Continuity of diabetes care for older adults in urban primary care in Bandung, Indonesia: a multiple-perspective qualitative study

Abstract Background Diabetes in later life requires long-term, coordinated, and age-sensitive primary care. In urban Indonesia, older adults with diabetes may move between community screening, primary care, referral hospitals, laboratories, pharmacies and household support. Multiple points of contact do not necessarily produce continuous care. This study explored how continuity of diabetes care for older adults is experienced by those involved in delivering and supporting care and what they considered priorities for improvement. Methods A descriptive qualitative study was conducted from December 2024 to February 2025 in four kelurahan within the catchment area of Puskesmas Babakan Sari, Bandung, Indonesia. Fifty-two participants were purposively sampled: 16 health workers, 12 older adults with diabetes, 12 community health volunteers and 12 family caregivers. Face-to-face semi-structured interviews lasting 20–70 min were audio-recorded, transcribed verbatim and analysed using hybrid deductive–inductive content analysis. Meiqari and colleagues’ continuity-of-care framework provided the initial deductive structure, while data not accommodated by the framework were coded inductively. Reporting followed COREQ. Results Five themes were generated: entering the pathway; information that does not travel; trust as a bridge; keeping care moving; and when care becomes hard to sustain. Participants described a service network with multiple points of care but weak connections between them. Continuity was undermined by manual records, lack of post-screening tracking, one-way referral without return information, limited counselling time, treatment fatigue, and mobility and transport barriers. Health workers emphasised systems and staffing; older adults and families prioritised completing care in a single visit; and volunteers emphasised training, recognition and clearer reporting channels. Proposed improvements included integrated records, functioning counter-referral, post-screening tracking, family-inclusive education, trained and supervised volunteers, interprofessional coordination and flexible follow-up. Conclusions Continuity was produced or lost at the connections between clinic, community, referral services and household. Strengthening continuity requires information that moves with the patient, referral information that returns to primary care, planned follow-up, and formal support for the family and volunteer roles that currently bridge gaps in the pathway.