Health Education with Leaflet Media on the Level of Knowledge of Mother's about Toddler Rearing Partners in Stunting Prevention

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INTRODUCTION
Stunting, which is often called stunting, is the condition of toddlers who have less length or height compared to their age. Regulation of the Minister of Health Number 2 of 2020 concerning Child Anthropometric standards, in the regulation states that the nutritional status of toddlers can be measured based on three indices, namely weight for age (BB/U), height for age (TB/U), and body weight (Black et al., 2017;Mugianti et al., 2018;Rahmadhita, 2020). Stunting can have a negative impact on toddlers, namely short-term and long-term impacts that need to be watched out for early on. This short-term impact causes growth failure, cognitive and motor development barriers, and non-optimal physical body size and metabolic disorders, while the long-term impact causes decreased intellectual capacity, permanent disturbance of the structure and function of nerves and brain cells which causes a decrease in the ability absorb lessons at school age (Aridiyah et al., 2015;Sumardilah, D. S., & Rahmadi, 2019).
Toddlers who experience growth disorders are characterized by short and very short physical condition which is a nutritional problem for toddlers which is still a problem in Bali. Bali is ranked 3rd in the prevalence of stunting with a total of 21.8% in Indonesia (Dinkes Bali, 2020;Riskesdas, 2018). The incidence of stunting has decreased compared to 2013, which was 37.2%. Toddlers in 2020 in each district include Jembrana as much as 2.3%, Tabanan as much as 8.0%, Badung as much as 6.1%, Gianyar as much as 4.8%, Klungkung as much as 7.3 %, Bangli as much as 6.3%, Karangasem as much as 10.8%, Buleleng as much as 7.2%, and Denpasar as much as 1.5%. The highest stunting cases occurred in Karangasem Regency, followed by Tabanan Regency, while the lowest stunting cases occurred in Denpasar Regency.
Based on the results of the Central Bureau of Statistics (BPS) projections, the population in Tabanan Regency by sub-district, which has the largest population in Kediri District, with a total of 96,260 people, while Selemadeg Barat District is a sub-district with a small population, with a population 19,600 people. There are 6 villages that enter the Kediri I Health Center Work Area including Abiantuwung Village, Banjar Anyar Village, Kediri Village, Nyitdah Village, Pandak Bandung Village, and Pejatin Village. Data from posyandu cadres in January 2022 found stunted children, namely 6 children in Banjar Anyar Village. The Under-five Mortality Rate (AKABA) is the number of children who die before reaching the age of 5 (five) years which can be expressed as a number per 1,000 live births. According to tabanan district health office stating that the under-five mortality rate has a chance of dying in the phase between after birth and before the age of five, it is necessary to take preventive measures, which means an action to anticipate stunting to create healthy generations in the future. Prevention efforts through health education are carried out to prevent and reduce the incidence of stunting (Gladys & Fikawati., 2018;Kirana et al., 2022). Health education is a form of health promotion that is focused on overcoming the direct and indirect causes of stunting (Choliq et al., 2020;Laili & Andriani, 2019).
Toddlers are an age group that is at risk of experiencing nutritional problems, one of the causes of stunting is the parenting style of mothers towards their toddlers. Previous study stated that the factors associated with the incidence of stunting were the mother's occupation, parenting style, family income, number of household members, parents' height, and exclusive breastfeeding (Wahdah et al., 2016). Impaired growth and development of children can be influenced by parenting style accompanied by the level of knowledge possessed by the mother in meeting the nutritional needs of children, because all children's needs are fully regulated by the mother (Lailatul & Ni'mah., 2015;Mitra, 2015). Good knowledge will create a good attitude, the intended knowledge is the habits of mothers in carrying out toddler parenting. Good parenting styles tend to have toddlers with better nutritional status compared to those with poor parenting styles. Providing health education contributes to changes in parental behavior. Information obtained by mothers about parenting can be through formal education or education from the media ( non-formal ), such as videos, radio, television, internet, newspapers, magazines, leaflets , etc. (Lailatul & Ni'mah., 2015;Rahayu et al., 2015). Increasing knowledge through health education in efforts to prevent stunting by using the right media. Leaflets are used as educational media because the presentation of leaflets is simple and concise, so that respondents can easily understand the material. Leaflet media are also easy to carry and economical to store (Saputra et al., 2021;Utaminingtyas & Muji Lestari, 2020).
According to a research study conducted using leaflet media on the level of knowledge and attitudes of mothers about stunting prevention in Telukan sub-district, Grogol sub-district (Yunitasari et al., 2021). This study involved 74 respondents who were taken by purposive sampling with a pretest and posttest research design, and the statistical test used was the Wilxocon test. The results of the analysis of the level of knowledge and attitudes of the mother show p value 0.000 or <0.05. Then H1 is accepted which shows that there is an effect of health education using leaflet media on the level of knowledge and attitudes of mothers about stunting prevention in Telukan Regency. Based on this background, researchers are interested in conducting research on the effect of health education using leaflet media on the level of mother's knowledge about parenting toddlers in preventing stunting in Banjar Anyar Village, Kediri District, Tabanan Regency in 2022.

METHODS
This type of research is pre-experimental with a pre-post test design in one group (one-group prepost test design). The design can be seen in Table 1. The population in this study were mothers who had toddlers in Banjar Anyar Village, Kediri District, Tabanan Regency as many as 708 respondents. The sampling technique used in this study is Probability Sampling with the Simple Random Sampling approach. The sample used in this study was 88 respondents who met the inclusion and exclusion criteria set by the researcher.
The data collection technique in this study used knowledge questionnaires related to stunting and toddler parenting. Validity test is knowledge and observation which means the principle of instrument reliability in collecting data (Nursalam, 2017). To test the validity of the questionnaire in this study using the person product moment correlation. The number of respondents used in the validity test, namely 30 respondents, was carried out in Abiantuwung Village, Kediri District, Tabanan Regency. Reliability is a similarity of measurement or observation results when facts or living statements are measured and observed many times at different times (Nursalam, 2017). This research questionnaire was calculated using the analysis of variance technique developed by Crobach Alpha , and the reliability value obtained was based on a questionnaire test on the level of mother's knowledge about parenting toddlers in preventing stunting , namely 0.665 (Sugiyono, 2017). The number of respondents used in the reliability test, namely 30 respondents, was carried out in Abiantuwung Village, Kediri District, Tabanan Regency.
Pre-test questionnaire was carried out before the intervention was given with a duration of 15 minutes, after that carrying out a health education intervention by providing counseling using leaflet media according to material related to toddler parenting in stunting prevention for 35 minutes, then a post-test was given after the intervention with a duration of 15 minutes. After the data was collected, it was then analyzed using the Wilcoxon test.

Results
The results of research on the effect of health education using leaflet media on the level of mother's knowledge about parenting toddlers in preventing stunting in Banjar Anyar Village, Kediri District, Tabanan Regency in 2022 are show in Table 2. Based on Table 2 , it shows that the characteristics of the respondents based on the age of the mother can be seen mostly aged 26-30 years as many as 50 respondents (56.8%). Characteristics of respondents based on recent education can be seen that most of the graduates are more than high school/equivalent as many as 83 respondents ( 94.3 %). Characteristics based on the mother's occupation can be seen mostly as housewives as many as 63 respondents (71.6%).  Table 3, it shows that of the 88 respondents before being given health education with leaflet media , it can be seen that as many as 11 respondents (12.5%) had a level of knowledge Enough. While the level of knowledge of respondents after being given health education with leaflet media experienced an increase in good knowledge of 85 respondents (96.6%). Normality test result is show in Table 4.  Table 4, the results of the analysis of this study used the Kolmogorov-Smirnov normality test because the number of samples used in this study was more than 50 respondents. The results of the normality test show that the data is not normally distributed with a significance value of 0.000 which is less than 0.05. This study used a non-parametric statistical test, namely the Wilcoxon test because the data is not normally distributed, the results can be seen in Table 5 . Based on Table 5, the results of the Wilcoxon test in this study obtained a p-value = 0.000 alpha <0.05, this means that the research hypothesis is accepted which shows that there is an effect of health education with media leaflets on the level of knowledge of mothers about toddler parenting in stunting prevention.

The Level of Knowledge of Mothers about Parenting Toddlers in Preventing Stunting Before and After Being Given Health Education using Leaflet Media
Based on the results of research that has been carried out in the domain of the level of mother's knowledge about parenting toddlers in preventing stunting in Banjar Anyar Village in 2022, it is stated that of the 88 respondents before being given health education most of them have a good level of knowledge with a percentage of 87.5%, the level of knowledge is sufficient with the percentage is 12.5% , and there are no respondents who have a low level of knowledge. After given health education the level of knowledge increases in the good knowledge category with a percentage of 96.6%, in the sufficient category with a percentage of 3.4%, and no respondents who have less knowledge. This means that mother's knowledge about parenting toddlers in preventing stunting has progressed and counseling from researchers has been well conveyed. Provision of health education this was carried out 1 time using the offline method, the activities coincided with the activities of the toddler posyandu which continued to implement health protocols (Aridiyah et al., 2015;Black et al., 2017). So that the provision of health education can be easily understood, researchers use leaflet media as an aid in the process of delivering material, this leaflet media is not only used at the place where health education is given but the media can be taken home by the respondent, so that it can be read again at any time (Fatmawati, 2017;Rizki et al., 2019).
This research is in line with research entitled the effect of health education using leaflet media on pregnant women's knowledge about lactation management at the Sukaraja Health Center, Tasikmalaya Regency (Saputra et al., 2021). The results obtained were knowledge of pregnant women before receiving health education about lactation management through the media the leaflet had good knowledge, namely 22.58% and after being given health education the level of good respondent knowledge increased to 93.33%, with a p-value = 0.000, then there was an effect of health education with leaflet media on the knowledge of pregnant women about lactation management in Puskesmas Sukaraja, Tasikmalaya Regency in 2021. Other research entitled The effect of balanced nutrition counseling for toddlers with media leaflets on mother's knowledge at Posyandu Tingkir Lor Village, Salatiga City (Utaminingtyas & Muji Lestari, 2020 The result that mother's knowledge before being given an instructor Han (pretest) obtained 61.8% with good knowledge. Whereas after being given counseling (posttest) it was found that 85.3% had good knowledge, these results showed that there was an increase in knowledge before and after being given counseling, using the Wilcoxon test to get a p-value = 0.000, then there was an effect of balanced nutrition counseling for toddlers with media leaflets on mother's knowledge at Toddler Posyandu, Tingkir Lor Village, Salatiga City. The results of previous research entitled the effect of health education using leaflet media on mother's knowledge about the management of ISPA in toddlers at Posyandu, stated that after being given health education most of the respondents (95.0%) had good knowledge, and judging from the results of the p value -value = 0.000 <0.05, which means that there is a significant influence between the knowledge of respondents before and after being given health education (Fatmawati, 2017). According to previous study health education is a process of change that aims to change individuals, groups and communities towards positive things in a planned manner through a learning process (Ramadhanti et al., 2019). This theory is in line with research conducted entitled Coastal tourism nursing to improve the safety of tourists at beach resorts, which states that providing health education can improve behavior including knowledge, attitudes, and one's actions (Achjar, 2020). A significant increase in knowledge occurred in the intervention group after the application of the tourist nursing model was proven by a p-value <0.05. The results of the researcher's analysis that t the level of knowledge of mothers about parenting toddlers in preventing stunting before being given health education there are still some levels of insufficient knowledge, at the time of measurement before intervention most of the respondents did have good knowledge because the respondents had previously received information about stunting from posyandu cadres and midwives who participate in toddler posyandu activities (Ekawati & Iriani, 2020;Erlanti et al., 2016;Sabilla, 2021). Even so, for respondents who still have a low level of knowledge, it is there that researchers will provide health education with leaflet media. Like previous studies, namely providing health education with leaflet media it is hoped that the level of knowledge of the respondents will increase and the mindset can change (Kuswanti & Rochmawati, 2020;Mona & Azalea, 2018). Health education is carried out to modify behavior through increasing skills, knowledge, and changing attitudes related to improving lifestyle towards a healthier one. According to researchers, health education regarding parenting for toddlers in preventing stunting is very important because remembering that mother's knowledge greatly influences behavior in parenting (Goudet et al., 2019;Saleh et al., 2021). Mothers are very important to know about the implementation of toddler parenting which is expected to prevent children from experiencing stunting . A person's knowledge will increase due to several factors, one of which is by providing information to someone. This information can be provided in several forms, one of which is health education, the more knowledge increases, the easier it is to apply the health information that has been received. Judging from the results of the analysis at the level of knowledge after being given health education with leaflet media, it was found that the respondents had experienced an increase in good knowledge, so that it could be said that the provision of health education had been successfully received by the respondents.

The Effect of Health Education using Leaflet Media on the Level of Mother's Knowledge about Parenting Toddlers in Preventing Stunting
Wilcoxon test, it was found that after being given health education using leaflet media , there was an increase in knowledge of 85 respondents (96.6%) in the good category, as many as 3 respondents (3.4%) in the sufficient category, and there was no respondents who experienced a decrease in knowledge both before and after being given health education with p-value = 0.000 <alpha (0.05) then Ha is accepted , this means that there is a significant increase in knowledge before and after being given the intervention.
The results of this study are in line with previous research entitled analysis of counseling using leaflets on mother's knowledge about stunting in toddlers in Cot Puuk Village, Gandapura District, Bireuen Regency (Misrina & Salmiati, 2021). This study used a research design, namely a pre-experimental design with a one group pretest posttest approach , a total population of 160 people, then samples were taken using proportional stratified random sampling of 114 respondents. The results of this study indicate that the majority of respondents before being given counseling had less knowledge, namely as many as 68 respondents (60%), then experienced an increase in good knowledge of 89 respondents (78%). The results of the Wilcoxon test showed a p-value (0.000) <alpha (0.05) then Ha was accepted and Ho was rejected, thus it can be concluded that there was an effect of being given counseling using leaflet media on mother's knowledge about stunting in Cot Puuk Village, Gandapura District, Kabupaten Bireuen. Other research entitled a comparison of the use of counseling methods with and without leaflet media on mothers' knowledge and attitudes about toddler growth and development (Ramadhanti et al., 2019). The results of his research showed that in the group that was given counseling interventions with leaflet media, a p -value = 0.004 < 0.05, this means that there is a significant effect on the counseling group with leaflet media before and after being given counseling. Whereas in the intervention that was only given counseling without media leaflets , it was found that p-value = 0.056 > 0.05, this means that there was no effect on the knowledge of the counseling group about media leaflet signs before and after being given counseling. The results of the analysis show that the counseling method using leaflet media is more effective in increasing knowledge compared to the counseling method without leaflet media .
The analysis from the researcher is that from the results of this study and related research, the level of knowledge about parenting toddlers in stunting prevention can be increased if the public gets good and correct information, both in terms of the content of the information and the method of delivering the information, so that someone who will receive the information will the easier it is to understand and it is hoped that it can change the mindset in a better direction. Provision of health education using leaflet media can increase mother's knowledge about parenting toddlers in preventing stunting in Banjar Anyar Village in 2022.

CONCLUSION
Based on the results of research on the effect of health education using leaflet media on the level of mother's knowledge about parenting toddlers in preventing stunting in Banjar Anyar Village in 2022 with 88 respondents, it can be concluded that 1.) Characteristics of most respondents aged 26-30 years (56.8%), last educated SMA/SMK (83%), work as a housewife (71.6%). 2.) The level of knowledge of mothers before and after being given health education using leaflet media experienced an increase in knowledge, namely (96.6%) good knowledge. 3.) There is a significant effect of health education using leaflet media on the level of mother's knowledge about parenting toddlers in preventing stunting with a p-value = 0.000 <alpha (0.05).