A digital–spiritual assistance Dzikry model to improve hemoglobin levels and antenatal care compliance: A quasi-experimental study

Abstract

BACKGROUND:

Maternal anemia remains a significant contributor to adverse pregnancy outcomes, particularly in low- and middle-income countries. Although universal health insurance has expanded access to antenatal care (ANC), coverage alone does not guarantee optimal utilization. Innovative approaches addressing behavioral, cultural, and motivational factors are needed. This study aimed to evaluate the effectiveness of a digital–spiritual assistance Dzikry model in improving maternal hemoglobin status and ANC compliance.

MATERIALS AND METHODS:

A quasiexperimental nonequivalent control group design with pretest–posttest measurements were conducted among 60 second-trimester pregnant women at a clinic in Tangerang, Indonesia. Participants were allocated to an intervention group receiving digital education, visit reminders, and spiritually oriented motivational support, or a control group receiving standard ANC services. Hemoglobin levels were measured at baseline and follow-up. Secondary outcomes included ANC compliance, maternal knowledge, and perceived communication quality. Data were analyzed using independent t-tests, Chi-square tests, ANCOVA, and logistic regression.

RESULTS:

Baseline characteristics were comparable between groups. The intervention showed a significantly greater increase in Hb levels compared to the control group (mean difference 0.7 g/dL; P = 0.004). A greater reduction in anemia prevalence was also observed. Additionally, the intervention group demonstrated higher ANC compliance, improved knowledge, and better communication scores. Women in the intervention group were more than three times as likely to achieve normal Hb status.

CONCLUSIONS:

The digital–spiritual assistance Dzikry model effectively enhances maternal engagement in ANC and improves hemoglobin levels, indicating its potential as a culturally adaptive strategy to maternal anemia in primary care settings.

Introduction

Maternal anemia remains one of the most persistent public health challenges affecting pregnancy outcomes worldwide. The World Health Organization (WHO) estimates that nearly 40% of pregnant women globally are anemic, with the highest burden occurring in low- and middle-income countries (LMICs). Anemia during pregnancy is associated with increased risks of maternal mortality, preterm birth, low birth weight, postpartum hemorrhage, and impaired neonatal development. Beyond its clinical consequences, maternal anemia reflects broader systemic problems, including inadequate nutrition, delayed access to antenatal care (ANC), and insufficient continuity of maternal health services.[1]

Over the past decade, many countries have implemented Universal Health Coverage (UHC) reforms to remove financial barriers to maternal care. Indonesia, through the National Health Insurance scheme (Jaminan Kesehatan Nasional, JKN), has made substantial progress in expanding coverage for antenatal, delivery, and postnatal services. Despite this expansion, the utilization of maternal health services at the primary care level remains suboptimal. A considerable proportion of women either initiate ANC late, fail to complete the recommended visits, or bypass primary facilities in favor of hospitals. Consequently, preventable conditions such as iron-deficiency anemia are often detected too late or remain insufficiently managed.[2]

The persistence of maternal anemia in insured populations suggests that coverage does not automatically translate into utilization or quality. Multiple studies have demonstrated that women’s engagement with ANC is shaped not only by availability and affordability, but also by knowledge, trust in providers, cultural beliefs, family influence, and perceived relevance of services. In many settings, biomedical recommendations compete with traditional norms and spiritual interpretations of pregnancy. Therefore, strategies that rely solely on financial protection or facility readiness may fail to produce optimal behavioral change.[3,4]

Continuity and adequacy of ANC are critical determinants of maternal hemoglobin (Hb) status. Regular visits enable early screening, iron–folic acid supplementation, nutrition counseling, infection management, and monitoring of adherence. Women who attend ANC consistently are more likely to receive timely interventions that prevent a decline in Hb levels. Conversely, poor attendance limits opportunities for early detection and reduces the effectiveness of supplementation programs. Improving ANC compliance is therefore a key pathway through which maternal anemia can be reduced.[5]

Recently, digital health innovations have emerged as promising tools to strengthen maternal service utilization. Mobile applications, SMS reminders, teleconsultations, and electronic education platforms have been shown to improve appointment adherence, enhance knowledge, and foster communication between women and providers. The WHO Global Strategy on Digital Health emphasizes that such technologies can reinforce health systems by empowering patients while supporting frontline workers. However, evidence regarding the translation of digital engagement into measurable biological outcomes, such as improved hemoglobin levels, remains limited. Many interventions report behavioral indicators without demonstrating clinical impact.[6]

Furthermore, digital approaches often overlook the sociocultural and spiritual dimensions that strongly influence maternal decision-making. In Indonesia and other predominantly religious societies, pregnancy is deeply embedded within faith, family values, and moral responsibility. Spiritual reassurance may affect how women interpret risk, adhere to medical advice, and maintain motivation for repeated visits. Interventions that fail to resonate with these dimensions may achieve limited acceptance, even if technologically sophisticated. Integrating spirituality into maternal health promotion has shown potential to improve emotional well-being, reduce anxiety, and increase engagement with care.[7] Faith-sensitive counseling can build trust and create meaning around preventive behaviors, including nutritional supplementation. Yet, such approaches are rarely incorporated into digital platforms or evaluated quantitatively. As a result, the combined potential of digital facilitation and spiritual reinforcement remains underexplored in the scientific literature.[8]

Another critical gap concerns the linkage between behavioral engagement and hematological improvement. While increased ANC attendance is generally assumed to enhance maternal health, empirical demonstrations of its association with Hb changes are scarce, particularly in primary care settings. Policymakers require evidence that investments in communication strategies and patient empowerment produce tangible physiological benefits. Without such proof, innovations risk being perceived as supportive rather than transformative. Primary care clinics represent a strategic arena for addressing maternal anemia. They are often the first contact point, closer to communities, and responsible for routine monitoring. Strengthening women’s attachment to these facilities can facilitate early detection and continuous management.

However, midwives frequently face constraints in time, educational resources, and follow-up mechanisms. Digital tools that standardize messages, provide reminders, and maintain patient engagement outside clinic hours could enhance efficiency while preserving personal relationships.[7] To respond to these challenges, a digital–spiritual assistance model was developed to accompany pregnant women throughout their ANC journey. The model combines evidence-based health education, Hb monitoring awareness, visit reminders, and faith-oriented motivational content designed to resonate with local values. By integrating biomedical guidance with spiritual reflection, the intervention seeks to create a holistic framework that supports both behavioral compliance and emotional readiness.[9]

Theoretically, this approach draws upon behavior change models suggesting that individuals are more likely to adopt preventive actions when information, cues to action, and personal meaning converge. Digital reminders function as external prompts, education improves perceived benefits, while spiritual narratives reinforce intrinsic motivation. Together, these components may enhance adherence to supplementation and clinic visits, ultimately contributing to better hemoglobin status. Despite the conceptual promise, rigorous evaluation is necessary. Questions remain regarding whether such integration can significantly improve Hb levels compared with standard care, and which accompanying factors—such as communication quality or maternal knowledge—modify the effect. Generating evidence from real-world primary care environments is essential to inform scalable maternal health strategies within UHC systems.[10]

This study is guided by an integrated behavioral framework combining the Health Belief Model and culturally adapted spiritual motivation [Figure 1]. The Health Belief Model suggests that health behavior is influenced by perceived benefits, barriers, and cues to action.[11] In this study, digital education enhances knowledge and perceived benefits, while reminder systems act as cues to action that promote consistent antenatal care attendance.[12]

Figure 1.

A theoretical framework

In addition, spiritual reinforcement strengthens intrinsic motivation and emotional engagement by aligning health behaviors with personal beliefs. Evidence also indicates that mobile health interventions can improve maternal service utilization and adherence.[13] Improved antenatal care engagement has been associated with better maternal nutritional status and hemoglobin levels. Therefore, the integration of digital and spiritual components is expected to influence both behavioral and biological outcomes in maternal health.

Therefore, this study aims to examine the effectiveness of a digital–spiritual assistance intervention in improving maternal hemoglobin levels and antenatal care compliance among pregnant women in a primary care setting. By linking behavioral outcomes with laboratory indicators, the research seeks to bridge the gap between service utilization and measurable health improvement. The findings are expected to contribute to global discussions on how culturally adaptive digital innovations can accelerate progress toward safer motherhood.

This study offers novelty by integrating digital health interventions with culturally grounded spiritual assistance (Dzikry model), and by linking behavioral outcomes (ANC compliance, knowledge, communication) with biological outcomes (hemoglobin levels), which remains limited in previous studies.

Materials and Methods

Study design and setting

This study employed a quasi-experimental design with a nonequivalent control group and pretest–posttest approach. The research was conducted at a Az-Zahra Clinic in Tangerang City, Indonesia, a primary healthcare facility providing integrated maternal services under the National Health Insurance (JKN) scheme. The study aimed to evaluate the effectiveness of a digital−spiritual assistance model in improving hemoglobin levels and maternal health behaviors among pregnant mothers.

Study participants and sampling

The study participants were pregnant mothers who met the inclusion criteria. A total of 60 participants were recruited and divided into intervention (n = 30) and control (n = 30). The sampling technique used was consecutive sampling based on predefined inclusion and exclusion criteria. Inclusion criteria: gestational age in the second trimester at recruitment, registered as JKN member, willingness to participate, planning to continue ANC and deliver within the facility network, able to use a mobile phone, provided informed consent. Exclusion criteria: Severe obstetric or medical complications requiring referral. Diagnosed hemoglobinopathies or chronic anemia. Inability to participate in follow-up assessments

Data collection tool and technique

Data were collected using structure questionnaires and hemoglobin measurements. The questionnaires instruments underwent validation by three experts in midwifery, public health, and health communication. A pilot test was conducted among 20 pregnant mothers outside the study sample to assess feasibility and clarity.

Construct validity was assessed using item–total correlations analysis with a minimum acceptable correlation coefficient of 0.304, and all items met the validity criteria. The knowledge scale consisted of 10 items and the communication scale consisted of 10 items. Reliability testing using Cronbach’s alpha showed coefficient of 0.821 for knowledge and 0.798 for communication, indicating good internal consistency.

Intervention

Women in the intervention group received access to a digital spiritual assistance platform with Dzikry model designed to: Provide structured maternal health education, deliver reminders for ANC visits and iron supplementation, reinforce motivation through culturally relevant spiritual messages, and facilitate communication between midwives and mothers. The assistance continued from recruitment in the second trimester until outcome measurement in the third trimester. The control group received routine ANC, including laboratory checks, counseling, and supplementation according to national guidelines.

Ethical considerations

Ethical approval was obtained from Research Ethics Committee Universitas Faletehan Number 005179/Universitas Faletehan/2025. Written informed consent was secured from all participants. Confidentiality, voluntary participation, and the right to withdraw were ensured. Participants in the control group continued to receive standard maternal services without restriction.

Statistical analysis method

Data were analyzed using statistical software. Descriptive statistics were used to summarize participant characteristics. Paired t-test and independent t-tests were used to compare mean difference in Hb levels within and between groups. Chi-square tests were applied to compare categorical variables. Multivariate logistic regression analysis was conducted to identify predictors of normal hemoglobin levels. A P-value of < 0.05 was considered statistically significant.

Results

A total of 60 pregnant women were assessed for eligibility during the recruitment period. Eight women were excluded due to referral needs or incomplete baseline laboratory data. Sixty participants were enrolled and allocated into the intervention group (n = 30) and the control group (n = 30). All participants completed the follow-up assessment, and no attrition was recorded.

As shown in Table 1, the majority of participants were aged in the intervention group was 27.4 ± 4.3 years (P = 0.681). The mean gestational age at enrollment was also similar between groups, at 22.1 ± 1.8 weeks in the intervention group (P = 0.553). Regarding educational attainment, the majority of participants in both groups had secondary or lower education 63.3% in the intervention group with no statistically significant difference (P = 0.790). Most participants were primiparous, accounting for 70.0% of the intervention group (P = 0.775). Household income distribution was also comparable between groups. Approximately 60.0% of women in the intervention group and 56.7% (P = 0.743). These findings indicate that the two groups were statistically similar in terms of sociodemographic and obstetric characteristics at baseline.

Table 1.

Baseline characteristic of pregnant women participating in the study (n=60)

Characteristic		Intervention (n=30)		Control (n=30)		P
Maternal age (years)		27.4±4.3		26.9±4.7		0.681
Gestational age at enrollment (weeks)		22.1±1.8		22.4±2.0		0.553
Education level						0.790
Secondary or lower		19 (63.3)		18 (60.0)
Higher education		11 (36.7)		12 (40.0)
Parity						0.775
Primiparous		21 (70.0)		20 (66.7)
Multiparous		9 (30.0)		10 (33.3)
Monthly household income						0.743
<IDR 5 million		18 (60.0)		17 (56.7)
≥IDR 5 million		12 (40.0)		13 (43.3)

Values are presented as mean±SD or n (%). Independent t-test was used for continuous variables and chi-square test for categorical variables

As shown in Table 2, baseline hemoglobin levels were comparable between the intervention and control groups. The mean baseline Hb level was 10.8 ± 1.1 g/dL in the intervention group and 10.7 ± 1.0 g/dL in the control group, with no statistically significant difference (P = 0.740). After the intervention period, hemoglobin levels increased in both groups; however, the increase was significantly greater among women receiving the digital–spiritual assistance. The mean follow-up Hb level reached 11.9 ± 1.0 g/dL in the intervention group compared with 11.1 ± 1.1 g/dL in the control group (P = 0.006). The mean change in hemoglobin (ΔHb) was + 1.1 g/dL in the intervention group and + 0.4 g/dL in the control group, resulting in a statistically significant difference between groups (P = 0.004). The mean difference in Hb change between groups was 0.7 g/dL (95% CI: 0.2–1.1).

Table 2.

Comparison of hemoglobin levels between intervention and control groups

Variable		Intervention (n=30)		Control (n=30)		P
Baseline Hb (g/dL)		10.8±1.1		10.7±1.0		0.740
Follow-up Hb (g/dL)		11.9±1.0		11.1±1.1		0.006
Mean change (ΔHb)		+1.1		+0.4		0.004
Mean difference between groups (95% CI)		0.7 (0.2–1.1)

ΔHb=change in hemoglobin level. Values are presented as mean±standard deviation (SD). Independent t-test was used to compare means between groups. ΔHb indicates change in hemoglobin levels. Confidence interval (CI) is reported at 95%

As shown in Table 3, At baseline, the prevalence of anemia (Hb <11 g/dL) was similar between the two groups. In the intervention group, 19 women (63.3%) were classified as anemic, compared with 18 women (60.0%) in the control group (P = 0.79). Following the intervention, the proportion of anemia declined in both groups, but the reduction was more pronounced among participants receiving the digital–spiritual assistance. Post-intervention anemia prevalence decreased to 23.3% (7 women) in the intervention group, whereas 46.7% (14 women) of the control group remained anemic. The difference between groups was statistically significant (P = 0.03).

Table 3.

Comparison of anemia prevalence before and after intervention between groups

Time point		Intervention (n=30)		Control (n=30)		P
Baseline anemia (Hb<11 g/dL)		19 (63.3)		18 (60.0)		0.79
Postintervention anemia		7 (23.3)		14 (46.7)		0.03

Values are presented as n (%). Chi-square test was used to compare proportions between groups

As shown in Table 4, significant differences were also observed in several behavioral and perceptual outcomes between the two groups. High antenatal care (ANC) compliance was reported by 90.0% of women in the intervention group compared with 65.0% in the control group (P = 0.003). Similarly, a higher proportion of participants in the intervention group demonstrated high maternal knowledge regarding anemia and pregnancy care (76.7%) compared with those in the control group (50.0%), with the difference reaching statistical significance (P = 0.020). Perceived communication quality with healthcare providers was also higher among women receiving the intervention. High communication quality was reported by 83.3% of participants in the intervention group compared with 60.0% in the control group (P = 0.040). Participant satisfaction scores were significantly higher in the intervention group, with a mean score of 4.6 ± 0.5 compared with 3.9 ± 0.6 in the control group (P = 0.002).

Table 4.

Comparison of behavioral and and perceptual outcomes between intervention and control groups

Outcome		Intervention (n=30)		Control (n=30)		P
High ANC compliance		27 (90.0)		19 (65.0)		0.003
High maternal knowledge		23 (76.7)		15 (50.0)		0.020
High communication quality		25 (83.3)		18 (60.0)		0.040
Satisfaction score		4.6±0.5		3.9±0.6		0.002

Values are presented as n (%) or mean±SD. Chi-square test was used for categorical variables and independent t-test for continuous variables. “High” categories were defined based on predetermined cutoffs

As shown in Table 5, multivariate logistic regression analysis identified several predictors associated with achieving normal hemoglobin status after the intervention. Exposure to the digital–spiritual assistance model was the strongest predictor, increasing the likelihood of achieving normal Hb levels by more than threefold (adjusted OR = 3.40; 95% CI: 1.22–9.49; P = 0.020). High maternal knowledge was also significantly associated with improved hemoglobin status (adjusted OR = 2.58; 95% CI: 1.09–6.10; P = 0.030). Likewise, high perceived communication quality with healthcare providers was associated with a greater probability of achieving normal Hb levels (adjusted OR = 2.11; 95% CI: 1.04–4.28; P = 0.040). In contrast, higher household income was not significantly associated with hemoglobin improvement in the adjusted model (adjusted OR = 1.28; 95% CI: 0.65–2.53; P = 0.180).

Table 5.

Multivariate logistic regression analysis of predictors for normal hemoglobin levels

Predictor		Adjusted OR (AOR)		95% CI		P
Digital–spiritual assistance		3.40		1.22–9.49		0.020
High maternal knowledge		2.58		1.09–6.10		0.030
High communication quality		2.11		1.04–4.28		0.040
Higher income		1.28		0.65–2.53		0.180

AOR=adjusted odds ratio, CI=confidence interval. Multivariate logistic regression analysis was performed to identify predictors of normal hemoglobin levels

Discussion

This study aimed to evaluate the effectiveness of a digital–spiritual assistance model in improving hemoglobin levels and maternal health behaviors among pregnant women. The findings clearly support the study hypothesis, demonstrating that participants who received the intervention experienced significantly greater improvements in hemoglobin levels (P = 0.004), reduction in anemia prevalence (P = 0.03), and enhanced behavioral outcomes compared to those in the control group.

The observed increase in hemoglobin levels in the intervention group (P = 0.004) suggests that the digital–spiritual assistance model plays a meaningful role in improving maternal nutritional status. This improvement may be attributed to better adherence to iron supplementation, increased awareness, and strengthened motivation supported by spiritual reinforcement.[14,15] Previous studies have shown that behavioral and educational interventions significantly improve iron supplementation adherence and reduce anemia in pregnancy. Moreover, digital health interventions have been increasingly recognized as effective tools to enhance maternal health outcomes through improved access to information and continuous support.[13]

In addition to biological outcomes, this study found significant improvements in maternal knowledge (P = 0.020) and communication quality (P = 0.040). These findings indicate that the intervention successfully addressed key cognitive and interpersonal determinants of health behavior. According to the Health Behavior Framework proposed by Glanz, knowledge, self-efficacy, and interpersonal communication are critical components influencing behavior change.[11] Improved knowledge enables pregnant women to better understand the importance of nutrition and supplementation, while enhanced communication quality facilitates more effective engagement with healthcare providers. Similar findings have been reported in maternal health studies where improved communication and counseling significantly increased compliance with antenatal recommendations.[16]

Importantly, the multivariate logistic regression analysis revealed that digital–spiritual assistance was the strongest predictor of achieving normal hemoglobin levels (AOR = 3.40; 95% CI: 1.22–9.49). This finding underscores the central role of the intervention in influencing maternal health outcomes, even after controlling for other factors such as knowledge, communication, and income. While maternal knowledge and communication quality were also significant predictors, household income did not show a statistically significant association with hemoglobin improvement (P = 0.180). This suggests that behavioral and psychosocial factors may play a more decisive role than socioeconomic status in this context, consistent with previous studies emphasizing the importance of empowerment-based interventions in maternal health.[17]

These findings reinforce the hypothesis that integrating digital support with spiritual approaches can effectively enhance both behavioral and clinical outcomes. The spiritual component may strengthen internal motivation, emotional resilience, and adherence behaviors, which are often not addressed in conventional health interventions. This integrated approach aligns with contemporary maternal health strategies that advocate for holistic, culturally sensitive, and patient-centered care models.

From a policy perspective, the findings of this study have important implications for maternal health programs, particularly in low- and middle-income countries. The demonstrated effectiveness of the digital–spiritual assistance model suggests that integrating technology-based education with culturally appropriate spiritual support can enhance the impact of existing antenatal care services. Health policymakers may consider incorporating such models into routine maternal health programs, including antenatal education, community health worker interventions, and digital health platforms.[2]

Furthermore, this approach supports global maternal health targets, including the WHO’s recommendations on improving maternal nutrition and reducing anemia during pregnancy. By addressing both behavioral and psychosocial determinants, this model provides a scalable and cost-effective strategy to improve maternal outcomes. Future policies should emphasize the integration of behavioral science, digital innovation, and cultural context to ensure more effective and sustainable maternal health interventions.[18]

This study has several limitations that should be considered when interpreting the findings. First, the quasiexperimental design with a nonrandomized approach limits the ability to establish causal relationships and may introduce potential selection bias. Although efforts were made to ensure comparability between groups, the absence of randomization remains an important methodological constraint. Second, this study was conducted at a single site, which may limit the external validity of the findings. The relatively small sample size (n = 60) may also reduce the statistical power and the generalizability of the results to broader populations. Third, the study did not include long-term follow-up, making it difficult to assess the sustainability of the intervention effects on hemoglobin levels and maternal health behaviors over time. Fourth, the intervention incorporated cultural and spiritual elements that are context-specific. While this approach enhances relevance and acceptability within the study setting, it may limit generalizability to populations with different cultural or religious backgrounds.

Despite these limitations, the study provides valuable insights into the effectiveness of a digital–spiritual assistance model. The findings demonstrate meaningful improvements in both biological and behavioral outcomes, supported by observed effect sizes that indicate practical significance in addition to statistical significance.

Future research is recommended to address these limitations by conducting randomized controlled trials, involving larger sample sizes, and implementing multisite studies across diverse settings. Longitudinal designs are also needed to evaluate the long-term sustainability of the intervention. Furthermore, adaptation and testing of the intervention in different cultural contexts are essential to enhance its broader applicability.

Conclusion

This study demonstrates that the digital–spiritual assistance model can effectively improve maternal engagement and hemoglobin (Hb) levels. These findings support the integration of innovative digital and culturally sensitive approaches into maternal health programs. In line with the WHO recommendations on antenatal care and anemia reduction, this intervention has the potential to enhance service utilization and improve maternal nutritional outcomes. Therefore, incorporating digital–spiritual strategies into existing maternal health policies and programs may contribute to achieving national and global targets for reducing maternal anemia and improving pregnancy outcomes. These findings support the integration of culturally adaptive digital interventions into primary healthcare policies, particularly within Universal Health Coverage frameworks such as JKN. Future research is recommended to further explore the effectiveness and scalability of the digital–spiritual assistance model in different settings and populations. Studies involving larger sample sizes and diverse sociocultural backgrounds are needed to enhance the generalizability of the findings.

AI policy statement

Artificial intelligence (AI) tools were used only to support language refinement and improve the readability of the manuscript. No AI tools were involved in the study design, data collection, data analysis, or interpretation of the findings. The authors carefully reviewed and edited all AI-assisted content and take full responsibility for the accuracy, integrity, and originality of the manuscript. The use of AI complies with the journal’s publication ethics policies.

Abbreviations

ANC: Antenatal Care; Hb: Hemoglobin; JKN: National Health Insurance; LMICs: Low- and Middle-Income Countries.

Ethical approval

This study was approved by the Research Ethics Committee of Universitas Faletehan, Indonesia (No. 005179/Universitas Faletehan/2025). Written informed consent was obtained from all participants prior to data collection.

Author’s contributions

MI: Conceptualization, methodology, data collection, writing—original draft. LMW: Supervision, formal analysis, writing—review and editing. EY: Data curation, validation, investigation.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of interest

There are no conflicts of interest to declare.

Funding Statement

This research was funded by the Fundamental Research Grant from the Ministry of Higher Education, Science, and Technology of the Republic of Indonesia.