Care beyond the clinic: community networks, elderly well-being, and social support in aging Indonesian villages

Abstract

Background: Rural ageing in Petir Village, comprising 3,584 residents across 13 hamlets, exposed gaps between clinic-based provision and the everyday social support required by older adults. Objective: This community engagement program aimed to strengthen coordinated care networks for 65 older residents through family, neighbour, cadre, and service participation. Method: A participatory planning–implementation–monitoring-evaluation design used baseline questionnaires, care-network maps, attendance sheets, product rubrics, observation logs, referral trackers, pre–post measures, and focus groups to assess participation, support availability, loneliness, well-being, care capacity, and institutional continuity. Results: Planning documented three coordination meetings, 65 baseline assessments, at least eight need categories, and six core instruments. Implementation comprised one orientation, four core sessions, 13 care circles, 52 scheduled mentoring meetings, 65 network maps and support plans, and up to 26 priority home visits. Monitoring and evaluation recorded 52 matched records, 75% mean attendance, 70% acceptable outputs, a 20% knowledge increase, a 20-percentage-point improvement in reachable support, and one institutional continuation plan, without treating these findings as causal effects. Novelty: Its novelty lies in integrating relational care mapping, situated mentoring, quantitative tracking, community validation, and institutional follow-up within a single data-grounded model for ageing-in-place community development, responsive to rural accessibility, caregiving burden, service reach, and diverse local care cultures.