Bridging medical doctors' education and population health needs to address health disparities in Indonesia

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This study aims to assess the current understanding and perspectives on public health skills and competencies among doctors in remote areas. A total of 93 participants in six remote districts participated in this study which used a rapid assessment procedures approach and focuses group discussion method. Overall, we found that current medical students should have both the medical skills and the ability to work within the local sociocultural context. The ability to early detect diseases and disaster mitigation is also needed. The findings suggest doctors have adequate health program management capabilities to provide recommendations in the formulation of local health policies. Therefore, educational institutions must develop sustainable strategic human resources according to regional characteristics for health across Indonesia. Keywords Keywords: health disparities, public health competence, rural doctor, Indonesia Introduction Consistent availability and adequate doctors are important for health equity as these enhance access, quality, and equity of health care [1–3]. However, the distribution of doctors alone is not sufficient to improve overall health access and equity without a strategic effort to strengthen doctors’ competencies and skills in adapting to the dynamic needs of localized health care systems and populations [4,5]. Currently, the diversity in contexts such as demographic characteristics of the populations, geographic areas, health systems, disease patterns, and social determinants related to access to health care remain challenging for both high-income countries (HICs) and low and middle-income countries (LMICs) [6,7]. However, the education pipeline to produce doctors with the required skills to effectively provide medical care within these disparate contexts is suboptimal for medical graduates in the context of LMICs [8]. For example, in Indonesia, there are 12,000 medical student graduates annually, but it is estimated that 513 community health centers ( Puskesmas) with no doctors at all, especially in disadvantaged areas, borderlands, and outer islands which are also known as Daerah Tertinggal, Perbatasan dan Kepulauan (DTPK) [9]. This situation is due to the unpreparedness of doctors to deal with complex health problems in the context of DTPK areas [9]. The role of educational institutions, therefore, must aim to train and produce more doctors who are adequately prepared with the knowledge and skills to identify and address local health needs, especially in the DTPK areas [10]. Previous studies in both HICs and LMICs have shown that doctors who are trained in skills for rural medicine, particularly in work with limited facilities and resources, are more likely to remain working in remote locations [11,12]. Public health curricula and community placements have been implemented as the general strategy by medical schools to educate their students on the needs of local populations' health issues [13]. Providing a public health curriculum aimed at rural health knowledge and skills can strengthen the awareness of medical students by promoting a view of health that includes the clinical and social determinants of health, well-being, disease, and disability, and the multidisciplinary and cross-sectoral interventions and policies needed to address these issues in the community [14–16]. However, implementation of such a public health curriculum has been limited, primarily focusing on generalized cognitive aspects of knowledge acquisition, neglecting affective and skill domains tailored to addressing disease contexts and risk factors in the local community [17]. In addition, the influence of social determinants on health status has been neglected despite that social factors are the root cause of many complex health problems [18,19]. Since 2020, the Ministry of Health (MoH) of Indonesia has established a human resource for health transformation policy intending to ensure health care workers are evenly distributed around the country, including in the DTPK areas. However, the existing geographical barriers makes the DTPK areas difficult to reach, and less attractive to doctors for living and working due to difficulties in obtaining essential commodities and the presence of unstable security situations, problems with the production of adequately training doctors to persist [20,21]. In addition to. Another critical issue is the orientation of medical education is predominantly hospital-based rather than focused on outpatient primary health care [21]. Although the strategy to intensify equitable distribution of doctors by recruiting students from remote areas and with rural backgrounds is considered successful in diminishing maldistribution, it does not guarantee young doctors’ readiness to work in remote and rural Puskesmas in their native place of origin [21,13,23]. This scarcity in terms of both quality and quantity has implications for the uneven capacity of the health care system in Indonesia [24]. In addition, conditions of social determinants of health vary between regions in Indonesia, so enhanced training for the development of skills targeted to the needs of local populations is necessary [25]. However, the specific information on the local context needed for better rural health training programs is limited and fragmented. Therefore, there is a need to assess public health skills and competencies among doctors in the DTPK areas . This study aims to assess the current understanding and perspectives on public health skills and competencies among doctors in the DTPK areas. Methods Study Design and Theoretical Framework This study used a rapid assessment procedures (RAP) approach and the qualitative focus group discussion method to explore the perceptions of rural doctors, local health policymakers, district health officers, remote and rural health workers, and community members about the required knowledge and skills for doctors to successfully practice in remote areas of Indonesia, particularly in the DTPK areas. RAP is a method for generating rich information in a short period [26]. Our design process was guided by Miles and Hubermas's quality standards for qualitative research [27] as well as COREQ reporting standards for qualitative research [28]. Ethical clearance was obtained from the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito General Hospital, and the number of the ethical clearance was KE/FK/0989/EC/2020. Verbal consent was received from participants prior to the initiation of group discussion activities. We adopted the Solar and Irwin [29] framework of social determinants of health to the context of our study characterized by underdeveloped areas, country borders, and remote islands, to consider geographic and topographical issues as well as social, economic, and political factors that result in persistent lack of health care access and poor health outcomes for rural populations. Study Setting The research was conducted in six districts representing the Daerah Tertinggal, Perbatasan dan Kepulauan (DTPK) areas. We used the definition of the underdeveloped area as districts that are less developed than other regions on a national scale and whose population public health development index is relatively less than one (< 1) [30]. The border area is part of the territory of the country which is located along the Indonesian border with other countries. Meanwhile, island areas are the outermost small islands with a population without adequate health care access. Sample and Recruitment We used purposive sampling [31] to select districts in which to collect data by considering regional representation, with the final selection of the Central Sumba, Serdang Bedagai, South Minahasa, North Minahasa, Ketapang, and Bengkayang districts for data collection. After we received a permission letter from the targeted government, we set an approved schedule for focus groups and field visits. Focus group participants were purposively recruited to include local stakeholders who have the main responsibility in human health resources policy development (e.g. for the formulation, development, implementation, monitoring, evaluation, and recruitment), consisting of the Regent, District Development Office ( Bappeda) , District Health Office, Hospital Director, Puskesmas , General Practitioners, health care workers (doctor, nurse, midwife, public health, surveillance staff), and community health workers. The criteria for recruiting focus group discussion (FGD) participants are presented in Table 1 . Table 1 Considerations in selecting FGD participants Actor Description Policy Maker The administrative leader or staff who is responsible for the formulation of policies and regulations relating to or affecting the health care system in their district District Health Officer The Health Officer is responsible for developing strategic planning, especially related to the management of health human resources in the district Secondary Health care facility staff Health Service Facilities are places used by the government and the community to provide health service activities, including promotive, preventive, curative, and rehabilitative services. Puskesmas staff Health workers are defined as public employees involved in the delivery of primary health care consisting of doctors, nurses, midwives, community health workers Community Health Worker (CHW) Health workers in the village are also invited as policymakers and not in community groups because they are part of the cross-sector in the district [insert Table 1 here] The FGD sample was recruited by considering potential participants’ institutional affiliation and geographic distribution. We sent an invitation letter to participate in the FGD through the official email of the government. Invitation letters for health care facilities were sent directly to the selected facilities assisted by local stakeholders. For CHWs, invitations were sent to those who are members of organized community groups such as the village health center and cadre. FGD Procedure The group discussion was carried out through separated the groups by the following factors the first with the local government and the health office, the second with the remote, borderland, and island Puskesmas to elicit specific information about their perspectives on the public health skills and competencies among doctors, and insights about the condition of health care services at the same time. The FGD question guide included questions that addressed participants’ perceptions of the skills, performance, and non-medical factors such as social determinants of health and health program. See Table 2 . [insert Table 2 here] Table 2 Focus Group Discussion Guide Questions Item Description Health Human Resources Policy dan strategic planning • What kind of doctor graduates are needed by the community in your location? • What are the important or special skills needed by a doctor to be ready to work in your location? • So far, have the skills of the doctors been able to meet the needs of medical and preventive services for the community? • What is your suggestion for a medical graduate institution education to be in line with the needs of the community in your location? Health service delivery, community health services • What additional skills need to be trained for doctors to adapt to local wisdom in inpatient and community care? • What are the non-medical factors that serve as a barrier for the community to reach health services? FGD sessions were moderated by a project team member and lasted between 60 and 80 minutes. FGDs were audio recorded after receiving permission from participants. The first author (PHS) facilitated FGDs in three districts, the fourth author (APS) facilitated FGDs in one district and the other FGDs in two districts were facilitated by trained facilitators. Data Analysis Audio recordings were professionally transcribed. We used Solar and Irwin's [29] framework to guide how we developed the codes and categories. In stage one, we conducted an inductive thematic analysis. PHS coded all FGD transcripts using open coding. PHS, JP, and APS independently read the transcripts and supporting quotations to increase analysis accountability. Through discussion, the researchers then grouped these inductively identified coded segments into larger categories according to the requisite skills of doctors in DTPK areas . Therefore, in the second stage of the analysis, we used interpretive analysis to categorize the focus group data according to social determinants of health framework and doctors’ skills domains. All transcripts were discussed repeatedly among the authors. We compared the coded transcripts of FGD results from each district to identify areas of overlap and divergence. AM (a national health workforce expert), reviewed the analysis documents to ensure there was no duplication of data and that all categories and sub-themes were relevant to public health skills and competencies. PHS, JP, and APS then translated all the code transcripts and all the selective quotes from Indonesian to English. In the next stage, the final manuscript was reviewed by REG (a medical anthropologist). Results We conducted 12 FGDs and the number of participants was about 5–8 participants for each group per district. A total of 93 individuals participated in a focus group: 4 policymakers, 36 district health officers (leaders and staff), 3 hospital representatives, 42 Puskesmas staff (doctor, nurse, midwife, public health, surveillance staff), and 8 community representatives. [insert Table 3 here] Table 3 Focus Group Participant Characteristics Demographics Number Gender Male 40 Female 53 Organization Executive/Health Regulator 4 District Health Office 36 Public and Private Hospital 3 Puskesmas and Puskesmas pembantu 42 Community 8 Main expertise and skill District Health Policy 6 District Health Strategic Planning 6 Health Workforce Management 12 Health Service Management 10 General Practice 7 Diseases Control and Prevention 7 Rural Health 37 Community Mobilization 8 Three main topics emerged from the framework analysis such as disaster mitigation planning and health security; practicing health programs management; and connecting evidence to decision-maker and effective advocacy. Disaster Mitigation Planning and Health Security Natural and non-natural disasters such as disease outbreaks result in the DTPK population’s need to develop resilience and strategies for adequate mitigation and response to these threats. Participants revealed that disasters such as floods and forest fires often hit certain areas in the region. Floods due to excessive rainfall during the rainy season were isolated in several areas so that Puskesmas doctors or staff did not refer patients living in those areas to hospitals. Therefore, doctors working in these remote areas need skills to both to respond to emergencies and advocate for disaster mitigation before emergencies occur. There are three Puskesmas in a remote and isolated area that fall into the very remote category, namely Puskesmas Lembah Bawang, Siding Health, and Suti Semarang. During the rainy season, they find it difficult to refer those patients due to the flooding that isolates and blocks the transportation routes from their place… ... smog due to forest fires often occurs every year … doctors must be prepared in any situation so they must be involved in disaster mitigation in the places where they work Most participants also said that borderland areas are vulnerable to becoming an entry point of disease importation and transmission, which increases the risk of disease outbreaks and pandemics. Our territory is located in the borderland area. However, the disease surveillance capacity in the borderland area is less effective...there has been local transmission caused by imported cases but underreported… Furthermore, participants recommended that prospective doctors in DTPK areas should be taught relevant knowledge related to disease surveillance systems in borderlands. Several imported cases were not recorded in our surveillance monitoring systems... so the doctor should be able to evaluate when the surveillance system does not work properly. Practicing Health Programs Management Participants said doctors should also be trained in health program management since most health service activities at the Puskesmas -level are health programs. We hope that educational institutions facilitate medical students to be exposed to regulations regarding the main tasks of Puskesmas and hospitals. Because we found doctors were not familiar with health programs such as how to plan, monitor, and evaluate According to the participants, doctors need training in clinical leadership skills and to understand and perform health programs implementation and evaluation approaches. Program management skills should help doctors to recognize and consider the fundamental factors required to achieve an effective local organizational strategy, adequate allocation of health resources and logistics, monitoring and evaluation of program implementation, and skills to lead and motivate inter-professional teams. Prospective doctors should be trained in how to capture messages or related issues in the community regarding program implementation at the Puskesmas….they also need to sharpen their preventive and promotional methods… I think medical students should also be taught about management functions, especially those relevant to program-based health services…they need to also be trained on how to allocate resources and strategic management… Connecting Evidence to Decision-makers and Effective Advocacy Most participants said that doctors have a large role in the development and implementation of regional health systems and therefore the decentralized health system model in Indonesia requires systems thinking skills. Doctors in remote and rural areas have wide opportunities during the health policy formulation process in the regions, but not all opportunities are used. Participants suggested that doctors should think systematically and be able to advocate supported by adequate evidence. Doctors are often invited to cross-sectoral mini-workshops and musrembang events [musyawarah perencanaan pembangunan] in our sub-district…but they don't give much input… When the doctor is asked to give a suggestion, we just focus on the clinical one because we find it difficult to combine it with other factors… According to participants, doctors in villages and remote areas have not contributed as expected by the local government to develop and influence health policies and development in the DTPK areas. The participants also said that doctors have not been widely involved in health planning because they are not able to translate mortality, morbidity, and risk factor data into concrete recommendations for policymakers. We hope that doctors will help us to interpret data such as morbidity and mortality due to disease ... but indeed we have difficulties because we are not supported by doctors or other health workers who know more about these data... The participants suggested that educational institutions should not only be knowledge-oriented but also need to train medical students in knowledge management techniques for the production of information and evidence as the basis for formulating health policies in the district. They should be taught surveillance, theory, and how to interpret data such as disease trends in rural or remote areas… Discussion Overall, we found prospective doctors in DTPK areas need to be prepared in two main domains. The first domain is disaster mitigation and health program management capabilities at the health system level. The second domain is health policy advocacy skills, in terms of being able to think about systems, and providing recommendations for health policy formation. A comprehensive understanding of health disparities affecting populations living in DTPK areas due to structural pressures, transportation barriers, insufficient medical resources, and lack of sufficient and adequately-trained health professionals is required of rural doctors to practice in ways that attend to the real needs of local populations [32]. Public health status in the DTPK areas is strongly related to the context in which there is an interaction between community characteristics, geographic location, and the type of health practice required for each particular context [33]. Doctors must be trained to provide services in situations where facilities and equipment are limited. We also found that doctors' knowledge and skills in health program management were very important to support their work in the DTPK areas. These results indicate that in DTPK areas, clinical leadership must be strengthened with program management skills to achieve an adaptive and well-performing healthcare system [34]. In disaster areas, doctors are required to be professionals in emergency response, understand disaster management, and provide input in disaster mitigation plans. This finding is in line with [35] who emphasized that in a disaster situation doctors become more professional during disaster response if they collaborate with other disciplines including the local disaster management bureau [35]. Doctors on duty in border areas must be trained in cross-border disease surveillance systems. Better training on infectious disease notification procedures reduces under-reporting and improves timely and effective reporting in border areas [36]. Effective systems-based healthcare requires an understanding of the features and characteristics of a system along with an understanding of how to think about the system, analyze it, and approaches to improve it. Physicians must understand all parts of the health care system from the medical care unit to the patient's family to community organizations. Systems thinking skills help doctors in the DTPK areas to think critically about how all of these dynamic parts can work together to improve patient health, cover their health and care needs, and anticipate as well as reduce safety threats or other problems. Through systems thinking, doctors can advocate using their expertise and power to improve the health and well-being of patients, communities, and society, for example through health campaigns and advocacy through mass media [37]. Our findings are in line with Boroumand et al. [38] who found that student engagement in health advocacy across medical schools can inspire long-term commitment to addressing health inequalities. Not only that, but advocacy can also be aimed at policymakers to enhance resource allocation for evidence-based health, agenda-setting, policy formulation, and implementation of health policies in the regions through the application of research data [39,40]. Previous research has shown that doctors' advocacy skills can strengthen professional organizations to provide recommendations for health policymaking [41]. This study has limitations inherent in the RAP process of collecting data quickly from a small number of districts. However, the districts were selected purposively to shed light on issues relevant to remote and rural areas of Indonesia. This study is the first in Indonesia to reveal the competency needs of doctors in DTPK during the implementation of the transformation of health human resources in Indonesia. Conclusion Reducing health disparities between regions in Indonesia can be achieved by bridging the need and availability of health care in each region. This study informs the needs and skills that are important for educational institutions and strategic health HR policymakers. Doctors in the DTPK areas must be trained with pioneering skills for disaster mitigation, strengthening healthcare program management capacities, and skills in translating empirical evidence for advocacy both for community empowerment and for the formulation of health policies. Declarations Ethics Approval and Consent to Participate Ethical clearance was obtained from the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito General Hospital, and the number of the ethical clearance was KE/FK/0989/EC/2020. Verbal consent was received from participants prior to the initiation of group discussion activities. Consent for Publication No Applicable. Availability of data and material The raw data collected for the current study are available from the corresponding author on reasonable request. Conflict of Interest The authors have no conflicts of interest to report. Funding No external funding was used to support this research and or the preparation of the manuscript. Authors' contributions PHS coded all FGD transcripts using open coding. PHS, JP, and APS independently read the transcripts and supporting quotations to increase analysis accountability. Through discussion, the researchers then grouped these inductively identified coded segments into larger categories according to the requisite skills of doctors in DTPK areas. Therefore, in the second stage of the analysis, we used interpretive analysis to categorize the focus group data according to social determinants of health framework and doctors’ skills domains. All transcripts were discussed repeatedly among the authors. We compared the coded transcripts of FGD results from each district to identify areas of overlap and divergence. AM (a national health workforce expert), reviewed the analysis documents to ensure there was no duplication of data and that all categories and sub-themes were relevant to public health skills and competencies. PHS, JP, and APS then translated all the code transcripts and all the selective quotes from Indonesian to English. In the next stage, the final manuscript was reviewed by REG (a medical anthropologist). Acknowledgements We would like to thank all participants in Bengkayang, Ketapang, Serdang Bedagai, North Minahasa, South Minahasa, and Central of Sumba who facilitated this research. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2193331","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":159310854,"identity":"13936712-b35b-4688-a168-6e9d01349bc2","order_by":0,"name":"Perigrinus Hermin Sebong","email":"data:image/png;base64,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","orcid":"","institution":"Soegijapranata Catholic University: Universitas Katolik Soegijapranata","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Perigrinus","middleName":"Hermin","lastName":"Sebong","suffix":""},{"id":159310855,"identity":"07437da6-aa0a-4e3c-9de0-b738baa08698","order_by":1,"name":"Jerico Pardosi","email":"","orcid":"","institution":"Queensland University of Technology School of Public Health and Social Work","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jerico","middleName":"","lastName":"Pardosi","suffix":""},{"id":159310856,"identity":"0bff98f1-2b25-422b-908c-5be585b2f66e","order_by":2,"name":"Roberta E Goldman","email":"","orcid":"","institution":"Warren Alpert Medical School of Brown University: Brown University Warren Alpert Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Roberta","middleName":"E","lastName":"Goldman","suffix":""},{"id":159310857,"identity":"12bd41e1-d1f2-4e0d-a165-21d6b125fb36","order_by":3,"name":"Anindyo Pradipta Suryo","email":"","orcid":"","institution":"Faculty of Medicine, Soegijapranata Catholic University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anindyo","middleName":"Pradipta","lastName":"Suryo","suffix":""},{"id":159310858,"identity":"99607b4d-4b45-4365-9e0a-bfc56e49e633","order_by":4,"name":"Andreasta Meliala","email":"","orcid":"","institution":"Gadjah Mada University Faculty of Medicine, Public Health, and Nursing: Universitas Gadjah Mada Fakultas Kedokteran Kesehatan Masyarakat dan Keperawatan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andreasta","middleName":"","lastName":"Meliala","suffix":""}],"badges":[],"createdAt":"2022-10-22 11:36:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2193331/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2193331/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":30285624,"identity":"3416cd51-8577-499d-9766-ddfd7d06d304","added_by":"auto","created_at":"2022-12-13 22:10:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":304342,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2193331/v1/034300dd-e1b8-49d8-8fc7-55bbfc9a3fe7.pdf"}],"financialInterests":"","formattedTitle":"Bridging medical doctors' education and population health needs to address health disparities in Indonesia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eConsistent availability and adequate doctors are important for health equity as these enhance access, quality, and equity of health care [1\u0026ndash;3]. However, the distribution of doctors alone is not sufficient to improve overall health access and equity without a strategic effort to strengthen doctors\u0026rsquo; competencies and skills in adapting to the dynamic needs of localized health care systems and populations [4,5].\u003c/p\u003e \u003cp\u003eCurrently, the diversity in contexts such as demographic characteristics of the populations, geographic areas, health systems, disease patterns, and social determinants related to access to health care remain challenging for both high-income countries (HICs) and low and middle-income countries (LMICs) [6,7]. However, the education pipeline to produce doctors with the required skills to effectively provide medical care within these disparate contexts is suboptimal for medical graduates in the context of LMICs [8]. For example, in Indonesia, there are 12,000 medical student graduates annually, but it is estimated that 513 community health centers (\u003cem\u003ePuskesmas)\u003c/em\u003e with no doctors at all, especially in disadvantaged areas, borderlands, and outer islands which are also known as \u003cem\u003eDaerah Tertinggal, Perbatasan dan Kepulauan (DTPK)\u003c/em\u003e [9]. This situation is due to the unpreparedness of doctors to deal with complex health problems in the context of \u003cem\u003eDTPK\u003c/em\u003e areas [9]. The role of educational institutions, therefore, must aim to train and produce more doctors who are adequately prepared with the knowledge and skills to identify and address local health needs, especially in the \u003cem\u003eDTPK\u003c/em\u003e areas [10]. Previous studies in both HICs and LMICs have shown that doctors who are trained in skills for rural medicine, particularly in work with limited facilities and resources, are more likely to remain working in remote locations [11,12].\u003c/p\u003e \u003cp\u003ePublic health curricula and community placements have been implemented as the general strategy by medical schools to educate their students on the needs of local populations' health issues [13]. Providing a public health curriculum aimed at rural health knowledge and skills can strengthen the awareness of medical students by promoting a view of health that includes the clinical and social determinants of health, well-being, disease, and disability, and the multidisciplinary and cross-sectoral interventions and policies needed to address these issues in the community [14\u0026ndash;16]. However, implementation of such a public health curriculum has been limited, primarily focusing on generalized cognitive aspects of knowledge acquisition, neglecting affective and skill domains tailored to addressing disease contexts and risk factors in the local community [17]. In addition, the influence of social determinants on health status has been neglected despite that social factors are the root cause of many complex health problems [18,19].\u003c/p\u003e \u003cp\u003eSince 2020, the Ministry of Health (MoH) of Indonesia has established a human resource for health transformation policy intending to ensure health care workers are evenly distributed around the country, including in the \u003cem\u003eDTPK\u003c/em\u003e areas. However, the existing geographical barriers makes the \u003cem\u003eDTPK\u003c/em\u003e areas difficult to reach, and less attractive to doctors for living and working due to difficulties in obtaining essential commodities and the presence of unstable security situations, problems with the production of adequately training doctors to persist [20,21]. In addition to. Another critical issue is the orientation of medical education is predominantly hospital-based rather than focused on outpatient primary health care [21].\u003c/p\u003e \u003cp\u003eAlthough the strategy to intensify equitable distribution of doctors by recruiting students from remote areas and with rural backgrounds is considered successful in diminishing maldistribution, it does not guarantee young doctors\u0026rsquo; readiness to work in remote and rural \u003cem\u003ePuskesmas\u003c/em\u003e in their native place of origin [21,13,23]. This scarcity in terms of both quality and quantity has implications for the uneven capacity of the health care system in Indonesia [24]. In addition, conditions of social determinants of health vary between regions in Indonesia, so enhanced training for the development of skills targeted to the needs of local populations is necessary [25]. However, the specific information on the local context needed for better rural health training programs is limited and fragmented. Therefore, there is a need to assess public health skills and competencies among doctors in the \u003cem\u003eDTPK areas\u003c/em\u003e. This study aims to assess the current understanding and perspectives on public health skills and competencies among doctors in the \u003cem\u003eDTPK\u003c/em\u003e areas.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Theoretical Framework\u003c/h2\u003e \u003cp\u003eThis study used a rapid assessment procedures (RAP) approach and the qualitative focus group discussion method to explore the perceptions of rural doctors, local health policymakers, district health officers, remote and rural health workers, and community members about the required knowledge and skills for doctors to successfully practice in remote areas of Indonesia, particularly in the \u003cem\u003eDTPK\u003c/em\u003e areas. RAP is a method for generating rich information in a short period [26]. Our design process was guided by Miles and Hubermas's quality standards for qualitative research [27] as well as COREQ reporting standards for qualitative research [28]. Ethical clearance was obtained from the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito General Hospital, and the number of the ethical clearance was KE/FK/0989/EC/2020. Verbal consent was received from participants prior to the initiation of group discussion activities.\u003c/p\u003e \u003cp\u003eWe adopted the Solar and Irwin [29] framework of social determinants of health to the context of our study characterized by underdeveloped areas, country borders, and remote islands, to consider geographic and topographical issues as well as social, economic, and political factors that result in persistent lack of health care access and poor health outcomes for rural populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThe research was conducted in six districts representing the \u003cem\u003eDaerah Tertinggal, Perbatasan dan Kepulauan (DTPK)\u003c/em\u003e areas. We used the definition of the underdeveloped area as districts that are less developed than other regions on a national scale and whose population public health development index is relatively less than one (\u0026lt;\u0026thinsp;1) [30]. The border area is part of the territory of the country which is located along the Indonesian border with other countries. Meanwhile, island areas are the outermost small islands with a population without adequate health care access.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample and Recruitment\u003c/h2\u003e \u003cp\u003e We used purposive sampling [31] to select districts in which to collect data by considering regional representation, with the final selection of the Central Sumba, Serdang Bedagai, South Minahasa, North Minahasa, Ketapang, and Bengkayang districts for data collection. After we received a permission letter from the targeted government, we set an approved schedule for focus groups and field visits. Focus group participants were purposively recruited to include local stakeholders who have the main responsibility in human health resources policy development (e.g. for the formulation, development, implementation, monitoring, evaluation, and recruitment), consisting of the Regent, District Development Office (\u003cem\u003eBappeda)\u003c/em\u003e, District Health Office, Hospital Director, \u003cem\u003ePuskesmas\u003c/em\u003e, General Practitioners, health care workers (doctor, nurse, midwife, public health, surveillance staff), and community health workers. The criteria for recruiting focus group discussion (FGD) participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConsiderations in selecting FGD participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicy Maker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe administrative leader or staff who is responsible for the formulation of policies and regulations relating to or affecting the health care system in their district\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict Health Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Health Officer is responsible for developing strategic planning, especially related to the management of health human resources in the district\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary Health care facility staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Service Facilities are places used by the government and the community to provide health service activities, including promotive, preventive, curative, and rehabilitative services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuskesmas staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth workers are defined as public employees involved in the delivery of primary health care consisting of doctors, nurses, midwives, community health workers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Health Worker (CHW)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth workers in the village are also invited as policymakers and not in community groups because they are part of the cross-sector in the district\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[insert Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003eThe FGD sample was recruited by considering potential participants\u0026rsquo; institutional affiliation and geographic distribution.\u003c/p\u003e \u003cp\u003eWe sent an invitation letter to participate in the FGD through the official email of the government. Invitation letters for health care facilities were sent directly to the selected facilities assisted by local stakeholders. For CHWs, invitations were sent to those who are members of organized community groups such as the village health center and cadre.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFGD Procedure\u003c/h2\u003e \u003cp\u003eThe group discussion was carried out through separated the groups by the following factors the first with the local government and the health office, the second with the remote, borderland, and island \u003cem\u003ePuskesmas\u003c/em\u003e to elicit specific information about their perspectives on the public health skills and competencies among doctors, and insights about the condition of health care services at the same time.\u003c/p\u003e \u003cp\u003eThe FGD question guide included questions that addressed participants\u0026rsquo; perceptions of the skills, performance, and non-medical factors such as social determinants of health and health program. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. [insert Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Discussion Guide Questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Human Resources Policy dan strategic planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; What kind of doctor graduates are needed by the community in your location?\u003c/p\u003e \u003cp\u003e\u0026bull; What are the important or special skills needed by a doctor to be ready to work in your location?\u003c/p\u003e \u003cp\u003e\u0026bull; So far, have the skills of the doctors been able to meet the needs of medical and preventive services for the community?\u003c/p\u003e \u003cp\u003e\u0026bull; What is your suggestion for a medical graduate institution education to be in line with the needs of the community in your location?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth service delivery, community health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; What additional skills need to be trained for doctors to adapt to local wisdom in inpatient and community care?\u003c/p\u003e \u003cp\u003e\u0026bull; What are the non-medical factors that serve as a barrier for the community to reach health services?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFGD sessions were moderated by a project team member and lasted between 60 and 80 minutes. FGDs were audio recorded after receiving permission from participants. The first author (PHS) facilitated FGDs in three districts, the fourth author (APS) facilitated FGDs in one district and the other FGDs in two districts were facilitated by trained facilitators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAudio recordings were professionally transcribed. We used Solar and Irwin's [29] framework to guide how we developed the codes and categories. In stage one, we conducted an inductive thematic analysis. PHS coded all FGD transcripts using open coding. PHS, JP, and APS independently read the transcripts and supporting quotations to increase analysis accountability. Through discussion, the researchers then grouped these inductively identified coded segments into larger categories according to the requisite skills of doctors in \u003cem\u003eDTPK areas\u003c/em\u003e. Therefore, in the second stage of the analysis, we used interpretive analysis to categorize the focus group data according to social determinants of health framework and doctors\u0026rsquo; skills domains. All transcripts were discussed repeatedly among the authors. We compared the coded transcripts of FGD results from each district to identify areas of overlap and divergence. AM (a national health workforce expert), reviewed the analysis documents to ensure there was no duplication of data and that all categories and sub-themes were relevant to public health skills and competencies. PHS, JP, and APS then translated all the code transcripts and all the selective quotes from Indonesian to English. In the next stage, the final manuscript was reviewed by REG (a medical anthropologist).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe conducted 12 FGDs and the number of participants was about 5\u0026ndash;8 participants for each group per district. A total of 93 individuals participated in a focus group: 4 policymakers, 36 district health officers (leaders and staff), 3 hospital representatives, 42 \u003cem\u003ePuskesmas\u003c/em\u003e staff (doctor, nurse, midwife, public health, surveillance staff), and 8 community representatives.\u003c/p\u003e \u003cp\u003e[insert Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Participant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExecutive/Health Regulator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Health Office\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic and Private Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePuskesmas and Puskesmas pembantu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain expertise and skill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Health Policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Health Strategic Planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Workforce Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Service Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases Control and Prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity Mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree main topics emerged from the framework analysis such as disaster mitigation planning and health security; practicing health programs management; and connecting evidence to decision-maker and effective advocacy.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDisaster Mitigation Planning and Health Security\u003c/h2\u003e \u003cp\u003eNatural and non-natural disasters such as disease outbreaks result in the \u003cem\u003eDTPK\u003c/em\u003e population\u0026rsquo;s need to develop resilience and strategies for adequate mitigation and response to these threats. Participants revealed that disasters such as floods and forest fires often hit certain areas in the region. Floods due to excessive rainfall during the rainy season were isolated in several areas so that \u003cem\u003ePuskesmas\u003c/em\u003e doctors or staff did not refer patients living in those areas to hospitals. Therefore, doctors working in these remote areas need skills to both to respond to emergencies and advocate for disaster mitigation before emergencies occur.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThere are three Puskesmas in a remote and isolated area that fall into the very remote category, namely Puskesmas Lembah Bawang, Siding Health, and Suti Semarang. During the rainy season, they find it difficult to refer those patients due to the flooding that isolates and blocks the transportation routes from their place\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e...\u003cem\u003esmog due to forest fires often occurs every year \u0026hellip; doctors must be prepared in any situation so they must be involved in disaster mitigation in the places where they work\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMost participants also said that borderland areas are vulnerable to becoming an entry point of disease importation and transmission, which increases the risk of disease outbreaks and pandemics.\u003c/p\u003e \u003cp\u003e \u003cem\u003eOur territory is located in the borderland area. However, the disease surveillance capacity in the borderland area is less effective...there has been local transmission caused by imported cases but underreported\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFurthermore, participants recommended that prospective doctors in \u003cem\u003eDTPK\u003c/em\u003e areas should be taught relevant knowledge related to disease surveillance systems in borderlands.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSeveral imported cases were not recorded in our surveillance monitoring systems... so the doctor should be able to evaluate when the surveillance system does not work properly.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePracticing Health Programs Management\u003c/h2\u003e \u003cp\u003eParticipants said doctors should also be trained in health program management since most health service activities at the \u003cem\u003ePuskesmas\u003c/em\u003e-level are health programs.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe hope that educational institutions facilitate medical students to be exposed to regulations regarding the main tasks of Puskesmas and hospitals. Because we found doctors were not familiar with health programs such as how to plan, monitor, and evaluate\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAccording to the participants, doctors need training in clinical leadership skills and to understand and perform health programs implementation and evaluation approaches. Program management skills should help doctors to recognize and consider the fundamental factors required to achieve an effective local organizational strategy, adequate allocation of health resources and logistics, monitoring and evaluation of program implementation, and skills to lead and motivate inter-professional teams.\u003c/p\u003e \u003cp\u003e \u003cem\u003eProspective doctors should be trained in how to capture messages or related issues in the community regarding program implementation at the Puskesmas\u0026hellip;.they also need to sharpen their preventive and promotional methods\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI think medical students should also be taught about management functions, especially those relevant to program-based health services\u0026hellip;they need to also be trained on how to allocate resources and strategic management\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eConnecting Evidence to Decision-makers and Effective Advocacy\u003c/h2\u003e \u003cp\u003eMost participants said that doctors have a large role in the development and implementation of regional health systems and therefore the decentralized health system model in Indonesia requires systems thinking skills. Doctors in remote and rural areas have wide opportunities during the health policy formulation process in the regions, but not all opportunities are used. Participants suggested that doctors should think systematically and be able to advocate supported by adequate evidence.\u003c/p\u003e \u003cp\u003e \u003cem\u003eDoctors are often invited to cross-sectoral mini-workshops and musrembang events [musyawarah perencanaan pembangunan] in our sub-district\u0026hellip;but they don't give much input\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen the doctor is asked to give a suggestion, we just focus on the clinical one because we find it difficult to combine it with other factors\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAccording to participants, doctors in villages and remote areas have not contributed as expected by the local government to develop and influence health policies and development in the \u003cem\u003eDTPK\u003c/em\u003e areas. The participants also said that doctors have not been widely involved in health planning because they are not able to translate mortality, morbidity, and risk factor data into concrete recommendations for policymakers.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe hope that doctors will help us to interpret data such as morbidity and mortality due to disease ... but indeed we have difficulties because we are not supported by doctors or other health workers who know more about these data...\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe participants suggested that educational institutions should not only be knowledge-oriented but also need to train medical students in knowledge management techniques for the production of information and evidence as the basis for formulating health policies in the district.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThey should be taught surveillance, theory, and how to interpret data such as disease trends in rural or remote areas\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall, we found prospective doctors in \u003cem\u003eDTPK\u003c/em\u003e areas need to be prepared in two main domains. The first domain is disaster mitigation and health program management capabilities at the health system level. The second domain is health policy advocacy skills, in terms of being able to think about systems, and providing recommendations for health policy formation.\u003c/p\u003e \u003cp\u003eA comprehensive understanding of health disparities affecting populations living in \u003cem\u003eDTPK\u003c/em\u003e areas due to structural pressures, transportation barriers, insufficient medical resources, and lack of sufficient and adequately-trained health professionals is required of rural doctors to practice in ways that attend to the real needs of local populations [32]. Public health status in the \u003cem\u003eDTPK\u003c/em\u003e areas is strongly related to the context in which there is an interaction between community characteristics, geographic location, and the type of health practice required for each particular context [33]. Doctors must be trained to provide services in situations where facilities and equipment are limited. We also found that doctors' knowledge and skills in health program management were very important to support their work in the \u003cem\u003eDTPK\u003c/em\u003e areas. These results indicate that in \u003cem\u003eDTPK\u003c/em\u003e areas, clinical leadership must be strengthened with program management skills to achieve an adaptive and well-performing healthcare system [34]. In disaster areas, doctors are required to be professionals in emergency response, understand disaster management, and provide input in disaster mitigation plans. This finding is in line with [35] who emphasized that in a disaster situation doctors become more professional during disaster response if they collaborate with other disciplines including the local disaster management bureau [35]. Doctors on duty in border areas must be trained in cross-border disease surveillance systems. Better training on infectious disease notification procedures reduces under-reporting and improves timely and effective reporting in border areas [36].\u003c/p\u003e \u003cp\u003eEffective systems-based healthcare requires an understanding of the features and characteristics of a system along with an understanding of how to think about the system, analyze it, and approaches to improve it. Physicians must understand all parts of the health care system from the medical care unit to the patient's family to community organizations. Systems thinking skills help doctors in the \u003cem\u003eDTPK\u003c/em\u003e areas to think critically about how all of these dynamic parts can work together to improve patient health, cover their health and care needs, and anticipate as well as reduce safety threats or other problems.\u003c/p\u003e \u003cp\u003eThrough systems thinking, doctors can advocate using their expertise and power to improve the health and well-being of patients, communities, and society, for example through health campaigns and advocacy through mass media [37]. Our findings are in line with Boroumand et al. [38] who found that student engagement in health advocacy across medical schools can inspire long-term commitment to addressing health inequalities. Not only that, but advocacy can also be aimed at policymakers to enhance resource allocation for evidence-based health, agenda-setting, policy formulation, and implementation of health policies in the regions through the application of research data [39,40]. Previous research has shown that doctors' advocacy skills can strengthen professional organizations to provide recommendations for health policymaking [41].\u003c/p\u003e \u003cp\u003eThis study has limitations inherent in the RAP process of collecting data quickly from a small number of districts. However, the districts were selected purposively to shed light on issues relevant to remote and rural areas of Indonesia. This study is the first in Indonesia to reveal the competency needs of doctors in \u003cem\u003eDTPK\u003c/em\u003e during the implementation of the transformation of health human resources in Indonesia.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eReducing health disparities between regions in Indonesia can be achieved by bridging the need and availability of health care in each region. This study informs the needs and skills that are important for educational institutions and strategic health HR policymakers. Doctors in the \u003cem\u003eDTPK\u003c/em\u003e areas must be trained with pioneering skills for disaster mitigation, strengthening healthcare program management capacities, and skills in translating empirical evidence for advocacy both for community empowerment and for the formulation of health policies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Medical and Health Research Ethics Committee (MHREC) Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito General Hospital, and the number of the ethical clearance was KE/FK/0989/EC/2020. Verbal consent was received from participants prior to the initiation of group discussion activities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo Applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data collected for the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was used to support this research and or the preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePHS coded all FGD transcripts using open coding. PHS, JP, and APS independently read the transcripts and supporting quotations to increase analysis accountability. Through discussion, the researchers then grouped these inductively identified coded segments into larger categories according to the requisite skills of doctors in DTPK areas. Therefore, in the second stage of the analysis, we used interpretive analysis to categorize the focus group data according to social determinants of health framework and doctors\u0026rsquo; skills domains. All transcripts were discussed repeatedly among the authors. We compared the coded transcripts of FGD results from each district to identify areas of overlap and divergence. AM (a national health workforce expert), reviewed the analysis documents to ensure there was no duplication of data and that all categories and sub-themes were relevant to public health skills and competencies. PHS, JP, and APS then translated all the code transcripts and all the selective quotes from Indonesian to English. In the next stage, the final manuscript was reviewed by REG (a medical anthropologist).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all participants in Bengkayang, Ketapang, Serdang Bedagai, North Minahasa, South Minahasa, and Central of Sumba who facilitated this research. We would also like to acknowledge Indra Adi Susianto, Fransisca Pramessinta Hadimarta, Ferry Santoso, Jonsinar Silalahi, Edward Hartono, Jessica Christanti, Vania Angeline Bachtiar, Ferdinandus Krisna Pukan, Gregorius Yoga Panji Asmara, Hotmaoeli Sidabalok, Lubertus Tri Haryanto and all of the DTPK team who have assisted in this study process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. The world health report 2006. 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The role of physicians and medical organizations in the development, analysis, and implementation of health care policy. Semin Radiat Oncol. 2008;18(3):186\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.semradonc.2008.01.006.10\u003c/span\u003e\u003cspan address=\"10.1016/j.semradonc.2008.01.006.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2193331/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2193331/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe diversity in contexts such as population demographics, high burden of diseases, and geographical areas experiences numerous challenges to health care accessibility and adequate health staff skills, particularly for those in the disadvantaged areas, borderlands, and outer islands. This study aims to assess the current understanding and perspectives on public health skills and competencies among doctors in remote areas. A total of 93 participants in six remote districts participated in this study which used a rapid assessment procedures approach and focuses group discussion method. Overall, we found that current medical students should have both the medical skills and the ability to work within the local sociocultural context. The ability to early detect diseases and disaster mitigation is also needed. The findings suggest doctors have adequate health program management capabilities to provide recommendations in the formulation of local health policies. Therefore, educational institutions must develop sustainable strategic human resources according to regional characteristics for health across\u0026nbsp; Indonesia.\u0026nbsp;\u0026nbsp; Keywords Keywords: health disparities, public health competence, rural doctor, Indonesia\u003c/p\u003e","manuscriptTitle":"Bridging medical doctors' education and population health needs to address health disparities in Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-13 22:09:49","doi":"10.21203/rs.3.rs-2193331/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5184762f-cacb-4dc0-af68-7bcf16385a09","owner":[],"postedDate":"December 13th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-12-13T22:09:49+00:00","versionOfRecord":[],"versionCreatedAt":"2022-12-13 22:09:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2193331","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2193331","identity":"rs-2193331","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}