THE ROLE OF “MY VILLAGE MY HOME” IN THE KNOWLEDGE AND ATTITUDES OF INTEGRATED HEALTH POST CADRES AND MOTHERS

1 Department of Epidemiology, Public Health, Universitas Airlangga, anasyia26@gmail.com 2 Department of Epidemiology, Public Health, Universitas Airlangga, fariani.s@fkm.unair.ac.id 3 Department of Health Promotion and Behavior, Universitas Airlangga, megatsari@gmail.com 4 Faculty of Public Health, Universitas Airlangga, ratna-d-w@fkm.unair.ac.id 5 Indonesian Epidemiologist Association (PAEI), arief.hargono@gmail.com 6 Department of Administration and Health Policy, Universitas Airlangga, djazulych@fkm.unair.ac.id 7 University of South Florida, United States of America, and Adjunct Professor at Faculty of Public Health, Universitas Airlangga (2018-2019), ypathak1@usf.edu Corresponding Author: Fariani Syahrul, fariani.s@fkm.unair.ac.id, Department of Epidemiology, Public Health, Universitas Airlangga, Jl. Dr. Ir. H. Soekarno, Mulyorejo, Surabaya City, East Java, 60115, Indonesia


INTRODUCTION
Nearly 1.7 million children under five years of age die from diseases that can be prevented by immunization in 2008. At the end of 2010, total of 19.3 million children worldwide did not have complete basic immunization, with more than half of these children located in India, Nigeria, and Indonesia (53%) (Mukherjee et al., 2015). Based on National Basic Health Research (Riskesdas) 2018, the coverage of complete basic immunization in Indonesia was only 57.90%, and complete basic immunization in East Java Province was only 69.20% (Kemenkes RI, 2019).
My Village My Home (MVMH) is a community level visual communication tool that provides a picture of the status of infant immunization in the village and allows people to see and follow-up on the immunization status of each infant (USAID, 2014). The program is intended to support the complete basic immunization service offered, both in quantity and quality, and has been used to assist community participation in basic immunization services.
Surabaya is the capital of East Java Province and the second largest city in Indonesia, after Jakarta. Surabaya City Health Office launched a complete basic immunization program using the MVMH method, but it has not yet covered all the Integrated Health Posts in the city. MVMH is a method for community empowerment that can also be used as an alternative support strategy to overcome the difficulties of immunization in Surabaya. By providing a visual picture of immunization status, MVMH allows the community to observe immunization directly and mobilizes the community to use immunization services. Immunizations reduce the morbidity and mortality rates of infants and immunization preventable disease (PD3I) programs can be strengthened in developing countries by improving access to immunization and reducing the number of immunization dropouts (Zewdie, Letebo, & Mekonnen, 2016). Data obtained from several surveys has indicated that community access to immunization programs is satisfactory, but that the number of dropouts is still high. Infants who received their first immunization did not complete the basic immunization (Harfiana, 2019).
Complete immunization status is influenced by several factors. The community components that influence complete immunization status include the community's behaviors, values, and beliefs regarding the immunization program. Community behavioral factors are related to knowledge, attitudes, and actions. Values or norms in the community can influence the family support and assessment of the halal vaccine (Yuda & Nurmala, 2018).
Some of the factors that lead to behavioral changes include knowledge, attitudes, beliefs, trust, values, traditions, etc. For example, a mother may decide to visit an Integrated Health Post because she knows that the purpose of the visit is to measure her baby's weight and immunize him/her against disease. Without the presence of knowledge and a good attitude, the mother might decide not to visit an Integrated Health Post (Notoatmodjo, 2012). Indeed, it has been found that mothers who have insufficient knowledge do not bring their infants to Integrated Health Posts for immunization (Triana, 2016).
A cadre is a person chosen by the community and trained to move the community to participate in community empowerment in the health sector (Menkes RI, 2019). In developing countries, the role of cadres is very important in increasing access to health services (Nzioki, Ouma, Ombaka, & Onyango, 2017), although Integrated Health Post cadres do not directly provide immunizations. Health workers in Integrated Health Posts assess the health of infants each month and therefore have a better knowledge of their health status. Health workers from local communities are considered to have an influence on the local community and are considered capable of providing health services (Profita, 2018). The knowledge and support provided by family members and Integrated Health Post cadres influences the achievement of Universal Child Immunization (UCI). Knowledge, attitudes, and support provided by families can have a positive influence on the willingness of mothers to give their babies DPT immunizations (Izza, Lestari, & Tumaji, 2017). The current study aimed to evaluate the role of MVMH in terms of the knowledge and attitudes of cadres and mothers of two-year-old infants in Surabaya.

METHODS
This study used an observational design with a retrospective cohort. The exposed population consisted of all cadres and mothers of children aged two years and under in the working area of the health centers who had received training or workshops on MVMH. The unexposed population consisted of all cadres and mothers of children aged two years and under in the working area of the health centers who had not received training or workshops on MVMH. The mothers were selected using simple random sampling from list of cadres and mothers in Integrated Health Post (Posyandu). The study was conducted in 30 health centers in Surabaya. The respondents in the exposed group consisted of 20 cadres and 20 mothers who had received training on MVMH, while the respondents in the unexposed group consisted of 40 cadres and 40 mothers who had not received training on MVMH. Data collection was carried out using a readable questionnaire. The variables under study focused more on the methods implemented in the complete basic immunization program.
The cadres' knowledge regarding MVMH was measured using eight questions that had correct and incorrect answers, while their attitude towards MVMH was measured using 10 questions that had "strongly disagree", "disagree", "agree," and "strongly agree" responses. Knowledge and attitudes were classified as "good" when the score was 70, "enough" when the score was 40-60, and "poor" when the score was less than 40. This study received an Ethical Eligibility Certificate from the Airlangga University, Public Health Faculty, Ethical Commission No. 560/EA/KEPK/2018.

Characteristics of Cadres and Mothers
The results indicated that most of the cadres were aged 41-50 years (38.30%), while the majority of mothers were aged 20-30 years (45%) or 31-40 years (45%). The average age of the mothers was 31.6 years, while the average age of the Integrated Health Post cadres was 47.6 years ( Table 1).

Knowledge and Attitudes of Cadres towards MVMH Media in Surabaya
When answering the questions designed to measure their knowledge of MVMH, 30% of the cadres who had received previous training answered the seventh question incorrectly. This question was: "Can MVMH display a list of infants and children who have incomplete immunizations?" Similarly, 27.50% of the cadres in the group who had not received training answered the fourth question incorrectly. This question was: "Can MVMH display a list of infants scheduled for immunization on the Integrated Health Post?" Table 2 shows that most of the Integrated Health Post cadres who had received previous training had good knowledge (80%), while the other 20% had enough knowledge. Most cadres who had not received training had good knowledge (90%), while 5% had enough knowledge and 5% had poor knowledge. The majority of cadres in both groups had good attitudes (Table 2).

Knowledge and Attitudes of Mothers towards MVMH Media in Surabaya
When answering the questions designed to measure their knowledge of MVMH, over a third of the mothers with cadres who had received previous training answered the eighth question incorrectly. This question was: "Does MVMH Home provide an overview of the immunization status of infants in Integrated Health Posts only?" A mother's knowledge regarding MVMH was only measured if they had previously seen and learned about the MVMH installed at the Integrated Health Post. Most of the mothers from the cadre group that had received training already knew about MVMH (90%), whereas half of the mothers in the cadre group that had not received any training did not know about MVMH (Table 3).
When answering the questions designed to measure their knowledge of MVMH, some of the mothers with cadres who had not received prior training answered the fourth question incorrectly. This question was: "Does MVMH display a list of infants scheduled for immunization on the Integrated Health Post schedule?" The fifth question was also answered incorrectly some of the time. This question was: "Can MVMH be used as a means of communication between midwives, cadres and the community related to immunization?" Most of the mothers in both groups had good knowledge ( Table 3).
Most of the mothers in the cadre group who had received previous training had good attitudes (60%), while the majority of mothers with cadres who had not received prior training had fairly good attitudes (50%) ( Table 3).

Characteristics of Cadres and Mothers
MVMH is a tool that can increase immunization coverage through the active participation of the community which is the mothers with children aged 2 years or under and the health cadres. The family and cadres have important roles in helping healthcare centers increase coverage and accuracy of basic immunizations (Jain, Taneja, Amin, Steinglass, & Favin, 2015). The majority of cadres included in the study were 40-50 years old. This is important as age is closely related to the level of cadre confidence, with older cadres more likely to have higher confidence and provide a more optimal service. Cadres serve as a link between the community and health workers, and the strength of cadres lies in their accessibility, cultural sensitivity, language, and service to locals (Sommanustweechai et al., 2016).
The majority of mothers included as respondents were aged 20-30 years. This is important as mothers over 20 years of age are more likely to immunize their children compared to mothers under 20 years of age as the former have more mature thoughts and more experience (Harmasdiyani, 2015). Age can affect a person's experience when it comes to decision making, and mothers aged 25 years or over tend to have more experience related to childcare compared to mothers under 25 years of age (Prihanti, Rahayu, & Abdullah, 2016). An increase in maternal age can correspond to an increase in childcare experience, which can help prevent the occurrence of illness in children (Hudhah & Hidajah, 2017).

Knowledge and Attitudes of Cadres towards MVMH Media in Surabaya
A person's behavior is influenced by three main factors: predisposing; reinforcing; and enabling. One of the predisposing factors that has the most influence on health behavior is knowledge. Sufficient knowledge of health is a basic foundation for positive attitudes and actions, and someone who has good health knowledge will also take good health actions. Knowledge itself is the result of understanding something through the five senses: sight; hearing; smell; taste; and touch. Most of human knowledge is obtained through the ears and eyes (Notoatmodjo, 2012).
Cadre knowledge regarding MVMH was measured using eight questions about the contents of MVMH, those who played an active role in MVMH, and its goals and benefits. Most cadres in both groups had good knowledge related to MVMH, however, two of the questions related to the purpose and benefits of MVMH were often answered incorrectly, indicating that these need to be reemphasized to cadres.
The fact that the majority of cadres in both groups had good knowledge of MVMH shows that it is simple to implement at Integrated Health Posts. Staff at Health Centers and the cadres at Integrated Health Post have the responsibility to provide information and to practice MVMH at Integrated Health Post. Not all cadres with good knowledge can play an active role in MVMH. This was related to social support, family, religious leaders, attitudes, beliefs, community leaders, and approval of facilities to carry out information and motivation. The information conveyed contained important messages, and information that is conveyed clearly and concisely tends to be easily accepted and understood by respondents (Kusyanti, 2015). The majority of cadres in both groups also had a good attitude towards MVMH, and they agreed to actively support the program. Cadres with a good attitude are able to understand and carry out their duties and roles in the MVMH program (Triana, 2016).

Knowledge and Attitudes of Mothers towards MVMH Media in Surabaya
Most of the mothers with cadres who had received training already knew about MVMH, whereas half of the mothers with cadres who had not received training did not know about it. Most of the respondents who knew about MVMH had sufficient knowledge about the program, however, there was a significant difference between mothers with cadres who had received training and mothers with cadres who had not received training regarding the needs of MVMH. Mothers with a good attitude towards MVMH are more likely to recognize the need to participate in immunization activities and to improve immunization status, and mothers play an important role in the program. The knowledge concerning individual feelings daily, and that can be made an important domain self-formation. Individuals who know will apply their knowledge in their daily lives. For example, parents/mothers with good knowledge regarding immunization are more likely to spread correct information and help provide immunizations when appropriate (Triana, 2016). Indeed, mothers who understand the importance of vaccinations can motivate other mothers to immunize their children. In contrast, mothers with poor knowledge regarding immunization are more likely to form unfavorable/negative attitudes (Adefolalu, Kanma-Okafor, & Balogun, 2017;Girmay & Dadi, 2019).
Cadres who have good knowledge and attitude towards MVMH have the potential to apply MVMH to the community. MVMH implementation in the city of Surabaya has a significant impact with increasing immunization coverage of 78.81 in 2017 to 95.77 in 2018 (Hargono et al., 2019).

CONCLUSION
Overall, the majority of cadres and mothers in both groups had good knowledge of MVMH, although it should be noted that the number of cadres and mothers who had good knowledge was higher in the cadre group that had received previous training. Also, half of the mothers with cadres who had not received training did not know about the existence of MVMH. On average, the cadres answered two questions regarding MVMH incorrectly, whereas the mothers answered an average of four questions incorrectly. The majority of cadres and mothers in both groups had a good attitude towards MVMH.