challenges, strategy and health treatment approach to nutrition and
Transcription
challenges, strategy and health treatment approach to nutrition and
INTERNATIONAL SEMINAR CHALLENGES, STRATEGY AND HEALTH TREATMENT APPROACH TO NUTRITION AND MOLECULAR EPIDEMIOLOGY Organized by : HEALTH POLYTECHNIC OF HEALTH MINSITRY MEDAN INSTITUTE OF HEALTH SCIENCE OF SUMUT MEDAN INSTITUTE OF HEALTH SCIENCE OF NAULI HUSADA MEDAN INSTITUTE OF HEALTH SCIENCE OF HAJI MEDAN AND UNIVERSITY OF PHILIPPINES, BURAPHA UNIVERSITY, NATIONAL EPIDEMIOLOGY NETWORK (JEN) AND PADJAJARAN UNIVERSITY (UNPAD) Date Vanue Website Email : Wednesday, 20 th May 2015 : Auditorium of Poltekkes Kemenkes Medan Jl. Djamin Ginting Km. 13.5 Lau Cih Medan : www.poltekkes-medan.ac.id : [email protected] 2015 USU Press Art Design, Publishing & Printing Gedung F, Pusat Sistem Informasi (PSI) Kampus USU Jl. Universitas No. 9 Medan 20155, Indonesia Telp. 061-8213737; Fax 061-8213737 usupress.usu.ac.id © USU Press 2015 Hak cipta dilindungi oleh undang-undang; dilarang memperbanyak menyalin, merekam sebagian atau seluruh bagian buku ini dalam bahasa atau bentuk apapun tanpa izin tertulis dari penerbit. ISBN 979 458 793 1 Perpustakaan Nasional Katalog Dalam Terbitan (KDT) Proceeding: Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology / Editor: Bhisma Murti [et.al.] – Medan: USU Press, 2015. xix, 371 p.: ilus.; 29 cm ISBN: 979-458-793-1 1.Strategy – Health Treatment I. Title Dicetak di Medan, Indonesia ii 2. Nutrition 3. Molecular Epidemiology AKNOWLEDGEMENT We convey our deepest thankful for great contribution from all distinguished resource person and sponsors in this conference. 1. The Chairman of Indonesian Agency For Development And Empowerment Human Resources Of Health 2. Health Department Head of the North Sumatra Province 3. All the Directors of Indonesian Health Polytechnic of Health Ministry 4. Joshua Ares Marcos, MD.DPAFP, MSc.,MPH,PhD (University of Philippines) 5. Prof. Dr. Aporn Deenan (Associate Dean For Research and academic affairs Burapha University) 6. Prof. dr. Bhisma Murti, MPH, MSc, Ph.D (Chairman of National Epidemiology Network (JEN) and Chairman of Community Health Magister of Sebelas Maret University 7. Prof. Dr.dr. Nurhalim Sahib from Padjajaran University (UNPAD) 8. Prof. Dr.dr. Bidasari Lubis SPA 9. The Chaiman of all Health Institute in North Sumatra Province 10. The Chairman of all Health Institution in North Sumatra Province 11. The Directors of Haji Adam Malik Center General Hospital dan dr.Pirngadi General Hospital 12. Sponsors : PT.Kimia Farma, PT. iii CONTENTS Page Acknowledgement .............................................................................................................. iii Content .............................................................................................................................. iv Steering Committee and Organizing Comittee ................................................................... v Welcome Speech of Director ............................................................................................. viii Report Speech of Committee Chairman ............................................................................. x Tentative Schedule Activities International Seminar ......................................................... xii List Presenter Oral Presentation ......................................................................................... xiv Poster List Presenter ........................................................................................................... xvii Oral Presentation ................................................................................................................ 1 Poster .................................................................................................................................. 237 iv STEERING COMMITTEE DAN ORGANIZING COMMITTEE SEMINAR INTERNATIONAL HEALTH POLYTECHNIC MEDAN, STIKESSU, STIKES NAULI HUSADA DAN STIKES RS HAJI MEDAN TAHUN 2015 A. Person in the monitor : drg. Usman Sumantri, M.Sc (Kepala Badan PPSDM Kesehatan Kemenkes RI) B. Person In Charge : 1. dr. Kirana Pritasari, MQIH (Kepala Pusat Pendidikan & Pelatihan Tenaga Kes) Dra. Ida Nurhayati, M.Kes (Direktur Poltekkes Kemenkes Medan) 2. C. Steering Committe 1 2 3 4 5 6 7 8 9 D. Organizing Committee Chairman Vice of the chairman Secretary Cashier Vice of cashier Secretariat Dra. Trini Nurwati, M.Kes. (Kepala Bidang Pengendalian Mutu Pusat Pendidikan dan Pelatihan Tenaga Kesehatan) dr.Rr. Siti Hatati Surjantini, M.Kes (Kepala Dinas Kesehatan Prov Sumut) Soep, S.Kp, M.Kes (Pudir I) Nelson Tanjung, SKM, M.Kes (Pudir II) Dra. Ernawaty, M.Si, Apt (Pudir III) Ir. Zuraidah Nasution, M.Kes (Komite Etik) Dr. Paul Sirait, SKM, MM. M.Kes (Ketua STIKESSU) Dra. Meiyati Simatupang, SST,M.Kes (Ketua STIKES Nauli Husada) Hj. Masdalifa, S.Kep, SKM, M.Kes (Ketua STIKES RS Haji Medan) : Fauzi Romeli, SKM, M.Kes : Elizawarda, SKM, M.Kes : Yusrawati Hasibuan, SKM, M.Kes : Hara Habibi Hasibuan, SE : Yusniar, SE Salim Fahri Harahap, S.Sos, MM : 1. (Koordinator) 2 Dodoh Khodijah, SST, MPH Manotar Sinaga, S.Kep (stikes Nauli 3 Husada) 4 Wan Masnah, SE, MM (Stikes RS Haji) v E. Section Programs and Events : 1. 2 3 4 F. Peer Review : 1. 2 3 4 5 G. Section Seminar : 1. 2 3 4 H. Section Accommodation Transportation : 1. 3 and Supplies I. Section Consumption 2 4 : 1. 2 3 4 J. Section Publication and : 1. Dokumentation 2 3 4 K. Seksi Fund & Sponsorhip : 1. 2 3 vi Tengku Sri Wahyuni, SST, M.Keb (Koordinator) Ronald Sagala, S.Kep, Ns.M.Kep (Stikes Nauli Husada) Evawani Martalena Silitonga, SKM, Msi (STIKESSU) Hj. Yusridawati, S.Kep, M.Kep (Stikes RS Haji) Prof. Dr. Bhisma Murti, MPH, MSc,Ph.D Prof. Dr. Apron Deenan Prof. Dr. dr. Nurhalim Sahib Jouhua Ares Marcos, MD.DPAFP, MSc, MPH, PhD Dr. Sri Wahyuni, SPd, M.Kes Endang Susilawati, SKM, M.Kes (Koordinator) Yulina Dwi Hastuty, S.Kep, Ns, M.Biomed Mazly Astuty, S.Kep, Ners,M.Kep (STIKESSU) Donal Nababan, SKM,M.Kes (STIKESSU) Betty Mangkuji, SST, M.Keb (Koordinator) Drs. Zainuddin Harahap, M.Kes Yuli Azni Hartaty Penarik, S.Kep.Ns (Stikes Nauli Husada) David Siagian, SKM, M.Kes (STIKESSU) drg. Adriana Hamsar, M.Kes (Koordinator) Suryani, SST, M.Kes Marisa Evi Sinurat, S.Kep.Ns (Stikes Nauli Husada) Roslenni Sitepu, SKp, MARS (STIKESSU) Bernike Doloksaribu, SST, M.Kes (Koordinator) Meilda Fitri Sitepu, S.Kep, Ns (Stikes Nauli Husada) Sri Malem Indirawati, SKm,Msi (STIKESSU) Juidah, S.Kep, SKM, M.Kes (Stikes RS Haji) Nelma, SSi, M.Kes (Koordinator) Idau Ginting, SST, M.Kes Della Winda Gultom, SE (Stikes Nauli Husada) L. M. Security Section Guest Section 4 Dian Fajariadi, Skep, Ners, M.Kep (STIKESSU) 2 Erba Kalto Manik, SKM, M.Sc (Koordinator) Mardan Ginting, SSi, M.Kes : 1. : 1. 2 Dra. Masniah, Apt, M.Kes (Koordinator) Eveline M. Siagian, SKM, M.Kes (Stikes Nauli Husada) Direktur, Dra. Ida Nurhayati, M.Kes NIP 196711101993032002 vii WELCOME SPEECH OF DIRECTOR Wassalam / Good Morning The honorable guest/ The Indonesian Agency For Development And Empowerment Human Resources Of Health….drg.Usman Sumantri, M.Kes Guest of honour/ Director of Medan Health Polytechnic of Health Ministry Guest Of Honour/ Health Department Head of the North Sumatra Province Guest of honour/ All the Directors of Indonesian Health Polytechnic of Health Ministry Guest of honour/ The Chaiman of all Health Institute in North Sumatra Province Guest of honour/ The Chairman of all Health Institution in North Sumatra Province Guest of honour/ The Directors of Haji Adam Malik Center General Hospital dan dr.Pirngadi General Hospital Distinguished Speakers/ from University of Philippines : Joshua Ares Marcos, MD.DPAFP, MSc.,MPH,PhD, from University of Burapha Thailand ; Prof. Dr. Aporn Deenan. (Associate Dean For Research and academic affairs Burapha University, Chairman of National Epidemiology Network (JEN) and Chairman of Community Health Magister of Sebelas Maret University : Prof. dr. Bhisma Murti, MPH, MSc, Ph.D, Prof.Dr.dr. Nurhalim Sahib from Padjajaran University (UNPAD) Excelency / The Lectures and all Health Students Excelency/ all steering committee Colleagues Ladies and Gentleman Good morning to everyone and thank you so much for joining us in International seminar. I wish to extend a warm welcome to our eminent speakers and delegates from the various country such Thailand and Philippines, and Speakers from JEN and UNPAD (Padjajaran University). Welcome to Medan that is one the best province of Indonesia. We are delighted and honored to have you all here with us to participate and share an important and valuable information to improve the quality of our health and life. Nowadays, the development of science, especially in the health field occur very rapidly. The development of health in terms of epidemiology and biomolecular also experienced substantial viii increases associated with the emergence of more and more different kinds of diseases, especially cancer. If the growth is not cancerous quickly stopped and treated and untreated, the cancerous growth will be very dangerous, and can spread to organs throughout the body called metastasis.The theme of this seminar is “ Challenges, strategy and treatment of health problem with nutrition and molecular epidemiology approach”. The theme highlights the overall description challenges, strategies and treatment of health problem through nutrition and molecular epidemiology and all this overview will help us to improve health and prevent the disease. At this special moment, I wish to take opportunity to say thank for all committee members and all those who have contributed their best effort in making this seminar succeed. I would like to thank the The Agency For Development And Empowerment Human Resources Of Health, director of Health polytechnic of health ministry Medan, North sumatera institute of health science (Stikes sumut) Nauli husada institute of health scienceand Haji institute of health science for the best support in making the seminar possible. I would like to thank all the distinguish speakers and reviewers for abstracts and posters that has submitted to this seminar. Last but not least, I would also like to thank to all participant for your participation and support for this seminar. Thank you very much for coming and your kind attention. Thank you…… ix REPORT SPEECH OF COMMITTEE CHAIRMAN Wassalam / Good Morning The honorable guest/ The Indonesian Agency For Development And Empowerment Human Resources Of Health….drg.Usman Sumantri, M.Kes Guest of honour/ Director of Medan Health Polytechnic of Health Ministry Guest Of Honour/ Health Department Head of the North Sumatra Province Guest of honour/ All the Directors of Indonesian Health Polytechnic of Health Ministry Guest of honour/ The Chaiman of all Health Institute in North Sumatra Province Guest of honour/ The Chairman of all Health Institution in North Sumatra Province Guest of honour/ The Directors of Haji Adam Malik Center General Hospital dan dr.Pirngadi General Hospital Distinguished Speakers/ from University of Philippines : Joshua Ares Marcos, MD.DPAFP, MSc.,MPH,PhD, from University of Burapha Thailand ; Prof. Dr. Aporn Deenan. (Associate Dean For Research and academic affairs Burapha University, Chairman of National Epidemiology Network (JEN) and Chairman of Community Health Magister of Sebelas Maret University : Prof. dr. Bhisma Murti, MPH, MSc, Ph.D, Prof.Dr.dr. Nurhalim Sahib from Padjajaran University (UNPAD). Excelency / The Lectures and all Health Students Excelency/ all steering committee Colleagues Ladies and Gentleman Good morning to everyone and thank you so much for joining us in International Seminar Challenges, strategy and treatment of health problem with nutrition and molecular epidemiology approach. I wish to extend a warm welcome to our eminent speakers and delegates from the various country such Thailand and Philippines, and Speakers from JEN and UNPAD (Padjajaran University). Welcome to Medan that is one the best province of Indonesia. We are delighted and honored to have you all here with us to participate and share an important and valuable information to improve the quality of our health and life. The theme of this seminar is “ Challenges, strategy and treatment of health problem with nutrition and molecular epidemiology approach”. x The Purposes of this seminar are : a.To increase understanding of current health problems (cancer) in the light of biomolecular b.To give awareness for prevention of cancer c.To give information and education about the prevention and treatment of cancer The Speakers of this seminar are : 1. University of Philippines : Joshua Ares Marcos, MD.DPAFP, MSc.,MPH,PhD 2. University of Burapha Thailand ; Prof. Dr. Aporn Deenan. (Associate Dean For Research and academic affairs Burapha University. 3. Chairman of National Epidemiology Network (JEN) and Chairman of Community Health Magister of Sebelas Maret University : Prof. dr. Bhisma Murti, MPH, MSc, Ph.D 4. Prof.Dr.dr. Nurhalim Sahib from Padjajaran University (UNPAD) 5. Indonesian Cancer Foundation of North Sumatera area 6. Physics practitioner from Murni Teguh Memorial Hospital and chairman of Indonesian medical physics in Sumatera: Ikhsan Bagatondi, ST, MSi. The Activity of seminar are : 1.Oral Presentation with audio-visual methods by ........... article 2.Panel Discussion between participants and speakers. 3.Poster Presentation by ........... Article Participants a.Students of health academy in North Sumatra b.Health workers (doctors, nurses, midwives, etc.) c.General participants And amount of all participants are one thousand and six hundreds (1600) persons. At this special moment, I wish to take opportunity to say thank for all committee members and all those who have contributed their best effort in making this seminar succeed. I would like to thank the The Agency For Development And Empowerment Human Resources Of Health, director of Health polytechnic of health ministry Medan, North sumatera institute of health science (Stikes sumut) Nauli husada institute of health scienceand Haji institute of health science for the best support in making the seminar possible. I would like to thank all the distinguish speakers and reviewers for abstracts and posters that has submitted to this seminar. Last but not least, I would also like to thank to all participant and delegates for your participation and support for this seminar. Thank you very much for coming and your kind attention. At last, I encourage all delegates and participants to participate actively in this seminar including oral presentation and poster and I wish we will have a very productive, successful and meaningful seminar. Thank you xi TENTATIVE SCHEDULE ACTIVITIES INTERNATIONAL SEMINAR WEDNESDAY, 20 MEI 2015 MC GENERAL ACTIVITIES: 1. Yetty Fauziah, M.Kep (STIKES Haji) 2. Hanna S Saragih, M.Kes (Department of Midwifery) TIME 07.00-07.45 ACTIVITIES REGISTRATION SPEAKER 07.45-08.30 Opening Dance ---------------------------------- Students from the Department of Midwifery Opening ------------------------------------------- Protocol National Ceremony ------------------------------ Melva Simatupang M.Kes Pray ------------------------------------------------ Ganti Tua Siregar SKP MPH Chairman Of The Committee Reports -----Fauzi Romeli SKM M.Kes Message From The Director Of health Polytechnic Medan ------------------Dra. Ida Nurhayati M.Kes MODERATOR & NOTULEN Committee Committee Guidance and Direction also opening the Head of Human Resources seminar -------------------------------------------- Development and Empowerment of Health .... drg Usman Sumatri M.Sc 08.30-09.00 Government policies in the handling and prevention of cancer in Indonesia drg Usman Sumatri M.Sc Moderator : Haripin Togap Sinaga BSc M.CN (Department of Nutrition) Notulen : Mazli Astuti 09.00-10.20 Epidemiology of cancer , carcinogenesis and a screening Universitas Sebelas MaretSurakarta Prof. dr. Bhisma Murti, MPH, MSc, Ph.D Molecular oncology: gene expressions, cell death signaling, and biomarker development Universitas Padjajaran Bandung Prof.Dr.dr. Nurhalim Sahib Moderator : Evawani Martalena Silitonga, SKM, MSi Notulen : Evi Irianti, SKM, M.Kes (Department of Midwifery) 10.20-10.50 10.50-11.00 Discuss Souvenir 11.00-12.20 The role of health professionals in the treatment of cancer Universitas Phillipine : Joshua Ares Marcos, MD.DPAFP, MSc.,MPH,PhD Moderator : Haripin Togap Sinaga BSc M.CN (Department of Nutrition) Cancer management: collaboration among health care professional Universitas Burapha Thailand: Prof. Dr. Aporn Deenan. (Associate Dean For Research and academic affairs Burapha University. Notulen : Donald Nababan, SKM, M.Kes (Stikes SU) Committee 12.20-12.50 12.50-13.00 13.00-14.00 Discuss Souvenir Rest and Lunch 14.00-15.00 Early recognition of childhood cancer Child Oncology Foundation Medan /Universitas Sumatera Utara Prof. Dr.dr. Bidasari Lubis, SPA The role of radiotherapy in cancer treatment Teguh Murni Internasional Hospital Ikhsan Bagatondi, St, M.Si 15.00-15.30 15.30-15.40 15.40-16.30 xii Discuss Souvenir Doorprice Performing Arts / Evaluation Poster Committee Committee Committee Moderator : Rosanty Muchsin, S.Kep, M.Kes (Stikes RS Haji) Notulen : Desi Ari (Department of Environmental Health) Committee Committee Sponsor Untuk oral presentasi : Rabu/ 20 Mei 2015 Waktu 14.00-14.30 14.30-14.45 Ruang I Kep Gigi Lt 2 Ruang II R. Rapat kebidanan ( Ruang III lab kebidanan( Ruang IV Lab terpadu( 25-30 ( 25-30 Orang ) 25-30 Orang ) 25-30 Orang ) Reviewer : Dr Joshua M Reviewer : Prof Aporn D Reviewer : Prof Bhisma M Reviewer : Prof Nurhalim Moderator : Donald N Moderator : Mazli Moderator : Sri Malem Moderator : Evi Irianti Notulen : Maya Notulen : Masrah Notulen : Kirana P S Notulen : Yulina Dwi H Sessi I Sessi I Sessi I Sessi I Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) (Soep , dkk, Nurlaili R dkk, (Farida dkk, Amira dkk, Renny (Nelson dkk, Hermansyah (Mustikawati dkk, Trisnawati, Bina M) dkk) Reviewer Orang ) dkk, Desi Sri dkk) Hotma dkk) Reviewer Reviewer Reviewer 15.00-15.30 Reviewer : Dr Joshua M Reviewer : Prof Aporn D Reviewer : Prof Bhisma M Reviewer : Prof Nurhalim Moderator : Evawani Moderator : Hotma Moderator : Desi Ari H Moderator : Haripin T Notulen : Amira P Notulen : Marlisa Notulen : Asnita S Notulen : Rosanti Muhsin Sessi II Sessi II Sessi II Sessi II Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) (Sartini 15.30-15.45 16.00-16.30 dkk, Delmaifanis (Nurlama dkk, Nurasnah dkk, (Nurul dkk, Herlinawati (Sri dewi dkk, Ikhsan B dkk, dkk, Idau G dkk) Risma D dkk} dkk, Hermansyah) Cindy dkk) Reviewer Reviewer Reviewer Reviewer Sessi III Sessi III Sessi III Sessi III Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) (Soep dkk, suryani dkk, (Netty Panjaitan, dkk, Suriani (Betty M, dkk, Dodoh, (Melva dkk, Desprin dkk, T.Sri wahyuni dkk) G dkk, Siti Marlina, dkk) dkk) 16.30-16.45 Mariaty dkk) Reviewer Reviewer Reviewer Reviewer Ruang II Ruang III Ruang IV 09.00- 09.30 Sessi I Sessi I Sessi I Sessi I 09.30- 09.45 Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Reviwer Reviwer Reviewer Sessi II Sessi II Sessi II Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Reviwer Reviwer Reviewer Sessi III Sessi III Sessi III Presentasi (3 presenter) Presentasi (3 presenter) Presentasi (3 presenter) Reviwer Reviwer Kamis/ 21 Mei 2015 Waktu Ruang I Reviwer 10.00- 10.30 Sessi II 10.30- 10.45 Presentasi (3 presenter) Reviwer 11.00- 11.30 Sessi III 11.30- 11.45 Presentasi (3 presenter) Reviwer Reviewer xiii LIST PRESENTER ORAL PRESENTATION NO 1. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 xiv TITLE Effects Of Breastfeeding Counseling Self-Efficacy (Bse) In Pregnant Women Towards Immediate Breastfeeding And Giving The Colostrum In Independent Effect Workstress; Psychological Distress On Immune System Kortisol Levelsand Immunoglobulins Gnurse The Effectiveness Of Lavender Aromatherapy In Reducing Pain Intensity Of Patients With Breast Cancer In Rb2 Rsup Haji Adam Malik Medan 2014 Qualitative Study Of Premarital Sexual Behavior In Girls Adolescent At Dharma Bakti Senior Senior High School 2014 Effectiveness Reject Power Test Of Neem Leaf Extract ( Azadirachta Indica Juss ) In Ethanol On The Bite Activities Of Aedes Aegypti Mosquito Description Of Anxiety Levels On School-Age Children During Having Been Hospitalized In Local General Hospital Of Dr. Djasamen Saragih Pematang Siantar The Influence Of Music Therapy On The Stress Due To Hospitalization In School Age Children At Dr. Pirngadi General Hospital Medan Mapping The Risk Factor Of Leptospirosis In Klaten District The Effect Of Isotonic Water To The Active Phase Of Primiparous Uterine Contractions Relationship Of Mother’s Knowledge About Polio Immunization In Village Mancang Community Health Centers With Mother’s Behavior Post Infant’s Polio Immunization Selesai- Langkat 2014 Effect Of Counseling Anxiety In Dealing With Labor Primigravida In The Community Health Centers Buket Hagu Lhoksukon North Aceh The Impacts Of Breastfeeding Counseling By Kader Kesehatan (Lay Health Workers) On The First Month Exclusive Breastfeeding (E1) Among Breastfeeding Women In Darul Imarah Sub-District Satisfaction Of People With Disabilities On Rehabilitation Services In Aceh Province Knowledge Description Of Pregnant Women On Bonding Attachment At Third Trimester In Sehat Maternity Clinic Of Pantai Cermin Sub District 2014 Acceptability Purple Sweet Potato Butter Cake And Carbohydrate Analysis For Diabetics Snack The Influence Of Cooking On Crude Fiber Content Of Boiled Spinach And Kale Steamed PRESENTER T. Sri Wahyuni dkk REVIEWER Dr Joshua M Triniswati Prof Nurhalim Nurlama dkk Prof Aporn Deenan Soep dkk Dr Joshua M Mariaty dkk Prof Nurhalim Farida dkk Prof Aporn Deenan Triyonita Prof Aporn Deenan Nelson dkk Prof Bhisma Murti Delmaifanis dkk Dr Joshua M Betty M dkk Prof Bhisma Murti Idau G dkk Dr Joshua M Nurlaili R dkk Dr Joshua M Hermansyah dkk Prof Bhisma Murti Suryani dkk Dr Joshua M Cindy dkk Prof Nurhalim Mustikawati Prof Nurhalim 17 Factors Affecting Knowledge Of Pregnant Women About Nutrition During Pregnancy In Portibi Sub District 2012 The Effectiveness Of Beethoven’s “Fur Elise’ As Classical Music Therapy On Lowering Stroke Clients’ Blood Pressure In The Inpatient Rooms Of Dr. Pirngadi Correlation Of Elderly Knowledge And Attitude To The Utilization Of Elderly Integrated Service Post In Community Health Center Of Tanah Tinggi Binjai 2013 Disaster Risk Index In Simeulue District (Study Case: Disaster Prone Areas Of Aceh Province) Anemia In Connection With Pregnancy Trimester Iii Postpartum Bleeding Events In Dandy Clinic Kec. Mabar 2014 Ida Nurhayati Dr Joshua M Afniwati dkk Prof aporn Deenan Elizawarda Prof Bhisma M Desi Sri dkk Prof Bhisma M Sartini B Dr Joshua M 22 Relationship Between Maternal Age With Severe Preeclampsia In Marzoeki Mahdi Hospital Bogor Dodoh K dkk Prof Nurhalim 23 Personal Hygiene During Menstruation In Female Teenegers At Junior High Schools 34 Padang City West Of Sumatera Indonesia Relationship Between Maternal Blood Glucose Level And Newborn’s Birth Weight In Maternity Clinic Of Medan Selayang District 2014 The Role Of Radiotherapy In The Treatment Of Cancer The Association Between Mother’s Education And The Amount Of Dental Caries In First Molar Teeth In 6-7 Years Old Of Sd Baptis Of Medan Denai In 2014 The Influence Of Antenatal Class Towards IIIrd Trimester Primigravida Mothers’ Level Of Anxiety In Facing Child Birth The Relationship Of Anxiety Level To The Sleep Og Inguinal Hernia Preoperative In Patient At Dr Pirngadi Hospital Medan Phenomenological Study On Pregnancy Care Experience In Mothers At Jorong Berastagi Nagari Ujung Gading, Lembah Melintang Subdistrict, Pasaman Barat, West Sumatera Parent Communication Relationship And Exposure Fornografi Knowledge Of Youth On Sexual Behavior In Adolescent In Sma Al-Abdi Bahlias Emplasment, Pt. Pp. Lonsum. 2014 The Effects Of Guided Imagery On Dysmenorrhoea Intensity And Hemoglobin Levels Factors Associated With Nutritional Status Street Children In The City Pematangsiantar Relationships Of Precipitating Factors And Predisposing Factor To Hypertension Incident In Internist Polyclinic Of Dr.Pirngadi General Hospital Medan 2014 Risk Factors Influencing ISPA In Toddler At Puskesmas Tanjung Paku Solok City 2014 Sri dewi dkk Prof Nurhalim Melva dkk Prof Nurhalim Ikhsan B Prof Nurhalim Herlinawati dkk Dr Joshua M Bina melvia Dr Joshua M Suriani dkk Prof Aporn Deenan Nurul Azmi / nur afidarti Prof Bhisma Renny dkk Prof Aporn Hotma S Prof Nurhalim Desprin S dkk Prof Nurhalim Risma D dkk Prof Aporn 18 19 20 21 24 25 26 27 28 29 30 31 32 33 34 Yulastri xv 35 36 37 38 xvi Description Of Knowledge Of Hiv/Aids By The Eleventh Year Student Of Sman 1 Kutalimbaru Deli Serdang District 2014 Factors Associated With Elderly Visits To Elderly Integrated Service Post In Durian Kenagarian Gadang Puskesmas Gambok Sijunjung 2014 Analysis Preparedness Of General Hospital Dr. Fl. Tobing Sibolga In Implementation Of Assurance National Health Policy 2014 Effect Of Cutaneousslowstrokebackmassage Stimulustodecreasepainintensityin Low Backpainpatients Inpuskesbundivisionii Of Pt.Sucfindomatapao Serdangbedagai Netty Panjaitan Okky Efriza Siti Marlina Dina Yusdiana, dkk POSTER LIST PRESENTER NO 1 2 3 4 5 6 7 8 9 10 11 12 13 TITLE The Knowledge Of Teenage Girls On Cervical Cancer Identification Of Native Plants Use As Traditional Medicine In District Central Kalimantan Province The Effect Of Family Psychoeducation Therapy Toward The Parent’s Ability To The Mental Retardation Child Independency In Slbn-1 Palangka Raya Factors Related To Exclusive Breast Feeding In Puskesmas Bukit Hindu Palangka Raya City Central Borneo 2012 Sexual Adjustment In Patients Diabetes Mellitus ANTIBACTERIAL EFFECT TEST OF RED BETEL LEAF (PIPER CROCTUM RUIZ & PAV.) THE GROWTH OF STAPHYLOCOCCUS AUREUS BACTERIA PRESENTER Erlin Puspita Asih Rusmani ORGANIZATION Health Polytechnic Jakarta I Health Polytechnic Kalteng Syam’ani Health Polytechnic Kalteng Berthiana dkk Health Polytechnic Kalteng Dina Indarsita dkk Health Polytechnic Medan Amriani dkk Health Polytechnic Medan Woman’s Knowledge And Attitudes About Participation In The Investigation IVA Test (Visual Inspection Of Acetic Acid) In Dusun IV Desa Tengah Pancur Batu Sub-District Deli Serdang Regency 2014 Menyirih Habits Relationship With Susceptibility Of Oral Health Perceived Communities In Kelurahan Lau Cih Medan Tuntungan 2015 Suswati, Yulina, Dewi M Keb Medan Etty S dkk JKG Test Different Seeds Tamarind With Cloves In Lowering Ohi-S On The Students Of Smk Yoshua Medan Medan Perjuangan Subdistrict 2015 A CORRELATION OF KNOWLEDGE AND ATTITUDE OF MOTHER IN PROVIDING THE COMPLEMENTARY FOOD OF BREAST MILK TO THE BABY IN AGE 0-6 MONTH AT SEKIP RURAL VILLAGE Adriana H dkk JKG Yenni Z dkk Gizi The Effect Of Olive Oil (Olea Europeae) Concentrations On Sun Protection Factor (Spf) Value Of Sunscreen Cream In Combination With Avobenzone And Octyl Methoxycinnamate In Vitro Evaluation Of Antibiotic Dose Appropriateness In Patients With Chronic Renal Failure In Haji Adam Malik Hospital Medan On Period January – June 2014 Maizatun dkk Farmasi USU Maya Natalia dkk Farmasi USU Panal Sitorus dkk Farmasi USU Study Antimicrobial Activity Of Ethanol Extract Curry Leaves (Murraya Koeningii L. Spreng) Against Staphylococcus Aureus And Escherichia Coli xvii 14 The Implementation Of Infection Precautionary Measures At Delivery Aid Process By Private Practice Midwives (Bps) At The sitinjak community Health Center Areaof South Tapanuli Regency 2014 Rosmawati dkk 15 Description Of Mother's Knowledge On Exclusive Breastfeeding In Infants Maslan D dkk 16 The Relationship Between Pregnant Women Knowledge About Prevention Mother To Child Transmission (Pmtct) With Voluntary Councelling And Testing (Vct) Checkup In Tomuan Village Pematangsiantar Period Of April- May 2015 Lastiur S dkk Siantar 17 Anxiety Level Of Families In Facing Schizophrenia Client Behavior At The Polyclinic Of North Sumatra Province Mental Hospital 2014 Johani Kep 18 Knowledge And Attitudes Relationship Of Diabetics Patients Against Diabetic Ulcers Incident At Medan Petisah Community Health Center (Puskesmas)Work Areas 2013 Dina Yusdiana Kep 19 Knowledge About Fluor Albus Hazards To Pregnant Women At Sundari General Hospital 2012 Yusrawati Hsb Keb Medan 20 Overview Of Knowledge And Public Attitude Toward The Use Of Medicine Without Prescription In Yasmin Pharmacy At Jalan Pinang Baris Medan Zulfa 21 The Correlation Between Women’s Knowledge Of Cervical Cancer And Perfoming Pap Smear Test In Obstetric And Gynecological Clinic Of Rsup H. 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The mothers do not know that breastfeeding soon after giving polio immunization may affect the effectiveness of the polio immunization given by mouth. The aim of research to determine the relationship of mother knowledge about polio immunization with the mother's behavior post infant’s polio immunization in Mancang village Community Health Centers Selesai Langkat. There ara 54 mothers as the samples who comes to immunizing infants aged 0-3 months, using purposive sampling. Data were analyzed using Fisher's Exact. Results of this study found that the majority of mothers were both knowledgeable and well behaved post polio immunization in infants 13 people (24.07%), and mothers who are less knowledgeable and less behaved 38 people (70.38). There is a significant relationship between mothers knowledge and behavior after the polio immunization, evidenced by the value of p = 0.000. Conclusions from this research is a relationship between mothers knowledge and behavior after the polio immunization because lower knowledge and behavior of the mothers are also getting less. Therefore, health workers are expected to provide information about polio immunization so that the knowledge and behavior to be better mothers . Keywords : knowledge, behaviors, polio immunization INTRODUCTION Nowadays, fact of the world especially in developing countries every 14.5 million children under five years old were die because of preventable diseases, malnutrition, dehydration due to vomiting and each year 3.5 million children under five die by diseases that could be prevented by immunization, According to Markum (2002 in Widayati, 2009 1) Results of Indonesian Demographic and Health Survey (IDHS) 2007 showed that Infant Mortality Rate (IMR) 34 per 1,000 live births and the Child under five Mortality Rate (CMR) 44 per 1,000 live births. Target achievement of the target in 2015 that Infant Mortality Rate (IMR) 23 per 1,000 live births and the Child under five Mortality Rate (CMR) 32 per 1,000 live births. Based on data from the Directorate General Sub-Directorate Immunization PPM and PLP Health Departement (2004) immunization coverage in Indonesia is per antigen coverage namely to 4 doses of polio reach the target of 85%. The first major outbreak in the United States occurred in 1916, more than 27,000 people affected by this disease and about 6,000 people die and most are children. There are only 1,266 cases of polio around the world until year 2004, mostly found in polio endemic countries, namely Yemen, Nigeria, India, Pakistan, Egypt, Afghanistan, that is in the world, approximately 25% was in Indonesia and was ranked third in this world. The number of polio cases in Indonesia until the date of 21 March 2006 was found in 305 children spread at 10 provinces in Indonesia, namely West Java (59 cases), Banten (160 cases), Central Java (20 cases), Lampung (26 cases), Jakarta (4 jerseys), North Sumatra (10 cases), Riau (3 jerseys), East Java (10 cases), Southern Sumatra (5 cases) and NAD (5 cases). According to the North Sumatra Health Office (2009), achievement of immunization programs in North Sumatra is quite high when viewed from immunization term which the 3 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 306.221 babies are being targeted. It is known that the third polio immunization for babies 286.359 (93.51%). Polio may cause mild or very severe illness symptoms. This disease can affect the digestive system and the nervous system. Polio causes fever, vomits and muscle stiffness and can affect the nerves resulting in permanent paralysis. The disease can paralyze breathing and swallowing muscles that support the process, causing death. Between two and five percent of people with polio will die from this disease and approximately 50% of patients who survive suffer permanent paralysis. Polio can be spread when feces contaminate people with food, water or hands (Proverawati and Andhini 2010 p.56) Poliomyelitis is an acute fever disease caused by the polio virus. There are about 95% of all polio infections. According to estimates of the ratio of the disease without any symptoms of the disease paralatik vary from 50:1 to 1000:1 (average of 200:1). Patients with an infection without excreting the virus with feces can transmit the virus to others. Approximately 4% - 8% of polio infection without clinical symptom. Paralysis occurs as a result of damage to the cells of motor neurons in the medulla spinalist spinal cord) caused due to virus invasion. This paralysis is asymmetrical so inclined to cause deformity (body shape disorder) which tends to stabilize or even become more severe. The vast majority of paralysis will strike the leg (78.6 percent), while 47.4 percent will strike the arm. This paralysis will go gradually and takes 2 days s / d 2 months). According to Nelson (2006 in Widayati 2009, 5) it is important for parents to know why, when, where, and how many times the child should be immunized. The main obstacle to the success of immunization of infants and children in a health care system that is low awareness and a lack need of immunization in community. The entrances to the immunization services are inaccurate, neglect opportunities for vaccine delivery and accurate source for public health and prevention programs. Immunization in infants and children not only give prevention of disease in the child, but also provide a wider impact because it can prevent transmission of the disease to other children. Therefore, the knowledge and attitudes of parents, especially mothers, is very important 2 to understand about the benefits immunization for children in Indonesia. of According to Ranuh (2006 in Widayati, 2009: 6) Mothers knowledge about immunizations affect the implementation of immunization, when the mothers knowledge about immunization are less, feeling of unnecessary or just going along with it, the course immunization in children would not appropriate with the schedule in both time and distance. If mothers knowledge about immunization are good, it’s expected of immunization distribution are on schedule, so that the immunization program can fulfill the quantity and quality of the baby’s health, finally have an impact on improving the health status and community resources in the future. Wahyuhono (2002, in Widayati 2009:8) claim that post-immunization behaviors also affect the success of immunization, where breastfeeding (breast milk) after polio immunization in infants aged 0-3 months can weaken the polio vaccine which dripped into the baby’s mouth, so that polio immunization is not effective. Milk that came out at the time of infants aged 0-3 months contain many antipoliomelitik substances that can neutralize the virus polio vaccine in the children’s gut thus inhibiting the formation of antibody substances. From the description above, we want to know about a Relationship Of Mother’s Knowledge About Immunization Polio With Mother’s Behavior Post Infants Polio Immunization in the Mancang village Community Health Centers Selesai, Langkat in 2014. METHOD This research is descriptive analytic with cross sectional. The design which measurements or observations were made at a certain moment or at one time. All mothers who come to give polio immunization for their baby in Community Health Centers Selesai Langkat during March to June 2014 as many as 115 people become population, and samples are part of mothers who gave polio immunization to their baby at the Community Health Centers Selesai Langkat on March - June 2014. Result Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 1 . Distribution Characteristics of Respondents Who Came For Infant’s Polio Immunisation in the Mancang village Community Health Centers Selesai, Langkat 2014 Characteristics of Respondents 1. Age <20 years 20 – 35 > 35 years Total 2. Education Elementary School Junior High School Senior High School Coledge Total 3. Work Does not work Work Total 4. Resources Mass media Family Health Workers Total Based on Table 1 it can be seen that the demographic characteristics of the mothers who come for their infant’s polio immunization at the age of 0-3 months, the majority of mothers aged 20-35 years old are 35 people (64.81%). Majority of mothers education 23 people (42.60 %) are High School. Majority of mothers job 29 people (53.70%) are unemployed. The source of information that majority given by health care workers can be as many as 32 people (59.25%). Mother knowledge about polio immunization in the Mancang village Community Health Centers Selesai, Langkat can be seen in the following table. f % 13 35 6 54 24,08 64,81 11,11 100 9 18 23 4 16,67 33,33 42,60 7,40 54 100 29 25 54 53,70 46,30 100 14 8 32 54 25,93 14,81 59,26 100 knowledge About Polio Immunization in the Mancang village Community Health Centers Selesai, Langkat 2014 No Maternal knowledge F % 1 2 38 16 70,38 29,62 54 100 Total Less Good Based on the table 2 data obtained on the mother's knowledge about polio immunization is the majority have less knowledge as many as 38 people (70.38%). Mother's behavior post infant’s polio immunization in the Mancang village Community Health Centers Selesai, Langkat 2014, can be seen in the following table 3. 3 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 3. Frequency Distribution Of Mother's Behavior Post Infant’s Polio Immunization In The Mancang Village Community Health Centers Selesai, Langkat 2014 Mother's behavior No Post infant’s polio immunization F % 1 Less 2 Good Total 41 13 54 75,93 24,07 100 Based on Table 3 data obtained on Mother's behavior post infant’s polio immunization is of 54 respondents the majority that behaves less as many as 42 people (77.78 %). Relationship mother’s knowledge about polio immunization with mother's behavior post infant’s polio immunization in the Mancang village Community Health Centers Selesai, Langkat 2014 are as follows: Table 4. Relationship Mother’s Knowledge About Polio Immunization With Mother's Behavior Post Infant’s Polio Immunization In The Mancang Village Community Health Centers Selesai, Langkat 2014 Mother Mother's behavior knowledge post infant’s polio value value about polio immunization Total count table immunization Good Less F % F % f % Less 0 0 38 70,38 38 70,38 Good 13 24,07 3 5,55 16 29,62 0,000 0,05 Total 13 24,07 41 75,93 54 100,0 Based on the research results, majority of mother who come to the community health centers for infant’s polio immunization has less knowledge about polio immunization as many as 38 people (70.38%), which behaves less in the Mancang village Community Health Centers as many as 41 people (75.93%). From the statistical test using Fisher's Exact test with significance level of 5% (0.05) was obtained p = 0.000. So that the results obtained are p < 0.05 then ha received. This means that there is a significant relationship between 4 mother's knowledge about polio immunization with the mother's behavior post infant’s polio immunization in the Mancang village Community Health Centers Selesai, Langkat 2014. Discuss Results of the research that has been done it can be seen that the majority of the 54 respondents are knowledgeable about as many as 38 respondents (70.38%) Sensing occurs through human senses, namely: the senses of sight, hearing, smell, taste and touch. Most of the human knowledge acquired through the eyes and ears. The researchers assumption of mother’s knowledge who give polio immunization to their baby in this study majority of them were less knowledgeable due to their lack of a sense of curiosity and concern for an information about polio immunization. Then it is advisable to all mothers to always be active in seeking information about polio immunization. From 54 respondents can be seen that 13 respondents aged < 20 years were majority knowledgeable as many as 12 respondents (22.22%), and of 34 respondents aged 20-35 years were majority less knowledgeable as much as 22 respondents (40,74%), and from 6 respondents aged > 35 years the majority knowledgeable about as many as 4 respondents (7.41%). Notoatmodjo (2007) stated that age is closely related to a person’s knowledge level because the more human lifespan increased the more the experience or the knowledge that they gained. So there is a gap with Notoatmodjo’s opinion that age affects the person's knowledge. Because in this study there are 6 mother aged > 35 years the majority of them were less knowledgeable as many as 4 respondents (7.41%) and this is because at this age the mothers seem do not care in searching for information because they are more focused on taking care of their family circumstances. Based on the results data obtained from 54 respondents, It can be seen that the 9 respondents graduated from elementary school that less knowledgeable as much as 9 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology respondents (16.67%), of 18 graduated from Junior High School that majority less knowledgeable as many as 14 respondents (25.92%), of the 23 respondents graduated from Senior High School that majority less knowledgeable as many as 14 respondents (25.92%), and of 4 respondents graduated from university that majority well knowledgeable as many as 4 respondents (7.41%). Education in general is all effort that planned to influence others; either individuals, groups and communities. So they will do what is expected by the education actors in the search for knowledge and aspects of life. The level of education has a close relationship with the social, cultural, political, economic, and so on. Education is also one of the factors that influence someone's perception to easily accept new ideas / technologies. There is no gap with Notoatmodjo that is with education someone can grow and develop through the learning process from the education because in the process of learning a person was given a lesson in order to become from not knowing to knowing. So that a person with low education, the lower of his knowledge level that he get, because the less educated tend to be more difficult to understand something or receive information. Vice versa, the higher one's education are more likely easier to receive information and to understand something. These affect their insight. Education also will affect mother’s mindset, attitude and actions. Based on the results of research conducted showed that of the 54 respondents, 25 respondents who worked that majority well knowledgeable as many as 13 respondents (24.07%), and of the 29 respondents who did not work that majority less knowledgeable as many as 26 respondents (48.14%). Work is an activity that is performed daily, the type of work performed can be categorized as not working, wiraswata, civil servants and private employees in all areas of work are generally required a good social relationship. Work owned an important role in determining the quality of human. It limits the gap between health information and practices that motivate a person to obtain information and to do something to avoid health problems. From the research there is no gap with Notoatmojo, where of the results obtained by respondents influential enough because some of the respondents worked. This is because the mother has made interaction with others so that the information about polio obtained and received by the mother. It can be seen from the results of the study. Mothers who work as many as 25 respondents and the majority from them who well knowledgeable as well as 13 respondents (24.07%) this is due to the mother who work had made more interaction with people around the workplace because they will exchange information and knowledge they have acquired. So that the mother's level of knowledge even get higher. While Mothers who do not work who less knowledgeable as many as 26 respondents (48.14%) this is due to the mothers who do not work did not gained much information because they had not made interaction with people outside their home environment so that mother’s knowledge is not much developed because the mothers do not work had less knowledge rather than those who work. Based on results of the research data obtained from 54 respondents pregnant women, it can be seen that 18 respondents who obtained the information from the mass media that majority less knowledgeable as many as 11 respondents (20.37%), of the 10 respondents who received information from family that majority less knowledgeable as many as 6 respondents (11.11%), and of the 32 respondents who received information from health official that less knowledgeable as many as 21 respondents (38.89%). According Notoatmojo (2007) Sources of information are all things that become intermediaries in conveying information, stimulate someone’s mind and ability. Other people around us is one among the social component that influence our attitude. According to the researchers assumption there is gap with Notoatmojo (2007), which is the information source obtained by the respondent did not affect his knowledge. The theory says the better sources of information will be the better of someone's knowledge. Examples 5 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology information source from the health care workers will be very good in providing information on polio immunization because health care workers are people who have been trained and trusted by the community in the health sector so that people will follow the advices from health workers. But the results obtained by researchers respondents who received information from health care worker that majority less knowledgeable as many as 21 respondents (38.89%). This may be due to mother neglected the information that health care worker submitted. Based on the study data showed that the majority of mother who give polio immunization to their baby in Public Health Centers Selesai 2014 that behaved less post polio immunization to their baby as many as 41 people (75.93%). One of the factors that influence the behavior is knowledge. Based on the results of the study, the majority of mothers who have less knowledge as many as 38 people (70.38%), 13 people (24.07%) behaved well post polio immunization on infants. So knowledge is an important domain of the formation of a person's behavior (Notoadmodjo, 2012 p.138). According to the researchers assumption the majority of respondents who behaved less due to his less knowledgeable or mothers who neglect the knowledge that she gets from health workers. Examples of health workers who provide information about polio immunization with breastfeeding but the mother does not care about the information she gets, possibly because the mother was busy taking care of the family and household. Relationship Of Mother’s Knowledge And Behavior Post Infant’s Polio Immunization In The Mancang Village Community Health Centers Selesai Langkat 2014 Based on the research that has been done shows that the value of p < 0.05 then there is a significant relationship between knowledge and behavior where the majority of mothers that well knowledgeable and well behave post polio immunization to the baby as much as 13 people (24.07%), and the majority of mothers 6 that less knowledgeable and less behave as many as 38 people (70.38 %). This is consistent with research Widayati (2009) in An- Nissa Maternity Hospital Surakarta that there is a significant relationship between mother’s knowledge about polio immunization with mother's behavior post polio immunization evidenced by p value of 0.0001. Conclusion The majority of respondents that less knowledgeable as many 38 respondents (70.38%; less behaved as much as 41 respondents (75.93%), and there is a significant relationship between mother’s knowledge with mother's behavior post polio immunization. This means that the lower the person's knowledge, the behavior is also increasingly less proven with p value of 0.000. References Arikunto,S.(2007) . Management Research Jakarta : Rineka Reserved . Anwar . (2004) . Human attitudes, theory and measurement. Jakarta : Library Learning . Bahiyatun(2009 ) . Textbook of Midwifery care Postpartum Normal. Jakarta : EGC Cornelia, A. (2013). Regarding the characteristic picture Mother Immunization Knowledge Base Village Karangsari Binong Subang. Midwife Education Journal , 82 . RI Health Department . (2006) . Training Modules Power Managing Immunization Health Center . Jakarta : Directorate General of PP and PL and the Center for Health Education and training of human resources . Hadinegoro , S. R. (2011) . Immunization guidelines in Indonesia. 4th edition. Jakarta : Agency Publisher Indonesian Pediatric Association . Hidayat,A.A. (2011). Midwifery Research Methods Data Analysis Techniques. Jakarta : Salemba Medika . Manuaba , Ida Bagus. (2012). Obstetrics Gynecology and Family Planning for Education Midwives. Jakarta : EGC Marimbi, H. (2010). Growth Nutritional Status and Immunization Basics In Infants Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology under five years old . Yogyakarta: Nuha Medika . Maryunani, A. (2010) . In Obstetrics Pediatrics . Jakarta : CV . Trans Media Info . Notoatmodjo,S. (2003) . Health Education and Behavior. Jakarta : Rineka Reserved. _____________ (2007). Public Health Sciences and Arts. Jakarta : Rineka Reserved . _____________ (2007). Research Methodology. PT Asdi Mahatsaya . Nursalam (2008). Concept and Implementation Guidelines of Nursing Research Methodology Thesis, Thesis, and Nursing Research Instruments . Jakarta : Salemba Medika . Proverawati and Andhini (2010) . Immunizations and Vaccinations . Yogyakarta: Nuha Medika . Widayati, Sri(2011). Relationship between maternal knowledge with the mother's behavior evidenced by postpolio immunization in the maternity hospital Surakarta An - Nissa . College of Health Aisyiyah Surakarta : Surakarta , 7 . Widayati , Siti Nur . ( 2012) . Relationship Between Immunizotion Mater-nal’s Knowledge With Complete-ness Polio Immunization in public health centers I Polokerto Sukoharjo. College of Health Aisyiyah : Surakarta , 33 . Zulkifli, Andi. (2007 ). Polio Disease Epidemiology.Scientific papers, 8. 7 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECTIVENESS OF NEEM LEAF EXTRACT (Azadirachta Indica Juss) IN ETHANOL AS REPELLENT FOR THE BITES OF AEDES AEGYPTY Mariaty Silalahi¹, Lestari Rahma¹, Nelma2, Dina Indarsita3, Rizky Ayu Lestari4 1,2 Health Polytecnic, Ministry of Health, Medan, Analyst Department Health Polytechnic, Ministry of Health, Medan, Nursing Department 3,4 Background : Aedes aegypti mosquito is the primary vector of dengue fever is common in tropical countries, including Indonesia. Control measures with eradication of vector / adult mosquitoes using plant neem (Azadirachta indica Juss) containing compound azadirachtin, salanin, nimbin and nimbidin which can inhibit the appetite of adult mosquito Aedes aegypti. The purpose of this study to determine the effect of neem leaf extract (Azadirachta indica Juss) on the growth and development of the mosquito Aedes aegypti. Methods : This research method using descriptive experimental (purely experimental test). Samples of neem leaf extract and as an indicator is adult mosquito Aedes aegypti. The consentration of neem leaf extract used 0% (g/ml) (control), 10% (g/ml), 20% (g/ml), 30% (g/ml), 40% (g/ml), 50% (g/ml), 60% (g/ml), and excuted the experiment twice. Results : Frequency bite of Aedes aegypti was 210 at concentration of 10%, 195 at concentration of 0%, 164 at concentration of 30%, 138 at concentration of 40%, 129 at concentration of 50%, 88 at concentration 60%. Keywords: Aedes aegypti, Azadirachta indica Juss In general, the Aedes aegypti mosquito is a big enough problem that concerns public health in countries with tropical climates, including Indonesia. Aedes aegypti is a vector of several serious diseases that can infect humans, such as malaria, encephalitis, "yelow fever", dengue fever, dengue, filariasis , and arboviruses. One of the major problems in Indonesia caused by the mosquito Aedes aegypti is dengue fever and dengue hemorrhagic fever. One of the major problems posed in Indonesia by the Aedes aegypti mosquito is dengue fever and dengue hemorrhagic fever. Dengue Hemorrhagic Fever (DHF) is one of the diseases that has no cure or vaccine. The treatment is supportive only in the form of bed rest and fluids intravena. Eradicate action, by wiping out mosquito lair and killing larva and adult mosquitoes, is the best course of action (Aradilla, 2009). This disease go into Indonesia in 1968 through the port of Surabaya. In 1980 DHF has been reported spread in all provinces in Indonesia. DHF clinical symptoms such as high fever which lasts continuously for 2-7 days and bleeding manifestations are usually preceded by seeing the typical signs such as 8 red spots (petechia) on patient’s body. The patients can experience shock and death. Until now the disease is still a public health problem. The main vector of DHF is garden mosquito called Aedes aegypti, while the potential vector is Aedes albopictus (Soegijanto, 2004). Thrombocyte and endothelial cells are estimated to have important role in the pathogenesis of dengue fever and dengue hemorrhagic fever, based on the fact that dengue fever caused thrombocytopenia accompanied by increased capillary permeability. The two components have long been known to be an unity of function in maintaining homeostasis, if one component injuries, it will affect the activity of other components. Thrombocytopenia (thrombocyte count <100,000/mm3) is one of laboratoric criteria in addition to increased hemotrokrit >20% of the criteria for dengue diagnosis, according to WHO (Soegijanto, 2006). In Indonesia, dengue disease is a health problem because there are many endemic areas. DHF endemic area in general is a source of spreading the disease to other areas. Every extraordinary events (KLB) dengue usually begin with an increasing Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology number of cases in that region. To limit the spreading of dengue disease eradicating mosquito lair movements, fogging, and larvatiditation are needed continuously (Widoyono, 2011). One of the plants that contain botanical insecticide (naturally) is the neem leaves (Azadirachta indica Juss). Plant neem (Azadirachta indica Juss) belonging to familia Meliaceae. Neem, especially the seeds and leaves, contain several components from secondary metabolic production allegedly very useful in agriculture field (pesticides and fertilizers) and in pharmaceutical field (cosmetics and medicines). Among others are Azadirachtin, salanin, meliantriol, Nimbin and Nimbidin which are the best essence in agricultural (pesticides and fertilizers) and pharmaceutical (cosmetics and medicines). Based on research conducted by RD Ndione, O Faye, M Ndiaye, A DIEYE, and JM Afoutou in 2007, using seeds of neem leaves against Aedes aegypti Linnaeus 1762, which also contains azadirachtin, salalinin, meliantriol, Nimbin and Nimbidin, capable to kill Aedes aegypti larva. The effect of neem leaf extract insecticides against Aedes aegypti larva (Aradilla, 2009). It is known that Azadirachtin is food appetite derivation and ecdyson blocker (insect growth hormone blockers). Salanin is one of food appetite derivation. Meliantriol act as a deterrent (repellent) so that insects are reluctant to approach these plants. Nimbin and Nimbidin have antimicrobial activity, antifungal and antiviral in humans and animals (Aradilla, 2009). Because of it, the research wants to know the effectiveness of neem leaves (Azadirachta indica Juss) known as natural reject test against Aedes aegypti mosquito. Objective 1. To determine the effectiveness of neem leaf extract (Azadirachta indica Juss) as a reject test of Aedes aegypti to break the chain of dengue fever spreading. 2. To know the effectiveness reject power test of neem leaf extract (Azadirachta indica Juss) in ethanol on the bite activities of Aedes aegypti. 3. To determine the concentration of neem leaf extract (Azadirachta indica Juss) as a reject power test against Aedes aegypti. Research Methods This study is a descriptive experimental study (experimental test pure) because researchers conducted experiments the effectiveness reject power test of neem leaf extract (Azadirachta indica Juss) in ethanol on the bite activity of Aedes aegypti mosquito and then described the results in article. Indicators in this study is Aedes aegypti mosquito adults because it has a better defense system o than larval instar III and IV, so that it can be assumed that the dose is able to avoid the adult mosquito. Equipment and Materials a. The container in the form of gauze confinement to put mosquito, b. glass funnel, c. measuring 5 ml pipette, d. measuring 10 ml pipette, e. pipette, f. glass, g. filter paper, h. paper cab, i. Aspirator, j. plastic cups, k. gauze, l. plastic bottles. Materials : a. Raw foods used for mosquito breeding such are rabbits or guinea pigs, b. Food ingredients used for breeding larva are floured chicken liver or fish pellets, c. Alcohol 70 %, d. Distilled water, e. Neem leaf powder. Procedures Aedes aegypti Rearing Procedures Breeding mosquitoes from egg bank of Aedes aegypti mosquito or catching it in the wild by using an aspirator; Aedes aegypti mosquitoes were caught incorporated into gauze cages measuring 50x50x50 cm; Mosquitoes in the confinement fed (guinea pig blood) for 45 minutes and 10% sugar water and then enter the water compartment, inside the container circled filter paper with 1/3 position filter paper into the water where mosquitoes lay their eggs. 9 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Every day the container is examined for the presence of eggs. If found, the next is the hatching eggs process is by way of filter paper containing the eggs, transferred to plastic trays measuring 20 x 30 cm or 30 x 40 cm and add water until 2/3 trays; Eggs that hatch into larvae (larvae) are given in the form of flour eat chicken livers and water nam; ve changed every 3 days to avoid deposition of food / in plastic cups filled with water ¼ section, then a plastic cup is inserted into the cage (cage) mosquito grown up. Neem Leaf Extract Production Procedures a. The neem leaves cleaned first with clean water and then drained at room temperature for a week. b. The results of dried neem leaves are blended to be ready in the experiment. Do immersion by putting the blended neem leaves earlier into the jar and add the alcohol 70%. c. Leave it for 7 days and at the same time shake it if sediment occured. d. After 7 days separate the wasted with the filtrate. e. Return the container / jar open. f. Make a dilution with the addition of distilled water. g. The dilution result is ready for experiments. Experimental Procedures a. Prepare the eggs of Aedes aegypti rearing results from the egg banks; let it stand for a week to happen ekslskion eggs into adult mosquitoes, b. Apply the extract on hand with neem leaf extract dilution, respectively - each 5% - 12.5%; on Testing repelan power required to close the glove fingers so as not to be subjected test mosquito bites; stopwatch to calculate the duration of contact between mosquitoes to test arm; No 1 2 3 4 5 6 7 10 c. d. e. f. In one test cages supplied 25 female mosquitoes in a state of hunger; The arms are used as bait to be equated first condition that is by washing with running water, then dried until it is completely dry; Each arm will be used as bait smeared repelan solution 0.1 ml to 30 cm2 surface area; For each treatment tested concentrations used one arm in one cage containing 25 mosquitoes in a state of hunger; Observations were made every 5 minutes in every hour up to six hours; Calculated number of mosquitoes that land and or biting the arm; power calculated by the formula: DR = (K - P) / K x 100%. Where DR is a repellent power, while K is the number of mosquitoes landed on the control arm, and P is the number of mosquitoes landed on the arm smeared repelan. Neem leaves can be deemed to have power when the value repelan repellent Power (DR) can reach 95%. Hypothesis : There is a difference in the reject power test of neem leaf extracts against Aedes aegypti mosquito bites with a concentration of 10%, 20%, 30%, 40%, 50%, and 60%. Data Analysis Used the analysis of one direction variance to determine whether there are differences between treatments 1, 2, and so on with more than one repetition (Sudjana, 1994). In this study, it will tested whether there are average differences in reject power of neem leaf extracts against Aedes aegypti bites at concentrations of 10%, 20%, 30%, 40%, 50%, and 60%. Tabel1. The procedures for making neem leaf extract Filtrate Aquadest Concentration (%) 0 mL (control) 100 mL 0 10 Ml 90 mL 10 20 mL 80 mL 20 30 mL 70 mL 30 40 mL 60 mL 40 50 mL 50 mL 50 60 mL 40 mL 60 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Results and Discussion The results of the research that has been done on the effect of repellen Neem leaf extract on Aedes aegypti as follows : Table 2. Effect of Neem Leaf Extracts Against Aedes Aegypti Within 2 Hours The concentration of neem leaf extract 0% 10% 20% 30% 40% 50% 60% Experiment 1 375 82 74 62 57 53 31 Experiment 2 375 128 121 102 81 76 57 Total 750 210 195 164 138 129 88 After two experiments, there is a difference between the experiment 1 and the experiment 2. At concentration of 10%, there is a difference between experiment 1 (82 mosquitoes bite the arm) and experiment 2 (128 mosquitoes bite the arm). At concentration of 20%, there is a difference between experiment 1 (74 mosquitoes bite the arm) and experiment 2 (121 mosquitoes bite the arm). At concentration of 30%, there is a difference between experiment 1 (62 mosquitoes bite the arm) and experiment 2 (102 mosquitoes bite the arm). At concentration of 40%, there is a difference between experiment 1 (57 mosquitoes bite the arm) and experiment 2 (81 mosquitoes bite the arm). At concentration of 50%, there is a difference between experiment 1 (53 mosquitoes bite the arm) and experiment 2 (76 mosquitoes bite the arm). At concentration of 60%, there is a difference between experiment 1 (31 mosquitoes bite the arm) and experiment 2 (57 mosquitoes bite the arm). Table 3. Effect of neem leaf extract in 15 minutes ( in 2 attempts ) The frequency of mosquito bites 10% 20% 30% 40% 50% 60% (in minute) 1 9 22 6 2 3 3 2 12 26 7 6 9 3 3 17 21 14 7 9 3 4 17 16 13 11 10 4 5 21 16 13 11 10 4 6 18 10 18 13 9 7 7 15 7 16 11 8 3 8 18 11 14 16 7 8 9 13 12 14 19 14 3 10 11 11 6 14 14 9 11 15 6 7 6 7 9 12 11 8 8 4 9 9 13 11 6 8 4 7 9 14 13 10 7 8 9 8 15 9 13 7 7 4 6 Total 210 195 164 138 129 88 11 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Concentration of 10 % from first minute 9 bites, in the second minutes 12 bites, the third minutes 17 bites, in the fourth minutes 17 bites, in the fifth minutes 21 bites, in the sixth minutes 18 bites, in the seventh minutes 15 bites, in the eighth minutes 18 bites, in the ninth minutes 13 bites, in the tenth minutes 11 bites, in the eleventh minutes 15 bites, in the twelfth minutes 11 bites, in the thirteenth minutes 11 bites, in the fourteenth minutes 13 bites, and in the fifteenth minutes 9 bites, the number of mosquitoes that bite the arm at a concentration of 10 % are 210 bites. At a concentration of 20 % from the first minute 22 bites, in the second minutes 26 bites, in the third minutes 21 bites, in the fourth minutes 16 bites, in the fifth minutes 16 bites, in the sixth minutes 10 bites, in the seventh minutes 7 bites, in the eighth minutes 11 bites, in the ninth minutes 12 bites, in the tenth minutes 11 bites, in the eleventh minutes 6 bites, in the twelfth minutes 8 bites, in the thirteenth minutes 6 bites, in the fourteenth minutes 10 bites, and in the fifteenth minutes 13 bites, the number mosquitoes that bite the arm at a concentration of 20% are 195 bites. At a concentration of 30% in the first minute 6 bite, in the second minutes 7 bites, in the third minutes 14 bites, in the fourth minutes 13 bites, in the fifth minutes 13 bites, in the sixth minutes 18 bites, in the seventh minutes 16 bites, in the eighth minutes 14 bites, in the ninth minutes 14 bites, in the tenth minutes 6 bites, in the eleventh minutes 7 bites, in the twelfth minutes 8 bites, in the thirteenth minutes 8 bites, in the fourteenth minutes 7 bites, and in the last fifteenth minutes 7 bites. The number of mosquitoes that bite the arm are 164 bites. At a concentration of 40 % in the first minute 2 bites, in the second minutes 6 bites, in the third minutes 7 bites, in the fourth minutes 11 bites, in the fifth minutes 11 bites, in the sixth minutes 13 bites, in the seventh minutes 11 bites, in the eighth minutes 16 12 bites, in the ninth minutes 19 bites, in the tenth minutes 14 bites, in the eleventh minutes 6 bites, in the twelfth minutes 4 bites, in the thirteenth minutes 4 bites, in the fourteenth minutes 8 bites, and in the fifteenth minutes 7 bites. The number of mosquitoes that bite the arm that are 138 bites. At a concentration of 50% in the first minute 3 bites, in the second minutes 9 bites, in the third minutes 9 bites, in the fourth minutes 10 bites, in the fifth minutes 9 bites, in the sixth minutes 9 bites, in the seventh minutes 8 bites, in the eighth minutes 7 bites, in the ninth minutes 14 bites, in the tenth minutes 14 bites, in the eleventh minutes 7 bites, in the twelfth minutes 9 bites, in the thirteenth minutes 7 bites, in the fourteenth minutes 9 bites, in the fifteenth minutes 4 bites. The number of mosquitoes that bite the arm are 129 bites. At a concentration of 60% in the first minutes 3 bites, in the second minutes 3 bites, in the third minutes 3 bites, in the fourth minutes 4 bites, in the fifth minutes 4 bites, in the sixth minutes 7 bites, in the seventh minutes 3 bites, in the eighth minutes 8 bites, in the ninth minutes 3 bites, in the tenth minutes 9 bites, in the eleventh minutes 9 bites, in the twelfth minutes 9 bites, in the thirteenth minutes 9 bites, in the fourteenth minutes 8 bites, and in the fifteenth minutes 6 bites. The number of mosquitoes that bite the arm are 88 bites. Based on the result obtained that there are 70% of mosquito that bite the arm at concentration of 10%; there are 72,14% of mosquito that bite the arm at concentration of 20%; there are 76,57% of mosquito that bite the arm at concentration of 30%; there are 80,28% of mosquito that bite the arm at concentration of 40%; there are 81,57% of mosquito that bite the arm at concentration of 50%; and there are 87,42% of mosquito that bite the arm at concentration of 60%. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 4. Descriptive Data in Each Reject Power Test Concentration of Neem Leaf Extracts Against Aedes Aegypti Anova: Single Factor SUMMARY Groups Count Sum Average Variance 0 3 1500 500 46875 0.1 3 420 140 4204 0.2 3 390 130 3721 0.3 3 328 109.3333 2641.333 0.4 3 276 92 1731 0.5 3 258 86 1519 0.6 3 176 58.66667 814.3333 Table 5. Results of Data Analysis of Variance Test of The Reject Power Test Concentration of Neem Leaf Extracts Against Aedes Aegypti ANOVA Source of Variation SS Df MS F P-value F crit Between Groups 419499.81 6 69916.63 7.957258 0.000713 2.847726 Within Groups 123011.333 14 8786.524 Total 542511.143 20 Based on the results if the data presented in Table 4.4 shows that the value of Fcount = 7.957258 and Fcriteria = 2.847726, and the P - value = 0.000713. Therefore Fhitung > Fcriteria or P - value < 0.005, this means that H0 is rejected. Conclusions based on the results of data processing are there are significant differences reject power test of neem leaf extract with a concentration of 10%, 20%, 30%, 40%, 50%, 60% against the bite activities of Aedes aegypti. In other words, the leaf extract of neem (Azadirachta indica Juss) is effective in reducing (rejected) the bite activities of Aedes aegypti. Conclusions 1. At a concentration of 10% the bite on the arm are 210 bites within 15 minutes. 2. At a concentration of 20% the bite on the arm are 195 bites within 15 minutes. 3. At a concentration of 30 % the bite on the arm is slightly reduced to 164 bites within 15 minutes. 4. At a concentration of 40 % the bite on the arm is reduced to 138 bites within 15 minutes. 5. At a concentration of 50% the bite on the arm reduced to 129 bites within 15 minutes. 6. At a concentration of 60% the bite on the arm reduced again to 88 bites in 15 minutes. 7. The higher concentration of the extract, the fewer number of bites on the arm at the same time. The entire test results indicate neem leaf extract as repelan which have protective power of less than 90% for 2 hours against Aedes aegypti contact. Neem leaf extract can serve as repelan, because it has the contents of ecdyson blockers and salanin. Recommendations 1. Informed public to use natural insecticides, one of it is an extract of neem leaves to replace the anti-mosquito lotion made from chemicals. 2. It is need to repeated the research by using other mosquito species with different methods in order to know whether the neem leaf extract affected broadly to all types of mosquitoes. 13 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Reference 1. Aradilla , U.S. 2009. Effectiveness Test larvicides Ethanol Extract Neem leaves ( Azadirachta indica ) against larvae of Aedes aegypti . Diponegoro University , Semarang . 2. Faculty of Medicine , 2004. Dengue Script Complete Training for Trainers pediatrician and Specialist Doctors in Case Management of Dengue . Jakarta : Hall Publisher University of Indonesia . 3. Hariana , A. 2008. Medicinal Plants and Usefulness . Series 2. New York: Organization . 4. Kardinan , A. 2007. Plant Repellent and Mosquito Repellent . Jakarta : Agromedia Library 5. Shinta.2012 . Media Health Research Volume 22. Potential Leaf Essential Oil Patchouli ( Pogostemon cablin B. ) , leaves Badotan ( Ageratum conyzoides L ) , Flower Boxwood ( Cananga odorata hook F & Thoms ) and leaves of rosemary ( Rosmarinus officinalis L ) For Against Aedes aegypti repelan , [ online ] available at < http://www.medialitbang.com/html > [ Accessed 13 march 2014 ] . 6. Soegijanto , S. 2006. The set of papers and Infectious Tropical Diseases in Indonesia . Volume 5. New York: Airlangga University Press . 14 7. 8. 9. 10. 11. 12. 13. 14. Soegijanto , S. 2004. Dengue Fever . Review and New Findings in 2003. Surabaya Era : Airlangga University Press . Soegijanto , S. 2006. Dengue Fever . Issue 2. Surabaya : Airlangga University Press . Susana, D & Light Uli J Sembiring . 2011. Health Entomology . Jakarta : Indonesian universities . Poster , 2010. Indonesian Herbal Nutritious Scientific Evidence and How Racik . Volume 8. Depok : Poster Organization . Warsidi , E. 2009. Hazard and Prevention of DHF . Bekasi : Key Partners . WHO , 200. Prevention and Pengendahalian Dengue and Dengue . Jakarta : Medical EGC . Widoyono . 2011. Tropical Diseases Epidemiology , Transmission , Prevention , and eradication . Issue 2. Jakarta : Erland . Yuniarsih , E.2010 . Test Effectiveness repelan Lotion Neem Oil ( Azadirachta indica Juss ) against Aedes aegypti . State Islamic University , Jakarta Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology CURRENT RADIOTHERAPY FACILITIES IN INDONESIA Ikhsan Bagatondi Nasution: Dodoh Khodijah Departement of Radiotherapy, Murni Teguh Memorial Hospital, Medan Jurusan Kebidanan Poltekes Kemenkes Medan ABSTRACT Background: WHO in 2014 declared globally cancer is a major cause of morbidity and mortality. Selection of cancer treatment includes surgery, radiotherapy or chemotherapy. Approximately 5060% of cancer patients require radiotherapy. Treatment of cancer in LMICs and challenge to make radiotherapy as a key component of cancer treatment that can be accessed patient is a foremost concern of all stakeholders both at national and international levels. Objective: Acquire an overview of the Indonesian radiotherapy facility in 2015. Methods: Using the results of studies conducted based on literature studies and field studies. Results: The development of Indonesian radiotherapy centers in 2015, when compared to 2008 increased by 22.72%. Overall there was 41 external radiotherapy equipment. There is 23 Unit using a Linear Accelerator and 18 Unit using Co-60 equipment. The Estimation of patients who will receive radiotherapy services in 2015 approximately 29,300 patients. When compared with patients who need radiotherapy approximately 199,940 patients, only 14.65% which can be served. Conclusion: Need an arrangement from the Indonesian Government to assist the treatment of radiotherapy for Social Security Organizing Bodies participants. Monetary cost is built on radiation techniques, not just in a class that is based on the number of hospital rooms. Key words: Radiotherapy, cancer and social security organizing bodies Introduction According to the WHO Cancer is a term for a large group of diseases that can affect any part of the body, also known as malignant tumors and neoplasms. Another trait of cancer is the creation of abnormal cells that grow quickly out of the habit which can then invade adjoining parts of the body and spread to other organs, the latter process is called metastasis, which is the leading cause of cancer deaths [1]. According to the World Cancer Report 2014, published by the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO), Globally cancer remains a major cause of morbidity and mortality with 14 million new cancer cases and 8 million cancer-related deaths reported in 2012 [2]. Approximately 60% of cancer cases occur in countries of Africa, Asia, Central and South America with 70% of cancer deaths are from these areas. According to the World Health Organization (WHO), the incidence of cancer between 2008 and 2030 is projected to rise 82% in the group of low-income countries (lower income countries), up 70% in the group of lowermiddle income countries (Lower middle Income Countries) and up 58 % in uppermiddle income countries (upper middle income countries). There is a rise in cancer incidence by 40% in high-income countries (HICs). The case in LMICs is equal to twothirds of all cases [3]. According to the World Bank, Indonesia groupped into Lower Middle Income country [4]. Indonesia is the world's fourth most Populous nation, with 249.9 million people [5]. The Ministry of Health of the Republic of Indonesia held a Basic Health Research (Riskesdas) in 2013, the results showed the prevalence of tumor / cancer in Indonesia is 1.4 per 1000 population. Indonesia's highest cancer in women is breast cancer and cervical cancer. Whereas in men are lung cancer and colorectal cancer. The highest prevalence occurs in Yogyakarta at 4.1 per 1000 population. The prevalence in North Sumatra is 1 per 1000 population [6]. The Government of Indonesia in 2015 through the Ministry of Health of the Republic of Indonesia has started commitments cancer prevention in Indonesia, together with national cancer prevention committee (KPKN) and Indonesia Cancer Foundation. Commitment Cancer Prevention activities in 15 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Indonesia, for special attention to: 1) Improvement of promotive and preventive efforts to raise public awareness about cancer; 2) Development of early detection in order to reduce the number of cancer deaths; 3) Treat cancer according to the standard, the necessary monitoring and evaluation of the effectiveness of alternative treatments that are offered through the mass media and electronic; 4) Improved quality of life for cancer patients through effective palliative effort; 5) Support all elements of society in a comprehensive cancer control and continuous [7]. The main purpose of diagnosis and treatment of cancer is to cure or prolong the life of patients and ensure the best quality of life that can be done for people with cancer. Selection of treatment modality should be done with caution between surgery, radiotherapy or chemotherapy. Selection is based on the best evidence-based treatment given available resources [8]. Radiotherapy uses radiation such as X-rays, gamma rays, electron beams or protons to damage cancer cells and stop the growth. Radiotherapy is the treatment of localized, directed only to the part of the body that requires [9]. High-energy radiation used will permanently damage the DNA of cancer cells. Other healthy body tissues will be affected temporarily, but these cells were able to repair this DNA damage and still grow normally [10]. Radiotherapy if used before surgery to shrink tumors so more easily removed when surgery is known as neoadjuvant treatment. If done after surgery to destroy remaining tumor known as adjuvant treatment [10]. Curative use of radiation called a radical treatment, aimed at providing long-term beneficial effects for patients. Radiation can also be given before or after chemotherapy to improve overall treatment outcomes. Palliative treatment aims to shrink tumors and reduce pain. Palliative treatment can also extend the life of [11] .Radiotherapy play an important role in the fight against cancer. Approximately 50-60% of all cancer patients in need of radiotherapy in the treatment of the disease [12,13]. The current situation of the treatment of cancer and cancer in LMICs challenge to make radiotherapy, as a key component of cancer treatment, which can be accessed in these countries has become a major concern that is recognized by all stakeholders both at the country level and internationally [14, 15]. 16 Methode This paper represented the results of a study conducted by literature studies [16,17] and field studies to obtain a picture of radiotherapy facility in Indonesia by 2015 [18]. Result Development of radiotherapy centers in Indonesia when compared with data from the literature [16,17] has increased by 22.72%. Overall there were 41 aircraft external radiotherapy, which uses Linear Accelerator Unit 23 18 Unit again while using Co-60, as seen in Table 1. One unit that uses a Co-60 is used for stereotactic radiation surgery (SRS) is Leksell Gamma Knife in Siloam Hospital Lippo Village. The calculations were carried out to see estimates of cancer patients that can be served with teletherapy equipment are 60 new patients / month. So if in the calculations for 1 year, then the number reached 720 patients that can be served for 1 teletherapy machine unit. This calculation is still within tolerance limits specified by the International Atomic Agency (IAEA) which mentions for the state Low Middle Income Countries such as Indonesia, One unit can serve 500-1000 Aircraft teletherapy patient per year [15]. Estimates of the number of patients who will receive radiotherapy services in 2015 approximately 29,300 patients. When compared with patients who need radiotherapy approximately 199 940 patients, only 14.65% which can be served. This figure is a rough idea of the conditions in Indonesia and will change if the use of Indonesia's population in the latest census. Estimates of the number of patients will decrease if accounted for more details about the down time and the number of fractionated radiotherapy equipment specifically for each type of cancer. Advanced radiotherapy techniques such as Intensity Modulated Radiation Therapy (IMRT) is already on the island of Sumatra, namely in the Murni Teguh Memorial Hospital, using IMRT QA equipment and software Gafchromic Film PTW Verisoft. In 2008, the radiation technique such as Intensity Modulated Radiation Therapy, Stereotactic Radiation Surgery (SRS), Stereotactic Body Radiation Therapy (SBRT) only in the General Hospital of the National Center Cipto Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Mangunkusumo, but now there Muchtar Riadi Comprehensive Cancer Center Hospital (MRCCC), and in the Siloam Hospital TB Simatupang. Both of the above hospitals have been using Rapid-Arc, which the advantages of this technique compared to IMRT is a faster treatment time. While Dharmais Cancer Hospital and Gading Pluit Hospital just the IMRT technique. Soetomo Hospital in Surabaya also has the ability to run this IMRT techniques. Data in 2008 stated that there are 8 active radiotherapy centers do Brachytherapy Technique. These performed in 2 Dimensions Brachytherapy technique, using the C-Arm. In the 2015's, 3D Brachytherapy techniques already exist in three hospitals in Indonesia, namely in Dharmais Cancer Hospital in Jakarta, Saiful Anwar General Hospital in Malang and Murni Teguh Memorial Hospital in Medan. Discussion In 2008, the entire hospital which have radiotherapy facilities owned by the Government of the Republic of Indonesia. Currently Private Hospital has had radiotherapy facilities. There are 2 Private parties who have radiotherapy facilities in Medan - North Sumatra ie Murni Teguh Memorial Hospital and Vina Estetica Hospital. There are six private hospitals have radiotherapy facilities in the island of Java, Pertamina Central Hospital, MRCCC Hospital, Siloam TB Simatupang Hospital, Gading Pluit Hospital in North Jakarta, Siloam Hospital Lippo Village in Lippo Karawaci, Banten and Ken Saras Hospital in Ungaran Central Java. Ownership Hospital by private parties would be a bit much into account the investment made in providing radiotherapy services. Today almost all hospitals work together in serving participants the social insurance agency participants should get radiotherapy services, the Hospital who have radiotherapy facilities should provide radiotherapy services with a predetermined amount of tariff value. The amount of rates depending on the class Hospital. If you look carefully you can bet that as the Government Hospital Referral Regions with the number of rooms in which more certainly has a higher grade than the Private Hospital. Noting that the Government has not been able to meet the adequate provision of radiotherapy facilities in Indonesia, the hospital had radiotherapy facilities need to be given incentives or take into account the rate is based technique Radiotherapy given to the patient. Currently there is a problem in view of the Government through INA-CBGs rates only know one Coding (excluded on Top Up) in an outpatient procedure that is Radiotherapy. There is no difference in rates between hospitals having LINAC Facility sophisticated techniques such as IMRT Hospital who have radiotherapy facilities Co-60 with 2D techniques. Thus the patient care 0f the social insurance agency can be maximized and encourage advances in techniques of treatment given. Conclusion Limitations on various things in this paper does not diminish the important message that Indonesia is still very short of radiotherapy centers. Shortcomings in terms of equipment availability and distribution, access to radiotherapy centers which are unevenly distributed and affordability of treatment. The Government of Indonesia through the program social insurance agency has made affordability of treatment is no longer a burden, but if the government has not been able to provide the rate calculation based radiotherapy technique, it needs to make cost sharing between the patient and the government [15]. So in the end the government's commitment in the Cancer Prevention activities in Indonesia with one of the points for special attention on Improving the quality of life of cancer patients through effective palliative efforts may be improving the quality of life of patients through effective curative measures. 17 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Tabel 1.Availability of Treatment PROVINCE No POPULATION AT 2010 CENSUS* RT C INCIDENCE C Need RT TREAT/YEAR NATIONAL o-60 (60%) *** LINAC ** 3 3 1 SUMATERA UTARA RS MURNI TEGUH MEMORIAL a. HOSPITAL b. RSUP H ADAM MALIK c. RS VINA ESTETICA 12.982.204 2 SUMATERA BARAT RSUP M DJAMIL PADANG 3 RIAU RSUD ARIFIN ACHMAD a. PEKANBARU 5.133.989 1 LINAC 2DIMENSION 5.538.367 1 4 SUMATERA SELATAN RSUP DR MOHAMMAD a. HUSIN 7.450.394 1 5 BANTEN RS SILOAM HOSPITAL - LIPPO a. VILLAGE 10.632.166 1 LINAC 3DC + IMRT LINAC 3DC LINAC 3DC 10.905 2160 0 1 7.188 4.313 720 1 I 0 7.754 4.652 720 1 10.431 6.258 720 8.931 500 8.071 10080 36.165 1440 27.201 3600 2.904 1440 31.480 4320 3.268 720 0 4.236 2.542 720 1 5.077 3.046 720 I I I LINAC 2DIMENSI0N I 0 I 1 14.885 LEKSELL GAMMA KNIFE PERFEXION**** 6 DKI JAKARTA RSUPN DR CIPTO a. MANGUNKUSUMO b. RS KANKER DHARMAIS RSPAD GATOT c. SOEBROTO d. RS MRCCC - SEMANGGI RS SILOAM - TB e. SIMATUPANG f. RS PERSAHABATAN h. RS PUSAT PERTAMINA g. RS GADING PLUIT 9.607.787 7 JAWA BARAT RSUP HASAN SADIKIN a. BANDUNG 43.053.732 8 JAWA TENGAH RSUD DR MOEWARDI a. SOLO RS DR MARGONO b. PORWOKERTO RSUP DR KARIADI c. SEMARANG RS KEN SARAS d. UNGARAN DAERAH ISTIMEWA 9 YOGYAKARTA 32.382.657 7 I 11 3 13.451 LINAC 3DC + IMRT+ IGRT+SRS/SRT LINAC 3DC + IMRT III II I LINAC 3DC LINAC RAPID ARC (VMAT) I I I LINAC LINAC LINAC LINAC I I I I RAPID ARC (VMAT) 3DC 3DC 3DC + IMRT 1 4 I 1 1 60.275 I I 1 4 45.336 I I LINAC 3DC II LINAC 3DC 3.457.491 I 1 1 1 4.840 I I 3 3 52.467 LINAC 3DC + IMRT II I LINAC 3DC I a. RSUP DR SARDJITO 10 JAWA TIMUR RSUD DR SOETOMOa. SURABAYA RSAL DR. RAMELAN b. SURABAYA RSUD SYAIFUL ANWAR c. MALANG 11 BALI RSUP SANGLAH a. DENPASAR 37.476.757 12 KALIMANTAN TIMUR RS ABDUL WAHAB a. SJAHRANI 3.026.060 Co-60 2D 3.890.757 3 1 0 II 1 5.447 I 1 Co-60 2D 13 KALIMANTAN SELATAN 3.626.616 18 0 18.175 1 I 0 0 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RSUD ULIN a. BANJARMASIN Co-60 2D I 14 SULAWESI SELATAN RS UNIVERSITAS a. HASANUDDIN RSUP DR WAHIDIN b. SUDIROHUSODO 15 ACEH 8.034.776 1 11.249 6.749 1440 Co-60 2D 4.494.410 0 0 I 0 6.292 3.775 0 16 BANGKA BELITUNG 1.223.296 17 BENGKULU 1.715.518 0 0 0 1.713 1.028 0 0 0 0 2.402 1.441 0 18 KALIMANTAN TENGAH 2.212.089 0 0 0 3.097 1.858 0 19 SULAWESI TENGAH NUSA TENGGARA 20 TIMUR 2.635.009 0 0 0 3.689 2.213 0 4.683.827 0 0 0 6.557 3.934 0 21 GORONTALO 1.040.164 0 0 0 1.456 874 0 22 JAMBI 3.092.265 0 0 0 4.329 2.598 0 23 LAMPUNG 7.608.405 0 0 0 10.652 6.391 0 24 MALUKU 1.533.506 0 0 0 2.147 1.288 0 25 KALIMANTAN UTARA 622.350 0 0 0 871 523 0 26 MALUKU UTARA 1.038.087 0 0 0 1.453 872 0 27 SULAWESI UTARA 2.270.596 0 0 0 3.179 1.907 0 28 PAPUA 2.833.381 0 0 0 3.967 2.380 0 29 KEPULAUAN RIAU 1.679.163 0 0 0 2.351 1.410 0 30 SULAWESI TENGGARA 2.232.586 0 0 0 3.126 1.875 0 31 KALIMANTAN BARAT NUSA TENGGARA 32 BARAT 4.395.983 0 0 0 6.154 3.693 0 4.500.212 0 0 0 6.300 3.780 0 33 PAPUA BARAT 760.422 0 0 0 1.065 639 0 34 SULAWESI BARAT 1.158.651 0 0 0 1.622 973 0 238.023.673 27 23 18 333.233 199.940 29300 TOTAL 2 1 LINAC 3 DC I * = Sensus Penduduk Tahun 2010 ** = DATA RISKESDAS 2013 HAL 86 ( 1,4 permil) *** = Assume 1 Equipment will treat 720 patient/year (60 patient/month) **** = Calculation based on 2 px/day x 5 day/week X 50 week, Ref : [20]. RT C = Radiation Therapy Center References World Health Organization. (2015). Cancer. Geneva. Forman D, Ferlay J. (2010). The Global And Regional Burden Of Cancer. WHO. Geneva. World Health Organization. (2010) Global Status Report On Noncommunicable Diseases. Geneva, Switzerland. Laporan Hasil Riset Kesehatan Dasar (2013). Canangkan Penanggulangan Kanker di Indonesia. Kementerian Kesehatan Republik Indonesia. Jakarta World Health Organization. (2015). Treatment of Cancer. Geneva. Cancer Council Victoria. (2014) Radiotherapy. Cancer Council Victoria. Melbourne. NHS. (2014). Radiotherapy Is A Treatment Involving The Use Of High-Energy Radiation. It's Commonly Used To Treat Cancer. NHS. IAEA. (2008). Division of Human Health, Setting up a Radiotherapy Programme: Clinical, Medical Physics, Radiation Protection and Safety Aspects. IAEA. Barton MB, Frommer M, Shafiq J. (2006). Role Of Radiotherapy In Cancer Control In Lowincome And MiddleIncome Countries. Lancet Onco. 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Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE CORRELATION OF ELDERLY KNOWLEDGE AND ATTITUDE TO THE UTILIZATION OF ELDERLY INTEGRATED SERVICE POST IN COMMUNITY HEALTH CENTER OF TANAH TINGGI BINJAI 2013 1 Elizawarda 1 Department of Midwifery, Poltekkes Kemenkes Medan Author's Corresponding (+6281263860665) ABSTRACT Introduction Indonesia is a country that has a population in the world's fourth most populous. With a population more than 200 million people in 2000 to 7.5% or 15 million inhabitants are elderly residents. According to the World Health Organization (WHO) report that elderly population in Indonesia in 2020 has reached 11.34% or 28.8 million people registered, 6.9% live babies that causes the elderly population in the world and based on Central Bureau of Statistics (BPS) in the years 20052010 the number of elderly people will be equal to the number of children is 8.5% of the population or about 19 million people. Given the level of health and well-being is improving the survival rate of Indonesia's population is also increasing (Hatta, 2006). Methods This research is an analytical study with cross sectional method aims to identify the knowledge, attitudes, and the correlation between knowledge and attitudes of elderly with utilization of elderly integrated service post in Community Health Center of Tanah Tinggi Binjai. The population of elderly who utilize was 120 peoples. The sampling technique used purposive sampling by 55 respondents. Result and Discussion Based on the research find that correlation between knowledge to the utilization of elderly integrated service post, the result P = 0.000 <0.05, the correlation between attitude to the utilization of elderly integrated service post with result P = 0.000 <0.05, meaning it can be concluded that there is a correlation between knowledge and attitude of elderly with utilization elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. The suggestion is that health professionals must be able to improve understanding of information on the utilization of elderly integrated service post . Keywords : Knowledge, Attitude, The Utilization of Elderly Integrated Service Post INTRODUCTION One indicator of the success of development is the increasing life expectancy of the population. With the increased life expectancy of the population, caused the number of elderly people from year to year (Resmana, 2011) Indonesia is a country that has a population in the world's fourth most populous. With a population of more than 200 million people in 2000 to 7.5% or 15 million inhabitants are elderly residents. Based on the projections of the Central Bureau of Statistics (BPS) in the years 2005-2010 the number of elderly people will be equal to the number of children is 8.5% of the population or about 19 million people. According to the WHO, elderly population in Indonesia in 2020 has reached 11.34% or 28.8 million people registered, 6.9% live babies that causes the elderly population in the world. Given the level of health and well-being is improving the survival rate of Indonesia's population is also increasing (Hatta, 2006). According to the National Commission on Elderly in its book entitled "Population Profile Erderly 2009" said that the proportion of the elderly population in Indonesia, there has been a significant increase over the last 30 years with a population of 5.3 million (4.48 percent of the total population of Indonesia ) in 1971 to 19.3 million (8.37 percent of the total population of Indonesia) in 2009. Then, based on population projections Elderly Indonesia in 2020, is expected to reach 28.99 million. The increase in the elderly population is due to an increase in life expectancy as a result of health care quality improvement (Elderly Population Profile, 2009) 21 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology According to the Health Profile of North Sumatera Province in 2011 that total population in North Sumatra amounted to 13,103,596 people, and the number of elderly in North Sumatra in 2011 recorded 797 813 people or 6.08%. As well as the number of elderly in the city of Binjai as many as 14 523 people. Elderly integrated service post should be a leading pioneer in tackling the problem of the increasing levels of the elderly in Indonesia. Namely by means of disseminating knowledge and attitudes about the need for quality of life of individuals and the importance of planning and inventory needs in the old days later. Results of research conducted to Dwi Handy (2011), in the community health center of Weru obtained information that runs through cadres of integrated service post. Of the 100 respondents who obediently follow integrated service post many as 29 people (29%), and as many as 71 people (71%) did not follow integrated. From these studies have proved that there is still a lack of awareness of the elderly to take advantage of the elderly integrated service post. From the 2011 data profile of North Sumatra showed that from 14.523 the number of elderly people, only 3,850 people or 26.51% got health services in Binjai. From the beginning of the survey that has been done in January 2013, in Health Community Center of Tanah Tinggi Binjai there were 120 elderly people, spread over two Integrated service post namely Habibi Habibah as many as 60 people and Timbang Langkat as many as 60 people. Preliminary data that got from interviews with elderly integrated service post officer in Community health center of Tanah Tinggi Binjai, generating that only 54 elderly people who implement and utilize the importance of integrated service post. Thus, while the conclusion of the authors stated that there is still a lack of knowledge and attitudes towards the use of erderly integrated service post. From the foregoing, we need a further study on the importance of the correlation between knowledge and attitude toward the existence and the utilization of elderly integrated service post. 22 RESEARCH METHODS This research was conducted with cross sectional study design on January to July 2013 were conducted at community health center of Tanah Tinggi Binjai. The population in this study were all erderly who utilize elderly integrated service post in Community health center of Tanah Tinggi Binjai in 2013, amounting to 120 people with a total sample of 55 elderly people using the formula by purposive sampling technique. The type of data used are primary and secondary data. With the measuring tool in the form of a questionnaire prepared by the author based on theoretical. The data has been obtained and then analyzed with the univariate and bivariate analysis. RESULTS AND DISCUSSION RESULTS The results of this study according on primary data conducted in community health center of Tanah Tinggi Binjai in 2013 obtained the following results: 1. Univariate Analysis a. Distribution of respondents based on the utilization of erderly integrated service post, knowledge and attitudes. Distribution of respondents based on the utilization of erderly integrated service post, knowledge and attitudes in community health center of Tanah Tinggi Binjai 2013 can be seen in the pie chart below: Chart 1. Frequency Distribution Of Respondents Based On The Utilization Of Erderly Integrated Service Post In Community Health Center Of Tanah Tinggi Binai 2013 Elderly Integrated Service Post 25 30 person person (45,5 %) (54.5 %) Unutilize Utilize Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on the chart 1 shown that total 45.5% (25 people) elderly have utilized intergrated service post. Chart 2. Frequency Distributionof Erderly Knowledge With Utilization Of Erderly Integrated Service Post In The Region Of Community Health Center Of Tanah Tinggi Binjai 2013 Elderly Knowledge 11 Person (20 %) 18 person (32,& %) Good Chart 3. Frequency Distribution of Erderly Attitude With Utilization Of Erderly Integrated Service Post In The Region Of Community Health Center Of Tanah Tinggi Binjai 2013 Elderly Attitude 37 Person (67,3 %) No The Utilization Yes No F % F % 18 100 0 0 7 26,9 19 73,1 5 45,5 6 54,5 30 54,5 25 45,5 Knowledg e Total P Value F % 18 100 0,000 26 100 11 100 55 Less Based on chart 2 shown that total of 20.0% (11 people) less knowledgeable about utilization of elderly integrated service post. 18 Person (32,7 %) Table 1 Frequency Distribution of Correlation Between Elderly Knowledge to the Utilization of Erderly Integrated Service Post in Community Health Center of Tanah Tinggi Binjai 2013 1 Good 2 Enough 3 Less Total Enough 26 Person (47,3) a. The distribution of respondents according to the relationship of knowledge with the utilization of erderly integrated service post can be seen in the table below: Negative Positive Based on the chart 3, as much as 32.7% (18 persons) Elderly being negative about the utilization of elderly integrated service post. 2. Bivariate Analysis From the table above was obtained that there 5 out of 11 (45.5%) of respondents who do not utilize the erderly integrated service post had less knowledge. While among the elderly who take advantage of integrated service post exist as much as 18 out of 18 respondents (100%) who have a good knowledge. Test results obtained by statistical values p value = 0.000 then it can be concluded there is a difference between utilization of integrated service post incidence proportion of Elderly who have a good knowledge of the elderly who have less knowledge (there is a significant relationship between the knowledge of elderly with utilization of integrated service post elderly). b. Distribution of respondents based on relationships with elderly attitude to utilization of of erderly integrated service post can be seen in the table below: Table 2 Frequency Distribution of Correlation Between Elderly Attitude to the Utilization of Erderly Integrated Service Post in Community Health Center of Tanah Tinggi Binjai 2013 The Utilization Yes No F % F % 29 78 8 21 F 37 % 100 0,000 Negative 1 5 17 94 18 100 Total 30 54,5 25 45,5 55 No Sikap 1 Positive 2 Total P Value From the results of the analysis of the correlation between the attitudes of the elderly with the utilization of erderly integrated 23 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology service post obtained that there are 29 of 37 (78,4%) of respondents utilizing erderly integrated service post have a positive attitude. While the elderly who do not utilize the erderly integrated service post seen that there was 1 of the 18 respondents (5.6 percent) who had a negative attitude. Test results obtained by statistical values p value = 0.000 then concludes there is a difference between utilization of erderly integrated service post to incidence proportion of elderly who have a positive attitude to the elderly who have a negative attitude (there is a significant relationship between the attitudes of the elderly with the utilization of erderly integrated service post). DISCUSSION a. Distribution of respondents based on the utilization of erderly integrated service post, knowledge and attitudes in community health center of Tanah Tinggi Binjai 2013. The research that has been conducted in Community Health Center of Tanah Tinggi Binjai in 2013, from the chart.1 shows the frequency distribution of integrated service post’s utilization is known that elderly who utilized integrated service post is as much as 30 elderly people (54.5%). According Notoatmodjo (2003), when the acceptance of new behavior or adoption of behavior through a process based on the knowledge, awareness and attitudes then the behavior will be lasting (long lasting). Conversely, if the behavior is not based on knowledge and awareness then it will not last long. The participation of the elderly to integrated service post supported by knowledge of integrated service post by elderly can be lasting. Utilization of health services by the family also affect the elderly integrated service post depends on family predisposition include family characteristics tend to use health services include demochartic variables, variables of social structure, as well as beliefs and attitudes toward medical care (Muzaham F, 1995). According to the assumptions of researchers, from the study due to lack of utilization of erderly integrated service post caused by lack 24 of knowledge and attitudes and support of the elderly families. From the research that has been done in the community health center of Tanah Tinggi Binjai in 2013, based on the chart 2 shows total of 20.0% (11 people) less knowledgeable about utilization of elderly integrated service post. Based on the amount of information obtained by the elderly about the use of erderly integrated service post then, according to Notoatmodjo (2007) mention that the more information got then more in knowledge also because the information is one of the factors that can affect a person's level of knowledge. It just proves that the utilization of elderly integrated service post affected by lack of knowledge about the utilization of erderly integrated service post so it caused unknown the benefit of it. John Locke an empiricism of Britain said that human beings are born minds is a kind of blank note book. In the scientific record books recorded sensory experiences. And further John Locke said, the rest of the knowledge we gain with ideas derived from the sensing and the first reflection and simple. Long story short, knowledge gained by empiricism is more because of the experiences that ever passed, how the complexity of knowledge can be traced to experiences (Prince, 2011). According to the researchers assumption, lack of knowledge about elderly integrated service post due to lack of information and experience about the utilization of erderly integrated service post. Based on the chart 3, as much as 32.7% (18 persons) elderly being negative about the utilization of elderly integrated service post. In this case, Thurstone stated that attitude is a form of evaluation or emotional response to something. Thus, the attitude pointing in the direction of positive and negative that has to do with one's psychological life. So, in terms of the attitude of the elderly to Utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai show negative positive attitude because attitude is the basis on readiness or willingness to follow the activities of elderly integrated service Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology post. With such a good attitude, the elderly tend always present or follow the activities held at elderly integrated service post. This is understandable because they are a mirror of one's attitude of readiness to react to an object. Readiness is a potential tendency to react in certain ways when people are faced with a stimulus that calls for a response. According to Gordon Allport, the attitude of a person's psychological readiness to react to stimuli originating from within or outside himself. Attitude shows on something that is still a potential which at times can actual when exposed to certain stimuli. According to the researchers assumption that negative attitude obtained from the elderly because it illustrates the attitude like or dislike a person against an object. Attitudes are often derived from their own experience or from others who are closest. Therefore, the introduction of integrated service post elderly need to be improved by health workers. b. Knowledge and attitudes correlation to the Utilization of Erderly Integrated Service Post in Community Health Center of Tanah Tinggi Binjai 2013 From the results of the relationship between knowledge of the utilization of elderly integrated service post analysis in Table 1 shows that there are as many as 5 of 11 (45.5%) of respondents who do not utilize elderly integrated service post have less knowledge. Whereas among the elderly who utilize integrated service post there were 18 of 18 (100%) of respondents who have a good knowledge. After the Chi Square test showed p value = 0.000. This figure gives the sense that the correlation between the level of elderly knowledge with utilization of integrated service post statistically significant, the less level of knowledge of the elderly, will be increasingly less the utilization rates of elderly integrated service post . The study results were presented appropriate to Notoatmodjo (2007), that someone who does not want to follow the integrated service post elderly can caused because the person is not or not yet know the benefits of integrated service post. Supported also by the theory of Lawrence Green mentioning that the behavior of a person in good health can be affected by three factors, one factor predisposing factors among embodied in knowledge. Results of the study according to the study conducted by Fitri Hayani (2012) argued that the respondents who have a good knowledge, many of them which utilize elderly integrated service post, while respondents who have less knowledge, they less utilize elderly integrated service post. Results of this study are also consistent with research conducted to Yunita Sriasih (2006) argued that there is a significant correlation between the level of knowledge on the utilization of elderly integrated service post. And researchers hope that the elderly improve their knowledge about elderly integrated service post. It can be concluded in this study that there is a correlation between knowledge of the utilization of elderly integrated service post which means the better knowledge of the elderly to the utilization of elderly integrated service post will be more willing to utilize it. So the results of this study did not find any gap between research results with the theory mentioned above. Based on table 2 of the research that has been conducted in community health center of Tanah Tinggi Binjai in 2013, shows the crosstabulation between attitudes and utilization of elderly integrated service post in Community health center of Tanah Tinggi Binjai in 2013. It is known that as much as 37 respondents who have a positive attitude about elderly integrated service post, and 29 respondents, or 78.4% of the elderly utilized integrated service post. Then the 18 respondents who had a negative attitude and one elderly respondents or 5.6% of the elderly do not utilize elderly integrated service post. After the Chi Square test, the results obtained p value = 0.000 <0.05. The rate gives the sense that the relationship between the attitude of the elderly to utilization of elderly integrated service post statistically significant. The meaning is that if the elderly have a positive attitude it will be more active to utilize the elderly integrated service post and if the 25 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology elderly have a negative attitude it will be increasingly less utilization of elderly integrated service post. The results showed the majority of elderly with a negative attitude has a inactive utilization of elderly integrated service post. This is consistent with the statement of Notoatmodjo (2003) that attitude will make a person toward or away from other people or other objects. In this regard a positive attitude makes the elderly did not utilize elderly integrated service post. Results of the study according to the study conducted by Fitri Hayani (2012) argued that the respondents who have a good attitude, many of them will utilize elderly integrated service post, while respondents who have less attitude, many of whom lack utilize the elderly integrated service post. Therefore, the better attitude about the use of elderly integrated service post, the better participation of the elderly integrated service post. Results of this study are also consistent with research conducted to Yunita Sriasih (2006) argued that there is a significant correlation between attitudes toward the elderly integrated service post program. Researchers hope that the elderly have a high attitude towards the elderly integrated service post . It can be concluded in this study that there is a correlation between the attitude of the elderly with the elderly integrated service post utilization which means the bad attitude of the elderly of elderly integrated service post utilization will be even less willing to take advantage of elderly integrated service post. So the results of this study did not find any gap between research results with the theory mentioned above. CONCLUSIONS AND SUGGESTIONS CONCLUSION Based on the results of research on the correlation of knowledge and attitude to the utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013 can be concluded as follows: 1. The results showed that as many as 20% of the elderly have less knowledge about the utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. 26 2. The results showed that as many as 32.7% of elderly had a negative attitude about the utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. 3. The results showed that as many as 45.5% of elderly who do not utilize elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. 4. There is a correlation between knowledge and utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. 5. There is a correlation between attitudes to the utilization of elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. SUGGESTIONS 1. Expected to head of community health center to be able to make a schedule extension, regulations and counseling on a regular basis of elderly integrated service post and sustainable (sustainable) in order to be used by elderly integrated service post in community health center of Tanah Tinggi Binjai in 2013. 2. To be more open in disseminating information to the elderly integrated service post and for further research of this study are expected to be developed. 3. Expected to health professionals to improve complete education and counseling activities in order to get the correct information about elderly and elderly integrated service post so that the knowledge and attitudes of the elderly to be good and positive. REFERENCES Arikunto, S, 2003, Prosedur Penelitian Suatu Pendekatan Praktek. Edisi Baru, Rineka Cipta: Jakarta Bandiyah, S, 2009, Lanjut Usia dan Keperawatan Gerontik, Nuha Medika:, Yogyakarta Depkes. RI, 1999,repository.USU.ac.id/bitsstream/ …/4/Chapter%20//pdf Dinkes Provsu, 2012, Profil Sumatera Utara Tahun 2011, Dinkes Provsu, Medan. Fallen, R dan Budi, R, 2010, Keperawatan Komunitas, Nuha Medika: Yogyakarta Hatta, 2011. http://www.scribd.com/doc/9207741 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 3/03-BAB-I- Integrated service post -Lansia (accessed at 2 Februari 2013) Hesti, W, 2007, Asuhan Keperawatan Pada Lanjut Usia di Tatanan Klinik,, Fitrimaya: Yogyakarta __________, W, 2010, Asuhan Keperawatan Pada Lanjut Usia di Tatanan Klinik,, Fitrimaya: Yogyakarta Hidayat, A, 2011, Metode Penelitian Keperawatan dan Teknik Analisis data, Salemba Medika: Jakarta Hutahuruk. Agustina 2005. Faktor-Faktor Yang Mempengaruhi Pelayanan Integrated service post Lanjut Usia. Medan : Tesis Program Administrasi dan Kebijakan Kesehatan Sekolah Pasca Sarjana Sumatera Utara Machfoedz, I, 2008, Metodologi Penelitian (Kualitatif dan Kuantitatif), Fitrimaya:, Yogyakarta Maryam, R, dkk, 2008, Mengenal usia Lanjut dan Perawatannya, Salemba Medika: Jakarta Muzaham, F.2005. Sosiologi Kesehatan. 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Medan W.Resmana,2011. eprints.undip.ac.id/32716/4/4_PENDA HULUAN.pdf (accessed at 10 Januari 2013 27 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RELATIONSHIP BETWEEN ANXIETY LEVEL TO SLEEP FULL FILLMENT OF INGUINAL HERNIA PREOPERATIVE PATIENTS AT DR.PIRNGADI HOSPITAL MEDAN Suriani br Ginting1, Agustina Boru Gultom1, Wiwik Dwi Arianti2 1, 2 Nursing Department of Poltekkes Kemenkes Medan Abstrak Anxiety is a condition that can be experienced by everyone in daily life. Usually we experience a state of anxiety when we deal with things out of the ordinary everyday activities ( Sylvia , 2008) . This effect is caused by anxiety disorders and sleep patterns of rest. According to Potter (2005 ), that the patients often experience preoperative anxiety. Pre operation is when the decision for surgical intervention will be done and it will cause complaints for patients who live with anxiety and cause sleep disorders. The purpose of this study was to determine the relationship between the level of anxiety on the fulfillment of the patient's sleep in pre inguinal hernia operation with the type of descriptive correlational cross-sectional study design with a total sample of 37 respondents were acquired in July 2014 by accidental sampling technique. Statistical analysis using chi square test . The results showed that the p value 0.00 ( p < 0.05 ) which shows the relationship between the level of anxiety on the sleep fulfillment of inguinal hernia preoperative in patients. It is recommended that improving preoperative nursing care to deal with cases of anxiety before undergoing surgery. Keywords : Anxiety, Sleep Fulfillment, Pre Operative BACKGROUND A hernia is a protrusion outside the organ or other tissue due to an increase in intraabdominal pressure that cause abnormal body openings ( Garcini , 2010). Inguinal hernia is a condition of the release of an organ or structure from its normal organ through a defect in the inguinal area that can not be returned to its original place manually and would have implications invasive surgery by restoring the structure of the organ is surgically ( Muttaqin & Sari , 2009), Inguinal hernia is one of the cases digestive surgery in the world. It is still a challenge in improving the health status of the community because of the costs required in the handling and loss of labor due to the slow pace of recovery and recurrence rate. The overall number of operations in France hernia surgery as much as 17.2 % and 24.1 % in the United States (Albiner , 2003) . In Indonesia hernia ranks eighth with a number of 291.145 cases. Inguinal hernia was found 25 times more in men than women (Albiner , 2004) . The surgical procedure will provide an emotional reaction to the patient. For example, 28 preoperative anxiety is an anticipation of a patient's experience that can be considered as a threat to its role in the life, integrity in the body, or even life itself . It is known that the troubled mind will directly affect the functioning of the body (Muttaqin & Sari , 2009) . The impact is often caused by a state of anxiety that can be manifested by all systems of the human body both physiologically, psychologically and spiritually. One impact is disturbance of rest and sleep patterns commonly from someone entering a hospital or health facility. Sleep is part of the healing of an illness . Achieving good quality sleep is important for health . Similarly to recover from illness , clients who are ill often need more sleep and rest than healthy clients. However , the disease usually prevent some clients to get adequate sleep and rest ( Potter , 2010) . According to research of Triningsih ( 2012) about the relationship between the level of anxiety to meet needs of the patient's sleep patterns preoperative in Jasmine ward of Panembahan Senopati Hospital Bantul, Yogyakarta, indicates that respondents who are at the level of anxiety being there as much Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology as 62.86 % , and as much as 54.28 % of respondents pattern need less sleep . And based on the results of the study showed a significant relationship between the level of anxiety with the fulfillment sleep patterns of 0,313 or 31.3 % with a significance of 0.020 ( sig.p < 0.05 ) . Based on preliminary studies conducted in hospitals Dr.Pirngadi Medan, found that the number of surgery patients in 2013 were 3169 patients. Inguinal hernia surgery patient data in 2013 were 372 people, in December 2013 there were 39 people .Based on interviews at 3 preoperative patients in hospitals of dr.Pirngadi Medan , where two patients undergoing surgery for the first time said patients feel anxious and disturbed sleep fulfillment , whereas the third patient to undergo a second surgery to say a little bit anxious but the fulfillment of sleep is not disturbed . Problems The formulation of the problem in this research is how relationship between anxiety level to sleep fullfillment of inguinal hernia preoperative patients at dr.Pirngadi hospital Medan. Research Objectives To describe the relationship between anxiety level to sleep fullfillment of inguinal hernia preoperative patients at dr.Pirngadi hospital Medan. Hypothesis There is a relationship between anxiety level to sleep fullfillment of inguinal hernia preoperative patients at dr.Pirngadi hospital Medan 2014. RESEARCH METHODS The type of research is descriptive correlative with cross sectional design with the aim to determine the relationship of the level of anxiety on the sleep fulfillment of inguinal hernia preoperative patient at Dr.Pirngadi Hospital Medan. Data were collected in June 2014. The population of this study were all patients who undergo inguinal hernia surgery, amounting to 372 people in 2013. Samples numbered 37 people, taken as many as 10% of the population with accidental sampling technique with the inclusion criteria: 1) Patients Inguinal hernia surgery is planned after the hospitalization 1-3 days in hospital, 2) Willing to be a respondent, 3) undergo the first surgery, 4) Adult patients with age ≥ 17 years. Data collection technique was done by interview using a questionnaire. Data were analyzed using univariate analysis with frequency distribution, bivariate analysis with chi-square formula. RESULTS AND DISCUSSION RESULTS Table 1 Respondents Frequency Distribution According To Anxiety Level To Face Hernia Inguinalis Pre Operative At Dr.Pirngadi Hospital No Category F % 1 Moderate 12 32,4 2 Mid 21 52,8 3 Severe 4 10,8 Total 37 100 Table 1 shows the level of anxiety of patients facing surgery inguinal hernia is a mild anxiety are 12 person( 32.4 % , Mid anxiety was 21 person ( 52.8 % ) and severe anxiety there are 4 people ( 10.8 % ) . Table 2 Respondents Frequency Distribution According To Sleep Fullfillment To Face Hernia Inguinalis Pre Operative At Dr.Pirngadi Hospital No Category F % 1 Unfullfilled 25 67,6 2 Fullfilled 12 32,4 Total 37 100 Table 2 shows the fulfillment of the sleeping patient in the face of an inguinal hernia operation are not fullfill as many as 25 people ( 67.6 % ) and fullfilled as many as 12 people (32.4 %) . 29 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 3 Cross Table Sleep Fullfillment to Anxiety Level of Inguinalis Pre Operative Patients At Dr.Pirngadi Hospital No Anxiety Level 1 2 3 Sleep Fullfillment Total Fullfilled F % Mild 9 24,3 Moderate 3 8,1 Severe 0 0 Total 12 32,4 P Unfullfill F % F % 3 8,1 12 32,4 18 48,6 21 56,8 0,00 4 10,8 4 10,8 25 67,6 37 100 Table 3 shows the fulfillment of sleeping patients undergoing inguinal hernia repair in the category are not fulfilled experiencing mild anxiety levels as much as 3 people ( 8.1 % ) , experienced mid anxiety level was as much as 18 people ( 48.6 % ) and experienced severe anxiety level of 4 people ( 10.8 % ). While the fulfillment of unmet sleep in the category experiencing mild anxiety levels were 9 people ( 24.3 % ) and anxiety level was as much as 3 people ( 8.1 % ) . DISCUSSION Anxiety is a disorder of mood ( affective ) which is characterized by feelings of fear or worries that deep and sustained, not impaired in reality , the personality remains intact, the behavior can be disturbed but within normal limits( Hawari , 2006).. Based on the results of the research showed that the level of anxiety in the face of surgery patients are at a level of anxiety was the number of 21 people ( 52.8 % ). This is likely due to patients undergoing surgery for the first time making the patient fear. Fears of patients may be afraid of anesthesia , fear of death, fear of the changes in body image, and may even fear the administrative costs of the hospital . Of all patients with average anxiety symptoms were anxious to statements regarding autonomic symptoms that include dry mouth, flushing, easy sweating, headache, head feels heavy as many as 8 people (21.6%). According to Hawari (2006) stated that in addition to feeling worried, bad feeling and irritability, physical complaints may occur in patients who experience anxiety as head ache and weight as well as easy to sweat. The patient's need for sleep can be disrupted due to the operation plan to be implemented. 30 Operation plan to make patient continue to think about the situation that disrupts sleep of surgery patients. Adequate rest is very necessary for patients who will undergo surgery due to adequate sleep can help cure patients (Muttaqin, 2009). Based on the results of the study showed there were as many as 25 people (67.6%) patients sleep needs are not met. Based on the answers of respondents who most needs are not met are sleeping on the question of whether there are no feelings / thoughts that disturb you before sleep experienced by 25 people (67.6%). This suggests that preoperative patients of hernia inguinalis sleep needs are not met. To avoid this effort that can be performed is counseling about the importance of adequate rest for the quality of healing and prevention of disease, support bedtime rituals by listening to music, watching television, worship and a warm bath before bed, creating a quiet environment, comfortable room temperature, suitable ventilation and lighting, improves comfort and relaxation such as wearing loose sleep, encourage the patient to urinate before going to bed and provide a comfortable position for sleeping. (Kozier, 1991) Anxiety experienced by individuals can have a detrimental effect both on the need for sleep . Anxiety can increase norepinephrine levels in the blood by stimulating the sympathetic nervous system . This chemical change can cause a lack of sleep stages of NREM sleep and REM sleep , and more changes in the stage of sleep and more frequent awakening during sleep ( Kozier , 1991) . Based on the analysis results obtained with the chi square test p value : 0.00 < 0.05 with a 95% confidence level indicates that there is a significant relationship between anxiety level to sleep fullfillment of inguinal hernia preoperative patients at dr.Pirngadi hospital Medan. The results are consistent with the statement of Potter and Perry (2010 ) which states that worried about personal problems or situations are often disturb sleep . Research results are also consistent with research Triningsih ( 2012) states that there is a significant relationship between the level of anxiety with the fulfillment sleep patterns of 0,313 or 31.3 % to p ; 0.02 < 0.05. So it is need an action to reduce anxiety by improving Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology perioperative nursing care by giving impetus to the disclosure of the patient's feelings, to listen, to understand the patient, providing information to patients about surgical procedures to get rid of such concerns and support the patient's spiritual beliefs . CONCLUSIONS AND RECOMMENDATIONS Based on the research results can be concluded that the anxiety level of inguinal hernia patients majority were in anxiety levels were as many as 21 people (52.8 %), the sleep fulfillment of hernia inguinalis preoperative patient majority were not met as many as 25 people ( 67.6 % ) and there is a significant relationship between the level of anxiety on the fulfillment of the patient's sleep in the face of pre inguinal hernia repair with p value = 0.00 ( p < 0.05 ) . Based on the results of the study suggested that nurses improve preoperative nursing care by delivering an attempt to reduce anxiety by giving impetus to the disclosure of feelings and provide information to patients about surgical procedures . REFERENCES Albiner,S, 2003. Perbandingan Nyeri Pasca Hernioplasty Shouldice Pure Tissue Dengan Lichtenstein Tension Free, Medan : USU Arikunto, 2010. Prosedur Penelitian Suatu Pendekatan Praktik. Jakarta : Rineka Cipta. Elvira, DS.,2008. Gangguan Panik. Jakarta : FKUI Faradila,N.,2009. Hernia, Riau : Faculty of Medicine –Universitas Riau Garcini, 2010. Mengenal Hernia. http://medicastore.com/artikel/291/Menge nal_Hernia.html, diakses 24 Februari 2014 Hawari,D., 2006. Manajemen Stress Cemas Dan Depresi, Jakarta : FKUI Kozier et al, 1991. Fundamental Of Nursing. Concepts, Process and Practice, California : Addison Wesley Lanywati,E., 2001. Insomnia Gangguan Sulit Tidur, Yogyakarta : Kanisius IKAPI Lukaningsih,LZ., dkk, 2011. Psikologi Kesehatan, Yogkarta : Nuha Medika Long, 1996. Perawatan Medikal Bedah. Terjemahan, Bandung : Yayasan IAPK Padjadjaran. Mansjoer,A., dkk, 2001. Kapita Selekta Kedokteran, Jakarta : Media Aesculapius FK UI Muttaqin,A.,dkk,2009. Asuhan Keperawatan Perioperatif, Jakarta : Salemba Medika. Muslimah, 2013. Mengatasi Susah Tidur, http://muslimahor.id/kesehatan muslimah/mengatasi-susah-tidur.html, diakses 11 Juni 2014 Nursalam, 2008. Konsep Dan Penerapan Metodologi Penelitian Ilmu Keperawatan, Surabaya : Salemba Medika Potter,PA., dkk, 2010. Fundamental Keperawatan, Edisi VII, Terjemahan, Jakarta : Salemba MEdika Prasadja, 2006. Efek Kurang Tidur, http://repository.usu.ac.id/bitstream/1234 56789/20113/4/Chapter%2011.pdf, diakses 11 Juni 2014 Riyanto,A. 2010. Modul Pengolahan dan Analisa Data Kesehatan, Yogyakarta : Nuha Medika Smeltzer dan Bare, 2002. Buku Ajar Keperawatan Medikal Bedah. Terjemahan, Jakarta : EGC Stuart, GW., 2007. Buku Saku Keperawatan Jiwa, Edisi 5, Terjemahan, Jakarta : EGC Sugiarto,E.,2008. The Secret of Sleep, Jakarta : Prestasi Pustaka Triningsih,W., 2012. Hubungan Antara Tingkat Kecemasan Dengan Pola Pemenuhan Tidur Pasien Preoperasi di Bangsal Melati RSD Panembahan Senopati Bantul Yogyakarta 31 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology DISASTER RISK INDEX IN SIMEULUE DISTRICT (Study Case: Disaster Prone Areas of Aceh Province) 1 Desi Sri Pasca Sari Sembiring 1, Ritha F. Dalimunthe 1,2, Delvian SP, MP 1, 3, R.Hamdani 1, 4 Study Program of Natural Resource and Environmental Management, Graduate School, University of Sumatera Utara, Jln. T.Maas, Medan, Indonesia 2 Department of Economic, Faculty of Economic, University of Sumatera Utara. Jln. Prof.T.M.Hanafiah Medan,Indonesia 3 Department of Forestry, Faculty of Agriculture, University of Sumatera Utara, Jln. Tri Dharma Ujung No. 1, Medan, Indonesia 4 Department of Social Anthropology, Faculty of Social Science and Politic, Jln.Dr Sofyan No3 University of Sumatera Utara, Medan, Indonesia Email Adress 1 [email protected], [email protected], [email protected], [email protected] ABSTRACT This study aims to: know the threats ,vulnerabilities and capacity in the research study and how is the disaster risk index of this area. The method of analysis used to define the results of the exploration problem is a descriptive study. To complement the descriptive explanation of some of the test that is : analyze the hazard,vulneribility and capacity do with make a table, map,disaster history and count Disaster Risk Index. From 8 regions in Simeulue are evenly distributed dissemination potential capacity. With an average score for the ability to anticipate threats of 1063, organizing ability and the ability of a solution of 889 monitoring and evaluation of 470. The region and the highest level of anticipation is East Simeulue and Alafan. From 8 regions in Simeulue are worrying spread of potential vulnerability. With an average score of between disaster index, variable economic conditions of 3843, the physical condition of the building has a score of 7848 and the condition of vulnerable 2880. Region and the highest level of vulnerability is Alafan and Salang. From 8 regions in Simeulue are evenly distributed dissemination potential capacity. With an average score for the ability to anticipate threats of 1063, organizing ability and the ability of a solution of 889 monitoring and evaluation of 470. The region and the highest level of anticipation is East Simeulue and Alafan. From the above calculations it can be concluded that the level of disaster risk is highest in Alafan and Salang. Keywords: Disaster Risk , Proneness, Simeulue Introduction Indonesia is a country with a highly potential for disaster . There are several potential disasters include natural disasters such as earthquakes, volcanic eruptions, floods, landslides, and others. Potential disasters in Indonesia can be classified into two main groups , namely the potential main hazard and the collateral hazard. The main potential hazards can be seen among others, on the map of potential earthquake in Indonesia, which indicates that Indonesia is a region with earthquake zones prone, landslide potential maps, maps of potential catastrophic volcanic eruptions, catastrophic potential map tsunami, flood potential maps and others. From the above indicators can be concluded that Indonesia has the potential major hazards (main hazard Potency) high. Certainly it is 32 very unfortunate for the country of Indonesia. Besides the high potential major hazards, Indonesia also has the potential collateral hazard potency (IDEP, 2007). A disaster defined as a serious disruption and functioning of society, causing widespread human, material or environmental losses, which exceed the ability of an affected society to cope using only its own resources (EEA, 2006). Disaster is defined also as a serious disruption of the functioning of a society, causing widespread loss of human life in terms of material, economic or environmental and are beyond the ability of the society to cope using their own resources ( UNISDR, 2004). By UN definition (Cardona, 2005), the risk of losses is a function of three components: hazard, element at risk and vulnerability. In Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology the case of risk of human losses, the element at risk is the exposed population. The hazard occurrence refers to the frequency of returning period at a given magnitude, whereas the vulnerability is “the degree of loss to each element should a hazard of a given severity occur"(Blaikie et al., 1994). Disaster Risk Reduction is a series of activities before, during and after a disaster is done to prevent , reduce , avoid , and recover from disasters. According to UNESCO/ISDR (2006 ), is a preparedness measures that enable governments, organizations, communities, and individuals to be able to respond a disaster situation quickly and appropriately. Included in the preparedness action is the preparation of disaster management plans, maintenance resources and personnel training. Preparedness activities focused on the development of plans to respond to disasters quickly and effectively. Preparedness, efforts are being made to anticipate disasters, through the appropriate steps to organizing and efficient, (Latif , 2008). Risk is the exposure to chance of loss It is a combination of the probability of an even occuring and the significance of the consequence, known as impact, of the event occuring. The term "risk "come from the early italian "risicare" meaning to dare (Bernstein, 1996). Simeulue island categorized proneness since they often experience an earthquake and tsunami , the Regional Disaster Management Agency ( BPBD ) Simeulue District has strong earthquake and tsunami occurred in 1907. Furthermore, on November 2, 2002 an earthquake reaching 9.3 on the Richter Scale ( SR ), December 26, 2004 reached 9.1 magnitude and tsunami reached 30 meters , March 3, 2005 earthquake reaching 9.1 magnitude, February 20, 2008 ,5 April 2009, August 18, 2009 and December 19, 2009. On January 16, 2011 an earthquake of 5.9 magnitude , January 18, 2011 the power of the SR 5.7 ,5 April 2010 with the strength of 7.2 Richter . On October 17, 2011 in Simeulue earthquake occurred again with a magnitude of 5.2 SR and January 11, 2012 with a strength of 7.1 SR and April 2012 with a strength of 8.5 Richter. On October 5, 2010 a cyclone hit West Teupah Subdistrict 5 and damaging homes and on March 30, 2011 back hurricanes in Central Simeulue and damaging three houses. So it can be concluded that these districts are areas that has prone to disasters. From the description of the history of this disaster Simeulue included in disaster-prone areas (TDMRC : Tsunami and Disaster Mitigation Research Center Syah Kuala University, 2011) and have been socialized in Aceh Province. On last 5 years of disaster : the tsunami and earthquake in Aceh /Nias 2004, and earthquake 2005, earthquake in West Sumatra 2006, tsunami Pangandaran West Java 2006 and other disaster. Maintsreaming Disaster Risk Management One of the areas in Indonesia that are routinely experienced the earthquake called Pulau Simeulue in Aceh Implementation of Disaster Risk Management : -Emergency Figure 1. Reseach Background -Rehabilitation and Emergency -Development (Mitigation and Preparedness) What are the hazards,vulnerabilities and Simeulue capacity as disasterprone area Graph 1.The background of this study Based on research Silbert, M, 2011, noted the importance of economic development to reduce vulnerability to disasters. Vulnerability analysis should take into account vulnerable groups such as women, the poor, and small island in developing countries. Based on the background, that is Simeulue proneness, the history of disaster and implemented policies and respect to disaster risk management, so the main problem of this reseach : What are the threats hazards, vulnerability and capacity in the study area and how is the disaster risk index of this area. Research Methodology The Reseach was done on June 2012-June 2013. The research location is determined by purposive sampling (Sudjana, 1988) the disaster proneness areas in the province of Aceh, Simeulue. Collecting data do in three ways, literate study, questionnaire and field observation. The method of analysis used to define the results of the exploration problem is a descriptive study. To complement the descriptive explanation of some of the test that is : analyze the hazard,vulneribility and capacity do with make a table, disaster history and Disaster Risk Index with the formula : 33 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Sample amount was determined using Taro Yamane’s formula (in Israel, 1992), as follows: n= N 1+N (e)2 n = sample amount; N = population amount; e = confidence level – 10 % RESULT AND DISCUSSION Based on Disaster Management Act to calculate the level of risk of Disaster Risk, it can be seen from three variables, namely, the threat (Hazard), Vulnerability and Capability. The vulnerability of a community is Determined by the level of disaster risk. Disaster risk is a function of the threat to the state of vulnerable, which can be changed by the existence of ability. By using this formula then when there are no vulnerabilities and threats, risks resulting value is 0, but on the contrary if a region has a value of more than 100 disaster risk, this means that the region has a high risk of disaster. With the model as follows: No Variabel 1 2 3 4 5 Tsunami Gempa Bumi Kebakaran Longsor Angin Topan In this study, researchers lowered these variables into a few factors and sub-factors in order to obtain the weighted value of each variable threats, vulnerabilities and capabilities. The following diagram decrease variables into a few factors based on a review of studies and the results of focus group discussions in Simeulue community. 3.1 Value Threat Threats are rare or extreme events of the environment due to human activity or natural because that adversely affect human life, property or activity to the level that caused the disaster (UNDP, 2009). Simeulue island consists of more than 40 islands located in the Indian Ocean and in the outer islands of Sumatera. From the observation and data analysis of the obtained multiple threat picture in this disaster-prone areas. Value is calculated through observation researchers threat while in the study by determining the location of impact and the weight of values were then calculated by multiplying the frequency of occurrence. Value threats in Simeulue district can be seen in Table 3.1. Frekuensi dan Penilaian Skor Dampak Bobot Teupah SelatanSimeulue Timur Teupah Barat Simeulue TengahTeluk Dalam Salang Simeulue Barat Antisipasi dampak f Skor f Skor f Skor f Skor f Skor f Skor f Skor 1 8 9 1 72 0 0 1 72 0 0 1 72 0 0 1 72 5 9 9 12 972 15 1215 13 1053 12 972 12 972 12 972 13 1053 4 5 5 5 125 8 200 4 100 4 100 4 100 4 100 5 125 5 3 3 1 9 1 9 1 9 2 18 2 18 1 9 1 9 5 4 3 1 12 1 12 2 24 0 0 0 0 1 12 1 12 Tolak Ukur Alafan f Skor 1 72 14 1134 5 125 4 36 2 24 Tabel 3.1. Frequency and Threat Assessment Scores From the above results, we can conclude that from 8 regions in Simeulue are evenly spread of potential threats. With above average scores index disasters, earthquakes pose a threat variables with the highest frequency, as many as 103. Then fires, landslides, hurricanes and tsunamis, respectively 39, 13, 8 and 1. Scores 34 for each indicator that the tsunami disaster threat of 360, Earthquake of 8343, amounting to 975 fires, landslides and hurricanes by 117 by 96. And the region which is the highest threat level are Alafan and Simeulue East. This is Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology because the region as the capital of Simeulue East sub-district is a densely populated area. At the time of the earthquake is easy there is a risk of fire because the stove fell, candles and fall short of current flow occurs. Triggers Another fire building construction material of wood. Mitigation of earthquake made hereditary society is making a house with basic materials so that the board is not too risky when the earthquake happened but on the other hand is more combustible material than brick building material. Position Simeulue is near the line of the meeting between the Indian plate. Australian and Eurasian plates. Sumatera island arc and the western section is part of the Eurasian plate. While the other plate is under the Indian Ocean. Limit the collision of two plates can be observed in the form of lines deep ocean trenches to the west of Sumatera to the Andaman Islands. In the collision region, the Indian Plate under Sumatera menunjam 50 " 60 cm / rock mass above referred to as the contact area of a subduction zone / penunjaman. The highly risk index is Alafan than the other, this was due to the earthquake epicentrum point located at coordinates 3.316 ° North latitude and 95.854 ° East line, with a depth of 30 kilometers and approximately 250 kilometers south of Banda Aceh and + 50 km from Alafan region so that the vibrations are stronger than other regions. 3.2 . Value Vulnerability According to the Ministry of Research and Technology of the Republic of Indonesia, the vulnerability is a condition of a community or society that leads or has an inability in the face of threats. Society is said to have vulnerabilities if they are not able to anticipate and survive a threat. The vulnerability arises because the pressure acts of individual or community. The forms of vulnerabilities that exist in society seen from indicators of economic conditions, the physical condition of the building and the condition of the vulnerable population. Susceptibility values calculated through observation while on-site research study by determining the impact and value weights are then calculated by multiplying the frequency of occurrence. The value threats in Simeulue district can be seen in Table 4. This would be a situation faced by people with potentially disaster areas in Simeulue district can be seen in Table 4 No 1 2 3 Frekuensi dan Penilaian Skor Dampak Variabel Bobot Teupah SelatanSimeulue Timur Teupah Barat Simeulue TengahTeluk Dalam Salang Simeulue Barat Antisipasi dampak f Skor f Skor f Skor f Skor f Skor f Skor f Skor Kondisi Ekonomi 3 7 9 15 945 10 630 6 378 5 315 4 252 6 378 7 441 Kondisi Fisik Bangunan 4 8 9 30 2160 15 1080 9 648 7 504 12 864 11 792 13 936 Kondisi Penduduk Rentan 3 8 8 7 448 5 320 8 512 4 256 5 320 7 448 4 256 Tolak Ukur Alafan f Skor 8 504 12 864 5 320 Tabel 3.2. Frequency and Vulnerability Assessment Scores From the above results, we can conclude that from 8 regions in Simeulue are worrying spread of potential vulnerability. With an average score of between disaster index, variable economic conditions of 3843, the physical condition of the building has a score of 7848 and the condition of vulnerable pensusuk 2880. Region and the highest level of vulnerability is Alafan and Salang. Subdistrict Alafan is the most vulnerable region from other regions . Physically this area directly facing the Indian Ocean with no obstacles. Alafan region includes areas that have economic resources low and limited access to transportation either by land or sea. Land access many disconnected because a lot of damaged roads and bridges , the network exit is also very limited because there is no port, so that when disaster strikes the area is extremely vulnerable to food aid, medicines and other. Access to communication and electric lighting is also inadequate in this area because there is no telecommunication networks and information that goes into this region. 35 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The second highest vulnerable region is the District Salang because this area is not hilly like many other areas. So they have to run far enough to reach the hill. But when the 2004 tsunami happened community can still save themselves for the hills , because the distance to the area is still quite safe. Results interview mentioned that knowledge has been acquired to save themselves from generation to generation, to save himself and family members, do not remember the others but continue to run to reach the hill. 3.3. Rated Capacity Ability is a combination of strength and existing resources within a community, social or organization that DAPT reduces the level of risk or the impact of disasters (ISDR, 2002). Existing capabilities in an environment can not be separated from the power of the parties therein (Ministry of Research and Technology of the Republic of Indonesia). From the observation and data analysis of the obtained several images in capacity of disaster-prone areas. Rated capacity is calculated through observation while on-site research study by determining the impact and value weights are then calculated by multiplying the frequency of occurrence. Rated capacity in Simeulue district can be seen in Table 5. Frekuensi dan Penilaian Skor Dampak Bobot Teupah SelatanSimeulue Timur Teupah Barat Simeulue TengahTeluk Dalam Salang Simeulue Barat Antisipasi hasil f Skor f Skor f Skor f Skor f Skor f Skor f Skor 1 Kemampuan Antisipasi Ancaman 7 9 7 17 1071 19 1197 18 1134 17 1071 15 945 15 945 16 1008 2 Kemampuan Mengorganisir Solusi 5 8 7 16 896 18 1008 14 784 15 840 15 840 15 840 16 896 3 Kemampuan Pengawasan & Evaluasi 7 8 5 12 480 12 480 11 440 12 480 11 440 12 480 13 520 No Variabel Tolak Ukur Alafan f Skor 18 1134 18 1008 11 440 Table 3.3. Frequency and Capacity Assessment Scores From the above results, we can conclude that from 8 regions in Simeulue are evenly distributed dissemination potential capacity. With an average score for the ability to anticipate threats of 1063, organizing ability and the ability of a solution of 889 monitoring and evaluation of 470. Region and the highest level of anticipation is East Simeulue and Alafan. Alafan have a high threat to the community in managing the risk of tsunami and earthquakes should be to greater capacity, such as in anticipation, community organizing, monitoring and evaluation. Although this indicator is to adopt disaster risk management system from the outside, but this indicator has been applied to the public, for example, people have been able to anticipate early on in the event of an earthquake and tsunami. When an earthquake is high then the village elders (customary village head and dean) immediately ascertain whether a tsunami through the receding sea water and dry well. If such symptoms occur they immediately announced to go up into the hills. For monitoring indicators and the solution is usually done by the village elders to ensure that all citizens have gone up a hilltop and 36 traditional elders have been able to make further plans after they were evacuated, for example, a search team go to the forest and fine food sources for people who evacuated in the Mount and Security team to ensure that the condition of the village safe. East Simeulue community is high capacity region because after the 2004 tsunami many NGOs are in, so local knowledge is getting applied and coupled simulation, in addition to the preparedness is further enhanced by the presence of an early warning system of the community in the form of wind chimes that have been applied. At the time of the 2004 tsunami eastern Simeulue relatively safer, harmful effects in an earthquake collapsed many houses but communities in Simeulue Timur has the capacity to anticipate the event of an earthquake with the development board. 3.4. Disaster Risk Index By using this formula then when there are no vulnerabilities and threats, risks resulting value is 0., But on the contrary if a region has a value of more than 100 disaster risk, this means that the region has a high risk of Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology disaster. Results obtained from observation through interviews and focus group discussions, grouped by the disaster areas in Simeulue District can be seen in table 6. No District 1 2 3 4 5 6 7 8 Reseach Variable Disaster risk Threats Vulnarabilities Capacity index Teupah 1190 Selatan Simeulue 1436 Timur Teupah 1258 Barat Simeulue 1090 Tengah Teluk 1162 Dalam Salang 1093 Simeulue 1271 Barat Alafan 1391 1688 2447 1618 2685 1538 2358 1075 2391 1436 2225 2030 2265 1633 2424 3553 2582 82 87 The figure was obtained from the conversion of the value set by the Disaster Management Act is equal to 100. From the above calculations it can be concluded that the level of disaster risk is highest in Alafan and Salang. The same thing was concluded by Bappeda Simeulue, 2012 in mapping disaster risk index Simeulue island with a GIS (Geographic Information System), that the District Alafan and Salang are the most risk areas on the island. 82 49 75 98 86 191 Table 3.4. Main Analysis Disaster Risk Index 1.Alafan 2.Salang Graph 2. Main Analysis Disaster Risk Indeks 2013 Alafan and Salang is the highly risk index area than the other , this was due to the earthquake epicentrum point located at coordinates 3.316 ° North latitude and 95.854 ° BujurTimur , with a depth of 30 kilometers and approximately 250 kilometers south of Banda Aceh and + 50 km from Alafan region so that the vibrations are stronger than other regions. Alafan Physically is an area directly facing the Indian Ocean with no obstacles. Alafan region includes areas that have economic resources low and limited access to transportation either by land or sea. Land access many disconnected because a lot of damaged roads and bridges , the network exit is also very limited because there is no port, so that when disaster strikes the area is extremely 37 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology vulnerable to food aid, medicines and other. Access to communication and electric lighting is also ineffective in this area because there is no telecommunication networks and information that goes into this region, it make difficult to communicate out of the island of Simeulue. Salang is the second highly risk cause there is no close hill around for evacuated place. The people must be run for 30 minute to reach the hill. 3.5.Conclusion From 8 regions in Simeulue are evenly distributed dissemination potential capacity. With an average score for the ability to anticipate threats of 1063, organizing ability and the ability of a solution of 889 monitoring and evaluation of 470. Region and the highest level of anticipation is East Simeulue and Alafan. From 8 regions in Simeulue are worrying spread of potential vulnerability. With an average score of between disaster index, variable economic conditions of 3843, the physical condition of the building has a score of 7848, and the condition of vulnerable 2880. Region and the highest level of vulnerability is Alafan and Salang. From 8 regions in Simeulue are evenly distributed dissemination potential capacity. With an average score for the ability to anticipate threats of 1063, organizing ability and the ability of a solution of 889 monitoring and evaluation of 470. Region and the highest level of anticipation is East Simeulue and Alafan. From the above calculations it can be concluded that the level of disaster risk is highest in Alafan and Salang. It can be seen from the disaster risk index Alafan shown 191 score and Salang area 98 score. Reference Applegate , D. Margaret Davinson , G , Whitney , M.Davidson.2006 . Improve of Observation for Disaster Reduction ; Near Term Opportunity Plan Executive Office of the President of the USA Bastian A , 2006. Familiar Living with Disaster . Sebuah Tinjauan Global tentang Inisiatif-inisiatif Pengurangan Bencana. MPBI. Jakarta, jilid 1 dan 2. Blaikie, P., Cannon, T., Davis, I., and Wisner, B.:1994 At Risk: Natural Hazards, Peoples Vulnerability, and Disasters, 38 Routledge, London,1994.MPBI . Jakarta , vol 1 and 2 . Carter, Nick W, 1991, Disaster Management, A Disaster Manager's Handbook, Manila,Asian Development Bank. Central Bureau of Statistics , 2011, Simeulue District in Figures Cordona , 2005, O. 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Pusat Kajian Tsunami ITB.Bandung Peduzzi, et, al, 2009, Assesing Global Exposure and Vulnerability towards natural hazards: the Disaster Risk Index, Journal Natural Hazards and Earth System Sciences, Published by Copernicus Publication on behalf of the European Geosciences Union Priest , Z , 2011. Islamic and Local Wisdom in Disaster Relief in Disaster Management Java .Jurnal , Volume 2 No. 1 June of 2011 , ISSN 2087636X , Jakarta Priotomo , E , I, 2006, The people of Simeulue Tradional Wisdom Pertaining to Smong Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Regional Disaster Management Agency Simeulue , 2011 Silbert,M, 2011, Small Island Economic Vulnerability To Natural Disasters, Dissertation.Graduate School Of The University Of Florida In Partial Fullfillment Of The Requirements For The Degree Of Doctor Of Philosophy.UniversityOf Florida Singarimbun , M. And Effendi , S. 1987. Methods Survey Research . LP3ES , Jakarta Sugiyono , 2005. Qualitative Research . Alfabeta , Bandung . UNDP, 2009, Basics of Capacity Development for Disaster Risk Reduction, Switzerland 39 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RELATIONSHIPS OF PRECIPITATING FACTORS AND PREDISPOSING FACTOR TO HYPERTENSION INCIDENT IN INTERNIST POLYCLINIC OF DR.PIRNGADI GENERAL HOSPITAL MEDAN 2014 Risma Dumiri Manurung, Tiurlan Mariasima Doloksaribu Department of Nursing Poltekkes Medan Abstract Hypertension is a condition where the systolic and diastolic pressure exceeds the normal threshold of 140/90 mmHg and is often called the silent killer because most people do not realize suffer from hypertension due to lack of understanding, education and the adverse effects of hypertension (Ridwan, 2010). Predisposing factors: age, heredity, gender and precipitating factors: body weight, smoking, and alcohol. This study aims to determine the relationship between predisposing and precipitating factors for hypertension in patients who were treated at the polyclinic dr Pirngadi in Medan 2014. Type analytical research with cross sectional design. Research conducted in dr Pirngadi Medan, the sample size of 80 people with sampling technique accidental sampling. Data processing and analysis using Chi-Square test, the hypothesis Ha accepted if there is a significant relationship predisposing and precipitating factors on the incidence of hypertension with a 95% confidence level (p ≤ 0.05). Research results showed no significant relationship. Suggested to the respondents to maintain a diet that prevents obesity, reducing salt intake, high fiber foods, improve lifestyle, avoiding stress and positive thinking. Keywords: Predisposing factors, factors Originator, Hypertension Hypertension is a condition where the systolic and diastolic blood pressure exceeds the normal threshold of 140/90 mmHg. The disease is also often referred to as the silent killer because most people do not realize had been suffering from hypertension, due to lack of understanding, education and the adverse effects of hypertension (Ridwan, 2010). World Health Organization (2011) mentions hypertension caused 8 million deaths per year worldwide and 1.5 million deaths per year in the region of Southeast Asia (Kartikasari, 2012) The prevalence of hypertension in Indonesia Results Household Health Survey (Survey) in 2001 showed that 8.3% of the population suffer from hypertension and increased to 27.5% in 2004 (Rahajeng, 2009). Patients with hypertension disease is quite high in the city of Medan (Medan city health office) in 2012, 46 736 people suffer from hypertension are compiled from the number of visits from 39 health centers and hospitals. Of this total, male patients as many as 23 497 people, or more than 23 239 women who only person (Andalas, 2012). 40 Individuals with a family history of hypertension had a two times greater risk of suffering from hypertension. The incidence of hypertension increases with age, and men have a higher risk of developing hypertension early (Anggraini et al, 2009). Obesity increases the incidence of hypertension due to fat causing a blockage in the blood vessels thus increasing blood pressure. High salt intake causes excessive expenditure of natriouretik hormone which indirectly increases blood pressure. Smoking habits influence in increasing the risk of hypertension (Anggraini et al, 2009). Rahajeng (2009) states predisposing and precipitating factors of hypertension are age, male gender, low education level, smoking habits, consumption of caffeinated beverages> 1 time per day, alcohol consumption, lack of physical activity and obesity. Results of a preliminary study in Hospital Dr Pirngadi Medan, ambulatory patients with hypertension in 2012 as many as 848 people, and increased in 2013 by 12. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RESEARCH METHODS Type of analytical research with cross sectional study design. Research conducted at the Internist Polyclinic of Dr. Pirngadi Medan Hospital , conducted from January to June 2014. The population was all patients with hypertension who came to the Internist Polyclinic of Dr. Pirngadi Medan Hospital. Sampling using accidental sampling with a sample size using formula Notoadmodjo (2005) . Univariate analysis of data by means of the frequency distribution table, then made a conclusion by using a formula percentage and Bivariate analysis using the chi-square test with 95% degree of confidence, α = 0.05 with HA hypothesis is accepted if p ≤ 0.05. 4:14 According to the table above shows that there is a statistically significant relationship between predisposing and precipitating factors to the onset of hypertension by 95% confidence level α = 0.05. The results include the results of the factor of age with p value = 0.014 (p ≤ 0.05), heredity with the result p value = 0.026 (p ≤ 0.05), and the gender factor with p value = 0.019 (p ≤ 0.05), the weight factor is obtained p value = 0.024 (p ≤ 0.05), non factor with the result p value = 0.006 (p ≤ 0.05), and of the factors of alcohol with the result p value = 0.004 (p ≤ 0.05). RESULTS 1. Univariate Analysis a. Age Factor Table 1. Distribution Frequency of Respondent According to Age Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Age N0 Frequency % Factor 1 <46 28 35 2 46-55 25 31,2 3 56-65 24 30 4 >65 3 3,8 Total 80 100 Tabel 1. Majority respondent aged >41 year as many as 58 person (72,5%). Tabel 2. Distribution of Age Factor Cross Tabulation To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent Condition Age Non No Hyperten Factor % Hyperten % si si 1 <46 11 39,3 17 60,7 2 46-55 17 68 8 32 3 56-65 17 70,8 7 29,2 4 >65 0 0 3 100 Total 45 56,25 35 43,75 Total % 28 25 24 3 80 100 100 100 100 100 Table 2. Respondent proportion hypertension higher 56-65 year as many as 17 person (70,8%) and in 46-55 years as many as 68%. b. Herediter Table 3. Distribution Frequency of Respondent According to Herediter Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Herediter Frequenc N0 % Factor y 1 Yes 41 51,2 2 No Total 39 80 48,8 100 Table 3. Majority respondent suffered from hypertension because of herediter factor as many as 41 persons (51,2%). Tabel 4. Distribution of Herediter Factor Cross Tabulation To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent Condition Herediter Non No Total Hyperten factor % Hypertensio % sion n Yes 28 68,3 13 31,7 41 No 17 43,6 22 56,4 39 Total 45 56,25 35 43,75 80 % 100 100 100 Table 4. Majority respondent herediter factor as many as 28 person (68,3%) and hypertension sufferer without any herediter factor as many as 17 person (43,6%). 41 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology c. Gender Table 5. Distribution Frequency of Respondent According to Gender Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 N0 Gender Frequency % 1 Man 46 57,5 2 Woman Total 34 80 42,5 100 Tabel 5. majority respondent were as many as 46 person (57,5%). Tabel 6. Tabel 4. Distribution of Gender Factor Cross Tabulation To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent condition No GentHyperten Total Non % % sion Hypertension 1 Man 31 67,4 15 32,6 46 2 Woman 14 41,8 20 58,2 34 Total 45 56,25 35 43,75 80 % 100 100 100 Table 6. Majority respondent who suffered hypertension were man as many as 31 person (67,4%) while woman as many as 14 person(41,8%). d. Weight Factor Table 7. Frequency Distribution of Respondent According to body weight Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Body N0 Frequency % weight 1 Normal 44 55 2 3 Thin 4 5 Fat 32 40 Total 80 100 Table 7. majority respondent have normal weight as many as 44 orang (55%). 42 Table 8. Cross Tabulation Distribution of Gender Factor To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent condition Non No Body Hyperten % Hyperten % weight sion sion 1 Normal 23 52,3 21 47,7 2 Thin 0 0 4 100 3 Fat 22 68,75 10 31,25 Total 45 56,25 35 43,75 Total % 44 4 32 80 100 100 100 100 Table 8. majority respondent who have overweight suffred hypertension as many as 22 person (68,75%), e. Smoking factor Table 9. Frequency Distribution of Respondent According to smoking Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Frequen N0 Smoke actor % cy 1 Smoker 48 60 2 Not smoker Total 32 80 40 100 Table 9. majority respondent were smoker as many as 48 person (60%). Table 10. Cross Tabulation Distribution of smoking factor Factor To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent condition Smoke r Non Hipertensi % factor Hipertensi 1 Smoker 33 68,75 15 2 Not 12 37,5 20 smoker Total 45 56,25 35 No % Total % 31,25 62,5 48 100 32 100 43,75 80 100 Table 10. majority hypertension respondent have smoking habit as many as 33 person (68,75%) while non smoker as many as 12 person (37,5%) Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 12. majority hypertension respondents have alcoholic habit as many as 26 person (74,5%). f. Alcohol Factor Table 11. Frequency Distribution of Respondent According to Alcoholic Factor at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Alcohol N0 Frequency % factor Alcoholic 1 35 43,8 2 Not alcoholic Total 45 56,2 80 100 Tabel 13 Frequency Distribution of Respondent According to Respondent Condition at Internist Polyclinic of DR. Pirngadi General Hospital Medan Tahun 2014 Respondent N0 Frequency % condition Hypertension 1 45 56,2 2 Table 11. majority respondent were non alcoholic as many as 45 person (56,2%). 35 43,8 Total 80 100 Table 13. majority respondent withi hypertension, condition as many as 45 person (56,2%) Tabel 12. Cross Tabulation Distribution of Alcohol factor Factor To Hypertension at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Kondisi Responden Alcohol Non No Total Hiperten factor % Hiperten % si si Alcoholi 1 26 74,5 9 25,7 35 c 2 19 42,2 26 57,8 45 Not alcoholic Total 45 56,25 35 43,75 80 Non Hypertension % 100 100 100 2. Bivariate Analysis Table 14. Related Predisposing Factor with Causing Factor to Hypertension Incident at Internist Polyclinic of DR. Pirngadi General Hospital Medan 2014 Respondent Condition Factor p Non Total % Hypertensi value % Hypertensi % on on Usia <46 11 39,3 17 60,7 28 100 46-55 17 68 8 32 25 100 0,014 56-65 17 70,8 7 29,2 24 100 >65 0 0 3 100 3 100 Total 45 56,25 35 43,75 80 100 Herediter Genetic Non Genetic Total 28 17 45 68,3 43,6 56,25 13 22 35 31,7 56,4 43,75 41 39 80 100 100 100 0,026 Gender 43 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Man Woman Total 31 14 45 67,4 41,8 56,25 15 20 35 32,6 58,2 43,75 46 34 80 100 100 100 Normal Thin Fat Total 23 0 22 45 52,3 0 68,75 56,25 21 4 10 35 47,7 100 31,25 43,75 44 4 32 80 100 100 100 100 Smoker Smoker Not smoker Total 33 12 45 68,75 37,5 56,25 15 20 35 31,25 62,5 43,75 48 32 80 100 100 100 26 74,3 9 25,7 35 100 19 42,2 26 57,8 45 100 45 56,25 35 43,75 80 100 0,019 Body weight Alcohol Alcoholic Not Alcoholic Total 0,024 0,006 0,004 According to the table above shows that there is a statistically significant relationship between predisposing and precipitating factors to the onset of hypertension by 95% confidence level α = 0.05. The results include the results of the factor of age with p value = 0.014 (p ≤ 0.05), heredity with the result p value = 0.026 (p ≤ 0.05), and the gender factor with p value = 0.019 (p ≤ 0.05), the weight factor is obtained p value = 0.024 (p ≤ 0.05), non factor with the result p value = 0.006 (p ≤ 0.05), and of the factors of alcohol with the result p value = 0.004 (p ≤ 0.05). DISCUSSION 1.Relationship between age factor with occurrence of hypertension The loss of tissue elasticity and large arteries become stiff causing blood at each beat of the heart is forced to pass through narrow blood vessels of the usually causing the rise in blood pressure which is a factor of old age patients with hypertension. (Susanto, 2010) Based on the results of the study conducted by researchers obtained the relationship of age with hypertension, the results showed that the proportion of respondents with higher hypertension condition at the age of 56-65 years, amounting to 17 people (70.8%). Results of bivariate analysis using the chisquare test p values obtained value = 0.014 (p ≤ 0.05) with a 95% confidence level. The p value indicates that there is a statistically significant relationship between the factors of age with hypertension, results are consistent with the results of research Kartikasari (2012) who says that age is a risk factor for 44 hypertension, where the risk of hypertension at age 60 years up is 11.340 times greater when compared with less than 60 years of age. This research is also consistent with the results of research conducted by Aris Sugiharto, where for ages 56-65 years had a 4.76 times greater risk of developing hypertension compared with 25-35 years of age. As well as research results Sigarlaki (2006) obtained the age group 56-77 years had the highest distribution that is (55.88%) for the occurrence of hypertension. Heredity Factors 2.Relationship between the occurrence of Hypertension Genetic factors in the family would cause the family has a risk of suffering from hypertension. It is associated with elevated levels of intracellular sodium and low ratio of potassium to sodium. Research conducted by Androgue and Madias regarding the pathogenesis of potassium and sodium in hypertension, said heredity influence on primary hypertension through several genes Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology involved in the regulation of vascular and renal reabsorption of sodium by (Kartikasari, 2012). 2012, found male patients as many as 23 497 people, or more than 23 239 women who only person (Andalas, 2012). Results of this study respondents who have a history of hereditary factors as much as 28 people (68.3%). Results of the analysis obtained by chi square test p value = 0.026 (p ≤ 0.05) indicates that there is a significant relationship between heredity with hypertension. 4.Relationship between Weight Factor with occurrence of hypertension Excess weight and hypertension often go hand in hand, because of the extra few kilograms makes the heart work harder. Pumping power of the heart and circulation of blood volume obese patients with hypertension was higher than hypertensive patients with normal weight (Sutanto, 2010). The results are consistent with research Anggraini, et al (2009), Hypertension is lowered or is genetic, individuals with a family history of hypertension had a two times greater risk of developing hypertension than those who do not have a family history of hypertension. Powered research Kartikasari (2012) said the subject with a family history of suffering from hypertension have an increased risk of hypertension 14.378 times greater when compared with subjects without a family history of suffering from hypertension. 3.Relationship between Factors Sex with occurrence of hypertension Men often experience signs of hypertension at the age of late thirties, while women often had hypertension after menopause. Woman's blood pressure, especially systolic, increased more sharply with age. After age 55, women do have a higher risk of developing hypertension. One of the causes of these patterns is the difference between the two sexes. Decreased estrogen production at menopause, women lose the beneficial effect that increases blood pressure. (Casey.A, 2012). So also based on the results of research conducted by researchers note that the gender factor associated with the occurrence of hypertension, with the result that the proportion of respondents found the condition of hypertension is higher in the male gender, amounting to 31 people (67.4%). Results obtained chi square test p value = 0.019 statistically show that there is a significant correlation between gender factor with hypertension. In line with the research Rahajeng (2009), the sex, the proportion of men in hypertension group was higher than the control and males were significantly at risk of hypertension 1.25 times that of the female. Data Health Office (DHO) Medan city in Results of research conducted by researchers note that the weight factor associated with the occurrence of hypertension, with hasi that the proportion of respondents with hypertension was higher in respondents who weigh as much fat as 22 people (68.75%). Based on the results obtained by the chi square test p value = 0.024 indicates that there is a significant relationship between the variables of weight with hypertension. Results of research supported by the National Institutes for Health USA (NIH, 1998) dalamAnggraini, et al (2009), the prevalence of high blood pressure in people with a Body Mass Index (BMI)> 30 (obese) is 38% for men and 32% for women, compared with a prevalence of 18% for men and 17% for women for those who have a BMI <25 (normal nutritional status according to international standards). 5.Relationship between Cigarettes with occurrence of hypertension Smoking causes an increase in blood pressure. Smokers can dihubungkandengan an increased incidence of malignant hypertension and the risk of experiencing ateriosklerosis renalyang artery stenosis (Anggraini, et al, 2009). Based on the results of the study conducted by researchers note that cigarette factors associated with the occurrence of hypertension, with the proportion of respondents that hypertension is higher among respondents who have a smoking habit of 33 people (68.75%). Results obtained chi square test p value = 0.006 indicates that there is a significant association between cigarette factors with hypertension. 45 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology In line with the results Oroh (2013) that respondents who have a habit of smoking had a six times greater chance of suffering from hypertension compared to those who did not have the habit of smoking. As well as research results Rahajeng (2009), based on smoking behavior, the proportion of respondents who had never smoked every day in hypertension group was higher (4.9%) than the control group (2.6%), and risk behaviors never smoked this significantly found by 1.11 times compared to never-smokers. Alcohol Factor 6.Related with Hypertension Occurrence Risk factor for hypertension consume alcohol. It has been demonstrated that consuming alcohol every day can raise blood pressure by 1.21 mmHg systolic and diastolic blood pressure by 0.55 mmHg for an average of one drink per day (Russell et al, 1991). Excessive alcohol use will also trigger a person's blood pressure. Besides being good for blood pressure, alcohol addiction will also make it difficult to remove (Susilo, 2011). Based on the results of the study conducted by researchers have known that the alcohol factor associated with the occurrence of hypertension, with the results that the proportion of respondents with hypertension condition was higher in respondents who have the habit of drinking alcohol as many as 26 people (74.5%). Results obtained chi square test p value = 0.004 indicates that there is a significant correlation between alcohol factor with hypertension. In line with the results of Casey (2012), excessive drinking, which is three times or more a day was a factor contributing 7% of cases of hypertension. Powered research Oroh (2013) of respondents who consume alcohol have a greater chance of 4.378 times suffer from hypertension compared to those who did not consume alcohol. Rahajeng (2009), based on the behavior of alcohol consumption, the proportion of alcohol one last month found higher in hypertensive group (4.0%) than in controls (1.8%). The risk of hypertension for those who consume alcohol one last month found meaningful, that is equal to 1.12 times. 46 CONCLUSIONS AND SUGGESTIONS CONCLUSION 1.There relationship of age on the incidence of hypertension with p value = 0.014. 2. Based on heredity: that there is a hereditary factor for hypertension with p value = 0.026 (p ≤ 0.05). 3.Berdasarkan sexes: that there is a male sex relationship with hypertension with p value = 0.019 (p ≤ 0.05). 4.Berdasarkan weight factor: there is a relationship of weight to hypertension with p value = 0, 024 (p ≤ 0.05). 5.Berdasarkan cigarette factors: that there is a relationship to the incidence of hypertension with chi square test was obtained p value = 0.006 (p ≤ 0.05). 6.Berdasarkan factors habit of drinking alcohol there is a significant relationship to hypertension, with p value = 0.004 (p ≤ 0.05). SUGGESTION 1.Tohealth workers of dr Pirngadi Hospital Medan especially poly diseases in order to further improve the education and health education about the relationship between predisposing and precipitating factors of hypertension. 2.To patients with hypertension are advised to avoid obesity, reducing salt intake, high fiber foods eat- improve lifestyles, and avoid stress and positive thinking. REFERENCES Adib, M. 2011. Pengetahuan Praktis Ragam Penyakit Mematikan yang Paling Sering Menyerang Kita. Jakarta : Buku Biru Arikunto, S. 2006. Prosedur Penelitian. Jakarta: Rineka Cipta Anggraini, AD. DKK. 2009. Faktor-Faktor yang Berhubungan dengan Hipertensi. Skripsi : FK UNR. Casey, A. dan Herbert B. 2012. Menurunkan Tekanan Darah. Jakarta : Bhuana Ilmu Populer Ellizabet, L. 2010. Stop Merokok Gerailmu. Yogyakarta Kurnia, R. 2007. Karakteristik Hipertensi. Skripsi : FKM USU Kartikasari, AN. 2012. Faktor Resiko Hipertensi. Jurnal : FK UNDIP Notoatmodjo, S. 2010. Metodologi Penelitian Kesehetan. Jakarta : Rineka Cipta Oroh, DN. 2013. Hubungan Antara Kebiasaan Merokok Dan Konsumsi Alkohol Dengan Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Kejadian Hipertensi. Jurnal : Ilmu Kesehatan Masyarakat,Fakultas Kedokteran Sam Ratulangi Politeknik Kesehatan Kemenkes. 2012. Panduan Karya Tulis Ilmiah. Medan Rahajeng, E. dan Sulistyowati T. 2009. Prevalensi Hipertensi dan Determinannya di Indonesia. Jakarta : Pusat Penelitian dan Farmasi Badan Penelitian Kesehatan DEPKES RI Ridwan, M, 2010. Tekanan Darah dan Pencegahannya. Jakarta : Dian Rakyat Sigarlaki. Herke . J.O. 2006. Karakteristik dan Faktor Berhubungan dengan Hipertensi. Jurnal : Ilmu Kesehatan Masyarakat,Fakultas Kedokteran UKI Susilo, Y. dan Ari W. 2011. Cara Jitu Mengatasi Hipertensi. Yogyakarta : Andi Sutanto. 2010. Cegah dan Tangkal Penyakit Modern. Yogyakarta : Andi Udjianti, WJ. 2010. Keperawatan Kardiovaskular. Jakarta : Salemba Medika http://www.medan-andalas.2012 (Diakses 7 Januari 2014) 47 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology PERSONAL HYGIENE DURING MENSTRUATION IN FEMALE TEENEGERS AT JUNIOR HIGH SCHOOLS 34 PADANG WEST OF SUMATERA INDONESIA Sri Dewi 1), Tintin Sumarni 2), Aini Yusra3) Solok Nursing Study Program of Poltekkes Kemenkes Padang ABSTRACT Menstruation is the natural monthly occurrence in healthy adolescent girls with the onset occurring anytime between the ages of 8 to 16 years old until pre-menopausal adult women, resulting in about 3000 days of a menstruation in an average woman’s lifetime. The neglect of menstruation and its implications for the dignity, health and safety of women is increasingly well documented. The current understanding is that menstruation causes girls to be absent from school, and that continued absence leads to dropout and attrition. The main objective of this study was therefore to focus on describe the reproductive personal hygiene upon menstrual period in female teenagers. The research design is descriptive with population female teenagers who has menstrual periods from class VII and VIII of Junior High School 34 Padang. The sample size was aimed at 175 respondents. Questionnaire was given all respondents and then analyze with distribution frequencies. The results shown that 93% respondents using sanitary pads. 69,1% respondents buy pad and 78,9% respondents dispose of pads. 77,1 % respondents using pads more than six hours. 57,1% respondents not have good vulva hygiene during menstruation. As a result of this study, we propose additional recommendations, including increasing facility for female students to get information about menstrual hygiene management. Menstruation should be taught and discussed with girls at an earlier age, prior to reaching menarche. Keyword: Menstrual Hygiene, Menstruation, Reproductive Health BACKGROUND Globally, approximately 52 % of the female population ( 26% of the total population) is of reproductive age (UN, 2010). In Indonesia, the number of teenagers increasing rapidly each years from 1970 until 2000 from 18% become 21% of the total population (Eny Kusmiran, 2009:3). Menstruation is the natural monthly occurrence in healthy adolescent girls with the onset occurring anytime between the ages of 8 to 16 years old until pre-menopausal adult women, resulting in about 3000 days of a menstruation in an average woman’s lifetime. The neglect of menstruation and its implications for the dignity, health and safety of women is increasingly well documented. Research exist on the challenges girls face while menstruating, their knowledge source and cultural traditions regarding menstruation. The current understanding is that menstruation causes girls to be absent from school, and that continued absence leads to dropout and attrition (Unicef, 2012). from the bellowing data shows an overview of the phenomenon of knowledge and action of adolescents on reproductive health it’s 48 Adolescent Reproductive Health Indonesias survey (IYARHS, 2002/2003) Showing that teens who know sign legally baligh, boys 55% -65%, women 36% - 69%. The person who spoke by teenagers about Reproductive Health, friends 68%, 14.4% parents, 14% of teachers, relative 30% (Marwanti, 2004). Adolescence begins with the very rapid growth and are usually referred to puberty. As proposed by Santrock (1993) puberty is a rapid change to the physical maturation invorving hormonal and bodily changes that occur primarily during early adolescence. With the rapid changes that pass the physical changes that can be observed such as height and weight in adolescents or so-called growth and sexual maturation as a result of hormonal changes. Adolescence is a period of transition marked by physical, emotional and psychological changes. Adolescence, between the age of 1019 years, is a period of maturation of the human reproductive organs, and usually called puberty. Adolescence is a transition period from childhood to adulthood. (Yani Widyastuti, 2009: 11). From several research since the last 100 years shows that there is a tendency accelerated Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology adolescents experience menarche. In 1860 the average age of adolescents experience menarche is 16 years 8 months and 12 years 3 months in 1975. There is decrease of menarche age is caused by the improvement of nutrition, improvement of health services, and community environments. If person sooner experienced menarche of course she will be sooner enter the reproductive period too. (Notoatmojo, 2011) Now Days in Indonesia the adolescent problems is very complex and worrying, this occurs because the teenager's knowledge about reproductive health is still lacking, only 17.1% of young women know properly about the treatment of their reproductive organs. To anticipate that problems, teens should have been equipped with a wide range of knowledge from their parents about how to reproductive health care (Marwanti, 2004). According to a research , 75% of deaths in adolescence occurs due to behavioral factors. Diseases due to behavioral problems such as injuries or accidents, sexually transmitted diseases, food disorders, reproductive health problems, smoking, drugs abuse, emotional problems and so on, which will affect your personal life, family, nation and country in the future (Tumbuh Kembang Anak dan Remaja, 2002). The impact of otherwise maintain reproductive organs during menstruation, reproductive organs can be affected by fungus or mites that can cause itching or discomfort, abnormal vaginal discharge and other sexually transmitted diseases (Eny Kusmiran, 2011: 24). According to Becker (1979), quoted from Notoadmojo (2003: 124) health behavior (Healt Behavior), things that include with one's actions or activities to maintain and improve their health. Including measures to prevent disease, maintain personal hygiene and reproductive health. One of way to take care of reproductive organs is by doing treatment during menstruation. Treatment during menstruation is also needed because the vessels in the uterus during menstruation is very susceptible to infection. Cleanliness should be very guarded because germs can easily enter and cause disease of the reproductive tract. Treatment during menstruation can be done by the pads should not be used for more than six hours, the pads should be replaced as often as possible when it is full by menstrual blood, note pads nature, sterile or non-sterile, do not use pants that are too tight, do vulva hygiane (Eny Kusmiran, 2011: 24). Researchers also conducted a preliminary study in SMPN 34 Padang, by doing interviews in SMP 34 Padang on January 4, 2014 were carried out on 10 female students, there are four female students, changing pads, two times a day during menstruation, 2 students say frequent use tight pants at the time of menstruation in order to feel comfortable, 2 students say changing pads, 3 times a day at first and second day during menstruation, and 2 students say often experience vaginal discharge before and after menstruation without knowing the cause and smelling. This research aims to describe the behavior of young women of reproductive organ preservation during menstruation in SMP Negeri 34 Padang. Methodology This is a descriptive study aimed to describe the behavior of young women of reproductive organ preservation during menstruation in junior high School 34 Padang 2014. The variables in this study are: the length of time the use of pads, pants usage, perform vulva hygiene (how to cleans vulva). The population in this study are all students of class VII consists of 7 classes with the number 108 person, and the class VIII which consists of 7 classes with the number of 115 person, bringing the total population of 223 people. The samples in this study using total sampling technique where the sample in this study all of population in SMPN 34 Padang who ever menstruate, the number of girls who ever menstruate are 175 person out of 223 students, while 48 other students had never experienced menstruation. 49 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Results & Discussion 1. Long time use of pads Most (77.1%) female students have less healthy habits in the use of sanitary napkins during menstruation in SMPN 34 Padang 2014. This study is same with research Suryanti B (2012), which examines the Adolescent Health Behavior When Menstruation is known that changing pads during menstruation slightly by 64%. Treatment during menstruation is also needed because the vessels in the uterus during menstruation is very susceptible to infection. Cleanliness should be very guarded because germs can easily enter and cause disease in the reproductive tract. One of the ways the treatment of reproductive organs is pads should not be used for more than six hours. (Kusmiran, 2011). In this study, the majority (77.1%) students who have unhealthy habits when use of pads during menstruation, this is due to lack of students know about the long time use of sanitary napkins during menstruation, in accordance with the opinion of Suryati (2012) that factors related to behavior of adolescent hygiene during menstruation is parental education, knowledge, attitude, availability of facilities cleaning tools and peer support. 2. Use of type / material pants The majority (57.1%) students have healthy habits in the use of materials / types of pants at the time of menstruation in SMPN 34 Padang 2014. One of the reproductive organs care during menstruation, it’s use materials / types of pants that can absorb sweat and wear pants that are not too tight , sometimes people prefer to wear pants that are too tight during menstruation their reason is more comfortable when wearing tight pants, because the pads are worn when menstruation is not loose when wearing tight pants. Use of pants that are too tight can lead to sexually transmitted diseases such as fungal infection, or experience other symptoms such as menstrual cramps, rashes and indigestion.Use of pants that can absorb perspiration can use underwear made from cotton, especially when active outdoor activities. Cotton easily absorb 50 sweat and moisture, as well as good for air circulation. In this study in the UKS of SMPN 34 Padang has been no organized activities for reproductive health problems, especially for the use of materials / types of pants that are healthy for the reproductive organs during menstruation, but the attendant health center has been giving counseling to the students of SMPN 34 Padang on reproductive health issues, so most great students already understand how to care for their reproductive organs, including the use of pants at the time of menstruation. This is accordance with the opinion of Wulandari, Nirvana, and Nurfarhanah (2012) who studied the picture of Understanding Students Regarding Adolescent Reproductive Health Through Information Services, understanding student at SMAN 1 Padang on adolescent reproductive health as much as 51% of students already have an understanding of adolescent reproductive health, and there are adolescent still don’t understand about the adolescent reproductive health (49%). 3. Measures vulva hygiene (how to clean vulva) The majority (55.4%) students have healthy habits in the act of vulva hygiene (how to clean vulva) when menstruation in SMPN 34 Padang 2014. This is done by majority of syudents have know about how to care for their reproductive organs, most students get information from parents and officials Lubuk Buaya health centers that have provided counseling on reproductive health in SMPN 34 Padang. When compared to the results of research Mulyanti (2001) in Purwakarta found that the maintenance of good hygiene practices by 25% and 75% of poor hygiene maintenance practices means is still low. According to Becker (1979), quoted from Notoadmojo (2003: 124) healthy behaviors (Healt Behavior), ie, things that connected with one's actions or activities to maintain and improve their health. Including measures to prevent disease, maintain personal hygiene and reproductive health. Vulva hygiene action is action to clean the female organ, one of them with clean water. The correct way is to wipe clean the Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology vulva from front to back. The purpose of do vulva hygiene during menstruation is to prevent infection of the female organs, maintaining the cleanliness of the vulva. Treatment of reproductive organs is extremely important. If not treated properly, it can cause various adverse effects, such as infection. How to care and maintenance can be carried out according to the demands of the religious, cultural and medical (Yani, 2009: 3). Conclusion Description the behavior of young women on the maintenance of the reproductive organs during menstruation in SMPN 34 Padang 2014 as follows: 1. It can be seen more than most (77.1%) female students have less healthy habits in the use of sanitary napkins during menstruation in SMPN 34 Padang 2014. 2. It can be seen more than most (57.1%) students have healthy habits in the use of materials / types of pants at the time of menstruation in SMPN 34 Padang 2014. 3. It can be seen more than most (55.4%) students have healthy habits in the act of vulvar hygiene (how cebok) at the time of menstruation in SMPN 34 Padang 2014. Suggestion Based on the research results and conclusions presented above, there are some things you want authors suggest that further improve student behavior on the maintenance of the reproductive organs during menstruation in SMPN 34 Padang 2014, among others, are as follows: 1. For SMPN 34 Padang Expected to SMPN 34 Padang in order to increase the interest to find resources related to reproductive health care during menstruation. With the information students can understand and appreciate that reproductive health care is very important for their future lives and future. 2. For institutions Expected in educational institutions mainly aimed at school teachers to provide clear information about reproductive health care during menstruation, and increase reading materials in the library, especially books related to reproductive health maintenance. The teacher education and school facilities that support reading, so that the students themselves will have a wider knowledge and a better understanding of and understand the function and benefits of reproductive health care for the students, especially during menstruation. 3. For Puskesmas Padang Lubuk Buaya Support health care workers is very influential on attitudes and behaviors to maintain hygiene during menstruation so it needs to be improved health education in schools so as to increase knowledge about the importance of clean and healthy behavior through counseling. 4. For Methodology is expected to further research to be able to do further research on other variables, the design and the different ways of measuring research relating to the behavior of young women on the maintenance of the reproductive organs during menstruation. 51 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology QUALITATIVE STUDY OF PREMARITAL SEXUAL BEHAVIOR IN GIRLS ADOLESCENT AT DHARMA BAKTI SENIOR HIGH SCHOOL 2014 Soep 1, Hanna Sriyanti Saragih 2, Wardati Humaira 3 1 Nursing Department of Medan Health Polytechnic of Health Ministry; Midwifery Department of Medan Health Polytechnic of Health Ministry Author Correspondency : [email protected] 2,3 ABSTRACT Adolescence is a transition period that is physically and psychologically, especially sexual hormones in the body marked by sexual maturity. Research carried out in 33 provinces in 2008, as many as 97% of middle and Senior High School teens never watched porn. Those who once embraced, kissing , masturbation , and oral sex reached 93.7 %. This study aims to determine the cause of premarital sexual behavior in adolescent girls at Senior High School of Dharma Bakti 2014. This research is a descriptive study using a qualitative approach , source of data obtained through observation and interviews with 6 informants at Dharma Bakti Senior High School and one teacher of Dharma Bakti Senior High School as a key informant. Data analysis techniques starting from data collection, data reduction, data presentation and conclusion. The results of research showed that sexual behavior that occurs is beyond the limit. According to the informant handrails, a hug and a kiss was common and reasonable. The cause of such behavior due to factors that lower knowledge, positive attitude that sees such behavior, media information and circumstances that support such behavior. Expected to health workers or the parties involved to provide education and health promotion particularly about early sex education or reproductive health in adolescents. Keyword : Behaviour, Sexual, Adolescent Adolescence is a transition period in which the physical and psychological changes from childhood to adulthood . This period is often referred to as puberty. Experts theorized that puberty term used to denote both the shape and the biological changes that occur with rapid physiological childhood from childhood to adulthood , especially changes in reproductive organs. Changes in sexual hormones in the body marked by sexual maturity so that sexual urge arises increasingly overflow (Ministry of Health, 2010). According to World Health Organization (WHO), adolescence is when the child has reached the age of 10-19 years. According to Law of Indonesia which No. 4 of 1979 concerning the welfare of children, adolescents are individuals who have not attained the age of 21 years old and unmarried. According to the Labour Law, the child was considered adolescents when it has reached the age of 16-18 years or are married and have own place. According to the Marriage Act of Indonesia no.1 of 1974 , when a teenage child is considered mature enough for marriage is 16 years for girls and 19 years for boys. Ministry 52 of Education and Culture considers adolescents aged 18 years when it is appropriate to graduate from Senior High School . Based on data from the Ministry of Health of the Republic of Indonesia in 2006, Indonesian teenagers (aged 10-19 years) amounted to about 43 million people or 19.61 % of the total population. In 2008 , the number of teenagers in Indonesia has estimated has reached 62 millions. In West Java by the Central Bureau of statistics (BPS) in 2008 there are number of adolescents (aged 10-19 years ) as many as 8.145.616 people, made up of 51.8 % men and 48.2 % women . Adolescent problems today's increasingly complex and worrying. Especially regarding the matter of sexual and reproductive health. It was triggered by the lack of information they take in. Just imagine, adolescents aged 13-18 years had premarital sex. Similarly, about 60% of them do it in her own home. Data gathered by the Indonesian Family Planning Association mentioned that in 2006 there were many teens having sex Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology without using any contraception tool to protect them. While the National Commission for Child Protection Survey conducted in 33 provinces in 2008, as many as 97% of middle and Senior High School teens ever watched porn. Those who once kissing, masturbation, and oral sex reached 93.7%. And adolescents junior who is not virgin as much as 62.7%, and that adolescents do abortions ever at 21.2%. According to the 2007 Demographic and Health Survey, young women and men aged 15-24 years who know about the fertile period, reached 65%. He also said young women and men who know the risks of pregnancy, sexual intercourse, each only 63%. Research on sexual transmitted diseases (STDs) conducted in Jakarta by University of Indonesia in 2005, showed teenagers knowledge about STDs is still very low, except for HIV / AIDS, namely 95%, and syphilis approximately 37% (Adhitya, 2012). In Indonesia, there are an estimated 1 million teenagers become pregnant outside of marriage , while worldwide an estimated 15 million teens become pregnant each year , 60 % of them became pregnant ( Hidayat in Tinceuli , 2010). From some studies say one of the causes of pregnancy outside of marriage is the inability to control biological urge of teenagers (Tinceuli , 2010) . Ministry of Health of the Republic of Indonesia revealed that from 1189 unmarried adolescents ( aged 13-19 years) in West Java and 922 teenagers in Bali , found 7% of adolescent girls in West Java and in Bali 5 % admitted never experienced in pregnancy. Chairman of the Network for Women and Children ( JPPA ) in Central Java , Widanti (2011 ) says that the number of girls who become pregnant will continue to increase, reflected in her research on junior and senior Senior High School level in 2010, which shows in each school have an average of four to seven students found are pregnant , even during the year increase of 10% to 15 % ( Ministry of health, 2011). The results of the few cities in Indonesia about the sexual behavior of adolescents who are at risk also in that case get 17.60 % in East Jakarta, Bogor 42.6 %, 48.1 % Pandeglang, Palembang 20.4 %, 14.1 % Prabumulih, and Depok 11.2 % (Shinta , 2009) . According to data from the Regional Health Research ( RISKESDA ) in 2010 found the number of adolescents ( male and female ) with the status of unmarried 63 048 86.7 % , had sexual intercourse with the number of males 3.0 % and females 1.1 %. Married Age : 10-14 years of 4.8 % and 41.9 % with 15-19 years.This means that sexual behavior before marriage has begun to occur at a very young age . In addition to the above data other health problems that can occur in adolescents are suffering from HIV / AIDS . Young people ( teenagers ) are the highest HIV / AIDS pain sufferers. According to the Minister of Health stated that North Sumatra needs attention of Provincial Health Office because of increasing HIV- AIDS case data. Based on data from the North Sumatra Health Office, the number of HIV cases in 2009 were 1096 and cases increased in 2012 of 2189 cases. While cases of AIDS in 2009, of 1553 cases and in 2012 there were 4241 cases. Moreover , the number of deaths due to AIDS in 2009 amounted to 338 increased in 2012 to 751. Regarding STDs , in 2009 amounted to 1845 cases and rise in 2012 to 4212 cases. Youth Companion research on sexual behavior in four cities showed 3.6% of adolescents in the city of Medan, 8.5% of adolescents in the city of Yogyakarta, 3.2% of adolescents in the city of Surabaya, and 31.1% in Kupang have free sexual intercourse. While the research conducted by Synovate Research on adolescent sexual behavior in four cities: Jakarta, Bandung, Surabaya and Medan with the number of respondents 450 people with ages between 15-24 years. This study resulted in that approximately 50% of respondents got the sex information from friends, watched porn film as much as 35% and only 10% for school. Ironically, only 5% of respondents get sex information from their parents, and as much as 81% of teens admitted more comfortable talking sex with his friends than to his parents. Adolescent sexual behavior is, however, very great risk of being infected by HIV / AIDS, as well as abortion. The third problem is the data that reinforce sexual behavior research which has been carried out in several cities in Indonesia (Julianti, 2012). A case of premarital sex occurs to a students of Darma Bakti Senior High School. She came to Suryani Maternal Clinic in Medan Johor to do planotest ( pregnancy test ) . The student came accompanied by her boyfriend. According to her, they had sexual intercourse at her boyfriend’s boarding house. Examination results were obtained that the 53 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology student was not pregnant. They protective form of a condom to pregnancy, but to ensure that she pregnant, and therefore they came midwife to do planotest. use a avoid is not to the Objective The general objective of this research is knowing the cause of premarital sexual behavior in adolescent girls in Dharma Bakti Senior High School of Medan in 2014. Advantage of Research Simple research activity is expected to provide benefits for both adolescents concerned as well as for society at large. Methods Research Design Design of this research is to use descriptive qualitative approach through in-depth interviews. This research was conducted in Dharma Bakti Senior High School of Medan. The study began in March to April 2014. Chronology of informant Search informants adolescents in accordance with the purpose of this research was conducted with snowball technique. Informants in this study were 6 teenagers and a teacher as key informant who know and can give answers to the questions researchers in both oral and written. On the implementation of in-depth interview, the interviewer use an interview guide and took data recorder by Multi Player 4 (mp4) with it is not known by the informant.. Data Collection Technique To do a fairly study required a complete data were obtained from data collection techniques. In this research, in-depth interviews, observation and documentation used as data collection. Data Analysis Methods Data obtained from indepth interview processed using qualitative data analysis rests on three related processes, namely : describing phenomena, classify, and see how the concepts that emerged was one with the other. 54 Results and Discussion Results 1. Knowledge All informants in this study have same opinion regarding the definition of adolescent, according to them adolescent is somebody who is already in Senior High School, big body, has been courting, has menstruation. Slightly different from the statement of key informant who said that in senior high school there were a few others have started familiar courtship and even pregnant while attending Junior High School (SMP). After the informant was asked about what the impact of social and dating style, those informants that revealed that teenage promiscuity that goes beyond these limits tend to lead to free sex, influence the development of more modern era and also the lack of parental role. In line with the statement of teenagers who become key informants in this study, key informant revealed the same thing that teenage promiscuity is now unnatural, and outside influences Westernized, and the influence of the mass media that can provide a big influence on adolescent promiscuity. For more information by in-depth interview about the knowledge of teens about premarital sex, back again in further question of what kind of sexual activities. Most informants said that the example of the sexual behavior for example handrails, a hug, a kiss that can rise to desire to make a love. Informants can not reply that its were question about the impact of premarital sexual behavior itself, virtually all informants say the same to the impact of aberrant sexual behavior, for example pregnancy, suicide ,destroyed future. In relation to the above key informants revealed that the cause of youth in deviant sexual behavior is influenced by several factors, friend , age , and environment. Analysis of research that all informants are not yet fully know properly about the definition of adolescents. All the informants who were asked have different opinions about the definition of adolescents. Most of informants said that they began to date since Senior High School and different with key informants statement that stated that most of them have begun dated at junior high school. Promiscuity of teenagers today is already very free. From the statement of some informants and also key informants stated that free promiscuity caused the sex behavior due to the influence of the Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology times and unsupportive environment. However, their opinions about premarital sex is good enough although still not so precise. The deeper excavated informants knowledge about sexual behavior informant statements regarding an example of premarital sexual behavior. According to informants that the impact of free sex was like pregnancy, depression, and loss of confidence. It is caused by several factors such as the influence of friends, the times, and the environment. 2.Attitude Adolescent attitude or response when asked about the sex education given in schools all said they agree and it is very important in order to know which ones are good too and that is not good, so do informant statement, once asked the attitudes or opinions of key informants about whether important sex education in schools agreed with the statement that it is very necessary to give sex education and hope there are certain parties that specifically conveying such information. Having asked internally or core of the extent to which the attitude of informants in dating some informants say honestly or openly revealed and there is also an informant that little secretive about the extent of his attitude in dating. In this case the opinion of the informants said that the attitude of the informant it was perfectly natural and still within normal limits. Informants said that the handrails, hugs, and kisses are common and reasonable, because it symbolizes affection of love. But when asked why the informant said ordinary and reasonable about the forces of dating, the most informants say for fear of losing, endearment. Then informant asked about why not to engage in premarital sex, most informants have the attitude and the reasons are almost the same, which is associated with self-esteem, fear of pregnancy, religion was banned, the future is still important. After in-depth questioning informants opinion about the causes of deviant sexual behavior is influenced several factors less attention to family, from friends, watch videos, invited a girlfriend, too dear, so someone desperate for a teenager to deviant sexual behavior. This is consistent with the opinion of key informants, about the causes of deviant sexual behavior in a person's teens can be due to many things, for example by reading adult books are not worth reading by teenagers, that can cause fatal curiosity later. All informants stated that there was a ban on the environment, culture , and norms against premarital sexual behavior . In line with the statement of key informants , that in terms of culture, especially the culture of Indonesia is still very strong , only Indonesia has detracted from western culture and consider deviant sexual behavior was a regular. Moreover, Indonesia is too likes to imitate new things. In this case the key informants said that it depends on the personality of each one how to achieve such changes. Researchers analyzed that it is important to give sex education in school to create good attitude of adolescent. The importance of sex education in order to know which ones are good and which is bad. Results obtained interviews about sexual behavior that has been done, informants found handrails, hugs and kisses are common. The reason they chose this attitude as an expression of affection, and equally willing . Though such behavior has violated the culture, religion, or customs that are around. And when asked the reason why they have not reached the stage of sexual intercourse, all informants found still thinking about self-esteem, and fear of getting pregnant . In this case the researchers could not agree with the positive attitude of the informant. And it turns out the reason someone who desperate to deviant sexual behavior because of the lack of attention to the family, media information, and call his girlfriend. This is consistent with the fact that the case today . Not much different from the statement of key informant who said the cause of deviant sexual behavior, for example by reading adult books that are not appropriate. In this study, most informants got information about premarital sexual behavior by media such as the internet, facebook, social media. Almost all informants say never watch or see porn things. Once asked in depth, that the influence of mass media on adolescent sexual activity and how the media response to some teenagers still fear, the need for self-esteem, not intentions, fear of pregnancy, and religious prohibitions. After being asked increasingly in a world where the influence of informants on the activities premarital sexual behavior in 55 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology adolescents, most teens say that it is the biggest influence of the mass media because it is free to access. In line with the statement of the key informants said that the mass media is one of the biggest causes adolescents to behave particularly concerned about deviant sexual behavior. Even though elementary school children already know the Internet sites that could endanger themselves . Analysis investigators that most of the informants said information media such as the Internet is giving a huge impact on the behavior of premarital sex. And all the informants claimed to have never watched a porn video and picture scenes inappropriate for show . This corresponds to the facts that occurred in the present , because the mass media are very easily accessible . In line with the opinion of the key informants said that children under the age was already easily access sites that are inappropriate for or on display in the show . 4. Situation and Conditions The results obtained after being asked how informants are interested in premarital sexual behavior is initially still shy , just want spoiled. The informant said that they often used park as dating place, because it is where the people going out, there are also those who say go to a movie, and eat together outside . More in-depth questioning of the relationship circumstances where an informant against premarital sexual behavior , informants said that they do such behavior because it is carried away and embarrassed in crowded places . There is also an informant who said that the sexual behaviors such as handrails , hugs and kisses already is commonplace and is not ashamed of that place was not so crowded in mind. Key informants mentioned that teens do things that are anomalous , particularly regarding premarital sexual behavior is influenced several occasions , for example when the house empty , so they take advantage of existing opportunities. Researchers analyzed that the romantic places and deserted situation commonly visited informants to do such sexual behavior. This statement is consistent with the fact that the case today . It is undeniable that the teens now have crossed the limits of reasonableness. In fact, each of us visited recreational places ensured that there are couples who are making love . Based on the results of interviews 56 conducted that sexual behavior such as handrails , a hug , a kiss , is commonplace . Even nowadays that teenage promiscuity had crossed the line and has reached the final stage which is the stage of sexual intercourse. Discussion 1. Knowledge According to the informants that the teen was who already in Senior High School, great body, is already courting and has menstruation. The statement illustrates that their lack of understanding about herself. According Pinem (2009) adolescence (10-19 years) is a special and important time, because it is a maturation period of human reproductive organs. Adolescence is also called puberty, is a unique transition period marked by a variety of physical changes, emotional and psychological. While the style of the current date according to them is not shameless, free, damaged, over the limit, is not thinking about the future, is not thinking about self-esteem. In accordance with the incident that occurred at this time. Impacts of dating style itself according to them has exceeded the limits and tends to lead to free sex, influenced by modern era and also the lack of parental role. Key informants in this study provide a statement in line with the informant that the association is now unnatural, and outside influences of westernized, and the influence of the mass media that can provide a big influence on adolescent promiscuity, making teens interested in try what they saw . The results showed that most of the informant know what they think about premarital sex that premarital sex is the activity of sleep together and sexual intercourse ( like husband and wife). In this case most of the informants already knew what it was premarital sex. From 6 informants interviewed four of them understand about premarital sex and the two of them do not understand what it is premarital sex. According to them the premarital sexual behavior such as handrails , a hug, a kiss that can give rise to desire . Disagrees with the informant who do not understand what premarital sex and what kind of example of premarital sexual behavior . According Boyke ( 2013 ) sexual behavior is behavior that arise because of the sexual drive . Forms of sexual behavior varies, ranging from dating , holding hands , hugging , making out , Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology to have sex . In this study once asked about the impact of sexual behavior that deviates some informants say so many negative impacts such as casual sex, pregnancy, stress, dropouts, suicides, broken because it thinks the future is destroyed . In this case the informant already knew quite well the impact of deviant sexual behavior. According Pinem (2009 ) as a result of premarital sexual behavior for adolescents, especially sexual intercourse like reproductive health disorders, STDs, unwanted pregnancy , psychological trauma ,the future of which was destroyed , gave birth to an unhealthy baby , cause shame in the family . As a result, many of these teens who are not virgins , and even pregnant ( Noviardi , 2013 ). The results are consistent with research Darmasih (2009 ) about the factors affecting premarital sexual behavior in adolescents of Senior High School in Surakarta, knowledge with premarital sexual behavior has a significant connection, it is stated that the better knowledge of teens about premarital sex , then the adolescent will have a better premarital sexual behavior. 2. Attitude According to Taufik Dariyo in the ( 2010) attitude predisposes ( determinants ) that gave rise to appropriate behavior with attitude . Attitude starts from the knowledge perceived as a good (positive) or not either (negative) , then internalized into him . If the perceived positively then one tends to be positive. The reason is because someone that agrees with what she knows . But otherwise if someone has a negative perception then it would tend to shy or do not do . The study provides an overview of all the informants overwhelmingly approved that the importance given sex education in schools so that they know where the good and the bad . This opinion is in line with key informants were also strongly suggest the existence of sex education was given in schools by certain parties to reduce the level of sexual behavior in adolescents today. With the early sex education is done in schools , the young people will increasingly know and understand the changes that occurred around her . According Esti (2008 ) administration of sex education in schools is good , that is for children to get the correct information about sexuality. Teaching sex explicitly into many classes and children we are inundated with information that has been prepared for them to understand . Results of this study most of the informants believe sexual behavior such as handrails , hugs , kisses , and others is an attitude that is still within reasonable limits. The behavior they do with reason because both want and like , which is a symbol of love for couples and justification for this attitude is considered not to harm one another . On the other hand informant reason not to have sexual intercourse for fear of being pregnant , the future shattered , depression. The researchers thought justified , which means teens are still know the limits of the impropriety or very fatal behavior. Sexual behavior is all behavior driven by sexual desire, both with the opposite sex or same sex. The forms of this behavior can be diverse, ranging from feeling attracted to behavior dating, petting, and intercourse. Sexual object can be a person (either similar or opposite sex), people in fantasy, or yourself. Most of this behavior does not have an impact, especially when it does not cause physical consequences for the person concerned or social environment. But some sexual behavior (which is done prematurely) actually can have the very serious psychological effects, such as guilt, depression, anger, and aggression (Sumiati et al, 2009). Results of this study most of the informants said that deviant sexual behavior is influenced by several factors less attention to family, from friends, watch videos, invited a girlfriend, too dear, so someone desperate for a teenager to deviant sexual behavior. In line with the opinion of key informants regarding the factors that cause young people in deviant sexual behavior with adults who have not read the book worth reading teenagers, that can cause fatal curiosity later. According Sumiati et al (2009 ) factors that cause premarital sexual behavior were hormonal changes that increase sexual desire teenager , prevailing norms , media information , supervision of parents, there is a tendency that the more freely between men and women . Results of the study ( Planned Parenthood Federation of America Inc. , 2004) in 1038 adolescents aged 13-17 years about sexual relations showed 16 % of teens agreed with sexual intercourse , 43 % did not agree with sexual intercourse , and 41 % stated that 57 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology one should not sexual intercourse ( Ririn , 2009). In this study , informants were asked about how their views on the environment , culture , norms that there is no prohibition against sexual behavior. All key informants and informant also said that there is a ban on the environment, culture and norms . The results are consistent with research Fitriana (2010 ) which showed that there was a significant correlation between attitudes about premarital sex sexual behavior. 3. Media Information Media information is a channel to convey a message that is used to facilitate the reception. Acceptance message for teens. Based on its function as a messenger ( Notoadmodjo , 2011) . The influence of the media information that increasingly have the ease of access by anyone, directly or indirectly, will be able to give effect also to the knowledge, attitudes and behavior. All informants in this study claimed have been exposed to pornographic media either intentionally or unintentionally . Media exposure like pornography is also considered as a tool to spur and stimulate sexuality itself. Most informants claimed that the information media such as the internet (social media) is the biggest influencers to give changes in premarital sexual behavior. According to Esti (2008) information media such as television, newspapers, magazines and other influences can create an obsession towards sex among adolescents. Junior high and Senior High School does not need and is not interested in sex drive imitation or fake. But the new power in his body made her sexual instincts wake and responsive. TV, magazines, etc. are the main source of sexual stimulation. The results are consistent with research of Taufik (2010) all informants and key informant also give the same explanation that the influence of the mass media is very possible for the occurrence of pre-marital sex through mobile phones, Internet and pornographic films among teens The results are consistent with research of Evi , et al ( 2013 ) who has interviewed informant about sexual behavior and found that informants influenced by the media information such as TV , HP , and internet. The mass media is most often used to obtain information about sexual behavior such as a 58 phone / mobile phone , computer / internet and VCD / DVD / CD. 4. Situation and Conditions Factors chance (the circumstances) of premarital sex is very important to consider , because if there is no chance of both space and time, premarital sex will not happen. Opening up opportunities for teens to have sex can be influenced by several factors such as: the business of parents, administration of excess facilities , shifting moral values in society ( Health Ministry , 2010). The results in this study there are many factors that support for the pre -marital sexual behavior among adolescents . One of them is the situation and favorable conditions for the occurrence of premarital sex behavior . Various places such as parks, because it is where the people going out, there are also those who say go to a movie, and eat together outside . This opinion is in line with the opinion of key informants who say the current situation is usually empty house, so they take advantage of existing opportunities. Most informants also said that deserted places not forever be a place where people in dating. Sometimes in a crowded place was a teenager now not shy in expressing affection towards their partners. Because they assume that the handrails, hugs, kisses, still a natural thing. They just think that sexual behavior was only when he had sexual intercourse with her partner. Results of research conducted to Taufik research (2010) on sexual behavior in adolescents analyst in the town of Pontianak obtained that most informants tend to argue that the circumstances that allow for the occurrence of pre-marital sexual relations that began when the couple spend time together, dating in a dimly lit and dark without the supervision of others. Conclusion 1. Knowledge Knowledge informants in this study indicate that the informant of 6 girls and 1 key informant obtained all informants define the different juvenile sense. There are four informants who can answer very well what it is premarital sex and the two informants did not understand at all like what was said premarital sex. Then there are three informants answer with good examples of sexual behavior and two informants said that in addition to Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology having sex then it does not include the behavior sex then one informant did not answer . In conclusion teens knowledge about premarital sex is still lacking . 2. Attitude Attitudes toward premarital sexual behavior informant date suggests that had passed the limits of reasonableness . From 6 informants studied revealed that sexual behavior been done already at stage 5 of the 12 stages of courtship behavior . Sexual behavior such as handrails , a hug , a kiss , a hug while kissing a sexual behavior that is still within reasonable limits. In conclusion, teenagers have positive attitude sex behavior. 3. Media Information Media information is a media that has a broad enough coverage. Information media such as the Internet is a medium that is a very big influencer for adolescents because it is very easy and fast to access. Results of the study found that from 6 adolescents informants including key informant argued that the mass media such as the internet is a very big influencers for teenage promiscuity. 4. Situation and Conditions The situation and conditions used by most of the informants in this study chose the circumstances that is quiet and romantic place. The results also show linkage with the lack of communication, lack of attention given by parents, thus allowing pre-marital sexual behavior. Of 6 young girl informants said there were five informants prefer a quiet place and only one person who said the place was not crowded rule. Recommendations 1. Expected teenagers to be able to improve the knowledge, attitudes and behaviors are positive about what the sexual behavior and the dangers of such behavior. 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Analisis Penyebab Perilaku Hubungan Seksual Pranikah Pada Remaja Di Kota Pontianak (Study Kualitatif). Tesis. Fakultas Kesehatan Masyarakat Universitas Indonesia. Depok. Diakses tanggal 13 januari 2104. 28. Wawan dan Dewi, 2010. Teori dan Pengukuran Pengetahuan sikap dan perilaku manusia. Yogyakarta: Nuha Medica 29. Widyastuti yani, dkk. 2009. Kesehatan Reproduksi. Yogyakarta: Fitramaya Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE SATISFACTION OF PEOPLE WITH DISABILITIES ON REHABILITATION SERVICES IN ACEH PROVINCE 1 Hermansyah1, Fahmi Ichwansyah2, Enny S3 Lecturer Ministry of Health, Health Polytechnic, Aceh Province Head Officer Ministry of Health, Health Research and Development Center, Aceh Province 3 Head Officer Handicap International, Aceh Province Email: [email protected] 2 Introduction Since military conflict and post-tsunami disaster affected Aceh Province, it caused people with disabilities. Disability is an interaction of three main things, including weakness or damage to body functions, activities of daily living and environmental conditions. The aim of this study is to explore the satisfaction of people with disabilities on rehabilitation services and its impacts on communities. Methods This quantitative survey was conducted in 3 months by using questionnaires to 200 people with disabilities in eight districts in Aceh Province. The data were analyzed descriptive by using a computer system. Result and Discussion This study showed that all respondents activities such as mobility, activities of daily living, household activities both in adults and children, participation and self reliance have changed significantly after undergoing the rehabilitation process by health officers. The majority of participants’ perception is in positive category (74.0%). About 35.5% of participants suggested that the equipment used for rehabilitation services should be improved to be in better quality. Thus, improving better health care services for people with disabilities is highly required. Keywords: Satisfaction, Rehabilitation Services, People with Disability Introduction Disability is a malfunction or reduced a function can be measured objectively/seen, because of the loss/abnormality of body parts/organs of a person, such as the absence of the hand, paralysis of certain parts of the body. These defects can always be for someone, which can produce different behaviors in different individuals, such as brain damage may make the individual is mentally retarded, hyperactive, blind, etc.1 According Article 1 in Indonesia Law No. 4/1997 on People with Disabilities (PwDs) states that disabled people are all people who have physical and or mental abnormalities, which may interfere with or an obstacle for him to conduct a proper activity, consisting of: physical disability, mental disability, as well as physical and mental disabilities (both).2 According to the most recent US cencus analysis, there are 40 million adults with a severe limitation in physical function who are considered “work disabled”.3 People with disabilities in the USA are protected by the Americans with Disabilities Act (ADA), which outlines the necessary environmental requirements for businesses and public areas such as curb cuts and ramps, and prevents discrimination from employment based on disability. In the USA, people with disabilities also have access to state-run programs such as vocational rehabilitation that are designed to assit in achievement of higher education and job placement/maintenance.4 Since military conflict and tsunami disaster affected Aceh Province, it caused people with disabilities.5 Because of that, we have to to support health and social initiatives related to disability issue, whatever the context, offering them assistance and supporting them in their efforts to become self-reliant. It could be important how to implements activities that will allow people with disabilities in Indonesia to have greater opportunities to exercise their rights to enhance their dignity.6 The formulated a strategy which stated that the specific objectives of the activities are to increase the capacity of institutions and services working in disability field, confirming to general public and decision makers are aware that disability is a human rights, development issue and empowering people 61 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology with disabilities and their organization to become active actors in their communities.1 This survey was expected to generate an output that is important to the performance and results of all activities taking place during this so it will benefit some interest groups, such as: 1)People with Disabilities; its open participation space for the disabled person and to evaluate the implementation of the rehabilitation services program that has received so far. 2)Government/program manager; obtaining the update information on the implementation of rehabilitation services in Aceh province; should be strengthening the public service skills and referral systems for people with disabilities; and should be integrating the program of physical rehabilitation services on people with disabilities into the Aceh's Health Insurance system. The Aims of study The aim of this study was to explore the satisfaction of people with disability on rehabilitation services, and its impact on community. The study specifically focused on assessing client satisfaction in terms of the quality of services (accessible, efficient and impactful) and the appropriateness of services considering the needs of people with disabilities in Aceh Province. Research design This study used a survey design with quantitative approach, namely a method that aims to describe the actual situation or phenomenon in which all variables were observed and measured at a point time simultaneously without an intervention or treatment. Site and study sample The survey was carried out in 6 regencies (Aceh Besar, Aceh Tengah, Bener Meriah, Bireuen, Pidie Jaya, Aceh Utara) and 2 municipalities (Banda Aceh, Kota Lhokseumawe) in Aceh Province. Samples for the survey has determined purposively by Handicap International as its working area. It was implemented its current rehabilitation project as many as 200 people with disabilities. The target groups of the survey are the persons with disabilities receiving physical rehabilitation services (Physical therapy, 62 Prosthetic Orthotic, Assistive devices) from Handicap International rehabilitation project in the period December 2010 to January 2011 at Public Health Center, Hospital regencies municipality level, and were willing to be a respondent in this survey without pressure or volunteer. Procedure The time period of data collection in this survey was took 3 months. Data collection was done by interviewing respondents face-toface with using questionnaires that were containing a series of questions ranging from general information, client status, the cause of malfunction, the service received, satisfaction levels and recommendations for improving the quality of rehabilitation services. Data collection was conducted by enumerators were selected by survey team and before surveys conducted all enumerators will be trained in the use of questionnaires, surveys ethics, and disability etiquette. Data processing is done in several stages, namely: editing, coding and data entry. Editing was an activity to examine each statement or question that has been filled such as charging completeness, consistency between the lists of questions with answers, answers and filling error correction. In the coding stage, make code was carried out by researchers of any information that has accumulated on the right column of the questionnaires. Furthermore the categorical value (score) for each indicators was made in the form of figures 5 (five) for indicators with a very good condition or agreed until the number 1 (one) for the category was less or not satisfied. Data Analysis The researchers conducted data analysis techniques used to the questionnaires instrument was conducted on each variable to determine the frequency and proportion of each variable with using the formula: Percentage = (f / n) x 100% where: f = Frequency, and n = Number of Respondents.8 The data processed were analyzed descriptively by using a computer and displayed in frequency distributions to have obtained a description in form of a table, graph or diagram. Interpretation of percentage, the survey team used calculated using the criteria: Less (1 to 20%); Less than half (21 to 40%); Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Almost half to more than half (41 to 60%); More than half (61 to 80%); and Almost entirely to whole (81 to 100%). Result and Discussion Based on data collecting results, its known that the total number of respondent in this survey was 200 people with disability which clustered in six Regencies namely Bener Meriah (22.5%), Bireuen (20.5%), Aceh Utara (20.0%), Aceh Tengah (15.0%), Aceh Besar (9.5%), and Pidie Jaya (2.0%) and two Municipalities namely Lhokseumawe (8.0%) and Banda Aceh (3.0%). It was found the most number of respondents was in Bener Meriah Regency (22.5%), whereas the least one was in Pidie Jaya Regency (2.0%). Table 1. Number of Respondents by Demographic Characteristics (N = 200) Characteristics of Respondents Gender Male Female Age Group (years) 0-4 5-9 10 - 14 15 - 19 20 - 60 Over 60 Educational background Not school yet No school Primary school / equivalent Junior high school / equivalent Senior high school / equivalent Bachelor degree Master degree Others Occupation Not working / housewife Civil servant / Army / Police Farmer / laborer Non government staff Businessman Others Monthly Family Income category Below Rp. 1.300.000, Above Rp. 1.300.000, - f % 91 109 45.5 54.5 31 16 5 4 97 47 15.5 8.0 2.5 2.0 48.5 23.5 43 34 45 20 24 29 1 4 21.5 17.0 22.5 10.0 12.0 14.5 0.5 2.0 44 23 34 6 17 76 22.0 11.5 17.0 3.0 8.5 38.0 131 69 65.5 34.5 Characteristics of People with Disability For this research result found 54.5% of them were female. Age group of majority was 20 to 60 years (48.5%). The most educational background was elementary school graduate or equivalent (22.5%). More type of occupation was no working (housewives) of 22.0%. More respondents (73.5%) were using the facilities financing sourced from Aceh's Health Insurance Program (Jamkesmas/JKA). Disability experienced by all age categories with different types of occupation that was being acted by the respondent. Types of disabilities experienced by respondent vary greatly which have been obtained from birth (congenital) or during their lives. To minimize it was needed to do exercises every day to consider the severity of the disability is experienced and is unable to do it themselves, and may also be caused by a lack of knowledge about exercises and activities that the respondent owned. More than 40 million people in the United States have a physical or mental impairment that significantly affects life activities and work performance. The total annual costs of disability are currently estimated at US300 billion.12 The factor of family income per month that was still under the monthly minimum wage provinces (Rp 1.300.000,-) have indicated the average on standard of living financially respondents were in categories with low economic status. Utilization of financing facilities sourced from Jamkesmas/JKA ongoing at this time of great help disabled people in the process of undergoing rehabilitation. Disability increases with age, and a variety of resources are available to older persons with disabilities. Older persons should discuss difficulties managing independent living with their physician and contact their local senior center to learn more about available programs, such as physical activity programs and home modification.12 Researchers analyzed data from Mexican-Americans older than 65 who were followed for 18 years. They concluded that, on average, this group of people spends more than half of their remaining years with serious physical disabilities that limit their ability to do everyday tasks.13 These findings indicate that poverty and lifelong disadvantages seriously undermine the health of many older Mexican-American. The family tends to step in to provide care to even seriously impaired older parents. It must develop policies and programs that complement the family in their ability to provide care to older infirm parents in order to improve quality of life both the older parents and their caregivers.13 63 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Source of information Source of information should be obtained by during the rehabilitation process more available from health workers (85.0%). Type of disability experienced varies widely from birth or acquired during their lives. Type of therapy given during rehabilitation was more using infrared (79.0%). Type of rehabilitation exercises and activities at home undertaken by 46.5% of respondents has been done everyday. Source of information obtained during the rehabilitation process was obtained from health officers with different educational backgrounds, both working in the public health center, hospital, or midwife in the village suggests that the role of health workers in socialized medical rehabilitation services are already well underway. Meanwhile, the World Health Organization provides the definition of disability into 3 categories: impairment, disability, and handicap. Impairment mentioned as a condition of abnormal or loss of structure or function of psychological or anatomical. Disability is the inability or limitations as a result of impairment to perform activities in a manner that is considered normal for humans. Handicap is a disadvantage for a person due to impairment, disability which prevents it from fulfilling the role of the normal (in the context of age, gender, and cultural factors) for the person concerned.1 Impairment is evaluated as a measured change in an individual’s health status. Disability is an individual’s inability to perform a task successfully. Disability is not necessarily related to any health impairment or medical condition; although a medical condition or impairment may cause or contribute to an ongoing disability.11 These are some of the disability definitions proposed by some experts, such as: a) someone who looks and act differently from ordinary people or other; b) a person who is the part of their body was not working for a long time and does not go away; c) someone who has a barrier to do usual daily activities (washing, eating, etc.); and d) someone who cannot learn, and cannot make their own decisions as anyone else. Of some of the definitions set forth above, we can conclude a larger sense that disability is an interaction between the three main things, namely: the weakness or damage to body functions, activities of daily living and environmental conditions. 64 Access to rehabilitation services Access to rehabilitation services site was easily accessible by the respondents in a close distance (≤2 km), travel time was short (≤10 minutes), and availability of the transportation. In addition, 96.5% was easy in administration, 77.5% in undergoing the rehabilitation process was accompanied by relatives or family member, and 72.5% have been ease of collecting cost to undergo the rehabilitation process. The Americans with Disabilities Act of 1990 requires that all medical practitioners be prepared to provide all patients “full and equal access to their health care services and facilities”. Many practices cannot accommodate patients with mobility impairment; therefore, adults who require a wheelchair for mobility may be denied the care that they need. Improved awareness is needed about the Americans with Disabilities Act requirements and the standards of care for patients with mobility impairment.14 Rehabilitation services Most participants identified the rehabilitation services along process such as: referral history was known 100.0% undergoing rehabilitation process at Public Health Centers, 16.0% to Hospital District, to the Provincial Hospital only 4.5%, while obtaining a referral to both the Hospital District and the Province Hospital was 2.5%. All respondent activities or abilities were mobility; activities of daily living; household activities both in adults and children alike; participation; and independence undergone significant changed after a rehabilitation process. Support given by the family after rehabilitation was able to overcome those aspects that complicate the lives of respondents. All of health officers have been providing good rehabilitation services to the respondent by health officers, namely: in Public Health Center (72.0%), the Hospital District (59.5%), and the Provincial Hospital (57.1%). Perception during rehabilitation process The following table represents the number of respondents based on the perception given by the respondents during their rehabilitation process in terms of various categories were as follows. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 2. Number of Respondents by Their Perception During Rehabilitation Process (N = 200) Respondent Perception During Rehabilitation Process f % You feel that you can do more things by yourself after using Rehabilitation services Absolutely not good 3 1.5 Not good 34 17.0 Good 150 75.0 Very good 13 6.5 Satisfy with your life before getting the rehabilitation intervention Absolutely not satisfy 7 3.5 Not satisfy 128 64.0 Satisfy 65 32.5 Satisfy with your life after getting the rehabilitation intervention Absolutely not satisfy 3 1.5 Not satisfy 42 21.0 Satisfy 146 73.0 Very satisfy 9 4.5 More independent in life Yes 137 68.5 No 63 31.5 Able to do all my Activities of Daily Living Yes 135 67.5 No 65 32.5 More self confidence Yes 157 78.5 No 43 21.5 More able to participate in family events Yes 138 69.0 No 62 31.0 No improvements, same as before Yes 34 17.0 No 166 83.0 My health has improved Yes 168 84.0 Not 32 16.0 More able to participate in social activities in the community Yes 130 65.0 No 70 35.0 The above table gives a detailed picture of respondents' perceptions during their rehabilitation process was as follows: Respondent felt able to do more things alone after undergoing rehabilitation services was good in the category (75.0%), feeling dissatisfied with your life before it underwent rehabilitation intervention (64.0%), feeling satisfied with your life after a rehabilitation intervention (73.0%), living more independently (68.5%), able to perform activities of daily living (67.5%), had more self-confidence (78.5%), better able to participate in family events (69.0%), felt there was progress, the same as before (83.0%), his health has improved (84.0%), and better able to participate in social activities in the community (65.0%). It can be concluded that respondents’ perception during their rehabilitation process was more in the positive category (74.0%). Rehabilitation services also require a referral system that starts at the level of basic services in health centers, and for people with disabilities who have more serious severity and if the clinic does not have the power physiotherapist and facilities that were not complete/available, then the respondent the opportunity to undergo a rehabilitation process at a higher level, namely District Hospital and 65 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Provincial Hospital. It has become very important because this study showed that all the respondents activities or abilities such as mobility; activities of daily living; household activities both in adults and children alike; participation; and independence change significantly after undergoing the rehabilitation process by health officers. Suggestions for improvement Rehabilitation services The following table represents the number of respondents based on their suggestions for improvements of rehabilitation services in the future. Table 3. Respondents’ Suggestions for Improvements of Rehabilitation Services (N=200) Respondents’ Suggestions for Improvements of The Rehabilitation f % Services Provide better quality materials/equipments 71 35.5 Home visits 29 14.5 Improve training 27 13.5 Provides regular visits to people with disabilities 18 9.0 More time for rehabilitation sessions 15 7.5 Give more information 14 7.0 Improve the attitude of the staff 8 4.0 Rehabilitation service center should be closer to the community 7 3.5 Other 7 3.5 Involving caregivers in the rehabilitation process 4 2.0 According to the table, the suggestions put forward by respondents to improve rehabilitation services in the future based on the first ranking was 35.5% of respondents suggested that the service provider and where service to provide materials or better quality equipment in order to speed up the recovery process in people with disability. In the United States, the American Medical Association’s Guides to the Evaluation of Permanent Impairment is the most commonly used source assessing and rating an invidual’s permanent impairments. Ultimately, in deciding on an appropiate level of work restrictions, the physician must evaluate the situation of each patient by considering 3 concepts: Capacity (work training, strength, endurance); Tolerance (ability to perfom sustained work at a given level), and Risk (probability bof substantial harm upon return to previous work duties). If an individual is not capable of returning to his or her previous employment, consideration may be given to increasing physical fitness and stamina, recognizing other abilities and talents, and perhaps vocational retraining.11 In this research study, we can learn about improve the quality of care and access to rehabilitation for people with disabilities through strengthening the identification and referral system; strengthening the skills of public services (midwives in charge of 66 identification and referral and rehabilitation staff at the subdistrict, district and province levels) through training and technical support to health authorities; integration of physical rehabilitation in the social insurance system of the Aceh Province (JKA); and establishment of mechanisms for incurred costs management at community level. Conclusion This quantitative survey identified the people with disabilities’ satisfaction related to rehabilitation services. First, type of rehabilitation exercises and activities at home should be carried out by the respondent everyday taking into account the severity of the disability and with the help of caregivers. Second, support given by the family after rehabilitation was able to overcome those aspects that complicate the lives of respondents. Third, to helped the people with disabilities to perform the activities to meet their basic needs through an exercise that continuously trained in order to reduce dependence on others. Finally, to improve rehabilitation services in the future to the service provider and a service to provide the material or equipment was better quality, home visits by health officer and increased training during rehabilitation so as to speed up the recovery process and improving the health care to people with disabilities. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Acknowledgments This survey was held in collaboration with Health Research and Development Center Ministry of Health, Aceh Province and Handicap International Branch Aceh Province, so we would like to sincerely thank to both of them. References 1. Aide Médicale Internationale. 2007. Disability/Kecacatan. Health Messenger, Majalah Kesehatan Untuk Pekerja Kesehatan Indonesia, Edisi 6/September 2007, Banda Aceh: PT. Aceh Media Grafika. 2. Undang-Undang Republik Indonesia Nomor 4 Tahun 1997 Tentang Orang Cacat. Jakarta. 3. Brault M. 2008. Americans with Disability: 2005, Current Population Reports. Washington, DC: US Cencus Bereau: p.70-117. 4. Wilbanks, Susan R and Ivankova, Nataliya V. 2014. Exploring Factors Facilitating Adults with Spinal Cord Injury Rejoining the Workforce: A Pilot Study. Disability and Rehabilitation, Early Online, p.1-11. 5. Forum Keperawatan Bencana Aceh, 2009. Keperawatan Bencana. Proyek Pendidikan Keperawatan Bencana Japanesse Red Cross Society di Banda Aceh dan Aceh Besar berkenaan dengan Program Rehabilitasi dan Rekonstruksi Tsunami di Indonesia. 6. Melati, A. 2011. Gambaran Kebahagiaan Pada Penyandang Tuna Daksa Dewasa Awal. Skripsi, Fakultas Psikologi Universitas Sumatera Utara. Access at: http://repository.usu.ac.id/bitstream/123456 789/28956/4/Chapter%2011.pdf. 7. Notoatmodjo, S. 2003. Metodologi Penelitian Kesehatan, PT. Rineka Cipta, Jakarta. 8. Arikunto, S. 1998. Prosedur Penelitian: Suatu Pendekatan Praktek. Edisi Revisi IV, Cetakan Kesebelas, Jakarta: PT. Rineka Cipta. 9. Supranto, J. 2001. Pengukuran Tingkat Kepuasan Pelanggan untuk Menaikkan Pangsa Pasar. Jakarta: Rineka Cipta. 10. Suryawati, dkk. 2006. Penyusunan Indikator Kepuasan Pasien Rawat Inap Rumah Sakit di Provinsi Jawa Tengah. Jurnal Manajemen Pelayanan Kesehatan, Vol. 09, No. 4. 11. Parasuraman, A Zeithaml, Valerie A. dan L Berry. 1991. Delivering Quality Service. New York: The Free Press A Divission of Mc Millan Inc. 12. Zeller, John L., Burje, Alison E., Glass, Richard M., 2007. Assessing Disability. JAMA, November 7, 2007, Vol. 298. No.17, p.2096. 13. Preidt, Robert. 2015. Older MexicanAmericans Often Disabled, Study Say. Journal of Gerontology, Series B: Psychological and Social Sciences, News Release, March 26, 2015. 14. Lagu, T., Hannon, N.S., Rothberg, M.B., Wells, A.S., Green, K.L., Windom, M.O., Dempsey, K.R., Pekow, P.S., Avrunin, J.S., Chen, A., Lindenauer, P.K., 2013. Access to Subspecialty for Patients with Mobility Impairment. A Survey. Annals of Internal Medicine. 19 March 2013. Vol. 158, p.441-446. 67 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EFFECT WORKSTRES : PSYCHOLOGICAL DISTRESS ON KORTISOL AND IMMUNOGLOBULIN’S LEVELS OF NURSE IN IMMUNE SYSTEM IN HAJI HOSPITAL MEDAN Tri Niswati Utami College of Health Sciences Nurliana Medan [email protected] ABSTRACT Work stress comes from the environment system. Environmental aspects such as social conditions, stressors and resources received by individual differences in life (such as family and work). Sources of stress in the work environment can cause a negative response. Psychological distress associated with the emotional state of the individual and social distress related to an individual's ability to relate to others. Individuals who do not have the ability to accept stressor can be affects physical and mental health and quality of life. Stress response in the form of biologycal response and perception of response. If the body's response is stronger and able to banish stress, the body under normal circumstances and the body is able to maintain the balance of the phase of stress so it does not harm the body. If prolonged stress, the body will perform activation response time, thus causing damage to the body, resulting in the risk of illness and injury. The purpose of this study was to determine the effect of work stress: psychological distress on the immune system and the cortisol levels of immunoglobulinG (IgG). The study design was observational with cross sectional study. Its about 23 samples were taken at random nurses in the ICU, ER and hospital of nursery Haji in Medan .The results showed that there was no significant relationship between the characteristics of the respondents with work stress. Based on r value=0.532 and p = 0.009. There is significant influence from psychological distress on the level of cortisol. Furthermore, on the result of r value =-0.719 and the value of p=0.000, is significant influence from psychological distress on the level of IgG. Keywords: distress, imune system, kortisol, Imunoglobulin G Introduction The hospital is a work environment that filled with sources of stress. Some data indicate that the stress levels of nurses is very high. Nurse work stress are found in the Intensive Care Unit, Emergency Unit and Nursery. Stress nurses working in Yogyakarta Private Hospital associated with the dual role conflict and social support. In fact, most nurses in Indonesia are women. Dual role performed by women is very risk with familywork conflict (Almasitoh, 2012). Stress nurses working in Dr. Pirngadi hospitals of Medan in 2010 amounted to 42.24% especially in night shift nurses (Putri, 2010). Distress is a negative psychological response to a stressor, as indicated by the presence of negative psychological state (Simmon& Nelson, 2001; Quick, 2002). Research work stress and psychological distress finding symptom sof anxiety and depress if appears as aprominent characteristic in distress, this situation may occur in different degrees. Behavioural stress symptoms such as: 1) Physiological symptoms such as : abdominal pain, increased heart rate and shortness of 68 breath, increased blood pressure, headaches and heart attack. 2) Psychological symptoms such as anxiety, tension, boredom, dissatisfaction in work, headache/migraine, muscle tension, insomnia or sleep. 3) Behavioral symptom ssuch as: delaying work, declining achievement and productivity, sabotage behaviours, increasing frequency of absence from work, eating disorder behaviour, losing appetite, drinking alcohol, being aggressive, stealing, declining quality of interpersonal relationships (family and friends) and a suicidal tendency(Robin, 2005). Methods The Subjects were nurses in Haji Hospital Intensive Care Unit (ICU), Emergency Unit and Nursery room at Medan. Samples were taken randomly as many as 23 nurses. Observational study was conducted using cross sectional study design. Work Stress measurement used questionnaires GHQ-12 (General Health Quesionaire-12) and imunitas measurement used conducted laboratory tests of blood cortisol levels and immunity examination IgG levels. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Frame work study Respondents GHQ-12 Psychological distress Social distress Low immunity: Kortisol IgG Picture 1. Frame work study; Subowo (2013), Pinel (2009) Hypotesis 1. There is no influence from characteristics of respondents on distress 2. There is influence from psychological distress on the level of cortisol 3. There isinfluence from psychological distress on the levelof IgG 4. There is influence from social distress on the level of cortisol. 5. There is influence from social distress on the level ofIgG Data Analysis The data obtained would be analyzed using statistic non parametric, including analysis of data normality, univariat, bivariat and then applying spearman correlation. Results Survey 23 respondents consisted of 15 respondents distress and 8 respondents is not distress. Characteristic of the respondents in this study are described based on age group, education and years of service shows in the table 1. Table 1. Data Characteristics of Respondents by Age group, Education and Years of Service in Haji Hospital Medan Number Category Frequency Percent (%) 1 Age 21 – 25 3 13 26 – 30 9 39 31 – 35 6 26 36 – 40 3 13 41 – 50 2 9 Total 23 100 2 Education Diploma 18 78.3 Bachelor’s degree 5 21.7 Total 23 100 3 Years of Services 5 – 10 11 47.8 69 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 11 – 15 16 – 20 >20 Total 8 2 2 23 34.8 8.7 8.7 100 Table 1 indicates the age majority is 26-30 years old as many as 39%. The most groups of education is Diploma as many as 78.3% and the most group years of service is 5-10 years as many as 47.8%. The Respondent are distres and not distres (normal) indicated at table 2. Table 2 Distribution of Respondents Distress Number Category 1 Distress 2 Normal Total Frequency 15 8 23 Percent (%) 65.2 34.8 100 Table 2 indicates the respondent are distress as many as 65.2% and normal as many as 34.8%.The influence of psychological distress with cortisol levels shows in table 3. Table 3 The influence from psychological distress on the level of cortisol and IgG Number Psychological Spearman rho (r) p Value distress 1 Kortisol 0.532 0.009 2 IgG -0.719 0.000 N 23 23 Table 3 indicates that the results, levels of cortisol value r=0.532 and p =0.009 showed a strong relationship and patterned positive, meaning that the higher levels of psychological distress will increase cortisol levels. Statistical test results obtained there is significant relationship between psychological distress with cortisol levels (p =0.009). IgG levels r=-0719 and the value of p=0.000 showed a strong relationship patterned level is negative, meaning that the higher levels of psychological distress will reduce levels of IgG. Statistical test results obtained there is significant relationship between psychological distress with IgG levels (p =0.000). Table 4. The Influence from social distress onthe immunity: the level of cortisol and IgG Number Social Distress Spearman rho (r) p Value N 1 Kortisol 0.135 0.540 23 2 IgG -0.340 0.113 23 The results levels of cortisol value r = 0135 shows no relationship/relationship is weak and the value of p = 0.540 showed no significant results. Statistical test results IgG r = -0.340 indicates the level and pattern of relationship is negative, it means increasing social distress will decrease slightly the level ofIgG. Statistical test result p = 0.113 showed no significant relationship between distress onthe levels of IgG. Discussion Respondent characteristics such as age, education and years of service variabels are with no influence on work stress; nurse distress. The results are consistent with the concept of distress a holistic models of 70 stress.The physical or psychological stimuli which the individual responds are commonly referred as either stressors or demands. Stressors at work take the form of role demands, interpersonal demands, physical demands, workplace policies and job conditions (Quick et al., 1984). The relationship between the worker and the work environment are not harmonized may lead to distress. Some research out lines that the labour relations and working environment are the right model for a negative response (Nelson et al., 2001). Influence stress on immune system According to data analysis with Spearman correlation (r) showed significant Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology relationship between psychological distress with increased cortisol levels as well as levels of IgG. This Research conducted immune system in elderly people, feelings of depression and anger can weaken the immune system. They are prone to stress and depresion. Stress causes physiological changes inthe body that weakens the immune system, and ultimately affect the health of so susceptible to disease, and the incidence of abnormalities ofthe immune system with the appearance of psoriasis and eczema.The glucocorticoid hormones and cortisol trigger the anti-inflammatory reactions in the immune system (Fatmah, 2006).The immune system as close relationship with the emotions, the relationship has been demonstrated since 1919, Japanese researchers found an association of physical and emotional set backs tuberculosis patients during their immune system in an emotional rage episode. In 1926 American researchers found the number of lymphocytes decreased in individuals who experience shock (Subowo, 2013). Conditions of distress is a negative response due to a stressor, stressor also activates the sympathetic nerve, there by increasing the amount of epinephrine and norepinephrine is released from the adrenal medulla. Segerstrom & Miller (2004) found that the effects of stress affects the immune function. Excessive distress can cause changesto health, such as disorders: psychological cardiovascular and muscle. Health problems occur because the body accept a state of stress and responds to stressful conditions through the brain. Instead the condition of tranquillity will enhance the immune system. Tranquility, positive thinking is a positive emotional response to increase optimistic attitude, so avoid the stress. Optimistic attitude cause a state of balance (Homeostasis). Homeostasis occurs because of the feedback mechanisms that limit excessive reactions and maintain normal conditions. Endurance immunologic response pattern of the prayer tahajud can decrease the cortisol hormone(Soleh, 2006). There are changes in the concentration of IgG and IgA levels before and after memorizing the holy AlQur’an in Qori (Laukha, 2010). The level of IgG significantly higher in the group of respondents who experience digestive disorders and disorders atopic dermatitis (Said dkk., 2012). Conclusion Work stress; psychological distress saffects the immune system, evidenced by an increase in cortisol levels and decrease in IgG. Unbalance demotions cause the body's immunity levels decrease. Inverse correlation between in creased levels of cortisol and decrease IgG. The immune system works to protect the body from infection, bacteria, viruses and cancer cells and other foreign substances in the body. Psychological distress in the long time run affect the immune system, decreased immune system and weak, the body susceptible to disease and increases the risk of cancer. References Almasitoh, U. H. (2011). Work stress Judging from Dual Role Conflict and Social Support on Nurse. PSIKOISLAMIKA, Islamic Psychological Journal (JPI), Vol. 8 No 1, 63-82. Fatmah. (2006). Low immunity response in the eldery. Health Magazine , Vol 10, No 1, 47-53, Jakarta. Laukha, M. (2010). Changes Immunoglobulin G (IgG) and immunoglobulin A (IgA) in AlQur'an memorizer in Depok Indonesia The foundation of Baitul Quran. Skripsi, UIN Syaruf Hidayatullah, 40-57, Jakarta Indonesia. Nelsons, D., Quick, J., & Simmons, B. (2001). Handbook of health psychology. Marwah: NJ: Elbaum. Pinel, J. P. (2009). Biopsychology. Yogyakarta: library studying Putri, R. (2010). Illustration of work stress on a night shift nurse in the emergency department of Dr. Pirngadi Hospital, Medan. University of Sumatera Utara. Quick, J. C., & Tetrick, L. E. (2002). Handbook Occupational Health Psychology. 97-116, America: The American Psychological Association (APA). Quick, J., & Quick, J. (1984). Organizational stress and preventive management. New York: Mc Graw-Hill. Robbins, S. P., & Judge, T. A. (2005). Organizational Behavior. New York: Prentice Hall. 71 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Said, I. P., Tabri, F., Ilyas, F., & Sjahril, R. (2012). The relationship between Ig G and IgM anti Helicobacter Pylori with events of Adult Atopic Dermatitis. University of Hasanuddin, 1 - 14, Makassar. Segerstrom, S., & Miller, G. (2004). Psychological stress and the human immunie system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 601-630. 72 Simmons, B., & Nelson, D. (2001). Eustress at work: The relationship between hope and health in hospital nurses. Health care management riview, 7-18. Soleh. (2006). Therapy of Prayer Tahajud to cure various diseases. Jakarta: Hikmah. Subowo. (2013). Clinical Immunology. 451 472, Jakarta: CV Sagung Seto. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE ASSOCIATION MOTHER’S EDUCATION AND THE AMOUNT OF FIRST MOLAR CARIES TEETH IN 6-7 YEARS OLD OF SD BAPTIS MEDAN DENAI 2014 Herlinawati, Intan Aritonang, Hasny Department of Dental Nursing, Polytechnic of Kemenkes Medan ABSTRACT Education is one of the factor that infuences of healthy status for someone. The participation of parents mostly a mother is very important in guidence, give understanding, improving and to preparing facility for their children that can to keep their oral hygiene. The first molar replace the first position that easy affected by caries because there is niches and fissure with the of teeth eruption at the child in 6-7 years old, so that the prevention to caries expecially the teeth are many niches and fissure on the surface is very important. The kind of research is using analitic survey with cross sectional desain. The population of this research are the all of children in 6-7 years old SD (elementary school) Baptis with numerals 40 children where as the sample is the total of population are 40 children. This research aims to knows that the relation of mother’s education with the total of the first caries molar of children in 6-7 years old. the result of this research it shows for 40 respondences, 32 children have caries (80%) on the first molar, while are not caries only 8 children ( 20%). The level of mother’s education is elementary school, all of the children have caries on the first molar. Based on chi square experimen have done, got the result there was any relation between mother’s education and amount of the total of first molar caries (p<0,05), the children in 6-7 years old SD Baptis have to keep their oral hygiene. Be excepted of the participation of parents in how to guide their children to maintain oral hygiene and defend growth and development of the children’s first molar so that it can oppose earlier caries. Keywords : Mother’s education, first molar caries teeth INTRODUCTION Healthy is the most important for every human to can do any activities as physically, physicology, and social prosperity completely and it is not only just do not have disease or weakness ( WHO). On of health efforts is to support the self sufficiency of society for health live ( Depkes RI 2010). According to Health Act no. 36 (2009) article 93 paragraph 1 and 2 that dental and oral health care aims to maintain and increase the society health level by prevention of dental caries, and to care the dental health by local government and also by individual dental health care, school and society. Based on result of research of basic health (2013), the national prevalence of dental and moral health is 25.9%, in which 14 provinces have a higher prevalence of dental and oral health over than national level. The national prevalence of teeth brushing in each day is 94.2% in which 15 provinces has the lower prevalence than national level. The education of dental health is designed and directed efforts to build a situation in which individual or society group change the old behavior with disadvantages for the dental health. The society has a motivation to improve the dental health care through dental health education. The dental health education has not yet realized effectively. This is indicates by the result of dental health survey of Depkes RI in 1990 in which the rate of dental tissue and niche is higher (Budiharto, 2008). Koentjoroningat (1997) said that education is a majoring in absorbed the educational knowledge of anyone related to the behavior to the absorbed knowledge. The higher educational level, the easier to absorbed the knowledge. Education is a personal characteristic element that always related to the individual/society health level. The higher individual educational level, the easier to absorbed the information of health issue. The easiness of anyone to get more information will influence the forming of health new behavior, such as the information about the 73 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology oral and dental care. In this sense, the formal education in Indonesia is consist of elementary school (SD), junior high school (SLTP), Senior High School (SLTA) and higher educational academic level (PT). the educational level determines the logical reasoning of anyone that enable him to absorbed any information and has a rational thinking into respond the information of the problems (Cumming, et.al., Azwar, 2007). Dental caries is found in the entire world, to any age, nation or economic condition. According to researcher in Europe nations and Asia as well as Indonesia, that 80 – 95%of child who age less than 18 years old have dental caries. The percentage of dental caries is increase for the development of human culture and only 5% of population who have immune to the dental caries (Tarigan, R. 2012). Generally, the people assume that child dental must not be cared because their teeth will changed by the old ones. (Suwelo, I.S. 1991). There are any parents who did not aware that adult’s teeth had growth on the age of 6 years. The growth of adult dental is assumed as milk teeth because the milk teeth has not yet be replaced. Therefore, more of the first molar has caries as one of dental and jaw development of the child that must be cared. (Susanto, GW 2011). The first molar is in the first position with caries because there is niche and fissure in addition to the dental eruption on the age of 6 – 7 years old. The prevention of dental caries with niche and fissure on its surface is very important (Sariningsih, E, 2014). Based on the preliminary survey of researcher, it indicates that of twenty child (in age of 6 – 7 years old) only three child without dental caries. Based on the aforementioned background, the writer interest to do a research on a correlation of mother’s education and the number of first molar caries of the child whose age 6 – 7 years old at SD Babtis of Medan Denai. Purpose of Research In order to study a association between mother’s education and the amount of dental caries in first molar teeth in 6 – 7 years old of SD Baptis of Medan Denai. Benefit of Research 1. As input to the parents especially for mothers who have child on age 6 – 7 74 years old at SD Baptis about the first molar caries. 2. As input to the child on age 6 – 7 years old at SD Baptis about the first molar caries. 3. As consideration for the next researchers about the first molar caries of the child whose age 6 – 7 years old. Hypothesis There is a correlation of mother’s education to the number of first molar caries of the child on age 6 – 7 years old at SD Baptis sub-district of Medan Denai. Method This research is analytic study with observation method and cross sectional design to study a correlation of mother’s education and the number of first molar caries of the child whose age 6 – 7 years old at SD Baptis of Medan Denai. Population and Sample of research Population is all of research object or studied object (Notoatmodjo, S 2010). The population in this research is all of the child whose age 6 – 7 years old at SD Baptis subdistrict of Medan Denai for 40 students. Sample is object will be studied and assumed represent all of population or a part of the studied objects./ (Notoatmodjo, S, 2010). In this research, the sample is child whose age 6 – 7 years old at SD Baptis subdistrict of Medan Denai. In the sampling, the researcher takes a part of population. If the number of population is greater (> 100) the sample is 10 – 15% or 20 – 25% or more. But if the number of population is less than 100, the population to be sample. In this research, the sample is all of child in age of 6 – 7 years old at SD Baptis sub-district of Medan Denai for 40 students (Total population). The primary data for educational level of mother is collected from the interview to the student and teacher. And the first molar were assessed and recorded on the assessment form. On this research, the number of dental caries is categorized to be four, i.e. : good = 0, medium = 1, poor 2 and 3, severe poor = 4. While the educational level was categorized in three : lower = elementary school, medium = SMP and SMA and higher = higher education. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The collected data were processed by any steps, i.e. editing, coding, data entry, cleaning data and the data was analyzed by statistical test using computer software. The univariance data was analyzed to study a depiction and characteristic of each variable. The bivariance data was analyzed to study a correlation between the mother’s education and the number of first molar caries was analyzed by statistical test using chi – square test with confidential level 95%, Results and Discussion Results of research Table 1.1. Frequency distribution of respondent based on educational level of mothers of the child on age 6 – 7 years old at SD Baptis sub-districf of Medan Denai of 2014. No Mother’s Number Percentage education (n) (%) 1 Elementary 6 15 school (SD) 2 Junior high 7 17.5 school (SMP) 3 Senior High 14 35 school (SMA) 4 Higher 13 32.5 education Total 40 100 Based on Table 1.1 it indicates that percentage of education level of mother of the child on age 6 – 7 years old at SD Baptis is elementary school (SD) for 6 person (15%), junior high school for 7 person (17.5%), senior high school for 14 person (35%) and higher education level for 13 person (32.5%). More of respondent is graduate of senior high school (SMA) (35%) and the few of respondent is graduate of elementary school (SD) (15%). Table 2.2. Frequency distribution of respondent based on the number of first molar caries of the child on age 6 – 7 years old at SD Baptis of sub-district of Medan Denai in 2014 First molar Number Percentage caries (n) (%) With caries 32 80 Without caries 8 20 Total 40 100 Based on table 1.2, it indicates that the number of percentage of first molar of the child on age 6 =- 7 years old at SD Baptis with caries is 32 child (80%) while percentage without caries is 8 child (20%). Table 1.3. A correlation of the education of mother and the number of first molar caries of the child on age 6 – 7 years old at SD Baptis sub-district of Medan Denai of 2014 Category of caries Good Medium Poor Very poor Total Educational level of mother SD SMP Unive and rsity SMA 0 4 3 0 3 8 1 5 1 5 9 1 6 21 13 Num ber 7 11 7 15 P (95%) 0.007 40 Based on Table 1.3 it indicates that the mother who graduate from junior and senior high school (SMA and SMA) has a higher rate of caries (4 of first molar) of the child for 9 child (22.5%). Based on results of chi-square test indicates that there is a significant correlation between the educational level of mother and the number of first molar caries (p < 0.05). Discussion Dental caries is dental tissue disease that indicated by the damage of dental tissue from the teeth furface (niche, fissure and interproximal area) to the pulp. Dental caries can found to each people and found on one of teeth surface or more and expand to the depth part of the teeth for example from email up to dentine and pulp. This caries is caused by carbohydrate, microorganism and salivary and the dental form and surface (Tarigan R, 2012). One of causal factor of dental caries is the less of awareness in care the dental and oral health such as to brush the teeth rightly and effectively in addition to the diet factor. Diet also influences the dental and oral health, because diet produces energy. For example carbohydrate protein, fat and minerals in addition to the influence of pre-eruption, post eruption of teeth. Diet also clean the teeth and will damage the dental caries. The food that clean the teeth is apple, guava, yam, etc. in contrary to the soft diet and patch to the teeth such as candy, biscuit, etc. (Tarigan R, 2013). 75 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on Table 1.2, it indicates that of 40 respondents, 32 of them has caries (80%) on the first molar, while without caries found to 8 respondent (20%). All of the child of the mother who graduate of elementary school has first molar caries. And the child from the mother who graduate of junior and senior high school of 21 child, 4 of the child have not caries. According to dictionary of Education (1984), education is a process where anyone develop any capabilities, attitudes and behavior in the society environment. Based on definition, it means that education is a tool to change the human behavior. Education is a process or activity for the personality development and individual or social capability. It means that education is a forming of mentality, i.e. attitude with capability in the form of intelligence, knowledge and skill. Education is all of efforts to build personality and human capability physically and spiritually in a long of live, either in or out of school for the development of unity of Indonesia and society (Hasibuan, 2005). Based on chi-square test there is a significant correlation between education level of mother and the number of first molar caries (p < 0.05). Education is one of factors influence individual health status. The role of parents especially mother is required to guide, and provide the child with understanding, facilities of dental and oral care. First molar tooth has a first position that attacked by caries because there is niche or fissure and the eruption time of the teeth for the child on age 6 – 7 years old. The prevention of caries for the teeth with niche and fissure on the surface is very necessary. Conclusion and Suggestion A. Conclusion Based on the result of research, the writer interest to withdraw a conclusion that the educational level of mother in junior and senior high school (SMP and SMA) has a higher rate of dental caries (4 first molar) for 9 child (22.5%) while the educational level of mother who graduate in elementary school all of the child have first molar caries. Based on chi-square test it indicates that there is a significant association between the educational level of mother and the number of first molar caries (p<0.05). It means that more 76 higher a mother education the amount of first molar caries teeth be lower. B. Suggestion 1. The school must build a mutual cooperation with society health center (Puskesmas) in dental health care activities in school (UKGS) in order to provide the child on age 6 – 7 years old with oral and dental health care especially to the first molar. 2. The child on age 6 – 7 years old at SD Baptis must maintain the dental and oral health by brush the teeth effectively and rightly. 3. The parents must play an important role in guide the child and maintain the oral and dental health of the child and maintain the growth and development of first molar of the child to prevent the dental caries early. DAFTAR PUSTAKA Budiharto. 2008. Pengantar Ilmu Perilaku Kesehatan dan Pendidikan Kesehatan Gigi. Buku Kedokteran. EGC: Jakarta Dictionary of Education (1984) Harshanur, W. I. 1995. Anatomi Gigi. Buku Kedokteran Gigi. EGC: Jakarta Herijulianti, E. 2002. Pendidikan Kesehatan Gigi. Buku Kedokteran Gigi. EGC: Jakarta Notoatmodjo, S. 2003. Pendidikan dan Perilaku Kesehatan. PT Rineka Cipta. EGC: Jakarta Notoatmodjo, S. 2010. Metodologi Penelitian Kesehatan. PT Rineka Cipta. EGC: Jakarta Sariningsih, E. 2014. Gigi Busuk dan Pocket Periodontal Sebagai Fokus Infeksi. PT Gramedia. Jakarta Susanto, G. W. 2011. Terapi Untuk Kesehatan dan Kecantikan Gusi. Erlangga Suwelo, S. I. 1991. Petunjuk Praktis Sistem Merawat Gigi Anak di Klinik. Buku Kedokteran. EGC: Jakarta Tarigan, R. 2012. Karies Gigi. Buku Kedokteran. Buku Kedokteran. EGC: Jakarta Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RELATIONSHIP BETWEEN MATERNAL BLOOD GLUCOSE LEVEL AND NEWBORN’S BIRTH WEIGHT IN MATERNITY CLINIC OF MEDAN SELAYANG DISTRICT 2014 Melva Simatupang, Yusrawati Hasibuan, Tri Marini SN Department of Midwifery, Poltekkes Kemenkes Medan Abstract According to IDF in 2012, there were over 300 million people worldwide are suffering from diabetes and approximately 60 million from that population are women who eventually are at reproductive age (15-49 years of age). In Indonesia, incidence of gestational diabetes mellitus is around 1.9-3.6% and the prevalence is around 1.9-3.65%. In addition to that, prenatal deaths from mothers who previously had gestational diabetes mellitus accounts for 3.5%. Thus, this study aims to investigate the relationship between maternal blood glucose level and newborn’s birth weight. This study is a quantitative study using cross sectional design. The population taken in this study was all pregnant women who attended Maternity Clinic of Medan Selayang District. From that population we assessed the total number of 51 people as our sample in which all were third trimester pregnant women who attended Maternity Clinic of Medan Selayang District from July to October 2014. Based on our study, we found that there is relationship between maternal blood glucose level and newborn’s birth weight (r = 0.569) and relationship between maternal weight gain and newborn’s birth weight ( r = 0.365). Meanwhile there isn’t any relationship appeared in gravidity status. The result obtained from using backward method showed r square 0.392, P value <0.05 and the most influential variable is maternal weight gain. Therefore, we suggest all health care providers to provide appropriate antenatal care in order to screen, control as well as manage the condition of gestational diabetes melitus. Keywords: blood glucose level, birth weight. Introduction Diabetes Mellitus (DM) is one of non communicable diseases, marked by the increase of blood glucose level due to insufficient insulin secretion or insulin resistency. Based on the recent report of IDF (International Diabetes Federation) in 2012, there were over 300 million people worldwide are suffering from diabetes and approximately 60 million from that population are women who eventually are at reproductive age (15-49 years of age). Insulin resistency usually begins in the middle of the pregnancy (20-24 weeks of gestation). Through facilitated diffusion on placental membrane in fetus circulation, there happens to be an abnormal energy source content that may contribute to later complications. In Indonesia, based on SulliavanMahan diagnosis criteria, it was reported that the prevalence of gestational diabetes mellitus is 1.9-3.65%. In case of individuals (pregnant women) who have familial history of diabetes mellitus, the prevalence is even increasing to 5.1 % and approximately 40 % of women that previously had gestational DM gave birth to overweight babies regardless the age of gestation and around 20-50% babies who were born from gestational DM mothers suffer from hypoglycemia (blood glucose < 30 mg/dl). Proportion of diabetes melitus in women who are actually at reproductive age is 3.6%, therefore firm strategies are needed in order to decrease the prevalence and prevent the case. Gestational diabetes mellitus will further lead to complications due to its efect on both metabolic and hormonal condition. The proportion of this type of disease accounts for 0.3-0.7%. Undetected or uncontrolled diabetes mellitus will not only danger the pregnancy but also the labor, therefore gestational DM is a life threatening condition for both mother and newborn. Babies who were born from mothers who previously had gestational diabetes mellitus will be more likely to suffer from type 2 diabetes mellitus. Aleida (2011) stated that gestational DM is a continous condition which means that it may happen to be persistent and women at reproductive age are more likely to develope that condition. Approximately 40-60% of women who had gestational diabetes mellitus develope diabetes or glucose intolerance afterwards. 77 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Gestational diabetes mellitus doesn’t only contribute to prenatal deaths but also prenatal morbidities. In addition to that, gestational DM also plays a role in increased ceasarean-section and higher risk of chronic hypertension for the mothers. Women who suffered from gestational DM are more likely to give birth to overweight babies, thus explaining why these women undergo ceasarean-section. Further more 20-50% of babies who were born from gestational diabetes mellitus mother suffer from hypoglycemia in the first 24 hours after birth. In the other hand, women who had diabetes mellitus prior to pregnancy are more likely to get more complicated pregnancy and labor, overweight babies, blood vessels narrowing and fetal death, babies with congenital defect at around 4.1%. In case of bad glycemic control through pregnancy, some other complications may appear, such as vascular complication which causes low birth weight, neurology defect (20%), hypoglycemia (2525%), hypomagnesemia, hyperbilirubinemia (20-25 %), neonatal asphyxia(25%) and neonatal acute respiratory distress syndrome (ARDS). A preliminary study that took place in Mahdarina Maternity Clinic in Medan Selayang District, assessing 7 pregnant women, showed a relationship between blood glucose level of third timester pregnancy women and newborn’s birth weight, r = 0.44. Based on that result, we are intrested in investigating the relationship between blood glucose level of pregnant women and newborn’s birth weight. The objective of this study is to investigate the relationship between maternal blood glucose level and newborn’s birth weight in Maternity Clinic of Medan Selayang District in 2014 by measuring several parameters, as well as to identify most influential factor that contributes to newborn’s birth weight. Therefore, we hypothesized that there is a relationship between blood glucose level of pregnant women and newborn’s birth weight. We expect that this study will provide additional information in order to increase health care by implementing early detection of the disease. Method This study was conducted by using cross sectional method in order to investigate 78 the relationship between maternal blood glucose level and newborn’s birth weight. This study took place in Maternity Clinic of Medan Selayang District from July to October 2014. The population of this study was all third trimester pregnant women that visited the Maternity Clinic of Medan Selayang District for medical check up through July till October 2014. Subjects are elligible when all the inclusion criteria can be fullfiled. Hence we determined several inclusion criteria as follows: 1. Third trimester pregnant women that has stated aggreement to this study 2. Pregnant women without any previously recorded complications, such as hypertension, heart diseases, pulmonary diseases and infection. We also determined the sample size by using this formula, n= 2 +3 (r = 0.44 and β = 0.1), thus the sample size became 51. In conducting this study we didn’t only use the secondary data but also the primary data. Primary data was obtained from direct interview with respondents using questionnaire instrument and venous blood was taken to measure the glucose level by using glucose meter. Blood sampling was only conducted after the respondents had been informed. Birth weight was measured directly at the first few minutes after birth. Instruments used during this study are as follows: 1. Questionnarie which assesses characteristics of respondents; age, age of current pregnancy, parity status, education level 2. Blood glucose measurement using glucose meter, alcohol swab, strip test, needle (lancet), and lancing device. 3. Baby scale We also applied several consecutive procedures as follows: A. Blood Sampling 1. Determining sample based on inclusion criteria. 2. Asking the agreement statement from the subjects through inform consent. 3. Assessing the questionnarie. 4. Instructing the participants to fast from 10 pm to 7 am next morning when blood Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 5. 6. 7. 8. 9. 10. 11. 12. sample will be taken. In this research, blood sampling procedure was conducted by standardized lab analysts and midwives. Preparing the patient. Applying tourniquet in the upper arm. Palpating the vein in which the blood will be taken. Applying the alcohol swab on the surface of the site. Using 3 ml syringe to take the blood, blood taken was 2 ml. Putting off the tourniquet. Transporting all blood sample to Health Laboratory of North Sumatra for blood glucose measurement. Colecting the result of the measurement. B. Weight gain was assessed from patient’s medical record. Patient is considered having weight gain when there is an increase of weight prior to delivery from weight recorded before pregnancy. Amount of gained weight was obtained by substracting weight prior to delivery from weight before pregnancy. C. Newborn’s birth weight was obtained from clinic’s documentation. All data were then analyzed using univariate, bivariate and multivariate analysis. Statistical analysis being used in this study was multiple linear regression. Results Table 1 Characteristics of patients at Maternity Clinic of Medan Selayang District 2014 Var. n Min Max Mea SD n Age 51 18 43 28.5 5.79 7 Blood 51 65 306 114. 44. Glucose 53 018 Parity 51 1 5 2 1 Weight Gain Birth Weight 51 7 21 51 2500 420 0 10.0 2 3123 .53 2.55 434. 20 Based on the above result, majority of pregnant women are around the healthy reproductive age. The avarage blood glucose level is mostly above normal (114.53 mg/dL). a. Bivariate Analysis After assessing both variables (blood glucose level and birth weight), we found that there is a significant positive relationship which means that the more the blood glucose level of a pregnant woman, the more likely she will give birth to overweight babies (r = 0.569). The result using correlation and regression mode showed that newborn’s birth weight is proportional to maternal blood glucose level (2480.471 + 5.615 (blood glucose)). Furthermore we also assessed the relationship of weight gain and newborn’s birth weight in which we found significant (r = 0.365 and r square = 0,33 with p < 0,05). We also found that newborn’s birth weight is not related to maternal parity status (r = 0.251, r square = 0.06, p = 0.76). b. Multivariate Analysis The regression equation that we obtained is “ Bith weight = 2085.106+5.133* blood glucose + 45.194* gained weight” which indicates that newborn’s birth weight is influenced by both maternal blood glucose level and gained weight during pregnancy. Discussion 1. Relationship between blood glucose level and newborn’s birth weight As seen in our study, there is a significant relationship between blood glucose level and newborn’s weight. This is in accordance with another study from Robert that stated that overweight babies are more likely to be born from mothers who previously had higher blood glucose level. This is also supported by Research group that found that there is a strong relationship between maternal blood glucose level and newborn’s weight. Another study by Vaishali et. al also supported this result in which higher maternal glucose level contributes to higher newborn’s birth weight. This study is in line with recent theory stating that there’s always been metabolic changes (hormones, glucose) which plays a role in supplying adequate nutrition for the fetus. Fetus gain glucose from maternal supply 79 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology through the placental membrane, thus fetal blood glucose level will represent maternal blood glucose level as well. The regulatory mechanism for glucose level is primarily done by insulin. When mother is not able to secrete adequate insulin to lower her high blood glucose level, the fetus will then compensate this by secreting more insulin which will also stimulate the growth of the fetus and later may lead to insulin insensitivity in the baby. 2. Relationship between maternal parity status and newborn’s birth weight Our study found that there is no relationship between maternal parity status and newborn’s birth weight. Through literature we found that the only difference between first and later pregnancy usually is felt as subjective feeling by mothers. Due to loosen endometrium, most women who are having the second pregnancy feel that their belly gets bigger much more quickly so that they feel that the babies are overweight or bigger than that in the first pregnancy (Murkoff et. al, 2006). 3. Relationship of maternal weight gain and newborn’s birth weight According to our study, there is a positive relationship between maternal weight gain and newborn’s birth weight. This result is in accordance with Shin Kim and team that found that only 5.6% normoweight women without DM that gave birth to overweight babies compared to 12.6% overweight/ obese women without DM that gave birth to overweight babies. Meanwhile in overweight/ obese women with DM the proportion is even increasing to 17.3%. Another study in Bunda Setia Maternity Clinic also found similar result that women who gained excessive weight during pregnancy are more likely to give birth to overweight babies (OR = 0.126). Normally maternal weight gain during pregnancy is approximately 9 to 13.5 kg (Mandriwati,2008). In second and third trimester, weight gain as many as 0.4 kg each week is considered normal in healthy women. In the other hand, women who are underweight or overweight are encouraged to gain 6 to 8 kg during second and third trimester or 9 to 11 kg respectively. 80 Another study showed that weight gain is positively correlated to newborn’s birth weight, p < 0.01, correlation strength: medium. Maternal weight is the result of addition of both maternal weight before pregnancy and weight during pregnancy. This serves as representation of maternal nutritional status prior to pregnancy. Maternal weight shows strong relationship to newborn’s birth weight in which underweight mothers are tend to give birth to underweight babies, while in the other hand, overweight mothers are more likely to give birth to overweight babies. Phaneendra et. al also mentioned that both excessive and insufficient weight gain during pregnancy can lead to serious problem for both mother and baby. Conclusion and Future Direction 1. There is a strong relationship between maternal blood glucose level and newborn’s birth weight (r = 0.569) in Maternity Clinic of Medan Selayang District 2014. 2. There is no relationship between parity and newborn’s birth weight in Maternity Clinic of Medan Selayang District 2014. 3. There is a relationship between maternal weight gain and newborn’s birth weight (r = 0.365) in Maternity Clinic of Medan Selayang District 2014. 4. Blood glucose level during pregnancy showed r square = 0.392 indicating that this variable is able to explain 39.2% variation in the dependet variable (newborn’s birth weight). 5. The most influential independent variable to newborn’s birth weight is maternal weight gain. Therefore, we suggest all health care providers to provide appropriate antenatal care in order to screen, control as well as manage the condition of gestational diabetes melitus. References Cunningham, F.Gary. 2007. Wliiam Obstetrics ed 22nd. Mc-GrawHill. Departemen Kesehatan R.I Laporan Hasil Riset Kesehatan Dasar (RISKEDAS) Indonesia Tahun 2007. 2008. Jakarta: Badan Penelitian dan Pengembangan Kesehatan. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Murkoff H, Einsberg A, Hathaway S,2006 Kehamilan, Medical Consultant.edisi 3, Jakarta : Arcan. IDF.Women and Diabetes, Internasional Diabetes.2012. [accsessed from http:// riskesdas.idf.org/women – anddiabetes. on 14th December 2012 Jurnal Kesehatan Reproduksi Vol.3. No.1.2012. Jakarta .Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan Republik Indonesia. Mansjoer, arif. 2000. Kapita selecta jilid 1. Jakarta : Media Aesculapius. Mochtar R, Sinopsis Obstetri Penyakit endokrin dalam Kehamilan Edisi 2.1998. Penerbit kedokteran. Prawirohardjo S, Buku acuan Nasional Pelayanan Kesehatan Maternal dan Neonatal. Yayasan Bina Pustaka 2000. Jakarta. JNPKR. Neil , Wendy R ,Perawatan Kehamilan, 2008 , penerbit Dian rakyat, Jakarta edisi ke 7. Sastroasmoro S,2011, Dasar – dasar Metodologi Penelitian Klinis, Sangung Seto Edisi ke 4. Accsessed from: http://www.blogdokter.net/2007/06/25/d iabetes-melitus-ii-pada-kehamilan/. Accsessed from: consumer.healthday.com on 26th October, Overweight Moms May Have Dangerously Big Babies, Excessive weight gain leads to serious problems for mothers and infants, study suggests IDF.Women and Diabetes, Internasional Diabetes.2012. [accsessed from http:// riskesdas.idf.org/women – anddiabetes. Diakses on 14th Desember 2012 Robert G , Denis , Pregnancy outcomes in women without gestational diabetes mellitus related to the maternal glucose level, Is there a continuum of risk? Diabetes carrier. Maternal Postprandial Blood Glucose Levels and It’s Relation with The Pregnancy Outcomes. Pregnancy Outcomes in Women Without Gestational Diabetes Mellitus Related to the Maternal Glucose Level Hyperglycaemia and Adverse Pregnancy Outcomes. 81 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology PHENOMENOLOGICAL STUDY ON PREGNANCY CARE EXPERIENCE IN MOTHERS AT JORONG BERASTAGI NAGARI UJUNG GADING, LEMBAH MELINTANG SUBDISTRICT, PASAMAN BARAT, WEST SUMATERA Nurul Azmi, Nur Afi Darti Abstract Pregnancy care is done during pregnancy which is more emphasized on the health of the mother. The objective of the study was to find out the experience in pregnancy care in mothers of Jorong Berastagi. The study was phenomenological qualitative with Colaizzi analysis. The samples were five mothers who had met the criteria, taken by using purposive sampling technique. The data were gathered by conducting in-depth interviews and field research. The result of the study showed that there were ten themes which described the characteristics of nursing care experiences in mothers pregnancy. The thematics categories included complaint during pregnancy, stimulus whitch causes the complaint, mothers response to the source for getting information about the fact that they had to accept about pregnancy, attempts to cope with complaint/pregnancy problem, the source of information to examine the pregnancy, any action for supporting health during the pregnancy which included medical and alternatives, the kinds of favored food during pregnancy, and activity during the third trimester of pregnancy, support which was obtained during pregnancy, and any culture which was believed during pregnancy. Since there was the deviation in pregnancy care in the study area, competent nurses were needed. In the implementation of holistic nursing care, nurses should give their respect to the local peoples cultural values so that the local people will easily accept modern medical science at Puskesmas in order to improve their health. Keywords : Experience, Pregnancy care, Phenomenology 1. Background Pregnancy is the most exciting and eagerly awaited every couple. Manuaba (2010), stating that the pregnancy is intrauterine fetal growth and development ranging from conception and ends until the delivery. Pregnancy lasts for about 10 months, or 9 calendar months, or 40 weeks, or 280 days (Bobak et al, 2005). Adaptation to the hormones of pregnancy is a result of pregnancy and mechanical stresses due to the growing uterus and other tissues. This adaptation of protecting a woman's normal physiological function, meet metabolic demands of pregnancy a woman's body, and provide for the needs for the development and growth of the fetus. (Medforth et al, 2011). The impact of the adaptation of pregnancy cause a sense of discomfort 82 during kehamlan like fatigue, frequent urination, nausea, vomiting, breast sensitive, prone to vaginal infections, decreased appetite, decreased muscle tone, lordosis, headache (Bobak et al, 2005). Prenatal care is very influential on the health and safety of the baby to be born. Women who regularly go to health care facilities for prenatal care will have good health and a healthy baby. While women who have poor health will be more susceptible cause of infant mortality. Quality antenatal care still needs to be improved continuously, because of the availability of referral facilities for high-risk cases can reduce maternal mortality (Sri, in 2013). Expectant mothers and maternity mortality is influenced by several factors: education, science, social, cultural, social, economic, geographical and environmental, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology mother Accessibility to health facilities as well as macro policies in the quality of health services. One of the factors that affect maternal mortality is the attitude and behavior of the mother during pregnancy itself and supported by the knowledge of the mother against her pregnancy. (Agustini, 2013). Indonesian society there is a traditional antenatal (Devy et al, (2011). Culture for the community an important thing, even among trusted and been a lifeline. Community jorongBrastagih, revealing some phenomena. In this ethnic culture phenomena in the experience of prenatal care , where pregnant women do pregnancy checks to artisan machination, even pregnant women already perform checks to midwives, but due to hereditary culture in this area, pregnant women still undergo the masseuse and also listen to messages from a masseuse in matters abstinence during a period of pregnancy. Ordering is also done so that the position of the fetus remains in place again, because the activity is believed to affect changes in maternal fetal position. But more about this culture is not yet known, so it is necessary to dig about the behavior of the public to know and dig Experience Pregnancy Care On Mothers in JorongBrastagihNagari Ujung Gadingsubdistrict Valley Crossing. 2. Research Methodology The research is a qualitative research with phenomenological approach, about Pregnancy Care Experience At Mothers in JorongBrastagih Ujung GadingsubdistrictNagari Valley Crossing. The inclusion criteria: 1) mothers Minang tribe, 2) Having a maximum of 5 years experience, 3) Willing to be a respondent to obtain richer information (rich information) as well as voluntary or not under pressure. The sample selection of this study through purposive sampling technique as much as 5 people having reached the saturation of data (Polit and Beck, 2008). Collecting data in this study conducted by the method of observation (passive participant observation) and in-depth interviews (depth interview).Data analysis method with approach Colaizzi (1978) in Polit en Beck, (2012). Member checking conducted by researchers to participants to validate the results of interviews and thematic results done during data analysis. 3. Results Ujung GadingNagari tribes divided into two parts, but the vast majority were ethnic MinangNagari as well as all residents of the Ivory UjuangMinang and indigenous people say that they use the custom also Minang. The end of the economic situation Nagari population was down to the middle of ivory, most of the population have jobs as farmers, farm employees and wirausaha.Tingkat education / graduate education in Nagari Ujung Gading most most elementary level as many as 11 264 inhabitants, as many as 13 051 inhabitants junior, Bachelor ( S1-S2) as many as 11 893, as many as 1,575 high school, kindergarten as many as 1,474 lives and Academy (D1-D3) 1,025 souls. The study involved five participants who have experience maximum prenatal care experience five years ago, the average age of the last child 5 years old, high school education background. All the participants are married and not working. 83 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 1. Categories and themes were obtained from all participants. No Themes 1. Complaints experienced during pregnancy Categories Do not want to eat and appetite Edema in legs Numbness in the feet Colds Dizziness dizzy view No appetite Nausea Body feels weak Pain in the nipple Myoma. 2. Stimulus that cause odor complaints The smell of cookingrice, chilifries, the smellmeatballsandmilk eat rice 3. Response to the acceptance of pregnancy the mother during Grumpyhusband pregnancy Lappingstomachwhile pregnant Wantto terminate the pregnancy Hate with pregnancy 4. Efforts to deal with complaints / problems of pregnancy Go to the midwife PHC Hospital Artisan buzz Alternative treatment Eating bark and areca 5. Sources of informationthat was obtainedforprenatal care Brother Family 6. Acquiredform of actionto knowingDJJ supporthealthcareduringpregnancyincludesmedicaland Knowing thedate of delivery alternative. Knowing thematernalandfetalhealth, ultrasound immunization obtainingvitamins Fixingthe position ofthe fetus relax the body Fetalhealth check Determining whentogive birth. 7. The preferred type of nutrition during pregnancy Milk milk bread Spicyfish curry Sourspicygoulash fried chicken CarrotsvegetablesandvegetableJipang steamedcakesusechili 8. Activities conducted in the third trimester of pregnancy Walk in the morning 9. Supportobtained duringprenatal careexperience Husband always concern availability husband Family and dear brother Husband helps her needs. Glad to neighbors Good socialization, Relationship with her husband, a good family Husband still mingingatkan to eat 10 Culturebelievedduring pregnancy During pregnancyshould not besitting behindthe Do not sitin front of thedoor 84 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 4. Conclusions and Recommendations Research results obtained from the fifth respondents about pregnancy care community in Jorong Brastagi found that this community has a cultural concept about prenatal care, and there are some cultural practices conducted for pregnancy care. The concept is in the form of complaints during pregnancy, the stimulus that causes the complaint, the response to pregnancy, tackling complaints of pregnancy, resources obtained for prenatal care, acquired form of action to support health care during pregnancy, type of preferred food during pregnancy, the activities conducted the third trimester of pregnancy, the support obtained during prenatal care and culture believed during pregnancy. do an alternative massage. Prenatal care is commonly done by mothers in JorongBrastagih is setting activities, alternative massage to improve the position of the fetus, the choice of food, and gained support during pregnancy. Women's health problems are increasingly complex and require a comprehensive settlement requires competent management nurses in the field. So in an effort to implementation of holistic nursing care nurses should respect the cultural values of society. Thus the public will be more receptive to modern science and by itself would make the decision to utilize health services at the health center which is expected to improve the health of local communities The cultural practice carried out during pregnancy that consume traditional foods, and 85 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology MAPPING THE RISK FACTOR OF LEPTOSPIROSIS IN KLATEN DISTRICT Nelson Tanjung1, Desy Ari Apsari2, Erba Kalto Manik3 1,2,3 Health Polytechnic, Ministry of Health, Medan, Evironmental Health Department email : [email protected] Background: Leptospirosis is a zoonotic, that occurs in many part of the world, most countries in Southeast Asia declared as endemic areas of leptospirosis. Indonesia is a country with high case fatality rate of leptospirosis reaching 7.1%, with a range between 2.5 - 16, 45%, in patients aged over 50 years the mortality rate can reach 56%. Klaten district includes one of the distribution of leptospirosis. Data in 2008 showed that 21 were positively infected by leptospires of 66 people under investigation. In 2010 there were 5 deaths from 15 cases were found. Cases continue to rise in 2011 and expanded in several villages and districts, especially areas that are near the area of rice fields and streams. Knowing distribution maps the risk factor of leptospirosis in Klaten. Methods: An observational study design with a combination of ecological and case-control study. Implemented in Klaten in 2011. Subjects were residents who are leptospirosis diagnosed or infected with Leptospira. Diagnosis is confirmed by a doctor based on clinical criteria of WHO-1982 and/or diagnostic test equipment (leptotec and/or MAT). Samples were taken of 210 people consisting of 105 cases and 105 controls. Analysis of data used is average nearest neighbor, Mc. Nemar and conditional logistic regression (CI: 95%). Results: The mapping distribution of leptospirosis in Klaten is clustered at coordinates 454 230, 9.15211 zone 49S, a radius of 423.86 meters. Mapping of risk factors in areas with poor sanitation. Risk factors showed that house sanitation (OR = 7.89, 95% CI: 2.68 to 23.21, p = 0.000), employment (OR = 3.77, 95% CI: 1.49 to 9 , 54, p = 0.005) and the presence of mice (OR = 3.58, 95% CI: 1.35 to 9.49, p = 0.010). Conclusion: Characteristics of cluster formation region is close to the rice field area, a densely populated residential houses at a distance close enough/meetings (less than 20 meters). The most dominant risk factor is a house sanitation. Key words: Mapping, risk factors, leptospirosis Leptospirosis including zoonoses that occur throughout the world, especially in the tropics and subtropis1. Most countries in Southeast Asia expressed as leptospirosis2 endemic areas. Leptospirosis incidence worldwide is difficult to know exactly, because the disease is often under diagnosed. Mild cases are often not diagnosed as leptospirosis. World Health Organization (WHO) noted that the incidence in temperate regions ranged between 0.1-1/ 100,000 population per year, whereas in the humid tropics tend to be higher at 10-100 / 100,000 population per year. During an outbreak in a high risk group the incidence can reach >100/100,000 penduduk3,4. Reports Leptospirosis Society (ILS), states that in 1999-2000 the outbreak of leptospirosis occur several countries, namely in India, Thailand, France, USA, Brazil, Uruguay, Indonesia and several other countries. In fact, the 2000 data mentioned 86 case fatality rate (CFR) in Indonesia (16.7%) ranks third in the world after Uruguay (100%) and India (21%)5. On average CFR leptospirosis in Indonesia is quite high at 7.1%, with a range between 2.5 to 16.45%. In fact, in patients aged over 50 years the mortality rate can reach 56%. Leptospirosis in Indonesia in the last 6 years (2004-2010) tends to increase, as a result of the increase in cases in several areas that are often flooded, especially in Jakarta and Central Java. It was reported that in 2007 the number of cases reached 666 with 57 deaths in 2008 fell to 263 cases with 16 deaths. Regional distribution of leptospirosis in Indonesia, West Java, Central Java, Yogyakarta, Lampung, South Sumatra, Bengkulu, Riau, West Sumatra, North Sumatra, Bali, West Nusa Tenggara, South Sulawesi, North Sulawesi, East Kalimantan and West Kalimantan. Recorded outbreaks in Indonesia occurred in Riau (1986), Jakarta (2002) (138 specimens Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology obtained with 44.2% positive), Bekasi (2002), and Semarang (2003)6.7. Leptospirosis disease was first discovered in the district of Klaten in 2005 were 3 cases. Based on the incident Klaten District Health Office carry out screening. Screening results indicate that 21 people tested positive for leptospira infection of 66 people were examined. Leptospirosis re-emerged in 2008 in the Northern District of Klaten. In 2010 there were 5 deaths of 15 cases were found. Until 2011 leptospirosis in Klaten district continues to increase8. The problems is disease already widespread in several villages and districts, especially areas that are close to the rice fields and streams. The rainy season, housing and environmental sanitation conditions where rats around the residence is thought to be the cause of the increase in cases. Mapping the incidence of leptospirosis is one attempt to obtain location information accurately mapping the spread of leptospirosis following risk factors. Reseach Methods This observational study design was used with a combination of ecological studies case control study, to study the distribution pattern and risk factors for leptospirosis in Klaten District. The variables studied were individual characteristics (income, occupation and education), and environmental (density residential, home sanitation, where rats and location of the cage). Subjects were people who were diagnosed with leptospirosis either found in hospitals and in the community survey results, confirmed by a doctor's diagnosis based on clinical criteria set by the WHO (1982) and or diagnostic test equipment (leptotek and or MAT). Sampling was done by purposive sampling. Spatial analysis is used to view the distribution pattern of leptospirosis. Results and Discussion 1. Mapping analysis of leptospirosis Results of the analysis showed that the average nearest neighbor nearest neighbor index (nearest neighbor ratio) from the point of the case was 0.7 (<1), the value of Z score : - 5.84 and p-value of 0.01, thus it can be said distribution pattern of leptospirosis in the district of Klaten is clustered distribution (clustered), as shown in Figure 1. Figure 1. Analysis of Leptospirosis Risk Factors in the district of Klaten April 2009 - August 2011 Regional grouping use cases seen Purely Spatial analysis Bernoulli model. Results of the analysis as shown in Figure 2 shows a grouping in the form most likely cluster centered at coordinates 454 230, 9.15211 UTM zone 49S, a radius of 423.86 meters and a p-value of 0.017, in the village of the District Senden Ngawen. Two secondary cluster, centered on the coordinates 470 031, 9.15427 UTM zone 49S, a radius of 102.59 meters and a p-value of 0.017, in the village of the District Kenaiban Juwiring. District of Karangdowo Karangjoho village centered on the coordinates 474 406, 9.1474 UTM zone 49S, a radius of 107.17 meters and p-value of 0.017. 87 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Figure 2. Clustered of Leptospirosis Grouping of leptospirosis cases that occurred in the Klaten district shows that the potential transmission of leptospirosis to the people who live in areas where clusters (most likely cluster and cluster secodary) are likely to be greater when compared to people living in other areas outside the clusters. Characteristics of cluster formation region (most likely cluster and cluster secodary) in general is an area with a high population density, the majority of the population worked as farmers or agricultural laborers and the distance between the houses are very close. Results indicate that the buffer in the case of point clusters of cases at the primary and secondary clusters tend to cluster in a radius of 15 m - 30 m (Fig 3). Leptospirosis cases are more common in residential areas with fairly high density of buildings, thus environmental conditions are very favorable for mice. Homes are fairly close distance rat facilitate moving from one house to another either for nesting and foraging. Results of research on leptospirosis transmission occurring in urban areas in Salvador, Brazil showed that leptospirosis transmission tends to occur in poor residential areas with fairly dense residential neighborhood poor sanitary conditions9. Similarly, the results of research conducted in São Paulo Southeastern Brazil, 88 stated that the increase in cases of leptospirosis occurs largely in the poor, who live in dense residential area and dirty10. WHO states that the environment is very dense slum is one of the risk factors of leptospirosis11. Figure 3. Buffer in Rice Fields Most Likely and Secondary Clustered Buffer in rice fields showed that 62.96% of cases of leptospirosis in the primary and secondary clusters tend to cluster in a radius of 15 m - 50 m from the edge of the fields, as shown in Figure 4. Based on Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology observations in the field looks a lot holes around the rice field which is a nesting and breeding place for rats. Habits make holes around the rice fields aims to nurture their children, besides mice will also make a hole in the dike irrigation to reside. Availability of rice can be used as indicators of an increase in the rat population, because this environment is a suitable habitat for the development of rat12. Sehgal research on leptospirosis epidemiological patterns, noted that leptospirosis is often seen in rural agricultural areas in some South and Southeast Asian countries including India's rural peninsula, Northeast Thailand, southern China and the Philippines. In which case the peak usually occurs in the growing season and the harvest season13. Results of multiple ring buffer against local roads or districts showed 44% of cases of leptospirosis stay at a radius of 15-50 m from local road / districts, but almost all of the cases live quite close to the road environment.. However results observations showed that 50.5% of cases stayed in a radius of <50 m of sewerage, most of these facilities are open sewerage. Sunaryo research on factors that affect the mapping and leptospirosis, stating that the spread of leptospirosis cases that form cluster in Semarang due to the environmental risk factors that slum with waste water disposal system which poor 14. Reis in an environmental impact study to Leptospira infection in slum dwellings mention that the house is located close to the sewerage open (<20 m) greater risk of Leptospira infection (PR = 1.42, 95% CI: 1, 14 to 1.75) 15. Bovet in the study also stated that the occurrence of leptospirosis in humans because of their interaction with the environment one of which is the physical environment associated with the state of the waste water ways16. Buffer river showed that 28.57% of the cases live in a radius of ≤ 50 m from the river. Nardone stated that the residence location adjacent to the river (ORMH = 3.0, 95% CI: 1, 6 to 5.6) is a risk factor associated with the incidence of leptospirosis. but in this study the proportion of cases who live very close to the river <30%, so it can be concluded that the risk factors for transmission of leptospirosis is not dominated by residential location close to river17. These results are similar to studies Sugunan which states that one of the risk factors for leptospirosis outbreak was soaking in water (OR = 3.23, 95% CI: 1.47 to 7.21), whereas one of the risk factors that could potentially cause acute leptospirosis is to make the river as a source of drinking water (OR = 4.4, 95% CI: 1.1 to 18.0)2. Visualization using satellite images on the Google Earth shows that the geography of the spread of leptospirosis tend to be similar among closely to the area of rice fields, settlements densely populated with houses close enough distance/conference (less than 20 meters). Primary cluster distribution region that is located in the village of the District Senden Ngawen and secondary clusters located in the village of the District Karangjoho Karangdowo and Village Kenaiban District of Juwiring, as shown in Figure 5. Figure 4. Buffer Rice Field in Most Likely Cluster 89 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Figure 5. Maps The Spread of Leptospirosis 2. Analysis of risk factors for leptospirosis Bivariable analysis aims to determine the relationship of each variable that is suspected as a risk factor to the incidence of leptospirosis. Mc.Nemar test results at 95% confidence level can be seen in Table 1. Table 1. Analysis Bivariable for Risk Factor of Leptospirosis Case Control OR Exp Unexp Income Low 33 43 Standart 13 16 Employment Exposure 21 43 Unexposure9 32 Educations Low 44 31 High 13 17 Density Exposure 2 9 Unexposure2 92 House sanitation Poor 43 54 Good 4 4 Present of rodents Exposure 7 42 Unexposure6 50 Cattle pen position < 50 mtr 29 44 ≥ 50 mtr 18 14 90 95%CI p 3,30 1,74-6,70 0,00* 4,78 2,29-11,14 0,00* 2,38 1,21-4,97 0,00* 4,5 0,93-42,79 0,03* 13,5 4,98-51,33 0,00 7 2,96-20,15 0,00* 2,44 1,38-4,49 0,00* The analysis showed that the income (OR = 3.30, 95% CI: 1.74 to 6.70, p; 0,00) is a risk factor for leptospirosis cases in the district of Klaten. This means that people who are included in the category of low-income or below the minimum wage (<Rp. 766 022) tend to be more likely to be exposed to leptospirosis. Data showed 58.10% and 72.38% of cases the respondents have incomes below the minimum wage (UMR). Okatini research that reveals that the individual characteristics such as socioeconomic level is a risk factor for the incidence of leptospirosis in Jakarta (OR = 1.93, 95% CI: 1.073 to 3.462, p: 0.039)18. Other studies have shown a positive correlation between individual characteristics, namely economic levels with the incidence of leptospirosis. Stated that the increase in cases mostly occur in poor people who live in the slums, inadequate sanitation conditions mentioned as a source of transmission of leptospirosis. Economic level low enough to trigger allegedly poor sanitation in the area 10. Employment (OR = 4.78, 95% CI: 2.29 to 11.14, p: 0.00), this means that people in occupations potentially comes in contact with the source of contaminants, (eg: farmers / farm workers, ranchers, ornamental fish sellers, abattoir workers, scavengers or other jobs that are associated with water and or sources of contaminants) are most likely to be exposed to leptospirosis. In accordance with Murtiningsih research that says that work as a Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology farmer (OR = 4.09, 95% CI: 1.18 to 14.12, p: 0.025) were risk factors for leptospirosis in Yogyakarta19. Sarkar also said that exposure to sources of contaminants in the workplace increases the risk of leptospirosis 20. Level of education (OR = 2.38, 95% CI: 1.21 to 4.97, p: 0.00) indicates that pertained education leptospirosis risk factors in Klaten District. Factors person's educational background is often associated with the type of work that ultimately have an impact on earnings. Someone who has a higher level of education are more likely to get a good job, a good income with standard anyway. Thus it would affect the quality of life. Research Okatini mentioned that the level of education (OR = 3.74, 95% CI: 1.72 to 8.21) were risk factors leptospirosis18. Residential density is a risk factor for leptospirosis (OR = 4.5, 95% CI: 0.93 to 42.79, p: 0,03). Residential density often associated with the arrangement of the house. If the house irregular arrangement will create places that can be used as a rat's nest, as well as the waste generated, it can be used as a source of food for rodents. Sanitary house seen in this study is based on several components of basic sanitation among waste management, waste water disposal, building construction, type of floor and rat proofing conditions. The results showed that 92.38% of cases of leptospirosis in the district of Klaten live in houses with poor sanitation. Hand and Ristiyanto in the research stated that hygiene / sanitation home (PR = 3.75, 95% CI: 1.28 to 10.16, p = 0.010) were risk factors for leptospirosis in Demak. The low quality of such services can be caused due to the handling of poor waste management21. The existence of rats (OR = 7, 95% CI: 2.96 to 20.15, p = 0.00) and the location of the enclosure (OR = 2.44, 95% CI: 1.38 to 4.49, p = 0.00), so it can be said that the exposure of these two factors can increase the risk of leptospirosis. The results showed that 97.14% of the cases seen rats around her house and 46.66% of them stated often see rats in the house (> 3 times/week). Similarly, the location of the enclosure which showed that 45.71% of cases put the cage together with a dwelling (0 meters from the house), while 28.81% making cattle pen in a radius <50 meters from the house. Results of multivariable analysis using logistic regression conditional test showed that the risk factors that have a relationship with the incidence of leptospirosis in Klaten district in order are sanitary housing (OR = 7.89, 95% CI: 2.68 to 23.21, p = 0.000), work (OR = 3.77, 95% CI: 1.49 to 9.54, p = 0.005) and the presence of rats (OR = 3.58, 95% CI: 1.35 to 9.49, p = 0.01) , The analysis also showed that 47.28% incidence of leptospirosis in Klaten district affected by their exposure to the three risk factors at the same time, as tampat in Table 2. Table 2. Multivariable Analysis of Risk Factors incidence of leptospirosis Variabel OR 95%CI p Pseudo Log R2 Li.hood House 7,89 2,680,000 sanitations 23,21 Employme 3,77 1,49-9,54 0,005 0,47 nt Present of 3,58 1,35-9,49 0,010 rodents -37,038 These results are consistent with research Sarkar in Salvador Brazil, which mentions the incidence of leptospirosis due to sanitary conditions poor housing as the collection of garbage, close to open sewers and the presence tikus20. Reis also mentions that Lepospira infections caused by environmental exposure associated with housing, work environment and a sign of the presence of rats 15. 3. Model spatial relationships Model of spatial relationships is the visualization of the distribution of risk factors that have an association with leptospirosis, the results of multivariable analysis consisted of sanitation home, work and the presence of rats. visualization of the distribution of three risk factors shows that the distribution of leptospirosis in the district of Klaten more are in areas with higher levels of residential density. 56.19% of cases spread in the area of an average residential density > 3.475 per home (Figure 6). 91 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Figure 6. Spread Mapping of Risk Factor Results overlay exposure to risk factors in cases of leptospirosis showed that 60% of cases of leptospirosis exposed by one or more of these three risk factors, while 40% of them are exposed to other risk factors outside the model. The frequency distribution of the combination of exposure to risk factors for leptospirosis in Klaten district can be seen in Table 3. Table 3. Exposure Risk Factors incidence of leptospirosis Exposure Risk Factors House sanitations Employment Present of rodents House sanitation and employment House sanitation and present of rodents House sanitation, employment and present of rodents Risk factors outside the model Cases N 23 11 5 16 5 % 21,90 10,48 4,76 15,24 4,76 3 2,86 42 40 Data in the table showed the dominant exposure of risk factors of the case are as much as 21.90% of sanitary home and work as much as 10.48%. Exposure to a combination of two risk factors showed 15.24% of cases of exposure to risk factors for home sanitation and jobs, 4.76% of cases of exposure to risk factors for the presence of rats and sanitary home. As for exposure to the combination of 92 three risk factors shows the proportion of 2.86%. Furthermore, 40% of whom leptospirosis cases are caused by exposure to other risk factors, among which are equally harmful activity contact with sources of contaminants and environmental factors. The results showed 82.9% of cases have a habit of activities related to the sources of contaminants in this water, including fishing, swimming or bathing cattle in the river, as well as looking eel, grazing and herding cattle in the fields. The data also showed that 69.5% of the cases are still found which build cattle sheds with a distance <50 meters from the main house and even some of them put the cage of the roof to the main house. On the other hand still found 82.9% of cases have a habit of activities related to the sources of contaminants in this water. Among the activities of fishing, swimming or bathing cattle in the river, as well as looking eel, grazing and herding cattle in the fields. This fact further strengthens the principle that the onset of disease epidemiology is needed more than one cause (multiple causation) 22. Conclusion 1. Distribution of leptospirosis cases in the district of Klaten is clustered. 2. The incidence of leptospirosis in the district of Klaten scattered in a radius of 15-30 meters in the surrounding rice paddies, 30- Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 50 meters around the local / district and less than 50 meters around the river. 3. Employment associated with the incidence of leptospirosis in Klaten District. Work as farmers / farm workers as well as work that allows a person exposed to contaminated water rat urine will increase the risk of transmission of leptospirosis. 4. The environmental conditions of housing and sanitary housing that is associated with the presence of rat leptospirosis cases in the district of Klaten. House poor sanitation and the number of mice around the house increases the risk of transmission of leptospirosis. 5. The mapping of leptospirosis in Klaten district associated with environmental factors. Home sanitary risk factors, the presence of rats and residential density is a risk factor dominant in the cluster area leptospirosis. Recommendations A. Klaten District Health Office through health centers seek to increase community participation in the control of risk factors for leptospirosis in both cluster and noncluster areas are: a. preferably in the cluster area activities: 1. motivate people to perform regular mutual cooperation to improve environmental sanitation housing 2. dissemination of the importance of using personal protective equipment when working, especially on jobs at risk Leptospira 3. encourage people to re-harness trap (mousetrap) in an effort to reduce pupolasi rats around the residence. b. preferably non-cluster region on activities: 1. The socialization of a clean and healthy lifestyle that focused on personal hygiene in an effort to prevent the occurrence of Leptospira infection, especially in those who frequently perform outside activities 2. Dissemination of the importance of using personal protective equipment when working, especially on jobs at risk Spira B. Klaten District Health Office should improve coordination with health centers in the implementation of leptospirosis surveillance and monitoring system of mice, primarily in regions or clusters and dense residential area and close to the area of agriculture (rice) and rivers. C. It needs further research to determine the level of endemicity or level of vulnerability to the spread of leptospirosis in the region of Klaten District. Reference 1. Gompf,S.G., & Velez,A.P, Leptospirosis. Medscape Reference, Retrieved from http://emedicine.medscape.com/article/22 0563-overview (2008). 2. Sugunan AP, Vijayachari P, Sharma S, Subarna R, Manikam P, Natarajaseenivasan K, Gupte MD, Sehgal, S.C, Risk Factor Associated With Leptospirosis During Outbreak in Middle Andaman, India, India J. Med Res 130, 67-73 (2009). 3. Widoyono, Penyakit Tropis, Epidemiologi, Penularan, Pencegahan dan Pemberantasan, Penerbit Erlangga, Surabaya(2005). 4. Ernawati Kholis, Leptospirosis As well as the Post-Flood Disease Prevention Method, Kedokteran Widya No. 274, F.K Universitas YARSI, Jakarta. www.jurnal.pdii.lipi.go.id,(2008). 5. ILS, ILS Worldwide Survei 1998, 1999, 2000, http://www.leptospirosis.org (2001). 6. Departemen Kesehatan, Pedoman Diagnosa dan Penatalaksanaan Kasus Penanggulangan Leptopsirosis di Indonesia, Dirjen PPM&PL, SubDit Zoonosiz, Jakarta, (2008). 7. Maciel, E. A. P., Carvalho, A. L. F. D., Nascimento, S. F., Matos, R. B. D., & L, E., Household Transmission of Leptospira Infection in Urban Slum Communities. Plos Neglected Trop. Dis., 2(1), 1-6. doi: 10.1371/journal.pntd.0000154 (2008). 8. Soares, T. S. M., , Maria do Rosario Dias de, O. L., & Laporta, G. Z., Spatial and seasonal analysis on leptospirosis in the municipality of São Paulo , Southeastern Brazil , 1998 to 2006. Rev Saude Publica, 44(2), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/203 39627 (2010). 9. WHO, Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group, Genewa, (2010). 10.Syamsuddin, Tingkah Laku Tikus dan Pengendaliannya, Balai Penelitian 93 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Tanaman Serealia, Maros, tersedia http://www.peipfi-komdasulsel.org/wpcontent/uploads/2010/06/28 (2007). 11. Sehgal, S. C., Sugunan, A. P., & Yachari, P. V. Outbreak of Leptospirosis After the Cyclone in Orisaa. The Natl. Med. J. of India, I(1), 22-23 (2002). 12.Sunaryo, Geographic Information System for the Determination Zone Mapping and Vulnerability Leptospirosis in Semarang, Loka Penelitian dan Pengembangan (P2B2), Banjarnegara (2009). 13. Reis, R. B., Ribeiro, G. S., Felzemburgh, R. D. M., Santana, F. S., Santos, C., Ravines, R. R., et al. Impact of Environment and Social Gradient on Leptospira Infection in Urban Slums. Control, 2(4), 11-18. doi: 10.1371/journal.pntd.0000228 (2008). 14. Bovet, P., Yersin, C., Merien, F., Davis, E., & Perolat, P. Factor Associated with Clinical Leptospirosis; a Populationbased Case-control Study in The Seychelles (India Ocean), Int. J. Epidemiol., p.583 – 590 (1999). 15. Nardone, A., Capek, I., Baranton, G., Campèse, C., Postic, D., Vaillant, V., et al. Risk factors for leptospirosis in metropolitan France: results of a national case-control study, 1999-2000. Clin. Infectious Dis, Washington D.C., America, 39(5), 751-3. doi: 10.1086/423272 (2004). 94 16. Okatini, M, Purwana R, Djaja IM, Relations Environmental Factors and Individual Characteristics Against Leptospirosis disease incidence in Jakarta, Makara, Kesehatan, Vol 11,(1)17 – 24 (2007). 17.Murtiningsih B, S. Budiharta, S Supardi, Risk Factor of Leptospirosis in Yogyakarta dan Sekitarnya, Berita Kesehatan Masyarakat, Universitas Gadjah Mada, Yogyakarta, Tahun XXI (1),17 -24 (2003). 18.Sarkar, U., Nascimento, S. F., Barbosa, R., Martin, R., Nuevo, H., Kalafanos, I., et al. Population-Based Case-Control Invetigation of Risk Factors for Leptospirosis During an Urban Epidemic. Am. J. Trop. Med. Hyg, 66(5), 605-610. Retrieved from http://www.ajtmh.org/content/66/5/605. (2002). 19. Handayani F.D., Ristiyanto, Distribution and Environmental Risk Factors Transmission of leptospirosis in Demak District, Media Litbang Kesehatan Volume XVIII no.4 (2008). 20.Timmreck, Thomas, Pengantar Epidemiologi, Edisi 2, Alih bahasa, Munaya Fauzia (et.al), Editor penterjemah : Palupi Widyastuti, Penerbit Buku Kedokteran, EGC, Jakarta (2005). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology DESCRIPTION OF KNOWLEDGE OF HIV/AIDS BY THE ELEVENTH YEAR STUDENT OF SMAN 1 KUTALIMBARU DELI SERDANG DISTRICT 2014 Netty Panjaitan, Surita Br Ginting Department of Nursing, Poltekkes Medan ABSTRACT This study is descriptive research by cross sectional design it is aimed to know the description of students knowledge of the eleventh grade of SMA (Senior High School) of HIV/AIDS. Independent variables are ages, gender and source of information which dependent variables are of students knowledge of the eleventh grade of SMA (Senior High School). The sample of this research is about 38 students. The result shows that good knowledge is about 16 students (42,1%), fair knowledge is about 13 students (34,2%) and lack of knowledge is 9 students (23,7%). Due to this research the respondents’ knowledge of HIV/AIDS commonly is good but it is hoped that students especially the eleventh grade of SMA (Senior High School) sustain and increase their understanding of HIV/AIDS in order they are out of HIV/AIDS infection earlier.. Keywords : knowledge, immune deficiency, HIV/AIDS References : 13 sources 1. The background Human immunodeficiency virus infection and acquired immune and deficiency (HIV/AIDS) are spectrum of conditions caused by infection with the Human immunodeficiency virus (HIV). Following initial infection, a person may experience a brief period of influenza- like illness. This is typically followed by a prolonged period without symptom. As the infection progresses, it interferes more and more with immune system, making person much more susceptible to common infections like tuberculosis, as well as opportunistic infection and tumors that do not usually affect people who have working immune system. Human Immunodefisiency Virus is transmitted primarily via unprotected sexual intercourse (including anal and oral sex), contaminated blood transfusions , hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding. There is no cure or vaccine. A disease outbreak which is a present over a large in the world and is actively spreading.. There are many misconception about HIV/AIDS, need health education Since its discovery, AIDS has caused an estimated 36 million deaths worldwide as of 2012.And in 2013 it resulted in about 1.34 million deaths. As of 2012 approximately 35.3 million people are living with HIV globally. The recording which has been held by World Health Organization (WHO) in the last few years show that the teenagers group which are very susceptible to HIV/AIDS. Uncommon situation of HIV/AIDS also occurred in North Sumatra, In the year of 2012, the amount of HIV case in North Sumatra were 3.573 cases. The highest case was dominated by the productive age of 20-29 years (47,8%), followed by the ages of 30-39 years (30,9%), and the group of ages 40-49 years (9,1%). Of this amount, 4.250 cases or 18,7% were dead.. Knowing that incubation period of HIV/AIDS which is taken a long time, it is about 5-10 years, it can be realized that the group ages of , 15-19 years has been infected by HIV/AIDS , they are about teenagers (Indonesia Health Profile, 2012 2. The significance of the study The significances of this study are generally as additional input and information to know the teenagers knowledge of HIV/AIDS so that it can be proposed to have service to the teenagers to realize the danger of HIV/AIDS earlier. 95 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 3. Research Method This study is descriptive which object is to know the description of the eleventh year student of SMA N 1 Kutalimbaru Deli Serdang District knowledge of HIV/AIDS. The design applied is cross sectional at the same time. 4. The method of collecting data Data collection which has been done in this study is by delivering the questioners , first the researcher introduced herself and explain the objective of the study, provide a letter of agreement as a respondent and give the questioner which should be filled by respondents and returned back to the researchers. From this research which entitled “Description Of Knowledge Of HIV/AIDS By The Eleventh Year Student Of SMAN 1 Kutalimbaru Deli Serdang District found which has been analyzed and presented in the following table: Table 4.1 Distribution Of Respondent’s Frequency Based On Age In SMAN 1 Kutalimbaru Deli Serdang District 2014 Age Frequence Percent (%) < 17 17 44,7 ≥17 21 55,3 TOTAL 38 100 Table 4.3 Distribution of Respondents Based On Source Of Information (SOI) In SMAN 1 Kutalimbaru Deli Serdang District 2014 SOI Electr.Media Print Media Medical staffs TOTAL male 13 34,2 female 25 65,8 TOTAL 38 100 From table 4.2 can be seen that total respondent who are male are 13 students (34,2%), female are 25 students (65,8%). 96 Percent %) 15,8 26,3 57,9 100 From table 4.3 it can be seen that total respondent who get information from electronic media are 6 students (15,8%) , print media are 10 students (26,3%) and medical staffs are 22 (57,9%). Table 4.4 Distribution Respondent Frequency Based On Knowledge In SMAN 1 Kutalimbaru Deli Serdang District 2014 Knowledge Frequency Percent(%) Good 16 42,1 Fair 13 34,2 Poor 9 23,7 TOTAL 38 100 From table 4.4 can be seen that respondent total who have good knowledge are 16 students (42,1%), fair knowledge are 13 students (34,2%) and poor of knowledge are 9 students (23,7%). From table 4.1 it can be seen that the total respondents which ages <17 years are 17 students (44,7%) and ≥17 years are 21 students (55,3%). Table 4.2 Distribution Of Respondents’ Frequency Due To Gender In SMAN 1 Kutalimbaru Deli Serdang District 2014 Gender Frequency Percent (%) Frequency 6 10 22 38 Table 4.5 Distribution of Frequency of Respondent knowledge about HIV/AIDS based on age in SMAN 1 Kutalimbaru, Deli Serdang District 2014 Ag e Knowledge Good F (%) <17 7 7,9 ≥17 9 23,7 To tal 16 42,1 Fair F 6 7 13 (%) 15,8 18,4 34,2 Poor F 4 5 9 (%) 10,5 13,2 23,7 To t a(%) l 17 21 38 44,7 55,3 100 From table 4.5 it can be seen that respondent the age of <17 years found good knowledge are 7 students (18,5%), fair knowledge are 6 students (15,8%) and poor knowledge 4 students (10,5%). While at the age of ≥17 years found good knowledge are 9 students (23,7%), fair knowledge are 7 students (18,4) and poor knowledge 5 students(13,2%). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 4.6 Distribution Of Frequency Of Respondents Knowledge About HIV/AIDS Based On Gender In SMAN 1 Kutalimbaru, Deli Serdang District 2014 Gen der Knowledge Good Fair Tot % Tot 2 5,3 5 Ma le Fe ma 14 le To tal 16 % 13,2 To tal (%) Poor Tot % 6 15,8 13 34,2 36,8 8 21,1 3 7,9 25 65,8 42,1 13 34,2 9 23,7 38 100 From table 4.6 it can be seen that respondent total can be seen respondent total of male found who have good knowledge are 2 students (5,3%), fair knowledge are 5 students (13,2%) and poor knowledge are 6 students (15,8%). While female found 14 students (36,8%) good knowledge, 8 students (21,1%) fair knowledge and 3 students (7,9%) poor knowledge. Table 4.7 Distribution Of Frequency Of Respondent Knowledge About HIV/AIDS Based On Information Sources In SMAN 1 Kutalimbaru, Deli Serdang District 2014 In For ma Tion Sour ces Electronic Me dia Print Me dia Medical Staffs TO TAL Knowledge Good Fair Jlh % J lh 2 5,3 1 3 7,9 11 16 (%) % Poor Jl h % To tal 6 2,6 15,8 3 1 7,9 2,6 6 10 15,8 26,3 28,9 6 15,8 5 13,2 22 57,9 42,1 13 34,2 9 23,7 38 100 From table 4.7 it can be seen that total respondent who have information of HIV/AIDS electronic media found good knowledge are 2 students (5,3%), fair knowledge is 1 student (2,6%) and poor knowledge are 3 students (7,9%). While those who have information of HIV/AIDS from print media found good knowledge are 3 students (7,9%), fair knowledge are 6 students (15,8%) and poor knowledge is 1 student (2,6%). Then those who have information of HIV/AIDS from medical staffs found good knowledge are 11 students (28,9%), have berpfair knowledge are 6 students (15,8%) and poor knowledge are 5 students (13,2%). 5. Discussion 5.1.Respondents of the age <17 years found have good knowledge about 7 students (18,4%), fair knowledge 6 students (15,8%) and lack of knowledge 4 students (10,5%). While the ages of ≥17 years found good knowledge 9 students (23,7%), fair knowledge is 7 students (18,4) and lack of knowledge 5 students (15,2%). Age causes the character, at the age of above 17 years known as adult age which the ability and the way of thinking in learning, understanding and receiving the change easily, so it influences the knowledge. This findings are relevant Notoatmodjo’s idea. 5.2. Respondents as male found 2 students (5,3%) they have good knowledge, having fair knowledge about 5 students (13,2%) and lack of knowledge is about 6 students (15,8%). While female found 14 students (36,8%) have good knowledge, 8 students (21,1%) fair knowledge 3 students (7,9%).Of the result of interview the researchers found the female knowledge is better than the male because female feel willing to know highly. There is the gab between theory which proposed by Cameron (2005), the research has been done on the knowledge of gender. Female is better in counting, and more aggressive. While female have verbal language better than male or they usually do their emotion in facing the problems. The result show that have lack of knowledge they are 6 students (15,8%). It is caused by they are lack of active and they have lack willingness to know something. 5.3. Information sources of HIV/AIDS found from electronic media, print sources and health staffs. Of the third sources of information, media or other information source can influence the respondent knowledge to get information of HIV/AIDS, that is by close friends with the respondents such as parents, teacher, friends and non government organization, Because the act of close friends can influence and imitate by other people. From the result of the research it shows that the majority of respondents who have good knowledge who get the information of HIV/AIDS are from medical staffs about 11 students (28,9%). 97 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Respondents who have lack of knowledge, they may be influenced by lack of knowledge to have information of HIV/AIDS which found by respondents. Information is needed to advance the knowledge of HIV/AIDS, in order the respondents realize the danger of HIV/AIDS earlier. Good information can give influence of the change or the increasing of knowledge which is relevant with Notoatmodjo’s idea, that is source of information influence knowledge if information of other people or other media This study is done by three assessments knowledge of respondents HIV/AIDS, the researchers devided into three categories they are, good, fair and poor. Based on the research it is found that the respondents who have good knowledge are dominant good knowledge they are 16 students (42,1%). Respondents who have good knowledge have less affected by HIV/AIDS, because the have known the HIV/AIDS and its preventive, while the respondents who have lack of knowledge have more influenced to have HIV/AIDS because of their less understanding of HIV/AIDS. 6. Conclusion Of the result of the study which entitled “ description of the eleventh year student of SMAN 1 Kutalimbaru Deli Serdang District knowledge of HIV/AIDS in 2014” can be found the conclusion as follows : 1. Respondents who have good knowledge are the dominant they are at the age of ≥17 years, they are 23,7%. 2. Respondents who have good knowledge at female are 36,8%. 3. Respondents the good knowledge of HIV/AIDS are found from medical staffs they are 28,9%. 4. The description of respondents knowledge of HIV/AIDS, generally are good. Respondents who have good knowledge are 42,1%, fair knowledge are 34,2% and lack of knowledge are 23,7%. 98 7. Suggestions 7.1. It is hoped that the government (health and educational department) medical staffs/ and relevant institutions to advance the teenagers’ knowledge by having service and good books of HIV/AIDS. 7.2. It is hoped that the parents to possess the knowledge of HIV/AIDS in order they can guide and teach their children at home. 7.3. It is hoped that non government organization (NGO) is active to advance the teenagers knowledge by having the service for the teenagers in their environments in order they are not infected by virus HIV/AIDS. 8. References Alimul, Azis. 2006. Riset Keperawatan dan Teknik Penulisan Ilmiah. Jakarta: Salemba Medika. Arikunto, Suharsimi. 2006. Prosedur Penelitian. Jakarta: Rineka Cipta. Darmawan, H. 2009. HIV/AIDS di Dunia. http://[email protected]. Diunduh tanggal 03 Januari 2014. Hutapea, Ronald, 2011.AIDS an PMS dan Pemerkosaan. Jakarta: Rineka Cipta. Joko,Profil D.Serdang www.google.com. Diakses 10/1/2014. Nasronudin, Margarita. 2007. Konseling, Dukungan, Perawatan dan Pengobatan ODHA. Surabaya: Airlangga University Pres. Niken, dkk, 2011. HIV/AIDS Kita Perlu Tahu. Yogyakarta : Penerbit Fitramay. Notoatmodjo, Soekidjo. 2007. Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta. Nursalam, 2009. Askep pada Pasien Terinfeksi. Salemba medika. Rudi, M. 2012. Indonesian Health Profile. www.google.com. Diakses 20 Desember 2013. Sarlito, Sarwono, 2011. Psikologis Remaja. Rajawali. Jakarta: Pers. Setyoadi, 2012. Strategi Pelayanan Keperawatan Bagi Penderita AIDS. Yogyakarta: Graha Ilmu. Yusfi, 2010. Mengungkap Tuntas HIV/AIDS. Jakarta: Rineka Cipta. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology FACTORS ASSOCIATED WITH ELDERLY VISITS TO ELDERLY INTEGRATED SERVICE POST IN DURIAN KENAGARIAN GADANG PUSKESMAS GAMBOK SIJUNJUNG 2014 Okky Perdana Putra, Efriza Stikes Fort De Kock Bukit Tinggi ABSTRACT Elderly IHC is the development of Government policy through health care for the elderly which operate through the PHC program, involving the participation of the elderly, families, community leaders and social organizations in its implementation. The average visit to Posyandu Elderly Elderly from January to March in Kenagarian Durian Tower Puskesmas Gambok Sijunjung is 48% of the population. This study aims to determine the relationship of knowledge, the role of Posyandu and support the family with a visit to the IHC Elderly Elderly. This research used descriptive analytic with cross sectional approach conducted in Kenagarian Durian Tower in 2014 with a sample of 159 respondents by using Chi-Square.Hasil research found there is a relationship between knowledge (pvalue = 0.001 and OR = 3.222), the role of cadres (pvalue = 0.010 and OR = 2.501) and family support (pvalue = 0.000 and OR = 11.410) with a visit to Posyandu elderly lansia.Diharapkan to family and health cadres to be able to increase the motivation of the elderly so that they are willing to attend to the elderly Posyandu each month. Keywords: Knowledge, Cadres, Family, Elderly Background Improving Social Welfare Elderly is a series of activities carried out in a coordinated manner between the Government and the community to empower the elderly so that the elderly can still perform their social function and play an active role in social life naturally, nation and state (PP No. 43 Th 2004) , While the efforts of health care for the elderly should be directed to maintain in order to stay healthy and productive life socially and economically in accordance with the dignity of humanity. Efforts to health care for the elderly is done by Government, Local Government and / society. (UU No. 36 Th. 2009). Integrated Service Post (Posyandu) Seniors according to the Guidelines for IHC Seniors, Elderly National Commission in 2010 is a further container service to the elderly in the community that the process of formation and implementation is done by the people together with non-governmental organizations, inter governmental and non-governmental sectors, private, social organizations and others with health care focused on promotive and preventive efforts. The Posyandu elderly can also be provided social services, religion, education, skills, sport and arts and culture as well as other services needed by the elderly in order to improve the quality of life through health and welfare to support them. In addition they can work and develop their own potential. There are several factors that lead to low behavior of the elderly visited Posyandu. Predisposing factors consist of education, knowledge, attitudes, and perceptions. Supporting factors consist of families, and the availability of time. And reinforcing factor is the attitude (Notoatmodjo, 2010). Sijunjung Health Department has 11 health centers, community health centers Gambok which has an area of 467.87 km2 work and 31% hilly terrain, there are 3 Nagari in Puskesmas Gambok, namely Muaro, Silokek, and Durian Tower. The average visit to Posyandu Elderly Elderly from January to March in Muaro Nagari is 685 elderly (58% of the population), in Nagari Silokek is 51 Elderly (51% of the population), and in Nagari Durian Tower is 126 elderly (48% of the population). Based on the data obtained the number of visits was lowest for the Nagari Durian Tower. And from preliminary studies done by interviewing elderly 8 in Nagari Durian Tower, 2 people say do not know about the benefits of Posyandu elderly, one person said the family did not want to drop off and accompany the implementation of the current 99 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology elderly Posyandu elderly, two people said their families while in the invented deliver Posyandu , one person said cadres never told schedule elderly Posyandu activities, one person said cadres often visit to the house, and one more person says he regularly to the IHC to determine their health status. The purpose of this study was to determine the factors associated with kunjunganLansia to IHC Elderly in Kenagarian Durian Tower Sijunjung 2014 Research Methodology This research uses descriptive analytical method with cross sectional approach. The research population is elderly aged 60 years and above in Kenagarian Durian Tower Sijunjung 2014, amounting to 263 people and is used as a sample of 159 elderly people. Analysis using univariate and bivariate analysis with chi-square test. Results and Discussion Table 1. Knowledge Relationships, cadres Role and Family Support with Visits to Elderly Integrated service post in Kenagarian Durian Gadang Sijunjung 2014 Variabel Respondents knowledge High Low Cadres role Plays not Participate Family Support Support Not support Elderly visit to integrated service post Good Not good N % n % n P OR 73 71.6 29 25 43.9 32 28.4 56.1 102 57 0.001 3.222 68 70.1 29 30 48.4 32 29.9 51.6 97 62 0.010 2.501 62 88.6 8 36 40.4 53 11.4 59.6 70 89 0.000 11.410 The elderly who have low knowledge visit to Posyandu elderly are not so good. This is because the elderly are not so aware of the understanding, benefits and types of activities carried out at the IHC Elderly. Elderly Some also said that they were reluctant to come to IHC because they feel bored with the activities at Posyandu elderly and they were afraid to check his health, for fear of the possibility of bad will happen to his health, so that the 100 elderly do not really care about any activities undertaken in IHC Elderly. If the Elderly get good service from the cadre, of course, the Elderly will be glad to visit Lansia.Sedangkan Posyandu cadres who do not play a role also in touch with not good visit to Posyandu elderly. This is illustrated by the statement of respondents who said that they did not come to Posyandu, cadres do not visit the house and invites elderly to come to Posyandu elderly, this is because the distance between home Elderly at home too much and cadres cadres also did not have a vehicle to visit the elderly to his home and kaderpun not always do counseling posyandu activities, this is because the material is very little known cadres and cooperation to the health such as health centers are still not optimal. According to researchers based on research that has been conducted for more than half of the respondents who have no family support turns Elderly visit to Posyandu well. This is illustrated, the statement of respondents stated that although the family did not have time to escort and assist the elderly to Posyandu elderly, and families are also less seek a healthy and nutritious meals for the elderly, but the elderly still have a high willingness to pay a visit to Posyandu elderly because elderly itself already know the information, benefits, and the type of activities carried out at the IHC Elderly. Elderly also consider counseling is done in Posyandu is important, because of the extension Elderly know information about health, so that they can maintain their health. Due to the high self-motivation elderly who have no family support still had a good visit to Posyandu. While there are some elderly people who receive family support but still not been to elderly Posyandu. This is illustrated by the statement of respondents who said that their family had to provide information about the benefits of Posyandu elderly, advising the elderly to maintain their health and provide good support to the elderly on the implementation of the Elderly IHC, but Elderly itself that does not want to pay a visit to IHC because they feel lazy and bored with the existing activities in the IHC Elderly and prioritize them to work and earn money while IHC Elderly implemented. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology One that can be done is a health center in order to add to the schedule of the Elderly IHC 2 times or 3 times in sebulandan can create new activities that the elderly do not feel bored to come to Posyandu elderly, such as the holding of competitions in sports and cooking among the Elderly .Diharapkan to family and health cadres to be able to increase the motivation of the elderly so that they are willing to attend to the elderly Posyandu each month. Conclusion 1. There is a significant relationship between knowledge of the Elderly with a visit to the IHC Elderly Elderly in Kenagarian Durian Tower Sijunjung 2014 with pvalue value = 0.001, and the value Odds Ratio (OR) = 3.222. 2. There is a significant relationship between the role of the health cadres with a visit to the IHC Elderly Elderly in Kenagarian Durian Tower Sijunjung 2014 with pvalue value = 0.010, OR = 2.501 and the value. 3. There is a significant relationship between family support with a visit to the IHC Elderly Elderly in Kenagarian Durian Tower Sijunjung 2014 with pvalue value = 0.000, OR = 11.410 and value. References The Republic Ministry of Health, Health Activity Management Guidelines Advanced age groups, Jakarta, 2003 KementerianKesehatanRepublikIndonesia, Guideline Development KesehatanLanjutUsia For Health Officer, Jakarta, 2010 NasionalLanjutUsia Commission, MenuaSecaraAktif, KerangkaKebijakan, Jakarta, 2007 Nugroho, KeperawatanGerontik, Jakarta2000 Notoatmodjo, S. 2010. Health Research Methodology. Jakarta: Rineka Reserved PosyanduLanjutUsia Implementation Guidelines, the Commission NasionalLanjutUsia, 2010 Government regulations Rino. 43 In 2004, TentangPelaksanaan UpayaPeningkatan welfare SosialLanjutUsia UndangRINo.36 Act of 2009 on Health UndangRINo.11 Act of 2009 on Social Welfare 101 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE INFLUENCE OF ANTENATAL CLASS TOWARDS IIIRD TRIMESTER PRIMIGRAVIDA MOTHERS’ LEVEL OF ANXIETY IN FACING CHILD BIRTH Bina Melvia Girsang Jln. Sukabangun II Kom.griya Palembang Sriwijaya University Email: [email protected] ABSTRACT Background: Anxiety is most experienced by primigravida mothers in IIIrd trimester. This anxiety could possibly be the cause of obstetrics complication which happens when the stress hormone(adrenalin dan noradrenalin) were release due to anxiety. The complication can be in such form as pre-eclampsia, eclampsia, hypertension risk during pregnancy, premature birth, and miscarriage. It can also be the reason of time taking-child birth in phase II. This complication needs such an antenatal treatment as antenatal class can facilitate the needs of service during pregnancy. This research’s purpose is to figure out IIIrd trimester primigravida mothers’ level of anxiety differences in facing child birth before and after taking the antenatal class. Method: This research is a quantitative research with pre-experiment design and only group pretest – posttest plan. It takes 15 people as a sample and uses quetionaire and observation sheet to collect data. The sample was taken by using simpel random sampling. Data collection was taken in Local Goverment Clinic on Merdeka Street–Palembang during November 20th to December 3rd 2013. Result: The result shows the following characteristic of respondents: the greatest number of ages in range <20 and >30 years are 9 respondents (60%), unemployed mothers are 11 respondents (73,3%), mothers with adequate income are 8 respondents (53,3%), and moderate-educated mothers are 10 respondents (66,7%). Statistic proves that there is a significant influence between IIIrd trimester primigravida mothers who participate in antenatal class and who do not in terms of anxiety level when facing child birth in Merdeka Local Government Clinic in Palembang (p value=0,000;≤0,05). Conclussion: Based on the research, the Antenatal class is expected to be implemented as an anteanatal services during pregnancy. Furthermore, the research is also expected to be able to conduct analysis towards other factors that can influence mothers’ anxiety level during pregnancy. Keywords : Primigravida Mothers, IIIrd Trimester, Antenatal Class, Anxiety INTRODUCTION Maternal and perinatal death remains a major problem in developing countries with a mortality rate of approximately 98-99 % .8 The number of maternal deaths in Indonesia itself is still relatively high among other ASEAN countries which is 223 per 100,000 live births , while the number of deaths in South Sumatra has increased compared to previous years , as many as 11 deaths from 30 305 in 2012 to 13 maternal deaths from 29. 415 in 2013.1,5 the mortality rate can be caused by obstetric complications and were aggragated by psychological state during pregnancy such as feelings of worry and anxiety.4 Pregnancy will cause numerous changes in the body due to hormone secretion by placenta. It 102 can trigger changes that require adaptation. In every pregnancy, especially first pregnancy not only physical canges but also psychological canges may disrupt and influence. The newly future mothers and sometimes are difficult to overcome by the mothers alone. This may be the explanation why primigravida possess higher level of anxiety compared to multigravida. Another reason in that primigravida may be easier to fear for child birth process due to myths and awful stories developed in society. This is in accordance with the research conducted by Utami and Lestari that stated that the anxiety level in prigravida is higher than that in multigravida.. . In the third trimester , the majority of pregnant women will experience severe anxiety due to increased fears and concerns that arise during Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology the labor.6 Anxiety can affect the psychological and physical well being of the the mother or the fetus if left untreated . High levels of anxiety can lead to complications such as preclampsia, eclampsia , the risk of hypertension in pregnancy and risk of preterm birth even miscarrieage.4,2 Severe anxiety can also cause prolonged second stage of labor.13 Nurses are attempted to help the mothers to overcome this problem, thus nurses have an important role in this case. Nurses must ve able to recognize the symptoms of anxiety and provide coreect information to the pregnant women. Hence, antenatal class is an effective way to address this problem. Through antenatal class, mothers may axquaire knowledge and may even able to consult their personal feelings or problems.17 Based on the results of preliminary studies on the Free Health Center Palembang from interviews with midwives at health centers it was known that there are already antenatal classes but only once or twice a year. The midwife also stated that many pregnant women complain of difficulty sleeping because of worrying about labor process . It is also supported by the results of interviews conducted with 3 and 2 primigravida mother multigravida , which indicates that the primigravida showed more severe anxiety symptoms compared to multigravida mother.Based on this background the researcher is interested in studying about how " Effects of Antenatal classes influence the level of anxiety in the third trimester primigravida Facing Labor at Merdeka Health Center Palembang . MATERIALS AND METHOD This research is a quantitative study using the methods of experimental research with preexperimental research design ; group pretest posttest only . The goal is to determine the differences in levels of anxiety in the third trimester primigravida face of labor before and after attending classes at the health center antental Merdeka Palembang. The sample in this study amounted to 15 respondents and the sampling technique is simple random sampling, which is done by the way of lottery . In order to prevent data deviation, we determine the inclusion and exclusion criteria. Illegible respondents are those who are primigravida, are not at 3 rd trimester pregnancy do not develop preeclampsia and eclampsia , and only pregnant women who experience mild to severe anxiety. The tools used in collecting the data in the form of a questionnaire Hamilton Anxiety Rating Scale ( HARS). Analysis used is Homogenety Marginal test with significance level of α = 0.05 . RESULT 1. Univariate Analysis. 1.1. Characteristics of Respondents A. Reproductive Age Table 1.1 Primigravida Frequency Distribution by Age Reproduction Trimester III n= 15 Frequency Percentage Reproductive Age Healthy 6 40% reproductive age Reproductive age is 9 60% not healthy Total 15 100% B. Jobs Table 1.2 Frequency distribution of the third trimester primigravida Based Jobs n = 15 Frequency Percentage Jobs Does not work 11 73,3% Work 4 26,7% Total 15 100% C. Income Table 1.3 Frequency distribution of the third trimester primigravida Based Income n = 15 Frequency Percentage Income Less 7 46,7% Enough 8 53,3% Total 15 100% 103 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology D.Education Table 1.4 Frequency distribution of the third trimester primigravida by Education n = 15 Frequency Percentage Education Sedang 10 66,7% Tinggi 5 33,3% Total 15 100% D. Anxiety levels primigravida IIIrd Trimester Before Following Antenatal Classes Table 1.5 Frequency Distribution Anxiety Level Results primigravida in the third trimester Cast Confronting Before Childbirth Antenatal Classes Anxiety level Before Frequency Percentage Antenatal Classes mild anxiety 8 53,3% Moderate anxiety 5 33,3% severe anxiety 2 13,3% Total 15 100% E. The anxiety level of the third trimester primigravida After Following Antenatal Classes Tabel 1.6 Results Frequency Distribution Level IIIrd trimester primigravida Anxiety in the Face of Delivery After Antenatal Class Anxiety levell Before Frequency Percentage Antenatal Classes not to worry 12 80% mild anxiety 2 13,3% Moderate Anxiety 1 6,7% Total 15 100% F. Bivariate analysis Table 1.7 Differences Anxiety Level III trimester primigravida in the Face Before Following Childbirth Antenatal and Postnatal Classes Following Antenatal Classes Anxiety Anxiety level After Antenatal level Before Classes Antenatal not mild Moderate Total P Classes Anxious anxiety anxiety Value mild anxiety Moderate anxiety severe anxiety Total 104 8 0 0 8 4 1 0 5 0 1 1 2 12 2 1 15 0,000 DISCUSSION 1. Characteristics of Respondents A. Reproductive Age The results howed that the majority of pregnant women who were not in healthty reproductive ager were 6 people (40%). The anxiety level for this group varied from mild to severe. In the other hand, the remaining pregnant women who were in healthy reproductive age showed only mild anziety level. It is thought that women who are under 20 years of age have not been ready to experience pregnancy, thus increasing their stress level. Meanwhile women who are above 35 years of age may have increased anxiety level due to their own health condition. Pregnant women who are above 35 years of age are more likely to develope more problems, such as miscarriage, cessarian section or delivering babies with genetic or chromosomal abnormalities. These may then increase their anxiety level. 6 B. Occupations. The results showed that the majority of respondents with no occupation were found to be in 11 people (73.3%). The anxiety level of this group varied from moderate to severe. While in the other hand, mothers who are still on occupation showed only mild level of anxiety. This may be exsplained by the fact that those respondents with no occupation tend to be more focused on fears and worries to give birth compared to those who still involve in certain job. 4 C.Income The results showed that the level of anxiety in respondents with less earning (46.7 %) ranged rom moderate to severe while the remaining 53.3% respondents with sufficient income only showed mild to moderate anxiety level. This may be due to the fact that pregnancy and xhild bearing require proper preparation and xost a lot of money which in turn causing worry and anxiety for those who earn less. 7 D. Education The results showed that the majority of respondents had completed medium/secondary level of education (66.7%). Less educated respondents experienced more severe anxiety level compared to highly educated one. This may be explained by the fact that the level of education influences one’s way of thinking in Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology self development and both in taking action or decision.15 Lower level of education will cause individual to experience more stress due to the lack of information. 2 E. Level III trimester primigravida Anxiety in the Face Before Following Childbirth Antenatal Classes Pre-test showed that out of 14 symptoms frequently complained by respondents, 60% is anxiety and feeling of depression and 53.3% complained of depressed mood. This may be due to the condition of the respondents who were all at first time experincing pregnancy. In antoher hand, physical state changes and the fact that the mothers are tend to become more tired also contribute to inceased level of anxiety.4 Respondents also showed concerns over labor process and their fetus development. Symptoms of too much complained of feeling depressed by the third trimester primigravida before attending antenatal classes as many as 53.3 % . This is due to the physical state of the mother's third trimester to be getting tired ditmbah with concerns over labor prose that arise as a result of a complaint with the enlargement janin.3 This situation results in feelings of mothers who become depression.13 Pre-test results also showed slight symptoms complained of by primigravida is a somatic symptom / physical or sensory . This is because the symptoms of somatic / physical usually appear in anxiety levels and heavy weight , while the results of the study only 13.3 % primigravida who experience severe anxiety and other than that there are no heavy anxiety levels , so that the sympathetic nervous system is not very active and not too showed symptoms sensorik.18 , 9 F. The anxiety level of the third trimester primigravida in the Face After Following Childbirth Antenatal Classes Post -test showed that promigravida experienced not only symptom of anxiety but also depression. This is because the degree of anxiety also affects the degree of depression. More severe anxiety will result in more severy emotional changes as well.18 In third trimester of pregnancy, mothers appear to fell more physical disdcomfort and tend to be more exhausted and dispirited. These lead to feelings of depression which can be reduced even after attending antenatal classes.18,10 After attending antenatal classes, respondents showed improvements on anxiety symptoms. Through antenatal classes, mothers were able to share their expereince to fellow participants or health workers in addition to learn and get more knowledge. Both somatic/sensory symptoms also were decreased after participating in antenatal classes. We found that there is no single participant who experiences severy anxiety anymore after attending the clasess. Somatic symptoms are not found anymore for it only appears to happen in severe anxiety.12, 16 G. Differences primigravida Anxiety Levels Before and After Antenatal Classes Results showed that there is a significant difference of anxiety level between those who participated in the classess and those who didn’t. As mentioned before, through classes participatns may also learn and get knowledge. This provision may improve the knowledge of pregnant women so that they can adapt to both physiological and psychological changes. 17 In case of participants who did not improve even after attending the classes, memory and cognitive limitation and lack of interest in learning may be able to explain that fact.16 CONCLUSION 1. Characteristics of the third trimester primigravida by age varied from 20-30 years of age as 6 people ( 40 % ) , and were aged > 30 years were 9 people ( 60 % ) . Third trimester primigravida job consists of primigravida who work as many as 4 people ( 26.7 % ) and that did not work as many as 11 people ( 73.3 % ) . Family income level of income varies quite as much as 8 people ( 53.3 % ) and who earn less by 7 people ( 46.7 % ) . Educational level primigravida third trimester consists of highly educated primigravida by 5 people ( 33.3 % ) , and the educated were as many as 10 people ( 66.7 % ) . 2. Levels of anxiety in the face of anxiety primigravida prior to attending the course consists of 8 persons ( 53.3 % ) experienced mild anxiety , 5 ( 33.3 % ) of people experiencing moderate anxiety and 2 ( 13.3 % ) experienced severe anxiety . 3. Primigravida level of anxiety in the face of anxiety after following a course consisting of 12 persons ( 80 % ) did not experience 105 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology anxiety , 2 ( 13.3 % ) experienced mild anxiety and 1 person ( 6.7 % ) experienced moderate anxiety . 4. There is a significant difference in the level of anxiety in the face of labor primigravida before and after attending antenatal classes at the health center with the Merdeka P value ( 0.000 ) . RECOMENDATION It is expected for freedom health center to implement antenatal class as a routine program for it can reduce the risk of pregnant women from getting anxiety which is dangerous. It is also expected that this research will trigger many more future studies to investigate not only the effect of ANC but also the effect of pregnancy exercise on anxiety level and other factors that may also contribute to anxiety level using control group and wider sample. REFERENCES 1. ________. The Top of Maternal Mortality in Indonesia and ASEAN Top. Date of access March 20th 2012 http://midwifecare.wordpress.com/2012/0 2/21/sekitar-20-30/: 2012. 2. Astria, Yonne , Nurbaeti, Irma & Rosidati, Catur. Characteristics relationship with third Trimester Maternal Anxiety in Polyclinic Obstetrics and Gynecology Hospital X Jakarta. Jurnal Vol. 10 No. XIX Oktober 2008 – Februari 2009, Hal 38 : 2009. 3. Cambell, Stuart dan Mackonochie, Alison. Pregnancy Day by day. Jakarta. Erlangga : 2005. 4. Detiana, Prilia. Pregnant Safe and Comfortable at the Top Age 30 Years. Yogyakarta. Media Pressindo : 2010. 5. Dinkes Palembang. Health Profile Palembang 2012. Palembang : 2012. 106 6. Effendi, Ferry dan Makhfudli. Community Health Nursing Theory and Practice in Nursing. Yogyakarta. Salemba Medika : 2009. 7. Farrer, Helen. Maternity Nursing. Jakarta. EGC : 2001. 8. Gde Manuaba, Ida bagus, et al. Introduction Lecture Obstetrics. Jakarta. EGC : 2007. 9. Gunawan, Adi. Hypnosos. The Art of Subconscious Communication Achieving Success with the Power of the Mind. Jakarta. PT. Gramedia : 2005. 10. Hamilton, Persis Mary. Maternity Nursing Basics, Ed. 6. Jakarta. EGC : 1995. 11. Indriyani, Diyan. Maternity Nursing at the Antenatal. Yogyakarta. Graha Ilmu : 2013 12. Kementerian Kesehatan Republik Indonesia. Guidelines for Pregnant Women Class. Jakarta : 2011. 13. Munir, Miftahul. Relations between Anxiety Level with Old Mother Maternity Kala II Midwives in Private Practice Kabupaten Tegal. Jurnal Sain Med, Vol. 3 No. 2, 46-49 : 2011. 14. Na’im, Jannatun Nur. Support Families with Level Kecemasn primiparous mother face Childbirth at Puskesmas Pamulang Tanggerang Selatan City. Jurnal Publikasi : 2013. 15. Notoadmodjo, Soekidjo. Health Education and Behavior. Jakarta. Rineka Cipta : 2003. 16. Tino, Rafi A. Answering myths Pregnancy and Breastfeeding. Yogyakarta. Medpress : 2013 17. Schott, Judith & Priest, Judy. Nursing Practice Series: Antenatal Classes, Ed 2. Jakarta. EGC : 2008. 18. Videbeck, Sheila L. Textbook of Psychiatric Nursing. Jakarta. EGC : 2008. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology ANEMIA IN CONNECTION WITH PREGNANCY TRIMESTER III POSTPARTUM BLEEDING IN DANDY CLINIC DISTRIC OF MABAR 2014 Sartini Bangun Departmen of midwifery Poltekkes Kemenkes Medan ABSTRACT Maternal mortality rate (MMR) in Indonesia is quite high which is 359 in 100000 live births.Generally, there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or management of both, and an indirect maternal deatht is pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. Fatalities during pregnancy but unrelated to pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths. The WHO notes that in 2014 the major direct causes of maternal deaths globally are severe bleeding/hemorrhage (27%), infections (11%), unsafe abortions (8%), high blood pressure during pregnancy/pre-eclampsia and eclampsia (14%), obstructed labour (9%), blood clot/embolism (3%) and pre-existng conditions (28%). In Indonesia 63,5% pregnant women have anemia and 59% found in Medan city. This research aims to know the relationship between iron deficiency anemia during 3rd trimester pregnancy and Postpartum haemorrhage (PPH). This in an analytical research with crosssectional data collection. Population were all women have given birth, the number of population is 286 people and each individual was chosen randomly and entirely by chance as many as 83 people. The data were obtained from both primary and medical records by using guetionaries as the instrument. The data were then analysed by common univariate and bivariate analysis using chi-square test. Research showed that out of 83 respondents, 46 women had history of anemia in 3rd trimester pregnancy and 27 women experienced postpartum hemorrhage (32,53%). 37 women were found with no history of anemia and still expereinced postpartum hemorrhage are 11 people (13,25%). Chi-square test with X2 coun>X2 table (6,93 > 3,841) indicates that there is a relationship between iron deficiency anemia and during 3rd trimester pregnancy and postpartum hemorrhage (PPH). To be expected to health workers to improve maternal motivation for regular antenatal health promotion of nutrition of pregnant women, especially the consumption of foods thet contain enough iron and vitamin c. Key words: Pregnancy, anemia of pregnancy, and postpartum hemorrhage Introduction One of strategic goals in health development in 2010-2014 is to reduce maternal mortality rate from 228 to 102 in 100.000 lives birth. And also to reduce infant mortality rate from 34 to 24 in 1.000 births ( Republic of Indonesia Health Ministry, 2010). Based on IDHS 2012, an average of MMR is 359 per 100,000 live births. In contrast to the 2007 IDHS AKI reached 228 per 100 thousand live births. This increase is probably caused by the distribution of health workers who are less prevalent in every region in Indonesia and the government made Jampersal program to reduce the death rate did not run effectivelyThis is certainly contrary to the government's target to reduce AKI up to 102 per 100 thousand in accordance with the 2015 MDG targets (Hamadi, 2013). In the other hand North Sumatra successfully reduced maternal and infant mortality rates in 2013, in September 2013, the maternal mortality rate was 126 inhabitants. This figures showed a decrease compared to the end of 2012 in which 274 AKI was found and the end of 2011 there were 313 inhabitants. Head of North Sumatra Health Office of Health Care: Kustinah said, that one of the causes of maternal mortality is due to bleeding during childbirth. If left untreated, condition may not be correctable anymore (DHO Provsu, 2013). According to the Household Health Survey of 2001, 90% of the causes of maternal death is indirectly due to frequent 107 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology complication during childbirth and immediately after childbirth. The cause is known by Trias Classical, ie bleeding (28%), eclampsia (24%), and infections (11%). While the indirect causes include pregnant women suffering from chronic energy deficiency (CED) 37%, anemia (Hb less than 11 g%) 40%. The incidence of anemia in pregnant women will increase the risk of maternal mortality compared to mothers who are not anemic (Gift, 2011) Anemia in pregnant women is a health problem associated with high incidence and complications that can arise both in the mother and the fetus. In the world there happens to be 34% of pregnant women with anemia of which 75% are in developing countries (WHO, 2005 in Syafa, 2010). In Indonesia, 63.5% of pregnant women are with anemia, whereas in the city of Medan, 59% of pregnant women are with anemia (Syaifuddin, 2008). In some studies, anemia is closely associated with high maternal mortality rate. Anemia causes low physical ability due to insufficient oxygen supply to body. In pregnant women, anemia increases the frequency of complications in pregnancy and childbirth. The risk of maternal mortality, the rate of prematurity, low birth weight and perinatal mortality rate increase (Boyle, 2008). Anemia in pregnancy can also cause interference his (inersio uteri), straining strength so the mother becomes weak and experiences prolonged labor. In addition anemia in pregnancy can also lead to atonic uterus and cause PPH (Melisa, 2013). In Indonesia, there are an estimated 14 million cases of bleeding in pregnancy. Every year at least 128,000 women bleed to death. Bleeding, especially post-partum hemorrhage, occurs suddenly and is more dangerous if it occur in women who suffer from anemia. A mother with bleeding can die in less than an hour (Sembiring, 2010). Meanwhile, deaths from hemorrhage often occurs due to a number of obstetric complications which predispose to bleeding and subsequent death if treatment is not available, including proper blood replacement therapy. The main causes of maternal deaths are haemorrhage reaches 40% - 60%, infections 20% 30%, eclampsia approximately 20% - 30%, while the indirect causes of maternal death ie maternal disease (5.6%) which will get worse with the onset of 108 pregnancy, such as heart disease, kidney or other chronic disease and iron deficinecy anemia in pregnant women (Nugroho, 2012). Based on the survey in the District Dandy Clinic Mabar year 2012-2014, the total number of 486 normal delivery childbirth, where in 2012 the number of women giving birth normally were 132 people and the number of mothers experiencing childbirth bleeding due to anemia is 9 cases, in 2013 the number of women with normal delivery were 146 people and 12 cases of bleeding due to anemia was found, and in 2014, 188 cases were normal delivery and 16 cases were bleeding due to anemia. Based on the description above, the writer interested in conducting research on the relationship of anemia in the third trimester of pregnancy with the incidence of postpartum hemorrhage in the District Dandy Clinic Mabar Year 2014, research issue is "Is there any relationship with the incidence of anemia in pregnancy is postpartum hemorrhage in the District Dandy Clinic Mabar 2014? ". Objective: The general is to investigate the relationship with the incidence of anemia in pregnancy is postpartum hemorrhage in the District Dandy Clinic Mabar 2014. Hypothesis: There is a relationship of anemia in the third trimester of pregnancy with the incidence of postpartum hemorrhage framework concept Independent Variables Dependent Variable anemia in pregnancy, postpartum hemorrhage, the parity age birth Operational Definition 1. Anemia in pregnancy is a state of maternal hemoglobin level less than 11gr% in the third trimester of pregnancy, which is taken from the documents of respondents 2. Post Partum Hemorrhage is the amount of blood that comes out of the birth canal more than 500 ml after the baby is born, the data from respondents document. 3. Risk factors for bleeding such as: age, parity and birth spacing is taken as the characteristics of respondents. Special goals a. To know the prevalence of anemia in pregnant women in the third trimester at Dandy Clinic District of Mabar 2014. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology b. To determine the frequency distribution of the incidence of post partum hemorrhage in the District Dandy Clinic Mabar 2014. c. To determine the relationship between anemia in pregnancy with postpartum hemorrhage in the District Dandy Clinic Mabar Medan 2014. 4 Anemia TM III Anemia Not anemia 46 37 55.42 44.58 5 Perdaraha Postpartu Perdaraha Not Perdarahan 38 45 45.78 54.22 83 100.00 Methods Frame work study Anemia Haemorragia pergnancy Age, Parity, Distance post partum Birth Analyt ical Cross-sectional study design. The population is all women giving birth in the District Dandy Mabar Clinic in 2014 as many as 284 people, and those with anemia during pregnancy 286 people. The sample is calculated using the formula in theory Notoatmodjo Tarro Yamane (2010), A large sample of 83 people taken at random systematic / random sampling. Analysis of Data was Univariatt Univariate and Bivariate statistical analysis using chi square test with a confidence level of 95%. Results The number of patients who delivered recorded in 2014 was 286 people, samples of 83 people with the following caracteristics : Table 4.1 Distribution Overview Dandy Mother Maternity Clinic District of Mabar 2014 No Other Factors Frequency Percentage (N) (%) 1 2 3 Age <20 years 20-35 years > 35 years 28 42 13 Parity ≤ 2 people > 2 people 32 51 Distance Birth <2 years > 2 years 47 36 33.74 50.60 15.66 Total From Table 4.1 above it can be seen that the majority of women giving birth in the age group of 20-35 years as many as 42 people (50.60%), and the remaining were in the age group <35 years as many as 13 people (15.66%) Based on parity, the majority of women are multiparous ie with parity> 2 accounts for 51 people (61.45%), and the remaining with parity ≤ 2 people as many as 32 people (38.55%) The majority of maternal with spacing <2 years were 47 people (56.63%), minority spacing> 2 years were 36 people (43.37%) Maternal characteristics based on a history of anemia of pregnancy, the majority of women suffer from anemia as many as 46 people (55.42%), and who do not have anemia as many as 37 people (44.58%). Based on the cases of postpartum hemorrhage were found to be maternal bleeding were 38 cases (45.78%) and mother did not bleed were 45 people (54.22%) Table 4.2 Relationship Analysis Anemia In Pregnancy Trimester III With Postpartum Bleeding Events in Clinical Dandy District of Mabar 2014 Bleeding events 38.55 61.45 No. Hb BleedingNot Total% Mother bleeding F 56.63 43.37 1 2 % F Statistics Test Results X2 X2 arithmetictable % Anemia27 32.53 19 22.89 46 Not 11 13,25 26 31,33 37 Anemia Total 38 45,78 45 54,22 83 55.42 6.931 3,841 44,58 P value = 0,008 100,00 109 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology From Table 4.2 above, out of 46 mothers who suffered anemia in the third trimester of pregnancy, were found to experience PPH as may as 27 mothers (32.53%) and the remaining 19 mothers (22.89%) did not develop PPH. In the other hand out 37 women who were found with out anemia, 11 were discovered to experience PPH, while hte other 26 were not (31.33%) Results of Chi-square test resulted x2 count > x2 table (6.931> 3.841) with df = 1, p value is 0.008 <0.05 which means that Ho is rejected and Ha accepted, thus there is a relationship between anemia in the third trimester of pregnancy and the incidence of postpartum hemorrhage Discussion Statistical analysis using Chi-Square test found that there is a relationship between third trimester pregnancy anemia and incidence of PPH. These results is accordance with other study (Ayu Wurianti,2010) which stated that there is relationship between 3rd trimester pregnancy anemia and PPH. This result is also consistent with the stury by Salis (2004), stating that there is a significant relationship between anemia and PPH. Maternal anemia experiencing postpartum haemorrhage may be due to inadequate nutritional intake, especially foods that contain iron. If the iron requirement is not sufficient then the level of hemoglobin in red blood cells is reduced. Lack of hemoglobin levels cause the amount of oxygen bound in the blood is also reduced, which results inadequate uterine contractions. Inadequate contraction will cause bleeding. This is in accordance with Arisman (2010) who said that anemia during pregnancy is associated with less nutritious food, inadequate absorption, and increased iron demand. Anemia can reduce the mother's immune system and elevate the frequency of complications of pregnancy and childbirth, one of which increase the risk of postpartum hemorrhage. Manuaba (2007) disclose any pregnant women with anemia are at risk for postpartum hemorrhage. Bodnar research results, et.al. (2011) The United States claimed that mothers who are anemic 3 times risk of experiencing postpartum hemorrhage compared with 110 mothers who did not have anemia. (OR = 2.76; 95% 1,25; 6,12). It is not in accordance with the research because there are still pregnant women with anemia but did not experience postpartum haemorrhage which were 19 people (22.89%) and pregnant women who are not anemic during pregnancy but expereinced postpartum hemorrhage as many as 11 people (13.25%). In the study we found, women with a history of anemia, but did not experience postpartum hemorrhage. This is due to the physical state mother, mothers of reproductive age are healthy or not included in the high-risk groups such as being too young or too old, and maternal hemoglobin level which is not so low or only presents to be mild anemia. We also found mothers who didn’t suffer anemia but still expereinced PPH. This is due to the weak state of the mother, or have a history of certain diseases, poor obstetric history such as previous history of placental abruption, maternal reproductive age which is healthy such as being too young (maternal age <20 years too old or> 35 years, the research is still Being too young (< 20 years of age) or too old (>35 years of age) may lead the woman to higher risk of complication during pregnancy. In women who are < 20 years of age, the optimal biologis and psychologis condition have not been reached. These lead to prolonged labor that may result in atonic uterus or other disorders that may lead to PPH. In the other hand, women who are > 35 years of age usually are weaker and unable to exert adequate force to push during delivery that also leads to PPH. This is consistent with study by aminuddin (2007) that stated that age is one of predeisposing factors of PPH. In addition to age, parity also influences the occurrence of PPH. Women with history of multiple parity tend to be inefficdient in every stage of labor which is the risk factor of PPH (Pritchard, 1991). Multiparities women tend to experience atonic uterus due to weaker myometrium, inadequate muscle tone, causing compression of vessels failure at the site of placental implantation which all lead to PPH. This is consistent with Winkjosastro (2002) which stated that high parity is one of the risk factors of postpartum hemorrhage. These results are consistent with research Pardosi (2009) that also concluded that parity was significantly associated with the incidence of postpartum hemorrhage. Pregnant women with parity of 1 or more than Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 5 are at risk of postpartum hemorrhage occurred 3.86 times more likely than pregnant women with parity 2-5. This research is in accordance with Salis (2004) and Syriac (2008) which stated there is a significant association between parity and postpartum hemorrhage. Spacing between births that are too close can cause pregnancy complications which will result in a decrease uterine contractions. According to Moir and Meyerscough (1972) cited Suryani (2008) mentions the distance between the birth of a predisposing factor for postpartum hemorrhage due to successive deliveries in short periods of time will lead to decreased uterine contractions become less good. It take 2-4 years for the mothers to regain their previously fit condition. According to Yuniarti (2004) the proportion of cases with spacing between birth less than 2 years was 41% (OR = 2.82). This indicates that women with spacing between birth < 2 years have 2.82 times higher risk of PPH. Mothers who did not suffer anemia indicated adequate nutritional status, good maternal preparation for pregnancy especially in primigravida, and healthy reproductive age. According to the authors, maternal anemia may be due to insufficient iron intake due to poor nutritional status. Iron defficeincy leads to low level of hemoglobin leading to inadequate supply of oxygen to uterus. In addition, anemia also lowers immune system which may increase complication during childbirth. Maternal health status, such as for being too young or too old for pregnancy also lead to increased risk of PPH. Conclusion 1. The number of women giving birth with a history of anemia in the third trimester of pregnancy were 46 people (55.42%) and with out anemia were 37 people (44.58%) 2. The number of mothers who suffered postpartum hemorrhage were 38 people (45.78%), and who didn’t suffer PPH 45 people (54.22%). 3. The statistical test Chi - square count obtained x2 table (6.931> 3.841) or the value of the probability p = 0.008 <0.05 means that there is a relationship of anemia in the third trimester of pregnancy with incidence of postpartum hemorrhage. References Arisman. 2010. Daily Life Nutrious. Jakarta : EGC Atikah. 2007. Anemia during the pregnancy. Jakarta : EGC Bodnar, et al.2011. Analyse the pregnancy Anemia effect to bleeding postpartum. Riset Jurnal. Airlangga University Surabaya Boyle, Maureen. 2008. Incidence during the labour. Jakarta : EGC Dina Darmin, dkk. 2013. Factor Incidence of Postpartum Haemorrhage at RSUD Majene. Riset Jurnal. (access in 15th February 2014) Dinkes. 2013. Caused of Mother Mortality Haelth. Articel Riset Kesehatan.(www.republika.co.id, access 08 th February 2014) Harmadi, S. 2013. High mother mortality cases. Kompas Megazine (www.kompas.co.id, access 05th February 2014) Hartini. 2012. 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The Relation Age, speacins labour, Labour history bad with casses Atonia Uteri in RSUD Dr.Saiful Anwar Malang. Study Riset Maternitas. (access 27th April 2014) Tarwoto, dkk. 2007. Anemia in Demografi Health Survey Indonesia 2012 (access 11 Februari 2014) Tarwoto, dkk. 2007. Anemia in Pregnancy. Jakarta : EGC Wiknjosastro. 2002. A Practical Hand Book Maternal and Neonatal Health Servis. Jakarta: JNPK-KR POGI Wuriyanti, Ayu. 2010. The Relation Hb with cases Haemorrhage Postpartum in RSUD Wonogiri. Health Riset Maternitas (access 17 th Januari 2014) Yulianti, Devi. 2006. Management Komplication Pregnancy & Labour. Jakarta : EGC Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology KNOWLEDGE DESCRIPTION OF THIRD TRIMESTER PREGNANT WOMEN ON BONDING ATTACHMENT IN SEHAT MATERNITY CLINIC OF PANTAI CERMIN SUB DISTRICT 2012 1. Suryani 1, Irmalinda2, Junita Karoiny Pardosi3 Midwifery Department of Medan Health Polytechnic of Health Ministry Midwifery Departement of Medan Health Polytechnic of Health Ministry Graduation of Midwifery Department of Medan Health Polytechnic Health Ministry Midwifery Department of Medan Health Polytechnic of Health Ministry Author Correspondency (+628126443796; [email protected]) 2. 3. ABSTRACT Bonding attachment prevents 22 % of infant deaths per year. The estimated number of deaths of newborns is 89/ 770 per year, or 246 newborns per day. This study aims to know the overview of pregnant women knowledge about bonding attachment, maternal characteristics by age, education , resources, and parity in the Sehat maternity clinic of Pantai cermin in 2012 . This type of research is descriptive. Population of 37 respondents pregnant women with total sampling technique. Collected data is primary data with questionnaires as measuring instrument. The results obtained knowledge about maternal bonding attachment with 70.27 %, a majority of age 20-35 years of 72.41 % and less of age < 20 years with 80 %, the majority of secondary education of 63.63 % and less of primary education of 91.67 %, 72.41 % majority of resources from health care workers and less of the mass media category of 62.5 %, and the majority of multiparous 77.78 % and less of scundipara with 68.75 %. Pregnant women knowledge about bonding attachment was still lacking. For this, it is expected that health workers through the efforts of counseling and providing information will help mothers increase their knowledge. Keywords References : Knowledge Pregnancy Third Trimester, Bonding Attachment : 21 sources ( 20006-2012) I.BACKGROUND World Health Organization (WHO) and United Nations Children's Emergency Fund (UNICEF) along with the other Scientific Community highly recommend early initiation breastfeeding and implementation of skin contact within one hour after birth ( Lennart , 2007) . In Indonesia based on data from the Ministry of Health in 2007 the infant mortality rate (IMR) reached 26.9 / 1,000 live births . In 2004, the infant mortality rate was about 30.8 / 1,000 live births (Health Department, 2009), the mortality rate of newborns (neonates) 20 per 1,000 live births. Meanwhile, the target is a reduction in IMR of 35 babies per 1000 to 26 babies per 1,000 live births ( Maryunani A , 2010) . According to Indonesian Household Health Survey in 2009, IMR ( aged 0-28 days ) was 20 per 1,000 live births, indicating that the number of newborn deaths is 89/770 per year, or 246 newborns per day or 10 newborns per hour. Meanwhile , the infant mortality rate by 0-12 months. Based on Survey held in 2009 was 35 per 1,000 live births ( Maryunani A , 2010 ) . According to the Indonesian Demographic and Health Survey in 2007, it was estimated that IMR is 34 per 1,000 live births ( Indonesian Health Department , 2011) . The government has established Indonesian Health Vision to decrease mother mortality rate (MMR) as one indicator of the final outcome in assessing health status in Indonesia. As expected in 2015 , the infant mortality rate (< 1 year ) was reduced to 17 per 1,000 live births (Department of Health, 2007) . The Central Bureau of Statistics of North Sumatra Province, estimated that IMR in 2010 113 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology in North Sumatra was 24.5 per 1,000 live births . This figure was better when compared to the previous year amounting to 26.90 per 1,000 live births ( Syafei C , 2010) . Delayed breast feeding initiation, even only after the first day, is shown to contribute to 2-4 times higher risk of mortality. In the other hand, skin to skin contact must be done properly as well. A proper skin to skin contact should not be done in hurry, should not be disturbed, should be without any cover or clothes, and must be done as early as possible after birth and last for an hour ( Elizabeth , 2012) . Skin to skin contact or attachment and early breasffeeding initiation in the first 1 hour after birth may prevent 22% risk of mortality in newborns under 1 month. Thus the first hour in newborns life is very important and both early breastfeeding and attachment are live saving action. Prevention of 22% risk of mortality is equal to saving 21 thousand babies per year. Hence these actions are for the survival of thousand babies hours afterwards (Lennart, 2007) . Formulation Of The Problem "How is the knowledge description of third trimester pregnant on bonding attachment in Sehat Maternity Clinic of Pantai Cermin sub district 2012 ? " Research Aim To find out knowledge description of third trimester pregnant on bonding attachment in sehat Maternity clinic of pantai cermin sub district 2012. Benefits Of Research 1. To add insight and knowledge of the author in applying knowledge acquired during the lectures, especially research methodology courses . 2. The results of this study can be used as reading material in the library of Medan midwifery study program. II.LITERATURE REVIEW 1. Bonding Attachment Bonding attachment has become increasingly popular. The implementation of early initiation of breastfeeding which coincides with the establishment of a bond attachment can help to 114 reduce the IMR. Normal infant development depends on the response of affection between mothers and babies who are meant to be united in both psychological and physiological relationships (Suherni, 2009). The aim of bonding attachment (Mitayani, 2010) are : a.To get warmth in infants b.To prevent infants lose body heat c.To increase fabric of affection between mother and baby. Bounding (bonds of affection) between mother and baby will be better if being done the first 1-2 hours for the baby has been ready. d. To reduce infant mortality due to hypothermia e.Mother and babies feel calmer f.Mother and fathers feel more happier for they finally meet the baby for the first time. 2. Benefits of Skin Contact from Baby to Mother Mother's chest will be appropriately warm during baby crawling looking to breast. This will reduce the number of deaths due to cold (hypothermia) (Mitayani, 2010). a.Mother and baby will feel calmer. Baby's breathing and heart rate become more stable. Baby will cry less frequently, thereby reducing energy consumption. b. Exclusive breastfeeding will become easier that would improve intelligence of the baby. Babies who are given early opportunities will become more successfully breastfeed exclusively and will take longer breastfed. c.Baby can get colostrums. Colostrum is the first content of milk with optimum quality and quantity which are in accordance with the baby’s ned. d.First colostrum contains some antibodies that can prevent infection in infants, thus ensuring the survival of the baby. e.The touch of the baby at around its mother’s nipple and surrounding areas, as well as baby’s reflex of sucking and licking are useful to increase the releas of oxytocin which is importan for : a. Helping the removal of placenta and avoiding maternal hemorrhage. b. Stimulating another hormone that makes mother becomes more, relaxed and loves her baby, thus putting the mother to more stable emotion, increasing endurance to pain and Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology much more happiness. c. Stimulating the release of breast milk. Elements And Methods of Performing Bounding Attachment ( Mitayani , 2010) 1.Touching 2.Eye Contact 3.Voice 4.Body odor 5.Entrainment 6.Rhythm of life 7.Early contact 8.Body Warmth 9.Rooming in 2.Knowledge Based Education Level Table 2 Knowledge Distribution of Respondents About Bonding Attachment Based On Education Level In Sehat Maternity Clinic o Pantai Cermin 2012 NoMother Education Knowledge Total Good Enough Less F % F % F % F % - 1 8,33 11 91,67 12 32,43 Basic Education (SD/SMP) 2 Middle 4 18,19 4 18,18 14 63,63 22 59,47 /secondary(SMA/same level) 3 University - 2 66,67 1 33,33 3 8,10 Total 4 18,19 7 18,92 26 70,27 37 100 1 III.RESEARCH METHODS This research is a descriptive study to determine knowledge description of third trimester pregnant on bonding attachment in Sehat Maternity clinic of pantai cermin sub district 2012 using a questionnaire measuring instrument. From Table 2. It is seen that out of 26 respondents who are less knowledgeable the majority elementary education graduates were which accounts for 11 respondents (91.67 %), and the remaining 14 respondents were secondary education graduates ( 63.63 % ) . The location was chosen for this study is in Sehat Maternity clinic of Pantai Cermin 2012. The research, has been done to complete the study, which was conducted from March until July 2014 . 3. Information Sources The population in this study were all pregnant women who came to visit Sehat Maternity clinic of Pantai Cermin 2014 for antenatal care from June to July of 2014 which accounts for 37 people . IV.RESULTS AND DISCUSSION RESULTS 1. Knowledge Based on Age Table 1 Knowledge Distribution Of Respondents About Bonding Attachment Based on Mother Age In Sehat Maternity Clinic Of Pantai Cermin 2014 No Mother Age 1 < 20 2 20 -35 3 > 35 Total Good F % - 4 13,8 - 4 13,8 Table 3 Knowledge Distribution of Respondents About Bonding Attachment Based on Information Sources in Sehat Maternity Clinic of Pantai Cermin in 2014 Information Sources F 1 Mass 1 Media 2 Health 3 Workers Total 4 No Knowledge Total Good Enough Less % F % F % F % 12,5 2 25 5 62,5 8 21,62 10,34 5 17,25 21 72,41 29 78,38 10,81 7 18,92 26 70,27 37 100 From table 3 it can be seen that 21 knowledgeable respondents gained information from health workers (72,41%) while the remaining 5 (62,5%) less knowledgeable respondents gained information from mass media.. Knowledge Total Enough Less F % F % F % 1 20 4 80 5 13,51 4 13,79 21 72,41 29 78,38 2 66,67 1 33,33 3 8,11 7 18,92 26 70,27 37 100 From Table 1, it can be seen that out of the 26 respondents aged 20-35 years the majority are less knowledgeable as many as 21 respondents ( 72.41 %) . 115 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 4. Knowledge Based on Parity Table 4 Knowledge Distribution of Respondents About Bonding Attachment Based on Parity in Sehat Maternity Clinic of Pantai Cermin in 2014 No Parity Knowledge Total Enough Less F % F % F % 1 50 1 50 2 5,40 3 18,75 11 68,75 16 43,24 1 Primipara 2 Scundipara Good F % - 2 12,5 3 Multipara 2 11,11 2 11,11 14 77,78 18 48,65 4 Grandemultipara - 1 100 - 1 2,71 Total 4 10,81 7 18,92 26 70,27 37 100 From Table 4 it can be seen that out of 26 less knowledgeable respondents, 14 were multiparous (77,78%) and 11 were scundipara (68,75%). DISCUSSION 1. Respondents Knowledge About Bonding Attachment Respondents in Sehat Maternity Clinic in 2014. Based on the results of the analysis, it is indicated that the majority of respondents are less knowledgeable about bonding attachment which accounts for 26 respondents (70.28 % ). Knowledge less than 70% is shown to prevent both breastfeeding initiation and attachment to be done properly. According to Notoadmojo, knowledge plays a critical role in interpreting the results to be obtained. Thus we believe that the implementation of breastfeeding initiation and attachment is positively correlated with information. Thus information delivery needs to be improved to increase the maternal knowledge of breastfeeding inititiation and attachment. 2.Respondents Knowledge About Bonding Attachment Respondents based on age in Sehat Maternity Clinic in 2014. The results showed that out of 26 respondents by 20-35 years, the majority knowledgeable about as many as 21 respondents (72.41%). Results of this study differs from study by Ika (2011) which suggests less knowledgeable respondents were at the age of 20-35 years 16.7%. 116 According to Arini (2012), maternal age is crucial in determining maternal health, pregnancy condition, child birth and post delivery condition. Mothers under 20 years of age are still not ready to face pregnancy, childbirth & to gsdyrt yhr nsny in yrtmd og noyh physiologyc and psycologycal matters. The results are consistent with the theory that there Siti (2012), which in theory may increase a person's age, will be more mature in thinking so more easily understand information to increase knowledge. And the authors assume that the lack of information from health workers affects the interest of mothers to seek information about bonding attachment. 3.Respondents Knowledge About Bonding Attachment Respondents based on education level in Sehat Maternity Clinic in 2014. From the result of 26 respondents, the less knowledgeable respondents were secondary education graduates which accounts for 14 respondents ( 63.63 ). It is contrary to Ika’s opinion (2011) which suggests that the majority of respondents have less knowledge about the intermediate bonding attachment were 3.33 % . According to Arini ( 2012) a low level of maternal education results in a lack of knowledge of mothers in dealing with problems. When mothers have higher education level, they are generally open to changes or new things to the maintenance of health. Education will also make a person seek experience so that the information received will be a knowledge . However, the authors assume that the mother's lack of interest in knowing about the importance of the bond is very influential on the mother's knowledge. From the research we unfortunately obtained that there were still less knowledgeable mother who actually have completed secondary education. From several questionnaire given to several respondents, it was found that majority of mothers thought that bonding or attachment to newborn may naturally occur, thus it become a matter of concern to mothers doesn’t. Hence, we suggest that information access enhancement from Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology health workers is the corner stone to improve mothers’ point of view regarding this issue. The knowledge of the respondents based on information sources showed on table 3 shows that out of 26 respondents, 21 were less knowledgeable and gained information from health workers. Based on the opinion of Em Zul Fajri and Queen April Twilight, information is lighting, notifications, news about something that supports the overall meaning of the mandate. Knowledge may be gained from several other sources, such as newspaper, radio, movies, televisions, but we argue that the fact of less provision of attachment/bonding may come from the lack of information gained from health workers. Thus, eventhough there have been numerous technological advance from the media when the information isn’t coreect, then the reepient will be wrong in taking sense and attitude. 4.Respondents Knowledge about Bonding Attachment Respondents based on parity in Sehat Maternity Clinic in 2014 Based on the result, it was shown that out of 26 respondents, the majority of the less knowledgeable mothers were multiparous as many as 14 respondents (77.78 %). The result is consistent with the theory mentioned by Notoatmodjo (2007), which in this study the authors get a good knowledge of what the mother had given birth wherein said higher parity theory, the more knowledge about bonding attachment for pregnant women. But the authors argue that majority of mothers thought that bonding to newborns is a natural thing, in additition to the lack of information from health workers contribute to the lack of provisions of newborns attachment. CONCLUSIONS AND SUGGESTIONS 1. Conclusion From the research, entitled "Knowledge Description Of third trimester Pregnant Women On Bonding Attachment In Sehat Maternity Clinic Of Pantai Cermin Sub District 2014" it can be summarized that : 1. From 37 respondents majority have less knowledgeable , as many as 26 respondents (70.28 %). 2. Based on age, majority less knowledgeable respondents aged 20-35 years of the 21 respondents (72.41 %). 3.Based on education, the majority of respondents are less knowledgeable on secondary education as much as 14 respondents ( 63.63 %) . 4.Based on sources, the majority of respondents were less knowledgeable who got information from health officials as many as 16 respondents (84.20%). 5.Based on parity, the majority of respondents with less knowledge were multiparous mothers as much as 14 respondents (77.78%). 2.Suggestions As for suggestions it can convey to the authors of this study as follows: a.For Educational Institutions The results of this study are useful to broaden and reading materials for students of midwifery in library. b.For Maternal Clinic For Sehat maternity clinic to be able to work together with the patient in establishing the health of mothers and babies to be able to providing complete information about health through counseling related to bonding attachment, early initiation of breastfeeding, which aims to attract the mother. c.For Next Researchers For further research can be performed descriptive and analytical methode so that the results obtained are more meaningful as a source of information related to the bonding attachment. 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Inisiasi Menyusu Dini, Jakarta ; Buku Indonesia Baru Diakses tanggal 20 juni 2012 http://www.idai.or.id/asi/artikel.asp? q=2011624154549 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EFFECT OF CUTANEOUSSLOWSTROKEBACKMASSAGE STIMULUSTODECREASEPAININTENSITYIN LOW BACKPAINPATIENTS INPUSKESBUNDIVISIONII OF PT.SUCFINDOMATAPAO SERDANGBEDAGAI *Dina Yusdiana Dalimunthe **Mula Tarigan ***Johani Dewita Nasution *) **) Nursing Department of Poltekkes Kemenkes Medan ***) Keperawatan USU Abstract Low back pain (LBP) is pain, aching, stiffness that occurs in the lower back. Lower back pain is not a disease but a symptom resulting from very diverse causes. The pain can also spread to other areas such as the upper back and groin. One non-pharmacologic measures to overcome this pain is to use stimulus cutaneous slow stroke back massage. Mechanism of action of cutaneous stimulus of slow stroke back massage in reducing pain intensity is by using the principle of gate control theory and the theory of endorphins. This study aims to determine the effect of cutaneous stimulus slow-stroke back massage on pain intensity in patients with low back pain. Thus, the design of this study using quasiexperimental design with Pre and Post test Without Control. Analysis of the data by using a paired ttest at 95% confidence level. Samples were patients with LBP in puskesbun Division II PT.Sucfindo Mata Pao Bedagai Serdang, as many as seven people taken by accidental sampling. The technique of collecting data by interview and observation. Based on the analysis using a paired t-test values obtained average (mean) the intensity of pain before administration of cutaneous stimulus slow-stroke back massage 4.7 (SD = 0.76), whereas the cutaneous stimulus after the slow-stroke back massage decrease with a value of 3.3 (SD = 0.49). In addition, test results obtained by value p = 0,000 (p≤0,05) which shows the significant difference between before and after the intervention, with a confidence level of 95% obtained the value t = 7.071 (t> 1.96), which means that the difference can be received with an average value difference (mean) of 1.43 (SD = 0.53), in which region the difference is in the range 0.93 to 1.92. It can be concluded that the stimulus cutaneous slow stroke back massage affects the intensity of low back pain sufferers pain (LBP). Thus, nurses can use this stimulus to overcome pain as non-pharmacological measures. Keyword: Slow-Stroke Back Massage, Pain Intensity, Low Back Pain (LBP) BACKGROUND Each individual is inseparable from the activity or work to make ends meet. Most of the activities and the work requires energy and muscle strength are large enough to cause a variety of complaints, one of which is lower back pain. Lower back pain or low back pain (LBP) is a pain, aching, stiffness that occurs below the waist area (Ismiyati, 2007). Lower back pain is not a disease but a symptom resulting from very diverse causes (Hakim, 2006). Almost everyone has experienced low back pain. Approximately 80% of everyone in his life has experienced pain in the lower back area due to postural faults regardless of gender, social and employment level (Cailiet, 2004). The incidence of low back pain (LBP), almost the same in all populations throughout the world, both in developed countries and in developing countries (Shocker, 2008). From the research of Cropcord Indonesia (2004) showed that patients with LBP on male gender prevalence was 18.2% and 13.6% in women. While the population had experienced lower back pain once and more during his life between 60% to 90% (Setyohadi, 2005). According to Rice (2002) in Shocker (2008) mentions the most common causes that can lead to LBP is back muscle stiffness and spasms due to poor body activity and tense 119 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology posture. In addition, various diseases can also cause LBP such as osteoarthritis, osteoporosis, fibromyalgia, scoliosis, and rheumatism. Ismiyati (2007) stated that there was an error postural or disproportionate body movements for a long time and continuously on the muscle and fascia will cause pain ensued lumbar muscle spasm and will undergo ischemic muscle. According to Setiawan (2008) that about 90% of all cases of LBP caused by mechanical factors, namely LBP on normal anatomic structures are overused or secondary to trauma or deformities, which cause stress or strain on the muscles, tendons and ligaments. Moreover, in terms of anatomical and functional, LBP also can be caused by abnormalities in the spine, where the spine is the support structure of the body and the head is always involved in various postures and motions so easy to crash. The absence of painsufferersare oftenafraid tomake amovethat disruptsdailyactivitiesandcan reduceproductivity.In addition, theexperienceof pain, is enough to makethe patient'sfrustratingto live adaily lifethat caninterfere withthe qualityof life of patients. Therefore, the primarytherapyis directedto deal withthispain(Potter &Perry, 2005). Pain managementcan beperformedwithpharmacological treatmentandnon-pharmacological therapy. Pharmacological therapyusinginhibitorsof cyclooxygenase(COX inhibitors) often causeside effects, namely gastrointestinaldisorders(Kozier, 2004). In addition, long-term usecan lead tobleedingin the gastrointestinal tract, peptic ulcer, perforationandrenal impairment(Daniel, 2006). Did you mean: Guidelines AHCPR (Agency for Healthcare Policy and Research) for acute pain penatalaksanan (1992) mentions that nonpharmacological intervention is appropriate intervention for patients who do not want to use drug therapy to overcome the pain and patients who feel anxious because they feel pain after using pharmacological therapy. Cutaneous stimulation, distraction, relaxation, guided imagery and hypnosis are examples of non-pharmacological interventions that are often used in nursing in managing pain (Potter & Perry, 2005). Stimulus cutaneous stimulation of the skin is done to relieve the pain on a scale of 6 or moderate pain by doing 120 massage and touch in the lower back. Massage and touch a sensory integration techniques that affect the activity of the autonomic nervous system (Mook, 2004). If people perceive touch as a stimulus to relax, then you will see the relaxation response. Relaxation is crucial in helping clients to improve comfort and free themselves from fear and stress due to illness and pain experienced are not resolved. Additionally relax also helps reduce anxiety, thereby preventing menghebatnya painful stimulus (Long, 2006). One type of cutaneous stimulus is massage (swabs) slowly lower back is to perform Slow-Stroke Back Massage (SSBM) for approximately 15 minutes at a speed of 60 times per minute and repeated smears every 4 hours. This massage is an act of giving comfort, which can ease the tension, relaxes the patient and improves circulation. The workings of SSBM causes the release of endorphins, thus blocking the transmission of pain stimuli (Potter & Perry, 2005). The technique for doing SSBM can be done by several approaches, one method is by rubbing the skin gently and rhythmically clients by hand, with a sweep speed of 60 times per minute. Long and soft sweep can provide peace and comfort for the patient, while the short and circular sweep tends to be more menstimulas This technique is simple and easy to do, so that every nurse and health institutions can apply to overcome the problem of pain, particularly in patients with LBP. (Caldwell & Hegner, 2003) Advantages of SSBM is this action can be done at home, allowing patients and families to make efforts in controlling pain. This can help the independence of clients and families in managing pain, particularly for patients who are difficult to obtain medical care facilities or patients who do not want to cope with the pain by using pharmacological therapy. Besides the cutaneous stimulus SSBM no need to use special tools that require huge costs that this stimulus can be provided to the community began with the economic level on up to the public under the economic (Potter & Perry, 2005). As in plantations PT.Sucfindo Mata Pao Bedagai Serdang area that has as many as five division, based on data puskesbun 2014, the number of people in the plantation of 800 heads of households, 650 of them work as employees of the plantation workers. The interview with the Head of Mata Pao Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology PT.Sucfindo Puskesbun Serdang Bedagai conducted by researchers on January 6, 2014, of the total population of as many as 65 people often come for treatment to puskesbun with complaints of experiencing pain in the lower back and the more pain when doing activities such as mendodos palm. Guidelines AHCPR (Agency for Health Care Policy and Research) for acute pain penatalaksanan (1992) mentions that nonpharmacological intervention is appropriate intervention for patients who do not want to use drug therapy to overcome the pain and patients who feel anxious because they feel pain after using pharmacological therapy , Cutaneous stimulation, distraction, relaxation, guided imagery and hypnosis are examples of non-pharmacological interventions that are often used in nursing in managing pain (Potter & Perry, 2005). Stimulus cutaneous stimulation of the skin is done to relieve the pain on a scale of 6 or moderate pain by doing massage and touch in the lower back. Massage and touch a sensory integration techniques that affect the activity of the autonomic nervous system (Mook, 2004). If people perceive touch as a stimulus to relax, then you will see the relaxation response. Relaxation is crucial in helping clients to improve comfort and free themselves from fear and stress due to illness and pain experienced are not resolved. Additionally relax also helps reduce anxiety, thereby preventing menghebatnya painful stimulus (Long, 2006). One type of cutaneous stimulus is massage (swabs) slowly lower back is to perform SlowStroke Back Massage (SSBM) for approximately 15 minutes at a speed of 60 times per minute and repeated smears every 4 hours. This massage is an act of giving comfort, which can ease the tension, relaxes the patient and improves circulation. The workings of SSBM causes the release of endorphins, thus blocking the transmission of pain stimuli (Potter & Perry, 2005). The technique for doing SSBM can be done by several approaches, one method is by rubbing the skin gently and rhythmically clients by hand, with a sweep speed of 60 times per minute. Long and soft sweep can provide peace and comfort for the patient, while the short and circular sweep tends to be more menstimulas This technique is simple and easy to do, so that every nurse and health institutions can apply to overcome the problem of pain, particularly in patients with LBP (Caldwell & Hegner, 2003) Advantages of SSBM is this action can be done at home, allowing patients and families to make efforts in controlling pain. This can help the independence of clients and families in managing pain, particularly for patients who are difficult to obtain medical care facilities or patients who do not want to cope with the pain by using pharmacological therapy. Besides the cutaneous stimulus SSBM no need to use special tools that require huge costs that this stimulus can be provided to the community began with the economic level on up to the public under the economic (Potter & Perry, 2005). As in plantations PT.Sucfindo Mata Pao Bedagai Serdang area that has as many as five division, based on data puskesbun 2014, the number of people in the plantation of 800 heads of households, 650 of them work as employees of the plantation workers. The interview with the Head of Mata Pao PT.Sucfindo Puskesbun Serdang Bedagai conducted by researchers on January 6, 2014, of the total population of as many as 65 people often come for treatment to puskesbun with complaints of experiencing pain in the lower back and the more pain when doing activities such as mendodos palm. Results of direct observations conducted by researchers during one week in puskesbun PT.Sucfindo Mata Pao Serdang Bedagai of from 6 s / January 11, 2014 the average number of visits per day as many as 50 people and 10% of them experienced low back pain with pain scale 6 or pain being. This number does not include those who did not check into Puskesbun for several reasons, such as the condition Puskesbun far from the settlement, did not want to take medicine or work that requires them to work every day so there is no time for treatment. During this time the employee has been receiving treatment from a doctor but could not overcome the perceived low back pain, it is caused by factors not taking medication as directed by your doctor on a regular basis and the fear of chemical drugs. Accordingly the researchers wanted to examine the provision 121 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology of SSBM to decrease the intensity of pain in patients with LBP in Puskesbun Division II PT.Sucfindo Mata Pao Bedagai Serdang. METHODOLOGY This research is a quasi experiment (quasiexperimental), with the draft Pre and Post Test Without Control (Control yourself sendir) that this study only intervene on a group without comparison. This research was conducted in Puskesmas Division II PT.Sucfindo Mata Pao Serdang Bedagai in January to October 2014. The population in this study were all employees in Puskesbun PT.Sucfindo Mata Pao Serdang Bedagai many as 650 people working as plantation laborers. Of the total number of employees is 65 people often come for treatment to Puskesbun with complaints experiencing lower back pain and more pain during activity mendodos oil. The sample size in this study was 10% of the population are already experiencing lower back pain so that the number of samples obtained as many as seven people. Collecting data in this study include primary data and secondary data. Primary data obtained by direct interviews with respondents using questionnaire containing questions about the experience back pain. Secondary data were obtained from medical record puskesbun PT.Sucfindo Mata Pao Serdang Bedagai such as the number of visits kepuskesbun treatment of employees, the data diseases suffered by employees and Puskesbun profile data. The data was then analyzed using univariate analysis to analyze the dependent variable LBP pain intensity before and after the intervention and bivariate analysis is a continuation of the univariate analysis to analyze the influence between two variables by conducting the tabulation and analysis of data by using a paired t-test ( Dependent Ttest) at the level of 95%. RESULT Univariate Analysis Based on the research that has been conducted on 7 patients who had experienced lower back pain, based on the known age of the respondents who experienced low back pain pain an average age of 49 years with more than half are in the age range 45-48 years (57.1 %), with the sex of the respondent approximately two-thirds were women 122 (71.4%), all respondents have tribes Java (100%) and 100% Muslim. Approximately two thirds of respondents (71.4%) had a primary education level, and all (100%) working as employees of a plantation in Serdang PT.Sucfindo Mata Pao Bedagai. Bivariate Analysis Bivariate analysis aims to determine whether there is influence cutaneous stimulus Slow Stroke Back Massage to decrease the intensity of pain in patients with low back pain in Division II PT.Sucfindo Puskesbun Mata Pao Bedagai Serdang. Pain intensity respondents before granting intervention cutaneous stimulus slow-stroke back massage measured using a scale Bourbanis for 3 days in a row every afternoon 1 times measurement. The results showed that the respondents perceived pain intensity before administration of the intervention (100%) reported moderate pain scale level 6. After respondents were given intervention cutaneous stimulus slow-stroke back massage for 15 minutes, immediately re-measurement of pain intensity using a scale Bourbanis. The results showed that pain intensity after administration of the intervention respondents cutaneous stimulus slow-stroke back massage obtained by about two-thirds of respondents (71.4%) reported mild pain level and more than a quarter (28.6%) in moderate pain. Based on the analysis found that pain intensity score respondent before giving cutaneous stimulus slow-stroke back massage was 4.7 with SD = 0.76. While the cutaneous stimulus after a slow-stroke back massage was 3.3 with SD = 0.49. This showed a decrease in the value of pain intensity after administration of cutaneous stimulus slow-stroke back massage. To determine differences in pain intensity before and after the intervention (pre-post), researchers used statistical analysis paired ttest. Results of the analysis obtained by value p = 0,000 (p≤0,05) which shows the significant difference between before and after the intervention, with a confidence level of 95% obtained the value t = 7.071 (t> 1.96), which means that these differences can be accepted by value difference average (mean) of 1.43 (SD = 0.53), in which region the difference is in the range 0.93 to 1.92. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology DISCUSSION 1. Intensity Pain Low Back Pain (LBP) Before Provision intervention Slow cutaneous stimulus-Stroke Back Massage Based on the survey results revealed that prior to the administration of cutaneous stimulation of slow-stroke back massage on pain of low back pain to see its effect on pain intensity, pain intensity was measured by using a pain scale Bourbanis on all respondents. The result showed that all respondents (100%) felt pain at the medium level. Based on the results of research on demographic data of respondents found that the average age of respondents was 49 years with more than half (57.1%) were in the age range 45-48 years. Long (1996) mentions that in adulthood easier to perceive the pain of the elderly. This is due to the advanced age there is a decrease in feeling and perceiving pain caused by degenerative decline in dealer path of pain and atrophy of nerve endings, so that the elderly needed more stimulus to evoke response from the pain in adulthood. Gender approximately two-thirds of respondents (71.4%) were female. This shows that women feel pain more easily than men. Indeed mechanism of pain in each gender are equal (Long, 1996). However, Potter & Perry (2005) mentions that the man expected to be more daring and resistant to pain than women despite the situation that causes pain is the same. All respondents (100%) working as an employee (farm workers) who use more power and a lot of activity, so it is easy to experience pain in the lower back. Bimariotejo (2009) mentions that the mechanical trauma and disruption caused because the muscles do work or perform activities with a heavy load can cause lower back pain. In addition, a job that requires standing and sitting for a long time can cause low back pain (Klooch 2006 in Shocker, 2008). 2. Pain Intensity Low Back Pain (LBP) After cutaneous administration of intervention Slow Stimulus-Stroke Back Massage After this is done stimulas cutaneous administration of slow-stroke back massage for 15 minutes immediately back pain intensity was measured using a scale Bourbanis. The results obtained are approximately two-thirds of respondents (71.4%) experienced a decrease in pain at mild levels and more than a quarter of respondents (28.6%) experienced pain at a moderate level. These results indicate that the reduction in pain intensity value of each individual is different although given the same stimulus. This difference is due to the subjective nature of pain and very individual (Mahon, 1994 in Potter & Perry, 2005), so the response provided between an individual and the other individual is not the same, depending on the factors that influence such as age, gender, past experience and (Smeltzer & Bare, 2002) as well as the meaning of pain and coping style (Potter & Perry, 2005). A decrease in pain intensity was associated with a reduction mechanism of gate control theory of pain, which is decreasing the intensity of pain occurs because the transmission of pain impulses are blocked by activating the A-beta fibers are abundant in the skin (Kenworthy, 2002 in Potter & Perry, 2005). These fibers will respond when performing massage on the skin gently (Guyton & Hall, 1997), so that after administration of cutaneous stimulus slowstroke back massage decreased pain intensity. Slow-stroke back massage works by encouraging the release of endorphins, thus blocking the transmission of pain stimuli (Potter & Perry, 2005). But the endorphin levels in each individual is different so the same stimuli perceived differently by different people. These levels are controlled by genes (Guyton & Hall, 1997; Potter & Perry, 2005). This causes all the respondents experienced a decrease in pain after the stimulus cutaneous administration of slow-stroke back massage. 3. Effect of Stimulus cutaneous Slow-Stroke Back Massage Against Pain Intensity in Patients with Low Back Pain (LBP) Based on the results of statistical tests with paired t-test, found the difference in pain intensity between before and after administration of cutaneous stimulus slowstroke back massage, where the value of the intensity of pain before administration of cutaneous stimulus slow-stroke back massaage was 4.7 with SD = 0, 76, while the cutaneous stimulus after the slow-stroke back massaage decrease in pain intensity with a value of 3.3 with SD = 0.49. 123 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on the test results of the statistical analysis paired t-test showed a significant difference, as evidenced by the value of p = 0.000 (p≤0,05). Based on the 95% confidence level is obtained the value t = 7.071 (t> 1.96), which means that these differences can be accepted with an average difference value (mean) of 1.43 (SD = 0.53), in which region the difference is in the range of 0.93 to 1.92. It shows that the stimulus cutaneous administration of slow-stroke back massage affects the intensity of pain in patients with low back pain (LBP) Reduction in pain intensity and a significant difference is due to the effect of stimulus cutaneous slow-stroke back massage, in the form of massage action on the back with a sweep gently for 15 minutes. With cutaneous stimulus slow-stroke back massage, can stimulate the fibers A beta are numerous in the skin and responds to a light massage on the skin so that the impulse delivered more quickly. This stimulation makes the input comes from the dominant impulse A beta fibers so that the gate closes and pain impulses can not be passed on to the cortexThe incidence oflow back pain(LBP), almost the sameinallpopulationsthroughout the world, both in developed countriesand in developing countries(Shocker, 2008). From the researchCropcordIndonesia(2004) showedthatpatients withLBPonmale genderprevalence was18.2% and13.6% in women. While thepopulationhad experiencedlower back painonceandmoreduringhis lifebetween60% to 90% (Setyohadi, 2005). According toRice(2002) inShocker(2008) mentionsthe mostcommoncausesthatcanlead toLBPisback musclestiffnessandspasmsdue topoorbodyactivityandtenseposture. In addition, variousdiseasescan also causeLBPsuch asosteoarthritis, osteoporosis, fibromyalgia, scoliosis, andrheumatism. Ismiyati(2007) stated that people perceive touch as a stimulus to relax, then you will see the relaxation response. Relaxation is crucial in helping clients to improve comfort and free themselves from fear and stress due to illness and pain experienced are not resolved. Additionally relax also helps reduce anxiety, thereby preventing menghebatnya painful stimulus (Long, 2006). One type of cutaneous stimulus is massage 124 (swabs) slowly lower back is to perform SlowStroke Back Massage (SSBM) for approximately 15 minutes at a speed of 60 times per minute and repeated smears every 4 hours. This massage is an act of giving comfort, which can ease the tension, relaxes the patient and improves circulation. The workings of SSBM causes the release of endorphins, thus blocking the transmission of pain stimuli (Potter & Perry, 2005). do SSBM can be done by several approaches, one method is by rubbing the skin gently and rhythmically clients by hand, with a sweep speed of 60 times per minute. Long and soft sweep can provide peace and comfort for the patient, while the short and circular sweep tends to be more menstimulas This technique is simple and easy to do, so that every nurse and health institutions can apply to overcome the problem of pain, particularly in patients with LBP (Caldwell & Hegner, 2003) Advantages of SSBM is this action can be done at home, allowing patients and families to make efforts in controlling pain. This can help the independence of clients and families in managing pain, particularly for patients who are difficult to obtain medical care facilities or patients who do not want to cope with the pain by using pharmacological therapy. Besides the cutaneous stimulus SSBM no need to use special tools that require huge costs that this stimulus can be provided to the community began with the economic level on up to the public under the economic (Potter & Perry, 2005). As in plantations PT.Sucfindo Mata Pao Bedagai Serdang area that has as many as five division, based on data puskesbun 2014, the number of people in the plantation of 800 heads of households, 650 of them work as employees of the plantation workers questionnairescontainingquestionsabout the experienceback pain. Secondary data were obtainedfrommedical recordpuskesbunPT.SucfindoMataPaoSerdang Bedagaisuch asthe number of visits to Puskesbun for treatmentof employees, the datadiseasessuffered byemployeesand Puskesbunprofile data. The data was thenanalyzed usingunivariateanalysisto analyze thedependent variableLBPpain intensitybefore and afterthe interventionandbivariate analysisisa Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology continuationofthe univariate analysisto analyzethe influencebetweentwovariablesby conductingthe tabulationandanalysisof databy using apairedt-test (Dependen). CONCLUSIONS AND SUGGESTIONS Conclusion The conclusion that can be drawn from this study are: 1. The results of measurements of pain intensity respondents using Bourbanis Scale (0-10) prior to the administration of cutaneous stimulation of slow-stroke back massage was found that all respondents experiencing pain at a moderate level. 2. The results of the measurement of pain intensity respondents using Bourbonais Scale (0-10) after stimulation of cutaneous slowstroke back massage obtained by about twothirds of respondents reported pain in mild level and more than a quarter in moderate pain. 3. Based on the software analysis using computerized statistical analysis found that there were differences in the intensity of pain before and after the administration of cutaneous stimulus slow-stroke back massage, where the value of pain intensity after administration stimulus respondents cutaneous slow-stroke back massage lower than during the prior administration Cutaneous stimulus slow-stroke back massage. In addition, test results of statistical analysis paired t test showed a significant difference, so it can be concluded that the stimulus cutaneous slow stroke back massage affects the intensity of low back pain sufferers pain (LBP). Suggestion 1. In the implementation of nursing care to pain, especially low back pain (LBP) nurses can provide stimulus cutaneous with the technique of slow-stroke back massage as an alternative to nursing as a nonpharmacological intervention for nurses / health professionals 2. For additional information in developing knowledge in the health institution that aims to improve the ability (skill) to overcome the pain for healthcare institutions. 3. The sample in this study perform work activities (not in a state of rest / bed rest), so that after administration of cutaneous stimulus of slow stroke back massage, there are several samples that have increased the intensity of back pain. For the expected characteristics of the sample in the next study is that the sample does not perform work activities, to be more visible how the effect of cutaneous stimulus slow stroke back massage on pain of low back pain (LBP). REFERENCES Bimariotejo. (2009). Low Back Pain (LBP). Taken February 20, 2010 from .backpainforum.com. Cadwell, E & Hegner, B R. (2003). Nursing Assistant: A Nursing Process Approach Edition 6. Jakarta: EGC. Daniel. (2006). Conventional NSAIDs Still selections. Taken February 23, 2010 from http://www.majalah.farmacia.com/def ault.asp. Guyton, A C & Hall, J E. (1997). Textbook of Medical Physiology, Indonesian editor: Irawati Setiawan Edition 9. Jakarta: EGC. Hakim. (1990). Pain Waist Down. Taken February 24, 2010 from www.emidicine.com. Ismiyati, S W & Cit, C R. (1997). Exercise Method William And Mc Kenzie At Waist Pain Below. Jakarta: TITAFI XIII. Kenworthy, Snowley, Gilling. (2002). Common Foundation Studies in Nursing, Third Edition. USA: Churchill Livingstone. Kozier, B; Glenora, E; Audrey, B; Shirlee, J S. (2004). Fundamental Nursing: Concept and Procedures. 8th edition. USA: Pearson Prentice Hall. Long, B and C. (1996). Medical Surgical Care (A Nursing Process Approach). Bandung: Foundation IAPK Padjadjaran. Mook, E & Chin, P W. (2004). The Effects of Slow-Stroke Back Massage on Anxiety and Shoulder Pain in Elderly Stroke Patients. Taken March 1, 2010 from http://www.scincedirect.com/science. Potter, P A & Perry, A G. (2005). Textbook Fundamentals of Nursing: Concepts, Process, and Practice 4th Edition Volume 2. Jakarta: EGC. 125 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Setyawan. (2008). Pain Waist Down (Low Back Pain). Taken February 22 from www.artikel_nyeri.com. Setyohadi, B. (2005). Aetiopathogenesis Waist Pain, Rheumatology Scientific Meeting And Pain Course. Jakarta: IRA. 126 Shocker, M. (2008). Effect of Stimulus Cutaneous: Slow-Stroke Back Massage for Osteoarthritis Pain Intensity. Taken February 20, 2010 from http://www.scribd.com. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RISK FACTORS INFLUENCING ACUTE RESPIRATORY TRACT INFECTION (ISPA) IN TODDLER AT PUSKESMAS TANJUNG PAKU SOLOK CITY 2014 Yulastri Politeknik Kesehatan Kemenkes Padang ABSTRACT This study aims to get a description of risk factors ISPA In Toddlers In Review Of Environmental and Nutritional Status in Urban Village of Puskesmas Tanjung Paku Solok City, 2014. This is a descriptive study with populations of all mothers with toddlers ever suffer from ISPA in the village of Tanjung Paku in the last 3 months of 2014. Samples were taken by systematic random sampling with the number of samples was 96 respondents. Data collected by observation, interview and documentation study. Then analyzed by univISPAate. Based on the research results suggested to the health workers to provide health education to the respondents who have children to improve access to the air vents in the home, among others, by opening a window in the morning and afternoon, organize planting trees around the house so as not to obstruct the air and light, provide balanced nutrition fit the needs of toddlers and set the number of occupants of rooms according to age in order to prevent the risk of transmission of ISPA. Keywords References : ISPA, Ventilation, Density Residential, Nutritional Status : 35 (1989-2013) BACKGROUND According to the WHO in 2008, acute respiratory infections (ISPA) is a disease that often occurs in children. Incidence by age group toddler estimated 0.29 episodes per child / year in developing countries and 0.05 episodes per child / year in developed countries. It shows that there are 156 million episodes per year in the new world, where 151 million episodes (96.7%) occur in developing countries. Most cases occur in India (43 million), China (21 million), Pakistan (10 million), Bangladesh, Indonesia and Nigeria respectively 6 million episodes. (Health Ministry, 2011). In Indonesia, ISPA is a health problem in children because of the high incidence of respiratory infection, especially in infants. Each child is estimated to have three to six ISPA episodes annually and result in approximately 20-30% of deaths (Mairuhu, 2012). ISPA is a leading cause of patient visits in health centers (40% - 60%) and treatment visits at the outpatient and inpatient care in hospitals (15% - 30%) (Ministry of Health, 2011). Acute respiratory tract infection is a disease affecting one or more parts of the respiratory tract from the nose to the alveoli, including adnexa tissue, such as the sinuses, middle ear and pleural cavity (Health Ministry, 2002). These infections are caused by viruses, fungi, and bacteria that will invade the host when ISPA decreased body resistance. Children aged under five years are groups that have immune systems that are still susceptible to diseases (Marhamah, 2013). In general, there are three risk factors, namely ISPA environmental factors, individual factors of children, and behavioral factors. Environmental factors can be seen from the factor of air pollution inside the home, ventilation and occupancy density. Factors individual child is influenced by age, birth weight, nutritional status and vitamins. While the behavioral factors are influenced by the mother or other family members to the prevention and control measures respiratory disease in infants (Maryunani, 2010). Ventilation allows the availability of fresh air in the house or room that is needed by humans, so if a room does not have a good ventilation system and over crowded it will lead to a state that can be detrimental to health (Millatin, 2010). Risk factors that residential density of a role in the incidence of respiratory disease is the density residential bedrooms are generally very vulnerable in developing 127 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology countries. When the density of occupancy bedrooms more than 2 people in the room except the toddlers did not participate as of the risk of ISPA will increase. Exposure to infectious agents in the family occurs more frequently in families that share a bed (Andayani, 2012: 7). Nutritional status is also an important risk factor for the occurrence of respiratory infections, because poor nutritional status is usually accompanied by poor immune status thereby increasing the risk of respiratory infection. (Sukmawati, et al, 2009). Based on a preliminary study that the researchers did on January 13, 2014, found the number of children suffering from ISPA from October to December 2013, of the four health centers in the city of Solok, obtained Puskesmas Tanjung Paku has the most number of patients with respiratory infection that as many as 308 people (38 %). Puskesmas Tanjung Paku consists of four wards. 4 villages of the region, the toddler most experienced by ISPA as much as 298 peoples (95.6%). In the initial survey conducted by researchers dated January 13, 2014 in the village of Tanjung Paku, many families who have been able to have their own homes, but less attention to vent some even do not have at all. Some homes are closed all day because the owners go to work or other daily routines. How stuffy and moist air in the house. Because of the lack of land, the house was built is not proportional to the number of people who occupy it, so that the house is too dense. There are habits of the people who still like to bring other family members to live together with his family, even though their home area no longer sufficient to accommodate many people. Mothers also say that eating aim is only to eliminate hunger alone. RESEARCH METHODS Research Design This is a descriptive study in order to see the risk factors of acute respiratory infection in infants in terms of environmental and nutritional status at Puskesmas of Tanjung Paku Solok 2014. 128 RESULTS AND DISCUSSION Result Table 1 Frequency Distribution of Respondents by Ventilation Houses at Puskesmas Tanjung Paku Solok 2014 No Ventilation f % 1 2 Adequate Inadequate Total 8 8,3 88 91,7 96 100 From Table 1 it can be seen that almost all respondents (91.7%) ventilation is not eligible. Ventilation is very useful to keep the air flow inside the house to keep it fresh. This means the balance of O2 required by the occupants of the house is maintained. Lack of ventilation will cause lack of O2 in the house which means CO2 levels that are toxic for the residents to be increased. Besides, insufficient ventilation will cause the humidity in the room rises due to the process of evaporation and absorption of fluid from the skin. Humidity is a good medium for bacteria, pathogens (bacteria that cause disease) (Notoatmodjo, 2003). This is consistent with the proposed Jawetz in Evita Naria et al (2008) that the lack of ventilation will increase the humidity of the house. Moist air will cause health problems, especially respiratory diseases occupants (Evita Naria, et al, 2008: 4). So ventilation is required to qualify Menkes RI No.1077 / Menkes / Per / V / 2011, ventilation of at least 10% of the floor area. Qualified ventilation can prevent the bad influence that can harm human health in a room. Good ventilation will allow wind movement and exchange of clean air becomes more smooth (cross ventilation). While the poor ventilation in the house causing air exchange less than the maximum. Indoor air will quickly turn into a stuffy and polluted. Without adequate ventilation, polluted air can not go out and replaced new air. Inadequate ventilation also cause less sunlight into the house. Without sufficient sunlight, pathogens in the house will multiply freely. Both of these increase the incidence of ISPA in Toddlers who live in homes with poor ventilation (Sri Andarini, et al, 2010: 7). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology This is consistent with research of Lindawaty in Rahmayatul Fillacano (2012) that children who live at home with vents that do not qualify at 3.07 times the risk of experiencing respiratory infection than children who live at home with a qualified ventilation (Fillacano, Rahmatul, 2013). Table 2 Frequency Distribution of Respondents by Density House at Puskesmas Tanjung Paku Solok 2014 Residential f % No. Density Not Solid 44 45,8 1. 52 54,2 solid Solid Jumlah 96 100 From table 2 it can be seen that over the majority of respondents (54.2%) categorized occupancy density solid. A healthy home building area should be sufficient for the occupants in it, meaning that the building floor area must be adapted to the number of inhabitants. Building area that is not proportional to the number inhabitants will cause overcrowded. It is not healthy, because in addition to causing lack of O2 consumption, also when one family member affected by infectious diseases, would be easily transmitted to other family members (Notoatmodjo, 2003: 151). Then the houses said solid area of the house is divided when the number of occupants is <10 m2 / soul. It is listed in the health requirements of housing RI No.1077 / Menkes / Per / V / 2011. This is consistent with research irianto (2006) that children who live with a solid home occupants at risk of experiencing ISPA 2.27 times compared with no solid occupants (Fillacano, Rahmatul, 2012: 77) Table 3 Respondents Frequency Distribution Based on Nutritional Status in Urban Village Puskesmas Tanjung Tanjung Paku Paku Solok 2014 No. 1. 2. 3. Total Nutritional Status Of Children Less Gizi Kurang Good F % 5 68 23 96 5,2 69,8 24 100 From Table 3 it can be seen that the majority (69.8%) categorized under five nutritional status of malnutrition Good or poor nutritional status describe a person's nutrient consumption. Nutrients are needed for the formation of immune substances such as antibodies. The better nutrition means better consumed so that the better nutritional status also immune. Good immune system causes the body's immune to the disease (Elyana, 2009: 8) Toddlers with poor nutritional will be more susceptible to respiratory infection than children with good nutrition for endurance factor is lacking. Infectious diseases alone will lead to malnutrition. In the state of malnutrition, children are more susceptible to severe respiratory infection attacks even longer (Maryunani, 2010: 15). This is consistent with research Sukmawati (2010) that children with recurrent respiratory infection in infants with more malnutrition status. CONCLUSIONS AND SUGGESTIONS From the description above can be concluded that most of the risk factors ISPA incidence in infants coming from the house ventilation because can not meet the needs and oxygen circulating properly, then the nutritional status of children under five with malnutrition and poor, and the condition of dense residential home. Based on the research results suggested to the health workers to provide health education to the respondents who have children to improve access to the air vents in the home between laindengan open the window in the morning and afternoon, organize planting trees around the house so as not to obstruct the air and light, providing balanced nutrition in accordance the needs of toddlers and set the number of room occupants according to age in order to prevent the risk of transmission of ISPA. REFERENCES Andayani. 2012. Faktor Resiko yang berhubungan dengan kejadian Infeksi saluran pernafasan akut pada balita di kelurahan Maricaya selatan Wilayah kerja puskesmas Mamajang Kota Makassar. Skripsi tidak diterbitkan 129 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Sri Andarin, dkk.2010. Faktor-Faktor yang Mempengaruhi Terjadinya Infeksi Saluran Pernafasan Akut (ISPA) pada Balita Pengunjung Puskesmas Rampal Celaket Kota Malang. 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Penilaian Status Gizi. Jakarta : EGC Sukmawati, dkk. 2010. Hubungan Status Gizi, Berat Badan Lahir (BBL), Imunisasi dengan Kejadian Infeksi Saluran Pernafasan Akut (Ispa) Pada Balita Di Wilayah Kerja Puskesmas Tunikamaseang Kabupaten Maros. Karya Tulis. Jurusan Gizi Poltekkes Makasar. Umbul, CW. 2004. Faktor Lingkungan Dan Karakteristik Santri Terhadap Kejadian Ispa Di Pondok Pesantren.Info Kesehatan ; VII (2); 97-102. WHO. 2002. Penanganan ISPA pada Anak di Rumah Sakit Kecil NegaraBerkembang. Jakarta : EGC http://www.library.upnvj.ac.id diakses 7 januari 2014 131 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology DESCRIPTION OF ANXIETY LEVELS ON SCHOOL-AGE CHILDREN DURING HAVING BEEN HOSPITALIZED IN LOCAL GENERAL HOSPITAL OF DR. DJASAMEN SARAGIH PEMATANG SIANTAR *Lisa Elita Rusriyani, ** Farida Linda Sari Siregar * Bachelor of nursing,Faculty of Nursing USU, ** Lecturer, Faculty of Nursing USU Email., [email protected] Abstract Having been hospitalized in children can cause anxiety and stress on all levels of age.The anxious children will feel tired because they cry continuously, don’t want to interact with a nurse, act fretfully, whine to return home, refuse to eat, that can slow the process of healing, decline the spirit to recover because they act uncooperatively to the care. This research aims to know the anxiety level of school age children during having been hospitalized. The research design used was descriptive. Sampling technique used was purposive sampling with a respondent sample of 66. Results of the study showed the majority of respondents are at a medium level of anxiety with the amount of 35 persons (53,0%) then had 25 people (37.9 percent) are at a level of anxiety, and 6 persons (9.1 percent) are at a severe level of anxiety. The research is recommendedto the nurse room to be more sensitive to each intervention will be awarded particularly on children, so it can minimize the impact of having been hospitalized in children. Keywords: Anxiety, School Age Children, Been Hospitalized INTRODUCTION Hospitalization in pediatric patients may cause anxiety and stress at all age levels (Ambarawati & Nasution, 2012). Sari & Sulisno (2012) in his research states that children who are anxious to experience fatigue because the child continues to cry, do not want to interact with nurses, cranky, whining to go home and hold, refuse to eat so slow the healing process, decreasing the spirit to heal, and uncooperative towards treatment. Causes of anxiety are influenced by many factors, both factors of personnel (nurses, doctors, and other health workers), new environmental and accompanying family when treatment (Ambarawati & Nasution, 2012). Hospitalization in pediatric patients may cause anxiety and stress at all age levels (Ambarawati & Nasution, 2012). Sari & Sulisno (2012) in his research states that children who In the school-age children who are hospitalized will emerge challenges to be faced such as overcoming a separation, adjustment to an unfamiliar environment for him, adjusting to a lot of people who take care of, and often have to relate and get along with children who are sick and experience painful therapy (Supartini, 2004). The reaction of children to hospitalization in children of school age are losing control of an impact on 132 the changing role within the family, children lose their social group because he used to carry out activities play or social interaction, fear of death, and their physical weakness (Deslidel, Hasan, Hevrialni, & Sartika, 2011). Results of previous studies show that 100% of children of school age were hospitalized suffered mild and moderate anxiety (Purwandari 2009 in Solikhah, 2011). Results of the study by Sari & Sulisno (2012) in hospitals Ambarawa reported that the prevalence of anxiety when the child reaches 75% of hospitalization. Based on the observation that there are 10 pediatric patients who were treated in Cempaka in dr. Djasamen Saragih Pematangsiantar, 7 of them are not cooperative to nursing actions given and anxiety are characterized by issuing a response crying child if there is a nurse came, showed a response anxiety, difficulty eating, difficulty sleeping, kicked, hit when performed invasive, causing delays in the process of care children. Parents also said her son became cranky, restless, often angry, and whine like home. METHODOLOGY The method used in this research is descriptive method. Descriptive study on this research aims to provide an overview anxiety levels in Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology children of school age during in hospitalization. Sampling in this study using purposive sampling with inclusion criteria: children aged 8-12 years who were hospitalized; no history of previous hospitalization; minimally treated for 2 days; be able to communicate; children are willing to engage in research; and obtain permission from the child's parents. The samples used in the study were as many as 66 respondents. Analysis performed in this study is the univariate analysis. Results of univariate analysis is presented in the form of a frequency distribution table and percentages. 2.Anxiety Results of research on anxiety in school-aged children hospitalization. Appropriate signs and symptoms kecamasan found that the majority of respondents are afraid of seeing syringes / other hospital equipment with a percentage of 62.1%. Then the results of the study also found that the second most appropriate signs and symptoms of anxiety that 43.9% (29 people) of school-age children in hospitalization restless and often wake up at night. Of the 66 school-age children were in hospitalization, the third most appropriate signs and symptoms of anxiety 39.4% (26 people) of school-age children in hospitalization cry when left parents while being treated. RESULTS AND DISCUSSION Research Result 1. Characteristics of Respondents Data obtained showed that the majority of Table. 2 Distribution Frequency and respondents aged 12 years (27.3%). Gender Percentage Anxiety During School male and female same number as many as 33 Age Children in hospitalization in (50%) of male respondents and 33 (50%) of dr. Djasamen Saragih female respondents. The majority of Muslim Pematangsiantar respondents (42.4%) and Christians (42.4%). f (%) Anxiety 40.9% of respondents had undergone yes no yes no hospitalization for 3 days. 1. Crying when left parents 26 40 39,4 60,6 Table1.Frequency Distribution Characteristics and Percentage of Respondents Characteristics of f (%) Respondents Age 8 years 13 19,7 9 years 14 21,2 10 years 9 13,6 11 years 12 18,2 12 years 18 27,3 Gender male 33 50% Female 33 50% Religion Islam 28 42,4 Chatolic 10 15,2 Christian 28 42,4 Long day care 2 day 19 28,8 3 day 27 40,9 4 day 13 19,7 5 day 2 3,0 6 day 5 7,6 2. Pay the nurse checks 3. Trembling when a nurse checking 4. Kicking when the treatment action 5. Anxious and often wake 6. bedwetting when treated 7. Sucking thumbs 8. Lazy talk / silent 9. Refuse to play 10. Feeling uneasy when doctors / nurses ask or explain something 11. Feeling tense when doctors / nurses ask or explain something 12. stuttering speech / dashed when talking with doctors / nurses 13. The speech quickly when talking with doctors / nurses 14. Fear of seeing syringes / other hospital equipment 11 55 16,7 83,3 18 48 27,3 72,7 10 56 15,2 84,8 29 5 7 21 20 37 61 59 45 46 43,9 7,6 10,6 31,8 30,3 56,1 92,4 89,4 68,2 69,7 22 44 33,3 66,7 17 49 25,8 74,2 4 62 6,1 93,9 5 61 7,6 92,4 41 25 62,1 37,9 3.Level of Anxiety The results showed anxiety levels in of school age during hospitalization majority of respondents are at the anxiety was 53.0% (35 children that the level of people). 133 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 3. Percentage Frequency Distribution and Anxiety Levels During School Age Children in hospitalization in dr. Djasamen Saragih Pematangsiantar Anxiety f (%) Mild Anxiety 25 37,9 Moderate anxiety 35 53,0 Weight Anxiety 6 9,1 Discussion Anxiety The results showed that children who experience child hospitalization in wards Cempaka in dr. Djasamen Saragih Pematangsiantar majority are at the level of anxiety was the number of 35 people (53.0%). This is consistent with several studies that, according Supartini (2004) which states that during the process of hospitalization of children can experience a variety of events indicated by the experience very traumatic and stressful, a variety of feelings that often appears in children, the anxiety, anger, sadness , fear, and guilt. The feeling can arise due to face something new and have never experienced before, insecurity and discomfort, feelings of losing something unusual happened, and something that feels painful. Results of this study are also consistent with the results of the study aidar (2011) which found that the majority of children in hospitalization are at moderate levels of anxiety (61.1%). In his research also states that during hospitalization can be a stressor factors in children. A child when facing a new environment is known to be experiencing feelings of fear and anxiety. The same opinion was also expressed by the research Solikhah (2011) which states that patients who have school-age children will experience anxiety hospitalization with an average are at moderate levels of anxiety. This was shown by the change in behavioral responses such as anxiety and tremors are an indicator of the level of anxiety in children. Results showed signs and symptoms of anxiety in the majority of school-age children are at hospitalization was afraid to see syringes / other hospital equipment with a percentage of 62.1% (41 people). This is in accordance with Keliat (2006) in Muafifah (2013) which says that the causes of stress in children such as hospital environment itself as building hospitals, wards, tools (syringes), white 134 clothing of health workers and social environment such interactions among pediatric patients. This condition is a source of stress (sterssor) which may affect the psychological condition of a child who at a certain level can cause a child to fall on the condition of anxiety, worry either mild, moderate, severe and panic. From the results of the study also showed that 43.9% (29 people) of school-age children in hospitalization restless and often woke up at night. This is in accordance Stuart & Laraia (1998) which says that someone who experienced anxiety will look at changes in affective responses as easily distracted, impatient, restless, tense and frightened. Sundari (2005) also says that anxiety is a state that shake because of the threat to health that is characterized by cold fingers, the faster the heart rate, sweating, headache, decreased appetite, not sleeping soundly, shortness of breath and chest. Of the 66 school-age children were in hospitalization, indicating appropriate signs and symptoms of anxiety 39.4% (26 people) of school-age children in hospitalization cry when left parents while being treated, it is according to Wong, Hockenberry, Wilson, Winkelstein, & Schwartz (2008) who explained that anxiety in school-age children is anxiety due to separation, injuries on the body and the pain and loss of control can also cause anxiety. The results showed that the majority of schoolage children were in hospitalization are at the level of anxiety was the number of 35 people (53.0%), the results of the study also found that 6 people (9.1%) were hospitalized schoolage children experience severe anxiety , Based on the results of research which found that school-age children who experience severe anxiety mostly aged 8 to 9 years. This is according to Wong, Hockenberry, Wilson, Winkelstein, and Schwartz (2008) who said that the younger children showed greater fear, anxiety higher than children greater. In general, older children have to learn coping methods to deal with discomfort, such as holding tightly, clenched fists or teeth, or try to act boldly with"grimace". From the results of the study also found that children of school age in hospitalization anxiety. There are many factors that make the child fall in a state of anxiety, anxiety either mild, moderate, severe, and some of them Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology panicked hospital environment, the nurse on duty, and medical equipment. Anxiety responses of children aged 8-12 years are related hospitalization during the study dilakukannnya child is seen crying when left parents while being treated, a child kicking / hitting nurses who will perform nursing actions, the child will only be accompanied by his family, the child looks gloomy, taciturn, and did not want to talk. At the time of the study the parents say that when children have trouble sleeping the night and often wake up at night, the child's parents also say that his child wetting the bed while in the hospital when at home when the child is not wetting the bed again. This sejalalan with the results Pratama (2012) which says that the response of children's anxiety related to hospitalization generally arise when the child first came to be hospitalized, at the time of the study dilakukkannya screaming child while doing nursing actions, crying and does not want to approachable, searching parents, cries when parents leave the room on an errand, reject and even send away others who considered foreign, always want the company and refused the company of others, do not want to move and tend to nap alone, and children also looks gloomy. CONCLUSION The majority of respondents are at the level of anxiety was with the majority of anxiety symptoms fear of seeing needles Hence it is expected that children are more sensitive to room nurse at every intervention that will be given, especially in pediatric patients in order to minimize the anxiety levels of children against the dreaded care measures such as conditions hospitalization, afraid to see syringes / other hospital equipment, and fear ofpain. BIBLIOGRAPHY Aidar, N. (2011). Hubungan peran keluarga dengan tingkat kecemasan anak usia sekolah (6-12 tahun) yang mengalami hospitalisasi di ruang III rumah sakit umum dr. Pirngadi Medan.Skripsi. Medan: Fakultas Keperawatan Universitas Sumatera Utara. Ambarawati, F. R., & Nasution, N. (2012).Buku askep bayi & balita.Yogyakarta: Cakrawala Ilmu. Arikunto, S. (2010).Prosedur penelitian suatu pendekatan praktik.Jakarta: Rineka Cipta. Deslidel., Hasan, Z., Hevrialni, R., & Sartika, Y. (2011). Buku ajar asuhan neonatus, bayi & balita. Jakarta: Penerbit EGC. Hurlock, E. B. (2004). Psikologi perkembangan: Suatu pendekatan sepanjang rentang kehidupan (5th ed.), Yogyakarta: Erlangga. Isaacs, A. (2004). Keperawatan kesehatan jiwa & psikiatrik (3th ed.), Jakarta: EGC. Mahanani, A. (2013). Durasi pemberian terapi musik klasik mozart terhadap tingkat kecemasan pada anak. Skripsi. Purwokerto: Fakultas Kedokteran dan Ilmu-ilmu Kesehatan Universitas Jenderal Soedirman. From http://keperawatan.unsoed.ac.id/conte nt/durasi-pemberian-terapi-musikklasik-mozart-terhadap-tingkatkecemasan-pada-anak, 25 Oktober 2013. Muafifah, K. (2013). Pengaruh clay therapy terhadap kecemasan akibat hospitalisasi pada pasien anak usia prasekolah di RSUD Banyumas.Skripsi. Purwokerto: Fakultas Kedokteran dan Ilmu-ilmu Kesehatan Universitas Jenderal Soedirman. From http://www.sharepdf.com/a33593b577fa405fb0370faa3 fb628ba/kholisatun_p1-p71.htm, 23 Juni 2014. Pratiwi, Y. S. (2012). Penurunan tingkat kecemasan anak rawat inap dengan permainan hospital story di RSUD Kraton Pekalongan.From www.journal.stikesmuh-pkj.ac.id, 9 Juli 2014. Sari, F. S., & Sulisno, M. (2012).Hubungan kecemasan ibu dengan kecemasan anak Saat hospitalisasi anak.Jurnal nursing studies 1(1):51-59. Wijayanti, F. A. (2012). Studi deskriptif dukungan peer group pada anak usia sekolah dan remaja yang dirawat di rumah sakit. Skripsi. Depok: Fakultas Ilmu Keperawatan Universitas Indonesia. Wong, D. L., Hockenberry, M., Wilson, D., Winkelstein, M. L., & Schwartz, P. (2008).Buku ajar keperawatan pediatrik edisi 6 volume 1.Jakarta: EGC 135 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECTS OF GUIDED IMAGERY ON DYSMENORRHOEA INTENSITY AND HEMOGLOBIN LEVELS Hotma Sauhur Hutagaol Prodi Kebidanan Padangsidimpuan Abstract Menstruation is the defined as the periodic efflux of the sloughed endometrium and blood out of the uterine cavity into the vagina and ultimately outside of a woman’s body. Irregular menstrual cycle length or number of days of menses may affect the levels of hemoglobin (Hb). Menstrual pain is pain during menstruation is felt in the lower abdomen and appear before, during or after menstruation. Guided Imagery is a relaxation technique guiding some one to focus in pleasant images to reduce pain. The aim of this study is to analyze whether the guided imagery is an effective technique for reduce dysmenorrhoea and maintain hemoglobin levels during menstrual cycle. This research is a quasy-experimental research with pre-test and post-test control goup. Data were analyzed using Mann_Whitney test, and the p-value of <0.05 was considered statistically significant. A total of 32 adolescents were studied (16 in treatment group, 16 in control group). After guided imagery, dysmenorrhoea reduced significantly in the treatment group (4.8 ± 0.8 to 2.6 ± 0.5, p=0.001) and there was no change in control group (4.6 ± 0.6). There was significant difference between the two groups (p=0.001). Decrease in hemoglobin levels were lower in treatment group (10.9 ± 0.5 gr% to 10.8 ± 0.4 gr%) compared to the control group (11 ± 0.6 gr% to 10.6 ± 0.5). However there was no significant difference between the two groups. This study concluded that guided imagery effective in reduce dysmenorrhoea and maintain hemoglobin levels. Keywords:Guided Imagery, Dysmenorrhoea Intensity, Hemoglobin Level INTRODUCTION Menstruation is the defined as the periodic efflux of the sloughed endometrium and blood out of the uterine cavity into the vagina and ultimately outside of a woman’s body. Irregular menstrual cycle length or number of days of menses may affect the levels of hemoglobin. Hemoglobin is the part of blood that contains iron, carries oxygen through the body, and gives blood its red color. Hemoglobin in unpregnancy female is present normally in blood to the extent of 11 to 12 grams in 100 milliliters. Menstrual cycles often are irregular through adolescence, particularly the interval from the first to the second cycle (Johnston, 2014). According to the World Health Organization’s international and multicenter study of 3,073 girls, the median length of the first cycle after menarche was 34 days, with 38% of cycle lengths exceeding 40 days. Variability was wide: 10% of females had more than 60 days between their first and second menses, and 7% had a first-cycle length of 20 days. Most females bleeds for 2-7 days during their first menses (17-19 year). Normal menstrual cycle interval in young 136 female typically 21 – 45 days. Menstrual flow length 2 – 7 days (ACOG, 2006). During menstruation, the muscles of the uterus contract in response to hormone-like substances called prostaglandins, produced by the lining of the uterus. The levels of the prostaglandins increase prior to menstruation, and peak at the start of the menses. The levels decline again as a woman menstruates, resulting in less uterine discomfort or cramps after the first few days of the menstrual period (Johnston, 2014). The level of Prostaglandin in female with dysmenorrhoea is ten times higher compare to female without dysmenorrhoea (ACOG, 2006). Most women experience some pain or discomfort during the menses. However, some experience dysmenorrhoea (painful periods) or “difficult menstrual flow”, which may present as moderate to severe cramps or pain in the lower abdomen or lower back, diarrhoea or constipation, heavy menstrual flow, frequent urination, nausea, vomiting, headache or dizziness. Primary dysmenorrhoea refers to recurrent, crampy lower abdominal pain that occurs during menstruation in the absence of other underlying conditions / disease (Johnston, 2014). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Dysmenorrhoea is also more prevalent in women who suffer from premenstrual syndrome (PMS) (Poornima, 2015). Several studies among American and Australian adolescents, have shown that adolescents with dysmenorrhea report that it affects their academic performance and social and sports activities, a distressing finding given the availability of effective medications (Eman, 2012). In Polytechnic of Medan Health Ministry, Midwifery Campus at Padangsidimpuan, estimated 35% student with dysmenorrhoea and about 5% can not do usual activities due to menstrual pain. Relaxation is more than a state of mind; it physically changes the way your body functions. When your body is relaxed breathing slows, blood pressure decrease and increase oxygen consumption, and some people report an increased sense of well-being. This is called the “relaxation response.” Being able to produce the relaxation response using relaxation techniques may counteract the effects of long-term stress, which may contribute to or worsen a range of health problems including depression, digestive disorders, headaches, high blood pressure, and insomnia (ACOG, 2006). Relaxation is an independent intervention to reduce pain intensity, improve pulmonary ventilation and increases blood oxygenation. Skeletal muscle relaxation is believed to reduce pain by relaxing the muscles, there are many evidence that show the effectiveness of relaxation in relieving pain. (Smeltzer, 2002). Relaxation in general as the most effective method, especially in patients who experience pain. Guided imagery is one of relaxation technique, that focus on pleasant images, through storytelling or descriptions designed to suggest mental images (also called visualization) to replace negative or stressful feelings and relax (NCCAM, 2013). So the aim of this study is to analyze the effects of guided imagery to reduce dysmenorrhoea and maintain hemoglobin levels. METHODS 1. Statement of the problem To analyze the effects of guided imagery to reduce dysmenorrhoea and maintain hemoglobin levels. 2. Operational Definition Dysmenorrhoea. Dysmenorrhoea can be defined as recurrent, crampy lower abdominal pain that occurs during menstruation in the absence of other underlying conditions/ disease. Guided imagery. Guided imagery can be defined as relaxation technique, that focus on pleasant images to replace negative or stressful feelings and relax. Hemoglobin Levels: Hemoglobin levels can be defined as the levels of hemoglobin in blood. 3. Hypothesis a. There is significant difference of menstrual pain (Dysmenorrhoea) between intervention and control group after guided magery b. There is significant difference of hemoglobin levels between intervention and control group after guided magery 4. Research design A quantitative paradigm was used in the study. A quasi-experimental design which involves both pre-test post-test control group design, an experimental group was used to study the effect of the intervention on dysmenorrhoea and hemoglobin levels and no intervention in control group. 5. Sample The sample chosen for the study was 32 female college students in the age group of 18 to 22 years with dysmenorrhoea. Sample size by Sastroasmoro formula with the value of SD from previous study is 1,17. 16 participants were assigned to the intervention group and 16 to the control group. The sample was chosen based on convenience sampling by approaching college students from Padangsidimpuan midwifery academy that showed dysmenorrhoea based on observation form. 6. Tool used NRS (Numerical Rating Scale) : The Numerical Rating Scale Form by Potter and Perry (2005) was used to see the intensity dysmenorrhoea of Participants. 7. Procedure College students of Padangsidimpuan midwifery academy were approached by the researcher for participation in the study through interview. Female students were asked whether they experienced dysmenorrhoea in relation to their menstrual cycle. These students were given NRS (Numerical Rating 137 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Scale) to identified their pain intensity. The participants were enrolled for the study based on their pain intensity of menses. 32 participants with moderate and severe pain of Dysmenorrhea were be selected and 16 participants were assigned to the intervention group and 16 to the control group respectively. Participants whose menstrual phase fell around the same time of the month were included so that the intervention can be given accordingly. Informed consent was be obtained from the participants. The researcher gave the participants the guide to do guided imagery and teach them until they can do it by themselves. The intervention consisted of the participants doing guided magery 15 minutes a day by 7.30 o’clock in the morning. The intervention began on the first day of dysmenorrhoea and ended on the last day of the menstrual cycle. The participants recorded their pain intenstity form by the first day of dysmenorrhoea and the last day of menses. The control group was not given any intervention. However they completed the NRS form, from the first day of dysmenorrhoea and the last day of menstrual cycle. DATA ANALYSIS Mann_Whitney-test was used to compare the intervention group and control group data. RESULTS AND DISCUSSION Results Table 1 showing the characteristic of the intervention group and control group Character Interventio Control Sig istic n Group Group Mean±SD Mean± SD Age 18,7 ± 1,0 18,7 ± 0,5 p>0,05 Age of 13,0 ± 1,1 13,5 ± 1,2 p>0,05 Menarche Pain 4,8 ± 0,8 4,6 ± 0,6 p>0,05 intensity Hemoglob 10,9 ± 0,5 11 ± 0,6 p>0,05 in levels Table 2 showing the results of mann_whitney test of post-test total score of guided imagery between intervention group and control group on intensity of dysmenorrhoea Dysmenorrhoea Mean ± SD p Intensity Intervention Group 2.6 ± 0.5 0.001 Control Group 4.6 ± 0.6 There is a significant difference between the intervention group (M=2.6 ± 0.5) and control group (M= 4.6 ± 0.6) on the post-test of guided imagery on the dysmenorrhoea intensity; p = 0.001. 5 4 3 2 1 0 Intervention Group Control Group figure 1. Mean of dysmenorrhoea intensity post test between intervention group and control group. Table 3 showing the results of mann_whitney test of post-test total score of guided imagery between intervention group and control group on hemoglobin levels Mean ± SD Hemoglobin levels Sig Intervention Group 10,8 ± 0,4 0,2 Control Group 10,6 ± 0,5 There is no significant difference between the intervention group (M=10,8 ± 0,4) and control group (M= 10,6 ± 0,5) on the post-test of guided imagery on the hemoglobin levels; p = 0.2. 11 10.8 There is no significant difference of characteristics between the the intervention group and control group. 10.6 10.4 10.2 Intervention Group 138 Control Group Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology figure 2. Mean of hemoglobin levels post test between intervention group and control group. DISCUSSION The purpose of the present research was to study the effectiveness of guided imagery on the intensity of dysmenorrhoea and hemoglobin levels. The results of the study indicate that guided imagery has had a significant effect on the intervention group, Leading to a reduction in the intensity of dysmenorrhoea. Lower reduction of hemoglobin levels compare to control group, However there is no significant difference between the two grup. Table 1 and 2 shows that the pre-test scores of the participants in the intervention group on dysmenorrhoea intensity is higher than the post-test scores, indicating a reduction in the dysmenorrhoea intensity after the intervention. The post-test scores between the intervention group is lower compare to the control group and with the Mann_Whitney test , statistically siginificant. Based on this, the hypothesis which states that there is significant difference in the dysmenorrhoea intensity of the participants in the intervention group compare to control group is accepted. Hence, based on these results, a conclusion can be drawn that guided imagery has a significant effect on the reduction of dysmenorrhoea intensity. Previous studies showed that guided imagery have an effect on the reduction severe dysmenorrhoea on three participants to mild dysmenorrhoea (Novarenta, 2013). Relaxation can control the pain by minimizing sympathetic activity in the autonomic nervous system. Adolescence can increase the activity of the parasympathetic nervous vegetative components, simultaneously. The technique can reduce the sensation of pain and control the intensity of adolescent reaction to the pain. Hormones adrenaline and cortisol that causes stress will decrease, adolescence can improve concentration and feel at ease making it easier to regulate breathing through respiratory frequency of less than 60-70 x / min. PaCO2 levels will increase and decrease the PH so that it will increase oxygen levels in the blood (Potter and Perry, 2005) In the relaxed condition, the body will stopthe production of adrenaline hormones and all hormones that is required when stress occured. Because of the sex hormones (estrogen and progesterone) and the stress hormone (adrenaline) are produced from the same chemical building blocks, when we reduce stress then will reduce the production of the sex hormone. Thus, the need for relaxation to provide an opportunity for the body to produce hormones that are important to get menstrual pain free (Sigit, 2010) The main principle of pain relief by relaxation lies in the physiology of the autonomic nervous system, which is part of the peripheral nervous system that maintains homeostatic internal environment of indvidu. At the time of the release of mediators such as bradikilin and prostagandin, would stimulate the sympathetic nerve, causing vasoconstriction which ultimately increases muscle tone that cause various effects such as muscle spasms that eventually suppress the blood vessels, reducing blood flow and increasing the speed of muscle metabolism that causes impulse transmission pain from the spinal cord to the brain will be perceived as painful (Tamsuri, 2007). Table1 and 3 shows that the reduction of hemoglobin levels is lower in the intervention group compare to control group. indicating a maintaining of the hemoglobin levels after menstruation. However there is no significant difference on the hemoglobin levels between the two groups. The hypothesis which states that there is significant difference in the hemoglobin levels of the participants in the intervention group compare to control group is rejected. Hence, based on these results, a conclusion can be drawn that guided imagery has a significant effect on the reduction of dysmenorrhoea intensity. Menstrual cycle length or number of days of menses may affect the levels of hemoglobin. Short cycle and excessive menstrual flow automatically increase blood loss. In this study both of the intervention group and the control group have a normal menstrual cycle interval and menstrual flow length. According to Smith (2007), each a human took 20.96% oxygen with a tidal volume 350 ml, then in a second a human took the oxygen about 73.36 ml. By maximizing the development of lung, then obtained maximal inspiration volume until 3000 ml, and the hemoglobin will bind oxygen with estimates 1.34 ml oxygen x hemoglobin/gram percent, 139 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology when hemoglobin levels are 14 x 350 ml = 6566 gram of oxygen per second are carried by the blood throughout the body. Hemoglobin is found in the red blood cells of the body. Each red blood cell (RBC) contains approximately 280 million hemoglobin molecules. The main function of hemoglobin is to transport oxygen from the lungs to the tissues and then transport CO2 back from the tissues to the lungs. Therefore, guided imagery as one of relaxation technique is useful as distraction, so that the patient's mind shifted focus from pain and at the same time optimizing oxygen inhalation for the stress cells. With the increase in oxygen uptake so the hemoglobin levels to bind oxygen will also increase. CONCLUSION Thus the hypotheses which stated that there is significant difference between the intervention group and the control group on were accepted. However, the hypotheses which stated that there is significant difference between the ntervention group and control group on hemoglobin levels were rejected. Thus, it can be concluded from the results of the present study that guided imagery has a significant effect in reducing the menstrual pain (dysmenorrhoea) and an optional choice to maintain hemoglobin levels in menstrual cycle. REFERENCES ACOG, 2006, Menstruation in girls and adolescents: using the menstrual cycles as a vital sign. ACOG Committee Opinion Number 349, 2006. Alimul A. 2006. Pengantar Kebutuhan Dasar Manusia. Surabaya: Salemba Medika. Eman, 2012. Epidemiology of Dysmenorrhea among Adolescent Students in Assiut City, Egypt. Life Science Journal; 9(1). 140 National Center For Complimentary and Alternative Medicine (NCCAM), 2013. Relaxation Techniques For Health. US. NIH. Novarenta A, 2013. Guided Imagery Untuk Mengurangi Rasa Nyeri Saat Menstruasi. Jurnal Ilmiah Psikologi Terapan. ISSN: 2301-8267 Vol 01, No.02 Agustus, 2013. Fak Psikologi Univ.Muhammadiyah Malang Perry, AG, Potter PA .2005. Buku Ajar Fundamental Keperawatan;Konsep, Proses dan Praktik , Vol.2 Alih Bahasa. Editor Monica Ester Dkk, Jakarta : EGC Poornima, 2015. The Effects of Classical Music based Chakra Meditation on the Symptoms of Premenstrual Syndrome. The International Journal of Indian Psychology ISSN 2348-5396 (e) | ISSN: 2349-3429 (p) Volume 2, Issue 3. Priharjo, R. 2003. Perawatan Nyeri. Jakarta. EGC Sastroasmoro S. 2011. Dasar-dasar Metodologi penelitian klinis. Jakarta: CV.Sagung seto. Smeltzer & Bare 2002. Keperawatan Medikal Bedah. Edisi 8. Vol 1. Alih Bahasa Agung Waluyo. Jakarta. EGC Sigit NP. 2010. Konsep dan Proses Keperawatan Nyeri. Edisi 1. Graha Ilmu. Yogyakarta Tamsuri A, 2007. Konsep dan Penatalaksanaan Nyeri. Jakarta. EGC Wirya I, Sari MD, 2013. Pengaruh Pemberian Masase Punggung Dan Teknik Relaksasi Nafas Dalam Terhadap Penurunan Intensitas Nyeri Pada Pasien Post Appendiktomi Di Zaal C Rs HKBP Balige Tahun 2011, Jurnal Keperawatan HKBP Balige, Vol.1 No.1, Juni 2013 ISSN 2338-369091 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECTIVENESS OF LAVENDER AROMATHERAPY IN REDUCING PAIN INTENSITY OF PATIENTS WITH BREAST CANCER IN RB2 RSUP HAJI ADAM MALIK MEDAN 2014 Nurlama Siregar, Masnila, Marlisa Lecturers of Nursing Department of Politeknik Kesehatan Kemenkes Medan Abstract Aromatherapy defines as a method to cure a disease by using fragrance which is come from the oil of floral essential, commonly the fragrance smell good, aromatic and relaxing, it commonly calls essential oil. Almost all of breast cancer patients feel pain. Pain is unpleasant sensory perception. Aromatherapy is one of non pharmacological methods to reduce pain. This study was conducted by a pretest-posttest design, a pretest applied priory before applying an intervention. After applied an intervention, a posttest was conducted. It had 27 samples. The data was taken from medial record and observation sheet. The findings showed that before applied lavender aromatherapy, there are 22 respondents (81,5%) who had severe pain intensity and after applied the lavender aromatherapy, mostly 24 respondents (88,9%) had mild pain. The statistic test result that there was a significant reducing in pain intensity with value p =0,00 and mean 0,851. Key words : lavender aromatherapy, reducing pain, breast cancer INTRODUCTION Breast cancer is a cold-blooded killer for women. Wolrd health Organization (WHO) stated that about 8-9% women in the world have had breast cancer, and it is the second largest numbers that Indonesian women had (Wenny Artanty, 2011). Globally it predicts that there are about 1.401.400 cases of cervix cancer in the last five years and 3.860.300 breast cancer in the last five years. Based on the cases, noticeably the incidence of breast cancer is dominant than cervix cancer. (Wijaya, 2010). The signs and symptoms of breast cancer is commonly pain, and including lumps and swelling in the breast which it cannot be moved from the breast tissue. Pain is a sensory and emotional perception which is not unpleasant because of the actual and potential damage tissue. Nurses spend more time with painful patients compare beside the other medical staff and they have chances to help the painful patient reducing their pain and the harmful effect (Brunner & Suddarth, 2008). The pain can be reduced by a treatment both pharmacologically and non-pharmacologically. Pharmacologically it involves the use of opioids (narcotics), non-opioids, adjuvant analgesic and co-analgesic. Nonpharmacologically it covers physical treatments, such as distraction, relaxation technique and therapeutics (Tamsuri, 2012). Aromatherapy is one of nn pharmacological treatment because it contains positive effect such as anti inflammatory, anti septic, analgesic, immunostimulant, stimulating circulation, stimulating appetite, diuretic, hormonal and others benefits. The essential oil has many different advantages, the aromatic of lavender evoke serenity, balancing, comfort, reducing pain and reducing stress. The lavender can be used to reduce pain because of its analgesic nature (Koensoemardiyah, 2009). Based on prior survey, medical record of RSUP Haji Adam Malik Medan in 2013 showed that the numbers of visiting were 1.145 times and the numbers of patients in the wards of RSUP Haji Adam Malik in 2013 141 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology were about 345 patients (Medical Record RSUP Haji Adam Malik Medan). The formulation of the problem in this study defined as the following: ”How is the effectiveness of lavender aromatherapy in reducing pain intensity of breast cancer patients in Rindu B2 A RSUP Haji Adam Malik Medan in 2014”. RESEARCH METHOD This study was conducted by queasy experimental method with pretest and posttest design. The populations were all breast cancer patients in RB2 A RSUP Haji Adam Malik Medan, they are about 345 patient in each year. The samples were 27 patients. The samples were selected by purposive sampling technique. The study collected the primary data. The data were taken by spreading observation sheet. The data were analyzed by editing process, scoring and tabulating. It applied univariate data analysis which used distribution analysis, frequency, and descriptive statistic to analyze the level of pain of breast cancer patient before and after applied lavender aromatherapy and bivariate data analysis with T-test Table 4.3 Frequency Distributions of Pain Intensity Before Lavender Aromatherapy Treatment No Pain Intensity 1 Mild 2 Moderate 3 Severe Total No Pain Intensity 1 Mild 2 Moderate 3 Severe Total No Age in Years 1 < 30 tahun 2 31-40 tahun 3 > 41 tahun Total Frequency (%) 0 0 12 44,4 15 55,6 27 100 Table 4.2 Frequency Distributions Based on Respondent’s Academic Level No Academic Level 1 SD 2 SMP 3 SMA 4 PT 5 TS Total 142 Frequency 11 6 8 1 1 (%) 40,7 22,2 29,6 3,7 3,7 27 100 F (%) 2 7,4 24 88,9 1 3,7 27 100 Table 4.5 Frequency Distributions of Pain Intensity Before and After Lavender Aromatherapy Treatment Pain Intensity Mild Table 4.1 Frequency Distributions Based on Age (%) 0 18,5 81,5 100 Table 4.4 Frequency Distributions of Pain Intensity After Lavender Aromatherapy Pre FINDINGS AND DISCUSSION A. Findings F 0 5 22 27 Moderate Severe Post F % F % 0 0 2 7,4 5 18,5 24 88,9 22 82,5 1 3,7 27 100 27 100 Total B. Discussion After observing the findings, it showed that majority respondents who had breast cancer in RB2 A RSUP Haji Adam Malik Medan had severe pain before applied lavender aromatherapy treatment. Based on physiologic responds, mostly respondents had red face, grimace, easy to get mad, and anxious. It is in line with the theory which stated almost all breast cancer patients feel pain. The findings showed that, mostly pain intensity before applied lavender aromatherapy were severe pain about 22 respondents (81,5%) and after applied lavender aromatherapy for 10-15 minutes, only 1 respondents (3,7%) felt severe pain. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The data found that pain intensity decreased after applied lavender aromatherapy. And the result of mean of two samples (paired sample t-test) that were used to showed the pain intensity before and after applied lavender aromatherapy were significantly different, they are p=0.00 (p<0.05), it meant that Ho is rejected and and Ha is accepted. It is concluded that applying lavender aromatherapy was effective in reducing pain intensity of breast cancer patients with an average value of reducing 0.851. Therefore the nurses who spend much time with patients, they should collaborate only with professionals but they may directly apply nursing intervention such as applying lavender aromatherapy. CONCLUSION The result of the study indicated that: 1. Applying aromatherapy is effective on reducing pain intensity of breast cancer patients in RB2 A RSUP Haji Adam Malik Medan 2014. 2. Pain intensity of respondents before applied lavender aromatherapy to breast cancer patients in RB2 A RSUP Haji Adam Malik Medan were mostly severe about 22 respondents (81,5%). Pain intensity of respondents after applied lavender aromatherapy to breast cancer patients in RB2 A RSUP Haji Adam Malik Medan were mostly moderate about 24 respondents (88,9%). 3. Ha is accepted and Ho is rejected, it meant lavender aromatherapy was effective on reducing pain of breast cancer patients. The statistic test showed that pain intensity before and after applied lavender aromatherapy were significantly different with the value p=0.00 (p<0,05). SUGGESTION 1. To Respondents It is suggested to breast cancer patients to apply lavender aromatherapy to reduce their pain, so they do not depend on analgesic drugs because the dosage of the analgesic become more and more 2. To the Hospitals Hospitals should applied an intervention such as lavender aromatherapy intervention to relieve or to reduce pain intensity of breast cancer patients. 3. To The Educational Institution It is also suggested to educational intuitions to improve students’ knowledge and ability more about the importance of non pharmacological therapy especially applying lavender aromatherapy to the breast cancer patients. 4. To the further researcher It is suggested to further researcher to make this study as preliminary data and a source of information for the cultivation of further research about the effectiveness of lavender aromatherapy on reducing pain intensity of breast cancer patients. REFERENCES Adiyati, Sri. 2010. Pengaruh Aromaterapi Terhadap Insomnia Pada Lansia Di PSTW Unit Budi Luhur Kasongan Bantul Yogyakarta, diunduh Januari 2014, from http://www.academia.edu.ac.id Alimul, A. 2007. Riset Keperawatan Dan Teknik Penulisan Ilmiah. Jakarta: Salemba Medika Amelia, Sherly. 2008. Efektifitas Aromaterapi Lavender Terhadap Penurunan Intensitas Nyeri Persalinan Kala I, diunduh Januari 2014, from http://www.repository.usu.ac.id Andarmoyo, Sulistyo. 2013. Konsep dan Proses Keperawatan Nyeri. Yogyakarta: Ar-ruz Media Artanty, Wenny. 2011. Bahaya Kanker Payudara. Yogyakarta: Tanisius Brunner & Suddarth 2008. Keperawatan Medikal Bedah. Jakarta: EGC Dean, Sarah. 2007. Aromaterapi. Jakarta: Karisma Ester, M. 2005. Pedoman Buku Ajar Fisiologi Kedokteran, diunduh Januari 2014, from http://www.repository.usu.ac.id Khasani & Amriyah. 2012. Pengaruh Aromaterapi Terhadap Nyeri Pada Pasien Post Operasi Sectio Caesarea Di RSUD Kajen Kabupaten Pekalongan, diunduh Januari 2014, from http://www.keperawatan.onsoed.ac.id Koensoemardiyah. 2009. A-Z Aromaterapi Untuk Kesehatan, Kebugaran, dan Kecantikan. Yogyakarta: Andi Notoatmodjo, Soekidjo. 2005. Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta Sugiyono. 2013. Metode Penelitian Pendidikan. Bandung: Alfabeta 143 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Tamsuri, Anas. 2012. Konsep Dan Penatalaksanaan Nyeri. Jakarta: EGC Pamungkas, Zaviera. 2011. Deteksi Dini Kanker Payudara. Yogyakarta: Bukubiru Purwoastuti, 2008. Kanker Payudara. Yogyakarta: Tanisius Prima, Iga 2011. Aromaterapi Lavender Sebagai Media Relaksasi. Diunduh 144 Januari 2014, from http://www.portalgaruda.org.com Sharma, Sumeet. 2009. Aromaterapi. Jakarta: Karisma Wijaya, D. 2010. Pembunuh Ganas Itu Bernama Kanker Serviks. Yogyakarta: Sinar Kejora Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology PARENT COMMUNICATION RELATIONSHIP AND EXPOSURE FORNOGRAFI KNOWLEDGE OF YOUTH ON SEXUAL BEHAVIOR IN ADOLESCENT IN SMA AL-ABDI BAHLIAS EMPLASMENT, PT. PP. LonSum 2014 Renny Sinaga, Kandace Sianipar Poltekkes Medan Prodi Midwifery Pematangsiantar Jl. Pane No. 36 Pematangsiantar According to WHO (World Health Organization) approximately one-fifth of the world's population are adolescents aged 10-19 years. About 900 million are in developing countries. The demographic data in the United States shows the number of adolescents aged 10-19 years about 15% of the population. In the Asia Pacific region where the population is 60% of the world population, one-fifth are adolescents aged 10-19 years. In Indonesia, according to the Central Bureau of Statistics 10-19 years age group is about 22%, consisting of 50.9% boys and 49.1% girls (Soetjiningsih, 2010) .In Indonesia sex behavior is increasingly rising , as a result of such behavior is a pregnancy outside marriage, rape, prostitution outbreak among teenagers, abortion, sexually transmitted diseases, sexual abuse, sexual perversion etc. There are a lot of the background events free sex in adolescents, such as lack of knowledge of sexuality, fornografi exposure in the mass media is very easy to access and lack of communication berkualitasnya parents and children. This research is a quantitative research, aims to determine the relationship of exposure fornografi, parent communication and knowledge of adolescents with adolescent sexual behavior in high school at Al-Abdi Bahlias Emplasment, Pt. Pp. Lonsum, population in this study is the student4grade XI in SMA AL-ABDI as many as 44 people. The whole population sampled. Analysis of the data used is descriptive statistics and inferential statistics. The results showed characteristics of the respondents is as follows, the majority of respondents had a number of relatives more than one person, the first communication about sex once in the can after 12 years old, parents work the majority of respondents are employees of the garden. Results of statistical test Chi Square with the results obtained fornografi exposure is not significantly associated with adolescent sexual behavior with the value ρ = 0.115. The next variable is the knowledge teens also not significantly associated with adolescent sexual behavior towards value ρ = 0.467, frequent communication of parents with teenagers, were significantly associated with adolescent sexual behavior. Schools are advised to further expand students' understanding of sexual health by adding knowledge about sexual health in the curriculum and with a more in-depth counseling. Keywords: Adolescent. fornografi, sexual behavior 1. BACKGROUND. According to WHO (World Health Organization) approximately one-fifth of the world's population are adolescents aged 10-19 years. About 900 million are in developing countries.The demographic data in the United States shows about 15% of the population is adolescents aged 10-19 years. In Asia Pacific region where 60% of the world population, one-fifth are adolescents aged 10-19 years. In Indonesia, according to the Central Bureau of Statistics about 22% are aged 10-19 years consisting of 50.9% boys and 49.1% girls (Soetjiningsih, 2010). In Indonesia, Free Sex is increasingly rising, that cause Outside marriage pregnancy, Rape, prostitution outbreak among teenagers, abortion, sexually transmitted diseases, sexual abuse, sexual perversion, etc.There are a lot of things that cause free sex in adolescents, such as lack of knowledge of sexuality, Pornography exposure in the mass media is very easy to access and lack of communication quality between parents and children. Pornography problem in adolescents often worried parents, educators, officials, governments, experts, and so on. In every second, 28. 285 people in the world viewing pornography on the Internet. Number of pornographic Web pages in the world reached 420 million. 70% of internet users are leading to pornographic sites. From various studies show that sexual behavior has a correlation with adolescent attitudes toward sexuality. Sexual behavior research in 4 cities shows that 145 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology in Surabaya 3.4%, Kupang 31.1% , Jogyakarta 8.5% and Medan 3.6% of adolescents have been actively involved sexually active (Soetjiningsih 2010 ). In Bali, Wingkie Pangkahila examined the sexual experiences of the students noted that 102 of 375 boys (27.2%) and 53 of 288 girls (18.4) said they had sex with his own friend or commercial sex workers (CSWs ). They often have sex as they watch so often in porno videos (Soetjiningsih, 2010). North Sumatra itself, is the third area accessed pornographic sites after Yogyakarta and Bandung. There are still many places in Siantar that are often encountered by students doing nasty Such as, Binaling or Flora inn. Knowing his daughter was in Flora Inn, a parent of Junior high student in Siantar,M, was angry. Even her daughter stayed with her boyfriend for two days. Then the old man made a report of complaints that M and her boyfriend was taken to the Central Police Services Integrated room with reasons have been abusing the child (Sumatra info, 2012). Parent communication identified as a protective factor to against the Adolescent sexual behavior that has a risk in reproductive health. Results showed that parent communication is an aspect that can strengthen the close relationship between parents and teenagers. (Martino et al, 2008) and also the norm internalization of values, beliefs, attitudes and expectations of parents on teenage (Forehand, R, et al , 2007) In addition to parental attitudes that are still not open about sex, parents also often do not understand the subject matter of this one. Nevertheless, parents remain the most powerful influence in shaping the moral teens about sex (Sarwono, 2012). Knowledge of adolescents about reproductive health is still very low. Only 17.1% of women and 10.4% of men who know the true about the fertile period and the risk of pregnancy, young women and men aged 15-24 years who know the chances of getting pregnant by having sex only once each totaled 55, 2% and 52% (Kumalasari, Andhyantoro, 2012). The things mentioned above makes the writer interested in conducting research on the relationship among Pornografi exposure, Parent communication and Knowledge of adolescents with Adolescent sexual behavior in high school AlAbdi Bahlias Emplasment, PT, PP. Lonsum, 2014. 146 II. RESEARCH METODE The type of research used is quantitative research with cross sectional design. The location study was SMA Al-Abdi Bahlias Emplasment, Pt. Pp. Lonsum, first survey conducted in February 2014 and the research will be conducted in April-June 2014. The location is selected because the high school students are a group of adolescents and according to research objectives, in SMA AlAbdi Bahlias Emplasment, Pt. Pp. Lonsum had never done research on "Relations Exposure pornography, parents communication and knowledge of adolescent with Sexual Behavior". The population in this study is 44 student as student in class 1 SMA AL-ABDI . Whole population as sampled. In this study, the instrument that researchers used is a questionnaire containing closed questions about the variables to be studied, the frequency of exposure pornography, knowledge adolescents, parent communication and adolescent sexual behavior variables. The Analysis used is descriptive statistics and inferential statistics. Descriptive statistics were used to display data frequency pornographic media exposure, parent communication, knowledge of adolescent and adolescent sexual behavior. In this case, the data is displayed in the form of frequency and percentage. Chi square test is used to determine the relation between frequency of exposure pornographic, parent communication, knowledge of adolescents with adolescent sexual behavior. Pearson Chi Square calculated at the time of crosstabulation between frequency of media exposure to pornography with parent communication, knowledge of juvenile and adolescent sexual behavior. III. RESULTS AND DISCUSSION 1. Characteristics of Respondents Characteristic Frequency Distribution of SMA AL-ABDI Student in Bahlias Emplasment, PT. PP. Lonsum, Bandar district . No Characteristic Gender - Male - Female Total Number Sib - 1 ps - > 1 ps Total Number N Percentage (%) 18 26 44 40.9 59,1 100 19 25 44 43,2 56,8 100 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Occupation 1. Farmer 2. Business 3. Gardener 10. Civil Servant 4. Pensions 11. Etc First communication of Sex 1. Age > 12 tahun 2. Age <12 tahun Total Number Parents monitoring - Poor - Good 5 5 25 1 7 1 11,4 11,4 56,8 2,3 15,9 2,3 36 8 44 81,8 18,2 100 10 34 22,7 77,2 Source: Data Primer June 2014 In this study the total population is 44 people that all students in the class 1 SMA Al Abdi, Emplasmen PT.PP Lonsum. The majority gender of respondents were female (59.1%) and the majority of respondents have Sib more than one person. The most of respondent’s parents has job as PT. PP Lonsum gardener and the minority was a civil servant. Questions about how old was responders get first information about the sexual, the majority of respondents (81.2, %) answer is after more than 12 years old. Parent behavior to children has impact for the perception and adolescent sexual behavior (Pangkahila 2007) 2. Sexual Behavior Sexual behavior in this study defined as sexual behavior carried out in conjunction with the others ranging from dating, hugging, kissing, petting, touching genitals and sexual intercourse undertaken without matrimony. Categories in this study were free sex with the high risk sex behavior with low risk. Indicating a high risk sex behavior made more dangerous, may threaten the possibility of pregnancy outside of marriage. Free sex with a low risk indicates sex actions undertaken merely ordinary things, such as a date, holding hands, kissing cheeks and forehead kiss, seduce and hug the shoulders. Table 4.2 Distribution Student / I Based on the sexual behavior of SMA AL-ABDI Bahlias Emplasment PT. PP. Lonsum , Bandar Simalungun District March to June 2014 Period No 1 2 Sexual behavior N Percentage (%) Low risk 32 72,7 High risk 12 27,3 Total 44 100 Source: Primary Data June 2014 Based on table 4.2, from 44 respondents 32 respondents classified their sexual behavior in the low risk category and 12 respondents (27.3%) sexual behavior with a high risk category. the result of McDonald Utomo research (2009) indicate premarital sexual behavior is caused by continuous stimulation through sexual material in the print media, the Internet, and through peer (peer). Teens start having sex before marriage is caused by various factors and factors that are important are situations that favor the occurrence of premarital sex. According Paikoff, (1995) adolescent premarital sex due to the situation or occasion teens together in a private room and the condition is called "situations of sexual possibility". In addition, adolescents declared that sex is done occasionally or rarely, so it is difficult to predict. Therefore, the reasons teens start having sex before marriage more is unknown, other than because of desire or sexual drive. Sex is considered to reflect the freedom, maintaining relationships, closeness, intimacy, or love. Curiosity and peer pressure and the pair may increase the incidence of premarital sex. 3. Exposure pornography with sexual behavior 147 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 4.3 Cross-tabulation pornography exposure with sexual behavior in high school students Abdi Bahlias Emplasment PT. PP. Lonsum ,Bandar Simalungun DistrictMarch to June 2014 Period Variable Sexual Behavior Low risk High risk F % F % Exposure Exposed 1982,6 4 17,4 pornograp hy Unexpos 1361,9 8 38,1 ed Numbe r ρ Value 23 115 21 In this study, exposure pornography is defined, namely the frequency of adolescents viewing pornography containing elements in the media, be in printed media (newspapers, magazines) and electronic media (television and internet). If teens always see pornography more than 1 time per month categorized adolescents are exposed to pornography and if only once or not at all never see categorized with unexposed pornography. The results showed the number of respondents exposed to the unexposed not much different. 82.6% of adolescents who are exposed to pornography admitted having sexual behavior considered low risk. The Commission on Obscenity and Pornography states that although erotica brief exposure can arouse sexual desire in both men and women. Moreover, it can cause emotional reactions such as restless, impulsive, aggressive and agitated (Rachmat, 2003). According to Santrock (2003), adolescents who are exposed to pornography media continuously, has the greater sexual desire. Pornography is drawings, sketches, illustrations, photographs, text, voice, sound, moving pictures, animation, cartoons, conversation, gestures, or other forms of messages through various forms of communication media and or performances in public, which contains obscenity or sexual exploitation which violate the norms of decency in society (Law No. 44, 2008). According Wallmyr and Welin (2006) adolescents who are often exposed to pornography media (more than 1 x per month) has a different idea about how to obtain information about sex with teens who had never exposed to pornographic media and youth media are rarely exposed to pornography (1 x per month) , Teenagers who rarely and never exposed to the media and 148 regards information about sex does not have to be obtained from pornographic media because the information can be obtained by asking friends, teachers and parents. From the test results using a chi-square statistic obtained ρ value 0,115> α = 0.05, so that H1 is rejected. The conclusion was that there is no correlation between the frequency of exposure to pornographic media with a frequency of adolescent sexual behavior in high school AlAbdi Bahlias Emplasment 2014. It showed even though teens admitted often exposed to pornography but they do not make risky sexual behavior cause gestation Research is not in line with the research Santrock (2003), adolescents who are exposed to pornography media continuously, the greater sexual desire. Adolescents receiving sexual messages from the media consistently pornography in the form of kissing, petting, even pre-marital sexual relations, but rarely explained as a result of sexual behavior that served as pregnant outside of marriage or an unwanted pregnancy. This makes teens do not think long to emulate what they saw. Teens consider their expertise and sexual satisfaction is in accordance with what they see. Similar thing also expressed by Zilmann and Bryan (2002) which states that when a person is repeatedly exposed to pornography, they will show a tendency to have a deviant perception about sexuality and also an increase in demand for the type of pornography that is more loud and distorted. Pornography can produce physiological and emotional arousal and increasing the level of stimulation is likely to produce some form of sexual behavior such as kissing, petting, masturbation or sexual intercourse. 4. Parent Communications Premises Adolescent Sexual Behavior Parent communication is defined frequency parents always give information and advice on sexually to adolescents. Categorized by good communication if the communication is done with a frequency more and worse if the communication is only once a month or not at all. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 4.4 Cross tabulation parent communication with sexual behavior in high school students Abdi Bahlias Emplasment PT. PP. Lonsum District of Bandar SimalungunPeriod from March to June 2014 Variabl e Commu Good nication Poor Sexual behavior Number ρ Low risk High risk Value F % F % F % 10 55,6 8 44,4 18 40,9 0,038 22 84,6 4 15,4 26 59,1 The results showed 59.1% of respondents said communication with parents is rarely performed and 40.9% of respondents said that communication is often done. Communication between parents and children can be a parental guidance that includes meeting the needs of children, providing motivation, religious education in the family. The purpose of communication between parents and children is to understand himself and the environment, make decisions carefully, to control impulses or desires that are less good and help in dealing with life in general so that teenagers do not fall into deviant behavior. Good communication between parents and children are expected to be able to sort out which one is good and which are bad about sex for himself. When parents are actively listening to the child the child's ability to express feelings and his heart is stimulated and increased. Thus the communication between parents and children has a very important influence in the formation of attitudes and sexual behavior of adolescents. In this study, although the teen said communication with poor people, but they tend to be low-risk sexual behavior. From the statistical test using chi-square value obtained 0.038 ρ <α = 0.05, so that H1 is accepted. The conclusion was that there is a relationship between the frequency of communication of parents with adolescent sexual behavior in high school Al-Abdi Bahlias Emplasment PT.PP.Lonsum 2014. This study is in line with the opinion of Fisher (in Kadarwati et al: 2008) which suggests that through communication parents have considerable influence on adolescent sexual attitudes and behavior. If the parents are willing to talk about sex with both teens tend to delay first sexual intercourse and develop an attitude similar to the tuanya.Sayang according to Hurlock (1980) only a few teenagers who wish to know the ins and outs about sex from their parents. Communication between parent and child can prevent teens from premarital sexual behavior, it is because there is established intensive communication between parents and child, sharing and problem solving together (Laily and Matulessy, 2004). In adolescence curiosity about sexual problems is very important in the formation of a new, more mature relationship with the opposite sex. Whereas adolescence information about sexuality issues should be started so teens do not seek information from another person or from sources that are not clear or even wrong at all. Giving information about sexual problems is important given to adolescents because it is associated with hormoneinfluenced sexual drive and often do not have enough information about their own sexual activity. Of course, it would be very dangerous for the formation of adolescent life, if he does not have the right knowledge and information. 5. Knowledge of adolescent sexual behavior In this study operationalized knowledge is the ability of students to understand about premarital sexual behavior and the impact of premarital sex. Knowledge categorized on 2 categories: knowledge of good and less. Good knowledge level if respondents correctly answered questions via a questionnaire of more than 60% and less knowledge level if the respondents answered less than 60%. Table 4.4 Cross-tabulation knowledge of sexual behavior in adolescents with high school students Abdi Bahlias Emplasment PT. PP. Lonsum, Bandar Simalungun District March to June 2014 period Variable Sexual Behavior Low risk High risk F % F % Knowled Good 19 70,4 8 29,6 ge Poor 13 72,7 4 23,3 Total 32 72,7 12 27,3 Numbe r ρ F % Value 27 10 0,467 0 17 10 0 44 100 From the table above were found knowledge of adolescents about sexual majority that 21 respondents (61.4%) are in Good category and 38.6% of respondents are in the Poor category. From 17 respondents who have poor knowledge, 13 people (72.7%) admitted having sex with a low risk, and of the 27 respondents who are knowledgeable both 149 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 19 respondents (70.4%) of respondents admitted with low-risk sexual behavior. From the test results using a chi-square statistic obtained ρ value 0,467> α = 0.05, so the conclusion is rejected H1 adolescent knowledge was not significantly associated with adolescent sexual behavior in high school Al-Abdi Bahlias Emplasment PT.PP.Lonsum 2014, although not statistically associated but when viewed from the cross tabulations, we can know that, the better knowledge of youth, the less risky sexual behavior against him. Knowledge associated with adolescent premarital sexual behavior (p value = 0.022 <0.05). According Notoatmodjo (2003), knowledge is the result of know, and this occurred after people perform sensing on a particular object. Good knowledge supported by the level of knowledge of good parents in providing information about premarital sex (Hurlock, 2004). According Syafrudin (2008), knowing a half is even more dangerous than not know at all. Formation of knowledge itself is influenced by internal factors, namely the individual way in response to external knowledge and a stimulus to transform this knowledge into better again. According to Prayitno (2008), A good knowledge is when respondents understand and know about premarital sex. According Amrillah (2006), the higher the reproductive health knowledge possessed, the lower adolescent has premarital sexual behavior, conversely the lower the reproductive health knowledge possessed if the higher adolescent has premarital sexual behavior. Knowledge is influenced by level of education, age, experience, occupation, income, culture, and association. Knowledge that is not appropriate, unrealistic expectations, low self-esteem, fear of not being successful or pessimistic, showing that teens have an immature personality and emotional instability, so easily influenced doing negative things, such as premarital sex. Good knowledge of sexuality could make teens have healthy sexual behavior and responsible. A false understanding of sexuality in adolescents make them try to experiment on the issue of sex without realizing the dangers of his actions, and when the problems posed by the sexual behavior began to emerge, teens are afraid to express these problems to the parents. V. CONCLUSION 150 1. In this study, there is no correlation between the frequency of exposure to pornographic media with a frequency of in high school Al-Abdi Bahlias Emplasment 2014.Fornografi exposure for class 1 student in SMA AL- Abdi PT.PP Lonsum adolescent sexual behavior 2. The communication of parents has a significant impact to adolescent sexual behavior in high school Al-Abdi Bahlias Emplasment PT.PP.Lonsum 2014. 3. Adolescent knowledge was not significantly associated with adolescent sexual behavior in high school Al-Abdi Bahlias Emplasment PT.PP.Lonsum 2014. VI. SUGGESTION a. For School This study can be reference for increasing students understanding about Sexual health by adding Sexual study in Curriculum. b. For Student Student can improve their knowledge about premarital sex, parent communication and the effect of pornography. BIBLIOGRAFI 1. Amrillah, AA, Prasetyaningrum, J.Hertinjung,WS,(2006), Hubungan antara Pengetahuan dan Kualitas Komunikasi Orang Tua –Anak dengan Perilaku Seksual Pranikah, Indigenous, Jurnal Ilmiah Berkala, Psikologi, Vol.8. No.1. 2006 2. Baldacchino, R. D. (2006). Nursing competencies for spiritual care. Journal of Clinical Nursing ,15, 885-896. 3. BKKBN,(2010), Masturbasi Yang Kelewat Sering Bisa Berbahaya,Http://Www.Bkkbn.Go.Id.Diaks es Tanggal 15 Maret 2014 4. Bungin B,(2003). Pornomedia : Kontruksi Sosial teknologi telematika dan perayaan seks di media massa, Jakarta,Kencana 5. Forehand,R,Armistead,l.long et al,(2007) efficacy of parent based sexual risk prevention program for African American preadolescents : randomized controlelled trial, arch pediatr adolesch med, 6. Hurlock, Psikologi B. Elizabeth. perkembangan 1980. Suatu Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 7. 8. 9. 10. 11. 12. Pendekatan Sepanjang Rentang Kehidupan, Erlangga. Kadarwati, dkk, (2008), Sikap Remaja Terhadap Perilaku Seks Bebas Lebih Dipengaruhi Orang Tua Atau Teman Sebaya, Indigenous Journal Ilmiah Berkala Psikologi, Vol.10.No.1.Mei 2008 Kompas, 2012. Hubungan dengan Ayah Pengaruhi Perilaku Seks Remaja, [online] <http://dkijakarta.bkkbn.go.id/ViewBe rita.aspx?BeritaID=677> [accessed: 14: 10 WIB, 18 Maret 2014]. Laily, N dan Matulessy,A, 2004, Pola Komunikasi Masalah Seksual Antara Orang Tua Dan Anak , Anima Indonesia Psychologikal Journal, Vol.19.No.2. Lia. 2012. Upaya Meningkatkan Kreativitas Anak Melalui Bermain Lukisan Biji Biji Pada Anak Kelompok B Di Tk Pertiwi Krakitan, Bayat, Klaten . Surakarta: UMS Martino, et al,(2008), Beyond “The Big Talk The Roles Of Breadth And Repetition In Parent Adolescent Communication About Sexual,Pediatric Kompas, 2012. Hubungan dengan Ayah Pengaruhi Perilaku Seks Remaja, [online] <http://dkijakarta.bkkbn.go.id/ViewBe rita.aspx?BeritaID=677> [accessed: 14: 10 WIB, 18 Maret 2014]. 13. Pangkahila W, (2007), Memperlambat Penuaan Meningkatkan Kualitas Hidup 14. Rakhmat ,J,(2003), Psikologi Komunikasi Bandung, PT, Remaja Rosdakarya 15. Sarwono, W.S., 2012. Psikologi Remaja. Jakarta : Raja Grafido Persada 16. Santrock, JW,(2003),Adolescence Perkembangan Remaja, Jakarta, Erlangga 17. Soetjiningsih, 2010. Tumbuh Kembang Remaja dan Permasalahannya. Jakarta: Sagung Seto. 18. Tarwoto, Aryani, R. dan Nuraeni., 2012. Kesehatan Remaja. Jakarta : Salemba Medika. 19. Utomo Idan Mc, Donald,P,(2009), Adolescent reproductive health in Indonesia contested values and policy studies, family planning vol.40.no.2. Verawati, 2014. Peran Pik Remaja Menghadapi Tingginya Trend Pacaran Dan Pengalaman Seksual Remaja,[online] <http://sulbar.bkkbn.go.id/ViewArtikel. aspx?ArtikelID=134 [accessed : 21:30 WIB, 19 Maret 2014] 151 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology ANALYSIS PREPAREDNESS OF GENERAL HOSPITAL Dr. FL. TOBING SIBOLGA IN IMPLEMENTATION OF ASSURANCE NATIONAL HEALTH POLICY 2014 Siti Marlina 1, Juanita 2, Siti Zahara Nasution 2 1 Alumni Program Pascasarjana FKM-USU, Medan 2 Staf Pengajar FKM-USU, Medan ABSTRACT The enforcement of Law No. 40/2004 on SJSN (National Social Assurance System) and Law No. 24/2011 on BPJS (Social Assurance Provider Board) needs complete preparedness by a hospital as health assurance provider. Dr. FL. Tobing General Hospital, Sibolga, is one of the hospitals which provide SJSN. The objective of the research was to find out the preparedness of Dr. FL. Tobing General Hospital, Sibolga, in implementing the policy in the National Health Assurance, in 2014. The research used qualitative method with ten informants who were regarded as the qualified persons who understood the preparedness in implementing health assurance program. The data were gathered by conducting interviews, observation, and documentation. The result of the research showed that socialization had been conducted by the management of the hospital and by BPJS Sibolga Branch. There was no preparedness in health facilities because of the lack of health equipment, human resources were ready both quantitatively and qualitatively, disposition of the implementation of health care in the hospital was good, and coordination between the structure of hospital bureaucracy and BPJS had been done well. The conclusion of the research was that the management of the hospital had no preparedness in health facilities for the implementation of the National Health Assurance Program. It is recommended that the management the hospital should complete and improve its facility and infrastructure, the government should pay more attention to the implementation of JKN program, and socialization to public should be optimized. Keywords: Implementation of Policy, National Health Assurance, Hospital INTRODUCTION The National Health Insurance (JKN) is part of the National Social Assurance System (BPJS) held by using the mechanisms of social health insurance which is compulsory (mandatory) based on Law No. 40 of 2004 on National Social Assurance System with the aim to meet the basic needs of a decent public health which is given to every person who has paid dues or dues paid by the government. JKN starting from 1 January 2014, which gradually toward thorough coverage (Kemenkes RI, 2013). JKN purpose generally is easier for people to access health services and obtain quality health services. Changes in the financing system toward a comprehensive coverage is a good thing but it has side effects and risks. Inequality availability of health facilities, health workers and geographical 152 conditions, give rise to new problems in the form of inequity between community groups (Kemenkes RI, 2013). Social Assurance Provider Board (BPJS) is an institution established to administer social assurance programs in Indonesia, according to Law No. 40 of 2004 and Law No. 24 of 2011. In accordance with Law No. 40 of 2004 on the Social Assurance, BPJS a non-profit legal entity. Under Law No. 24 In 2011, BPJS will replace a number of existing social assurance institutions in Indonesia, namely PT Health Insurance Agency. Askes Indonesia became BPJS Health and social assurance institutions manpower PT. Jamsostek into BPJS Employment (Sijabat, 2012). Transformation PT Askes and PT Jamsostek into BPJS done gradually. In early 2014, PT Askes will be BPJS Health, then in Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 2015 the turn of PT Jamsostek into BPJS Employment (Ariyanti, 2013). The principle of social assurance benefits is usually the form of cash and the value of health services appropriate basic life needs such as food, clothing, shelter and basic medical needs. Provision of social assurance benefits is based justice in the sense that benefits provided applies to all citizens of the rich countries, poor or nearly poor, because social assurance is a permanent lifetime. The third principle is the cornerstone in the implementation of the social assurance system sustainable (Kemenkes RI, 2012). In order to materialize the implementation of a sustainable social assurance system, the social assurance held nationwide by forming an independent BPJS based social assurance law. Social assurance guarantees provide certainty for the community in order to achieve the fulfillment of basic life evenly as mandated by Article 28H of paragraph (1) of the Constitution of the Republic of Indonesia Year 1945 has affirmed that every person has the right to obtain medical care, and in Article 34 paragraph (3) shall be declared the state responsible for the provision of health care facilities and public service facilities are decent (Kemenkes RI, 2012). As stated in Article 2 of Law of the National Social Assurance System (SJSN), the Social Assurance organized by the principles of humanity, the principle of benefit and the principle of social justice for all Indonesian people. If the implementation of the Social Assurance is not based on the three principles, then there is a violation of that law. Or negligence in covering and serving the health insurance for the poor, including poor people, basically a violation of the principle of humanity. Then, the principle of social assurance benefits in the design should provide significant benefits for the participants, not least to guarantee the fulfillment of basic needs for participants including a comprehensive health services, while the principle of fairness in the administration of the Social Assurance applies to all levels of society, rich, medium or poor order created the principle of cooperativeness (Purwoko, 2012). Social Assurance System is a system of social protection for all citizens. Social protection has a strategic role to address the vulnerability due to the risk of natural and economic risks. As we know that Indonesia is one of the disaster-prone areas and the impacts of disasters resulting relocate the budget required to rebuild the damaged infrastructure. The disaster also left many families losing possessions and life, so it is quite difficult in an effort to improve people's welfare (Zaelani, 2012). One health care provider JKN program in Sibolga City is General Hospital Dr. FL. Tobing Sibolga which is the General Hospital of Class B Non Education, seeks to provide health services as much as possible in accordance with the facilities and tools available, have 204 beds 204, Human resources 338 people, medical services include specialist outpatient services, inpatient care and support services for the installation of medical services. In general, any type of outpatient services take place every weekday and is open to any public or patient health insurance (ASKES) / poor family health insurance (ASKESKIN) / Community Health Insurance (JAMKESMAS) with or without a referral. Medical record data General Hospital Dr. FL Tobing Sibolga (2012) shows the value of Bed Occupancy Rate (BOR) 50% (national standard of 60% -80%), and Length Of Stay (LOS) was 4 days (standard 2 days) with the highest proportion of patient visits askes 45.24 %, ie 40.06% of patients general, and 13.5% of patients jamkesmas. This condition shows that the public interest to come for treatment to the General Hospital Dr. FL Tobing Sibolga still low. Viewed from the aspect of management at the General Hospital Dr. FL Tobing Sibolga, still encountered problems of lack of services in accordance with Standard Operating Procedure in every unit of services, such as nursing care and midwifery care. This is indicated by the lack of reports on the development of nursing care of patients and the patients are still many complaints against the availability of drugs and consumables in hospitals. Based on the results of the initial survey conducted by researchers in January 2014, it is known from the aspect of the facility is very adequate hospital, where medical support units also function optimally as radiology, laboratory and blood services unit. But the results of a brief interview with 153 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology the head of medical services and treatments suggested that health services for participants JKN still not well served, it is seen from the limited socialization JKN program for service providers in hospitals, as well as the still weak coordination with BPJS in the claiming process. Currently the General Hospital Dr. FL Tobing Sibolga also preparing health care participants of the National Health Insurance. Based on the above, the authors are interested in knowing the extent of readiness of the General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. Based on the background described, the problems in this research are: how Readiness General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. This research aimed to analyze readiness General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. The benefits of this research are: 1. This research is expected to be input for the Hospital of the readiness of the implementation of the National Health Insurance policy so that it can be taken into consideration in improving the implementation of National Health Insurance. 2. It is expected that this research can be used as an additional reference regarding health policy and learning materials as well as contribute ideas in preparation for the implementation of the National Health Insurance policy at the hospital. 3. This research can increase knowledge and scientific insights scientific author on the readiness of hospitals in the implementation of the National Health Insurance policy RESEARCH METHODS The method used in this research is qualitative research. This research therefore only describe how analysis Readiness General Hospital FL Tobing Sibolga in the Implementation of the National Health Insurance Policy 2014. Qualitative research is a type of research that revealed the objective conditions of the phenomenon that occurs with the approach of in-depth interviews (Sugiyono, 2006). 154 Research conducted at the General Hospital dr. FL. Tobing Sibolga. The choice of location is based on the consideration of the research has not been done the same with this research, because the policy is still relatively new JKN as of 1 January 2014. The research began by surveying beginning in January 2014, the collection of data with in-depth interviews and observations conducted in July 2014. Qualitative research is not intended to make a generalization of research. Therefore, in qualitative research, is not known for the sample population. The subject of research became an informant who will provide the necessary information during the research process (Maleong, 2002), informants are people who used to give information about the situation and condition of background research. Informants in research in all the elements that are involved in policy implementation JKN program in General Hospital Dr. FL Tobing Sibolga consisting of: 1. Components General Hospital Dr. FL. Tobing Sibolga a. Director of the General Hospital Dr. FL Tobing Sibolga b. Head of Medical Services and Treatments c. Head of Planning and Development d. Chairman of the Medical Committee e. Head of Pharmacy Installation 2. Components branch BPJS Sibolga the head unit hospital services. 3. Inpatients and outpatients at the General Hospital Dr. FL Tobing Sibolga. Based on the above, the research determines informants using purposive sampling and snowball sampling are. Sampling with purposive sampling technique means that the sampling technique based on certain considerations namely, informants authors choose are the ones who are involved directly to the issues being studied. Snowball Sampling The samples are still provisional data sources and will develop later after researchers in the field. (Sugiyono, 2005). Snowball sampling is used when in the process of data penggumpulan there's more varied opinion, the researchers will look for another informant so that the necessary data is sufficient to describe the phenomena related to the objectives of this research . Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Data analysis in qualitative research is rather complicated because the data are quite a lot of variety and there is no standard pattern. According to Bogdan, who was quoted by Sugiyono (2005), data analysis is the process of systematically searching for and compiling the data obtained from interviews, field notes and other materials that can be easily understood and the findings can be communicated to others. Data analysis was performed by organizing the data, translate it into the units, synthesize, organize into a pattern, choose what is important and what will be learned and make inferences that can be passed on to others. Sugiyono (2005), citing the opinion Spradley, also argued that the analysis in the research of any kind, is a way of thinking, relating to systematically test for something to define the part, the relationship between parts, and its relationship to the whole. Thus, the analysis is to look for a pattern. Based on the statement of the experts, Sugiyono (2005) concluded that the data analysis is the process of systematically searching for and compiling the data obtained from interviews, field notes, and documentation, by way of organizing data into categories, describe into the units, perform synthesize, organize into a pattern, choose what is important and what will be learned and make conclusions so easily understood by myself and others. According Sugiyono (2005) Miles and Huberman cites the opinion that the activity in qualitative data analysis is done in an interactive and takes place continuously at every stage of research so as to completion, and the data until saturated. RESULTS AND DISCUSSION Readiness Communications Communication is one of the means to disseminate information or orders from superiors to subordinates and from subordinates to superiors. The information provided should be clear, accurate in time delivery of information and information submitted must be consistent or significant permanent or not plus-added or subtracted. According to Hovland, Janis & Kelley communication is a process through someone (communicator) deliver stimulus (usually in the form of words) with the aim of changing or shaping the behavior of others (Riswadi, 2006). While Harold Laswell said communication is basically a process that describes the "who" says what channel what to whom, and with what result or outcome. Laswell paradigm indicates that communication includes five elements, namely communicator, message, media, communicant and effect. JKN program policies made by the central government in this case the Ministry of Health are socialized to other interested parties through a socialization program JKN. JKN socialization at the General Hospital Dr. F.L. Tobing is done in cooperation with BPJS Sibolga, socialization is done by creating a meeting / conference or delivered at the time the apples or the circular letter to the hospital management, all nurses, specialists, general practitioners, and all associated with the hospital and the patient. Dissemination to patients conducted by the Health Office of Sibolga City and BPJS. General Hospital Dr. FL. Tobing Sibolga is a hospital into a referral health services on the west coast of North Sumatera, where the policy JKN with BPJS as the responsible person must be involved in the program. In general, the communication between the hospital with BPJS no problem. BPJS which holds the mandate of the laws directly apply JKN automatically on January 1, 2014, including in cooperation with health care is the hospital. General Hospital Dr. FL. Tobing Sibolga with BPJS branches can work together with effective communication and better coordinate with each other. Effective implementation will be realized if the implementation of policy implementation to know what will be done. George Edward III suggests three variables that can measure the success of the first communication, namely the transmission or distribution of information. Distribution of good information will produce good policy implementation as well. In this research , the distribution of information is good. Information about JKN received by the hospital received. This is due to the special meeting held to discuss the program with the BPJS JKN. The second variable is the clarity of the information received by the policy implementer of policy makers should be clear and not confusing or ambiguous. In the results 155 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology of this research showed that the informant was aware of the policy implementation JKN unknown content of information disseminated in the form of policy regulations, regulations on JKN, a presidential decree, the minister of health regulations, the method of payment (contribution), referrals, benefit from JKN, the membership of the National Health Insurance, national formulary, e-catalogs, and the Compendium alkes and others concerning the JKN program, while the content (content) submitted by BPJS is PT. ASKES changes to BPJS health. The third variable is the consistency. The information disseminated via the communication must be consistent, the information disseminated should be fixed and unchanging. Message JKN program has consistently delivered good message to implementing policy and to the parties concerned. This means that the individual is given the same message without any changes. It can be seen with the statement by the informant for the delivery of organizational communication socialization and mass communication in which media organizations to produce and disseminate widely the message to the public is through the media of radio, television, newspapers and leafleat and banners. This research is in line with research Lilian (2013) which is a form of socialization of health insurance programs carried out through leaflets and direct socialization kepadapasien who came for treatment at the health center Batua Makassar. Socialization among hospitals with BPJS done by a meeting between the leadership and the vision to unite the common goal for this JKN program. The unification of this vision should be able to bring the constitutional mandate JKN not to the interests of a particular institution. Therefore, strong leadership can encourage impelemntasi policies to conform with the original purpose as by USAID (2010), which states that leadership is a very substantial factor in policy implementation. Leaders at the top level is policy makers, technical breaker, which decided to cooperate or not on the institution they leads. Therefore, the leadership could be a solution to overcome the problems of communication between institutions that could impede the implementation of this JKN. Good communication occurs for two reasons, first the intensity in establishing 156 coordination and collaboration between the two institutions. The second is the lack of clarity in implementing this program. This happens because prior to the enactment of the JKN General Hospital Dr. FL. Tobing Sibolga has been implementing the program JAMKESMAS and other health insurance programs. The involvement of hospitals in the delivery of programs JKN the key factor in the success of the program. When linked existing socialization field are performed only at the device level only, while for the public to very little or very minimal. This is in line with research Muliaddin et al (2005) and research Riegel et al (2013) which states that the dissemination to the public still needs to be done and further optimized to provide insight to the public about the benefits of the health insurance program. In contrast to research Hastuti (2010) that the socialization conducted by the health department regarding the health program in health centers Magelang district is considered good enough. Readiness Resources In the implementation of the policy should be supported by the resources both human resources, material and regulations or guidelines. Goals, objectives and policy content, despite being communicated clearly and konsiten, but if the lack of resources to implement the, then the implementation will not run properly. The existence of factor resources in order to implement policies JKN Program plays an important role in the success of the policy inplementasi, without adequate resources, what is planned will not be the same as what is ultimately implemented. Indicators of resources in the implementation of existing policy 3 that policy instrument that is the source of funds, human resources, and facilities. Policy instruments related to the dissemination of information. No policy information in two forms, namely information relating to the way of doing policy implementation and compliance of information regarding the implementation of the implementing rules and laws that have been established. Policy instruments is one form of information that describes the program or activity that must be done in order to implement the policy, from the data informant mind that they have a Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology policy instrument JKN program that is the president of the Republic of Indonesia regulation No. 12 Year 2013 on Health Insurance, regulation Repubik health minister of Indonesia Number 71 of 2013 on health care in the National Health Insurance. Regulation No. RI health minister 28 2014 on guidelines for the implementation of JKN program, health minister's decision No. 328 / Menkes / IX / 2013 on the national formulary, health ministerial regulation No. 59 of 2014 concerning the standard rates of health services in the administration of the program JKN, health ministerial regulation No. 27 2014 on technical guidelines Indonesian system Base Case Group (INA-CBGs) and others. Funds or financial aspect is a very important aspect in supporting the implementation of policies JKN. Based on the survey results revealed that the financial resources in the implementation of JKN program in General Hospital Dr. FL. Tobing Sibolga prepared with the payment system (claiming) INA CBGs where hospitals are already doing education and training on computerized data management INA CBGs held in Jakarta. Based on the above statement can be concluded that the health resources or health personnel in the General Hospital Dr. FL. Tobing Sibolga classified prepared in providing health services in JKN program. Human resources are not only talking about the number of health workers alone. Due to successful implementation of policies is also strongly influenced by the ability of (quality) of these resources. This is according to Edward III which states that the principal amount in analyzing the resources needed for the implementation of the policy is to analyze the magnitude and quality. It was found that the availability of health workers in health service delivery in the era of JKN according to the informant is sufficient or adequate, but instead according to researchers both in terms of the amount still lacking, it can be seen from the number of available 204 bed compared with the amount Source its human General Hospital Dr. FL Tobing Sibolga which is about 338 people consisting of basic medical personnel (doctors and dentists), specialist doctors, nursing and midwifery personnel, medical support staff and non-medical support personnel. Human Resources for specialist doctors in the General Hospital Dr. FL Tobing Sibolga suffice as many as 17 people, just not all the medical specialists are / live in the city of Sibolga so if suddenly required will hinder the process of work in the General Hospital Dr. FL. Tobing Sibolga. This is in accordance with the opinion of informants stated that for anesthesia personnel just one person, if the doctor is unable to attend the hospital will be shorthanded. Nursing staff at the General Hospital Dr. FL. Tobing Sibolga also inadequate seen from the number of nursing personnel, only 164 people while 204 bed, based Pemenkes no. 340 / Menkes / Per / III / 2010 that the ratio of nursing staff and the bed was 1: 1, it is compared with the opinion of the informants who said that the nursing staff at the General Hospital Dr. FL. Tobing Sibolga is enough. Informants stated that education and training had been conducted by a team at the hospital JKN held in Jakarta for the management of computer data for INA CBGs. Training is needed not only for the power that would operate a computer for recording and reporting administration, but also health workers need to do the training, including the hospital director. Director of the General Hospital Dr. FL. Tobing Sibolga has never participated in the training because the director of the General Hospital Dr. FL. Tobing Sibolga only is the task of implementing the newly served by June 2014. Observation and in-depth interviews to health facilities for aspects of the physical appearance of a physical building standard is good, the location is easy to reach the community, well-organized health services, medicines and consumables sufficient, for there are still some health facilities are lacking because of broken tools and still in improvements, such as a HD yet prepared at the General Hospital Dr. FL Tobing Sibolga and planned to be prepared in 2014, for the infrastructure still not ready because medical equipment is lacking and needs to be completed. This research is in line with research conducted Luti et al (2012), which states that the condition of the facilities and infrastructure of health services in the district of Lingga archipelago area pretty much inadequate, eg medical devices, drugs, facilities, transportation, and communication tools so that access to reach or reach people is still inadequate. 157 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Assessing the adequacy of health workers is not an easy thing. Differences in rural and urban areas in terms of sociological, geographic, demographic, infrastructure gives trouble to create a standard of how the need for health workers in the hospital. Based on the above it can be concluded that the information resources, funds, human and infrastructure related to one another. Although the policy instruments already owned by the informant, still required the deployment and administration of the instrument more so that implementers can find the National Health Insurance program as a whole. Funding for health insurance programs using INA CBGs and hospitals no difficulty because the existing hospital management training. Human resources already owned General Hospital Dr. FL. Tobing is sufficient and abilities they have been good. Facilities and infrastructure are still very limited, coupled with a tool is still inadequate. Disposition Readiness Other factors that are considered influential on policy implementation is the attitudes and perceptions of policy implementation to the task and its responsibility. If the executor behave like honesty, commitment to the democratic nature of a particular policy then it is likely they give support to the policy (Winarno, 2012). Integration of the characteristics of the structures. Patterns of behavior, interests, education, capabilities, and potential of a person. Disposition is one important factor in the implementation of effective policies. If the policy implementers have a tendency or a positive attitude in the implementation of the policy implementation is likely to be run in accordance with the original purpose. And if the policy implementers to be negative then the implementation of the policy will not run effectively or even the implementation of the policy will fail. Based on the research results get that from the disposition in the running policy were quite prepared JKN obtained from interviews to patients at the General Hospital Dr. FL. Tobing Sibolga well treated in inpatient and outpatient in the room stated that the attitude of specialist doctors, general practitioners, nurses, midwives and administrators in providing good health services, does not 158 discriminate with other patients. The same thing was also stated by the head of medical services and treatments as well as chairman of the medical committee that they look objectively attitude of health workers in providing better health services. Referring to the above regarding the attitude of the implementers in the General Hospital Dr. FL. Tobing Sibolga, research findings show a positive attitude and support towards the implementation of JKN, the General Hospital Dr. FL. Tobing Sibolga Sibolga with BPJS branches have the same commitment to the program JKN. Commitments related parties is strongly needed in strengthening the implementation of this JKN. Hospital as health services are wellprepared mengintegasikan themselves with this JKN program. BPJS constitutively already very ready to apply JKN, though always in the process of refinement. Commitment is a predisposing factor in self impelementator a policy, then it is proper implementation of this JKN supported by the commitment of all parties concerned. Even if there are problems that commitment should be able to solve these problems by improving communication and coordination. When, in principle, all parties want to fix this JKN the operational constraints should also be addressed. In applying JKN program director of the hospital should be able to have a positive attitude and be able to compile and menetapkankan staff appropriately and selectively. A positive attitude shown by the ability to carry out their duties with full responsibility. A positive attitude held by the director of the hospital will affect the staff to be positive as well to the program, so that the staff are motivated and doing their best to carry out his duties. Proper staffing would also ensure the implementation of good policies. Someone will perform optimally when placed on the specialty. Bureaucratic Structure Readiness Although the resources to implement a policy of sufficient and implementers of what and how to do it, and they have a strong desire to do so, the implementation could be ineffective because ketidakefisiensinya bureaucratic structure. The policies are so complex demands the cooperation of many people, when the Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology bureaucratic structure is not conducive to the policy, then this will lead to resource becomes ineffective and impede the course of policy. Bureaucracy as implementing a policy must be able to support policies that have been decided by way of a well coordinated. In this research , the standard bureaucratic structure that is intended is Standard Operating Procedure (SOP). Based on the results of the research showed that the standard operational at the General Hospital Dr. FL. Tobing Siboga in the implementation of this JKN ready. It can be seen from the secondary data that the author can General Hospital Dr. FL. Tobias has been carrying out accreditation and obtain the value of "B". An operational standard-setting concrete efforts in maintaining the quality of health services. Various countries are implementing national health insurance implement operational standards for the implementation of health care. For example in Ghana to implement that facility health care providers should provide standardized equipment and services. Later in the Philippines which sets standards that health care must have been operating for 3 years and is accredited and must conform to the standards Phil Healths especially in the relationship between human resources, equipment, and physical structure (Hsiao, 2007). CONCLUSION Based on the results of this research concluded that: 1. Readiness Communications Communication about JKN already quite ready and well established where hospitals in the dissemination of cooperation with BPJS to socialize in hospital visits from their banners installed in some parts of the hospital. 2. Readiness Resources a. Health manpower resources in running JKN program can’t meet the health care has not been effective due to the quantity and quality of resources available health workers have not been adequate. b. The readiness of health facilities in the program so far have not seen JKN readiness due to the infrastructure that still need to be completed 3. Readiness Disposition Commitment as one form of disposition in carrying out policies JKN ready. Overall the parties have agreed and are committed to implement JKN as well as possible. 4. Readiness Bureaucratic Structure Coordination of JKN program in General Hospital Dr. FL. Tobing BPJS Sibolga Sibolga to run properly. Hospitals as health care providers are ready to provide services and BPJS as the giver of the budget prepared by claiming system. ADVICE 1. Communication Expected to hospitals and BPJS order to improve socialization JKN with clear information dissemination and provide technical guidance JKN in order to provide information and socialization completely and correctly to all employees and staff in the hospital. 2. Resources a. Expected to hospitals in order to meet the human resource needs by proposing health workers and improve the quality of health personnel in accordance with the needs of patients through training. b. Recommended to the hospital to pay more attention and increase more facilities facilities and infrastructures in accordance with the strategic plan of the hospital. 3. Disposition Expected to hospitals to be able to maintain a good commitment to conduct regular meetings, and carry out monitoring and evaluation in order to improve JKN services at the General Hospital Dr. FL. Tobing Sibolga 4. Structure of Bureaucracy Expected hospital with BPJS can maintain and improve the coordination for the smooth implementation of JKN in Sibolga City 159 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECT OF ISOTONIC WATER TO THE ACTIVE PHASE OF PRIMIPAROUS UTERINE CONTRACTIONS Delmaifanis, Dra.Maryanah, Karningsih Jurusan Kebidanan Poltekkes Kemenkes Jakarta III ABSTRACT Nutrition and hydration is very important during the delivery process to ensure adequate energy and maintain normal fluid and electrolyte balance for mother and baby. One of the symptoms of dehydration are fatigue and it can interfere with the progress of labor and make it difficult for the mother to be more motivated and active during labor. One alternative rehydration on maternity is the provision of isotonic water . The purpose of this study was to determine the Effect of Isotonic Water to the Active Phase of Primiparous Uterine Contractions. The study design used a quasi - experiment . The population of this study were all birth mothers in the maternity ward of the pimary health care Cengkareng , West Jakarta , the sample is partially primiparous women giving birth in the delivery room PHC Cengkareng 2014. The sampling technique uses accidental sampling technique which amounts to 30 mothers who were divided into groups and group intervention control . The results showed there are Effect of Isotonic Water to the Active Phase of Primiparous Uterine Contractions. independent t -test , p value 0.000 < α ( 0.05 ) . Suggested for midwives to provide isotonic drinks on maternity as an alternative rehydration that adequate maternal contraction , so that labor can run well Key word : primiparous, uterine contraction, isotonic water Some factors that cause uterine contractions in adequate because the secondary factors, among others: the bladder is full, the influence of drugs, lying position, inadequate intake of food and drinks ahead of labor, exhaustion and dehydration. Many attempts to streamline the technique of uterine contractions, among others, ambulation, change position, emptying the bladder, nipple stimulation, and feeding and drinking. Food consumption suggested in the group of mothers at delivery was bread, biscuits, vegetables, fruits, low-fat yogurt, soups, isotonic drinks, and fruit juices (O'Sullivan et al, 2009). Kubli et al (2002), conducted a study of the effect of isotonic drinks compared to drinking only mineral water during labor at random, at 60 Capital in London. At the end of the first stage of labor, the mother who is only drinking water experienced a state of ketosis and lowering serum glucose levels. The volume of the stomach, vomiting and the incidence of vomiting in the second volume of the same group. There is no difference between the two groups on the results of labor. However, 160 isotonic drinks are advised to avoid the occurrence of ketosis in the mother during childbirth The purpose of this Research to determine the effect of isotonic drinks to quality maternal uterine contractions in primiparous in the first stage of the active phase Method Study design This research was a quasi experiment with a "cohort" using partograf. Administration of isotonic drinks during childbirth performed in the first stage of the active phase as much as 200 ml per hour. The research was done at the Public health center Cengkareng, West Jakarta in June - December 2014. Data collection using interviews and direct observation to the respondents. The instrument used is partograf sheet, and check list. Subjects The number of samples in this study were 30 Mother Maternity primiparous taken by purposive sampling were divided into two groups, 11 cases and 19 controls. Subject criteria were: maternal age 21-30 years, Estimated fetal weight 2500-3500 grams, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 1. shows the characteristics seen in the two groups of respondents is almost the same, based on the age of women giving birth there are 2 people aged 30-35 years in the group not given isotonic (control), general education level educated respondents junior high schools, high schools, there is one person who had elementary school, and 1 college. Most of the birth mothers are housewives physiological pregnancy, no accompanying diseases, not drink isotonic water in the last 24 hours, antenatal care four times, height> 145 cm, did not follow gymnastics pregnant regularly. Analysis All data were analyzed by using independent ttest to compare the average duration of uterine contractions in cases and controls Table 2. The results of T-test at the beginning of the observation showed that respondents with normal distribution value is 0.608, greater than 0.05. While the length of his long time there was no significant difference p> 0.05 Table 3. Results of T-test at the end of the observation showed that respondents with normal distribution t value is 0.872, greater than 0.05. While his long duration significant difference p <0.05 RESULTS Limitations of this study is that a minimum number of samples and the ratio of the amount of the treatment group and the control is lacking, so that respondents drawn less representative of the population. Besides, to see the quality of uterine contractions do not use tools that can really measure his strength is Cardiotocografi (CTG) but only by observing the length of his, it is consistent with the observation that there is in partograf. Variabel Umur 30 - 35 tahun 20 – 30 tahun Pendidikan SD SMP SMA PT Pekerjaan Tidak Bekerja Bekerja Not given isotonic Given isotonic Jumlah drinks (n=19) drinks (n=11) % % f f f % 2 18 100 64,3 0 10 0 35,7 2 28 6,7 93,3 0 9 9 1 0 61,1 45,7 100 1 2 8 0 100 38,9 54,3 0 1 11 17 1 3,3 36,7 56,7 3,3 14 5 63,6 62,5 8 3 36,4 37,5 22 9 71 29 Table 1. Characteristics of respondents by group Long contraction of the uterus early observations T test n Mean SD SE 0,608 Eksperimen 11 33,64 7,77 2,344 Control 19 31,84 6,91 1,586 Table 2. Duration of uterine contractions before being given isotonic drinks Group P value 0,518 Long end of the observation of uterine contractions T test P value n Mean SD SE 0,872 0,000 Eksperimen 11 52,27 3,43 1,03 Control 19 46,58 3,36 0,77 Table 3. Long contraction of the uterus in the first stage after the treatment in PHC Cengkareng 2014 Group 161 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Discussion Based on the results of the study showed that there are differences in the length of his maternal active phase of the first stage between the intervention group (given isotonic drinks) and control group (given sweet tea and mineral water) visible from the average length of his. Monitoring results at the end of the duration of his observations showed the intervention group over the 53 seconds compared to the control group 46 seconds. In addition, the results of the statistical test p value of 0.05 ˂ thus it can be concluded there is a significant correlation between the administration of isotonic drinks on the quality of his at birth mothers when one phase of PHC active in Cengkareng, West Jakarta Isotonic drinks are beverages that can help replace fluids and electrolytes lost in conjunction with human perspiration. Isotonic drinks needed by the body to maintain the condition of the body's cells in a state of homeostasis. When the body is in a state of homeostasis, all processes in the body to run well. Meanwhile, if the body is dehydrated, it will affect the entire organ work and processes in the body (Winarti, 2006) According to the study, dehydration makes the body more tired. This fatigue occurs because inhibition of glycogen breakdown process changes into energy. The lactic acid should be used as a power, does not work because the body is dehydrated. The content of sodium, potassium, contained in an isotonic drink has an important role in maintaining the balance of the liquid electrolyte, so the body does not easily lose fluid and become dehydrated. Additionally, sodium and potassium also plays a role in nerve transmission, regulation of enzymes, and muscle transmission Muscles may contract due to the release of energy available in the form of ATP in the muscle cells. ATP in the cell are limited and can be used as an energy source in just 1-2 seconds. Muscle contraction will persist if the ATP that has been reduced reshaped. The reestablishment of ATP can be derived from creatine phosphate, glucose, glycogen, and fatty acids. Prolonged contraction of muscles can cause muscle fatigue. This is due to the inability of the process of muscle contraction and cell metabolism. Solving process energy 162 for muscle contraction in an anaerobic cell known as the Kreb cycle, where the glycogen or glucose will be split into pyruvic acid to produce energy in the form of ATP and NADH2. Then pyruvat acid is converted to acetyl Co A is then entered into the mitochondria for complete oxidized into CO2 and H2O to produce great energy If the shortage of ATP, the action potential of muscles and nerves become weak, if it occurs in the smooth muscle of the uterine myometrium resulting kontrakasi weak and inadequate. Barriers blood flow to the muscles that are contracted also resulted in muscle fatigue. Fatigue is caused by lactic acid product. This product is produced from anaerobic process. Therefore, at the time of delivery in addition to the need for ion replacement drinks, then sought the metabolic pathway to produce ATP are aerobic If maternal dehydrated, there will be a disruption in the body's systems, including fatigue and lack of energy in straining. Lack of energy, fatigue, and dehydration can cause uterine contractions mother becomes weak, it can hinder the delivery process because it can cause birth complications, such as prolonged labor, and obstructed. By administering isotonic beverages, is expected to prevent dehydration, and accelerate the process of formation of energy in the mother so that the mother still has enough power to meneran and delivery process can be run quickly and smoothly, without any complications This study is also in line with research conducted by Nurlailis taken from Surabaya university journal in 2010 that examined the effect of sweat pocari against labor contractions in the region of PHC Gemarang, Madiun. From the statistical test can be concluded that there is a significant difference between the intensity of pain before intervention and after intervention (p <0.05). From the results of this study are known to exist pocari effect of sweat on labor contractions Conclusions And Suggestions It was found that statistically there is the effect of isotonic drinks on the quality of his (the duration of his) maternal primipara in the first Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology stage in the active phase of PHC Cengkareng 2014 Suggestion 1. Isotonic drinks can be a good alternative in order to fulfill the maternal fluids, for birth attendants can encourage the birth mothers to use isotonic fluids during labor, especially first stage so that labor can run more smoothly. 2. It is recommended to do more research on the effectiveness of isotonic drinks in maternal, with better research design, sampling more and more representative so that the results can be generalized and used in general REFERENCES Adzab, Faisal. 2011. Classification of Sport and Process Energy Solutions. http //: Modul_ikor 2.pdf accessible Februai 16th, 2014. Arikunto, S. 2010. Research Procedure A Practical Approach. Jakarta: Rineka Reserved Ministry of Health, 2008. Normal Delivery Care. Jakarta: Ministry of Health in 2008 Eka, Arsita. 2012. Maternal And Child. Yogyakarta: Nuha Medika Guyton, 2002. Human Physiology and Mechanisms of Disease. EGC, Jakarta. JNPK-KR MOH RI, 2008. Normal Delivery Care and Early Initiation of Breastfeeding. Jakarta: National Network of Clinical Training. Kristanti, Elin Yunita. 2012. Nutrition You Need to Know During Labor Capital. http //: nutrisiuntukbangsa.org accessed February 16, 2014 Kumarawati, Erma. 2011. Differences in Quality of His Birth On Mother Maternity with and without administration of Pocari Sweat Pocari Sweat. http //: jurnalpoltekkessurabaya.com accessed February 16, 2014. Kubli M et al, 2002. An evaluation of isotonic "sports drinks" during labor. Accessed 30 November 2014 Manuaba, I.B.G. 2009. Understanding the Female Reproductive Health. Jakarta: EGC Mochtar, R. 2005. Synopsis Obstetrics. Jakarta: EGC. Notoatmodjo, S. 2007. Health Research Methodology. Jakarta: Rineka Reserved. Nurlailis, 2010. Effect of sweat on his pocari labor. http //: journal Poltekes Surabaya.com accessed July 20, 2014 RH Philpott, Castle WM. Cervicographs in the mangement of labor in primigravidae. The alert for detecting abnormal labor. Br J Gynecol Obste Commonw Prawirohardjo, Sarwono. 2008. Obstetrics. Jakarta: YBP-SP Puspitasari, Yanti. 2010. Influence of Consumption by Pregnant Women Pineapple against Uterine Contraction. http //: digital_137191 Yanti Puspitasari.pdf. accessed February 16, 2014. Rahmawati, Eka Nani. 2013. The effectiveness of the Quality Provision Isotonic Drinks His Mother Maternity At Kala 1 Phase Active In midwives in independent practice. Revelation Kab. Demak. http //: up2makbidngudiwaluyo.com accessed February 16, 2014 Rustam, M. 1998. Synopsis Obstetrics: Physiology Obstetric, Obstetric Pathology. Jakarta: EGC. Saifuddin, Abdul Bari. National Reference Books, 2002. Maternal and Neonatal Health Services. Jakarta: YBPSP. Saifuddin, Abdul Bari. 2006. Maternal and Neonatal Health Services. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo. Saifuddin, Abdul Bari. 2010. Obstetrics. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo. Varney, H, et al. 2008. Textbook of Midwifery Care. Jakarta: EGC 163 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology ACCEPTABILITY PURPLE SWEET POTATO BUTTER CAKE AND CARBOHYDRATE ANALYSIS FOR DIABETICS SNACK Cindy Novilia, Fitri, Yessi Alza Departement of Nutrition, Politeknik Kesehatan Kementrian Kesehatan Riau email : [email protected] ABSTRACT Purple sweet potato is a functional food, containing high anthocyanins, fiber, amylose and low glycemic index. Sweet potato is one of carbohydrates source that potentially as local resources for an effort of staple food diversification. Cake is popular bakery products that have sweet taste and soft texture. Butter cake gives distinctive aroma of butter and savory favored. In Indonesia, patients with diabetes mellitus have increasing from 1.1% (2007) to 1.5% (2013). Snack for diabetics must have appropriate nutritional value and can control blood glucose to prevent the risk of complications in patients with diabetes mellitus. Diabetics need snacks that have appropriate nutritional value that does not cause hypo/hyperglycemia. This study is based on experimental research design using a randomized block design (RAK) with 3 formula substitution of wheat flour and purple sweet potato and 1 control, organoleptic (sensory) test and analysis of carbohydrates. Organoleptic (sensory) data were analyzed using One Way ANOVA, and carbohydrate test data were analyzed using Luff Schrool methods. Our result in the research on the acceptability purple sweet potato butter cake showed significant real difference of the sensory score included flavour, aroma, colour and texture by used 75% concentration of purple sweet potato and also increases the sensory scores of the product, resistant starch content and acceptability of cake. The carbohydrates analysis of purple sweet potato butter cake showed that the starch in butter cake with 75% concentrate of purple sweet potato is 27.77%. Keywords : butter cake, sweet potato, carbohydrate, diabetics Introduction Diversification of daily food is still not in accordance with the pattern of the ideal food contained in the food pattern of hope (PPH). Based on the National Socioeconomic Survey (2009-2013) found that the rate of sweet potato consumption had decreased 18.20% from 2011 to 2013. The consumption level of rice exceeds the recommended limits, conversely the rate of sweet potato consumption is smaller than the recommended, that is < 36kg / capita / year (Ariani, 2010). Sweet potato is alternative food ingredient in Indonesia (Andrianto, 2004). Purple sweet potato is functional foods (Winarno, 2004). Sweet potato is one source of carbohydrates that potentially as local resources in an effort to diversification of staple food. Therefore, due to the high productivity potential and easily obtained on the local market, regional and international. Sweet potato price levels are low and affordable by all segments of society can be 164 one important factor to encourage diversification (Anjak, 2010). Purple sweet potato contains the pigment anthocyanins higher than other types of sweet potato (Aripnur, 2010). Anthocyanins have the potential to reduce blood sugar levels (anti hyperglycemia) (Richana, 2012) and can be a natural colorant for food (Suprapta, 2003). Purple sweet potatoes have high levels of dietary fiber that is 4.72% per 100 grams (Nintami, 2012). Cake is popular bakery products that have sweet taste and soft texture. Butter cake give distinctive aroma of butter and savory favored (Ardiarini, 2012). In Indonesia, patients with diabetes mellitus have increasing from 1.1% (2007) to 1.5% (2013) (Badan Litbangkes, 2013). Diabetics need snacks that have appropriate nutritional value that does not cause hypo/hyperglycemia (Aviaty, 2013). Our objective was attempt a novel approach that effort increasing variations food processing with purple sweet potato as the main ingredient and study the effect of purple sweet potato in butter cake as snack for diabetics. The aim of this study was to Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology investigate the best product and carbohydrate value of purple sweet potato butter cake. Methods This study is based on experimental research design using a randomized block design (RAK) with 3 formula substitution of wheat flour and purple sweet potato and 1 control, hedonic test and analysis of carbohydrates. Organoleptic (sensory) evaluation of the product to determine the texture, flavour, aroma and colour of the product. The test score were analyzed using One Way ANOVA to find the best product. The best product was further analyzed with Luff Schrool methods. Cake formulation and preparation The ingredients for this cake were used corn sugar and milk flour for diabetics. The cake ingredients were weighed using an analytical balance. First, eggs were manually broken and yolk was separated from albumen. Butter and sugar were mixed at high speed until uniform, the yolk was added at a steady rate (about 3 min) and after that the purple sweet potato was added, mixed well. The flour and milk flour were added, the cake batter was further mixed at a steady rate (about 5 min). The albumen was mixed at high speed in other bowl (about 3 min). After all the albumen was added into cake batter and stir well. Filled cake batter (30 g) into cupcake cup and baked. Four butter cake purple sweet potato have different containing variable purple sweet potato and wheat flour concentrations : 0%, 25%, 50%, 75% and were baked at 120ºC temperatures for 40 min. The cake were cooled on a wire racks at 27 ºC for 35 minutes before organoleptic (sensory) and chemical evaluation. Organoleptic (sensory) evaluation Twenty five member panelists comprising of students from Politeknik Kesehatan Kementrian Kesehatan Riau evaluated the samples using the 5 points hedonic scale method. Scores were given to the scales: (5) Like very much, (4) Like slightly, (3) Like moderately, (2) Dislike moderately, (1) Dislike very much. The coded samples were presented to panelist to evaluate for the attributes : flavour, colour, aroma and texture. Evaluation of the cake was conducted 1 hour after baking. Sensory testing was done on all 4 types of cake. Each panelist was presented with 4 coded randomized samples. Each sample was coded with three random digit numbers and the positions of the samples were randomized. Panelists were seated in individual sensory booths. The score were analyzed by ANOVA. Statistical analysis Data were analyzed with SPSS version 16.0 using one – way Analyzed of Variance (ANOVA). Significant differences were tested using the Duncan Multiple Range Test. Two replications were used for chemical evaluation. Chemical Analysis Carbohydrate was determined based on Luff Schrool Method. Results Sensory evaluation Result of these studies with ANOVA indicated that there is significant difference (p<0.01) between each samples in terms of flavour, colour, aroma and texture. Table 1. Results of sensory evaluation of four types of cake Control Flavour Colour Aroma Texture 3.60 ± 0.913 4.16 ± 0.554 4.16 ± 0.554 3.76 ± 0.879 Purple Sweet Potato 25% 3.40 ± 0.816 2.92 ± 0.862 3.88 ± 0.600 3.24 ± 0.831 50% 3.76 ± 0.663 3.28 ± 0.792 4.00 ± 0.707 3.92 ± 0.702 75% 4.72 ± 0.542 4.80 ± 0.408 4.48 ± 0.586 4.72 ± 0.458 *Mean values in the same row which are not followed by the same letter are significantly different (p<0.01). Mean ± standard deviation (n = 25) Results for the flavour were around 84 – 100% showed in Fig 1. This indicated the high scored of flavour is product with 75% purple sweet potato concentrate. 165 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Figure 1. Flavour result of sensory test. Note n = 25; 5 hedonic scale Results for the colour were around 64 – 100% showed in Figure 2. This indicated the high scored of colour is product with 0% and 75% purple sweet potato concentrate. Figure 2. Colour result of sensory test. Note n = 25; 5 hedonic scale Results for the aroma were 100% showed in Fig 3. This indicated that all types of product have high scored. Figure 3. Aroma result of sensory test. Note n = 25; 5 hedonic scale 166 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The sensory result for the texture showed in Table 4. Results for the texture were 80-100%. This indicated that all the types of product were the favorite product. Figure 4. Texture result of sensory test. Note n = 25; 5 hedonic scale The sensory score of the cookies was presented in Table 1. Cake prepared from purple sweet potato with 75% concentrate were rated high in flavour, colour, aroma, and texture with significant difference (p<0.01) as compared to control, and the cake were scored high by the panelist. The aroma of purple sweet potato butter cake gives distinctive aroma of butter and savory favored. The colour of purple sweet potato butter cake with 75% concentration are shown in purple colour that really give eye-catching. The texture of purple sweet potato butter cake have soft texture and sweet taste from corn sugar and milk flour for diabetics. Purple sweet potatoes attracted interest as a healthy food additive and a potential source of natural food colorants due to their high level of anthocyanins (Winterhalter, 2011) and also the sweet potato anthocyanins have antioxidant activity (Hardoko, 2010). Purple sweet potatoes have high levels of dietary fiber that is 4.72% per 100 grams (Nintami, 2012). Resistant starch Result indicated that resistant starch of purple sweet potato butter cake with 75% concentrate is 27.776% with two replication. The main content of purple sweet potato is a starch. Sweet potato starch content consists of 30 – 40% of amylose and 60 - 70% of amylopectin (Nintami, 2012). At the metabolic level, the effect of resistant starch on glucose delivery is likely to have a positive impact on insulin responses and that gives effect for the utilization of fat which stored, that may influence appetite signals (Tapsell, 2004). Conclusions Incorporation of purple sweet potato on baking cake process did not change the functional properties but increases the sensory scores of the product, resistant starch content and acceptability of cake, especially for butter cake. References Andrianto, T.T., & N. Indarto 2004. Ubi Jalar dan Kentang. Absolut. Yogyakarta. Anjak, 2010. Prospek Pengembangan Ubi Jalar Mendukung Diversifikasi Pangan dan Ketahanan Pangan. Diakses dihttp: //pse.litbang.deptan.go.id/ind/pdffiles/ anjak_2010_10.pdf Ardiarini, M.D., 2012. Pembuatan Cake dari Tepung Ketan Hitam. Universitas Negeri Yogyakarta. Skripsi. Program Studi Teknik Boga Fakultas Teknik. Ariani, M., 2010. Diversifikasi Konsumsi Pangan Pokok Mendukung Swasembada Beras. Prospiding Pekan Serealia Nasional. Balai Pengkajian 167 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Teknologi Pertanian Banten. ISBN : 978-979-8940-29-3 Aripnur, 2010. Ubi Jalar Ungu. http://www.banjar-jabar.go.id. Diakses tanggal 25 Juni 2010 Avianty, S., 2013. Kandungan Zat Gizi & Tingkat Kesukaan Snack Bar Ubi Jalar, Kedelai Hitam Sebagai Alternatif Makanan Selingan Penderita Diabetes Melitus Tipe 2. Artikel Penelitian Universitas Diponegoro. Semarang. Badan Litbangkes, 2013. Laporan Riskesdas 2013. Diakses di www.litbang.depkes.go.id/sites/.../rkd 2013/Laporan_Riskesdas2013.PDF Hardoko, L.H., & T.M. Siregar, 2010. Pemanfaatan Ubi Jalar Ungu (Ipomoea batataws L. Poir) Sebagai Pengganti Sebagian Tepung Terigu dan Sumber Antosianin pada Roti Tawar. Jurnal Teknologi dan Industri Pangan, 21 (1). Nintami, A.L. & N. Rustanti, 2012. Kadar Serat, Aktivitas Antioksidan, Amilosa 168 dan Uji Kesukaan Mi Basah Dengan Substitusi Tepung Ubi Jalar (Ipomoea batatas var Ayamurasaki) Bagi Penderita Diabetes Melitus Tipe 2. Jurnal of Nutrition College, 1(1). Richana, N., 2012. Ubi Kayu dan Ubi Jalar. Nuansa Cendekia. Bandung. Suprapta, 2003. Pengaruh Lama Blanching Terhadap Kualitas Stik Ubi Jalar (Ipomoea batatas L.) dari Tiga varietas. Prospiding Temu Teknis Nasional, Tenaga Fungsional Pertanian. Tapsell, Linda C., 2004. Diet and metabolic syndrome : where does resistant starch fit in?. Journal of AOAC Internasional, 87 (756-60). Winarno, F.G., 2004. Kimia Pangan dan Gizi. Penerbit Gramedia. Jakarta Winterhalter, Peter, et al., 2011. Anthocyanins in Purple Sweet Potato (Ipomoea batatas L.) Varieties. Global Science Books. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EFFECTS OF BREASTFEEDING COUNSELING SELF-EFFICACY (BSE) IN PREGNANT WOMEN TOWARDS IMMEDIATE BREASTFEEDING AND GIVING THE COLOSTRUM IN INDEPENDENT PRACTICE MIDWIVES, PEMATANGSIANTAR Tengku Sri Wahyuni, Juliani Purba, Sri Hernawati Sirait Prodi Kebidanan Pematangsiantar Poltekkes Kemenkes Medan Jln. Pane no 36 Kel. Tomuan Kec. Siantar Timur Kota Pematangsiantar ABSTRAC Breast milk is the best food for babies. The success of breast feeding is influenced by environmental factors, physical, social, economic, political, and psychological. The psychological factor is related to the attitude of mothers towards breastfeeding process which is influenced by confidence about the ability of mothers to breastfeed is described as self-efficacy. This quasi experimental research a prospective cohort study, aims to analyze the effect of BSE on counseling pregnant women trimester III towards immediate breastfeeding and feeding of colostrum. Sampling is determined by means of consecutive sampling, divided into two groups who received counseling BSE and not given individual counseling reponden. 44. Analysis of the wear test bivariat chi-square (χ2), with a level of significance of 0.05 and p < CI (95%) while the multivariate analysis using multiple logistic regression. Bivariat analysis results showed that parity is associated with immediate breastfeeding with a value of p = 0.005; RR: 1.67; CI = 1.10-2.53 and administering colostrum with value p = 0,038; RR = 1.54; CI = 0.98-2.44. BSE is associated with immediate breastfeeding with a value of 0.001 p <; RR = 2.36; CI = 1.36-4.08 and administering colostrum with value p = 0,013; RR: 1,77; CI = 1.04-2.99. Results of the multivariate analysis indicates that BSE is the most dominant variable influenced by immediate implementation of breastfeeding with a value of 0.001 p <; RR = 8,26; CI = 2.78-24,51 and so is by administering colostrum with value p = 0,019; RR = 3,17; CI = 1.21-8.34. The midwife is expected to provide more intensive counseling about should BREAST FEED and ought to follow training about counseling of exclusive breast milk. Braest milk counselor to become so as to enhance the achievement of exclusive BREAST MILK Key word : counseling, BSE, Immediate Breastfeeding, early initiation, administering colostrums. Introduction The United Nation International Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) recommended exclusive breast feeding up to a 6 month old baby (American Academy of Pediatric, 2005). The Ministry of health has been targeting exclusive breast feeding in infants 0-6 months amounting to 80% by 2014 (Kemenkes, 2013). According to the results of the Susenas 2010 in quotation in the Health profile of 2011 brings coverage of exclusive breast feeding in infants 0-6 months nationally is 61,5% while the Northern Sumatra Province only 56,6% (Ministry of HEalth, 2012). In the town of Pematangsiantar's achievements for the exclusive BREAST MILK in the year 2012 is only 34,78% (Health Office Pematangsiantar, 2013) Based on studies Entwistle et al (2010) in multiple causes of the research results from maternal factors don't provide BREAST MILK among others are: experience, socioeconomic status, smoking habit, the attitude of the mother, the support from health care providers, spouse and mother's self-confidence (self-efficacy) to provide breast milk. The importance of selfefficacy for breastfeeding has been proven in several studies. BSE is counseling needs to be done to be able to motivate pregnant mothers so that they can successfully deliver BREAST MILK exclusively. Results of the study and RahmawatiHusna (2008) States that what if pregnant mothers are given counseling III 169 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The sample in this study all pregnant women trimester III checks the pregnancy and childbirth aid in getting 15 BPM Pematangsiantar on the following; 1) inclusion criteria are willing to be sampled in the study until the specified deadline since pregnant in the 3rd trimester until 3rd day of post-partum 2) Has been getting ASI counseling of midwife 4)spontaneous vaginal type of birthing. 4) Singleton pregnancies with gestational age 37 weeks or more 5)Baby birth weight of 2,500 – 4,000 grams, and exclusion criteria are: 1) the mother has an anatomic abnormality 2) mother with obstetric complications (such as bleeding post!, hypertension) 3) baby asphyxiation and there are signs of infection 4) congenital abnormalities with the Baby, such as labioschizis or labiopalatoschizis. Data analysis was carried out through the 3 stages: univariate, bivariat use statistical test of chi-square (χ2), with a level of significance of p < 0.05 and Confidence Interval (95%). Relative risks (RR) were calculated using a 2 x 2 table and multivariate logistic regression, using multiple (logistic regression). trimester exclusive BREAST MILK intensively, then 23,92 more likely to conduct immediate breastfeeding and giving the colostrum in the first three days of the birth of the baby than mothers who get counseling about BREAST MILK exclusively is not as intense. Research Methods This type of research this includes observational prospective cohort design in quantitative, aiming to analyze the effect of BSE on immediate breastfeeding counseling and giving the colostrum. These studies compare the intervention group counseling BSE on pregnant women trimester III with the control group, so there are two groups of subjects. This research use questionnaire instruments adopted from researchdone by Zakiah (2011), where the self efficacy questionnaire obtained by use of a questionnaire being translated from breastfeeding self efficacy scale questionnaireshort form (SF-BSES) as many as 14 item questions. Results and discussion Results Table 1 characteristics of Respondents with Relationship Counseling BSE in Pematangsiantar 2014 No Characteristic Respondents Konseling BSE Yes 1. 2. 3. 4. 170 Age Healthy reproduction (2035 years) Unhealthy reproduction (<20 and >35 years) Parity Multipara Primipara Education Level High(SMA-PT) Low (SD-SMP) Occupation Employee Unemploye No Value p RR 95%CI 0,74 0,90 (0,50-1,62) Total n % 50,6 77 100 5 45,5 11 100 54,4 41,9 26 18 45,6 58,1 57 31 100 100 0,26 1,29 (0,80-2,09) 42 2 51,2 33,3 40 4 48,8 66,7 82 6 100 100 0,67 1,53 (0,48-4,85) 7 37 46,7 50,7 8 36 53,3 49,3 15 73 100 100 0,77 0,92 (0,51-1,65) n % 38 49,4 39 6 54,5 31 13 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 2 BSE Counseling Relationship towards BSE in Pematangsiantar 2014 No 1 2 Counseling of BSE Yes No BSE Low High n 36 25 % 81,8 56,8 n 8 19 Total % 18,2 43,2 n 44 44 % 100 100 Value P RR 95%CI 0,011 1,44 (1,07-1,93) Table 3 characteristics of the Respondentst's relationship with towards Immediate Breastfeeding in Pematangsiantar by 2014. N o 1. 2. 3. 4. Characteristic respondents Age Healthy reproduction (20-35 years) Unhealthy reproduction (<20 and >35 years) Parity Multipara Primipara Education Level High(SMA-PT) Low (SD-SMP) Occupation Employee Unemploye Immediate Breastfeeding Yes No Total n % n % n Value p RR 95%CI % 50 64,9 27 35,1 77 100 1,000 1,02 7 63,6 4 36,4 11 100 43 14 75,4 45,2 14 17 24,6 54,8 57 31 100 100 0,005 1,67 (1,10-2,53) 52 5 63,4 83,3 30 1 36,6 16,7 82 6 100 100 0,418 0,76 (0,51-1,12) 9 48 60,0 65,8 6 25 40,0 34,2 15 73 100 100 0,671 0,91 (0,58-1,42) (0,63-1,64) Table 4 relationship of Characteristics of respondentsts by administering Colostrum in Pematangsiantar by 2014. N o 1. 2. 3. 4. Characteristic respondents Age Healthy reproduction (20-35 years) Unhealthy reproduction (<20 and >35 years) Parity Multipara Primipara Education Level High(SMA-PT) Low (SD-SMP) Occupation Employee Unemploye Administering theColostrum Yes No Total n % N % n Value P RR 95%CI 0,751 0,87 (0,53-1,43) % 43 55,8 34 44,2 77 100 7 63,6 4 36,4 11 100 37 13 64,9 41,9 20 18 35,1 58,1 57 31 100 100 0,038 1,54 (0,98-2,44) 48 2 58,5 33,3 34 4 41,5 66,7 82 6 100 100 0,396 1,75 (0,55-5,52) 7 43 46,7 58,9 8 30 53,3 41,1 15 73 100 100 0,383 0,79 (0,44-1,40) 171 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 5 Relationship BSE Respondents withImmediate Breastfeeding Pematangsiantar in 2014 N o 1 2 Immediate Breastfeeding Yes No Total BSE High Low n 48 9 % 78,7 33,3 n 13 18 % 21,3 66,7 61 27 n Value P % 100 100 0,000 RR 95%CI 2,36 (1,36-4,08) Table 6 Relationships BSE Respondents by Administering Colostrum in Pematangsiantar 2014 Administering the colostrum N BSE Value RR NO Yes Total o P 95%CI n % n % n % 1 High 40 65,6 21 34,4 61 100 0,013 1,77 (1,04-2,99) 2 Low 10 37,0 17 63,0 27 100 Table 7 the final results of the logistic regression analysis of double effect of BSE On Counseling pregnant women Trimester III towards Immediate Breastfeeding in Pematangsiantar 2014. No Variable Coefficient Value p Exp (B) 95% (B) CI for Exp (B) 1. Parity 1,466 0,007 4,33 1,49 - 12,52 2. BSE 2,112 0,000 8,26 2,78 - 24,51 Constanta - 1,921 - Table 8 the final results of the double logistic regression analysis effect of BSE Counseling on Pregnant Women III Trimester towards The administering of Colostrum in Pematangsiantar 2014 No Variable Coefficient Value p Exp (B) 95% (B) CI for Exp (B) 1. Parity 0,919 0,052 2,50 0,99 - 6,34 2. BSE 1,156 0,019 3,17 1,21 - 8,34 Constanta -0,971 Discussion Characteristics Of Respondents a. Age Of the 77 respondents aged healthy reproduction (20-35 years) there were 50 respondents (64,9%) was doing immediate breastfeeding, there are 43 respondents (55.8%) of colostrum that gives, and of the 11 respondents aged reproduction is not healthy (< 20 and > 35 years) there are 7 respondents (63,6%) that do immediate breastfeeding colostrum that gives Results and statistical tests show that age does not relate to conduct 172 Immediate Breastfeeding and feeding colostrum with (p = 1,000) and (p = 0,751).Administering colostrum on this research is not related to age, this might be due to mothers who become the respondents in this study already understand the importance of giving of colostrum they get counseling on BSE for the respondent who got the treatment as well as counselling on BREAST MILK given by a midwife at the time gave the pregnancytreatment. BSE counseling and counseling BREAST MILK given to Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology respondents without differentiating the age of respondents. Giving BREAST MILK is a very complex interaction between mechanical stimulation, the nerve, and various hormones. At the age of healthy reproductive hormone produced naturally is still pretty much stable. In addition, the formation of breast glands histologically and biochemistry that is affected by the hormones estrogen and progesterone called mammogenesis already underway since the fetus and will have formed a perfect pregnancy age on the healthy reproduction (Suradi, 2007). b. Parity Research results get 57 respondents (64,8%) with multipara parity, it is also found on the research of Rahmawati (2009) about number of respondents with parity multipara as much (65,45%) in Makasar. Chi-square test result indicates the parity is related to perform immediate breastfeeding with a value of p = 0.005. The relative ratio obtained amounted to 1.67 with 95% CI: 1.102.53. As well as administering colostrum shows parity is associated with giving the colostrum (p = 0,038). The relative ratio of 1.54 obtainable with 95% CI: 0.982.44.Multiple logistic regression test results obtained immediate breastfeeding related parity (p = 0.007), relative ratios obtained amounted to 4.33 with 95% CI: 12,52-1.49, whereas for the grant of colostrum unrelated parity (p = 0,052). The experience of successful breastfeeding may boost confidence, as well as a strong desire in the mother to breastfeed her baby. Achievement (performance accomplihment) in nursing is the first factor influencing BSE (Dennis, 2003). Wardani (2012) in the results of his research also says that breastfeeding success experience, knowledge and understanding of nursing techniques become important factors of selfefficacy. Results of research from Muaningsih (2013) reported that the experience of breastfeeding was formerly the most influential factors towards the value of BSE. Experience the events that ever lived, experienced, and perceived either long-or just happened. Experience can occur in any person, good experience sad, uplifting, and boasts. Mothers who breastfeed successfully before having a joyous experience and boast. Mothers who breastfeed have previously failed a sad experience. Breastfeeding experience is certainly only a mother obtained at multiparity (Muaningsih, 2013). In the current study might experience as a multipara mother breastfeeding experience is a good way. The experience of motherhood may be the success of breast feeding in early labor, experience the success of exclusive breast feeding, the experience of getting the growth and development of infants with breast feeding may also experience so even its economic if given breast milk. All good experiences perceived mother certainly had an impact on the value of BSE's mother. The value of high BSE-related implementation of immediate administering colostrum and breasfeeding. Research in Lebanon finds mother multipara has the possibility of 2.6 times more likely to provide exclusive BREAST MILK compared to primipara. The higher the number the more parity increase success rate of exclusive breast feeding (Al-Sahab et al, 2008). The success of exclusive breast feeding may be preceded by implementing immediate breastfeeding and administering of colostrum. c. Education For variables of education 82 respondents with higher education in mind there are 52 respondents (63,4%) was that do immediate breastfeeding and from 6 respondents with low education there are 5 respondents (83,3%) was that do immediate breastfeeding. There are 48 respondents (58,5%) that provide the colostrum from the 6 respondents with low education there were 2 respondents (33.3 percent) that provide the colostrum. Chisquare test results indicate that education does not relate to conduct Immediate Breastfeeding colostrum feeding andvalue p respectively 0,671 and 0,396. Education is not related to the implementation of immediate breasfeeding and administering colostrum. This may be due to the knowledge of the ASI could've obtained from different media and with a language that is easily understood by all levels of education. Easy to acquire this information will certainly affect the level of BSE mother regardless of level of education. Research in Brazil in 2005 found a mother who received primary and secondary education with duration of education has 9 years < risk to stop breast feeding as many as 1.2 times. The lower the mother's level of 173 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology education is also the lower the success rate of exclusive breast feeding (Mascarenhas, 2006). Immediate breastfeeding is one of the factors that affect the probability of breast feeding success in the newborn (Fikawati, 2010) d. Occupation /Jobs For variables of the work of the 15 respondents who worked there (60.0%) of respondents 9 that do immediate breastfeeding, there are 7 respondents (46,7%) of colostrum and giving of the 73 respondents who don't work there are 48 respondents (65,8%) that do immediate breastfeeding as well as there are 43 respondents (58,9%) is giving the colostrum. Chi-square test result of work unrelated to do immediate breastfeeding (p = 0,671) and is not related to give colostrum (p = 0,383). Mothers who are not working may be more have the opportunity to carry out immediate breastfeeding and administering colostrum because they have the time and opportunity more in preparing for the laktasinya. Whereas, working mothers may not heed the immediate implementation of breastfeeding and feeding colostrum because of his work situation will accelerate the use of infant formula milk. In this research the status of a job does not affect the implementation of immediate breasfeeding, this might be due to working mothers have also been able to plan well during lactation to be traversed. Mothers can already anticipate a short maternity leave with the preparation time of lactation is good, the way time works on BREAST MILK storage and fulfillment needs BREAST MILK for her baby while moms working . Immediate Breastfeeding The results showed that more respondents are implementing immediate breastfeeding i.e. 57 respondents (64,8%). This immediate breastfeeding figures higher than obtained by Rahmawati (2009) only (57,3%) respondennya that implement immediate breastfeeding. High results the implementation of immediate breasfeeding in this study may be due to the success of the BSE counselling has been given intensive support of midwife birthing support helper program IMD/immediate breasfeeding. A baby at the age of less than 30 minutes should be immediately disusukan to 174 his mother, in this case not for giving nutrients but to learn nursing mother's breast is preparing to start producing breast milk. Feeling happy to see baby can breastfeed and satisfaction will stimulate the glands secretes oxytocin posterior hipofisis to speed up spending on ASI (Lawrence and cit Ac Fikawati, 2003). In addition, immediate breastfeeding needs to be implemented because the movement to suck in the newborn will culminate at the time was 20-30 minutes, so in late lactation reflex will be reduced and weakened (Roesli and Fikawati, 2003). Breastfeeding is a start toward immediate success of breastfeeding exclusively. immediate breastfeeding mom can make sure to breastfeed. Research results Fikawati dkk, (2010) found that the important factors that led to the failure of the exclusive BREAST MILK because the mother was not facilitated doing immediate breastfeeding. A newborn baby was given only BREAST MILK since the beginning had great opportunities to successfully BREAST FEED exclusively. Administering Colostrum For granting this research on colostrum, obtained 50 respondents (56,8%) of colostrum that gives only the first 3 days and this result is slightly lower than that obtained Rahmawati, (2009) is gaining (57,2%). On the results of this research administering of colostrum is lower than the results of the implementation of immediate breasfeeding. This may be caused because mothers who carry out immediate breasfeeding not necessarily give colostrum only up to 3 days post-partum. The least amount of colostrum produced may lead to the assumption that the mother's colostrum insufficient food/fluid requirements needed by the baby. Colostrum is very important for the baby a lot more because it contains antibodies 10 – 17 times compared to mature BREAST MILK and can provide protection for infants until the age of 6 months. Colostrum is the first fluid secreted by the glands of the breast, contains tissue debris and residual material contained in the alveoli and the ducts of the breast glands before and after the period of puerperium. Colostrum is thick viscous liquid with a yellowish color, more yellow than with ASI matur, secreted on the first day until the 3rd or Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 4th. Composition from day to day is always changing (Roesli, 2009). Breastfeeding Self-Efficacy (BSE) The results of this research to get respondents who have breastfeeding selfefficacy is high i.e. 61 respondents are(69,3%). From 61 respondents rated high BSE there are 48 respondents (78,7 percent) that do immediate breastfeeding, and there were 40 respondents (65,6%) that provide the colostrum. Of the 27 respondents who have a low value of BSE there are 9 respondents (33.3 percent) that do immediate breastfeeding and there are 10 respondents (37%) which gives the results of statistical tests with colostrum test chi-square indicates that BSE is related to perform Immediate Breastfeeding (p < 0.001). The relative ratios of gained 2.36 with a 95% CI: 1.36-4.08 and relate to give colostrum (p = 0,013). The relative ratio obtained for 1,77 with 95% CI: 1.04-2.99 Multiple logistic regression test results obtained the BSE-related variables (p < 0.001). Based on the value of the coefficient (B) it can be seen that the variables associated with parity do immediate breastfeeding. Of the relationship of the variables can be viewed from the value exp (B) or RR by 8,26 with 95% CI: 2.78-24.5. As well as administering colostrum, BSE-related variables obtained grant of colostrum (p = 0,019). Of the relationship of the variables can be viewed from the value exp (B) or RR 3,17 with 95% CI: 1.21-8.34. There is a difference between people who have a low and high self efficacy. A person with low self-efficacy will tend to feel helpless, unable to do the settings on the circumstances that happened in her life by the time they mengahadapi barriers, they will quickly give up, when on the first attempt had been wound up. A person with low selfefficacy will not make any attempt to address existing barriers, because they believe that the actions that they do will not bring any influence. Low self efficacy can undermine the motivation, lower cognitive ability, interferes with aspirations, and indirectly may affect physical health (Schultz 2005) On the other hand, a person with high self-efficacy believe they can cope with events and situations effectively. They have high confidence with regard to their capabilities as compared to people who have low self efficacy and they only showed little doubt against myself. They see the difficulty that exists as something that is challenging, than as something threatening, they are also actively seeking to find a new situation. High self efficacy reduces the fear of failure, increase aspirations, as well as improving how problem solving and analytical thinking ability (Schultz, 2005). In General, venture capital and readiness to provide BREAST MILK can be seen from the value of BSE's mother. The value of mothers high BSE make efforts and readiness to give BREAST MILK are also high BSE towards the mother to give BREAST MILK has a very big role. The role determines selection behavior. The role of self efficacy, as the determining the amount of effort and endurance in overcoming obstacles and circumstances that are wonderful to give breast milk in the future (Kingston,2007). Mother Self-efficacy to give BREAST MILK has a very big role. First determine the role the selection behavior. The second role of self efficacy as a determinant of the amount of effort and endurance in overcoming obstacles and circumstances that are wonderful to give breast milk. The third role affects the mindset and emotional reactions. Mothers who have low self efficacy for breastfeeding has always considered himself less able to handle the current situation as well as in anticipation of the coming situation. The fourth role as prediction for further behavior. (Spaulding, 2007; Kingston dk, 2007)). Conclusion Maternal characteristics (parity) is associated with immediate breastfeeding with a value of p = 0.005; RR = 1.67 CI = 1.10-2.53 and administering colostrum with value p = 0,038; RP = 1.54; CI = 0.98-2.44, while age, parity, education and employment are not related. Bivariat analysis BSE affect immediate breastfeeding with a value of p = 0.000; RR = 2.36; CI = 1.36-4.08, and also giving the colostrum to BSE with a value of p = 0,013; RR = 1,77; CI = 1.04-2.99. Multivariate analysis of BSE is the most dominant variable influenced by immediate implementation of breastfeeding with a value of 0.001 p <; RR = 8,26; CI = 2.78-24,51 and 175 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology so is by administering colostrum with value p = 0,019; RR = 3,17; CI = 1.21-8.34. Bibliography Al-Sahab B., Tamim H., Mumtaz G., Khawaja G., Khogali M., Afifi R., 2008. Predictors of breastfeeding in a developing country: result of a prospective cohort study. Pub Health Nutr. American Academy of Pediatric, 2005. Work Groupo nBreastfeeding. Breastfeeding and the use of human milk. Pediatrics. Dennis C.L., 2003. The breastfeeding selfefficacy scale: psychometric assessment of the short form. J Obstet Gynecol Neonatal Nurs. Dinas Kesehatan Kota Pematangsiantar, 2013. Profil Kesehatan Kota Pematangsiantar tahun 2012. Dinkes Pematangsiantar, Pematangsiantar Entwistle, F., Kendall, S., Mead, 2010. Breastfeeding support – the importance of self- efficacy for low income women. Material and child Nutrions. Fikawati S, Ahmad Syafiq, 2003. Hubungan antara menyusui segera (immediate breasfeeding) dan pemberian ASI eksklusif sampai dengan empat bulan. Jurnal Kedokteran Trisakti, Jakarta, MeiAgustus 2003, Vol.22, No.2. ------------------------------------, 2010. Kajian implementasi dan kebijakan air susu ibu eksklusif dan inisiasi menyusui dini di Indonesia. Makara kesehatan. KementerianKesehatan RI, 2013. Rencana Operasional Promosi Kesehatan Ibu dan Anak. Kementerian Kesehatan RI, Jakarta. 176 Kingston, D., Dennis, C.,& Sword, W., 2007. Exploring breastfeeding self-efficacy. The Journal of Perinatal end Neonatal Nursing. Muaningsih, 2013. Studi Komparasi Antara Breastfeeding Self-Efficacy Pada Ibu Menyusui di RSSIB dengan non RSSIB dan Faktor Yang Mempengaruhinya. Tesis. FIK Prodi Magister Ilmu Keperawatan, Depok, Tidak dipublikasikan. Rahmawati R., Husnah, 2008. Pengaruh Konseling ASI eksklusif pada ibu hamil trimester ketiga terhadap penyususan dini dan pemberian kolostrum. Jurnal Poltekkes Makasar, Makasar. Roesli U, 2008. Inisiasi menyusu dini plus ASI eksklusif. Jakarta: PustakaBunda .Schultz D.P.,Schultz S.E., 2005. Theories of personality. Edisi ke-8. Australia: ThomsonWadswarth Spoulding, D.M., 2007. Breastfeeding Self Efficacy in Women of African descent. Proquest Dissertations and thesis. Suradi R, TobingH.K.P, 2007. Bahan bacaan manajemen laktasi. Cetakan ke-3 Jakarta:Program Man.ajemen Laktasi Perkumpulan Perinatologi Indonesia. Wardani, M.A., 2012. Gambaran tingkat self efficacy untuk menyusui pada ibu primigravida. Skripsi. FIK UI. Depok. Tidak dipublikasi. Zakiah, 2011. Hubungan efikasi diri dengan lama pemberian Air Susu Ibu selama 2 bulan Postpartum di Kota Banjarmasin.Tesis : Fakultas Kedokteran Universitas Padjajaran, Bandung Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EFFECT OF MUSIC THERAPY ON THE STRESS OF SCHOOL AGE CHILDREN WHO EXPERIENCE HOSPITALIZATION AT THE HOSPITAL dr. PIRNGADI MEDAN *Tryonita Debora, **Nur Asnah Sitohang *student in the faculty of nursing USU ** lecturer in the faculty of nursing Email: nur75 [email protected] ABSTRACT Stress due to hospitalization of children is a response to situations that cause stress, changes, claims adjustment, care delivery by an unknown person and loss of independence. Children who are hospitalized are not comfortable with the state of the environment, separation from parents and peers, limitation of activity, injury and bodily pain and fear of pain it self. Stress can be overcome by giving the management of psychotherapy, such as music therapy. Music therapy can also improve mental function, speed healing, increase the sense of well-being. The purpose of this study was to determine the effect of music therapy on the stress of hospitalization in children of school age in hospitals dr.Pirngadi Medan. Research design using a quasi-experimental with pre-post test design. The sampling technique is total sampling and number of samples 31orang. Data were analyzed using the Wilcoxon test. Results of research before given music therapy average score of stress a child is11.61 and a standard deviation of 2.155. After being given music therapy 1.16 average and standard deviation of 3.606. Statistical test results obtained P value of 0.000 concluded that there was an effect of music therapy on the stress of hospitalization in school age children. This study proves that music therapy can reduce stress in children. It is advised to apply this therapy as one of the interventions in providing nursing care to the child. Keywords: music therapy, stress, hospitalizations, school-age children INTRODUCTION School-age children, vulnerable to disease and ultimately children required hospitalization. Illness and hospitalization are often the first crisis faced by children (Wong, 2008). Hospitalization is a crisis situation that requires children hospitalized or stayed in the hospital for intensive treatment, which causes a change in the child's psyche. In Indonesia, 30% of 180 children between 3 to 12 years had experience with the hospital. Most children received treatment in hospital less than six days. And the time needed to care for sick children 20-45% more than at the time to treat adults (Wong, 2008). The hospital environment is certainly very different from the environment in the home, different shapes and atmosphere. The response that occurs when a child is treated like fear, decreased appetite, even children often cry, do not want to drink milk or eat foods that are given. Response occurred because the hospitalized child care is a stressful experience for both the child and parents. Stress comes from the child itself and from outside, namely environmental factors. Stress faced by individuals can be affected by physical, emotional, intellectual, social and spiritual (Wong, 2008). School-age children who are hospitalized will have some problems like experiencing a separation, the adjustment to the new environment, adjustments to the nurses who take care of it and hang out with a sick child. Parting is the biggest stress that caused the hospitalization of children. One of the factors that affect the stress of hospitalization was losing control. Many hospital situation which decreases the amount of control felt by the child. Lost control in children are caused by changes in routine, and dependency that must be obeyed. One of the problems of children is centered on boredom (Wong, 2008). Stress in children is one of the effects of psychological changes occur due to a stress or crisis in children. Child reaction to the crisis was influenced by their 177 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology developmental age, their previous experience with illness, separation from families, pain and hospitalization. They acknowledged losing his routine and feel worried that they are not able to adjust. If a child is hospitalized, then the child will easily run into crisis because: (1) children experience stress as a result of changes in the health status and the environment in the habit, and (2) the child has a number of limitations to menyeselesaikan problems coping mechanisms and events are pressing (Wong, 2008). Stress can be overcome by giving the management of psychotherapy, psychotherapy is one of music therapy. Not only adults need music to calm down, children also need to listen to music with a certain rhythm to exercise patience, and can lower the stress. For this purpose needed quiet room (Young & Koopsen, 2007). Music has become a place for expression and communication, and without us knowing music is also used to manipulate feelings. Music is also one of the ways to make the child be quiet. The skills that children get from the music leads to the belief of the larger, better language skills, fine motor skill acquisition, temporary consciousness, creativity, and increased concentrations of. Music therapy can also improve mental function, speed healing, increase the sense of well-being. Music is a useful tool for someone to find harmony within himself. It is necessary also because of the presence of harmony within oneself and it will be easier to cope with stress, and pain (Djohan, 2009). Music is widely used for healing, calming and improve the physical and physiological conditions. Listening to music can alter moods and can be raised or lowered, and give room for reflection (Sheppard, 2007). Data obtained from medical records Dr.Pirngadi Hospital Medan, school-age children who experience hospitalization in the period January 2013 to January 2014 as many as 322 people Research conducted Farida (2010) that had the aim to determine the effectiveness of music therapy on postoperative pain reduction of school-age children in the department of human rights, the results obtained in the control group, the effect of music therapy on postoperative pain intensity was not significant, while in the intervention group 178 therapy music has a significant influence on the intensity of pain. Thus inferred music therapy is effective against post-surgical pain intensity in children. The purpose of this study was to determine the effect of music therapy on stress as a result of hospitalization in children of school age in hospitals Dr.Pirngadi Medan. RESEARCH METHODOLOGY The research design was quasi experimental with pre post test design approach. This study only tested a group of subjects where the group observed before the intervention and then observed again after intervention. The population in this study were children aged 612 years as many as 31 children in April-May 2014. The sampling technique using total sampling method. Inclusion criteria were: children aged 6-12 years; willing to be the respondent; has been hospitalized at least 2 days; can speak Indonesian well; the level of awareness compos mentis; do not suffer from hearing loss and pronunciation; parents agree their children to be the respondent. Exclusion criteria of the study was children with special needs (autism, hydrocephalus disease, hyperactivity, tunagarahita, were in isolation rooms); patients taking anti-stress medications and anxiety. This study was conducted from 15 April to May 15, 2014 at the inpatient unit jasmine and roses. This research was carried out by considering the ethics of research. The questionnaire consisted of demographic data and stress questionnaire consisting of 21 questions. Data collection is done in the room Bed and Rose. Data analysis using Wilcoxon statistical test. 3.RESULTS AND DISCUSSION 3.1.Result The results based on the characteristics of respondents, the majority of the male sex as many as 19 people (61.3%), aged 12 years as many as 7 people (22.6%), Batak tribe as many as 20 people (64.5%), Islam as much as 18 people (58.1%), never cared for as many as 18 people (58.1%), and length of hospital for 2 days as many as 15 people (48.4%). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology b. Stress characteristics of children before being given music therapy Table 1 Distribution of respondents by stress children before being given music therapy in hospitals dr. Pirngadi Medan 2014 Variable Mean Median SD Stress 11,61 12,00 2,155 Based on research results gained an average of score stress respondent before being given music therapy 11.6,standard deviation 2.155 and median 12.00. b. Stress children after therapy being given music Table 2 Stress children after being given music therapy The Hospital Dr. Medan Pirngadi 2014 (n=31) Variable Mean Median SD Stress 1,16 0,00 3,606 Based on research results gained an average of score stress respondent after being given music therapy 1.16, standard deviation of 3.606 and the median 0.00. c. Effect of music therapy on stress due to hospitalization in school age children Statistical analysis showed after being given music therapy, 27 children has decreased and 4 children alike stress before and after music therapy. P values = 0.000 , it can be concluded that there is a significant effect of music therapy on children who experience stress of hospitalization. 3.2.Discussion Based on the results obtained from the data the majority of respondents aged 12 years. The older age of the child, a person's level of stress and increasingly constructive force in the use of coping with the problems encountered. School-age children who are hospitalized will normally arise fear of doctors and nurses, because in their shadow that the nurses would be hurt by injecting. The home environment is certainly very different from the atmosphere and forms with treatment rooms. In addition, children also have limited activities such as day-to-day activities with their peers and family. Stress in children of school age are stress due to separation from his Max peer group, suffered injuries on the body and pain, 12 and loss of control can also lead to stress (Wong, 2008). The results based on experience hospitalized in the hospital the majority of 18 people (58.1%) had experienced. This is in accordance with the opinion of Wong (2008) that strongly influence individual experiences stress response because it can be used as a learning experience in dealing with a problem. Diminishing stress response when compared to someone who first hospitalized and face the problem. Children are not familiar with the hospital environment and medical procedures will be undertaken. Child for the first time experienced a hospitalization there was initially very difficult to interact with other people even with strangers. The response appears, the child tends to cry or get angry when approached, even he did not hesitate to sulk on his parents. For the assistance of a parent who is always there beside the child, all obstacles can be overcome with good. Some children who have 4-5 days of treatment tend to interact well. Emotional reaction at school-age children often cry, angry and bereaved as a healthy form in overcoming stress due to hospitalization (Elfira, 2011). Listening to music in children can be trying to find internal harmony, increase selfconfidence, develop skills to deal with problems and pain and relaxation. This will be easier to cope with stress, tension, pain and various disturbances or negative emotions experienced. In addition to music through the sound can also change the frequency is not harmonious vibrations back to normal, healthy and can restore normal circumstances (Djohan, 2006). 4. Conclusions and suggestions Research shows that music therapy can reduce stress in children who are hospitalized. For it was suggested to the nurse who served in the 179 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology children's ward be able to use them as one interventions to improve child welfare REFERENCES Aidar, N. (2011). Hubungan peran keluarga dengan tingkat kecemasan anak usia sekolah (6-12 tahun) yang mengalami hospitalisasi di ruang III Rumah Sakit Umum Dr. Pirngadi Medan. Medan : FKEP USU http://repository.usu.ac.id/handle /123456789/27095. Bassano, M. (2009). Terapi Musik dan Warna. Yogyakarta : Rumpun. Djohan.(2009). Psikologi Musik. Yogyakarta : Galang Press. Farida, A. (2010). Efektifitas terapi musik terhadap penurunan nyeri post operasi pada anak usia sekolah di RSUP Haji Adam Malik Medan. Medan : FKEP USU. http://repository.usu.ac.id/handle/12345 6789/20095. Foster, R.L.R., Hunsberger, M.M., Anderson, J.J.T. (1989). Family-Centered Nursing 180 Care of Children. Philadelphia : W.B. Saunders Company. Natalina, D. ( 2013). Terapi Musik Bidang Keperawatan. Jakarta : Mitra Wacana Media. Schulte, E.B., et al. (2001). Thompson’s Pediatric Nursing 8 th edition. Philadelphia : W.B. Saunders Company. Sheppard, P. (2007). Music Makes Your Child Smarter. Jakarta : PT Gramedia Pustaka Umum. Sunaryo. (2004). Psikologi Untuk Keperawatan. Jakarta : EGC. Wong, D.L., Kasprisin, C.A., Hess, C.S. (2008). Buku Ajar Keperawatan Pediatrik Edisi 4 (Editor : Egi Komara Yudha). Jakarta : EGC. Patricia. (2008). Buku Ajar Keperawatan Pediatrik Edisi 6 volume 1 (Editor : Egi Komara Yudha). Jakarta : EGC. Young, C., Koopsen. C.(2007).Spritualitas, Kesehatan dan Penyembuhan.Medan : Bina Media Perintis Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECTIVENESS OF BEETHOVEN’S “FUR ELISE’ AS CLASSICAL MUSIC THERAPY ON LOWERING STROKE CLIENTS’ BLOOD PRESSURE IN THE INPATIENT ROOMS OF DR. PIRNGADI REGIONAL GENERAL HOSPITAL, MEDAN, IN 2014 Afniwati, Amira Permata Sari Tarigan, Endang Susilawati Instructors of Nursing Department, Poltekkes Kemkes, Medan ABSTRACT Music therapy is a therapy that uses a systematic, controlled, and directed music to heal, rehabilitate, educate, and train children and adults who suffer from physical, mental or emotional ailments. A steady rhythmic music which gives a regular rhythm will give balance to a person’s heart beat and pulse that can lower his blood pressure. This study is a quasi-experimental design of one group pre-post test, which aims to find out the effectiveness of Beethoven classical music therapy on lowering stroke patients’ blood pressure at Dr. Pirngadi Regional General Hospital. The population was all stroke patients caused by hypertension and treated in Dr. Pirngadi Regional General Hospital, and 23 of them were used as the samples, taken by using purposive sampling technique. The data were gathered by using observation sheets, before and after music therapy intervention and analyzed by using pair t-test at the significance level of 95%. The results of the research showed that after classical music therapy intervention, systolic blood pressure had a significant reduction. The average content of systolic blood pressure before the intervention was 157,5 mmHg. 5 minutes after the intervention it was 154,7 mmHg , 10 minutes after the intervention it was 149,2 mmHg, and 15 minutes after the intervention it was 145, 8 mmHg at pvalue < 0.001. The average diastolic blood pressure before the intervention was 98,4 mmHg, 5 minutes after the intervention it was 94.3 mmHg, 10 minutes after the intervention it was 91.8 mmHg, and 90.5, and 15 minutes after the intervention it was 90.5 mm/Hg at p-value < 0.001. It is recommended that Beethoven Classical music should be needed for health care and a policy for the provision of complementary therapies should be set in the Inpatient Rooms, especially in the Stroke Unit. Keywords : Music Therapy, Blood Pressure 1. Background Stroke is an acute neurological dysfunction which is caused by blood circulation disorder and it occurs abruptly (in seconds) or at least swift (in hours) with the symptoms and token which are in line with disturbed brain focal area (World Health Organization, 2005). The number of stroke patients tends to increase each year, not only attacks old people but also young and productive people. Nowadays, Indonesia is recognized as the country with the largest number of stroke patients in Asia (Yastroki, 2009). Stroke ranks the third in causing death in the United States. Referring to the report of the American Heart Association, about 795,000 people in the United States are attacked by stroke each year. Of that number, 610,000 people undergo the first stroke while 185,000 of them undergo relapses. Nowadays, there are four million people in the United States live in physical disability because of stroke and 15% to 30% of them suffer from permanent defect (Centers for Disease Control and Prevention, 2009). In Asia (Thailand and China) there are more rates of incidence of bleeding. In the last few years, there was a tendency for life span of the people who were affected by stroke to be longer (Hamzah, 2006). This rate becomes worse by the shift of ages in stroke patients since stroke now begins to attack younger and more productive people, and even more than that, it also attacks teenagers (Gemari, 2008). Economically, the incidence of stroke has bad effect because of defect, for it will decrease the productivity and economic capacity of the people and the Nation (Yastroki, 2009). According to the survey in 2004, stroke is the number one killer in public hospitals throughout Indonesia. It is estimated that 500,000 people are affected by stroke. Of that number, one third of them return to normal, and the other one third undergo mild until 181 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology moderate functional disorder, while the remaining one third undergo serious functional disorder which forces them to continuously stay on bed (HIMAPID FKM UNHAS, 2007). Stroke is a health problem which needs to be paid specific attention. Based on Riskesdas (Basic Health Research), it was found that stroke is the cause of death, and the principal physical disability in almost all hospitals in Indonesia. The rate of the incidence of stroke is increasing from year to year. In every seven people who die in Indonesia, one of them is affected by stroke (DEPKES, 2011). Hypertension is one of the causes of 17.5 million cases of stroke all over the world. It is the condition in which blood pressure increases. There are many factors which can influence the incidence of blood pressure; they are, among others, age, stress, medication, obesity, smoking, and alcohol. The relapse of human blood pressure can be warded off by using pharmacological therapy such as anti-hypertension medicines and non-pharmacological medicines which include healthy life behavior and music therapy. Music therapy is a type of therapy by using systematic, controllable, and guided music in curing, rehabilitating, educating, and training children and adults who suffer from physical, mental, and emotional disorder. Music which consists of the combination of rhythm, harmony, and melody has been believed to have the influence on healing ailments. Stable rhythmical music which gives harmonious rhythm will provide harmony for human heartbeat and pulse (Natalina, 2013). The use of music as a therapy has been known since the ancient Greece era and it began to be applied during World War I and World War II. The use of music as the medium of therapy in hospitals also has been developed in the last few years. A research conducted by Chavin in 2004 revealed that listening to classical music could decrease the level of apprehensiveness and stress so that one’s body undergoes relaxation which would bring about the lowering in blood pressure and pulse. The result of the research conducted by Asrin et.al showed that music therapy which has dominant moderate frequency is 182 significant for controlling blood pressure response of primary hypertension patients. The result of the research conducted by Sarayar et.al indicated that there was the influence of classical music on the lowering in blood pressure of pre-hemodialysis patients in Dahlia BLU Room of RSUP Prof. Dr. R.D. Kandou, Manado at p-value = 0.00 (α = 0.0). The result the preliminary research in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan, showed that there were 144 patients affected by stroke from October until December, 2013. In general, stroke is caused by hypertension. Based on the background above, the researcher was interested in studying the effectiveness of music therapy on the lowering in stroke patients’ blood pressure in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan, in 2014. 1.1. Objective of the Research 1.1.1. General Objective To find out the influence of the therapy of Beethoven classical music on blood pressure of stroke patients which were given music therapy in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan. 1.1.2. Specific Objectives a. To find out the average of blood pressure of stroke patients before they were given music therapy in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan. b. To find out the average of blood pressure of stroke patients after they were given music therapy in the Inpatient Rooms of RSUD Dr. Pirngadi, Medan. c. To analyze the disparity in the average of blood pressure of stroke patients before and after they were given music therapy in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan. 1.2. Formulation of the Problems How far was the effectiveness of the therapy of Beethoven classical music on the lowering in blood pressure of stroke patients in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan? Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 1.3 Hypothesis of the Research Beethoven classical music therapy was effective in lowering blood pressure of stroke patients. 1.4 Significance 1.4.1 Patients/Families and People Increasing the outlook and the science on music therapy in lowering blood pressure so that patients/families and people could apply it in their homes to control blood pressure. 1.4.2 Hospitals The management of the hospital attempted to determine the policy in applying complementary therapy for stroke patients besides the therapy of anti-hypertension medicines. 2. Research Methodology 2.1. Types of Research The type of the research was quasi experiment, using one group. Pre and post tests would be conducted in order to measure the success in the intervention by the design model as follows: O1 X O2 Explanation: O1 = Blood pressure of stroke patients before intervention X = Intervension of Beethoven classical music therapy O2 = Patients’ blood pressure after intervention 2.2. Conceptual Framework Pre Test Blood Pressure Stroke Patients Post Test of Music Therapy Blood Pressure of Stroke Patients Picture 3.1. Conceptual Framework of the Research Independent variable in the research was music therapy and dependent variable was blood pressure of stroke patients. 2.3. Location and Time of the Research The research was conducted in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan. The data were gathered from September until October, 2014 2.4. Population and Samples The population was all stroke patients caused by hypertension who were treated in the Inpatient Rooms of Dr. Pirngadi Regional General Hospital, Medan. The samples were taken by using Lameshow formula as follows: Explanation: n = minimum number of samples Z1-/2 = value of table Z at 5 % = 1,96 Z1- = value of table Z at 10% = 1,28 = standard deviation (can be taken from the research conducted by Sarayar et.al = 14,24) 1-2 = variance of mean value pre and posttest (=12) Based on the calculation of the samples in this research, the minimum number of samples was 15 respondents. At the time the data were gathered, the samples were 23 respondents. The samples were taken by using purposive sampling technique which was determined by the following criteria: 1. Adults 2. Diagnosed medically as affected by nonhemorrhagic stroke which was caused by hypertension. 3. Treated in the Stroke Unit of Dr. Pirngadi Regional General Hospital, Medan. 4. Fond of music 2.5 Definition of Operational What it meant by Operational was: 3.5.1. Music therapy: A type of medication which was done by having the respondents listen to classical music, Beethoven, with moderate frequency (750-3,000 Herzt). 3.5.2. Blood pressure of stroke patients was the result of measurement on the pressure undergone by blood in systolic and diastolic blood vessel systemically in human body at mmHg; tensimeter of Nova brand was used as measuring device. 2.6. Data Gathering Process The activities in data gathering in this research began by measuring respondents’ 183 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology blood pressure, followed by their listening to Beethoven relaxing classical music in 15 minutes, using phonograph record, ‘Websong.’ They wore headsets in listening to the music. After that, their blood pressure was measured again by using tensimeter, ‘Nova’. The measurement was conducted three times: 5 minutes, 10 minutes, and 15 minutes after the intervention. 2.7. Processing Plan and Data Analysis The data were processed by using computer in order to find out the average blood pressure of the stroke patients, using univatriate analysis and to find out the influence of Beethoven classical music therapy on respondents’ blood pressure, using bivatriate analysis and paired t-test at the significance level of 95%. 3. Result of the Research 3.1. Description of the Research Location Dr. Pirngadi Hospital was established on August 11, 1928 by the Dutch Colonial Government. It was named “GEMENTA ZIEKEN HUIS.” The laying down of its cornerstone was conducted by a ten year-old girl, Maria Constantia Macky, the daughter of Medan Mayor, Dr. W. Bays, who was appointed as the Director of the hospital. During the Japanese occupation, the hospital was expropriated and changed its name to “SYURITSU BYUSONO INCE.” An Indonesian by birth, Dr. RADEN PIRNGADI GONGGO PUTRO, was appointed as the director of the hospital, and his name has been inaugurated as the name of the hospital until now. After Indonesia proclaimed its independence on August 17, 1945, Dr. Pirngadi Hospital was expropriated and taken care by the RIS (Interim Republic of Indonesia) of East Sumatera Partition State. By the rapid political upheaval at that time, on August 17, 1945 all RIS partition states were abolished and changed to NKRI (Unitary State of the Republic of Indonesia). Dr. Pirngadi Hospital was also expropriated and taken care by the central government/the Ministry of Health in Jakarta. In the period of 1950 to 1952 Dr. Pirngadi General Hospital played an important role in the historical process of the establishment of the Medical School (the Faculty of Medicine), University of Sumatera Utara because one of the requirements for establishing the Faculty 184 of Medicine, University of Sumatera Utara, was that the faculty had to own a hospital as the supporting facility. Besides that, the faculty had to have instructors (usually doctors), either Dutch or native Indonesian, who worked at Dr. Pirngadi General Hospital. Since the establishment of the Faculty of Medicine, University of Sumatera Utara, on August 20, 1952, Dr. Pirngadi Hospital has been automatically become the Teaching Hospital which was used as the Clinical Secretariat for the medical students of the University of Sumatera Utara. RSU (General Hospital) H. Adam Malik became the Teaching Hospital of the Faculty of Medicine, University of Sumatera Utara, in January 1993, Dr. Pirngadi General Hospital changed its status from the Teaching Hospital to the Hospital for Teaching so that by this status Dr. Pirngadi General Hospital with its facilities and capacity was not only used as the education place for aspirant doctors from the Faculty of Medicine, University of Sumatera Utara, but also the aspirant doctors from other faculties in North Sumatera, West Sumatera, and Lampung. There are no correct data which indicate when Dr. Pirngadi General Hospital was handed its ownership from the central government to the North Sumatera Provincial Administration. In line with the implementation of Regional autonomy, Dr. Pirngadi General Hospital was handed its ownership from the North Sumatera Provincial Administration to Medan City Administration on December 27, 2001. After Dr. Pirngadi General Hospital belonged to Medan City Administration, the latter paid serious attention to develop the hospital by rehabilitating and improving it in all fields. The effort was realized by the Regional Regulation of Medan No. 30/2002 on September 6, 2002 on Institutional Change from Dr. Pirngadi General Hospital to the Health Care Service of Dr. Pirngadi General Hospital, Medan. In consequence, there was the organization, personnel, and management restructuring, and Dr. H. Sjahrial R. Anas, MHA was appointed as its Director. This was followed by the improvement of facility, infrastructure and the procurement of sophisticated devices as the support for the service. In this era, history recorded a big and bold move of Medan Mayor when he built the extension of 8 (eight) stories, furnished by Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology sophisticated facilities. Its cornerstone laying was performed on March 4, 2004, and the building was operated on April 16, 2005. Based on the human resources, facilities, and infrastructure of Dr. Pirngadi General Hospital in implementing education, its status was then changed from the Hospital as the Place for Education to the Education Hospital. Based on the recommendation from IRSPI (Indonesian Education Hospital Association), feasibility study on the Dr. Pirngadi General Hospital, Medan, to become the Education Hospital was conducted. The assessment (visitation) team consisted of Director of Specialist Medical Care, Director General in charge of Medical Care, the Head of Legal and Organizational Bureau, the Secretary General of the Department of Health, the Chairperson of the Education General Hospital Association and the Head of Legal and Organization Department, and the Secretary of Directorate General of Medical Care. Finally, on April 10, 2007, Health Care Service of Dr. Pirngadi General Hospital, Medan, officially declared that the hospital became the Education Hospital, based on the Decree of the Minister of Health of the Republic of Indonesia No. 433/Menkes/SK.IV/2007. 3.2. Univatrate Analysis 3.2.1. Respondents’ Characteristics There were 23 respondents in this research. Their characteristics could be seen in the following table: Table 3.1. Respondents’ Characteristics Related to the Effectiveness of Music Therapy in Lowering Blood Pressure at Dr. Pirngadi Regional General Hospital, Medan. Karakteristik n % Age Younger Adult 26-35 years old Older Adults 36-45 years old The Young Elderly 46-55 years old Middle Aged 56-65 years old Old People > 65 years old 3 8 8 4 13,0 34,8 34,8 17,3 Sex Male Female 14 9 60,9 39,1 Ethnic Group Acehnese Bataknese Javanese Karonese Malayunese Padangnese 2 8 5 4 3 1 8,7 34,8 21,7 17,4 13,0 4,3 Occupation Government Employee Indonesian National Army/Police Force Teacher Entrepreneur Private Company Employee Farmer Rickshaw Driver Housewife 5 1 2 4 2 4 1 4 21,7 4,3 8,6 17,3 8,7 17,3 4,3 17,3 Total 23 100 185 ebelum tervensi Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on Table 3.1 above, it was seen that the majority of the respondents’ characteristics were as follows: 39.1% of the respondents were 50 to 59 years old, 60.9% of them were males, 34.8% of them were Bataknese, 73.9% of them were Moslems, and 21.7% of them were government employees. 3.2.2. Respondents’ Lifestyle Respondents’ lifestyle and habit could be seen from their smoking habit, their consumption of meat, and their physical exercises. The frequency of respondents, based on their lifestyle could be seen in the following table. Tabel 3.2. Respondents’ Lifestyle Related to the Effectiveness of Music Therapy on Lowering Blood Pressure in Dr. Pirngadi Regional General Hospital, Medan, in 2014 Lifestyle n % Smoking Yes No 15 8 65,2 34,8 Meat Consumption Each Week Each Month Sometimes Hari Raya/New Year 8 4 9 2 34,8 17,4 39,1 8,7 Physical Exercises Every Day Twice a Week Each Week Sometimes Never 1 2 10 3 7 4,3 8,7 43,5 13,1 30,4 Total 23 100 From the table above, it could be seen that, in general, respondents had the habit of smoking (65.2%), the habit of sometimes consuming meat (39.1%), and the habit of doing physical exercises each week (43.5%). 3.2.3. Description of the Respondents’ Average Blood Pressure before and after the Intervention Tabel 3.3. The Average of Respondents’ Systolic Blood Pressure before and after the Intervention of Beethoven Classical Music Therapy Before 5 Minutes 10 Minutes 15 Minutes Intervention After After Intervention After Intervention Intervention 157,5 mmHg 154,7 mmHg 149,2 mmHg 145,8 mmHg Based on the table above, it could be seen that the average value of respondents’ blood pressure became lower after 15 minutes of the intervention (145.8 mmHg). 186 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Tabel 3.4. The average of Respondents’ Diastolic Blood Pressure before and after the Intervention of Beethoven Classical Music Therapy 5 Minutes 10 Minutes 15 Minutes Before After After Intervention After Intervention Intervention Intervention 98,4 mmHg 94,3 mmHg 91,8 mmHg Table 3.4 above showed that the average value of respondents’ diastolic blood pressure became lower after 15 minutes of giving music therapy than that after giving 5 and 10 minutes of music therapy. 3.3. Bivatriate Analysis 3.3.1. The Effectiveness of Beethoven Classical Music Therapy on the Lowering in Stroke Patients’ Blood Pressure in Dr. Pirngadi Regional General Hospital, Medan The effectiveness of Beethoven classical music therapy on the lowering in respondents’ systolic blood pressure was viewed from the average disparity of respondents’ systolic blood pressure before the intervention and after the intervention in the 5th, 10th, and 15th minutes by using paired t-test because all variables had normal distribution of data (the result of Kolmogorov Smirnov test). Tabel 3.5. The Average Disparity of Respondents’ Systolic Blood Pressure before and after the Intervention of Beethoven Classical Music Therapy Systolic Mean SD P Value Before Intervention After 5 Minute Intervention After 10 Minute Intervention After 15 Minute Intervention 157,5 154,7 149,2 145,8 10,4 9,6 0,000 9,6 0,000 9,7 0,000 90,5 mmHg From Table 3.5 above, it could be seen that there was significant average disparity of systolic blood pressure between before the intervention and after the intervention, either in the 5th minute (p-value < 0.001), the 10th minute (p-value < 0.001), and the 15th minute (p-value < 0.001). In the 5th minute after the intervention, there was the lowering in blood pressure of 2.8 mmHg, in the 10th minute there was the lowering in blood pressure of 8.3 mmHg, and in the 15th minute there was the lowering in blood pressure of 11.7 mmHg. 3.3.2. The Effectiveness of Beethoven Classical Music Therapy on the Lowering in Respondents’ Diastolic Blood Pressure in Dr. Pirngadi General Hospital, Medan The effectiveness of Beethoven classical music therapy on respondents’ diastolic blood pressure was viewed from the average disparity of respondents’ diastolic blood pressure before and after the intervention in the 5th, 10th, and 15th minutes by using paired ttest. Tabel 3.6 The Average Disparity of Respondents’ Diastolic Blood Pressure before and after the Intervention of Beethoven Classical Music Therapy Diastolic Before Intervention After 5 Minute Intervention After 10 Minute Intervention After 15 Minute Intervention Mean 98,4 94,3 91,8 90,5 It could be seen that there was the average disparity of diastolic blood pressure before and after the intervention in the 5th minute (p-value < 0.001), in the 10th minute (p-value < 0.001), and in the 15th minute (p-value < 0.001). In the 5th minute after the intervention, there was the lowering in diastolic blood SD 2,6 2,7 2,8 3,1 P Value 0,000 0,000 0,000 pressure of 4.1 mmHg, in the 10th minute there was the lowering in diastolic blood pressure of 6.6 mmHg, and in the 15th minute there was the lowering in diastolic blood pressure of 7.9 mmHg. 187 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 4. DISCUSSION 4.1. Discussion This research was conducted on stroke patients, caused by hypertension; they were given Beethoven classical music therapy, entitled “Fur Elise.” Before the intervention of classical music therapy, the result of the patients’ blood pressure was high: their systolic blood pressure was in the average range of 157.5 mmHg, and their diastolic blood pressure was in the average range of 98.4 mmHg. Blood pressure of 190/110 was undergone by a respondent who was 53 years old. This indicated that the age factor did not always influence on the increase in an individual blood pressure; there were other factors such as lifestyle which was undergone by a respondent who was 53 years old. He used to smoke and was overweight. After the patients were given music therapy, there was the lowering in their blood pressure; it could be seen from the result of the measurement. In the first five minutes, after the music therapy had been given, there was no significant lowering in the blood pressure. There was only a lowering in the respondents’ systolic blood pressure in three respondents from 150 mmHg to 140 mmHg (two respondents) and from 170 mmHg to 160 mmHg (one respondent) so that the average value was 154.7 mmHg. In the second ten minutes, respondents’ systolic blood pressure was measured again. The result indicated that there was the lowering in blood pressure of 19 respondents. The lowering occurred in the systolic blood pressure of 10 mmHg from the previous blood pressure so that the average value was 149.2 mmHg. The lowering in systolic blood pressure was clearly seen in 15 minutes after the intervention so that the average value was 145.8 mmHg. Diastolic blood pressure also lowered, like what happened to systole blood pressure. In the beginning, respondents’ diastolic blood pressure was 80 - 100 mmHg. Diastolic blood pressure only occurred in one respondent. Five minutes after the intervention, diastolic blood pressure lowered to 10 mmHg. It was continuously stable until 15 minutes after the intervention, starting from the first day to the third day. The same was true to the average value. The average value of diastolic 188 blood pressure in five minutes after the intervention was 94.3 mmHg. The next ten minutes the average value of diastolic blood pressure was 91.8 mmHg, and the next 15 minutes diastolic blood pressure was 90.5 mmHg. The result of statistic paired t-test at the significance level of 95% showed that there was the significant result in the first 5 minutes, 10 minutes, and 15 minutes after the intervention at p-value = 0.000 from the first day until the third day when this research was conducted. It was found that music therapy could decrease a person’s level of stress so that there was a relaxation to the physiological response when music was listened to by a person who had hypertension. Besides that, music therapy could heal man physically and psychologically. Some researchers from The Neuro, through MRI scan proved that brain released dopamine substance (hormone which is related to brain system, gives comfort and strength to motivate a person proactively to do a certain activity). The music therapy could also decrease andrenocorticotropic hormone (ACTH), a stress hormone (Djohan, 2005). Through music, a person can also release his hidden emotion and bad memory. It is also very effective to make human body relaxed because body, emotion, and soul release sigh of relieve. This condition is in line with the result of the research by Chavin (2004) which stated that listening to music could decrease the level of apprehensiveness and stress so that human body would relax and would bring about the lowering in blood pressure and pulse. Music is able to trigger strong feeling and release it from the body like poison which is discharged from a wound (Merrit, 2003). The spread of music is very potential to give resonance of its listener’s feeling from negative to positive feeling and to increase the feeling of delight and peacefulness (Salapessy, 2001). Besides that, through music a person can make an effort to find internal harmony (inner metabolism of human body so that the process can run properly. With better metabolism, human body will be able to build better antibody system so that it will be guarded against any disease (Satiadarma, 2001) Therefore, music is a beneficial device for a person to find a harmony in his soul. This is Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology important because by harmony in one’s self, he will easily cope with his stress, tense, pain, and various types of disturbance or negative emotion (Ortiz, 1997). Besides that, music, through its sound, can change unharmonious frequency to come back to normal and healthy vibration so that it can recede to the normal condition (Salampessy, 2001). Music therapy is therapeutic which means that it can cure ailments. One of the reasons is that music produces rhythmical response caught through ears and processed in the body nervous system and gland in the brain which reorganizes the interpretation of the sound to the internal rhythm of his sense of hearing. This internal rhythm influences. The result of the research conducted by Asrin et.al showed that music therapy which dominantly in moderate frequency was very significant to handle the response of blood pressure in primary patients. The result of the research conducted by Sarayar et.al showed that there was the influence of classical music therapy on the decrease in blood pressure of pre-hemodialysis patients in Dahlia BLU Room of RSUP Dr. R. D. Kandou, Manado at p-value < 0.05 (p < 0.01). 4.2. Limitation of the Research In this research, there was no control group; the control was blood pressure before the intervention. Besides that, this research was conducted by ignoring participating disease and medical therapy of antihypertension which was given to respondents. The researcher was afraid if it would be bias in this research. 5. CONCLUSION AND SUGGESTION 5.1. Conclusion The conclusion of the research was that music therapy was effective in decreasing blood pressure of stroke patients caused by hypertension. It was indicated by the result of statistic paired t-test which indicated that there was significant result at p-value < 0.05 (p < 0.001) for 5 minutes, 10 minutes, and 15 minutes after the intervention of Beethoven’s “Fur Elise” classical music therapy. should be facilitated by classical music therapy as a complementary therapy in lowering their blood pressure. 5.2.2. Health Service It is recommended that a policy should be made in providing the facility for music therapy in the Inpatient Rooms where stroke patients are being treated, especially the facility for music therapy in the Stroke Unit. REFERENCES Asrin, et.,al., 2009, Upaya Pengendalian Respon Emosional Pasien Hipertensi Dengan Terapi Musik Dominan Frekuensi Sedang Kerja Puskesmas Purwokerto Timur Banyumas., accessed on April 1 2014. Brunner & Suddart. 2002, Buku Ajar Keperawatan Medikal Bedah (Vol.2).Jakarta: EGC. Chang, E, etl, 2010, Patofisiologi ; Aplikasi Pada Praktik Keperawatan, EGC, Jakarta Djohan, 2006, Terapi Musik ; Teori dan Aplikasi, Galang Press, Jakarta Goldszmit A, 2013, Stroke Essensial, Indeks, Jakarta Junaedi I, 2011, Stroke, Waspadai Ancamannya, CV. Andi Offset, Yogyakarta Natalina, D. 2013. Terapi Musik Bidang Keperawatan, Mitra Wacana Media, Jakarta Sastroasmoro, S. et.al., 2010. Dasar-Dasar Metodologi Penelitian Klinis, Jakarta : Sagung Seto. Sarayar, et.al,. 2013. “Pengaruh Musik Klasik Terhadap Penurunan Tekanan Darah Pada Pasien Pra-Hemodialisis Di Ruang Dahlia BLU RSUP. Prof. Dr. R. D. Kandou Manado,” ejournal keperawatan (e-Kp) Volume I. Number 1. August 2013 accessed on March 27, 2014. Sylvia, P, 2006, Patofisiologi ; Konsep Klinis Proses-Proses Penyakit, Volume 1, EGC, Jakarta Yudoyono, S. et.al., 2011, Cara Jitu Mengatasi Hipertensi, Copyright, Yogyakarta 5.2. Suggestion 5.2.1. Patients/Families/People It is recommended that stroke patients, caused by hypertension, 189 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology FACTORS ASSOCIATED WITH NUTRITIONAL STATUS STREET CHILDREN IN THE CITY PEMATANGSIANTAR Desprin Sinulingga*, Diana** *Alumni of the public health, STIKes Sumatera Utara, Indonesia **Public Health, STIKes Sumatera Utara, Indonesia, [email protected] ABSTRACT Street children are a group at risk of malnutrition because of the life they lead are likely to behave at risk. Nutritional problems of street children is influenced by several factors such as age, gender, activity, shelter, health care utilization, and diet. This research is analytic. The sample used in this study were street children in the city where the sample is taken Pematangsiantar acidental sampling during the months from October to December 2013. Methods of data collection is done by using the primary data and secondary data. The results showed that there were 13.2% more nutritional status of street children, 52.8% good nutritional status, nutritional status 30.2% less and 3.8% severe malnutrition. There is no correlation between age and nutritional status of street children p = 0.973. No association with gender nutritional status of street children p = 0.208. There is a relationship between activity and nutritional status of street children there is a relationship p = 0,012.Tidak residence and nutritional status of street children p = 0,059.Tidak no association between health service utilization and nutritional status of street children p = 0,733.Ada the relationship between diet nutritional status street children p = 0.002. Suggested to Pematangsiantar of Regional Government and relevant agencies to pay more attention to the health of street children through education about nutrition and the provision of health services for street children, either in the form of supplementary feeding and drugs, and to the parents should pay attention to food consumption serves children with diverse wide and varied menu every meal. Keywords: street children, nutritional status Background Of The Problem Increasing the number of street children will improve nutrition and health issues. This is due to street kids who fall into the category of children and adolescents in need of good nutrition and good health to support its growth. According to UNICEF (2008) children are still growing and developing so that children are more susceptible than adults to the poor living conditions such as poverty, non-fulfillment of health care, nutrition, clean water, shelter, and environmental pollution. The influence of disease, malnutrition, and poverty threaten the future of the children and the communities in which they live. According Moeliono (2001) operationally it can be said that street children are children aged 5-18 years who spent more than four hours of his time on the streets either for work or other activities. One of the health problems that occur in the state of street 190 children are malnourished due to irregular eating behavior. The state of malnutrition is one of the factors that cause a person easily susceptible to infectious diseases, it is because the natural immune system owned .In addition weakened health status of poor street children can also cause nutritional status becomes bad (Indriani, 2006). In Makassar in 2012 conducted research that street children have nutritional skinny because activity on the streets who spent 4-8 hours per day, do not take advantage of good health care, do not live with their parents, and generally those who have thin nutrition over the age of 13 years and male sex (indina et al, 2012). Today the growth of street children in Indonesia increasing Pematangsiantar for example, which is very easy to see street children in various streets in the city Pematangsiantar. Among them, in the way Sutomo, the tax department Horas, Merdeka, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Tomuan area, Parluasan station, Marihat, corner 2, the area Tanjungpinggir. Of the whole place, according to the city Department of Social Pematangsiantar, overall street children who often move in the region - the region amounted to 113 people. In everyday life, street children interact with various social elements that are in the way, both among children and adults with various backgrounds activity. When they've been on the road, all the resources they have deployed to brief earn.Street singers the form of money, shining shoes, to beg is a favorite work that occupied by street children there. In 2012 the NGO Fokrat in town Pematangsiantar held free medical treatment to street children and of the results of the examination disebutkn that the majority of street children have malnutrition. Based on the description above, the writer interested in conducting research entitled " factors associated with the nutritional status of street children in the city Pematangsiantar " . Types Of Research This type of research is analytic aims to determine what are the which affects the nutritional status street children in Pematansiantar Location Research The study was conducted in the city Pematangsiantar. Population Research The population of street children in the city Pematangsiantar totaling 113 people consisting of about 23 people Sutomo street, neighborhood pajakHoras 15 people, Merdeka 17 people, 13 people Tomuan area, Parluasan station 15 people, Marihat 10 people, local intersection 2 as many as 5 people, and the Cape region edge 15 people. Obtained a sample of 53 street children in the city of Causeway siantar consisting of Jalan Sutomo 10 people, 8 horas Tax, Freedom 10, Tomuan 5 people, Parluasan 5 people, Marihat 5 people, Simpang2 5 people, Tanjungpinggir 5 people. acidental sampling technique sampling. Method Of Collecting Data The collection of primary data include age, gender, residence, activities, health service utilization, and eating is done with the interview. While nutritional status by using the gauge height and weighing in to street children. Data Analysis Methods Univariate analysis is used to see each distributed frequency variable and bivariate analysis to examine the relationship between the variables of age, sex, place of residence, activity, and utilization of health services and nutritional status, diet by using chi squere. Results And Discussion Based on research conducted in the city Pematangsiantar about the nutritional status of street children then obtained as a result of the following: Table 1. Relationship Age With Street Children Nutritional Status No Age 1 14-16 2 17-18 Total More F % 4 57,1 3 42,9 7 100 Nutritional status Good Less F % F % 15 52 7 47 14 48 8 53 29 100 15 100 Bad F % 1 50 1 50 2 100 Total F 27 26 53 % Prob % 50,9 p 0,973 49,1 100 191 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on statistical test obtained by value p = 0.973 (P> 0.05), meaning Ho accepted meaning no correlation between age on nutritional status of street children. This is in line with research conducted by Yunita (2008) on street children under the care of NGOs YAKMI that street children aged 14-16 years and 17-18 years old there are also severe malnutrition. It is caused by factors from both inside and outside child jalanan.Factor from within like some of them in his time had experienced infectious diseases such as diarrhea, respiratory infections, and there is also affected by tuberculosis who often colaps.Where circumstances such as This can have a negative impact on health and nutrition mereka. Than external factors, ie the majority of them also have bad habits such as smoking, drinking alcohol as drinking wine, beer, etc. Not only that there are also street children who use illicit drugs such as drugs, where circumstances can also have a negative impact on their health and nutrition. (Arisman, 2002). This is in line with the opinion Jessor (1996), which says that adolescence is a period of risk to health, so at this time of great need for nutrients Table 2. Relationship Sex With Street Children Nutritional Status Nutritional Status More Good Less Bad Total % Sex No F % F % F % F % F % Prob 1 Male 6 85,7 18 62 13 87 2 100 39 73,6 2 Female 1 14,3 11 38 2 13 0 0 14 26,4 p 0,208 Total 7 100 29 100 15 100 2 100 53 100 Based on statistical test obtained by value p = 0.208 ( P > 0.05 ), meaning Ho accepted meaning there is no relationship between gender and nutritional status of street children . As well as research conducted by Yunita (2008 ) that the street child sex more men who are not good nutritional status compared with street women children.The sex is due to habits they were not as good as smoking and drinking alcohol will not affect either the health and nutritional status of the only street children. Male doing more activity than street children who are women like driving around for busking , polish , and begging that should street children male sex more requires good nutrition than women because they are more active than women. ( Arisman , 2004) . Table 3. Activity Relationship With Street Children Nutritional Status Nutritional Status More Good Less Bad Total % No Activity F % F % F % F % F % Prob Heavy 1 Work 2 28,6 13 45 13 87 2 100 30 56,6 2 Light Work 5 71,4 16 55 2 13 0 0 23 43,4 p 0,012 Total 7 100 29 100 15 100 2 100 53 100 Based on statistical test obtained by value p = 0.012 (P <0.05), meaning that Ho refused meaning there is a relationship between activity and nutritional status of street children. According to research conducted by the Bagong 2000, in the city of Semarang on the activities of street children, street children have a high activity. While long working street children varied, where street children work 6-8 hours per day, 9-12 hours to 13 hours This is because there are too few of them were living with their parents so that their nutritional intake enought.Not only that portion among them are also able to meet their own food needs from the singing, shining shoes and begging so that the frequency of eating three times a day enough so that the need and be well nourished because as we all know the more severe the longer the activity and we do these activities hence the need nutrients that would be even greater. (Guthrie, 2005). 192 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology From the analysis it also appears that there also appeared to respondents who were not strenuous activity but has poor nutritional status, this happens because of their bad habits such as smoking, alcoholism, and drug abuse that affect their health and nutritional status (Arisman, 2004) Not only that there are also some of those who have a habit - eating habits are not as good as just skip two meals and prefer food snack. As we know most of the snack is not just empty calories but contain few nutrients. Snacked in fact not prohibited, as long as know how to choose snacks that will nutrients. (Arisman, 2004). Table 4. Relationship With Nutritional Status Shelter for Street Children Nutritional Status Total % Prob More Good Less Bad No Shelter F % F % F % F % F % 1 Good 5 71,4 22 76 7 47 0 0 34 64,2 2 Not Good 2 28,6 7 24 8 53 2 100 19 35,8 p 0,059 Total 7 100 29 100 15 100 2 100 53 100 Based on statistical test obtained by value p = 0.059 ( P > 0.05 ) , meaning Ho accepted meaning there is no relationship between the nutritional status of children living on the streets. And the results of the analysis can also be seen that there is also street children who live not good but turned out to have a good nutritional status , it is because some of them can meet the needs of their own meal from the singing , shining shoes and begging so they do not miss the 3 meals a day so it needs to be nourished in activity although they have quite severe because as we all know the more severe the longer the activity and we do these activities , the need for nutrients that would be even greater . ( Guthrie , 2005) . Table 5. Relationship With Health Care Utilization Street Child Nutritional Status Nutritional Status Health More Good Less Bad Total % Care No Utilization F % F % F % F % F % Prob 1 Good 3 42,9 10 35 5 33 0 0 18 34 2 Not Good 4 57,1 19 66 10 67 2 100 35 66 P:0,733 Total 7 100 29 100 15 100 2 100 53 100 Based on statistical test obtained by value p = 0.733 (P> 0.05), meaning Ho accepted means there is no relation between the utilization of health services on the nutritional status of street children. From the results of this research is that there are street children a good health service utilization appears to have no good nutritional status, this is because some of them were exposed to tuberculosis in which the disease treatment should be sustainable but they do not follow up treatment provided by the health service such as buying prescription medicine given by a midwife or doctor because of their inability and to check the state of their health back like a check back to the lab so that when their health declines will have an impact on the nutritional status of their own. (Indriani, 2006). Table 6. Eating Behaviour Relationships With Street Children Nutritional Status Nutritional Status Total % Prob More Good Less Bad Eating NO Behavior F % F % F % F % F % 1 Good 7 100 22 76 4 27 1 50 34 64,2 2 Not Good 0 0 7 24 11 73 1 50 19 35,8 p 0,002 Total 7 100 29 100 15 100 2 100 53 100 193 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on statistical test obtained by value p = 0.002 (P <0.05), meaning that Ho refused meaning there is a relationship between eating behavior and nutritional status of street children From the analysis it can be seen that street children good eating behavior turns nutritional status is not good, it is due to street children generally consume more junk food (junk food) because they think the food is easy to obtain, in addition to more.The call junk food because very little (in fact there is none at all) contain calcium, iron, folic acid, vitamins A and C, while the content of saturated fat, cholesterol, and high sodium. (Arisman, 2004). From the analysis it also appears that there are street children who despite eating behavior are not well turned out good nutritional status, this is due to their lifestyle which is as good as rarely smoke and rarely drank alcoholic beverages. In addition, street children eating behavior is not good but good nutritional status do not have heavy activity because they do not get around but only in one place to do activities streets. Conclusion From the research we concluded that there was no relationship between age and nutritional status of street children, there is no relationship between gender and nutritional status of street children, there is a correlation between activity and nutritional status of street children, there is a relationship between the nutritional status of children living on the streets, not there is a relationship between the use of health services and nutritional status of street children, there is a relationship between eating behavior and nutritional status of street children. Suggestion To the Regional Government to pay more attention Pematangsiantar health of street children through education about nutrition and the provision of health services for street children, either in the form of supplementary feeding and medication, the parents should pay attention to food consumption serves children with diverse and varied menu every meal. This study is expected to be useful for other researchers, so that further research could explore other factors that may be associated with nutritional status of street children. 194 DAFTAR PUSTAKA Arisman, 2004. Gizi Dalam Daur Kehidupan. Jakarta : EGC Almatsier, Sunita. 2004. Prinsip Dasar Ilmu Gizi. PT Gramedia Pustaka Utama. Jakarta. Baliwati, dkk. 2004. Pengantar Pangan dan Gizi. Penebar Swadaya. Jakarta Brown, J.E . 2005. Nutrition Through The Life Cycle. Thomson Wadsworth.USA Guthrie, 2005. Human Nutrition. Masby. New York Hamid,A. 2008. Peta Masalah Kesejahteraan Sosial Anak.www.depgos.go.id (dibuka pada tanggal 28 oktober 2013 pukul 23.00) Indina, dkk. 2012. Gambaran Status Gizi Anak Jalanan Di Kota Makassar. www.masalah gizi anak jalanan.com (dibuka pada tanggal 11 November 2013 pukul 22.00) Indriani,D.S .2006. 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Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Siagian,2002.Epidemiologi Gizi.Jakarta : EGC Subhansyah, Aan T dkk. 2005. Anak Jalanan Di Indonesia. YLPS Humana. Yogyakarta. Supariasa, dkk. 2001. Penilaian Status Gizi. EGC. Jakarta. Soekirman. 2000.Ilmu Gizi Dan Aplikasinya Untuk Keluarga Dan Masyarakat. Jakarta www.masalah gizi anak jalanan.com ( dibuka pada tanggal 12 November 2013 pukul 10.00) Yunita. 2008. Gambaran Status Gizi Anak Jalanan Di Bawah Asuhan LSM YAKMI MEDAN. FKM USU. Medan 195 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RELATIONSHIP BETWEEN MATERNAL AGE WITH SEVERE PREECLAMPSIA IN MARZOEKI MAHDI HOSPITAL BOGOR Dodoh Khodijah, Mumun Munigar Prodi Kebidanan Pematangsiantar Poltekkes Kemenkes Medan Jurusan Kebidanan Poltekkes Kemenkes Jakarta I ABSTRACT Background: Preeclampsia and eclampsia are the leading cause of death after bleeding and infection. Severe preeclampsia is a joint complication and cause of Maternal mortality ranges between 9.8% 25.5%. Objective: To determine maternal age relationship with the incidence of severe preeclampsia in Maezoeki Mahdi Hospital Bogor in 2013. Method: survey with a cross sectional approach. Data was obtained from the patient medical record. The population in this study was all women giving birth at Marzoeki Mahdi hospitals Bogor in 2012, with a sample of 94 people. Results: The prevalence of mothers delivered with severe preeclampsia in Marzoeki Mahdi Hospital Bogor as much as 24.5%. Mother age who has a significant relationship with the incidence of severe preeclampsia, whereas parity, gestational age and a history of pre-eclampsia do not show a significant association. Conclusion: Maternal age who has a significant relationship with the incidence of severe preeclampsia. Suggestion: To examine the ANC regularly, at least four times during pregnancy can prevent severe preeclampsia. Keyword: Age and Severe Preeclampsia. Introduction National development is essentially the integral human development, one of which is development which is aimed at improving the ability of health and quality of life of healthy people in order to manifest optimal health status. One indicator of the health of a country is the Maternal Mortality Rate (MMR) and Infant Mortality Rate (MMR). This was due to the mother and baby are groups which have a large degree of vulnerability to disease and death. The current status of maternal and child health in Indonesia is far from being the expected, characterized by high MMR and IMR. Based on the Indonesian Demographic and Health Survey (IDHS) 2007 MMR data obtained at 228 per 100,000 live births, this figure is still high when compared with neighboring countries such as Malaysia (62 per 100,000 live births), Sri Lanka (58 per 100,000 live births), and the Philippines (230 196 per 100,000 live births). As for the data IMR in Indonesia for 32 per 1,000 live births (IDHS 2012). But this rate is still relatively high when compared with the ASEAN countries such as Singapore (3 per 1000 live births), Brunei Darussalam (8 per 1000 live births), Malaysia (10 per 1,000 live births), Vietnam (18 per 1,000 live births), and Thailand (20 per 1,000 live births). From all provinces, West Java ranks first for Maternal Mortality Rate and Infant Mortality Rate, followed by Central Java, East Nusa Tenggara, Banten and East Java. Bogor District Health Office reported that from January to November 2010, there were 60 mothers died during childbirth. According to data from the Child Health Program Reports of West Java Province Year 2010 - 2012, the number of neonatal deaths was reported in West Java reached 3624 and infant mortality reached 4,650. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The main causes of maternal deaths in Indonesia are haemorrhage, infection, eclampsia, obstructed labor and complications of abortion (Anwar, 2010). Eclampsia is the most common disease causing maternal mortality rates ranged from 9.8% -25.5% while the higher infant mortality is 42.2% 48.9%. (Wiknjosastro, 2006). The placental ischemia is main cause of preeclampsia, according to theory. However, this theory cannot explain all things related to the disease. Apparently not just one factor, but many factors that leads to preeclampsia and eclampsia (multiple causation). Factors that are often found as a risk factor among others nulliparous, multiple pregnancy, age less than 20 years old or over 35 years, has a history of descent, and obesity (William, 2002) The incidence of severe preeclampsia in hospital Marzoeki Mahdi Bogor increased by 3.23% in 2010 and increased to 8.04% in 2011. From these data, the authors wanted to determine the relationship of maternal age on the incidence of severe preeclampsia in Marzoeki Mahdi Hospital Bogor. patients. The population for this study is all mothers who were hospitalized Marzuki Mahdi in 2012 with a sample size of 94 people are the whole mothers who suffer from severe preeclampsia. The analytical method used univariable and bivariable by using Chisquare. Research Result Univariable Analysis Table 1. Frequency Distribution of Age, Parity, Age of Pregnancy and History of Preeclampsia Marzoeki Mahdi Hospital Bogor Nu Variable 1 Age 2 Parity 3 Gestational age 4 History of severe preeclampsia Categories High risks Low risks High risk Low risk High risk Low risk Yes No Frequency 27 (28,7%) 67 (71,3%) 60(63,8%) 34(36,2%) 84(89,4%) 10(10,6%) 8 (8,5%) 84 (91,5%) Bivariable Analysis At this stage bivariable analysis to determine the relationship of the independent variables with the dependent variable, external variable freely and external variables with the dependent variable. The statistical test used is Chi-Square. Results of the analysis are presented in the following table. Method This study uses an observational study with a cross sectional approach to look at the relationship of independent variables and the dependent variable being measured simultaneously. The data in this study using secondary data from medical records of Table 2. Relationship Respondent Characteristics with Severe Preeclampsia (n = 94) Variable Maternal Age High Risk Low Risk Parity High Risk Low Risk Gestational Age Aterm Preterm History of Preeclampsi Yes No Information : 2 = Chi-Square RP = Ratio Prevalens Severe Preeclampsia Yes (%) No (%) 2 p RP 95% CI 15 (55,6) 12 (17,9) 12 (44,4) 55 (82,1) 13,32 0,01* 5,73 1,04-1,55 18 (30,0) 9 (26,5) 42 (70,0) 25 (73,5) 0,03 0,867 1,19 0,78-1,22 22 (26,2) 2 (20,0) 62 (75,8) 8 (80,0) 2,30 0,129 1,41 0,92-1,54 4 (57,1) 23 (26,4) 3(42,9) 64(73,6) 7,79 0,01* 3,7 1,07-1,57 p = p-value CI = Confidence Interval * = significant 197 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology From the above data can be seen in the incidence of high-risk severe preeclampsia at the age of 15 people (55.6%) and those who have a history of previous severe preeclampsia (57.1%). Statistical analysis showed significant correlation between maternal age and previous history with events severe preeclampsia with OR of 5.7: 3.7 This case illustrates that mothers who lived (20 years /> 35 years) have a risk of severe preeclampsia 5, 7 times when compared to maternal age 20-35 years, and women who have a history of previous severe preeclampsia had 3.7 times the odds for the severe preeclampsia. Parity variable prevalence as high risk (30%), low risk parity group of (26.5%) and at the gestational age ≥ 37 weeks of (26,27%). Statistical analysis showed no significant correlation between parity and gestational age with the incidence of severe preeclampsia. DISCUSSION The prevalence of severe preeclampsia. Based on the overall results of the study found the incidence of birth mothers with severe preeclampsia in 2012 were 112 respondents of 1393 mothers who gave birth at the Hospital Marzoeki Mahdi or by 8.04%. This figure increased compared to the incidence of severe preeclampsia in the previous year 50 people (3.23%) of the 1548 severe preeclampsia mother. High incident at the hospital may be caused Marzoeki Mahdi Marzoeki Hospital is a referral from health centers and private practices surrounding midwives, Relationship Dependent Independent Variables Variable and 1. Maternal Age severe preeclampsia highest prevalence by age is at high risk age group is 55.6%. Results of calculation of statistical test showed no association with the incidence of maternal age severe preeclampsia, with OR = 5.73, this illustrates that birth mothers aged <20 years / 35 years had 5.73 times the risk factors for preeclampsia occurs when compared to maternal age 30-35 years. This is according to research conducted by Koeswarsono et al (1991) in the RSU Gunung Wenang, Manado (1991) reported that the highest frequency of patients with eclampsia are at the age of 15-20 198 years, while the highest frequency severe preeclampsia occurs at age> 35 years, Agus ( 2001) also reported the results of his research found that age <20 years have a risk of severe preeclampsia 1.75 times and 2.47 times at the age of> 35 years. Septi (2007) reported in RSUPN Dr. Cipto Mangunkusumo also found the highest proportion of patients with severe preeclampsia was highest at age <20/35 years as much as 37.5% and Sudhaberata (2001) said the same thing. Cunningham also said in his maternal age> 35 years increases the likelihood of severe preeclampsia. severe preeclampsia high incidence in the age group <20 years due to the growth in terms of biological and reproductive development is not yet fully ready or mature, the young woman is not ready to bear the moral burden that the lack of awareness of prenatal care (Astuti, 2002) and contrary on maternal age> 35 the year in which the health condition and reproductive decline and degenerative diseases that already exist. 2. Parity severe preeclampsia highest prevalence of patients at high-risk groups, namely maternal P1 / P≥4 as much as 30% compared with maternal P2 / P3 are as much as 26.5%. The test results were not statistically significant relationship. This is not in accordance with the results of research conducted by Agus (2001) reported that the first parity has occurred severe preeclampsia risk was 0.62 times compared to the second and third parity. Research conducted by Septi (2007) in RSUPN Dr. Cipto Mangunkusumo also reported patients with severe preeclampsia in maternal parity first or fifth as much as 21.15% higher than the second and fourth parity is 6.00%. He concluded that the first or fifth parity had 4.2 times the risk of severe preeclampsia occurs. It is also inconsistent with the theory that the first pregnancy increases the risk of preeclampsia ten times more frequently (Chapman, 2006). Cunningham argued renal biopsy results of women with preeclampsia and find gromerulonefritis krinik at 205 nullipara. Manuaba (2007) also found a higher risk primigravid has to happen severe preeclampsia. Adequate nutrition and regular ANC can reduce the risk of preeclampsia in maternal as Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology proposed by Manuaba (2007) which says that the provision of adequate calcium in the diet may reduce the occurrence of preeclampsia. 3. Gestational Age Univariable analysis results obtained severe preeclampsia patients mostly in the age group of high-risk pregnancies (≥37 weeks) as many as 22 people (26,27%), while in the group of gestational age <37 weeks only 2 people (20%). OR = 1.41. This case illustrates that birth mothers with gestational age 37 weeks had 1.41 times the risk of SEVERE preeclampsia when compared with birth mothers with gestational age <37 weeks. Results of calculation of statistical test showed no significant relationship. This is not in accordance with the theory that the more her pregnancy affects normal placental changes such as thickening of blood vessel walls and villi which accelerate the process of preeclampsia and hypertension that generally occurs in the third quarter (Wiknjosastro, 2005). The theory put forward by Manuaba, et al (2005) that in general. Preeclampsia and eclampsia develop after the 20th week of her pregnancy and increasingly more likely onset of preeclampsia. Regular antenatal care in accordance with the policy of a minimum program of antenatal visits carried out at least four times during pregnancy can recognize early complications that could be pursued early detect the presence of severe preeclampsia. Conclusion 1. Prevalence severe preeclampsia occurs at age the age at high risk (71.3%) and the risk parity (P1 / ≥P4) which (63.8%), with the highest risk for gestational age (89.4%), while for the variable history of preeclampsia genetically contained the highest proportion in the age group is not at risk. 2. There is a significant relationship mother's age and history of the events severe preeclampsia, parity and gestational age do not have a meaningful relationship. Suggestion 1. Provide counseling to the EFA to plan a pregnancy on maternal age 20-35 years. 2. Early detection severe preeclampsia at the time of the ANC, especially mothers who have a family history of the severe preeclampsia. References 4. History of preeclampsia The result showed the highest severe preeclampsia patients with a history of preeclampsia maternal family in the amount of 57.1% or 4 out of 7 people at risk group. A history of poor labor triggers predisposing factors. Results of calculation of statistical test looks for meaningful relationships with OR = 3.71, maternity with a history of preeclampsia have a risk of 3.71 times occur in preeclampsia compared mothers who no history of preeclampsia. Results of this research is supported by the theory advanced by Chapman (2006) which states a family history of a genetic relationship, mother or sister increased risk of 4-8 times, also stated that the basic conditions contribute maternal and are the factors that determine the occurrence of preeclampsia. Chesley and Cooper (1986) studied the sister, daughter, granddaughter and daughtereclampsia than women who give birth, they conclude preeclampsia very likely lowered. Cooper and Liston (1979) found that susceptibility to preeclampsia depend on a recessive gene. (Cunningham, 2006) Chapman, V. 2006. Asuhan Kebidanan, persalinan, dan kelahiran. Jakarta: EGC Cunningham. 2006. Obstetri Williams. Vol I . Jakarta : EGC. Departemen kesehatan RI. 2008. Profil Kesehatan 2007 Ermiyati. 2008. Hubungan Karakteristik Ibu Hamil Dengan Kejadian Preeklamsi Berat Di Rumah Sakit Lanud Atang Sendjaya Periode Januari Sampai Desember 2007. Karya Tulis Ilmiah Politeknik Kesehatan Jakarta I. Hidayat, A dan Aziz A. 2009. Metode Penelitian kebidanan dan teknik Analisis data. Jakarta: Salemba Medika. Mansjoer, A. 2001. Kapita Selecta Kedokteran. Edisi 3. Jalarta: Media Aeculapius Manuaba, I.B.G. 2007. Ilmu Pengantar Obstetri . Jakarta: EGC. Neville dan George M. 2001. Essensial obstetric Dan ginekologi. Edisi 2. Jakarta: Hipokrates Saifuddin, AB, Dkk. 2002. Buku Acuan Nasional Pelayanan Kesehatan Maternal 199 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology dan Neonatal. Jakarta : yayasan Bina Pustaka Sarwono Prawirohardjo. ________________. 2006. Standar Pelayanan Medik Obstetri Dan Ginekologi . Jakarta : Balai Penerbit FKUI. Sastrawinata dan Sulaiman .2005. Obstetri Patologi.Jakarta: EGC. Situmorang, S. 2008. Hubungan Karakteristik Ibu Bersalin dengan Kejadian Preeklamsi Berat Atau Eklamsi Di RSUPN Dr. Cipto Mangunkusumo Periode Ilmiah Politeknik Kesehatan Jakarta I. Sukandar, A. 2001. Gambaran Epidemiologi kejadian Preeklamsi-eklamsi serta faktor- 200 faktor yang berhubungan di RSUP Dr. Hasan Sadikin Bandung 1999-2000. Skripsi fakultas Kesehatan Masyarakat Universitas Indonesia. Varney, H. 2007. Buku Ajar Asuhan Kebidanan. Vol I . Jakarta : EGC. Widyastuti, Palupi. 2002. Modul Eklamsia: Materi Pendidikan Kebidanan/WHO. Jakarta: EGC Winkjosastro, dkk. 2006. Ilmu Kebidanan. Jakarta : Yayasan Bina Pustaka Sarwono. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology FACTORS AFFECTING KNOWLEDGE OF PREGNANT WOMEN ABOUT NUTRITION DURING PREGNANCY IN PORTIBI SUB DISTRICT 2012 1 Ida Nurhayati 1 Nutrition Department, Medan Health Polytechnic of Health Ministry ABSTRACT Malnutrition in pregnant women can cause risks and complications in the mother. Many pregnant women, especially in early pregnancy, not yet aware that pregnancy causes an increase in energy metabolism. In Indonesia (SUSENAS and UNICEF Survey) reported that of the approximately 4 million pregnant women, half of whom suffered anemia and a million other chronic energy deficiency. This study aims to determine the factors that affect the mother's knowledge about nutrition during pregnancy in the district Portibi 2012. This type of research is descriptive correlative with cross sectional approach. The population of pregnant women in Portibi sub district as many as 205 people. Samples taken as many as 51 people. Techniques using simple random sampling. The study was conducted in March until July 2012. The results obtained at most pregnant women are less knowledgeable of 28 people (54.90%), most aged 20-35 years is 34 people (66.67%), most have 2-4 parity as much as 29 people (56.87 %), the most widely by the third trimester of pregnancy in which 23 people (45.10%), at most get information about nutrition during pregnancy from the environment (friends, family, parents) that 22 people (43.14%). Chi-square test results showed no significant correlation between maternal age (X2count = 1.6975) parity (X2count = 0.9937), gestational age (X2count= 0.1888), resources (X2count = 1.422) with mother's knowledge about nutrition during pregnancy. Expected to health workers, especially in Portibi sub district to be more active in holding counseling on nutrition during pregnancy so that she can increase the level of knowledge. Keywords : Factors That Influence, Knowledge, Nutrition of Pregnant Women References : 27 (2002-2011) I. BACKGROUND World Health Organization (WHO) (2005) reports that there were 52 % of pregnant women suffer from anemia in developing countries. In Indonesia ( SUSENAS and UNICEF Survey) reported that of the approximately 4 million pregnant women, half of whom suffered anemia and a million other were chronic energy deficiency (Samhadi, 2007). Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) is one of the indicators to assess the success of health services in a country. MMR in North Sumatra in 2008 was 290 / 100,000 live births, the rate is still high when compared with the national MMR were 228/ 100,000 live births. MMR is already experiencing a decline compared to 2006 was 315 / 100,000 live births (North Sumatra Health Profile , 2008) . A total of 40.7 % of women aged 15-49 years consume energy below the minimum requirement and as much as 37.1 % for protein consumption below minimum requirements. In North Sumatra , the figures were respectively show the 43,1 % and 22.3 % ( Riskesdas (Basic Health Research) , 2010). The contribution of carbohydrate consumption of Indonesian society towards energy consumption is 61 % , slightly above the recommended figure of General Guidelines for Balanced Nutrition. While the contribution of protein to energy consumption is only 13.3 %, and the contribution of fat to energy by 25.6 % (Riskesdas, 2010). Studies in Maros, North Sulawesi who studied the diet and hemoglobin levels in pregnant women showed a decrease in the number of pregnant women who have severe anemia 201 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology from the first trimester (1.6 % to 0 % in the second trimester). Pregnant women suffering from anemia was increased in the second trimester of 8.6 % which is the first trimester was 12.5% to 21.1 % in the second trimester, and decreased in the third trimester to be 15.4 %. Similarly with mild anemia from 18.8 % in the first trimester increased to 24.4 % in the second trimester, and decreased in the third trimester to be 21.1 % (Fatima , 2011) . Based on research conducted to Simanjuntak (2009) in Rantauprapat (North Sumatra) of 86 pregnant women who are anemic obtained 77.9% aged 20-35 years and 64.47% had a history of one or more parity than4. Wahyudi et al. (2009) in his research in Kulon Progo, Yogyakarta claimed nutritional status is influenced by the amount and type of food consumed, the individual household income and mother's knowledge of health and nutrition. From the initial survey conducted by the author in the Portibi Julu sub district on 24-25 March 2012 found that from 10 pregnant women, there are only two people who know about the increased nutritional needs of the mother during pregnancy and no one knows clearly how much balanced nutrition it needs. II. RESEARCH METHODS Design of this research is correlative with the aim to identify factors of maternal age, parity, gestational age and resources to influence mother knowledge about the mother's nutrition during pregnancy in the Portibi sub district 2012. This research was conducted in the Portibi sub district on March-July in 2012. Population and sample of this research is all pregnant women in Portibi sub district as many as 205 people while the sample is 25% of the population of as many as 51 peoples with simple random sampling technique. Data were collected through questionnaires and analyzed using univariate and bivariate. III . RESULTS AND DISCUSSION UNIVARIATE ANALYSIS Univariate analysis based on maternal age, parity, gestational age, maternal source of 202 information and knowledge about nutrition during pregnancy is described as follows : 1. Knowledge Chart 1 Distribution of Respondents Knowledge About Nutrition During Pregnancy in Portibi sub district in 2012 Knowledge 23 person 28 person Good Less From the above chart it can be seen that the respondents' knowledge about nutrition during pregnancy majority with less knowledge as much as 28 respondents (54.90 %) and a good knowledge of minority respondents as many as 23 respondents ( 45.10 % ). 2. Mother Age Chart 2 Age distribution of Respondents in Portibi SubDistrict in 2012 Mother Age 0 25.49 % 23.53 % 50.98 % < 20 years 20-35 years > 35 years Based on the above chart can be seen that majority of pregnant women aged 20-35 years were as many as 26 people (50.98 % ) and the least was < 20 years as many as 12 people ( 23.53 % ) . Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 3. Parity Chart 3 Parity distribution of Respondents Portibi in Portibi Sub District in 2012 5. Sources of Information Chart 5 Sources of Information of Respondents in Portibi Sub District in 2012 Sources of Information Parity 0 19.61 (>4) 33.33 (01) 22 % 37.25 % Health Workers 19.61 % 47.06 % 2-4 Mass Media Environment Based on the above chart can be seen the majority of respondents parity is 2-4 as many as 24 people (47.06 %) and most minorities are > 4 as many as 10 people (19.61 %) . 4. Gestational Age Chart 4 Gestational Age Distribution of Respondents in Portibi Sub 2012 Gestational Age 1st Trimester 0 45.1 % 27.45 % 27.45 % 2nd Trimester 3rd Trimester Based on the above chart can be seen in the majority of the gestational age of the respondents was the third trimester as many as 23 people (45.10 %), while for the first trimester and second trimester have the same amount of respectively 14 people ( 27.45 % ) . Based on the above chart can be seen in the majority of resources for environmental respondents came from as many as 22 people (43.14 %) and the minority comes from the mass media as many as 10 people (19.61 %) . BIVARIATE ANALYSIS Bivariate analysis to determine the influence of knowledge, maternal age,parity, gestational age and maternal resources about nutrition during pregnancy is described as follows : 1. Knowledge Respondents according to Mother Age Based on the research conducted, the distribution of respondents' knowledge about nutrition during pregnancy by maternal age can be seen in the chart below: Table 1 Distribution Of Respondents Knowledge About Nutrition During Pregnancy According to Mother Age In Portibi Sub District in 2012 Knowledge No Parity Good Less F % F % 6 35,29 11 64,71 1 0-1 12 50 12 50 2 2-4 5 50 5 50 3 >4 Total 23 45,10 28 54,90 Total F 17 24 10 51 X2 X2 Count Table % 33,33 47,06 0,994 5,991 19,61 100 203 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology From above table can be seen that from 12 respondents were aged < 20 years the majority have less knowledge of 8 people (66.67 %), of the 26 respondents were aged 20-35 years the majority of knowledgeable well as 14 people ( 53.85 %), from 13 respondents were aged > 35 years the majority of no less knowledgeable of 8 people ( 61.54 %) . Chi - square test results stating Ho is rejected if the X2 count > of X2 table , which means no significant effect . Instead Ho accepted if X2 count < than X2 table , which means there is no significant influence . Results of analysis with chi-square test with df = 2 , X2 count (1.697 ) < from X2 table ( 5.991 ), then Ho is accepted, it means that there is no significant relationship between age and the mother's knowledge about nutrition during pregnancy. 2. Respondents Knowledge According to Parity Based on the research conducted, the distribution of respondents' knowledge about nutrition during pregnancy is based on parity can be seen in the table below: Table 2 Distribution of Respondents Knowledge About Nutrition During Pregnancy Based on Parity in Portibi Sub District in 2012 No Mother Knowledge Age Good Less F % F 4 33,33 8 1 <20 2 20-35 14 53,85 12 5 38,46 8 3 >35 Total 23 45,10 28 Total % 66,67 46,15 61,54 54,90 F 12 26 13 51 X2 X2 % Count Table 23,53 50,98 1,697 5,991 25,49 100 Based on the above table it is known that out of 17 respondents who have a 0-1 parity majority knowledgeable about 11 people (64.71%), of the 24 respondents who have parity 2-4 and 10 respondents who have parity> 4 each 12 people (50%) and 5 (50%) were either knowledgeable or less. Chi-square test results stating Ho is rejected if the X2 count > of X2 table, which means no significant effect. Instead Ho accepted if X2 count < than X2 table, which means there is no significant influence. Results of analysis with chi-square test with df = 2, X2 count (0.994) < from X2 table (5.991), then Ho is accepted, it means that there is no significant influence between the number of parity which is owned by the mother's knowledge about nutrition during pregnancy. 204 3. Respondents Knowledge According to Gestational Age Based on the research conducted , the distribution of respondents' knowledge about nutrition during pregnancy is based on gestational age can be seen in the table below: Table 3 Distribution of Respondents Knowledge About Nutrition During Pregnancy Based on Gestational Age in Portibi Sub District 2012 No 1 2 3 Gestational Age 1st Trimester 2nd Trimester 3rd Trimester Total Knowledge Total X2 X2 Good Less F % F % F % Count Table 6 42,86 8 57,14 14 27,45 0,189 5,991 7 50 7 50 14 27,45 10 43,48 13 56,52 23 45,10 23 45,10 28 54,90 51 100 Based on the above table it is known that from the 14 respondents in the first trimester of pregnancy were less knowledgeable, majority there are 8 people ( 57.14 % ) , of the 14 respondents who are in the second trimester of pregnancy there are 7 people ( 50 % ) were knowledgeable good, and of 23 respondents with the majority of the third trimester of pregnancy there were 13 people are less knowledgeable ( 56.52 % ). Chi-square test results stating Ho is rejected if the X2 count > of X2 table , which means no significant effect. Instead Ho accepted if X2 count < than X2 table , which means there is no significant influence. Results of analysis with chi-square test with df = 2 , X2 count ( 0.189 ) < from X2 table ( 5.991 ), then Ho is accepted, it means that there is no significant relationship between gestational age at maternal knowledge about nutrition during pregnancy . 4. Respondents Knowledge According to Information Sources Based on the research conducted, the distribution of respondents' knowledge about nutrition during pregnancy based on information resources can be seen in the table below. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 4 Distribution of Respondents Knowledge About Nutrition During Pregnancy Based on Information Sources in Portibi Sub District 2012 No 1 2 3 Information Knowledge Sources Good Less F % F % Health 7 36,84 12 63,16 Workers Mass Media 6 60 4 40 Environment 10 45,45 12 54,55 Total 23 45,10 28 54,90 Total F 19 10 22 51 X2 X2 Count Table % 37,25 1,422 5,991 19,61 43,14 100 Based on the above table it is known that from the 19 respondents who received information about pregnancy from a majority of health personnel knowledgeable about 12 people (37.25%), of the 10 respondents who use the mass media as the source of the majority infoermasi good knowledge there are 6 people (60%) , and of the 22 respondents who use the environment as a source of information less knowledgeable majority of 12 people (54.55%). Chi-square test results stating Ho is rejected if the X2 count > of X2 table, which means no significant effect. Instead Ho accepted if X2 count < than X2 table, which means there is no significant influence. Results of analysis with chi-square test with df = 2, X2 count (1.422) < from X2 table (5.991), then Ho is accepted, it means that there is no significant relationship between resources with knowledge of mothers about nutrition during pregnancy. DISCUSSION 1. Relationship between Respondents Knowledge About Nutrition During Pregnancy to Mother Age in Portibi Sub District in 2012 Based on the results, the mother at the age of 20-35 years a majority of well knowledgeable as many as 14 people (53.85%). Chi-square test results showed no significant difference between maternal age with knowledge of mothers about nutrition during pregnancy. This is indicated by X2 count (1.697) < from X2 . Results of this study did not show any significant relationship between maternal age with knowledge of the mother can be caused by many other factors not examined include geographic factors, sample size, socioeconomic circumstances and so forth. This study is also in line with research by Syska Dwi (2010) in Singapore with titles relationship between the characteristics of pregnant women with knowledge about pregnancy stating that the absence of a significant relationship between age and knowledge of pregnant women. 2.Relationship of Respondents Knowledge About Nutrition During Pregnancy to Parity in Portibi Sub District in 2012 Based on the results of research conducted mothers who have a good knowledge of the majority in the 2-4 parity as many as 12 people (50%), the same thing also happens to mothers with less knowledge. While minorities either good or less knowledgeable having parity > 4 are each as many as five people (50%). Results of analysis with chi-square test was not a significant difference between the number of maternal parity owned with knowledge about nutrition during pregnancy by X2 count value (0.994) < from X2. Results of this study are not consistent with previous research by Rida Wahyuli Sirait (2011) in Medan, where the research results revealed a significant relationship between the number of parity with the knowledge of pregnant women. According to the author assuming no significant effect between maternal parity possessed with knowledge about nutrition during pregnancy due to a different place of study, the number of samples, research time and other factors that are not known by researchers. 3.Relationship between Knowledge to Gestational Age During Pregnancy in Portibi Sub District in 2012 Each trimester in pregnancy have different nutritional needs. Based on the results of 51 respondents majority in the third trimester and at most have less knowledge of as many as 13 people (56.52%) and the minority in the first trimester with a good knowledge of as many as 6 people (42.86%). Results of analysis with chi-square test df = 2 shows the value X2 count (0.189) <from X2 table (5.991) which means there is no effect of pregnancy on the mother's knowledge about nutrition during pregnancy. Results of this study are not consistent with previous research by Maulina Mawaddah (2011) in the field that states the existence of a significant relationship between gestational age with a knowledge of pregnant women. 205 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 4.Relationship of Respondents Knowledge About Nutrition During Pregnancy to Information Sources in Portibi Sub District in 2012 Based on the results of 51 respondents the majority of resources took the information from environment as much as 22 people (43.14%) and the minority of the mass media as many as 10 people (19.61%). Results of analysis with chi-square test with df = 2, show the value X2 count (1.422) < from X2. Results of this study are not consistent with previous research by Yulia Lilis Suryani (2003) in Yogyakarta, which stated that there was a significant relationship between resources with knowledge. According to the authors these differences could be due to many factors such as geographical conditions, sample size, study time, and other variables that are not included in this study. According to the assumption of the authors of the above results show that knowledge about nutrition of pregnant women during pregnancy included in the poor category, and this is because the majority of women get information from the environment (family, friends, parents) where information is limited and less accurate when compared to information from health professionals or the mass media. Knowledge is linked to exposure to the mass media (television, radio, magazines) and interaction with the environment. Mother obtain information from various sources, and for resources in rural areas most frequently used are environment such as friends, family and people who believed as community leaders or religious leaders, health workers also. CONCLUSIONS AND SUGGESTIONS CONCLUSION 1. Knowledge of pregnant women most is less by 28 respondents (54.90%) and the results of chi-square test with df = 2, 95% confidence level, α = 0.05 showed no significant difference between maternal age ( X2 count (1.697) < X2 table (5.991)), parity (X2 count (0.994) < X2 table (5.991)), gestational age (X2 count (0.189) < X2 table (5.991)), resources (X2 count ( 1.422) < X2 table (5.991)) with knowledge of mothers about nutrition during pregnancy. 206 2. Based on the mother's age, most aged 20-35 years as many as 26 people (50.98%). 3. Based on parity, parity 2- 4 at most have as many as 24 people (47.06%) and there are those who have parity > 4 as many as 10 people (19.61%). 4. Based on gestational age, most in the third trimester as many as 23 people (45.10%). 5.Based on resources, most of the environmental gain as many as 22 people (43.14%) SUGGESTION 1. For head of portibi and health centers in the Portibi sub district Especially expected to elements of society to health workers in the sub district of Portibi must improve further education and health promotion particularly about nutrition during pregnancy so that the knowledge of pregnant women are getting better at keeping her pregnancy. 2. For other researchers Similar research is needed further with larger samples and using other methods. REFERENCES Aizid, Rizem. 2010. Menu-menu Murah dan Sehat Ibu Hamil. Buku Biru: Yogyakarta Arikunto, S. 2006. Prosedur Penelitian, Suatu Pendekatan Praktek.Edisi Revisi . Rineka Cipta : Jakarta Arisman. 2009. Gizi dalam Daur Kehidupan : Buku Ajar Ilmu Gizi. Edisi 2. EGC :Jakarta Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan RI. 2008. Laporan Hasil Riset Kesehatan Dasar 2007. Jakarta ___________________.2011. Laporan Hasil Riset Kesehatan Dasar 2010. Jakarta Dewi, Syska. 2010. Hubungan Antara Karakteristik Ibu Hamil Dengan Pengetahuan Tentang Kehamilan. Stikes Dharma Husada : Bandung Dinas Kesehatan Provinsi Sumatera Utara. 2009. Profil Kesehatan Provinsi Sumatera Utara Tahun 2008. Medan Ellya, Eva Sibagariang. 2010. Gizi Dalam Kesehatan Reproduksi. TIM : Jakarta Erfandi. 2009. Faktor - Faktor yang Mempengaruhi Pengetahuan (http://www.google.com/search/faktor Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology - faktor - yang – mempengaruhi pengetahuan/) diakses pada tanggal 15 Juni 2012 pukul 16.05 WIB Fatimah, St., Veni Hadju, Burhanuddin Bahar, Zulkifli Abdullah. 2011. Pola Konsumsi dan Kadar Hemoglobin pada Ibu Hamil di Kabupaten Maros, Sulawesi Selatan. Makara Kesehatan : Makassar Hasibuan, Yusrawati.2011.Diktat Biostatistika. Medan Hunter, Hannah Hulme, dan Dodds, Rosemary. 2005. Makanan yang Aman untuk Kehamilan. Penerbit Arcan: Jakarta Hurlock, Elizabeth B. 2002. Psikologi Perkembangan, Edisi Kelima. Erlangga : Jakarta Kementrian Kesehatan RI. 2011. Profil Kesehatan Indonesia 2010. Jakarta Mawaddah, Maulina. 2011. Hubungan Pengetahuan Ibu Hamil Tentang Antenatal Care dengan Kunjungan Antenatal Care di Desa Laut Dendang Kecamatan Percut Sei Tuan Kabupaten Deli Serdang Medan. Universitas Sumatera Utara : Medan Mitayani, dan Sartika, Wiwi. 2010. Buku Saku Ilmu Gizi. TIM :Jakarta Muliarini, Prita. 2010. Pola Makan dan Gaya Hidup Sehat Selama Kehamilan. Nuha Medika : Yogyakarta Notoadmodjo, S. 2005. Promosi Kesehatan, Teori dan Aplikasi. Rineka Cipta; Jakarta __________.2010. Metodologi Penelitian Kesehatan. Rineka Cipta :Jakarta Politeknik Kesehatan Medan.2006. Panduan Menyusun Karya Tulis Ilmiah (KTI). Medan Purwitasari, Desi, dan Maryanti, Dwi. 2009. Gizi Dalam Kesehatan Reproduksi. Nuha Medika : Yogyakarta Saminem. 2008. Seri Buku Asuhan Kehamilan Normal. EGC :Jakarta Sirait, Rida Wahyuli. 2011. Hubungan antara Jumlah Paritas Dengan Pengetahuan dan Sikap Ibu Hamil Tentang Pemakaian Alat Kontrasepsi dalam Rahim di RSUD Dr. Pirngadi Medan. Universitas Sumatera Utara : Medan 207 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EFFECT OF COUNSELING ANXIETY IN DEALING WITH LABOR PRIMIGRAVIDA IN THE COMMUNITY HEALTH CENTERS BUKET HAGU LHOKSUKON NORTH ACEH Idau Ginting¹ , Dina Indarsita² , Evi Desfauza¹ , Nurul Asma¹ Department of obstetric¹ , Department of nursing² ABSTRACT Anxiety is a psychological problems facing labor that is often experienced primigravida, research Salfariani (2012) showed that 59.1 % primigravida of 22 maternal choose sectio caesarea labor without medical indication for anxiety normal delivery. Mei and Huang (2006) showed that anxiety can lead to prolonged labor and cause Post Partum Haemoragic, Suririnah (2005) concluded that to overcome the anxiety necessary counseling / counseling regarding preparations for the birth mother to change perceptions about childbirth. The purpose of this study was to determine the effect of counseling on anxiety facing labor in primigravida. This type of research is pre experiment with the design of one group pretest - posttest design . A sample of 40 people is primigravida third trimester of gestation 28-32 weeks in Puskesmas bouquet Hagu. The independent variable in this study is the counseling, the dependent variable is anxiety facing labor. Data collected using a questionnaire. Data analysis using t - tests dependent test (paired t - test). The results of bivariate analysis showed a significant effect of counseling on reducing anxiety facing labor in primigravida (p = 0.00). The study concluded counseling can minimize anxiety primigravida face childbirth , so that counseling can be used as a model or an alternative treatment for overcoming and preventing anxiety facing labor. Keywords : Counseling , anxiety , preparation for childbirth. INTRODUCTION Maternal mortality is still a big issue where around 800 women die every day throughout the world due to pregnancy or birth complications. In 2010, 287,000 women died during and after pregnancy and childbirth. The ratio of maternal mortality in developing countries is 240 per 100,000 births compared to 16 per 100,000 in developed countries (WHO, 2012). Indonesia is a developing country. Demographic and Health Survey 2012 showed the maternal mortality rate increased sharply compared to a survey in 2007. The survey found that as many as 359 maternal deaths per 100,000 births increased from the 2007 survey where the maternal mortality rate is only 228 deaths per 100,000 live births (Sufa, 2013, 1). 208 The Indonesian government began in 2013 to implement the Gold Program or Expanding Maternal and Newborn Survival in cooperation with the United States government to reduce maternal mortality rate which is still high in Indonesia (Wardah, 2013, 9) in addition to realizing the Millennium Development Goals (MDGs) in 2015 for reducing the MMR to 102 / 100,000 live births (Ministry of Health Affairs, 2011a). Estimates of the Indonesian population health development program targets in 2014 from 252.124.458 of the total population, there are 5.290.235 of pregnant women and 5.049.770 of birth mothers (Health of Department RI , 2011). Pregnancy is a challenge of the turning point of family life and is usually followed by stress and anxiety, whether expected or unexpected Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology pregnancy. For starters family, pregnancy is a period of transition from childhood to parenthood with the permanent characteristic and have a responsibility (Susanti, 2008, p.15). Bobak et al. (2005, p.125) describe the growth requires mastery of certain developmental tasks in receiving pregnancy, identifying the role of the mother, rearranging the relationship between mothers and daughters and between her and her partner, building a relationship with the unborn child, and preparing to face childbirth experience. Many women, especially primigravida and nullipara, will actively prepare for childbirth (Bobak et al., 2005, hal.130). Experienced mothers have a tendency to tell their stories for new mothers, whether about its profit or risky, but the report always describes about pain (Perkins, 1980 in Mander, 2004, p.99). Anxiety can arise due to fears of a safe delivery for herself and her child (Rubin, 1975 in Bobak et al., 2005, p.131). Dick-Read (1920-1950) taught his patients that if someone fear the childbirth, she will become tense and make her sense the pain more severe (Simkin, 2008, p.147). Kurniawati and Wahyu’s research (2007) of the 30 samples showed primigravida anxiety more higher than multigravida when facing labor which from 15 primigravida mother; 4 women experience mild anxiety; 3 people experience moderate anxiety, and 1 mother experience severe anxiety, while from 15 multigravida mother; only 1 woman experience severe anxiety and 1 mother had moderate anxiety. Another study showed anxiety is very influential on labor. Mei and Huang’s research (2006) showed the influence of anxiety and depression primigravida mother in facing the labor may lead to prolonged labor and caused postpartum hemorrhage. While Michel Odent’s observation in Simkin and Ancheta (2005) showed anxiety in the mother is a response of 'fight or escape' during childbirth. It causes excessive catecholamine levels at one time which result in increasing length of time. . The results of the study mentioned above shows the anxiety is one of the factors that can affect a person in facing the labor which can not be ignored. Crowe and Von Bayer (1989) in Mander (2004, p.102) survive to teach the reality of childbirth can be done which research shows that women who taught in realistic anxiety about childbirth experience less labor pain. Suririnah (2005,3) suggested that the mother who will face delivery, have different experiences, depending on who and how the mother responded, the best suggestion is every mothers prepare themselves with knowledge and mental readiness that childbirth is a natural process. This can be overcome by doing a counseling or counseling. Issues that need to be addressed are aspects of the physiology of pregnancy, birth, emotional changes that occur during pregnancy and family planning in the future. Hastuti’s research on November 2007 until August 2009 regarding counseling of reducing anxiety and achievement of primiparous maternal coping mechanisms on the study of the levels of cortisol, uterine contractions, and long maternity on 218 pregnant mothers sampled research at Puskesmas Tegalrejo and Mergangsang, Yogyakarta clarify that counseling can minimize maternal anxiety at first childbirth (primiparous). Salfariani’s research (2012) at The Bunda Thamrin Hospital Medan on 22 maternal also showed 59.1 % primigravida and do not have experienced in previous maternity choose sectio caesarea labor without medical indication for normal delivery anxiety, so that researchers in the study concluded the need for counseling and counseling before the labor is to determine the choice carefully in taking a childbirth action. Estimates of the population of Aceh by targeted health development program in 2014 there were 4,731,705, which consists of 111,991 pregnant women and 106,901 birth mothers (Health of Department RI, 2011b). Observations from the study site was observed from Pemantauan Wilayah SetempatKesehatan Ibu dan Anak (PWS-KIA) at The Community Health Centers Buket Hagu Lhoksukon North Aceh recorded in 2013 there were 443 pregnant women targeted. Recording up to December 2013 show from 35 villages in 209 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology the region of the health centers, there are 58 third trimester pregnant women, where 40 people are primigravida. health centers, hospitals and birth centers as preventive measures to reduce the level of primigravida anxiety in facing the labor. Preliminary observations which researchers observe when visiting the integrated services posts held at Dayah village end of December 2013 there are three primigravida of five third trimester pregnant women tell her anxiety about childbirth to the village midwife. The primigravida anxiety at the thought of childbirth process later, because of inexperienced as well as they generally have the same understanding that delivery was a daunting process, creepy, and painful, and the fear of not being a good mother to baby. RESEARCH METHODS On the basis of various theories regarding the effectiveness of counseling and the results of previous studies showing the effect of counseling can reduce anxiety when facing the labor, researchers interested in applying counseling on reducing anxiety in primigravida at Puskesmas bouquet Hagu to determine the extent of the effect of counseling can reduce anxiety in facing the labor on primigravida mothers, as an appropriate counseling needs to be done on every obstetric services. Formulation Of The Problem Based on the description of the background issues above, the problem can be formulated as follows : whether there was an effect of counseling on anxiety facing labor in primigravida ? Research Purposes 1. To determine the effect of counseling on anxiety facing the labor in primigravida. 2. To know the anxieties facing the labor before given counseling on primigravida. 3. To know the anxieties facing the labor after given counseling on primigravida. 4. To determine the effect of counseling on anxiety facing the labor in primigravida. Benefits Of Research 1. Can contribute to policy-makers in designing a program of counseling to reduce anxiety in pregnant women in facing the labor. 2. Can provide information and inspiration for medical workers to implement counseling in 210 This type of research is pre-experimental research design with one group pretest posttest means to determine causation by involving a group of subjects. The group of subjects was observed prior to the intervention, and then observed again after intervention (Nursalam, 2003). Population The population is all primigravida In The Community Health Centers Buket Hagu Lhoksukon North Aceh and meet the inclusion and exclusion criteria . a. Inclusion criteria : 1) Mother primigravida. 2) Pregnant women 28-32 weeks. 3) Willing to participate in the study. 4) Residing in Puskesmas bouquet Hagu. b. Exclusion criteria, namely mothers with a history of adverse pregnancy : 1) The presence of diseases that accompany pregnancy is a disease that affects the mother before pregnancy, such as heart disease, kidney. 2) The presence of complications in pregnancy are abnormalities that arise during pregnancy, such as bleeding. Samples The sample in this study were taken overall primigravida Trimester III In The Community Health Centers Buket Hagu Lhoksukon North Aceh using saturated sample method or the socalled total population, where the entire population in this study were sampled, with a population of 40 people. Place Research Place this study is The Community Health Centers Buket Hagu Lhoksukon North Aceh. The working area is a rural health center transmigration. Researchers used two villages to facilitate this research; Meucat village and Ulee Tanoh village. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Time Research This study was conducted from October 2013 to June 2014. Data processing Processing of the data in this study performed quantitatively. Data processing was performed with computerized and then analyzed. According Hastono (2007, p.6) there are four stages in the processing of data that must be passed, namely : a. Editing is an activity to check the content of form or questionnaire to know its answer is complete, clear, relevant , and consistent. Respondents’ answer in the questionnaire of this study are in accordance with the purpose of research. b. Coding is an activity to change data shaped letters into data numbers. Encoding performed on the data characteristics of the respondents, while variable coding research is not done because it is a numeric data. c. Processing is an activity to process the entry data so that it can be analyzed, the entry is done by clicking on the data from the questionnaires into a computer program package. d. Cleaning is an activity rechecking data that already have been re-entry so that there are no errors. After checking, there are no errors in the data research. Data Analysis After processing data is done, then performing data analysis using a computerized. According Notoatmodjo (2005, p.188) phases of data analysis are as follows : a. univariate analysis Univariate analysis performed on each variable of the results of research and this analysis produces distribution and percentage of each variable. In this study, univariate analysis was conducted to determine the distribution of respondents' characteristics and anxiety before and after given counseling. b . bivariate analysis Bivariate analysis conducted on two variables are allegedly associated or correlated. In this research, bivariate analysis was conducted to determine the effect of anxiety in facing the labor in primigravida with a statistical test t - tests dependent (paired t - test). This statistical test comparing the average respondents anxiety before and after given counseling, see the standard deviation, and hypothesis testing (p-value). The value of p is to see statistical significance, when the value of p < 0.05 considered as there are significant influence between these variables. If the opposite where the value of p > 0.05, it can be said that there is no influence of these variables. Research Result 1. Univariate Analysis Univariate analysis was used to describe the characteristics of the respondents, the average respondents anxiety before and after given counseling, as well as the respondents' answers. Respondents characteristic distributed by age, education, and work. The number of respondents consisted of 40 people primigravida third trimester with gestation around 28-32 weeks which measured anxiety in facing the labor before and after the given counseling, then also calculated the frequency distribution of respondents' answers to questionnaire about their anxiety. Table 1 Distribusi Frequency Characteristics Of Respondents In The Community Health Centers Buket Hagu Lhoksukon North Aceh Tahun 2014 (n=40) Characteristics of respondents Ages 17 years 18 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years Education Colledge Senior High School Junior High School Elementary School Work Government Employees Private Merchant Does Not Work f % 1 2 4 6 3 6 9 5 2 1 1 2,5 5 10 15 7,5 15 22,5 12,5 5 2,5 2,5 11 14 10 5 27,5 35 25 12,5 7,5 15 10 67,5 3 6 4 27 Analysis of the results showed that most of the respondents were in the age group 24 years as much as 22.5%. The majority of respondents 35% of high school graduates. A total of 27 respondents (67.5%) did not work. 211 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 2 Distribution of Respondents by Anxiety Before And After Given Counselling In The Community Health Centers Buket Hagu Lhoksukon North Aceh Tahun 2014 ( n = 40 ) Mean variables Research SD Min-Max 95% CI Median Anxiety Before Given 23,8 4,1 17-34 22,5-25,1 Counseling 24 Anxiety After Given Counseling 21,4 21,5 The analysis showed an average score of anxiety primigravida before counseled 23.8 (95% CI=22.5 to 25.1), the median score of 24 with a standard deviation of 4.1. Low anxiety scores of 17 and 34. The highest interval estimation results can be concluded that 95% believed the average score of anxiety primigravida before counseled between 22.5 to 25.1. The higher anxiety scores are more higher than after counseled where the average score of anxiety primigravida after counseled 21.4 (95% CI=20.6 to 22.5), the median score of 21.5 with a standard deviation of 3.5. Low anxiety scores of 16 and 30. The highest interval estimation results can be concluded that 95% believed the average score of anxiety primigravida before counseled between 20.6 to 22.5. 2. bivariate analysis Bivariate analysis is used to observe the effect of independent variables (counseling) with the dependent variable (anxiety in the face of labor). Statistical analysis showed a significant effect of counseling on reducing anxiety in the third trimester primigravida in facing the labor because it has a value of p < 0.05, which means primigravida anxiety can be minimized by providing counseling. The results in detail can be seen in Table 3 below. Table 3 Effect of Counseling Against Facing Anxiety Childbirth in primigravida In The Community Health Centers Buket Hagu Lhoksukon North Aceh 2014 ( n = 40 ) Variabel Mean SD Anxiety before given counseling 23,8 4,1 Anxiety after being given counseling 21,4 3,5 212 Beda Mean SD p 2,4 2,3 0,00 3,5 16-30 20,6-22,5 Statistical analysis showed a decrease in anxiety in primigravida before and after the given counseling, where the average of anxiety before counseled 23.8 with SD 4.1 after counseled the average of anxiety primigravida 21.4 with SD 3.5. The average difference of the anxiety primigravida before and after counseled 2.4 with SD 2.3. The p-value = 0.00 indicates a statistically significant effect of counseling on reducing anxiety in the face of labor in primigravida. Discussion a. Anxiety facing labor in primigravida before given counseling The results of this study at the beginning of the questionnaire distributed obtained an average score of primigravida anxiety when facing labor 23.8. Lowest score obtained by respondents from scale measuring anxiety item 17 while the highest score 34. Generally anxiety experienced primigravida looks from sleep disorders, which in this study almost all respondents (85 %) experienced insomnia, often woke up in the middle night, even nightmares in medium scale. Even in small amounts there is also primigravida who experience tension, fear, and heavy physical symptoms (2.5%) due to anxiety. This shows that anxiety does exist and can not be removed, which can be done only by minimizing it. Anxiety is a natural response of the body indicated when thinking about a matter that can be life-threatening. Anyone can experience anxiety no exception primigravida. The first pregnancy is something that is awaited by every newly married woman, but the process of pregnancy with various changes which sometimes unsettling of girlhood and the state of labor is already envisioned as a Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology painful process makes young mothers feel anxiety and fear when approached interpretation of birth date. Anxiety is already being felt by pregnant women from the beginning of pregnancy, but the mother’s physical condition who gradually stable and robust to ensure the threat of abortion does not exist, then the anxiety disappears by itself. But upon entering the three trimesters of pregnancy that grew big accompanied by physical discomfort, the anxiety is emerged and peaked. It is often feared by mother who pregnant for first time usually feel labor pain. This fact is consistent with the theory expressed by Janiwarty and Pieter (2013, p.263) psychological conditions that often accompany the mother before the birth of a baby is a sense of fear and anxiety. Susanti (2008) added at the end of three trimesters, the mother worried about things in which the health and safety of childbirth. In more detail Laderman (1984) in Susanti (2008, p.38) explains that primigravida is worry about painful childbirth or cutting of the perineum. These results are also consistent with research Azizah et al. (2013) which shows, from 31 respondents, 11 primigravida (35.5%) had severe anxiety before being given treatment. Research Kurniawati and Wahyu (2007) even clarify primigravida anxiety when compared with mothers who have given birth which 15 sample of primigravida appear 4 women experience mild anxiety, 3 people experience moderate anxiety, and 1 mother experiences severe anxiety. It is much higher than the 15 multigravida which only 1 mother experiences severe anxiety and 1 mother experiences moderate anxiety. b . Anxiety face of labor in primigravida after given counseling The results of further research is the result from post-test which is done by distributing the same questionnaires in interval of one month later, which is expected in the time interval. Results of lasting interventions still leave a trace in primigravida long-term memory. Respondents’ anxiety after being given counseling obtained a score of 21.4. Lowest anxiety scores obtained from primigravida is 16 while the highest score is 30. Results of analysis of these studies showed there is change of anxiety in facing the labor on primigravida. There is an average decline in respondents’ anxiety, with an average difference of 2.4. Judging from anxiety scores obtained from primigravida there is also appears a decrease in respondents’ anxiety. The things which worried by the respondents are not much different with anxiety before given counseling. The majority of respondents (85%) still having trouble sleeping in the medium scale, while there is a change anxiety in the weight once scale, it appears there is no longer fear experienced by primigravida. Decreased anxiety occurs because the respondents gained knowledge from counseling. Counseling provides information to primigravida which can change the perception of new mothers who become pregnant the first time about delivery. The high initial anxiety about delivery can be minimized. This is in line with the theory put forward Simkin et al. (2008) many predisposing factors can reduce or increase the anxiety felt by a woman, including one of knowledge about delivery. In this study, respondents' knowledge gained from counseling can reduce primigravida anxiety, according to the statement Pieter (2012) one of the counseling function is the function of development, namely increasing client’s knowledge which is able to change the wrong perception about herself. The results of this study are also consistent with research Azizah et al. (2013) of 31 respondents, 11 respondents ( 35.5%) had severe anxiety before being given counseling which showed that almost half primigravida experience anxiety when they will face the labor, compared to after being given counseling 14 respondent (45.2%) had mild anxiety. c. Influence of counseling to anxiety facing labor in primigravida Analysis of the results obtained by value p=0.00 which means that the value is smaller than 0.05. The final result of these studies we can conclude there is the influence of 213 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology counseling to anxiety facing labor in primigravida, the given counseling in this study can minimize anxiety in primigravida. Anxiety primigravidas before being given counseling seem higher than after being given counseling could have been affected by the respondent's own characteristics. Respondents were generally aged 24 years, which according to Santrock (2003, p.26) that age is early adulthood which may become a factor in influencing higher baseline anxiety. Mappiare Becker (1983) in Zulkaida (2010) reveals one of the characteristics that stand out in this period are the presence of emotional tension. Purwanto (1999, p.72) adds emotion experienced by adults will be different with the emotional events experienced by children, it is because adults are more influenced by various experiences in their emotions as a result of interaction with the social environment so that these emotions can be useful for health and can also interfere with physical and behavior health, which one is anxiety (Purwanto, 1999, p.74). Primigravida’s education in this study were an average of high school graduates (27.5%) could be increase the anxiety by affecting the experience gained by early adult women from the social environment as expressed Purwanto (1999). Primigravidas that do not have their own experience of childbirth will learn about the labor from mothers who have been through the labor. The reality in the field, from the story of multigravida who already captured by respondent is delivery is a long and painful process. This is in line with the theory put forward Perkins (1980) in Mander (2004, p.99) experienced mothers have a tendency to tell their stories for new mothers, whether about its profit or risky, but the report always describes about pain. Young mothers who mostly just graduated from high school, where, according to Papalia et al., 2011 (hal.675) currently high school graduates alone can not be categorized as students. Mothers who just graduated to high school will just adopt the experience in herself, that she was also going through a painful labor and this is certainly inverse ratio with educated early adulthood, as explained 214 Papalia et al. 2011 (hal.675) they will use printed and written information to be active in society and to develop their knowledge. Surely the experience gained from the environment will be compared with academic information and then find a solution. The location of this research which is the rural resettlement, where they still adopts a common concept. The young mothers innocently receive any information obtained from mothers who had experienced labor at the village, especially if that person is trustwhorty or influential in the environment, it is a true story and should be trusted. It is also showed evident in the antenatal classes which formed once a week by midwife, was forced to rescheduled twice a week, by combining several nearby villages are also still appears empty, or sometimes just some mother who attend. Other possibilities that make anxiety of young mothers in this study seem high before being given the counseling were the majority of respondents who also not working (67.5%) where their chance of finding a right solution from the problems solving, such as a visit to a health facility is very limited because it depends on their husband financial, also affect anxiety. Their habits in reaching the health facilities only when they feel pain or physical discomfort, whereas many physical discomfort arises due to maternal anxiety which is getting closer to labor. The analysis above is disclosed in accordance with the theory of David A. Tomb (1993) in Riyadi and Purwanto (2009, p.43) anxiety is a unpleasant sensation of fear and can not be justified which often accompanied by physiological symptoms and when combined with the understanding of anxiety in existential-humanistic approach in which anxiety is a basic of human characteristic (Corey, 2010, p.76), then those two theories can be deduced as anxiety is human characteristic that has a form of tension against anything that threatens which accompanied by the physiological changes. People who have the introvert characteristics (closed), they will be harbored insecurities, while the anxiety felt by primigravid will give impact on the fetus, this situation eventually Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology causes anxiety and are often not expressed to midwife, so the midwife only diagnose it only as a physical disorders, without paying attention to pregnant women’s psychological. This is in line with the theory put forward Aprilia and Ritchmond (2011) which shows the anxiety has a major influence pain on the mother in late pregnancy, where anxiety and stress indirectly makes the brain work and secrete Corticotrophin-Releasing Hormone (CHR) which is the master of stress hormones that will trigger the release of stress hormones glucocorticoids. Stimulation of the excess production of glucocorticoid from the mothers would cause muscle tension and stiffness. Laderman (1984) in Susanti (2008, p.38) clarify the fact that he thinks primigravida anxiety sometimes is not stated, but the midwife must know its gesture / sign. The fact in the field nowadays, the midwife generally has been able to understand the sign and to reduce primigravida anxiety in facing the labor, most midwives had been advised mothers and teached the right preparation of labor, which can be said in counseling. Generally, performed counseling is curative, midwives give the counseling after the anxiety has an impact on physical disturbance. In this research to reduce the anxiety of respondents counseling is done with group dynamics approach is preventive. 40 young mothers stimulated to tell their anxiety about childbirth. Results of the discussions showed their anxiety arise when they imagine labor pain and fear can not have a normal delivery. It is concluded and made the discussed topic. To support the results of the discussion, the researcher displays video of labor, researchers showed a picture of labor pain that would be felt by the mother. Some mothers seem to wince at the expression on the face of the mother in video that shows tremendous pain during straining, but the mothers will grinned when the baby borns, feel as happy as the mother in the video. This fact that according to the theory put forward Laderman (1984) in Susanti (2010, p.38) mothers should be given education / counseling about appropriate behavior during childbirth. The best preparation for childbirth is to realize a healthy reality of pain, balance the risk with a sense of happy and desire for the ultimate prize in the form of a baby. Further analysis of the results in this study are consistent with research Hastuti on November 2007 until August 2009 regarding counseling in reducing anxiety and achieving the primiparity maternal coping mechanisms on the study of the levels of cortisol, uterine contractions, and long maternity on 218 pregnant women who become research samples in PHC Tegalrejo and Mergangsang, Yogyakarta which indicates counseling can minimize maternal anxiety at first childbirth (primiparous). Other studies that show the positive effect of counseling performed by Crowe and Von Bayer (1989) in Mander (2004, p.102) who consistent to teach the reality of labor can be done which it shows that women who taught in realistic about labor anxiety through counseling experienced less delivery pain. Ridgeway and Matthews (1981 ) and Wallace (1984 ) in Susanti (2008, p.21) concludes that the intervention on anxiety has a beneficial effect, namely through one of preparation to face the anxiety include anticipation, education / counseling, knowledge and strategy. Conclusion Based on the results of research and discussion can be concluded as follows : 1. Primigravidas anxiety before counseled obtained an average score of anxiety 23.8 (95% CI = 22.5 to 25.1), the median score of 24 and a standard deviation of 4.1. 2. Primigravidas anxiety after counseled obtained an average anxiety score of 21.4 (95% CI = 20.6 to 22.5), the median score of 21.5 and a standard deviation of 3.5. 3. There was a significant effect of counseling on the decreased anxiety in facing the labor in primigravida (p = 0.00). Suggestion Based on the conclusions that have been suggested, then the suggestion that can be given as an act of anticipative and corrective as follows : 1. For Health Policy Makers The results could be used as a consideration for the local health department to make a concrete policy regarding counseling as an 215 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology obligation activity which health care institutions must done in order to reduce the risk of death from childbirth in addition to the service of clinical skills, such as required midwives to have counselor certificate. 2. For Health Care Agencies The process and the results of this study can serve as a model or an alternative treatment to overcome and prevent the occurrence of anxiety in facing the childbirth, which can be applied in health centers Hagu bouquet, more health centers, hospitals, and other maternity clinic. 3. For the next Researcher This study should be followed by next researcher using individual counseling so that they can be compared with the results of this study which uses group counseling methods, thus it can be concluded that the counseling methods can reduce effectively the primigravida anxiety. BIBLIOGRAPHY Aprilia , Y. and Ritchmond , B. ( 2011) . Gentle Birth : Comfortable Childbirth Without Pain . Jakarta : PT Gramedia Widiasarana Indonesia Astuti , B. ( 2012) . Individual Counseling module . Yogyakarta: Faculty of Education University of Yogyakarta . Azizah , R. N. , Susanti , E. , & Janah , M. ( 2013 ) . Extension influence Childbirth Preparation Against Anxiety Level primigravid Facing Labor in Puskesmas Badas Kediri. Retrieved November 14, 2013 , from http://stikesbm-pare.ac.id . Bobak , I.M. , Lowdermilk , D.L. , & Jensen , M.D. (2004 ) . Maternity Nursing Textbook . Maria A. Wijayarini interpreter , Peter . 6. Issue I. Jakarta : EGC . Corey , G. (2010 ) . 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Yogyakarta: ANDI 217 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE INFLUENCE OF TYPE COOKING ON LEVELS OF CRUDE FIBER FROM WATER SPINACH BOILED AND STEAMED Mustikawati, Alkausyari Aziz, Hesti Atasasih Department of Nutrition, Politeknik Kesehatan Kementerian Kesehatan Riau. ABSTRACT Fiber is part of a carbohydrate, largely derived from plant cell walls contain cellulose, hemicellulose and lignin. The role of dietary fiber on health began to emerge after the experts compare the high incidence of colon cancer in advanced industrial countries that consumption of fiber is low compared to developed countries. Based on the results of research conducted in America, Africa and Asia found that people with a Western diet is generally low in fiber, many people who have found the incidence of colon cancer (Kusharto, 2006). The average fiber consumption of Indonesian society was 10.5 g / day, which is still below the recommended nutrients, ie 20-30 g / day. The largest source of fiber found in vegetables, one of the vegetables that contain fiber are water spinach. The research results, Rahayu (1998) in Hery (2001) shows the dietary fiber in vegetables after cooking changes. For it is necessary to study the fiber content of water spinach that has undergone a cooking process to determine the effect of cooking on the type of crude fiber content (Crude Fiber) water spinach boiled and steamed. Crude fiber content research will be carried out by methods Apriyanto (acid hydrolysis method) with two trials (Duplo). From the results obtained crude fiber content in 100 grams of water spinach namely by boiling (5,12%), steamed (2,38%) and then the water spinach with the untreated / fresh (1,33%). Keywords: Fiber, Water Spinach, Boiled, and Steamed INTRODUCTION Among the various substances in food, fiber is non nutritional substances most widely discussed benefits to health. Fiber is part of a carbohydrate, largely derived from plant cell walls contain cellulose, hemicellulose and lignin. The chemical composition of dietary fiber varies depending on the composition of the producing plant cell walls. Dietary fiber is divided into two groups, namely: 1. Dietary fiber soluble (soluble dietary fiber), are included in this fiber is pectin and gum is the inside of the cell vegetable food. The fiber found in many fruits and vegetables 2. Insoluble fiber (insoluble dietary fiber), are included in these fibers are cellulose, hemicellulose and lignin, which are found in cereals, legumes and vegetables According Astawan and Wresdiyati (2004) in Dyah (2011), Dietary fiber can not be digested and absorbed by the human digestive tract, but it has a very important function for health maintenance, disease prevention and as an important component in nutrition therapy. For school age children, the fiber is also important because it will provide health effects on adult life, in order to prevent degenerative diseases such as coronary heart 218 disease, diabetes mellitus, and colon cancer (Puspamika, 2014). The average fiber consumption of Indonesian society was 10.5 g / day, which is still below the recommended nutrients, ie 2030 g / day. Source of dietary fiber that is very easy to be found is on vegetables and fruits. Vegetables is a menu that is almost always present in the daily dish of Indonesian society, both in the raw state (fresh vegetables) or after processed into various forms cuisine. One of the vegetables that contain fiber are water spinach. Water spinach is always of vegetables produced in Indonesia. From the survey of vegetable production in Indonesia in 19972013 conducted by Badan Pusat Statistik said that the production water spinach in 2013 amounted to 308477.2 tons (Badan Pusat Statistik, 2014). IPB student research results, Rahayu (1998) in Hery (2001) shows the dietary fiber in vegetables changes after cooking. Spinach is not the type of vegetables consumed in a raw state (fresh vegetables) so that the vegetables water spinach will do the cooking process. With the ripening process the vegetables it will affect the fiber content contained in these vegetables. The results Rahayu (1998) in Hery (2001) shows the Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology dietary fiber in vegetables changes after cooking. In this study samples of the type cooking water spinach will be limited, which kind of cooking water spinach is boiling and steaming. While crude fiber content of research will be done with Apriyanto method (method Hidolisis Acid) with two trials (Duplo). MATERIALS AND METHODS Time and Place Research : This study was conducted in March 2014. The experiments were conducted at the Laboratory of Chemical Integrated Basic in Politeknik Kesehatan Kementerian Kesehatan Riau. Materials : Water spinach, H2SO4 0.325 N, NaOH 1.25 N, dan Aseton / Alkohol. Instrument : Erlenmeyer, flask, Spray Bottle, chemical glass, Petridisk, Hot Plat, Funnel, Spatula, Autoclave, Whatman filter paper 41, Oven, Analytical Scales, Pipette Volume, Stove, Knives, Test Sieve 60 Mesh, Waring Blender, and Thermometer. Sample Preparation Fresh water spinach sorted and washed, then finely chopped and separated into three sections. The first part steamed (T = 100 ° C, t = 7 min), the second part is boiled with water temperature of 100 ° C for 3 minutes, while the third part is not done any treatment. Then the whole water spinach dried in an oven (T = 60 °C, t = 6-12 hours) with a separate container. Once dried, milled water spinach with waring blender and sifted 60 mesh. Determination of Levels of Crude Fiber A total of 2 gram sample of free water was added to 500 ml Erlenmeyer flask and add 100 ml of H2SO4 0.325 N. The mixture is hydrolyzed in an autoclave for 15 minutes at a temperature of 105°C and cooled and 1.25 N NaOH is added 50 ml. Then do the hydrolysis back in the autoclave for 15 minutes. Examples filtered with filter paper that has been dried and known weight. The filter paper was washed successively with hot water, 25 ml of 0.325 N H2SO4, hot water and finally using acetone / alcohol 25 ml. The filter paper is dried in the oven at 105°C for 1 hour and continued until the weight. RESULT Sample was identified in the Laboratory of Botany Department of Biology, State University of Riau with the identification type / species as follows: Kingdom : Plantae Division : Magnoliophyta Class : Magnoliopsida Nation : Solnales Tribe : Convolvulaceae Marga : Ipomea Species : Ipomoea reptan Poir Local Name : Kale Crude fiber are plant fibers that are not soluble in water. Insoluble fiber is considered as fiber healthy intestinal. This fiber does not dissolve in water, so the this fiber passes through the gastrointestinal tract relatively intact, and accelerate food trip and waste through the intestines. Insoluble fiber is very beneficial for our body, because it helps smooth bowel movement reducing constipation and diarrhea. Insoluble fiber also helps to remove toxins from the colon, and reduce the risk of colon cancer because insoluble fiber helps maintain the pH (degree of acidity) of the intestines (Wibowo, 2012). Based on the test results crude fiber content that has been done using acid hydrolysis method (Apiyantono, 1988) it is known that the crude fiber content of 3 types of treatment on the sample is a sample control, sample boiled and steamed samples can be seen in Table 1. Table 1. Crude Fiber Content Research Results Types of treatment Crude fiber content in 100 g 1,33% Water spinach Control 5,12% Boiled Water spinach 2,38% Steamed Water spinach Based on the table can be seen that there are differences in the content of crude fiber content between water spinach from each treatment. High crude fiber content of most of the research that has been done is water spinach with this type of trial, namely by boiling (5,12%), steamed (2,38%) and then the water spinach with the without trial / fresh (1,33%). Water spinach has a manifold fiber hemicellulose, so the water spinach include 219 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology sources of insoluble fiber. Boiled water spinach has a higher fiber content caused by cooking medium used. At the time of boiling, water spinach directly in contact with water for 3 minutes at a temperature of 100°C, thereby it will reduce levels of soluble fiber which then will increase levels of insoluble fiber. While the steamed water spinach has a lower fiber content than the boiled water spinach because of steamed water spinach has a cooking medium in the form of water vapor so the water spinach is not directly in contact with water, thereby decrease of the soluble fiber is not as much as steamed water spinach water spinach stew. Water spinach without treatment has a lower fiber content than the other treatments because the water spinach is not cooked so that the levels of soluble fiber does not experience many changes. CONCLUSIONS There are differences of crude fiber content in water spinach after cooking process of each treatment. High crude fiber content of most the research that has been done is water spinach with this type of treatment, namely by boiling (5.12%), steamed (2,38%) and then the water spinach with the untreated / fresh (1,33%). REFERENCES Aji, Kurniawan. 2012. Pemanfaatan Serbuk Biji Salak (Salacca Zalacca) Sebagai Adsorben Cr(VI) Dengan Metode Batch Dan Kolom. Dalam Jurnal Sains Pomits. Vol 1. No 1. Hal 1-6. Andarwulan, N. Feri Kusnandar, Dian Herawati. 2011. Analisis Pangan. Jakarta. Dian Rakyat Badan Pusat Statistik. 2007. Pola Makan Dan Minum. Tangerang. BPS Badan Pusat Statistik. 2014. Produksi Sayuran dan Buah-buahan Semusim di Indonesia 1997-2013. Jakarta. BPS Badan Standarisasi Nasional. 2009. Cara Uji Makanan Dan Minuman. Jakarta. BSN. SNI 01-2891-1992 Balai Penelitian Tanaman Sayuran. 2014. Manfaat Mengkonsumsi Sayur Kangkung Untuk Kesehatan. Lembang. Pusat Penelitian Dan Pengembangan Holtikultural Budia, dkk. 2013. Teknologi Proses Ekstrusi Untuk Membuat Beras Analog Extrusion 220 Process Technology Of Analog Rice. Dalam Jurnal Pangan. September 2013. Vol 22. No 3. Hal 263-274 Dyah, I, Muwakhidah, Lilik Indriyani. 2011. Pengembangan Model Pendidikan Gizi Dengan Media Leaflet Terhadap Peningkatan Pengetahuan Tentang Serat Makanan (Dietary fiber) Pada Remaja Di Smk Dwija Dharma Boyolali. Dalam Jurnal Kaesehatan. Vol 4. No 1. Hal 31-40 Fransistik, R, Nora Idiawati, Lia Destiarti. 2012. Pengaruh Waktu Fermentasi Campuran Trichoderma Reesei Dan Aspergillus Niger Terhadap Kandungan Protein Dan Serat Kasar Ampas Sagu. Dalam JKK. Tahun 2012. Vol 1. No 1. Hal 35-39 Hernawati. 2007. Peranan Berbagai Sumber Serat dalam Dinamika Kolesterol pada Individu Hiperkolesterolemi dan Normokolesterolemi. Bandung. Jurusan Pendidikan Biologi Universitas Pendidikan Indonesia. Hery, S. 2001. Serat Makanan, Benteng terhadap Berbagai Penyakit. Dalam Majalah Intisari No.456 Juli 2001. Johantika, E. 2002. Pemanfaatan kangkung Darat (Ipomea reptans poir) Dalam Pembuatan Biskuit Tinggi Serat Makanan. Skripsi. Fakultas Teknologi Pertanian IPB. Bogor. Kays, S. 2011. Cultivated Vegetables of The World : a multilingual onomasticon. Netherlands. Wageningen Academic Publishers, University of Georgia Kusandryani, Yenni dan Luthfy. 2006. Karakterisasi Plasma Nutfah Kangkung. Dalam Buletin Plasma Nutfah. 2006 Vol 12. No 1. Hal 30-33 Kusharto, Clara M. 2006. Serat Makanan Dan Peranannya Bagi Kesehatan. Dalam Jurnal Gizi dan Pangan. November 2006. Vol 1. No 2. Hal 45-54. Manvar, N, Desai. 2013. Phytochemical And Pharmacological Profile Of Ipomoea Aquatica. April 2013. Dalam Indian Journal Of Medical Sciences. Vol 67. No 3. Hal 49-60 Muchtadi, D. 2000. Sayur-sayuran sumber serat dan antioksidan : Mencegah Penyakit Degeneratif Jurusan Teknologi Pangan Dan Gizi, Fakultas Teknologi Pertanian. IPB. Bogor Oka, A. 2007. Pengaruh Pemberian Pupuk Kascing Terhadap Pertumbuhan Tanaman Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Kangkung Darat (Ipomea reptans Poir). Dalam J. Sains MIPA. Desember 2007. Vol 13. No 1. Hal 26-28 Perdhana, dkk. 2013. Pengaruh Penggunaan Tepung Ikan dan Menir Kedelai Terproteksi dalam Ransum terhadap Kecernaan Nutrien pada Sapi Persilangan Simmental Peranakan Ongole Jantan. Dalam Jurnal Tropical Animal Husbandry. Januari 2013. Vol 2. No 1. Hal 1-7 Prabasini, H, Dwi Ishartani, Dimas Rahadian. 2013. Kajian Sifat Kimia Dan Fisik Tepung Labu Kuning (Cucurbita Moschata) Dengan Perlakuan Blanching Dan Perendaman Dalam Natrium Metabisulfit (Na2s2o5). Dalam Jurnal Teknologi Pangan. April 2013. Vol 2. No 2. Hal 93-102 Puspamika, Niati, D, Sutiari, N. 2014. Konsumsi Serat pada Anak Sekolah Dasar Kota Denpasar. Dalam Artikel Penelitian Community Health. Januari 2014. Vol 2. No 1. Hal 133 – 140 Puspitarini, R. 2012. Kandunga Serat, Lemak, Sifat Fisik, Dan Tingkat Penerimaan Es Krim Denga Penambahan Berbagai Jenis Bekatul Beras Dan Ketan. DalamArtikel Penelitian. Program Studi Ilmu Gizi Fakultas Kedokteran. Universitas Diponegoro. Semarang Santi, Sunarti, Santoso, Triwisari. 2012. Komposisi Kimia Dan Profil Polisakarida Rumput laut Hijau. Dalam Jurnal Akuatika. September 2012. Vol 3. No 2. Hal 105-114 Santoso, A. 2011. Serat Pangan (Dietary fiber) Dan Manfaatnya Bagi Kesehatan. Dalam Jurnal Magistra. Maret 2011. Vol XXIII. No 75. Hal 35-40. Sofiari, E. 2009. Karakterisasi Kangkung (Ipomoea reptans) Varietas Sutera Berdasarkan Panduan Pengujian Individual. Dalam Buletin Plasma Nutfah. 2009 Vol 15. No 2. Hal 49-53 Suratman, Priyanto, D, Setiawan, A.D. 2000. Analisis Keragaman Genus Ipomoea Berasarkan Karakter Morfologi. Dalam Jurnal Biodiversitas. Juli 2000. Vol 1. No 2. Hal 72-79 Survei Sosial Ekonomi Nasional. 2012. Pengeluaran Untuk Konsumsi Penduduk Indonesia (Expenditure For Consumption Of Indonesia). Jakarta. Badan Pusat Statistik Tensiska, 2008. Serat Makanan. Padjajaran. Jurusan Teknologi Industri Pangan Unpad Wibowo, L, Fitriyani, E. 2012. Pengolahan Rumput Laut (Eucheuma Cottoni) Menjadi Serbuk Minuman Instan. Dalam Jurnal Vokasi. Juni 2012. Vol 8. No 2. Hal 101 109. Yuliarti, N. 2008. Hidup Sehat Dengan Sayuran. Yogyakarta. Cakrawala. 221 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE IMPACTS OF BREASTFEEDING COUNSELINGBYKADER KESEHATAN (LAY HEALTH WORKERS) ON THE FIRST MONTH EXCLUSIVE BREAST FEEDING (E1) AMONG BREAST FEEDING WOMEN IN DARUL IMARAH SUB-DISTRICT 1. Nurlaili Ramli,1PutriSanty1 Midwifery department of healthpolytechnic Kemenkes Aceh. [email protected] ABSTRACT Background: The coverage of exclusive breastfeeding in Aceh Province is still low, with a median of 0.6 months (BPS & Macro International, 2007), while in DarulImarahSub-District, the figureis 0.5% (Aceh Besar District Health Office, 2011). The involvement of kaderkesehatan (lay health workers) in the programs of maternal and child health is very effective in reducing morbidity and mortality through the promotion of breastfeeding practices. Objective: To determine the impacts of counselinggiven by kaderkesehatan (lay health workers) on the first month exclusive breastfeeding (E1) among breastfeedingwomen in DarulImarahSub-district. Methods: This study was an experimental study with a controlled trial design. The subjects were the third trimester pregnant women in DarulImarahSub-districttaken with two stage sampling technique. Sixteen womenwere selected for each the intervention group and the control group. The primary data collection was done by the health workers and enumerators to obtain data on exclusive breastfeeding done at birth, one week after birth and during 1 month after birth. Data analysis usedStatasoftware program, chi-square test, and RR (95% CI). RESULTS: The proportion of the firstmonth exclusive breastfeeding was higher in the intervention group compared with that in the control group. The statistical analysis showed that the counselinggiven by the health workers influenced the provision of exclusive breastfeeding (P = 0.01; CI: 1.11 to 6.84). Conclusion: The provision of breastfeeding counseling by the health workers influenced the success of exclusive breastfeeding (E1) in DarulImarah Sub-district. Keywords: breastfeeding counseling, health workers, exclusive breastfeeding INTRODUCTION Breastfeeding is a way of providing adequate nutrition for the newborn’s growth and development.Colostrum administeredat the first hours after birth is the perfect food for the newborn. Breastfeeding is subsequently given until the child is two years old. The Indonesian government changed the recommendation of exclusive breastfeeding from four months tosix months in 2003.1 Exclusive breastfeeding is given to newborns up to the age of 6 months and continued with supplement feeding.2 The WHO and UNICEF recommended exclusive breastfeeding as an effort to decrease morbidity, mortality in infants and under-five children.1Exclusive breastfeeding can reduce the risk of acute and chronic diseases, including diarrhea, respiratory tract infections, urinary tract infections, otitis media and asthma. Shorter and less intensive breastfeeding period will 222 cause the baby to be less protected. The development of cognitive value for infants breastfed for 6 months or more will increase when compared to the infants who are never breastfed.3-4 Breastfeeding is also one of the factors that can prevent obesity in the baby’s next life period.5 A research in 2005 found that 13 % of women stopped breastfeeding their babies in the first month due to the babies who were unable to be breastfed and the perceptions thatthe breast milk production was not enough to their babies.6 During the period beforethe milkwasproduced, the babies weregiven breast milk substitute, for example, water, tea, and honey untilthe breast milkcameout.7-8 A survey conducted in groups of women in England and Wales with differences in social status showedthat the prevalence of breastfeeding at birth was 71% and would decline to 54% atthe first two weeks after Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology birth, 44% at six weeks and 28% at fourth month. This decreased prevalence causeddisadvantage for mothers and infants as a result of the termination of breastfeeding practices faster than the time expected.9 The Indonesian government has set a policy of exclusive breastfeeding in the Decree of the Minister of Health of the Republic of Indonesia No. 450 / Menkes / SK / IV / 2004 and it has been amended by the Government Regulation No. 33 in 2012.10 However, the patterns and trends of breastfeeding in Indonesia are getting worse every year, the duration of breastfeeding becomes shorter and theweaned age of baby is sooner. Data of Indonesian Demographic and Health Survey (IDHS) in 1997 showed that the coverage of exclusive breastfeeding was 52% and in the 2002-2003 it decreased to 40% and decreased again to 32% in2007. The figure was still lower than the figure worldwide that was 38% and lower than the target coverage of exclusive breastfeeding in Indonesiaby 80%.11This suggests that the practice of exclusive breastfeeding be continuously decreasing caused by modernization lifestyle. This decline will negatively affect child morbidity and mortality, andother problems of maternal and child health willincreasingly be faced.1,12 This phenomenon requires a change of mindset on how to improve the factors that influence the practice of breastfeeding in Indonesia. The decisions of breastfeeding babies are influenced by factors of mothers and family. Appropriate support and direct advice can positively affect the initiation of breastfeeding and the sustainabilityof breastfeeding.13 The WHO publications and systematic review of breastfeeding promotion program involving communities have proven to increase breastfeeding compared to the promotion carried out by health professionals.14-16 Breastfeeding promotion and communitybased support are one of the key components of a comprehensive program to improve the practice of breastfeeding.17 The involvement of Lay Health Workers (LHWs) in maternal and child health programs is very effective in reducing morbidity and mortality through the promotion of breastfeeding practices. Usually, LHWsonly receive informal job training without a formal professionaleducation but are often involved whether getting paid or doing the job voluntarily.18A research in the US showed that the counseling provided by the outreach health workers could improve knowledge and promote changes in health behavior in women fromminority ethnic groups.19 In Indonesia, the outreach health workers are better known askaderkesehatan (lay health worker).20Kader kesehatanis local people selected and reviewed by the community to work voluntarily.21 Counseling is a process of assistance carried out by the counselor to the individual in order to solve a problem or optimize potential owned.22The provision of breastfeeding counselors in health care facilities and public facilities is one of the responsibilities of the local government in an effort to increase the coverage of exclusive breastfeeding in community.10 A study using the outreach health workers showed that this had effectively enhanced the promotion of the improvement of exclusive breastfeeding for breastfeedingwomen.23-24,18 However, a Randomized control trial study showed that breastfeeding counselors’supportsdid not significantly increase the exclusive breastfeeding in the intervention group.25 The average duration of breastfeeding practice in Indonesia is 20.7 months, while in Aceh Province the median of breastfeeding is 19.7 months and the median duration of exclusive breastfeeding is 0.6 months.1 Exclusive breastfeeding in Aceh Province in 2010 was 4.30 percent26 while in Aceh Besar Districtthe exclusive breastfeeding was 1.1 percent and in DarulImarohSub-district it was 0.5% .27 Such data showed that exclusive breastfeeding was still not in line with expectations;therefore,the researchers were challenged to conduct this research on the impacts of breastfeeding counseling by the kaderkesehatan in improving exclusive breastfeeding for breastfeedingwomen in DarulImarahSub-district ofAceh BesarDistrict. This study is expected to give consideration for the Health Office of Aceh BesarDistrict for decision-making in an effort to increase coverage of exclusive breastfeeding. RESEARCH METHODOLOGY This was an experimental study with a controlled trial design, which compared an intervention to another intervention or by the comparison. The research saw the effect of 223 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology two kinds of intervention to the women so that there would be two groups of research subjects, each of which would receive different interventions.28 Group A (intervention) received get a leaflet and breastfeeding counseling from the kaderkesehatanon exclusive breastfeeding and Group B (control group ) only got a leaflet. The study was conducted in DarulImarahSubdistrict on July 16 to October 15, 2012. DarulImarahSub-district has 32 villages andthe chosen villages by purposive sampling technique as the intervention group wereLampeneuen, LampenerutGampong, Lamsidaya, Lamkawe, Deunong, KutaKarang, Leugeu, and Payaroh while the villages as the control group wereLamcot, Bayu, LamblangManyang, Lambheu, LamblangTrieng, Punie, Lamreung and Lamsidaya. The reason for choosing the location of this studywas because the coverage of exclusive breastfeeding was low at 0.5%, compared with itscoverage in theDistrict (1.1%). The population in this study was all third trimester pregnant women in DarulImarahSubdistrict that met the criteria for inclusion. The sampling was done by two stage sampling method, by modifying the purposive sampling and total sampling technique.29The sampling stages conducted were as follows: 1) the purposive sampling technique was based on the consideration that, from 32 villages in the Sub-district of DarulImarah,16 villages were taken based onthe low coverage of exclusive breastfeeding, the highest total of V4 and the same characteristics and 2) using the total population to determine the research subjects included in the intervention group and the control group. The data collected were the primary data,i.e.,data obtained directly from the field by spreading questionnaire containing questions on the respondents’characteristics. Breastfeeding counseling was conducted by a kaderkesehatanin the gestational age of ≥ 36 weeks, shortly after birth, when the baby was 1 week old and when baby was 1 month old. The exclusive breastfeeding data were obtained by direct interviews to the womenshortly after birth, when the baby aged 1 week and 1 month. In the intervention group,observation 1, 2 and 3 wasdone by the kaderkesehatan, whereas for the control group, the data collection was done by enumerators 224 who had been trained on how to fill out the questionnaire. The research instrument used in this study was a questionnaire. The variable ofexclusive breastfeeding was measured by interviewing the women immediately after birth, 1 week and 1 month after birth using research instruments from the Community Nutrition and Research Laboratory of UGM. The intervention in the intervention group was breastfeeding counseling and leaflets by cadres, while the control group was given only a leaflet by the kaderkesehatan. The counseling was given for 1 hour to the women before birth, with a due date estimation in July. Before the kaderkesehatan providedcounseling, they were giventraining on exclusive breastfeeding. The training was organized by the researchers in collaboration with Breastfeeding CounselingFacilitator Coach Team, Department of Midwifery,Aceh Health Polytechnic. Training activities were held for 3 days or 21 course hours based on implementation guidelines of breastfeeding counseling training and breastfeeding counseling facilitators.30Thematerials of the training were adjusted to the counseling training module for the participants.31 The training for the kaderkesehatan was carried out on July 16-18, 2012 attended by 8 people. The trained kaderkesehatanwere from Lampeneuen, LampenerutGampong, Lamsidaya, Lamkawe, Deunong, KutaKarang, Leugeu, and PayarohVillage. RESULTS AND DISCUSSION The characteristics of kaderkesehatan The number of kaderkesehatanused in this study was 8 people, coming from Lampeneuen, LampenerutGampong, Lamsidaya, Lamkawe, Deunong, KutaKarang, Leugeu, and Payaroh Village. Of 8 kaderkesehatan, 1 (8%) was 20 years old and 7 kaderkesehatanwere 30-40 years old (92%). Half of the kaderkesehatan had higher education background and the other fourgraduated from high school. The characteristics of the respondents Research subjects in this study were 32 respondents consisting of 16 respondents in the intervention group and 16 respondents in the control group. The results of homogeneity test showed no difference in age, education, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology and parity in both the intervention group and the control group with p valueof > 0.05. The impacts of breastfeeding counseling by the kaderkesehatanonone month exclusive breastfeeding The research was conducted from July 16 to October 15, 2012 to 16 villagesin the working area of DarulImarah Health Center of Aceh Besar District. At the time of this research after the selection process, there were32 pregnant women (16 in intervention group and 16 people in control group). The results showed a decrease in the frequency of exclusive breastfeeding between the intervention groups and the control group. There were changes in the frequency of exclusive breastfeeding from at birth to the baby was one month old. In the intervention and control groups, the frequency of breastfeeding shortly after birth was respectively 81.25% and 75% while the frequency of breastfeeding when the baby was one month old wasrespectively 68.75% and 25%. The results of the data analysis on the impacts of breastfeeding counselinggiven by the kaderkesehatanon the first month exclusive breastfeedingshowedthat the intervention group gave exclusive breastfeeding almost 3 times higher than the control group (RR = 2.75 95% CI: 1.11 to 6.84). The statistical analysis showed the presence of differences in the proportion of the first month exclusive breastfeeding between the intervention group and the control group (p <0.05). This proved that the intervention in the form of breastfeeding counseling given by the kaderkesehatan increasedexclusive breastfeeding almost 3 times in the intervention group. Discussion The results of the statistical analysis showed that the independent variables were proved to be significantly to the firstmonth exclusive breastfeeding (E1) among thebreastfeeding women (p <0.01). This study showed that breastfeeding counselingfor the intervention group carried out by the kaderkesehatancould affect the first month exclusive breastfeeding by 2.75 times compared with the control group who were only given leaflets. Around 68.7% in the group that got leaflets and breastfeeding counselinggave exclusive breastfeeding to their babies than those who were given only the leaflet, ie,25%. This result was consistent with the literature review, indicating that the interventions made by the health workers/kaderkesehatanwere 2.78 times more effectively toincreaseexclusive breastfeeding practices.18 A research in Congo showed that, the intervention group who received health promotion, 57.7% respondents gaveexclusive breastfeeding compared to 2.7% in the the control group who gave their babies exclusive breastfeeding. In addition,a research in Glasgow showed that the prevalence of breastfeeding was higher in the group given both counselingand leaflet compared tothose who were given leaflet alone although statistically the results of the study were not significant.32Support provided by counselorsis most effective matter in increasing the duration of exclusive breastfeeding.16 Support given by a counselor functions as a process of giving aid done against individuals in order to solve a problem or to optimize her/his potential, which is called counseling.22 Breastfeeding counselling given by kaderkesehatancan make a woman continue exclusive breastfeeding up to the age of 6 months.23 This study showed that 68.75% of women continued to provide exclusive breastfeeding to their babies up to the age of one month after being given counseling by the kaderkesehatan. The researchers of this studystated thatthe visits done the kaderkesehatanto provide counseling on breastfeeding would make the womencontinue breastfeeding their babies, because they knew the difficulties or obstacles in the process of breastfeeding so that they were able to overcome problems that came up in accordance with the information provided by the kaderkesehatan. Breastfeeding counselingshould begiven during pregnancy; thus, itis expected shortly after the birth,a womancan breastfeed immediately. Childbirth is the right time for the baby to get breast milk. Breast milk is a nutrient that is able to meet all the nutritional elements for the development of the baby to be healthy and intelligent children in the future. Exclusively breastfed infants will decrease gastrointestinal infections and atopic eczema at the age of 1 year.34 The results of this study showed that the in the intervention group there were 31.25% of 225 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology breastfeeding women whodid not breastfeed their babies exclusively. This happened due to several factors, including the assumption that the baby was crying because of hunger so that the baby was given formula milk and the culture of the people of Aceh who fed their babies withbanana to avoid the baby not to be fussy because of starvation. The percentage of prelactealfeeding was higher in the control group than in the intervention group, ie, 75% vs. 31.25%. Prelacteal food provided in both the intervention group and the control group was formula milk, honey and bananas. Exclusive breastfeeding was breastfeeding only without additives drinks and food such as formula milk, orange juice, honey, tea, water, bananas, papaya, milk porridge, biscuits, and rice porridge except medicines and vitamins if needed.34 A research in China also mentioned that failure in exclusive breastfeeding was due to traditional beliefs that existed in China and early provision of formula feeding to the babies.35Substitutive food such as formula milkfor a baby was given if there were barriers to breastfeeding, either because the baby refused to drain the milk or becausethe women’s breast was ill.36 The results of this study also showed a decrease in exclusive breastfeeding from at birth to the baby was 1 month old in both the intervention group and the control group.The decrease in the first month exclusive breastfeeding was more common in the control group than in the intervention group. A research carried out in Germany also showed a decrease in exclusive breastfeeding; 90% of women gave exclusive breastfeeding shortly after birth and this declined to 44.7% at two months later.37We concluded that the declinein the practices of exclusive breastfeeding was due to the information that was not given repeatedly to the control group;leaflets were only given when the gestational age was ≥ 36 weeks. For the intervention group given leaflets and visited 3 times after birth, 68.75% were still exclusively breastfeeding their babies at the age of 1 month. This happened because the women always got information about the solution of problems that might occur during the process of breastfeeding as well as family that supported them to be able to breastfeed exclusively. The women who receive information about breastfeeding are 226 more interested and have a high confidence in breastfeeding their babies.38 In this study there wasstill some shortages, among others,predisposing factors consisting of women’s knowledge, beliefs, values, attitudes, beliefs and psychology that were not analyzed. Likewise, we also did not analyze theenabling and reinforcing factors that came from family. A qualitative approach was also not performed in this study, so that factors related to the success of breastfeeding were not studied in depth. CONCLUSIONS AND SUGGESTIONS Conclusion Practically and statistically there wasan influence of breastfeeding counseling given by the kaderkesehatanin the first month exclusive breastfeeding (E1) in DarulImarahSub-district and the proportion of the first month exclusive breastfeeding was higher in the intervention group that was given leaflets and counselingon breastfeeding than those who were given only leaflets. Suggestion Health Office of Aceh Besar District is suggested to empower the kaderkesehatan in providing breastfeeding counseling in order to increase the coverage of exclusive breastfeeding in DarulImarahSub-district. Further researchshould examine other factors such as women’s knowledge and education and should conduct a qualitative approach in order to gain more information about the main factors that influence the practices of exclusive breastfeeding. DAFTAR PUSTAKA BPS, & Macro International. (2007). Survei demografi kesehatan Indonesia. Calverton, Maryland, USA: Macro International. WHO. (2010). Breastfeeding. Retrieved 3 Mai, 2010, from http://www. who.int/ breastfeeding/htm Hediger, M. L., Overpeck, M. D., Kuczmarski, R. J., & Ruan, W. J. (2001). Association between infant feeding and overweight in young children. JAMA, 285(19), 2453-2460. Van Rossum, C., Buchner, F., & Hoekstra, J. (2006). 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Banda Aceh. 227 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Dinkes Kab. Aceh Besar. (2011). Profil Kesehatan Kabupaten Aceh Besar Tahun 2011. Kota Jantho. Hulley, S., Cummings, S., Browner, W., Grady, D, Hearst, N., & Newman, T. (2001). Designing Clinical Research. Philadelphia: Lippincott Williams & Wilkin. Murti, B. (2010). Desain dan ukuran sampel untuk penelitian kuantitatif dan kualitatif di Bidang Kesehatan (Second ed.). Yogyakarta: Gadjah Mada University Press. Depkes RI. (2007b). Pedoman penyelenggaraan pelatihan konseling menyusui dan pelatihan fasilitator konseling menyusui. Jakarta. Depkes RI. (2007c). Pelatihan Konseling menyusui bagi peserta. Jakarta: Depkes RI. Mclnnes, R. J., Love, J. G., & Stone, D. H. (2000). Evaluation of a communitybased intervension to increase breastfeeding prevalence. Journal of Public Health Medicine, 22(2), 138145. Kramer, M. S., Chalmers, B., Hodnett, E. 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Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology ANALYSIS PREPAREDNESS OF GENERAL HOSPITAL Dr. FL. TOBING SIBOLGA IN IMPLEMENTATION OF ASSURANCE NATIONAL HEALTH POLICY 2014 Siti Marlina 1 , Juanita 2, Siti Zahara Nasution 2 1 Alumni Program Pascasarjana FKM-USU, Medan 2 Staf Pengajar FKM-USU, Medan ABSTRACT The enforcement of Law No. 40/2004 on SJSN (National Social Assurance System) and Law No. 24/2011 on BPJS (Social Assurance Provider Board) needs complete preparedness by a hospital as health assurance provider. Dr. FL. Tobing General Hospital, Sibolga, is one of the hospitals which provide SJSN. The objective of the research was to find out the preparedness of Dr. FL. Tobing General Hospital, Sibolga, in implementing the policy in the National Health Assurance, in 2014. The research used qualitative method with ten informants who were regarded as the qualified persons who understood the preparedness in implementing health assurance program. The data were gathered by conducting interviews, observation, and documentation. The result of the research showed that socialization had been conducted by the management of the hospital and by BPJS Sibolga Branch. There was no preparedness in health facilities because of the lack of health equipment, human resources were ready both quantitatively and qualitatively, disposition of the implementation of health care in the hospital was good, and coordination between the structure of hospital bureaucracy and BPJS had been done well. The conclusion of the research was that the management of the hospital had no preparedness in health facilities for the implementation of the National Health Assurance Program. It is recommended that the management the hospital should complete and improve its facility and infrastructure, the government should pay more attention to the implementation of JKN program, and socialization to public should be optimized. Keywords: Implementation of Policy, National Health Assurance, Hospital INTRODUCTION The National Health Insurance (JKN) is part of the National Social Assurance System (BPJS) held by using the mechanisms of social health insurance which is compulsory (mandatory) based on Law No. 40 of 2004 on National Social Assurance System with the aim to meet the basic needs of a decent public health which is given to every person who has paid dues or dues paid by the government. JKN starting from 1 January 2014, which gradually toward thorough coverage (Kemenkes RI, 2013). JKN purpose generally is easier for people to access health services and obtain quality health services. Changes in the financing system toward a comprehensive coverage is a good thing but it has side effects and risks. Inequality availability of health facilities, health workers and geographical conditions, give rise to new problems in the form of inequity between community groups (Kemenkes RI, 2013). Social Assurance Provider Board (BPJS) is an institution established to administer social assurance programs in Indonesia, according to Law No. 40 of 2004 and Law No. 24 of 2011. In accordance with Law No. 40 of 2004 on the Social Assurance, BPJS a non-profit legal entity. Under Law No. 24 In 2011, BPJS will replace a number of existing social assurance institutions in Indonesia, namely PT Health Insurance Agency. Askes Indonesia became BPJS Health and social assurance institutions manpower PT. Jamsostek into BPJS Employment (Sijabat, 2012). Transformation PT Askes and PT Jamsostek into BPJS done gradually. In early 2014, PT Askes will be BPJS Health, then in 2015 the turn of PT Jamsostek into BPJS Employment (Ariyanti, 2013). 229 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The principle of social assurance benefits is usually the form of cash and the value of health services appropriate basic life needs such as food, clothing, shelter and basic medical needs. Provision of social assurance benefits is based justice in the sense that benefits provided applies to all citizens of the rich countries, poor or nearly poor, because social assurance is a permanent lifetime. The third principle is the cornerstone in the implementation of the social assurance system sustainable (Kemenkes RI, 2012). In order to materialize the implementation of a sustainable social assurance system, the social assurance held nationwide by forming an independent BPJS based social assurance law. Social assurance guarantees provide certainty for the community in order to achieve the fulfillment of basic life evenly as mandated by Article 28H of paragraph (1) of the Constitution of the Republic of Indonesia Year 1945 has affirmed that every person has the right to obtain medical care, and in Article 34 paragraph (3) shall be declared the state responsible for the provision of health care facilities and public service facilities are decent (Kemenkes RI, 2012). As stated in Article 2 of Law of the National Social Assurance System (SJSN), the Social Assurance organized by the principles of humanity, the principle of benefit and the principle of social justice for all Indonesian people. If the implementation of the Social Assurance is not based on the three principles, then there is a violation of that law. Or negligence in covering and serving the health insurance for the poor, including poor people, basically a violation of the principle of humanity. Then, the principle of social assurance benefits in the design should provide significant benefits for the participants, not least to guarantee the fulfillment of basic needs for participants including a comprehensive health services, while the principle of fairness in the administration of the Social Assurance applies to all levels of society, rich, medium or poor order created the principle of cooperativeness (Purwoko, 2012). Social Assurance System is a system of social protection for all citizens. Social protection has a strategic role to address the vulnerability due to the risk of natural and economic risks. As we know that Indonesia is 230 one of the disaster-prone areas and the impacts of disasters resulting relocate the budget required to rebuild the damaged infrastructure. The disaster also left many families losing possessions and life, so it is quite difficult in an effort to improve people's welfare (Zaelani, 2012). One health care provider JKN program in Sibolga City is General Hospital Dr. FL. Tobing Sibolga which is the General Hospital of Class B Non Education, seeks to provide health services as much as possible in accordance with the facilities and tools available, have 204 beds 204, Human resources 338 people, medical services include specialist outpatient services, inpatient care and support services for the installation of medical services. In general, any type of outpatient services take place every weekday and is open to any public or patient health insurance (ASKES) / poor family health insurance (ASKESKIN) / Community Health Insurance (JAMKESMAS) with or without a referral. Medical record data General Hospital Dr. FL Tobing Sibolga (2012) shows the value of Bed Occupancy Rate (BOR) 50% (national standard of 60% -80%), and Length Of Stay (LOS) was 4 days (standard 2 days) with the highest proportion of patient visits askes 45.24 %, ie 40.06% of patients general, and 13.5% of patients jamkesmas. This condition shows that the public interest to come for treatment to the General Hospital Dr. FL Tobing Sibolga still low. Viewed from the aspect of management at the General Hospital Dr. FL Tobing Sibolga, still encountered problems of lack of services in accordance with Standard Operating Procedure in every unit of services, such as nursing care and midwifery care. This is indicated by the lack of reports on the development of nursing care of patients and the patients are still many complaints against the availability of drugs and consumables in hospitals. Based on the results of the initial survey conducted by researchers in January 2014, it is known from the aspect of the facility is very adequate hospital, where medical support units also function optimally as radiology, laboratory and blood services unit. But the results of a brief interview with the head of medical services and treatments suggested that health services for participants Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology JKN still not well served, it is seen from the limited socialization JKN program for service providers in hospitals, as well as the still weak coordination with BPJS in the claiming process. Currently the General Hospital Dr. FL Tobing Sibolga also preparing health care participants of the National Health Insurance. Based on the above, the authors are interested in knowing the extent of readiness of the General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. Based on the background described, the problems in this research are: how Readiness General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. This research aimed to analyze readiness General Hospital Dr. FL. Tobing Sibolga in the implementation of the National Health Insurance Policy 2014. The benefits of this research are: 4. This research is expected to be input for the Hospital of the readiness of the implementation of the National Health Insurance policy so that it can be taken into consideration in improving the implementation of National Health Insurance. 5. It is expected that this research can be used as an additional reference regarding health policy and learning materials as well as contribute ideas in preparation for the implementation of the National Health Insurance policy at the hospital. 6. This research can increase knowledge and scientific insights scientific author on the readiness of hospitals in the implementation of the National Health Insurance policy RESEARCH METHODS The method used in this research is qualitative research. This research therefore only describe how analysis Readiness General Hospital FL Tobing Sibolga in the Implementation of the National Health Insurance Policy 2014. Qualitative research is a type of research that revealed the objective conditions of the phenomenon that occurs with the approach of in-depth interviews (Sugiyono, 2006). Research conducted at the General Hospital dr. FL. Tobing Sibolga. The choice of location is based on the consideration of the research has not been done the same with this research, because the policy is still relatively new JKN as of 1 January 2014. The research began by surveying beginning in January 2014, the collection of data with in-depth interviews and observations conducted in July 2014. Qualitative research is not intended to make a generalization of research. Therefore, in qualitative research, is not known for the sample population. The subject of research became an informant who will provide the necessary information during the research process (Maleong, 2002), informants are people who used to give information about the situation and condition of background research. Informants in research in all the elements that are involved in policy implementation JKN program in General Hospital Dr. FL Tobing Sibolga consisting of: 4. Components General Hospital Dr. FL. Tobing Sibolga a. Director of the General Hospital Dr. FL Tobing Sibolga b. Head of Medical Services and Treatments c. Head of Planning and Development d. Chairman of the Medical Committee e. Head of Pharmacy Installation 5. Components branch BPJS Sibolga the head unit hospital services. 6. Inpatients and outpatients at the General Hospital Dr. FL Tobing Sibolga. Based on the above, the research determines informants using purposive sampling and snowball sampling are. Sampling with purposive sampling technique means that the sampling technique based on certain considerations namely, informants authors choose are the ones who are involved directly to the issues being studied. Snowball Sampling The samples are still provisional data sources and will develop later after researchers in the field. (Sugiyono, 2005). Snowball sampling is used when in the process of data penggumpulan there's more varied opinion, the researchers will look for another informant so that the necessary data is sufficient to describe the phenomena related to the objectives of this research . Data analysis in qualitative research is rather complicated because the data are quite a lot of variety and there is no standard pattern. According to Bogdan, who was quoted by 231 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Sugiyono (2005), data analysis is the process of systematically searching for and compiling the data obtained from interviews, field notes and other materials that can be easily understood and the findings can be communicated to others. Data analysis was performed by organizing the data, translate it into the units, synthesize, organize into a pattern, choose what is important and what will be learned and make inferences that can be passed on to others. Sugiyono (2005), citing the opinion Spradley, also argued that the analysis in the research of any kind, is a way of thinking, relating to systematically test for something to define the part, the relationship between parts, and its relationship to the whole. Thus, the analysis is to look for a pattern. Based on the statement of the experts, Sugiyono (2005) concluded that the data analysis is the process of systematically searching for and compiling the data obtained from interviews, field notes, and documentation, by way of organizing data into categories, describe into the units, perform synthesize, organize into a pattern, choose what is important and what will be learned and make conclusions so easily understood by myself and others. According Sugiyono (2005) Miles and Huberman cites the opinion that the activity in qualitative data analysis is done in an interactive and takes place continuously at every stage of research so as to completion, and the data until saturated. RESULTS AND DISCUSSION Readiness Communications Communication is one of the means to disseminate information or orders from superiors to subordinates and from subordinates to superiors. The information provided should be clear, accurate in time delivery of information and information submitted must be consistent or significant permanent or not plus-added or subtracted. According to Hovland, Janis & Kelley communication is a process through someone (communicator) deliver stimulus (usually in the form of words) with the aim of changing or shaping the behavior of others (Riswadi, 2006). While Harold Laswell said communication is basically a process that describes the "who" says what channel what to whom, and with what result or outcome. 232 Laswell paradigm indicates that communication includes five elements, namely communicator, message, media, communicant and effect. JKN program policies made by the central government in this case the Ministry of Health are socialized to other interested parties through a socialization program JKN. JKN socialization at the General Hospital Dr. F.L. Tobing is done in cooperation with BPJS Sibolga, socialization is done by creating a meeting / conference or delivered at the time the apples or the circular letter to the hospital management, all nurses, specialists, general practitioners, and all associated with the hospital and the patient. Dissemination to patients conducted by the Health Office of Sibolga City and BPJS. General Hospital Dr. FL. Tobing Sibolga is a hospital into a referral health services on the west coast of North Sumatera, where the policy JKN with BPJS as the responsible person must be involved in the program. In general, the communication between the hospital with BPJS no problem. BPJS which holds the mandate of the laws directly apply JKN automatically on January 1, 2014, including in cooperation with health care is the hospital. General Hospital Dr. FL. Tobing Sibolga with BPJS branches can work together with effective communication and better coordinate with each other. Effective implementation will be realized if the implementation of policy implementation to know what will be done. George Edward III suggests three variables that can measure the success of the first communication, namely the transmission or distribution of information. Distribution of good information will produce good policy implementation as well. In this research , the distribution of information is good. Information about JKN received by the hospital received. This is due to the special meeting held to discuss the program with the BPJS JKN. The second variable is the clarity of the information received by the policy implementer of policy makers should be clear and not confusing or ambiguous. In the results of this research showed that the informant was aware of the policy implementation JKN unknown content of information disseminated in the form of policy regulations, regulations on JKN, a presidential decree, the minister of Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology health regulations, the method of payment (contribution), referrals, benefit from JKN, the membership of the National Health Insurance, national formulary, e-catalogs, and the Compendium alkes and others concerning the JKN program, while the content (content) submitted by BPJS is PT. ASKES changes to BPJS health. The third variable is the consistency. The information disseminated via the communication must be consistent, the information disseminated should be fixed and unchanging. Message JKN program has consistently delivered good message to implementing policy and to the parties concerned. This means that the individual is given the same message without any changes. It can be seen with the statement by the informant for the delivery of organizational communication socialization and mass communication in which media organizations to produce and disseminate widely the message to the public is through the media of radio, television, newspapers and leafleat and banners. This research is in line with research Lilian (2013) which is a form of socialization of health insurance programs carried out through leaflets and direct socialization kepadapasien who came for treatment at the health center Batua Makassar. Socialization among hospitals with BPJS done by a meeting between the leadership and the vision to unite the common goal for this JKN program. The unification of this vision should be able to bring the constitutional mandate JKN not to the interests of a particular institution. Therefore, strong leadership can encourage impelemntasi policies to conform with the original purpose as by USAID (2010), which states that leadership is a very substantial factor in policy implementation. Leaders at the top level is policy makers, technical breaker, which decided to cooperate or not on the institution they leads. Therefore, the leadership could be a solution to overcome the problems of communication between institutions that could impede the implementation of this JKN. Good communication occurs for two reasons, first the intensity in establishing coordination and collaboration between the two institutions. The second is the lack of clarity in implementing this program. This happens because prior to the enactment of the JKN General Hospital Dr. FL. Tobing Sibolga has been implementing the program JAMKESMAS and other health insurance programs. The involvement of hospitals in the delivery of programs JKN the key factor in the success of the program. When linked existing socialization field are performed only at the device level only, while for the public to very little or very minimal. This is in line with research Muliaddin et al (2005) and research Riegel et al (2013) which states that the dissemination to the public still needs to be done and further optimized to provide insight to the public about the benefits of the health insurance program. In contrast to research Hastuti (2010) that the socialization conducted by the health department regarding the health program in health centers Magelang district is considered good enough. Readiness Resources In the implementation of the policy should be supported by the resources both human resources, material and regulations or guidelines. Goals, objectives and policy content, despite being communicated clearly and konsiten, but if the lack of resources to implement the, then the implementation will not run properly. The existence of factor resources in order to implement policies JKN Program plays an important role in the success of the policy inplementasi, without adequate resources, what is planned will not be the same as what is ultimately implemented. Indicators of resources in the implementation of existing policy 3 that policy instrument that is the source of funds, human resources, and facilities. Policy instruments related to the dissemination of information. No policy information in two forms, namely information relating to the way of doing policy implementation and compliance of information regarding the implementation of the implementing rules and laws that have been established. Policy instruments is one form of information that describes the program or activity that must be done in order to implement the policy, from the data informant mind that they have a policy instrument JKN program that is the president of the Republic of Indonesia regulation No. 12 Year 2013 on Health Insurance, regulation Repubik health minister of Indonesia Number 71 of 2013 on health 233 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology care in the National Health Insurance. Regulation No. RI health minister 28 2014 on guidelines for the implementation of JKN program, health minister's decision No. 328 / Menkes / IX / 2013 on the national formulary, health ministerial regulation No. 59 of 2014 concerning the standard rates of health services in the administration of the program JKN, health ministerial regulation No. 27 2014 on technical guidelines Indonesian system Base Case Group (INA-CBGs) and others. Funds or financial aspect is a very important aspect in supporting the implementation of policies JKN. Based on the survey results revealed that the financial resources in the implementation of JKN program in General Hospital Dr. FL. Tobing Sibolga prepared with the payment system (claiming) INA CBGs where hospitals are already doing education and training on computerized data management INA CBGs held in Jakarta. Based on the above statement can be concluded that the health resources or health personnel in the General Hospital Dr. FL. Tobing Sibolga classified prepared in providing health services in JKN program. Human resources are not only talking about the number of health workers alone. Due to successful implementation of policies is also strongly influenced by the ability of (quality) of these resources. This is according to Edward III which states that the principal amount in analyzing the resources needed for the implementation of the policy is to analyze the magnitude and quality. It was found that the availability of health workers in health service delivery in the era of JKN according to the informant is sufficient or adequate, but instead according to researchers both in terms of the amount still lacking, it can be seen from the number of available 204 bed compared with the amount Source its human General Hospital Dr. FL Tobing Sibolga which is about 338 people consisting of basic medical personnel (doctors and dentists), specialist doctors, nursing and midwifery personnel, medical support staff and non-medical support personnel. Human Resources for specialist doctors in the General Hospital Dr. FL Tobing Sibolga suffice as many as 17 people, just not all the medical specialists are / live in the city of Sibolga so if suddenly required will hinder the process of work in the General Hospital Dr. FL. Tobing Sibolga. This is in accordance with 234 the opinion of informants stated that for anesthesia personnel just one person, if the doctor is unable to attend the hospital will be shorthanded. Nursing staff at the General Hospital Dr. FL. Tobing Sibolga also inadequate seen from the number of nursing personnel, only 164 people while 204 bed, based Pemenkes no. 340 / Menkes / Per / III / 2010 that the ratio of nursing staff and the bed was 1: 1, it is compared with the opinion of the informants who said that the nursing staff at the General Hospital Dr. FL. Tobing Sibolga is enough. Informants stated that education and training had been conducted by a team at the hospital JKN held in Jakarta for the management of computer data for INA CBGs. Training is needed not only for the power that would operate a computer for recording and reporting administration, but also health workers need to do the training, including the hospital director. Director of the General Hospital Dr. FL. Tobing Sibolga has never participated in the training because the director of the General Hospital Dr. FL. Tobing Sibolga only is the task of implementing the newly served by June 2014. Observation and in-depth interviews to health facilities for aspects of the physical appearance of a physical building standard is good, the location is easy to reach the community, well-organized health services, medicines and consumables sufficient, for there are still some health facilities are lacking because of broken tools and still in improvements, such as a HD yet prepared at the General Hospital Dr. FL Tobing Sibolga and planned to be prepared in 2014, for the infrastructure still not ready because medical equipment is lacking and needs to be completed. This research is in line with research conducted Luti et al (2012), which states that the condition of the facilities and infrastructure of health services in the district of Lingga archipelago area pretty much inadequate, eg medical devices, drugs, facilities, transportation, and communication tools so that access to reach or reach people is still inadequate. Assessing the adequacy of health workers is not an easy thing. Differences in rural and urban areas in terms of sociological, geographic, demographic, infrastructure gives Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology trouble to create a standard of how the need for health workers in the hospital. Based on the above it can be concluded that the information resources, funds, human and infrastructure related to one another. Although the policy instruments already owned by the informant, still required the deployment and administration of the instrument more so that implementers can find the National Health Insurance program as a whole. Funding for health insurance programs using INA CBGs and hospitals no difficulty because the existing hospital management training. Human resources already owned General Hospital Dr. FL. Tobing is sufficient and abilities they have been good. Facilities and infrastructure are still very limited, coupled with a tool is still inadequate. Disposition Readiness Other factors that are considered influential on policy implementation is the attitudes and perceptions of policy implementation to the task and its responsibility. If the executor behave like honesty, commitment to the democratic nature of a particular policy then it is likely they give support to the policy (Winarno, 2012). Integration of the characteristics of the structures. Patterns of behavior, interests, education, capabilities, and potential of a person. Disposition is one important factor in the implementation of effective policies. If the policy implementers have a tendency or a positive attitude in the implementation of the policy implementation is likely to be run in accordance with the original purpose. And if the policy implementers to be negative then the implementation of the policy will not run effectively or even the implementation of the policy will fail. Based on the research results get that from the disposition in the running policy were quite prepared JKN obtained from interviews to patients at the General Hospital Dr. FL. Tobing Sibolga well treated in inpatient and outpatient in the room stated that the attitude of specialist doctors, general practitioners, nurses, midwives and administrators in providing good health services, does not discriminate with other patients. The same thing was also stated by the head of medical services and treatments as well as chairman of the medical committee that they look objectively attitude of health workers in providing better health services. Referring to the above regarding the attitude of the implementers in the General Hospital Dr. FL. Tobing Sibolga, research findings show a positive attitude and support towards the implementation of JKN, the General Hospital Dr. FL. Tobing Sibolga Sibolga with BPJS branches have the same commitment to the program JKN. Commitments related parties is strongly needed in strengthening the implementation of this JKN. Hospital as health services are wellprepared mengintegasikan themselves with this JKN program. BPJS constitutively already very ready to apply JKN, though always in the process of refinement. Commitment is a predisposing factor in self impelementator a policy, then it is proper implementation of this JKN supported by the commitment of all parties concerned. Even if there are problems that commitment should be able to solve these problems by improving communication and coordination. When, in principle, all parties want to fix this JKN the operational constraints should also be addressed. In applying JKN program director of the hospital should be able to have a positive attitude and be able to compile and menetapkankan staff appropriately and selectively. A positive attitude shown by the ability to carry out their duties with full responsibility. A positive attitude held by the director of the hospital will affect the staff to be positive as well to the program, so that the staff are motivated and doing their best to carry out his duties. Proper staffing would also ensure the implementation of good policies. Someone will perform optimally when placed on the specialty. Bureaucratic Structure Readiness Although the resources to implement a policy of sufficient and implementers of what and how to do it, and they have a strong desire to do so, the implementation could be ineffective because ketidakefisiensinya bureaucratic structure. The policies are so complex demands the cooperation of many people, when the bureaucratic structure is not conducive to the policy, then this will lead to resource becomes ineffective and impede the course of policy. Bureaucracy as implementing a policy must be 235 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology able to support policies that have been decided by way of a well coordinated. In this research , the standard bureaucratic structure that is intended is Standard Operating Procedure (SOP). Based on the results of the research showed that the standard operational at the General Hospital Dr. FL. Tobing Siboga in the implementation of this JKN ready. It can be seen from the secondary data that the author can General Hospital Dr. FL. Tobias has been carrying out accreditation and obtain the value of "B". An operational standard-setting concrete efforts in maintaining the quality of health services. Various countries are implementing national health insurance implement operational standards for the implementation of health care. For example in Ghana to implement that facility health care providers should provide standardized equipment and services. Later in the Philippines which sets standards that health care must have been operating for 3 years and is accredited and must conform to the standards Phil Healths especially in the relationship between human resources, equipment, and physical structure (Hsiao, 2007). CONCLUSION Based on the results of this research concluded that: 1. Readiness Communications Communication about JKN already quite ready and well established where hospitals in the dissemination of cooperation with BPJS to socialize in hospital visits from their banners installed in some parts of the hospital. 2. Readiness Resources a. Health manpower resources in running JKN program can’t meet the health care has not been effective due to the quantity and quality of resources available health workers have not been adequate. b. The readiness of health facilities in the program so far have not seen JKN readiness due to the infrastructure that still need to be completed 3. Readiness Disposition Commitment as one form of disposition in carrying out policies JKN ready. Overall 236 the parties have agreed and are committed to implement JKN as well as possible. 4. Readiness Bureaucratic Structure Coordination of JKN program in General Hospital Dr. FL. Tobing BPJS Sibolga Sibolga to run properly. Hospitals as health care providers are ready to provide services and BPJS as the giver of the budget prepared by claiming system. ADVICE 5. Communication Expected to hospitals and BPJS order to improve socialization JKN with clear information dissemination and provide technical guidance JKN in order to provide information and socialization completely and correctly to all employees and staff in the hospital. 6. Resources a. Expected to hospitals in order to meet the human resource needs by proposing health workers and improve the quality of health personnel in accordance with the needs of patients through training. b. Recommended to the hospital to pay more attention and increase more facilities facilities and infrastructures in accordance with the strategic plan of the hospital. 7. Disposition Expected to hospitals to be able to maintain a good commitment to conduct regular meetings, and carry out monitoring and evaluation in order to improve JKN services at the General Hospital Dr. FL. Tobing Sibolga 8. Structure of Bureaucracy Expected hospital with BPJS can maintain and improve the coordination for the smooth implementation of JKN in Sibolga City. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Poster 237 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 238 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology ANXIETY LEVEL OF FAMILIES IN FACING SCHIZOPHRENIA CLIENT BEHAVIOR AT THE POLYCLINIC OF NORTH SUMATRA PROVINCE MENTAL HOSPITAL 2014 Johani Dewita Nasution, Endang Susilawati Nursing Department of Poltekkes Kemenkes Medan Abstract Background: Schizophrenia is a disease that affects the brain and causes thoughts, perceptions, emotions, movement, and behavior strange and disturbed. In doing care clients with mental disorders, it is necessary to support families because families occupying vital factor in the treatment of mental patients at home. Objective: To determine the level of families anxiety in the face of the behavior of schizophrenia client. Methodology: The study design was descriptive with cross sectional approach and using the questionnaire. The number of samples of this study were 42 families that were taken by using accidental sampling technique in psychiatric Hospital of North Sumatra Province in 2014. Results: The results of this study indicate that the behavior is not regularly experience severe anxiety as much as 61.5%, the catatonic behavior were found to have severe anxiety as much as 62.5%, and paranoid behavior experience severe anxiety as much as 68.5%. Conclusions and Recommendations: The results of this study showed respondents expressed experiencing severe levels of anxiety in the face of schizophrenia client behavior. Therefore, it needs to be improved, especially on family counseling of schizophrenia client in dealing with schizophrenic client's behavior so that the level of anxiety experienced can be overcome or wane. Keywords: Anxiety, Schizophrenia Behavior. BACKGROUND World Health Organization (WHO) defines health as a state of complete physical, mental and social and not merely the absence of disease or infirmity. Mental health is a healthy state of emotional, psychological and social are visible from satisfying interpersonal relationships, behavior and effective coping, positive self-concept and emotional stability (Videbeck, 2008). There are two types of mental disorders which can be found in the community, namely mild mental disorder and severe mental disorder. Mild mental disorder is a mental disorder emotional examples. Severe mental disorder one of which is schizophrenia. Most of the patients were treated at a mental hospital is patients with severe mental disorder of schizophrenia. Schizophrenia itself is a form of psychosis that is often encountered everywhere. Marasmis (2005) stated that Schizophrenia can also be interpreted as a persistent and serious brain disease resulting in psychotic behavior, concrete thinking, and difficulty in information processing, interpersonal relationships, and solve problems (Stuart, 2007). According to Videbeck (2008), defines schizophrenia as a disease that affects the brain and causes thoughts, perceptions, emotions, movement, and behavior strange and disturbed. Schizophrenia is a disorder that occurs in brain function (Nancy Anderkanson, 2008) that the latest evidence about the attacks of schizophrenia is a matter that involves a lot of factors that include changes in the physical structure of the brain, changes in the chemical structure of the brain, and genetic factors (Iyus Joseph , 2011). Based on data from the APA (The American Psychiatric Association), in the United States there are 300 thousand patients with schizophrenia who experience an acute episode each year. The mortality rate of patients with schizophrenia 8 times higher than the death rate in the general population.Patients with schizophrenia who tried to commit suicide as much as 20-50%, and 10% of them successfully (Iyus Joseph, 2011). 239 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology The prevalence of schizophrenia patients in Indonesia is 11.6% or 17.4 million people experiencing mental illness and usually occurs around age 12 to 18 years had suffered from schizophrenia. When Indonesia's population of about 241 million people, it is estimated at about 2.5 million people who suffer from schizophrenia. And schizophrenia in the general population are 11.6 when projected by the Indonesian population is approximately 241 million people in 2012, there are 500 thousand to 2.5 million people who have schizophrenia. Large numbers is a challenge primarily for health ministries in addressing this issue (Dien Emawati, 2009). Approximately 0.46% of the total population of Indonesia or the equivalent of 1.09315 million people at risk of severe mental disorder. Results of Health Research (Riskesdas) In 2007, there were more than one million people in Indonesia are at risk of developing severe mental disorders including schizophrenia. Of about one million inhabitants, only 38 260 people are served with adequate care at the Mental Hospital (RSJ), General Hospital (RSU), as well as community health centers (Puskesmas). There are still many Indonesian people who do not fully understand about this disease, so patients are not treated properly as treated in the health care center. In addition, based on data from the Ministry of Health in 2013, there were still about seven provinces in Indonesia which has no Mental Hospital (RSJ) and four provinces still do not have mental health professionals. Given the complexity of mental health problems including schizophrenia in Indonesia. Range anxiety response can be described starting from the individual responses to anticipate anxiety, mild, moderate, severe, panic, with a range of adaptive responses in anticipation anxiety, mild and moderate anxiety. Maladaptive response range contained in the heavy anxiety and panic. Anxiety level has different characteristics, the light level anxiety increased alertness, sharpening the senses, and the expansion of the visual field. At moderate levels of anxiety, cognitive already focused on stressors, the narrowing of the field of perception but still able to carry out something and take the desperation with 240 the help of others. At severe levels of anxiety, attention totally focused on things even more specific to the field of perception is very narrow and is unable to think of anything else. Similarly, the level of anxiety is very severe, the individual loses control, rationality and narrowing of individual perception, are not able to do any activity, even though a lot of referrals to others. According to Friedman (1998) defines the family as a social system. The family is a small group of individuals who have a close relationship with each other, interdependent organized in one single unit in order to achieve certain goals. According padila (2011) The family is composed of individuals who are united by ties of blood marriage and adoption. Family members often live together in one household or if they separate, still considers as their home. Family members interact and communicate with each other in the family's social role as husband and wife, father and mother, son and daughter. The family uses the same culture taken from society with its own characteristics. In doing care of clients with mental disorders, it is necessary to support families because families occupying vital factor in the treatment of mental patients at home. This is because the family is the closest support system for 24 hours together with the patient. Families will determine whether patients will relapse or stay healthy. Family consistent support will make patients able to maintain an optimal treatment program. In the presence of family members who experience mental illness, it will affect the system requirements on the family. This is consistent with the results of a survey conducted by Biegel et.al, 1995, quoted from Stuart and Laraia, 2001, that of families who have family members with schizophrenia are at increased stress and anxiety the family, it is marked by a different response to every member of the family in readiness receiving family members who experience mental illness (Windyasih, 2008). Based on a preliminary study of the families who have family members affected by schizophrenia in the Regional Mental Hospital Clinic of North Sumatra Province 2014 said Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology that they were very anxious in the face of the client because the client is exposed schizophrenia client can not live independently and do not want to work so troublesome families and add the economy burden in the family to pay for treatment of the client. Based on the survey of researchers on 27 January 2014 at the North Sumatra Regional Mental Hospital (RSJ) that the number of patients with mental disorders outpatient in 2013 from January to December amounted to 15.205 people. Data in the last month which in December amounted to 1,130 people. This data was obtained from the Medical Record of Mental Hospital of province of North Sumatra. Based on the above background, researchers are interested in studying how the anxiety level of the family in the face of schizophrenia client behavior in the Mental Hospital of North Sumatra province 2014. RESEARCH METHODS This study used a descriptive method to design "cross-sectional" is a method that can dig a few variables in the same time to measure how the anxiety level of the family in the face of the client's behavior at the Polyclinic schizophrenia of Mental Hospital of North Sumatra Province 2014. The study was conducted at the Polyclinic schizophrenia of Mental Hospital of North Sumatra Province 2014 in January-May 2014. The population in this study are families who have family members with schizophrenia in outpatient at Polyclinic schizophrenia of Mental Hospital of North Sumatra Province 2014 as many as 1,130 people in December. Sampling was done by accidental sampling is to take the case or the respondent who happened to be there. The sample size in this study was 42 respondents. The type of data in this study is composed of primary and secondary data. Primary data is data obtained directly from the respondents by means or through questionnaires. Secondary data is data obtained from the Regional Mental Hospital in North Sumatra Province on the number of clients with schizophrenia in the Polyclinic. Data analysis is the measurement of each respondent's answer, then displayed in the form of a frequency distribution table that sought the percentage for each of the respondents. Data analysis is to describe the univariate analysis of the percentage of entire research variables and presented in the form of a frequency distribution table. RESULTS AND DISCUSSION Research Result The results showed the level of anxiety in the face of the behavior of the client families schizophrenia in the Mental Hospital Clinic of North Sumatra province of Medan 2014 based on client behavior schizophrenia are disorganized behavior, catatonic and paranoid. From the results of this research is that clients schizophrenia disorganized behavior as much as 3 respondents (7.1%) regularly and as many as 39 respondents (92.9%) irregular. Catatonic behavior as much as 10 respondents (23.8%) did not catatonic and as many as 32 respondents (76.2%) catatonic. Paranoid behavior as much as 7 respondents (16.7%) are not paranoid and as many as 35 respondents (83.3%) paranoid. Mild anxiety levels by 5 respondents (11.9%), while as many as 10 respondents (23.8%), weigh as much as 26 respondents (61.9%) and panic as much as one respondent (2.4%). Distribution of research results based on the level of anxiety of respondents schizophrenia disorganized behavior in Mental Hospital Clinic of North Sumatra province of Medan 2014 indicate that of the three respondents (100%) orderly behavior as one of the respondents (33.3%) were family concerns, two respondents (66 , 6%), heavy anxiety and no family with mild anxiety or panic. Of the 39 respondents (100%) disorganized behavior as much as five respondents (12.8%) families mild anxiety, 9 respondents (23%) were family concerns, 24 respondents (61.5%) heavy anxiety and only 1 respondent (2 , 56%) categories panic anxiety. Distribution of research results based on the level of catatonic anxiety of schizophrenia respondents behavior indicates that out of 10 respondents (100%) catatonic behavior as one of the respondents (10%) mild anxiety, 3 respondents (30%) were family concerns, 6 respondents (60) heavy anxiety and there was no panic, while families of the 32 respondents (100%) catatonic behavior as much as 4 respondents (12.5%) mild anxiety, 7 respondents (21.8%) were family concerns, 20 respondents (62.5%) heavy anxiety and only 1 respondent (3.12%) categories panic anxiety. 241 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Distribution of research results based on the level of anxiety of schizophrenia respondents with paranoid behavior indicates that of the seven respondents (100%) are not paranoid behavior as much as 2 respondents (28.5%) mild anxiety, 3 respondents (42.8%) were family concerns, 2 respondents ( 28.57%) heavy anxiety family and no family to panic, while 35 respondents (100%) paranoid behavior as much as 3 respondents (8.5%) mild anxiety families, seven respondents (20%) were family concerns, 24 respondents ( 68.5%) heavy anxiety and only one respondent (2.8%) categories family of panic anxiety. Discussion Based on the research that has been done that every respondent who has a family member who suffered from schizophrenia have different anxieties in the face of schizophrenia clients ranging from mild anxiety, moderate, severe, and panic. From the results obtained from this study is the most severe anxiety. For these conditions, the researchers sought a way to provide education on the disease of schizophrenia, positive attitudes of health workers may also increase the good service so that families get information about schizophrenia in order to face the schizophrenic client behavior. The majority of respondents to the client's behavior is irregular in the regular behavior of a minority of schizophrenia and each respondent experienced severe anxiety at regular or irregular behavior and anxiety panic disorganized behavior. Disorganized behavior associated with traits like behavior chaotic, incoherent speech, hallucinations and often clear, flat affect, or inappropriate, disorganized and delusions that often involve sexual themes or religious. Social impairment is often found in people with schizophrenia irregular. They also showed ignorance and giddy mood, strangulation and speak a no (Jeffrey S. Nevid, et al 2005). According to the authors based on research that has been done that the behavior is not regularly found in the majority of clients who are experiencing schizophrenia and in need of support and control of the family because of the irregular behavior of clients often neglect their appearance and personal hygiene and should not be separated from the drug, and control of health personnel that the illness recover quickly and do not recur. 242 The behavior of respondents with catatonic schizophrenia at a client more than catatonic behavior. Each respondent was experiencing anxiety weight on whether or not catatonic behavior and anxiety panic on catatonic behavior. The main symptoms that differentiate patients with schizophrenic catatonic schizophrenia is a disorder other motor behavior very clearly displayed by sufferers (APA, 2000). According to the authors catatonic behavior is a behavior that is very dangerous for the family and people around client schizophrenia because it involves both extremes of motion that a time could turn into a rowdy phase agitated or injure another person. The behavior of respondents with paranoid schizophrenia clients with the highest number compared paranoid behavior and each respondent is experiencing severe anxiety and paranoid behavior not be being paranoid anxiety and panic anxiety paranoid behavior. Paranoid schizophrenics have cognitive functions and emotions that are relatively stable, so they tend to be more "normal" when compared to patients with other subtypes of schizophrenia (Straus and Aloy, Accolla, and Bootzin 1996). Thera are also evidence stated that paranoid schizophrenics tend to have less severe disruption in the functioning of the work and functions for independent living (APA, 2000). According to the authors paranoid behavior in dire need of attention and family support so that clients are not dissolved in the hallucinations of schizophrenia clients. And should not be separated from family control, drug and medical personnel so that the client illness recover quickly and do not recur. CONCLUSIONS AND SUGGESTIONS Conclusion From the results of research on the anxiety level of the family in the face of the client's behavior at the Polyclinic schizophrenia Mental Hospital of North Sumatra province with the number of respondents 42 people can be concluded that the majority of families in dealing with clients on the behavior of disorganized schizophrenia experience severe anxiety and panic anxiety minorities. More families experiencing severe anxiety and are in dealing with clients on the behavior of catatonic schizophrenia. More families Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology experiencing severe anxiety and a little panic in the face of a client on the behavior of paranoid schizophrenia. Suggestion Suggested to health personnel so that the level of anxiety experienced by the family in dealing with family members who have schizophrenia can be reduced , should increase counseling on how to cope with anxiety in the face of behavior clients of schizophrenia. Expected to clients family in order to keep control schizophrenia and routinely bring clients for treatment and further enhance knowledge in dealing with clients schizophrenia. For further research in order to carry out further research on other variables that have not been examined in this study . REFERENCES Abdi Susanto.2013. 1 Juta Penduduk Indonesia Berisiko Gangguan Jiwa Berat-Kedaulatan Rakyat Online.(http://health.liputan6.com/read/6 78786/1-juta-lebih-penduduk-Indonesiaberisiko-alami-gangguan-jiwaDiakses 29 Januari) Aloy, Lauren B, dkk. 1996. Abnormal Psychology: Current Perspectives. International Edition: McGraw-Hill inc. Arikunto, S. 2010. Prosedur Penelitian Suatu Pendekatan Praktik, Edisi Revisi VI, Rineka Cipta: Jakarta. Cancro, Robert & Lehman, Heinz E. 2000. Schizophrenia: clinical features dalam Kaplan &sadock’s comprehensive textbook of Pshychiatry7thedition. Benjamin J, Sadock’s, dkk. Philadelphia: lippncott Williams &wilknis. Ermawati. 2011. Asuhan Keperawatan Klien Dengan Gangguan Jiwa. Jakarta: CV. Trans info Media. Friedman, 1998.Keperawatan Keluarga, Edisi 3. EGC: Jakarta. Gawil W. Stuart. 2007. Buku Saku Keperawatan Jiwa, Jakarta: EGC Gunawan Pamungkas.2011.Konsep Kecemasan. (http://teorikecemasan.blogspot.com/Diakses 2 februari 2014). Hawari, Dadang. 2009. Pendekatan Holistik Pada Gangguan Jiwa Skizofrenia.Jakarta: FKUI. Hawari, Dadang. 2013. Manajemen Stres, Cemas dan Depresi, Edisi 2, Cetakan 4. Jakarta: FKUI. Jeffrey S. Nevid, dkk.2003. Psikologi Abnormal. Jilid 2.Jakarta: EGC. Nasir, Abdul & Abdul Muhid. 2011. DasarDasar Keperawatan Jiwa. Jakarta:Salemba Medika. Notoadmodjo, S. 2010. Metode Penelitian Kesehatan. Jakarta: RinekaCipta. Padila. 2012. Buku Ajar Keperawatan Keluarga. Yogyakarta :NuhaMedika. Politeknik Kesehatan Kemenkes Medan. 2012. Penyusunan KaryaTulis Ilmiah Sayyid Siliwangi.2011. KTI Keperawatan Jiwa Skizofrenia Residual (http://sayyidsiliwangi.blogspot.com/diak ses 2 Februari 2014) Suliswati. 2005. Konsep Dasar Keperawatan Kesehatan Jiwa. Jakarta : EGC. Videbeck, Sheila L.2008.Buku Ajar Keperawatan Jiwa. Jakarta: EGC. Yosep, Iyus. 2011. Keperawatan Jiwa. Jakarta: Rafika Aditama. 243 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology MOTHER KNOWLEDGE DESCRIPTION ABOUT DIARRHEA IN TODDLER Ratni Siregar Midwifery Study Program of Padangsidimpuan Abstract Diarrheal disease is still a public health problem in developing countries such as Indonesia, due to its morbidity and mortality are still high. Therefore we need healthy behavior to prevent diarrhea. Behavior is influenced by knowledge. Purpose of this study to describe mothers' knowledge of diarrhea in toddler. Design of this research is descriptive with a population of 320 people and a large sample was determined with a sample of at least 20% ie 64 people. The results showed that by the age that mother with higher has better knowledge of diarrhea. Higher educated mother has better knowledge of diarrhea. Based on Parity, the more often the mother giving birth and caring for babies, the better knowledge of diarrhea. Keywords: Mother, diarrhea, Toddler BACKGROUND Diarrheal disease is still a public health problem in developing countries such as Indonesia, due to its morbidity and mortality are still high. Morbidity survey conducted by Subdit diarrhea, the Ministry of Health from 2000 s / d in 2010, the tendency incidence rose. In 2000, Diarrhea 301/1000 inhabitants, in 2003 rose to 374/1000 population, 2006 rose to 423/1000 inhabitants and in 2010 to 411/1000 inhabitants. Extraordinary Events (KLB) diarrhea is still often the case, the CFR is still high. In 2008 outbreaks in the 69th District of the number of cases of 8133 people, 239 deaths (CFR 2.94%). In 2009 outbreaks in 24 Districts with the number of cases 5,756 people, with 100 deaths (CFR 1.74%), while in 2010 an outbreak of diarrhea in 33 districts with the number of 4204 patients with 73 deaths (CFR 1.74%.) (Indonesian Health Ministry, 2011) One step in the achievement of the MDG's (Goal to-4) is to reduce child mortality into 2/3 from 1990 to 2015. Based Household Health Survey (SKRT), Mortality Study and the Health Research from year to year, it is known that diarrhea remains a major cause of infant mortality in Indonesia. The main causes of death from diarrhea is improper governance both at home and in health facilities. To decrease mortality due to diarrhea governance need rapid and precise (Indonesian Health Ministry, 2011). 244 Diarrhea is a condition where a person suffers from diarrhea-diarrhea, watery stool, can be mixed with blood and mucus sometimes accompanied by vomiting. So that diarrhea can cause fluid drained out of the body through feces. If the diarrhea patients lose a lot of body fluids then this can lead to death, especially in toddler and children under five years of age (Hasan, 2005). Fairly high incidence of diarrhea in the city Padangsidimpuan, the problem of diarrhea in the city in 2012 Padangsidimpuan attack all age groups for 2016 cases (13.55%). The age group that is often attacked by diarrheal diseases are children aged 5 years dibwah many as 675 cases and school-age children (elementary and secondary) as many as 409 cases (Padangsidimpuan City Health Office, 2012). Based on a preliminary survey of researchers in sustainable padangmatinggi village found of 10 mothers who have children who were interviewed about the mothers of diarrhea only four people who know about diarrhea. Questions include understanding, causes, prevention and treatment of diarrhea. The village padangmatinggi sustainable toddlers figure is also quite high. Or cognitive domain knowledge is very important for the formation of a person's actions or behavior. When knowledge better then expected action or behavior will be good too. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Therefore, researchers interested in studying picture mothers' knowledge of diarrhea in children under five in Sub Padangmatinggi 2015. Purpose To describe mothers knowledge of diarrhea in toddler. Benefits Of Research This study can serve as guidelines and experience as well as a means of selfdevelopment is very valuable, to apply science in midwifery services. Results of this study are expected to be input or ideas - new ideas in applying science in the practice of midwifery services, especially on diarrhea in toddler. RESEARCH METHODS This research is a kind of descriptive research that aims to reveal the mother's knowledge on diarrhea On toddlers. The data used are primary data is data obtained directly from the respondents. The population in this study are all mothers who have children aged 0-5 years in sub padangmatinggi sustainable as many as 320 people. The samples of at least 20% is the number of samples in this study, so the sample size is as much as 64 people. Samples obtained by proportioned stratified random sampling. After all the data collected with the total, the researchers conduct data analysis in several stages, starting with the editing, coding, entry, and tabulating. Data analysis can be done by looking at the percentage of the data collected and presented in the table - the table of frequency distribution RESULTS AND DISCUSSION Table 1. Frequency Distribution of Respondents by Knowledge Knowledge F Percentage (%) Good 16 25 Enough 26 40,62 Less 22 34,38 Total 64 100 Based on the table 1 above it can be seen that the majority of respondents knowledgeable enough as many as 26 people (40.62%) and a good knowledge of minority as many as 16 people (34.48%). Table 2. Frequency Distribution of Respondents by Age. Age F Percentage (Tahun) (%) ‹20 tahun 16 25 20 – 35 Tahun 20 31,25 ›35 tahun 28 43,75 Jumlah 64 100 Based on the above table it can be seen that the majority of respondents over the age of 35 years as many as 28 people (43.75%) and minority aged <20 years as many as 16 people (25%). Table 3. Distribution of Knowledge Respondents by Age No Age . Category Good F % Enough F % 6 37,50 9 45 1 ‹20 2 20 – 35 6 30 3 ›35 35,71 11 10 Less F % 10 62,50 5 25 39,29 7 25 Total f 16 20 % 100 100 28 100 Based on the above table it can be seen that mothers with less than 20 years of age the majority of less knowledgeable in the amount of 62.50%. At the age of 20-35 years the majority of knowledgeable enough in the amount of 45%, and in the age over 35 years the majority of knowledgeable enough in the amount of 39.29%. Table 4. Distribution of Respondents by Education Level Education Level Frequency Percentage (%) Basic (SD, SMP) High (SMA) University Total 21 26 17 64 32,81 40,63 26,56 100 Based on the above it can be seen that the majority of high school educated many as 26 people (40.63%) and college educated minorities as many as 17 people (26.56%). 245 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 5. Distribution of Respondents Knowledge About diarrhea by Education No. Pendidikan 1 2 3 Dasar (SD, SMP) SMA Kategori Baik Cukup F F % 6 Perguruan Tinggi 10 23,0 8 58,8 2 Total Kurang % F 38,0 13 9 11 42,3 9 0 7 41,1 8 % f % 61,9 21 100 0 34,6 26 100 1 17 100 8 Based on the above table it can be seen that the majority of college education good mother knowledge that is equal to 58.82%, while the majority of mothers with primary education less knowledge that is equal to 61.90%. Parity Table 6. Distribution of Respondents by Parity Primipara Scundipara Multipara Grandemultipara Total Frequency Percentage (%) 14 16 19 15 64 21,88 25 29,69 23,43 100 Table 7. Distribution of Respondents Knowledge About diarrhea Based on Parity 1. 2. 3. 4. Good Category Enough f % F % F Primip 1 7,14 ara Scund 1 6,25 6 37,50 ipara Multip 5 26,3 1 52,63 ara 2 0 Grand 10 66,6 5 33,33 emulti 7 Total Less 13 % 92,86 F 14 % 100 9 56,25 16 100 4 21,05 19 100 - - 15 100 Based on the above table it can be seen that the more often a woman giving birth and caring for a child, the better knowledge of the mother would be. DISCUSSION Knowledge is the result of sensing out after a commit to a particular object. Sensing occurs 246 According to the author the assumption that the mother's knowledge on diarrhea is influenced by several factors, such as age, education and parity. In the opinion of Arikunto, 2002 that will influence the life of a person would do, in that it can do a lot and work hard which middle age will reach the point of peak of his career and productivity. In this study is not obtained from the research gaps, where the higher the better a person's age knowledge of diarrhea. Based on Table 6 above it can be seen that the majority of respondents berparitas multiparas many as 19 people (29.69%), and a minority of respondents berparitas primiparity many as 14 people (21.88%). No. Parity through human senses are senses of sight, hearing, smell, taste and touch. Most of the human knowledge acquired through education, experience itself, the experience of others, the media and the environment. Or cognitive domain knowledge is very important for the formation of one's actions. Knowledge requires a physical boost in growing confidence and encouragement behavioral attitude every day so that it can be said that knowledge is a stimulus to the actions of a person (Notoadmodjo, 2003). According to the author assuming the higher the person's age the better the person's way of thinking. Because a lot of experience in caring for children during the life of the respondents obtained. So that mothers will understand more about the causes and prevention of the diarrhea events. On the basic of the experience that the mother's mother is expected to more quickly find the incidence of diarrhea, how the prevention of diarrhea that does not occur in children under five. Based on the level of education can be seen that the higher the education level, the better a person's knowledge. According to Hurlock (2002), education is also one of the factors that influence a person's perception because it can make a person more receptive to new ideas and new technologies. The higher one's education is certainly more extensive information received both formally and informally, followed by training or seminars have been followed. A person with higher education tend to have more curiosity over again so that the information obtained, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology especially health information more widely accepted than lower educated. According Prawirohardjo, mothers who have never given birth would have less knowledge about diarrhea than those who had never been pregnant gave birth because the experience will add to the knowledge and information gained from either the mother or the health workers of the mass media and the print media. According to the assumptions of researchers, there is no gap between the theory and the results achieved, where the results showed that the higher the mother's parity, the more the mother's experience in knowing the causes and treatment of diarrhea for children under five. So the better knowledge of mothers about diarrhea for children under five. CONCLUSIONS AND SUGGESTIONS Conclusion 1. The majority of respondents knowledgeable enough as many as 26 people (40.62%) and a good knowledge of minority as many as 16 people (34.48%). 2. Based on the obtained results that the mother's age to age less than 20 years the majority of less knowledgeable in the amount of 62.50%. At the age of 20-35 years the majority of knowledgeable enough in the amount of 45%, and in the age over 35 years the majority of knowledgeable enough in the amount of 39.29%. 3. The level of knowledge based education result that the majority of college education good mother knowledge that is equal to 58.82%, while the majority of mothers with primary education less knowledge that is equal to 61.90%. 4. The more often a woman gave birth to the better knowledge of the mother would be. Suggestion Be able to increase or maintain their knowledge and add knowledge about diarrhea to follow health counseling about diarrhea in the local health center or midwife clinic. REFERENCES Arikunto S, 2002, Prosedur Penelitian, Edisi Revisi V, Penerbit: Rineka Cipta, Jakarta. Hasan.R. Dkk, 2005, Ilmu kesehatan Anak, Jakarta: Bagian Ilmu kesehatan Anak Fakultas Kedokteran UI. Kemenkes RI, 2011. Situasi Diare di Indonesia. Buletin dan Jendela Data Informasi Kesehatan. Mochtar R, 2002, Sinopsis Obstetri Fisiologi dan Patologi, EGC, Jakarta. Nelson WE, 2005, Ilmu Kesehatan Anak, Edisi 15, Vol. 1. EGC:Jakarta Ngastiyah, 2005, Perawatan Anak Sakit, Jakarta: Buku Kedokteran EGC Notoadmodjo S, 2003, Ilmu Kesehatan Masyarakat, Cetakan Kedua, Rineka Cipta, Jakarta. Prawirohardjo Sarwono, 2002, Buku Acuan Nasional Pelayanan Kesehatan Maternal dan Neonatal. Ramali.A, 2006, Kamus Kedokteran, Jakarta: Djambatan 247 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE DESCRIPTION OF KNOWLEDGE PREGNANT MOTHER TO DEGREE GINGIVITIS IN PASAR MIRING VILLAGE OF DISTRICT DELI SERDANG 2013 Asnita Simaremare, Sondang Siregar, Sri Junita Nainggolan, Reti Pratiwi Department of Dental Nursing, Health Polytechnic Medan ABSTRACT Introduction : A pregnant mother in pregnancy period required knowledge for personal and health care for the fetus. Especially knowledge in maintaining oral health, in this case the health of the gums. Because approximately 50-75% of pregnant mother has an experience gingivitis. This is not only due to the primary factors in the form of plaque and calculus but also because during pregnancy the hormonal changes. The purpose of this study is to describe the level of knowledge of pregnant mother on the degree of gingivitis in Pasar Miring Village District Deli Serdang. Methods : This is a descriptive study with survey method, conducted in 3 months. Data collected in the form of primary and secondary data. This study population were 32 the first trimester pregnant mothers and samples taken from the entire population that was 32 maternal in 5 Posyandu. To measure the level of knowledge about gingivitis pregnant mother by using a questionnaire and doing examination to known the degree of gingivitis. Result : From the data obtained the number of pregnant mother with good criteria knowledge level is 9 people (28.1%) and the number of pregnant mother who have gingivitis by 1 person (grade 1) and 8 (grade 2), 22 pregnant mothers (68.8%) had a moderate criteria knowledge level in which the number of pregnant mothers with gingivitis as many as 6 person (degree 0), 7 person (1st degree), 7 person (2nd degree) 2 person (3rd degree) and only 1 person (3.1%) with the bad level of knowledge with gingivitis where there is 1 person (grade 2). It can be concluded from the results of this study, the level of knowledge of pregnant mothers in the first trimester in Pasar Miring Village, including criteria being the degree of gingivitis in the second most common. This results indicate that the degree of gingivitis in pregnant mother is not only influenced by the level of knowledge but also due to hormonal changes during pregnancy, especially in the first trimester. It is expected for pregnant mother to always keep the gums healthy by brushing well and properly, to consume fruits and vegetables that contain fiber and water, cleaning tartar, and check the state of your teeth and mouth to the dental clinic in order to get action in accordance with the conditions of the pregnant mother. Keywords: Knowledge Level, Degree Gingivitis IINTRODUCTION In the Republic Act no. 23/92 on health, explaining that to achieve optimal health status for the community. Organized efforts to approach health maintenance of health (promotion), disease prevention (preventive), the healing of disease (curative), and restoration of health (rehabilitative), which conducted a comprehensive, integrated, and sustainable (Mochtar,2008). Oral and dental problems in Indonesia is a public health problem. This is due to public awareness of oral health maintenance is low. In the pregnancy period usually devoted attention to the pregnancy and the baby that will be born. While attention to other body parts almost forgotten, because it is not associated with pregnancy. This opinion is 248 wrong, considering all the members of the body are basically mutually supporting each other, thus requiring particular attention. The higher level of knowledge that one's life will be more quality, the higher the growth and well-being of the person. Including pregnant mother during pregnancy necessary knowledge for personal and health care for the fetus. Not only maintain pregnancy health concerns also maintain oral health, especially the health of the gums. Because approximately 50-75% of pregnant mother has an experience of gingivitis. This is caused by the primary factors that plaque and calculus as well as a secondary factor that hormonal changes. Therefore, it needs a good knowledge to reduce the negative impact of Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology gingivitis during pregnancy. (www.pregnancy.org,2005). According to Maulana (2006), maternal gum disease or gingivitis is enlarged gums pregnancy in pregnant mother due to hormonal activity of the hormone estrogen and progesterone. Hormone progesterone greater influence on the process of inflammation. Hormonal and vascular changes during pregnancy may aggravate the inflammatory response to bacteria, especially if the mother has a medical and dental oral hygiene is poor. THE AIMS OF STUDY To describe the level of knowledge about gingivitis pregnant mother against the degree of gingivitis in Pasar Miring Village District of Deli Serdang, 2013. Specifically of this research to determine the level of knowledge of pregnant mother about (the causes of gingivitis during pregnancy, the prevent gingivitis that occurs during pregnancy, the average knowledge level of pregnant woman, and determine the degree of gingivitis that occurs in pregnant mother, and the last to determine the knowledge level overview of pregnant mother about the degree of gingivitis. METHODS This research is a descriptive study by using a survey method to determine the level of knowledge of mothers understood description of gingivitis on the degree of gingivitis in Pasar Miring Village District of Deli Serdang 2013. The location of this research conducted in 5 Posyandu in Pasar Miring Village District Deli Serdang 2013. Time research March to Mei 2013. The population in this study were all pregnant mothers in the first trimester in Pasar Miring Village District of Deli Serdang, amounting to 32 people. Sample of research partly or representative of the population studied. In this case leads to the idea Arikunto (2002), when the subject is less than 100, it is better taken all of the population. In this study the sampling carried out on all pregnant women in the first trimester in Pasar Miring Village District of Deli Serdang which is the respondent amounting to 32 people, total population. The data collected in this study are secondary and primary data. The collection of secondary data, namely data obtained from the mother's midwife clinic of the pregnant mother's womb. Then the primary data collection is done by giving questionnaires and examinations degrees gingivitis pregnant mothers. The data has been collected, processed manually with the following steps: 1) The process of editing: Performed by checking questionnaires that had been filled with the purpose of data results. 2) The process of coding: By changing the data already collected into the figures to facilitate data processing. 3) Tabulating: The data that have been collected are analyzed and presented in the form of a frequency distribution table. RESULTS AND DISCUSSION RESULT From the research that has been done, then the data obtained knowledge pregnant mothers about the degree of gingivitis by giving questionnaires and examinations gingivitis in 32 pregnant mothers in the first trimester in Pasar Miring Village District of Deli Serdang 2013 are as follows: Table 1. Frequency Distribution of knowledge level for pregnant mother about the causes of gingivitis in Pasar Miring Village District of Deli Serdang. Knowledge Number of Percentage criteria Maternity Good 8 25 Median 23 71,9 Poor 1 3,1 TOTAL 32 100 Table 1 above shown that out of 32 pregnant mothers are levels of knowledge about the causes of gingivitis by criteria were as many as 23 pregnant women (71.9), 8 pregnant mothers (25%) have a good level of knowledge of mothers and 1 pregnant mother (3.1%) had a poor level of knowledge. 249 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Table 2. Frequency Distribution Knowledge Level for pregnant mother about the Prevention of Gingivitis in Pasar Miring Village Merbau District of Deli Serdang Knowledge of Number of Percentage Criteria Maternity Good 9 28 Median 22 68,9 Poor 1 3,1 TOTAL 32 100 From table 2 above shown that out of 32 pregnant mothers, there is a degree of knowledge of pregnant mother on the prevention of Gingivitis with median knowledge level were as many as 22 pregnant mothers (68.9%), 9 pregnant mothers (28%) have a good knowledge level and one pregnant mother (3.1%) had a poor level of knowledge. Table 3. Average Level Knowledge Pregnant Mother in Pasar Miring Village District of Deli Serdang Knowledge Criteria Level Good % Medium % Poor Maternity The level of knowledge of pregnant 8 25 23 71,9 1 mothers about the causes of gingivitis The level of knowledge of pregnant mothers 9 28 22 68,75 1 about the prevention of gingivitis Average 9 28,1 22 68,8 1 % 3,1 3,1 3,1 Based on the table 3 shown that the average pregnant mother who has a good knowledge level is 9 person (28.1%), 22 pregnant mothers (68.8%) with a moderate level of knowledge and one pregnant mother (7%) with the level of poor knowledge. Table 4. Frequency Distribution Degree of Gingivitis for Pregnant Mother in Pasar Miring Village District of Deli Serdang Number of Degree of pregnant % Gingivitis mother Degree 0: Nothing gingivitis 250 6 18,7 Degree 1: slight inflammation, no bleeding when probing Grade 2: moderate inflammation, slight bleeding on probing Grade 3: severe inflammation, spontaneous bleeding on probing TOTAL 8 25 16 50 2 100 32 100 4. From the table above it can be seen that there are 32 pregnant mothers who have been examined found 6 pregnant mother (18.7%) had gingivitis degrees 0, 8 pregnant mother (25%) had gingivitis degree 1, 16 pregnant mother (50%) gingivitis degree 2, and 2 pregnant mothers (6.3%) experienced grade 3 gingivitis. Table 5. Overview Knowledge Level Against Pregnant Mother About Gingivitis Gingivitis Degrees in Pasar Miring Village District of Deli Serdang. Degree of Knowledge Gingivitis Amount % Level 0 1 2 3 Good 9 28,1 - 1 8 Medium 22 68,8 6 7 7 2 Poor 1 3,1 - - 1 TOTAL 32 32 6 8 16 2 From the data obtained in this study, it was found the number of pregnant mother with good knowledge of the criteria level is 9 person (28.1%) where the number of pregnant mother who have gingivitis by 1 person (grade 1) and 8 (grade 2), 22 pregnant mothers (68.8%) had a moderate level of knowledge in which the number of pregnant mothers with gingivitis as many as 6 people (degree 0), 7 person (grade 1), 7 (2nd degree), and 2 (grade 3), and 1 pregnant mother (3.1%) with the level of knowledge with gingivitis bad only one person (grade 2) Discussion Based on the data that has been obtained from 32 pregnant mother in the first trimester in Pasar Miring Village Merbau District of Deli Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Serdang in 2013 found that the level of knowledge about the causes of gingivitis for pregnant mothers with good criteria as much as 8 pregnant mothers (25%), 23 pregnant mothers (71, 9%) with moderate criteria and 1 pregnant mother (3.1%) had a poor level of knowledge. While the results of a questionnaire on the prevention of gingivitis found 9 pregnant mothers (28%) have a good level of knowledge, with the criteria being as much as 22 pregnant mothers (68.9%), and one pregnant women (3.1%) had a poor level of knowledge. The average level of knowledge of pregnant mother who included both criteria are 9 person (28.1%), 22 pregnant mothers (68.8%) with a moderate level of knowledge and one pregnant women (3.1%) with a poor level of knowledge. This indicates that the level of knowledge of pregnant mothers about gingivitis in Pasar Miring Village, including criteria for being. According the theory that knowledge is influenced by education, media and exposure information, (Notoatmodjo, 2003). Pregnant mothers in Pasar Miring Village have an average education level high school / equivalent and never get information about gingivitis from television or newspaper media. From the results of gingivitis of 32 pregnant mothers there are 6 pregnant women (18.7%) had gingivitis degrees 0, 8 pregnant mothers (25%) had gingivitis degree 1, 16 pregnant mothers (50%) had gingivitis degree 2, and 2 pregnant mothers (6.3%) had gingivitis degree 3. Most of the pregnant mothers in the first trimester in Pasar Miring Village gingivitis degree 2 that occurs inflammation being in the form of gingival redness, edema and slight bleeding occurs when probing. It is due to hormones pregnancy, estrogen and progesterone, the risk of inflammation or gingivitis be larger. Gingivitis gravidarum medical terms, pregnancy gravidarum, or hyperplasia gravidarum. (www.pregnancy.org). From the data obtained in this study, it was found the number of pregnant mothers with good knowledge of the criteria level is 9 people (28.1%) where the number of pregnant mother who have gingivitis by 1 person (grade 1) and 8 (grade 2), 22 pregnant mothers (68.8%) had a moderate level of knowledge in which the number of pregnant women with gingivitis as many as 6 people (degree 0), 7 person (grade 1), 7 (2nd degree), and 2 (grade 3), and 1 pregnant mother (3.1%) with the level of knowledge with gingivitis bad where there is one person (grade 2). It can be concluded from the results of this study, the level of knowledge of pregnant mother in the first trimester in Pasar Miring Village, including criteria being the degree of gingivitis 2 is the most common form of gingival inflammation was on a reddish color, there is a slight edema and bleeding on probing. In other words gingivitis is not only influenced by aspects of knowledge, but there are many other factors that also affect the occurrence of gingivitis. So although the level of knowledge of pregnant mothers including criteria were however most pregnant mother experience gingivitis first trimester of 2nd degree. Cause of gingivitis during pregnancy is a primary factor in the form of local irritation from plaque and tartar because during pregnancy there is a change in the maintenance of oral hygiene that may be caused by feelings of nausea, vomiting, feeling of fear when brushing your teeth due to gum bleeding arise or the mother is too tired with her pregnancy so she lazily brushing teeth. This situation by itself would add to the buildup of plaque that aggravate the situation gums of pregnant mother. In addition the secondary factors such as an increase in the concentration of hormones, causing dilation of blood vessels resulting in increased blood flow to the gums become more red, swollen and bleed easily. The act of gingivitis treatment in pregnant mother is to eliminate all kinds of local irritation that plaque and tartar by brushing teeth properly and clean the tartar. Pregnant mothers should also check the state of your teeth and mouth to dental clinics so that appropriate countermeasures can be given to pregnant mother as well as consume fruits that contain vitamin C and vegetables contain water and fiber (Maulana, 2006). CONCLUSION From the research that has been done shown of a knowledge level against pregnant mother about Gingivitis degrees in Pasar Miring Village Merbau District of Deli Serdang in 251 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 2013 with a sample of 32 pregnant mother in first trimester, it can be concluded as follows: 1. The level of knowledge of pregnant women about the causes of gingivitis in Pasar Miring Village District of Deli Serdang in 2013 were most numerous in the category of being as many as 23 person (71.9%). 2. The level of knowledge of pregnant mother on the prevention of gingivitis in Pasar Miring Village District of Deli Serdang in 2013, the most numerous category where that 22 person (68.75%). 3. The average level of knowledge of pregnant mother in Pasar Miring Village District of Deli Serdang District in 2013 including the criteria being that 22 pregnant mothers (68.8%). 4. The degree of gingivitis of 32 pregnant women in Pasar Miring Village District of Deli Serdang In 2011, the most widely experienced by pregnant mother is the degree of gingivitis 2 of the 16 pregnant mother (50%). 5. The level of knowledge about gingivitis pregnant mother on the degree of gingivitis is a good criterion of knowledge level is 9 people (28.1%) where the number of pregnant mother who have gingivitis by 1 person (grade 1) and 8 (grade 2), 22 mothers pregnant (68.8%) had a moderate level of knowledge in which the number of pregnant mother with gingivitis as many as 6 people (degree 0), 7 person (grade 1), 7 (2nd degree), 2 (grade 3), and 1 pregnant mother (3.1%) with the level of knowledge with gingivitis bad where there is one person (grade 2). SUGGESTION 1. It is expected that the cadre's or midwife can provide counseling to pregnant mothers in every implementation Posyandu. To increase knowledge and awareness of pregnant mothers in the village sloping 252 market in terms of maintaining oral health, especially the health of the gums. 2. It is expected that the cadre's or midwife attention to the state of the gums of pregnant mother, especially in the first trimester so as to reduce the negative impact of gingivitis that occurs during pregnancy. 3. It is expected for pregnant mother to always keep the gums healthy by brushing well and properly, to consume fruits and vegetables that contain fiber and water, cleaning tartar, and check the state of your teeth and mouth to the dental clinic in order to get action in accordance with the conditions of the pregnant mother. REFERENCES Arikunto, S., 2002, Procedure Research, Rineka Cipta, Jakarta Houwink, B., et al, 1993, Preventive Dentistry, Gadjah Mada University Press, Yogyakarta Ircham, M., 1994, Taking Care of Dental Health and Mouth, Liberty, Jakarta Machfoedz, I., 2008, The Research Methodology (Qualitative and Quantitative), Fitramaya, Yogyakarta Maulana, M., 2006, The Intelligent Facing Pregnancy and Baby Sitting, AR-Ruzz Media, Yogyakarta Mochtar, M., et al, 2008, Science Teeth and Mouth Disease, Yoga Ink, Medan Notoatmodjo, S., 2005, The Health Research Methodology, Jakarta Nurfarida 2009, Scientific Paper, Polytechnic Ministry of Health, Medan Panjaitan, M., 1995, Preventive Dentistry, University of North Sumatera Press, Medan Pintauli, S., 2008, Improve of Dental Health and Mouth,University of North Sumatera Press, Medan Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology KNOWLEDGE ABOUT FLUOR ALBUS HAZARDS TO PREGNANT WOMEN AT SUNDARI GENERAL HOSPITAL 2012 Yusrawati Hasibuan Midwifery Departement of Poltekkes Kemenkes Medan Abstract One of the most important organs and sensitive area that require special care is reproductive. In Indonesia, women who experience vaginal discharge, more than 75%. Fluor Albus closely related to humid weather conditions that facilitate development of fungal infection. Fluor Albus occurs almost in all ages, including during pregnancy, which can result in a high risk, premature rupture of membranes, so that premature birth or babies born with low birth weight. This study is cross sectionale, The population of all pregnant women who come to the Sundari General Hospital of Medan in April 2012 as many as 67 people with accidental sampling. Results of research knowledge pregnant women about the dangers of vaginal discharge during pregnancy majority less (70.1%). Based education is basic education 52.2%. Sources of information about flour albus 13.4% obtained from the family environment and 56.7% of the mass media. Primigravidae 34,4% and 11.9% of grandemultipara. Obtained relationship between knowledge about the dangers of fluor albus with resources and pregnancy. Keywords : Knowledge, Pregnancy, Flour Albus BACKGROUND One of the most important organs and sensitive and require special care is reproductive. Knowledge and good care is a decisive factor in maintaining reproductive health, if not kept clean will cause infection. One of the signs and symptoms of infectious diseases of the female reproductive organ is the occurrence of fluor albus. Fluor albus is one problem that has long been an issue for women . In the case of the reproductive physiological, many women complain of vaginal discharge and felt very uncomfortable, itchy, smelly, sometimes even sore. Results of the study of female reproductive organs , it turns fluor albus related to daily habits , namely a lack of self-awareness of organ intimate hygiene ( Manuaba , 2008) . Fluor albus disease affects about 50% of the female population and about almost at all ages. In Indonesia, over 75% had experienced vaginal discharge. It is closely related to humid weather conditions that facilitate development of fungal infection such as that of the fluor albus disease (Korekjos, 2011). Pregnant women also often experience vaginal discharge during pregnancy (Elmanan, 2011). According Dwina (2008), a woman more susceptible to vaginal discharge during pregnancy, during pregnancy because of hormonal changes that one consequence is an increase in the amount of fluid production and a decrease in vaginal acidity. All of this contributes to an increased risk of vaginal discharge, especially those caused by fungal infections. Discharge can be normal (physiological) and abnormal (pathological). Under normal circumstances, the discharge tends to clear or slightly yellow and viscous like mucus and is not accompanied by the smell or itching. However, if the discharge is accompanied odor, itching, pain when urinating or color is greenish or mixed with blood, then this can be considered abnormal (Ellya, 2010). Fluor albus in pregnant women can lead to a high risk in the early amniotic, so that premature birth or babies born with low birth weight. The most common cause of abnormal 253 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology vaginal discharge is infection. Three factors that affect their own bodies, environmental and viruses or germs. Figures overall prevalence of vaginal discharge is not known for certain, largely because the condition is often diagnosed and treated solely by the patient (Yuxie, 2008). Qomariah (2002) explained that the Reproductive Tract Infection (RTI) is a global health problem whose effects are infertility, ectopic pregnancy, miscarriage, premature rupture of membranes, increased risk of contracting HIV and even death. It is shown that the vaginitis is the most common gynecological problems occur in primary health care and 90% are caused by bacterial vaginosis, candidiasis and trichomoniasis. Data Cipto Mangunkusumo hospital, from 71 cases of flour albus, with complaints of itching amounted to 86.1%, with 87.5% of complaints burning, and fluor albus 81.1% (Medical, 2008). RESEARCH METHODS This study is cross sectionale . The population of all pregnant women who come to the Sundari General Hospital of Medan in April 2012, the average pregnant women who visit each month 200 people , sample as many as 67 people. Sampling with accidentally. The X2 test analysis used to determine the relationship of the characters of pregnant women with vaginal discharge. 254 RESULTS AND DISCUSSION RESULTS 1. Knowledge Chart 1 Distribution of Respondent Knowlegde About FlourAlbus at Sundari Hospital of Medan 2012 Based on chart.1 by 47 ( 70.1 % ) pregnant women have lack knowledge about the dangers of flour albus. 2. Sources of Information Chart 2 Respondent Sources of Information at Sundari General Hospital of Medan in 2012 Based chart.2 as much as 9 ( 13.4 % ) pregnant women gain knowledge about the dangers of flour albus from families and 56.7 % of the mass media . Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 3. Education Distribution Chart 3 Distribution of Respondent Education at Sundari General Hospital in 2012 Based chart.3 of 35 ( 52.2 % )pregnant women have a basic education. 4. Pregnancy Chart 4 Distribution of Respondent According to Pregnancy at Sundari General Hospital in 2012 Based on chart 4, majority respondents were grandemultigravida as many as 11,8% and primigravida as many as 34,3%. DISCUSSION 1. Knowledge Based on the chart 1 the majority of pregnant women knowledge about flour albus were less (70.1%). Knowledge is the result of the idea, and this occurred after people perform sensing on a particular object. Sensing occurs through the five senses, the senses of sight, hearing, smell, taste and touch. Most of the human knowledge acquired through the eyes and ears. According to Nursalam (2007) generally a good knowledgeable person will behave properly in accordance with what he knows and knows what benefits derived from such behavior, whereas less knowledgeable person will behave less well because they do not know about the objectives, benefits in personal care or hygiene vagina. Clean the vagina does not need to use excessive vaginal cleaning use ordinary soap is enough to avoid kejadinya whitish (Murtiastutik, 2009). Discharge prevention by avoiding the use underwear that is too tight, the use of underwear made from nylon or polyester (cotton) and do not use excessive vaginal cleaning wash the genital area from front to back instead of vice versa in order not to infect bacteria from the anus to the vagina. 2. Sources of Information The source of information is everything that mediates who provide information, stimulate the mind and ability. By getting information about health, one can determine and change behavior to get a healthy lifestyle. After getting this information, so that the person will behave according to their knowledge. In the second chart, as many as nine (13.4%). pregnant women gain knowledge about the dangers of flour albus of families and 56.7% of the mass media. When traced more pregnant women are a source of information about the whiteness comes from a family. Morepregnant women to get information about health or danger of discharge from many sources, then the mother can change her behavior in accordance with the knowledge or information he got. So that the mother can prevent complications during pregnancy and mothers can live healthily. 3.Education Based chart.3 of 67 respondents as many as 35 (52.2%) have basic education (primary school, secondary school). According to Notoadmojo (2003), education has the most important role in determining the quality of the human being. Education is essentially an event of delivering a message to the community, group or individuals in obtaining better knowledge. So the higher one's education is the easier of the person receiving the information. With higher education, the person will tend to be easy to get the information. The more information the more knowledge in the can, and is more exposed compared with lower educated. The results are consistent with Mc Carthay and Maine (1992) in Lubis (2012) says that women with higher education tend to be more 255 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology attention to the health of himself and his family. 4. Pregnancy Based on the chart 4. grandemultigravida obtained as much as 11.8% and 34.3% were primigravidae. Primigravidas is generally less knowledge about flour albus while grandemultigravida were the majority have a good knowledge of flour albusand no less knowledgeable because they already have experience in previous pregnancies, so that they are more aware of the dangers of vaginal discharge during pregnancy and to prevent the risk of complications to baby.Respondent with less knowledgeable majority occur because of the lack of experience possessed by respondents that have not been used to the things that will affect pregnancy, besides that the majority of respondents also have a basic education so that mindset and undeveloped knowlwedge to accept the information obtained, this research also obtained better than primigravidae and multigravida. CONCLUSION From the research that has been done can be concluded that the majority of respondents are knowledgeable about as much as 70.1%. Respondents who obtained the majority of resources from less knowledgeable family. Education respondents in basic education as much as 52.2%. Primigravidas majority of respondents are less knowledgeable and grandemultigravida majority of the good knowledge of flour albus. The higher the education, the better knowledge. Respondents multigravida have better knowledge than primigravidae. So the more often pregnant women, then the better knowledge will received by mother about the dangers of vaginal discharge during pregnancy. SUGGESTION For pregnant women are expected to be able to increase their knowledge about the dangers of vaginal discharge during pregnancy, to prevent complications for both mother and baby. Increased knowledge can be done through the 256 mass media and attending health education either given health care workers and other informants. For health workers are expected to be able to improve services through health promotion and dissemination to all pregnant women and families about the dangers of vaginal discharge during pregnancy, because of the results very little fluorine albus respondent gets knowledge of health care workers. REFERENCES Andira.,S.2010. Kesehatan Reprodiksi.Yogyakarta. EGC Arikunto,Suharsimi. 2003. Prosedur Penelitian. Jakarta: Rhineka Cipta Elmanan.2011. Miss V. Yogyakarta: Buku Biru Ellya eva,dkk. 2010. Kesehatan Reproduksi Wanita. Jakarta: TIM Hidayat. 2010.Metode Penelitian Kebidanan dan Teknik Analisis Data. Jakarta: Salemba Medika Kasdu.2005. Solusi Problem wanita Dewasa. Jakarta: Puspa Sehat Kenneth,Levene J. 2009. Obstetri williams. Jakarta: EGC Nursalam. 2003,Konsep & Penerapan Metodologi Penelitian Ilmu Keperawatan. Jakarta: Salemba Medika Notoatmodjo,S.2007. Promosi Kesehatan dan Ilmu Perilaku. Jakarta: Rhineka Cipta ________,S.2007. Pendidikan dan Perilaku Kesehatan. Jakarta: Rhineka Cipta Manuaba.2008. Memahami Kesehatan Reproduksi Wanita. Jakarta: Arcan ________.2008.Gawat-Darurat-ObstetriGinekologi&Obstetriginekologi Sosial untuk Profesi Bidan. Jakarta. EGC ________.2009. Memahami Kesehatan Reproduksi Wanita. Jakarta: Arcan ________.2010. Ilmu Kebidanan, Penyakit kandungan, dan KB. Jakarta: EGC Pujiningsih.2010. Permasalahan Kehamilan yang Sering Terjadi. Yogyakarta: Oryza Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology KNOWLEDGE AND ATTITUDES RELATIONSHIP OF DIABETICS PATIENTS AGAINST DIABETIC ULCERS INCIDENT AT MEDAN PETISAH COMMUNITY HEALTH CENTER (PUSKESMAS)WORK AREAS 2013 1 1 Dina Yusdiana Dalimunthe Nursing Department of Poltekkes Kemenkes Medan Abstract Background: Diabetes mellitus is a state of chronic hyperglycemia accompanied by metabolic disorders due to hormonal disturbances, which cause a variety of chronic complications in the eyes, kidneys, nerves and blood vessels and accompanied by lesions in the basal membrane in the examination with an electron microscope. Objective: To determine the relationship of knowledge and attitude of Patients with diabetes on the incidence of diabetic ulcers in the working area of Petisah health centers in 2013. Methodology: This study uses correlation analytic design with cross sectional approach. Total sample is 35 person taken by using accidental sampling technique in Medan Petisah community health center. Results: The results showed that 16 person (46%) both knowledgeable and 8 (23%) knowledgeable enough. Having a positive attitude as much as 22 person (63%) while the negative attitude as many as 13 person (37%). The majority of respondents that do not suffer from diabetic ulcers were 19 person (54%) with positive insidence, while a minority of respondents who did not suffer from diabetic ulcers 2 (6%) to be negative on the incidence of diabetic ulcers. There is a significant relationship between knowledge and attitudes on the incidence of ulcers of diabetic patients in Medan Petisah community health center in 2013 with p value <0.05. Conclusions and Recommendations: Because there is a significant relationship between knowledge and attitudes on the incidence of ulcers of diabetic patients, it is expected that person with diabetes mellitus are more favorable to what was already known that health problems such as diabetic ulcers it happened increasingly unavoidable. Keywords: Knowledge, attitudes, diabetes mellitus, diabetic ulcers BACKGROUND Long term plan of development in the health sector is the implementation of quality health care, equitable, human and able to realize a strong, healthy, intelligent, and productive. For the health development of human resources directed to improving the welfare of families and communities, and heighten public awareness of the importance of life. To realize optimal public awareness organized health efforts with thorough approach to health care, one of them with the knowledge of diabetes mellitus (Health Ministry, 2008). Diabetes become a serious illness and received attention in the community. This is because diabetes can lead to complications that attacks the entire body. Diabetes Mellitus case today continues to rise with increasing levels of affluence, changing lifestyle and diet, as well as age (Badawi, 2009). Everyone can suffer from Diabetes Mellitus both young and old. High levels of blood glucose continuously or prolonged exposure may cause complications of diabetes. Based on research of Murray (2000), every 19 minutes there is one person who is blind and one person in the world amputated due to complications of Diabetes Mellitus. Various complications can occur if the management of Diabetes Mellitus is not optimal (Maulana, 2009). According to World Health Organization (WHO) data (2007) the number of patients with Diabetes Mellitus in the world reached 246 million person, which is about 40% of the total world population. The first of the highest order, namely India (37.77 million), China (20.8 million), followed by the United States (17.7 million) and which ranks fourth, namely Indonesia (17 million) peoples with diabetes mellitus. In 2000, there were approximately 257 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 5.6 million of Indonesian peoples who suffer from diabetes mellitus. However, in 2006 this number increased sharply to 14 million peoples and a continuous increase in number from year to year, and in 2007 reached 17 million (Pearson, 2008). Diabetes is one of the most expensive disease to treat because it requires long-term care, not only to regulate blood sugar levels, but is also associated with serious medical complications. Many person in these countries can not afford to buy the drugs they need to control their diabetes. Similarly, countries with little public health budgets. They must find cost-effective ways to prevent the disease at an early stage or treat complications in a way that is more effective as exercising and eating healthy foods regularly. If not, it will be at risk of diabetes. That is how they control diabetes (Carol, 2011). Research results related diabetes mellitus has been done by Barry J. Goldstein in various countries such as Asia, Latin America and the Middle East, recorded 21% of patients with this disease did not control routine to their specialist physician. More than half (58%) of the physicians surveyed believe that patients do not always tell them about the progression of the disease so that the doctors can not help with the maximum. In Asia, Latin America and the Middle East nearly three-quarters of patients (74%) surveyed said that will be very useful when there is good communication between health workers with diabetes mellitus patients. This shows the lack of public knowledge due to a lack of communication between health workers and patients with diabetes mellitus or otherwise. (Harold, 2012). According Sidartawan (2008), the increasing prevalence of diabetes mellitus in several developing countries lately still highlighted. Increasing per capita income and changes in lifestyle, especially in big cities caused an increase in the prevalence of degenerative diseases, such as diabetes called diabetes, coronary heart disease (CHD), hypertension, and others. Diabetes has also been included in the list of "Asian disease". In 2003 alone an estimated 89 million person in Asia suffer from diabetes. Recorded 4 of 5 countries in the world with the largest number of diabetics in Asia, namely: India (32.7 million person), China (22.6 million person), Pakistan (8.8 258 million person), and Japan (7.1 patients ). While the number of patients with diabetes mellitus is found in Southeast Asia: Singapore 10.4%, Thailand 11.9% 8% Malaysia and Indonesia 5.7%. Of Indonesia's population, diabetes mellitus is approximately 17 million person (2006) in which only 50% were aware of diabetes and among them only 30% who came for treatment regularly and about 15% among patients with diabetes mellitus gangrene will experience during life. Person with diabetes mellitus need to give more attention to the health of the feet because diabetes can cause complications known as diabetic foot (diabetic foot). Diabetic foot is one of the complications of diabetes are still unnoticed. Whereas the consequences of the diabetic foot is already deteriorated can cause gangrene and lead to amputation (Nabyl, 2009). Based on preliminary surveys that have been conducted by researchers on February 26, 2013 in Medan Petisah community health center (Puskesmas) , the number of patients with Diabetes Mellitus were 414 patients recorded in 2010. Subsequently , in 2011 recorded 451 person and in 2012 there were 475 patients . In other words , person with diabetes mellitus is increasing from year to year and became one of the 10 top health problems in the health center. Therefore, researchers interested in conducting research on knowledge and attitudes relationship of diabetics patients against diabetic ulcers incident at Medan Petisah community health center (puskesmas) work areas in 2013. RESEARCH METHODS The type of this research is the correlation analytic method that studies find a relationship between the dependent variable and independent variables. The study design was cross-sectional approach where data each variable measured in the same time. (Nursalam, 2010). This study was conducted in Medan Petisah Community Health Center (Puskesmas) .This study began in April 2013 till June 2013. As for the population in this study were all patients with diabetes mellitus in Medan Petisah Community Health Center (Puskesmas) as many as 475 patients in 2012, Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology with an average of 39 person per month. The sample size in this study was 35 respondents. With a sampling technique is done by Accidental Sampling by coincidence anyone who met the appropriate requirements and desired data. The type of data in this study consisted of primary data and secondary data. Primary data is data obtained directly from respondents through questionnaires. Secondary data is data obtained from Medan Petisah Community Health Center (Puskesmas) about the data amount with diabetes who come to the clinic for treatment. Data processing techniques through: 1) Editing, Before the data obtained by checking the data to check the questionnaires that have been entered, clarify, see the completeness, accuracy in testing the questionnaire; 2) Coding, Editing Once done, followed by encoding the data to facilitate the entry of data by computerized methods; 3) Cleaning the data, carried out when there is an error in entering the data; and 4) Tabulating, to simplify data analysis, data processing and retrieval of data conclusions incorporated into a frequency distribution table. Data were analyzed with: a. Univariate analysis This analysis is used to determine descriptive overview of each variable. Data collected and analyzed descriptively by looking at the percentage of the collected data and generate the proportion of each of the variables being measured and presented in the form of a frequency distribution table. b. Bivariate analysis This analysis was conducted to look at the significance level of the relationship between independent variables and the dependent variable. Statistical tests were used to analyze the relationship between any independent variables (knowledge and attitude) with dependent variables (incidence of diabetic ulcers) in this study is the chi-square test for scale independent variables and the dependent variable is categorical scale. Confidence level used is 95% with a significance level of = 0.05. The provisions of meaningful relationship if ρ values <0.05. Ha received means that there is a significant correlation between the two variables studied and the relationship is said to be significant if ρ value> 0.05. Ha rejected. RESULTS AND DISCUSSION Research Result 1. Univariate Analysis From the results of a study of 35 respondents based on the respondents' knowledge on the incidence of diabetic ulcers in Medan Petisah Community Health Center in 2013, majority of 16 person (46%) good knowledge of 8 person, while a minority (23%) knowledgeable enough. Attitudes of respondents to the incidence of diabetic ulcers at Medan Petisah Community Health Center in 2013 and the majority of respondents have a positive attitude as much as 22 person (63%), while respondents with a negative attitude as many as 13 person (37%). The incidence of diabetic ulcers majority of respondents did not suffer as much as 21 person (60%), while a minority suffer from as many as 14 person (40%). 2. Analysis Bivariat From the results of research conducted on 35 respondents obtained knowledge of the distribution of the results of the relationship of diabetes mellitus on the incidence of Diabetic Ulcers in Medan Petisah Community Health Center, as in Table 1 below: Table 1. Distribution of Respondents Frequency According To Diabetic Mellitus Patients Knowledge to Diabetic Ulcers Incident At Medan Petisah Community Health Center 2013 Ulkus Diabetikum Incident Knowled No Do not ge Suffers Suffer F % F % 1 Good 2 6 14 40 2 Enough 3 8 5 14 3 Less 9 26 2 6 Total 14 40 21 60 Total ρvalue F 16 8 11 35 % 46 23 0,001 31 100 From Table 1 above, Distribution of Respondents Frequency According To Diabetic Mellitus Patients Knowledge to Diabetic Ulcers Incident At Medan Petisah Community Health Center 2013, can be seen that of the 16 respondents knowledgeable good majority of a total of 14 person (40 %) and do not suffer incidence of diabetic ulcers, followed of 11 respondents knowledgeable less , the majority were 9 person (26 %) suffer from diabetic ulcer incidence and from 8 259 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology respondents knowledgeable enough majority as much as five person (14 %) do not suffer the incidence of diabetic ulcers . While the distribution of the attitude of person with diabetes mellitus relation to the incident Diabetic Ulcers in Medan Petisah Community Health Center can be seen in table 2 below : Table 2. Distribution of Respondents Frequency According To Diabetic Mellitus Patients Attitudes to Diabetic Ulcers Incident At Medan Petisah Community Health Center 2013 Ulkus Diabetikum Incident ρTotal No Attitude valu Do not Suffer e suffer F % F % F % 1 Positive 3 9% 19 54% 22 63% 2 Negative 11 31 2 6% 13 37% 0,000 % Total 14 40 21 60 35 100 From Table 2 that explained the distribution of respondents frequency according to diabetic mellitus patients attitudes to diabetic ulcers incident at Medan Petisah Community Health Center 2013 can be seen that the positive attitude of the majority of the 22 respondents were 19 person (54%) do not suffer the incidence of diabetic ulcers and of 13 respondents majority being negative as many as 11 person (31%) do not suffer incidence of diabetic ulcers. Discussion Based on the analysis Chi Square (Person Chi Square) knowledge and attitude of person with diabetic ulcers on the incidence of diabetic ulcers, acquired respectively p-value <0.05 with a confidence level of 95%. This shows that there is a statistically significant relationship between knowledge and attitudes on the incidence of ulcers of diabetic patients in Medan Petisah Community Health Center in 2013. Results of a study of patients with diabetes mellitus knowledge in accordance with the theory of Henry and Goddess (2012) that knowledge is the result out and this happened after person hold to a particular object sensing happens through the human senses of sight, hearing, smell, taste and touch with their own 260 .With the basic knowledge proves that respondents who have a good knowledge not suffer from diabetic ulcers in patients with diabetes mellitus. While the attitude is a reaction or response of someone who is still closed to a stimulus or object. Stimulus received related to the knowledge of person with diabetes mellitus on the incidence of diabetic ulcers will determine the patient in addressing this. This study is in line with the theory of Notoadmodjo (2007), states that knowledge is strongly influenced by education as in patients with diabetes mellitus. If the knowledge of patient well then there is no diabetic ulcers as many as 14 person (40%). It must be emphasized also that does not mean someone who is less educated lower the absolute knowledge. It is given that the increase is not absolute knowledge gained from formal education, but also obtained through nonformal education such as print media, electronic, health education that will increase someone knowledge. As in this study, there were 2 person (6%) were suffering from Diabetic ulcers. Notoatmodjo (1997), quoted by Wawan and Goddess (2010) also expressed the attitude is a reaction or response of someone who is still closed to a stimulus or object. Stimulus received related to the knowledge of person with diabetes mellitus on the incidence of diabetic ulcers will determine the patient in addressing this. Researchers assumptions about knowledge: the knowledge of someone can be influenced by several factors: education, interests, experience, age, and environmental information. Education greatly affects a person to have a good knowledge. The more education obtained from both formal and nonformal education to be better knowledge. Researchers assumptions about attitudes can be formulated that attitudes towards certain things is influenced by several factors: personal experience, the influence of others that are considered important, the influence of culture, media and emotional factors. Greatly affect someone experience to have the positive attitude towards the events that happened. The more experience in diabetic mellitus gained, the more able he is to be positive about the incidence of diabetic ulcers. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology CONCLUSIONS AND SUGGESTIONS Conclusion 1. Based on the analysis and discussion of the results of research that variable knowledge on the incidence of diabetic ulcers have p value = 0.001 (p <0.05) with a confidence level of 95% have a relationship with the incidence of diabetic ulcers. This is shown by the majority of respondents who do not suffer from diabetic ulcers as many as 14 person are knowledgeable both on the incidence of diabetic ulcers, while a minority of respondents who did not suffer from diabetic ulcers are less knowledgeable on the incidence of diabetic ulcers and knowledgeable both on the incidence of diabetic ulcers but suffer from diabetic ulcers are as many as 2 person (6%). 2. Based on the analysis and discussion of the results of research that variable attitudes toward the incidence of diabetic ulcers have p value = 0.000 (p <0.05) with a confidence level of 95% have a relationship with the incidence of diabetic ulcers. This is shown by the majority of respondents who do not suffer from diabetic ulcers as many as 19 person (54%) were positive on the incidence of diabetic ulcers, while a minority of respondents who did not suffer as much as 2 diabetic ulcers (6%) were the negative attitude towards the incidence of diabetic ulcers. Suggestion Recommended for all patients with diabetes mellitus in Medan Petisah Community Health Center continue to improve knowledge either through direct or indirect experience, both formal and informal education that the incidence of health problems such as diabetic ulcers increasingly unavoidable and diabetes mellitus in order to be positive about what already known by person with diabetes so that health problems such as diabetic ulcers it happened increasingly unavoidable. As for Medan Petisah Community Health Center in order to further improve programs that can encourage everyone with diabetes mellitus to improve knowledge and more positive attitudes towards the incident that it can be minimized further. REFERENCES Arikunto,S.,2006. Prosedur Penelitian Suatu Pendekatan Praktik. Edisi Revisi VI. Jakarta: Rineka Cipta Badawi, 2009.Melawan dan Mencegah Diabetes. Yogyakarta: Araska Printika Russel,2011.Bebasdari 6 Penyakit Paling Mematikan.Yogyakarta : Media Pressindo Maulana,2009. Bersahabat dengan Diabetes.Jakarta: Penebar Plus Notoadmodjo,S., 2007.Metode Penelitian Kesehatan. Jakarta: Rineka Cipta PoliteknikKesehatan,2006.Panduan Penyusunan KTI.Medan Sidartawan.2008.Hidup Secara Mandiri dengan Diabetes Melitus, Kencing Manis, Sakit Gula. Jakarta: Balai Penerbit Fakultas Kedokteran Universitas Indonesia. Nabyl.2009.Cara Mudah Mencegah dan Mengobati Diabetes Melitus.Yogyakarta: Genius Printika Prasedjo, 2005.Melawan dan Mencegah Diabetes.Media Pressindo.Yogyakarta Vitahealth, 2006. Diabetes.PT Gramedia Pustaka Utama. Jakarta. Wawan, A. danDewi, M.,2011. TeoridanPengukuranPengetahuanSikapd anPerilakuManusia.Jakarta :NuhaMedika. http://www.newsmedical.net/news/20110915/10632/In donesian.aspx http://diabetesmelitus.org/perawatan-kakidiabetes/#ixzz2NrRa7hXF 261 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology STUDY ANTIMICROBIAL ACTIVITY OF ETHANOL EXTRACT CURRY LEAVES (MURRAYA KOENINGII L. SPRENG) AGAINST STAPHYLOCOCCUS AUREUS AND ESCHERICHIA COLI Panal Sitorus 1, Djamidin Manurung 2, Ernawaty2 1.Departement of Pharmaceutical Biology, Faculty of Pharmacy, Sumatera Utara University 2. Polytechnic Health Ministry of Medan Corresponding Outhor Email: [email protected] ABSTRACT Curry (Murraya koeningii L. Spreng) is included in Rutaceae family. Curry leaves are used in herbal medicine and effective antimicrobial agent empirically. The porpose of this study are to extract Murraya koeningii L. Spreng leaves with ethanol, Karacterization, phytochemical screning of simplex and ethanol extract and study its antimicrobial activity of curry leaves extracts, against Staphylococcus aureus and Escherichia coli. Extraction with maceration was carried out by using ethanol 96% at simplex, phytochemical screening and study antibacterial activity curry leaves extracts at Staphylococcus aureus and Escherichia coli conducted as invitro agar diffusion method by using paper disk. The result of simplex and ethanol extract characterization obtained water value 4.63%; 10.50% respectively, water soluble extract value 28.42%; 55.53% respectively, the ethanol soluble extract value 14.83; 6.,21% respectively, the total ash value 8.84%; 4.52% respectively and the acid insoluble ash value 1.13 %; 0.85%. The result of phytochemical screening of simplex and extract showed the presence of flavonoids, glycosides, tannins and saponins. The results of study antimicrobial activity of ethanol extract of curry leaves can inhibit the growth of Staphylococcus aureus at concentration of 500 mg/ml, with an effective diameter inhibition zone of 15.03 mm and Escherichia coli at a concentration of 300 mg/ml, with effective diameter inhibition zone of 14.16 mm. Keywords: Murraya koeningii L. Spreng , Antimicrobial, Staphylococcus aureus, Escherichia coli Introduction Plants have an important as medicine. The use of plants as traditional medicine is still used by the people in Indonesia, and traditionally used to treat various types of diseases and effective empirically. The herbs / plants had much success treating some diseases can not be treated with conventional drugs (chemistry) . Natural inggredients of traditional medicinal plants Indonesia is still a lot that has not been studied, one of which is a plant greeting Koja/curry (Murraya koeningii L. Spreng) ,3,6,19,24. Plants regards Koja (Murraya koeningii L. Spreng) included in the class family Rutaceae, this plant comes from the region of India and Sri Lanka. Koja/curry high regards plants have 0.8 to 4 meters and a diameter of 15-40 cm, the leaves form a double compound, pinnate shaped, small, pointed tip, dark green and shiny. The flowers are white and small fruit is green when young and purple after being cooked, 3, 4,5 262 Koja/curry leaves numerous in Aceh province which is called "leaf temurui". Koja/curry leaves used extensively by the community as flavorings cuisine and has a versatile role in traditional medicine. The bark and roots are used to treat venomous animal bites. Leaves to cure dysentery, insect bites, drug injury, diarrhea and vomiting.. The leaves and roots are also used traditionally as, anthelmintic, analgesic, curing hemorrhoids, inflammation, itching and can reduce hair loss, 3,7,11,13,16. Efficacy of curry leaves in the health field has been widely studied, including anticancer and anti-inflammatory effects, antioxidants antidiabetic and antibacterial,11, 13,16,18,19,. Several researcher had tested the antibacterial essential oil of curry/Koja leaves using the bacterium Escherichia coli, Staphylococcus aureus and Salmonella typhi, the results showed where the essential oil of curry leaves have inhibitory effect on the species of bacterial, 22. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Koja/curry leaves contain secondary metabolites such as tannins, flavonoids and essential oils,1,12,23. Based on the analysis it can be concluded that ethanol extract of curry leaves exhibited the antibacterial activity against Escherichia coli and Staphylococcus aureus. 13,20.22,24 Material And Methods This study is done by experimental methods.This study involves collecting materials, characterization, phytochemical screening of simplex ,extraction and test antimicrobial activity of the extract curry leaves against Staphylococcus aureus and Escherichia coli. Determination of the antimicrobial activity of extracts of curry leaves performed with agar diffusion method. The principle of this study is to use a solid medium and then the paper disc diameter inhibitory ( clear zone ) bacteria were measured with calipers, 9,14. Material The materials used in this study were curry leaves (Murraya koeningii L. Spreng). distilled water, Nutrient Agar(Difco). The chemical used unless otherwise stated are pro-analysis grade, i.e: ethanol, n-hexane, mercury (II) chloride, iodine sodium hydroxide, bismuth(III) nitrate, iron (III) chloride, potassium iodide, benzene,α-naphthol, concentrated nitric acid, concentrated hydrochloric acid, sulfuric acid concentrated, lead ( II ) acetate, acetic acid anhydride, isopropanol, Sodium chloride, chloroform, methanol, Amil alkohol magnesium powders and The microbias were used bacteria Staphylococcus aureus ATCC 25923 and Escherichia coli ATCC 25 922 . Sampling The collection of materials was done purposively without comparing with the same plants from the other regions. The samples used are curry leaves(Murraya koeningii L.Spreng), taken from Jl. Sempurna kec. Medan Baru, North Sumatera. Identification of Samples Identification of Curry/Koja (Murraya koeningii L.Spreng) leaves was performed in Bogoriense Herbarium, LIPI, Jakarta, Indonesia. Extraction Extraction was conducted with ethanol by using maceration method. 300 g simplex powder was macerated with 2250 ml of ethanol in a container and let stand at room temperature for 5 days protected from light. Maserat was separated with residues. Residues washed with 750 ml of ethanol. All off maserat combined and evaporated by rotary evaporator at 40 ° C to obtain the extract ethanol , then dried with freeze dryer at - 400C for ± 24 hours and obtain ethanol extract,7,8,11. Characterization of Simplex Characterization of simplex are to inspection simplex characteristics and study of groups of chemical compounds of ethanol extract curry leaves.4,5. Test Antimicrobial Activity of Extract The test solution of ethanol extract of curry leaves with various concentrations and test the antimicrobial activity of the extract against Staphylococcus aureus and Escherichia coli. Determination of the antimicrobial activity of extracts of leaves curry performed with agar diffusion method. The principle of this study is to use a solid medium and then the paper disc diameter inhibitory (clear zone) bacteria were measured with calipers,9,10,15,1720,21.. Test Solution Extrac Curry leaves With Various Concentrations The ethanol extract weighed 5 g dissolved in dimethyl sulfoxide (DMSO) to 10 ml of the extract concentration is 500 mg / ml, then made further dilution to obtain the extract with a concentration of 400 mg / ml; 300 mg / ml; 200 mg / ml; 100 mg / ml; 75 mg / ml and 50 mg / ml. Then put the paper into the extract discs with various concentrations, let for 30 minutes, 1,2,9,10. 1.Bakteri Staphylococcus aureus Inoculum (0.1 ml) put into a sterile petridish, then pour the media Nutrient order of 20 ml with a temperature of (45-50) 0C. Further cup rocked on the surface of the table, sothat the media and the bacterial suspension well blended . After that, implanted paper disk, soaked ethanol extract of curry leaves with various concentrations. Then incubated at 25°C for 48 hours. Furthermore, the diameter of inhibition 263 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology zone surrounding paper disk was measured with calipers, 4,5. 2.Bakteri Escherichia coli Inoculums(0.1 ml) put into a sterile petridish, then pour the media Nutrient order of 20 ml with a temperature of (45-50)0C.Further cup rocked on the surface of the table , sothat the media and the bacterial suspension well blended . After that, implanted paper disk. soaked ethanol extract of curry leaves with various concentrations. Then incubated at 25 °C for 48 hours. Furthermore, the diameter of inhibition zone surrounding paper disk was measured with calipers, 4,5 Results and Discussion Characterization Simplex The result of simplex and extract characterization shown in Table 1. Below, 4,5. Table1. Caracterization of Simplex and Extract No Parameter Result Simplex Extrac (%) t(%) 1 water value 4.63 10.50 2 water soluble 28.42 55.53 extract 3 ethanol 14.83 65.21 soluble extract 4 total ash value 8.84 4.52 5 acid insoluble 1.13 0.85 ash value Phytochemical screening The result of phytochemical screening of simplex and extract ethanol curry leaves showed the presence of flavonoids, glycosides, tannins and saponins was shown in Table 2. Below,12 Table 2 Chemical compounds of curry leaves No Parameter Result Simplex Extract 1 Alkaloids 2 Flavonoids + + 3 Saponins + + 4 Tanins + + 5 Glikosids + + 6 Steroid/ + + Triterpenoid Test Antimicrobial Activity 264 The results of test antibacterial activity of ethanol extract of curry leaves against Staphylococcus aureus and Escherichia coli was shown in Table 3. Below Table 3. Antimicrobial Activity of Ethanol Extract NO ConcentraRegional diameter Bacterial Growth tion Inhibition (mm)* extract S.a E.a Etanol mg/ml 1 500 15,03 17,66 2 400 13,53 15,90 3 300 12,26 14,16 4 200 11,10 13,16 5 100 10,40 11,73 6 75 9,40 11,03 7 50 8,26 9,50 8 Blank Specification: ( * ) = Average measurement 3x , ( - ) = No results The test results showed that the antimicrobiial activity of the ethanol extract of curry leaves can inhibit the growth of bacterium Staphylococcus aureus at concentration of 500 mg / ml with an effective diameter of inhibition area of 15.03 mm and the bacterium Escherichia coli at a concentration of 300 mg / ml with a diameter of inhibition area of 14 , 16 mm. The minimum inhibitory concentration of ethanol extract can inhibit the growth of Staphylococcus aureus at concentrations of 50 mg / ml with inhibition area diameter of 8.26 mm and Escherichia coli at a concentration of 50 mg / ml with the diameter of Inhibition zone of 9.50 mm The antimicrobial activity of a substance to inhibit the growth of microorganisms depend on the extract concentration, l0,15,17,21. Conclusions and suggestions Conclusion From the analysis of the data above it is concluded that: 1. Characteristics powder simplex and ethanol extract curry leaves respectively obtained water value 4.63%; 10.50%, water soluble extract value 28.42%; 55.53%, the ethanol soluble extract value 14.83; 6.,21%, the total ash value 8.84%; 4.52% and the acid insoluble ash value 1.13 %; 0.85%. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 2.Phytochemical screening of simplex powder and ethanol extract of curry leaves showed that the chemical compounds of flavonoids, steroid /triterpenoids, tannins, saponins, and glycosides. 3.The antimicrobial activity of ethanol extract of curry leaves against Staphylococcus aureus and Escherichia coli effectively showed that the antimicrobial activity can inhibit the growth of Staphylococcus aureus at a concentration of 500 mg / ml with an effective diameter of inhibition zone of 15.03 mm and Escherichia coli at a concentration of 300 mg / ml with an effective diameter of the inhibition zone of 14.16 mm. Suggestions It is suggested to further research to study ethanol extrac of curry leaves against molds. Reverences 1.Baskaran, Rathabai dan Kanimozhi (2011). 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Pharm. 2(2): 51-53. 265 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology 20.Pelezar, M.J., dan Chan, E.C.S (2008).Dasar-Dasar Mikrobiologi I. Jakarta: Penerbit UI-Press. Hal. 101. 21.Pratiwi, S.T. (2008). Mikrobiologi Farmasi. Jakarta: Penerbit Erlangga. Hal. 105-117, 140-142 22.Rajendran,M.P. (2013). Chemical Composition, antibacterial and antioxidant profile of essential oil from Murraya koenigii (L.) leaves, 266 Avicenna Journal of Phytomedicine, India. 23.Robinson, T. (1995). Kandungan Organik Tumbuhan Tinggi. Bandung: ITB. Hal. 71-72. 24.World Health Organization. (2011). Quality Control Methods For Herbal Material. Switzherland: WHO. Hal. 29-38. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECT OF FAMILY PSYCHOEDUCATION THERAPY TOWARD THE PARENT’S ABILITY TO THE MENTAL RETARDATION CHILD INDEPENDENCY IN SLBN-1 PALANGKA RAYA Syam’ani* Nursing Major, Polytechnic Health Ministry of Palangka Raya, G. Obos Street No. 30, 73111, Palangka Raya e-mail: [email protected] Abstract . The problem of mental retardation associated with all portions, especially the family/parents. Family environment influential directly in educating a child because at the time of birth and for the next period, children and families requiring assistance another person to carry out his life. Families of children with mental retardation often have more complex problems in the formation of personality, behavior and meeting the needs of children. The aims is to determine the effect of family psychoeducation therapy on the parent’s ability in a mental retardation child's independence. This research use “one group-pretest-postest design”. The samples in this study were 32 respondents who are parents of children with mental retardation and school in SLBN 1 Palangka Raya. The results of this study indicate that the family’s ability in the mental retardation child's independence after family psychoeducation therapy increased significantly by 1.61 with p value = 0.000 (α 0.05). It can be concluded that there is a significant change in the average ability of the family in the mental retardation child's independence before and after family psychoeducation therapy. The research recommends family psychoeducation therapy as one of the independent nursing intervention for families who have mental retardation child to increase the child's independence Keywords: family psychoeducation therapy, parent’s ability, mental retardation child Refferences: 19 (1995 – 2010) INTRODUCTION Nursing as health system integrity in Indonesia take an important role to cover mental health problem. Mental health nursing will be give an optimal contribution if nurse using problem solving method in nursing process on their care to client, including their care to mentally rearded child. Mental retardation is a condition of mental development that stalled or incomplete, which is mainly characterized by the presence of skills impairment during development period, so give effect on all levels of intelligence, ie cognitive ability, language, motoric, and sociality (Lumbantobing, 2001). Mentally retarded child is not capable of learning and adapting because of low intelligence, usually an IQ below 70. They also have behavioral disorders of social adaptation where children have difficulty adjusting to the surrounding community, childish behavior is not in accordance with the age (Soetjiningsih, 1995). The incidence of the mentally retarded is quite a lot, especially in developing countries and causing of anxiety or dilemma of families, communities and countries. In Indonesia, the incidence of mental retardation was reported quite high. From the results of the Household Health Survey conducted Agency for Health Research and Development Department of Health show the prevalence of mental retardation is five per 1000 population (Atika, 2003). Research in various countries found that the prevalence of moderate and severe mental retardation in the age group 15-19 years is approximately 3.0 to 4.0 per 1000. Few studies have also found that people with mental retardation who suffer from psychiatric disorders and behavioral disturbances frequency high enough. There is also a few families in Indonesia who do not understand how to care the children with mental retardation optimally because they think that they do not have hope in the future (Muchayaroh, 2002). The actual prevalence rate of mental retardation in children is higher than the reported figures, as most surveys report only severe cases only. Research in various countries found that people with mental retardation who suffer from psychiatric 267 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology disorders and behavioral disorders is quite high frequency. In the survey conducted by Rutter, et al found that nearly a third of them felt "disturbing" by his parents (Lumbantobing, 2001). Issue of mental retardation is associated with all sides, especially the family / parents. Family environment directly influential in educating a child because at birth and for the next period that is long enough for children that need help from family and others to carry out his life. Families of children with mental retardation often have a more complex problem in the formation of personality, behavior and meeting the children need. Families who have children with disabilities tend to provide an overload protection on their children so that children have a limited opportunity to gain experience in accordance with the level of development. The increasing age of the child RM then the parents have to make adjustments, especially in fulfilling child needed daily so that later they do not have a prolonged dependency and cause problems that are not fun, so it takes particular care to parents by helping independence of children with mental retardation, One treatment that can be given to parents is through family psychoeducation therapy. Family psychoeducation therapy is one of the elements of family mental health care programs by providing information and education through communication t both therapeutic and educational approaches and pragmatic (Stuart & Laraia, 2005). Family psychoeducation given in 5 sessions consist of session I: identification of the problem, session II: how to care for family members who are experiencing problems, session III: stress management, session IV: load management and session V: community empowerment. Research on family psychoeducation therapy have been carried out. This therapy showed an increase in outcomes in clients with schizophrenia and other severe mental disorders (Anderson, 1983 in Levine, 2002). Results of another study conducted by Mc. Farlane (1995), shows the same thing, where family psychoeducation therapy proven effective in lowering the relapse of patients with schizophrenia. Based on the exposure, researchers are interested in studying about family psychoeducation therapeutic effect on the 268 ability of parents to mental retardation child's independence in SLBN 1 Palangkaraya. Methods The design of this research study: "onegroup pre-test-post-test design" are defined according to Prasetyo & Jannah (2005), namely: an experimental group measured the dependent variable (pre-test), and then given stimulus, and remeasured dependent variable, without a comparison group. Sampling by using total sampling, which all parents who have mental retardation child, totaling 32 respondents, who attended the SLBN-1 Palangkaraya and met the inclusion criteria. Samples that have met the inclusion criteria measurements were taken prior to the characteristic ability of parents in a child's independence mental retardation as observation first stage (pre-test). The observations contained in the data collection sheets that have been available. Furthermore, parents are given family psychoeducation therapy, and then observed their behavior as a response to observations of the second phase (post-test). The observations contained in the data collection sheets, as is done in the first phase. Then analyzed to determine the change in the ability of parents in a child's independence mental retardation before and after the intervention. Population and Sample In this study population is the parents who have children with mental retardation who attend school at the State Special Schools 1 (SLBN-1) Palangkaraya. Sampling by using total sampling, which all parents who have children with mental retardation, totaling 32 respondents who attended the SLBN-1 Palangkaraya and met the inclusion criteria. Methods This study using questionnaire with some closed questions to identify the ability of parents in a mental retardation (MR) child's independence before and after therapy family psychoeducation. The data was collected by distributing a questionnaire containing a list of questions filled out by respondents. Pre-test done 1 day prior to treatment. Pre test was conducted on the family in this case is the 32 parents who have children in school in the RM and SLBN 1 Palangkaraya. At this Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology stage the researchers assessed the ability of parents in a MR child's independence, to determine the initial capability prior to intervention of family psychoeducation therapy. After the pre-test, each respondent is then given family psychoeducation therapy as many as five sessions. Post-test conducted on day 14 after the family psychoeducation therapy ended. At this stage the researchers assessed the ability of the family in the MR child's independence. Data Analysis Data analysis techniques using pre-test requirements analysis and test the effect. To test that is pre-requisite analysis using normality test where normality test data in this study using a non-parametric statistics on the value of Kolmogorov-Smirnov. According Priyanto (2010) suggested that the data are expressed in normal distribution if the significance is greater than 0.05. In this study, the significance value was 0.32 so it can be concluded that the data were normally distributed. Meanwhile, to perform calculations using the formula test the effect of pre-test and post test one group design is a statistical test by using test dependent sample t-test (Paired t-test). Results Parent’s Ability in MR child’s independence The ability of parents in a MR child's independence before the family psychoeducation therapy can be seen in the table below: Table 1 Parent’s Ability Before Psychoeducation therapy (n = 32) Characteristic N Mean SD Minimal Maksimal Parent’s 32 74,75 9,608 41 – 88 ability before intervention The results showed that total of 32 parents who have children with RM shows the average ability in the child's independence before family psychoeducation therapy is 74.75. With a standard predetermined value, the researchers concluded that the average ability of the family in a child's independence prior to therapeutic intervention RM family psychoeducation is at a level good enough. After the intervention of family psychoeducation therapy, the ability of the family in the MR child's independence can be seen in the following table: Table 2 Parent’s Ability After Psychoeducation Therapy (n = 32) Characteristic n Mean SD MinimalMaksimal Parent’s 32 80,66 11,218 53 - 97 ability after intervention Table 3. Analysis of Changes in Parent’s Ability Before and After Psychoeducation Therapy (n = 32) Variable Parent’s ability a. Before b. After Mean SD SE t p value 74,75 9,608 1,699 0,000 80,66 11,218 1,983 4,69 4 difference5,91 1,61 Discuss After the intervention of psychoeducation therapy there is improvement in the ability of the MR child's independence become 80.66. With a standard predetermined value, the researchers concluded that the average ability of the family in the child's independence after give intervention RM family psychoeducation therapy is increased to good. It’s mean that in line with that proposed by Carson (2000) that psychoeducation is a tool that is increasingly popular family therapy as a strategy to reduce the risk factors associated with the development of behavioral symptoms. So in principle, psychoeducation can help family members to increase knowledge about the disease through the provision of information and education to support treatment and rehabilitation of patients as well as increased support for the family members themselves Effect of Psychoeducation Therapy towards Parent’s Ability to MR Child’s Independence Family psychoeducation therapy is one elements of family mental health care programs by providing information and 269 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology education through therapeutic communication. Psychoeducation program is an approach both educational and pragmatic (Stuart & Laraia, 2005). In this study, given intervention in the form of family psychoeducation therapy to the 32 respondents who have children with moderate mental retardation, with the aim of providing a deeper understanding to the families of children with mental retardation and how to care. Statistical test results in this study by using dependent test sample t-test (Paired ttest) demonstrated that the parent’s ability after the family psychoeducation therapy increased significantly by 1.61 with a p value = 0.000 (α 0.05). It can be concluded that the α 5% no significant change in the average ability of the family in the child's independence RM before and after therapeutic intervention in the form of family psychoeducation (p value 0,000 <α 0.005). Mohr (2006) divides the role of families who have children with mental retardation into 5 (five), portions: 1). to respond to every need of the family members especially need stimulation of growth and development in children with intellectual challenges, 2). help any psychosocial problems in the family active and as a result or care for children with intellectual challenges, 3). division of tasks associated with the equitable distribution of the stimulation of growth and development of children with intellectual challenges, 4). encourage interaction within and outside the family, as well as 5). improving the quality of health in each family member. This is one of them can be met through family psychoeducation therapy. The inability of the family to manage stress occurs because of a conflict between: a strong desire to have a healthy child, and simultaneously (together) occurs fear and anxiety when what it does will lead to a mistake for their children. This can affect the ability of families in child care so that it will interfere / impede child development RM. Through family psychoeducation therapy, the expected family as a system that can provide support in the establishment of sustainable health care in helping the mentally retarded child's independence, not only provide physical treatment but also psychological and social care. Research has been done by Nurbani (2009) states that family psychoeducation can help decrease anxiety 270 and burden of the family in caring for family members who have suffered a stroke. Based on the explanation given then the family psychoeducation can be a form of therapy for families with MR children in order to cope with anxiety and burden of caring for MR children which in turn can enhance the ability of families in the child's independence RM. Family as the smallest unit closest to the MR child, should be able to act as caregiver for MR children. That is what the family is very large role in helping the MR child independence. Form of management of the child's family RM, reinforces the concept that intervention is needed not only on for the child, but also the family as a system requires intervention. This is evidenced by research conducted by Miltiades and Pruchno (2001) in Maes, Broekman, Lecturer & Nauts, 2003) which confirms that the intervention should be given not only focus on children RM as an individual, but also involves directly to the needs of the family. Therefore, nursing interventions that focus on the MR child's family not only restore their state, but also to develop and enhance the ability of families to cope with the load and family health problems, particularly the psychosocial problems that may arise as a result of caring for mental retardation children. Conclusions Total of 32 parents who have children with MR shows the average ability in the child's independence before family psychoeducation therapy was 74.75 (at the level of Pretty Good). The results showed that, out of a total of 32 parents who have children with MR shows the average ability in the child's independence after a given family psychoeducation therapy was 80.66 (at the level of Good). Results of statistical analyze by using test dependent sample t-test (Paired ttest) demonstrated that the ability of the family in the MR child's independence after the family psychoeducation therapy increased significantly by 1.61 with a p value = 0.000 (α 0.05), then it can be concluded that there is a significant change in the average ability of the family in the MR child's independence before and after therapeutic intervention in the form of family psychoeducation therapy (p value 0,000 <α 0.005) Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Refferences 1. Carson, V. B. (2000). Mental Health Nursing: The Nurse-Patient Journey. (2th edition). Philadelphia: W.B. Saunders Company. 2. Friedman, (2010). Family nursing theory and practice. (Edisi 5). Jakarta: EGC. 3. Keliat, Budi Anna. (1995). Participation of Families In Care Mental Disorders Jakarta : EGC 4. Lumbantobing, S. M. (2001). Children With Mental Retarded. Jakarta : FKUI 5. Maes, Broekman, Dosen & Nauts. (2003). Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems. Journal of Intellectual Disability Research, volume 47, part 6, p 447-455 6. McIntyre, Blacher & Baker. (2002). Behaviour/mental health problems in young adults with intellectual disability: The impact on families. Journal of Intellectual Disability Research, volume 46 part 3, 239-249 7. Mohr.W.K. (2006). Psychiatric mental health nursing (6th ed). Philadelpia: Lippincott Williams dan Wilkins. 8. Muchayaroh, Luluk. (2002). Children With Mental Retarded Perception Families Against Children With Mental Retardation in Poli YPAC Physiotherapy Branch Malang. Undergraduate Thesis. http://digilib.itb.ac.id. Copyright © 2002 by UPT. Perpustakaan Muhammadiyah University of Malang. Gived at April 2012. 9. Notoatmojo, Soekidjo. (2002). Health Research Methodology.Jakarta : PT. Rineka Cipta. 10. Nurbani. (2009). psychoeducation: Anxiety and Family Expense (caregiver) in Caring for Stroke Patients in RSUP dr. 11. 12. 13. 14. 15. 16. 17. 18. 19. Cipto Mangunkusumo. Tesis. FIK-UI: Jakarta. Nursalam. (2003). Concept and Implemen-tation Methodology of Nursing Research: Guidelines for Thesis, Thesis and Nursing Research Instruments. Jakarta : Salemba Medika Pearce, John. (2000). Overcome Anxiety and Fear Child: Helping Children Ways Against Fear and Developing Confidence. translation: Liliana Wijaya. Jakarta : Penerbit Arcan Rasmun. (2001). Psychiatric mental health nursing integrated with the family: Concepts, theories, nursing care and interaction process analysis (API). Jakarta: CV Sagung Seto Resch, Mireles, Benz, Grenwelge, Peterson & Zhang. (2010, Maret). Giving parents a voice: A qualitative study of the challenges experienced by parents of children with disabilities. American Psychological Association Journals. Vol. 55, No. 2, 139–150 Soetjiningsih. (1995). Tumbuh Kembang Anak. Jakarta : EGC. Stuart, G. W. & Laraia, M.T. (2005). Principles and Practice of Psychiatric Nursing. (7th edition). St. Louis: Mosby. Utami, Yuniara R. (2009). Adjustment and Parenting Parents of Child Mental Retardation. Surakarta: Faculty of Psychology, University of Muhammadiyah. Varcarolis, Elizabeth M., et al. (2006). Foundation of Psychiatric Mental Health Nursing A Clinical Approach. (5th edition). Sounders Elsevier: St. Louis Missouri Walujani, Atika. (2003). Mental Health, New Understanding, New Hope. http:www. kompas.com. gived at april 5, 2013. 271 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology EVALUATION OF ANTIBIOTIC DOSE APPROPRIATENESS IN PATIENTS WITH CHRONIC RENAL FAILURE IN HAJI ADAM MALIK HOSPITAL MEDAN ON PERIOD JANUARY – JUNE 2014 Maya Natalina, Aminah Dalimunthe*, Khairunnisa, Imam Bagus Sumantri Faculty of Pharmacy, University of Sumatera Utara, Medan. email : [email protected] ABSTRACT Antibiotic is a substance produced by microbes that can inhibit or eradicate other microbes. In patients with chronic renal failure, the adjustment dose of antibiotic based on creatinine clearance. As some antibiotics are mainly excreted through renal, therefore it is necesarry to adjust the dose. One important indicator to reach therapy is the accuracy in giving dose to inhibit the progression of renal disease and to maintain the patient’s life quality. The aim of this study was to evaluation of antibiotic dose appropriateness in patients with chronic renal failure in Haji Adam Malik Hospital Medan on period January – June 2014. The method of dose adjustment in patients with renal failure is based on the drug clearance by Cockcroft-Gault equation. There are 82 medical records of patients with chronic renal failure which fits the inclusion criteria and used as a sample. The result showed that the majority of patients with chronic renal failure was at 39 – 48 years old (30,5%) and female (51.2%). Based on the stage, the majority of patients with chronic renal failure was stage 5 (72%), followed by stage 4 (18.3%), stage 3 (8.5%) and stage 2 (1.2%). The most widely antibiotic which used by patients with chronic renal failure was ceftriaxone (59.7%). The dose appropriateness of antibiotic was 93%. There was no difference of dose in patients with chronic renal failure in Haji Adam Malik Hospital Medan on period January – June 2014 based on characteristics of age, sex and stage chronic renal failure. It can be concluded that the dose of antibiotic use in patients with chronic renal failure on period Januay – June 2014 was appropriated, in accordance with standard treatment recommended by Haji Adam Malik Hospital Medan. Key words: Dose appropriateness, antibiotic, chronic renal failure BACKGROUND Chronic kidney disease is a pathophysiological process with diverse etiologies, can result in a progressive decline in renal function, and generally end up with kidney failure requiring renal replacement therapy which remains, in the form of dialysis or kidney transplantation (Suwitra, 2006). Chronic renal failure (CRF) is one disease that is not contagious and is a state of impaired renal function which is a chronic, progressive and irreversible underway (can not be returned to its original state) (Romauli, 2009). Criteria for chronic renal disease is kidney damage (renal damage) that occurred more than three months, in the form of structural or functional abnormalities, with or without a decrease in glomerular filtration rate (GFR). Manifestations is pathology and there are signs of renal disorders including abnormalities in the composition of blood or urine or abnormalities in imaging tests (imaging tests) 272 and glomerular filtration rate (GFR) of less than 60 ml / min / 1,73 m2 for 3 months, with or without damage Renal (Suwitra, 2006). According to Aslam (2003), the signs and symptoms of disease with chronic renal failure (CRF) include nocturia, edema, anemia (ironresistant, normochromic, normocytic), electrolyte disturbances, hypertension, bone disease (renal osteodystrophy), neurological changes ( lethargia example, mental disorder), impaired muscle function (eg, muscle cramps, sore feet) and uraemia (eg, decreased appetite, nausea, vomiting, pruritus). Uraemia (urea in the blood), which illustrates the high levels of blood urea, is often used as another word for renal failure (acute and chronic). Now, the prevalence of chronic renal failure (CRF) is increasing every year in developing countries. According to the research results Hallan, et al., 2006 states that the prevalence of chronic kidney disorders in the general population of Europe is equal to 10.2%, and Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology the prevalence of the United States in the amount of 11.5%. Based on data from the United State Renal Data System (USRDS) in 2013 estimated that more than 20 million (or more than 10%) of adults in the United States have chronic kidney disease per year. Cases of kidney disease in the world per year increased by more than 50%. Based on the survey results of Perhimpunan Nefrologi Indonesia (PERNEFRI) showed 12.5% (approximately 25 million people) of the population in Indonesia decreased kidney function (PERNEFRI, 2009). In recent years, patients with kidney failure in Indonesia is relatively high, reaching 300,000 people but not all patients can be treated by the medical staff, the new estimated 25,000 patients who can be treated, meaning that there are more than 80 percent of patients who have not received treatment (Susalit, 2012). Antibiotics are a group of drugs most commonly used today. Excessive use of antibiotics and is not appropriate in some cases, cause problems antimicrobial resistance. The use of more than one antibiotic for treatment of infection is still a controversial issue today (Aslam, 2003). Antibiotics are substances produced by microbes that may inhibit or eradicate microbes other types. Drugs used to kill microbes, cause infection in humans, must have selective toxicity properties as high as possible. This means that the drug must be very toxic to microbes, but relatively non-toxic to its hospes (Abidin, 2010). On impaired renal function, a dose of antibiotics adapted to creatinine clearance (creatinine clearance). Dose of medication is very important for a drug with toxictherapeutic ratio is narrow, or who are suffering from kidney disease. In general with creatinine clearance 40-60 ml / min maintenance dose reduced by 50%. When the creatinine clearance 10-40 ml / min, other than maintenance dose reduced by 50% should also extend the provision doubling the distance and try to avoid drugs that are nephrotoxic. List of antibiotics with the main elimination through the kidneys and require dose adjustment among others: the majority of ß-lactams, aminoglycosides, TMP - SMX, monobactam, ciprofloxacin, levofloxacin, gatifloxacin, gemifloxacin, vancomycin, nitrofurantoin, Phosphomycin, tetracycline, daptomycin, carbapenem, polymyxin B , colistin, and flucytosine (Ministry of Health, 2011). In some studies related to the adjustment of drug doses in patients with chronic renal failure, there are several methods to estimate the exact dosage regime for patients with renal impairment. Dose adjustments in patients with renal impairment is based on the patient drug clearance. Two common approaches to pharmacokinetics dose adjustments include methods based on drug clearance and methods based on the elimination half-life (Hassan, et al., 2009). Application of pharmacokinetics aims to improve the effectiveness of therapy or lowering the side effects and toxicity in patients. Dose adjustments in the form of a decrease in the total maintenance dose is often needed. Changes in dose are often encountered is lowering the dose of the drug or drug delivery interval prolongation, or a combination of both (Shargel and Yu, 1999). According to Aslam (2003), to select and determine the drug dosage required knowledge of the physiological changes that occur in the elderly, (such as decreased renal function, with the consequent decrease in drug clearance) and the frequency of drug side effects is higher. Therefore, some antibiotics excreted primarily through the kidneys, a dose adjustment is necessary and monitoring of drug levels in serum against certain medications in the elderly. In general, the class of beta-lactam antibiotics have side effects that most rare and lightest. Based on this background, it is necessary to study to look at the suitability dose of antibiotic use in patients with chronic renal failure are implemented in Haji Adam Malik Hospital. METHOD This research was conducted at the General Hospital Haji Adam Malik Medan is located at Jalan Bunga Lau number 17 in November 2014. As for the method, stage, flowcharts, operational definitions, data analysis, and the workings of this study. This study is non experimental and descriptive method design (design) cross-sectional study with 273 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology retrospective approach. The study was conducted in Haji Adam Malik Hospital with retrieval and data collection conducted in November 2014 with data collection for six months of observation, ie from January 2014 June 2014. amounted to (30.5%) and the lowest age group were in the age group 19-28 years amounted to (3.7%). These results indicate that age group are more likely to suffer CRF at the age group he was around thirteen years younger that are in the age group 39-48 years. Population and Sample The population in this study were all patients with chronic kidney disease who received antibiotic therapy in Haji Adam Malik Hospital in the period January 2014 - June 2014. Characteristics Stadium Descriptions regarding patient demographics were also conducted to determine disease stage chronic renal failure suffered by the patient. Distribution characteristics of CRF stage suffered by the patient can be seen in the table below. Data Analysis Data were collected from medical records checked and processed using the program Statistical Product and Service Solutions (SPSS) version 18.0, then presented in tabular form. RESULTS AND DISCUSSION This research has been conducted in Haji Adam Malik Hospital in November 2014. The data is taken from the medical records of patients hospitalized with a diagnosis of chronic kidney disease in the period January 2014 - June 2014. Based on the results of the research, found chronic renal failure patients is about 132 people and 82 patients from medical records of patients who met the inclusion criteria data to be used as research subjects. Based on the characteristics of the age of the subjects of this study, the age range of patients according to the table below. Table 1 Frequency Distribution Age Chronic Renal Failure Patients In Hospital Haji Adam Malik period January 2014 - June 2014. Frequency Age (years Percentage (Patients old) (%) Number) 19 – 28 3 3,7 29 – 38 12 14,6 39 – 48 25 30,5 49 – 58 22 26,8 59 – 68 13 15,9 ≥ 69 7 8,5 Total 82 100 In the above table shows that the age distribution in the age group 39-48 years 274 Distribution Characteristics Stage Chronic Renal Failure Patients In Hospital Haji Adam Malik period January 2014 - June 2014. LFG Stadiu Frequen Percenta (ml/min/1,73 m cy ge (%) 2 m) I >90 II 60 – 89 1 1,2 III 30 – 59 7 8,5 IV 15 – 29 15 18,3 V <15 59 72 Total 82 100 Table 3 Based on the results obtained from the characteristic table stage CRF suffered by patients in the period January 2014 - June 2014 showed that of 82 patients with CRF were using antibiotics, the majority were in stage 5 (72%). The small number of patients hospitalized in conditions of CRF stage 2 and the absence of CRF patients in stage 1 because the condition at an early stage the patient has not felt the complaint (asymptomatic) and the state of the glomerular filtration rate (GFR) was normal or even increased (Suwitra, 2006) , According Sjamsiah (2005), this is because in general the symptoms or clinical manifestations of the disease is the appearance of chronic renal failure is the sudden or gradual, even some that do not cause obvious symptoms early so that the decline in renal function are often not perceived even ignored by patients and only detected after his kidney condition worsened and the more severe clinical manifestations are usually on the condition of late-stage (stage 5). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Use of Antibiotics Based on the results of the study, of 129 antibiotic use in patients with CRF in Haji Adam Malik Hospital Medan period January 2014 - June 2014, the most widely used antibiotic was ceftriaxone (59.7%), followed by ciprofloxacin (29.5%), meropenem (5.4%), and metronidazole (3.9%). Data details can be found in Table 3.4 below. Tabel 4 Distribution Use of Antibiotics in Patients with Chronic Renal Failure In Haji Adam Malik Hospital period January 2014 June 2014. No Anibiotic Frequency 1 2 3 4 5 6 Cefotaxime Ceftazidime Ceftriaxone Ciprofloxacin Meropenem Metronidazole Total 1 1 77 38 7 5 129 Percentag P e (%) value 0,8 0,8 59,7 29,5 0,000 5,4 3,9 100 Appropriate Dose Antibiotic in Patients with CRF Results dispensing appropriate of antibiotic dosage in patients with CRF can be seen in Table below. Table 5 appropriate Dose of Antibiotic in Patients with Chronic Renal Failure in Haji Adam Malik Hospital Medan period January 2014 - June 2014. \appropriate Dose of Antibiotic Frequeny Appropriate Not appropriate Total 120 9 129 Percentage (%) 93 7 100 In this study showed dose conformity percentage of antibiotic use that from 129 the amount of antibiotics used in patients with CRF in Haji Adam Malik Hospital Medan period January 2014 - June 2014, acquired 120 number of antibiotics (93%) that their use complies with the standards on the treatment recommendations CRF patients, while 9 number of other antibiotics (7%) its use does not comply with the recommended standards. Results of the dose dispensing appropriate of antibiotic use in patients with CRF based on the characteristics of age, sex, and stage of CRF can be seen in the table below. Table 6 Appropriate Dispensing Antibiotic Dose in Patients with Chronic Renal Failure in Haji Adam Malik Hospital Medan period January 2014 - June 2014 Based on Characteristics of Age, Gender, And Stadium CRF. Appropriate Dosage Appropriate Not Appropriate Characteristic (Number of (Number of Patients) Patients) 19 – 28 3 0 29 – 38 11 1 Group 39 – 48 24 1 Age (Year 49 – 58 19 3 s Old) 59 – 68 11 2 69 – 79 6 1 Female 36 6 Sex Male 38 2 II 1 0 III 7 0 Stadium IV 15 0 V 51 8 P Value 0,806 0,157 0,327 Based on the research that has been written in the table above can be seen that the characteristics of age, almost every age group there is a dose of antibiotics is not appropriate where the largest number were in the age group 49-58 years (3 people), then in the age group 59 - 68 years (2), at any other age group only one person, and only in the age group 1928 years who did not have dosing of antibiotics are not appropriate. On the characteristics of gender shows that female gender who have suffered the greatest number of nonconformities dose antibiotic use as many as six people. Then on the characteristics of the patient's CRF stage, it can be seen that only on stage 5, which has a discrepancy dose antibiotic use as many as 8 people. Stage 5 is the stage with the state of renal function has worsened and the patient began to experience symptoms severe enough because the kidneys are no longer able to maintain fluid and electrolyte homeostasis in the body, and therefore are expected to pay more attention to the dosing of antibiotics and also drug- Other medicines will be given so as not to worsen the patient's condition. In Table 6 shows that there are 8 people CRF patients who experienced a number of mismatches dose of antibiotic use in accordance with the recommended dose, while in table 3.5, there are 9 number of antibiotics whose use is not in accordance with the recommended dose. The difference is because 275 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology there is a discrepancy figures panggunaan doses of antibiotics for 2 number of antibiotics that are given to a patient. In the seven other patients who had mismatches dose, each patient experienced a dose discrepancy antibiotic use antibiotics only for one number so that when added together it will remain there nine the number of antibiotics whose use is not in accordance with the recommended dose. CONCLUSIONS The percentage of the most widely used antibiotics in patients with chronic renal failure is ceftriaxone (59.7%), followed by ciprofloxacin (29.5%) and meropenem (5.4%). Analysis of the data showed that there are significant differences in the types of antibiotics that are used in patients with chronic renal failure in Haji Adam Malik Hospital Medan period January 2014 - June 2014. The level of dose conformity in the use of antibiotics are used in patients with chronic renal failure in Haji Adam Malik Hospital Medan the period January 2014 - June 2014 has been good, a total of 120 the number of antibiotics (93%) dose use has been in accordance with the recommended standard treatment guidelines based on the analysis of data and there is no difference suitability dose use of antibiotics in patients with chronic renal failure in Haji Adam Malik Hospital Medan the period January 2014 - June 2014 based on the characteristics of age, sex and stage of chronic renal failure. BIBLIOGRAPHY Abidin, Z. (2010). Antibiotik. Diambil dari http://meetabied.wordpress.com /2010/06/03/antibiotik. Tanggal akses 8 Oktober 2014. Aslam, M., dkk. (2003). Farmasi Klinis. Jakarta: PT Elex Media Komputindo Kelompok Gramedia. Halaman 137139, 328. Hallan, SI., Josef C., Brad, C.A., Arne, A., Neil, R.P., Solfrid, R., Hans, A.H., Stian, L., dan Jostein H. (2006). International comparison of the 276 relationship of chronic kidney disease prevalence and ESRD risk. Journal of the American Society Nephrology. 17(8): 2275 – 84. Hassan, Y., Al-Ramahi, R., Abd, A.N., dan Ghazali R. (2009). Drug use and dosing in chronic kidney disease. Annals of the Academy of Medicine. 38(12): 1095 – 103. Ministry of Health RI (2011). Pedoman Umum Penggunaan Antibiotik. Jakarta: Kementerian Kesehatan Republik Indonesia. Halaman 48. PERNEFRI. (2009). Konsensus Dialisis. Jakarta : Perhimpunan Nefrologi Indonesia. Halaman 21 – 34. Romauli. (2009). Karakteristik Penderita Gagal Ginjal Kronik (GGK) Yang Di Rawat Inap Di Rumah Sakit Umum Daerah Dr.H.Kumpulan Pane Tebing Tinggi Tahun 2007-2008. Skripsi. Medan: Fakultas Kesehatan Masyarakat Universitas Sumatera Utara. Shargel, L., dan Yu, A. (1999). Applied Biopharmaceutics and Pharmakokinetics. 4th ed. Mc GrawHill Companies. Halaman 532. Sjamsiah, S. (2005). Farmakoterapi Gagal Ginjal. Surabaya: Universitas Airlangga. Halaman 214. Susalit. (2012). Teknik Baru Pengobatan Gagal Ginjal. Diambil dari http://koranjakarta.com/index.php/detail/view01/8 1403. Tanggal akses 10 Oktober 2014. Suwitra, K. (2006). Penyakit Ginjal Kronik. Dalam: Sudoyo, A.W., Setiyohadi, B., Alwi, I., Marcellus, S.K., Setiati, S. Edisi keempat. Buku Ajar Ilmu Penyakit Dalam Jilid I. Jakarta : Pusat Penerbitan Departemen Ilmu Penyakit Dalam FK-UI. Halaman 570–572. USRDS. (2013). Annual Data Report: Atlas of Chronic Kidney Disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease. 1(16): 1 – 148 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology WOMAN’S KNOWLEDGE AND ATTITUDES ABOUT PARTICIPATION IN THE INVESTIGATION IVA TEST (VISUAL INSPECTION OF ACETIC ACID) IN DUSUN IV DESA TENGAH PANCUR BATU SUB-DISTRICT DELI SERDANG 2014 Suswati, Dewi Meliasari Department of Midwifwery, Polytechnic of Health, Medan ABSTRACT Low coverage of early detection or screening is one of the reasons why increasing the incidence rate of cervical cancer reach out 1.4 million women in the world, this study aimed to know the woman’s participation in investigation IVA test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang regency 2014. This study used descriptive method. Population was all of women that had married who become subject investigation IVA test (Visual Inspection of Acetic Acid) in Dusun IV, sample were taken as many as 57 people. Sampling technique was used total sampling. This study conducted from March until July 2014. The result of study showed from 57 respondent, the majority of respondents didn’t want to participate in investigation IVA test (Visual Inspection of Acetic Acid) were 35 people (61.40%), majority of the less knowledgeable were 25 people (43.90%), the majority that have supportive stance were 37 people (65.00%), well knowledgeable with the supportive stance were 18 people (48.64%), and well knowledgeable women’s majority with supportive stance about participation in investigation IVA test were 18 people (48.64%). Respondent’s knowledge and attitudes about participation in investigation IVA test (Visual Inspection of Acetic Acid) were less knowledgeable and supportive stance. Hopefully, for midwives and health workers more increase information about health. So, hopefully women can be more participation in investigation IVA test (Visual Inspection of Acetic Acid). Keywords : Woman’knowledge, attitudes, IVA Test INTRODUCTION Cervical Cancer is important health issues for women around the world. Cervical cancer is a malignancy that occurs in the cervix caused by Human Papilloma Virus (HPV). HPV is transmitted through sexual contact and its infection occurred in 75% of women who had been sexually. This cancer has invaded more than 1.4 million women worldwide (Depkes, 2009). According to International Agency for Research on Cancer (IARC) in Depkes (2008), cervical cancer took second place of all cancers in women with the incidence rate of 9.7% and 9.3% the number of deaths from all cancers for women in the world. According to World Health Organization (WHO) predicted that more than 500.000 new cases of cervical cancer were found in the world and 90% of all cases are in the developing countries. if it is not followed up with immediately, deaths due to cervical cancer in Indonesia is expected to increase almost 25% in the next ten years is 16 per 100.000 women (Astana, 2009). Based on the evaluation of cervical cancer management at H. Adam Malik hospital and Pirngadi hospital during the last 5 years cervical cancer. Data analysis included age, parity, clinical stage, histopathology type, method of treatment. With the results during this period obtained a number of 303 patients with cervical cancer. The largest age group is 40-49 years is 151 cases (49.83%), Lili. (2010). In Indonesia screening programs (early detection) has not been a priority in the government program. Many cases of cervical cancer were not detected by health workers caused by the lack of awareness and participation of women in the early detection of cervical cancer, so this has resulted in women belatedly realized their cervical cancer (Diananda, 2009). Besides Pap Smears, early detection can be done by IVA (Visual Inspection of Acetic Acid) that inspection with acetic acid 4%. In Indonesia itself, a factor of late diagnosis and the expensive medicines and 277 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology care costs are a major obstacle treatment cervical cancer (Setiawan, 2010). The results of tests IVA (Visual Inspection of Acetic Acid) in health centers Pancur Batu Deli Serdang. From 235 people as a target IVA programs that is in the Desa Tengah only 63 people or (18.80%) who want to come and doing the IVA test (Visual Inspection of Acetic Acid). RESEARCH METHODS The research is Descriptive research in which the data taken is the primary data. Data obtained from the questionnaire assessment that aimed to know women's participation in the development of inspection IVA test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang regency 2014 (Notoatmodjo, 2010.a). Populations in this study were all women, including inspection targets IVA (Visual Inspection of Acetic Acid) in Dusun IV in 2014 which amounts to 57 people. The numbers of samples in the study were 57 people using total sampling technique that was the entire population of 57 people who sampled the study (Suliystyaningsih, 2011). This research was done in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang regency 2014 because there are still many women who did not want to do inspection IVA test (Visual Inspection of Acetic Acid) by reason of shame and did not know about the IVA test (Visual Inspection of Acetic Acid). The research was done from June – August 2014 Data have been collected, the processed manually with the following steps (Notoatmodjo 2010.a) : a. Editing Process Checking list of questions that have been submitted to the respondents, when did inspection completeness of questionnaire answers still found respondents who did not answer all the questions fully so that researchers did confirm to respondent to fill in all questionnaires fully. b. Coding Process The author clarified existing answers by giving a code-shaped figure. Namely 1,2,3......to 57 in which names and respondents answer replaced in numbers. c. Scoring Process Calculating or scoring on the respondents answer. Value was given depending on the number of question and 278 appropriate with the predetermined measurement aspect. Measurement of knowledge conducted based on the total value of respondents answer from all the questions that given with the total questions as many as 20 in the form of multiple-choice questions a. If it is true gets the score 5 b. If it is wrong gets the score 0. Measurements conducted on the attitudes based on the total value of the respondents' answers from all the questions that given with the total questions as many as 20 questions. For the supporting question a. Totally Agree: TA (Score 4) b. Agree: A (Score 3) c. Disagree: DS (Score 2) d. Totally Disagree: TDS (Score 1) For the question did not support the category a. Totally Agree: TA (Score 1) b. Agree: A (Score 2) c. Disagree: DS (Score 3) d. Totally Disagree: TDS (Score 4) Data analysis conducted by using Descriptive Analysis by looking at the percentage of data that has been collected and presented in the form of a frequency distribution tables and an explanation, about everything related to the woman's participation in the investigation IVA test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang 2014. RESULT AND DISCUSSION RESULTS The results of this study based on the primary data had been conducted for respondent’s participation obtained as follows : Table 1 Distribution of respondent's participation in the investigation IVA test (Visual Inspection of Acetic Acid) Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang 2014 No Respondent’s Sum participation in F % investigation IVA test 1 Want 22 38.60% 2 Do not want 35 61.40% Total 57 100% Based on the table 1 above can be seen that the participation of respondents are Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology willing to participate in the investigation IVA test (Visual Inspection of Acetic Acid) in Desa Tengah Pancur Batu sub-district were 22 people (38.40%) and the respondents who would not participate in the investigation IVA test (Visual Inspection of Acetic Acid) in Desa Tengah Pancur Batu sub-district were 35 people (61.40%). Table 2 Distribution of respondent's knowledge about participation in the investigation IVA test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu subdistrict Deli Serdang 2014 No Knowledge Sum F % 1. Good 15 26.30% 2. Enough 17 29.80% 3. Less 25 43.90% Total 57 100 Based on the table 4.1.2 above can be seen that the majority of respondents knowledge in the investigation IVA test (Visual Inspection of Acetic Acid) in Desa Tengah Pancur Batu sub-district less knowledge as many as 25 people (43.00%) and good knowledge of minority as many as 15 people (26.30%). Table 3 Distribution of respondent's participation in the investigation IVA test (Visual Inspection of Acetic Acid) based on Attitude in Dusun IV Desa Tengah Pancur Batu subdistrict Deli Serdang 2014 No Attitude F % 1 Support 37 65.00% 2 Not Support 20 35.00% Total 57 100 Based on table 3 above can be seen that from 57 respondents majority were supportive as many as 37 people (65.00%), and the minority did not support as many as 20 people (35.00%). Table 4. Distribution of respondent's knowledge about participation in the investigation IVA test in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang 2014 (Visual Inspection of Acetic Acid) No Attitude Knowledge Good F % 1 Support 18 48.6 4 2 Not Support 2 10 Enough F % 14 37.8 5 4 20 Sum Less F % F 5 13.5 37 1 12 70 20 % 100 100 Based on table 4 above can be seen that the majority of good knowledgeable respondent with the supportive stance were 18 people (48.64%), and the minority of enough knowledgeable with not supportive stance were 2 people (10%). DISCUSSION From the results, it can be known about the respondent's participation in the investigation IVA test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang regency 2014 based on knowledge and attitude. Based on the result of research, can be known that respondents majority with less knowledgeable were 25 people (43.90%), enough knowledgeable were 17 people (29.80%), good knowledgeable were 15 people (26.30%). Basically, knowledge consists of all facts and theories that enable someone for resolve their problems. The knowledge obtained either from direct experience or through the others experience. If the person's level of knowledge higher in daily life it would be good because it is based on science. According to the assumption of the author, the results of this study are consistent with the statement Notoatmodjo. From the results showed that woman who did not want to do inspection IVA test (Visual Inspection of Acetic Acid) are less knowledgeable, where knowledge affects the woman's participation in the investigation IVA test (Visual Inspection of Acetic Acid). The results obtained by researchers accordance with the results of the study from Melva (2009), stated that the knowledge is good, then the woman will be aware to check the IVA test because it is important to health. 279 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Based on the result of research, can be known that from 57 respondents’ respondents’ majority have supportive stance in investigation IVA test (Visual Inspection of Acetic Acid) were 37 people (65.00%) and not supportive stance were 20 people (35.00%). According to Notoatmodjo (2010), after someone knows the stimulus or the next object processes then assess or act towards an object or object stimulus. Then conduct an assessment or opinion which known to be practiced or implemented in daily life. According to the assumption of the author, the results of this study are consistent with the statement Notoatmodjo, because the results showed that woman who did not want to do inspection IVA test (Visual Inspection of Acetic Acid) have not supportive stance which the attitude affects someone to participate in investigation IVA test (Visual Inspection of Acetic Acid). The result of this study is consistent with Masrina (2008) stated that respondents have good attitude because respondents have knowledge, balance in belief, it is also consistent with theory of Walgito, that not supportive attitude appear because the unpleasant feelings caused by the lack of resources IVA test either benefit or how it works. But there is also woman with good knowledge but still not support; this case happened because she has not confidence to do in daily life. Based on the result of research, from 37 respondents respondent’s majority have good knowledge with supportive stance in investigation IVA test were 18 people (48.64%), enough knowledge were 14 people (37.85%) with supportive stance, and minority less knowledge with not supportive stance were 5 people (13.51%). From 20 respondents majority less knowledge with not supportive stance in investigation were 12 people (70%), enough knowledge with not supportive stance were 4 people (20%), and minority good knowledge with not supportive stance were 2 people (10%). According to Notoatmodjo (2010) after someone knows the stimulus or the next object processes then assess or act towards an object or object stimulus. Then conduct an assessment or opinion which known to be practiced or implemented in daily life. The results of this study are consistent with the theory of Notoatmodjo (2010), 280 because from the result of research found that respondents that have good knowledge with supportive stance in investigation in IVA test. While woman didn’t want to check in IVA test have less knowledge with not supportive stance. This research is consistent with the result of research from Evidasanti (2010) said that knowledge and attitude will affect woman’s perception in doing check in IVA test. CONCLUSION From the result of research and discussion “Woman’s Knowledge and Attitudes about Participation in the Investigation IVA Test (Visual Inspection of Acetic Acid) in Dusun IV Desa Tengah Pancur Batu sub-district Deli Serdang regency 2014” can be conclude that : 1. Woman’s less knowledge were 25 people (43.90%), compared with good knowledge were 15 people ( 26.30%). It can be happened because less knowledge will affect the woman’s participation in doing IVA test (Visual Inspection of Acetic Acid). 2. Not supportive stance were 20 people (35%). It can be happened because woman’s knowledge still low about investigation IVA test, so it affected woman’s participation in doing IVA test. 3. Woman didn’t want to check in IVA test have less knowledge with not supportive stance were 12 people (70%). It can be happened because woman’s knowledge and attitude affect in doing IVA test. REFERENCES Arifin, Zainal. 2010. Learning Evaluation. Rosda karya, Bandung. Astana, Mahesa. 2009. Friends with Cancer. Araska. Yogyakarta. Depkes. 2008. Depkes RI Profile, Cervical cancer. Diananda, Rama. 2009. Know the Ins and Outs of Cancer. Kata hati. Jogjakarta. Dunleavey, Ruth. 2009. Cervical cancer, a guide for Nurse. 2009. Willey – Black Well. Sidney Australia. Emilia. 2010. Women's Reproductive Health. Araska. Yogyakarta. Fariz, Aziz. dkk. 2008. Gynecologic Oncology. Bina pustaka Sarwono Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Prawiroharjo. Jakarta. Indrapraja. Cervical Cancer and Prevention. Dalam Nugroho, Taufan. 2010. Jakarta. Pustaka Pelajar. Lili. Garliah. 2009. Cervical Cancer Research Report. Medan Indonesia. FK.USU. Marmi, dkk. 2011. Pathological Midwifery Care. Yogyakarta. Pustaka Pelajar. Nazir, Moh. 2009. Research Method. Ghalia Indonesia. Bogor. Nugroho, Taufan. 2010. Women's health, Gender and Problems. Nuha Medica. Yogyakarta 281 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology THE EFFECTS OF PEPINO (Solanum muricatum) EXTRACT TO THE DECREASE OF GLUCOSE CONTENT IN BLOOD OF WHITE RATS Ratus novergicus) Riris Opposunggu, Bernike Doloksaribu, Oslida Martony Department of Nutrition Health Polytechnic of Kemenkes Medan ABSTRACT The developing countries face the health problem. One of them is degenerative disease. The prevalence of diabetes mellitus in the world is increase drastically in the last decade and it estimate this number is increase in the future In Indonesia, it increase from 2.5 million in 1994 to be five million in 2010. Manganese mineral in pepino has function as anti diabetic, in addition to the content of –sitosterol and stigma sterol as active compound as anti hyperglycemia on pepino extract. This research aims to study the influence of pepino extract to the decrease of glucose content in blood of white rats. The population in this research is white rats (Rattus norvegicus) and sample in this research is 16 white rats. This research is experimental study. The collected data was primary data by take the data of experiment result, i.e. data of measurement of beginning blood glucose content and end blood glucose content of the white rats using digital glucose test. Based on the results of statistical test using Anova test, the value of p (0.000) < α (0.05), it means that there is an influence of pepino extract to the decrease of blood glucose content on white rats. The result of analysis by Duncan test, the application of pepino extract will decrease the blood glucose contant for 67.5 mg/dl. The application of pepino extract for 1 ml/day during 2 weeks will decrease the blood glucose content for 67.5 mg/dl Keywords : Blood glucose contant, Pepino INTRODUCTION A. Background The developing countries face the health problems and one of them is degenerative disease. The national health survey indicates that the increasing of prevalence of diabetes mellitus for 8.3% of the population in 1996. In 2003, 194 million of people in the world whose the age 20 – 79 years old are diagnosed with diabetes mellitus disease. In 2025 it estimates the number to be 72% of 333 million people in the world. (Matsura, 2005) The data of World Health Organization (WHO) indicated that the number of patient with diabetes mellitus in Indonesia is in the fourth position after India, China, USA for 17 million people (8.6%). Even 7.5% of population in Java and Bali have diabetes mellitus (Alidjaja, 2003). WHO estimates, the global prevalence of Diabetes Mellitus type 2 will increase from 171 people in 2000 to be 366 millin in 2030. Indonesia is in the fourth big nation with the diabetes mellitus in the world. Pepino (Solanum Muricatum) as member of family Solanaceae (eggplant) contains gum, B-cytosterol and Stigmasterol and the lower 282 glychemic index. The content of Manganese in pepino has a function as co-factor of any enzymes that help a process to regulate the insulin because its glychemical index is lower that delay the increasing of blood glucose content and to maintain the normal glucose content, B-cysterol and Stigmasterol tht increase the production of insulin (HGakimah, 2010). Problem Formulation What the influence of application of pepino (Solanum Muricatum) extract to the decrease of blood glucose content of white rats (Rattus Novbergicus). B. The Objective of this Research 1. General Objective To study the influence of the application of pepino (Solanum Muricatu) extract to the decrease of blood glucose content of white rats (Rattus Novergicus). 2. Specific Objective a. To study the beginning blood glucose content of white rats (Before the application of glucose 1 ml/day during 1 week). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology b. To study the end blood glucose content of white rats (After the application of pepino extract 0.5 ml, 0.75 ml, 0.1 ml during 2 week). c. To analyze the influence of the application of pepino extract to the decrease of blood glucose content of white rats. C. Purposes of Research As information to the patient of diabetes mellitus about the influence of the application of pepino extract to the decrease of blood glucose content. METHOD OF RESEARCH A. Location and Time of Research This research was conducted at chemical laboratory of Nutrition Department of Politekkes Kemenkes Medan since June up to August 2014. B. Type and Design of Research This research is poor experimental study using randomization. The choosing of research object for groups and application of treatment is using RAL method with Posttest Only Design Group. C. Population and Sample Population in this research : white rats in species of Rattus Novergicus Strain Wister that consist of 16 white rats, the number of sample is 3 for each repetition and 4 treatment (X0, X1, X2, X3) and 4 reserves so it needs 16 white ratas. 1. White rats (Rasttus novergicus) is experiment animals in white color and body weight is 250 gr, age 2 months 2. Blood glucose content is the measurement of blood glucose content of white rats before the application of glucose 50% for 1 ml/day. 3. The end blood glucose content is the measurement of blood glucose content of white rats after the application of pepino extract in dosage 0.5 ml, 0.75 ml and 1 ml during 2 weeks. 4. Glucose 50% is 50 gr glucose crystal dissolved into 100 ml aquadest D. Procedure of Research The procedure of research are : 1. Preparation a. Cage preparation b. Choosing the experiment animal (male white rats) c. Numbering of white rats d. Preparation of glucose solution 50% 2. Experiment phase With four groups (X0, X1, X2 and X3), the experiment procedure are as follows : Step 1 : Adaptation during two days Step 2 : In the third day, the glucose 50% was applied in dosage 1 ml/day Step 3 : In the eleventh day, to apply the pepino extract in dosage 0.5 ml/day, 0.75 ml/day and 1 ml/day during fourteen days in group X1, X2, X3 while group X0 did not get the pepino extract and only as control. On the 26th day, the blood was took and to measure the blood glucose content on group X0, X1, X2 and X3. Type and Method of Data collecting The type of data is primary data Data processing and analysis The applied statistical test is One Way Anova Test (p = 0.05) to test the comparison of average of blood glucose content on white rats in each groups. If in One Way Anova test there is different average, so it need the advanced analysis (Post Hoc Test Tukey ) (p = 0.05) to determine group with the different of average of blood glucose content on whire rat. RESULTS AND DISCUSSION The blood glucose content of white rats Table of analysis of blood glucose content of white rats No Treatment Group N KGD White rats (mg/dl) Mean ± SD 1 Control (X0) 4 141.50 ± 3.10a 2 Treatment (X1) 4 130.00 ± 3.55a 3 Treatment (X2) 4 116.50 ± 8.58b 4 Treatment (X3) 4 95,50 ± 6.55c Note *) the different notation indicates the significant difference )p < 0.05) The average of blood glucose content on group X3 has a lower content (95.50 ± 6.55) it means that the application of pepino extract in dosage 1 ml/day decrease more the blood glucose content, while the higher one is in group X0 (141.50 ± 3.10) The result of analysis by One Way Anova indicates that there is decrease of glucose content significantly (p<0.05) on the treatment group of X1 (130.00 ± 3.55) if compared toi 283 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology KDG Tikus Putih (mg/dl) treatment X0 (141.50 ± 3.10), treatment group of X2 (116.50 ± 8.58) and treatment group of X3 (95.50 ±6.55). based on the results indicate that the higher of dosage of pepino extract, the higher of decrease of blood glucose content on white rats. This proves that decrease of blood glucose content in dosage 1 ml give a maximum result in decr5ease blood glucose content. Depiction of comparison of the average of blood glucose content of any groups before analysis by One Way Anova is as follows : 200 141.5 130 116.5 95.5 100 0 X0 X1 X2 X0 X1 X2 X3 Perlakuan X3 Figure : The Average of Blood glucose content of white rats. Based on the figure, it indicates that there is change of blood glucose content that different in group X0, X1, X2 and X3. The application of pepino extract in the various dosages, i.e. 0.5 ml, 0.75 ml and 1 ml will decrease the blood glucose content of white rats. The decrease of blood glucose content of white rats is caused by the compound of β-cytosterol and stigmasterol as active compound that give an effect of anti hyperglycemic β-cysterol and st5igmasterol on pepino extract as unsaturated fitosterol. Β-cytosterol and stigmasterol is a combination and compound of fitosterol that provide a good synergic effect than the single compound (Hakimah, 2010) Based on results of Homogeneous test, p value = 0.087 (p value > 0.05) indicates that the variance of sample groups is same or homogenous. Based on results of Anova Test, p value = 0.000 (p value < 0.05) and indicates that the average of blood glucose content on treatment group is not identicfal or there is difference of average of decrease of blood glucose content on white rats by the application of pepino extract with the various dosages. Based on result of Anova Test value < 0.05 is not identical or there is difference of average, the test is continued by see the p value of the Multiple Comparison table. And p value on Multiple Comparison table, p value = 284 0.000 (p value < 0.05), this result indicates the average of blood glucose content on each treatment is not same. Conclusion The application of pepino extract for 1 ml will decrease blood glucose content of white rat for 67.14 mg/dl while the application of pepino extract for 0.5 ml will decrease the blood glucose content of white rats for 27.7 mg/dl. Suggestion It is sugg4ested to the patient with the higher blood glucose content to decrease the glucose content by consume pepino. Bibliography Almatsier, Sunita. 2004. Prinsip Dasar Ilmu Gizi. Gramedia Pustaka Utama. Jakarta Alidjaja, Juniarta, 2003. PerananFunction Food Dalam Upaya pencegahan dan Pengobatan Beberapa Penyakit. Jurnal Pertemuan Ilmiah Nasional (PIN) AsDI ke III. Yogyakarta Candra , Budiman,2007, Metodologi Penelitian Kesehatan, Jakarta. Indra R. M. 1999, Penelitian Eksperimental dalam Buku Ajar Metodologi Penelitian, Malang, FK Universitas Brawijaya. Ide, Pangkalan. 2010. Health Secret of Pepino. Mencicipi Pepino si Buah Ajaib, Pendatang Baru Asal Pegunungan Andes sebagai Obat Dewa. Jakarta : PT. Gramedia Pustaka Utama. Handayani, Diah. 2007. Peranan Micronutrient Pada Diet Diabetes Mellitus. Seminar 2nd Malang Nutrition UpDate- Santika Hotel 3-4 Nopember 2007 Hakimah Ainun indi. 2010. 81 Macam Buah Berkhasiat Istimewa. Syura Media Utama. Jawa Tengah. Matsura. 2005. Core Competencies In Diabetes Care. Jurnal, NCD Malaysia 2005, Volume 4, No 2. Enrico Marentek. 2006 Retensi Insulin Pada Diabetes melitus Type 2. Jurnal, Makasar Nurjanah Nunung, 2006. Taklukkan Diabetes Dengan Terapi Jus. Puspa Swara. Jakarta Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology SATISFACTION LEVEL OF OUTPATIENT TO THE PHARMACY INSTALLATION SERVICE AT RS KUSTA PULAU SICANANG BELAWAN Sitanggang, Rosmayani Silitonga, Cory Karlina Purba [email protected] Abstract Leprosy is chronic transmitted infection disease caused by Mycrobacterium lepra. These bacteria attract the skin and periphery nerves on human being. This research aims to study the satisfaction level of the outpatient to the pharmacy installation service with sample of 64 respondents of outpatient who stay at lodging of RS Kusta P. Sicanang, Belawan who have be cared. In order to get the data of results, each respondent fill the questionnaire based on the received service. The satisfaction level of outpatient on 5 studied dimension, such as : (1) the respond of officer is satisfactory 75.52%, (2) Reliability of officer is quite satisfactory 71.06%. (3) Guarantee for the availability of medicines is quite satisfactory 68.39%. (4) the empathy of officer is quire satisfactory 68.59% and (5) physical condition of hospital is quite satisfactory 61.81%. the performance of officer or staff of Pharmacy Installation is based on the expectation of the patient so the client is satisfied and quite satisfied to the service of hospital. Keywords : Service of Pharmacy Installation officer, satisfaction level of the outpatient, Rumah sakit Kusta P. Sicanang. Introduction Hospital is a place to do the health care by : The increasing of health level Disease preventive Treatment Halth recovery harmoniously, integrally and continuously in Puskesmas (Health Center), Hospital type E, type D, type C, type B and type A. Method of Research This research applies descriptive method, i.e. a depiction of the satisfaction level of outpatient to the service of pharmacy installation to the outpatient who stay at lodging of hospital. The collected data of this research are : (1) Primary data, i.e. data collected from the patient directly through direct interview and questionnaire. (2) secondary data is data of patient from hospital, (3) the data was collected in 2 weeks. The sample was took by purposive sampling method with criteria is patient who stay in lodging around the hospital. The Data Analysis The characteristic of respondent based on gender and age NoRespondent Number (person)Percentage (%) 1 Gender Male 32 50 Female 32 50 2 Age range 15-25 (years) 12 19.75 25 – 35 (years) 35 – 50 (years)11 17.19 > 50 (years) 30 46.87 11 17.19 Characteristic and type of service Charact Type of service No. of eristic SM M CM No Questi of (5) (4) (3) onnaire service 1 Respons 3 27 103 55 e 2 Reliabili 5 39 131 123 ty 3 Quarant 8 23 202 220 ine 4 Empath 4 21 103 100 y 5 Physical 5 3 103 145 KM SKM Total Percent (2) (1) 6 1 725 75.52 22 5 1137 71.06 65 2 1715 71.06 29 3 878 68.59 58 11 989 61.81 285 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology SM M CM KM = Very satisfactory = Satisfactory = quiet satisfactory = not satisfactory Conclusions The satisfaction level of outpatient on 5 studied dimension, such as : (1) the respond of officer is satisfactory 75.52%, (2) Reliability of officer is quite satisfactory 71.06%. (3) Guarantee for the availability of medicines is quite satisfactory 68.39%. (4) the empathy of officer is quire satisfactory 68.59% and (5) physical condition of hospital is quite satisfactory 61.81%. the performance of officer or staff of Pharmacy Installation is based on the expectation of the patient so the client is satisfied and quite satisfied to the service of hospital. References Ahaditomo ( 2003, 1995) Pelayanan yang berhubungan dengan penggunaan obat, Jakarta. Azwar (1996) Pelayanan Kesehatan Bermutu, Jakarta. Charles, J.P dan Amalia.2003, Farmasi Rumah Sakit, Teori dan Penerapan, EGC: Jakarta. Ditjen PP-Pl (2007). Buku Pedoman Pemberantasan Penyakit Kusta 286 Dermawan (2008), Pusat Latihan Kerja Nasional. RS. Kusta P. Sicanang. Makasar. Kotler, Philip dan Amstrong, G.1997, Dasardaras Pemasaran, Jakarta: Prenhalindo. Kotler, Philip dan Kevin Lane Keller, 2008, Manajemen Pemasaran (Marketing Management, Thirtennth Edition) : Jakartta. Naafs dan Wheate (1978). Interval waktu antara awal anti lepra Pengobatan dan perkembangan reaksi pada pasien Lepra, Jakarta. Parasuman, dkk (1998). Skala Servqual; yang terbagi atas lima dimensi, Yogyakarta. Supranto, (1997). Kual;itas Pelayanan Penyedia Jasa, Jakarta. Tjiptono dan Fandy. 2008, Sevice Management Mewujudkan Layanan Prima, Jogjakarta Watson dan Jean M (1996). Tindakan penting untuk mengurangi resiko cacat pada penderita kusta, Jakarta. Wexley dan Yukl (1997), Kepuasan Konsumen, Jakarta. http://bhogey.com/2009/11/fungsi-tugas-dantipe-tipe-rumah-sakit.html http://repository.usu.ac.id/bitstream/12345678 9/21823/4/Chafter%20ii/pdf Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology OVERVIEW OF KNOWLEDGE AND PUBLIC ATTITUDE TOWARD THE USE OF MEDICINE WITHOUT PRESCRIPTION IN YASMIN PHARMACY AT JALAN PINANG BARIS MEDAN Zulfa Ismaniar Fauzi [email protected] ABSTRACT Healthy is a health condition, either physics, psychic, spiritual or social that enable anyone for productive life either socially or economically. One of efforts to increase the health level of society is a pharmacy related work and one of pharmacy service by pharmacy is self medication or the using of medicine without prescription. This research is a descriptive study. The method of data collecting is a survey by distribute the questionnaire to the respondent. The population in this research is 1623 and the number of sample is 94 respondent. The results of research indicates that all of respondent, 83% know the definition of self medication, know the type of medicine use in self medication (82.6%), 83.0% of respondent know that the antibiotic must be used up in the determined period and 73.4% know that did not all of diarrhea treated by antibiotic. The attitude of respondent to the using of medicine without prescription is profitable to he people (45.7%), is hazardous for health without direction of using (55.3%), is cheaper than medicine with prescription (51.1%) and must known based on clear direction (48.9%) Based on this research it concluded that the people has a good knowledge for 53 respondent (56.4%). The people who has a good attitude is 51 persons (54.3%). Keywords : Knowledge, Attitude of user of medicine without prescription INTRODUCTION According to the Act No. 36 of 2009, healthy is a health condition, either physics, psychic, spiritual or social that enable anyone for productive life either socially or economically. The health development as one of efforts of the national development in order to achieve the awareness, willingness and capability for health life for each people in order to realize the society health level optimally. The implementation of health activities by maintenance approach, health service, health promotion, diseases prevention, disease treatment (curative) and rehabilitation. One of efforts for the increasing of health level of society is through pharmacy related work, and the place of the pharmacy activity is pharmacy. Self medication can be performed for the mild, general and non active diseases (Wulandari, 2010). The using of medicine in self medication is one of health attitude. The type of medicine used by people in self medication is free drugs, limited free drugs and Pharmacy Compulsory drug. Factors influence the increasing of self medication is the development of innovative pharmacy technology, type and brand that known by society, the change of regulation about the medicine or pharmacy, the awareness of society on the importance of health , the influence of information or advertisement, the easiness to get the medicine and the high price of health condition. METHOD OF RESEARCH This research describe an overview of knowledge and public attitude toward the using of medicine without prescription in Yasmin Phrmacy Jalan Pinang Baris Medan. The data was processed using descriptive method with survey research model in cross sectional study, i.e. a research to study the correlation dynamic between the risk factors with effect and approach method, observation or data collecting, simultaneously. (Sugiyono, 2010). SAMPLING The sample of this research is took by purposive sampling based on certain consideration determined by researcher, based on known characteristic (Notoatmodjo, S. 2010). The criteria of sample is a consumer who buy the medicine without prescription. 287 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology RESULT Category of Knowledge of Respondent to the Using of Medicine without prescription at Yasmin Pharmacy Jalan Pinang Baris Medan. No Category of Frequency Percentage Knowledge 1 Good 53 56.4 2 Good 16 17.0 enough 3 Poor 24 25.5 4 Bad 1 1.1 Total 94 100.0 Category of Attitude of Respondent to the Using of Medicine without prescription at Yasmin Pharmacy Jalan Pinang Baris Medan. No Category Frequency Percentage of Attitude 1 Good 51 54.3 2 Enough 34 36.2 3 Poor 9 9.6 4 Bad 0 0.0 CONCLUSION Generally people already have a good knowledge. This is indicated by the majority of respondents drug users without prescription in pharmacies Yasmin Jalan Pinang Baris Medan. This research concludes that the people has a good knowledge for 53 respondent (56.4%) and the respondent who have a good attitude is 51 respondent (54.3%) REFERENCE Anief, Moh.1997. Ilmu Meracik Obat. Gajah Mada University Press. Yogyakarta. Anonim.2012. Penggolongan Obat Menurut Permenkes. 288 http://Apotekonlines.blogspot.com/2012/1 2/Penggolongan-obat-menurut permenkes.html Anonim. 2013. Hal Yang Harus Diperhatikan Saat Melakukan Swamedikasi. http://pharmaselfcare.wordpress.com/201 3/04/30/swamedikasi-an introduction.html Aspuah, S.2013. Kumpulan Kuesioner dan instrument Penelitian Kesehatan. PT. Nuha Medika. Yogyakarta Bogadenta, A. 2013. Manajemen Pengelolaan Apotek. Ed.II. D-Medika. Yogyakarta. Kartika, U.S.M.2010. Pola Penggunaan Obat Dalam Upaya Pasien Melakukan Pengobatan Sendiri Di Beberapa Apotek. Skripsi. Fakultas Farmasi. Universitas Sumatera Utara. Medan. Manan, El. 2014. Buku Pintar Swamedikasi. Ed.I. Saufa. Yogyakarta. Nazir, Moh. 2011. Metode penelitian. Graha Indonesia. Jakarta. Notoatmodjo, S. 2002. Metode Penelitian Kesehatan. Rineka Cipta. Jakarta. Notoatmodjo, S. 2010. Promosi Kesehatan, Teori dan Aplikasi. PT. Rineka Cipta. Jakarta. Sugiyono. 2010. Metode Penelitian Kuantitatif, Kualitatif dan R&D. Ed.X. PT. Alfabeta. Bandung. Syamsuni, A.H.2006.Ilmu Resep. Penerbit Buku Kedokteran. EGC. Jakarta. Tjay, T.H. dan Kirana R. 2007. Obat-Obat Penting. Ed. V. PT. Elex Media Komputindo. Jakarta. Wulandari, N .2010. Swamedikasi. http://nikenwulandari.blogspot.com/2010/01/swamedi kasi.html. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology FACTORS CAUSE NEONATAL ASPHYXIA OCCURRENCE OF NEONATAL ASPHYXIA IN THE PERINATOLOGY OF DR.PIRNGADI GENERAL HOSPITAL MEDAN 2014 Tiurlan Mariasima Doloksaribu, Risma Dumiri Manurung Department of Nursing, Poltekkes Medan Abstract Neonatal asphyxia is a condition in which a baby can not breathe spontaneously and regularly soon after birth so can cause infant growth is not optimal due to lack of oxygen from the mother to the fetus that can cause the baby hypoxia. The occurrence of asphyxia due to several factors such as maternal age, gestational age, parity, birth weight, type of delivery and prolonged labor. This is a descriptive study that aims to describe the causes of neonatal asphyxia in newborns in Perinatology space Hospital Dr. Pirngadi MedanTahun 2014. This study was a survey, and the population in this study were all women who give birth to babies with neonatal asphyxia, amounting to 90 people. The result showed that majority of respondents (80%) age <20 years, 41.3% of respondents preterm gestational age (28-36 weeks), 47.4% of respondents grandemultipara (number of children> 5), 51.1% of respondents having a baby with normal birth weight, 57.1% of respondents do not normal childbirth and 59.3% of respondents who gave birth to a baby with neonatal asphyxia experienced prolonged labor. Mother suggested to give more attention to health both before and after childbirth and health workers also to improve their knowledge and skills in performing the management of asphyxia by means ranging from aspects promotive, curative, rehabilitative so that mortality and morbidity in infants decreased. Keywords : Causes, asphyxia Neonatorum Bibliography : 25 readings (2005-2013) BACKGROUND Neonatal asphyxia is a form of emergency newborn respiratory depression that continues to cause various complications and is a cause of mortality and morbidity in infants (Maryunani A, 2009). WHO data (2005) mentions approximately 23% of neonatal deaths are caused by asphyxia with the proportion of stillbirths is greater (Sari et al, 2011). In 2011, Indonesia is the fifth highest IMR for ASEAN countries is 35 per 1,000, Myanmar 48 per 1000, Laos and Timor Leste and Cambodia 46 per 1000 36 per 1000 with 32% of cases of prematurity, asphyxia 30%, infections (22%), congenital anomalies (7%), and others 9% (Herianto et al, 2012). Various factors causing neonatal asphyxia including preterm labor, prolonged labor, preeclampsia and eclampsia, delivery by actions, infant factors and other factors (JNPK-KR, 2007). Asphyxia if it lasts too long can cause brain bleeding, brain damage and possible developmental delays and lead to lifelong disabilities such as blindness, deafness, brain defects and death, therefore it is necessary interventions and appropriate action to minimize the occurrence of infant deaths (MOH, 2008). Tahir study (2012) showed that the factor delivery (prolonged labor, type of delivery, and premature rupture of membranes) at risk of having a baby with neonatal asphyxia percentage of mothers who experienced prolonged labor amounted to 20.3% (OR = 3.417; 95%) and those who do labor act of 57.7% (OR = 4.444; 95%) and women who experienced premature rupture of 37.9% (OR = 2.471; 95%) had statistically proven meaningful relationship. While research Herianto, et al (2012) showed that the proportion of women aged <20 years and> 35 years of 46.7%, based on parity mothers with parity nullipara and grandmultipara by 66.7% 289 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology and by birth weight is known that infants with low birth weight by 33.3%. Data Medical Record Hospital Dr Pirngadi Medan the number of babies suffering from neonatal asphyxia in 2011 as many as 41 people, in 2012 as many as 23 people and in 2013 as many as 26 people. RESEARCH METHODS Type a descriptive study with survey research design is a method that describes the relationship between the various variables studied, from objects that have a unit or individual that is quite a lot. Location perinatology research conducted in space Hospital Dr. Pirngadi Medan, which was conducted in December 2013 - June 2014. The population is all women who give birth to babies with neonatal asphyxia in a room Perinatology Hospital Dr. Pirngadi field with the total population is 90 people baby. Sampling using the total population taken by collecting status / medical record from 2011 respondents as many as 41 people, in 2012 as many as 23 0rang and by 2013 as many as 26 people so the total number of samples as many as 90 people. Data analysis Descriptive see the proportion of variable maternal age, maternal gestational age, parity, body weight infants, the type of delivery and prolonged labor RESEARCH RESULT An overview of research results factor in the neonatal asphyxia in newborns in hospitals perinatology space Dr.Pirngadi field include maternal age, maternal gestational age, parity, infant birth weight, type of labor, prolonged labor and neonatal asphyxia classification. decline, and at age <20 years of reproductive organs of a woman also has not functioned perfectly so that the risk of having a baby with asphyxia. At the age of 20-35 years of age known as safe for pregnant and do labor. However, from the research can be seen that at this age there is 42.9% of mothers give birth to babies with severe asphyxia, it is because in this age of mothers giving birth many abnormally (sectio). In addition to the 20-35 year-old women who can give birth to a baby because of the possibility of maternal neonatal asphyxia is accompanied with other diseases that are being experienced as premature rupture of membranes, solutio placenta, and placenta previa. In line Herianto study (2012), that the proportion of mothers aged 20-35 years gave birth neonatal asphyxia by 53.3%, at age <20 years and> 35 years of 46.7%. Herianto research results mentioned that the aging will be followed by changes in the development of organs in the pelvic cavity and this situation will affect the life of the fetus in the womb. Tahir research results (2012) showed that the proportion of mothers who gave birth at most neonatal asphyxia at the age of 25-28 years that is equal to 24.2%. Therefore, the age factor to be considered in a marriage that neonatal asphyxia at birth does not occur. DISCUSSION 1.Mother age Age is one component of reproductive status, Hanifa (2005) suggested that in the group of 20-35-year-old mother's maternal mortality rate is lower than that seen in women aged less than 20 years, and compared with a group of mothers aged 35 years or more. 2.Gestation Pregnancy postdates (posterm) has a close relationship with perinatal morbidity and mortality, babies born to mothers over 42 weeks due to a decrease in the hormone progesterone stimulate the birth process and increases uterine sensitivity to oxytocin. The result showed that 100% of infants experiencing severe asphyxia due to the aging of the placenta resulting in reduced supply of food and oxygen from the mother to the fetus, besides pregnancy that is too long can lead to oligohydramnios. From the research that has been done can be seen that the majority of mothers were aged <20 years gave birth asphyxia 80% by weight and maternal age> 35 years also gave birth asphyxia 50% by weight. According to this theory is because in the age> 35 years of a woman's reproductive function began to Based on the results of the study showed that women with gestational age between 28-36 weeks (preterm) gave birth asphyxia as many as 46 people with severe asphyxia 41.3%. It's caused by babies born preterm organ - not yet mature organs such as the liver, respiratory system, kidneys, gastrointestinal (digestive 290 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology system), and thermoregulatory. This causes the respiratory system, especially the baby's lungs are not yet working optimally, the surfactant is still less so that there is the possibility of the development of lung disorders, respiratory muscles are weak, so the baby's cry sounded weak and whimpering infant may suffer as a result of asphyxia (Maryunani A, 2013). Hartatik research results (2013) says that infants with neonatal asphyxia majority of preterm gestational age by 28 people (70%) gave birth asphyxia risk 2.9 times. In line Wahyuningsih research, E (2011) says that the pregnancy term, the potential occurrence of respiratory depression newborn asphyxia continues to be decreased by 87% at 28-40 weeks gestation Mansjoer (2005), stating that neonatal asphyxia usually occurs in babies born to mothers with preterm birth or through time. 3.Parity Manuaba (2004) suggested that high parity enable the occurrence of complications of pregnancy and childbirth that can cause disruption of transport oxygen from the mother to the fetus which would cause asphyxia. Based on the survey results revealed that mothers who give birth to children more than 5 (grandmultipara) gave birth to a baby with asphyxia was as much as 100%, and primiparous mothers who gave birth to children with severe asphyxia as many as 18 people (47.4%). Wahyuningsih research results, E (2011) as many as 16 people (53.3%) of respondents parity primiparity asphyxiated due to the content of the muscles are still stiff and not perfect so the ability of low conception this causes frequent occurrence of complications such as his disorder hypotonic so that blood flow to the uterus is reduced resulting in decreased oxygen to the placenta. 4.Baby Weight Table 4. known that babies born with normal weight did not experience severe asphyxia 41.9%. Maryunani, A (2009) suggested that infants with low birth weight or <2500 grams growth is normally recorded have difficulty breathing immediately after birth because of the number of functioning alveoli is still small, and the surfactant is less so easy alveoli collapse during the expiratory lead to respiratory distress such as respiratory distress and neonatal asphyxia. Results of this study also found that 51.1% of infants with normal weight suffered severe asphyxia due to other factors such as occurred nuchal cord, childbirth complications and others. Herianto (2012) suggests that there is a significant relationship between low birth weight with neonatal asphyxia, OR 3.5 times the risk of having a baby with neonatal asphyxia. 5.Delivery type Many indications that resulted in a mother should do is not normal delivery as the location of the abnormality of the fetus, prolonged labor, placenta previa preeklampsi and eclampsia etc. (Purwaningsih W, 2010). Based on the research as much as 57.1% of babies were born with severe asphyxia on respondents who gave birth to the action section. Bobak et al (2005) states that babies born via sectio Caesaria more often with respiratory infections or neonatal asphyxia because the baby whose birth too fast can not experience the adaptation or transition between the world inside the womb and outside the womb. Consistent research Tahir (2012), women with abnormal labor 57.7% risk of having a baby with 4.44 times asphyxia. 6. Parity Babies are too long in the birth canal is bad as fetal heart rate fast / irregular, there is meconium in the amniotic fluid that can lead to infant hypoxic even asphyxia. The severity of injury increases with the length of labor that risk rises rapidly after more than 24 hours in primi and more than 8 hours on a multi (Oxorn, 2010). These results indicate the respondents who experienced prolonged labor gave birth to babies with severe asphyxia by 59.3%. Oxorn, (2010) states that the duration of labor, the higher morbidity and mortality of fetal asphyxia and becoming more frequent, consistent with research Tahir (2012), suggests that women who experienced prolonged labor 291 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology due to his inadequate 3.41 times the risk of having a baby neonatal asphyxia. Really need to pay attention during childbirth pelvic abnormalities, premature rupture of membranes, his disorders, obstructed labor leaders to avoid prolonged labor. CONCLUSION 1.Majority respondents (80%) gave birth to infants with asphyxia Neonatorum age <20 years. 2.Majority (41.3%) of respondents preterm gestational age (28-36 weeks) gave birth asphyxia. 3.Majority respondents (47.4%) grandemultipara (number of children> 5) gave birth to a baby with neonatal asphyxia. 4.Baby with normal birth weight neonatal asphyxiated by (51.1%) 5.Respondent with abnormal childbirth (57.1%) gave birth to a baby with neonatal asphyxia. 6.Respondent who gave birth to a baby with neonatal asphyxia experienced prolonged labor (59.3%). ADVICE 1.To health workers, especially in the field Dr.Pirngadi perinatology hospitals to provide health education for pregnant women as well as for personnel attending births for more attention to the course of the delivery process and must always be alert to the conditions of labor complications that can reduce the incidence of neonatal asphyxia. 2. For the mother should follow the family planning program, to plan a pregnancy, pay attention to nutrition during pregnancy, antenatal Another 3.Researchers advised to examine other factors causing the occurrence of neonatal asphyxia and how the relationship between the factors studied the incidence of neonatal asphyxia. DAFTAR PUSTAKA Alimul, A. 2007. Riset Keperawatan dan Tehnik Penulisan Ilmiah. Salemba : Mudika Bobak, dkk. 2005. Buku Ajar Keperawatan Maternitas Edisi 4. EGC : Jakarta Depkes RI. 2008. Profil Kesehatan Provinsi Jawa Tengah 2008. www.dinkesjatengprov.go.id. [diakses tanggal 17 februari 2011] 292 Hanifa. 2011. Hubungan berat badan lahir dengan kejadian asfiksia pada bayi baru lahir di RSUD Prof.Marjono Soekarjo. FK Universitas jenderal soedirman. Purwokerto Hartatik. 2013. Pengaruh umur kehamilan pada bayi baru lahir dengan kejadian asfiksia di RSUD Dr.Moewardi. Stikessu Aisyiyah Surakarta Herianto dkk. 2012. Faktor-faktor Yang mempengaruhi Terjadinya Asfiksia Neonatorum di RS Umum ST Elisabet Medan. http://www.geogle.com. JNPK-KR, 2007. Pelatihan Asuhan Persalinan Normal Asuhan Esencial Persalinan. Revisi, 2007 : Jakarta. Kristiyana SW. 2010. Asuhan Keperawatan Neonatus dan Anak. Muhamedika : Jakarta. Maeleeny. 2011. Gambaran asfiksia neonatorum pada bayi baru lahir di RS umum haji adam malik medan. FK USU Medan Mochtar, R. 2012. Sinopsis Obstetri. EGC : Jakarta. Mansyoer. 2005. Kapita selekta kedokteran. Media Aesculapius : Jakarta Manuaba. 2004. Ilmu kebidanan penyakit kandungan dan keluarga berencana untuk pendidikan bidan. EGC : Jakarta Maryunani A, Eka. 2013. Asuhan Kegawatdaruratan Maternal dan Neonatal. TIM: Jakarta Maryunani A, Nurhayati. 2009. Asuhan Kegawatdaruratan dan Penyulit Pada Neonatus. TIM : Jakarta Notoadmodjo, soekidjo. 2007. Metodologi Penelitian Kesehatan. Rineka cipta : jakarta. Oxorn, dkk. 2010. Ilmu Kebidanan: Patologi dan Fisiologi Persalinan. C.V Andi Offset : Yogyakarta. Purwaningsih W. 2010. Asuhan Keperawatan Maternitas. Muhamedika : Yogyakarta. Rukiyah A, Lia. 2010. Asuhan Neonatus Bayi dan Anak Balita. TIM : Jakarta. Saifuddin, AB. 2006. Buku Panduan Praktis Pelayanan Kesehatan Maternal dan Neonatal. Yayasan Bina Pustaka Sarwono Prawirohardjo : Jakarta. Sari dkk. 2011. Pencegahan dan Penatalaksanaan Asfiksia Neonatorum. Health Technology Assessment Indonesia Departemen Kesehatan Republik Indonesia. Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Sudarti, A. 2013. Asuhan neonatus resiko tinggi dan kegawatdaruratan. Muhamedika : Jakarta. Tahir dkk. 2012. Resiko Faktor Persalinan Dengan Kejadian Asfiksia Neonatorum. Skripsi. FKM Universitas Hasanuddin Makassar. Wahyuningsih, E., Saifuddin. 2011. Hubungan paritas dengan kejadian asfiksia di Rumah Sakit Islam Surakarta. Wiknjosastro. 2005. Ilmu kebidanan. Yayasan Bina Pustaka. Jakarta 293 Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology COMPARISON OF LEVELS LEPTIN IN VISCERAL AND NON VISCERAL OBESITY Yulina Dwi Hastuty Department of Midwifery , Poltekkes Kemenkes Medan Abstract This study aims to determine the ratio between the levels of leptin, visceral and non-visceral obesity. To achieve the goal, examination and laboratory studies include measurement of height, weight, waist and pelvis as well as the levels of leptin. The study population was all persons suspected of obesity obtained by accidental sampling. Analysis of the results using SPSS with significance level of p <0.05. The results showed that the percentage of obesity is more prevalent in women than in men and obese highest age group was found in the age group 31-40 years. Leptin levels did not differ between visceral obesity with non-visceral obesity (p> 0.05) and leptin levels were higher in women than men (p <0.05). Key words: leptin, visceral obesity, non-visceral obesity Introduction Obesity is a global problem in developed countries and developing countries. The prevalence of obesity is increasing in recent years and has led to serious health problems. Globally, at least 2.8 million deaths each year linked to weight gain and obesity which 300,000 occur in the United States and 350,000 in Southeast Asia (Rahmouni et al, 2005: WHO / SEARO, 2011). Based on data from the Noncommunicable Disease in SouthEast Asia Region in 2008 the prevalence of individuals with a BMI ≥ 25 kg / m2 increased from 2.7% to 8.9% in Bangladesh, 1.6% to 10% in Nepal and 11% to 15% in India, while in Indonesia percentage reached 16% in men and 25% in women (WHO / SEARO, 2011). For the North Sumatra region data obtained from the Regional Health Research (Riskesda) in 2007 showed the percentage reached 11.9% overweight and 13.5% obese. In 2010 the percentage of overweight in males 10.9% and 12.8% in women, while the percentage of obese 9.4% in males and 17.4% in women (Riskesda, 2010) Increasing the number of individuals with obesity is bad for health, considering obesity is a chronic disease that is polygenic or monogenic which may result in some circumstances or pathological dysfunction (Klein & Romijn, 2008). Some things that can influence obesity, including genetic factors, food intake, neuroendocrine mechanisms, social, cultural and lifestyle (Librantoro, 2007). In Indonesia, lifestyle changes that lead to Westernization causes changes in diet refers 294 to a diet high in calories, fat and cholesterol that have an impact on the increased risk of obesity (DirKes, 2009). Obesity is defined as a condition there is an excessive accumulation of body fat, According to the standard body mass index (BMI), BMI> 25 kg / m2 categorized as obese (Asia-Pacific, 2000). Normally the excess fat will be stored layer of subcutaneous, but due to malfunctioning or damage the layer of accumulated visceral fat (Ibrahim, 2009). Fat distribution in different places have implications for morbidity (Flier, 2006; Ibrahim, 2009). Abdominal and intraabdominal fat has greater significance than the fat that is distributed in the lower extremities or the whole body (Flier, 2006). Obesity is also a factor presdiposisi occurrence of hypertension, dyslipidemia, diabetes, cardiovascular disease, renal failure and inflammatory responses (Bravo, 2006). Prospective studies using anthropometric measurements found that visceral obesity is closely linked with hypertension, diabetes and cardiovascular disease (Tchernof, 2007). Obesity can be divided into abdominal or visceral obesity and obesity periper or nonvisceral (Wajchenberg, 2000; Klein & Romijn, 2008), which distinguishes them is that visceral fat had the glucocorticoid receptor and androgen more, metabolism is more active, more sensitive to lipolysis and more resistant to insulin. Visceral adipose tissue (VAT) has a greater capacity to produce Free Fatty Acid (FFA), increases glucose and more sensitive to adrenergic stimulation (Ibrahim, 2009). Challenges, Strategy and Health Treatment Approach to Nutrition and Molecular Epidemiology Today has been much studied matters related to obesity, including the causes of obesity and the resulting risks. Leptin is a hormone that is considered to play a role in causing obesity. Leptin was first discovered in 1994 on obese mice (gen ob / ob), is a 16 kDa peptide produced largely by adipose tissue that acts as a major regulator in the regulation of energy balance and body weight (Friedman, 1998). The main function of leptin is to provide a signal of energy stores in the body to the central nervous system so that the brain can make adjustments required to balance energy intake and expenditure (Friedman & Halaas, 1998; Enriori, 2006). Leptin levels decreased within 12 hours after starvation or during fasting and increased after several days of consuming a lot of food (Klein & Romijn, 2008). As a control of the energy balance in humans, leptin is an anti-obesity hormone that is based on the hypothesis that high leptin levels will prevent the occurrence of obesity (Bravo et al, 2006). Unfortunately this does not happen, most obese individuals have higher levels of leptin, but does not stimulate the expected loss of fat mass (Myers, 2008; Oswal, 2010). Some researchers have found that higher leptin levels in obese people compared to people with normal weight (Considine, 1996). Leptin levels are also found to be higher in women with hypertension compared to non-hypertensive and leptin levels were higher in pre-menopausal women compared to postmenopausal (Khokhar, Et al, 2010). Leptin suppress gene expression acetil Karboxylase CoA, fatty acid synthesis and lipid synthesis, biochemical reactions that contribute to the accumulation of lipids (Fruhbeck, 2001: William, 2002: Turner, 2006) Although there has been much research on leptin, but until now has not been widely studied how the comparison levels leptin between visceral and non-visceral obesity. METHOD 1. Equipment and Materials Tools used: meter, microtaise, 96-Wells Microplate with anti-human leptin, Micropipettes, Multichannel pipettes, pipette and tips, Elisa test kits, syringes 5 cc, centrifuge, incubator, test tubes, silicon tubes containing EDTA, tissue, handscoon, measuring cup 100 ml, software for data analysis ELISA. Materials used: plasma samples, wash buffer concentrate, standard (recombinant human leptin), Sodium Azide 0:09%, deionized water (distilled water), buffer concentrations, leptin detection antibody (Biotinylated anti-human leptin), HRPStreptavidin concentrate, Tetramethylbenzidine (TBM) one-step substrate reagents, Stop Solution (sulfuric acid). 2. Working procedures a. Data collection Study subjects who meet the criteria for obesity, requested willingness to follow the research, and then made a personal anamnesis, previous medical history and physical examination. All subjects who entered the inclusion criteria are required to complete a research agreement. The whole subject of further sampled measured BB, TB, pelvic and waist circumference were then categorized into or non-visceral visceral obesity. b. Measurements Weight (BB) and Height (TB) Weighing performed by the weighing stand (platform beam balance scale) which has been calibrated prior to the accuracy of 100 grams. Measurements carried out by way of a subject standing upright on the scales and then figure appointed needle (scale) scales read as a result (in kg). Height measurement is done by using a measuring instrument upright (microtaise) up to 0.1 cm accuracy. Measurements were made with upright, face facing straight ahead without wearing footwear, the result is read in cm. c. Waist Circumference Measurements (LP) and Pelvic Ring (LPA) Waist circumference was measured in an upright position and quiet. Shirt or obstructions removed measurement. Place the tape measure on the top edge Crista illiaca dextra. Measuring tape looped around the abdominal wall as high as Crista illiaca. Make sure the measuring tape is not too tight leather pressing and parallel to the floor. Measurements were made at the end of a normal expiration. Read waist circumference in centimeters. Circumference measurements of the pelvis (LPA) was performed using a measuring tape in a standing position and breathe as usual. Measured by circling the pelvis at the point of m