Consumer perspectives on reproductive health after using the Jakpros smart mobile health application : A cross-sectional , qualitative study [ version 1 ; peer review : awaiting peer review ]

Good reproductive health is important for individuals and also Background: for the development of children. Knowledge plays an important role in women’s reproduction health. Our study examined women’s perspectives and knowledge of reproductive health after using the free Jakarta Reproduction Sehat (Jakpros) application (app) on a daily basis for two weeks. Our study used a cross-sectional, qualitative design. The sample Methods: consisted of 12 participants from two sub-district general hospitals in Jakarta. Participants were chosen using purposive sampling and consisted of women of reproductive age who had completed previous questionnaires on their use of Jakpros. We used descriptive analytics and a qualitative method. Data were collected by direct observation in small focus group discussions. Participants said that after they used the Jakpros app, they were more Results: aware of their reproductive health. Their knowledge increased after counselling combined with Jakpros usage. They also said that the features in the app made it easier to contact their doctor and to access their nearest hospital. Jakpros is a convenient way to access reliable reproductive Conclusion: health information.

On submission to F1000Research, all manuscripts undergo plagiarism checks as standard-this is detailed in our Originality policies. Upon submission, authors are also required to declare that the article is not under consideration or review by another publisher. At this stage in the publication process, our plagiarism detection software did not identify any significant duplication of text. Following publication of the article, the F1000Research editorial team were notified of a high degree of similarity between this manuscript and one already published in the Institute of Physics (IOP) Conference Series: Earth and Environmental Science (B Wiweko et al 2019 IOP Conf. Ser.: Earth Environ. Sci. 248 012038 https://iopscience.iop.org/article/10.1088/1755-1315/248/1/012038/pdf). On investigation, the extent of overlap between these two publications was substantial, and this was deemed a case of duplicate publication. Duplicate publication is a major ethical issue and, as a member of the Committee on Publication Ethics (COPE) and a follower of the International Committee of Medical Journal Editors (ICMJE) recommendations, F1000Research takes such matters seriously.
In response to our concerns, corresponding author Budi Wiweko acknowledged that publication misconduct has taken place and has been informed that, due to the extent and nature of duplication between the articles published in F1000Research and IOP, F1000Research will retract the article and publish a linked retraction notice.
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Introduction
Good reproductive health is important for individuals and also for the development of children. Reproductive health is, or should be, a serious concern for every woman. A nation's mortality and morbidity are dependent on the reproductive health of its citizens. Knowledge plays an important role in women's reproduction health. For example, it informs them on how and when to seek health services 1 .
Mobile health applications (apps) are rapidly proliferating and are widely used around the world to access health information 2 . In 2018, more than 50% of people worldwide had at least one mobile health app on their device 3 . There are more than 100,000 smartphone health apps available today. The main goal of internet-based health apps is ready accessibility 4 . Mobile health apps have a number of benefits: they enable fast, easy searches of almost unlimited health information 2 ; they bring doctors and patients closer together; and they provide health information at any time 5 .
The increasing popularity of mobile health apps is due to a number of things. Firstly, people are more comfortable sharing their experiences, expressing emotions, and exchanging ideas on specific topics within a like-minded community. Secondly, people are curious and want more information about their health experiences 6 . Mobile health apps have been successful in reducing health costs. Preventive action by internet disseminated information is much more efficient than manual methods such as brochures, leaflets or posters 7 . Technology has the potential to alleviate time management issues involved in counselling, treatment waits, and registration 7 .
One limitation of mobile health apps is that, due to the lack of quality controls on the internet, they vary widely in quality and accuracy. Providing good-quality, evidence-based health information to patients is an important goal 6 .
Due to the increasing popularity of mobile health apps, the Jakarta Reproduction Sehat (Jakpros) smart mobile app was developed in 2018 ( Figure 1). This free app is specifically designed to provide women with a convenient way to improve reproductive health knowledge. Jakpros has a section that shows the nearest hospitals from patients to help them access medical care. Other features include an educational page with general information on reproductive health, which is divided into several sections (e.g. contraception, high-risk pregnancy, cancer). Furthermore, the Jakpros application has a question and answer service supported by obstetrics and gynecology doctors ( Figure 2B).
Currently, the Jakpros app is used in several subdistrict hospitals in Jakarta. The aim of the present study was to examine perspectives and knowledge of reproductive health issues in women who used Jakpros as part of their daily activity. Our results will help us improve the usage and quality of the Jakpros app for women in the community.

Methods
This study follows on from our past quantitative research 8 . In the previous study, participants used the Jakpros smart mobile app for 2 weeks. During this time, they read the educational page feature to enrich their knowledge ( Figure 2A). They could also consult their healthcare providers about their complaints or for health information ( Figure 2B). We saw an improvement in health knowledge using pre-and post-test questionnaires. In the current study, we explored participants' opinions and detailed perspectives on reproductive health and the Jakpros application. We used a qualitative method to analyze the main topic.
We explored the different perspectives and behaviors of participants in detail. We adopted phenomenology study as our basic paradigm. The goals of this paradigm are to evaluate participants' experience to be as factual as possible. Furthermore, it describes the different perspectives of the participants 9 .
Participants and study setting Participants were recruited in May 2018. All participants had participated in a previous quantitative study of Jakpros. We recruited participants from two sub-district hospitals in Jakarta: Tanjung Priok Subdistrict Hospital and Tanah Abang Subdistrict Hospital. We used purposive sampling of women with the following criteria: • They had previously participated in our quantitative research.
• They had used the Jakpros application for 2 weeks.
• They lived in Jakarta.
• They provided written informed consent to participate.
Our study method was focus group discussion and direct observation during these discussions. The study consisted of two groups of six participants interviewed on different days. Discussions were held in the hospital hall. Our research team for the discussions consisted of two obstetrics and gynecology specialists (AR and SO) and one general practitioner (IPP).

Use of Jakpros
The participants were instructed to use the Jakpros app for two weeks on a daily basis. Information on nutrition during pregnancy, contraception and family planning, cervical cancer, and high-risk pregnancy were given to participants in the Jakpros app, such as.

Data collection
The list of questions was prepared by our obstetrics and gynecology specialist from Universitas Indonesia. Each participant was interviewed within 10 minutes using a list of questions.
The reproductive section of the discussion used the same questions as our previous questionnaire 8 by modifying the quantitative questions into qualitative questions. For this study, we were able to record participants' answers and their perspectives too. Participants were asked about their reproductive knowledge in areas such as cancer, cervical cancer, pregnancy care, contraception, and high-risk pregnancy. We asked these questions to measure participants' knowledge after using Jakpros for 2 weeks. Next, we focused on participants' use of the Jakpros application. They shared their personal experiences of using it in their day-to-day lives. Participants were asked about obstacles and benefits of using the application.
In the discussion, we asked questions and participants took turns to answer them. We also facilitated the discussion. We emphasized that there were no wrong or right answers, we did not offer opinions and took a neutral stance to answers. We tried to make the discussion as relaxed as possible so participants would enjoy it. Each discussion lasted one hour, we audiorecorded all of the discussion and documented it with photos. For data analysis, we transcribed the data from audio-recorder into narrative document.

Results
The discussion forum was conducted with 12 participants from two sub-district hospitals in Jakarta. Most of them were homemakers, 24-38 years old with high school diplomas as their highest educational qualification. All had participated in our previous quantitative study, which included a post-test questionnaire. This current study was a qualitative study, with results obtained using focused discussion.

Cervical cancer in reproductive health
Our first question was about cancer in reproductive health, and the discussion of perspectives went into considerable depth. Early identification and treatment of cancer improves outcomes, so awareness can be life-saving. Answers were promising; participants knew about several types of cancer in women and their initial symptoms, and the etiology of cervical cancer and that it is preventable by HPV vaccination. Some of them knew about the type of examination for detection of malignancy, and treatments such as radiotherapy or hysterectomy in cervical cancer. They understood about the importance of hygiene in cervical cancer prevention, and that more sexual partners increases the risk of cervical cancer.

Anemia and nutrition in pregnancy
The second question was about anemia and nutrition in pregnancy. Anemia and nutrition are related, and this information is covered in the Jakpros education section. Most participants did not know the initial symptoms of anemia, or the main nutrition components recommended during pregnancy, but most participants knew the main symptoms of anemia. They knew about tests and treatment for anemia, but there was less understanding of the importance of iron in food. Surprisingly, just one participant noted that postpartum hemorrhage can have anemia as a complication. Their answers about nutrition showed only basic knowledge.

High-risk pregnancy
This was the last question about reproductive health. In this section, we asked about the signs of high-risk pregnancy. We wanted to see how aware participants were of its symptoms. They seemed to know early signs, but not much beyond that. They knew it affected both the fetus and themselves. For this question, participants did not describe their experiences. They offered fewer comments than for the previous question. We assumed that they had never been in that situation, or that they did not know much about this topic. But we considered it positive that they were aware of early signs of risk.

Discussion
In this study, we explored participants' knowledge and perspectives of reproductive health and experiences of the Jakpros application after using it on a daily basis for two weeks. Firstly, they could recognize the early signs of cancer or something wrong with their bodies (e.g. bleeding, bumps in breast). Furthermore, for cancer, they knew about basic diagnostic examinations and treatment. Our results were the qualitative study from our previous quantitative study, which found that women are likely to inform themselves of signs and risk factors for cancer in reproductive systems. They were alert to its signs and risk factors 10 . According to another previous study, patients search the internet for further information about their symptoms and rely on this information to make decisions about their health 11 . In our study, we found that participants understood about cervical cancer prevention. They told us that to prevent it people have to maintain good genital hygiene, not change sexual partners, and have regular HPV vaccinations. They agreed that sexually active or married people should have routine examinations routinely too for prevention and early detection. In a previous study, social media has been found to be an effective platform for increasing knowledge and awareness of cancer 12 .
When we asked about contraception, we found that participants were more confident and willing to speak. They could explain what contraception was used for, and also knew about the benefits and side effects of various types of contraception. They involved their husbands and doctors in making their decisions about contraception. They perceived contraception as a way of controlling pregnancy. They told us that family planning was important and required the cooperation of their husbands and consideration of their own bodies and needs. They depended on their social networks for information in making their decisions about contraception. The participants said they were more comfortable obtaining information from their doctors after they read information in Jakpros application. However, they were also interested in further discussion on social media.
For the discussion on pregnancy, we asked participants about anemia, nutrition, and high-risk pregnancy. They knew the definition of anemia, and its early signs, examination, treatment and prevention. They agreed that anemia in pregnancy is a serious condition. Also, they said that nutrition was important in pregnancy, and they could name the nutritional components how they function in pregnancy. They were aware of early signs of high-risk pregnancy. They considered that to prevent pregnancy becoming high risk, women should have regular antenatal care visits and keep a healthy lifestyle during pregnancy. In our past study we found that pregnant women tend to use mobile health applications -for example, to network within communities of people who have the same condition as them. Pregnancy can be stressful, and women can get reassurance by sharing their experiences in online discussion groups. Women also appreciate the convenience of being able to access advice and information any time 13 .
The increasing use of digital devices impacts community expectations for accessing health information. All participants agreed that Jakpros provided a service that helped them access information. Our previous study showed that people like to get information as fast as possible and from wherever they are 8 . Most of our respondents felt that going to the doctor required too much effort to go to doctor 13 .
Previous studies have described how poor-quality information online can lead to health consumers making ill informed decisions 6 Our study showed that patients did not hesitate to get information from Jakpros, and they felt this platform delivered reliable medical information. In particular, they appreciated the free advice from doctors about their reproductive problems.
In response to participant comments, there are a number of things we could do to improve the quality of the app. Firstly, to update the educational page more regularly. Secondly, to improve doctor responses to questions, ideally within 24 hours. Lastly, we hope to extend the information on doctor availability from a few sub-district hospitals to all hospitals in Jakarta.
In our previous quantitative study, we found that user knowledge increased after two weeks' use. This current study demonstrated users' perspectives on reproductive health after using the app. In addition to basic knowledge of reproductive health, their level of awareness had increased, as was observed in the previous quantitative study 8 . The knowledge and awareness provided by Jakpros can help inform women's important decisions on their reproductive health.
Limitations of this study include the lack of perspective study of the consumers as the references of our qualitative and previous quantitative study of Jakpros application, and the short time allocated to the previous quantitative study.

Conclusions
Respondents felt that Jakpros was a helpful application for daily use. Future development of this application is still needed to improve its features. Our aim for Jakpros is that it will one day be a platform for women to access reliable health information that they can apply in their lives.

Ethical approval
This study was approved by the Ethics Committee of the Faculty of Medicine Universitas Indonesia, Jakarta (Committee reference number: 1326/UN2.F1/ETIK/2018).