Data Flow Diagram Result in the Database
Scope of the System
Posyandu information system is a system which is developed to support Posyandu data management and analysis. The collected data was recorded by the CHWs, which includes the username and password, mother’s identity, pregnant mother’s identity, physical examination of a pregnant mother, under-five identity, and physical examination of under-five. This information could also be seen by the CHWs in the monthly report section of the application. The form was already categorized into a monthly and yearly national form. Meanwhile, parents could see the information about their under-five children by performing the following steps: registering username and password, login, and choosing their children’s data, which were already recorded by the CHWs. Afterward, other information that could be accessed by the parents includes their identity, physical examination (of a pregnant mother), their children’s identity and physical examination, as well as mother and child health book. The information is depicted in Figure 3.
Initial Phase Qualitative Research Result (2017)
The first result consists of the qualitative part of the study, where the input collected from the CHWs and mothers are combined in one table and divided into themes, key insights, and quotes. The Supplemental Table 1 shows the main problem faced by the CHWs, which is unorganized yearly data record and reporting. They stated that the data was manually hand-written in their notebook. It was easier for them than to write immediately to the big book report, or Posyandu information system (PIS) book, where one of them confirmed that “the paper notebook can be used immediately.” Another informant also ascertained that, “if the data is written directly to the PIS as the mothers come, it will make my head blown (since it is) confusing.” The CHWs also did not have time to put children’s names in an orderly manner, as suggested by one of the informants. Then, the issue of delay to report to the Puskesmas was also present. This was due to the double burden: data entry to their personal book and report entry to the big book. The CHWs felt that they had to write more redundant works. A worker stated in the FGD that, “(…) we have to write the names to the Posyandu information system book in an orderly manner.” They indicated that they required a solution such as mHealth application to facilitate the data recording and reporting process. The CHWs described it as, “(something) like a tool, but it can be re-accessed, like an archive. Because we need it when Puskesmas requests (a report), sometimes it can be accessed again.”
As for the mothers in Supplemental Table 1, the app would help them supervise their under-five children’s growth and development. The mothers quoted that, “(We) need to know our child’s development so that we can monitor by ourselves for our child.”. Moreover, working mothers need to monitor their children’s growth while their family or neighbor were in charge of taking care of them to Posyandu. One mother said, “For example, this (child), the child is taken care of by another person (because) the mother is working.” They expected not to have to ask the CHWs for a few times to know about their children’s growth, because “(it was) just not practical.” It is suggested that mothers need Posyandu mHealth application “so that we can look at it privately (and immediately). Thus, we do not have to ask the CHWs continuously”.
The activities, including the quoted difficulties above, act as the input to extend the context in the blueprint of the app. Besides, other inputs such as the registration, connection with children’s data, data entry that can also have automatic report output in governmental form, child growth graph, and automatic alert of child growth were also recorded. The main list of features is depicted in the Supplemental Table 1.
Figure 4 illustrates the initial phase of the mobile app for CHWs/cadre and mothers using the touch screen smartphone. In the beginning, the application for CHW and mothers differs in the registration menu. Quoted from one of the informants, “First, we click on the Posyandu app, then we register in it, after that we click it once more, then we are connected to our children’s data.” Mainly, personal data and the name of the nearest Posyandu were needed in the registration before they could logvin according to their role as a cadre or a mother.
Table 1. Number of participants in each phase of the study
Participants
|
Number of participants in each phase year
|
2017
|
2018
|
2019
|
Qualitative
|
Qualitative
|
Quantitative
|
Qualitative
|
Quantitative
|
CHWs
|
13
|
12
|
171
|
10
|
156
|
Mothers
|
14
|
|
|
|
|
Midwives
|
|
|
|
11
|
|
Middle Phase Qualitative Research Result (2018)
Table 2 illustrates the qualitative theme and key insights that emerged during the training in 2018, as indicated in the table. The cadre recommended that the notification feature on the monthly weight data should be automated. Height was measured according to government and WHO guidelines. However, they confirmed that, “We do not measure the height monthly but only once every several months.” After the cadres enter the required data, they wanted to see the online information on whether the under-five growth chart was increasing or decreasing automatically. Also, the expected the information to be available anytime. To quote, “We want it to be like (…) online reporting, so we do not need to measure the number of decreases.” (Supplemental Table 2). By doing so, they expected that the app would ease their duties in Posyandu by recording the data and, at the same time, submitting the report to the Puskesmas directly. Nonetheless, when imagining if the app were used in Posyandu, sometimes they still felt confused about some obstacles, “A while ago, some data was successfully stored, but some was unsuccessful.” They estimated that the posyandu situation would be unsupportive when it was crowded, “During the Posyandu working day, it will remain crowded so that the data entry will be done after the end.” They also worried about the internet quota availability when they ran out of money.
Considering the pros and cons, the cadre still believed that the app could be a great assistance for them. The learning process played as a central role. During the training, they stated that, “We think we can use it because we are used to using and playing with a handphone. However, before that, the application should be made available first.” The app was available during the training but in the APK form and we had not published it yet on Google Play (GP) at the time. In the late 2018, we launched it on GP to make it more available and accessible. During the learning process, they needed more written information in the form of a guidebook. The cadres also coordinated with the village officers regarding the solution of any app-related issue. One of the issue was related to the internet quota, where it was stated that “(…) the Posyandu does not have any budget (to cover it). I asked the villagers about the internet quota fee and they already shook their heads.” Regardless, it was expected that the cadres could use the app and put them into practice at the Posyandu after the training was ended. They also expressed their interest on using the app, “If using the application if possible, then so be it, (I) cannot wait to use it.” More information regarding the feedback can be seen in the Supplemental Table 2.
Table 2. Theme and Key Insight from 2018 Analysis
No
|
Theme
|
Key Insight
|
1
|
Under-five Data Input
|
- Under-five body weight measurement
- Under-five body height measurement time
- Under-five body height measurement according to WHO
|
2
|
Under-five Data Display
|
- Under-five data can be accessed anytime
- Under-five measurement result display
- Parents can access under-five data
|
3
|
Posyandu Mobile app Components
|
- Posyandu mobile app menu
- Online report
|
4
|
Benefits of Posyandu Mobile app
|
- Posyandu reporting and recording is easier than the big book report
- Facilitate cadre’s duties in Posyandu
|
5
|
Obstacles in using Posyandu mobile app
|
- Confused/need to adapt
- Unsupportive Posyandu situation
|
6
|
Learning process
|
- Cadre’s knowledge of Posyandu mobile app
- Cadre’s skills on the use of Posyandu mobile app
- Cadres need more training about the app
|
7
|
Posyandu mobile app guidebook
|
- Significance of Posyandu mobile app guidebook
- Guidebook format
- Guidebook size
- Guidebook writing style
- Images in the guidebook
|
8
|
Information in the guidebook
|
- Instruction
- How to register an account/log in
- How to input Under-five data
- How to input pregnant mother data
|
9
|
Cadre’s expectation
|
- Tablet/HP provision
- Use of application in Posyandu
|
10
|
Cadre’s worries
|
- Internet quota availability
|
Final Phase Qualitative Research Result (2019)
Table 3 below demonstrates a few feedbacks from the cadres and village midwives on the development of the application version. Tables 3 and 4 incorporate the ideas from the cadres and midwives in separate FGDs. When using the app during the Posyandu activities, some corrections would be required, as quoted from one of the informants “Here, the name of my village in this application is wrong.” Other feedback recommended to insert a photo in the account information and an alternative password. As a supervisor of cadres in several Posyandus, one of the midwives suggested that, “(…) in the future, it would be great if there is an access for the Village Midwife and not only for the cadres.”, which would bring a positive impact for the next app development. Creation of a website was also discussed for the reporting purpose. The midwives perceived that reporting with a laptop would be easier than with a handphone. More feedback is depicted in Table 3.
Table 3. Cadre and Village Midwives FGD Result on Posyandu Mobile app Development
No.
|
Theme
|
Key Insight
|
Noteworthy Quotes
|
1.
|
Identity
|
Village name correction in the editing menu
|
“Here, the name of my village in this application is wrong.”
|
2.
|
Account
|
Account owner photo
|
“Ma’am, can’t we put our photo so that there will not only be our name (displayed) in it? Even Google mail has the owner’s photo. This will result in a higher sense of belonging.”
|
|
|
Alternative password
|
“Oh, I forgot the password. It is not possible to login. It would be great if an alternative password exists.”
|
|
|
Individual account for Village Midwife
|
“That is, in the future it would be great if there is an access for the Village Midwife and not only for the cadres. So, it will not be a hassle to enter (the data) one by one. Now, there is only 5 Posyandu in one village in different locations, and one single Village Midwife handles even 13 Posyandu.”
|
3.
|
Website
|
Web creation
|
“We hope that there will be a Web to monitor at a larger scale for the Midwife. The Web can make it easier to read the report.”
|
4.
|
New menu
|
Pregnancy age automatic calculation
|
“It is hoped that after the input of the first day of the last period, the pregnancy age will be automatically calculated in the next examination schedule.”
|
We analyze the advantages and disadvantages of the implementation of this application, as indicated in Table 4 from the side of the user, organization, technology, and environment.
Table 4 illustrates the resistance of some cadres to change their behavior from paper-based to digital-based services. In practice, the village midwives assisted in supervising and motivating the implementation of the app during the Posyandu activities. Continuous organizational support from the village was vital in 2019 as shown by the research results depicted in Table 4, which was also applicable in the previous year. Standard operating procedure (SOP) was essential to be issued by the government, which should address the leadership of the village office, subdistrict, Puskesmas, and district health office (DHO). The SOP would strengthen the implementation of the app even though there would be a double work burden at the beginning of the change, which would disappear once they were already accustomed by it.
Table 4. Advantages and Disadvantages Analysis of Posyandu mobile health application
No
|
Analysis Result
|
Advantages
|
Disadvantages
|
1
|
User
|
|
|
|
|
Cadre’s approval of the application
|
|
|
|
Problem solution by the cadre when facing a difficulty
|
|
|
|
Cadre’s skill in operating Posyandu Mobile app
|
|
|
|
|
Time-consuming because there is a reluctance in the part of some cadres to change into digital system-based services
|
2
|
Organization
|
|
|
|
|
Presence of a village midwife leadership as the direct supervisor of Posyandu activities
|
|
|
|
|
Cadre’s facility in the implementation of Posyandu mobile app is still necessary
|
|
- Standard Operating Procedure (SOP)
|
Positive response in the advocacy of the government
|
Double work burden between manual and digital tasks because there is no SOP which regulates the implementation of Posyandu mobile app
|
3
|
Technology
|
|
|
|
|
|
|
|
|
Appropriate and correct use of the application
|
|
|
|
User-friendliness of the application when being operated the cadre
|
|
|
|
Availability of the application in Google Playstore to be used or operated
|
|
|
|
Conformity of the application menu with the needs of the cadre or as planned by the government
|
|
|
|
Real-time condition of the application to display the information or examination result
|
In the region with low network coverage, an offline version of the application is needed for data entry which will be submitted after the network appears
|
|
|
|
Application bugs need to be fixed
|
|
|
|
|
|
|
|
Unstable network for some providers/carriers
|
|
|
|
Some versions of android are not compatible with the application
|
|
|
|
Some cadres do not have internet quota
|
4.
|
Environment
|
|
The situation that is not conducive (queueing issue) during Posyandu’s business time
|
Also, technology is the core part of this implementation. Software and hardware analysis are crucial. In 2018, the app was submitted and launched on Google Play (GP). In 2019, it was available in the GP store of android handphone to be downloaded and operated. The app answered the users’ needs as identified in the previous years of action research, such as real-time data entry and report. However, in the region with low network coverage, an offline version was still needed for the next app development. Thus, the data submission could be made after the network was available. Some handphones found that the unstable network issue persisted, while other phones were not compatible with the app version. It was crucial to continuously improve the version to make it more compatible with all phones.
Evaluation of the cadre’s knowledge and skills in the implementation of Posyandu mobile app during the training (2018) and Posyandu activities (2019) were conducted as an ongoing research.
The respondent characteristics are shown in Table 5. The majority of the respondents was more than 35 years old, and most of them received secondary level of education or Junior High School). In 2018, the respondents consisted of 171 Posyandu cadres. We found a decline of 8.77 % in 2019. The reason for this was because some respondents were no longer reachable and could not be followed up. Both groups consisted of 15 people. The rest of the respondents could be evaluated up to 79 people in the treatment group and 77 in the control group. Hence, the total number of respondents that could be assessed was 156 people.
Table 5. Respondent Characteristics in Pasawahan Sub-District, Purwakarta District 2018 and 2019
Characteristics
|
2018
|
2019
|
Treatment
(n=86)
|
Control
(n=85)
|
Treatment
(n=79)
|
Control
(n=77)
|
Age (year)
26-35
36-45
46-55
Education
Elementary School
Junior High School
Senior High School
|
18
32
36
24
32
30
|
22
33
30
31
33
21
|
16
31
32
21
30
28
|
19
33
25
26
30
21
|
The comparison between the knowledge during the training (2018) and the implementation of the Posyandu application (2019) is shown in Table 6.
Based on the Table 6, the knowledge and skills level of the cadres during the training and Posyandu activities have a significant average score difference equals to the value of p<0.05. This score shows that there is a difference in knowledge and skills between the training period and the performance of Posyandu activities. The effect of knowledge and skills were 0.34 (medium) and 0.21 (small), respectively, according to Cohen (29, 30).
Figure 5 illustrates provincial distribution across 34 provinces in Indonesia until 31 December 2019. As many as 964 posyandus were registered to Posyandu mobile app from almost all provinces in Indonesia. The highest number recorded was in the study area, which was in West Java (34.54%). The rest was in other provinces that shown their interest in registering their Posyandu. After West Java, we identified Belitung, Jakarta, Central Java, and Yogyakarta in an orderly manner from the highest number of registrations. There was no registration from North Kalimantan and Maluku at the time.
Table 6. Comparison of Knowledge and Skills during Training and Posyandu Activities
Variable
|
Occasion
|
Value
|
|
Min
|
Max
|
Mean
|
P-Value
|
Effect
|
Knowledge
|
Training
|
84
|
100
|
94.69
|
*0.0000
|
0.34
|
Posyandu Activity
|
76
|
100
|
91.91
|
Skill
|
Training
|
7.69
|
100
|
85.63
|
*0.0097
|
0.21
|
Posyandu Activity
|
27.63
|
100
|
93.05
|
*Wilcoxon signed-rank test