EFFECTIVENESS OF FORMING BREASTFEEDING SUPPORT GROUP PROGRAM TO IMPROVE EXCLUSIVE BREASTFEEDING

Background: Exclusive breastfeeding is a problem of maternal and child health in Indonesia. With Breastfeeding Support Group, exclusive breastfeeding is expected to improve. Sugihwaras Village and Sumbergede Village have been initiating Breastfeeding Support Group program. However, the framework of Breastfeeding Support Group program and intervention methods for pregnant and breastfeeding mothers in both villages were different.Aim: It analyzed the effectiveness of forming Breastfeeding Support Group program and intervention programs for pregnant and breastfeeding mothers to improve exclusive breastfeeding in Sugihwaras Village and Sumbergede Village.Methods: This study used a case study approach to the formation of Breastfeeding Support Group program. Comparative analysis was done descriptively by selecting samples from the Fieldwork Report of Group 14 and 15 in the period of 2017/2018, Faculty of Public Health, Universitas Airlangga. This study applied total sampling technique and descriptive analysis by comparing community’s characteristics (as input), a form of intervention and program management (as a process), and results of evaluating the formation of Breastfeeding Support Group (as an output).Results: Community’s characteristics in both villages tend to be similar, and the average duration of each program was the same. Sumbergede Village focused on the readiness of forming cadres for Breastfeeding Support Group program, while Sugihwaras Village focused on breastfeeding mothers and their husbands. Indicator analysis of the program showed that Sumbergede Village (80.00% achieved) had a 5.71% higher percentage of attainment compared to Sugihwaras Village (85.71% achieved). Analysis of the program’s strengths and weaknesses pointed out that Sumbergede Village had more values and power in resources in its region.Conclusion: The intervention program in Sumbergede Village tends to be more effective. It has greater potential to be a sustainable program in the following year to improve 100% exclusive breastfeeding. Keywords: Breastfeeding Support Group, exclusive breastfeeding, intervention, effectiveness.


INTRODUCTION
In achieving the second goal of SDGs (Sustainable Development Goals) aimed to end hunger, achieve better food security and nutrition as well as sustainable agriculture, health sectors must ensure that babies have access to safe, nutritious, and sufficient food all year around. This goal has been embedded in The First 1000 Days of Life program. The First 1000 Days of Life program is a golden age period often also referring as a window of opportunities (Cusick and Georgieff, no date). In this period, the rapid growth occurs and does not occur in other age groups. Therefore, fulfilling nutrition for babies and mothers needs special attention. Giving nutrition for babies is in the forms of exclusive breastfeeding because babies only need that in the golden age period (Indonesian Republic Government, 2012).
Exclusive breastfeeding is giving breastmilk to infants since 6-month old without adding and/or changing with other foods or drinks. The Indonesian Healthy Family Approach in 2016 compiled by the Ministry of Health stated that exclusive breastfeeding (age of 0-6 months) for infants is one indicator of healthy families. The World Health Organization recommends that all infants must be exclusively breastfed from 0 months to 6 months of age. After that, they must receive supplemental foods, but continously get breastfed for at least two years (Indonesian Ministry of Health, 2016). One of the current Healthy People 2020 goals is to increase the proportion of infants who have ever been breastfed into 81.9% as a part of the Maternal, Infant, and Child Healthy goals (Healthy People 2020, 2014. Another objective is to increase the proportion of six-month breastfed infants to 60.6% (Silbert-Flagg, Balbier and Blakey, 2016).
The global study of Lancet Breastfeeding Series in 2016 proved that exclusive breastfeeding can decrease the number of deaths due to infections in infants under three months old by 88%. It also showed that a total of 31.36% of 37.94% of children were sick because they did not accept exclusive breastfeeding (Hajeebhoy, 2016). However, the need for breastfeeding in several regions in Indonesia has not been fulfilled yet. Bojonegoro District Health Profile Data in 2017 showed that the exclusive breastfeeding coverage decreased from previous two years, which were 89.4% in 2015 and 88.2% in 2016. Likewise, Nglumber Primary Healthcare Center in Kepoh Baru Sub-district only reached 70.3% (Bojonegoro District Health Office, 2017). Nglumber Primary Healthcare Center is the first-level primary health facility. This institution is responsible for public health in its working areas including two villages that have not reached 100% of the exclusive breastfeeding coverage. The villages are Sumbergede Village and Sugihwaras Village, which are 2 of 25 villages in the adjacent of Kepoh Baru Sub-district. Sugihwaras Village is located in the East part of Sumbergede Village.
Unachieved exclusive breastfeeding in the two villages come from internal factors or external factors. The internal factors consist of knowledge, education, employment, and socio-economic conditions of breastfeeding mothers. While, the external factors are the availability of healthcare facilities, work environment, groups or communities, and family as one of the closest to breastfeeding mothers. Family factor tends to be overlooked in this case (Februhartanty et al., 2012). It is a motivation for nursing mothers. Verbal support and physical support (assistance) during breastfeeding determine the success of exclusive breastfeeding. Forms of motivation given by family, especially husbands both verbally and physically will affect mothers' psychology and foster a sense of self-confidence. Thus, breastfeeding mothers are more enthusiastic and more consistent in giving exclusive breastfeeding to their babies. Nevertheless, the source of motivation cannot just come from family because the environment of breastfeeding mothers indirectly becomes a determining factor for the success of exclusive breastfeeding (Raffle et al., 2011).
Breast Feading Support Group is well-known as one of the 10 steps to successful breastfeeding in national and international level (World Health Organization, 2019). Breastfeeding Support Group is a group formed of 6-12 pregnant women and mothers who meet regularly in home visits. It aims to exchange experiences, discuss and provide mutual support related to maternal and child health, especially pregnancy, breastfeeding and nutritional fulfillment. Breastfeeding Support Group was carried out specifically for mothers who want to successfully breastfeed their infants in the early breastfeeding initiation and sixmonth exclusive breastfeeding. It also continues to provide more than two Breastfeeding Support Group is vital because mothers have a sense of being supported, loved, and cared about. There will be positive emotions that will increase their oxytocin hormone so that breast milk production will work smoothly. Breastfeeding Support Group makes pregnant women have confidence to breastfeed (Yunianti, Rofi'ah, and Rubiyanti, 2017). Breastfeeding mothers can get support and also learn from the experiences of other breastfeeding mothers, thus babies will get the best food/nutrition from the beginning. Husbands and family members also need to support the success of breastfeeding, and health workers can maintain breastfeeding stages by involving Breastfeeding Support Group members (Yunianti, Rofi'ah, and Rubiyanti, 2017).
Activities in Breastfeeding Support Group provide more opportunities for breastfeeding mothers to actively participate in the health promotion and health education. Education is not only activity with one-way learning method, such as counseling, workshop, and distribution of leaflets, but also sharing forums. Therefore, participants can also convey an obstacle in giving exclusive breastfeeding. Sharing forums are more likely to enrich information transfer, both knowledge and experience of each participant in the forum. Hence, breastfeeding mothers can get advice for their obstacles and constraints.
The study about the Breastfeeding Support Group at Wonoayu Primary Healthcare Center in Sidoarjo City found that mothers who participated in Breastfeeding Support Group had an opportunity to provide exclusive breastfeeding at 3.701 times compared to mothers who did not participate (Wati and Muniroh, 2018). There is a significant relationship at 72.4% between participation of breastfeeding mothers in the Breastfeeding Support Group and success of exclusive breastfeeding for infants aged 6-9 months in Working Area II of Bantul under Kasihan Primary Healthcare Center (Purwanti, 2015). Then, based on research conducted by Nurrohmah, Prawitasari, and Nisman (2015) showed that the role of Mother Support Group significantly affects exclusive breastfeeding behavior. Women who take a part in the Mother Support Group have 12.85 times higher chance of doing exclusive breastfeeding than women who did not participate. Possible contributions from husbands' support and social support affect exclusive breastfeeding behavior (Nurrohmah, Prawitasari, and Nisman, 2015).
In line with the research, Sugihwaras and Sumbergede Villages have created a program involving Breastfeeding Support Group that aims to increase mothers' motivation during breastfeeding for infants aged 0-6 months. Although they have the same type of problems and causal factors, the forms of intervention provided do not need to be the same. The selection of interventions provided is determined by considering local culture, the capabilities of the community, the capacity of those who support Breastfeeding Support Group, the availability of supporting facilities, and other factors.
People responsible for conducting the Breastfeeding Support Group are midwives in each village. Technically, it was planned that midwives will be assisted by Breastfeeding Support Group volunteers. Volunteer recruitment and intervention have been formulated by Sugihwaras Village and Sumbergede Village. Breastfeeding Support Group used different methods and were discussed further in this study. Therefore, this study aimed to compare which forms of interventions or programs are more effective and have potentials to continue in the following year. The results of this study were expected to be suggestions and considerations in decision-making for villages that have problems with the same community's characteristics as the community of Sugihwaras Village and Sumbergede Village.

METHOD
This study used a case study approach to Breastfeeding Support Group programs. It compared interventions in the forms of education and action program to potential community. These interventions were aimed to maintain Breastfeeding Support Group which is expected to improve exclusive breastfeeding behavior behavior.
The sample used was the community of two villages in Kepoh Baru Sub-district, Bojonegoro District (Sugihwaras Village and Sumbergede Village). The sampling was taken from the data of Field Work Report of Group 15 and 14. The report were compiled by students with Academic Year 2017/2018 from Faculty of Public Health, Universitas Airlangga . The inclusion criteria in this study were Breastfeeding Support Group members, varying from breastfeeding mothers who have infant aged <2 years, volunteers, community leaders, and village government. The selected sample size used total sampling. Totally, there were 74 samples from both villages.
The technical analysis used was descriptive analysis by comparing community's characteristics (as input), the forms of intervention or program (as a process), and the attainment of the program's success (as an output). Community's characteristics and forms of intervention were independent variables, while the effectiveness of Breastfeeding Support Group program was a dependent variable. To simplify the analysis, Sugihwaras Village was coded as Group A, while Sumbergede Village was assigned as Group B. The potential sustainability of Breastfeeding Support Group formation can be concluded based on the most effective analysis. Indicators that determine the effectiveness of the program can be obtained by calculating the percentage of success based on the evaluation of each intervention or programs and compare the strengths and weaknesses of each program.

Community's Characteristics
Sugihwaras Village and Sumbergede Village are two adjoining villages. Hence, they have relatively similar community's characteristics, in terms of education, work, culture, even health status and health problems. Understanding community's characteristics is essential and must be carried out by each researcher to observe the intervention. It aimed to find out community's condition, capacity, strength, values, and norms in the targeted areas. The comparison of community's characteristics between Group A and Group B is shown in Table 1. In terms of education level, it indicated that more than 50% of respondents have a junior high school or high school certificate. This means the level of education in Group A and Group B is still relatively low because only less than 11% of the community have graduated from Higher Education.
The analysis of community's characteristics viewed from types of work in the two groups shows that most people become farmers, farm laborers and employees of private companies. It means the economic level of the community is still classified into a middle economic level. Whereas, based on gender, the number of men and women is 50%: 50%.
A study stated that sociodemographic and psycho-social characteristics positively influenced the duration of breastfeeding. These chracteristics include time when the decision to breastfeed was made, intended duration of breastfeeding, household income, and smoking habit during pregnancy. Mothers who more often attended Breastfeeding Support Group will continue breastfeeding for at least six months if they decide to breastfeed after birth. Mothers are expected to breastfeed for longer than six months, have higher monthly household income and do not smoke during pregnancy (Bosnjak et al., 2009).

Analysis of Intervention Programs
Promotion/education/counseling has often been done but cannot improve the exclusive breastfeeding coverage. While an increase in knowledge is not enough to change behavior, breastfeeding mothers need skills and supports to give them trust, acceptance, recognition, and appreciation from other peers. The mutual support is more easily shaped into peer groups with the same experience and environmental situation (Susilo, Kurdant, and Siswati, 2012). To provide a solution for not fulfilling the exclusive breastfeeding coverage, both team were assigned to Sugihwaras Village and Sumbergede Village, Kepoh Baru Sub-district, Bojonegoro District. Two programs involving the Breastfeeding Support Group were created in different forms or concepts. Both programs in the two villages have in common, consisting of a series of activities in one program. Table 2 explains the analysis of program forms or concepts in both Group A and Group B. The number of activitites compared for both interventions was 4:3. It means that the intervention given to Group A was more intensive than to Group B. Group A conducted meeting for 4 times per month, while Group B met only 3 times. The average duration of activities in Group A is 2 hours 15 minutes. Meanwhile, Group B have an average duration of 2 hours 20 minutes. To conclude, the duration difference is at 5 minutes.
Interventions in both groups were designed through health promotion and education with the topic of exclusive breastfeeding. They have the same targets, which are pregnant and breastfeeding mothers and their husbands. However, the target of Group A come from volunteers on immunization who also play a role as Breastfeeding Support Group volunteers because there is no enough incentives for additional volunteers. Thus, the volunteers on immunization have double responsibility in escorting pregnant women and breastfeeding mothers. breastfeed. Breastmilk pumps are given as rewards although the effectiveness of such rewards is unproven. The use of breastmilk pumps increases in line with the high proportion of mothers who express breastmilk (Crossland et al., 2016). Mothers who work often cause not to achieve exclusive breastfeeding coverage.
The success of information transfer in the activities was evaluated based on the results of the pre-test and post-test. Pre-test and post-test inform how much information the participants have obtained. The use of media for conducting activities in each group indicates that Group A are more skilled in delivering information to participants. Therefore, by using more varied media, participants tend to be more receptive to conveyed information. Concrete media provide a direct description to participants about the right implementation of the information. Thus, participants do not need to imagine how to implement the information into daily life. In Activity II, both groups used an individual approach through home visit.
Activities in the program involve families, the closest people to breastfeeding mothers, and community groups that influence motivation for breastfeeding. Although the names and concepts of activities II in each group are different, the activities have the same goal to enhance supports from the social environment around breastfeeding mothers. For example, they may increase mothers' self-confidence for full breastfeeding duration until their baby is 6 months old. In a study of To show support and commitment to the program, the Village Head needs to be present and sign a letter of agreement on recruiting exclusive breastfeeding volunteers and forming the management structure. In Group I, the Village Government takes a part in the activities, perfroming more positive value compared to Group II activities that only involve the community. The involvement of Village Government proves that they are aware of the health burden, which not only health workers but also the Village Government in the village need to solve. The Regulation of Indonesia Government Regulation No.33 of 2012 about Exclusive Breastfeeding obliges the Village Government to implement a national policy on exclusive breastfeeding, carry out an advocacy and socialization, provide technical training, foster, monitor, evaluate, and supervise the implementation of exclusive breastfeeding programs in health service facilities, health education units, workplaces, public facilities, and activities in the community. The Village Government assist to carry out the duties of District Government at the village level. Therefore, the Village Government is obliged to be committed in carrying out the national mission. Activity II in Group A only involves the main targets (breastfeeding mothers) and secondary targets (their families). The initiators of Breastfeeding Support Group transfer information about family roles as motivators during breastfeeding period.
Besides, Group B utilize more information media for Activity II, such as a guidebook, module, and pocketbook for Exclusive Breastfeeding Support Group volunteers, as well as a letter of agreement on forming the structure of Exclusive Breastfeeding Support Group. Group A on Activity II only use two media, for example e-poster and exclusive breastfeeding calendar. In comparison with Group A, Activities II were better prepared in terms of consolidation with the Village Government, media, and Human Resources (HR) to form more structured Exclusive Breastfeeding Support Group volunteers. In spite of that, the media used by Group A are more creative and interesting for nursing mothers. Fauziyyah (2018) conducted a study on the effectiveness of using media to increase mothers' knowledge and attitude towards complementary food in Kenep Village Sukoharjo District. Similarly to the findings of this present study, it showed that there was an increase in maternal knowledge after nutrition education by distributing leaflets of 10.2%, pocketbooks of 10.3% and videos of 18%.
Suhertusi, Desmiwarti and Nurjasmi (2015) found that respondents who watched health-promotion film had a higher average increase in personal knowledge than respondents who received leaflets (p=0.001). In a nutshell, the success of information delivery is influenced by the right methods and media. Methods and media which convey interesting sentences will affect the message delivery. Creative healthpromotion media can illustrate abstract and difficult concepts to be more concrete (Suhertusi, Desmiwarti and Nurjasmi, 2015).
In Group B, it is noticable that they have Exclusive Breastfeeding Support Group volunteers and promoting materials to assist inclusive breastfeeding practices in Sumbergede Village. Exclusive Breastfeeding Support Group volunteers help health workers in the village. They are expected to accompany breastfeeding mothers intensively in Sumbergede Village. The structured human resources will facilitate to plan, organize, implement, and controll activities. In line with the resutls, the establishment of Muhammadiyah Klaten Breastfeeding Support Group in 2015 perfomed strong and independent institutions, as well as conducted training for motivators who can transform awareness, commitment, willingness, knowledge, skills and affections to community members (Sutaryono and Purwaningsih, 2015).
Exclusive Breastfeeding Support Group is considered very effective to increase support during breastfeeding. In relation to the effectiveness, Breastfeeding Support Group (86.4%) in the working area of Tembarak Primary Healthcare Center in Temanggung District received support express breast milk exclusively, and only Breastfeeding Support Group (31.8%) who received leaflets exclusively breastfed (Yunianti, Rofi'ah, and Rubiyanti, 2017).
Unlike Group B which consist of two activities, Group A have three activities. Activity III of Group A is a follow-up of Activity II (monitoring and evaluation of the exclusive breastfeeding calendar). Activity III aims to find out whether a calendar helps mothers to increase the frequency of everyday breastfeeding, ideally every two hours or 8-12 times a day. Activity III was carried out for one week with two visits to breastfeeding mothers' houses, usually on the 3rd and 6th day. The initiators of Breastfeeding Support Group in the third activity put stickers on each door to appreaciate mothers who succeed in ideal breastfeeding frequency in a day.
Group B monitor Activity III by looking at how intensive breastfeeding mothers use a pocketbook. Moreover, they conducted home visit as Group A did. Breastfeeding reminder will make mothers more motivated to increase the frequency of breastfeeding for their babies. Research on professional breastfeeding support for first-time mothers stated that early professional breastfeeding support, especially weekly telephone support, significantly increased the rates of exclusive breastfeeding in the early postnatal period and the overall duration of breastfeeding across the first 6 months (Fu et al., 2014). When compared with the standard support group, 60% participants receiving professional telephone support were more likely to give breastmilk almost twice exclusively at the first-month postpartum. Across the first 6 months, participants receiving professional telephone support were about 20% less likely to stop breastfeeding if compared with the standard support group (Fu et al., 2014). Providing mothers with telephonebased peer support at least six-month personal breastfeeding in the postpartum is an effective intervention for maintaining breastfeeding in the community with high breastfeeding initiatives (Forster et al., 2019). It confirmed that to change a behavior, it needs a continuous intervention. Rayfield, Oakley and Quigley (2015) found breastfeeding support was more likely to be effective if it was proactive, delivered face to face and provided on an on-going basis.
From the results of the intervention program in the two groups analyzed, the intervention in Group B uses more informative media and more ready preparation compared with the intervention in Group A. Although Group A makes and uses calendar media more interesting than other media.
Both programs evaluated the frequency of breastfeeding with home visit method and printed media as an everyday reminder. However, the duration of the intervention in each meeting is little different. Once both groups have formed Breastfeeding Support Group volunteers, assistance and monitoring of breastfeeding frequency (Group B) were directly carried out by Breastfeeding Support Group volunteers that have been approved. While, Group A only got pocket book which contains myth-fact information about exclusive breastfeeding.

Program Success Analysis
Success can be measured in two basic ways. First, it involves setting goals or targets and then comparing actual activity to the goal. A successful program is seen from how many indicators are achieved under the plan. If the program has the same or excessive indicators of success designed before the program implementation.
Based on Table 3, it shows Group A have five indicators and Group B consist of seven indicators. Overall, the indicators in each group have covered the program success at ≥80%. When they are accumulated, the indicator success in Group A is 80% (4 of 5 indicators are achieved), while in Group B, it is 85.71% (6 of 7 indicators are achieved). Thus, Group B have higher indicator success than Group A.
When analyzing strengths and weaknesses of both programs, it can be explained that Group A had more active participants, more creative media, and more innovative and interesting theoretical materials. However, speaking about the weakness of program, the Village Government in Group A did not involve in forming Basic Support Group and not participate to improve exclusive breastfeeding behavior and allocate higher budget for the activities. Whereas, Group A only analyzed general characteristics of the community but prospective volunteers. The intervention in Group A focuses on pregnant and breastfeeding women, not empowered volunteers.
While, Group B hadlower budget for the program whic is more efficient allocation and obtained support in the formation of Breastfeeding Support Group program. They also analyzed specifically prospective volunteers and addressed intervention focusing on their readiness and skills. However, the weaknesses include less attractive media, and passive breastfeeding mothers' participation.
From the analysis of strengths and weaknesses, Group B received more material and physical support, such as human resources. Even, the support also comes fromthe commitment of Breastfeeding Support Group members in health care facilities, such as families, health workers, and the Village Government. The percentage of the success indicator in Group B was higher than in Group A. Thus, the intervention in Group B tends to be more effective. Group B involved many resources, for example human resources, financial resources, goods, etc. Human resources are an important component that influences the effectiveness of community empowerment programs as well as health problem solution in Group A and Group B.
A community empowerment is expected to improve the quality of Human Resources (HR), especially in shaping and changing the behavior of community to achieve a high level of health status. Thus, the policies and commitments are important and become the power in the interventions on large numbers of targets.
The existence of policies can help and facilitate an effective coordination system to change people's behavior. In the implementation of Activity II, Group A used an individual approach. Individual approaches require more energy to visit each target (breastfeeding mother). While, Group B used a group approach and an individual approach, such as intervention and group approach (Exclusive Breastfeeding Support Group). The membership and its structure of the Exclusive Breastfeeding Support Group Volunteers is a minimum of 10 volunteers (achieved) 2.

Program Success Group
Volunteers' knowledge and skills in assisting target mothers (pregnant women and mothers breastfeeding 0-6 months) increased by 10% (achieved) 3.
Obtained commitment Exclusive Breastfeeding Support Group to support all activities increased by 80% (target achieved) 4.
A Letter of Support for Exclusive Breastfeeding Support Group Volunteers from the Village Head was issued (achieved) 5.
Modules and pocketbook for Exclusive Breastfeeding Support Group Volunteers have been compiled (achieved) Monitoring and Evaluation The number of participants who wanted to be a part of the Exclusive Breastfeeding Family was > 30% (achieved) Exclusive Breastfeeding Support Group Session II (Keping/Kelompok Pendamping II) None