Adherence to weekly iron/folic acid (IFA) supplementation, a vital intervention to combat anaemia among adolescent girls, remains a global challenge, including in Maluku Province, Indonesia. This study assessed the effect of “Jaga Diri” application, in enhancing knowledge and adherence to IFA supplementation among adolescent girls from Salahutu Sub-District of Maluku Province, Indonesia.
Methods
In mid-2024, a quasi-experimental study was conducted among 82 adolescent girls from two senior high schools in Salahutu Sub-District, Maluku Province, Indonesia. The intervention group used the “Jaga Diri” Android-based application for four weeks, which delivered weekly reminders and brief educational messages on anaemia and iron–folic acid (IFA) supplementation, while the control group received routine school-based services. Knowledge was measured using a validated 15-item questionnaire. Adherence was defined as consumption of ≥75% of the provided weekly IFA tablets over the previous four weeks, assessed by self-report, and supported by haemoglobin measurement. Group differences were analyzed using non-parametric and chi-square tests, and multivariable binary logistic regression was used to assess factors associated with high knowledge and adherence.
Results
After four weeks of using the “Jaga Diri” application, adolescent girls from the intervention school showed a significantly higher level of knowledge about anaemia (p = 0.011) and adherence to weekly IFA supplementation (p < 0.001) than those from the control school. The improved adherence was shown by the reduction of anaemia prevalence in the intervention school, from 35% to 17.5%. In the control school, the prevalence increased from 19% to 28.6%.
Conclusions
The “Jaga Diri” application effectively improves knowledge about anaemia and adherence to IFA supplementation among adolescent girls. Further investigation with larger and more varied groups are required to confirm its effectiveness before it can be widely implemented in larger areas of Maluku and Indonesia.
anaemiadigital healthfemale studentsiron folic acid tabletsmobile healthThe author(s) declared that financial support was received for this work and/or its publication. The authors declared that financial support was received for data collection activities from the Faculty of Medicine Universitas Pattimura, Indonesia (Grant Number: 1165/UN13/SK/2024).section-at-acceptanceHealth Communications and Behavior ChangeIntroduction
Anaemia is a blood disorder characterized by a lack of red blood cells and haemoglobin (Hb) in the body (1). The Hb plays a vital role in binding oxygen and transporting it throughout the body via the bloodstream. In anaemic conditions, reduced levels of Hb impair the blood's ability to carry oxygen, disrupting the body's functions and overall performance (2).
According to the World Health Organization, approximately one-third of women of reproductive age worldwide—equivalent to around 539 million women aged 15–49 years; experience anaemia (2). The prevalence of anaemia varies widely across countries. In Indonesia, data from the 2023 Indonesian Health Survey (3) reported that anaemia affected 16.3% of adolescent girls aged 5–14 years and 15.5% of those aged 15–24 years. This indicates an improvement compared to the 2018 survey, in which affected 26.8% of adolescent girls aged 5–14 years and 30.2% of those aged 15–24 (4, 5).
The Government of Indonesia has undertaken substantial initiatives to reduce anaemia prevalence, particularly among adolescent girls, including the introduction of weekly IFA supplementation in 2014 (6). However, studies indicated that the distribution and uptake of these supplements among adolescent girls remain significantly below the targeted levels (7, 8). These efforts are further hindered by low motivation and poor adherence among adolescent girls, undermining the effectiveness of anaemia prevention strategies (9). There were several factors reported to be associated with adolescent girls' adherence to IFA supplementation, such as parents' level of education (9, 10), cues to action (9), motivations to consume IFA tablets, as well social supports (10) including supports from school (9, 11).
One potential approach to improve adherence to IFA supplementation is digital interventions (12). In the current era, digital interventions are gaining popularity due to their effectiveness and ability to be tailored to individual needs (13, 14). Several studies have reported the positive impact of digital including mobile interventions on adherence to IFA supplementation among young women in Indonesia (15–17). Meta-analytic evidence also suggested the effectiveness of digital interventions of (e.g., mHealth and messaging-based approaches) in improving adherence to IFA supplementation and haemoglobin levels, with potential implications for reducing anaemia risk (18, 19). These interventions may work through repeated reminders and accessible health education that strengthen knowledge and sustain adherence behaviours.
Maluku, one of Indonesia's largest archipelagic regions, faces unique challenges in healthcare delivery due to its geographic dispersion and limited infrastructure. A previous study conducted in several senior high schools in Ambon City, the capital of Maluku, revealed low adherence to weekly IFA supplementation, with only 15% of students complying, while the prevalence of anaemia was alarmingly high at nearly 50% (20–23). Digital interventions could, therefore, offer a practical solution by bridging these gaps through mobile technology. Such tools can deliver consistent health messages and reminders directly to users, ensuring that even those in remote islands could access critical health information and support. Moreover, leveraging digital platforms could address the shortage of health workers in reaching far and underserved areas as health services could be provided remotely, reducing the need for physical presence and ensuring support for communities in isolated areas.
In early 2024, a research team from the Faculty of Medicine at Universitas Pattimura developed the “Jaga Diri”, an android-based application, serving as a reminder to consume IFA tablets. Following four weeks of implementation, an evaluation was conducted to assess its effectiveness. This study was designed as a pilot, school-based quasi-experimental intervention to assess the feasibility and preliminary effectiveness of a digital health application in a real-world setting. Two schools were purposively selected based on operational feasibility, comparable characteristics, and collaboration with local health and education authorities. While this non-randomized approach allowed implementation under routine conditions, it may introduce selection bias and limit generalisability, which should be considered when interpreting the findings. The objective of this analysis was to determine the impact of the “Jaga Diri” application on improving knowledge about anaemia and enhancing adherence to IFA supplementation among adolescent girls in Salahutu Sub-district, Maluku Province, Indonesia.
Materials and methodsResearch design and study site
This research was carried out from May to June 2024, in two senior high schools, i.e., SMA Negeri 5 Central Maluku (intervention) and SMA Negeri 47 Central Maluku (control), located in Salahutu Sub-District, Maluku Province. We used an analytical design with a quasi-experimental approach. The control school did not receive the “Jaga Diri” application intervention, while the intervention school was provided with the application as part of the intervention. This study was conducted in two schools in Salahutu Sub-District, Maluku Province: SMA Negeri 5 Central Maluku served as the intervention school, while SMA Negeri 47 Central Maluku served as the control school.
Population and sampling
The senior high schools were selected using purposive sampling based on the following criteria: (1) located in Salahutu Sub-District of Central Maluku District; (2) government-owned school; (3) had a minimum enrolment of 100 female students (grades X to XII); (4) received Weekly IFA from local community health centres; (5) sufficient distance from each other to minimize the risk of contamination; and (6) willingness to participate in the study. Of the five government-owned senior high schools in Salahutu Sub-District, two schools (SMA Negeri 5 Central Maluku and SMA Negeri 47 Central Maluku) were selected for this study—one as the intervention and the other as the control school (24).
The inclusion criteria for study subjects were: (1) female students from Grades X and XI, and (2) willing to participate in the study. For the intervention school, subjects should have a communication device (smartphone, tablet, or laptop) with regular internet access and were willing to install the application.
This study was conducted as a pilot quasi-experimental study, and the sample size was determined by the available number of eligible students in the participating schools. In total, there were 40 adolescent girls from SMAN 5 Central Maluku (intervention school) and 42 from SMAN 47 Central Maluku (control school) included (Figure 1).
Map of study site.
Map highlighting the study site in Ambon, Central Maluku District, and Haruku Island, Indonesia. The top section shows Ambon city and marked schools. A legend indicates sub-districts, land, sea, and infrastructure. A bottom map inset shows the location in Southeast Asia, with nearby islands and countries. Map layout by Sean Istia, created January 29, 2025.
No formal exclusion criteria were defined; non-participation and loss to follow-up occurred due to operational reasons such as school absenteeism and technical constraints. In the control group, the decline in participants in the study was due to their absence during data collection, both at the beginning and the end of the study. Meanwhile, in the intervention group, the decrease in participants was attributed to various reasons corresponding to different stages of the study. For instance, during the pre-test phase, 107 participants were excluded due to school absenteeism, as a local government event related to scholarships required their attendance on very short notice, making it impossible to reschedule the data collection. Furthermore, 25 participants dropped out after the pre-test due to technical issues with their devices, which prevented the application from being installed before its explanation could be provided (Figure 2).
Research flow chart.
Flowchart depicting a research process for two schools in Salahutu Sub-district. It starts with data collection. SMAN 5 (intervention group, initial n=177) and SMAN 47 (control group, initial n=60) are selected, excluding 111 due to absenteeism. Both groups undergo a pre-test. The intervention group sees socialization and app installation, dropping to 52, then 47 after more dropouts. Post-test includes 40 in intervention and 42 in control group. Data collection and analysis (n=82) lead to research results.Intervention
In this study, adolescent girls from the intervention school were required to install and use the “Jaga Diri” application and receive routine services provided by the local health centre. The “Jaga Diri” application, developed in 2024 by the Faculty of Medicine at Universitas Pattimura, is a reminder tool for taking IFA supplementation. It incorporates a reminder alarm commonly used on smartphones, enhanced with features that deliver health messages to educate users about anaemia and the importance of IFA supplementation. Currently, this application is exclusively available on the Android platform. Unlike other anaemia intervention apps, such as Aneminfo (16) and TeenFit (17) focusing mainly on providing educational content to encourage compliance indirectly, “Jaga Diri” also integrates a direct reminder feature to prompt users to take their IFA tablets regularly. This combination of direct reminders and educational support sets it apart from applications that rely solely on improving knowledge to enhance adherence among adolescent girls (a detailed explanation of the “Jaga Diri” application is provided in Supplementary File 1). Students in the control school received only the routine services provided by the local health centre, in accordance with national guidelines. These services consisted of brief health education sessions delivered by health workers or teachers, together with general monitoring of tablet distribution records. No digital reminders, structured follow-up, or individualized adherence monitoring were included as part of the routine services. To ensure a consistent supply, IFA tablets were distributed by the research team to all schools involved in the study (both control and intervention).
Evaluation method
There were two cross-sectional surveys carried out: one before the intervention (as baseline) and another after the intervention (as endline). Both surveys used structured questionnaires to assess adherence to IFA supplementation and knowledge about anaemia and IFA supplementation. The adherence questionnaire comprised four items addressing IFA consumption over the previous four weeks. Using a four-week period for this evaluation aligns with studies by Kang and Park (25), Riegel (26), and Goldstain (27). Some studies even used shorter evaluation periods, such as three weeks or as brief as 2 h (28).
To assess the level of knowledge, a questionnaire consisting of 15 questions was administered, focusing on general information about anaemia and the significance of IFA supplementation. The questionnaire used in this study was adopted from another study conducted in Indonesia that has also been tested for validity and reliability (29). The blood Hb test was performed using the HemoCue HB 301 device to determine the anaemia status of adolescent girls. In this study, the involvement of teachers was limited to avoid potential bias in data collection and to ensure the independence and objectivity of responses. The questionnaire was administered through face-to-face interviews by trained enumerators at both baseline and endline to ensure consistent understanding of the questions.
Outcome variables
The outcome variables of this study were: (1) the level of knowledge about anaemia and (2) adherence to IFA consumption among adolescent girls. Adherence referred to the practice of consuming at least 75% of the IFA tablets provided, i.e., equivalent to three out of four tablets. Blood Hb levels were also measured to validate adherence to IFA supplementation.
We assessed adolescent girls' knowledge and awareness about anaemia and weekly IFA supplementation using 15 questions that covered different topics including the signs and symptoms of anaemia, the benefits of IFA supplementation, recommended consumption practices, and its possible side effects. Each correct answer was given a score of 1, while incorrect answers received a score of 0. The level of knowledge was classified as high or low according to the median score. Participants scoring above the median categorized as having high knowledge and those scoring below categorized as having low knowledge.
Data analysis
Descriptive analyses were conducted to summarise baseline characteristics using frequencies and percentages. The normality of continuous variables, including knowledge scores and haemoglobin levels, was assessed using the Kolmogorov–Smirnov test. As these variables were not normally distributed, between-group comparisons at baseline and endline were performed using Mann–Whitney U tests. Differences in categorical outcomes, including anaemia status and adherence to weekly IFA supplementation, were analysed using chi-square tests, after confirming that the expected cell counts met the assumptions required for this analysis.
Multivariable binary logistic regression analyses were conducted to assess factors independently associated with (1) high knowledge of anaemia and IFA supplementation and (2) adherence to weekly IFA supplementation at endline. Models were adjusted for a limited number of pre-specified covariates, including age and relevant baseline characteristics, to control for potential confounding while avoiding overfitting. Adjusted odds ratios (aORs) with 95% confidence intervals were reported. All analyses were performed using IBM SPSS Statistics for Windows, version 23.
Ethics approval
Ethical approval was granted by the Ethics Commission of the Faculty of Medicine, Universitas Pattimura, under approval letter number 014/FK-KOM.ETIK/VIII/2024. Prior to data collection, the objectives of the study were clearly explained to all participants, and written informed consent was obtained. Their voluntary participation was emphasized, with the option to decline or withdraw at any time. The confidentiality and anonymity of all participant information were strictly maintained.
Results
The distribution of 82 respondents (40 in intervention schools and 42 in control schools) by age and anaemia status at the beginning of the study is presented in Table 1. The proportion of anaemia in adolescent girls was higher in the intervention school (35%) than control school (19%).
Frequency distribution of subjects by age and of anaemia status in control and intervention school.
Variable
Intervention (n = 40)
Control (n = 42)
n
%
n
%
Age (years)
15
17
42.5
5
11.9
16
17
42.5
21
50.0
17
4
10.0
10
23.8
18
2
5.0
6
14.3
Paternal occupation
Formal
6
15.0
2
4.7
Informal
28
70.0
34
81.0
Don't know/not working
6
15.0
6
14.3
Paternal highest educational attainment
Completed primary school
5
12.5
6
14.3
Completed junior high school
4
10.0
2
4.7
Completed senior high school
16
40.0
23
54.8
Academy/University
4
10.0
0
0
Don't know
11
27.5
11
26.2
Maternal occupation
Formal
5
12.5
2
4.7
Informal
32
80.0
37
88.1
Don't know
3
7.5
3
7.2
Maternal highest educational attainment
Completed primary school
4
10.0
7
16.7
Completed junior high school
3
7.5
4
9.5
Completed senior high school
18
45.0
18
42.9
Academy/University
5
12.5
4
9.5
Don't know
10
25.0
8
19.0
Menarche status
Not yet
1
2.5
1
2.4
Yes
39
97.5
41
97.6
Ever heard of anaemia
No
14
35.0
17
40.5
Yes
26
65.0
25
59.5
Status of anaemia
Anaemia (<12 g/dL)
14
35.0
8
19.0
Non-Anaemia (≥12 g/dL)
26
65.0
34
81.0
Body Mass Index
Underweight (<18.5 kg/m2)
19
47.5
23
4.8
Normal (18.5–<25 kg/m2)
20
50.0
17
40.5
Overweight/obese (≥25 kg/m2)
1
2.5
2
4.8
Table 2 presents differences in knowledge levels regarding anaemia and iron–folic acid (IFA) supplementation among adolescent girls at baseline and endline in both the intervention and control schools. In the intervention school, the proportion of adolescents with a high level of knowledge increased significantly from 47.5% at baseline to 85.0% at endline (p < 0.001). In contrast, no significant change in knowledge level was observed in the control school between baseline and endline (p = 0.510). At baseline, mean knowledge scores were comparable between the intervention and control groups (9.40 vs. 9.45). By endline, however, the intervention group demonstrated a higher mean knowledge score than the control group (10.63 vs. 9.83), indicating greater improvement following the intervention. The distribution of correct responses for each knowledge item in the intervention and control schools at baseline and endline is shown in Figures 3, 4, respectively.
The difference between the level of knowledge about anaemia and IFA supplementation between subjects in control and intervention school at baseline and endline.
Group
Level of knowledgea about anaemia
p-value
Low
High
nb
%
nb
%
Intervention
Baseline
21
52.5
19
47.5
<0.001
Endline
6
15.0
34
85.0
Control
Baseline
20
47.6
22
52.4
0.510
Endline
17
40.5
25
59.5
Knowledge was categorised as low or high based on the median score of the study population. Scores below the median classified as low knowledge and scores equal to or above the median classified as high knowledge.
The number of participants included in the analysis.
Distribution of correct answers for each knowledge question Among female students in the intervention school. *McNemar value <0.05.
Bar chart comparing pre and post percentages for knowledge and practices related to iron tablets. The chart includes categories like avoiding tea with iron tablets, their safety, timing of intake, and anemia symptoms. Orange bars represent post-intervention, and blue bars represent pre-intervention, with increased post percentages across all categories.
Distribution of correct answers for each knowledge question Among female students in the control school. *McNemar value <0.05.
Bar chart comparing pre and post percentages of knowledge about iron tablets and anemia-related information. Key insights include advice on consumption with water or juice, avoiding certain drinks, misconceptions about iron tablets, dosage recommendations, and anemia symptoms. Orange bars represent post-data and blue bars represent pre-data, highlighting improvements in awareness.
Table 3 presents the differences in adolescent girls' adherence to weekly IFA supplementation (defined as consuming at least 75% of the tablets provided) before and after the implementation of the “Jaga Diri” application. In the control schools, there was no significant difference in adherence between baseline (4.8%) and endline (7.1%) (p = 1.000). In contrast, the intervention schools showed a significant increase in adherence, with the proportion of adolescent girls adhering to weekly IFA supplementation rising from 5.0% at baseline to 80.0% at endline (p < 0.001).
The difference between adherence to weekly IFA supplementation between subjects in control and intervention school at baseline and endline.
Group
Adherencea
Non-adherence
p-Value
n
%
n
%
Intervention
Baseline
2
5.0
38
95.0
<0.001
Endline
32
80.0
8
20.0
Control
Baseline
2
4.8
40
95.2
1.000
Endline
3
7.1
39
92.9
Adherence referred to the practice of consuming at least 75% of the IFA tablets provided (three out of four tablets).
These findings were also confirmed when we compared the levels of knowledge and adherence between the intervention and control groups at endline (Table 4). A statistically significant difference was observed in the proportion of adolescent girls with a high level of knowledge and awareness about anaemia and IFA supplementation (p = 0.006), as well as adherence to weekly IFA supplementation (p < 0.001).
Comparations the levels of knowledge and adherence between the intervention and control groups at endline.
Variable
Intervention
Control
p-value
na
%
na
%
High level of knowledge
25
59.5
33
86.8
0.006
Adherence
30
78.9
3
7.1
<0.001
The number of participants included in the analysis.
Based on the multivariable binary logistic regression analysis (Table 5), adolescents in the intervention group had significantly higher odds of having high knowledge compared with those in the control group [adjusted odds ratio (aOR) = 4.94, p = 0.011], after adjustment for age and baseline knowledge. Baseline knowledge was also a significant predictor of endline knowledge (aOR = 5.24, p = 0.005), whereas age was not independently associated with knowledge. The model showed acceptable fit (Nagelkerke R2 = 0.25).
Results of multivariable binary logistic regression to assess factors associated with high knowledge and adherence.
Variable
High level of knowledgea
Adherenceb
aOR
95% CI
p-value
aOR
95% CI
p-value
Group
Control
1.00
1.00
Intervention
4.94
1.44
16.95
0.011
44.53
10.49
189.07
<0.001
Age (in years)
1.00
0.53
1.89
<0.001
0.59
0.25
1.39
0.229
Knowledge level at baseline
Low level
High level
5.24
1.66
16.52
0.005
Adherence at baseline
Non-adherence
1.00
Adherence
0.49
0.02
10.39
0.649
Knowledge was categorised as low or high based on the median score of the study population. Scores below the median classified as low knowledge and scores equal to or above the median classified as high knowledge.
Adherence referred to the practice of consuming at least 75% of the IFA tablets provided (three out of four tablets).
Furthermore, adolescents in the intervention group also had significantly higher odds of adherence compared with those in the control group (aOR = 44.53, p < 0.001), after adjusting for age and baseline adherence (Table 5). Neither age nor baseline adherence was independently associated with adherence in the adjusted model. The model demonstrated good fit (Nagelkerke R2 = 0.64). To confirm adherence, we also evaluated the difference in the proportion of anaemia between female students in intervention and control schools. Our study found that in the intervention school, the proportion of anaemia reduced from 35% to 17.5%, while in the control, the proportion increased from 19% to 28.6%.
This study also examined changes in the weekly consumption rate of IFA supplementation after the intervention, as illustrated in Figure 3. Initially, 45% of adolescent girls in the intervention school consumed the tablets, while 55% did not. Over time, adherence improved progressively with continued use of the “Jaga Diri” application. Adherence rates increased from 68% in the second week to 80% in the third week, reaching 100% by the final week of the study (Figure 5).
Percentage of taking IFA each week after intervention (intervention school).
Bar chart showing percentage of progress over four weeks. Blue bars represent "Not taking IFA," and orange bars represent "Taking IFA." Week 1: 55% not taking, 45% taking. Week 2: 32% not taking, 68% taking. Week 3: 20% not taking, 80% taking. Week 4: 0% not taking, 100% taking.Discussion
The study found that the “Jaga Diri” application significantly improved knowledge about anaemia and adherence to weekly IFA supplementation among adolescent girls. Adolescent girls in the intervention school demonstrated improved knowledge about anaemia and its prevention compared to those from the control school. The intervention also led to a steady increase in the consumption of IFA supplementation over the study period, with adherence rates being substantially higher in the intervention school. This study emphasizes the promise of mobile health interventions, such as the “Jaga Diri” application, in improving knowledge and adherence to IFA supplementation among adolescent girls. The results highlight the need to integrate technology-based approaches into public health initiatives to more effectively prevent and control anaemia.
The “Jaga Diri” application was aimed to improve adherence to IFA supplementation and enhance knowledge about anaemia prevention among adolescent girls. The existing applications for IFA interventions generally focused on a single objective: improving knowledge (indirectly enhancing adherence) or serving as a reminder alarm to encourage compliance. In contrast, the “Jaga Diri” application integrates both functions—it not only acts as a reminder or alarm for taking iron-folic acid tablets but also serves as a platform to enhance users' knowledge. Another advantage of this application is its flexible knowledge feature, which could be accessed via a website with customizable content. Unlike most IFA educational applications, which are pre-packaged and, although operable offline, tend to offer static and monotonous content, the “Jaga Diri” application provides a dynamic and adaptable learning experience.
We found that the “Jaga Diri” application has a positive influence in improving knowledge in adolescent girls about anaemia. This aligns with previous research (16, 17), which showed increased knowledge about anaemia due to using mobile interventions. The health messages integrated into the application improved adolescent girls' knowledge about anaemia by providing consistent, targeted, and easily digestible information. This consistent exposure helps users internalize important details over time without feeling overwhelmed. Simple messages tailored to the user's needs could address common questions, misconceptions, and the benefits of adherence in a straightforward manner, making complex topics more approachable (30).
The findings of this study highlight the effectiveness of the “Jaga Diri” application in improving adherence to IFA supplementation among adolescent girls. The application's reminder features ensure consistent engagement by providing timely prompts that help users establish a routine for taking supplements. These reminders reinforce the habit of adherence and deliver concise, targeted health messages to enhance understanding of anaemia prevention. Adolescents often face challenges like busy or unstructured schedules, and the reminders help integrate IFA supplementation into their daily activities (31). Furthermore, the reminders are customizable, allowing users to set specific times and frequencies, making the intervention more user-centred and adaptable to individual needs. When paired with motivational and educational messages, the reminders create a supportive system that fosters accountability, emphasizes the importance of adherence, and offers a sustainable and practical solution to overcome barriers such as forgetfulness and lack of routine (12, 15). This combination makes the “Jaga Diri” application a useful tool for enhancing compliance among adolescent girls.
The findings of this study should be interpreted with caution. The quasi-experimental design, inclusion of only one school per study arm, and absence of randomization limit causal inference and raise the possibility of unmeasured confounding. In addition, adherence to weekly IFA supplementation was primarily assessed through self-report, which may be subject to recall and social desirability bias, despite support from haemoglobin measurement. These methodological considerations may affect the internal validity and generalisability of the findings. In line with the WHO guidance, haemoglobin measurement was included as a supportive indicator rather than a definitive confirmation of adherence, as short-term changes in Hb are insufficient to reliably reflect supplement intake or sustained physiological response. Furthermore, the observed improvement in haemoglobin levels over the relatively short intervention period should be interpreted cautiously, as it may partly reflect biological variability or measurement variation rather than sustained physiological improvement.
Nevertheless, this study also found that, despite the significant impact of the “Jaga Diri” application in improving adherence, some adolescents in the intervention school (20%) still did not comply with consuming weekly IFA supplementation. This non-compliance aligns with findings from Ningtyias et al. (32), that identified factors such as laziness, boredom, dislike of the tablet's taste, or side effects like nausea as common reasons for not taking weekly IFA supplements. Further research is needed to explore the underlying reasons for non-compliance among students and develop more targeted strategies for improving adherence.
The “Jaga Diri” application significantly improves IFA adherence in archipelagic regions like Maluku. These regions often face logistical challenges, such as limited healthcare infrastructure, geographic isolation, and inconsistent access to health services, which can hinder the distribution and monitoring of IFA supplementation programs. Mobile health applications overcome these barriers by providing a scalable and accessible platform that reaches users directly, regardless of location. Features such as reminders and educational messages ensure consistent engagement and support, even in areas with limited physical access to healthcare providers (33). Additionally, the offline functionality of the “Jaga Diri” application is particularly advantageous in regions with intermittent internet connectivity, ensuring uninterrupted use. Digital interventions can play a crucial role in addressing anaemia and improving overall health outcomes in geographically dispersed communities by empowering adolescents with the tools and knowledge to manage their health.
This study demonstrates several key strengths. It tackles a pressing public health issue, i.e., anaemia among adolescent girls, using the innovative “Jaga Diri” application, which integrates reminder features and educational messages, aligning with the increasing relevance of mobile technology in health interventions. The quasi-experimental design, with baseline and endline evaluations, ensures a thorough assessment of the application's impact on knowledge and adherence to IFA supplementation. The study enhances its methodological rigour by incorporating objective measures such as Hb levels alongside self-reported data.
Strengths and limitations
Sample attrition might have impacted the study's statistical power to detect differences. To reduce sample loss in future studies, it is advisable to strategically plan data collection schedule, such as at the start of the school term or academic year. The real-world application of the intervention in a school setting underscores its practical feasibility while focusing on Maluku Province, a geographically challenging and underrepresented area. It adds value by providing insights applicable to other resource-limited regions. Despite these strengths, several limitations should be acknowledged. The study was conducted in only two schools, with one school per study arm, which increases the possibility of unmeasured confounding, and restricts the generalisability of the findings. The requirement for smartphone access in the intervention group might have introduced selection bias, as those without compatible devices were unable to participate. In addition, substantial participant attrition due to school absenteeism and technical constraints may have further affected representativeness. The short follow-up period also limited the ability to assess sustained adherence and longer-term behavioural change. Moreover, the “Jaga Diri” application is currently compatible only with Android devices, restricting accessibility for users of other operating systems. Although offline functionality is beneficial in low-connectivity settings, it limits opportunities for real-time monitoring and interaction between users and researchers. Thereby, future research should involve larger and more diverse populations and longer follow-up periods.
Conclusions
This study demonstrates the significant impact of the “Jaga Diri” application in improving knowledge about anaemia and adherence to weekly IFA supplementation among adolescent girls. The application effectively combines reminder features with targeted health messages, fostering consistent engagement and enhancing understanding of anaemia prevention. Over time, its use increased adherence rates and a notable reduction in anaemia prevalence in the intervention group. The flexibility of the application, including its offline functionality and customizable content, makes it particularly suitable for geographically dispersed and resource-limited areas like Maluku. Despite its success, some users remained non-compliant, highlighting the need for further research into addressing barriers such as side effects, boredom, and lack of motivation. However, these findings should be interpreted with caution, as the short intervention duration, participant attrition, and lack of randomization inherent to the quasi-experimental design limit causal inference and generalizability. The study underscores the potential of mobile health interventions as scalable and practical tools to address public health challenges, particularly in archipelagic regions. Future developments should focus on expanding the application's compatibility and features while validating its effectiveness in broader and more diverse populations to maximize its impact and sustainability.
However, these findings should be interpreted with caution, as the short intervention duration, participant attrition, and lack of randomization inherent to the quasi-experimental design limit causal inference and generalisability.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
Ethical approval was granted by the Ethics Commission of the Faculty of Medicine, Universitas Pattimura, under approval letter number 014/FK-KOM.ETIK/VIII/2024. Prior to data collection, the objectives of the study were clearly explained to all participants, and written informed consent was obtained. The study maintained the confidentiality of all participant information. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin.
We express our gratitude to the Rector of Universitas Pattimura, the Dean, and the entire academic community of the Faculty of Medicine, Universitas Pattimura, and the Suli and Liang Health Centres, Central Maluku District staff. We also thank Dr. Yoslien Sopamena, MKM, for his guidance in developing the intervention messages used in this study, and we appreciate the participation of the principals, teachers, and students of SMAN 5 Central Maluku and SMAN 47 Central Maluku. Our thanks also extend to all enumerators and field workers for their valuable support. We also gratefully acknowledge the Varians Statistik Kesehatan for providing the boot camp and mentoring to improve the manuscript writing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Edited by: Toshiyo Tamura, Waseda University, Japan
Reviewed by: Samson Peter Mvandal, Muhimbili National Hospital, Tanzania
Ratih Wirapuspita Wisnuwardani, Mulawarman University, Indonesia