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IMPORTANCE OF INCREASING KNOWLEDGE OF EXCLUSIVE BREASTFEEDING AS AN EFFORT TO PREVENT STUNTING
1Ratna Dian Kurniawati, 2Afifah Nurul Salsabila, 3Supriyatni
1,2,3Public Health Study Program, Faculty of Health Sciences. Bhakti Kencana University Soekarno Hatta St., Number 754, Penyileukan, Bandung, West Java
Email: [email protected] ABSTRACT
Exclusive breastfeeding is a perfect source of nutrition for babies containingall the nutritional components to meet the baby health in ideal baby growth and development. The low level of exclusive breastfeeding can have an impact on the decline in the baby's immune system and health. The phenomenon is that not all postpartum mothers want to give exclusive breastfeeding. Some refuse on the grounds of working, spoiling their appearance, breast milk does not come out, and other reasons related to myths about breastfeeding. This study aimed to determine the effect of leaflet media counseling on knowledge of exclusive breastfeeding for infants in Cisaranten Kidul Village. The method in this research is quantitative with a quasi-experimental design. The research sample was 50 mothers with babies divided into twogroups. Sampling technique using Purposive Sampling. Data analysis through Wilxocon. The results showed an increase in knowledge before and after being given counseling by 13.45%. The Wilxocon test analysis is 0.00 < 0.05, which means that leaflet media counseling has an effect on increasing knowledge of exclusive breastfeeding. Efforts to increase understanding of exclusive breastfeeding must continue to pursue to increase the coverage of exclusive breastfeeding as an indicator of clean and healthy living behavior and prevent stunting for a stunting- free generation. There is a need for cross-program and cross-sector collaboration that enhances partnerships in increasing knowledge about the importance of exclusive breastfeeding.
Keywords: Knowledge, Stunting Free Generation, Exclusive Breastfeeding, Leaflet Media
INTRODUCTION
Exclusive breastfeeding can reduce infant mortality. It Indonesia, is ranked in sixth place in ASEAN countries, which is 35/1,000 of the total births. Government Regulation No. 33 of 2012 states that breastfeeding is allowed in infants within 6 months by not replacing it with additional food or other drinks (President of the Republic of Indonesia, 2012). The perfect source of nutrition for babies is exclusive breastfeeding. It contains all the nutritional components needed to fulfill the baby’s health as an effort to comply with the ideal conditions for the growth and development of the baby. Exclusive breastfeeding is given to infants from 0 to 6 months. Various sources recommend that exclusive breastfeeding can continue until two years. The World Health Organization (WHO) targeted that in 2025 the achievement of Exclusive Breastfeeding will be up to 50%. This phenomenon occurs in Latin America, and the Caribbean is 32%, Central Africa is 25%, East Asia is 30%, South Asia is 47%, and developing countries are 46%. Globally, only 40% of the babies got exclusive breastfeeding, which is still below the target. The Central Statistics Agency in 2018 stated that the highest exclusive breastfeeding in Indonesia was in North Maluku province, 64.28,% and the lowest was in North Sumatra, 33.62%. In 2019, the highest was in Papua province, 79.05,% and the lowest was in Bangka Belitung Islands province, 39.64%. In 2020 the highest exclusive breastfeeding was in the Special
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Region of Yogyakarta province, 78.93%, and the lowest was in Central Kalimantan province, 52.98%
(Central Statistics Agency, 2021).
Breast milk has many advantages for babies, providing good growth and development.
Exclusive breastfeeding is an important thing and is one of the indicators of Perilaku Hidup Bersih dan Sehat (PHBS), and it can prevent stunting. The causes of stunting in children are body height and maternal education, premature birth and birth length, exclusive breastfeeding for six months, and household socioeconomic status (Sutriyawan et al. l 2020). Breast milk contains very useful antibodies and can save babies from the risk of fungal, bacterial, viral, and parasitic infection. Its content has a composition according to what the baby needs, especially for their intelligence level, prevents them from allergies due to formula consumption, and consuming breast milk is a form of love from mother to babyThe advantages of breastfeeding are also will feel in adulthood period; reducing the risk of developing hypertension, cholesterol, obesity, and type 2 diabetes. Babies who do not receive exclusive breastfeeding are susceptible to severe diseases such as diabetes, heart disease, and hypertension after they grow into an adult. There is also a risk of malnutrition and obesity (Yusrina and Devy, 2017). The baby, ideally, gets exclusive breastfeeding until the age of 6 months. They will experience rapid growth in both weight and height. Above six months and over, babies begin to receive Supplementary Foods as Complementary Foods for Breastfeeding. As the baby grows and develops into a toddler, the problem of eating difficulty accompanies by a decrease in the quality and quantity of breast milk (Sutriyawan et al. l, 2020).
In 2019, Exclusive breastfeeding for babies in Bandung city was 21,873, or 68.41%. The coverage of exclusive breastfeeding in Bandung city shows an increasing pattern. (Bandung City Health Office, 2019). Exclusive breastfeeding in the UPT Puskesmas Riung Bandung working area in February 2021, from a total of 219 coverage of exclusive breastfeeding, reached 48 or only 21.9%. Preliminary studies stated that they were still far from the target, which was 40% (Ministry of Health, 2021). This situation happens because not all postpartum mothers want exclusive breastfeeding, and working mothers refuse to give exclusive breastfeeding. The lack of mothers’ knowledge and understanding regarding the importance of exclusive breastfeeding for babies and the lack of family support, husbands, and health facilities affect exclusive breastfeeding. Data from UPT Puskesmas Riung Bandung for the last three years shows the fluctuating numbers. In 2018, exclusive breastfeeding recorded at 60.64%, in 2019 was also 60.64%, and in 2020 was exceeded the target, and in 2021 was decreased.
The study results on June 13th, 2021, through interviews, 33.3% of mothers did not give an exclusive breastfeeding because their breast milk did not come out on the first day of birth.Almost all mothers said they knew that in exlusive breastfeeding starting from 0 to 6 months. Information obtained that mothers can give exclusive breastfeeding with additional formula, milk, and or other food.
Nevertheless, mothers do not know exactly when is the best time to give, other than breast milk,
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especially Supplementary Feeding. All mothers stated that they only knew about exclusive breastfeeding without knowing its advantages and importance for babies aged 0-6 months.
Skinner in (Notoatmodjo, 2020) mentions that behavior is a person's reaction or response to a stimulus. Behavior arises because of the stimulus process of the organism to the reaction. Skinner stated that the theory of S-O-R (Stimulus-Organism-Response) is a stimulus to an organism, then the organism gives an answer. According to Notoatmojo, knowledge is strongly influenced by human education because the more education a human being has easier it is for humans to get access to information, and the more knowledge or information the human has. In contrast to humans with low education, the impact on the inhibition of receiving the report (Notoatmodjo, 2007). The common insight of the mother when it comes to exclusive breastfeeding for babies is proportional to the mother’s knowledge. Mothers with high knowledge, can agree to changes to protect their health. Education can encourage someone to find out experience or access information so that what is received will become knowledge (Listyaningrum and Vidayanti, 2016).
Kimati et al. said that the counseling affected the changes in mother’s knowledge and babies exclusive breastfeeding. Situros and Silalahi in 2020 also mentioned the effect of health promotion on increasing understanding of pregnant mothers about exclusive breastfeeding in stunting prevention before and after health promotion. At the same time Pusparina stated that there was a difference in expertise with leaflet media interventions on increasing wisdom. Meanwhile, Meliyanti said that there was an effect of using leaflet media on increasing knowledge through counseling by 63.5%.
Based on the description, researchers are interested in knowing the effect of leaflet media on increasing knowledge about exclusive breastfeeding as an effort to prevent stunting. By setting the objective; is to determine the impact of leaflet media on the growing knowledge about exclusive breastfeeding as an effort to prevent stunting.
METHOD
This research is quantitative with a Quasi Experiment Design. This research aims to determine the causal relationship by giving or applying an intervention or treatment to one or more experimental groups. Afterward, the treated group was compared with the control group or the untreated group (Notoatmodjo, 2018).
The population in this research were mothers with babies aged 0-6 months in Cisaranten Kidul Village, Riung Bandung Health Center working area. The minimum number of samples is 25 for the experimental and 25 for the control groups. The total number of samples is 50 of pregnant women who meet the criteria. The criteria are mothers who have babies aged 0-6 months and live in the Cisaranten Kidul Village area and are willing to be a respondent. The sampling technique used Non-Equivalent Control Control Group Design using Purposive Sampling, and the sample selection is made by determining the sample first (Sugiyono, 2019).
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Data on increasing knowledge related to exclusive breastfeeding were collected through pre- test and post-test. Posttest was taken after 3x leaflet media interventions in the experimental group. The control group is the group that is not given any intervention. To facilitate the process of intervention, communication is focused only on WhatsApp groups (WAG). Pre-test and post-test were distributed via google form link to the experimental and control groups. Data analysis is to determine the distribution of frequency and percentage, as well as bivariate analysis using the Wilxocon test because the data did not distribute normally.
RESULTS AND DISCUSSION
Based on table 1, it can see that in the experimental group that most (60%) mothers who have babies 0-6 months have a good knowledge before intervention through leaflet media, and after the intervention, there was an increase in the number of mothers with good knowledge; almost all (96%).
Based on the stages of the research process, the frequency distribution data obtained are as follows:
Table 1. Distribution Frequency of Knowledge in Experimental Group through Leaflet Media on Exclusive Breastfeeding
Total Percentage (%)
Knowledge During Pre-test
Good 15 60
Sufficient 4 16
Deficient 6 24
Knowledge During Post-test
Good 24 96
Sufficient 1 4
Jumlah 25 100
Based on table 2, it can see that in the control group, there was no change; only some of the mothers who had babies 0-6 months had good knowledge. The control group didn’t give any intervention. In the experimental group, there was an increase in knowledge after being given the intervention. There was a significant increase, and there were no more mothers with less knowledge.
While in the control group, there was no significant difference in ability because no intervention was given. The common can occur due to educational factors, lack of stimulus, characteristics of mother, personal experience, and difficulty obtaining the information. There are still many people with low education who have limited access to information. A culture that becomes a habit can also be a factor that hinder behavior change due to the rejection of information which leads to low knowledge.
Table 2. Distribution Frequency of Knowledge in Control Group on Exclusive Breastfeeding
Total Percentage (%)
Knowledge During Pre-test
Good 12 48
Sufficient 9 36
Deficient 4 16
Knowledge During Post-test
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Total Percentage (%)
Good 10 40
Sufficient 6 24
Deficient 9 36
Jumlah 25 100
Research shows that some mothers answer the question that if breast milk does not come out, formula milk should be given However, before the milk cannot come out, they can still do other ways such as more exclusive breast milk or more intensity of breastfeeding more often, lactation massage before giving formula milk. There were still many participants who answer these questions. The phenomenon of trust to health workers as providers of health informationstill has to be pursued.
Community still trusts their environment, their families, and the people who influence them. In other words, an unsupportive climate can make it challenging to increase knowledge. At this time, low education does not necessarily mean that they also have inadequate knowledge. The improvement of science and technology can be reached by all levels of society can reach the improvement of science and technology through smartphones, where information about health and others is widely available on social media from trusted sources. It can be concluded that low education is not entirely a benchmark for inadequate knowledge.
Ismawati, in her research, mentions that the use of leaflet media has four categories, namely the very effective category of 1 respondent (5%), the effective category of 11 respondents (55%), the less effective category of 7 respondents (35%), and the ineffective category of 1 respondent. (5%). The results means that the use of leaflet media effectively increasis moother’s knowledge. The results illustrate by an increase in the value of pre-test to post-test (Ismawati, 2016). In line with Merdhika, the average score before counseling was 14.87 with a standard deviation of 3.529 and after counseling the average score was 18.25 with a standard deviation of 1.945, and the p-value was 0.000. The result means that there is a difference in the level of mother’s knowledge before and after giving counseling about exclusive breastfeeding (Merdhika et al. 2014).
Knowledge, attitudes, and actions are a part of forming a behavior process. Before adopting a behavior, you must first know what its benefits are. A person can give a stimulus with health education/
counseling (Kurniawati et al., 2022). In this research, intervention through leaflet media became the right stimulus. Knowledge can increase because of the catalyst. According to Skinner, the response arises because of the stimulus. One factors that affect the level of knowledge is the information obtained from various sources, both from health promotion, print media, and electronic media (Notoatmodjo, 2020). Information as a stimulus will affect a person level of knowledge. If a person gets a lot of information, they tend to have broader knowledge (Merdhika et al., 2014). Knowledge is the result of knowing. The process of knowledge happens when someone has sensed a specific object. Sensing can be through hearing, sight, smell, taste, and touch. In general, human knowledge can obtain through the
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eyes and ears. Knowledge is a domain that has a vital role, and the cognitive domain has six levels, namely, know, understand, apply, analyze, synthesize and evaluate (Notoatmodjo, 2020).
The results of this research is not in line with Sumiati's research which states that knowledge in the intervention group has a value of: 0.135 meaning there is no difference in knowledge before and after the intervention (Sumiati, 2018).
Table 3. The Differences in Knowledge Before and After Intervention Through Leaflet Media in the Experimental Group
Ranks
N Mean Sum of Ranks
Experimental group Negative Ranks 3 5.83 17.50
Positive Ranks 21 13.45 282.50
Ties 1
Total 25
Based on the Wilcoxon test results in table 3, it can see that there are different results, namely the difference (negative) between pre-test and post-test experimental groups of three mothers with 0-6 months baby. The mean value of the negative ranks provides information that there is a decrease (reduction) from pre-test to post-test value of 5.83%. The value in positive ranks gives information that there is an increase in results of 21% of respondents from pre-test to post-test with an increase of 13.45%.
The results of Wilxocon test statistic stated that the Asymp.Sig (2-tailed) value was 0.00 < 0.05, means that there was a difference between pre-test and post-test results in experimental group. It can conclude that in experimental group there is an effect of increasing knowledge through leaflet media about exclusive breastfeeding for baby in Cisaranteun kidul village in 2021.
Table 4. The Differences in Knowledge in the Experimental Group Ranks
N Mean Sum of Ranks
Experimental group
Negative Ranks 10 14.75 147.50
Positive Ranks 12 8.79 105.50
Ties 3
Total 25
Test Statistics
Z Asymp. Sig(2-tailed)
-0.683 0.494
Test Statistics
Z Asymp. Sig(2-tailed)
-3.801 0.000
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The Wilcoxon test in table 4 shows a difference (negative) between the pre-test and post-test control groups of 10 respondents. The mean value of the negative ranks states that there is a decrease (reduction) from the pre-test value to the post-test value of 14.75. The positive rank value says that there is an increase in results as many as 12 respondents from pre-test to post-test, with a rise of 8.79. The Wilxocon test statistic gave information on the Asymp. Sig (2-tailed) value of 0.494 > 0.05, meaning that there was no difference between pre-test and post-test result in the control group in the control group, there was no increase in knowledge about the effect of exclusive breastfeeding on the baby in Cisaranten Kidul in 2021.
The level of mother's knowledge increased in the experimental group after being given an intervention using leaflet media. The increase is significant so that no more knowledge lacking categorized. Leaflets can affect the level of knowledge of the experimental group that give the intervention. Compared with the control group, there is no increase in knowledge because it does not receive any intervention. The leaflet media used includes various information about exclusive breastfeeding. Providing information helps more easily convey information or messages because of the stimulus given to the experimental group. The stimulus received a response in intervention process which was repeated in experimental group, so experimental group experienced increase in knowledge and effect of using leaflet media that had been done. Different from the control group, who did not receive a stimulus in the form of an intervention, there was no significant difference in knowledge because they did not receive a stimulus in the form of the intervention. Hence, it can conclude that leaflet media can use as a media tool for health promotion to increase knowledge in the community.
The research is in line with Ismawati that there is an effect of using leaflet media on the level of knowledge of postpartum mothers about the technique of baby feeding. From these results, the probability value (P) = 0.000. Thus the value of P (0.000) < (0.05). The result means that there is an effect of using leaflet media on the level of knowledge of postpartum mothers about babies breastfeeding techniques (Ismawati, 2016).
Notoatmodjo stated that media tools are needed to increase effective results in increasing knowledge. The function of the media is to help convey information. The selection and the use of media aids is one of the critical components to do to help the use of the senses as much as possible. The senses can obtain knowledge through sight by 83%, hearing 11%, while the remaining 1% is taste, 2% of touch and 3% of smell (Notoatmodjo, 2020). Media is one of the tools in the educational process. The media has the advantage of stimulating interest, and educational goals, overcoming the passive attitude of academic targets, and can provide stimulation, experience and cause the same perception, encourage the target desire to know, explore, and finally offer a better understanding and stimulate the target to forward messages to others, providing information formally and informally. The provision of leaflet media is one of the transfers of non-formal information that used in health education (Notoatmodjo,
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2020). Knowledge is the basics that shape a person experience and becomes a stimulus for behavior change.
The existence of continuous efforts through cross-sectoral collaboration from Puskesmas and local government through Family Welfare Empowerment can be a solution in efforts to increase knowledge (Kurniawati et al., 2021).
CONCLUSIONS AND RECOMMENDATIONS
There was a significant increase in knowledge about exclusive breastfeeding in the experimental group that given after intervention through leaflet media. With the Asymp.Sig (2-tailed) value of 0.00 < 0.05, means that there is a difference between the results of the pre-test and post-test. It said that that there is an effect of increasing knowledge through leaflet media about exclusive breastfeeding for babies in Cisaranteun Kidul in 2021.
It is needed to cross-program and cross-sector collaboration in the form of partnership that can empower the community to increase knowledge, understanding, and application of exclusive breastfeeding. The high rate of exclusive breastfeeding can drive changes in the prevention of stunting;
for a quality generation.
ACKNOWLEDGMENT
The authors would like to thank the Head of the Faculty of Health Sciences, Head of UPT Puskesmas Riung Bandung, and Kelurahan Cisaranteun Kidul, who have permitted for this research.
The authors also thank all team who supported this research activity.
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