Progress in Lowering the Number of Malnutrition Cases in Toddlers in Bone Regency, South Sulawesi

This study aims to analyze the factors, thus advancement Bone Regency in lowering malnutrition case in Toddler. This research uses qualitative research with a case study approach. Data were obtained by in-depth interviews and unstructured observations to 22 resource persons consisting of health workers, policy makers (stake holder), community leaders and cadres. Study results shows that all puskesmas carry out the PSG program, moreover the health worker perform the duties with positive attitude and good awareness. Availability of human resources for health care services for malnourished toddlers is 2-4 people, therefore at posyandu helped by 2-5 cadres. As well as support from stakeholder, and good participation from the community. However, there still a lack of knowledge from the community leaders, and cadres about PSG work program. Moreover, there is a shortfall for the availability of health worker in undernourished toddler, also the lack of awareness by some health workers towards teamwork. Inconclusion, the work program, attitude and health worker awareness, human resource availability, stake holder support, and community participation is proven to play a role in progress to reduce the number of cases of malnutrition at Bone Regency. Stakeholders are expected to make new adaptations or innovations to adjust to the situation during the Covid-19 pandemic, improve the teamwork system, add health workers who serve in undernourished toddlers, and increase more massive and active socialization about the PSG program.

The data shows a decrease in cases of malnutrition in children under five by 1.5 percent in 2019 when compared to 2018, but if you refer back to the existing data, malnutrition is still a very serious problem, therefore the problem of malnutrition must be addressed and carried out immediately. prevention. So far, various important strategies and national action plans have been prepared by the government as an effort to improve nutrition, as well as to address and prevent the problem of undernutrition from happening again. Indonesia is ranked 10th out of 44 countries in the Hunger and Nutrition Commitment Index (Hunger and Nutrition Commitment Index), this shows that the government is serious about eliminating malnutrition in Indonesia. The SUN (Scaling Up Nutrition) Movement is a global effort from various countries in order to strengthen commitments and action plans to accelerate nutrition improvement, especially handling nutrition from 1,000 days from pregnancy to children aged 2 years, and in Indonesia it is called the National Movement for the Acceleration of Nutrition Improvement in Framework for the First 1000 Days of Life (1000 HPK Movement), (Ministry of People's Welfare, Guidelines for Planning the 1000 HPK Movement Program, 2013). As well as monitoring nutritional status (PSG) which is one of the government programs and is implemented throughout Indonesia.
It is hoped that the appropriate strategy and program planning can overcome and prevent malnutrition in children in Indonesia. To achieve this, it is necessary to have roles and responsibilities, especially health workers, in providing health services that are right on target, and with actions that focus on planning existing programs to achieve progress. As well as cooperation from various cross-sectors, and community participation, it is also hoped that the government's seriousness in determining and supporting existing policies, so that the problem of malnutrition can be resolved.
The prevalence of malnutrition in Indonesia in 2018 was 17.7 percent (Riskesdas, 2018), and in 2019 it was 16.29 percent (SSGBI results report, 2020). South Sulawesi Province has 17.9 percent of cases of malnutrition. With 10 districts/cities that had the highest prevalence of malnutrition cases in 2017, namely Pangkep (30.9 percent), Gowa (28.8 percent), Takalar (26 percent), Jeneponto (24 percent), Pinrang (24.9 percent). percent). Then Maros (24.7 percent), Bone (23.8 percent), Luwu (23.6 percent), Wajo (23.5 percent), and Pare-pare (23.2 percent); (Monitoring of Nutritional Status, 2018). Bone Regency is in seventh place with cases of malnutrition in South Sulawesi, but based on the results of the annual report of the Bone Regency Health Office, the number of cases of malnutrition which was 6.33 percent in 2018, decreased in 2019 to 1.71 percent. This shows the success of Bone Regency in reducing the number of malnutrition cases, which is below the national malnutrition target in the 2019 Medium-Term Development Plan (RPJM) of 17 percent. Based on a preliminary study

Methods
This research was conducted at the Puskesmas in the working area of Bone Regency, South Sulawesi. Qualitative research method, with a case study approach, this research is retrospective in nature, namely evaluating or assessing an event that has occurred previously or in the past, to explain the results or conclusions in the future.
The sample was selected by purposive sampling based on predetermined criteria, which consisted of 20 informants from health workers, 22 stakeholders from the informants, 20 informants from the Integrated Service Post (POSYANDU) cadres, and 20 informants from community leaders.
Data collection techniques with in-depth interviews with informants. Interview guidelines as research references, camera documentation tools to photograph field conditions, observation sheets or field notes to record information, and/or mobile phones to record the interview process. The type of research analysis is content analysis, which is then interpreted and presented in the form of narratives and matrices. Content analysis is used to draw conclusions through efforts to find the characteristics of the message, and is carried out objectively and systematically (Bungin, 2015).

Work Programs that Support Progress
This study shows that the program that supports progress is the work program for monitoring nutritional status (PSG), with 23 performance indicators, and implemented in all puskesmas working areas of Bone Regencys.
"I know that the PSG program has 23 indicators, all of which are carried out with responsibility, and all must be achieved, carried out inside and outside the puskesmas building, such as posyandu" (R, 51 yrs, Kes Officer).
The knowledge of PSG stakeholders and health workers is very good, can explain 23 performance indicators, but the knowledge of community leaders (toma) and cadres is only little or less.
"I only know the activities, but it's not clear, I mean I don't know what they mean and how many there are. There are many activities carried out at the posyandu, not only weighing, but usually the puskesmas officers giving counseling, giving vitamin A, I also help in it. All activities carried out at the posyandu are going well" (RB, 25 yrs old, cadre).
The PSG program has standard operating procedures (SOP), and uses health operational assistance funds (BOK) for the implementation of activities. Another supporting program is the nutrition-aware family program (KADARZI). The PSG program is considered very good and useful, because it is right on target and helps reduce malnutrition.
"If there is a KADARZI name here, a family aware of nutrition, this program is one of the Ministry of Health's strategic plans to reduce malnutrition, the goal is for families to be able to recognize nutritional problems of their family members, and be able to overcome them. In my opinion, it is suitable, because its performance is the same as the PSG program, and is supported by the government" (AZS, 36 years old, Stakeholder of PKM Ajangale).

Health Staff Attitude
This study shows that the attitude of health workers in carrying out their duties and responsibilities is responsible, such as visiting the homes of undernourished toddlers, being disciplined, being kind, loving children, friendly in communication, caring, attentive, diligent in work, happy to help. residents, and close to cadres, children and residents.
"They already know their respective job responsibilities, what their duties are, if the report is deposited before the 5th, it is already available. I noticed that in caring for patients, no one is indifferent, there is another one that I like the most, who is friendly" (S, 52 yrs, Stakeholder of PKM Watampone).
The duties and responsibilities of health workers are different, such as the person in charge, field coordinator, measuring TB/PB, administering vitamin A, filling out registrations, conducting surveys for children under five, and assisted by cadres.
"I help, such as weighing and measuring body length, it is also customary to give milk, biscuits, iodized salt, and vitamins. Every month, they change their duties with other cadres" (S, 41 yrs old, cadre).
In teamwork, the attitude of health workers is good and responsible with their respective duties and obligations, coordinating and helping each other.
"Okay, all the ladies here are close, they usually go on home visits. I see that in the team everyone is good, working to help each other" (N, 59 yrs, Cadre).
Management of undernourished toddlers is registered first, weighs weight, measures head circumference and PB/TB, provides counseling to mothers about nutritious food consumed by toddlers, and next month it is recommended to come back to posyandu, given PMT, and monitored for growth and development.
"Monitored, see the progress, if there is a sign of a decrease in body weight, it means that you have entered a supervised toddler, so you need to give PMT" (FY, 25 yrs, Kes Officer).

Health Officer Awareness
This study shows that the awareness of health workers in carrying out their duties and obligations is very good and good, aware and understands their respective jobs.
"In carrying out their main duties and functions, they are very responsible, they know the responsibilities of their respective duties, they already know and The duties and responsibilities of health workers are different, namely measuring TB/PB, as field coordinator, in charge, providing counseling and counseling, administering vitamin A, conducting surveys for children under five. In teamwork, the attitude of the health workers is good, such as mutual coordination and assistance with other team members, for example there are those who replace if someone is unable to enter, take turns providing counseling / counseling, measuring TB / PB, giving vitamin A. Cadres help such as recording register books , weighing weight, filling KMS, distributing PMT milk or biscuits. Every month the duties of cadres take turns / rotate tables, for example this month filling out KMS the next month weighing. The management of undernourished and malnourished children under five must receive preventive interventions for the management of malnutrition or be referred (PMK, 2020) Awareness is a factor that influences the behavior and motivation of health workers in carrying out their duties and obligations. The better the knowledge possessed, the higher the level of awareness (Nemati et al., 2020). In carrying out their duties and obligations, the awareness of health workers is very good, namely knowing and understanding what has become their obligation, completing their work well, being responsible for their duties. Such as continuing to make home visits even during the Covid-19 Pandemic, if there are activities/field schedules that have previously prepared all the tools and materials to be used, reports are completed on time. Good health workers and cadres can increase visits by mothers who have toddlers to posyandu (Fitriyah et al, 2019). But if they are treated poorly, they tend to ignore the advice given and do not want to visit again (Pohan, 2007).
In teamwork, the awareness of health workers is good. As with cadres and fellow officers coordinate and help each other. However, in carrying out their duties and obligations as team members, there are still health workers whose awareness is still lacking or non-existent, such as not complying with the existing schedule of activities, namely those who do not attend or are absent during activities or work programs, so they rarely participate in team activities. to posyandu. And there are also those who are lazy to carry out their duties and obligations, hoping that their tasks are handed over to other team members present, while team members have their own duties, causing piling up tasks to one person, disrupting the tasks of other team members, also causing delays in activities. In teamwork, awareness is needed so that they can carry out and complete their respective duties properly and correctly. Because the job satisfaction of health workers is influenced by colleagues (Mubarak et al, 2016).
Availability of human resources, is the availability of health workers on duty and provide health services to children under five at the puskesmas. The availability of human resources for health workers is related to the use of health services, so that people want to take advantage of health services (Mujiati & Yuniar, 2016). There are 2 to 4 health workers who specialize in handling malnutrition in each puskesmas. Even though they already exist, it is felt that they are still lacking or not enough, because of the wide and large work area that is the obligation and responsibility in their duties, so there is a need for additional health workers who are specialized in the service of undernourished children under five.
The lack of health workers has an impact on increasing workloads and hours, thus affecting the quality of health services so that they are not optimal (Hidana et al., 2018). And it can be a bad factor in the behavior of health workers in carrying out their duties (Indriani et al., 2018). Health workers are placed according to their competencies, because the quality of human resources is directly proportional to their competencies (Nawawi, 2012). There are 2 to 5 cadres in each posyandu, all assisting health workers, there are no cadres on special duty in the service of undernourished children under five. Cadres have an important role in motivating mothers of toddlers to visit posyandu (Subagyo et al., 2015). Training and technical guidance are provided to increase the knowledge and skills capacity of health workers by the Bone Regency Health Office, South Sulawesi Provincial Health Office, and the Ministry of Health. Improving service quality, one of which is by improving the quality and quality of human resources (Suparyanto, 2013). Cadres are also given training and reflection. Thus increasing confidence to share with the public about health (Salamah & Sulistyani, 2018). And will increase their knowledge (Didah et al, 2019).
Stakeholders know and strongly support the health services for undernourished children under five, the support provided directly or indirectly. The support provided can affect the public or many groups (WHO 1984, in Notoatmodjo S 2012. The availability of health facilities in Bone Regency, such as puskesmas and posyandu, is quite complete, and health workers are also available. According to Dever (1984) who cited the Donabedian Utilization model, the skills and expertise of health workers are one of the factors that influence the community in the use of health services (Indriani et al., 2018). Fostering and supervising is a stakeholder task that is carried out regularly, and there have been many efforts made by stakeholders in supporting health services for undernourished children under five, so that it is hoped that it can provide better benefits and changes for the progress of Bone Regency in reducing cases of malnutrition in children under five.
Community participation is participating, or community involvement in assisting and supporting activities at the posyandu. This participation is very much needed because participation can support the success of the program (Mahardika et al., 2018). This participation includes being diligent in bringing their toddlers to the posyandu, namely mothers around the posyandu helping prepare and cooking PMT such as Manado porridge or green beans, cleaning and preparing posyandu equipment such as scales, rugs/carpets, and the Village Government preparing special ADD for PMT, namely purchase of 1 shelf egg/recipient family and making porridge for undernourished toddlers, which are included in the list of recipients, are made by the puskesmas from the findings of the Village Midwife and health workers in the field, and submitted to the Village Government. Health workers collaborate with cadres and community leaders, so that the community can be active in promotive and preventive activities (Chasanah, 2015).
Community participation is one of the posyandu cadres. Each posyandu has 2 to 5 cadres, helping such as taking register books, filling out KMS, distributing PMT milk or biscuits, weighing weight, and together with health workers going to the homes of residents with toddlers according to the list, distributing PMT and iodized salt. Cadres are selected by and from the local community, who are willing and able to voluntarily work together in various activities (Depkes RI, 2003). Community participation cannot be separated from the influence of community leaders (toma). Good toma support plays an important role in the utilization of health services by the community (Darmawan, 2016).
These participations are turning their house into a posyandu, being involved in meetings held by the local government, helping to call or picking up toddlers and their mothers at home if there is no transportation to the posyandu, directing and mobilizing residents to diligently bring their toddlers to the posyandu, providing land/home yards. personally to build a posyandu, together with residents and the Village Government to help establish a posyandu, and to socialize the activities/ schedule of posyandu announced through loudspeakers at the mosque, for example the exact schedule of the market day will be moved forward or postponed the day before, because if the posyandu coincides with that day there will be a lot of people Parents are active in the market so they cannot bring their toddlers to the posyandu. A person's behavior in society is much influenced by someone who is considered important, such as a toma, so that what Toma says and does tends to be used as an example and obeyed. The support provided can make the community actively participate in posyandu activities (Umayana & Cahyati, 2015).

Conclusion
We conclude that the PSG work program, attitudes and awareness of health workers, availability of human resources for health workers, stakeholder support, and community participation are proven to have a relationship with the progress of Bone Regency in reducing the number of cases of malnutrition in children under five. It is hoped that stakeholders and health workers will make adaptations or innovations to adjust the situation during the Covid-19 pandemic, so that health services, especially for undernourished children under five, can continue. Knowledge of community leaders and cadres about the PSG program is still lacking, so a more massive and active socialization is needed to increase knowledge. Health workers on special duty for health services for undernourished toddlers already exist, but they are felt to be lacking or not enough, so stakeholders are expected to add health workers. In teamwork, there are still team members who have low or less awareness to carry out their duties and obligations in the team, such as not attending or not participating in an activity, being lazy at work, and hoping that their tasks are done and completed by their teammates. So it is hoped that stakeholders can improve the teamwork system, for example by giving warnings or reprimands to the health workers.