The Health Promotion Strategy in Preventing Under The Red Line in Growth Toddlers at Kuta Baro District

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Jurnal Sains dan Aplikasi April 2023 eISSN 2656 – 8446

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The Health Promotion Strategy in Preventing Under The Red Line in Growth Toddlers at Kuta Baro District

Diza Fathamira Hamzah ¹* Sri Rosita ²

Cut Juliana ³

1,2,3 Facultas Kesehatan Masyarakat Universitas Serambi Mekkah, Banda Aceh

Corresponding author e-mail :[email protected]

ABSTRACT

Under the red line is one illustration of malnutrition in toddlers. This can be prevented by strengthening health promotion as one of the prevention efforts. This study aims to determine the relationship between health promotion strategies and the prevention of under-fives under the red line. This type of research is descriptive -analytic with a survey design. The population in this study was 136 people with a sample of 58 mothers under five who were drawn using the accidental sampling method. Data collection was carried out using a questionnaire that had been designed by the researcher. Data analysis was performed univariately and bivariately using the chi- square test with 95% confidence intervals. The results showed that there was a significant relationship between advocacy (p value = 0.001), atmosphere building (p value = 0,03) and community empowerment (p value = 0.001) and prevention of under-fives under the red line. It is suggested to the Aceh Besar District Health Office to increase health promotion efforts in preventing under the red line by conducting training for cadres of service post integrated on a regular basis so that health promotion activities can be carried out optimally, besides that it is necessary to establish a under the red line budgeting policy for prevention of 10% of the village goverment funds.

Keywords : Health Promotion, Nutritional Status, Public Health, Toddler, Malnutrition.

INTRODUCTION

Nutritional problems in children, especially toddlers, need to be handled properly because of the potential for high mortality rates. World Health Organization (WHO) states that more than half of infant and toddler deaths are caused by nutritional conditions. Children who are malnourished have a risk of dying 13 times greater than normal children. WHO estimates that 54% of the causes of infant and toddler deaths are based on malnutrition.

Meanwhile, according to The United Nations Children's Fund (UNICEF) in 2012, an estimated 165 million children under the age of five worldwide are stunted.(Brár et al., 2020).

Indonesia is a country that still has several nutritional problems such as undernutrition, stunting and obesity. Nationally, based on the 2018 basic health research, the prevalence of malnutrition status in children aged 0–59 months according to the weight for age index in 2013 was 19.6%, in 2018 it decreased by 17.7%, still exceeding the 2019 national medium-term development plan target by 17%( Ministry of Health of the Republic of Indonesia, 2018).

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Under the red line in growth is the condition of toddlers who experience growth retardation due to malnutrition so that when they are weighed, their weight are below the red line curve in the maternal and child health handbook. The Maternal and Child Health Book (MCH) is a book that contains a growth curve for toddlers based on the anthropometric index of weight for age which functions as a tool to monitor the health and growth of toddlers, not only that, notes in the maternal and child health book showed the nutritional status of children (Ningtyias et al., 2020).

Nutritional problems, especially under the red line in growth case, can be prevented, through health promotion efforts. Health promotion is an effort to improve the ability of the community through learning from, by and for the community, so that they can help themselves, and develop their activities by community-based, according to socio-culture and supported by health-oriented public policies. Health promotion aims to prevent health problems, maintain and improve the public health degree, which can be seen by the toddlers’

nutritional status. Toddlers are the next generation who have the ability to be developed in continuing nation development. The nutritional problem in Indonesian toddler is currently facing the growth problem, namely whose weight is below the red line in maternal and child health book. Body weight which is below the red line describes a state of severe malnutrition caused by low consumption of energy and protein from daily food and occurs over a long period of time.(Gemechu et al., 2021).

Various strategies have been developed for preventing and overcoming the problem of malnutrition and undernutrition which is found by implementing prevention efforts through a comprehensive approach, which prioritizes health promotion (advocacy, atmosphere building and community empowerment), prevention efforts in the form of treatment activities, and recovery for sufferers toddler with under the red line (Saaka et al., 2021).

The percentage of under the red line among toddlers 0-59 months in Aceh is 8.4%.

The area with the highest percentage of under the red line toddlers was Simeulue District with 84%, followed by Bener Meriah 31% and Gayo Lues 21% under the red line cases from 2011 to 2015 in Aceh Besar District have decreased, and increased again in 2018 with the discovery of 7 toddlers who are under the red line and all of them had get treatment(Aceh, 2019).

Kutabaro District is one of the areas in Aceh Besar District with a large number of toddlers. The number of toddler weighed in Kuta Baro District increased from 67.99% to 71.2% or 1.650 toddlers weighed from 2.318 toddlers in the Work Area of the Kuta Baro Public Health Center, Aceh Besar District. The number of malnourished toddlers as many as 129 cases. Based on the report from the Kuta Baro Health Center, the highest number of under the red line toddlers were in Lambro Bileu Village as many as 19 cases of 51 villages in the Working Area of the Kuta Baro Public Health Center.(Rahmayanti et al., 2021).

The results of the researchers' interview with 20 mothers of toddlers in the working area of the Kuta Baro Public Health Center stated that there were no regulations from the sub-district or an appeal from the village head that required mothers to bring their toddlers to be weighed at the service post integrated. Beside, the mother of the under the red line toddler also said that she had never received counseling about nutritional management for toddlers. In addition, community participation in weighing toddlers at service post integrated is less enthusiastic. It is showed that the health promotion strategy has not been done effectively. The nutrition officer at the Kuta Baro Public Health Center continues to suppress cases of under the red line toddlers by distributing supplementary feeding. In fact, supplementary feeding is not the only solution in dealing the problem of malnutrition

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45 toddlers. Therefore, it is important to analyze the health promotion strategy in preventing under the red line toddlers In The Work Area Kutabaro Public Health Center.

METHOD

This research is an analytical research with a survey design. This research was conducted in Lambro Bileu Village, Kuta Baro District, with the consideration that the location of this research was based on Lambro Bileu Village being the largest area with under the red line Toddlers in June 2022. This research was conducted in June 2022. The population in this study were all mothers who have toddlers in Lambro Bileu Village, Kuta Baro District, Aceh Besar District, as many as 136 people. Sampling was carried out using the Slovin formula as follows.

n = ^𝑁

1+𝑁(𝑑)² = ¹³⁶

1+136(0,1)² = 57.6 ≈ 58

Sampling was carried out by accidental sampling, which is in this research, the researcher waited in the village and every mother who had a under the red line toddler who was found would be directly interviewed with inclusion criteria including: toddlers are underline toddlers in Lambro Bileu Village, healthy mothers and toddlers, and willing to be response.

Data collection is done by using primary data and secondary data. For under the red line toddler data, it is obtained through weighing data for toddlers at service post integrated (secondary data). The health promotion strategy in this study was measured based on three variables, namely: advocacy, ambiance development (government community and private support), and community empowerment. The evaluation of the assessment of health promotion strategies in overcoming under the red line toddlers was measured by using questionnaire that had been designed by the researcher. If the interview results are worth above the value set by the researcher in each variable, then the results will be categorized as good and vice versa.

RESULT

The incidence of under the red Line toddlers in Lambro Bileu Village was motivated by various factors, including the following.

1. Univariate analysis a. Level of education

A person's level of education greatly influences a person's ability to remember and analyze the information obtained. The education level of mothers in this study can be seen in the Table 1.

Table 1 Education Level of Mothers Under The Red Line Toddlers

Level of education n %

Base 37 63,8

Advanced 21 36,2

Amount 58 100

The results showed that the majority of under the red line toddler’s mothers had basic education (elementary and junior high school) as many as 37 people (63.8%).

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b. Under The Red Line Toddlers

The large number of under the red line toddlers illustrates the condition of fulfillment of nutrition that is not achieved in an area. The results of the study showing can be seen in the Table 2.

Table 2 Number of Under The Red Line Toddlers in Lambro Bileu Village

Under The Red line

n %

Yes 39 67,2

No 19 32,8

Amount 58 100

Based on the research results listed in table 2, it shows that the majority of toddlers in Lambro Bileu Village are classified as under the red line (67.2%), therefore several health promotion efforts are needed to deal with this problem.

c. Government Advocacy

Table 2 shows the number of under the red line toddlers. In this case, it can be said that Lambro Bileu Village must work hard to overcome this problem. For this reason, support from the government is needed in terms of health advocacy as a form of support in terms of the village government's approach and motivation regarding under the red line alleviation which can be manifested in material and non-material forms. The results of research on government advocacy can be seen in the Table 3.

Table 3 Government Advocacy in Handling under the red line Toddlers Government

Advocacy

N %

Great 27 46,6

Poor 31 53,4

Amount 58 100

Based on the results of the research listed in table 3, it shows that the advocacy efforts of the Lambro Bileu Village government are still relatively poor, which shows that the majority of under the red line toddler’s mothers think that the village government is still lacking firmness in issuing certain policies in responding to nutritional problems, especially BGM problems (53.4 %).

d. Ambiance Development (Government Support)

Fostering the atmosphere is a concrete action to create a social environment that is conducive to the adoption of nutrition treatment. The results of research on atmosphere building can be seen in the Table 4.

Table 4 Fostering the Ambiance Development of Under The Red Line Problem Management

Ambiance Development

n %

Great 24 41,4

Poor 34 58,6

Amount 58 100

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47 Table 4 shows that the majority of under the red line mothers in Lambro Bileu Village feel that efforts to foster an atmosphere are still weak (58.6%).

e. Community Empowerment (Counseling)

Community empowerment is a form of government motivation in providing information and assistance so that they are able to deal with nutritional problems. The results of research on community empowerment can be seen in Table 5.

Table 5 Community Empowerment Activities About Under The Red Line Toddlers

Community empowerment

n %

Great 25 43,1

Poor 33 56,9

Amount 58 100

Table 5 shows that the majority of under the red line mothers feld lack of community empowerment (56,9%) in the form of counseling conducted by the Lambro Bileu Village government in conveying good nutrition materials for under the red line prevention.

2. Bivariate Analysis

a. Relationship between Advocacy and Prevention of Incidence of Toddlers Under The Red Line

One of health promotion efforts is to carry out health promotion efforts in the form of nutrition advocacy. The results of research on the relationship between nutrition advocacy and the incidence of under the red line can be seen in the Table 6.

Table 6 Relationship between Nutrition Advocacy and the Incidence Of Under The Red Line Toddlers

As we can see in the Table 6 above, it can be defined that 31 respondents sated advocacy (government policies) were not optimal, it was found that 19 respondents (61.3%) had under the red line toddler and 12 other respondents (38.7%) with toddlers did not under the red line. The results of the chi-square test obtained P-Value of 0.001. It showed that there is a relationship between advocacy (Government Policy) and the prevention of under the red line toddlers (p <0.05).

b. The Relationship between Ambience Development (Government Support) and the Under The Red Line Toddler Incident

Another health promotion effort is build an ambiance development (government support) in preventing the incidence of under red line toddlers. The results of research on ambiance development with the incidence of under the red line toddlers. It can showed in this Table 7.

No. Advocacy

Under The Red Line p- values

Yes No

n % n %

1. Great 20 74,1 7 25,9

0.001 2. Poor 19 61.3 12 38,7

Total 39 67,2 19 32,8

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Table 7 Relationship between the Ambiance Development and the Incidence of Under The Red Line Toddlers

Based on table 7, it can be defined that of the 34 respondents who said counseling was not good it was found that 22 respondents (64.7%) had under the red line toddlers and 12 other respondents (35.3%) did not have. The results of the Chi-square analysis showed that the p-value 0.03. It showed that there is a relationship between government support and under the red line prevention (p<0.05).

c. The Relationship between Community Empowerment and Under The Red Line Toddler Prevention.

Community empowerment plays an important role in terms of improving community health status, especially nutritional status. Based on the research results, the relationship between community empowerment and the incidence of under the red line toddlers can be seen in the following table.

Table 8. The Relationship Between Community Empowerment and the Incidence of Under The Red Line Toddlers

Table 8 shows that of the 33 mothers of toddlers who stated that community empowerment was not good, it was found that 22 people had under the red line toddlers (66.7%) and 11 people did not have (33.3%). The results of statistical tests using the chi- square test found that the p-value was 0.001, so it can be stated that community empowerment has a relationship with under the red line toddlers prevention (p <0.05).

Discussion

Univariate analysis

Table 1 showed that most of the mothers who have under the red line toddlers have basic education (63.8%). Education is one of the influential predisposing factors in the growth and development children. In general, mother’s educational level is the basis to receive and analyze the information. So that the information can be applied in their daily life eventual. Therefore, the importance of the mother's educational level in maintaining health and providing balanced nutrition so that the child's growth and development process can be optimal (Putu et al., 2022).

No.

Ambiance Development (Government Support)

Under The Red Line P-value

Yes No

n % n %

1. Great 17 70,8 7 29,2

0.03

2. Poor 22 64,7 12 35,3

Total 39 67,2 19 32,8

No. Community empowerment

Under The Red Line

p- values

Yes No

n % n %

1. Good 17 68.0 8 32.0 0.001 2. Not good 22 66,7 11 33,3

Total 39 67,2 19 32,8

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49 The number of mothers' education levels that are still classified as basic education can be used as a benchmark for the incidence of under the red line in Lambro Bileu Village. Table 2 shows that most of the toddlers in Lambro Bileu Village belong to the lower red line (67.2%). The incidence of under the red line is the condition of malnutrition in an area. The point of determine under the red liner toddlers is based on indicators of weight for age. The incidence of under the red line has not been able to define significantly whether the toddler is experiencing malnutrition or stunting. However, the incidence of under the red line in toddlers is the starting point for nutritional problems or malnutrition (Princess et al., 2020).

The number of incidents of under the red line toddlers should ideally be a concern for the local government to make various efforts to overcome this problem. The efforts to overcome the problem of under the red line can be done with nutritional advocacy activities. Nutritional advocacy is a form of support or commitment in the health sector, such as maintaining a clean and healthy lifestyle. Table 3shows that the majority of under the red line toddler mothers feel that the government's advocacy activities in terms of issuing policies regarding the prevention of under the red line incidents are classified as not good (53.4%). Based on this, it can be said that there is a lack of support from stakeholders in the form of issuing policies related to strict sanctions regarding the implementation of service post integrated.(Hidayat, 2018).

The efforts to tackle nutritional problems can be carried out with ambience development activities. Fostering the ambience is an activity that involves other figures/individuals who have an important role in society to change nutritional behavior to be more optimal (Fadjriah & Krishnasari, 2020). The results of the research listed in Table 4 showed that most mothers who have under the red line toddlers feel that efforts to build an atmosphere by stakeholders, in this case cadres, village head, and health workers, have not done good ambience development (58.6%).

Health promotion will not be maximized if it is not accompanied by the implementation of community empowerment, especially in the form of counseling which aims to increase public knowledge and awareness, especially about the importance of monitoring body weight and good nutritional intake for toddlers. Table 5 shows that most mothers who have under the red line toddlers feel that there is still lack of community empowerment activities in the form of counseling about nutritional intake and weighing (56.9%).

Bivariate Analysis

Advocacy Relationship in Prevention Under The Red Line Toddlers

Based on statistical tests using the Chi-Square Test, the P value is 0.001. This showed that there is an advocacy relationship (Government Policy) in preventing under the red line toddlers in Lambro Bileu Village. Most of the respondents stated that advocacy (government policy) was not good in Lambro Bileu village. This showed that according to respondents the government or health workers rarely provide socialization related to under the red line toddlers prevention more specifically in Lambro Bileu village. Advocacy (government policy) is a strategic and planned effort or process to gain commitment and support from related parties (stakeholders), namely formal community leaders (for example the government; village head, district head, health office, mayor, Regional People's Representative Assembly, related agencies) which are generally government policy makers or government funders can be measured from the availability of policies (regulations, instructions), facilities/infrastructure, human resources, socialization, and completeness of

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data, funds and others that support under the red line toddlers prevention activities in toddlers (Khumairah et al., 2022).

The results of observations and interviews conducted with several mothers of under the red line toddlers showed that so far there has only been provision of supplementary food and formula milk for their toddlers but it was given only once by the officers, then until now never again. The results of interviews that researchers conducted with the Kuta Baro Health Center said that government policies that specifically deal with under the red line toddlers problems are integrated with the prevention of malnutrition. So far, the only government policy is the Aceh Besar Regent Regulation Number 31 of 2020 concerning the prevention and handling of stunting in Aceh Besar District. Another finding that the researchers found was that the policy makers in the village did not provide good direction to the community about the benefits of the service post integrated so that the community was interested in coming regularly to weigh their toddlers (Hidayat, 2018).

Other findings were obtained by researchers that there were many advocacy activities (government policies) carried out by program makers, in this case the Aceh Besar Health Service and Kuta Baro Public Health Centers, but overall they were not optimal because even though there was commitment from the local government but not yet produce a local regulation that binds the community to participate the prevention of under the red line toddler, such as regulations regarding mandatory weighing for every toddler, regulations on mandatory exclusive breastfeeding. Regulations or instructions should be a firm form from the local government so that the community would participate in preventing under the red line toddlers (Armalia Reny Wijayanti Ananda, 2022).

Relationship Development (Government Support) in Prevention Under The Red Line Toddlers

Based on statistical tests using the Chi-Square Test, P. Value of 0.03 was obtained.

This showed that there is a relationship of atmosphere building in the prevention of under the red line toddlers. Based on findings in the field and interviews with respondents so far, health workers and cadres of service post integrated are only waiting for mothers with toddlers to visit the service post integrated or public health center. Until now there has been no further intervention to await the visit of mothers under five to the service post integrated.

So far, whoever comes to the mother of the toddler is the one who is given the service, whereas if there are mothers of toddlers who do not come consecutively as long as the service post integrated is not a problem (they are not asked or seen at their home).

Health workers can be role models in attitudes and behavior. Therefore, the knowledge, attitude, and behavior of health workers who serve in public health center must be completely consistent with the services provided. For example: friendly (not impressed by stress), not smoking, maintaining hygiene or personal hygiene and health, and so on (Fadjriah & Krishnasari, 2020).

The importance of government support in this case aims to create opinions or a social environment that encourages individual members of society to carry out the introduced behavior. Someone will be motivated to do something if the social environment for example family at home, people who are role models/idols, social gathering groups, religious assemblies, and even the general public has a positive behaviour opinion (Yanti & Alkafi, 2020).

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51 Community Empowerment Relations (Counseling) in Prevention of Under The Red Line Toddlers

Based on statistical tests using the Chi-Square Test, a P value of 0.001 was obtained, this indicates that there is a relationship between counseling in the prevention of under the red line toddler. The findings is based on the observations of researchers show that the low level of interest from mothers under red line toddler from the results of interviews with respondents caused by the the opening hours of service post integrated which are only once a month, and sometimes parents (mothers under five) do not have time to bring their toddlers because of work or other activities. In fact, many toddlers do not come or are weighed at the service post integrated because there is an assumption that the service post integrated is the only one place for immunization for these toddlers, so that if the toddler has finished his immunization period (9 months), they will never come to the service post integrated again to be weighed. This condition causes the nutritional status of many toddlers to not be monitored, because parents do not realize that their toddlers already have nutritional problems, so the toddlers cases are hard to find. In addition, the nutrition post in the village has not been established and the posyandu cadres are also less active and the public health center staff assigned to the village area also live in other villages and are rarely in places where residents can visit when they need services.

Ideally, the community empowerment that is carried out is in the form of community- based health units activities that have been made together with the community and community leaders in the work area such as having cadre of service post integrated facilities.

Community empowerment is the process of providing information continuously and continuously following the progress of the target, as well as the process of assisting the target, so that the target changes from not knowing to knowing or being aware (knowledge), from knowing to wanting (attitude), and from willing to being able to carry out behavior.

introduced (practice) (Sugianti, 2020).

Conclusion

The implementation of advocacy, ambience development, and community empowerment, have a relationship with the incidence of under red line toddlers (p<0,05). It means that health promotion strategy in preventing under the red line toddlers in Lambro Bileu Village has not been felt by the community, especially mothers of under the red line toddlers. Therefore, it is recommended to the Kuta Baro Public Health Center to improve the quality of health promotion especially malnutrition prevention in order to improve community participation by utilize health facilities to prevent the nutritional problems.

Beside, it is important to budget policies for the prevention of malnutrition especially under the red line toddlers from the village government funding so that the number of under the red line toddlers would not be increase in every single year.

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