
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-275
10.4103/jehp.jehp_1565_23
Review Article
Structural equation modeling for skills analysis of health cadres based on knowledge and attitudes about health promotion and body immunity of pregnant women
Yusriani Yusriani
Alwi Muhammad Khidri
Herli A
Syahrani Vadiah
Department of Public Health, Universitas Muslim Indonesia, Makassar, Indonesia
Address for correspondence: Dr. Yusriani Yusriani, Department of Public Health, Universitas Muslim Indonesia, Makassar, Indonesia. E-mail: yusriani.yusriani@umi.ac.id
2024
29 7 2024
13 27501 10 2023
22 4 2024
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
The health problem of pregnant women is a public health problem that needs to get major attention because it has an impact on the quality of life and future generations. Then examine the data/information empirically and theoretically. The sample units in this study were the skills of cadres in increasing the Immunity of Pregnant Women with the independent variables namely knowledge and attitudes. The sampling technique in this study was total sampling, then a sample of 85 cadres was obtained in the two puskesmas. The data collected is primary data, obtained from questionnaires filled out by health cadres, based on the data that has been obtained, then processing and analyzing the data is carried out according to the research objectives, and presented in tabular form accompanied by narrative as an explanation of the table. The research results obtained were that there was a significant relationship between the knowledge of cadres and the skills of cadres in carrying out health promotion to increase the immunity of pregnant women (P value 0.032 < 0.05). There is a significant relationship between the knowledge of pregnant women’s immunity and the skills of cadres (P value = 0.025 < 0.05), there is a significant relationship between the attitudes of cadres and the skills of cadres in health promotion to increase the immunity of pregnant women (P value = 0.004 < 0.05). The most significant factors for the skills of cadres in carrying out health promotion to increase the immunity of pregnant women.

Attitudes
body immunity
health cadres
knowledge
skills
==== Body
pmcIntroduction

Health cadres are part of the community chosen by the community and volunteers to improve community health and promote the prevention of maternal mortality in the community. Health cadres play a very important role in the implementation of Posyandu, as cadres can become community mobilizers for healthy living.[1] The role of cadres in community empowerment is a community mobilizer that enables the community to promote health so that people can change their health behavior.[2] The tables play an important role as a provider of information to the public, so the tables play an important role in increasing the body immunity of pregnant women, which will have an impact on improving the quality of life of pregnant women.

Improving maternal health is one of the Sustainable Development Goals (SDGs) approved by the international community in 2015. The SDGs highlight the reduction of maternal mortality in the world, which is less than 70 deaths per 100,000 newborns.[3] Currently, research on pregnant women with COVID-19 has had several problems between mothers and newborns, but more research evidence is still needed.

Respiratory illness during pregnancy is a problem that can affect COVID-19 and requires medical treatment.[4] During the COVID pandemic, there were changes in residential care. Pregnant women reduce examinations in health services and use communication to know the evolution of the health of the mother and the fetus. Click or tap here to enter text.[56] In this COVID pandemic we must improve the immune system, that is, the strength to defend the body against bacteria, viruses, and organisms that we can touch, consume, and breathe every day. Washing hands with soap is an act of hygiene, washing hands and fingers so that human beings are clean with soap and water breaks the payroll chain.[7]

Things that can increase endurance are eating a balanced nutritious diet. The correct intake of food during pregnancy is recommended for the growth and development of fetuses, as well as to prevent pregnancy complications and consume foods with a balanced and safe diet, reactivate the immune system, and reduce the risk of chronic diseases and infectious diseases. Increase the consumption of fruits, such as bananas, oranges, alguaceos, pineapples, apples, papaya, mangosteen, etc., Fiber-rich vegetables can store our immunity, leafy greens, eggplants, bean sprouts, yucca leaves, pumpkins, and others. Adaptation of nutrition, especially vitamins and minerals, is necessary to maintain the immune system. Vegetables and fruits are the best sources of different vitamins, minerals, and fibers.[8]

Pregnant women are vulnerable groups at high risk of anemia. During pregnancy, blood volume has increased to create iron stores from the placenta, fetus, and breast milk. Anemia will reduce body resistance to prevent infections, including COVID-19 infection and the illnesses it causes. In addition, anemia in pregnant women will increase the weight of low-birth-weight babies, which will undoubtedly increase the risk of stunting. To prevent food anemia in pregnant women, at least 90 blood additives TTDs are delivered during pregnancy, starting as early as possible. Daily iron supplements during pregnancy can reduce the risk of maternal anemia by 70% and iron deficiency by 57%. Meanwhile, the treatment of anemia refers to the instructions for the administration of tablets of blood additives.[9] Pregnant women are a vulnerable group that harms the spread of COVID-19.[10] Due to the low level of immunity, pregnant women will be able to help against viruses that attach to the life of the fetus during pregnancy, due to the immunity of the mother.[11]

A cadre is someone who believes they are closer to the community, especially pregnant women. The chart facilitates the transmission of monitors and health information, especially with pregnant women, and encourages mothers to live healthy behaviors during pregnancies. The cadres are at the forefront and have a close relationship with the community, in favor of the sustainability of health development, given their direct presence in the structure of a community.

There are still few studies on the abilities of cadres in health promotion using the method of modeling structural equations Structural Equation Modeling Method (SEM). Based on this explanation, it is necessary to conduct research on the health promotion capacities of cadres in the work areas of Bontonompo I Health Center and Bajeng Health Center, using the SEM. The objective of this research was to determine its impact on the promotion of the health of pregnant women and on body immunity, in the skills of the working cadres of the Bontonompo I Health Center and the Bajeng Health Center.

The study aims to determine the skills of the working cadres of the Bajeng Health Center and Health Center, using the SEM method, and then analyzing the empirical and theoretical data/information.

Material and Methods

Study design and setting

This study was conducted by Dr Yusriani at Bajeng Health Center and Health Center. using the SEM method, and then analyzing the empirical and theoretical data/information. This research is quantitative, using analytical and indirect methods.

Study participants and sampling

In this study, a complete sampling was carried out and, subsequently, detected in both health centers. we collect 110 samples from health centers but we choose 85 best samples for analysis. At Bajeng Health Centre we collected 45 samples and also 40 samples were collected from Bontonompi I Health Centre.

Data collection tool and technique

The data collected are first-level data, obtained from questionnaires full of health tables, based on the data obtained, then process and analyze the data, according to the objectives of the research, which are presented as tabular, together with the narrative, as an explanation of the table.

Tools

For the purpose of this research, a sociodemographic questionnaire was used to collect sociodemographic data. It has general sociodemographic data (age, sex, education, work, income, seniority).

The ability of the cadres was used to investigate the abilities of the cadres to increase the immunity of pregnant women that is the most widely used measurement tool to assess the abilities of the cadres to increase the immunity of pregnant women. The questionnaire consists of 35 items evaluated on a Guttman-type scale 1–2 (1 = No 2 = Yes). Each answer provides a score from 0 to 1, with a Guttman scale, and becomes two units of elements. Adding units of 35 questions, the final score ranging from 0 to 35 is obtained. Higher scores represent higher levels of skill and are used to identify disordered skills above or above 50.

Sanitary conditions are measured through a questionnaire. The questionnaire consists of nine items on the role of health cadres in health promotion and 23 items on knowledge of conditions related to immunity in pregnant women. The questionnaire was evaluated on a Guttman scale of 1–2 (1 = False 2 = Verification). Each answer provides a score from 0 to 1, with the Guttman scale, and becomes two units of elements. The sum of 32 questions gives a score from 0 to 32. Higher scores represent higher levels of knowledge and a value of 50 or higher is used to identify agitated knowledge.

The attitude of health cadres is measured through a questionnaire. The questionnaire consists of 10 items on the role of health cadres in health promotion and 39 items on the attitude of cadres regarding the immunity of pregnant women. The questionnaire was evaluated on a Likert scale, from 1 to 4 (1 = very good 2 = Very post-truth). Each answer provides a score of 1 to 4, turning the Guttman scale into a 2-item unit. Adding the units of 49 questions, the final score is obtained, between 1 and 196. Higher scores represent higher levels of knowledge and 62.5 or higher are used to identify the confused attitude.

Feasibility of research instruments

By demonstrating the validity and reliability of this study, it was done for each of its dimensions. That is using 30 pieces of data before handing it over to the real respondents. Value test results can demonstrate that the AVE (Average Variance Extracted) value and cross-load value of all variables meet all requirements. The results of reliability tests can also demonstrate that this is a reliable research tool since Cronbach’s alpha value is greater than 0.6.

Ethical considerations

All procedures performed in the study conducted with human participants coincide with the registration of the number Universitas Muslim Indonesia (KEPK UMI), according to the register of numbers (UMI-12306290). Informed consent was obtained from all study participants. Kesehatan Muslim was authorized in writing by the Ethics Committee of the University of Indonesia (KEPK UMI) and was identified according to the registration number (UMI-12306290), and has been communicated to Bontonompo I Health Center and Bajeng Health Center. A written notification has been sent to the health cadres and they have been briefly informed of the objectives, method, and perspective of the research. If the health cadres agreed to participate in the examination, they would sign an authorization form.

Statistical analysis

Data from MS Excel (version 11. Microsoft Corporation, Redmond, WA, USA) and Armonk, NY, USA). The data have been processed using descriptive statistical methods that are presented according to the frequency and percentage of the categorical variables. The Chi-Square test for skill health tables was used to assess the relationship between the independent variables. < rated it as 0.05.

The unit of analysis is that of tables to increase the immunity of pregnant women, with independent variables, that is, knowledge and attitude. In this research, a complete sampling was carried out and, subsequently, 85 cases were detected in both health centers.

Results

Bontonompo I Health Center in Bontorambo, Kec. About 40 km from Gowa airport (Sungguminasa). It has 5.438695 coordinates and 119.832291 coordinate points that is Pa’bundukang Village, Salajangki Village, Tindang Village, Tanrara Village, Sengka Village, Jipang Village, Bontosunggu Village, Salajo Village and one village, Kelurahan Bontoramba. In total, 42,337 souls.

Geographically Shown in Table 1, the Bontonompo I Health Center is in the lowlands, with alluvial soil conditions (most are used to grow rice), so most populations live as farmers. The working area of the Bontonompo I Health Center is about 22 km2. Bajeng Jl. Nuhung Dg. Bani Health Centre, Kec. Bajeng, Kab. Gowa, with coordinates −5.258334 Longitude and 119.574356 Latitude. Covering six villages that is Panciro Village, Bontosunggu Village, Tangkebajeng Village, Bone Village, Maradekaya Village, and Lempangan Village, then it has four villages that is Matallo Village, Limbung Village, Kalebajeng Village, and Tubajeng Village. In total, 69,973 people. Bajeng Health Center, Kab. Gowa is the lowland region, with an area of 34.39 km2 or 57.24% of the total Kec. Village/10 work areas.

Table 1 Distribution of respondent characteristics at the Bontonompo I Health Center and the Bajeng health center

Characteristics	Number of Cadre	
Frequency (n)	%	
Age	
  <40 Years Old	52	61,2	
  41–45 Years Old	14	16,5	
  >45 Years Old	19	22,3	
Old Cadres (Years)	
  <5	44	51,8	
  6–10	31	36,5	
  >10	10	11,7	
Education	
  SD/M. Ibtidaiyah	6	7,1	
  SLTP/M. Tsanawiyyah	12	14,1	
  SMU/M. Aliyah	58	68,2	
  Diploma/Academy	5	5,9	
  College	4	4,7	
Job Cadres	
  Self-employed/self-employed	15	17,6	
  Free labor is not in agriculture	3	3,5	
  Private employees	2	2,4	
  Teachers and Village Staff	2	2,4	
  Cadre	34	40,0	
  IRT	29	34,1	
Length of work (hours)	
  <3	54	63,5	
  4–6	21	24,7	
  >6	10	11,8	
Cadre Family Income	
  <Rp. 2.500.000	72	84,7	
  Rp. 2.600.000–Rp. 5.000.000	8	9,4	
  >Rp. 5.000.000	5	5,9	
Total	85	100	
Source: Primary Data (2023)

Measurement model analysis (Outer Model)

The analysis of this measurement model shows the relationship between latent variables and their indicators. In this measurement model, there are three stages of analysis.

Model initial test

In the initial test of the model, it was performed for the test of indicators, as a measure of latent variables, to obtain valid indicators with high load values. The tables on health promotion and body immunity have a value of 0.6 > for these indicators to be valid as a measure.

Then try the latest model with the second application form. In the construction of image knowledge, the dimension consists of two buildings, that is, the knowledge of images about the knowledge of cross-body immunity, since the indicators for the construction of image knowledge use two-dimensional indicators. Also, as an indicator for the construction of table postures, using indicators on the attitude of the immune tables of pregnant women and building attitudes. This is measuring it again and again because it reuses/repeats indicators in their dimensions.

Outer model test

The external model is a model that determines the relationship between latent variables and indicators, or it can be said that the external model defines how each indicator relates to its latent variables. The external model is interpreted based on a number of things, including convergent value values, discriminator value values, quantifiability, and extracted mean variation AVE.

Convergent validity

The convergent value measures the size of the load factor for each construction, it is recommended that a load factor greater than 0.70 is expensive, but a load factor of 0.5–0.60 can be accepted, provided that the model is developed. In this convergent validity test, indicators are a first-order test for testing indicators as a constructive measure. The model of the PLS algorithm and the values of the entire load indicator are shown below in the image and in the table.

Figure 1 shows that of all the indicators in each construct, it obtains an indicator loading value of > 0.5 so that it is valid as a measure of the construct.

Figure 1 The PLS Algorithm Model. Source: Primary Data, (2023)

Discriminant validity

The discriminatory value is useful to evaluate whether a variable has an adequate discriminatory value, that is, when comparing the correlation between the indicator and the expected construction, it must be higher than the correlation with other constructions. If the correlation of the indicator has a higher value than the correlation between the indicator and other buildings, the variable is said to have a high discriminatory value.

The cross-load Table 1 shows that the evaluation value of the X1A1 indicator for health promotion is 0.780, 0.204, 0.375 on immunization of the pregnant body, the attitude of the table regarding immunity of the pregnant body is 0.384, and its attitude to the health of pregnant women is 0.3812. Also, to promote health, knowing the table on the immunity of the body of pregnant women, the attitude of the table with the immunity of the body of captunos, and other indicators related to the attitude of the table for the promotion of pregnancy health have a load value higher than that of the construction company. The results of the total value of the cross-load are as follows:

Composite reliability

A high composite reliability value represents the good robustness of each indicator in the latent variable to measure > that variable. The complete compound values of alienability are presented in the following shows that the composite reliability value builds cadre skills in health promotion 0.907, 0.900 graphs, 0.931 knowledge of the tables on the immunity of pregnant women, 0.931 on the health promotion tables of pregnant women 0.930, 0.901 on the immunity of pregnant women and 0.911 on the health promotion tables of pregnant women. All six builders had a reliability value of 0.70>, so they are said to have good internal strength.

Average variance extracted (AVE)

The AVE value indicates that in the construction that this variable can obtain, the value of the variable of each indicator is higher than the variation produced by measurement defects. The value of the AVE is expected to be >0.5. The AVE develops cadre skills to promote the health of pregnant women, 0.584, the knowledge of the table is 0.475, the knowledge of the table on body immunity for pregnant women is 0.529, the knowledge of the table on health promotion for pregnant women is 0.659, the attitude of the table is 0.566, the attitudes of the tables on body immunity for pregnant women are 0.759 and the graphs on health promotion for pregnant women are 0.759 Are. The postures are 0.595. Building the knowledge of the tables has a value of 0.5<.

Uji model structural (Inner Model)

To test the structural model you see the value of R2, that is, the goodness of the fit test. The Cadre Skills Contract for Pregnancy Health Promotion obtained the R2 value of 0.308 and it is interpreted that the changes in the cadres’ skills can be explained through a constructive knowledge of the graph on the bodily immunity of pregnancy, the knowledge of the chart on the health of pregnancy, the attitude graph on the body immunity of pregnant women and the charts to promote the health of pregnant women. track (0.308). The remaining 100% and 79.2% are outside the variables analyzed (100–30.8%). The R-square values of other buildings appear entirely in the table.

The next test is to warn and answer about the importance of the influence of independent buildings on the subordinate. Testing with a significance level of 5% if the t-statistic value is >1.96 then the null hypothesis (H0) is rejected The t-value of the effect coefficient of the Latente construction company was obtained from the PLS Bootstrapping show in Figure 2. The results of the PLS Bootstrapping model have been presented below.

Figure 2 The PLS Bootstrapping Model. Source: Primary Data, (2023)

The values of the parameter coefficient can be seen in the value (the original sample), the standard error (standard deviation), and the statistical values t and p can be seen below in the table.

Discussion

The relationship between the knowledge of the role of cadres in carrying out health promotion to increase the immunity of pregnant women and the skills of cadres

Respondents know and understand everything they understand in this study, related to their role in promoting the health of pregnant women. Most of a man’s knowledge is obtained by the sense of sight and the sense of hearing. The knowledge of a person is a measure to interconnect an action. Therefore, knowledge provides an important contribution to doing something to change a person’s behavior. From the results of interviews conducted through a questionnaire, most of the cadres knew the health promotion jobs of pregnant women, counseling skills to build the confidence of pregnant women, solutions, and skills to listen and analyze the problems of pregnant women. The permanent record of the health status of pregnant women, in their imaging areas, consists of the improvement of the immune system of pregnant women, knowledge of simple action tables of permanent reports, compliance with the mother’s health manual, in this case, the transmission of health is a way to advise pregnant women, which is very important in the care and immunity of pregnant women. The role of imaging/immunity/pregnant women and other important ideas in their role as health care in their territories?

Based on the results of the Chi-Square test in Table 2, in this study, the P value = 0.032 was found and the P value was < 0.05, which means that there is a significant relationship between the knowledge of the role of the cadres in promoting the health of pregnant women and the skills of the cadre. The results obtained by the researchers showed that the respondents knew their role in promoting the health of pregnant women, as shown by the data, that is, there were 59 respondents, or (69.4%) had sufficient knowledge and capacity. In fact, 52 respondents (61.2%) had the least knowledge of health promotion for pregnant women, while 26 people (30.6%) and nine respondents (10.6%) had the least knowledge.

Table 2 The relationship between knowledge and skills of cadres in the working areas of the Bontonompo I Health Center and the Bajeng Health Centerin Gowa Regency

	Skills Of Cadres	Total	P	
Less	Good	
n	%	n	%	n	%	
Knowledge of the Role of Cadres in carrying out Health Promotion	
   Not enough	9	10,6	17	20,0	26	30,6	P=0,032	
   Enough	7	8,2	52	61,2	59	69,4	
   Amount	16	18,8	69	81,2	85	100,0	
Knowledge of cadres about the immunity of pregnant women	
   Not enough	8	9,4	14	16,5	22	25,9	P=0,025	
   Enough	8	9,4	55	64,7	63	74,1	
   Amount	16	18,8	69	81,2	85	100,0	
Source: Primary Data, (2023)

In this case, most health cadres have fairly good knowledge. Know the tables to promote the health of pregnant women. Knowledge or cognition is a very important domain in shaping one’s actions (evident relationship). From experience and research, it has been shown that knowledge-based behavior will be more durable than non-knowledge-based behavior. It can be interpreted to know or understand after seeing or understanding knowledge (presence, experimentation, or teaching). Knowledge of the cadres can increase, along with the time the cadres have had, along with the experience in using the cases and the skills that have been supported. With greater knowledge, it is hoped that better service will be given to the community. Green explained that knowledge is a factor before the device and that determines personal attitude.

The relationship between pregnant women’s immunity knowledge and cadre skills

From Table 2 the results of the test performed in this study, the P value = 0.025 reached < 0.05 euros, which means that there is a significant relationship between the knowledge of images about the immunity of pregnant women and the abilities of the cadres. The results obtained by the researchers show an increase in the immunity of pregnant women, while 63 of the 85 respondents recognize the immunity of pregnant women and 22.9%.

In this case, Table 3 most health pictures know that the immunity of pregnant women has increased. A person’s knowledge can increase along with an experience that improves the quality of health services. Some of the factors influencing cadres’ knowledge and skills are the frequency of participation in cadre training, education, cadre activity, and cadre duration. Based on[12] He suggests that the ability of cadres to perform their work and obtain good results influences the number of periods in which they have worked as cadres, that the longer they become cadres, the more qualified the cadre will be to work in Prussian activities. However, it has rejected the results of the investigation carried out. Click or tap here to enter text.[13] In Magelang, with the method of learning knowledge problems and skills of nutritional cadres, it was discovered between 1 and 5 years.

Table 3 The Relationship between Attitudes and Skills of Cadres in the Working Areas of the Bontonompo I Health Center and the Bajeng Health Center in Gowa Regency

	Skills Of Cadres	Total	P	
Less	Good	
n	%	n	%	n	%	
Attitudes of cadres about Health Promotion of Pregnant Women	
   Negative	8	9,4	10	11,8	18	21,2	P=0,004	
   Positive	8	9,4	59	69,4	67	78,8	
   Amount	16	18,8	69	81,2	85	100,0	
Attitude of cadres about the immunity of pregnant women	
   Negative	2	2,4	0	0,0	2	2,4	P=0,001	
   Positive	16	18,8	67	78,8	83	97,6	
   Amount	16	18,8	69	81,2	85	100,0	
Source: Primary Data, (2023)

According to the researchers’ cases, a person’s knowledge and skills influence education, exposure to information, activity, parity, and continuing education. The greater the knowledge, the more skilled the cadre will be, and conversely, the lower the knowledge of the cadre, the less qualified. The educational level, the exposure to information, activity, and continuous training are closely linked since the educational level is good, but if there is no risk of information (anthropometric measurements) and the cadres are not active, a lack of knowledge and skill of the category cadres. And that was also confirmed in the investigation.[14] This knowledge is the variable that most influences the skills of the cadres to perform post-rheumatic activities.

According to Table 4 lesser-known cadres, they are 10 times more likely to be unqualified than known cadres.[15] He explained that the level of knowledge and skill of the cadres will be better if basic or higher education has five basic specific modules, is active for coaching, and has a high frequency of participation in coaching. The great value of the knowledge and skills of the cadres is due to the formative and formative activity of the cadres. This result coincides with the research.[16] In fact, the better the knowledge of the image, the more skilled it is, and vice versa, the less informed the tables, the more skilled they are at measuring BB and television.

Table 4 The relationship between knowledge and the attitude of cadres in the Working Areas of the Bontonompo I Health Center and the Bajeng Health Center in Gowa Regency

	Attitude	Total	P	
Negative	Positive	
n	%	n	%	n	%	
Knowledge of cadres About Health Promotion of Pregnant Women	
   Not enough	1	1,2	21	24,7	22	25,9	P=0,453	
   Enough	1	1,2	62	72,9	63	74,1	
   Amount	2	2,4	83	97,6	85	100,0	
Knowledge of cadres about the Immunity of Pregnant Women	
   Not enough	12	14,1	14	16,5	26	30,6	P=0,020	
   Enough	12	14,1	47	55,3	59	69,4	
   Amount	24	28,2	61	71,8	85	100,0	
Source: Primary Data, (2023)

The relationship between the attitudes of cadres in health promotion to increase the immunity of pregnant women and the skills of cadres

The results of the study showed that of the 85 respondents in the work areas of Bontonompo I Health Center and Bajeng Health Center, with positive attitudes, toward fulfilling roles and obligations, 67 respondents or 78.8% had negative behavior and 18 or 21.2% had a negative behavior. cadres who fulfill their functions and obligations. From Table 3 the results of the Chi-Square test performed in this study, the P value = 0.004 reached < 0.05 euros, which means that there is a significant relationship between attitudes, in this case, from Table 5 the role and obligations of cadres in promoting health to Table 4 increase immunity from the capacities of pregnant women. Like the health personnel, the cadres also have a good understanding, and the attitude of the cadres is also good. According to a study conducted by Hari Basuki Notobroto in four districts of East Java, most respondents played well.[17] According to data from MCHR. In the tables, mothers will be invited to increase the mother’s health data, documents, and presentations. This, in Notoatmodjo’s opinion, indicates the suitability of reactions to stimuli that are received daily, since these are emotional reactions against social stimuli. With positive encouragement, you will also encourage positive behavior.[18]

Table 5 Cross-loading value

	Cadre Skills in Pregnant Women’s Health Promotion	Cadre Knowledge about Pregnant Women’s Body Immunity	Cadre Knowledge about Pregnant Health Promotion	Cadre’s Attitude towards Pregnant Women’s Body Immunity	Cadre’s Attitude towards Pregnant Health Promotion	
X1A1	0,204	0,375	0,780	0,384	0,382	
X1A2	0,159	0,434	0,815	0,368	0,390	
X1A3	0,162	0,188	0,613	0,256	0,174	
X1A6	0,255	0,388	0,909	0,357	0,301	
X1A7	0,264	0,400	0,916	0,357	0,322	
X1A8	0,244	0,356	0,778	0,464	0,421	
X1A9	0,283	0,428	0,833	0,362	0,298	
X1b10	0,191	0,694	0,307	0,441	0,475	
X1b11	0,271	0,706	0,317	0,371	0,410	
X1b13	0,368	0,838	0,206	0,450	0,477	
X1b15	0,469	0,800	0,278	0,426	0,457	
X1b16	0,279	0,697	0,381	0,398	0,247	
X1b17	0,369	0,782	0,204	0,438	0,348	
X1b22	0,385	0,708	0,339	0,484	0,409	
X1b3	0,361	0,711	0,476	0,506	0,512	
X1b4	0,415	0,691	0,406	0,682	0,596	
X1b5	0,451	0,689	0,326	0,493	0,443	
X1b6	0,422	0,759	0,425	0,458	0,523	
X1b9	0,367	0,627	0,278	0,407	0,439	
X2a1	0,389	0,621	0,349	0,607	0,797	
X2a2	0,359	0,494	0,314	0,564	0,801	
X2a4	0,389	0,514	0,365	0,555	0,786	
X2a5	0,336	0,459	0,452	0,599	0,769	
X2a6	0,279	0,450	0,319	0,606	0,720	
X2a8	0,253	0,408	0,234	0,400	0,715	
X2a9	0,307	0,405	0,171	0,481	0,806	
X2b2	0,447	0,595	0,434	0,896	0,599	
X2b24	0,432	0,585	0,419	0,939	0,608	
X2b25	0,369	0,589	0,419	0,912	0,675	
X2b3	0,483	0,637	0,420	0,884	0,704	
X2b31	0,393	0,485	0,341	0,893	0,613	
X2b37	0,391	0,486	0,359	0,801	0,506	
X2b4	0,462	0,577	0,333	0,850	0,581	
X2b5	0,336	0,556	0,423	0,782	0,656	
Y14	0,817	0,517	0,253	0,534	0,487	
Y15	0,736	0,412	0,094	0,339	0,239	
Y17	0,764	0,362	0,192	0,230	0,163	
Y18	0,819	0,332	0,296	0,351	0,413	
Y19	0,836	0,295	0,217	0,293	0,309	
Y22	0,688	0,358	0,159	0,280	0,251	
Y8	0,671	0,369	0,249	0,408	0,325	
Source: Primary Data, (2023)

Azwar’s theory suggests that it is a mechanism that evaluates attitude, forms views, colors feelings, and determines the tendency of that individual toward other individuals or toward something that opposes. Behavioral components include cognitive, affective, and behavioral elements. According to other studies, the relationship between cadres’ attitudes toward cadres’ functions and cadres’ practices. These results coincide with the theory of L. Green, where attitude is one of the main factors to change a person’s behavior (factors). Attitude is a person’s closed response to a special stimulus or object, which includes opinion and emotional factors (happy-unhappy, lack of consensus, good-not-good). The attitude of the approved cadres implies that the cadres must voluntarily fulfill the obligations and responsibilities related to the functions of the cadres, which makes it possible to carry out reinforcing factors (in this case, helping the party leader, helping the people) and improving the practice of the support cadres of health personnel.

It is a person appointed, elected, or appointed to lead the development of the expected finger behavior in a person who is in a social situation. Therefore, the role of a cadre, with its skills or abilities, is expected to lead the development of a posyandu.

The relationship between the attitude of immunity of pregnant women and the skills of cadres in an effort to increase the immunity of pregnant women with the skills of cadres

The results showed Table 6 that 83% or 97.6% of respondents had a positive attitude toward the immunity of pregnant women, while two respondents or 2.4% had a negative attitude toward the immunity of pregnant women, while 83 of the 85 respondents (97.6%) had a positive attitude and 67 (78.8%). This percentage is higher than respondents who have a negative attitude about efforts to boost pregnant women’s immunity, as they have negative behavioral skills with two respondents (2.4%) and then respondents (0%). From the test results, in this study, the P value = 0.0401 was found, so the P- > value was 0.05, which means that there is no significant relationship between efforts to increase the immunity of pregnant women and the abilities of their cadres.

Table 6 Composite reliability value

Contact	Composite Reliability	
Skills of Cadres in Health Promotion for Pregnant Women	0,907	
Cadre Knowledge	0,900	
Knowledge of Cadres About Immunity of Pregnant Women	0,931	
Knowledge of Cadres About Health Promotion for Pregnant Women	0,930	
Attitude of Cadre	0,901	
Attitude of Cadres Towards Pregnant Women’s Body Immunity	0,962	
Attitudes of Cadres towards Pregnant Women’s Health Promotion	0,911	
Source: Primary Data, (2023)

Lawrence Green, in 1980, suggests that attitude is a factor that also influences a person’s behavior. Attitude is a predisposing factor for someone to do something. This attitude is also influenced by several factors. According to Azwar, factors influencing attitudes are personal experience, culture, people considered important persons, media, educational institutions, and religious institutions, as well as emotional factors within the individual.[19]

Cadres play an important role in improving nutrition and public health. Cadres can be empowered as a community group that can provide education and counseling to pregnant women, mothers of children, and child mothers. Five in improving nutritional status and nutritional intake.[20] The results of several studies show that cadre empowerment is effective in increasing mothers’ knowledge, attitudes, and actions, as well as in improving the nutritional status of children and families.[21] In this community service activity, mothers with children from 0 to 24 months are considered to meet the requirements for the fulfillment of their obligations, such as assistance to mothers with children from 0 to 24 months in the growth monitor and compliance with nutritional intake.

The relationship between the knowledge of cadres in health promotion and the attitudes of cadres in health promotion

The results showed in Tables 7 and 8 that 63 out of 85 respondents (74.1%) had sufficient knowledge 62 had a positive attitude (72.9%), those had less knowledge about the effort to increase the immunity of pregnant women (25.9%), and one respondent (1.2%) had a negative behavior.

Table 7 R2 Value

Endogenous Contract	R 2	
Skills of Cadres in Health Promotion for Pregnant Women	0,308	
Knowledge of Cadres About Immunity of Pregnant Women	0,713	
Knowledge of Cadres About Health Promotion for Pregnant Women	0,677	
Attitude of Cadre	0,421	
Attitude of Cadres Towards Pregnant Women’s Body Immunity	0,873	
Attitudes of Cadres towards Pregnant Women’s Health Promotion	0,745	
Source: Primary Data, (2023)

Table 8 Coefficient Values (Original Sample), Standard Error and T-Statistics

Direct Influence Path	Original Sample (O)	Standard Deviation (STDEV)	T Statistics (|O/STDEV|)	P	Information	
Knowledge of Cadres About Pregnant Health Promotion - > Skills of Cadres in Pregnant Health Promotion	–0,225	0,304	0,740	0,009	Significant	
Knowledge of Cadres About Immunity of Pregnant Women - > Skills of Cadre in Health Promotion of Pregnant Women	0,091	0,291	0,314	0,003	Significant	
Attitude of Cadres towards Pregnant Health Promotion - > Skills of Cadres in Pregnant Health Promotion	0,134	0,257	0,523	0,001	Significant	
Attitudes of Cadres Towards Immunity of Pregnant Women - > Skills of Cadre in Health Promotion of Pregnant Women	0,333	0,357	0,932	0,002	Significant	
Knowledge of Cadres About Pregnant Health Promotion - > Attitude of Cadres towards Pregnant Health Promotion	0,060	0,059	1,007	0,314	Not significant	
Knowledge of Cadres About Immunity of Pregnant Women - > Attitude of Cadres about Immunity of Pregnant Women	0,084	0,058	1,448	0,148	Not significant	
Source: Primary Data, (2023)

The approximate in Table 8 results of the test were obtained in this study, that is, the P value = 0.0453, so the value obtained at 0.05 > P means that there is no significant relationship between the knowledge of the immunity of pregnant women and the immune behavior of pregnant women. Knowledge is the result of knowledge, and that happens after people feel a certain object. Knowledge can be obtained, among others, through curricular education, not through curriculum and extracurricular education, and knowledge can also be acquired through the knowledge of other people, such as listening, live watching television, radio, books, and other communication tools. Meanwhile, attitude is the reaction or response of someone who is still close to a stimulus or object. The manifestation of this attitude cannot be seen immediately, but can only be interpreted in advance from a closed behavior.[22]

Becoming a cadre of poyas is a community way of participating in the health sector. The role of cadres in the maternal health program is to raise awareness of all health problems related to the health of pregnant women and newborns and to become an activator of existing community groups or agencies. One of the functions of maternal health charts is to assist health professionals in identifying and locating pregnant women through home visits. Human resources and elected by the community. Cadres are the direct driver of community health-related activities and, through collaboration between health professionals, families, and EU leaders, problems are expected to be overcome in stages.[23]

According to, Wawa and Dewin[24] there are three components that adapt knowledge (cognitive), affective and psychomotor. The formation of a new behavior begins cognitively, which means that the subject previously knows the stimulus as material or object. The new knowledge generates the response of the subject’s attitude. According to Yusriani and Alwi,[25] it is a person’s opinion or belief about a fixed object or state, along with certain feelings, and gives the basis for someone to respond or compete in some way.

The relationship between the knowledge of pregnant women’s immunity and the attitude of cadres in increasing the immunity of pregnant women

The results showed that of the 85 respondents, 59 (69.4%) had positive knowledge and behavior, 47 respondents (55.3%), a higher percentage than those who had less knowledge in efforts to increase the immunity of pregnant women, 26 (30.6%) and 12 respondents (14.1%).

The results of the Chi-Square test performed in this study were 0.020, so the P value was < 0.05, which means that there was a significant relationship between the knowledge of the immunity of pregnant women and the immune behavior of pregnant women.

Notoatmodjo argues that knowledge is the fruit of the knowledge that people feel when they feel a certain object. The level of knowledge influences the intensity of attention and the perception of objects. Good knowledge and clear understanding are factors that lead to participation growth.[26] According to the previous opinion, this study shows a significant relationship between the role and knowledge of images in the detection of risk factors for pregnant women. The results of this research coincide with Kusnadi’s research, as the frames have a great deal of knowledge. Saragih explained that, with the participation of screening tables for pregnant women, knowledge is good for detecting risks for pregnant women. Bangsawan, according to Soni, has a better level of activity than cadres of little knowledge.[27] A positive attitude tends to approach, like, and expect some objects. Meanwhile, a negative attitude tends to avoid, hate, and loosen some objects. Work attitude is the result of evaluating and valuing people or events at work of people or events, or from a person’s response to something.[28]

Conclusion

There is a significant relationship between knowing the role of cadres in health promotion, and increasing the immunity of pregnant women with the abilities of cadres. This is verified from the results of the research and a value (0.032 < 0.05) is obtained. Significant relationship between the immunity of pregnant women and the abilities of the cadres. This is demonstrated by the results of the study (P = 0.025 < 0.05). This is a significant relationship between the attitudes of the cadres in promoting health to increase the immunity of pregnant women and the abilities of the cadres. According Table 3 to the results of the study, this has nothing to do with the immune attitude of pregnant women and the abilities of the cadres (P = 0.004 < 0.05), since the results of the study show that those who obtained value reached value (P = 401 > 05). There was no significant relationship between the knowledge of the cadres in health promotion and the attitude of the cadres in health promotion, obtaining a clear value from the results of the study (P = 0.453 > 0.05). A significant relationship between the knowledge of the immunity of pregnant women and the increase in immunity of pregnant women, reached the value of the research results (P = 0.020<.05). Based on Table 7 the results of research related to the skills of cadres in health promotion using the Smart PLS, it can be concluded that the resulting model is good, with a moderate value of 0.308. The model obtained is as follows: Y =0.713 × 1 + 0.677 × 2 + 0.873 × 3 + 0.745 × 4+ζ Efforts are needed to improve the skills of cadres in health promotion, in increasing the immunity of pregnant women, through changes in knowledge and attitudes, education and training.

Ethical approval

This study was approved by The ethical permissions issued by Komisi Etik Penelitian Kesehatan Universitas Muslim Indonesia (KEPK UMI) can be identified by the number register (UMI-12306290).

Consent to participate

Universitas Muslim Indonesia, Makassar waived the requirement for written consent because of the study design.

Data availability

No supplementary files are included, and the data can be provided upon justification.

Personal thanks

All parties involved in this research, especially for the willingness of the cadres who took part in this research conducted in Gowa Regency, with special thanks to the regional government of Gowa for their invaluable support throughout the research process. The author expresses his sincere appreciation to the Directorate of Research, Technology and Community Service, Directorate General of Higher Education, Research and Technology, Ministry of Education, Culture, Research and Technology of the Republic of Indonesia for the large financial contribution to this research, authorship, and publication of this article as part of the Higher Education Excellence Basic Research (PDUPT) program.

Authorship

YY is the corresponding author and was in charge of the manuscript conceptualization, methodology, writing the original draft, editing the manuscript, data collection, and curation, and was responsible for data analysis. MKA contributed to the analysis, and interpretation of the findings, and provided critical feedback for the final draft of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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