Abstract

Premarital screening is a thorough medical examination conducted before marriage. It includes checks for reproductive health, genetic disorders, infectious diseases, and blood-borne infections. The primary goal of this screening is to reduce the risk of chronic illnesses for couples and their future children. Additionally, premarital screening can help prevent maternal and infant deaths, birth defects, and growth problems by identifying risk factors early in both the mother and the unborn baby. However, despite its benefits, premarital screening is not widely practiced or culturally accepted in many societies. The objective of this study was to identify factors that influence the behavior of individuals towards premarital screening. The study employed a systematic review method, searching databases like Google Scholar and Scopus for quantitative research articles published between 2018 and 2023. Using keywords such as “premarital” and “screening,” 1,151 articles were initially found, but only 10 met the specific criteria for inclusion and were analyzed in detail. The findings indicated that factors such as older age, being female, higher education levels, having parents in consanguineous marriages, a family history of genetic diseases, good knowledge, positive attitudes, and the presence of government regulations positively influence premarital screening behavior. In conclusion, health promotion efforts should be strengthened to increase public awareness about the importance of premarital health screening. Moreover, future research is encouraged to explore this topic using different methods, including cross-sectional and qualitative studies, to gain a deeper understanding of premarital screening behaviors.

Keywords: Premarital; Screening; Marriage; SDGs

Introduction

In 2021, the World Health Organization (WHO) reported that roughly 40,618 children worldwide are born with thalassemia each year, with about 62.8% of these children needing lifelong blood transfusions (WHO, 2021). The WHO has highlighted 11 countries in the sub-region with a high incidence of thalassemia, including Indonesia in Southeast Asia. In Indonesia, the carrier rate varies between 3% and 20%, and more than 2,500 children are born with thalassemia annually (WHO, 2021). It is estimated that around 258,347 individuals with thalassemia in Indonesia require continuous blood transfusions throughout their lives (BPJS Kesehatan, 2021). Data from Indonesia’s Badan Penyelenggara Jaminan Sosial (BPJS) shows that catastrophic or high-cost illnesses accounted for the highest health expenditures in the country in 2021, reaching approximately IDR 90.33 trillion. This represents a 25-31% increase in total healthcare spending since 2014. The leading diseases contributing to these costs include heart disease, cancer, stroke, kidney failure, thalassemia, hemophilia, leukemia, and liver cirrhosis (BPJS Kesehatan, 2021). Among these, thalassemia and hemophilia are genetic disorders passed down from parents (Al-Kindi et al., 2019). Marriage is a significant life event for many individuals and often marks an important milestone. From a healthcare perspective, it is crucial to pay attention to the health status and medical background of both partners prior to marriage. One preventive strategy to avoid various health complications related to marriage is premarital screening (Suresh et al., 2023). As we approach the 2030 Sustainable Development Goals (SDGs), which aim to provide universal access to sexual and reproductive health services — including family planning, education, and integrating reproductive health into national policies — premarital screening behavior remains a key concern (United Nations, 2023).

Premarital screening involves testing couples planning to marry for common genetic diseases such as thalassemia, hemophilia, and sickle cell anemia, as well as infectious diseases like hepatitis B, hepatitis C, and HIV/AIDS (Alhosain, 2018). This screening can help lower maternal and infant mortality rates and reduce birth defects (Al-Balushi & Al-Hinai, 2018). Early detection through premarital screening can also help prevent the birth of stunted children (Shojaiefar et al., 2021). Furthermore, it helps limit the spread of these diseases, thereby lessening the financial burden on individuals and the national healthcare system (Natarajan & Joseph, 2021). Additionally, premarital screening provides an opportunity for healthcare workers to educate couples and equip them with the knowledge needed to form healthy families and raise healthy children (AlOtaiby et al., 2023). In some countries, premarital screening has become compulsory and is a requirement for marriage. For example, in Saudi Arabia, the program is widely accepted by couples to promote a healthy life and offspring free from genetic diseases (Al-Shroby et al., 2021; Alhusseini et al., 2023). Indonesia has also implemented premarital screening programs (Kemenkes RI, 2019), involving multiple agencies such as the Ministry of Health, BKKBN, Ministry of Religious Affairs, and Puskesmas. However, the program’s implementation has not been optimal (Fitriani, 2020). Although policies support the program, specific guidelines for health check-ups prior to marriage are lacking. Due to limited knowledge and information, most individuals do not undergo health screening before marriage (BKKBN, 2020). Despite its importance, premarital screening remains underutilized in Indonesia. Raising awareness about the benefits of screening before marriage could prevent numerous long-term health issues for both partners and their future children (Saffi & Howard, 2015). Hence, it is critical to examine the factors influencing premarital screening practices to guide reproductive health programs and implement effective public health preventive measures.

Research Method

A systematic review was conducted focusing on research articles that employed quantitative methods, published between 2018 and 2023. The study used a cross-sectional approach to comprehensively analyze various scientific article search engines. The researchers performed searches using the keywords ‘premarital’ AND ‘screening’ in both English and Bahasa Indonesia across Google Scholar and Scopus databases.

Article selection was based on title, abstract, publication year, and research methods. The process also involved applying predefined inclusion and exclusion criteria. The exclusion criteria included: (1) publications in non-accredited journals, and (2) articles not written in English or Indonesian. Inclusion criteria required: (1) quantitative studies using primary data, (2) findings related to factors influencing premarital screening behavior, (3) publications within the last five years (2018–2023), and (4) availability of full-text access.

An initial search yielded 1,151 articles across multiple search platforms. After screening titles and abstracts, 30 articles remained. Further filtering based on year and inclusion criteria narrowed the selection to 19 articles. Ultimately, 10 articles that most thoroughly examined the determinants of premarital screening behavior were included for detailed analysis.

Findings

An analysis of the ten selected articles revealed seven key factors influencing premarital screening behavior. These determinants include age, gender, educational attainment, parental consanguineous marriage, family history of genetic disorders, awareness and perceptions, and the impact of government policies. Further information on these findings is summarized in Table 1.

DISCUSSION

Age

As people grow older, their decision-making tends to become more thoughtful and mature, which often influences their behaviors, especially regarding health. This means older individuals are likely to take more factors into account when deciding to undergo premarital screening. Oluwole et al. (2022) found strong evidence supporting this, with results showing high significance (p < 0.001). Similarly, Zedan Zaien et al. (2022) confirmed this association. A multiple regression analysis further revealed that age has a significant positive relationship with the practice of premarital health screening (p = 0.007). For example, a study in Saudi Arabia showed that people above 20 years old are more inclined to participate in premarital screening than their younger counterparts (Zedan Zaien et al., 2022).

Sex

Gender also plays a significant role in the decision to get premarital health screening. Research among university students in Qatar found that women tend to have a higher awareness and knowledge about premarital screening compared to men, with statistical significance (p < 0.01) (Al-Shafai et al., 2022). On the other hand, a study conducted in Oman by Alkalbani et al. (2022) reported the opposite pattern, where men showed a stronger willingness to undergo premarital screening than women, possibly reflecting cultural differences in attitudes toward screening.

Educational Level

Formal education, which is a structured learning process aimed at influencing behavior (Notoatmodjo, 2007), appears to be positively linked to better health behaviors. Aga et al. (2021) discovered that third-year college students were more supportive of premarital health screening than first-year students (p < 0.001). Additionally, research from Saudi Arabia underscores the importance of education level in the decision to pursue premarital screening, showing a statistically significant impact (p = 0.019) (Zedan Zaien et al., 2022).

Parental Endogamous Marriage

Endogamy refers to marrying within one’s social or familial group, often including cousin marriages (KBBI, 2023). Such unions increase the risk of inherited genetic disorders like sickle cell anemia, thalassemia, epilepsy, and hemophilia—these conditions can be up to 20 times more common in populations practicing consanguineous marriage. Consequently, premarital screening is strongly encouraged to reduce the chances of passing on these hereditary diseases (Bener et al., 2019). However, research by Gosadi et al. (2021) highlights that some consanguineous couples hesitate to get screened before marriage. One major reason is their belief in destiny—that marriage outcomes, including health risks for their children, are predetermined and thus unavoidable, leading them to accept these risks without premarital health checks (Gosadi et al., 2021).

History of Genetic Diseases

A key factor influencing the decision to undergo premarital screening is having a personal or family history of genetic disorders. This connection is supported by Al-Shafai et al. (2022), whose research shows that individuals or families with a background of genetic diseases are more inclined to participate in premarital health screening. This tendency may stem from their prior exposure to information about the condition or increased interest due to the disease’s impact on themselves, their relatives, and the potential effects on future children (Al-Shafai et al., 2022).

Knowledge and Attitude

The likelihood of engaging in premarital screening is also shaped by individuals’ knowledge and attitudes toward such programs. People with better awareness and positive perceptions about premarital screening are significantly more likely (p<0.001) to get screened before marriage, as noted by Bindhani et al. (2020). Supporting this, Al-Shafai et al. (2022) found that despite mandatory premarital screening in Qatar, some couples still skip the process due to a lack of understanding about the program.

Government Regulations

Government policies mandating health screening as a condition for marriage documentation play an important role in promoting premarital screening. Research from Nigeria indicates that policy development improves community access to screening services and raises screening rates (Oluwole et al., 2022). Similarly, studies from India suggest that regulations help increase public acceptance, encouraging individuals to complete health checks prior to marriage (Bindhani et al., 2020).

Conclusions

Premarital screening has become an important public health strategy aimed at identifying potential health risks before marriage, thereby helping to prevent the transmission of genetic disorders, sexually transmitted infections, and other conditions that could negatively affect the health of future children. This review has identified several factors that significantly influence individuals’ decisions to participate in premarital screening programs. These factors include demographic characteristics such as age and gender, educational attainment, parental consanguinity (marriage between relatives), family history of genetic diseases, the level of knowledge and attitude towards screening, and the role of government regulations and mandates.

Understanding these determinants is essential for tailoring premarital screening initiatives in Indonesia and similar settings, where the burden of genetic diseases and reproductive health risks remain significant. The insights gained can help policymakers and health program developers design more effective screening programs that reach a wider population and encourage participation.

Age and gender are important demographic factors that influence health behaviors, including premarital screening. Younger individuals, who are more likely to be entering marriage for the first time, may differ in their awareness, perceptions, and motivations related to screening compared to older adults. Gender also plays a crucial role; women often have more interaction with healthcare systems, especially regarding reproductive health, which may increase their likelihood to undergo premarital health checks. Men, on the other hand, may have less access to or engagement with such programs due to cultural or social reasons, potentially leading to lower screening rates. Addressing gender disparities in access and attitudes is therefore critical to ensure equitable health outcomes.

Educational attainment strongly correlates with health literacy and the ability to understand and act upon health information. Individuals with higher education levels are generally more aware of the benefits of premarital screening and better equipped to comprehend the potential consequences of genetic disorders or sexually transmitted infections for themselves and their families. Education fosters a more positive attitude towards health interventions and increases the likelihood of proactively seeking screening services. Conversely, those with limited education may face barriers due to lack of knowledge or misconceptions about screening, which can lead to reluctance or refusal to participate. Public health campaigns that are sensitive to varying literacy levels and that use clear, accessible language can help bridge this gap.

Consanguineous marriages—unions between close relatives—are culturally accepted and prevalent in some communities, including parts of Indonesia. Such marriages increase the risk of inheriting autosomal recessive genetic disorders due to the higher probability of both partners carrying the same harmful genes. Awareness of parental consanguinity as a risk factor often influences couples to seek premarital screening to assess potential genetic risks for their offspring. However, cultural norms and traditions can sometimes discourage open discussion or discourage screening altogether. Strategies that respectfully address cultural sensitivities while emphasizing the health benefits of screening are necessary to encourage informed decision-making among consanguineous couples.

A personal or family history of genetic disorders is one of the strongest motivators for premarital screening. Individuals who have firsthand experience with genetic diseases—whether through their own health or through relatives—tend to have a heightened awareness of the risks and implications. This awareness often leads to increased willingness to undergo screening, as they recognize the potential impact of these diseases on themselves, their spouses, and future children. Research, including findings from Al-Shafai et al. (2022), confirms that prior exposure to genetic conditions fosters greater interest and proactive behavior toward premarital health checks. Educational initiatives targeting families with a history of genetic disorders could leverage this awareness to promote screening participation.

The level of knowledge about premarital screening and the attitudes individuals hold toward it are pivotal factors in determining screening behavior. Positive attitudes and accurate understanding of what premarital screening entails, its benefits, and its implications significantly increase the likelihood of participation. Studies have shown that individuals with good knowledge and favorable attitudes toward premarital screening are more likely to undergo such checks (Bindhani et al., 2020). Conversely, misinformation, fear of stigma, or underestimation of risk can result in reluctance. This is evidenced by observations from countries like Qatar, where premarital screening is mandatory, yet some couples fail to participate due to a lack of awareness or understanding (Al-Shafai et al., 2022). Tailored educational programs that promote awareness and dispel myths are crucial for improving attitudes and increasing screening uptake.

Government involvement through regulations and mandates plays a critical role in facilitating premarital screening. Policies that require health screening before the legal registration of marriage have been effective in increasing screening rates and enhancing public acceptance of such programs. In Nigeria, the implementation of mandatory premarital screening policies improved community access to screening services and increased participation rates (Oluwole et al., 2022). Similarly, in India, government regulations have helped normalize premarital health inspections, encouraging more couples to undergo screening before marriage (Bindhani et al., 2020). These examples highlight the power of policy to influence health behaviors at a population level, particularly when combined with accessible and affordable screening services.

Indonesia faces a considerable public health burden related to genetic diseases, sexually transmitted infections, and risks associated with infant disabilities and mortality. Premarital screening offers a proactive approach to mitigate these challenges by identifying health risks early and enabling informed decision-making by prospective couples. The multifaceted factors identified in this review provide a comprehensive framework for developing premarital screening programs that are responsive to the Indonesian context. Specifically, programs should address demographic disparities by designing gender-sensitive and age-appropriate interventions. They should incorporate educational components that are culturally relevant and accessible to individuals with varying literacy levels. Programs also need to respect and engage with cultural practices such as consanguinity, providing counseling and support that honors traditions while emphasizing health risks. Furthermore, targeting families with known histories of genetic diseases for focused outreach and education is important. Enhancing public awareness and promoting positive attitudes through health worker involvement and community engagement can further motivate people to undergo health checks before marriage. Finally, leveraging government policy to mandate and facilitate screening while ensuring services are accessible and affordable will maximize the program’s reach and impact.

To deepen understanding and improve premarital screening strategies, further research employing diverse methodologies is recommended. Cross-sectional studies can help quantify and identify the most dominant factors influencing screening behavior across different populations. Such quantitative data provide evidence-based guidance for targeted interventions. Qualitative research, on the other hand, can explore the nuanced reasons behind reluctance or refusal to participate in premarital screening. Understanding cultural beliefs, social pressures, fears, and misconceptions through interviews or focus groups can inform the design of more empathetic and effective programs. Combining both quantitative and qualitative approaches will yield a more holistic understanding of premarital screening behavior, enabling stakeholders to tailor programs that are both evidence-based and culturally sensitive.

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