Understanding health-seeking behaviours of people in Indonesia; and developing, piloting, and evaluating a culturally appropriate intervention for people with diabetes

Indonesia is facing a dual burden of communicable and non-communicable diseases. Childhood-immunisation coverage is lower than most countries in Southeast Asia, with vaccine-preventable disease outbreaks frequently reported. Prevalences of non-communicable diseases are also rising, including type 2 diabetes. Diabetes is further linked to tuberculosis and stunting - health problems which remain common in Indonesia. Understanding people’s health behaviour is an important step to establishing effective interventions. In Indonesia, a multicultural country with multiple health providers, health-related behaviour is more complex. I aimed to improve outcomes related to child immunisation or diabetes through implementing an intervention based on understanding people’s health behaviour. Two stages of studies were conducted. A qualitative study explored the perceptions, beliefs and behaviour of diverse communities in relation to child immunisation and diabetes. Six focus groups involving 53 mothers and six focus groups involving 45 people with diabetes were performed in West Sumatera and East Nusa Tenggara. Recorded discussions were transcribed, translated, and analysed for common themes. For child immunisation, themes underlined the role of fathers and community-based health workers in influencing mothers’ behaviour. Issues related to Posyandu (an outreach programme for mother and child health) including lack of financial support, and potential missed opportunities were highlighted. Diabetes patients’ behaviour in managing the disease was prompted by the individual lay evaluation of the disease and its treatment, a process influenced by family and peers with diabetes. This process changed the appeal and acceptability of specific health services. Further, cultural beliefs, family and community support challenged people with diabetes in practising self-management behaviours. This qualitative work on diabetes revealed a complex situation contributing to late diagnosis, uncontrolled blood glucose, and prevalent diabetes-related complications. Therefore, while acknowledging the importance of child immunisation, I subsequently focused on diabetes. Informed by the literature review and qualitative work, a quasi-experimental pilot study was developed and conducted in Kupang, East Nusa Tenggara. Usual care was compared to an intervention consisting of ten sessions of weekly group activities including education, exercise, and healthy snacking, conducted in collaboration with primary health centres (PHCs). Sixty-seven participants were recruited from four PHCs, and were allocated into groups (intervention: 36; control: 31) based on the PHCs they were registered in. Participants were 60% female, mean age 57, and had diabetes for an average of 4.5 years. Groups did not differ at baseline. Counter to prediction, no effects of the group-based intervention over usual care were observed. However, both groups made statistically significant improvement in HbA1c (intervention improved from 8.26%±1.89 to 7.84%±1.82; control from 8.35%±2.60 to 7.95%±2.53). Exploratory analyses found more intervention than control participants achieved an HbA1c reduction of 0.5% (43% compared to 31%). The intervention appears to have provided a positive impact through stimulating local healthcare providers to more intensively manage their diabetes patients, including the control group. These findings are important for government and related stakeholders in managing health problems related to child immunisation and diabetes. Tailored interventions – based in socio-cultural context – to influence behaviour should be established, to improve child immunisation uptake and diabetes patients’ outcomes