The review, authored by Yuan Sui, Wanyue Zhang, Bin Duan, Jie Wu, Lihong Wang and Xianmei Xiao, organizes the evidence around four broad categories of intervention: biological control agents, natural antimicrobial compounds, physical treatments, and innovative packaging technologies. By summarizing how each approach works, the authors aim to provide a consolidated picture of what sustainable postharvest protection currently has to offer.

At the center of the paper is a proposed Integrated Postharvest Disease Management framework, abbreviated IPDM. Rather than depending on any single treatment, the strategy layers multiple preventive methods that overlap in time and mode of action, with the stated goals of reducing postharvest losses and maintaining produce quality simultaneously.

The review also highlights the practical value of multi-omic analyses, which combine genomic, transcriptomic, proteomic and metabolomic data. According to the authors, these tools can elucidate the mechanisms of pathogenicity in spoilage organisms and the resistance responses of host tissues, knowledge that could inform the design of more targeted interventions.

As a review article, the work synthesizes and interprets existing literature rather than presenting new experimental results, and the shared version is an accepted manuscript that will be replaced by the final Version of Record. Its contribution lies in framing physiological insight and emerging technologies within a single, sustainability-oriented management strategy for vegetables after harvest.

Subject of Research: Sustainable integrated management of postharvest diseases in vegetable crops

Article Title: Sustainable postharvest vegetable disease management: integrating physiological insights and innovative technologies for quality preservation

Article References: Sui, Y., Zhang, W., Duan, B., Wu, J., Wang, L., & Xiao, X. (2026). Sustainable postharvest vegetable disease management: integrating physiological insights and innovative technologies for quality preservation. npj Science of Food. https://doi.org/10.1038/s41538-026-01201-y

Image Credits: AI Generated

DOI: 10.1038/s41538-026-01201-y

Keywords: postharvest disease, vegetables, integrated disease management, biocontrol, natural antimicrobials, packaging technologies, food quality, multi-omics, food loss, sustainability, npj Science of Food, review

The disease in question, powdery mildew, is caused by the fungus Erysiphe cichoracearum. It announces itself as minute discolored specks on sunflower leaves, from which a powdery white mass radiates outward until entire leaves are coated. Under the warm conditions typical of tropical regions, the infection can escalate to complete defoliation, and the resulting loss of photosynthetic surface translates directly into fewer and lighter seeds. While sunflower is among the world’s most cultivated oil crops, with global production around 40.21 million tons annually across roughly 26.05 million hectares, Ethiopia’s national average yield sits at only about 1.033 tons per hectare, dragged down in part by this and other fungal diseases.

The research team set out to test whether pairing host resistance with chemical control could suppress powdery mildew epidemics more effectively than either strategy alone. They evaluated two sunflower varieties, the improved Russian black and a local variety, in combination with three fungicides: propiconazole 25% EC, a systemic triazole; wettable sulphur 80%, a contact fungicide; and mancozeb 80%, another contact product. Each fungicide was applied either once or twice per season, producing fourteen treatment combinations that were arranged in a randomized complete block design with factorial structure and three replications under field conditions.

The choice of fungicides reflects three distinct modes of action. Propiconazole, as a triazole, moves systemically through the xylem of the plant and blocks the biosynthesis of ergosterol, an essential component of fungal cell membranes; without this sterol, the fungal cell wall is irreversibly damaged and the pathogen dies. Wettable sulphur interferes with cellular respiration in fungal pathogens, while mancozeb reacts with sulfhydryl groups in fungal proteins. Because these chemicals attack the fungus in different ways, the researchers reasoned that their performance under field conditions might differ substantially, and the data confirmed that prediction.

Disease assessments were rigorous. Ten plants per plot were randomly selected from central rows and marked for repeated observation, with incidence calculated as the percentage of plants showing symptoms and severity rated on a 1-to-9 scale that was converted to a percent severity index. From these repeated measurements, the team computed the area under the disease progress curve, or AUDPC, a single value that integrates initial disease intensity, the rate of epidemic development, and the duration of the epidemic, providing a compact signature of how aggressively the pathogen spread in each plot.

The results were striking. At Debub Ari, untreated local variety plots suffered a mean disease severity of 63.7 percent, while plots planted with Russian black and sprayed twice with propiconazole showed only 3.7 percent, a 94.2 percent relative reduction. At Salamago, the corresponding values were 39.25 percent for untreated local plots and 5.92 percent for the best treatment. Plots of the improved variety treated twice with wettable sulphur and plots receiving a single propiconazole spray also performed strongly, reducing severity by 86.3 percent and 81.6 percent respectively compared with the untreated local check. The AUDPC analysis mirrored these patterns: untreated local plots accumulated 778.74 percent-days of disease at Debub Ari and 489.93 percent-days at Salamago, whereas Russian black with two propiconazole applications kept the epidemic to just 102.84 percent-days at the first site, with wettable sulphur treatments close behind at the second.

Correlation analysis revealed how tightly the disease was linked to productivity. At Salamago, percent severity and AUDPC were almost perfectly correlated with each other, and grain yield showed strongly negative associations with both disease measures. Head diameter and thousand seed weight also declined as disease pressure rose. Similar negative relationships between disease parameters and yield emerged at Debub Ari, confirming that every increment of mildew severity translated into measurable losses in the components that determine final harvest weight.

Yield data told the same story from the opposite direction. The highest yields came from Russian black plots treated with propiconazole twice, reaching 2869.8 kilograms per hectare at Salamago, followed by 2841.3 kilograms per hectare with a single sulphur spray and 2834.9 kilograms per hectare with two sulphur applications. Closely similar trends appeared at Debub Ari. Untreated local variety plots, by contrast, yielded just 1289.5 kilograms per hectare at Debub Ari and 1574.6 kilograms per hectare at Salamago. Plant height and head diameter also responded to treatment, with the tallest plants and largest heads generally found in the improved variety under effective fungicide programs.

The economics proved equally persuasive. In a partial budget analysis that accounted for fungicide costs, local market prices, and a 10 percent downward adjustment of experimental yields to reflect realistic farm conditions, the highest net benefits came from Russian black sprayed once with propiconazole, followed by the two-spray propiconazole program and the sulphur treatments on the same variety. Untreated local plots delivered the lowest returns by a wide margin. Gap analysis summarized the practical advantage: treated plots reduced mean disease severity by roughly 91 percent compared with usual agro-pastoral practice and offered a 45.58 percent yield advantage over unsprayed controls.

The authors conclude that integrating the improved Russian black variety with propiconazole 25% EC at 0.1 percent concentration, followed by wettable sulphur 80% where appropriate, offers farming communities in South Omo a reliable and affordable strategy against powdery mildew. Because propiconazole is already available in local markets and provides both curative and protective action, adoption barriers are low. For a crop that anchors edible oil production across the region’s drought-prone landscapes, the study suggests that a modest investment in variety choice and spray timing can transform powdery mildew from a chronic yield thief into a manageable problem.

Subject of Research: Integrated management of sunflower powdery mildew using resistant varieties and fungicides in southern Ethiopia

Article Title: Management of sunflower powdery mildew through varieties and fungicides application in Debub Ari and Salamago districts of South Omo, Southern Ethiopia

Article References: Adila, W., Jerjero, T., & Bekele, F. (2025). Management of sunflower powdery mildew through varieties and fungicides application in Debub Ari and Salamago districts of South Omo, Southern Ethiopia. Innovations in Agriculture, 8, 1-7. https://doi.org/10.3897/ia.2025.143321

Image Credits: AI Generated

DOI: 10.3897/ia.2025.143321

Keywords: sunflower, powdery mildew, Erysiphe cichoracearum, fungicides, propiconazole, wettable sulphur, Ethiopia, South Omo, plant pathology, crop yield, integrated disease management, agronomy

The review, led by M. S. Gambo of Aliko Dangote University of Science and Technology in Nigeria together with colleagues in India and Nigeria, contrasts two very different epidemiological stories. In the Old World, Tomato leaf curl New Delhi virus (ToLCNDV) has undergone a remarkable intercontinental expansion from its origin in the Indian subcontinent, reaching Southeast Asia, the Middle East, North Africa and, since its first detection in Spain in 2013, the Mediterranean Basin. In the New World, persistent complexes such as Squash leaf curl virus (SLCV) and Cucurbit leaf crumple virus (CuLCrV) remain endemic threats to squash, melon and pumpkin production. Both scenarios are amplified by the spread of the whitefly vector Bemisia tabaci, climate-driven shifts in vector distribution and changing agricultural practices.

Symptom expression in the field is highly variable, which complicates diagnosis. CuLCrV typically induces downward leaf curling in watermelon and squash, whereas SLCV more often causes upward leaf cupping and severe distortion. ToLCNDV infection in zucchini, melon and cucumber is characterized by vein hypertrophy on young leaves, although severity varies with cultivar and environment. Mixed infections add further complexity: in Lebanon, co-infection of Watermelon chlorotic stunt virus (WmCSV) and SLCV produced more intense yellowing, leaf deformation and dwarfing than either virus alone, and similar multivirus disease complexes have recently been described in Saudi Arabia. The authors stress that visual symptoms should be treated only as a first filter, to be confirmed by molecular assays before any epidemiological or management decision is made.

At the molecular level, begomoviruses carry circular single-stranded DNA genomes of roughly 2.5 to 2.8 kilobases, either as a single component (monopartite) or as two components, DNA-A and DNA-B (bipartite). Bipartite genomes predominate among New World viruses, while both arrangements occur in the Old World. DNA-A encodes the replication-associated protein Rep, the transcriptional activator TrAP, the replication enhancer REn, the multifunctional C4 protein that contributes to symptom development and host defense suppression, the coat protein that mediates encapsidation and vector transmission, and, in many Old World viruses, the V2 pre-coat protein involved in movement and silencing suppression. DNA-B encodes the nuclear shuttle protein and the movement protein, whose coordinated action is essential for systemic infection.

This architecture is a platform for evolution. Multiple recombination breakpoints have been identified in the Rep and coat protein genes of ToLCNDV and linked to host-range expansion and intercontinental dissemination, allowing the virus to infect more than 11 cucurbit species as well as tomato, potato and numerous weed hosts. Pseudorecombination—the exchange of DNA-A and DNA-B components between compatible bipartite viruses—has generated novel lineages with altered symptom severity and host range, and the frequent co-infection of multiple begomoviruses in fields with high whitefly pressure provides abundant raw material for such reshuffling. Satellite molecules deepen this complexity. Betasatellites, circular DNAs of about 1.3 kilobases, encode the βC1 protein, a potent suppressor of host RNA silencing that drives severe leaf curling, enations and stunting; they have been found associated with ToLCNDV and WmCSV in cucurbits and correlated with increased symptom severity and higher viral DNA accumulation. Alphasatellites, by contrast, generally do not intensify symptoms but may modulate transmission or replication, while deltasatellites—non-coding defective derivatives of the helper genome—have so far not been definitively characterized in association with any major cucurbit-infecting begomovirus, a gap the authors say warrants systematic surveys.

Tissue-level biology reinforces the epidemiological picture. Cucurbit-infecting begomoviruses are strongly phloem-limited: classical ultrastructural work on SLCV in zucchini revealed abundant virions and large nuclear inclusion bodies in vascular parenchyma and maturing sieve elements, with sieve element necrosis appearing within days of infection. Immunolocalization and in situ hybridization confirm that CuLCrV is strictly phloem-limited and not sap-transmissible, in contrast to many mechanically transmissible cucurbit RNA viruses such as the potyvirus-like Squash yellow leaf curl virus, which produces cytoplasmic pinwheel inclusions. This phloem restriction explains why begomoviruses are acquired and inoculated by phloem-feeding whiteflies and supports management tactics that target vascular feeding stages, including systemic insecticides, rather than contact approaches alone.

On the diagnostic front, the review offers a comparative framework spanning conventional and quantitative PCR, isothermal amplification, rolling-circle amplification, serology, portable sequencing and emerging CRISPR-based assays. Laboratory PCR and qPCR remain the benchmark for high-confidence diagnosis, with qPCR detecting as little as 10 to 100 femtograms per microliter, but they require thermocyclers, reliable power and trained personnel. Isothermal methods such as loop-mediated isothermal amplification (LAMP) and recombinase polymerase amplification (RPA) approach PCR-level sensitivity with simpler equipment: LAMP assays for ToLCNDV in pumpkin return results in 30 to 45 minutes, and RPA for Squash leaf curl Philippines virus in pumpkin in 15 to 30 minutes, making both suitable for field-adjacent testing. Portable nanopore sequencing platforms such as MinION can resolve whole genomes and mixed infections within one to three days but remain constrained by cost, infrastructure and bioinformatics demands. No single method is optimal in all contexts, and the authors argue that the choice should match the surveillance purpose, from seed-health certification to outbreak investigation.

Management remains anchored in host resistance, which is the most sustainable strategy but is complicated by the genetics of the resistance sources identified so far. In cucumber, the Cy-1 locus on chromosome 1 encodes CsRDR3, a DFDGD-class RNA-dependent RNA polymerase that functions in transcriptional gene silencing and is orthologous to known antiviral genes in tomato and pepper; map-based cloning narrowed the locus to a 209-kilobase interval, and virus-induced gene silencing of CsRDR3 abolished resistance, confirming its causal role. In pumpkin, the cultivar Punjab Nawab carries digenic recessive resistance to mixed infections of Squash leaf curl China virus and ToLCNDV, controlled by loci on chromosomes 7 and 17, with the major locus fine-mapped to a 103-kilobase interval and captured by nine KASP markers suitable for marker-assisted selection. In melon, a major quantitative trait locus on chromosome 11 reduces ToLCNDV accumulation. Because resistance in these crops is largely recessive and quantitative, the authors advocate gene pyramiding—stacking Cy-1 with additional cucumber QTLs on chromosomes 2, 6 and 7, or combining the two pumpkin loci—to reduce the probability of resistance breakdown.

Complementary tactics are maturing at different speeds. Biological control with the parasitoid Encarsia formosa and reflective aluminum mulches that disorient whiteflies are already commercial, while exogenous double-stranded RNA sprays targeting ToLCNDV genes remain experimental, and CRISPR/Cas9 editing of host susceptibility factors such as eIF4E in cucumber is still at the laboratory stage. Seed certification based on PCR or rolling-circle amplification testing is under development, a notable gap given documented seed transmission of CuLCrV in squash. Vector management is further complicated by rapid insecticide resistance in whitefly populations and by the lack of region-specific strategies that account for local virus–vector complexes, including differences between B. tabaci biotypes such as MEAM1 and MED in transmission efficiency and insecticide susceptibility.

Looking forward, the review sets out a research agenda that couples genomics with artificial intelligence and climate science. The authors call for multiplex LAMP and RPA assays capable of simultaneously detecting ToLCNDV, SLCV, CuLCrV, WmCSV, SLCCNV and associated betasatellites, validated across multiple cucurbit-producing regions and embedded in standardized international seed-health protocols. AI-driven predictive models should link viral genomic changes to epidemiological outcomes, providing early warning of high-risk variants, while machine-learning forecasts trained on whitefly population dynamics, weather and cropping patterns could generate short-term risk alerts delivered through simple channels such as SMS. Modeling future disease hotspots under climate-change scenarios would guide targeted deployment of resistant cultivars and vector management. The unifying message is that begomoviruses will keep evolving faster than any single control measure; only sustained, multidisciplinary investment spanning virology, vector biology, host genetics and climate science can turn today’s fragmented knowledge into durable protection for the world’s cucurbit fields.

Subject of Research: Begomovirus diversity, epidemiology and management in cucurbit crops

Article Title: Global emergence of begomoviruses in cucurbits: diversity, epidemiology, and management strategies

Article References: Gambo, M. S., Hurakadli, M. S., Baghel, M. M., Suleiman, S. A., Jangra, N., & Dagar, A. (2026). Global emergence of begomoviruses in cucurbits: diversity, epidemiology, and management strategies. Frontiers in Virology, 6, Article 1890227. https://doi.org/10.3389/fviro.2026.1890227

Image Credits: AI Generated

DOI: 10.3389/fviro.2026.1890227

Keywords: begomovirus, cucurbits, Bemisia tabaci, ToLCNDV, plant virology, recombination, betasatellite, diagnostics, host resistance, RNA interference, CRISPR, integrated disease management

Charcoal rot disease, caused by M. phaseolina, is among the most damaging soil-borne diseases of cotton. The pathogen is remarkably versatile, infecting more than 500 plant species across roughly 75 botanical families. Its persistence in fields is largely due to melanized microsclerotia, robust multicellular survival structures that allow the fungus to endure in soil and plant residue for extended periods. Symptoms typically emerge during flowering and boll development, manifesting as wilting, desiccation of stems and leaves, and ultimately plant death, with complete mortality sometimes observed in affected patches. Because no highly resistant cotton cultivars exist, systemic fungicides remain the primary means of suppression, but chemical control often delivers inconsistent results, and the emergence of fungicide-resistant strains has intensified the search for sustainable alternatives.

The research team, led by Ofir Degani, set out to characterize how different disease management regimes shape the community of fungi recoverable from cotton roots. The field trial compared three approaches: conventional chemical management using the fungicide azoxystrobin, biological management based on Trichoderma seed coating, and an integrated strategy combining both. In previously reported agronomic results, the biological and integrated treatments increased cotton yield by up to 17 percent, reduced visible disease symptoms by up to 27 percent, and decreased pathogen DNA levels in roots by up to 37 percent, performing as well as or better than standard chemical management. The integrated biological-chemical approach conferred a statistically significant advantage in plant health over purely chemical interventions.

To probe the root-associated fungal world, the researchers collected roots from 84 field plots at two points in the growing season, once at mid-season when all plants were asymptomatic and again at season’s end when half the sampled plants showed visible charcoal rot symptoms. After surface sterilization to remove epiphytic contaminants, internal root tissues were plated onto potato dextrose agar to recover viable endophytic microorganisms. Approximately 300 isolates emerged, from which 66 representative morphotypes were selected and molecularly identified using ribosomal DNA markers and phylogenetic analyses anchored to type strains. The final collection comprised 56 fungal and 10 bacterial isolates spanning 24 fungal species across 11 genera.

The temporal patterns were striking. Aspergillus dominated the mid-season recovery, representing 30 to 43 percent of fungal isolates from asymptomatic roots, followed by Trichoderma at 14 to 20 percent. By season’s end, however, Alternaria had become the most frequently recovered genus in symptomatic plants, accounting for 35 percent of isolates. The numbers of recovered fungal isolates and taxa increased modestly in asymptomatic plants but rose sharply in symptomatic plants, a pattern consistent with the idea that declining host vigor opens ecological niches for secondary colonists, latent pathogens, and saprotrophs. This progressive diversification supports an emerging view of plant disease in which severity reflects cumulative microbial interactions rather than the action of a single dominant pathogen.

Management regime left its own fingerprint on the recovered community. The highest taxon richness was consistently observed in plants under integrated or chemical management, likely reflecting partial suppression of dominant taxa that preserves ecological space for subdominant colonists. In contrast, Trichoderma seed coating was associated with markedly lower recovery of fungal isolates and taxa, with richness declining from 29 percent to as low as 9 percent in asymptomatic plants by season’s end. Whether this reduction reflects suppression of opportunistic pathogens or broader effects on non-target root fungi remains an open question that sequencing-based community profiling will need to resolve. The finding raises an ecologically important consideration: biological interventions may reshape the entire root microbiome, not just the pathogen they target.

To understand how these co-occurring fungi interact with M. phaseolina, the team selected four representative isolates for controlled testing: Aspergillus niger, Alternaria alternata, Rhizopus arrhizus, and the Fusarium-like pathogen Neocosmospora solani. In dual-culture plate assays, antagonism proved highly species-dependent. A. niger and N. solani emerged as potent competitors, while R. arrhizus consistently showed growth stimulation or neutral interactions, physically overgrowing other colonies without effectively suppressing them. Notably, diffusible extracellular compounds exerted stronger inhibition than direct contact in several combinations, with N. solani suppressing M. phaseolina growth by 74 percent in the culture-conditioned medium assay. Volatile-mediated antagonism, by comparison, was weak and inconsistent, suggesting that in the dense, hydrated environment of cotton roots, soluble metabolites may matter more than airborne signals.

The biocontrol strain Trichoderma asperellum P1, used in the field seed coating, showed its strongest activity in direct confrontation assays, achieving 55 percent inhibition of M. phaseolina growth, with volatile-mediated inhibition at 51 percent and a shallow liquid assay at 38 percent. A solid-medium growth-fluid format produced negligible inhibition of just 3 percent, a result the authors attribute to differences in how antifungal compounds diffuse and remain stable across assay matrices. To connect this activity to a chemically defined natural product, the researchers tested commercial 6-pentyl-alpha-pyrone, a compound previously isolated from P1 culture medium. The results were dramatic: at nominal concentrations of 400 to 800 micrograms per milliliter, 6-PP inhibited M. phaseolina by 94.5 to 100 percent through 72 hours, with effects that were both concentration- and time-dependent.

The greenhouse seedling assay added a critical in planta dimension. Over 33 days, co-inoculation experiments revealed that certain root-associated fungi can influence early pathogen establishment even when no visible symptoms develop. Quantitative PCR revealed mean reductions in M. phaseolina root DNA of 92 percent with A. niger, 94 percent with N. solani, and 99 percent with A. alternata, compared with only 47 percent for R. arrhizus. After statistical adjustment for multiple comparisons, only the reduction associated with A. alternata remained significant, underscoring the need for rigorous validation. Early seedling development itself was largely unaffected, consistent with the latent nature of charcoal rot during its invasion stage, but the molecular diagnostics clearly detected differences in pathogen colonization that visual assessment could not.

The broader implications reach beyond a single crop or pathogen. The study demonstrates that charcoal rot severity is shaped by microbial context rather than pathogen presence alone, and that specific co-occurring fungi can either suppress or enable pathogen colonization during early plant development. The authors caution that their culture-dependent, morphotype-selected approach captures only a subset of the recoverable root community and cannot establish community-wide restructuring or causality. Still, the framework they propose, integrating field isolation with functional interaction assays and molecular diagnostics, offers a practical path toward microbiome-informed disease management. Future priorities include validating these interactions across diverse field conditions, developing multispecies biocontrol consortia, and combining culture-based functional testing with next-generation sequencing. As synthetic fungicides face mounting resistance and regulatory pressure, the message from Israeli cotton fields is clear: the most durable defense against one of agriculture’s most persistent pathogens may lie in cultivating the right fungal neighbors.

Subject of Research: Root-associated fungal community dynamics and biological interactions affecting cotton charcoal rot disease management

Article Title: Dynamics of culture-recovered cotton root-associated fungi under charcoal rot disease and preventive management regimes

Article References: Etedgi, E., Demenchuk, D., Dimant, E., Hadari, P., & Degani, O. (2026). Dynamics of culture-recovered cotton root-associated fungi under charcoal rot disease and preventive management regimes. Frontiers in Fungal Biology, 7, Article 1928692. https://doi.org/10.3389/ffunb.2026.1928692

Image Credits: AI Generated

DOI: 10.3389/ffunb.2026.1928692

Keywords: cotton, charcoal rot, Macrophomina phaseolina, Trichoderma, root microbiome, biological control, 6-pentyl-alpha-pyrone, qPCR, integrated disease management, endophytic fungi, Aspergillus, Alternaria

The research, led by Lintang Dian Saraswati of Queensland University of Technology and Diponegoro University, together with colleagues in Australia and Indonesia, focused on the Collaborative Framework for the Care and Control of Tuberculosis and Diabetes, a strategy Indonesia adopted in 2015. Detailed standard operating procedures followed in 2021, specifying that people with diabetes should receive chest X-ray screening for tuberculosis as part of their regular care. Yet little was known about how the patients themselves experience this screening, and that gap is precisely what the team set out to fill.

Between August and November 2023, the researchers conducted three focus group discussions involving eighteen participants and two in-depth interviews in Semarang City and Klaten District in Central Java. Participants were recruited purposively from both hospital and non-hospital settings, capturing perspectives from patients navigating different tiers of the Indonesian health system. Semi-structured guides with open-ended questions allowed respondents to describe their journeys through screening in their own terms, from the first referral slip to the moment the X-ray image was taken.

To make sense of the transcripts, the team applied a hybrid deductive-inductive thematic analysis anchored in the Health Belief Model, a classic psychological framework that explains health behaviour through perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. This approach let the researchers test whether the model’s constructs emerged in patients’ accounts while remaining open to themes the framework did not predict. The result is a layered map of the psychological and practical terrain a diabetic patient must cross before an X-ray actually happens.

The study’s central finding is that personal health beliefs and interpersonal support are the engine of participation. Patients who understood that diabetes silently raises their tuberculosis risk, and who felt encouraged by family members or trusted health workers, were far more willing to undergo screening. Cues to action, such as a nurse’s reminder or a relative’s insistence, often tipped the balance toward attendance. In the language of the Health Belief Model, perceived susceptibility and perceived benefit had to be activated by social reinforcement before they translated into behaviour.

Against those facilitators stood a cluster of structural barriers that no amount of personal motivation could easily overcome. Many participants had limited awareness of tuberculosis symptoms and, crucially, of the biological link between the two diseases, meaning they saw no reason to be screened when they felt well. Fear of nosocomial infection, the worry that visiting a clinic or hospital to prevent one disease might expose them to another, emerged as a particularly potent deterrent in the aftermath of a pandemic that made waiting rooms feel hazardous. Logistical challenges, including travel to facilities and time away from work, compounded the reluctance.

Financial concerns formed a second axis of inequity, but in a way that surprised the researchers. Indonesia’s Social Security Agency on Health, known as BPJS, covers the cost of screening for enrolled patients, dramatically reducing direct out-of-pocket expenditure. Yet participants described administrative and referral-related burdens that consumed time and patience: paperwork, queues, and the requirement to move through a hierarchy of first-level facilities before reaching secondary care. Paradoxically, the two self-funded participants in the study reported greater flexibility in accessing services, hopping directly to convenient providers, although the authors caution that these accounts should be interpreted as illustrative rather than representative, given the tiny number of such respondents.

The technical logic behind the programme is sound. Chest radiography can detect pulmonary tuberculosis in people who produce no sputum and report no cough, which is exactly the profile of many diabetic patients whose immune suppression blunts the classic symptoms of the disease. Systematic screening of this high-risk group is a cornerstone of the World Health Organization’s framework for collaborative tuberculosis-diabetes care, because every case caught early interrupts a transmission chain and prevents the catastrophic costs of late diagnosis. Indonesia’s 2021 standard operating procedure was designed to make such screening routine rather than opportunistic, embedding it in the chronic-care visits that diabetic patients already attend.

What the new study demonstrates is that a technically elegant procedure lives or dies at the level of human experience. A patient who fears the clinic, cannot decode the referral system, or does not grasp why an asymptomatic person needs a lung image will simply not arrive, no matter how sophisticated the radiography equipment waiting for them. The authors argue that health systems should therefore launch targeted educational campaigns that address two specific gaps: the risk posed by asymptomatic tuberculosis in diabetic patients, and the exaggerated fear of catching infection inside health facilities. They further recommend streamlining bureaucratic referral processes so that coverage on paper translates into equitable access in practice.

The findings carry weight far beyond Central Java. The twin epidemics of tuberculosis and diabetes intersect across South Asia, Southeast Asia and sub-Saharan Africa, and collaborative screening programmes are being rolled out in many of the same high-burden settings. By grounding programme evaluation in patients’ perspectives rather than administrative statistics, the study offers a template for implementation science: identify the beliefs that motivate, the fears that paralyse, and the paperwork that exhausts, then redesign the pathway around them. For Indonesia’s national programme, the message is clear. The X-ray machines are in place and the insurance coverage exists; the remaining task is to make the journey to the screening table feel safe, understandable and worth every patient’s time.

Subject of Research: Patient perspectives on chest X-ray tuberculosis screening within Indonesia's collaborative tuberculosis-diabetes programme

Article Title: Barrier and facilitator for chest X-ray tuberculosis-diabetes mellitus (CXR TB-DM) programme from patient’s perspective: a qualitative study

Article References: Saraswati, L. D., Pardosi, J. F., Widjanarko, B., & Gatton, M. L. (2026). Barrier and facilitator for chest X-ray tuberculosis-diabetes mellitus (CXR TB-DM) programme from patient’s perspective: a qualitative study. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14427-8

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14427-8

Keywords: tuberculosis, diabetes mellitus, chest X-ray screening, Indonesia, health belief model, qualitative research, BPJS, nosocomial infection, health systems, patient barriers, Central Java, public health