•  
  •  
 

Abstract

Despite global commitments to eliminating mother-to-child transmission of human immunodeficiency virus, syphilis, and hepatitis B, gaps remain in understanding the behavioral and systemic drivers of screening coverage in decentralized health systems such as Indonesia. This study aimed to analyze individual behavioral determinants and structural health system barriers affecting triple elimination screening coverage among pregnant women, focusing on perceived susceptibility and automatic compliance. A mixed-methods sequential explanatory study was conducted in Central Jakarta, Surabaya, and Karawang. The quantitative phase involved a cross-sectional survey of 1,224 pregnant women, with Health Belief Model variables analyzed using logistic regression. The qualitative phase comprised three focus group discussions with 18–24 healthcare professionals and policymakers, followed by thematic analysis using the World Health Organization Health System Framework. Quantitative coverage reached 93% (n = 1,134), revealing a substantial knowledge–behavior gap, as only 3.6% of participants knew the official program terminology. Multivariate analysis showed that screening behavior was significantly predicted by perceived susceptibility (AOR = 4.824, 95% CI: 2.371–9.813, p = 0.001), self-efficacy (AOR = 2.677, 95% CI: 1.084–6.610, p = 0.033), and higher parity (AOR = 1.894, 95% CI: 1.244–2.883, p = 0.003). Qualitatively, screening was sustained by automatic compliance within routine antenatal care rather than maternal health literacy. Program resilience was undermined by procurement delays, fragmented digital platforms, and social stigma, resulting in partner testing refusal. High screening coverage was driven by clinical automation, not self-directed patient awareness. Enhancing resilience requires shifting toward internalized community ownership while addressing digital and supply-chain fragmentation.

References

  1. World Health Organization. Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. Geneva: World Health Organization; 2021.
  2. World Health Organization. Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030. Geneva: World Health Organization; 2022.
  3. Kementerian Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan Republik Indonesia Nomor HK.01.07/Menkes/322/2019 tentang Pedoman Nasional Pelayanan Kedokteran Tata Laksana Hepatitis B. Jakarta: Kementerian Kesehatan RI; 2019.
  4. Kementerian Kesehatan Republik Indonesia. Laporan kinerja program eliminasi penularan ibu ke anak HIV, sifilis, dan hepatitis B. Jakarta: Kementerian Kesehatan RI; 2023.
  5. Dinas Kesehatan Jawa Barat. Evaluasi implementasi program triple eliminasi di fasilitas kesehatan primer. Jawa Barat: Dinas Kesehatan Jawa Barat; 2023.
  6. Prasetyo B, Izza A, Khairunnisa ZD, Rizal MM, Cahyaningtyas FE, Poempida FP, et al. Does human development index's level shape maternal triple elimination program? Insights from East Java, Indonesia. Journal of Public Health Research. 2026; 15 (1). DOI: 10.1177/22799036261423722.
  7. Azhali BA, Setiabudi D, Alam A. Evaluating the impact of triple elimination program for mother-to-child transmission of HIV, syphilis, and hepatitis B in Indonesia. Narra J. 2023; 3 (3): e405. DOI: 10.52225/narra.v3i3.405.
  8. Harjana NPA, Nita S, Sebayang M, Mukuan OS, Widihastuti AS. Determinant of service utilization for triple elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B among women living with HIV during COVID-19 pandemic in Indonesia. Intisari Sains Medis. 2022; 13 (2): 452-459. DOI: 10.15562/ism.v13i2.1408.
  9. Yulfiana, Suryawati C, Sriatmi A. Factors associated with utilization triple elimination examination by pregnant women in Indonesia: scoping review. Media Publikasi Promosi Kesehatan Indonesia. 2024; 7 (5): 1165-1173. DOI: 10.56338/mppki.v7i5.5176.
  10. Harrison J, Lind P, Sawleshwarkar S, Pasupathy D, Yapa HM. Rapid systematic review of interventions to improve antenatal screening rates for syphilis, hepatitis B, and HIV in low- and middle-income countries. International Journal of Gynecology & Obstetrics. 2024; 166 (1): 3-26. DOI: 10.1002/ijgo.15220.
  11. Sabin L, Haghparast-Bidgoli H, Miller F, Saville N. A systematic review of barriers and facilitators to antenatal screening for HIV, syphilis or hepatitis B in Asia: perspectives of pregnant women, their relatives and healthcare providers. PLOS One. 2024; 19 (5): e0300581. DOI: 10.1371/journal.pone.0300581.
  12. Anes CC, Bouway DY, Asriati, Tuturop KL, Yufua AR, Pariaribo K. Faktor-faktor yang memengaruhi ibu hamil terhadap pemeriksaan triple eliminasi di Puskesmas Maripi Kabupaten Manokwari Provinsi Papua Barat. Jurnal Kesehatan. 2023: 291-300.
  13. Ayunda ND, Arso SP, Nandini N. Pelaksanaan program triple elimination pada ibu hamil di Puskesmas Karanganyar Kota Semarang menggunakan model CIPP. Media Kesehatan Masyarakat Indonesia. 2023; 22 (3): 209-216. DOI: 10.14710/mkmi.22.3.209-216.
  14. Sari RDP, Satriani S, Andeska DP, Sutarto S. Spatial analysis of sexually transmitted infection vulnerability among pregnant women in Bandar Lampung: policy implications for Indonesia's Triple Elimination Program. IJID Regions. 2025; 16. DOI: 10.1016/j.ijregi.2025.100730.
  15. Novita, Indriani PLN, Anggraini A, Sari EP. The role of knowledge, motivation, and information sources in compliance with triple elimination examination in the work area of the UPTD Betung Public Health Center. Journal Health & Science. 2025;9(3):257-267.
  16. Wulandari LPL, Lubis DS, Kurniati DPY, Sumintang K, Ardrini DAM, Mariani P, et al. Challenges to integrating programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B into antenatal care: experiences from Indonesia. PLOS Global Public Health. 2024; 4 (3): e0002977. DOI: 10.1371/journal.pgph.0002977.
  17. Bustami A, Anita A. Pencegahan transmisi virus hepatitis B pada masa perinatal. Jurnal Ilmiah Keperawatan Sai Betik. 2020; 15 (2): 145. DOI: 10.26630/JKEP.V15I2.1843.
  18. Andriani L, Diamanda L. Tingkat pendidikan dan usia ibu hamil tentang triple eliminasi di Jorong Pahambatan Nagari Balingka Kabupaten Agam. Jurnal Ilmu Kesehatan. 2024; 8 (1): 147. DOI: 10.33757/jik.v8i1.962.
  19. Kementerian Kesehatan Republik Indonesia. Laporan cakupan skrining ibu hamil 2022. Jakarta: Kementerian Kesehatan RI; 2022.
  20. Lubis D. Evaluasi pelaksanaan skrining HIV pada ibu hamil di Kabupaten Rokan Hulu tahun 2022. Syntax Literate: Jurnal Ilmiah Indonesia. 2022; 7 (9).
  21. Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Nomor 52 Tahun 2017. Jakarta: Kementerian Kesehatan RI; 2017.
  22. Ban HJ, Kim HS. Applying the modified Health Belief Model (HBM) to Korean medical tourism. International Journal of Environmental Research and Public Health. 2020; 17 (10): 3646. DOI: 10.3390/ijerph17103646.
  23. Conner M, Norman P. Predicting long-term healthy eating behaviour: understanding the role of cognitive and affective attitudes. Psychol Health. 2021; 36 (10): 1165-1181. DOI: 10.1080/08870446.2020.1832675.
  24. Hekmat K, Kamali F, Abedi P, Afshari P. Explaining mothers' experiences of performing fetal health screening tests in the first trimester of pregnancy: a qualitative study with content analysis approach. International Journal of Africa Nursing Sciences. 2023; 18: 100565. DOI: 10.1016/j.ijans.2023.100565.
  25. Sari KD, Murwati M, Umami DA. Hubungan usia dan tingkat pendidikan ibu hamil terhadap kepatuhan kunjungan antenatal care di Puskesmas Muara Pinang Kabupaten Empat Lawang tahun 2023. Jurnal Multidisiplin Dehasen (MUDE). 2023; 2 (4). DOI: 10.37676/mude.v2i4.4835.
  26. Amungulu ME, Nghitanwa EM, Mbapaha C. An investigation of factors affecting the utilization of antenatal care services among women in post-natal wards in two Namibian hospitals in the Khomas region. Journal of Public Health in Africa. 2023; 14 (3): 7. DOI: 10.4081/jphia.2023.2154.
  27. Alcock S, Leal M, Beukes J, Nyati LH, Thompson U, Norris SA. Maternal age and parity influences on health outcomes: a multivariable regression analysis of mothers and infants. BMC Pregnancy Childbirth. 2025; 25 (1): 1094. DOI: 10.1186/s12884-025-08194-8.
  28. Chien SY, Chuang MC, Chen IP, Yu PH. Primary drivers of willingness to continue to participate in community-based health screening for chronic diseases. International Journal of Environmental Research and Public Health. 2019; 16 (9): 1645. DOI: 10.3390/ijerph16091645.
  29. Marcilly R, Kuziemsky C, Nohr C, Pelayo S. Context sensitive health informatics: sustainability in dynamic ecosystems. Stud Health Technol Inform. 2019; 265.
  30. Sulyastini NK, Duarsa DP. Study fenomenologi pemeriksaan triple eliminasi pada ibu hamil di Kabupaten Buleleng tahun 2023. MIDWINERSLION: Jurnal Kesehatan STIKes Buleleng. 2023; 8 (1): 88-99. DOI: 10.52073/midwinerslion.v8i1.300.
  31. Nongrum MS, Dhaliwal BK, Na Y, Jamir T, Shekhawat S, Rao K, et al. Disconnected data: mHealth data systems and challenges for primary health care workers in India. SSM Health System. 2025; 5: 100124. DOI: 10.1016/j.ssmhs.2025.100124.
  32. Sugg HVR, Shaw N, Vesterlund EM, Woodford J. Mixed-methods integration during data analysis in clinical trials of complex healthcare interventions: how is it done, and what can it do? Protocol for a systematic methodological review. BMJ Open. 2025;15(12):e112876. DOI: 10.1136/bmjopen-2025-112876.
  33. Sari RPE, Suhartati S, Yuliantie P, Lestari YP. Hubungan persepsi, sumber informasi dan sikap ibu hamil terhadap pemeriksaan triple eliminasi. An Idea Health Journal. 2024;4(3):2797-0604.
  34. Kusuma PJ, Djuari L, Machin A, Fauzi AA. Knowledge, attitude and practice of primary care physicians in dealing with acute stroke in Indonesia. Journal of Health Science and Medical Research. 2021. DOI: 10.31584/jhsmr.2021800.
  35. Liu J, Wu J, Shi Y, Gao H, Tang T. Core belief as the key driver: overcoming knowledge-behavior gap in influenza vaccination and recommendation among health care workers for infection control. American Journal of Infection Control. 2026; 54 (6): 673-679. DOI: 10.1016/j.ajic.2025.12.006.
  36. Goniewicz K, Carlström E, Hertelendy AJ, Burkle FM, Goniewicz M, Lasota D, et al. Integrated healthcare and the dilemma of public health emergencies. Sustainability. 2021; 13 (8): 4517. DOI: 10.3390/su13084517.
  37. Yuningsih SS, Pratiwi A, Fatmawati H, Meistika I, Mayangsari I, Khotimah NK, et al. The association between pregnant women's knowledge of triple elimination and compliance with screening examinations. Jurnal Penelitian Pendidikan IPA. 2025; 11 (11): 1334-1338. DOI: 10.29303/jppipa.v11i11.12761.
  38. Nagy-Pénzes G, Vincze F, Sándor J, Bíró É. Does better health-related knowledge predict favorable health behavior in adolescents? International Journal of Environmental Research and Public Health. 2020; 17 (5): 1680. DOI: 10.3390/ijerph17051680.
  39. Vicerra PMM. Knowledge-behavior gap on COVID-19 among older people in rural Thailand. Gerontology and Geriatric Medicine. 2021; 7: 2333721421997207. DOI: 10.1177/2333721421997207.
  40. Alyafei A, Easton-Carr R. The Health Belief Model of behavior change. Treasure Island (FL): StatPearls Publishing; 2024.
  41. Irawati D, Madinah A, Wayanti S, Esyuananik. Health Belief Model theory approach to analyze pregnant women's ability to prevent anemia. Jurnal Kesehatan. 2024;15(1):31-38. DOI: 10.26630/jk.v15i1.4216.
  42. Taflinger S, Sattler S. A situational test of the Health Belief Model: how perceived susceptibility mediates the effects of the environment on behavioral intentions. Social Science & Medicine. 2024; 346: 116715. DOI: 10.1016/j.socscimed.2024.116715.
  43. Jiraniramai S, Pinyopornpanish K, Wongpakaran N, Angkurawaranon C, Champion VL, Chitapanarux I, et al. Association between sociodemographic factors and health beliefs related to breast cancer screening behavior among Northern Thai women: a hospital-based study. Scientific Reports. 2024; 14 (1): 7596. DOI: 10.1038/s41598-024-58155-y.
  44. Fong AJ, Llanos AAM, Ashrafi A, Zeinomar N, Chokshi S, Bandera EV, et al. Sociodemographic and health correlates of multiple health behavior adherence among cancer survivors: a latent class analysis. Nutrients. 2023; 15 (10): 2354. DOI: 10.3390/nu15102354.
  45. Cho MK, Cho YH. Role of perception, health beliefs, and health knowledge in intentions to receive health checkups among young adults in Korea. International Journal of Environmental Research and Public Health. 2022; 19 (21): 13820. DOI: 10.3390/ijerph192113820.
  46. Driever EM, Stiggelbout AM, Brand PLP. Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists. Patient Education and Counseling. 2022; 105 (8): 2702-2707. DOI: 10.1016/j.pec.2022.03.025.
  47. Klein WMP, Cerully JL. Health-related risk perception and decision-making: lessons from the study of motives in social psychology. Social and Personality Psychology Compass. 2007; 1 (1): 334-358. DOI: 10.1111/j.1751-9004.2007.00023.x.
  48. Tshuma N, Muloongo K, Nkwei ES, Alaba OA, Meera MS, Mokgobi MG, et al. The mediating role of self-efficacy in the relationship between premotivational cognitions and engagement in multiple health behaviors: a theory-based cross-sectional study among township residents in South Africa. Journal of Multidisciplinary Healthcare. 2017; 10: 29-39. DOI: 10.2147/JMDH.S112841.
  49. Zaman A, Fadlalmola HA, Ibrahem SE, Ismail FH, Abedelwahed HH, Ali AM, et al. The role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes: a systematic review and meta-analysis. European Journal of Midwifery. 2025; 9: 10. DOI: 10.18332/ejm/200747.
  50. Shaetonhodi NG, de Vos L, Brock P, Davey DJ, de Voux A, Medina-Marino A. Factors influencing implementation of point-of-care tests for maternal and newborn screening and diagnosis in low-resource settings: a systematic review. BMC Global and Public Health. 2026; 4 (1): 34. DOI: 10.1186/s44263-026-00261-2.
  51. Anuar H, Shah SA, Gafor AH, Mahmood I, Ghazi HF. Usage of Health Belief Model (HBM) in health behavior: a systematic review. Malaysian Journal of Medicine and Health Sciences. 2020; 16 (Suppl 11): 201-209.
  52. Lange AE, Mahlo-Nguyen J, Pierdant G, Allenberg H, Heckmann M, Ittermann T. Antenatal care and health behavior of pregnant women—an evaluation of the Survey of Neonates in Pomerania. Children (Basel). 2023; 10 (4): 678. DOI: 10.3390/children10040678.
  53. Raghunathan K, East C, Poudel K. Barriers and enablers for implementation of clinical practice guidelines in maternity and neonatal settings: a rapid review. PLOS One. 2024; 19 (12): e0315588. DOI: 10.1371/journal.pone.0315588.
  54. Rój J. Inequality in the distribution of healthcare human resources in Poland. Sustainability. 2020; 12 (5): 2043. DOI: 10.3390/su12052043.
  55. Escañuela Sánchez T, Linehan L, O'Donoghue K, Byrne M, Meaney S. Facilitators and barriers to seeking and engaging with antenatal care in high-income countries: a meta-synthesis of qualitative research. Health & Social Care in the Community.  2022; 30 (6): e3810-e3828. DOI: 10.1111/hsc.14072.
  56. Rahmalia A, Wisaksana R, Laga M, van Crevel R, Peeters Grietens K. Facilitators and barriers to status disclosure and partner testing of women living with HIV in Indonesia: a mixed methods study. Sexual and Reproductive Health Matters. 2022; 30 (1): 2028971. DOI: 10.1080/26410397.2022.2028971.
  57. Saeed F, Mihan R, Mousavi SZ, Reniers RL, Bateni FS, Alikhani R, et al. A narrative review of stigma related to infectious disease outbreaks: what can be learned in the face of the COVID-19 pandemic? Front Psychiatry. 2020; 11: 565919. DOI: 10.3389/fpsyt.2020.565919.
  58. Shrimpton L, Addison M, Cavener J, Scott S, McGovern W. Exploring the impact of stigma on health and wellbeing: insights from mothers with lived experience accessing recovery services. International Journal of Environmental Research and Public Health. 2024; 21 (9): 1189. DOI: 10.3390/ijerph21091189.
  59. Kebede AA, Gessesse DN, Aklil MB, Temesgan WZ, Abegaz MY, Anteneh TA, et al. Low husband involvement in maternal and child health services and intimate partner violence increases the odds of postpartum depression in northwest Ethiopia: a community-based study. PLOS One. 2022; 17 (10): e0276809. DOI: 10.1371/journal.pone.0276809.
  60. Health and Disability System Review. Health and Disability System Review—interim report. New Zealand: Health and Disability System Review; 2019.
  61. Herd P, Moynihan D. Health care administrative burdens: centering patient experiences. Health Services Research. 2021; 56 (5): 751-754. DOI: 10.1111/1475-6773.13858.
  62. Mbunge E, Jack CL, Sibiya MN, Batani J. Review of implementation barriers and strategic approaches for improving mHealth systems utilization in Africa: lessons learnt from South Africa and Kenya. Telematics and Informatics Reports. 2025; 19: 100228. DOI: 10.1016/j.teler.2025.100228.
  63. Filip R, Gheorghita Puscaselu R, Anchidin-Norocel L, Dimian M, Savage WK. Global challenges to public health care systems during the COVID-19 pandemic: a review of pandemic measures and problems. Journal of Personalized Medicine. 2022; 12 (8): 1295. DOI: 10.3390/jpm12081295.
  64. Naghavi M, Wang H, Lozano R, Davis A, Liang X, Zhou M, et al. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015; 385 (9963): 117-171. DOI: 10.1016/S0140-6736(14)61682-2.
  65. Aung HL, Thiri H, Win NY. Health behavior through cultural context and behavior change models in Myanmar. 2025.
  66. Pilli L, Veldwijk J, Swait JD, Donkers B, de Bekker-Grob EW. Sources and processes of social influence on health-related choices: a systematic review based on a social-interdependent choice paradigm. Social Science & Medicine. 2024; 361: 117360. DOI: 10.1016/j.socscimed.2024.117360.
  67. Dardouri M, Korbi F, Motakef HI, Lamine H, Nageeb SM, Alshammari B, et al. General self-efficacy among pregnant women attending antenatal care units in Tunisia and its association with family quality of life: a multicenter cross-sectional study. Healthcare (Basel). 2025; 13 (23): 3069. DOI: 10.3390/healthcare13233069.
  68. Vainauskienė V, Vaitkienė R. Enablers of patient knowledge empowerment for self-management of chronic disease: an integrative review. International Journal of Environmental Research and Public Health. 2021; 18 (5): 2247. DOI: 10.3390/ijerph18052247.
  69. Ogu UU, Ebenso B, Mirzoev T, Uguru N, Etiaba E, Uzochukwu B, et al. Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria. BMC Health Serv Res. 2023; 23 (1): 1280. DOI: 10.1186/s12913-023-10210-6.
  70. Nawabi F, Krebs F, Vennedey V, Shukri A, Lorenz L, Stock S. Health literacy in pregnant women: a systematic review. International Journal of Environmental Research and Public Health. 2021; 18 (7): 3847. DOI: 10.3390/ijerph18073847.
  71. Molero A, Calabrò M, Vignes M, Gouget B, Gruson D. Sustainability in healthcare: perspectives and reflections regarding laboratory medicine. Annals of Laboratory Medicine. 2021; 41 (2): 139-144. DOI: 10.3343/alm.2021.41.2.139.
  72. Fernandez DM, Larson JL, Zikmund-Fisher BJ. Associations between health literacy and preventive health behaviors among older adults: findings from the Health and Retirement Study. BMC Public Health. 2016; 16 (1): 596. DOI: 10.1186/s12889-016-3267-7.
  73. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Global Health. 2018; 6 (11): e1196-e1252. DOI: 10.1016/S2214-109X(18)30386-3.
  74. World Health Organization. Building health system resilience to public health challenges: guidance for implementation in countries. Geneva: World Health Organization; 2024.

Download

Share

COinS
 
 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.