Implementation preventive program for diabetic mellitus (PROLANIS) at Community Health Center in Indonesia: A qualitative study

INTRODUCTION

Diabetes mellitus (DM) has skyrocketed since 1980, ballooning from 108 million to 537 million (8.5%) cases in 2021 alone [1–3]. This alarming trend is projected to continue, reaching 643 million by 2030 and a staggering 783 million by 2045 [4]. A chronic disease often affecting older adults and adults in general, diabetes comes in various forms. Notably, type 2 diabetes tends to strike individuals from lower-middle to upper-middle income classes [2,5–7]. Fortunately, type 2 patients can significantly improve their quality of life by adopting healthy habits like dietary changes, regular physical activity, and weight management. Studies have shown that comprehensive interventions, like those offered in diabetes prevention programs (DPPs), can effectively prevent diabetes in obese individuals [6–8]. Additionally, a systematic review revealed that more intensive interventions lead to better outcomes for existing diabetes patients, including improved quality of life, lower blood sugar levels, reduced body weight, and fewer complications [9].

While preventing diabetes can prevent future complications, expanding healthcare interventions toward prevention and control remains a challenge for Indonesia’s Ministry of Health. The implemented Chronic Disease Prevention Program PROLANIS, offering medical consultations, educational groups, SMS reminders, home visits, and health monitoring for hypertension (HT) and diabetes patients, shows promise but suffers from low coverage [8]. Health programs in the form of interventions have a positive impact, but these services have low coverage. In research conducted by Assupina. et al. [10], regarding the evaluation of the PROLANIS program in Palembang City, it shows that program implementation is still less [10]. One of the problems revealed in this research is the failure to organize club activities due to a lack of energy and facilities. Research by Assupina et.al. [10] points to several obstacles: lacking energy and facilities hindering club activities, insufficient infrastructure and resources hampering program delivery, inconsistent management practices across healthcare settings, and varying participant engagement. Additionally, Sari [11] and Sitompul et al. [4] highlighted that geographical disparities, uneven distribution of facilities, and diverse viewpoints due to the unavailability of standard operating procedures (SOPs) among health workers and stakeholders further exacerbate implementation challenges, particularly in remote areas [11,4]. Other research has found that geographical factors, availability of health facilities, and perceptions of health workers and stakeholders are the causes of unsuccessful implementation due to differences in developed areas and underdeveloped areas [9].

While Community Health Centers, popularly known as Puskesmas, serve as the first point of medical care for many Indonesians, their role extends beyond initial consultations. One notable example is the PROLANIS program, specifically targeting elderly individuals with diabetes or HT who frequent these facilities. Recognizing the program’s potential impact across diverse regions, this research delves into the nuances of its implementation across five Indonesian locations chosen based on the country’s Universal Health Coverage regionalization. By examining real-world variations in practice, this study aims to illuminate the implementation landscape of PROLANIS and inform its future optimization.

METHODS

RESULTS

Nineteen health workers from diverse Indonesian regions (illustrated in Fig. 1) participated in this study, offering valuable insights into the PROLANIS program. The majority of participants fell within the 32-39 age range, and women were prominently represented. As Table 1 details, nurses formed the primary informant group, though doctors and even a pharmacist contributed perspectives from various community health centers. To glean a comprehensive understanding of their experiences, we analyzed the research findings through the lens of two key CFIR domains: intervention characteristics and implementation processes. This multifaceted approach aimed to illuminate the strengths, challenges, and nuances of PROLANIS implementation across diverse Indonesian contexts.

Intervention characteristic

Implementation discusses what is being implemented, and what is the type, core, and origin of the program being implemented, as well as components that need to be adjusted [14–16]. 5 points are discussed in implementation characteristics including, intervention resources, relative advantage, adaptability, complexity, and cost. Intervention resources refer to an organization or group that develops programs and sponsors them, typically a credible and reputable organization [14]. Relative advantage refers to the advantage of the program implemented, while adaptability refers to the flexibility of the implemented program and the possibility to modify the program according to local resources, in this case, the local context. Complexity refers to a measure of the difficulty of implementing this program, either in terms of connections or coverage and cost as the financing point of a program [17,18].

Figure 1. Five regionalization of research. [Click here to view]

Intervention resources

As part of the National Health Insurance Program (BPJS), the PROLANIS program, being implemented progressively since 2016, has adapted its approach in certain rural areas around Denpasar. These areas, where local communities traditionally organize through Banjar groups, benefit from PROLANIS activities both at the community health center and within their own communities, ensuring easier participation for older residents.

“...around 3,400 local residents here participated in the PROLANIS program’s medical consultations and group education activities, organized by their community health center (Puskesmas). These activities are considered by BPJS in their evaluation of Puskesmas performance, which can ultimately influence UHC funding allocations to individual Puskesmas. This incentivizes Puskesmas to effectively engage residents in PROLANIS activities, aiming to improve health outcomes and optimize resource allocation within the UHC system...” (Denpasar, informant 4).

“…For a long time, people in Banjar have enjoyed participating in regular exercise through a local gathering. When the BPJS PROLANIS program arrived in 2016, we realized it could complement our existing activities. So, we reached out to PROLANIS and invited them to bring their resources and activities to our community...” (Yogyakarta, informant 5).

Relative advantage

The PROLANIS program’s focus on pain management in chronic diseases like diabetes is seen as beneficial for both patients and community health centers (Puskesmas). Patients not only gain better awareness of their pain and effective management strategies, but also develop a deeper understanding of the importance of medication adherence, leading to improved pain control. For Puskesmas, this translates into improved performance by helping them achieve their target blood sugar level goals set by Badan Penyelenggara Jaminan Sosial (BPJS), demonstrating successful disease management within the community.

“….the PROLANIS participants are eager to stay active, even if their legs sometimes falter. They enthusiastically participate in gymnastics, and their supportive WhatsApp group allows them to ask questions, share their experiences with managing their conditions, increasing compliance taking medicine by counseling pharmacy and exchange health tips. Their knowledge about healthcare extends beyond hypertension and diabetes; they quickly grasp new information on various health topics and confidently differentiate between different medications. …” (Kupang, informant 10).

Adaptation

One region cleverly adapted the PROLANIS program by integrating it with their established Posyandu village outreach services. This means that PROLANIS activities such as physical exercises and educational sessions are now conducted directly within the villages, eliminating the need for elderly residents to travel to the community health center. This innovative approach not only eases participation for older individuals but also fosters a more inclusive environment and strengthens community engagement in health initiatives.

“…As an adaptation, we combine PROLANIS activities like physical exercises and educational sessions with regular monthly health checks in the villages. These combined sessions, conducted together with Puskesmas staff (Pusling)...” (Boalemo, informant 13)

Complexity

Puskesmas faces challenges in implementing PROLANIS due to shortages of medicines and limited human resources. This can lead to delays in services, reduced activity frequency, or limitations in reaching all participants. The funding for PROLANIS activities comes from BPJS through monthly claims.

“...One recurring issue, both this year and in previous years, has been access to prescribed medications. Sometimes, when I receive a new prescription, the medication might be out of stock at the pharmacy. In these situations, I may resort to skipping the dose or even trying to find a substitute, which raises concerns about medication adherence and potential health risks. Another problem I encountered involved a referral I received. I was referred to a specialist for further evaluation, but the referral number turned out to be incompatible with the PROLANIS program, causing confusion and delays. To address these challenges, it would be helpful to have clearer distinctions in referral channels and medication stock management systems for both PRB and PROLANIS patients. This would ensure smoother access to needed healthcare services and avoid unnecessary complications....” (Boalemo, informant 13).

“…. Yes, we’re facing human resource challenges due to ongoing staff shortages. This makes it difficult for us to hold regular PROLANIS educational sessions...” (Palangka Raya, Informant 16).

Cost

The claim for financing the activity program is carried out for one activity per group, which consists of the costs of educational speakers, exercise instructors, and food. Medical and laboratory costs are costs incurred based on BPJS treatment claims.

“….For a group of 30 participants, the individual activity program costs per session are as follows: Rp. 500,000 for the educational speaker’s honorarium, Rp. 300,000 for the gymnastics instructor, and Rp. 390,000 for light refreshments. Additionally, each group claims Rp. 15,000 per month through BPJS for medication refills and specific lab checks under the program’s capitation arrangement. This arrangement covers medicine, while individual lab check costs are factored into the total based on actual usage...” (Boalemo, informant 14).

Implementation process

The implementation process explains how health workers act in delivering activity programs. The implementation process consists of planning, engaging, executing, reflecting, and evaluating. Planning refers to the steps to implement the program developed, looking at the description of the initial plan to start implementing PROLANIS. Engaging refers to a participation process involving officials and activity participants. Informants are asked to describe efforts to involve health workers and participants. Execution refers to the stages of implementing activities, steps, schedules, and things that need to be considered during the activity. Reflection and evaluation refer to the facilitator’s perceptions of the implementation of activities.

Planning

The planning was carried out in a structured manner by screening and diagnosing patients of HT and DM. Participants joined groups on social media to determine PROLANIS activity schedules. This group functions as a communication facility between facilitators and activity participants. In planning, the facilitator adapts to field conditions and activity participants.

We collaborate with mobile health centers to conduct screening methods for non-communicable diseases like diabetes (DM) and HT. Once individuals are diagnosed, we follow up with them through targeted activities called “Pusling.” These Pusling activities typically involve directly visiting their communities to provide comprehensive support. We conduct basic health checks, deliver nutrition education sessions, and offer health promotion information, before completing the full program cycle for that location and moving on to the next. (Boalemo, informant 13)

…the first step before starting is to make an announcement in the WhatsApp group to the participants by telling them that there will be gymnastics and education session along with the exact schedule. For us, we just need to invite officers such as nurses, then me, doctors, and maybe the administration….(Yogyakarta, informant 1)

Engaging

As previously explained in the adaptation point, facilitators recruited and screened participants during village visits. The facilitators were nurses, nutritionists, pharmacists, and doctors. The facilitator involved can change according to the activities planned by the community health care.

“... Our PROLANIS activity team consists of 6–7 members, including 1 doctor and 5 nurses. The nurses, trained in basic gym instruction, will lead the combined exercise session alongside dedicated gym instructors. Meanwhile, a designated area will be set up for participants to have their blood pressure checked before or after the workout. As an innovative addition for 2023, we’re incorporating traditional acupressure techniques into the exercise routine. Trained professionals will apply acupressure points during breaks.” (Kupang, informant 11).

Executing

PROLANIS activities are generally carried out once every 2 weeks on a rotating basis. Participants in the HT group will get their own schedule and participants in the DM group will get their own schedule. This group will receive medical consultations and also different laboratory checks, while the material presented in the activity is tailored to the participants’ needs. The facilitator allows HT club participants to take part in DM club activities and vice versa, although not all health centers enforce it.

Figure 2. Relationship intervention characteristic. [Click here to view]

Figure 3. Relationship implementation process. [Click here to view]

.…. implementation is in accordance with what is recommended by BPJS, DM and HT targets...the schedules are also different. 2nd week is for DM, HT is in week 4. For example, if you want to take part in both, you can do so... because sometimes there are educational activities such as physiotherapy for DM...(Denpasar, informant 7)

Reflextion and evaluation

Reflection and evaluation points, the informants emphasized the budget and also human resources. Informants who have problems with human resources have difficulty dividing their time due to the double job desk at the community health center.

…this program is good, because at the Community Health Center we have a target,…a target to control DM patients by what percentage to be able to get full capitation….(Yogyakarta, Informant 4).

DISCUSSION

In this study, we examined the implementation of the program across three geographically distinct 5 regions, Reginal I (Yogyakarta), Regional II (Denpasar), Regional III (Boalemo), Regional IV (Palangkaraya), and Regional V (Kupang) Figure 1. These areas showed that most informants carried out PROLANIS activities according to operational standards set by UHC. Activities originating from UHC are carried out routinely every month by the PROLANIS activity implementation team at the Community Health Center. PROLANIS activities at community health centers generally started in 2016. Variations in program complexity were observed in terms of characteristics, adaptation, and complexity.

PROLANIS activity implementation is significantly influenced by regional adaptations, as Figure 2 demonstrates. This relationship extends to intervention resources and program design. For example, in Denpasar, the facilitator identified an existing tradition of community physical activity called the “Banjar” association. They cleverly adapted this practice by integrating it with village customs to effectively invite more people to join organized PROLANIS activities. The facilitator in Denpasar creatively adapted the existing tradition of community physical activity called the “Banjar” association. By integrating it with village customs like [specific custom used], they effectively encouraged larger participation in organized PROLANIS activities. Similarly, in Boalemo, partnering with the “pusling” mobile health center proved immensely beneficial. “Pusling” teams visiting villages routinely for medical checkups seamlessly incorporated PROLANIS activities into their schedule. This involved gathering patients in a container for interactive sessions of gymnastics and educational workshops focused on diabetes management. Informants in Boalemo particularly emphasized the value of this approach for elderly patients. They not only received physical activity and education about pain management within the familiar “pusling” setting, but also gained access to treatment, traditional health practices like acupressure, and valuable opportunities for peer interaction and knowledge exchange about healthy diets and exercise routines. Such comprehensive support, along with the scientifically proven benefits of physical activity and education, is likely to contribute to weight loss in diabetic patients, increased medication adherence [19], and even prevention of diabetes [6,7,20,21]. These benefits include increasing patient productivity and increasing compliance with taking medication with counseling from pharmacists, doctors, and other health workers so that the health quality of prolanis participants is more focused and controlled.

Human resource limitations emerged as a significant barrier in Region IV (Palangkaraya), mirroring findings from research on DPP implementation that highlight time constraints as a major hurdle [21,22]. This lack of available personnel made it difficult to cater to the high participant enthusiasm in Region IV (Kupang), leading to concerns about exceeding the allocated budget. Drug management proved challenging in both Region III (Boalemo) and Region IV (Kupang), partly due to their location in urban areas with challenging transportation networks. This limited the local affordability of medications and made reliable drug distribution systems difficult to implement. Concerns about drug availability in remote areas echo findings from previous research highlighting barriers to essential medicines in developing countries, often related to production or access limitations [23–25].

While the National DPP offers a general framework, variations in its implementation across regions are vast, and largely influenced by adaptation and complexity. This is evident in program planning, where each region customizes its approach to suit local needs. As Figure 3 showcases, a common practice involves involving participants in schedule design through their representatives, known as club leaders, who then liaise with the facilitator team [22,26,27]. Interestingly, some regional adaptations show remarkable similarities. For example, Regions III and IV share effective strategies for reaching out to villages, often by collaborating with mobile health centers like “pusling” programs. This aligns with research findings demonstrating that program managers readily modify evidence-based interventions based on factors like target audience needs, resource availability, and their own expertise [28–30]. Notably, in PROLANIS, activities are always facilitated by healthcare professionals within community health centers (Fig. 3). This approach, with its built-in support and guidance, has demonstrably positive impacts on patient compliance, as studies have shown that independent activity and without therapy supervision by health worker (pharmacist and doctor) can sometimes lead to reduced adherence [31].

Prior observational studies in the DIPLOMA evaluation highlighted variations in how providers delivered the program, emphasizing the importance of program adaptation for effectiveness [32] This is echoed by research on type 2 diabetes self-management programs, where barriers of cost, time, and cultural mismatch can prevent participation by members of underrepresented groups [20]. However, studies also offer promising examples of programs successfully adapting to meet the specific needs of these communities. Such targeted approaches demonstrate the potential for culturally appropriate and individualized program delivery to improve acceptance and efficacy within marginalized cohorts [33].

While the COVID-19 pandemic did severely impact on the implementation and delivery of the NHS DPP, local leads suggest that this led to an increased focus within localities on prevention work. There was recognition that people who had a diagnosis of diabetes were shown to be at higher risk of developing severe COVID-19 disease and at a greater risk of death [34] compared to people without a diabetes diagnosis. In addition, those from South Asian or Black ethnic origin were at increased risk of mortality from COVID-19 compared to those from white ethnicities [35]. Local leads identified how providers worked quickly to deliver the NHS DPP remotely and supported patients in using technology. This reflects similar reports of innovation in diabetes care during the pandemic, to transfer to a digital platform [36].

This study significantly advances knowledge on the implementation of the National DPP across diverse settings in Indonesia. However, it’s important to acknowledge some limitations. Interviewing only 1 program facilitator at each of the 19 community health centers from 5 regions prevented the full capture of the range of perceptions regarding PROLANIS activity implementation. Additionally, limiting our focus to in-depth interviews with facilitators means the perspectives of resource persons and policy providers from BPJS Indonesia are currently missing. Including their insights in future research would provide a more nuanced understanding of program design, resource allocation, and potential modifications for improved effectiveness.

CONCLUSION

This study identified the CFIR domain of adaptability as crucial for PROLANIS activities. Informants emphasized the need to adapt activities to both geographical conditions and specific participant needs. These adaptations, along with the program’s focus on physical activity and education by health workers, were supported by data showing improved blood sugar control, weight management, and increased adherence and overall well-being in elderly diabetes patients. While most community health centers adhered to operational standards to a considerable degree, informants in remote areas highlighted the need for increased budget and human resources to ensure optimal program delivery. Addressing these resource challenges, along with continued adaptability to diverse contexts, can significantly enhance the nationwide impact of PROLANIS activities, particularly in regions where support for elderly diabetes patients is most crucial. A future perspective on prolanis activities based on interview results could be useful for preventing patient complications, increasing compliance, as well as reducing overall treatment costs for diabetes both from insurance and also for the patient.

ACKNOWLEDGMENTS

The authors would like to thank the Ministry of Research, Technology, and Higher Education Republic of Indonesia.

AUTHOR CONTRIBUTIONS

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work. All the authors are eligible to be an author as per the International Committee of Medical Journal Editors (ICMJE) requirements/guidelines.

FINANCIAL SUPPORT

There is no funding to report.

CONFLICTS OF INTEREST

The authors report no financial or any other conflicts of interest in this work

ETHICAL APPROVALS

The study protocol was approved by Medical and Health Research Ethics Committee of Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia (Approval number: KE/FK/1652/EC/2022; Date: 26 DEC, 2022). Potential participants were thoroughly informed about the study through detailed information sheets, and their written consent was secured.

DATA AVAILABILITY

All data generated and analyzed are included in this research article.

PUBLISHER’S NOTE

All claims expressed in this article are solely those of the authors and do not necessarily represent those of the publisher, the editors and the reviewers. This journal remains neutral with regard to jurisdictional claims in published institutional affiliation.

USE OF ARTIFICIAL INTELLIGENCE (AI)-ASSISTED TECHNOLOGY

The authors declares that they have not used artificial intelligence (AI)-tools for writing and editing of the manuscript, and no images were manipulated using AI.

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