Yosellina1, Dr Inka Barnett2, Sigit Sulistyo1
1Wahana Visi Indonesia, Jakarta Email: [email protected]
2Institute of Development Studies, UK Email: [email protected]
Abstract
Malnutrition among children remains a major health problem in Indonesia. Posyandu, a national community-based health and nutrition program, aims to reduce malnutrition through monthly growth monitoring and nutrition counselling. Service delivery on community-level is often hampered by data errors during growth monitoring, lack capacity in delivering nutrition counseling, delays in reporting, etc. Mobile phone technology has the potential to overcome these constraints. This paper discusses the interim results of an evaluation of mPosyandu, an android- based application for Posyandu, to assist in capturing and calculating nutritional status, reporting, and nutrition counselling.
The evaluation uses mixed method -quantitative and qualitative to look at the impact of the mPosyandu application on data quality and timeliness during growth monitoring, responsiveness to the data and the provision of feedback to mothers, and quality of nutrition counselling. Since October 2014, 4 Posyandu in Jakarta District and 10 Posyandu in Sikka District were chosen as pilot sites that represent urban and rural contexts respectively. Data on the application of the mPosyandu application took place monthly and included observations, interviews, focus group discussions and surveys with cadres (community volunteers in the posyandu), caregivers and healthcare staff. Mobile-phone based and traditional paper-based growth monitoring and counselling took place in parallel in each of the 14. The findings from initial 6 months of the pilot suggest a significant difference in the outcomes of the calculations ofchild’s nutrition status between the manual and mobile-phone based growth-monitoring. In Jakarta, the paper-based nutrition status calculations had an error rate of 11% compared to mobile phone based data due to inaccuracy in determining children’s age. Cadres who used mobile phones were more likely to provide immediate feedback to caregivers (56.7%) compared to cadres without mobile phone (7.2%). Perceptions about the use of mobile phones for posyandu were positive with 91% of the caregivers feeling that the phone improves Posyandu’s service quality.
mPosyandu has the potential to improve Posyandu service quality by strengthening the data quality of growth monitoring and increasing the likelihood of cadres in providing immediate feedbacks to the caregivers.
Kata kunci : mobile phones, Posyandu, nutrition, growth monitoring
1. Background
Child under nutrition remains one of the most devastating realities in many parts of the world. The usage of mobile phone technology may offer innovative opportunities to tackle persistently high level of child under nutrition. Application of mobile phone technology to improve access, quality, timeliness and lower costs of nutrition services delivery, is becoming increasingly popular with international agencies and non-governmental organisations, as well as national and local-level organisations and institutions(1).
Mobile phones have been employed to facilitate nutrition surveillance and community-based growth monitoring, nutrition behavior change
communication and promotion and management of nutrition-related diseases. Available technology options range from application of simple handsets and short message services (SMS) to sophisticated smart phone applications with audio-and video recordings on behavioural change and disease management.
Wahana Visi Indonesia is piloting the use of mobile phones to improve nutrition service delivery including community-based growth monitoring and nutrition counselling in Indonesia. The mobile phone has been integrated into the existing national nutrition service delivery through the Posyandu programme. Posyandu is monthly service posts at sub-village level that form the lowest level of the primary health care infrastructure in Indonesia.
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2. Methods
Wahana Visi Indonesia together with District Health Offices in Jakarta and Sikka, has designed a mobile phone-based application using CommCare platform to address some challenges which hinder nutrition service delivery in the posyandu. The mobile posyandu application (mPosyandu) uses Android smart phones to facilitate both growth monitoring and nutrition counselling in the posyandu. For growth monitoring, the application can be used to register the child, collect anthropometric measurements, calculate z-scores and classify a child’s nutritional and growth velocities. The application is also capable of generating summary reports from the data and aggregating single records according to different criteria (e.g. percentage of underweight children, growth trends and average weight for single children, etc.). The completed growth monitoring form for each child is saved on the mobile phone and submitted via general packet radio service (GPRS) to the cloud-based, password-protected server. The mobile phone is being integrated in step 3 of posyandu 5 steps workflow.
For nutritional counselling, the application can be used to assess underlying illness and the current feeding practices of a child during home-based counselling sessions, and to analyse this initial information to identify potential challenges and provide tailored nutrition messages based on the analysis.
Wahana Visi Indonesia together with the Institute of Development Studies (IDS) set out to evaluate the application of mPosyandu for nutrition service delivery. The impact evaluation is co-funded by Wahana, DFID-UK and UNICF.
A total of 14 study sites has been selected consists of four urban posyandu and ten rural posyandu. The study sites (i.e. Posyandus) for this study were purposefully selected by the Wahana Visi Indonesia team prior to the start of the evaluation.
Selection criteria included proximity to major roads (to enable easy access), access to electricity (important to be able to charge the mobile phone) and existing partnerships between the posyandu and the local Wahana Visi Indonesia team.
Tabel 1. Study sites, number of cadres and children
Study sites
Number of posyandu
Number of cadres
Number of children North
Jakarta 2 14 210
East
Jakarta 2 14 430
Sikka 10 50 500
Total 14 78 1140
We set out to evaluate the piloting of the mobile phone application for nutrition service delivery started in January until December 2015. This evaluation aims to understand the effect of the mPosyandu on nutrition service delivery in urban and rural Posyandus in Indonesia. The evaluation started with a formative phase in the initial three months. This formative evaluation aims to assess the acceptability of the mobile application to the cadres.
The summative phase of the evaluation aims to examine the impact of the mPosyandu application on growth monitoring activities, specifically to assess the impact on nutritional data accuracy and on real- time responsiveness during posyandu day.
To assess a child’s nutritional status, a cadre in the step 3 of posyandu needs to plot the anthropometric measurements of the child on the growth chart and interpret the child’s pattern of growth chart. For the purpose of the evaluation, we add one cadre in step 3 to use the mPosyandu application. Therefore in step 3 there were two cadres, one is using a paper-based system (calculating nutritional status by plotting child’s weight to the growth chart) and the other one is using mPosyandu application to automatically calculating child’s nutritional status.
The evaluation team has decided to use comparative causal inference design based on Mill’s Method of Difference (4,5), a direct observation of the posyandu procedures, and exit interviews with caregivers. The detail of evaluation protocol is described in separate publication(2). The evaluation is expected to be completed by early of 2016.
3. Results
Implementation of mPosyandu application in Posyandu began in October 2014. For the purpose of the piloting, each Posyandus received two mobile phones. We developed a formal contract with cadres, health staff, and village governments during phone hand-over including mechanisms to reduce the risk of loss of phones, how to maintain the phone, and the replacement for phone loss.
We used a cascading training approach to train cadres on how to use the mPosyandu application. We trained 23 health workers in Jakarta and Sikka districts. The health workers then trained total of 74 cadres in Jakarta and Sikka District. The health workers received training on how to use the mPosyandu application and how to retrieve the data from the server. The cadres received training on how to use smart phones, how to subscribe for internet data package, and how to use the mPosyandu application. The formal pilot evaluation data collection started in January 2015.
Within the formative phase evaluation (first three months of the evaluation), we conducted acceptability assessment interviews with 15 cadres in Jakarta and 10 cadres in Sikka. The results
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indicated that in Jakarta and Sikka most of the cadres liked using mobile phones in their daily activities.
The cadres also perceived that mobile phone can improve the quality of posyandu services in terms of improving accuracy of calculating nutritional status, data recording, and as a tool to provide feedbacks.
The Sikka cadres had a slightly better opinion about using mobile phone during posyandu (mean score of 3.7) compare to Jakarta cadres (mean score of 3).
The cadres also believed that mobile phone can facilitate home-based counseling by guiding the identification of the the cause of a child’s undernutrition, providing automated tailored advice cadres could give to the caregivers, and having pictures and videos to help communicating the advice.
To assess the impact of the mobile phone on data accuracy we compared the results of mobile phone-based data base with the paper-based data base.. Some cadres still used the old guideline in determining a child age. We excluded children whose age calculation differed in the mobile-phone based and paper-based data base Therefore the difference in the child’s nutritional status can only be attributed to the differential effectiveness of these two procedures in calculating nutritional status, not to the difference in determining a child’s age.
We found there were 11% cases which have different nutritional status. Since the mPosyandu application is using automated nutritional status calculation therefore this finding shows that there was 11% of inaccurate nutritional status calculation using paper-based system. We also found that 34%
of cases that are determined manually using paper- based system was inaccurately in calculating child’s age.
We also compared the step 3 observation results between cadres who using mobile phone and cadres who using paper-based on the likelihood to provide immediate feedbacks to the caregivers. We found that cadres use mobile phones are more often provide immediate feedback (56.7%) compared with those without mobile phone (7.2%). The results of exit interviews also shows that 91% of the caregivers perceived of using mobile phones in Posyandu improves Posyandu’s service quality.
4. Discussions
In the formative phase, we found that most of the cadres perceived the use of mPosyandu as helpful for growth monitoring in Posyandu. From the exit interviews with the caregivers, we also found that most of the caregivers who visited posyandu perceived that using mobile phones in Posyandu improves Posyandu’s service quality.
The evaluation data also suggest that mPosyandu can help to strengthen data accuracy and the likelihood of cadres providing immediate
feedback on a child’s nutritional status to the caregivers during posyandu sessions.
The production of accurate data is essential for effective growth monitoring and management of nutritional status of children at community level(3). Doubt about the accuracy of growth-monitoring data have been identified as a major reason for why data is often not taken up by local, regional, and national policy makers to inform nutrition-related decision making.
Overall, we found that mPosyandu was associated with improvement of data accuracy in calculating nutritional status. The mPosyandu application can reduce the risk of inaccurate plotting and thus incorrect assessment of the nutritional status of a child because it allows cadres to calculate automatically and correctly z-score based on the anthropometric measurements.
We also found that many cadres are still using the old guideline in determining child age and therefore are more likely to miscalculate the nutritional status. Using the mPosyandu enable the cadres to use the correct child age calculation.
Additionally, we found that the cadres who were using mobile phone were more likely to provide immediate feedbacks to the caregivers. The provision of immediate feedback during growth monitoring and promotion sessions is for the first step in successful behavior change for better child nutrition.
5. Conclusion
Six months after the pilot implementation, the results show the using of mPosyandu may improve data accuracy and the likelihood of cadres in providing feedbacks. They suggest that potential use of mobile technology in posyandu to improve the posyandu nutrition service delivery in Indonesia.
6. References
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2. Barnett I, Befani B, Sulistyo S, Yosellina, O'Leary M. Designing a mixed-method impact evaluation for a mobile phone application for nutrition service delivery in Indonesia. s.l. : IDS, 2014.
3. Ashworth, A, Shrimpton, R and Kamil, K.
Growth monitoring and promotion: review of evidence of impact Supp.1:86-117, s.l. : Maternal & Child Nutrition, 2008, Vol. 4.
4. John W. Parker A System of Logic, London:
Mill, J. S. 1843.
5. Bennett, A. 'Process Tracing and Causal Inference', in H. Brady and D. Collier (eds),
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Rethinking Social Inquiry, Lanham, Maryland:
Rowman and Littlefield . 2010