Conclusions: Simulation-based online training efficiently improved the knowledge and attitudes of nursing students towards older adults, improving their ability to address social isolation and loneliness. The high satisfaction and adhesion to the best educational practices underline the usefulness of high-fidelity online simulations, especially in situations in which face-to-face training is not feasible, and accessibility and equilibrium could be guaranteed between work and personal life.Introduction: The population of older adults is rapidly increasing worldwide, presenting both prospects and complexities for society and healthcare professionals to maximize the functional capacity of this age group. Social isolation and loneliness significantly affect this population. The objective was to determine the effectiveness, satisfaction, and perceptions of the simulation-based education practices of a training program for nursing students, which was created to palliate the social isolation and loneliness of older adults. Method: A quasi-experimental study was conducted with nursing students who participated in an online training program using teleservice based on high-fidelity clinical simulation. The program included asynchronous theoretical training and synchronous practical training using an online platform. Five scenarios were designed using simulated phone calls to address the social isolation and loneliness of older adults. Results: Twenty-five nursing students participated in the program, and they had a mean age of 27.44, with 76% of them being women. After the training program, the participants showed statistically significant improvements ( The global elderly demographic is expanding at a swift pace, presenting both prospects and complexities for society and healthcare professionals with respect to optimizing the functional capabilities of this age group .Social isolation and loneliness are two important problems of public health that strongly affect this population group. Social isolation, understood as “the dissociation of social relations, connections with institutions or community participation”  is assocHowever, living alone, being socially isolated, and feeling lonely, are different conditions, and even if there is a causal association, experiencing one of the conditions does not mean experiencing the others .Loneliness is defined as “a subjective and negative feeling”  that accThe COVID-19 disease, due to SARS-CoV-2, disproportionately affected older adults, with higher mortality rates observed in this population . Beyond Given this background, it is necessary to propose interventions to improve the situation of isolation and loneliness relative to older adults, with the expectation that they will have a positive impact with respect to their lifestyle, health, and quality of life and at the same time a decrease in the number of adverse events and the need for health resources. To design these interventions, two important aspects must be considered. On the one hand, the responsibility for taking care of these matters has mainly fallen on civil society, social services, and citizen associations, and in general terms, they are not part of the healthcare priorities of the Spanish health system . The secThe “distance” interventions applied up to the present day have been classified into five categories: (1) videoconferences; (2) telephone calls; (3) online discussion groups/forums; (4) use of social networks; (5) interventions with multiple tools . Many stPresently, there is no doubt that clinical simulation is an essential component of health science education . ClinicaThe existing data show the importance of addressing the problem of the social isolation and loneliness of older adults given their provoked increase due to the pandemic, the repercussions on physical and mental health, and the increase in the demand for health system services. In Spain, there are currently no measures or social policies implemented to help prevent them, and the evidence on the prevention of isolation is still scarce . There iOur study is framed within the first phase of the telehealth program “HELPeN”, directed to older adults in social isolation who live in the community. This telecare program comprises a telephone-based intervention led by nurses specializing in community health, geriatrics, and mental health. These expert nurses serve as mentors and supervisors for volunteer nursing students. The program was executed using a series of telephone calls, during which a comprehensive health and quality-of-life assessment will be conducted. Individualized care plans and interventions were implemented, and elderly individuals were continuously monitored for a duration of 9 months. We anticipate that this intervention positively impacted the lifestyle, health, and overall quality of life of the elderly population. Furthermore, it is expected to reduce feelings of loneliness and social isolation, consequently enhancing their quality of life. This, in turn, is anticipated to lead to a reduction in adverse events and a decreased demand for healthcare resources.The objective of the present study was to determine the effectiveness, satisfaction, and perceptions of the simulation-based education practices of an online training program for nursing students created to palliate the social isolation and loneliness of older adults.A quasi-experimental study with pre–post measurements was conducted with a non-randomized intervention group composed of nursing degree students who participated in a high-fidelity clinical simulation (HFCS) telecare online training program in order to address social isolation and loneliness in older adults.The target population consisted of 25 s and third-year students enrolled in the Nursing Degree at the University of Murcia (UM), Spain, during the 2022–2023 academic year; they voluntarily participated in the training program, which was not integrated into the Bachelor of Nursing curriculum.A non-probabilistic sampling method was used, as the HFCS-based training was offered to all second and third-year students who wanted to participate in a volunteer program to mitigate loneliness in older adults.The inclusion criteria were as follows: (1) students enrolled in the 2nd and 3rd year of the Nursing Degree, (2) took part in the volunteer training program to mitigate loneliness in older adults, and (3) signed the informed consent form. The exclusion criteria were as follows: (1) students who had medical or health conditions that could affect their active participation in the training program or the volunteer service.A training program was designed in two online modalities lasting 25 h and distributed over 3 differentiated weeks.Training took place using the virtual platform of the University of Murcia within the Sakai environment, which is a robust system that provides support to 4 million users in education environments to promote cooperative teaching, learning, and research . The asyEach student accessed each of the modules in Sakai and viewed their contents. They had to pass a test on the contents before being able to access the next module.In the asynchronous training, a calendar was proposed to ease completion. All participants had to complete the asynchronous online portion and pass an exam before taking part in the synchronous practical training.The synchronous practical training took place using the online communication tool Zoom during an eminently practical session that lasted 5 h. Practical training was based on potential scenarios that students could face during the volunteer program HELPeN. In the volunteering program, the students must make a call once a week for a total of 36 weeks. A script was developed to help students during interventions and was implemented in each of the calls to older adults in order to favor effective interventions .Simulation Design Process:The design of the simulation program was performed according to the guidelines from the International Nursing Association of Clinical and Simulation Learning (INACSL) .Five clinical scenarios for telephone interviews were designed, which addressed different situations related to the telecare offered by the volunteers to older adults who suffered from social isolation and loneliness in a community context . All sceEach session was structured and comprised prebriefing, briefing, simulation, and structured debriefing according to the INACSL guidelines .The first half-hour of the session was used for prebriefing and to establish a psychologically safe environment. For this, various group dynamics were implemented based on the practices proposed by Rudolph, Raemer, and Simon  and the Once the prebriefing ended, simulated telephone interview scenarios were conducted. A briefing session took place before each simulated scenario, in which information on the proposed scenario was presented to participants. Afterwards, a simulated telephone interview took place, during which the facilitators turned the camera off and adopted the role of a simulated patient, to simulate a telephone call in which the student played the role of a volunteer who had to make different types of clinical and social decisions and manage resources via the Electronic and Digital History Record ICEBE platform, which was developed for the management of the HELPeN program. The observing students completed a checklist about the situation, with respect to the positive aspects and aspects that could be improved upon, to assist in posterior analyses and reflection on the scenario. When each simulated telephone call ended, a structured debriefing took place  in whichSocio-demographic (age and gender) and academic year characteristics were assessed.To assess the participant’s knowledge, their knowledge relative to the asynchronous part of the course was measured objectively. This was performed by five professors who were members of the research team. They were experts in training and research in geriatric nursing, with more than five years of experience. The objective test comprised 24 multiple-choice questions with four options, of which one was correct. The questions were theoretical in nature and related to the contents of the course and volunteer program. This test was given at the start and end of the training program.To assess the attitudes of the students towards older adults, Kogan’s attitudes towards old people (KAOP) scale was utilized . This scTo assess the satisfaction with the training program of the participants, the adapted version of the Students’ Satisfaction Scale was utilized . EighteeLastly, to assess the perceptions of the best educational practices via simulations, the Educational Practices Questionnaire (EPQ) was utilized . El EPQ A data collection form was designed using the measurement instruments described above, and the Google Forms online tool was used.At first, the form with all measurement instruments  was sent through the virtual classroom so that all participants could complete it and send it before the start of the training program.Then, after the end of the synchronous part of the training program , the data collection form with the measurement instruments was sent again.The data were analyzed with IBM SPSS Statistics software version 22.0 for Windows . A descriptive analysis was conducted relative to the study’s variables. The mean and standard deviation were utilized for quantitative variables, and frequencies and percentages were used for categorical ones.t-test with a Bonferroni correction for multiple comparisons. For each variable, the effect size was calculated using Cohen’s d to assess the magnitude of the effect of the intervention, with the use of the values proposed by Ferguson [As most measurement results did not obtain a normal distribution, the pre- and post-data were subjected to a Bootstrap analysis . The comFerguson , in whicThe study, approved by the Ethics Committee of the University of Murcia, Spain , involved students who willingly participated and had provided written informed consent after a prior explanation of the study’s objectives. The research was carried out in strict adherence to the principles and guidelines outlined in the Declaration of Helsinki .n = 19) being women. With respect to their academic year, 68% were enrolled in their 2nd year, and 32% in their 3rd year of the Nursing Degree.The final sample comprised 25 nursing students who had a mean age of 27.44 (SD = 12.38) years old, with 76% , and in the variable “attitudes of the students towards older people”, it was 49.24 .The descriptive analysis of the Student Satisfaction Scale is shown in We present a training program based on online clinical simulations to provide training to nursing students in order to reduce the social isolation and loneliness of older adults. Our results show the positive effects of this training program on the improvement in the knowledge of students, the positive attitudes towards older adults, the high satisfaction, and the positive perception of clinical-simulation-based practices. After the high-fidelity simulation training, our students improved their total scores with respect to all variables.Our objective was to train nursing students to make simulated phone calls in order to palliate the social isolation and loneliness of older adults, and these phone calls met the requirements proposed by the INACSL  during tAlthough previous studies have shown the effectiveness of simulation-based training on geriatrics education , which iStandardized patients were included in the simulated scenarios. Their inclusion was shown to be effective in other studies that utilized the same education strategy , which fRegarding the faithfulness of the simulated scenarios, students expressed that the simulation was indeed realistic. This realism stemmed from the contextualization of the scenarios to closely resemble the actual volunteering situations that are likely encountered, thereby facilitating their application in clinical practice. The attainment of such a high level of fidelity in these simulated scenarios can be attributed to the adherence to established standards in both the design of simulation-based training and scenario development . To achiThe high degree of satisfaction of the students and their perception that the high-fidelity clinical simulation-based session met the best educational practices in terms of simulation standards in the training program were perfectly in tune, with a very positive assessment provided by the students. These results are congruent with other studies that utilized face-to-face ,61 and oThe results of the satisfaction with respect to the online learning modules showed that all items were positively scored by the participants, with mean high scores of 4.70 over 5 obtained in all dimensions . Also, the scores obtained in the “agree/strongly agree” response scale were 100% relative to all items, except for items three “With the online modules I have learned more in this course than in a face-to-face course” and twelve “The amount of work required for the modules of the HELPeN training program is adequate for understanding their content”. This could be due to students’ preference for face-to-face learning and that the work overload perceived by students in the training program was high because the training course simultaneously took place with their official university courses.Likewise, the results from the Educational Practices Questionnaire showed that the perception of the high-fidelity clinical simulation session met the best educational practices in terms of simulation standards and obtained high scores of 4.5 over 5 in all dimensions, except for the collaboration dimension. The collaboration weakness outlined in These results are supported by the fact that the training program followed international recommendations on the design of activities based on clinical simulations , the useFinally, it is worth emphasizing that the primary benefit of simulation-based training resides in its capacity to bridge the gap between theory and practical application, fostering a valuable learning experience from errors. Students underscored these aspects in their satisfaction survey, aligning with their recognition of effective educational practices within the realm of simulation, a consensus that is also supported by findings from prior research studies ,66,67.The present study is not without limitations. One methodological limitation pertained to the use of convenience sampling and the relatively modest sample size, thus constraining the generalizability of the findings. Nonetheless, to enhance the study’s external validity, the pre- and post-data underwent bootstrap analysis via a simulation involving 1000 participants. Another limitation, which was not very frequent, was the existence of technical problems during online simulation sessions (videoconference). However, these problems could be common in real phone calls given the lack of coverage or skills of older adults with respect to the use of a mobile phone, which would make the scenario more realistic. Another limitation of our study was the bias due to the use of self-reporting scales. However, all these instruments were validated, obtained high validity and reliability, and have been utilized in many international studies. Lastly, in future studies, long-term monitoring should be implemented to ensure that the knowledge and attitudes towards older adults of nursing students are maintained in the long term.The online clinical simulation-based training initiative, emulating realistic scenarios via simulated telephone interactions, effectively addresses the educational requirements of nursing students engaging in a telecare volunteering program aimed at alleviating social isolation and loneliness among elderly individuals. In this sense, the study shows how training using a virtual modality via high-fidelity simulations is plausible, well received by students, and exhibits a high degree of learning consolidation.The online clinical-simulation-based training program, characterized by its high-fidelity approach, enabled nursing students to enhance both their favorable attitudes towards older adults and their knowledge of addressing social isolation and loneliness in this demographic. Prior to encountering real-world scenarios, the cultivation of these competencies ideally takes place via simulated interactions with elderly individuals, affording students the chance to empathize with these individuals and comprehend their emotions and experiences. Also, the development of these skills can provide benefits that are directly related to performing high-quality telecare to palliate the social isolation and loneliness of older adults.The online high-fidelity simulation was highly satisfactory and met the best educational practices in simulation, which defines it as a useful option in contexts in which the face-to-face training activities of students and health professionals are not possible, or it could be used to favor accessibility and aspects, such as professional and personal reconciliation.Although our findings are promising, it is important to emphasise the need for further research aimed at implementing similar initiatives in actual practice. To effectively bridge the gap between education and practice, future studies should explore the sustained influence of simulation training on nursing students in order to provide high-quality care to older adults experiencing social isolation. Such research should also explore long-term benefits.


This research aims to determine the influence of smart city policy and community needs on the effective implementation of such initiatives, considering the existence of a digital divide within Tangerang City. The digital divide presents a significant challenge for local governments as they strive to ensure equitable and inclusive access to adequate public services for the entire community. A quantitative method of explanatory survey approach was used in this research with questionnaires sent as part of the data collection process in 13 districts of Tangerang City. A total of 400 participants were utilized and data processing was carried out using the SEM-PLS model. Building a smart city was intended to enhance the quality of life by using urban information and technology to increase service effectiveness and cater to community needs. By harnessing information communication technology, the government proactively monitored city dynamics, drove positive changes, and enhanced residents' quality of life. This enabled direct engagement with both residents and infrastructure, making technology an indispensable component of smart city development. Through this mutual utilization, local governments and communities could equally benefit from the advantages and conveniences offered by smart city. RegionsIn line with bureaucratic reforms with the use of ict, Tangerang City as one of the most developed cities in Banten Province, having a geographical location directly adjacent to the DKI Jakarta area, has considerable potential and opportunities for the development of regional competitiveness. This is in line with the vision and mission of the city to realize a livable environment and attract investors and tourism through access to technology .The city of Tangerang which is located west of Jakarta, is one of the fastest growing cities in Indonesia. Significant population growth, economic advancement, and urbanization in the city pose challenges in resource management, public services, and infrastructure development. In facing this challenge, the government has taken steps to increase the utilization of Information and Communication Technology (ICT) and implement smart city initiatives. However, in designing and implementing effective smart city solutions, it is important to understand issues, such as the digital divide and society's need for ICTs. The digital divide refers to differences in access, utilization, and understanding of technology among different groups of people. The diverse needs of society should be the basis for the development of relevant and useful ICT services. To achieve this goal, smart city policy that focuses on digital inclusion, civic participation, and proper data management is needed ,5.A new breakthrough made by the Tangerang City government in terms of providing excellent service to the community is through the “Tangerang-Live” application which has advanced to version 4.0. The word “Live” means creating a livable, investor-friendly, visitable, and e-city. The existence of this application aims to realize the vision and mission of Tangerang, namely “the realization of an advanced, independent, dynamic and prosperous environment with a “Moral Karimah” community .Tangerang Live is a single application (Single Sign On) that integrates various existing service applications, resulting in a synergistic technological solution, for easier and more effective functionality. The features provided, include the Live Broadcast service which contains the latest news and information on tourism and tourist destinations, Laksa (suggestion box aspiration service), Emergency 112 enabling the report of urgent events to relevant agencies, licensing services, population services and other economic information) . AccordiThe development of an e-government, supported by ICT, aims to enhance administrative efficiency, performance, community engagement, and services. It serves as a vital foundation for the advancement of smart government initiatives . Smart cThe realization of smart city should also not only rely on the utilization of information technology, but more importantly in the development of smart people, where individuals who are part of the government system are aware of their participation in realizing smart city . Smart cSeveral smart city-related research on the utilization of technology in healthcare systems for smart city applications include  IoT-baseFurthermore, research conducted on the alternative conceptions of intelligent citizenship ,28 usingThe research carried out  on the iThis research is important because it measures smart city policy and ict-based smart city service (community needs) for the implementation of Tangerang Live application through a digital divide. This is to enhance the knowledge of the implementation and utilization of technology applications in Tangerang, while simultaneously examining the digital divide. The use of digital technology in terms of better governance is a top priority. The use of more intense and innovative web technologies can help public administration modernize the structure and function of government in improving overall performance, from the process of strengthening e-governance to fostering greater transparency, accountability, and engagement between administratives and their citizens.This research aims to determine the influence of smart city policy and community needs on policy implementation with a digital divide in Tangerang. This is to achieve Tangerang city's vision of becoming a smart city and serve as a pilot model for other regions. As a manifestation of all system development that has been built by Tangerang City regional government, it should also be supported by the community.22.1Smart city policy serves as a framework or guide in planning and implementing smart city initiatives. This policy covers strategic decision-making related to ict infrastructure, data use, cybersecurity, community participation, and other aspects related to smart city applications. In theoretical debates, smart city policy is important because it can create a clear foundation, provide the right direction, and regulate the wise use of ICTs. Good policy should also address issues, such as data privacy and security ,42.Globalization, with its profound impact on humanity, has caused significant changes, prominently marked by the widespread availability of the internet, an evidence of the remarkable advancement of information technology . PresentSmart city development needs to be supported by social, economic, environmental conditions, and with participatory government . SeveralSmart city according to IBM  “is the Based on expert opinions, a “smart city” can be defined as a technologically driven community that emphasizes the importance of monitoring and integrating services with IT intelligence. This approach aims to optimize access to information and public services while educating citizens about its significance. The term “policy” refers to manner with which the city is structured to work together cohesively as a whole. As a result of the demands of smart city, different ideas evolve in time (or new ones are developed). Large urban areas require majority of the attention while creating smart city, because of their intricate networks and systems. Attention should be given to small city that is rapidly expanding or whose growth is anticipated in the future. The goal is to develop an analysis that can predict the problem, as well as assessing the level of preparedness by providing actionable steps that can be swiftly implemented .The growth of the city is largely dependent on its infrastructure, which is essential to both the operation of commercial organizations and the general well-being of the populace. In urban management, infrastructure is classified into two groups, namely soft  and hard . Soft , is in the form of social, cultural, and other facilities, while hard  infrastructure, is presented as transportation, telecommunications, water, and energy networks . Smart cHypothesis 1Smart city policy has a positive influence on digital divideHypothesis 2Smart city policy has a positive influence to policy implementationTechnologically, its policy aims to build integrated city information and management  combinin2.2People's need for ICT is becoming an important factor in smart city applications. ICT can improve people's quality of life in various aspects, such as efficiency, comfort, safety, and public participation. Within the framework of smart city, ICT is used to connect city infrastructure, services, and resources to provide better benefits to society. Therefore, understanding the needs of society related to technology and the ability to utilize it is a crucial factor in designing appropriate smart city solutions and applications ,62.Building pioneering infrastructure and executing smart city programs are top priorities for municipalities in the globe when formulating economic development strategies . GeneralSmart city creates a foundation for human-centered socio-economic well-being and quality of life , for insTo execute innovation and deploy technology, smart city services are a combination of social constructions and technological innovations that interact and influence one another . In partServices for “smart city” are those that concentrate on modernizing and changing the environment and are often related with urban management of national or municipal governments . When peHypothesis 3Community needs have a positive influence on digital divideHypothesis 4Community needs have a positive influence on policy implementationTo increase municipal infrastructure integration, efficiency, quality of life, transparency, and public involvement, smart city services heavily rely on information . Researc2.3The digital divide refers to the division or gap in access, utilization, and understanding of ICT among individuals, groups, or regions. In the context of smart city applications, the digital divide is important because it can exacerbate social and economic inequality. To achieve inclusive smart city, efforts are needed to reduce the digital divide through equitable access to ICT infrastructure, digital skills training, and equal opportunities in technology utilization ,72.The difference in access to ICT and the usage of the internet for different purposes across people, homes, enterprises, and geographical areas at different socioeconomic levels is known as “digital sniffing” . VariousThe OECD countries have started making positive efforts that will guarantee their citizens, businesses, and territories access to these technologies and services. This is because access to and development of information, communication, and e-commerce resources are increasingly seen as being crucial for economic and social development (for efficiency and due to network effects) . To addrThe term “digital divide” refers to the disparity of access to ICT, telematics, and the use of the internet for a variety of purposes between individuals, households, businesses, (or communities), and geographic areas at different socioeconomic levels . The digA disparity in access to computers was the first meaning of the phrase “digital divide”. Before the internet was invented, social and economic disparities caused by the development of ICT also resulted in the emergence of a digital gap . It willThe fundamental factor relating to the disparity between those who have access to digital media and the internet, and those who do not have this opportunity is often referred to as the “digital divide” . The issThe unequal development of communication network infrastructure or laws in each area is the root of Indonesia's digital divide . People Hypothesis 5The digital divide has a positive impact on policy implementationThe digital divide encompasses infrastructure access , intertw2.4A framework for implementation analysis model developed by Ref. . In mappThe challenges related to theoretical and technical implementation, as well as the diverse range of items and intended modifications, should be considered as separate variables when assessing the difficulties and regulatory measures involved. Intervening variables include the ability of the policy to structure the implementation process with indicators of clarity and consistency of objectives, the use of causal theory, the accuracy of source allocation, hierarchical integration among implementing agencies, rules and implementing agencies, the recruitment of implementing officials, and openness to outside parties. Other factors are in terms of measures of socioeconomic, technical circumstances, public support, constituent attitudes, as well as variables outside of policies that have an impact on the implementation process, support of higher officials, commitment, quality of leadership, and implementing officers.Dependent variables, such as the five stages of the implementation process, including understanding the implementing institution/agency, object compliance, tangible findings, acceptance of results, and finally leading to revisions of the policies implemented.According to Ref. , findingIn the context of the present technological advancements and urban transformations, model development in 33.1This quantitative research was conducted using an explanatory survey approach. The data collection was conducted through the survey method using a questionnaire filled out by respondents. Direct surveys were conducted by direct observation and giving questionnaires to respondents representing community groups. Online surveys can also be used to cover more geographically dispersed respondents. Data collection was carried out for 2 months (March to April 2022). Leveraging previous literature research and expert judgments, a robust approach was employed to develop a research instrument comprising 71 carefully crafted statements. The data analysis technique used was SEM-PLS  .This research adheres to a set of ethical principles for research, upholding scientific integrity, human rights, and dignity, which correlate with the guidelines and regulations of Research Ethics Commission (KEP) Universitas Padjajaran no. 17023190042. Ethical approval was obtained from the head of the department of public administration at the faculty of social and political science, Universitas Padjajaran, Bandung. In accordance with the guidelines of the general code of ethics of the Universitas Padjajaran Bandung, active informed consent was obtained from all community who participated in this research.3.2This research was conducted in Tangerang municipality due to its strategic position, directly adjacent to DKI Jakarta, being a concentrated resident, trade, and industrial area. The infrastructure in Tangerang is expected to serve as a model that can be replicated and duplicated by other regencies and cities in Indonesia, coupled with the main support in the form of the internet of things (IoT), big data, and cloud computing. This is to ensure that public services and community empowerment in the context of implementing regional development are more optimal. In the future, Tangerang is also expected to be a pilot project in the development of place branding for regency and city areas in Banten Province, as a center of rapid growth to attract domestic and foreign tourists, as well as investors through Soekarno-Hatta International Airport.The analysis involved all Tangerang City communities who are in 13 districts and have used the Smart City Tangerang Live application as well as those who already carrying out activities . A samplObservations were conducted on productive-age individuals who used the Live application in 13 districts. Apart from the users of Tangerang Live application, observations were also made regarding the State Civil Apparatus at the Tangerang city communication and information service, which serves as the manager of Tangerang Live application, as well as the technology infrastructure supporting this application.3.3Descriptive analysis was used to analyze respondents' demographics, regarding gender, age, recent education, marital status, and occupation. This is conducted to determine the identity of the respondent, and represents the collection of data on each respondent's demographic using SEM (Structure Equation Modeling) software. Data processing is carried out for 1 month (May 2022). The outer model testing phase includes assessing the validity & reliability of indicators and constructs. The goodness of fit model testing stage involves evaluating the prediction power, the feasibility of the model, and the significance of the influence of exogenous variables on the endogenous see .Table 4C44.11.From the results, the age ranges from 15 to 21 years old (55%), indicate that the millennial age is very dependent on the application in facilitating their service of interest. For example, by utilizing the provided application options, changes to identity cards, such as applying for modification, can be implemented efficiently.2.Many application users are females, as this gender uses the application for various services, such as accessing online market. The online market menu provides a choice of types of products, including vegetables, meat fruits, etc. Besides, there are also product promo notifications from every traditional and modern market in the city.3.When viewed from the book entitled “Tangerang city in numbers for the year 2022"  published by the central statistics agency, it is stated that as many as 564,747 individuals of productive age from the age of 15 years onwards have completed high school education. This figure is 49.6% of the total productive age in Tangerang city, which is 1,141,720 people.4.There are many Tangerang Live application services that are indeed needed by unmarried respondents, such as the plesiran choice menu. This feature provides information for tourist attractions in Tangerang City area, by meeting the respondents' need to explore and discover local destinations. Tangerang Live application offers transportation routes for various modes of transportation, facilitating access to the tourist attractions. It also provides valuable information regarding the historical background of these attractions, enhancing the overall experience for users.5.Employees are synonymous with workers in the private sector who have their time consumed by work in the office, making it difficult to manage population administration documents effectively. Tangerang Live application has captured the interest of private employee due to its efficient in the management of population documents. One notable service is the neighborhood association introduction service, which offers various services such as assistance in obtaining certificates of death, widow/widower, and Taxpayer Identification Number.There were several questions in the research questionnaire that measuring the objective condition of the respondents related to demographics profile, including age, gender, marital status, last education, and occupation. The description of the respondents represented by the five profile questions is as follows:4.2According to 4.3In this section, hypothesis testing will be carried out based on the results of the analysis using the partial least square method. The results of the analysis obtained showed that, of the five hypotheses put forward, all proved to be statistically significant. The results of more complete analysis and hypothesis testing can be seen in the next description.The results from 2, amounting 0.2227 (22.27%). The community needs have a positive significant impact on the digital divide with a loading of 0.477 or an influence of 0.4772 accounting for 0.2275 (22.75%). Smart city policy has a positive significant effect on policy implementation with a loading of 0.330 or an influence of 0.3302 amounting 0.1089 (10.89%). The community needs variable has a positive significant influence on policy implementation with a loading of 0.17 or an influence of 0.17 2 accounting for 0.0289 (2.89%). The digital divide has a positive impact on policy implementation with a loading of 0.258 or an influence of 0.2582 amounting 0.067 (6.7%).Based on 5In the context of implementing smart city, the implementation of policy, has been reflected in the executive decree as stated in Tangerang Mayor Regulation Number 108 of 2018 concerning the Tangerang smart city masterplan 2017–2027. Mayor Regulation Number 108 shows the full support of the executive to build and develop Tangerang as a smart city, which will further drive the bureaucratic machinery or apparatus. In addition, the issuance of Mayor Regulation Number 108 can also be an indication of the support and seriousness of the Tangerang City regional government in terms of implementing smart city.The existence of executive decisions as stated in Mayor Regulation Number 108 above is in line with the research that highlighted the importance of policy implementation at the executive level. Previous research  indicateSome of the existing Tangerang Live application innovations include 1) Open API (Application Program Interface) policy including data standardization, integration, and public API development. 2) Development of a collaboration system with the Penta helix model that involves the local governments, universities/academics, private sector, society, and the media. 3) Integrated services, including the Tangerang Live and one-stop-shop concept for all services.The local government through the communication and information Service implements Tangerang Live application as a digital platform for the third space of citizens consisting of 1) a digital society, where Tangerang Live application will facilitate interaction between the community, 2) The digital economy, bridging the interaction between the community and the business sector, to make the economy run in accordance with the government's expectations, and 3) Digital government, where interaction between the community and the government becomes easier through applications.Tangerang Live application initiated by the government has several advantages, including 1) Effective, facilitating services in the Tangerang City area. 2) Innovative, Tangerang Live application will always be developed and have innovations to implement the smart city concept. 3) Easy to use, the Tangerang Live start page has a user-friendly and minimalist design, making it simple and easy to navigate. 4) Feature-rich, various features are found in Tangerang Live application. Smart city policy of Tangerang can affect the overall implementation of ICT policy by accelerating and increasing the use of communication technology in supporting the development of a smarter, more efficient, and sustainable Tangerang City.The variety of complexities that exist in the city which tends to be unavoided will in turn increase pressure in the economy , social , and the environment . Smart city initiatives are employed to address the complexity of problems faced by modern cities. The implementation of smart city will have implications for the need to issue supporting policies and regulations, which is necessary in transforming a city into a smart city.The policy has an influence on the digital divide since smart city requires access to good technology and infrastructure to operate effectively. However, not all residents have the same access to technology and the internet. When the smart city policy only focuses on developing technology and infrastructure, without paying attention to the gap among the residents, there will be a digital divide. This can result in inequalities in opportunities to access digital information and services, as well as gaps in the ability to benefit from technology and innovation.To overcome the impact of the digital divide from smart city policy, the regional government should ensure that all citizens of the city have equal access to technology and the internet. One method to achieve this is by enhancing the accessibility of technology infrastructure, while offering training and education programs to individuals who have limited skills in using technology. By this method, the digital divide can be reduced and opportunities to leverage technology and innovation can be extended to all citizens of the city.Policy implementation appears to be at a relatively good level. It is important to note that this analysis uses hypothetical numbers and considers only four finite factors. For a more comprehensive evaluation, more complete data and a detailed assessment of various aspects of policy implementation are needed, such as resource management, public participation, and policy impact evaluation. The digital divide can affect the implementation of policy designed with the assumption that all citizens have equal access to technology, and difficulties may arise when there is gap among residents within the city.For example, when a smart city policy in Tangerang is designed to optimize online services (Tangerang Live application) and the use of technology in various aspects, but not all city residents have adequate internet access and technological devices, then the policy will not work effectively and may fail in its implementation. The impact of the digital divide can also affect the participation of the residents in the policy process. Residents who do not have adequate access to technology and internet may not be able to obtain information and engage in the public participation process conducted online. This can reduce the participation of citizens and the impact can reduce the effectiveness of the policy implemented.To overcome the impact of the digital divide on policy implementation, the government should ensure that the policy implemented pays attention to the technology gap among residents. Governments can improve the accessibility of technology infrastructure, provide training, and education about technology to people who are less skilled in using technology. In this manner, policy implementation can run more effectively and public participation can be increased. Communities greatly benefit from ICT innovation, active participation in urban contexts, high-quality services, and an improved quality of life through the use of ICT. A significant positive change and development can be fostered by enhancing these aspects. To meet this need, investment in the development is required as well as implementation of innovative ICT solutions, attention to community participation, improving the quality of services, and ensuring equitable access.Increasing needs for ICT can widen the digital divide as not all city residents have equal access to technology and the internet, resulting in technological gap among the citizens. This gap has an impact on the opportunity for the people to access information, utilize digital services, and benefit from innovation. With the development of ICT, the gap can further deepen the economic and social gap between residents. When the community's need for ICT is managed properly, this can affect the reduction of the digital divide in the city. The government should pay attention to the needs of the community for ICT and ensure that the technological infrastructure built cover all city residents. In addition, the administration should also provide training and education on ICT for people who are less skilled in using technology.The implementation of policy is important to meet the needs of the people for ICT, which include 1) The development of adequate infrastructure can facilitate access. This includes the construction of extensive and quality internet networks, provision of cell phones, public Wi-Fi, hotspots, etc. 2) Training and development of human resources is needed to improve the technology skill of the resident's community through live training or online courses. 3) Regulations and policies that can help people access services and information online safely. This includes personal data protection, cybersecurity, and copyright. 4) Empowering micro, small, and medium enterprises (MSMEs) in the use of ICT can help them improve the quality of products and services and expand market reach. Implementation of this policy is expected to assist the people of Tangerang City in fulfilling their ICT needs, thereby enhancing their quality of life and welfare.62 accounting for 0.2275 (22.75%) of the relationship. This is the strongest relationship value, considering the constant changes and developments that the city undergoes, specifically in the rapid evolving field of ICT. Change often occurs in a very fast and unstoppable time, and in turn has an impact on the patterns and lifestyle of the people. The results and various research indicate that the digital divide in smart city context is evident in the work culture and the availability/support of sufficient ICT infrastructure. The digital divide arises because of a paradigm shift in work culture, from the old manual work culture to automation in the digital era . To address this, policy promoting digital mindset and enhancing human resources capacity through various forms of training and education should be implemented, enabling individuals to effectively utilize ICT devices. To enhance support and availability of adequate ict infrastructure, one approach is to establish collaboration with external parties.The Community Needs Variable has a positive significant impact on the Gap with a loading of 0.477 or an influence of 0.477The community needs have a positive significant effect on Policy Implementation with a loading of 0.17 or an influence of 0.17 2, accounting for 0.0289 (2.89%) of the relationship. This is the weakest relationship value, where the complexity of the problem is increasing, ranging from the need to build green open space, decent housing, adequate infrastructure, support for business space (business), and the availability of recreational facilities. Additionally, there are challenges in formulating regulations that effectively support smart city initiatives.One of the research limitation is the lack of indepth exploration regarding policy implementation strategies that are in accordance with the conditions of bureaucratic development in Tangerang City, specifically, and Indonesia in general. This include a need to investigate appropriate forms of work and support in the context of regional work tools specific to Tangerang. Another aspect that could have been explored is the influence of culture, as it plays a significant role in determining the applicability of successful strategies implemented in other cities and countries to the context of Indonesia, particularly Tangerang. Cultural considerations may necessitate modifications and adaptations to ensure the effectiveness of these strategies.7Based on the conclusions stated above, the following will outline the implications of research both theoretically and practically.7.1To measure the effect of policy related to the implementation of smart city in the future, the regional government should be able to prepare various regulations needed. The findings provide further support to the notion that leadership plays a crucial role in the successful implementation of smart city policy, highlighting its positive influence. Future research can consider the leadership factors needed for policy implementation, particularly focusing on the role of effective communication as a bridge between stakeholders in formulating regulations in accordance with the objective conditions encountered in the field. This will mitigate the digital divide that may arise in the implementation of smart city, both at the level of regional devices as service providers and the community as recipients of services. This is essential as the primary objective of smart city to provide better public services.7.2Based on the results, it is observed that policy implementation plays an important role in smart city development. Therefore, local governments and mayors as regional leaders can formulate the necessary regulations and demonstrate leadership capabilities in the context of implementing smart city. In an effort to reduce digital divide as an inevitable factor influencing the implementation of smart city, there is need for breakthroughs in terms of providing digital infrastructure, as well as building efforts that can encourage and also involve various stakeholders. When policy implementation is supported by proper guidance, the availability of adequate digital infrastructure support and the involvement of external elements can help address potential digital divide that may arise from smart city implementation.81.In addition to the importance of policy implementation in supporting the realization of smart city, local governments should prioritize and encourage efforts to involve various stakeholders and communities through practical initiatives and collaborations. Efforts to promote external involvement are crucial to bridge the implementation gaps in the context of limited existing human resources (state civil apparatus). Furthermore, when involving communities or private parties, it is important to prioritize the implementation of directed and sustainable education and training programs. This approach aims to address the existing knowledge gap effectively and ensure adequate skill development.2.For future research should consider the need for more in-depth exploration related to the forms of policy implementation that align with the actual conditions of bureaucratic development, specifically in Tangerang City and more broadly in Indonesia. This research should also examine the appropriate forms of work and support in the context of regional work tools. In this case, cultural considerations should also be taken into account, as what may have been successfully implemented in other countries may require modifications when applied in the context of Indonesia.Toddy Aditya; Conceptualization, research method, formal analysis, writing—original draft preparation, writing—review and editing.Sinta Ningrum, Heru Nurasa. and Ira Irawati; project administration, supervision.All authors have read and agreed to the published version of the manuscript.Education Fund Management Institution of Lembaga Pengelola Dana Pendidikan (LPDP), (No: 20200421351518 for Toddy Aditya). The APC was funded by Universitas Padjadjaran.This research was funded by the Not applicable.Not applicable.All the data are in the manuscript.No additional information is available for this paper.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Maternal and child health (MCH) improvement has been prioritised in resource-constrained countries. This is due to the desire to meet the global sustainable development goals of achieving a maternal mortality rate of 70 per 100000 live births by 2030. The uptake of key maternal and child health services is crucial for reducing maternal and child health mortalities. Community-Based Interventions (CBIs) have been regarded as among the important strategies to improve maternal and child health service uptake. However, a paucity of studies examines the impacts of CBIs and related strategies on maternal and child health. This paper unveils the contribution of CBIs toward improving MCH in Tanzania.Convergent mixed method design was employed in this study. Questionnaires were used to examine the trajectory and trend of the selected MCH indicators using the baseline and end-line data for the implemented CBI interventions. Data was also collected through in-depth interviews and focus group discussions, mainly with implementers of the interventions from the community and the implementation research team. The collected quantitative data was analysed using IBM SPSS, while qualitative data was analysed thematically.Antenatal care visits increased by 24% in Kilolo and 18% in Mufindi districts, and postnatal care increased by 14% in Kilolo and 31% in Mufindi districts. Male involvement increased by 5% in Kilolo and 13% in Mufindi districts. The uptake of modern family planning methods increased by 31% and 24% in Kilolo and Mufindi districts, respectively. Furthermore, the study demonstrated improved awareness and knowledge on matters pertaining to MCH services, attitude change amongst healthcare providers, and increased empowerment of women group members.Community-Based Interventions through participatory women groups are vital for increasing the uptake of MCH services. However, the success of CBIs depends on the wide array of contextual settings, including the commitment of implementers of the interventions. Thus, CBIs should be strategically designed to enlist the support of the communities and implementers of the interventions.The online version contains supplementary material available at 10.1186/s12884-023-05638-x. Efforts to reduce maternal and child mortality have remained a top priority at the national and international levels. As such, signs of maternal and child mortality reduction have been witnessed globally. For instance, between 2000 and 2017, the maternal mortality rate was estimated to have been reduced by 38% . EvidencEvidence suggests that improving adherence to maternal and neonatal health continuum of care protocols, including antenatal care (ANC) and postnatal care (PNC) services, can reduce the burden of maternal and neonatal mortality –8. ANC oWhile attendance of ANC is highly promoted, the uptake of these services in LMICs is still low. At the global level, for instance, 71% of pregnant women receive ANC services, and 95% of them are from developed countries, while only 69% are from SSA , 15. DatCommunity-based interventions (CBIs) such as participatory women groups and home visits by trained community health workers (CHW) have shown effectiveness in reducing the burden of maternal and child mortality and morbidity in LMICs –22. A bo-2020) was implemented. The two districts were selected because they exhibited an unacceptably low uptake of maternal and child health services, including ANC, PNC and FP services. For instance, in Kilolo and Mufindi districts, attendance of ANC within twelve weeks (first trimester) was 16.8% and 27%, respectively; and pregnant women who completed four ANC visits and above in 2018 stood at 27.1% in Kilolo and 23% in Mufindi [This study employed a convergent mixed method design to examine the effects of WG interventions towards improving MCH. Mixed methods facilitated the triangulation of findings to gain a complete picture of the explored issues . In addi Mufindi , 35. Apa Mufindi –38. In a Mufindi . Table 1According to the Comprehensive Council Health Plan, 2018, Kilolo District was supposed to have 1247 health workers, but only 756 were available, while in Mufindi district, the ideal number of health workers was expected to be 1326, but only 822 were available. This indicates that of the two districts, none had the required number of health workers.The IMCHA project was implemented in Kilolo and Mufindi districts from 2015 to 2020. The overall project aim was to develop, adopt and implement CBIs to improve maternal, newborn and child health outcomes to inform policy and scale-up in Tanzania. Participatory Action Research (PAR) through women's groups intervention in collaboration with the Implementation Research Team (IRT) worked with community members to address MCH challenges. The PAR was implemented through a series of meetings with implementers of the interventions, namely Women Groups (WGs), Male Champions (MCs), Women Group Supervisors (WGS), village leaders, community gatekeepers and health care providers. The PAR was facilitated by the IRT from the University of Dar es Salaam and health managers from Iringa Region in collaboration with the HealthBridge Foundation of Canada. Details of PAR phases and the series of meetings through which the IMCHA project was implemented are described elsewhere , 38. OveThe study was conducted in health facilities in Kilolo and Mufindi districts where WG interventions were implemented. Five wards were purposively selected in each district as they had implemented the project. In each ward, two villages were selected for the study as they also implemented the WG interventions. From the selected villages, 13 health facilities from 10 wards were included. From the selected health facilities, baseline and end-line data were collected to determine the trajectory and trend of the MCH before and after the interventions. Participants in this study were purposively sampled from those who directly participated during the implementation of the interventions. As indicated in Table Data was collected through closed-ended questionnaires, in-depth interviews (IDIs), Focus Groups Discussions (FGDs) with participants, and document reviews. The questionnaires were administered to the in charge of each health facility in the respective wards where interventions were implemented. The questionnaires were structured to capture some MCH outcomes like ANC, FP, PNC, and male involvement during the five years of implementing the project. These data revealed the trajectory and trends of the selected MCH indicators. Researchers collected the baseline data using the questionnaire  and (CJM) were responsible for the literature search, after which they shared the documents accessed with all authors for use during their inputs in manuscript development.Qualitative data was analysed using thematic analysis . The audThis study got approval from the Ethical Committee of the National Institute for Medical Research of Tanzania (NIMR) withcertificateNo: NIMR/HQ/R.8a/Vol.IX/2119. The Regional Administrative Officer in the study region also approved the study. Moreover, verbal informed consent was obtained from all participants. Verbal consent was preferred to written consent because it was assumed that asking respondents and participants to sign consent forms would create fear and thus discourage them from participating in the research. Similarly, data was only accessible to the team members; and no individual identification was attached to the findings. Lastly, all quotes used to illustrate participants’ views had no personal identities.This section presents the significant findings of the study. The results revolve around two major themes: primary improvement of selected major MCH services and secondary improvement of MCH services. The primary theme had five sub-themes: attendance of ANC within the first trimester, four or more ANC visits, male involvement in MCH services, uptake of PNC and use of modern contraceptives. The secondary theme had three sub-themes, including awareness and knowledge of matters pertaining to MCH, attitudes among healthcare workers, and empowerment of women group members.As indicated in Table The implementation of CBIs through WGs targeted the improvement of MCH services like ANC, PNC, uptake of family planning and male involvement primarily. The following section describes how the implemented interventions improved that continuum of care.th week of pregnancy. Participants asserted that before the implementation of the interventions, few pregnant women used to attend ANC on time. To testify to the observed changes, one healthcare provider stated thus:The WGs played an extraordinary role in increasing the number of pregnant women who come for ANC services. In the last three years, more women have sought services at this facility. You know, women in the village do not think it is important to go to a health facility, especially in the 1st trimester, especially if one is feeling well. We have been involved in this project and recorded significant changes in women's attitudes as more and more attend ANC voluntarily and without expecting a looming health challenge .Participants articulated an apparent increase in the number of pregnant women who started ANC visits during the first trimester, at the 12When I reported to this village during my first appointment, I received many complaints regarding women who attended ANC very late. These days, however, things have changed for the better. I can now stay even two months without hearing such complaints .Village leaders reported having witnessed similar changes in their respective villages; as one village leader rightly put it:Since we started sensitising communities, much has been witnessed regarding the early attendance of ANC. Our approach of identifying pregnant women who have not attended ANC on time and accompanying them to the facility has changed everything. So, we have reasons to celebrate .During FGDs, participants echoed the same views regarding the changes they had witnessed:The revelations from the participants above were in congruence with evidence from health facilities. As indicated in Fig. Findings from the study revealed an increase in the number of pregnant women who completed four ANC visits. It was revealed that as many pregnant women started ANC on time, they continued to attend subsequent ANC clinics. Additionally, it was reported that sensitisation meetings through folk media underscored the importance of completing four ANC visits and the risks associated with failing to complete all the visits. The data extracted from the facility registers indicated that the percentage of pregnant women who completed 4 or more ANC visits increased by 11% and 29% in Kilolo and Mufindi districts, respectively, as Fig. Indeed, at my facility, I have visibly witnessed an increase in the number of women completing all four visits and above. There is a clear difference between the time before the implementation of the intervention and after the intervention. The sensitisation of the communities through public meetings, some of which I happened to attend, has contributed to the increased number of pregnant women who now complete four visits at this facility .Evidence from the health facilities further revealed that of all ten health facilities, seven showed a positive increase of pregnant women completing four or more ANC. In contrast, two health facilities did not record any changes in the number of women who completed four ANC visits. In particular, the facilities that recorded the highest increase in ANC visits were Itungi in Kilolo District, with a 37% increase, and Kibengu in Mufindi District, with an increase of 35%. In congruence, during interviews, participants reaffirmed the reported changes as stated by one of the participants;Of course, there was a tendency of slumbering among pregnant women when it came to the completion of all four visits. But our efforts have enabled them to see the necessity of accomplishing all recommended visits. Throughout the meetings, we used to inform the community members about the risks pregnant women might face if they did not complete four visits. As we kept disseminating this health message in this village, attitudes kept transforming .In support of this view, WG members reiterated during FGD sessions that the WGs approach to the implementation of interventions revitalised pregnant women to complete four ANC visits. This was elaborated by one WG member thus:Men's involvement in MCH was said to have had positive consequences for ANC uptake. Specifically, it facilitated increased knowledge of prenatal and postnatal danger signs as well as family planning methods. Ultimately it decreased the barriers related to gender and culture in embracing MCH services. In addition, as part of the strategies for the Prevention of Mother to Child Transmission (PMTCT), couples were expected to participate in HIV/AIDS counselling and testing during the first ANC visit. This is one way of encouraging and promoting male involvement in MCH. Notably, one of the objectives of the IMCHA project was to improve male involvement in PMTCT services. Findings from the facility register revealed that the number of couples participating in PMTCT services increased by 5% and 13% in Kilolo and Mufindi districts, respectively. Figure Our presence as male champions during the sensitisation meetings and in other informal gatherings inspired our fellow men to start accompanying their partners to health facilities as something normal. The more we spoke to them about the importance of accompanying their partners, the more their attitudes changed (IDI with MC MDC).As captured in Fig. Much has been evidenced since the implementation of the interventions. For example, the shyness among men to accompany their partners that we used to witness in the past has relatively changed. And the complaints I used to get from healthcare workers over men who don't accompany their partners are also diminishing (IDI with VMT KDC).Similarly, Village Management Teams complimented the views of male champions views as said by one member;For the first time at our facility, we started witnessing many clients coming for PNC services. However, further improvement is still needed. Previously, mothers who came were more interested in vaccination for their newborn babies only .Receiving postnatal care (PNC) within 48 h is important for preventing maternal and infant deaths. This study tracked changes in the utilisation of PNC services. An analysis of quantitative data revealed that at least 95% of women in the intervention villages received PNC within two days after birth. Data showed further that PNC increased by 14% (from 36 to 51%) in Kilolo District and 31% (from 33 to 64%) in Mufindi District. Such changes were also echoed in the IDIs and FGDs conducted with health workers. During interviews, one of the health workers had this to say regarding the increased use of PNC services;In the public meetings, Women groups identified the challenges related to the women's use of modern family planning methods as one of the key issues affecting the proper uptake of MCH services. It was revealed that women in the intervention villages were not abiding by proper birth spacing, a situation locally referred to as "Kufudikira” in Hehe and Bena languages. As such, WGs strategies focused more on sensitising the community to make use of modern family planning methods. Findings from the study revealed that given the intensive sensitisation approaches, there was a significant improvement in the uptake of family planning methods. Data from the facility registers in Kilolo and Mufindi districts recorded an increase in the number of women who started using family planning methods. This is depicted in Fig. We are now experiencing increasing demand from women wishing to use FP methods more than before. This is also because I have personally participated in sensitisation meetings where we discussed the importance of FP with community members. The good thing is that most of the WGs members have also been role models since those not using FP are now using some methods .Findings suggest that the use of modern contraceptives increased by 31% (from 50 to 81%) and 24% (from 49.5% to 73.4%) in Kilolo and Mufindi Districts, respectively. In addition, qualitative findings from IDIs and FGDs attested to an increase in the number of women who used FP. This was attested to the increased number of women who requested health workers to initiate FP for them compared to the previous situation. This was verified by one health worker thus:As the implementation of the interventions gained momentum, other impacts beyond statistical outcomes were revealed. These impacts revolved around the changes experienced at the entire community level, attitude changes among health workers, and empowerment among the implementers of the interventions, as delineated below.During interviews and FGDs, participants reaffirmed increased awareness among community members about MCH services, contrary to the situation before the implementation of the interventions. Participants were of the opinion that the number of people who got information through public meetings and home visitation kept increasing. As such, participants articulated different views, which were clear indicators that the awareness of matters pertaining to MCH had increased to a great extent. The implementers of the interventions testified that their understanding of MCH issues increased after their active engagement in implementing the designed strategies. For example, they started to understand the risk associated with the reluctance to follow all prescribed guidelines, which became a starting point for them. In the same vein, the implementers of the intervention explained further that they managed to assist teenage girls who happened to be at school reasonably well. This was facilitated by using the knowledge and understanding they had gained as they participated in implementing the interventions.“We were called not once, not twice to different households to solve ANC issues (FGD with WG member in KDC)". The belief that WGs were able to solve different community issues proves how the community acknowledged their roles. This was followed by the community members' appreciation of the role played by the implementers of the interventions in solving health challenges, especially regarding MCH issues. For example, during FGDs, one of the WG members said, community members desired for the project to have started earlier, they would have benefited a lot more. It was also reported that community members also referred teenage girls who got pregnant to health facilities for ANC services.Secondly, community members started recognising WGs as an integral part of improving MCH services in their respective jurisdictions. Participants reported that as they continued to implement the interventions, community members got used to calling WG members to visit their households to solve their health problems as well as non-health issues, including gender-based violence. Reinforcing this, one participant attested, I highly appreciate the roles played by the implementers of the interventions. Many community members are now taking steps to come to the facility for ANC services. Through the implemented interventions, every community member knows the dos and don'ts when pregnant .The third indicator of increased awareness and knowledge was the increased number of community members who attended sensitisation meetings. It was said that initially, only a few community members participated in the meetings. But as the information about the presence of WGs circulated, the number of attendees in the meetings increased. This was coupled with the increased readiness of community members to inform WGs about pregnant women who had not attended MCH services. This went hand in hand with community members informing WGs about teenage girls who got pregnant and never visited any health facility for ANC services. Overall, participants associated the increased number of community members utilising MCH services with a high level of awareness among the community. Interviews with participants emphasised that instilling awareness in the community simplified the role of health workers who provided MCH services. One health worker succinctly put it:An analysis of interviews revealed changing patterns of behaviour among health workers who formerly used rude language. Participants disclosed that before the implementation of the interventions, some health workers used to portray a negative attitude towards pregnant women who sought MCH services. First, it was revealed that health workers participated in training, meetings and workshops at different times during the implementation of the interventions. Findings showed that community members started observing changes in the provided services after a series of meetings. This went hand in hand with the strengthening of Health Facility Governing Committees (HFGCs) in all intervention villages. The participation of HFGC in training and sensitisation meetings increased the awareness and understanding of their roles in the whole MCH continuum of care. As such, HFGCs could now closely follow up on all health service provisions, including MCH services.“We got a platform to meet with health workers several times and informed them about community perceptions on the provision of MCH services” . It was revealed further that health workers increased their commitment to the provision of MCH services compared to the situation before, as reinforced by one of the village management team members:Healthcare providers have improved the way they handle their clients. As a result, there has been a drastic drop in the number of community members who come to my office complaining about mistreatment. As of now, health workers are aware of the sensitisation meetings conducted monthly in our hamlet to discuss not only issues of the community but also how health workers handle clients .The second reason for the change of attitude was fueled by health workers' understanding that women group members were aware of the challenges that pregnant women encountered as they sought MCH services. It was revealed that WGs were capable of engaging health workers on these issues, as illustrated by some women during FGDs thus: As supervisors, after being selected, we were trained to communicate with fellow women to convince them to utilise all the required services as pregnant mothers and those who had given birth. The training has been really helpful. Since our recruitment over four years ago, I have managed to closely and cordially interact with health facility workers and cordially with village leaders. I even spoke with the regional medical officer about our work when he visited the community. (IDI with WGS in KDC).The implementation of WG interventions in 20 villages resulted in the empowerment of women group members. During FGDs with women groups, it was revealed that through participation in the implementation of interventions, they built their capacity to deal with many challenges they could not handle before the interventions. Findings suggested that such empowerment was attained mainly through different activities during the implementation of the interventions. It was revealed that WGs participated in a cycle of four phases that covered eight (8) meetings in the intervention villages. The meetings encompassed WG identifying priority MCH problems as well as prioritising and strategising ways to solve the MCH problems. Through these meetings, WGs got the opportunity to interact and discuss different MCH issues, which broadened their horizons of understanding the causes and impacts of MCH issues and how to address them. For example, during the IDIs with WGS, one participant uttered:It was further revealed that WGs also participated in the review meetings and workshops that allowed them to interact and socialise with stakeholders from the village to the regional level. In all these meetings, WGs were allowed to present and discuss their experiences while implementing the interventions. Through these processes, WGs got the opportunity to interact and socialise with community members, family members, district, and regional health managers, and researchers from the University of Dar es Salaam. This, in turn, broadened their skills, self-esteem, courage, confidence and knowledge of WGs, which enabled them to address MCH issues, among others. The analysis of documents, interviews and FGDs revealed different aspects in which WGs experienced empowerment before and after the intervention, as illustrated in Table "This research has empowered women in this village. Previously, it took a lot of work for women to speak in meetings. But now, we see women speaking confidently and even asking questions in meetings. This is a great change .Some village and ward leaders also confirmed that participation in the women's groups had empowered women. It was noted that women could confidently speak in front of men in meetings. Specifically one participant noted;Women have now been empowered. I am surprised to see many women now speaking in meetings. We thank the IMCHA team for building confidence of these women” .“Another respondent added:This study examined the effects of community-based interventions in Kilolo and Mufindi districts. The focus was mainly on the changes in intermediate outcomes, such as the uptake of ANC, PNC and FP following the implementation of the IMCHA project. The study findings demonstrate that CBIs through WGs can improve MCH services, as evidenced by an increased percentage of women who started ANC within the first trimester and those who completed four or more ANC visits. Other observed positive changes include the increased number of couples who sought PMTCT services, the increased number of those who received PNC within 48 h as well as the increased uptake of modern FP methods. The effect was also experienced by the implementers of the interventions, who expressed an increased level of awareness and knowledge on matters pertaining to MCH, change of attitudes among health care providers and empowerment of women group members.The findings are congruent with studies in other LMICs that have demonstrated that CBIs are effective in increasing the uptake of maternal and child health services. For instance, in a systematic review by Sarkar  conducteKadumbashree, reported similar findings [The contribution of CBIs may not be proven by only reflecting on statistical measures but also by qualitative changes. As  assertedfindings . Specififindings . Furtherfindings . Membersfindings . Scholarfindings , 50.Crafting and designing interventions is critical for the success of the CBIs through women's groups. As revealed in the implemented interventions in Iringa Region, the WGs passed through four phases that enabled them to design and implement several strategies, namely the use of community sensitisation meetings, household visitations of pregnant women, engagement of male champions, engagement of health workers, health facility governing committees, and community gatekeepers Notably, in health services, interventions that focus on holistic improvement of the lives of women yield positive and sustainable result. In addition, evidence has shown that the use of income-generating activities has the potential to increase the retention of members beyond the project grant period and address poverty , 52. ThiWhile it is important to attribute the overall improvement of MCH uptake in the intervention villages to the implemented WG interventions in the study area, it is also worth appreciating the government efforts exerted during the implementation of the interventions, specifically from 2015 to 2020. In this period, the government increased investment in the health sector, including the construction of health facilities in Mufindi and Kilolo districts , 35. In This study aimed at exploring the impacts of CBIs through WGs in rural settings, specifically in Iringa, Tanzania. It has been demonstrated that implementing CBIs through WGs in resource-constrained countries is an important strategy that can help improve MCH services. Impressive results were seen in MCH services in several villages. Furthermore, the study has delineated the impacts beyond the continuum of care of MCH services, including community empowerment and increased knowledge. This is very important if LMIC countries aspire to improve MCH, as espoused in SDGs 3.1 and 3.2. Given the potential benefits of CBIs through WGs, the study recommends that the government of Tanzania and other LMICs should contemplate scaling up the intervention, mostly in rural areas where uptake of MCH is persistently low. It is thus advised further that for a better and smooth implementation of the interventions, there is a need to prepare a manual or guidebook that will provide guidance to regional and district health managers on how to implement WG interventions. It is further recommended that the government ensures that districts and health facilities set aside budgets in their annual health plan to support CBIs through WGs, especially when community members demonstrate their readiness to implement the interventions. However, the effective participation of community members in all phases of the design and implementation of the intervention is of utmost importance.Additional file 1.