Why we studied diabetes screening uptake in Aceh, Indonesia
Published in Healthcare & Nursing, Social Sciences, and General & Internal Medicine
The story behind the research
When we started our research project in 2019, the ambition of Indonesia’s health system was clear: free, community-based screening services for noncommunicable diseases (NCDs) such as hypertension and diabetes were rolled out broadly — every community health center (“Puskesmas”) and many village level “Posbindu” (health posts) offered screening. Yet, uptake remained surprisingly low.
We began asking: why? If the financial and logistical barriers are largely addressed (i.e. screenings are free and local), what holds people back from actually going? Are there knowledge gaps? Misconceptions? Attitudes that deter action? And how much does socioeconomic status or education play a role in who gets screened?
Our aim was to probe these barriers, from the perspective of the individuals—their knowledge, beliefs, and behaviors (KAP)—in a representative sample of adults aged 40–70 who should be screened per WHO PEN guidelines but who had not been recently screened. We believed that a deeper understanding of these “demand-side” obstacles could inform better strategies to close the gap in screening uptake, beyond just increasing supply.
Our approach
To explore these questions, we conducted a cross-sectional, population-based survey across the Indonesian province of Aceh in our paper "Hypertension and diabetes screening uptake in adults aged 40–70 in Indonesia: a knowledge, attitudes, and practices study". Using a two-stage cluster random sampling design, we selected 152 villages to capture a mix of urban and rural contexts and recruited adults aged 40 to 70 years — the target group for hypertension and diabetes screening under national guidelines. The study ultimately included 2,080 respondents, providing one of the largest datasets to date on community-level NCD screening behavior in Indonesia.
Data were collected through structured face-to-face interviews led by trained local enumerators. The questionnaire, adapted from WHO’s STEPS framework and national health surveys, captured four domains:
- Sociodemographic characteristics (e.g., education, income, residence);
- Knowledge of hypertension and diabetes risk factors and screening needs;
- Attitudes toward preventive screening and perceived personal risk; and
- Practices related to past screening experiences and health-seeking behaviors.
What stood out to us most
One of the most striking findings was that about 41% of respondents had never had any blood pressure or glucose check—despite free, local screening availability. Whenever respondents had been screened before, blood pressure checks were far more common than glucose checks: nearly everybody had a blood pressure measurement, but only ~21% had a blood glucose check in their last screening. That suggests that hypertension screening may be more opportunistically integrated into health encounters. In contrast, glucose testing often requires more resources, lab support, or is treated as a conditional add-on, not standard care.
We found critical gaps in the understanding of diabetes and hypertension: while most respondents were aware of these conditions, many did not know about which lifestyles may lead to diabetes and hypertension nor that they can start off ‘silently’ – without any symptoms. Instead, it was commonly believed that only those feeling ill should undergo screening.
We also saw clear socioeconomic gradients: living in rural areas, having lower education, and being in lower wealth quintiles were all strongly associated with lower knowledge and lower screening uptake. It reinforced our belief that universal access alone is not sufficient; equity in health demands addressing awareness, beliefs, and social determinants.
What this means going forward
From our work, several actionable lessons emerge:
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Make screening guidelines and risk messaging more salient
Many people don’t see screening as relevant unless symptoms arise. Health education campaigns need to stress that hypertension and diabetes can be “silent” and that people without symptoms should still be screened. -
Differentiate strategies for hypertension vs. diabetes
The barriers appear disease‐specific—blood pressure measurements seem more normalized in care contexts, while glucose testing is rarely routine. Tailored strategies may be needed for each, including that health systems could equip more frontline facilities with affordable point-of-care glucose devices and protocols. -
Leverage trusted community platforms
Posbindu screening posts were underutilized (only 9% of last screenings) despite being very local. Strengthening their visibility, reducing resource constraints, and reframing usage so people don’t dismiss them as for “the elderly only” could help. -
Target disadvantaged groups with additional support
Lower-educated, rural, and lower-wealth individuals lag in both knowledge and uptake. Interventions (e.g. community outreach, peer education, mobile reminders) should especially prioritize those groups.
We hope our work helps health planners in Indonesia — and other settings with persistent gaps in NCD screening — in their efforts to holistically bridge the last mile: not just offering services, but ensuring they are seen, understood, trusted, and accessible by everyone. While there are some evidence-based approaches on how to achieve this (also see our paper on the effect of SMS reminders on diabetes and hypertension screening uptake in the same study population), more large-scale, effective, and innovative ideas are needed to ensure NCD care for all!
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