Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13068 Development of the "Mother Give Me Exclusive Breastfeeding" e-booklet based on Android as a nutrition educational media Septa Katmawanti,1 Farah Paramita,1 Agung Kurniawan,1 Siti Khuzaimah A. Sharoni,2 Rosuzeita Fauzi,2 Dea Aflah Samah,1 Yassinda Thasia Audina,1 Muhammad Irfan Syahputra,1 Reza Pahlevi,1 Intan Gumilang Pratiwi3 1Department of Public Health, Faculty of Sport Science, Universitas Negeri Malang, Malang, East Java, Indonesia; 2Centre for Nursing Studies, Faculty of Health Sciences, Universiti Teknologi Mara, Selangor, Puncak Alam, Malaysia; 3Department of Midwifery, Politeknik Kesehatan Negeri Mataram, Mataram, West Nusa Tenggara, Indonesia Abstract Undernutrition is one of the most serious and least addressed challenges worldwide. The significant relationship between this condition and children’s feeding practices makes exclusive breast- feeding an early and appropriate intervention. Therefore, this study aimed to develop health promotion media in the form of an Android-based booklet titled “Mother Give Me Exclusive Breastfeeding”. The development method model adopted was ADDIE (Analysis, Design, Development, Implementation, Evaluation). A total of 20 mothers of toddlers participated in prod- uct feasibility testing. The results showed that the product had an average total percentage of 80%, signifying high suitability for usage. The study subjects rated the E-Booklet very positively, showing great enthusiasm for engaging with the content presented in the “Mother Give Me Exclusive Breastfeeding” E-Booklet. In conclusion, further study was needed to maximize the role of this product in enhancing mothers’ understanding of exclusive breast- feeding and ensuring access to facilities such as gadgets, technol- ogy devices, and internet or wifi networks. Introduction Undernutrition is a leading cause of death among children under the age of 5, affecting nearly half of these young lives glob- ally. In addition, low- and middle-income countries are particular- ly vulnerable to this condition.1 Undernutrition is divided into four forms, namely wasting, stunted, underweight, and vitamin and mineral deficiencies. According to global statistics from 2020, 149, 45, and 38.9 million children under 5 are estimated to be stunted (too short for age), wasted (too thin for height), and over- weight or obese, respectively.1,2 The World Bank and Nutrition report in 2019 stated that undernutrition is one of the most serious and least addressed challenges worldwide.3 The significant rela- tionship between this condition and children’s feeding practices makes exclusive breastfeeding an early and effective combating approach.4 This is in accordance with the 2030 Sustainable Development Goals (SDGs), where breastfeeding is considered the first step towards ensuring a healthy and prosperous life.5 Numerous mothers around the world still do not adhere to exclusive breastfeeding practices. According to data from UNICEF in 2021, only 65% of mothers worldwide provide exclu- sive breastfeeding to babies for up to 2 years, with a mere 48% ini- tiating the practices.6 In Indonesia, the 2018 National Basic Health Research Report, known as Riskesdas, showed that out of 94% of mothers with children under 2 years old, only 37.7% practiced exclusive breastfeeding. The province with the lowest coverage was West Nusa Tenggara (NTB), standing at 20.3%. While there has been progress, with NTB reporting a coverage rate of 81.8% in 2020, certain districts such as Mataram City still fall behind the national target of 80%, recording only a 68.2% coverage rate in the same year.7,8 Low coverage of exclusive breastfeeding in the Mataram area is caused by various factors, including sociodemographic, pre- and postnatal, and psychosocial factors. Sociodemographic factors comprise age, occupation, education, knowledge, socioeconomic status, and place of residence. Additionally, pre- and postnatal fac- tors such as parietal and type of delivery contribute to this issue. Psychosocial factors, including family support, health worker sup- port, exposure to formula milk, and attitudes, also influence breastfeeding practices.9,10 An influence of psychosocial factors is the misconception among some mothers that formula milk is bet- ter than exclusive breastfeeding. This misconception may arise due to a lack of understanding of proper breastfeeding techniques, limited access to counseling services, inadequate family and med- ical support, and insufficient education on breastfeeding. Education level, as a sociodemographic factor, is particularly sig- nificant. Lower levels of education among mothers often correlate with the levels of breastfeeding, thereby hindering the achieve- ment of exclusive breastfeeding at the age of 0 to 6 months.11 Nutrition education can be provided to help increase knowledge and awareness of the importance and benefits of exclusive breast- feeding, enhancing the practices in the Mataram area. According to WHO in the book The Health Aspects of Food and Nutrition, nutrition education is a planned effort to improve nutritional status through changes in behavior related to food production, prepara- tion, food distribution in the family, prevention of dietary diseases, and child care.12 In essence, nutrition educators serve as a multidi- mensional process to change the behavior of people related to diet and healthy living in everyday life.13 Significance for public health The 2030 Sustainable Development Goals underscore the significance of breastfeeding as a pivotal step toward attaining a robust and prosperous life. Implementing e-books can facilitate convenient access to information and enrich understanding of exclusive breastfeeding through electronic devices, advanc- ing cognitive function and comprehension. Consequently, this may precipitate favourable behavioural shifts, particularly among breastfeeding mothers, within their daily routines. [page 148] [Healthcare in Low-resource Settings 2024;12(s1):13068] Non -co mmerc ial us e o nly Nutrition education can be provided through educational media, including E-Booklets. E-books, or electronic books, are media used as a learning environment with applications containing multimedia databases of instructional resources.14 The increasing number of activities related to gadgets and the user-friendly nature of these devices enhance their use as a breakthrough medium for exclusive breastfeeding nutrition education. The introduction of E- Booklets can significantly facilitate mothers’ access to educational material and increase knowledge related to exclusive breastfeeding anytime and anywhere. Furthermore, E-booklets offer several advantages, including search and cross-reference functions, hyper- text links, bookmarks, explanations, highlighting, multimedia objects, and interactive tools. These features render the material exceptionally beneficial for increasing the knowledge of mothers through the use of gadgets or smartphones.15 Android-based E-Booklet with visual technology is a break- through that needs to be developed as a medium of nutrition edu- cation for breastfeeding mothers in Mataram. This medium can stimulate more optimal brain performance, thereby enhancing comprehension and fostering positive behavioral changes in every- day life. Furthermore, the resulting long-term impact of the initia- tive is an increase in the coverage of exclusive breastfeeding in the city of Mataram, NTB. Therefore, it is crucial to conduct a study titled “ Development of the “Mother Give Me Exclusive Breastfeeding” E-Booklet based on Android as a nutrition educa- tional media”. Materials and Methods In this study, the development method adopted adhered to the ADDIE model, a learning design based on a systems approach. ADDIE stands for Analysis, Design, Development (or Production), Implementation (or Delivery), and Evaluation. This model is ver- satile and applicable to diverse forms of product development including models, learning strategies, methods, media, and teach- ing materials. Utilizing the ADDIE model streamlines and enhances the efficiency and effectiveness of product development processes.16 Robert Maribe Branch’s review of the book “Instructional Design: The ADDIE Approach” describes the activ- ities conducted at each stage.17 Analysis In the analysis phase, instructional problems, instructional goals, and learning objectives were defined. This phase also iden- tified the learning environment as well as current knowledge and skills. Furthermore, it was the initial stage where the problem of exclusive breastfeeding coverage in Indonesia was analyzed. Based on the results of the literature study, the lowest exclusive breastfeeding coverage observed was in the West Nusa Tenggara region. In addition to analyzing the problems to be studied, a solu- tion analysis was also conducted in media development. The anal- ysis showed that booklet media was developed from digital form into an E-Booklet related to exclusive breastfeeding. Design During the design phase, the focus shifts to defining targets, selecting assessment instruments, determining content to be devel- oped, and analyzing the material to be presented along with the choice of media to be used. At this stage, the framework for the E- Booklet framework to be developed was discussed, comprising aspects such as the title, colors used, content structure, and digital media functionalities. Development The creation and incorporation of the designed content assets were conducted in this phase. Subsequently, the programmer worked to integrate the necessary technology. Implementation In this phase, the product series was tested on several groups of people by assessing the feasibility and effectiveness using a questionnaire. Subjects for evaluation were selected through the probability sampling technique, ensuring an equal opportunity for each element (member) of the population to be included as a sam- ple member. In this study, respondents were selected using consec- utive sampling techniques, with inclusion criteria specifying moth- ers with children aged 6-60 months, willingness to participate, and proficiency in reading and writing. The sample size comprised 20 mothers selected from 2 health centers with the lowest exclusive breastfeeding coverage, namely Ampenan and Cakranegara Health Centers in Mataram City.18 Evaluation The evaluation phase is used to provide opportunities for feed- back from users through the analysis of administered question- naires. The study conducted is in the form of quantitative data analysis. The results of the assessment in the validation and trial process, comprising statements such as not good, less good, good, and very good were converted into quantitative data with a score of 1 to 4. Product data analysis was conducted by validators using a Likert scale. The criteria for Likert Scale Assessment are present- ed in Table 1. Descriptive data analysis was adopted to convert quantitative data into qualitative data. After obtaining the score, the feasibility percentage was calculated and interpreted in line with the theory applied by Suharsimi Arikunto in 2013.19 P= f N X 100% where: P = percentage number f = score obtained N = overall score After determining the percentage, the feasibility of the media can be evaluated based on the following criteria in Table 2. 4th International Nursing and Health Sciences Symposium Table 1. Likert scale assessment. Alternative answer Score Very good 4 Good 3 Not good 2 Not good at all 1 Table 2. Likert scale assessment. Percentage Criteria 76% < skor ≤ 100% Excellent 51% < skor ≤ 75,% Good to go with minor revisions 26% < skor ≤ 50% Promising with major revisions 0% skor ≤ 25% Unsuitable for use [Healthcare in Low-resource Settings 2024;12(s1):13068] [page 149] Non -co mmerc ial us e o nly A feasibility analysis was conducted on each aspect of the assessment, categorizing results into not feasible, less feasible, fea- sible, and very feasible. Additionally, the need for revisions was determined based on feedback from material experts, media experts, and respondents engaged in the E-Booklet trial group at the Cakranegara Health Center and Ampenan Health Center areas of Mataram City. The study adhered to the code of ethics, designat- ed by ethics number 421/PP2MKEI/II/2021. Results and Discussion Respondent characteristics The sample size of respondents in this study amounted to 20 mothers with children aged 0-3 years. Furthermore, information on the characteristics of respondents, including age, latest education, and occupation, are presented in Table 3. The distribution of respondents according to the characteristics showed that the majority of mothers fell within the age range of 25 - 35 (60%). Age played a significant role in readiness, comprising physical, mental, and social aspects. Maternal age also influences maternal health throughout pregnancy, childbirth, postpartum development, and child care. Mothers over 25 years of age and above have more experience and mental availability to care for children. However, hormone production decreases at age 30, which can interfere with lactation. Mothers over 30 years old have more children, and their cumulative experience may impact current breastfeeding practices.20,21 Based on the level of education and the characteristics of respondents, the majority had at least a high school education (50%). It is important to note that mothers’ edu- cation level influences nutritional status. Higher levels of maternal education often facilitate greater receptiveness to change and adap- tation. It enhances understanding about nutrition and elevates attention to children’s nutritional needs.21–23 In addition to educa- tion level, employment status can also determine the level of exclusive breastfeeding, with 75% of respondents being unem- ployed or homemakers. Work will provide experience and influ- ence a person’s knowledge. Mothers who are busy outside the home and interacting with many people will have broader knowl- edge than those spending more time at home. This is because there are many relationships and opportunities to obtain wider informa- tion.24,25 With the rapid development of technology, innovation is needed for easy understanding of information and knowledge. An android-based E-Booklet product with visual technology was introduced as a medium for nutritional education on exclusive breastfeeding in the working area of Mataram City, NTB. With the majority of respondents being homemakers or not employed, the flexibility of accessing E-Booklet anytime and anywhere is partic- ularly advantageous. Product feasibility trial results The results of the feasibility trial of android-based E-Booklet products with visual technology as a medium for nutrition educa- tion on exclusive breastfeeding in the working area of Mataram City NTB are presented in Table 4. 4th International Nursing and Health Sciences Symposium [page 150] [Healthcare in Low-resource Settings 2024;12(s1):13068] Table 3. Respondent chareacteristics. Respondent chareacteristics Total Presentage (%) Age ≥ 24 years 4 20 25-35 years 12 60 ≤ 36 years 4 20 Last Edu Not in School 1 5 Elementary 2 10 Junior High School 2 10 Senior High School 10 50 Diploma/ Bachelor Degree 3 15 No information 2 10 Work Employed 5 25 Not Working/Housewife 15 75 Table 4. Product feasibility results. No Question Average (%) Category 1 The design on the cover of E-Booklet is attractive. 78 Excellent 2 The typeface on the cover of E-Booklet is attractive. 78 Excellent 3 The typeface on the content of E-Booklet is attractive 78 Excellent 4 The font size on the content of E-Booklet is easy to read. 79 Excellent 5 The color on E-Booklet is attractive. 83 Excellent 6 The font color on the cover is attractive. 81 Excellent 7 The font color on the content of E-Booklet is attractive. 81 Excellent 8 The picture on E-Booklet is clear. 89 Excellent 9 Images on the content of E-Booklet help in understanding the material. 81 Excellent 10 Images on the content of E-Booklet help in remembering the material. 81 Excellent 11 The material in E-Booklet is easy to understand. 84 Excellent 12 The material in E-Booklet is easy to remember. 79 Excellent 13 The message contained in E-Booklet is easy to apply. 76 Excellent 14 The message contained in E-Booklet is easy to remember. 76 Excellent 15 The material in E-Booklet is complete. 79 Excellent 16 The material in E-Booklet is presented sequentially. 84 Excellent Total 80 Excellent Non -co mmerc ial us e o nly The assessment results of 20 respondents who had filled out a questionnaire as a feasibility test stated that the E-Booklet was “very suitable for use” (80%). This positive reception was a result of the meticulous attention paid to various aspects of the media design, aimed at enhancing readers’ comprehension and practical application of the information in everyday life. These aspects include the design of the product cover, font selection, color scheme, image clarity, and understanding of the material provided. Education in health promotion interventions is an approach commonly used to provide knowledge and information as well as enhance the development of individuals/groups to make informed choices regarding certain health-related behaviors. The 3 aspects of learning in health education activities include cognitive (infor- mation and understanding), affective (attitudes and emotions), and behavioral (skills). The integration of online media in the learning process facilitates interaction among users, enabling two-way communication even across different locations.26 The study results showed that education using technology is much more effective in providing knowledge about Health. This was also conveyed by Goncalves in 2019, where the use of technology in increasing knowledge and attitudes had a much more significant increase compared to conventional media.27 Technology-based Health Education is also important for breastfeeding mothers. According to a study conducted by Tama 2020, breastfeeding mothers tend to refrain from receiving information about appropriate and accurate practices, which comprised the success rate of early initiation.28 Several studies have been conducted on developing education- al media for managing exclusive breastfeeding. Katmawanti’s study in 2021 stated that the emo demo method effectively increased the knowledge and attitudes of mothers. The recommen- dations of this study include implementing other educational media to increase the knowledge and attitudes of mothers who do not offer exclusive breastfeeding.29 Katmawanti also conducted investigations on measuring knowledge and attitudes regarding exclusive breastfeeding in 2021 in Batu City, East Java. The results show that the booklet can increase the knowledge and attitudes of mothers who have not previously provided the intervention. This study is an innovation from several previous reports using technol- ogy-based education Yektiastuti in 2016 explained that Android users could improve cognitive, metacognitive, and socio-cultural abilities.30 Conclusions In conclusion, E-Booklet media was suitable for use and implementation as a nutritional education medium to increase cov- erage of exclusive breastfeeding. Based on suggestions, the limited gadget facilities and internet networks owned by respondents in the local area caused the need for further development related to E- books. Additionally, further study was needed to maximize the role of this product in the comprehension of exclusive breastfeeding, such as testing the effectiveness of the level of knowledge and atti- tudes before and after the provision of E-Booklet intervention. This report can be used as a reference for health practitioners in developing health education media regarding exclusive breastfeed- ing. With the development of an Android-based E-Booklet product with visual technology as a media for nutritional education in the working area of Mataram City, NTB, the coverage of exclusive breastfeeding was expected to increase. References 1. Nounkeu CD, Dharod JM. Integrated approach in addressing undernutrition in developing countries: A scoping review of integrated water access, sanitation, and hygiene (wash) + nutri- tion interventions. Curr Dev Nutr 2021;5:1–12. 2. World Health Organization (WHO). Malnutrition [Internet]. Word Health Organization. 2021 [cited 2021 Jan 13]. Available from: https://www.who.int/news-room/fact-sheets/detail/mal- nutrition 3. The World Bank. The World Bank and Nutrition [Internet]. The World Bank. 2022 [cited 2022 Dec 13]. Available from: https://www.worldbank.org/en/topic/nutrition/overview 4. UNICEF (United Nations Children’s Fund). Global Nutrition Report 2020: Action on equity to end malnutrition [Internet]. unicef.org. 2020 [cited 2021 Jan 14]. Available from: 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13068] [page 151] Correspondence: Septa Katmawanti, Department of Public Health, Faculty of Sport Science, Universitas Negeri Malang, Jl. Semarang No.5, Sumbersari, Kec. Lowokwaru, Malang, East Java, Indonesia. Tel.: +623413301130 - Fax: +62341551921. E-mail: septakatma.fik@um.ac.id Key words: breastfeeding; e-booklet; undernutrition Contributions: SK is the person in charge, director, and determinant of the concept of study and article writing, FP is the coordinator of data col- lection, AK is the coordinator of instruments and data analysis, SKAS, and RF act as consultants and reviewers in the study and article writing, DAS, YTA, MIS, RP, and IGP as a team of data collectors, analyzers and article writing. Conflict of interest: the authors declare no conflict of interest. Funding: the authors are grateful to the LPPM Universitas Negeri Malang, for supporting the entire course of study both in terms of funds and administration. Ethics approval: the study adhered to the code of ethics, designated by ethics number 421/PP2MKEI/II/2021. Clinical trials: not applicable. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 13-15 October 2023, Universitas Brawijaya, Malang, Indonesia. Acknowledgment: the authors are grateful to the Universitas Negeri Malang for providing the opportunity to conduct the entire series of stud- ies. The authors are also thankful to the Mataram City Health Office, Ampenan Health Center, and Cakranegara Health Center, for participat- ing in this study. Received: 5 November 2023. Accepted: 8 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13068 doi:10.4081/hls.2024.13068 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.Non -co mmerc ial us e o nly https://data.unicef.org/resources/global-nutrition-report-2020/ 5. United Nations. THE 17 GOALS | Sustainable Development [Internet]. 2023 [cited 2023 Aug 14]. Available from: https://sdgs.un.org/goals. 6. UNICEF (United Nations Children’s Fund). Too few children benefit from recommended breastfeeding practices [Internet]. unicef.org. 2021 [cited 2021 Jan 14]. Available from: https://data.unicef.org/topic/nutrition/breastfeeding/ 7. NTB Provincial Health Office. Percentage of Babies Who Receive IMD and Exclusive Breastfeeding in NTB Province | One Data NTB [Internet]. 2022 [cited 2023 Aug 14]. Available from: https://data.ntbprov.go.id/dataset/persentase-bayi-yang- mendapat-imd-dan-pemberian-asi-eksklusif-di-provinsi-ntb 8. Rahmadhona D, Affarah WS, Wiguna PA, Reditya NM. Factors Influencing the Success of Exclusive Breastfeeding in Mataram City. Unram Med J 2017;6:12–6. 9. Febriyanti H. Factors Related to Exclusive Breastfeeding in Health Workers Who Have Babies in Pringsewu Regency in 2017. Midwifery J J Kebidanan UM Mataram 2018;3:38. 10. Ampu MN. The Relationship Between Mother’s Education Level and Exclusive Breastfeeding in Infants at Neomuti Health Center in 2018. Intelektif J Ekon Sos Hum 2018;2:9– 19. 11. World Health Organization. The Health Aspects Of Food And Nutrition. Manila:Word Health Organization. 1979. 12. Ministry of Health of the Republic of Indonesia. Nutrition Counseling. Jakarta: Center for Health Human Resources Education, Ministry of Health of the Republic of Indonesia; 2018. 13. Danardono A, Rudibyani RB, Emmawaty Sofia ES. The Effectiveness of E-Book Media to Improve Students’ Metacognition and Concept Mastery. J Pendidik dan Pembelajaran Kim. 2019;8:495–508. 14. NFH A, Rahman ES. Effectiveness Of The Implementation Of Interactive E-Books For Basic Programming Subjects For Vocational High School Students. Jurnal Media Elektrik 2020;17:14–8. 15. Tanjung MR. Multimedia Application Development For Introduction And Learning Of Origami With The Addie Approach. 2014 [cited 2023 Aug 14]; Available from: https://www.academia.edu/9570475/Pengembangan_Aplikasi _Multimedia_Pengenalan_Dan_Pembelajaran_Origami_Deng an_Pendekatan_Addie 16. Branch RM. Instructional Design: The ADDIE Approach [Internet]. Boston, MA: Springer US; 2009. 17. West Nusa Tenggara Health Office. Percentage of Babies Who Receive IMD and Exclusive Breastfeeding in NTB Province [Internet]. One Data NTB. 2020 [cited 2022 Jan 14]. Available from: https://data.ntbprov.go.id/dataset/persentase-bayi-yang- mendapat-imd-dan-pemberian-asi-eksklusif-di-provinsi-ntb 18. Arikunto S. Research procedures a practical approach. Jakarta: Rineka Cipta; 2013; 19. Fadlliyyah UR. Determinant Factors Influencing Exclusive Breastfeeding in Indonesia. Ikesma 2019;15:51. 20. Ulfah HR, Nugroho FS. The relationship between age, occupa- tion and maternal education with exclusive breastfeeding. Intan Husada J Ilm Keperawatan 2020;8:9–18. 21. Afriyani R, Savitri I, Sa’adah N. The Influence of Exclusive Breastfeeding at BPM Maimunah Palembang. J Kesehat 2018;9:331–5. 22. Rani H, Yunus M, Katmawanti S, Wardani HE. Systematic Literature Review Determinants of Exclusive Breastfeeding in Indonesia. Sport Sci Heal 2022;4:376–94. 23. Katmawanti S, Paramita F, Kurniawan A, et al. The effects of exclusive breastfeeding booklets on mothers’ knowledge in providing exclusive breastfeeding in Mataram City, Indonesia. Healthc Low-resour S 2023;11:11211. 24. Ramli R. The relationship between knowledge and maternal employment status with exclusive breastfeeding in Sidotopo Village. J Promkes Indones J Heal Promot Heal Educ. 2020;8:36–46. 25. Sembada SD, Pratomo H, Fauziah I, et al. Utilization of online media as a means of health education for adolescents: a litera- ture review. PREPOTIF J Kesehat Masy 2022;6:564–74. 26. de Sousa Gonçalves M, Celedônio RF, Targino MB, et al. Construção e validação de cartilha educativa para promoção da alimentação saudável entre pacientes diabéticos. Rev Bras em Promoção da Saúde 2019;32. 27. Tama TD, Astutik E, Katmawanti S, Reuwpassa JO. Birth pat- terns and delayed breastfeeding initiation in Indonesia. J Prev Med Public Heal 2020;53:465. 28. Supriyadi, Katmawanti S, Arviolika Y, Samah DA. Development of Educational Media For Type II Diabetes Mellitus Patients in the Work Area of Kedundung Health Center, Mojokerto City. KnE Life Sciences 2021;32–42. 29. Yektyastuti R, Ikhsan J. Developing Android-Based Instructional Media of Solubility to Improve Academic Performance of High School Students. J Inov Pendidik IPA 2016;2:88–99. 30. Sugiyono D. Educational research methods quantitative, qual- itative and R&D approaches. Bandung:Alfabeta; 2013. 4th International Nursing and Health Sciences Symposium [page 152] [Healthcare in Low-resource Settings 2024;12(s1):13068] Non -co mmerc ial us e o nly