The Influence of Transcultural Nursing Based on Health Education on Knowledge, Attitude, Mother Actions and Family Support among Breastfeeding Mother

Introduction: Providing additional food other than breast milk before 2year-old babies in Kupang City are babies given "regal" biscuits, "milcuit" biscuits, and "banana" s because the baby does not feel hungry. Providing "regal" biscuits, "milna" and "banana" biscuits as a complement to give breastfeeding before the age of 2 years because parents believe these biscuits can eliminate hunger for the baby. The purpose of this study was to explain the effect of Transcultural Nursing-based health education on knowledge, attitudes, actions of mothers, and family support in breastfeeding.


INTRODUCTION
Providing additional food other than breast milk before the baby is two years old in Kupang City is the baby is given "regal" biscuits, "milcuit" biscuits, and "banana" s with the reason that the baby does not feel hungry. Providing "regal" biscuits, "milna" and " banana" biscuits as a complement to breastfeeding before the age of 2 years because parents believe these biscuits can eliminate hunger for the baby. Based on the results of Riskesdas in 2013 and 2018, the coverage rate for exclusive breastfeeding declined. The coverage of exclusive breastfeeding nationally 37.3% (Kemenkes, 2018). This data decreased were based on Riskesdas 2013 National breastfeeding coverage was 54.3%. Data on the Indonesian Health Profile also shows East Nusa Tenggara has decreased breastfeeding coverage from 79.45% in 2017 (Indonesian Ministry of Health, 2018) to 70.07% in 2018 (Kementerian Kesehatan Republik Indonesia, 2019). Data obtained from the registration book of the Bakunase Health Center in Kupang City of East Nusa Tenggara in June 2019 contained 40 infants aged 0-2 years. Based on the results of interviews with 40 baby mothers, only ten mothers, or about 39.5% still breastfeeding. Based on these data, it appears that breastfeeding coverage is still low compared to 80% of the national target.
The low coverage of breast milk is caused by many factors, including many mothers find it difficult to meet personal goals and to comply with expert recommendations for continued breastfeeding, even though the initiation rate is increase breastfeeding (Kadir, 2014). Ethnic, cultural, and racial factors also play an essential role in exclusive breastfeeding. Studies conducted (Jones et al., 2015) suggest racial and ethnic minority women have lower breastfeeding rates than white women in the US. White women have the opportunity to participate in support meetings in exclusive breastfeeding. Trusted tradition, and social environment influence support for breastfeeding mothers in exclusive breastfeeding (Choiriyah, Hapsar and Lismidiati, 2016). Mothers obey the practice of giving food/drinks other than breast milk to infants less than two years old because they follow the words of parents who already believe it is hereditary (Hervilia, Dhini and Munifa, 2016).
The health education method is an application of the concept of education in the health field. Health education is an activity to provide or increase public knowledge in maintaining and improving health. The breastfeeding c concept of education is a learning process. This means that in education there is a process of development or change toward more mature, better and more mature individuals, groups or communities, from not knowing about health values to knowing, from not being able to overcome health problems to be able to overcome health problems (Saputro, 2018). The purpose of this study was to explain the effect of Transcultural Nursing-based health education on knowledge, attitudes, actions of mothers, and family support in breastfeeding.

METHOD
This research is a research with pre-post test design in one group ( One-group pre-post test design ). The subject group was observed before the intervention was carried out, then observed again after the intervention. In this study, breastfeeding mothers will be measured twice, pre-test, and post-test as knowledge, attitude, family support, and actions in breastfeeding. The population in this study is breastfeeding mothers who have babies aged 0-2 years. Who routinely have their babies examined at the Bakunase Public Health Center in Kupang City, residents domiciled in Bakunase1, Bakunase 2, and Airnona during November 2019.
The inclusion criteria in this study were breastfeeding mothers who had babies aged 0-2 years old, breastfeeding mothers whose children were also taken care of by grandmothers or sisters, breastfeeding mothers who could read and write, while the exclusion criteria were breastfeeding mothers who were not willing to be respondents. The sample size in this study was determined using purposive sampling in a population of 65 people, a confidence level of 95%, and an error rate of 5%, obtained 30 samples.
The mother's knowledge questionnaire in exclusive breastfeeding was developed based on the concept of exclusive breastfeeding theory and the knowledge questionnaire about breastfeeding from Vijayalakshmi (2015) uses a scale of knowledge level consisting of 15 questions.
Assessment of the mother's knowledge variable with code 0 = false, 1 = true then the researcher sums up the score and changes it in the form of a percentage and gives a code on the assessment of the mother's knowledge with; good: total score of 76% -100% (Code 3), enough 56% -75% (code 2), and less ≤ 56% (code 1).
Iowa Infant Feeding Attitude Scale (IIFAS). IIFAS or the Iowa infant feeding attitude scale designed in 1999 by De La Mora and Russel to measure maternal attitudes towards breastfeeding and predict the choice of methods to be used in infant feeding has been widely used in international research (Dusdieker, 1999;Utami, 2018).
The questionnaire on the actions of mothers in exclusive breastfeeding was developed from a previous research questionnaire, according to Vijayalakshmi (2015), and the concept of exclusive breastfeeding theory uses a Likert scale consisting of 10 questions.
Social factors questionnaire and family support for respondents. Social and family support factor questionnaire using the Nursalam questionnaire (2017), which was modified by researchers into 17 questions and includes emotional support, appreciation support, support, material/facility support, and information/knowledge support. Questionnaire guidelines are measured on a Likert scale. Answer choices consist of always = 4, often = 3, sometimes = 2, and never = 1 with less categories = <55%, enough = 55-75%, good => 75% The dependent variable was knowledge, attitudes, actions, and family support measured by the mother's knowledge questionnaire, the mother's attitude questionnaire, the mother's action questionnaire, and the social and family support questionnaire. The independent variable is transcultural nursing-based health education measured by Standard Operational Procedure (SOP).
The normality test using Kolmogorov-Smirnov where the results showed the value of several variations of the significant value of more and less than 0.05, it can be concluded that this research data is not normally distributed, so it is breastfeeding able to use the Wilcoxon test in analyzing respondent data (Table 1)

RESULT
From table 2, it can be seen that the majority of mothers aged 31-40 years amounted to 53.3%, a total of 16 people, and respondents aged 20-30 years amounted to 40.0%, many 12 people, and other respondents aged 41-50 years amounted to 6 7% of 2 people. Most of the age of the baby are babies aged six months -1 year by 50.0%, many 15 people and others one year -2 years and three years -4 years by 46.7% and 3.3% many 14 babies and one the baby. Most of the respondents in their education level graduated from high school by 76.7% totaling 23 people and a small number of others from elementaryjunior high school and university level by 6.7% and 16.7% by two people and five people. Most respondents' monthly income is < 1,500,000 IDR in the amount of 56.7% totaling 17 people.  Table 3 showed that prior knowledge was given in the good and sufficient treatment category of 11 respondents (37%), and respondents in the lacking category were eight respondents (26%). In the post-test / after the treatment of respondents with a good category of 29 respondents (97%), and less categories amounted to 1 respondent (3 %). Respondents with enough categories as many as 1 respondent (3.3 %). Wilcoxon analysis results show the value of p = 0.000, which means there is a difference in knowledge between pre-test and post-test in the group. This is caused by the provision of transcultural nursing-based health education that involves religious leaders, community leaders, health workers, and researchers themselves. The attitude of the mother before being given a positive category treatment was three respondents (10%) and for the negative category 27 respondents (90%). The attitude of the mother after being given a positive category as many as 24 people (80%) and for the negative category as many as 6 respondents (20%). Wilcoxon analysis results show the value of p = 0.000, which means there is a difference in knowledge between pre-test and post-test in the group. The actions in the treatment group before being given the majority treatment in the negative category were 30 respondents (100.0% ), and no action was found in the positive category. Actions in the treatment group after being given the majority treatment in the negative category were 29 respondents (96.7%) and found actions in the positive category were one respondent (3.3%). Social and family support in the treatment group before being given majority treatment in the good category was 21 respondents (70%) and nine respondents (30%) and found no social and family support in the poor category. Social and family support in the treatment group after being given the majority treatment in the good category were 24 respondents (80%), and six respondents (20%) were in the sufficient category, and no social and family support was found in the poor category.

DISCUSSION
The results of this study showed that Wilcoxon test values with p: 0,000 showed that there was a strong influence of transcultural nursing-based health education on knowledge, attitudes, actions of mothers, and family support in breastfeeding. This is in line with research (Jones, Power, Queenan, & Schulkin, 2015), which says that ethnic, cultural, and racial factors also play an important role in exclusive breastfeeding. The influence of transcultural nursing-based health education on maternal attitudes is very influential because mothers breastfeeding at the Bakunase health center where they are given health education after breastfeeding mothers become more understanding to clean their breasts before breastfeeding their babies using soap. (Hervilia, Dhini and Munifa, 2016) in their research said that the mother's attitude in giving breastfeeding was influenced by the health education that the mother had received when re-controlling at the hospital. The influence of transcultural nursing-based health education on knowledge has a strong influence. This is in accordance with research (Hastuti, Machfudz and Febriana, 2015) which says that there is a strong relationship of breastfeeding mothers 'experience with mothers' educational levels when giving milk to their babies, where when the culture of nursing mothers is good than when they give birth to their second or third child then they already have knowledge about how to breastfeed properly. This is the same as mother's attitudes that after being given transcultural nursingbased health education have changed because there is a strong influence, research (Pradany & Margawati, 2016) says that there is a strong relationship when transculturalbased nursing health education in nursing mothers class toward mothers' attitudes breastfeeding. Providing additional food other than breast milk before the baby is 2 years old in Kupang City is the baby is given "regal" biscuits, "milcuit" biscuits, and "banana" s with the reason that the baby does not feel hungry. Providing "regal" biscuits, "milna" and " banana" biscuits as a complement to breastfeeding before the age of 2 years because parents believe these biscuits can eliminate hunger for the baby. The provision of Transcultural nursingbased health education in the work area of the Bakunase Public Health Center has never been made. Direct involvement from religious leaders, community leaders, and health workers in providing education can add insight into breastfeeding mothers and families who are present in sorting out how to breastfeed properly. Social and family support for nursing mothers is very influential

CONCLUSION
Based on health education, Transcultural nursing gives effect to the knowledge of the mother in breastfeeding, after the administration of health education is increasing breastfeeding in the knowledge of mothers breastfeeding. Based on health education, Transcultural nursing gives effect to the breastfeeding mother's attitude. The attitude of the mother in breastfeeding be grown to deliver milk to children. Transcultural nursing -based health education has an influence on the actions of mothers in breastfeeding, the actions of mothers in giving breastfeeding are increased. Transcultural nursing -based health education influences family support for mothers in breastfeeding has a major influence on family support for mothers in breastfeeding. For nurses, the results of this study can be used as information in providing nursing care to breastfeeding patients by providing transcultural nursing -based health education interventions as an alternative or companion to increase maternal knowledge, maternal attitudes, and maternal actions when breastfeeding. For further research, researchers can then conduct research-based health education Transcultural nursing at different targets and can perform analyzes of factors related to knowledge, attitude, mothers' action, and family support in breastfeeding