Evaluation of Health Workers’ Role in Preventing the Incidence of

Low Birth Weight Babies: A Qualitative Study Based on the Theory

of Planned Behavior

Anafrin Yugistyowati

, Muhammad Akhyar

, Suminah

and Ari Probandari

Community Development/ Empowerment Counseling in Health Promotion, Postgraduate School,

Universitas Sebelas Maret, Surakarta, Indonesia

Faculty Teacher Training and Education, Universitas Sebelas Maret, Surakarta, Indonesia

Faculty of Agriculture, Universitas Sebelas Maret, Surakarta, Indonesia

Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia

Keywords: Low Birth Weight, Health Workers Role, Prevention of LBW, Theory of Planned Behavior.

Abstract: Cases of Low Birth Weight (LBW) Babies are still the leading cause of neonatal death in Indonesia.

Community health centers must conduct antenatal care examination services as program organizers and

pregnant women as program participants. Evaluation viewed from the Theory of Planned Behavior (TPB)

aspect of health workers needs to be carried out to determine the effectiveness of the LBW prevention program

that is already running. This research aims to explore the role of health workers in preventing LBW incidents

based on TPB aspects. This research uses a qualitative approach with a holistic single case study design. The

sampling technique used purposive sampling of twelve health workers who served at the Maternal and Child

Health Polyclinic and had a minimum length of service of 1 year. The instrument used was an interview guide

prepared based on TPB aspects. Validity of research data using data and method triangulation, thematic

analysis using the Colaizzi Model. The research results identified eleven themes, namely: 1) The role of health

worker communicators, 2) The role of health worker facilitators, 3) The role of health worker counselors, 4)

The role of health worker motivators, 5) The role of health centers in preventing LBW, 6) Constraints and

obstacles to the LBW prevention program, 7) Budget development and allocation of funds for LBW

prevention, 8) Performance of health workers, 9) Resources that support program implementation, 10)

Schedule for implementing the LBW prevention program, 11) Cross-program collaboration. Officer

performance includes officers' roles as communicators, counselors, facilitators, and motivators through TPB

theory related to officers' attitudes, norms, and motivation in implementing the program. These three aspects

are integrated to form behavior that supports the success of the LBW prevention program. There needs to be

an ongoing evaluation of obstacles in implementing the program.

1 INTRODUCTION

Improving maternal health, child health, family

planning, and reproductive health is still a priority in

the National Medium-Term Development Plan in the

health sector for 2020-2024 (Ministry of Health the

Republic of Indonesia, 2020). One indicator is the

decline in the percentage of infant mortality per 1000

live births. According to 2018 Riskesdas data, the

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neonatal mortality rate in Indonesia decreased from

49.1 per 1000 live births to 12.7% of deaths per 1000

live births (Riskesdas, 2018). The neonatal mortality

rate is important, considering that the decline is quite

slow compared to the infant and toddler mortality

rates. Neonatal death is closely related to maternal

death (BPS, 2020). Neonatal deaths are often caused

by abnormalities in pregnancy, premature births,

neonatal infections, and low birth weight babies

208

Yugistyowati, A., Akhyar, M., Suminah, and Probandari, A.

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of Planned Behavior.

DOI: 10.5220/0013668200003873

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 208-222

ISBN: 978-989-758-740-5

(Perry et al., 2010). The Sustainable Development

Goals (SDGs) program targets a reduction in the

prevalence of LBW cases by 30% during the period

2012 to 2030. However, based on current LBW cases,

this target is still too low to be achieved in 2030

(WHO, 2019).

Low Birth Weight (LBW) babies are babies

weighing less than 2500 grams at birth without

considering gestation time (Noorbaya, 2019). LBW is

one of the main causes of neonatal death. In addition,

LBW cases are at risk of morbidity and mortality,

growth and development problems such as cognitive

and language development, stunting conditions, and

chronic diseases as adults (Pristya et al., 2020;

Hockenberry & Wilson, 2015; Kamilia, 2019). In

2020, it was reported that the main cause of neonatal

death for babies aged 0-28 days in Indonesia was

LBW cases at 35.2% (Ministry of Health the Republic

of Indonesia, 2021). Cases of infant deaths due to

LBW in 2021 have decreased to 34.2% (Ministry of

Health of the Republic of Indonesia, 2022). However,

the trend in the Infant Mortality Rate (IMR) due to

LBW is still a major factor that needs important

attention.

The highest LBW cases in D.I Yogyakarta

Province during the 2015-2020 period were in Kulon

Progo Regency, with a case percentage of 42.32%

(DIY Health Service, 2021). Based on data from the

Kulon Progo District Health Service, the incidence of

LBW in the last five years, from 2017 to 2021, tends

to remain above 300 cases per year (Kulon Progo

District Health Service, 2021). Therefore, there is a

need for research related to efforts to prevent LBW.

Promotive and preventive interventions that can

support child survival aim to reduce IMR to 16 per

1000 live births in 2024 (BPS, 2020). Practical

implications for reducing LBW in Indonesia are that

the government must increase Antenatal Care (ANC)

examination visits through health promotion

programs and maintain ANC facilities and service

quality (Safitri et al., 2022). There is a need for

behavioral support to minimize the occurrence of

LBW births during pregnancy and proper care for

LBW (Pillitteri, 2003). Relevant research shows that

there is a significant relationship between ANC and

the incidence of LBW, so the role of health workers

is needed to encourage more ANC attendance

(Weyori et al., 2022; Uwimana et al., 2023).

These promotive and preventive efforts can be

carried out by applying the concept of health behavior

theory, namely the Theory of Planned Behavior. In

this theory, behavior can be predicted using a social

psychology approach to understand several

determinants of health behavior, including maternal

behavior during pregnancy, to prevent LBW and

maternal behavior in providing LBW care BBLR

(Aschenbrenner et al., 2016). The behavior displayed

by a person is influenced by the intention to behave,

while the intention is determined by three factors,

namely attitude toward behavior, subjective norms,

and perceived behavioral control. Apart from that, a

person's intentions are also influenced by individual,

social, and knowledge factors (Ajzen, 2012; Conner

& Sparks, 2015 ).

Pregnant women's intention to seek health

information is a function of psychological variables.

Attitude is the most important factor influencing the

intention to seek health information, and intention has

a positive and significant effect on health

information-seeking behavior kesehatan (Shamlou et

al., 2022). The three aspects in the TPB theory,

namely attitudes, subjective norms, and behavioral

control originating from internal factors of the

mother, should be the most effective efforts and can

be developed to optimize ANC service efforts to

prevent LBW (Ajzen, 2005; Islam et al., 2023).

One way of knowing the existence of health

workers is based on their role. The officer's role is

closely related to the program that has been

implemented (Olaniran et al., 2017). In general, the

role of officers includes preventive and promotive

services to provide good quality public health

(Malcarney et al., 2017). Thus, to investigate the role

of health workers, it can be viewed from preventive

and promotive service programs (WHO, 2018).

Preventive services really determine the level of a

particular case because they prevent it before the case

occurs (Salkeld, 1998). One of the main crucial cases

for a pregnant mother is the potential for giving birth

to an LBW baby.

Prevention efforts can be carried out directly in

LBW cases, namely pregnant women. Health services

at the downstream level, such as sub-district health

centers and sub-district level health centers, should be

carried out optimally so that program targets can be

achieved in accordance with the targets that have

been set (Luthfia & Alkhajar, 2019; Mays et al.,

2004). Kulon Progo Regency has the highest number

of LBW cases compared to other regencies in DI

Yogyakarta Province (Kulon Progo District Health

Service, 2021). In 2021, the Nanggulan Community

Health Center, which covers six villages, found 34

LBW cases.

Based on the results of interviews conducted at the

Nanggulan Community Health Center with the

person in charge of the maternal child health clinic

and four respondents from pregnant women, several

problems were found, including a lack of knowledge

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of

Planned Behavior

209

of pregnant women regarding the importance of

preventing LBW during pregnancy, low awareness of

pregnant women regarding preventing LBW, and low

participation. Pregnant women to take part in

programs held by the Community Health Center. In

addition, pregnant women respondents stated that the

role of health workers is very important, especially in

supporting mothers' knowledge regarding nutritional

needs during pregnancy. From the perspective of

health workers, efforts to prevent LBW have been

implemented in accordance with the program from

the Community Health Center. However, health

workers still need to implement aspects of TPB

theory in promotive and preventive efforts to prevent

LBW incidents.

2 METHODS

This research sought to explore the role of health

workers in preventing the incidence of lbw at the

kulon progo district health center. our research

questions were as follows:

a. What is the role of health workers in efforts to

prevent lbw incidents at the kulon progo district

health center based on tpb aspects?

b. How can we evaluate the role of health workers

in efforts to prevent lbw incidents at the kulon

progo district health center based on aspects of

performance, organizational factors, resources,

budget development, fund allocation, programs

and schedules, and cross-program and sectoral

collaboration?

2.1 Participants

This type of research is qualitative research with a

holistic single case case study research design

(Notoatmodjo, 2012). We chose this approach

because it seeks to describe human life and actions

specifically in certain locations with a focus on one

case, namely the role of health workers in preventing

LBW. This research was conducted at the Nanggulan

Community Health Center with twelve informants as

participants. Purposive sampling was used to select

participants. The inclusion criteria for this study

were: (1) Health workers serving in maternal and

child health polyclinics; (2) Health workers who are

actively involved in LBW prevention service

programs, and (3) Health workers with a minimum of

1 year of service.

2.2 Materials and Procedure

2.2.1 Materials

This research instrument uses two instruments to (1)

explore the role performance of health workers based

on TPB aspects in the form of a description of

attitudes, beliefs about norms, a description of

intentions and behaviour shown by health workers in

the LBW prevention program; (2) evaluating the role

of health workers in the form of aspects of

organizational factors, resources, budget

development, fund allocation, programs and

schedules, and cross-program and sectoral

collaboration. This interview guide was developed

from Ajzen's theory of planned behaviour theory to

explore the current role of health workers. This

instrument consists of 10 questions.

Data collection in this research was carried out by

conducting in-depth interviews using interview

guides, voice recorders and field notes. The interview

guide was used to ask participants questions. Field

notes were used as a tool to record participants' non-

verbal responses during interviews. A voice recorder

was used as a tool to record participants during the

interview phase of the research.

2.2.2 Procedure

Data collection was carried out from January 2023 to

February 2023. The researcher explained the aims

and procedures of the research to obtain approval for

participation from participants who met the inclusion

criteria. Each participant was interviewed at two

meetings according to the time contract. The first

interview was used to explore the role performance of

health workers, and the second interview was

conducted the following day to evaluate the role of

health workers and triangulation. The triangulation

techniques chosen are data triangulation and method

triangulation. Data triangulation was carried out by

conducting interviews with the person in charge of

the maternal and child health polyclinic, while

method triangulation was carried out by collecting

field notes in the form of participants' non-verbal

responses during interviews. The data obtained from

the field was then confirmed by the person in charge

of the relevant maternal and child health polyclinic

regarding the mandatory LBW prevention program,

program implementation indicators, and the role of

health workers in implementing the LBW prevention

program. In this way, more complete data will be

obtained so that research data bias can be minimized.

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210

The average length of interview for each participant

was 45 to 60 minutes.

2.3 Data Analysis

Data analysis uses the Collaizi method approach. This

method includes six sequential data analysis steps

(Creswell & Poth, 2007), including: (1) I was

bracketing by writing a reflective journal about the

researcher's perceptions before and after the

interview, (2) We are identifying important

statements from the transcribed data, (3) I am

grouping significant statements into meaningful

groups, (4) I am compiling textual descriptions of

experiences through the formulation of themes, (5)

We are structuring structural descriptions of

participants' experience statements, and (6) It is

building and combining textual descriptions and

structural descriptions so that they represent the

overall essence of the participant's experience. This

process is repeated for each participant until no new

information is obtained (data saturation). The process

of translating codes into final themes was carried out

through discussions between the research team.

2.4 Ethical Consideration

This research was approved by the ethics committee

of Alma Ata University with number

(KE/AA/I/101015/EC/2023). Research participants

were explained about the research objectives, data

confidentiality, data published, and their right to

withdraw from the research.

2.5 Rigor

The trustworthiness of qualitative data is assessed

based on credibility, dependability, confirmability,

transferability, and authenticity (Creswell & Poth,

2007). In this research, credibility was confirmed by

member checking, triangulation, and reflective

journal writing. Member checks and triangulation

confirm reliability. Checking is carried out by

checking the accuracy of the data that has been

collected from participants while triangulating the

data and methods. Confirmability was assessed using

exploratory audit procedures—investigative audit by

consulting the data transcript and analysis process

with the research advisor. Transferability and

authenticity are sought by collecting descriptions of

interview transcripts and quoting participant

statements that support the conclusion.

3 RESULTS AND DISCUSSION

3.1 Results

A total of 12 health workers were interviewed

personally by researchers according to the agreed

time contract. Participants completed all

questionnaires regarding demographic information,

and the sociodemographic characteristics of health

workers are reported in Table 1.

Table 1. Participants characteristics

Code

Karakteristik

Age

(

ears)

Gender Education

level

Profession Length of work

(

ears)

P1 40

Female

Diploma Midwife

P2 43 Female Diploma Midwife 15

P3 46 Female Bachelor Health promoter 16

P4 40 Female Diploma Midwife 17

P5 29 Female Diploma Nurse 4

P6 30 Female Bachelor Nutritionist 4

P7 30 Male Bachelor Doctor 1

P8 54 Male Bachelor Nutritionist 30

P9 44 Female Diploma Midwife 24

P10 41 Female Diploma Nurse 13

P11 29 Female Bachelor Health promoter 5

P12 38 Female Diploma Nurse 10

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of

Planned Behavior

211

Based on Table 1, the research participants were

twelve health workers, the majority of whom were

female and over 30 years old, ten people (83.33%).

Most of the participants had an education level of at

least d3 level, seven people (58.33%), most of the

health workers were midwives, four people (33.33%),

and most of the participants' experience in carrying

out their duties was more than ten years - eight people

(66.67%). Based on the results of the research data

analysis, several themes were obtained according to

the research objectives. There are eleven themes: four

for the first research question and seven for the

second research question. Table 2, shows the

qualitative study findings.

Table 2. Qualitative study findings

Themes Sub-Themes

Theme 1: The role of health

worker communicators

Subtheme 1: Communicator's attitude

Subtheme 2: Behavior that needs to be emphasized as a communicator

Subtheme 3: Norms believed to be a communicator

Subtheme 4: Controlling behavior as a communicator

Subtheme 5: Lack of intention as a communicato

Theme 2: The facilitative role

of health workers

Subtheme 1: Provision health education media

Subtheme 2: The role of community health center program innovation

Subtheme 3: Good facilitator attitude

Subtheme 4: Behavioral norms as a facilitator

Subtheme 5 Perceived control which is believed to be a facilitator

Subtheme 6: Intention as a

ood facilitato

Theme 3: The role of health

worker counselors

Subtheme 1: Provision counseling service media

Subtheme 2: Preparing counseling materials

Subtheme 3: The attitude when becoming a counselor

Subtheme 4: The norms believed to be a counselor

Theme 4: The motivator role

of health workers

Subtheme 1: Personal approach efforts

Subtheme 2: Sense of empathy

Subtheme 3: Share ex

eriences with

atients.

Theme 5: The role of

community health centers in

preventing LBW

Subtheme 1: The role of supervision

Subtheme 2: Empowerment of health cadres

Subtheme 3: The role of midwives in ensuring ownership and use of

KIA books

Theme 6: Obstacles and

barriers to LBW prevention

rams

Subtheme 1: Obstacles and barriers from pregnant women

Subtheme 2: Obstacles and barriers for health workers

Theme 7: Development of

budgets and allocation of

funds for LBW prevention

Subtheme 1: Special fund allocation

Subtheme 2: PMT budget

Subtheme 3: Regulation of the use of funds

Subtheme 4: Budget sources

Subtheme 5: Budget reporting

Theme 8: Performance of

health workers

Subtheme 1: Profesi dan peran tenaga kesehatan yang terlibat

Subtheme 2: Pro

ram monitorin

dan evaluasi

dilaksanakan

Theme 9: Resources that

support program

lementation

Subtheme 1: Readiness of human resources

Subtheme 2: Facilities and infrastructure in program implementation

Theme 10: Schedule for

implementing the LBW

prevention program

Subtheme 1: class schedule for pregnant women,

Subtheme 2: Integrated ANC schedule

Subtheme 3: Schedule for administering blood supplement tablets

Subtheme 4: Schedule of examinations for

nant women

Theme 11: Cross-program

collaboration

Subtheme 1: Program service areas

Subtheme 2: Forms of cross-

rogram collaboration activities

Theme 1: The role of health worker

communicators

The first theme, based on the TPB aspect, describes

the role of health workers as communicators. There

are four subthemes within this theme based on the

experiences shared by participants during their

interviews. They said that to play the function of a

communicator, a health workers must have: (1) A

polite attitude, build a relationship of mutual trust,

ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH

212

and relaxed communication; (2) Behavior that needs

to be emphasized is calmness and giving praise; (3)

Norms that are believed to be in accordance with

Puskesmas regulations and standard operating

procedures; (4) Control behavior such as empathy,

caring and being a good listener; and (5) intention as

a communicator, namely lack of commitment to

standard operating procedures (SOP) and preparation

of complete educational materials. Several

participants conveyed their experiences in the role of

communicator as follows:

"What builds communication is that we have to

build a relationship of trust, that is, we need to apply

polite attitudes, a relationship of mutual trust and

relaxed communication to patients." (P1)

"... when carrying out an examination, don't be in

a hurry, we will provide the results of the examination

and then we will essentially give appreciation if the

family is there." (P3)

Theme 2: The facilitative role of health workers

The second theme was the role of health workers as

facilitators; they conveyed: (1) Providing health

education media such as food models, leaflets,

“Kesehatan Ibu dan Anak” or KIA books, and flip

sheets; (2) The role of innovation in public health

center programs such as rescue groups for high-risk

pregnant women, classes for pregnant women, giving

blood supplement tablets to young women, and

classes for prospective brides; (3) The attitude as a

facilitator is full of enthusiasm and concern; (4)

Behavioral norms as a facilitator, namely politeness

and providing facts; (5) Perception of control which

is believed to be a personal approach and blending

into society; and (7) Intentions as a good facilitator,

namely calling the heart, customer satisfaction and

increasing the capacity of pregnant women. Some

participant statements are as follows:

"… We also use food models. Sometimes mothers

ask and I give examples of good vegetables like this,

animal protein like this with a set of food models."

(P6)

"Because there are people who are sad too, what

if it's like this, Doc? We have to be able to calm down

but also provide facts." (P7)

Theme 3: The role of health worker counsellors

The third theme, namely the role of health worker

counselors, includes (1) Providing counseling service

media such as WA group, Facebook Community

Health Center, and Instagram Community Health

Center; (2) Preparing counseling materials such as the

health of pregnant women and children; (3) The

attitude when becoming a counselor is to be open, use

language that is easy to understand, and provide

feedback; (4) The norms believed to be a counselor

are a personal approach, implementing

communication stages, and inviting you to sit relaxed.

"… during counseling, we give theories first. "We

use language that is easy to understand, although

sometimes there are health terms that we have to

explain to pregnant women." (P5)

"There are actually no rules, but in

communicating, we have pre-interaction,

implementation, and evaluation stages." (P9).

Theme 4: The motivator role of health workers

The fourth theme formulated, namely the motivator

role of health workers, includes efforts to take a

personal approach and empathize and share

experiences with patients. Participant statements are

as follows:

"The first time we meet a pregnant woman we

have to build trust first. We build trust so that he will

automatically say what the problem is." (P2)

"In providing motivation, I usually try to make

the patient believe that it is right or wrong. I share my

experience and hope that patients will be motivated

to do the same." (P11)

Theme 5: The role of community health centers in

preventing LBW

In the second question regarding evaluating the role

of health workers, seven themes were formulated,

including (1) The role of Community Health Center

in preventing LBW; (2) Obstacles and barriers to

LBW prevention programs; (3) Development of

budget and allocation of funds for LBW prevention;

(4) Performance of health workers; (5) Resources that

support program implementation; (6) Schedule for

implementing the LBW prevention program; and (7)

Cross-program collaboration. The fifth theme

conveyed by participants was the role of Community

Health Center as a single health service agency in

preventing LBW incidents. Participants conveyed

supervision activities for the LBW prevention

program through (1) Empowering Health cadres and

(2) The role of midwives in ensuring ownership and

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of

Planned Behavior

213

use of KIA books. The participant's statements

included:

"… so for monitoring we also involve cadres. So,

for example, cadres ask every day whether their PMT

has run out via WA communication." (P8)

"… during ANC, midwives must ensure that

pregnant women have books. But sometimes it is not

read, so health workers can ask whether pregnant

women read MCH books at home." (P9)

Theme 6: Obstacles and barriers to LBW

prevention programs

The sixth theme is obstacles and obstacles to the

LBW prevention program, including (1) Obstacles

and barriers from pregnant women, namely not being

willing to be visited, busy factors, non-cooperative

responses of pregnant women, and cultural beliefs;

(2) Obstacles and barriers for health officers include

unplanned schedules, poor communication between

staff, workload of health officers, limited number of

human resources, and differences in health worker

performance targets. The participant statements are:

"… LBW prevention programs mean classes for

pregnant women and most mothers work, so they

don't go to those meetings." (P4)

"… which is an obstacle because of the

environment in the village, so the traditional beliefs

are still strongly believed. Then there is influence

from grandmothers or in-laws because they will

provide information that has been passed down from

generation to generation." (P12)

Theme 7: Development of budgets and allocation

of funds for LBW prevention

The seventh theme in this research is budget

development and fund allocation in the LBW

prevention program, with supporting sub-themes,

namely (1) Special fund allocation, (2) PMT budget,

(3) Regulation of the use of funds, (4) Budget

sources; and (5) Budget reporting. Supporting

statements are:

"Most of the budget sources come from BOK,

while procurement of PMT biscuits comes from the

center." (P8)

"Reporting on the allocation of allocated funds

such as RPK, and every month there is a UKM

meeting. For example, at the beginning of each year,

what we want to do is then broken down every month;

at the next UKM meeting, each program is

communicated." (P9)

Theme 8: Performance of health workers

The eighth theme formulated was the performance of

health workers in preventing LBW incidents. The

sub-themes concluded were (1) The role of the health

workers involved, namely the role of the midwife, the

role of the nutritionist, the role of the health promoter,

the role of the nurse, and the role of the doctor; and

(2) Implementing monitoring and evaluation, namely

monitoring by the coordinating midwife and

monitoring from the Health Service. The participant

statements are:

"Midwives and nutritionists, sometimes together

with health promoters. "But more often midwives

have roles and duties in implementing preventive

LBW services in the form of classes for prospective

brides and grooms who educate about LBW risk

factors and their impact on children." (P9)

"Yesterday, there was supervision at the end of the

year from the family health sector asking about the

reasons for the high LBW. "It turns out that most

mothers who give birth are LBW due to hypertension

and other comorbidities." (P10)

Theme 9: Resources that support program

implementation

The ninth theme regarding evaluation of the role of

health workers is resources that support program

implementation, which is supported by subthemes (1)

Readiness of human resources (HR and competency

improvement programs, (2) Facilities and

infrastructure in program implementation, namely

teaching aids, assessment sheets, scales, metline, and

ultrasound equipment. The supporting participant

statements are:

"There is a real need for updated knowledge;

science is increasingly developing, so we need

occasional training or workshops or other activities

to increase knowledge of whether there are better

resolutions in preventing LBW." (P2)

"Yes, it is very adequate, there are also

anthropometric examinations and ultrasound

examinations." (P9)

Theme 10: Schedule for implementing the LBW

prevention program

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The tenth theme that can be concluded from the

participants' statements is the schedule for

implementing the LBW prevention program,

including activities for pregnant women's classes,

integrated ANC, giving blood supplement tablets to

young women, and examination of pregnant women.

Some of the participant statements are:

"… clear preventive services, namely ANC twice

a week on Wednesdays and Saturdays. This service

provides five units of maternal and child health,

dental health, nutritional counseling, laboratory

checks, and general health services. LBW preventive

services in this building are good. "For services

outside the building, we don't really understand

whether there is a regular schedule or not." (P7)

"...class activities for pregnant women 4 times a

year." (P2)

Theme 11: Cross-program collaboration

The eleventh theme in this research is cross-program

collaboration, which is supported by sub-themes: (1)

Program service areas, namely public health efforts

and individual health efforts; (2) Forms of cross-

program collaboration activities, namely

collaboration to update knowledge, discuss problem-

solving, and network development. The supporting

participant statements are:

"... actually UKP and UKM are mutually

sustainable; if pregnant women check at the

Community Health Center, the services are also the

same from medical records, KIA, dental clinic,

nutrition clinic, laboratory, pharmacy, and general

clinic." (P7)

"This form of collaborative activity provides many

benefits, we in one sub-district can get to know each

other and the programs we deliver can also be

understood." (P1)

3.2 Discussion

Based on the categories in the themes found, these

categories can be used to answer research objectives

related to LBW prevention in terms of the TPB

aspect, namely attitudes, norms, perceived behavioral

control, intentions and behavior of officers or

facilitators, and in terms of performance,

organizational factors, resources, development of

budgets and fund allocations, programs and

implementation schedules, as well as cross-program

collaboration.

The communication aspect is an important part of

life. Communication is the way we convey

information to other people (Thomas, 2017). Health

workers act as communicators who can convey

informative messages to patients, the community, and

other sectors. According to (Shields & Flin, 2013),

health workers' communication skills are included in

non-technical abilities, which are related to social and

cognitive abilities. This communication ability is the

basis for health workers in providing services.

Research conducted by (Yusriani, 2021), on

health worker communication influencing the

behavior of pregnant women in preventing

hypertension states that effective health worker

communication greatly influences how pregnant

women respond to information about hypertension.

The findings of this research show that the most

common cause of LBW incidents in the Nanggulan

Community Health Center area is pregnant women

with high risk, one of which is hypertension.

Therefore, it is hoped that health workers will be able

to increase and maintain their role in providing good

information to pregnant women to reduce the risk of

LBW.

The findings of this research are that the material

presented by officers in the LBW prevention program

includes women's reproductive health, physical and

psychological health, the purpose and prevention of

LBW, the impact of LBW events, fetal growth and

development, and nutrition and supplements that need

to be consumed during pregnancy. This material is

relevant to the LBW prevention efforts described

previously. One of the causes of LBW is premature

rupture of membranes, as mentioned in (Setiati &

Rahayu, 2017; Wijaya & Darusalam, 2022), which

stated that the majority of pregnant women

interviewed did not understand reproductive health.

Therefore, health workers need to be more active in

providing educational materials to pregnant women,

starting from pre-wedding preparations and

continuing during the pregnancy process. Providing

repeated education will certainly make mothers

remember the health material better.

Apart from providing health services, health

workers also play a facilitator role. The facilitator is

tasked with helping a group of people understand the

goal or health workers as a medium that facilitates the

achievement of a goal (Malcarney, 2017). In this

research, it was found that officers provided

educational media in the form of food models,

leaflets, KIA books, and flip sheets. This is used to

make it easier to transfer information to pregnant

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of

Planned Behavior

215

women. With the media, it is hoped that it will be

easier for pregnant women to understand what is

explained by health workers so that efforts to prevent

LBW can be achieved by increasing the knowledge

of pregnant women. This is in line with research

conducted by (Buraini, 2023), that the effect of health

education using leaflets on the knowledge of pregnant

women and leaflet media is more effective in

increasing the knowledge of pregnant women.

Health workers at the Nanggulan Community

Health Center created the "Kelambu Siti” or rescue

group for high-risk mothers. This innovation was

carried out in an effort to prevent and monitor high-

risk pregnant women. This innovation was carried out

in collaboration with assigned cadres. Thus, the role

of health workers in efforts to prevent LBW can be

said to be responsive in an effort to support the

success of the program. The need for innovation to

reduce maternal mortality rates by monitoring high-

risk pregnant women is in accordance with research

conducted by (Surya et al., 2022), which found a

monitoring program that can be used by both cadres

and health workers using an application to make

monitoring at-risk pregnant women easier. This is

done to reduce the deaths of pregnant women because

monitoring can be carried out optimally and as early

as possible. This innovation can also be implemented

at the Nanggulan Community Health Center,

considering that the LBW rate is still high in the area.

Apart from innovations for high-risk pregnant

women, the implementation of classes for pregnant

women, which are carried out as an effort to prevent

LBW, is considered not very effective because not all

pregnant women can take the class, and it has not

been proven to reduce the incidence of LBW. This is

supported by research conducted by (Agustiningsih &

Muwakhidah, 2017; Yulisa & Imelda, 2018), which

stated that there was no difference in cases of LBW

between subjects who attended classes for pregnant

women and those who did not take classes for

pregnant women.

Anemia is one of the problems that occurs in

young women. If a teenage girl becomes pregnant,

she will not be able to provide nutrients for herself

and the child she is carrying, so she is at risk of giving

birth to LBW. Therefore, giving blood supplement

tablets to young women is very necessary, as has been

implemented at the Nanggulan Community Health

Center. The administration of blood supplement

tablets shows an increase in HB levels in young

women. This is in line with research conducted by

(Adfar et al., 2023; Mozaffari-Khosravi et al., 2010 )

who stated that giving Fe tablets had a significant

effect on increasing Hb levels in anemic adolescent

girls.

The behavioral norms and attitudes of officers

when acting as facilitators must be taken into account.

This is because the behavior of health workers can

influence the behavior of pregnant women while they

are facilitators. One of the behaviors is providing

education to pregnant women about pregnancy,

recommendations for taking blood supplement

tablets, as well as the risks experienced by pregnant

women during their pregnancy and the impact on the

pregnant mother and her fetus (Terpstra et al., 2011;

Malcarney el al., 2017). This is also confirmed by

research conducted by (Lubis & Hastuty, 2018)

which states that there is a significant relationship

between the behavior of health workers in

disseminating blood supplement tablets and the

compliance of pregnant women with taking blood

supplement tablets. It is known that if pregnant

women lack iron, it will cause anemia, which can

result in the risk of LBW.

The findings of this research are that there are still

many pregnant women who do not know the benefits

of taking blood supplement tablets given by officers.

Health workers must explain this by first

investigating the history of taking blood supplement

tablets during pregnancy and then showing it with

facts. If pregnant women do not take blood

supplement tablets regularly, the risk of anemia will

increase by showing laboratory results of low Hb

levels. Then, the risks that pregnant women can

experience if they experience anemia are explained.

It is hoped that by providing these facts, pregnant

women can change their behavior and become more

obedient to taking blood supplement tablets.

A counselor is someone who has expertise in the

field of counseling services. As health workers we are

required to be able to provide counseling to both

individuals and the community. In terms of efforts to

prevent LBW, it is hoped that officers can provide

counseling for pregnant women (Terpstra et al., 2011;

Malcarney el al., 2017). A counselor must be able to

explore all possible problems experienced by his

client. We must pay attention to our professional

attitude when becoming a counselor. These attitudes

include responsibility, awareness of behavioral norms

that must be maintained, skill in using a personal

approach and broad insight with openness with the

person being counselled (Kim et al., 2016). A

personal approach to pregnant women in providing

counseling will increase pregnant women's

compliance. This is in accordance with research by

(Juwita, 2018) which states that there is a significant

relationship between counseling and the level of

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216

compliance of pregnant women with consuming

blood supplement tablets.

Apart from counseling using a personal approach,

counseling can also be done by utilizing

developments in information technology. This can be

done via WA group media, Facebook, and also

Instagram. The current pandemic has forced health

workers to think of other ways to provide counseling,

not only face-to-face but also by utilizing media such

as WA Group and other social media (Naslund et al.,

2019). This is in accordance with research conducted

by (Habibah et al., 2021).which states that counselors

also use online counseling media through the WA

Group application.

Apart from counseling media, something that

must also be considered is counseling material. To

increase the knowledge of pregnant women, it is

necessary to provide counseling about their health.

According to Astuti (2023), the difference in the level

of knowledge of pregnant women who receive

counseling and those who do not receive counseling

has a significant relationship to the compliance of

pregnant women in consuming blood supplement

tablets. Therefore, we as counselors must not forget

to continue to provide counseling to every pregnant

mother to reduce the incidence of anemia and the risk

of LBW births.

The motivational aspect is something that

encourages mentality and drives human behavior. As

health workers, we must be motivators for pregnant

women that officers can provide counseling for

pregnant women (Terpstra et al., 2011; Malcarney el

al., 2017). This is so that we can encourage pregnant

women to change their health behavior so that

pregnant women can improve their health behavior to

reduce the risk of complications during pregnancy for

both the mother and the fetus she is carrying.

According to Ryan and Deci (2016) there are two

basic forms of motivation, one of which is extrinsic

motivation. Where motivation arises from outside a

person and then encourages that person to foster a

spirit of motivation in that person to change their

attitudes and behavior. According to (Arisanti, 2021),

pregnant women are included in a group of high-risk

factors who are vulnerable to health problems or

disorders, one of which is mental health. Therefore,

as health workers, we must be able to take a personal

approach and also empathize with pregnant women

by becoming motivators who will assist during and

after pregnancy. Apart from that, we can also share

our experiences so that pregnant women can know

that what they are experiencing can also be

experienced by other people.

The role and involvement of health cadres are also

very important in efforts to prevent LBW. One of

them is monitoring pregnant women. This is done as

a form of collaboration between health workers and

cadres to reduce maternal mortality. This is in line

with research conducted by (Susanto, 2017), which

states that active posyandu cadres are agents of

change. The role of posyandu cadres in suppressing

MMR and IMR includes conducting data collection,

health communicators, persuasive approaches,

visitations, being a liaison, and carrying out

supervision and evaluation. This was also discovered

when researchers conducted research where health

cadres actively participated in monitoring pregnant

women in the Nanggulan area and joined a rescue

group for high-risk pregnant women.

In this research, it was found that midwives

played a role in the use of KIA books. Apart from

that, the KIA book is a simple but effective tool as an

information tool that health workers can use as an

educational medium. This is in line with research

conducted by (Pandora, 2018), which states that there

is a relationship between book use and pregnant

women's attitudes toward health. In this study,

mothers' negative attitudes towards health were

greater in mothers who did not read KIA books. From

this, the use of KIA books educational media can

change mothers' attitudes towards health.

The program to prevent LBW incidents at the

Nanggulan Community Health Center has not been

optimal. Obstacles and obstacles to the LBW

prevention program come from pregnant women and

also from health workers. The research findings

include obstacles from pregnant women, namely not

being willing to be visited, busy factors, the response

of pregnant women, and also the culture that pregnant

women still believe in. This can happen because

pregnant women feel less satisfied with the services

provided by health workers. Research conducted by

(Murti et al., 2018), stated that factors related to

pregnant women's satisfaction were facilities and

access to health facilities. Another obstacle for health

workers is the workload of health workers. Health

workers are burdened with multiple tasks, so they

cannot carry out their performance optimally. This is

in accordance with research conducted by (Hakman

et al., 2021), which states that there is an influence

between workload and performance in caring for

patients.

In implementing program activities, Community

Health Centers usually receive funding from the

central government through health operational

assistance (called BOK). Unfortunately, in the list of

activities in the BOK budget, there are no specific

Evaluation of Health Workers’ Role in Preventing the Incidence of Low Birth Weight Babies: A Qualitative Study Based on the Theory of

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217

activities for preventing LBW. To provide additional

food for pregnant women with Chronic Energy

Deficiency, community health centers usually do not

budget themselves but instead receive additional food

(called local PMT) in the form of biscuits for pregnant

women from the central government. Meanwhile,

local PMT funded by BOK is specifically for

underweight toddlers. This is due to regulations from

the center regarding the use of BOK funds with

targets that have been determined by looking at the

results of the previous year's program achievements

in the budget desk. The budget is then used for

activities that have been approved by the Ministry of

Health, whose reporting will be monitored every

month by the Health Service and the Ministry of

Health (Naftalin et al., 2020; Nuryana,2023).

In terms of PMT for pregnant women, the local

government itself does not budget specifically, so

PMT for pregnant women only comes from the

Ministry of Health in the form of biscuits. This is in

line with research conducted by (Laeliyah, 2017),

which states that Community Health Centers lack the

human resources and infrastructure to manage the

KIA program, there are no operational funds

available for preventive and promotive activities from

the APBD, and they only rely on BOK funds.

The role of health workers in efforts to prevent

LBW is apart from being a communicator, counselor,

facilitator, and motivator. This role is carried out in

accordance with the competence of each health

worker. One of them is the role of midwives in

providing counseling to pregnant women. When

carrying out a pregnancy check at the Community

Health Center, the examination is carried out by a

midwife. During each examination, the midwife will

provide counseling to pregnant women. This aims to

increase the capacity, both knowledge and skills, of

pregnant women. Skills in conducting counseling

itself will influence the results of the counselling

(Biro, 2011).

Research conducted by (Erlandia & Gemiharto,

2014) stated that all midwives carry out counseling,

but not all midwives carry out counseling correctly.

Therefore, it is also necessary to monitor and evaluate

both the coordinating midwife and the health service

to improve the quality of services that are already

running. This was also expressed by Marita et al,

(2021) in her research entitled Quality of Minimum

Service Standards for Pregnant Women's Health,

which stated that the output of health services for

pregnant women has not met the target, so the quality

of service standards for pregnant women needs to be

improved.

Resources in efforts to prevent LBW incidents

consist of human resources and infrastructure. The

readiness of human resources in providing services to

pregnant women must be considered. Good readiness

when providing material, knowledge, and self-

confidence. Apart from that, the competency of health

workers must also comply with standards so that they

can provide services in accordance with their

respective professional competencies. Competency

development is also needed to update old knowledge

with new knowledge (Lestari, 2020). In research

conducted by (Suhartina, 2020), there was a

significant influence on patient satisfaction between

competence, reliability, insight, empathy, and

physical evidence. Apart from that, according to

(Amir et al., 2021), leadership at the Community

Health Center has a very important role in improving

performance and service quality. Obstacles to

improving the performance of Community Health

Center organizations include a lack of training and

job guidance to improve the competency of health

workers (Yolanda et al., 2021).

Facilities and infrastructure such as scales,

metline, and ultrasonography are supporting factors

for LBW prevention program services. The

infrastructure provided by health facilities is one of

the factors that influences the health status of

pregnant women. This is confirmed by research

conducted by Susanti (2017), which states that

midwife competence, community knowledge, and

health facilities influence the health status of pregnant

women.

Programs carried out by health workers to prevent

LBW include pregnant women's classes, bride and

groom classes (“kelas catin”), and youth posyandu,

as well as integrated ANC. Apart from that, there is a

PMT program to provide additional nutrition by

providing biscuits, blood supplement tablets, and

folic acid. Programs run by health workers are carried

out according to a predetermined schedule. However,

some programs and implementation days do not

match the predetermined schedule. Pregnancy classes

are held four times a year, in classes 2 times a year,

and ANC programs are held every week on

Wednesdays and Saturdays. The class for pregnant

women itself is carried out to increase the knowledge

of pregnant women. This is in line with research

conducted by Kaspirayanthi (2019), which states that

mothers who take classes for pregnant women will

have better knowledge and a positive attitude in

recognizing the danger signs of pregnancy.

Implementing integrated ANC is an effort to

prevent LBW by improving the health status of

pregnant women. This is done by detecting from the

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218

start the risks that may occur from the results of

examinations during integrated ANC (Shulz & wirtz,

2020). This is in line with research conducted by Siwi

et al. (2023) that the reason pregnant women must

undergo an integrated examination is that pregnant

women will detect risk factors so that they can be

anticipated and treated early.

Cross-program collaboration includes

collaboration between public health efforts (UKM)

and also individual health efforts (UKP) at

Community Health Centers. Health service facility

that organizes first-level UKM and UKP by

prioritizing promotive and preventive efforts

(Sulaiman, 2021). Collaboration across LBW

prevention programs includes maternal and child

health, nutrition, health promotion, environmental

health, and doctor programs. The benefit of this cross-

program collaboration is that they complement each

other's knowledge so that the knowledge gained by

pregnant women is more comprehensive. The

obstacle experienced in cross-program collaboration

was conflicting schedules.

Research conducted by Mahirawati (2017), states

that cross-program involvement is needed to reduce

the prevalence of chronic lack of energy. This is in

accordance with the facts found in the field by

researchers that services for pregnant women must

involve cross-programs to provide maximum services

from several sciences that will complement each

other. Apart from that, according to (Chabibah &

Khanifah, 2019), one form of cross-sectoral

collaboration in the education and health sectors is to

become a facilitator who is expected to encourage

agents of change in society, especially in reducing

maternal mortality.

4 CONCLUSIONS

The conclusions of this research include the

following:

a. Health workers responsible for the LBW

prevention program at the Kulon Progo district

health center include doctors, nutritionists, nurses,

midwives, and health promotion. Health workers

have a minimum education of diploma with a

minimum length of service of 1 year and a

maximum of 30 years.

b. The performance of health workers includes the

role of officers as communicators, counselors,

facilitators, and motivators through TPB theory

related to attitudes, subjective norms, and motives

of health workers in implementing LBW

prevention programs. These three aspects are

integrated to form behavior that will support the

implementation and success of the LBW

prevention program.

c. The completeness of facilities, implementation of

supervision, and evaluation determines the

performance of officers in implementing LBW

prevention program. Organizations that do not

support the needs of health workers will

experience obstacles and hinder performance.

d. Human resources supporting the success of LBW

prevention programs are determined by HR

readiness, HR competency, and competency

improvement programs.

e. Budget development and allocation of funds that

are not focused on LBW prevention programs will

hinder the success of the program. The program

and schedule for implementing the LBW program

should be focused so that the program objectives

can be achieved.

f. Cross-program and sectoral collaboration needs to

be improved, especially regarding schedule

management and collaboration skills of health

workers.

This research recommends evaluating the

obstacles to implementing LBW prevention programs

and focusing on management and administration.

LBW prevention program to ensure work team

assignment letters.

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