Study design and population

This is a descriptive cross-sectional study with a mixed methods approach, integrating both quantitative and qualitative data collection and analysis methods. Using an embedded design, the qualitative study provided data supporting the quantitative study. Study recruitment and data collection were performed between 1 November 2022 and 1 October 2023.

The target population in this study were residents living in the city of Depok, Indonesia. Being a supporting neighbour city of the capital Jakarta, Depok is an urban city demographically characterised by its many migrant residents coming from rural areas across Indonesia. Similar to other areas in Indonesia, the primary healthcare service for the population is provided by the Community Health Center, a free-for-public, government-funded healthcare facility.

Quantitative approach: The interviewer-assisted questionnaire

Quantitative data were collected from 300 households residing in three subdistricts in Depok (Mekarjaya, Curug, and Tirtajaya) with an interviewer-assisted questionnaire. The three subdistricts were purposively selected by the Depok City Health Office, based on their relatively higher prevalence of maternal and children health issues compared to other subdistricts. The sample size was 100 households per subdistrict, calculated based on a 95% confidence level, a 10% precision level, a 50% proportion of events, and a design effect of 1.

The sampling procedure followed a two-stage cluster and random sampling method within each subdistrict to select the households. In the first stage, twenty neighbourhoods/hamlets from each of the three subdistricts were selected as the clusters using the probability proportional to size method. In the second stage, five households per hamlet were randomly selected using a computer-based random generator from the household list of each selected hamlet. Data enumerators visited the households and asked the heads of the households and their spouses to complete the questionnaires.

The cross-sectional questionnaire aimed to assess the level of knowledge, attitudes, and stigmas related to maternal and neonatal health issues and surveillance. These variables were evaluated as understanding the cultural-social norms, perceptions, and attitudes towards health issues is essential to designing a well-accepted relevant surveillance system [8].

Qualitative approach: In-depth interviews and focus group discussions

To gain comprehensive qualitative insights from multiple perspectives of the community, informants for the in-depth interviews were selected purposively, including community leaders, health volunteers, medical staff at the Community Health Centre, and stakeholders from the local administrative and health authorities at the subdistrict, district, and city levels. The interviews were done during daytime, working hours, at their offices or places as visited by the data enumerators.

After the interviews, focus group discussions (FGDs) with representatives of the stakeholders and elements of the community were conducted to identify potential solutions or best practices in the community that are applicable to developing a community-based surveillance system. During the FGDs, the moderator guided the discussion using guide topics. The FGDs were held at the University of Indonesia, Faculty of Public Health, and were fully recorded and transcribed by study assistants.

For interviews and FGDs, there was no time limitation per data collection session, but they ended when data saturation was reached, or when no additional information was obtained. The interviews and FGDs were performed in Indonesian language. The involvement of multiple stakeholders/policymakers was aimed to help in planning actionable interventions, as well as reinforcing local policies. The characteristics of the respondents for the in-depth interviews and FGDs were described in S1 Table.

Data analysis

For the quantitative data, a weighted analysis was performed to account for the sampling design. Data were presented as mean (SD) for continuous variables or proportion (%) for categorical variables. For the qualitative data, all interviews and FGDs sessions were transcribed and re-read, and common themes were identified using the framework approach and qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH). After familiarisation with the data, the main themes were highlighted, and thematic analysis was performed.

Ethics statement

This study had been reviewed and approved by the Ethics Committee of the Faculty of Public Health, Universitas Indonesia (No.Ket-563/UN2.F10.D11/PPM.00.02/2022). All participants signed written informed consent. No minors were included, and no personal information that could identify individual participants was reported in the present study.

Quantitative analysis: Descriptive characteristics of the study population

As shown in Table 1, the quantitative study population has an equal proportion of men (50.1%) and women (49.9%). Most respondents who filled in the questionnaires were the heads of the households (43.5%) or their spouses (43.9%). The majority of respondents (87.7%) were married, and approximately half of them (49.9%) were high school graduates. Two-thirds (69.1%) of the respondents never smoked, whereas 24.8% are current smokers.

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Table 1. Descriptive characteristics of study participants [quantitative survey; n = 601; 50% men].

https://doi.org/10.1371/journal.pone.0332469.t001

Knowledge of warning signs in pregnancy, childbirth, and newborn babies.

When asked about the warning signs that have to be looked into in pregnant mothers, bleeding/haemorrhage (40.5%) and hypertension (18.6%) were the most chosen options from the answers. A quarter (22.5%) of participants responded that they did not know the warning signs. The proportion of respondents who answered that they did not know the warning signs was disproportionately higher in men (34.2%) than women (10.7%) (see Table 2).

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Table 2. Quantitative analysis: Respondent’s knowledge of maternal and child health.

https://doi.org/10.1371/journal.pone.0332469.t002

In regard to warning signs during childbirth, around 25.1% of respondents chose premature rupture of the membrane, 42.7% answered massive bleeding during and after delivery, and 10.9% answered prolonged contraction or prolonged labour. A quarter respondents (24.1%) answered that they did not know the warning signs during childbirth, with again a disproportionate proportion between men (35.2%) and women (12.9%). When asked about warning signs in newborn babies, the most chosen answers are jaundice (54%), babies not crying (19.3%), and small born or low birth weight babies (17.6%). Around 15.1% answered that they did not know the warning signs in newborn babies, and this is more so in male (23.2%) than female (7.0%) respondents (see Table 2).

Qualitative analysis: Barriers to establishing a community-based surveillance system for maternal and child health [Table 3]

1. 1. The High Mobility of Residents

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Table 3. Barriers and opportunities in establishing community-based surveillance on maternal and child health [qualitative analysis].

https://doi.org/10.1371/journal.pone.0332469.t003

The biggest identified challenge is the high mobility of incoming and outgoing migrants from rural areas all over the country who reside temporarily in Depok to seek jobs in the city or the capital, Jakarta. These migrants bring along their families, including their children, who often have undernutrition problems (stunting or wasting). Despite some intervention programs having been carried out to prevent stunting, as the influx exceeds the outflow of migrant families, the number of children with stunting always appears to be high in the city.

This theme emerges repeatedly and consistently across various stakeholders, including district and subdistrict public officials, Community Health Centre medical staff, and local health volunteers, as illustrated in the following direct quotes. Complete statements are available in Table 3.

“Many incoming migrants, mostly those who rent houses temporarily, are sometimes unnoticed and unreported to the head of the neighborhood … Thus, they become unregistered at the Integrated Health Service Post.” (Subdistrict Official)

1. 2. Inadequate Capacity of the Health Volunteers

Another challenge was the inadequate capacity of the health volunteers, which hindered the delivery of surveillance. For example, as health volunteers are generally older, many are not digitally adept at utilising online reporting tools. Also, it was observed that the health volunteers often did not perform anthropometric measurements (weight and height) in a correct manner to the children at the local ‘Integrated Health Service Post’ (Indonesian: Posyandu), which is an activity organised regularly by health volunteers in the community to monitor the health of pregnant mothers and children, supervised by the village midwives. This measurement error led to inaccurate reporting of the children’s nutritional status.

“We sometimes observed that the health volunteers did not weigh the children in a correct manner …” (Community Health Center Medical Staff)

1. 3. Stigma Related to Sensitive Maternal and Child Health Issues

Sometimes families or community members avoid surveillance or house visits by health volunteers, especially in cases the public sees as shame, such as when mothers are pregnant out of marriage. The avoidance was also shown by their hesitancy to have their conditions checked or examined by health professionals.

“What we often find is that the parents are reluctant if health issues of their children are known by other people, especially those issues that the public sees as a shame …” (Health Volunteers)

1. 4. Late Response from Healthcare Providers

Another potential barrier was the sometimes-late response from healthcare providers after a case was reported. This sometimes makes community members less eager to report when other new issues are found in their community, as they thought their report was meaningless.

“… The delayed response from the relevant agencies leads to the community becoming reluctant to be involved in the subsequent government programs.” (Head of Village)

1. 5. Unwillingness to Participate in Families with Middle-High Socioeconomic Status

In addition, sometimes families reject visits from health volunteers simply because they do not know the enumerator/visitor or have no time to be surveyed. This was particularly often in higher-income neighbourhood clusters with middle-high socioeconomic status families.

“There is a challenge in reaching the residents who live in gated communities, as they are generally very difficult to be visited. We often got rejected when we house visited …” (Health Volunteers)

Qualitative analysis: Opportunities in establishing the community-based surveillance [Table 3]

1. 1. The Community’s Positive Perceptions on Surveillance

Most residents perceived that detecting, recording, and reporting certain medical conditions were necessary for health monitoring. There was, in fact, already a reporting mechanism from the community to the Community Health Centre. This was done mainly by health volunteers conducting house visits to the community members who had a suspected case, or the community members informed the health volunteers when they found a suspected case, and the health volunteers relayed the information to the Community Health Centre. The medical staff at the Community Health Centre then verify the instances by checking the health conditions of the individuals with the suspected case.

“In general, the community is open to community-based surveillance. In many instances, community members even have a high awareness of self-reporting their condition …” (Head of Village)

1. 2. The Existing Community Empowerment Activities

A best practice that has been organised routinely by community members to their community is the ‘Blessed Friday’ program, in which in this program, nutritious food products (raw or ready-to-eat) are distributed to families in need every Friday of the week. These foods are prepared by the community for families with socioeconomic disadvantages, and those with stunted children are given priority as targets for this program. Besides the ‘Blessed Friday’ program, another best practice is the weekly Qurán recitation events, in which in this mass congregation, the community/religious leaders often remind the public to check their condition at the Community Health Center and help those who are ill.

“Currently, the ‘Blessed Friday’ program is regularly conducted in all villages. There, food products such as vegetables, meat, rice, and other things are given to those in need for free.” (District Official)

1. 3. The Active Role of Health Volunteers

Health volunteers play a major role in identifying health issues in the community. One of their primary roles is to organise the routine Integrated Health Service Post activities (‘Posyandu’), during which the general health of pregnant mothers and children’s growth is monitored. The volunteers then report if any high-risk pregnancies are detected, as well as the anthropometric measurement data of the children, to the Community Health Center. In cases of high-risk pregnancies, the volunteers also routinely visit the mothers at home to monitor their general health status.

“… They (the health volunteers) conduct house visits, or what we call “sweeping”, in the neighborhoods to identify if there are new pregnant women in the community.” (Community Member)

1. 4. Potential Collaboration between Stakeholders and Community Organisations

Monthly coordination meetings between health volunteers, district and subdistrict officials, and medical staff of the community health centre are regularly held to evaluate and solve health issues in the community. However, they believe that more stakeholders should be invited or involved in the coordination meetings, such as private healthcare services, academic institutions, local (para)military force, youth organisations, and the office of communication and informatics, as they have distinguished roles that each contribute to better surveillance system.

For example, involving private hospitals and midwife practices in the area may strengthen the referral network between healthcare facilities. Academic institutions may aid in providing health information sessions regarding a particular issue in the community, or help detect health issues and suggest relevant potential interventions by doing research. The local (para)military officers may be involved in surveillance activities (e.g., household visits), as the community tend to consider personnel ‘in uniform’ more seriously. Youth organisations can be asked for their ideas as they are generally more well-educated and innovative, and may explore new funding opportunities to finance the community-based surveillance system. Meanwhile, the Information Office (Diskominfo) can help in conveying public health messages or reducing stigmas of certain sensitive issues.

“The ‘Blessed Friday’ program may also invite charity organizations or private industries via their CSR to participate as donors in providing free foods for those in need in every village. The health office or the city’s mayor can help coordinate to involve these donors”. (Community Health Center Medical staff)

1. 5. Digital Communication Channels

Developing a user-friendly digital tool to record cases is potentially welcomed by the community, and maintenance should be prepared. In fact, in the subdistrict of Tirtajaya, there is already an online Google sheet that can be filled by households and health volunteers whose data is sent directly to the Community Health Centre. This online spreadsheet is called the ‘Healthy Family Card’, in which households independently report their health issues to the tool.

Besides this online spreadsheet, digital mobile applications, such as WhatsApp groups, are also seen as efficient coordination channels between stakeholders (community health centre staff and the district and subdistrict officials), as well as information source for the community during the Covid-19 pandemic. For example, there is a specific WhatsApp group dedicated to pregnant mothers in the community, in which in the group the health volunteers routinely provide information on maintaining a healthy pregnancy. Social media such as Instagram and TikTok are also seen as communication channels that are particularly relevant and preferred by the younger generation of mothers.

“To communicate with each other, there is a WhatsApp group between all volunteers in the district and subdistricts with the medical staff at the Community Health Center. If there is an emergency, the volunteers can contact the Community Health Center immediately to obtain help.” (District Official)

Strengths and limitations of the study

This study employs a robust mixed-methods approach, integrating quantitative surveys with qualitative insights to provide a comprehensive understanding of community-based maternal and child health surveillance. The large sample size (300 households) and diverse stakeholder insights enhance representativeness and real-world applicability, capturing on-the-ground challenges and best practices from multiple levels of community and healthcare stakeholders, making the findings highly relevant for policy and intervention planning.

However, several limitations exist. The cross-sectional design restricts the ability to infer causal relationships between identified factors and surveillance effectiveness. Additionally, self-reported data from the household survey may be subject to recall or social desirability bias, particularly on sensitive topics such as stigma and healthcare-seeking behaviors. Although the quantitative survey included community members (heads of households) involved in community-based surveillance, the qualitative analysis has yet to incorporate perspectives from pregnant women, mothers with infants, or men as husbands. Future studies are encouraged to include these groups in qualitative interviews to better capture end-user perspectives. Lastly, while the study covers three subdistricts in Depok, its generalizability to other regions in Indonesia may be limited due to variations in health system infrastructure and socio-cultural factors. Future research should consider longitudinal studies and broader geographic coverage to strengthen applicability.

Public health implications

This study highlights several actionable strategies to strengthen maternal and child health surveillance and service delivery. First, targeted maternal and child health education, particularly for men on obstetric danger signs, alongside efforts to foster paternal involvement, should be promoted, as husbands play a crucial role in household decision-making and access to healthcare services. Second, to prevent under-surveillance problems among migrant populations, gated communities, and stigmatized cases, tailored approaches could work, including: (1) proactive outreach in densely populated rental housing clusters and informal settlements to better reach migrant households; (2) cooperation with resident associations and private clinics to improve surveillance participation among higher socioeconomic groups in gated communities; and (3) public campaigns to reduce stigma and normalize health-seeking behaviour to better to capture sensitive cases, e.g., unwanted pregnancies. Third, leveraging user-friendly digital tools such as mobile-phone-based data reporting systems may help increase participation in community-based surveillance, including in the three aforementioned groups. A pilot initiative integrating digital tools into community-based surveillance is recommended as the next step, with this study serving as a benchmark for future evaluations. Lastly, strengthening the role, capacity, and support for health volunteers is essential, and this can be achieved by providing regular training and basic equipment, genuine recognition, and small incentives (transport allowances) to sustain volunteer performance. These strategies can be implemented through intersectoral collaboration across the health, social welfare, education, and civil registration sectors.