Corresponding Author: Alfiana
E-mail: [email protected]
INTRODUCTION
Maternal and Child Health (MCH) is a target in the Sustainable Development
Goals (SDGs), namely reducing child mortality and improving
maternal health. The MCH program strives for conditions for mothers and
children to be mentally and physically healthy. This effort is to form strong
human resources for the next generation as a development capital (WHO, 2019). The
World Health Organization (WHO) stated in 2019 that around 830 women worldwide
die every day due to complications of pregnancy and childbirth; overall, the
Maternal Mortality Rate (MMR) is 303,000/100,000 live births. Almost all
maternal deaths occur in developing countries, 550 people in Sub-Saharan Africa
and 180 people in South Asia. This is still in the high category because it has
not yet reached the target of the Sustainable Development Goals (SDGs), which
is <70 per 100,000 live births (Werdiyanti,
2017).
AKI
is still a serious health problem in developing countries. Indonesia is a developing country with a high maternal
mortality rate. Based on Maternal Mortality Rate (MMR), and Infant Mortality
Rate (IMR).
The success of maternal health efforts, among others,
can be seen from the Maternal Mortality Rate (MMR) indicator. Based on data
from the Indonesian Ministry of Health (Kemenkes), the maternal
mortality rate increased
by 300 cases from 2019 to around 4,400 deaths
in 2020, while infant mortality in
2019 was around 26,000 cases, an increase of nearly 40 percent to 44,000 cases
in 2020 live
birth. The five biggest direct causes of maternal death are bleeding at 30%,
preeclampsia at 27.1%, infection at 7.3%, prolonged labor at 1.8%, abortion at
1.6%, and others at 40.8%. Infant deaths are 22.23 per 1000 live births (Anggraini
et al., 2020).
Target of reducing MMR in Indonesia to 131 in 2030 with
an average target of 5.5% reduction (Kemenkes, 2017). In
2019 the maternal mortality rate in Aceh again increased by 172/100,000 LH and
the same condition occurred again in 2020, namely 172/100,000 LH, when compared
to last year (Dinkes, 2021). Based on the data and information center, it is
known that Indonesia has 9,966 Puskesmas units and 9,239 Puskesmas that have
carried out classes for pregnant women (92.71%), while in Aceh Province there
are 340 Puskesmas and 298 puskesmas of which (87.65%) have carried out classes
for pregnant women. Meanwhile, Aceh Besar Regency from 28 Puskesmas and 28
Puskesmas has implemented classes for pregnant women (100%).
Implementing classes for pregnant women in Aceh
Besar District have been implemented since 2020 with a target number of pregnant
women 11.492 Soul. From the observations made by the author on
several pregnant women who visited the Community Health Center in Aceh Besar
District, it
was found that most pregnant women were less obedient in attending classes for
pregnant women. They think attending classes for pregnant women can take time
to rest and work. They also thought that the material provided would be the
same as that delivered by the midwife during the prenatal check-up. There were
6.0 % of pregnant women who said they still did not understand managing
pregnancy and the danger signs of pregnancy. However, they still did not want
to attend classes for pregnant women. Meanwhile, 40 % of pregnant women attended
classes for pregnant women twice, even though they were already in two third
trimester of pregnancy.
Based on this
description, this study aimed to analyze the determinants of compliance of pregnant
women in attending the pregnant women's class program in Aceh Besar District. Research that analyzes the determinants of pregnant
women's compliance in participating in pregnant women class programs in Aceh Besar
District has several benefits as providing useful information for relevant
parties, such as the government, health institutions, and health organizations,
to design more effective and efficient pregnant women class programs. By
knowing the factors that affect the compliance of pregnant women in
participating in the pregnant women class program, related parties can adjust
the program so that it is easier to follow and more effective in improving the
knowledge and skills of pregnant women.
METHODS
This study uses a
quantitative approach using a cross-sectional design where the involvement of
researchers is observational. A quantitative approach was carried out to
determine the determinants of pregnant women's compliance in attending the
pregnant women's class program in Aceh Besar District. The population in this
study included all classes of pregnant women in 3 (three) Aceh Besar Community
Health Centers, namely the Indrapuri Health Center, Kuta Baro Health Center,
and Darul Imarah Health Center, a sample of 180 people was selected using
accidental sampling. Data was collected using a questionnaire through Google
Forms to test its validity and reliability. Data analysis was carried out using
the smarts application to describe the determinants of pregnant women's
compliance in attending the pregnant women's class program in Aceh Besar
District.
An Equation may
either appear in-text or as a separate item; in such a case, it should be
indicated by a number in parentheses on the right column margin. Such equations
are referred to in-text as Eq. (1), and so on.
RESULTS AND DISCUSSION
Characteristic Respondents
Data on the respondents'
characteristics include age, education, employment, and income. The complete
data processing results can be seen in the following table:
Table
1. Frequency Distribution of Respondent
Characteristics at the Aceh Province Psychiatric Hospital
|
Characteristics
|
Category
|
Amount
|
|
f
|
%
|
|
Age
|
Non-Risti
(21-35 Years)
|
102
|
56,7
|
|
Risti
(<20 years and >35 years)
|
78
|
43,3
|
|
Education
|
Basic
(elementary/junior high school/equivalent)
|
1
|
0.6
|
|
Intermediate
(high school/equivalent)
|
144
|
80.0
|
|
Height
(Diploma/college)
|
35
|
19,4
|
|
Work
|
Does not
work
|
135
|
75.0
|
|
Work
|
45
|
25.0
|
|
Income
|
Under UMR
|
167
|
92.8
|
|
≥UMR
|
13
|
7,2
|
From
Table 1 above, it is known that the majority of respondents are non-risk
mothers, as much as 56.7%, with secondary education (80.0%), not working (75.0%
and income below the minimum wage (92.8%).
Research Result
Data
analysis with Partial Least Square
(PLS) requires two stages to assess the Fit Model of a research model. In the measurement model ( outer
model ), the relationship between the indicators and the variables is evaluated
by assessing the validity and reliability. Variable validity was analyzed in
two components (1) convergent and (2) discriminant validity. Meanwhile,
composite reliability and Cronbach's alpha were assessed to measure the
reliability of variables.
Convergent Validity
Assessment of convergent validity
is based on
the correlation between item
scores/components score estimated with PLS Software. Assessment of convergent validity is based on the
correlation between the item score/component score estimated by the PLS
software. The
test was carried out twice.
The initial research stage of developing a measurement scale of a loading value
of 0.5 to 0.6 was considered sufficient. In this study, a loading factor limit
of 0.60 will be used. The results of the first convergent validity test can be
seen as follows.
Internal factors
Factors include age, education, employment, income,
motivation, and parity.
Figure 1.
Outer Internal Factor Model
Figure
1 shows that some indicators are less than 0.6, so these variables must be
excluded from the model; more details can be seen in the following table:
Table 2. Internal Run Factor Loading Test Results 1
|
Variable
|
Loading Factor
|
Information
|
|
X1.1
|
0.809
|
Continue testing the model
|
|
X 1 .2
|
0.198
|
Removed from the model
|
|
X1.3
|
0.167
|
Removed from the model
|
|
X1.4
|
0.877
|
Continue testing the model
|
|
X1.5
|
0.951
|
Continue testing the model
|
|
X1.6
|
0.933
|
Continue testing the model
|
Table 2 shows that indicator X1.2
and indicator X1.3 are excluded from the model because their values are less
than 0.6. For further testing, the second test was carried out, and the
following results were obtained:
Figure 1. Outer Internal Factor Model
Figure
2 shows that all indicators have a value of more than 0.6, so the model test
can continue. More details can be seen in the following table:
Table 1Internal Factor Loading
Test Results Run 2
|
Variable
|
Loading Factor
|
Information
|
|
X1.1
|
0.803
|
Continue testing the model
|
|
X1.4
|
0.875
|
Continue testing the model
|
|
X1.5
|
0.955
|
Continue testing the model
|
|
X1.6
|
0.938
|
Continue testing the model
|
Table
3 shows that the value of the loading factor for the indicator X1.1 is 0.803,
X1.2 is 0.875; X1.5 is 0.955, and X1.6 is 0.938.
External
Factors
External factors
consist of knowledge, attitudes, family support, and mileage. The results of
the loading factor test are as follows:
Picture 2Outer External Factor Model l
Figure 3
shows that all indicators have a value of more than 0.6, so it is feasible to
be included in the model; more details can be seen in the following table:
Table
4. External Factor Loading Test Results
|
Variable
|
Loading
Factor
|
Information
|
|
X2.1
|
0.882
|
Continue testing the model
|
|
X2.2
|
0.915
|
Continue testing the model
|
|
X2.3
|
0.880
|
Continue testing the model
|
|
X2.4
|
0.886
|
Continue testing the model
|
Table 4 shows that
the value of the loading factor for the indicator X2.1 is 0.882, X2.2 is 0.915;
X2.3 is 0.880, and X2.4 is 0.886.
Obedience
The
compliance factor for pregnant women consists of participation,
continuity/consistency, benefits, and impacts. The results of the
loading factor test are as follows:
Figure 3Outer Model of Compliance with Pregnant Women
Figure 4
shows that all indicators have a value of more than 0.6, so it is feasible to
be included in the model; more details can be seen in the following table:
Table 2. Loading
Test Results for Compliance Factors for Pregnant Women
|
Variable
|
Loading
Factor
|
Information
|
|
Y1.1
|
0.847
|
Continue testing the model
|
|
Y1.2
|
0.865
|
Continue testing the model
|
|
Y1.3
|
0.890
|
Continue testing the model
|
|
Y1.4
|
0.651
|
Continue testing the model
|
Table 5 shows that
the loading factor value for the Y1.1 indicator is 0.847; Y1.2 of 0.865; Y1.3
is 0.890, and Y1.4 is 0.651, so all of them are feasible to continue for model
testing.
Pregnant
Women Class
The maternal class factor consisted of the percentage of
pregnant women, the percentage of officers, the percentage of families, and the
percentage of cadres. The results of the loading factor test are as follows:
Picture 4. Outer Model Class for Pregnant Women
Figure 5
shows that all indicators have a value of more than 0.6; more details can be
seen in the following table:
Table 3. Results of the Class Factor Loading
Test for Pregnant Women
|
Variable
|
Loading
Factor
|
Information
|
|
Y2.1
|
0.841
|
Continue testing the model
|
|
Y2.2
|
0.861
|
Continue testing the model
|
|
Y2.3
|
0.954
|
Continue testing the model
|
|
Y2.4
|
0.948
|
Continue testing the model
|
Table 6 shows
that the loading factor value for the Y2.1 indicator is 0.841; Y2.2 of 0.861;
Y1.3 is 0.954, and Y2.4 is 0.948, so all of them are feasible to continue for
model testing.
Reliability Test ( Average Variance Extracted (AVE)
Validity and
reliability criteria can also be seen from the reliability value of a construct
and the Average Variance Extracted (AVE) value of each construct. The construct
is highly reliable if the value is 0.70 and the AVE is above 0.50. Table 7 will
present the Composite Reliability and AVE values for all variables.
Table
4. Composite Reliability, Crpmbach Alpha, and Average Variance Extracted
|
Variable
|
Composite
Reliability
|
Cronbach Alpha
|
Average
Variance Extracted
|
|
Internal factors
|
0.791
|
0.652
|
0.596
|
|
External factors
|
0.806
|
0.678
|
0.515
|
|
Compliance with Pregnant Women
|
0.770
|
0.668
|
0.686
|
|
Pregnant Women Class
|
0.897
|
0.846
|
0.508
|
Source: Data processing with
SmartPLS, 2023
Based on Table 7, it
can be concluded that all constructs meet the reliability criteria. The value
of composite reliability indicates this ˃ 0.70; Cronbach alpha > 0.6, and AVE ˃ 0.50 as the criteria recommended by Fornell and Lacker (Ghozali, 2016).
Test Models
The model
test is used to see the relationship between the research model's constructs by
including indicators with a loading factor value greater than 0.6. So the shape
of the model is as follows:
Figure 5. Outer Model Class for Pregnant Women
Figure 6
shows that internal factors affect compliance with pregnant women with a value
of 0.560 > 0.5; external factors influence the compliance of pregnant women
with a value of 0.818> 0.5; and compliance of pregnant women affects the
implementation of pregnant women classes with a value of 0.536> 0.5. The
test results show that internal and external factors affect the compliance of
pregnant women, then the compliance of pregnant women affects the
implementation of pregnant women's classes
Structural
Model Testing (Inner Model)
The structural or inner model is
evaluated by looking at the percentage of the variance explained, namely by
looking at R 2 for the dependent latent construct using the
Stone-Geisser Q Square test and looking at the structural path coefficient.
Estimation stability was tested with t-statistics through the bootstrapping procedure. The results
of the PLS R-Squares represent the total variance of the construct described by
the model. The following presents the results of calculating the value of R-Squares:
Table
5. R-Square value
|
Variable
|
R-Squares
|
|
Compliance with Pregnant Women
|
0.694 _
|
|
Pregnant Women Class
|
0.6 67
|
Source: Data processing with SmartPLS, 2023
����������� This study uses several variables that affect the compliance of pregnant women and their impact on the class of
pregnant women. Table 4.8 shows that
the R-square value for the service satisfaction variable is 0.694.
These results indicate that internal and external factors can influence
pregnant women's compliance variable by 69.4 %, and the
remaining 30.6% is influenced by other factors. While the R-square value for
the implementation of the class for pregnant women is 0.667 or 66.7%, which means
that internal factors and external factors can influence the implementation of
the class for pregnant women by 66.7%, and the remaining 33.3% is influenced by
other factors.
Hypothesis test
The basis for testing the
hypothesis in this study is the value contained in the output result for inner weight.
The estimation output results for testing the structural model can be seen in
the following table:
Table
6. Inner Model Results
|
|
Original
Sample
|
Sample
Means
|
Standard Deviation
|
T -
Statistics
|
P Value
|
|
External Factors ->
Compliance with Pregnant Women
|
0.300
|
0.304
|
0.065
|
6,778
|
0.016
|
|
Internal Factors ->
Compliance with Pregnant Women
|
0.159
|
0.165
|
0.078
|
4,668
|
0.043
|
|
External Factors -> Class of
Pregnant Women
|
0.297
|
0.296
|
0.122
|
3,426
|
0.049
|
|
Internal Factors -> Class of
Pregnant Women
|
0.560
|
562
|
0.120
|
3,679
|
0.045
|
|
Compliance -> Pregnant Women
Class
|
0.536
|
0.545
|
0.073
|
7,323
|
0.000
|
Source: Data
processing with SmartPLS, 2023
The table
above shows that internal factors affect the compliance of pregnant women
(p=0.043<0.05), external factors affect the compliance of pregnant women
(p=0.016<0.05), and compliance of pregnant women affects the implementation
of pregnant women classes (p=0.000<0, 05). In summary, the results of
testing the internal variables and external variables on the compliance of
pregnant women in attending classes for pregnant women are as follows:
Figure
7. Internal Variables and External Variables on
Compliance of
Pregnant Women in Taking Pregnant Women Classes
����������� Figure
7 shows that internal and external factors affect pregnant women's compliance.
The results showed that the factors that influenced the implementation of
classes for pregnant women were external factors, with a tcount of 6.778>
1.624.
The Influence of Internal Factors on the
Compliance of Pregnant Women in Participating in the Class Program for Pregnant
Women in Aceh Besar District
The results
of testing the research model show that internal factors influence pregnant
women's adherence with a value of 0.560. In contrast, hypothesis testing
results show a positive and significant influence of internal factors on
pregnant women's compliance in attending pregnant women's classes in Aceh Besar
District (p=0.043). The internal factors in this study's analysis are age,
income, motivation, and parity.
Age
The results
showed that the age of pregnant women affected the compliance of pregnant women
in participating in the class program for pregnant women in Aceh Besar District
(t count = 6.424 > t table 1.624). Age is the length
of a person's life in years from birth until now. The old enough will affect the level of maturity and one's
ability to think and work (Muti'ah et al., 2021).
The results of this study are not
in line with research conducted by not finding an age tendency towards
adherence. This means that certain age groups do not affect the actions of
pregnant women to obey/not participate in health programs, one of which is the
class of pregnant women (Kamidah, 2015).
This study's results align with a
study conducted by (Sarah et al ., 2021) which stated that the more mature the level of maturity and
strength of a person will be more mature in thinking and working. Certain
matters, such as the mother's decision to act obediently or disobediently in
participating in a health program, it does not require the level of maturity of
one's thinking; other factors influence the mother's actions more, such as the
results in this study that family support/involvement will be very influential (Renyoet et al., 2016). In another study conducted by (Wulan et al ., 2020) there was a relationship between the age of pregnant women and ANC
compliance at the Suruh Health Center, Semarang Regency. Respondents who were
less than 20 years old did not comply with ANC. In terms of trust, more mature
people will be trusted than people who need to be more mature. This is a result
of the experience and maturity of his soul. The more mature a person is, the
more mature and regular the way of thinking is to do antenatal care (Wulan et al., 2020).
Income
The results
of testing the hypothesis show that income affects pregnant women's compliance
in participating in the class program for pregnant women in Aceh Besar District
(t count = 34.689 > t table 1.624).
The results
of this study are in line with Berg's theory cited by Sarah et al ., income is the factor that most determines the
quantity and quality of obtaining health services. The size of one's income
will affect the individual's attitude toward doing something. Increasing
household income, especially for poor households, can increase access to health
services to a level considered better because this increase in income allows
them to pay all existing costs to obtain more optimal
health services (Lestari, 2018).
However, getting basic health
services is no longer related to income. Because everything is provided free of
charge by the government, several studies have found that there is no
significant correlation between income and compliance with pregnant women. One
of them is the research by (Ramawati & Mursiyam, 2018) which concluded that income does not affect the compliance of
pregnant women in consuming Fe tablets; this means that high and low income
does not affect the compliance of pregnant women (Ramawati & Mursiyam, 2018).
Motivation
The results of
testing the hypothesis show that income affects pregnant women's compliance in
participating in the class program for pregnant women in Aceh Besar District (t
count = 14.127 > t table 1.624). Motivation is the
basis that moves a person to behave. This urge is in a person who moves to do
something according to his inner urge. Someone's actions based on certain motivations contain a theme according
to the underlying motivation (Samosir, 2020).
The motivation of pregnant women
to attend classes for pregnant women needs to be increased, considering the
importance of this to add insight about health during pregnancy, among others,
to prevent or reduce things that are not desirable both during pregnancy and
during childbirth by carrying out efforts to anticipate these things. Negative
and meet the needs of pregnant women as well as possible and as early as
possible through promotion and prevention; for example, pregnancy checks should
be carried out at least four times during pregnancy.
According to research conducted by
Samosir, the results showed that most pregnant women had high motivation to
attend classes for pregnant women, 53% of respondents, and a small proportion
of pregnant women had low motivation to attend classes for pregnant women, namely
47% of respondents. Mothers with high motivation tend to attend classes for
pregnant women more regularly than those with low motivation (Samosir, 2020).
Parity
The results
of testing the hypothesis show that parity affects pregnant women's adherence
to participating in the class program for pregnant women in Aceh Besar District
(t count = 6.363 > t table 1.624). Parity is the
number of living children or pregnancies that produce fetuses that can live
outside the uterus. Parity is best if ≤ 3 times,
and bad if ≥ 3 times. Parity is a level that shows the number of times a
mother gives birth. Parity consists of 4 levels, namely nullipara, which means
that the mother has never given birth at all, primipara which means the mother
has given birth once; multipara means that the mother has given birth > 1
time and the last is grande multipara, where the mother has given birth > 5
times (Risneni & Yenie, 2017).
The results of this study are different
from those of Mariyana et al ., which stated that between parity and compliance in participation
in classes for pregnant women, a p-value of 0.714 was obtained, meaning that
parity, especially primiparas, did not directly affect compliance with pregnant
women in participating in classes for pregnant women in the Pemalang
sub-district. Malang Regency (Mariyana et al., 2017). According to Kertiasih & Ani, maternal gestational age and parity are important in pregnant
women's compliance with consuming Fe tablets increase (Kertiasih & Ani, 2021).
The Influence
of External Factors on the Compliance of Pregnant Women in Participating in the
Class Program for Pregnant Women in Aceh Besar District
The results of testing the
research model show that external factors affect compliance with pregnant women with a
value of 0.818. In contrast, the results of
hypothesis testing show that there is a positive and significant influence of
external factors on compliance
with pregnant women in attending
classes for pregnant women in Aceh Besar District (p=0, 0 16). External factors which are the unit of analysis in this study
are knowledge, attitude, family support, and distance of the residence. The
proximity of their residence and the availability of adequate facilities will
make it easier for pregnant women to check their pregnancy and be able to carry
out ANC regularly. In testing the relationship between the distance between
residence and the place of antenatal care with adherence to carrying out ANC in
the working area of the Waihaong Health Center, it was found that there was no
statistically significant relationship (p=0.456).
Knowledge
The results
of testing the hypothesis show that knowledge affects pregnant women's
compliance in participating in the class program for pregnant women in Aceh
Besar District (t count = 35.768 > t table 1.624). Knowledge is one of the important factors to form a complete
attitude. The better one's knowledge, the better the attitude that will be
formed to create a good action. Pregnant women with good knowledge about
maintaining health during pregnancy tend to form a positive attitude towards
compliance so that obedient actions will arise (Hastanti, 2021).
Most mothers with good health knowledge during pregnancy tend to attend
classes for pregnant women. Wulan et al. stated that the proportion of good knowledge would increase
pregnant women's compliance. Compliance in attending classes for pregnant women
is a form of behavior that can be realized due to knowledge obtained from
outside and beliefs and encouragement from other people (health workers,
neighbors, close friends). Knowledge plays an important role in determining the
attitudes and behavior of respondents to attend classes during pregnancy and
comply. This shows that knowledge is very important in determining compliance
in attending classes for pregnant women. With the knowledge about classes for
pregnant women, mothers tend to participate in the class program for pregnant
women regularly (Wulan et al., 2020).
Knowledge is one of the factors
that influence the compliance of pregnant women. According to research the disobedience
of pregnant women in attending classes for pregnant women as recommended by
health workers is an impact of their ignorance about the importance of the
benefits of classes for pregnant women to improve health during pregnancy (Erwin et al., 2017). Based on the results of this study, it was found that the high
level of knowledge of pregnant women and their compliance in attending classes
for pregnant women cannot be separated from the role of officers in socializing
classes for pregnant women in Aceh Besar District. Thus, it can be concluded
that the higher the knowledge of pregnant women about health care and a healthy
way of life during pregnancy, the higher the consideration for compliance in
the class program for pregnant women.
Attitude
The results
of testing the hypothesis show that attitudes influence pregnant women's
compliance in attending the pregnant women's class program in Aceh Besar
District (t count = 5.595> t table 1.624). Attitude
shows the connotation of the suitability of reactions to certain stimuli, which
in everyday life are emotional reactions to social stimuli. Attitude is also a
form of evaluation or feeling reaction towards an object in favor or impartiality
which is a certain regularity in terms of feeling ( affection), thought
(cognition), and predisposition to action (conation) towards an object in the
surrounding environment. That attitude
is a readiness or willingness to act and not the implementation of certain
motives. Attitude is an action or activity, but it is a predisposition to the
action of behavior. Attitude is still a closed reaction, not an open reaction
or open behavior.
According to the theory explained
by Mar'at in Erwin et al., attitude consists of 3 important interconnected components. The
components forming the attitude structure are the cognitive (perceptual)
component which contains beliefs, beliefs, knowledge, and personal experiences
of a person, the affective (emotional) component, which relates to a person's
ability to judge an object; and the conative component (the behavioral
component) which relates to a tendency to act. Attitude is a predisposition for
the formation of an action. Pregnant women with a positive attitude tend to act
obediently in taking iron tablets. Conversely, pregnant women with a negative
attitude tend to act disobediently to attending classes for pregnant women. The
results of this study align with the research of (Ramawati & Mursiyam, 2018) who found that another factor that plays a very important role in
adherence is the attitude of pregnant women. Pregnant women with a good
attitude will understand the importance of health during pregnancy and tend to
be more obedient.
Family
support
The results of hypothesis testing
showed that family support affects the compliance of pregnant women in
participating in the pregnant women's class program in Aceh Besar Regency (t count = 14,472>t table 1,624).�
The family acts as feedback to guide the mother in dealing with
pregnancy problems and as a source and validator of family identity. The family
gives praise for encouraging pregnant women in pregnancy checkups, exchanging
opinions about pregnancy, and resolving problems by way of deliberation (Worang et al., 2014). The relationship between family support and pregnant women's
compliance in participating in pregnant women's classes was put forward by Sinurat & Sipayung, which found a significant association between family support and
pregnant women's adherence to attending classes for pregnant women. This is
shown from pregnant women who are obedient and routine in attending classes for
pregnant women more often in pregnant women with good family support (Sinurat & Sipayung, 2021).
The higher the family support, the
higher the level of compliance of pregnant women in participating in health
programs. Family support is support provided by family members (husbands,
wives, and relatives) so that the individual who is given support feels that he
is cared for, valued, gets help from meaningful people and has strong family
ties with other family members. Individuals who obtain high family support will
become individuals who are more optimistic in the face of health and life
problems and more skilled in meeting psychological needs (Sari et al., 2017).
Residential
Distance
The results
of testing the hypothesis show that the distance of residence affects the
compliance of pregnant women in attending the class program for pregnant women
in Aceh Besar District (t count = 16.551> t table 1.624).
The distance from the place of residence to the health facility where the class
for pregnant women occurs is directly related to the mother's obedience to
attending the class. Pregnant women who live closer to health facilities can
attend classes for pregnant women 2.66 times compared to those who live farther
away (Nurfitriyani &
Puspitasari, 2022).
The distance
where the mother lives is far away can reduce the mother's motivation to come
to the health facility and take classes for pregnant women due to fatigue while
on the road and other factors such as no transportation or incurring costs for
transportation. Pregnant women who live far from the place where pregnant women
classes are held but want to take regular pregnant women classes because these
pregnant women already know the good benefits of their participation in routine
pregnant women classes.
The Variables That Most Influence Internal Factors and External Factors on
the compliance of pregnant women in attending pregnant women classes in Aceh
Besar District
The results
showed that the most dominant internal factor influencing pregnant women's
compliance in attending classes for pregnant women was income (t count =
34.689 > t table 1.624). Income or family income is the total
real income of all household members, which is used to meet both collective and
individual needs in the household. Thus, income
is an illustration of the economic position of the family in society. Income can influence a family's
consumption pattern (Ode Salma et al., 2022).
While the
external factor that most dominantly influences pregnant women's compliance in
attending classes for pregnant women is knowledge (t count = 35.768
> t table 1.624). Knowledge is the basic drive to be curious, to
seek reasoning, and to organize experience. The existence of elements of
experience that were originally inconsistent with what is known by the
individual will be rearranged, rearranged, or changed in such a way as to
achieve consistency. Knowledge results from knowing, which occurs after people
sense a certain object. Sensing occurs through the human senses: sight,
hearing, smell, taste, and touch. Most human knowledge is obtained through the
eyes and ears (Soekidjo Notoatmodjo, 2014). The higher the level of knowledge, the
better the level of compliance.
The significant
relationship exists between knowledge and attendance, distance to where they
lived and worked, husband's support, ownership of the MCH Handbook, and parity
towards adherence to attending classes for pregnant women (Risneni & Yenie, 2017) (Tanberika & Susanti,
2021). The factors that influence pregnant women's adherence in attending pregnant
women's classes are knowledge, a distance of residence,
family support (husband/parents/in-laws), and parity. Going along with it, (Ismailar et al.2020) concluded that five dominant variables
influence a person's adherence to health services: knowledge, cultural beliefs,
family support, friend support, and health facilities (Ismainar et
al., 2020).
The factors that most influence pregnant women's compliance in
participating in the class program for pregnant women in Aceh Besar District.
The results
showed that external factors most influenced the adherence of pregnant women in
attending pregnant women's classes (p=0.016). External
factors or factors that come from outside that can affect the compliance of pregnant women
in taking classes for pregnant women are knowledge, attitudes, family support,
and distance of residence; these four factors can explain the compliance of
pregnant women in attending classes for pregnant women by 69.7% and the rest is
influenced by other factors.
Good knowledge about the benefits of classes for pregnant
women, supported by a positive attitude and the existence of maximum family
support and proximity to residence, will significantly increase the compliance
of pregnant women in attending classes for pregnant women. It is also known that good knowledge will
strengthen individuals or pregnant women in making decisions about behavior. In
this case, what is meant by knowledge is information about the benefits of
pregnancy and participating in classes for pregnant women. This happens
because, apart from knowledge, many other factors influence health utilization.
Several reasons include perceived needs, attitudes, and beliefs regarding
health services (Prameswari & Ali, 2019).
The same
thing also happens in the correlation between attitude and adherence, where a
positive attitude from pregnant women towards the class of pregnant women can
significantly increase their compliance in attending classes for pregnant
women, and vice versa, because according to Green's theory attitude is one of
the determining factors in health behavior. (Desmariyente & Hartati,
2019). Another external factor is family support.
Encouragement from the closest family can increase pregnant women's compliance
in attending classes for pregnant women. The existence of support from the
family will increase the motivation of mothers to attend regularly in carrying
out classes for pregnant women, but low family support causes lower obedience
among pregnant women in attending classes for pregnant women (Risneni & Yenie, 2018). In addition to the three factors above, the
distance to where you live also contributes to the compliance of pregnant women
in attending classes for pregnant women. Distance of residence that is too far
from being pregnant will cause the desire of mothers to attend classes for
pregnant women to decrease, and vice versa, so that distance to the residence
is a priority factor that must be considered in increasing adherence of
pregnant women to their participation in classes for pregnant women.
CONCLUSION
Based on the research
and discussion results, it can be concluded as follows: 1) There is an
influence of internal factors on pregnant women's compliance in attending the
pregnant women's class program (p=0.043). 2) There is an influence of external
factors on the compliance of pregnant women in participating in the class
program for pregnant women (p=0.016). 3) The internal factor that most
influences the compliance of pregnant women in attending the class program for
pregnant women is income, with a tcount of 34.689 > table of 1.624, and the
external factor that most influences compliance of pregnant women in attending
the class program for pregnant women is knowledge with a tcount of 35.768 >
ttable of 1.624. 4) The factors that most influence the compliance of pregnant
women in attending classes for pregnant women are external factors (tcount
6.778 > ttable 1.624).
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