Data Flow Diagram Result in the Database
Scope of the System
Posyandu information system is a system developed to support Posyandu data management and analysis. The collected data were recorded by CHWs, which includes usernames and passwords, mother identities, pregnant mother identities, pregnant mother physical examination results, toddler identity, and toddler physical examination results. This information can also be accessed by 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 toddlers by performing the following steps: registering using username and password, logging in with the registered credentials, and selecting their children’s data that were already recorded by the CHWs. Information that can be accessed by the parents also includes their identity, physical examination results (of a pregnant mother), their children’s identity and physical examination results, and mother and child health book. The information is depicted in Figure 3.
Initial Phase Qualitative Research Results (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. Table 2 and the details in Supplemental Table 1 show the main problems faced by the CHWs, which is an unorganized yearly data record and report. They stated that the data was hand-written in their notebook. It was easier for them than to write immediately to the big book report, or the Posyandu information system (PIS) book, where one of them confirmed that “the paper notebook can be used immediately.” Another CHW also ascertained that “if the data is written directly to the PIS as the mothers come, it will blow my head (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 CHW. Then, there was also an issue of delay to report to the Puskesmas. This was due to the double burden: data entry to their personal book and report entry to the big book. The CHWs felt that their works were redundant. 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 toddlers’ growth and development. The mothers stated 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 members or neighbors were in charge of taking them to the 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 was suggested that mothers need Posyandu mHealth application “so that (they) can access it privately (and immediately). Thus, (they) do not have to ask the CHWs continuously.”
The activities, including the quoted difficulties above, serve 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 features are depicted in Supplemental Table 1.
Figure 4 illustrates the initial phase of the mobile app for CHWs/cadres and mothers using touch screen smartphones. In the beginning, the application for the CHWs 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 can log in according to their role as a cadre or a mother.
Middle Phase Qualitative and Quantitative Research Results (2018)
Table 3 and Supplemental Table 2 illustrate the qualitative theme and key insights that emerged during the training about the use of the Posyandu mHealth application by CHWs in 2018. The cadres 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 toddler growth chart was increasing or decreasing automatically. Also, they 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 the app to 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 being used in Posyandu, sometimes they still felt confused about some obstacles, “A while ago, some data was successfully stored, but some were 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 cadres still believed that the app could be a great assistance for them. The learning process played 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 mobile phone. However, before that, the application should be made available first (on Google Play).” The app was available in the APK form during the training and we had not published it yet on Google Play (GP) at the time. In late 2018, we launched it on GP to make it more widely available and accessible.
During the learning process, they needed more written information in the form of a guidebook. The cadres also coordinated with village officers regarding the solution of any app-related issue. One of the issues was 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 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 in 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 Supplemental Table 2.
Final Phase Qualitative and Quantitative Research Result (2019)
Tables 4 and 5 and the detail on supplemental Tables 3 and 4 present the cadres and village midwives FGD results on the Posyandu mobile app development, and advantages and disadvantages analysis of the Posyandu mobile health application, which 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 inserting 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. The 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 mobile phone. More feedback is depicted in Table 4/Supplemental Table 3.
We analyze the advantages and disadvantages of the implementation of this application, as indicated in Table 5 and Supplemental Table 4, from the side of the user, organization, technology, and environment.
Table 5 and Supplemental Table 4 illustrate the resistance of some cadres to change their behavior from paper-based to digital services. In practice, 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 these tables, which was also applicable in the previous year. A Standard Operating Procedure (SOP) was essential to be issued by the government, which should address the leadership of the village office, sub-district, 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, which would disappear once they are accustomed to it.
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 to be downloaded and operated on an Android mobile phone. 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, data submission could be made after the network was available. Some mobile phones found that the unstable network issue persisted, and other mobile phones were not compatible with the app version. It was crucial to continuously improve the version to make it more compatible with all mobile phones.
Evaluation of the cadres’ knowledge and skills in the implementation of the Posyandu mobile app during the training (2018) and Posyandu activities (2019) were conducted as ongoing research.
The respondent characteristics are presented in Table 6. The majority of the respondents were older than 35 years old and most of them received a 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.
The comparison between the knowledge during the training (2018) and the implementation of the Posyandu application (2019) is shown in Table 7.
Based on Table 7, the knowledge and skills 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 Posyandu activities period. The effect of knowledge and skills were 0.34 and 0.21, which is respectively considered small and medium according to Cohen (30, 31).
Figure 5 illustrates provincial distribution across 34 provinces in Indonesia until 31 December 2019. As many as 964 Posyandus were registered to the Posyandu mobile app from almost all provinces in Indonesia. The highest number (34.54%) recorded was in the study area, which was West Java. 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; sorted from highest to lowest number of registrations. There was no registration from North Kalimantan and Maluku at the time.