"They hide because they fear": Barriers and opportunities for tuberculosis control in rural Indonesia through the PRECEDE-PROCEED lens.

BACKGROUND: Tuberculosis (TB) remains a significant public health challenge in rural Indonesia, where structural barriers, limited health literacy, and persistent stigma hinder effective disease control. Systematic exploration of contextual obstacles and opportunities for youth empowerment interventions in TB control remains limited. OBJECTIVE: This study explored contextual barriers and opportunities to enhance TB awareness and community involvement in rural Indonesia, using the PRECEDE-PROCEED model to identify predisposing, enabling, and reinforcing factors influencing TB control behaviours. METHODS: An exploratory qualitative study using a phenomenological approach was conducted in Central Java, Indonesia (February-August 2024). Data were collected through semi-structured interviews with 18 key informants and two focus group discussions with 11 participants. Reflexive thematic analysis was conducted using NVivo 12, with trustworthiness ensured through prolonged engagement, triangulation, member checking, and COREQ adherence. RESULTS: Nine themes emerged across three domains. Predisposing factors included persistent TB misconceptions and stigma characterised by fear, shame, and social avoidance. Enabling factors comprised structural barriers (inadequate housing, poor ventilation), weaknesses in TB detection (human resource shortages, low TPT coverage), suboptimal health cadre effectiveness, and resource constraints. Reinforcing factors encompassed inconsistent treatment supervision, limited multi-stakeholder involvement, notably absent educational institution engagement, and programme evaluation gaps. Critically, these barriers interacted across domains through cascading mechanisms, with stigma amplifying system weaknesses and undermining supervision. CONCLUSION: TB control in rural Indonesia faces interconnected barriers across all three PRECEDE-PROCEED domains. Young people and schools are underutilised resources with strong potential as agents of change, justifying the development of community-based youth empowerment interventions.