplinary TB care.
Data analysis was performed by using R (https://www.r-project.org) V.4.2.2. The psych package was used for the reliability test to identify Cronbach’s alpha (should be >0.70 for a sufficiently reliable item).21 For descriptive analysis, numerical data were presented as means and SD, and categorical data as numbers and percentages. Pharmacists’ view on the factors affecting CPS implementation in multidisciplinary TB care that is based on a Likert scale is presented in a figure, where the percentage value represents total disagreement (sum of strongly disagree and disagree), neither agree nor disagree and total agreement (sum of agree and strongly agree).
Logistic regression was conducted to assess the probability of hospital pharmacists being part of multidisciplinary TB care based on an optimal probability cut-off value. The optimal probability cut-off value was determined to balance the true positive rate (proportion of actual pharmacists as part of multidisciplinary TB care that was correctly predicted as such) and the false positive rate (proportion of actual pharmacists not as part of multidisciplinary TB care that was predicted as part of multidisciplinary TB care).
Preliminary steps were completed to ensure data suitability for logistic regression before the final analysis. (1) A baseline model was built, then the colinearity of continuous independent variables was assessed based on a colinearity matrix (online supplemental table 3), a scatter plot of colinearity (online supplemental figure 1) and the variation inflation factor (online supplemental table 4). Then, baseline model accuracy was calculated based on the number of hospital pharmacists participating in multidisciplinary TB care (online supplemental table 5). (2) The data were split into training and test data. Then, the training model was created using training data. The performance of the training model based on test data, with a baseline cut-off value of 0.5, was obtained (online supplemental table 6). (3) Using the baseline model, a receiver operating characteristic curve was created to determine the best cut-off value using the test data (online supplemental figure 2). (4) The performance of the training model based on test data (online supplemental table 7) and the baseline model based on complete data (online supplemental table 8) with a best cut-off value of 0.63 were obtained. The performance of each model is described in online supplemental table 9. (5) With the best cut-off value, the linear relationship analysis figures between any continuous independent variables and the logit transformation of the dependent variable were created (online supplemental figure 3). (6) The final model was built using the best cut-off value; its performance is shown in online supplemental table 10.
Simple logistic regression was then performed, followed by multiple (backward) logistic regression to assess variable importance and selection based on the optimal probability cut-off value of 0.63, with a significance level of p<0.05. A crude OR (cOR) is presented for simple logistic regression analysis, and an adjusted OR (aOR) is for multiple (backward) logistic regression analysis. See online supplemental appendix section 6 (logistic regression) for details on logistic regression variables and model selection.
In total, 2424 people accessed the survey link, of which 1473 responded, and 976 participated. Of those, 577 were hospital pharmacists (5.5% of all hospital pharmacists in Indonesia), and 439 hospital pharmacists providing TB-related CPS completed the survey (online supplemental figure 4) from different areas across Indonesia (online supplemental figure 5). Pharmacists’ characteristics are provided in table 1.
Around three-quarters of hospital pharmacists were female, and the mean age was 31.2±6.22 years. They graduated 6.5±4.28 years ago and had 3.5±3.31 years of working experience in a hospital setting. Mainly, they worked in a hospital with a Paripurna (or equivalent) accreditation status, equipped with a TB specialty polyclinic, located mostly in Java and Jakarta provinces (online supplemental table 11). However, almost 80% never had TB-related training and were not specifically assigned to provide TB-related CPS. Around 36% of them were part of a multidisciplinary TB care team.
TB-related CPS activities provided by hospital pharmacists
When providing TB-related CPS, patients, nurses, patient support (medication use supervisors) and physicians were the recipients who mostly interacted with the pharmacist, using medical records, laboratory test results and TB registration records as the primary sources of clinical data information. Medication safety and adherence were the focus of CPS, conducted by more than 90% of the pharmacists, with adherence monitoring and drug use evaluation as the two most conducted activities (table 2).
Hospital pharmacists’ views on TB-related CPS
Pharmacists generally agreed that external grants/incentives, policies and standards supported TB-related CPS implementation, but there was less consensus regarding the supportive role of external grants/incentives, around 67%–72%, compared with the other factors, around 85%–94%. See online supplemental table 12 and figure 6 for further details on hospital pharmacists’ views related to the outer setting.
Within the inner setting, there were many factors associated with TB-related CPS. Most pharmacists agreed that adequate provisions existed for budgeting, prioritisation, responsibility, technology, autonomy, infrastructure, human resources, information access and the TB-related CPS process. However, 33%–35% of pharmacists expressed disagreement on the appropriateness of financial incentives for the services provided by the pharmacist (figure 1). See online supplemental table 13 for further details on hospital pharmacists’ views related to the inner setting.
Most pharmacists agreed that TB-related CPS implementation was based on current scientific evidence. However, just over half viewed that CPS was implemented within a sufficient time frame and was easy to implement (54%), and a slightly higher percentage of pharmacists viewed that CPSs are easy to implement (54%–61%). See online supplemental table 14 and figure 7 for further details on hospital pharmacists’ views related to the intervention characteristics.
On average, 80% or more of pharmacists agreed that they were supported by other healthcare professionals and felt that they had the necessary experience, skills, knowledge, competence and motivation to deliver effective TB-related CPS. See online supplemental table 15 figure 8 for further details on hospital pharmacists’ views related to individual characteristics.
Proportion of hospital pharmacist involvement in multidisciplinary TB care
In group comparisons (table 3), a significant difference was observed in the proportion of pharmacists who participated or did not participate in a multidisciplinary TB care team based on whether they ever received TB-related training (p<0.001), hospital accreditation (p=0.041), having a TB specialty clinic in their hospital workplace (p=0.003) and specifically assigned to provide CPS for TB care (p<0.001).
The number of years after graduating and working in the hospital was not a significant factor in group comparisons; however, in simple logistic regression analysis, ‘5–9 years after graduating’ (cOR 1.59, 95% CI 1.02 to 2.48) and ‘5–9 years of work experience’ (cOR 1.78, 95% CI 1.07 to 2.94) significantly predicted pharmacists’ involvement in multidisciplinary TB care. Furthermore, ‘ever received TB-related training’ (cOR 4.36, 95% CI 2.70 to 7.150), ‘working in a Utama-accredited hospital’ (cOR 0.29, 95% CI 0.09 to 0.65), ‘having a TB specialty clinic’ (cOR 1.94, 95% CI 1.28 to 2.99) and ‘specifically assigned to provide TB-related CPS’ (cOR 9.32, 95% CI 5.67 to 15.76) was associated with the probability of being involved in multidisciplinary TB care.
Multiple (backward) logistic regression was performed to determine the most influential factors that predicted pharmacists’ involvement in multidisciplinary TB care. Non-influential factors in multiple logistic regression are omitted, and no aOR value is presented. The results showed that ‘5–9 years of work experience’ (aOR 1.99, 95% CI 1.09 to 3.61), ‘ever received TB-related training’ (aOR 3.51, 95% CI 2.03 to 6.14), ‘working in a Utama-accredited hospital’ (aOR 0.24, 95% CI 0.07 to 0.68) and ‘being specifically assigned to provide TB-related CPS’ (aOR 8.42, 95% CI 4.99 to 14.59) were the most influential (table 3).
Around one-third of hospital pharmacists were involved in multidisciplinary TB care, and one-quarter had TB-specific tasks. Most hospital pharmacists were female, young professionals in an early-to-middle career stage, working in a hospital of the highest accreditation with specialty TB polyclinics. Most TB-related CPS was directed at patients, followed by patient support (medication use supervisor) and other healthcare professionals (nurse, physician). TB-related CPS mainly focused on medication safety and adherence. Pharmacists’ views on TB-related CPS implementation factors were generally positive, except for financial incentives. Mid-range career experience, ever-received TB-related training, working in a mediocre accredited hospital and specific assignments to provide TB-related CPS significantly predicted pharmacists’ involvement in multidisciplinary TB care teams.
In Indonesia, CPS implementation and development is still in its early stages,22 especially for TB with a patient-centred multidisciplinary care model. Thus, our finding of the low involvement of pharmacists in this type of care is plausible. A national study showed that young female pharmacists are more likely to engage in patient-centred activities,23 which might be the case for TB care, as we also found a higher proportion of young females (in their 30s) than male pharmacists working in hospitals, that is in line with that study.
Many factors determine the TB care process and outcomes. Non-adherence to treatment is a significant factor causing inadequate drug effectiveness and adverse reactions, leading to drug resistance.24 25 Pharmacist intervention through CPS can address these issues,25–28 but its implementation is challenging18 and requires a comprehensive and collaborative approach focusing on the unique traits of each patient.2 7
Despite the limited number of patients receiving collaborative TB care,9 we found that patients were the most likely to receive CPS, indicating their high involvement with pharmacists, and this could improve TB understanding and the quality of care,29 30 motivating them to adhere to their treatment.31 However, our study did not elaborate on the relationship between greater involvement, better engagement and treatment outcomes.
Drug effectiveness is determined by its bioavailability, predicting TB treatment outcomes,5 which can be maintained and improved by adhering to the medication. Directly observed therapy), or supervised medication administration, is one of the strategies to enhance TB medication adherence. Supervised medication administration by non-healthcare professionals with adequate health education positively influences TB patient outcomes.32 Our findings highlight the role of CPS in supporting non-healthcare professionals, as indicated by the high number of medication-use supervisors receiving CPS.
Aside from the patients themselves, healthcare professionals have a pivotal role in TB treatment initiation and adherence.33 Nurses who clinically manage patients have a higher engagement with patients than pharmacists. Improved knowledge of medication preparation and administration errors of nurses would increase patients’ safety, averting undesirable effects of medication administration.34 While collaborative pharmacist-nurse medication adherence interventions are limited, our study found that nurses were the healthcare professionals who mostly received CPS. Educating patients about TB care and medication by nurses significantly improves adherence and quality of care31; hence, high pharmacist interaction with nurses through CPS can facilitate the transfer of drug-related knowledge that benefits patients.
Physicians, the primary persons responsible for TB patient care, often need to share their duties with pharmacists and nurses,35 but their interactions with pharmacists are slightly different compared with other recipients of CPS. Physicians need pharmacists to be more proactive within their scope of expertise and open communication related to patient care when necessary.10 36 37 Due to this type of interaction, our study found lower physician involvement as a recipient of CPS. However, this does not warrant lower engagement quality because physicians acknowledge pharmacists’ role in patient care.38
The pharmacist’s perceived and actual role is partially defined by their clinical and communication skills, which remain significant obstacles across various disease conditions,10 39–41 as might be the case in TB care. Therefore, despite pharmacists’ positive views and other healthcare professionals’ acknowledgement of their capacity for effective TB care, only a limited number of pharmacists had a specific TB-related CPS assignment or were part of multidisciplinary TB care teams, as seen in this study. Although policies, infrastructure and quality care are in place, this gap persists and suggests that pharmacists’ competencies have not yet been translated into added value in the TB care process.
The TB-related CPS emphasises medication adherence and safety, as per current policies and guidelines,2 7 since poor medication adherence and adverse drug reactions are still prevalent24 32 42 43 and must be addressed. Non-adherence to TB medication negatively affects health outcomes and costs; hence, implementing cost-effective adherence interventions is necessary for successful outcomes.42 We found that adherence monitoring was a top priority in TB-related CPS. Notably, digital adherence technologies (DAT) increasingly support adherence interventions in TB.44 45 Besides monitoring and supporting adherence directly, combining DAT with therapeutic drug monitoring (TDM) could further aid personalised TB care.46 47 The latter, TDM, was not part of the top listed CPS activities in Indonesia; only drug therapy monitoring was more of an activity to ensure safe, effective and rational drug therapy for patients, not specifically assessing blood drug concentration. However, TDM uptake by hospital pharmacists is increasingly acknowledged globally as part of optimal TB drug dosing.48
Regarding medication safety, we found that drug use evaluation is essential for monitoring adverse events and vital to TB care success,49 which indicates CPS activities are done according to the evidence that despite the proven effectiveness and safety of the WHO standard regimen,50 with possible drug resistance occurrence,24 close monitoring of adverse events43 is needed through drug use evaluation.
Regarding healthcare services provided in a regulated setting like a hospital, accreditation status indicates its quality and patient safety, whereas specialised healthcare services are available in a higher accredited hospital.51 A higher level of accreditation does not necessarily predict pharmacist involvement in TB care. The availability of general services also plays a role, as most TB cases are typically less severe3 and preferably managed through general health services.2 We found that a higher accredited hospital may have lesser predictive value for pharmacist involvement in multidisciplinary TB care, especially for moderately accredited hospitals, due to the balance between specialised and general service availability.
Additionally, financial incentives adequacy is essential and may improve professional practice when providing CPS.52 While it is true that providing clinical and non-clinical services is part of the standard services by the pharmacist,53 with an immature professional recognition system,54 augmented by variability in the remunerated service, patient eligibility and fees, making standardised financial incentives difficult, despite growing financial support.55 The inadequacy is stressed by our finding, where perceived financial incentives still lag, even with presumably supportive policies, infrastructure, quality care and self-competence of the pharmacist.
Our study showed that higher working experience is an added value for healthcare professionals, especially for pharmacists involved in TB care, which is best at the mid-range level. We argue that they are technically involved with patient services and can simultaneously manage TB cases. Apart from work experience, competence in TB care is built through technical and managerial knowledge, which can be obtained through education and training.56 Unfortunately, our study showed that most pharmacists had limited TB-specific training; this could undermine the TB care process. Though this study showed fewer pharmacists ever receiving TB-related training, the TB-related training and specific assignment to provide TB-related CPS determine pharmacists’ involvement in multidisciplinary TB care. They are greatly affected by pharmacist competencies through education and training.57
Several strengths and limitations should be noted. A strength was the nationwide survey in Indonesia based on the sampling adequacy and participating pharmacist workforce proportion.23 The survey was extensively validated and reported according to the CHERRIES checklist.
We applied a strict rule on the online survey based on the device identity and idle time to avoid duplicated participation; hence, when the survey was accessed and started but not completed within 24 hours, it could not be reaccessed from the same device (based on cookies) and considered incomplete. While we targeted hospital pharmacists, the announcement was received by all pharmacists within the SIAP. With further filtering questions in the questionnaire, hospital pharmacists’ who provided TB-related CPS as a participant was ensured. A limitation is that it is self-reported and an internet-based survey; hence, it relies on participant access and customary internet use. This could result in some institutions having many hospital pharmacists responding and fewer in other institutions. However, a limited response rate does not necessarily increase the selection bias level,57 though the generalisability of results needs further study.
To further strengthen multidisciplinary TB care, several recommendations can be made. First, hospital pharmacists will benefit from additional TB training. Second, proper financial incentives should be provided. Third, the commitment of the local leaders to encourage and assign CPSs in TB is essentially needed. Finally, more evidence is needed on the added value of hospital pharmacists’ involvement in TB care and the effectiveness of the TB-related CPS itself.
Around one-third of hospital pharmacists are part of multidisciplinary TB care, with medication adherence and drug use monitoring as primary tasks. Pharmacists’ experience, training, assignment to provide TB-related CPS and financial incentives are key elements for further implementation of hospital pharmacists in multidisciplinary TB care. Pharmacists should proactively support current TB care and conduct operational research, sharing data with healthcare peers and fostering a collaborative multidisciplinary TB care team.
Data availability statement
Data are available on reasonable request. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to security and privacy concerns.
Patient consent for publication
This study involves human participants ethical approval for the study was obtained from the Research Ethics Committee of Universitas Padjadjaran Bandung, number 955/UN6.KEP/EC/2022. Informed consent was obtained from all subjects involved in the study. Participants gave informed consent to participate in the study before taking part.
The authors would like to acknowledge the contributions of The Indonesian Pharmacist Association (IAI) for their assistance, support and collaboration during various stages of this research project. Their expertise and valuable insights significantly contributed to the success of this study.
Contributors Conceptualisation, DI, MJP and JFMvB; methodology, DI, ISP, MJP and JFMvB; software, DI; validation, DI and AA; formal analysis, DI; investigation, DI and AA; resources, MJP; data curation, DI; writing—original draft preparation, DI; writing—review and editing, ISP, MJP and JB; visualisation, DI; supervision, MJP and JFMvB; project administration, DI and AA; funding acquisition, DI and MJP All authors have read and agreed to the published version of the manuscript. Guarantor, DI.
Funding This study was funded by a scholarship to DI provided by the Directorate General of Higher Education, Ministry of Education, Culture, Research and Technology of the Republic of Indonesia.
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