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Asian Journal of Health and Science
p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol. 3 No. 11 November, 2024
Factors Influencing Officer Compliance in the Implementation of
Integrated Management of Childhood Illness (IMCI) at Community
Health Center in Banda Aceh City
Siska Safriana1*, Raihan2, Anidar3,
Teuku Muhammad Thaib4, Eka Yunita Amna5, Nora Sovira6
1Universitas Syiah Kuala, Indonesia
2,3,4,5,6 Rumah Sakit Umum dr Zainoel Abidin Banda Aceh, Indonesia
Emails: siisiska27@gmail.com1, raihanrais5@gmail.com2, Anidarlatif@yahoo.com3,
thaib_tm@yahoo.com4, eya.delima18@gmail.com5, norasovira@unsyiah.ac.id6
Abstract
Integrated Management of Sick Toddlers (IMCI) is an integrated approach to improving
child health and well-being, which aims to reduce morbidity and mortality and promote
growth and development of children under five. Despite its importance, challenges in the
quality of IMCI implementation in PHC centers still exist. This research aimed to identify
factors that influence staff compliance in implementing IMCI at health centers in Banda Aceh
city. This research method used an analytic observational research with a cross-sectional
design, involving 64 IMCI service providers from November 2023 to June 2024. Data were
collected using questionnaires and analyzed using the chi-square test and multivariate
logistic regression. The results showed that staff compliance in implementing IMCI was
39%. Internal factors that significantly influenced compliance were motivation (OR=14.3,
95% CI: 3.039-67.505) and knowledge (OR=8.63, 95% CI: 1.694-43.978). External factors
included the availability of complete logistics facilities (OR=8.05, 95% CI: 1.706-38.04). This
research identified Ulee Kareng Health Center as having the highest number of PIA service
providers (17%), while Banda Raya Health Center had the lowest number (7%). Most of the
PIA service providers were aged 19-44 years (68.8%), mostly female (96.9%), and had high
educational qualifications (93.7%). The implications of this research underscore the
important role of motivation, knowledge, and logistical support in improving staff
adherence to IOP protocols. The results of this research have implications for strengthening
health care systems and improving the quality of IYCF implementation to meet the health
needs of children under five in Banda Aceh city.
Keywords: Integrated management of sick children, compliance, knowledge, motivation,
logistics, IMCI officers, puskesmas.
INTRODUCTION
Regulation of the Minister of Health of the Republic of Indonesia Number 25 of 2014
states that every child has the right to grow and develop and has the right to survival and
protection from violence and discrimination, which needs to be carried out in an integrated,
comprehensive, and sustainable manner (Kementerian Kesehatan, 2020). One of the goals of
child health efforts is to ensure children's survival by reducing the mortality rate of
newborns, infants, and toddlers (Ministry of Health, 2014). The coverage of under-five health
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services in Aceh province from 2017-2021 fluctuated, and there was a very significant decline
in 2021. Factors causing very low toddler health service coverage (Kilov et al., 2021);
(Compilation, 2021)
Child mortality in Indonesia shows a decrease in mortality rates. According to the
Directorate of Nutrition and Maternal and Child Health, the number of under-five deaths in
2021 was 27,566; this figure is lower than in 2020 (28,158 deaths) (Indonesian Ministry of
Health, 2022). Infant mortality rate (IMR) is also one of the indicators used to determine the
degree of public health. The Infant Mortality Rate (IMR) in Aceh from 2017 to 2022 has
fluctuated; in 2017 and 2018, it was at 10/1,000 Live Births (LH), and in 2022, the IMR
decreased again to 10/1,000 LH with a good category, but not by the target set by the Aceh
Health Office, which in 2022 set a performance target for IMR of 8/1,000 LH (Health, 2022).
The most common cause of neonatal death in 2021 was the condition of Low Birth Weight
(LBW), which amounted to 34.5%, and asphyxia at 27.8%. Other causes of death include
congenital abnormalities, infections, COVID-19, neonatal tetanus, and others. The main causes
of death in the under-five group (12-59 months) were diarrhea at 10.3% and pneumonia at
9.4%. Other causes of death were dengue fever, congenital heart defects, drowning, injuries,
accidents, other congenital abnormalities, COVID-19, parasitic infections, and other causes
(Indonesian Ministry of Health, 2022).
The newborn mortality rates found in Indonesia point to issues about the quality of care
received by infants (UNICEF, 2020). One of the efforts in reducing under-five mortality rates
is improving health workers' skills at health centers through the Integrated Management of
Sick Toddlers (IMCI) approach since 1997. Implementing IMCI has been going on for a long
time, but there are still many obstacles in practice, and it has not been optimized (Ministry of
Health, 2020).
Efforts to reduce the mortality rate of newborns, infants, and toddlers, according to the
Minister of Health Regulation Number 25 of 2014 article 21 concerning health services for
infants, children under five, and preschoolers, health services for infants, children under five
and preschoolers are carried out, among others, through the provision of exclusive breast
milk (ASI), the provision of complementary foods (MPASI) starting at the age of 6 months,
the provision of complete basic immunization for infants and the implementation of IMCI /
MTBM (Ministry of Health, 2014).
The IMCI chartbook has been revised thrice in 2003, 2008, and 2015. From 2020 to
2022, the latest version of the 2015 IMCI chartbook was revised. National conditions, policies,
and guidelines conducted this fourth revision. This revision was held by the Ministry of
Health in Jakarta and invited MTBS experts and facilitators from various provinces (Laksono
et al., 2023). The World Health Organization (WHO) recommends updating the Integrated
Management of Childhood Illness (IMCI) based on the latest guidelines and research on
clinical management (World Health Organization, 2005).
Research on IMCI in several provinces in Indonesia in 2016 showed that 80% of health
centers in the eastern region had implemented IMCI. However, only 25% of health centers
reached all children under five. 90% of health centers have been trained in IMCI, but only
15% have conducted post-training monitoring. Only 25% of health centers received
supervision from the District Health Office in implementing IMCI. Monitoring and supervision
of staff compliance is needed, as well as increasing the availability of equipment and
supporting facilities/infrastructure for implementing IMCI (Suparmi et al., 2018).
Research on implementing IMCI at the Puskesmas of Pasuruan Regency found that the
number of officers is not proportional to the number of sick toddlers visiting;. However,
Standard Operating Procedures (SOPs) are available, not all officers use IMCI in child health
services, coaching has not been carried out routinely, supervision is still general, and no
follow-up is given (Firdaus & Mawarni, 2013). MTBS research has also been conducted at
Puskesmas Indrajaya and Delima, Pidie Regency, Aceh Province. The results showed that the
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implementation of IMCI at Indrajaya Health Center was 75.4%, and at Delima Health Center
was 62.2%. Factors associated with staff performance in implementing the IMCI program are
staff motivation and facilitative supervision. It is expected that there will be an increase in
employee motivation through good teamwork, training, coaching, and supervision in a
planned and continuous manner through facilitative supervision and providing feedback in
order to increase MTBS coverage and improve the workability of MTBS officers (Faktor et al.,
2021). Problem-solving efforts through cross-sectoral cooperation are related to further
activating posyandu and increasing community empowerment. Health services for sick
toddlers are services for toddlers using an integrated management approach for sick
toddlers. (Compilation, 2021).
Improving the quality of IMCI services through workplace training or workshops was
held in Aceh Jaya District and Langsa City at the end of 2018. In 2019, the Ministry of Health
(MOH) decided to hold similar training in three locations, namely Singkil City, Simeulue, and
Sabang. The ten provincial expert trainers in Aceh consisted of three provincial Health Office
staff, three pediatricians from the Aceh Branch of the Indonesian Pediatric Association, two
midwives from the Aceh Provincial Indonesian Midwives Association, two nurses from the
Indonesian Nurses Association in Aceh, the district Health Office had at least two staff trained
to supervise IMCI facilitation and 49 puskesmas had at least two staff trained to be IMCI
mentors. As a result, IMCI implementation increased from 6% in February 2019 to 94% in
June 2020 (Moh, Itagi, UNICEF, 2021).
One of the obstacles to implementing IMCI is the lack of personnel trained for it because
training requires a large amount of money. However, the IMCI Workshop is very important
and is one of the standards of child health services at the primary care level (Indonesian
Ministry of Health, 2020). If factors associated with implementing IMCI in low- and middle-
income countries are known, the likelihood of reducing infant morbidity and mortality can
be increased (Mauricio & Sierra, 2020).
Based on the background description above, this study aims to determine the factors
that influence officer compliance in the implementation of Integrated Management of Sick
Toddlers (IMCI) at the Puskesmas Working Area in Banda Aceh City. Thus, the benefit of this
study is to contribute to improving the quality of child health services by understanding the
factors that influence staff compliance in the implementation of Integrated Management of
Sick Toddlers (IMCI). The results of this study are expected to serve as a basis for policy
makers and managers of health facilities in Banda Aceh in improving the compliance of health
workers through the provision of more focused training, increased work motivation,
facilitative supervision, and the provision of adequate logistical facilities.
RESEARCH METHOD
This research utilized a quantitative approach with an analytic observational design,
employing cross-sectional data collection. Conducted across 11 health centers (Puskesmas)
within Banda Aceh Cityspecifically Baiturrahman, Banda Raya, Jaya Baru, Batoh, Kuta
Alam, Lampulo, Lampaseh Kota, Meuraxa, Jeulingke, Kopelma Darussalam, and Ulee
Karengthe study targeted health workers involved in Integrated Management of Childhood
Illness (IMCI). The sampling technique used was purposive sampling, focusing on MTBS
officers, general practitioners, midwives, and nurses who actively provided IMCI services.
This resulted in a final sample of 63 participants who met the research inclusion criteria.
Data were collected through structured questionnaires designed to assess
demographic factors, knowledge, motivation, and logistic support, along with other elements
relevant to compliance in IMCI implementation. Data analysis began with validity and
reliability testing to ensure instrument quality. Univariate analysis was performed to
describe individual variables, followed by bivariate analysis to explore relationships between
variables. Finally, multivariate analysis, specifically logistic regression, was applied to
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identify the most significant factors influencing compliance among IMCI implementing
officers.
RESULT AND DISCUSSION
An overview of the number, basic characteristics, and compliance of IMCI officers in health
centers in the working area of Banda Aceh City
Banda Aceh City's geographical location is between 05º30′ —05º35′ LU and 95º30′ —
99º16′ East. It consists of 9 sub-districts, 70 villages, and 20 urban villages with a total area of
± 61.36 km² (Figure 1).
Figure 1. Overview of the Banda Aceh Municipality54
Source:
Regional Development Planning Agency of Banda Aceh City.
The administrative boundaries of Banda Aceh City are to the north, bordering the
Malacca Strait. Darul Imarah District and Ingin Jaya District, Aceh Besar Regency border the
south. Peukan Bada District, Aceh Besar Regency border the west. The Barona Jaya sub-
district and the Darussalam sub-district, Aceh Besar district.54 border the East
Health service facilities in Banda Aceh City consist of 11 non-inpatient health centers,
68 clinics, and 15 hospitals based on hospital ownership in Banda Aceh City consisting of 3
Aceh government hospital units, 1 Banda Aceh City government hospital unit, 2 TNI / POLRI
hospital units, nine private hospital units.
Table 1. Number of employees of health centers in the city of Banda Aceh.
Health Center
Number of Health
Center Employees
Personnel involved in IMCI services
Number(n)
Percentage(%)
Baiturrahman
50
5
10
Batoh
60
8
13
Jaya Baru
47
5
11
Banda Raya
60
4
7
Kuta Alam
51
6
12
Lampulo
42
4
9
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Health Center
Number of Health
Center Employees
Personnel involved in IMCI services
Lampaseh City
49
8
16
Meuraxa
52
4
8
Jeulingke
46
5
11
Kopelma Darussalam
51
6
12
Ulee Kareng
52
9
17
The research subjects were 64 IMCI poly officers from all 11 Puskesmas in Banda Aceh
City, namely Baiturrahman Puskesmas, Banda Raya Puskesmas, Jaya Baru Puskesmas, Batoh
Puskesmas, Kuta Alam Puskesmas, Lampulo Puskesmas, Lampaseh Kota Puskesmas,
Meuraxa Puskesmas, Jeulingke Puskesmas, Kopelma Darussalam Puskesmas and Ulee Kareng
Puskesmas. The highest percentage of officers involved in IMCI services is Ulee Kareng Health
Center, which is 17%, as described in Table 1. The characteristics of the research subjects are
presented in Table 4.2 as follows:
Table 2. Basic characteristics of IMCI staff
Characteristics
Frequency (n)
Percentage (%)
Age
Adults (19-44 years )
44
68,8
Pre-elderly (45 - 59 years old)
20
31,5
Gender
Male
2
3,1
Female
62
96,9
Education
Low (< DII)
4
6,3
60
93,7
Total
64
100
Based on age group, the research subjects were dominated by the age group 19-44
years (68.8%) and female gender (96.9%). Most of the subjects came from Ulee Kareng
puskesmas, with a percentage of 14.1%, followed by Batoh and Lampaseh Kota puskesmas
(12.5% each). 93.7% of the research sub2).
Staff compliance in implementing IMCI procedures was assessed by monitoring the
completion of the IMCI recording form. The compliance assessment standard is 80%, by the
standards of the Ministry of Health of the Republic of Indonesia.45
Table 3. Percentage of MTBS form completion compliance
Health Center
CFR Form Completion Rate (%)
Value Interpretation
Baiturrahman
53
Non-compliant
Batoh
91*
Compliant
Jaya Baru
82*
Compliant
Banda Raya
66
Non-compliant
Kuta Alam
79
Non-compliant
Lampulo
83*
Compliant
Lampasas City
83*
Compliant
Meuraxa
76
Non-compliant
Jeulingke
51
Non-compliant
Kopelma Darussalam
67
Non-compliant
Ulee Kareng
46
Non-compliant
Four (36.3%) out of 11 puskesmas complied with the MTBS Recording Form, namely
Puskesmas Batoh, Puskesmas Jaya Baru, Puskesmas Lampulo, and Puskesmas Lampaseh
Kota, as described in Table 3. Compliance assessment By the standards of the Ministry of
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Table 4. Percentage of Compliance of Health Center Staff
Health Center
Officer Compliance
Compliant
Non-compliant
n (%)
n (%)
Lampaseh City
8 (12,5)
0 (0)
Batoh
8 (12,5)
0 (0)
Jaya Baru
5 (8)
0 (0)
Lampulo
4 (6)
0 (0)
Ulee Kareng
0 (0)
9 (14)
Kopelma Darussalam
0 (0)
6 (9,5)
Kuta Alam
0 (0)
6 (9,5)
Jeulingke
0 (0)
5 (8)
Baiturrahman
0 (0)
5 (8)
Banda Raya
0 (0)
4 (6)
Meuraxa
0 (0)
4 (6)
Total (100%)
39%
61%
The compliance of the health centers is in line with the compliance of the respondents
in each health center; therefore, 25 (39%) out of 64 health workers completed the IMCI
recording form as described in Table 4.
The relationship between internal factors and compliance of health center staff in
implementing IMCI
Table 5 presents the relationship between internal factors and puskesmas staff
compliance in implementing IMCI. Compliance was more common in the adult group
(45.5%). 24 people (38.7%) were female, with high education (40%), a new MTBS clinic
tenure (40%), high motivation (65.6%), and high knowledge (52.6%).
Table 5. The relationship between internal factors and staff compliance with IMCI
implementation at Puskesmas in the working area of Banda Aceh City.
*Significant (p<0.05)
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Based on the statistical analysis of the Chi-Squared test, it was found that motivation
and knowledge were internal factors that significantly (p<0.05) influenced staff compliance
in implementing IMCI in the Puskesmas working area of Banda Aceh City, as described in
Table 5.
The relationship between external factors and compliance of health center staff in
implementing IMCI
Table 6 presents the relationship between external factors and puskesmas staff
compliance in implementing IMCI. Compliance was found to be 58.8% at puskesmas with
complete logistics facilities. Other factors, such as MTBS training, workload, and supervision,
did not affect the compliance of MTBS implementation.
The relationship between external factors and staff compliance with implementing IMCI at
Puskesmas in the working area of Banda Aceh City.
*Significant (p<0.05)
Based on the statistical analysis of the Chi-Squared test, it was found that complete
logistics facilities were an external factor that significantly (p<0.05) influenced staff
compliance in implementing IMCI at the Puskesmas in the working area of Banda Aceh City
as described in Table 6.
Factors that most influence staff compliance with IMCI implementation
Multivariate analysis was conducted on internal factors (motivation and knowledge)
and one external factor (logistics), which in the previous bivariate analysis showed a
significant p-value <0.05.
Table 7. Factors that most influence staff compliance with IMCI implementation at Puskesmas
in the working area of Banda Aceh City
*Logistic regression
Based on Table 7 above, the logistic regression test found that knowledge (OR 8.63;
IK95% 1.694 - 43.978), motivation (OR 14.32; IK95% 3.039 - 67.505), and logistics (OR 8.05;
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IK95% 1.706 - 38.04) were factors associated with staff compliance in implementing IMCI
(p<0.05).
Furthermore, based on this data, the probability of compliance can be calculated. The
calculation of the probability of compliance in health workers with knowledge, motivation,
and logistics characteristics is as follows:
Based on the above formulation, health workers with high knowledge and motivation,,
as well as complete logistics at the health center,, are 1.105 times more likely to be adherent
to implementing IMCI at the health center in the working area of Banda Aceh City.
An overview of the number, basic characteristics, and compliance of IMCI officers in health
centers in Banda Aceh City
Of all the MTBS officers of health centers in Banda Aceh City, the most MTBS officers in
this research came from Ulee Kareng Health Center, totaling nine people (14.1%), and the
least from Banda Raya Health Center, four people (6.6%). This result is not much different
from the research conducted by (Website et al., 2023) that the implementation of Integrated
Management of Sick Toddlers (IMCI) at Puskesmas Kota Ratu was carried out by doctors and
IMCI officers and health workers at the Puskesmas was sufficient. Namely, four people in the
IMCI clinic had good service performance and competent staff. According to the IMCI and
malnutrition training module, health workers at the Puskesmas play a role in implementing
IMCI by their competence and authority. To provide comprehensive management of sick
toddlers according to standards, capacity building is needed for facilitators and health
workers in child health services (doctors, midwives/nurses, and nutritionists) as the IMCI
service team at puskesmas. However, researchers did not find any theory or standard
provisions from WHO, the Ministry of Health, the Health Office, or puskesmas regarding the
number of staff that must be present in IMCI services.
The subjects in this research were 64 IMCI poly officers from all health centers in the
working area of Banda Aceh City, which amounted to 1 1 Puskesmas. This research showed
that officers who were compliant in filling out the IMCI recording form were 39%. The
findings of this research do not differ much from the research (Radiyanti et al., 2016) At the
Karanganyar Regency Health Center, which showed that most respondents 45.5% completed
the MTBS sheet. Staff compliance in implementing the IMCI procedure was assessed by
monitoring the completion of the IMCI recording form. The standard for compliance
assessment was 80%, by the standards of the Ministry of Health of the Republic of Indonesia.
This recording form is a very important tool for recording the child's condition and the results
of examinations and actions or treatment provided by health workers so that continuous
health services are organized (Indonesian Ministry of Health, 2022).
Puskesmas that are compliant in filling out the IMCI recording form in the Banda Aceh
City area are 4 puskesmas (36.3%) out of a total of 11 puskesmas namely, Puskesmas Batoh,
Puskesmas Jaya Baru, Puskesmas Lampulo, and Puskesmas Lampaseh Kota. Puskesmas with
a percentage assessment of filling out the best MTBS recording form of 80% and above are
Puskesmas Batoh (91%), Puskesmas Lampulo (83%), Puskesmas Lampaseh Kota (83%), and
Puskesmas Jaya Baru (82%). According to data from the Ministry of Health based on the
results of monitoring and evaluation in 2020 at puskesmas throughout Indonesia, it was
found that puskesmas that had implemented IMCI reached 93.8% but with a low level of
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officer compliance, namely only 54.6% (Indonesian Ministry of Health, 2022). (Indarwati,
2014) found that most health centers did not use the IMCI form to handle sick toddlers, so all
patients who came were generally treated without looking at the age level. The officer
revealed that there was no time to use the IMCI form because many patients and activities
had to be handled. If using the IMCI form, the time to serve patients would not be enough, as
one patient takes 10-15 minutes. Therefore, most officers did not comply with the procedures
in IMCI.
The age category of most subjects in this research was the adult category, with an age
range of 19-44 years, as many as 44 people (68.8%). This result is not much different from
research (Afolalu, 2020) on 90 health workers in Ekiti, Nigeria, which found that the majority
(37.8%) were aged 30-35. However, in theory, age affects productivity; the older the worker,
the more his productivity decreases (Robbin, 2010). The difference in the age category of
respondents is due to variations in the age category in each research.
The majority of the subjects of this research were female, as many as 62 people
(96.9%). Research (Afolalu, 2020) on 90 health workers in Ekiti, Nigeria, found the same
thing, namely, 84.4% of female subjects. Likewise with research (Tshivhase et al 2016) on
208 IMCI officers in South Africa found that the majority were women (90%) because IMCI
officers in South Africa are mostly nursing staff and are dominated by women. According to
WHO data, in 2019, 234 million workers in the health and social sector worldwide were
dominated by women. Over the past 18 years, the number of female health workers in 104
countries has reached 67%. In most countries, most female workers are nursing and
midwifery personnel (WHO, 2019).
There will be 47 million people in Asia Pacific countries in 2021 working in the health
and social work sector, and women account for 67.6% of the workers. This is in line with the
global trend, where the number of working women is 71.4%. (Sectoral & Market, 2022). The
number of health human resources (HR) in health care facilities in Indonesia in 2023 was
2,077,473 people consisting of 183,694 medical personnel (8.8%), 1,317,589 health workers
(63.4%), and 576,190 health support personnel (27.8%). Within the scope of health workers,
nursing and midwifery workers occupy the highest proportion, 44.3% and 26.2% of all health
workers, respectively (Indonesian Ministry of Health, 2022). However, the data in Indonesia
does not mention the proportion of health workers by gender.
Based on data from the Aceh Provincial Health Office in 2023, the overall ratio
between health workers working in health centers in Aceh Province varies, with the ratio of
men and women ranging from 1: 3-6. The number of health workers at the Banda Aceh City
health center consists of 5 male nurses, 68 female nurses, and 163 midwives (Aceh Health
Office, 2023). The proportion of the subjects of this research was predominantly female due
to the proportion of dominant health workers being female.
This research found that the higher education category (Diploma III / III and/or above)
was found to be higher, reaching 93.7%. The same results were also found by (Banhae et al.,
2022) the majority of MTBS officers' education at the puskesmas was DIII 66.7%,
undergraduate 30%, and Masters 3.3%. Research (Radiyanti et al., 2016.) of 77 respondents
also found that the majority had a DIII education (94.8%), and a small proportion (5.2%) had
a bachelor's degree, and it was stated that a person's level of education affects awareness of
the importance of health which can encourage the need for health services including the IMCI
program. Based on data from the Ministry of Health, in 2023, the number of DIII polytechnic
graduates is 19,995 people, DIV 9,752 people, and professional programs 4,336 people and
nursing research programs in Indonesia have the most graduates, namely 6,171 DIII
graduates, and 1,849 DIV graduates. In general, there are more DIII graduates than DIV
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graduates in almost all research programs. The number of health workers in Indonesia who
served in health centers was 530,338, an increase compared to the previous year, which was
521,304 people. The highest number of health workers in puskesmas are midwives at
221,323 and nurses at 165,742 (Indonesian Ministry of Health, 2022). The data is in
accordance with the results of this research; the majority of health workers at puskesmas
have educational qualifications above the same as Diploma III.
The relationship between internal factors and compliance of health center staff in
implementing IMCI
This research found that MTBS officers who were compliant in filling out the MTBS
recording form and had high motivation 65.6% and there was a significant relationship
(p<0.001) between compliance in filling out the MTBS recording form and high motivation
and health workers who had high motivation had compliance in filling out the MTBS
recording form 0.75 times greater than officers who had low motivation. The results of this
research are in accordance with (Banhae et al. 2022) in the Kupang City Health Center of 30
health workers had high motivation and compliance reached 66.6% (p = 0.000), and a
significant relationship between work motivation and compliance with filling out MTBS
forms by MTBS officers. The results of this research are not much different from the findings
of (Omphemetse et al., 2019b) at Puskesmas Lubuk Buaya Padang; 62.2% of IMCI staff had
high motivation. Work motivation refers to intrinsic factors such as achievement, recognition,
work itself, and responsibility, as well as extrinsic factors such as policy, administration,
supervision, interpersonal relationships, and working conditions related to work motivation.
(Swarjana I ketut, 2022). However, in this research, the implementation of IMCI at the
puskesmas has not provided rewards in the form of certificates, rotating trophies, or others,
and periodic facilitative supervision has also not been routinely carried out to increase the
motivation of IMCI officers.
This research also found that health workers with high knowledge about IMCI and who
were compliant in implementing IMCI were 52.6%. This high knowledge was statistically
significantly associated with compliance. These results are also in accordance with research
(Marta, 2021) at the Baso Health Center in West Sumatra on 30 health workers, which
showed a significant relationship between officer knowledge and compliance with MTBS
implementation (P = 0.003). In accordance with the research of (Picauly et al., 2023) on 80
MTBS officers in Kupang Regency, East Nusa Tenggara Province found that MTBS officers
with high knowledge reached 63.63% and there was a relationship between high knowledge
and officer compliance in implementing MTBS (p=0.026). In theory, high knowledge of
health workers about MTBS affects the proper implementation of MTBS (N. Siregar et al.,
2021)
Different from the research of (Damiete et al., 2023) studied 52 nurses in Nigeria, only
12 of whom had attended IMCI training and found that both nurses who had and had not
attended IMCI training showed low knowledge of IMCI and there was no difference in the
effect of knowledge between the two groups and it was explained that these findings might
indicate a lack of assistance and supervision regarding IMCI protocols, the limitations of the
research were the use of a new MTBS knowledge scale that was not standardized, and a cross-
sectional design that made it difficult to determine causal relationships (Damiete et al., 2023)
IMCI officers who were compliant in implementing IMCI were in the adult category (19-
44 years old) as much as 45.5%, and there was no association between age and education
with officer compliance in implementing IMCI (p=0.120). These results are not much
different from those (Handayani, 2012) of 100 health workers; 57.8% of officers aged >35
years had good performance, but no relationship was found between age and MTBS officer
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performance. In theory, age affects productivity, where the older the worker, the lower the
productivity because skills, speed, dexterity, strength, and coordination decrease over time.
(Robbin, 2010). This theory is consistent with this research, where 75% of CFR officers were
non-compliant in the pre-elderly category (45-59 years old). However, non-compliant
officers in the adult category (19-44 years) reached 54.4% as well; this result may be due to
the grouping of officer compliance, namely 25 people compliant and 39 people non-compliant
and associated with the classification of adult and pre-elderly age, thus affecting the results
of the majority percentage of CFR officer non-compliance.
Most of the respondents were female and compliance with the implementation of IMCI,
but statistically, no relationship was found with officer compliance in implementing IMCI
(Kabupaten & Raya, 2008) also found similar results in the Nagan Raya District, possibly due
to the disparity in the number of male and female respondents, where women dominated up
to 95.9% of all IMCI officers. The gender variable is difficult to intervene in, but it can be taken
into consideration when appointing female officers to be in charge of implementing MTBS
services. Likewise, in this research, female IMCI officers dominated up to 96.9%. This is in
accordance with WHO data, which notes that health workers in 104 countries are dominated
by women, up to 67%. (WHO, 2019). In this research, the MTBS officers were predominantly
female because the distribution of MTBS officers at the health centers in Banda Aceh City was
dominated by women.
Forty percent of MTBS officers at puskesmas who were compliant in implementing
MTBS in the Banda Aceh city area had educational qualifications of DIII and higher, but there
was no relationship between education and officer compliance in filling out MTBS forms. In
line with research by (Banhae et al. 2022) on 30 health workers showed that the majority of
respondents' education was DIII Nurse, namely 16 respondents (66.7%), but the relationship
between education and compliance of MTBS officers was not analyzed, and it was argued that
higher education level (DIII), MTBS officers will easily understand guidelines related to MTBS
management. In this research, researchers found that 40% of CFR officers who were
compliant and 60% who were not compliant were highly educated. This is different from the
theory, which states that the non-compliance of officers implementing IMCI is due to their
low education (Omphemetse et al., 2019b). In this research, MTBS officers were dominated
by DIII educational qualifications and higher than that because the distribution of MTBS
officers at the Banda Aceh City health center was dominated by DIII educational qualifications
and higher than that.
Of MTBS officers who were compliant in implementing MTBS, 40% had a working
period of under 2.5 years (new to work category), and 64.3% who were not compliant had a
long working period no relationship was found between working period
and officer compliance in implementing MTBS. The results of this research are in line with
research (Banhae et al., 2022) on IMCI officers at the Kupang City Health Center; there was
no relationship between the length of service and officer compliance in implementing IMCI.
Different results were obtained (Handayani, 2012) in a research of 100 health workers at the
Kulon Progo Regency Health Center. , 62.5% of officers with a tenure of 3 years or more had
good performance and showed a significant relationship between tenure and MTBS officer
performance (p=0.020), officers with a tenure of more than 3 years had a risk of 2.9 times
having poor performance compared to tenure above the same as 3 years. Officers who have
worked for a long time have become accustomed to the conditions of their duties so that it is
easier to complete the tasks assigned to them. Length of service of ten, called seniority, shows
a positive relationship with work productivity. Someone who has worked for a long time will
have broader insights and more experience that can shape behavior (Robbin, 2010). The
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longer the officer's service, the more skillful he is in carrying out his duties because he has a
lot of experience. The different results found in this research may be due to officers being
accustomed to the conventional method, which is a faster process than the IMCI approach.
The relationship between external factors and compliance of health center staff in
implementing IMCI
The external factor associated with staff compliance in implementing IMCI is logistical
completeness (p=0.001). (Website et al., 2023) Also a relationship between complete
facilities and/or logistics in the implementation of IMCI (p=0.009). Some types of logistics
that must be prepared include drugs, vaccines, medical devices, IMCI chart books,
management forms for sick toddlers and young infants, outpatient register books, referral
forms, MCH books, and several other IEC media that support the implementation of IMCI both
print and audiovisual. (IMCI 2019). Some types of logistics that are already available at the
Banda Aceh City puskesmas include recording forms, MTBS chart books, MCH books,
outpatient register books, length, and height measuring instruments, LiLA measuring tapes,
available nutrition counseling posters/leaflets, infant and child weight scales, available
immunization stations, available cold chains that are functioning properly and available
medicines include paracetamol, amoxicillin, cotrimoxazole, metronidazole, albendazole,
pyrantel pamoate, iron/folate tablets, vitamin A 200.000 IU, vitamin A 100,000 IU, 1%
chloramphenicol eye ointment, ORS, ringer lactate infusion fluid, 0.9% NaCl infusion fluid
were also available.
In this research, it was found that there were still health centers in Banda Aceh City that
did not have an IMCI service place/room, effective IMCI service flow, Corner Oral
Rehydration Efforts (URO), equipment such as axilla thermometers, children's blood
pressure gauges, timers/watches with second hands, while for drug availability it was
sufficient but there was no primaquine drug, and Artemisin Combination Therapy (ACT).
Research conducted by (Anggraini et al., 2022) by purposive sampling concluded that
facilities and infrastructure, although considered sufficient, are still equipment and drugs
that are not available to support the implementation of IMCI; there is no MTBS special room
that is separate from other rooms, there is no special funding related to the implementation
of IMCI at the Nanggalo Health Center and Lubuk Buaya Health Center (Anggraini et al.,
2022).
Health workers who were compliant in implementing IMCI and had attended training
were 41.7%. However, there was no relationship between MTBS training and staff
compliance in implementing MTBS. In contrast to (Kilov et al., 2021), a research of 531 health
workers in 47 health facilities in Malawi, South Africa, found that more than half of the health
workers scored below 50% for the MTBS knowledge variable and health workers who had
attended MTBS training had an effect on increasing compliance with MTBS officers. In
contrast research (Picauly et al. 2023) on 80 MTBS officers in Kupang Regency, East Nusa
Tenggara Province, found that MTBS officers who had attended MTBS training reached
85.29% and there was a relationship between high knowledge and officer compliance in
implementing MTBS (p=0.000). Research (Health, 2018) of 291 health workers in Ethiopia
found the most common problem in IMCI implementation was the lack of trained staff
(56.2%). Lack of training among professional nurses was identified as an obstacle affecting
the proper implementation of IMCI (Omphemetse et al., 2019a). The survey showed that the
main barriers to improving IMCI include inadequate training budget and human resource
issues (staff turnover and motivation). These barriers illustrate the causes of poor health
worker performance (Omphemetse et al., 2019b). Integrated management of sick children
has been shown to be effective in improving the quality of pediatric health services,
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increasing healthcare cost savings, and possibly reducing the number of child deaths in
developing countries. However, many countries still experience barriers in health worker
training and health systems, as well as political and financial constraints in the
implementation of IMCI. (Lastianingsih, 2021).
In this research, it was found that health workers who had a light workload and
complied were 45.7% and did not comply with 54.3%. While health workers with heavy
workloads were 31% compliant and 69% non-compliant. Health workers with a light
workload were 0.5 times more compliant in implementing IMCI than those with a heavy
workload, but no relationship was found between workload and compliance in filling out the
IMCI form. The results of this research are similar in line with research (Hartati et al., 2023)
showed that there was no relationship between officer workload and the completeness of
filling out the Integrated Management of Sick Toddlers (IMCI) form at the Puskesmas. But in
contrast to the findings (H. K. Siregar, 2024), respondents with moderate workload have a
2.9 times greater risk of reduced performance in implementing the IMCI program than
respondents with light workload, and there is a relationship between workload and
midwives' performance in implementing the IMCI program at Puskesmas Indrajaya and
Delima, Pidie Regency (p=0.015), excessive workload includes assessing the physical
activities needed to complete work such as visiting patients, making reports and completing
all work and there are 14.7% of respondents with low workload but have poor performance;
this may be due to lack of leadership supervision (H. K. Siregar, 2024). In this research, it was
also found that the light workload of CFR officers who were not compliant reached 54.3%;
this may also be due to a lack of supervision by the leadership.
(Indarwati, 2014) conducted research at the health center in Bantul Regency and found
that the implementation of IMCI in most health centers has not been effective. This condition
is due to the limited number of MTBS personnel who have been trained, the transfer of
personnel who have been trained, the lack of time to use the IMCI form due to the many
patients and activities that must be handled, and the lack of complete supporting facilities
and infrastructure.
The results of this research showed that respondents who received good supervision
supervision showed a non-compliance rate of 65.6%. There was no relationship between
facilitative supervision and staff compliance when implementing IMCI. In contrast to
research conducted by (Website et al., 2023) on 30 health workers who found a relationship
between leadership support and the implementation of IMCI. (Damiete et al., 2023)
Recommended periodic MTBS refresher training accompanied by mentoring and supervision
for health workers to improve the effectiveness of the MTBS strategy. Facilitative supervision
is part of quality management with a process approach, namely by researching the
performance of health workers in their workplace (Indonesian Ministry of Health, 2022).
Effective supervision of primary healthcare workers is important to maintain and improve
practice after IMCI training. (Strengthening, n.d.).
Facilitative supervision of health workers involved in IMCI services at puskesmas and
their networks can be carried out internally by the head of the puskesmas and the puskesmas
doctor assisted by the coordinating midwife. Externally, it is carried out by the person in
charge of IMCI-related programs at the District Health Office (MCH, P2M, Nutrition,
Immunization, Community Health, Surveillance, Person in Charge of Drugs and Person in
Charge of Infrastructure and Equipment), and professional organizations such as the
Indonesian Doctors Association (IDI), the Indonesian Midwives Association (IBI), and the
Indonesian National Nurses Association (PPNI). The implementation time of facilitative
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supervision is divided into 2 times. The first is routine, which is carried out twice a year, and
the second is during post-training and post-orientation supervision (4-6 weeks) (2019 IMCI)
Data reported by WHO reported that supervision was only conducted 6.3% of the time in the
last six months at community-level health facilities in countries with high under-five
mortality rates (World Health Organization., 2017). In this research, facilitative supervision
was carried out by the Banda Aceh City Health Office together with the Banda Aceh branch of
UNICEF only once in 2024 due to limited funding for the IMCI program. Therefore, cross-
sectoral cooperation is needed to optimize the implementation of facilitative supervision in
IMCI services.
Factors that most influence staff compliance with IMCI implementation
The factors that have the most influence on staff compliance in implementing IMCI in
this research are knowledge (p = 0.009), motivation (p = 0.001), and logistics (p = 0.008).
Health workers with high knowledge are 8.6 times more compliant than those with low
knowledge. These results are different from Purwanti's research in Banyumas Regency on 99
respondents, which found that knowledge has no significant relationship with officer
performance (p=0.163) and p-value <0.25 so that it is continued to multivariate analysis
obtained health workers who have high knowledge, have good performance 2.1 times better
health workers who have low knowledge (Purwanti, S. 2010). This research is also different
from Firdaus's research in Nagan Raya Regency, where respondents with a high level of
knowledge had a proportion of compliance of 52.4%, while respondents with a low level of
knowledge had a proportion of compliance of 44.1% and a proportion of respondents with a
high level of knowledge had a proportion of compliance of 44.1%.
There is no significant relationship between knowledge and staff compliance when
implementing IMCI procedures in Nagan Raya District. The OR value is 1.393, which means
that respondents with high knowledge have a 1.3 times greater chance of being compliant
than respondents with low knowledge. However, in theory it is said that MTBS officers to be
able to provide comprehensive services require an increase in MTBS knowledge according to
standards (Indonesian Ministry of Health, 2022). Good knowledge of IMCI officers will
provide optimal IMCI services (Lastianingsih, 2021).
Health workers with high motivation were 14.3 times more compliant in implementing
IMCI than those with low motivation. This result is in accordance with research (Purwanti, S.
(2010). In Banyumas Regency, 99 respondents found that high motivation was associated
with officer performance (p=0.007) and health workers who had high motivation had good
performance 3.8 times greater than respondents who had low motivation. This research is
also in line with research (Radiyanti 2016) 77 health workers found a significant relationship
between motivation and the completeness of the IMCI sheet with (p=0.011) and health
workers who had less motivation had a 1.7 times risk of not completing the IMCI sheet
compared to health workers who had good motivation. In theory, one of the motivations for
implementing IMCI is the training and retraining (refreshing) of health workers and the
availability of logistics (Damiete et al., 2023).. In addition to the skills and knowledge of
health workers in implementing IMCI, commitment and motivation are also needed because
a lack of commitment from health workers will affect the implementation of IMCI, which is
expected to reduce child mortality or child health status (Lastianingsih, 2021).
Health workers with health centers that have complete logistical equipment are 8 times
more compliant in implementing IMCI than those with incomplete logistics. The results of
this research are in accordance with research (Hidayati & Novita, 2023) in Lebakwangi,
Kuningan Regency, West Java Province, which found that the facilities and infrastructure
factor had an effect of 3.38 times on compliance with the implementation of IMCI. The same
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305
thing was also found (Health, 2018) of 185 IMCI officers in Ethiopia found that 44% of IMCI
officers reported that the most common problem encountered was the lack of medicines and
essential supplies in the implementation of IMCI. Therefore, support for the health care
system is in line with improving access to supplies of medicines and other equipment for
optimal IMCI implementation (Health, 2018).
Logistics is an important and integral part of IMCI services. It must be planned properly,
maintained and ensured to be ready to use. This condition will only be achieved if it is
supported by a recording and reporting mechanism according to applicable rules. (2019
IMCI) The lack of resources such as space, chart booklets and IMCI-recommended medicines
also makes it difficult for professional nurses to implement IMCI (Omphemetse et al., 2019b).
The main barriers in scaling up IMCI include weak mentoring and supervision systems, and
lack of facility readiness (drug procurement and supply chain management). In general, these
barriers describe the causes of poor health worker performance (Omphemetse et al., 2019b).
A systematic review conducted by Pinto et al. concluded that factors that influence the
implementation of IMCI include leadership, logistical support, monitoring and supervision,
and coordination (Pinto et al., 2024).
CONCLUSION
The conclusion of this study is that the distribution of Integrated Management of Sick
Toddlers (IMCI) officers in Banda Aceh City health centers is uneven, with the highest
number in Ulee Kareng Health Center and the lowest in Banda Raya Health Center. The
majority of IMCI officers are 19-44 years old, mostly female, and have at least a DIII education.
The compliance of health center staff in implementing PPI was classified as moderate, as
many as 25 people (39%). The main internal factors influencing compliance were knowledge
and motivation, while external factors included the availability of logistical facilities. Among
these factors, motivation had the strongest influence on compliance, followed by knowledge
and logistical support..
This study contributes valuable recommendations for IMCI program managers within
the Health Office, emphasizing the need to enhance staff knowledge, boost motivation
through targeted training and incentives, and secure ongoing logistical support at health
centers. Additionally, regular evaluations of IMCI data recording and reporting procedures
aligned with the Integrated Health Center Recording and Reporting System (SP2TP)are
necessary to ensure compliance with standardized practices. Future research should
consider employing a prospective cohort design to reduce bias and capture more precise,
comprehensive insights, thereby supporting the enhancement of IMCI implementation
quality in broader regions..
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Copyright holders:
Siska Safriana, Raihan, Anidar, Teuku Muhammad Thaib,
Eka Yunita Amna, Nora Sovira (2024)
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AJHS - Asian Journal of Health and Science
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