INTRODUCTION

Premarital screenings were first implemented in Middle Eastern countries, such as Saudi Arabia and Iran, which established immunization and genetic screening programs in response to a high incidence of genetic diseases [1]. Indonesia also supports efforts to prevent genetic disorders, sexually transmitted infections, and reproductive health issues, aligning with the World Health Organization’s focus on family health. In line with these efforts, the Joint Instruction of the Ministry of Religious Affairs and the Ministry of Health Number 2 of 1989 mandated tetanus toxoid immunization for prospective brides and grooms. Additionally, the Regulation of the Minister of Health of the Republic of Indonesia No. 97 of 2014 reinforces the importance of premarital screenings as part of pre-pregnancy health services that support healthy pregnancies and childbirth.

The premarital screening program represents a preventive effort to improve the reproductive health of prospective brides and grooms as well as their future offspring [2]. Without such screening, individuals may struggle to identify health issues— such as human immunodeficiency virus (HIV) and syphilis— that can be exacerbated by low knowledge of prevention and the presence of partners engaging in risky sexual behavior [3]. Moreover, mothers are at high risk of transmitting infections to their children during pregnancy, delivery, or breastfeeding [3]. There is also evidence suggesting that risks for conditions like diabetes mellitus in children, as well as maternal nutritional deficiencies, may be associated with increased rates of stunting in newborns [4,5]. In light of these risks, it is crucial to cultivate a strong intention to undergo premarital screening, yet some individuals still forgo this important step [6,7].

According to the theory of planned behavior (TPB), intention is the primary predictor of behavior [8]. The intention to undergo premarital screening should ideally be established when individuals reach marriageable age, defined by Indonesian Law Number 16 of 2019 as a minimum of 19 years. College students, who generally range from 18 years to 24 years old, merit special attention because the average age of first marriage among those with higher education is 23.62 years [9,10]. This suggests that they are likely to marry after completing their studies, underscoring the importance of raising awareness about premarital screening at an early age. Research has shown that reduced intention to undergo screening is linked to lower participation rates; for instance, Schoenborn et al. [11] found that a decline in screening intention was associated with a decreased likelihood of receiving screening after 18 months. Another study reported that individuals with low screening intentions were 8.83 times more likely to forgo cervical cancer screening [12].

Several studies have documented a lack of interest in premarital screening among college students in the Middle East [13,14]. In Indonesia, few studies have examined college students’ intentions regarding premarital screening. One study focusing on non-health students found that 63.0% did not wish to undergo premarital screening [15]. A preliminary study conducted by our team at UIN Jakarta, which involved 28 undergraduate students from both non-health and health faculties, revealed that 43.0% did not intend to undergo comprehensive premarital screening. These findings suggest that even early adults in higher education—who typically have an open mindset and extensive access to information—may exhibit low intentions to participate in premarital screening, providing a benchmark for understanding similar issues among young adults in other contexts.

The intention to undergo premarital screening is believed to be influenced by several factors, including a positive attitude toward screening, high knowledge levels regarding the screening process, family members’ experiences with genetic testing, and a family history of genetic diseases [14,16,17]. A comprehensive study is needed to clarify the relationship between these factors and the intention to undergo premarital screening.

Given the limited number of studies in Indonesia on this topic, the present study aims to assess the extent to which young adults of marriageable age, such as college students, intend to undergo premarital screening and to identify the factors influencing this intention. The findings from this study will provide a basis for recommendations regarding health education programs and interventions designed to promote effective premarital screening.

METHODS

Study Design

This study was designed to identify variables significantly associated with the intention to undergo premarital screening without establishing causal relationships. We employed a quantitative, cross-sectional study design. This design allowed for the simultaneous collection of independent and dependent variable data, thereby providing an efficient approach in terms of time and resources.

Sample Size Calculation

The study population consisted of all active undergraduate students at UIN Jakarta, totaling 32 000 students. UIN Jakarta shares characteristics with other Indonesian universities, including diverse personal, social, economic, cultural, ethnic, and religious backgrounds. A notable feature of UIN Jakarta is its specialized field of Islamic studies, which is not offered by few other universities in Indonesia except for similar institutions.

Due to the large and diverse population, as well as its multiple campuses, we employed a multistage random sampling technique to select our sample. Figure 1 illustrates the sampling stages and the sample sizes at each stage.

The sample size for describing the intention to undergo premarital screening was calculated using the formula for estimating proportions with absolute precision. With a 95% confidence level, 5% precision, and an assumed prevalence of low screening intention of 50%, the minimum required sample size was 385 students. For hypothesis testing, multivariate analysis required a sample size of at least 10 times the number of variables under study [18]. In this study, with 9 research variables, a minimum of 90 samples was needed. To satisfy both objectives, we selected 563 students, which included a 46.0% reserve sample, while applying exclusion criteria for those who were married, divorced, or widowed.

Measurement Data

The dependent variable in this study was the intention to undergo premarital screening, categorized into three groups: no/low, moderate, and high. A “high” intention was defined as students planning to undergo all seven types of screening, with both themselves and their partners as targets. A “moderate” intention was assigned when students planned to undergo only 3-6 types of examinations and did not include both partners. The “no/low” intention category applied to students who either did not intend to undergo any screening or planned to undergo fewer than three types, without targeting both partners.

The TPB provided the framework for examining the determinants of premarital screening intention. Independent variables included background factors (sex, major field of study, hereditary disease history, family member experience, information exposure, and level of knowledge), attitude toward the behavior, and perceived behavioral control. All variables were measured using an instrument developed by the research team. Initially, question items were formulated based on the operational definitions derived from relevant literature and expert theories. All items were written in Indonesian and administered via a Google Form.

Premarital screening intention was assessed by asking respondents about their future plans. The variable “sex” was determined by asking respondents to select their biological sex. The major field of study was identified based on the academic program in which the students were enrolled at UIN Jakarta. The hereditary disease variable was measured by asking respondents whether any family members had a history of hereditary diseases. Family member experience was determined by asking whether any family members had previously undergone premarital screening.

Information exposure was assessed by asking respondents whether they had ever seen or heard about premarital screenings. Knowledge was measured with 10 questions covering the following aspects: (1) definition; (2) ideal timing for the examination; (3) location of examination service providers; (4) benefits of the examination; (5) target population for the examination; and (6) basis for the recommendation of premarital screenings. Each correct answer was scored as 1, and incorrect answers were scored as 0. Total scores were then categorized into low and high knowledge levels using Bloom’s cut-off point, with scores below 60% classified as poor and scores of 60% or above as good knowledge [19].

Attitude toward the behavior was measured by asking respondents to indicate their likes, dislikes, feelings, or emotions related to premarital screenings. Perceived behavioral control was measured by assessing respondents’ beliefs about their ability to undergo premarital screenings. Both constructs were measured on a 4-point Likert scale (ranging from strongly agree to strongly disagree). Total scores for attitude and perceived behavioral control were calculated, and the median score was used as the cut-off point.

The instrument underwent both validity and reliability testing. Content validity and construct validity were assessed. Content validity was evaluated by two experts from UIN Jakarta in the relevant fields, and five respondents outside the sample reviewed the clarity and readability of the items. The content validity index for all items exceeded 0.80, indicating good validity [20]. Construct validity was confirmed through exploratory factor analysis, which yielded a Kaiser-Meyer-Olkin measure of sampling adequacy above 0.50, Bartlett’s test of sphericity with p-value ≤0.05, and factor loadings above 0.40 [21,22]. Reliability was assessed using the test-retest method with the intraclass correlation coefficient, where all items showed coefficients greater than 0.70, indicating stability over time [22]. Additionally, Cronbach’s alpha values for the attitude and perceived behavioral control constructs were above 0.60, confirming the reliability of these measures.

Statistical Analysis

Descriptive statistics were used to analyze the data and provide an overview of the variables. Since all variables were categorical, frequencies (n) and proportions were calculated. To assess the significance of relationships between background factors, attitudes, perceived behavioral control, and the intention to undergo premarital screening, ordinal logistic regression analysis was employed. This method was chosen because the dependent variable (intention) is ordinal in nature.

We conducted a series of assumption tests for ordinal logistic regression. The proportional odds (PO) assumption initially returned a p-value <0.05, indicating that it was not met. Consequently, the partial proportional odds (PPO) test was performed as recommended by Harrell [23] when the PO assumption fails for certain variables. The PPO test yielded a p-value >0.05, supporting the use of a generalized ordinal logistic model. Multicollinearity was assessed, and all independent variables had variance inflation factor values below 10, indicating no significant multicollinearity. The generalized ordinal logistic regression model produced a log-likelihood chi-square probability value of <0.05 [24], demonstrating that the model significantly explains the variability in the dependent variable. This model was deemed to be suitable for use in our study analysis. The overall statistical analysis was conducted using Stata version 14 (StataCorp., College Station, TX, USA).

Ethics Statement

Data were collected offline in classroom settings during May 2024 using a self-administered Google Form. Prior to completing the questionnaire, respondents were provided with detailed information about the study and the questionnaire. Consent was obtained by asking respondents to initial the informed consent form, thereby ensuring voluntary participation. This study was approved by the Ethical Review Committee of the Faculty of Health Sciences, Universitas Islam Negeri (UIN) Syarif Hidayatullah Jakarta (Un.01/F.10/KP.01.1/KE.SP/04.08.020/2024).

RESULTS

The final sample comprised 563 college students, of whom 67.9% were female and 58.6% were enrolled in non-health majors. A majority did not have a family history of hereditary diseases (92.4%), and 66.3% had been exposed to information about premarital screening. Additionally, 53.5% reported that family members had experience with premarital screenings, 59.1% demonstrated high knowledge levels, 58.1% exhibited negative attitudes toward premarital screening, and 63.2% had negative perceptions of behavioral control regarding the screening process (Table 1).

Among the 563 students, 73 (13.0%) displayed low or no intention to undergo premarital screening. In contrast, 245 students (43.5%) fell into the moderate intention category, and another 245 (43.5%) reported a high intention. Among the 546 students who intended to undergo screening, 36.4% indicated that they did not wish to have the blood glucose test, as illustrated in Figure 2. Furthermore, 96.3% of these students expressed a desire to undergo the screening with their partners (Supplymental Material 1). However, only 27.3% preferred to have the screening six months before marriage (Supplymental Material 2). These results underscore the need for improved education and accessible testing options to promote premarital screening among college students.

The data further revealed that students with low or no intention to undergo screening were more likely to be male, enrolled in non-health majors, lacking a family history of hereditary diseases, without family members who had experienced premarital screening, not exposed to screening information, possessing low knowledge levels, and exhibiting negative attitudes and perceptions of behavioral control. More detailed comparisons are provided in Table 2.

Generalized ordinal logistic regression analysis indicated that knowledge level, attitude, perceived behavioral control, and major field of study were significantly associated with the intention to undergo premarital screening. Among these factors, knowledge was the most influential determinant. Students with low knowledge were 2.84 times (95% confidence interval [CI], 1.58 to 5.10) more likely to have low or no intention to undergo screening compared to those with high knowledge. Similarly, students with negative attitudes were 2.85 times (95% CI, 1.41 to 5.75) more likely to exhibit low screening intention compared to those with positive attitudes. A negative perception of behavioral control increased the likelihood of low intention by 1.53 times (95% CI, 0.78 to 3.01), and being enrolled in non-health majors increased the odds by 1.96 times (95% CI, 1.04 to 3.68). Variables such as sex, family health history, exposure to information, and family members’ experience did not show a significant association with screening intention (Table 3).

DISCUSSION

According to the Ministry of Health of the Republic of Indonesia, an ideal premarital screening should include seven tests: an HIV/AIDS test, a basic physical examination, a urine test, a hepatitis B detection, a blood type and rhesus test, a blood glucose test, and a toxoplasmosis, rubella, cytomegalovirus, herpes and other agents (TORCH) panel. These screenings are ideally conducted 3 months to 6 months before the wedding at community health centers or hospitals, targeting both brides and grooms [2,25]. Performing the screening within this timeframe allows sufficient opportunity for counseling, support, and treatment prior to the wedding [26]. This guideline provides a benchmark for understanding how college students should ideally approach premarital screening and highlights areas where educational interventions may be beneficial for promoting healthier behaviors.

In this study, nearly all college students expressed an intention to undergo premarital screening. These findings align with previous research indicating that college students are generally aware of the importance of such screenings [14,27]. Students with high screening intentions are more likely to make informed decisions regarding the types of tests and targets recommended by the Indonesian Ministry of Health. However, the presence of a subset of students with low intention suggests that not all have a strong desire to undergo comprehensive premarital examinations. Notably, students with low intention were primarily interested in HIV/AIDS tests, likely reflecting heightened public concern over increasing HIV cases [3].

The low level of interest in complete premarital screening among some college students is concerning, as comprehensive testing can mitigate risks for diseases that threaten maternal and newborn health—such as HIV, diabetes mellitus, anemia, and chronic energy deficiency, which are major contributors to stunting in children [3-5]. Various barriers may explain the reluctance to engage in comprehensive screening. For example, the cost of examinations is often seen as prohibitive; studies by Hebatallah et al. [28] and Mangai et al. [29] have identified cost as a significant barrier. Other barriers include the fear of receiving abnormal results that could jeopardize marriage prospects, the negative social stigma associated with genetic diseases, and perceptions that premarital screening contradicts religious values by challenging the notion of divine destiny [30-32].

Our findings demonstrate that knowledge, attitude, perceived behavioral control, and major field of study significantly influence the intention to undergo premarital screening. Of the four factors found to be related to the intention of premarital screening, knowledge emerged as the main determinant for some college students at UIN Jakarta regarding future intentions for screening. The same findings were also observed in several previous studies [33,34]. Previous research also found that many students are unaware of the comprehensive premarital screening programs in all aspects [14]. The deficiency in knowledge largely results from inadequate dissemination of information, about premarital screening [35]. This leads many students, especially those in non-health majors, to lack a strong intention to undergo screening before getting married later.

Moreover, insufficient information appears to shape students’ perceptions regarding the ease of undergoing screening. Some students harbor negative beliefs about their ability to complete premarital examinations, a finding supported by previous research [36,37]. As a result, they tend to have low intentions. This is also supported by previous research showing negative perceptions affect students’ reluctance to undergo premarital screening [30,35]. Perceptions regarding premarital screening among college students can be changed by focusing education on the benefits obtained from the screening [37]. Limited knowledge and information can also lead students to have a negative attitude toward premarital screening. The most dominant negative attitude among students is choosing the type of examination based solely on their current health conditions, resulting in a lower overall intention. While transforming these attitudes is feasible, it requires enhancing students’ knowledge and increasing their exposure to reliable information [36].

This study also found that sex, exposure to information about premarital screenings, family members’ experiences, and hereditary disease history did not show a significant relationship with the intention to undergo premarital screenings. This suggests that knowledge, perceived behavioral control, and attitude toward premarital screening play a more crucial role in influencing individuals’ intentions to undergo such screenings. These results are consistent with the TPB, which serves as the main theoretical foundation of this research. Developed by social psychologists, the TPB has been widely used to help us understand various behaviors, including health behaviors [8,38]. According to the TPB, the determinant of behavior is the intention to engage in that behavior. Intention represents a person’s motivation; it is conceptualized as an individual’s conscious plan or decision to exert effort to perform a specific behavior.

Based on the TPB, intention is determined by three variables. The first is attitude, which refers to an individual’s overall evaluation of the behavior. Attitude is a function of salient behavioral beliefs, representing the perceived consequences of the behavior (for example, believing that undergoing premarital screening will reduce the risk of hereditary diseases). The second is the subjective norm, which involves an individual’s belief about whether important others think they should perform the behavior [8]. Subjective norms stem from normative beliefs, which are perceptions of these important individuals’ preferences (for instance, believing that one’s family thinks they should undergo a premarital screening) [8]. The third variable —perceived behavioral control—measures the extent to which individuals feel that the behavior is under their personal control, based on their beliefs about having access to the necessary resources and opportunities (for example, having easy access to facilities where they can undergo a premarital screening) [8]. Of these three variables, two—attitude and perceived behavioral control—were found to be significantly related to the intention to undergo premarital screenings. Meanwhile, the subjective norm factor was not examined in this study because our preliminary research indicated that the data related to subjective norms were homogeneous, making further analysis impossible. This constitutes one of the study’s limitations. In addition, the TPB itself has certain limitations, such as predicting people’s intention to behave at only one point in time without considering other factors (e.g., emotional, habitual, or impulsive influences) [39].

In conclusion, our research found that many young adults with higher education lack a strong intention to undergo premarital screening. Insufficient knowledge, coupled with negative attitudes and perceptions of behavioral control, were significantly associated with lower screening intentions. Therefore, it is imperative to enhance educational efforts regarding premarital screening.

The importance of such screening must be clearly communicated to students as it not only assesses genetic risks but also evaluates general health and the potential for chronic or infectious diseases. The Ministry of Health and healthcare professionals should intensify efforts to raise awareness through comprehensive and widespread campaigns. Additionally, universities should incorporate premarital screening education into curricula and extracurricular activities. Given that social media is a primary information source for students, it could serve as an effective medium for promoting premarital screening in alignment with young adults’ internet usage patterns [40].

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

We would like to express our gratitude to all the deans of the faculties at UIN Jakarta who have granted permission and facilitated the data collection process in their respective faculties.

Author Contributions

Conceptualization: Amran Y, Fasya TN. Data curation: Fasya TN. Formal analysis: Amran Y, Fasya TN, Salamah H. Funding acquisition: None. Methodology: Amran Y, Fasya TN. Project administration: Fasya TN, Salamah H. Visualization: Amran Y, Fasya TN. Writing – original draft: Amran Y, Fasya TN, Salamah H. Writing – review & editing: Amran Y, Fasya TN, Salamah H.

Figure. 1.

Sampling technique.

Figure. 2.

Percentage of college students’ preferences for type of examination for future premarital screening. TORCH, toxoplasmosis, rubella, cytomegalovirus, herpes and other agents.

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