Factors Related to the Low Visiting of Babies to Integrated Healthcare Center

Introduction: As a form of community participation in utilizing Integrated Healthcare Center, it can be seen from the coverage divided by the number of targets (D/S). Based on data from the Integrated Healthcare Center Karangan Public Health Centre, the community visits to the Integrated Healthcare Center in 2022 reached (65.2%). From the data It is seen that this achievement is very far from the national target of 85%. Objective: This study aims to find out the factors of the low visiting of babies to Integrated Healthcare Center in the work area of Karangan Public Health Centrein 2023. Method: The research method was observational analytic with a cross-sectional approach. The population in this study was 80 toddlers aged 12-59 months in the work area of Karangan Public Health Centre in 2023. Results and Discussion: It is hoped that Health Promotion about the benefits of Integrated Healthcare Center needs to be carried out so that respondents want to bring their children to routine activities every month at the Integrated Healthcare Centerand for further researchers to continue this research by looking at others factors related to the visit of the mother toddler to the Integrated Healthcare Center. Conclusion: It showed that occupation, education, knowledge factors do not affect the low toddler visit to Integrated Healthcare Center while family support and mother's attitude affect the low toddler visit to Integrated Healthcare Center.


Introduction
In Indonesia, the number of puskesmas spread in 2013 was 9,599 units, Auxiliary Puskesmas 23,875 units, and Polindes 42,656 units.Although basic health service facilities in all sub-districts, equity and affordability of health services are still an obstacle.This facility is not yet fully accessible to the community, especially related to transportation costs and distances (Wulandari et al., 2016) According to a UNICEF report, there were 37 deaths of children under the age of five out of 1,000 births in 2020 (Hastuti, 2020).This figure is down compared to 2015 which was 43 deaths.Sub-Saharan Africa has the highest under-five mortality rate at 74 deaths from 1,000 births.Central and South Asia followed with 37 child deaths.It is known that premature birth, pneumonia, diarrhea, and malaria are the leading causes of death in children under the age of five.
The cause comes from lack of health awareness as well as health facilities.WHO in 2018 estimated that there were 51 million toddlers who experienced nutritional problems.Toddlers who died due to nutritional problems reached 2.8 million people (Nurdin et al., 2019).African and Asian countries including Indonesia are one of the countries that have the highest nutritional problems (World Health Organization, 2016) Basic Health Research Data (Riskesdas) in 2018, the proportion of malnutrition and undernutrition in toddlers was 13.8% where North Sulawesi was 15% and the highest in East Nusa Tenggara was 29.5% (Ministry of Health of the Republic of Indonesia, 2018).Toddler visits to the Integrated Healthcare Center in Indonesia in 2018 were 68.37% while in 2019 experienced an increase to 73.86%.But with the pandemic Covid -19 In 2020 it experienced a significant decline (Wulandari et al., 2016) The results of interviews with cadres of the Integrated Healthcare Center obtained information that mothers said they were lazy to weigh their children at the Integrated Healthcare Center, as many as 71.42% because mothers of toddlers felt that their children who had received complete immunization no longer needed to come to the Integrated Healthcare Center and 2 of them said they were busy working and taking care of other children so they were lazy to bring toddlers to the Integrated Healthcare Center.So the purpose of this study is to determine the factors associated with the visit of the Integrated Healthcare Center for toddlers (1-5 years) in the Puskesmas work area.
Based on demographic data from the Integrated Healthcare Center program of the Karangan health center in 2022, for the last 9 months from January to September there is an average monthly of 369 toddlers, while the expected target is 719 toddlers.
According to demographic data, Puskesmas Karangan is divided into 7 Pdan villages, each village has an Integrated Healthcare Center with toddler visits at the Integrated Healthcare Center on average, including the Integrated Healthcare Center of Pengadan Village in the form of 80 toddlers with a target of 180 toddlers visits, 'Integrated Healthcare Center in Baay Village in the form of 40 toddlers with a target of 60 toddlers in visits, Integrated Healthcare Center in K Village.
Across the form of 30 toddlers with the target of visiting 90 toddlers, the Integrated Healthcare Center of Karangan Village in the form of 74 toddlers with the target of visiting 112 toddlers, the Integrated Healthcare Center of Karangan Hilir Village forming 80 toddlers with the target of visiting 122 toddlers, the Integrated Healthcare Center of Batu lepod Village forming 30 toddlers with the target of visiting 90 toddlers and the Integrated Healthcare Center of Mukti Lestari Village forming 35 toddlers with the target of visiting 65 toddlers.The purpose of this study is to determine what factors can be associated with low visits by toddlers to the Integrated Healthcare Center in the work area of the Karangan Public Health Center in 2023.

Method
The type of research conducted in this study is observational analytics with a cross sectional approach.This study design is prioritized to determine the influence of factors of work, education, family support and maternal attitudes with toddler visits at the Integrated Healthcare Center.The total population is 80 toddlers with purposive sampling techniques so that to determine the population size (N), the sample count in this study is 44.4 toddlers if rounded to 45 toddlers.The place of research was conducted at UPT Puskesmas Karangan.The research will be conducted in March 2023.In this study, univariate analysis explained the average education, employment, knowledge, family support, maternal behavior and toddler visits.And bivariate analysis, namely with data analysis used is a chi square test or tested individually and multiple logistic regression or tested together.Based on table 3, it shows that the frequency based on the high level of knowledge category is 15 respondents with a percentage of 33.3% and the low knowledge level category is 30 respondents with a percentage of 66.7%.Based on the table, it shows that the frequency based on the good family support category is 20 respondents with a percentage of 44.4% and the low knowledge level category is 25 respondents with a percentage of 55.6%.Based on the table, it shows that the frequency based on the category of good maternal attitude is 24 respondents with a percentage of 55.3% and the low level of knowledge category is 21 respondents with a percentage of 46.7%.Based on the table shows that the frequency based on the category of the number of active visits is as many as 20 respondents with a percentage of 44.4%.The category of the number of inactive visits was 25 respondents with a percentage of 55.6%.Based on the results of bivariate analysis in table 4.7, it was found that respondents who had higher education with active toddler visits were 12 people (52.2%) and inactive ones were 11 people (47.8%) with a total of 23 respondents.While respondents who had less education but active toddler visits were 8 people (36.4%) and inactive ones as many as 14 people (63.6%) with a total of 22 respondents.Based on the chi square statistical test, a p value of 0.286 (p > 0.05) was obtained, which means that statistically there is no relationship between educational variables and toddler visits in the Public Health Center Work Area.Based on the results of bivariate analysis in table 4.8, it was found that respondents who worked with active toddler visits were 8 people (42.1%) and inactive ones were 11 people (57.9%) with a total of 19 respondents.While respondents who did not work but visited active toddlers as many as 12 people (46.2%) and those who were inactive as many as 14 people (53.8%) with a total of 26 respondents.Based on the chi square statistical test, a p value of 0.787 (p > 0.05) was obtained, which means that statistically there is no relationship between occupational variables and toddler visits in the Public Health Center Work Area.Based on the results of bivariate analysis in table 4.9, it was found that respondents of high knowledge with visits of active toddlers as many as 9 people (60%) and inactive Unmul Liyani, Hilda, Rosalin Ariefah Putri/KESANS Factors Related to the Low Visiting of Babies to Integrated Healthcare Center as many as 6 people (40%) with a total of 15 respondents.While respondents whose knowledge is low but visits by active toddlers are 11 people (36.7%) and those who are inactive as many as 19 people (63.3%) with a total of 30 respondents.Based on the chi square statistical test, a p value of 0.138 (p > 0.05) was obtained, which means that statistically there is no relationship between knowledge variables to toddler visits in the Public Health Center Work Area.Based on the results of bivariate analysis in table 10, it was found that respondents supported families both with active toddler visits as many as 14 people (70%) and inactive ones as many as 6 people (30%) with a total of 20 respondents.While respondents with poor family support but active toddler visits were 6 people (24%) and inactive as many as 19 people (76%) with a total of 25 respondents.Based on the chi square statistical test, a p value of 0.002 (p < 0.05) was obtained, which means that statistically there is a variable relationship between family support for toddler visits in the Public Health Center Work Area Based on the results of bivariate analysis in table 4.11, it was found that respondents had good maternal attitudes with active toddler visits as many as 16 people (66.7%) and inactive ones as many as 8 people (33.3%) with a total of 24 respondents.While respondents with poor maternal attitudes but active toddler visits as many as 4 people (19.4%) and inactive as many as 17 people (80.6%) with a total of 21respondents.Based on the chi square statistical test, a p value of 0.001 (p < 0.05) was obtained, which means that statistically there is a variable relationship between maternal attitudes towards toddler visits in the Working Area of the Public Health Center

Discussion
The results showed that most respondents with low and inactive education levels visited the Integrated Healthcare Center as many as 14 people (63.6%).The results of the chi square statistical test obtained a p value of 0.286 (p > 0.05) which means that statistically there is no relationship between educational variables to toddler visits in the Public Health Center Work Area.
The education that a person undergoes has an influence on improving his thinking ability, in other words people who are more educated will make more rational decisions, generally open to accept new things compared to individuals with lower education (Ministry of Health RI, 2016).
The results of this study are in line with Hindhu Mathi's (2013) research in (Matanah et al., 2017) who said there was no significant relationship between respondents' education and the level of maternal participation in weighing toddlers to the Integrated Healthcare Center working area of the Darussalam Health Center, Medan Petisah District.The absence of a relationship between education and maternal participation rate in this study can be due to other factors such as lack of motivation of mothers to monitor the development of their children, lack of support from community leaders, mothers' work, and others.
The results showed that most respondents were not working and who were not active visiting the Integrated Healthcare Center as many as 14 people (53.8%).The results of the chi square statistical test obtained a p value of 0.787 (p > 0.05) which means that statistically there is no relationship between occupational variables and toddler visits in the Public Health Center Work Area.
Satriani's (2019) research in (Damayanti et al., 2022) shows that there is a relationship between work and toddlers to the Integrated Healthcare Center in the working area of the Mangkoso Health Center, Barru Regency which states that work is work that must be done, especially to support their lives and family life.Work is not a source of pleasure, but more of a boring, repetitive, and challenging way of making a living.While work is generally a time-consuming activity.
Work for mothers will have an impact on family life and time for childcare will be reduced, so mothers of toddlers who have to work outside the home have time to participate in the Integrated Healthcare Center may be very less or not at all to participate in the Integrated Healthcare Center.While housewives may have more time to rest and take time to bring their children to the Integrated Healthcare Center.
Work is an economic demand that must be met.For mothers who work both at home as housewives and who work outside the home do not take the time to go to the Integrated Healthcare Center for the reason of busy work that must be done (Rehing et al., 2021).
Mothers who work at home spend their time doing various chores and who work outside the home such as in offices and other workplaces do not have the opportunity to go to the Integrated Healthcare Center because the activities of the Integrated Healthcare Center are usually carried out in the morning along with their work time (happy Apriasih, 2022) Iriana and Corina's research also states that maternal work affects the cognitive and emotional development of children in mothers who return to full-time work compared to mothers who work half the time (Hondralis & Kleinert, 2021).Based on the journals studied, there are 5 journals that explain the existence of occupational variables affecting mothers of toddlers during visits to the Integrated Healthcare Center.
The results showed that most respondents with low knowledge and inactive toddler visits were 19 people (63.3%).The results of the chi square statistical test obtained a p value of 0.138 (p > 0.05) which means that statistically there is no relationship between knowledge variables to toddler visits in the Public Health Center Work Area.
The results of this study cannot answer the research hypothesis that mothers who have good knowledge have a greater chance of making visits to the Integrated Healthcare Center compared to mothers who have less knowledge.Although statistically good knowledge shows a significant relationship, it is practically necessary to consider that knowledge is one of the factors associated with maternal inactivity in making visits to the Integrated Healthcare Center.
According to the researchers, mothers of toddlers with good knowledge but have a frequency of weighing toddlers not good can be associated with other factors where these factors shape behavior without prior knowledge, namely distance, shelter and family support (Pristiani et al., 2016).The distance of the mother's residence to the Integrated Healthcare Center is close, making it easier for mothers to visit the Integrated Healthcare Center on the day of the Integrated Healthcare Center.There is a lack of awareness in oneself that it is important to come to the Integrated Healthcare Center Most of the respondents' knowledge was good but did not visit the Integrated Healthcare Center because respondents followed their husbands to work for days and far from the respondents' residences so they did not have time to bring their children to the Integrated Healthcare Center.In addition, respondents already know about the meaning of Integrated Healthcare Center, activities carried out at the Integrated Healthcare Center, the benefits of the Integrated Healthcare Center and the flow of table services at the Integrated Healthcare Center when weighing toddlers at the Integrated Healthcare Center.
In the results of the study, there were still respondents who had less knowledge, this was due to respondents not understanding about the Integrated Healthcare Center and lack of exposure to information because most respondents did not work or IRT was busy with household chores did not have time to exchange information like working mothers, causing maternal knowledge to be lacking.
According to research conducted by (Radhiah et al., 2021) In line with the results conducted by the researchers, namely the results of bivariate analysis, there was no influence between knowledge and active behavior of visits by mothers of toddlers to the Integrated Healthcare Center The results showed that most respondents with poor family support and inactive toddler visits were 19 people (76%).The results of the chi square statistical test obtained a p value of 0.002 (p < 0.05) which means that statistically there is a variable relationship between family support for toddler visits in the Public Health Center Work Area.Research conducted Sriwulan et al (2020) shows that there is a relationship between family support and visits by mothers of toddlers to the Integrated Healthcare Center at the Unmul Liyani, Hilda, Rosalin Ariefah Putri/KESANS Factors Related to the Low Visiting of Babies to Integrated Healthcare Center Integrated Healthcare Center Linggasari Village, Ciamis Regency in 2017, with ρ value = 0,049 (α=0,05).
Better family support will increase visits by mothers of toddlers to the Integrated Healthcare Center.This support provides motivation to mothers in bringing their children to the Integrated Healthcare Center to find out the growth and development of their children.In addition to family support, other factors that influence the visit of mothers of toddlers to the Integrated Healthcare Center are age, attitudes and support from Integrated Healthcare Center cadres and local community leaders.
Snehandu B. Kar's theory states that behavior is a function of: a person's intention to act in connection with health or health care (behavior intention); social support from the surrounding community (social support); Accessibility of information: presence or absence of health information or health facilities; Personal autonomy concerned to take action or decision; Action situations that allow for action.If it is associated with this theory, it can be said that family support as a form of social support is one of the factors that influence behavior.
According to researchers, from the number of respondents who have family support, it was found that the results of making regular visits to the Integrated Healthcare Center, the family support they get is in the form of information about the importance of visiting the Integrated Healthcare Center, accompanying mothers both to health facilities and the Integrated Healthcare Center to check for babies and toddlers, and also supporting mothers such as reminding mothers to visit Integrated Healthcare Center.Family support will make mothers more willing to visit the Integrated Healthcare Center every month.The existence of family support such as providing information, willing to drop off and accompany mothers while at the Integrated Healthcare Center makes mothers not feel alone.
The results showed poor maternal attitudes and inactive toddler visits as many as 17 people (80.6%).Based on the chi square statistical test, a p value of 0.001 (p < 0.05) was obtained, which means that statistically there is a variable relationship between maternal attitudes towards toddler visits in the Public Health Center Work Area.
This research is in line with research conducted by Nurlutfia, et al ( 2018) that respondents who have a bad attitude towards toddler visits at the Integrated Healthcare Center are higher at 34 people (83%) compared to respondents who have a good attitude towards toddler visits at the Integrated Healthcare Center, which is as many as 7 people (17%), from these results it is clear that there is a relationship between attitudes Toddler mothers to visit Toddlers at the Integrated Healthcare Center.
Attitude is a reaction or response of someone who is still closed from someone to a stimulus or object (Notoatmodjo, 2019).According to Theodore Newcomb, one of the experts in social psychology, states that attitude is a readiness or availability to act and is not an executor of a particular motive.From the above understanding, it can be concluded that attitude is a person's willingness or response to an object in a certain environment.If the attitude of the mother of a toddler about the Integrated Healthcare Center is positive, then the mother of the toddler will attend the Integrated Healthcare Center regularly every month and vice versa if the attitude of the mother of a toddler about the Integrated Healthcare Center is negative, the presence of the mother of the toddler will not be routine every month.This means that although the stimulus is the same for some people, everyone's response is different (Notoatmodjo, 2017).
Mothers with less attitudes are influenced by lack of interaction between cadres of the Integrated Healthcare Center, less active to the Integrated Healthcare Center due to distance of residence, access to transportation is not affordable.In addition, complete immunization of toddlers is a reason for mothers to be less active in bringing and weighing their toddlers to the Integrated Healthcare Center.Mothers of toddlers with less attitude but diligent in doing Integrated Healthcare Center can be influenced by the influence of peers who invite to be active in the Integrated Healthcare Center, so there is a special enthusiasm because they have colleagues to go to the Integrated Healthcare Center together.The process of changing the attitude of mothers to be more active in participating in posayandu can be encouraged by providing an individual approach by conducting counseling for healthy families, while in the counseling process explained the importance of the Integrated Healthcare Center, so it can be concluded that respondents with a good attitude, it will also be good to participate in the Integrated Healthcare Center.

Conclusion
The conclusion in this study is that there is a relationship between family support and maternal attitudes towards the low visits of toddlers to the Integrated Healthcare Center in the work area of the Public Health Center in 2023.
Unmul Liyani, Hilda, Rosalin Ariefah Putri/KESANS Factors Related to the Low Visiting of Babies to Integrated Healthcare Center

Result Analisa Univariat Table 1 Frequency of education level respondents
Based on the table shows that the frequency based on the job category of respondents who work is as many as 19 respondents with a percentage of 42.2%.The job category of respondents who did not work was 26 respondents with a percentage of 57.8%.

Table 4
Frequency of respondents based on family support

Table 5
Frequency of Respondents Based on Mother's Attitude

Table 6
Frequency of Respondents Based on the number of visits

Table 7
Frequency of Respondents Based on Higher education with toddler visits

Table 8
Frequency of Respondents Based on work with toddler visits

Table 9
Frequency of Knowledge-Based Respondents with Toddler Visits

Table 10
Frequency of Respondents Based on family support with toddler visits

Table 11
Frequency of Respondents Based on mothers' attitudes with toddler visits