The relationship between access to and utilization of traditional medicine in Naman Teran, Karo Regency, Indonesia

¹Faculty of Public Health, Universitas Sumatera Utara, Medan, Indonesia, ²Faculty of Social and Political Sciences, Universitas Sumatera Utara, Medan, Indonesia, ³Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

^&Corresponding author
Dhani Syahputra Bukit, Faculty of Public Health, Universitas Sumatera Utara, Medan, Indonesia

Introduction    

Indonesia boasts a diverse ethnic, cultural, and biological heritage that serves as valuable capital for the development of traditional knowledge. The wealth of biological resources spread throughout the archipelago and across various ecosystems, combined with local knowledge passed down through generations, has given rise to a complex and highly valuable system of ethnomedicine, or traditional medicine [1]. According to the WHO, there are two main approaches to the healing process: modern medical treatment and traditional medicine. While both differ philosophically and methodologically, they share similarities in terms of human rights perspectives and clinical practices that encompass the treatment of specific conditions [2]. Traditional medicine encompasses knowledge, skills, and practices rooted in culture, beliefs, and community experience, used to maintain health, prevent disease, and treat physical and mental illnesses [3]. In this study, traditional medicine refers operationally to community-recognized healing practices and treatments provided by traditional healers or through the use of locally available natural remedies, including herbal preparations and culturally based therapeutic practices. As a cultural heritage, traditional medicine is deeply rooted in community identity, emphasizing a balance between the physical, spiritual, and experiential aspects of health [4]. In Asia, Africa, and many developing countries, traditional medicine remains the primary treatment of choice for some communities, and in developed countries, the trend toward the use of alternative and complementary medicine is also increasing. Data shows that approximately 75-80% of the population in developed countries have used methods such as acupuncture, herbal therapy, meditation, and other holistic treatments [5]. In Indonesia, knowledge of traditional medicine reflects local wisdom passed down from generation to generation, demonstrated through the use of medicinal plants, healing practices, and their integration with the surrounding culture and environment.

Accessibility is one of the main reasons people choose traditional medicine. The widespread distribution of treatment facilities, even in remote villages, the ease of obtaining natural ingredients for medicine locally, the relatively affordable cost, and the simple procedures make these traditional treatment methods more accessible than modern facilities [6,7]. In this study, access is defined as the community's perceived ease of obtaining traditional medicine services, including geographical proximity, availability of information, administrative simplicity, flexibility of services, and the availability of natural medicinal resources. In addition to serving as an alternative, traditional medicine is also an important part of public health services, especially in rural areas. Furthermore, these traditional healing practices are imbued with social values such as togetherness, solidarity, and respect for local wisdom [8,9]. Traditional medicine continues to hold a special place in society due to its flexibility, willingness to provide home visits, and proximity to patients in emergency situations [10]. Their popularity is reinforced by cultural factors, community trust, and informal communication networks that allow information about their expertise and services to spread widely through families, neighbors, and communities [11,12]. Taken together, these factors suggest that both structural accessibility and socio-cultural acceptance jointly shape community reliance on traditional medicine. This shows that despite the progress of modernization, traditional medicine remains an important option in the Indonesian health system.

The utilization of traditional medicine in Indonesia remains relatively high, with the 2018 Basic Health Research (Riskesdas) reporting that 48% of the population uses ready-to-consume traditional herbal remedies and 31.8% prepare herbal medicines independently. Data from 2024 indicate a higher prevalence of traditional medicine use in North Sumatra, with 3% of men and 2.09% of women reporting access to such services, compared to the national average of 1.77% and 1.39%, respectively. This phenomenon is strongly influenced by socio-cultural factors, including cultural norms, community beliefs, and recommendations from family members and local leaders. Naman Teran Subdistrict in Karo Regency exemplifies this dynamic, as its community continues to rely on traditional medicine as a primary means of treatment, shaped by strong ancestral values and social cohesion. The local social environment plays a pivotal role in treatment-seeking behavior, where trust, solidarity, and shared experience reinforce the preference for traditional healing practices.

However, the lack of regulation, formal training, and standardized oversight for traditional healers in this area has led to inconsistencies in hygiene practices, safety standards, and service quality, potentially posing health risks. These conditions highlight the importance of examining determinants of traditional medicine utilization in Naman Teran Subdistrict. Naman Teran Subdistrict in Karo Regency was selected as the study setting due to its reliance on traditional medicine and its strong cultural continuity in traditional healing practices. The area is characterized by rural geographical conditions, limited access to formal health services, and a predominantly homogenous ethnic population, making it a relevant setting to examine the role of access in shaping traditional medicine utilization at the community level. Despite the prominence of traditional medicine use, empirical evidence on how access-related factors influence the utilization of traditional medicine, particularly in rural areas of Indonesia, remains limited. Previous studies have predominantly focused on socio-cultural beliefs and individual preferences, while structural determinants such as access have received less attention. While socio-cultural factors play an important role in shaping health-seeking behaviour, this study focuses on access as a structural determinant, including geographical accessibility, availability of information, administrative simplicity, service flexibility, and availability of natural medicinal resources.

Based on the issues described above, this study aims to examine the relationship between access and the community’s decision to utilize traditional medicine in Naman Teran, Karo Regency. Utilization of traditional medicine in this study refers to the reported use of traditional healing services or remedies by community members as a healthcare option within the defined study period. Specifically, this study seeks to determine the level of community access to traditional medicine services, identify the proportion of the community that utilizes traditional medicine as a healthcare option, assess whether perceived access to traditional medicine-measured through geographical availability, information access, administrative simplicity, service flexibility, and the availability of natural medicinal resources-is significantly associated with its utilization, and evaluate the extent to which access influences the likelihood of choosing traditional medicine after adjusting for sociodemographic characteristics. Understanding these determinants is essential, as traditional medicine continues to play a central role in rural health systems despite limited regulatory oversight and variations in service quality. The findings of this study are expected to provide evidence-based insights that can support local governments and health stakeholders in developing culturally sensitive and inclusive health policies. Ultimately, this research contributes to efforts to integrate traditional practices more safely and effectively into the broader healthcare system, thereby improving service quality and promoting better health outcomes for rural communities.

Methods     

Study design: this study employed a quantitative approach with a cross-sectional design, which provides an overview of certain phenomena at a specific point in time. This method is considered cost-efficient; however, it has limitations in establishing causal relationships [13].

Setting: this research was conducted in Naman Teran District, Karo Regency, North Sumatra, Indonesia, focusing on 12 villages, including Kutarayat Village, Naman Village, Sigarang-Garang Village, Sukanalu Village, Kutambelin Village, Sukandebi Village, Sukatepu Village, Gung Pinto Village, Kebayaken Village, Kuta Tonggal village, Ndeskati Village, and Kutagugung Village.

Study population: the study population consisted of individuals who had used traditional medicine services in Naman Teran Subdistrict. Although population figures were derived from household records (14,411 households) to determine proportional sample allocation, the unit of analysis was the individual. Households served only as the sampling frame. During field visits, one respondent was selected per household using a simple selection procedure in which all eligible adult household members were listed and one was chosen based on availability and willingness to participate after eligibility screening. Eligible participants were residents of the selected villages who reported prior use of traditional medicine services, confirmed through an initial screening question ("Have you ever used traditional medicine services for health treatment?") prior to data collection.

Sample size: the sample size of 300 respondents was determined using proportional stratified random sampling, where each village was treated as a stratum, and the number of households served as the sampling frame. The proportional allocation approach was applied to ensure that the sample reflected the population distribution across villages, following standard stratified sampling procedures described in survey methodology literature [14[RU1.1]. The number of respondents selected from each village was calculated proportionally using the following formula:

n_h = sample size in stratum h N_h = population size in stratum h N = total population n = total sample size (300 respondents) Based on the proportional sampling method applied, the largest number of samples came from Kutarayat village (56 respondents from 2,700 population), Naman (35 respondents from 1,692 population), Sigarang-garang villages (35 respondents from 1,678 population), Sukanalu village (27 respondents from 1,350 population), Kutagugung village (27 respondents from 1,318 population), and Ndeskati village (27 respondents from 1,280 residents), Kutambelin village (22 samples from 1,044 population), Sukandebi village (21 samples from 1,004 population), Sukatepu village (17 samples from 820 population), Gung Pinto village (13 samples from 609 population), Kebayaken village (12 samples from 555 population), and the smallest number of samples came from Kuta Tonggal village (8 respondents from 361 population). The total sample size consisted of 300 respondents.

Variables: the independent variable was "community's access to traditional medicine", defined as the perceived ease of obtaining traditional medicine services, including geographical proximity, availability of information, administrative simplicity, service flexibility, and accessibility of traditional medicine resources. Access was categorized as "good" or "poor" based on questionnaire scores. The dependent variable was the "community's decision in choosing traditional medicine", defined as the decision to choose or not choose traditional medicine for health treatment, and categorized as "choose" or "not chosen". In this study, traditional medicine refers to naturalistic traditional medicine, namely the use of herbal remedies and natural materials derived from plants, animals, or minerals, excluding spiritual, supernatural, or ritual-based practices.

Data source/measurement: primary data were collected using a structured questionnaire administered through the KoboToolBox application. The questionnaire consisted of 21 questions designed to assess how the community accessed and selected traditional medicine services, including ease of location coverage, administrative procedures, and availability of treatment materials. Data collection was conducted through face-to-face interviews, each lasting approximately 20 minutes. Data collection was conducted from September 2 to September 10 in 2024.

Bias: to minimize selection bias, proportional stratified random sampling was applied across all villages. Information bias was reduced by using a standardized questionnaire and providing guidance to respondents before data collection. Only respondents who had used traditional health services were included in the study.

Quantitative variables: all variables in this study were analyzed in categorical form. The decision to choose traditional medicine was categorized as "Choose" or "Not chosen". Access to traditional medicine was classified into "good" and "poor categories". Age, education, and Income were grouped into predefined categories, while Gender was categorized as "male" or "female".

Data collection: data collection was conducted using a structured questionnaire through the KoboToolbox application to obtain primary data on how the community accesses and chooses traditional medicine services, including ease of geographical access, administrative processes, and availability of natural treatment materials. A household list obtained from village administrative records was used as the sampling frame. Based on the proportional allocation for each village, trained data collectors conducted systematic household visits starting from randomly selected locations within each village. Potential participants were identified through household visits in each village based on proportional allocation of the sample. Eligible respondents were approached directly by trained data collectors and invited to participate after eligibility screening and written informed consent was obtained following an explanation of the study objectives and procedures. The eligible respondent per household who had previously used traditional medicine was included in the study. Data were collected through face-to-face interviews. Each interview lasted approximately 20 minutes, and a total of 21 items in the questionnaire were administered to all respondents. Data collection was conducted from September 2 to September 10, 2024.

Data analysis: statistical analysis was performed using IBM SPSS Statistics. The data analysis in this study consisted of descriptive statistics summarizing respondent characteristics and multivariate analysis using binary logistic regression to examine the relationship between access to traditional medicine and community decisions to choose it. Multivariate analysis was performed using binary logistic regression to examine the association between access to traditional medicine and community decisions to choose traditional medicine while controlling for gender, age, education, and income. The results were presented as odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). Statistical significance was set at p<0.05.

Ethical approval: this study received ethical approval from the ethics committee of University Sari Mutiara Indonesia, reference No. 3471/F/KEP/USM/VII/2025.

Results     

The results of the research on the relationship between access and people's decision to choose traditional medicine in Naman Teran District in 2024 are explained as follows:

Participants: a total of 300 respondents from Naman Teran District were included in the analysis. All respondents met the criteria who reported prior use of traditional medicine services and completed the questionnaire during the study period.

Demographic characteristics of respondents: the results showed that the majority of respondents were female (58%, n = 174). This may indicate that women in this area may have greater involvement in traditional medicine practices. Based on age group, the majority of respondents were in the >45 years category (49%, n = 147). This may suggest that older individuals are more likely to utilize traditional medicine due to their higher health needs and reliance on accessible healthcare options (Table 1). In terms of education, the majority of respondents graduated from senior high school (42%, n = 126). This may influence their perception of traditional medicine, as this level of education often allows individuals to balance modern health knowledge with cultural values, making them more open to utilizing traditional practices alongside formal healthcare services. Based on income level, most respondents were in the middle-income category (55%, n = 165). This indicates that economic aspects may have a significant influence on the choice of health services, as people with middle to lower incomes tend to choose traditional medicine because it is more affordable.

Measured variables

Community decisions in choosing traditional medicine: based on the data presented, there is a positive tendency toward traditional medicine, with a relatively balanced distribution. Of the total 300 respondents studied, 170 respondents (56.7%) chose to use traditional medicine, while 130 respondents (43.3%) did not. The cumulative percentage shows that the "not choose" category reached 43.3%, and when combined with the "choose" category, the cumulative percentage reached 100%. This indicates that traditional medicine still holds a significant place in people's health preferences (Table 2).

Classification of community access based on category: based on the data presented, there is a significant different between the "poor" and "good" access categories. Of the total 300 samples analyzed, 240 respondents (80%) fell into the "poor" category, while 60 respondents (20%) were classified as having "good" access. The cumulative percentage shows that the "poor" category reached 80%, and with the addition of the "good" category, the cumulative percentage reached 100%. This indicates a considerable imbalance, with a ratio of 4:1 between "poor" and "good" conditions. The very high dominance of the "poor" category suggests that most respondents experience sub-optimal conditions, which may require targeted attention or interventions for improvement (Table 3)

The relationship of between access to community decisions to choose traditional medicine: the results of the analysis on the relationship between access to traditional medicine and the community's decision to use it showed that access was significantly associated with the community's decision to choose traditional medicine (p-value < 0.05). The adjusted odds ratio (aOR) for access was 2.89, after controlling for respondent characteristics, indicating that people who perceived access to traditional medicine as easy were 2.89 times more likely to choose it compared to those who reported difficult access (Table 4).

Discussion     

The results showed a significant relationship between access and community decisions to choose traditional medicine in Naman Teran District in 2024. These findings indicate that perceived accessibility is an important structural determinant influencing healthcare-seeking behavior in rural communities. Access to traditional medicine plays a crucial role in shaping community decisions to select traditional medicine as an alternative to the healing option. Although demographic characteristics were described, the primary contribution of this study lies in demonstrating that access remained significantly associated with utilization even after adjustment for sociodemographic factors. Based on the characteristics of respondents, the majority were women (58.0%), most were 45 years old (48.7%), and most had completed high school or an equivalent education (42.0%). Nearly half of the respondents were Christian (50.0%), the majority belonged to the Karo tribe (92.7%), and more than half had a moderate income (55.0%). Most respondents chose traditional medicine (56.7%), and a majority reported living in a poor social environment (80%). Based on multivariate analysis, after controlling for respondent characteristics, the access variable remained significantly associated with traditional medicine use, with an aOR of 2.89 (95% CI: 1.76-4.77) and a p-value of <0.001. This indicates that respondents who have easier access to traditional medicine are 2.89 times more likely to choose traditional medicine compared to those with limited access, after adjusting for other factors.

Several factors hinder the optimal utilization of health facilities in the community. Geographical accessibility is a significant barrier, particularly in rural and remote areas, where individuals often must travel long distances to reach health services [15[RU2.1]. Affordability is another key issue, as treatment costs can limit people's ability to seek medical care when needed [16]. In addition, the quality and availability of services affect utilization rates, as inadequate facilities in certain regions contribute to unmet healthcare needs. Cultural factors, such as stigma surrounding certain diseases and deeply rooted traditional beliefs, may further impact access to and utilization of health services [17]. These structural and socio-economic barriers help explain why traditional medicine remains an attractive and practical healthcare option in geographically constrained rural settings such as Naman Teran. Broadly, the level of health service utilization is influenced by two main aspects: those originating from healthcare providers and those originating from the community as healthcare users.

A study conducted by Rankoana et al. (2022) in Limpopo, South Africa, found a significant correlation between accessibility and people's decisions to choose traditional medicine as an alternative healing method. Approximately 25% of respondents stated that they preferred traditional medicine due to easier access compared to formal or conventional healthcare services available in the area [18]. Similarly, a study by Ayatollahi et al. (2020) in Iran found that access and cost were significant factors influencing the choice of traditional medicine. In that study, 97.3% of participants reported using traditional medicine, with 89.2% citing lower costs and 87% citing easier and faster access as primary reasons [19]. In Nigeria, Mbah et al. (2019) also found that rural farmers had high access to traditional medicine through markets and practitioners, with socioeconomic factors such as age, education, income, and farming experience influencing access [20].

The findings of this study were consistent with those of Saputri et al. (2023), who reported that among 63 respondents with easy access to health services, 54 respondents (85.7%) indicated sufficient utilization, while 9 respondents (14.3%) reported underutilization. Statistical analysis using the chi-square test showed a p-value of 0.000 (<0.05), indicating a significant relationship between accessibility and utilization of health services at Traditional Puskesmas in Makassar City [21]. Similarly, Fitriani et al. (2021) reported that 25 respondents (80.6%) had easy access to treatment services at health facilities, whereas 6 respondents (19.4%) reported easy access to traditional medicine services. In contrast, 69 respondents (95.8%) experienced difficulty accessing health facilities, while 9 respondents (8.7%) faced difficulty accessing traditional medicine services. The chi-square test showed a p-value of 0.020 (<0.05), demonstrating a significant relationship between accessibility and the decision to choose treatment services [22]. In line with this, Rifka et al. (2023) reported that 73.8% of Indonesians used traditional health services, with distance being a significant factor influencing utilization [23]. Supporting evidence from Liana et al. (2017) also showed that distance from health facilities significantly influenced the use of traditional medicine. Multivariate analysis using the Binary Logistic Regression Test revealed a p-value of 0.001 and an OR of 0.167, indicating that respondents living closer to health facilities were less likely (0.167 times) to use traditional medicine. The probability of traditional medicine use was 90.93% among respondents who lived far from health facilities [24].

According to the 2018 basic Health Research (Riskesdas), the ease of community access to healthcare facilities is primarily influenced by two factors: the distance between their residence and the facility, and the time required to reach it [25]. Distance or accessibility plays a crucial role and has a significant impact on the utilization of health services. Accessibility, affordability, and availability remain the main determinants influencing health service utilization [26]. In the context of treatment-seeking behavior, many individuals delay visits to healthcare facilities until their health condition deteriorates seriously. Interestingly, even when people experience a noticeable decline in health-such as reduced immunity or physical weakness-they may still avoid seeking medical care. Instead, they prefer self-treatment using traditional remedies passed down through generations, including herbal preparations or other natural methods. Decisions to use traditional medicine are often driven by considerations such as distance to healthcare facilities, treatment costs, and long-standing cultural beliefs in the effectiveness of traditional healing practices. However, the results of this study contradict those reported by Cahyani et al. (2019), who found no significant relationship between accessibility and healthcare utilization (p-value > 0.05) [27]. Similarly, Hidayah et al. (2020) also reported no significant association between accessibility and health service utilization (p-value = 0.471) [28]. These inconsistencies may reflect contextual differences in infrastructure, urban-rural distribution of services, or cultural reliance on traditional healing, suggesting that the influence of accessibility may vary substantially depending on local healthcare system organization and community norms. Traditional medicine continues to play an important role in global public health, with many populations utilizing both traditional and modern medical systems [29]. Studies indicate that access and cultural factors strongly influence preferences for traditional medicine over modern healthcare. In Nigeria, for example, the high cost of modern healthcare encourages rural populations to seek more affordable traditional medicine options [30].

Therefore, people's perceptions of access to traditional medicine play a crucial role in shaping their healthcare choices. These perceptions encompass the ease of obtaining herbal ingredients, hereditary knowledge of traditional practices, and belief in the effectiveness of traditional treatments. The choice of traditional medicine is influenced by multiple factors, including social networks, cultural preferences, and intergenerational beliefs. Research across various countries shows that sociodemographic factors, health conditions, and inherited knowledge significantly affect the decision to use traditional medicine [31]. In addition, growing attention to the nutraceutical value of local foods further strengthens the appeal of traditional healing, as many traditional remedies are derived from foods rich in bioactive compounds such as polyphenols, flavonoids, vitamins, and minerals [32-34]. Advances in nutraceutical processing and traditional knowledge together enhance the perceived effectiveness of these natural therapies, reinforcing community trust in traditional medicine. According to the Health Belief Model, people's perceptions of traditional medicine are influenced by experiences and trust developed over generations. Perceived trust reflects the extent to which individuals believe in the efficacy of herbal medicines and traditional healing methods [35]. Traditional medicine is often valued for its safety when used appropriately according to established theories and practices. Individuals with positive experiences of traditional medicine are more likely to use these methods again when facing health issues. Moreover, people's perceptions of traditional medicine often align with their cultural values and sense of safety (perceived appropriateness). As a result, many individuals choose traditional medicine as their first line of treatment before seeking modern medical care.

Limitations: this study utilized a cross-sectional design, which limits the ability to establish causal relationships between access and traditional medicine utilization. Because exposure and outcome were measured simultaneously, temporal relationships cannot be confirmed. Future longitudinal or cohort-based studies are therefore recommended to better evaluate causal pathways and changes in healthcare-seeking behaviour over time. Data were collected through self-reported questionnaires, which may be subject to recall or social desirability bias. Additionally, the study was conducted in a single district with a predominantly homogeneous ethnic composition, which restricts the external validity of the findings and limits generalizability to urban populations or regions with different cultural, infrastructural, or healthcare system characteristics. Multi-site studies involving diverse geographic and socio-cultural settings are recommended to improve generalizability.

Conclusion     

This study identified access as an important determinant of the community's utilization of traditional medicine in Naman Teran District, Karo Regency. Rather than focusing on specific statistical estimates, the findings indicate that perceived ease of access-including geographical availability, information access, service flexibility, administrative simplicity, and the availability of natural medicinal resources-plays a central role in shaping healthcare choices in rural communities. Traditional medicine continues to function as a relevant and culturally embedded healthcare option despite ongoing healthcare modernization. These results suggest that both structural accessibility and local socio-cultural context should be considered when understanding treatment-seeking behaviour in similar rural settings. The observed association between access and traditional medicine utilization underscores the importance of health policies that acknowledge and appropriately regulate traditional practices while strengthening their accessibility, service quality, and safety standards. Developing inclusive and culturally responsive healthcare strategies may help improve service coordination between traditional and formal health systems and support more equitable healthcare access in rural Indonesia. Future studies are encouraged to examine additional structural, cultural, and health-system factors influencing traditional medicine use and to explore practical models for safe integration of traditional and modern healthcare services.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Dhani Syahputra Bukit: conceptualization, study design, data collection, and writing main draft; Kintoko Rochadi: data analysis, interpretation of results, and review and edit; Nurmaini Nurmaini: data collection, research instruments, and review and edit; Henri Sitorus: literature review, data curation, visualization, and review and edit; Ida Yustina: statistical analysis, methodology, and review and edit; Tri Krianto: methodology, administrative support, and review and edit; Sri Malem Indirawati: data analysis and review and edit; Etti Sudaryati: software, sources, and review and edit. All the authors have read and approved the final version of this manuscript.

Acknowledgments     

We express our sincere gratitude to all respondents and parties who contributed to this study. This article forms part of the author's dissertation work. Special thanks are extended to the respondents for their valuable input and to the supervisors for their constructive guidance and suggestions.

Tables and figures     

Table 1: socio-demographic characteristics of respondents participating in the study on access and utilization of traditional medicine in Naman Teran District, Karo Regency, North Sumatra, Indonesia, collected from September 2-10, 2024 (n=300)

Table 2: community decisions regarding the use of traditional medicine among respondents in Naman Teran District, Karo Regency, North Sumatra, Indonesia, based on survey data collected from September 2-10, 2024 (n=300)

Table 3: classification of community access to traditional medicine services among respondents in Naman Teran District, Karo Regency, North Sumatra, Indonesia, based on survey data collected from September 2-10, 2024 (n = 300)

Table 4: association between access to traditional medicine and community decisions to use traditional medicine, analyzed among respondents in Naman Teran District, Karo Regency, North Sumatra, Indonesia

References