Mycobacterium tuberculosis infects one-third of the world's population and imposes a global burden of an estimated 8 million new cases and 1.8 million deaths yearly . More than 90% of global tuberculosis (TB) cases and deaths occur in the developing world, where 75% of cases are in the most economically productive age group (15-54 years). An adult with TB loses on average three to four months of work time [1, 2].
Indonesia with a population of over 220 millions carries the heavy burden of TB. Indonesia still ranks third among the 22 high-burden countries . In Bandung, one of the cities in West Java Province, Indonesia, case detection rate (CDR) did not reach the Indonesia target of 70% . The Government of Indonesia considers TB control to be a high priority within the health-care system [3–5]. A strategy for incremental involvement of the private practitioners in DOTS (Directly Observed Treatment) implementation had been developed.
Private General Practitioners (PPs) are the first contact for TB patients. Their involvement is linked to the success of the TB control . In Indonesia, it is generally believed that about a third of all TB cases might be partly or completely managed in the private sector . Many studies indicated that PPs tended to deviate from recommended tuberculosis management guidelines . Physicians' adherence with guidelines varies with different types of "patient" and with the length of clinical experience [6–10]. Adherence to program recommendations such as National Tuberculosis Programs (NTPs) is important for TB control.
Many strategies can be used to improve the adherence. Since clinical behavior is still a form of human behavior, psychological models of behavior change may be applied to modify practices of healthcare professionals [11–14].
Counseling, a face-to-face psychoeducation method can promote positive human interactions. The Catharsis Education and Action (CEA) method is a counseling technique that takes on many features of Carl Roger's person-centered psychotherapy. This method brings out the psychological concerns that result from wrong perception of reality and hinder appropriate behavior. These have been called emotionally critical misperceptions (ECMs). If addressed appropriately, barriers are lifted and educational inputs are better received. This method focuses not only on the problems but also on the opportunities for improvement and development [15–17]. As its name implies, the CEA method consists of three phases: catharsis, education and action. In the catharsis phase, the counselor spends time to clarify or define the problem. In the process, hidden emotions surface and ventilated so that they do not disturb the analytical functions of the mind [17–19]. In this phase, the PPs' problems in their management of tuberculosis patients are clarified and defined. Concerns about barriers and enablers to adherence to NTP (such as personal interest, patient choice and availability of diagnostic equipment and treatment) are addressed and explored. Through the utilization of active listening skills, genuineness, empathy and unconditional positive regard, one can accurately pinpoint and correct the most anxiety-provoking ECM. Once the ECM identified and corrected, it will now be easier to objectively analyze the problem. In this study, the discussion focused on identifying suspected TB patients, performing laboratory examination, treatment for TB patients, organizing follow ups, maintaining TB registries and DOTS implementation. It is in the education phase, that misperceptions are corrected using scientific evidence or the latest information available about the problem. It is presumed that appropriate behavior changes will be easier to accomplish after emotional burdens are released and new information and insight are provided. Implementation of the needed behavioral changes heralds the action phase .