Role of Public Health Center Staffs in Socialization, Education and Campaign to Increase Exclusive Breastfeeding Coverage

Background: The achievement of breastfeeding in Surakarta City in 2017 was 76.7% while the target of infants with exclusive breastfeeding is 80%. The lowest achievement of exclusive breastfeeding was at Gilingan Public Health Center (66.1%). The role of health center staff is very important in improving and supporting social breastfeeding efforts. Method: The study was descriptive qualitative research using a case study approach. The informant of this research consists of 2 main informants and 3 triangulation informants with a purposive sampling technique. Results: The role of health center staff in socialization were in the form of counseling and individual counseling; education program were in the form of class for pregnant women and class for parents with under-five children. There has been no health campaign implementation in the World Breastfeeding Week celebration. Conclusion: The socialization and education program could be implemented but for the campaign has not been implemented. It was because of a lack of coordination by Gilingan Public Health Center’s staff.

success of exclusive breastfeeding behavior, both from family and from health officers or those who help with childbirth (Waits et al., 2018). The role of health officers was very important in protecting, enhancing, and supporting breastfeeding efforts must be seen in terms of their broad involvement in social aspects (Khanal et al., 2015).
Several studies also shown that health promotion activities of health workers play a very important role in achieving the target of exclusive breastfeeding (Little et al., 2019;Pemo et al., 2020) . The role of officers in health promotion was very much needed in relation to Community Based Health Efforts/Upaya Kesehatan Berbasis Masyarakat (UKBM) in the form of preventive and promotive measures to be realized in accordance with the Decree of the Minister of Health Number 1114/Menkes/SK/VII/2005 concerning regional health promotion guidelines.
A preliminary study at the Gilingan Public Health Center in Surakarta City showed that there are health center officers who have a special task to increase the coverage of exclusive breastfeeding. But unfortunately there were problems regarding the realization of socialization programs, education and campaigns on exclusive breastfeeding . The ineffective implementation of health promotion programs was one of the factors affecting the coverage of exclusive breastfeeding at Gilingan Health Center.
Therefore, it was necessary to conduct a study to analyze the role of health care center officers in socialization, education, and campaigns to increase exclusive breastfeeding coverage in the working area of the Gilingan Public Health Center.

METHODS
This type of research was qualitative research that produces descriptive data in the form of words with in-depth interviews. This study used a case study approach, in which the case in the study was the role of Public Health Center officers to increase the coverage of exclusive breastfeeding. The researcher also acts as a human instrument to determine the focus of the research, selecting research informants as the data source, interpreting the data and concluding existing findings. The focus of this research was the role of Public Health Center officers in socialization, education and campaigns to increase exclusive breastfeeding coverage.

INTRODUCTION
Exclusive breastfeeding is a strategic investment in improving the quality of human resources. The strategic value of exclusive breastfeeding has stimulated world awareness to create an event in the form of World Breastfeeding. Through this global breastfeeding week, it hoped that the whole world will provide support for mothers, as heroes for children, families and society, and provide the best for their children to continue optimize children's growth and development. Every 1-6 August is celebrated as the day of World Breastfeeding which is held for one week to remind the public how important breastfeeding is for the development of babies. Currently there were more than 170 countries that have organized world breastfeeding week with various activities, including in Indonesia (Kepmenkes No. 450 Th. 2004Tentang Pemberian ASI, 2020. Exclusive breastfeeding can reduce 13% of child mortality. About 50-60% of child deaths under 5 years caused by malnutrition and sub-optimal breastfeeding. However, unfortunately the achievement of exclusive breastfeeding in Indonesia has not reached the expected number, it was 42% (Kementrian Kesehatan Republik Indonesia, 2016). Scope of exclusive breastfeeding in the province of Central Java also not optimal, which amounted to 61.60%. In line with the scope of exclusive breastfeeding at the provincial level, the realization of exclusive breastfeeding in Surakarta also low at occupying 10th rank lowest in Central Java with a coverage of 52.43% (Dinas Kesehatan Provinsi Jawa Tengah, 2017).
The achievement of exclusive breastfeeding in the Surakarta city was still far from the national target. Nationally, the target of baby that exclusively breastfed from the Ministry of Health is 80%, while the achievement in Surakarta in 2017 was 76.7%. Of all Public Health Center in Surakarta, the lowest coverage of exclusive breastfeeding was at Gilingan Health Center, which is only 66.1% (Dinas Kesehatan Surakarta, 2016).
Several previous studies examined the factors causing the inadequacy of exclusive breastfeeding coverage. There were four determinants of exclusive breastfeeding coverage, namely knowledge of exclusive breastfeeding, family support, myths/beliefs and promotion of formula milk. These four factors influence each other in the success of exclusive breastfeeding (Widdefrita & Mohanis, 2013). Mothers also need support from the people around them to support the this study were two people, namely an officer of the Gilingan Public Health Center who occupies the field of health promotion and a nutritionist. While the triangulation informants totaled three people, namely a breastfeeding motivator and two breastfeeding mothers who used health services at the Gilingan Public Health Center. The sampling technique used in this study was purposive sampling. How to collect data using semi-structured interviews and observations. Processing and analysis of data is done by means of coding, data reduction, data presentation, conclusion and verification.

RESULTS AND DISCUSSIONS
In this study, researchers interviewed 2 main informants at the Gilingan Public Health Center and 3 triangulation informants who were in the working area of the Gilingan Public Health Center. The Table 1 & 2 of the characteristics of research informants after conducting interviews. The role of Public Health Center officers can determine health development towards a healthy Indonesia. According to (Maulana, 2017), the various roles of Public Health Center officers ranging from customers, counselors, motivators, facilitators and communicators should be carried out at the Gilingan Public Health Center. Public Health Center should lead to Public Health Efforts/Upaya Kesehatan Masyarakat (UKM) that focus on preventive and promotive (Kim et al., 2018). This is still a problem in the scope of the Public Health Center. Gilingan Public Health Center officers do not play a role in health promotion so that the coverage of exclusive breastfeeding is the lowest in Surakarta.
Research by Ihudiebube-Splendor et al (2019) states that if in an area that have low kno-wledge about exclusive breastfeeding and lack of intention. Health officers can train the population to be able to increase their intention by combining facility-based and methods, such as breastfeeding counseling, education, and in-house support especially for pregnant and expectant mothers.

Socialization of the Exclusive Breastfeeding Program
Health officer is someone who is respected, respected in the eyes of the client because has a high status in accordance with his education. Its role is needed so that health officers must be able to provide conditions that can influence clients to be able to behave positively towards health (UCL Institute of Health Equity, 2013). Social support from health officers can be seen when implementing health services, namely by explaining, inviting, giving sympathy and providing examples for healthy behavior (Widdefrita & Mohanis, 2013).
The role of health officers in supporting exclusive breastfeeding was very important. In fact, the lack of midwives, coupled with a lack of developmental professionals on breastfeeding promotion and support, is an additional barrier to the promotion of exclusive breastfeeding (Little et al., 2019;Pemo et al., 2020). Socialization in the form of counseling can be the first step for health workers to support exclusive breastfeeding. According to Nuzhat et al., (2019) the importance of strong counseling on the practice of breastfeeding can help rebuild lactation, especially infants who are acutely ill.
Based on the interview, the form of providing information for the Gilingan Public Health Center officers was individual counseling and several times with the form of counseling which was also distributed with the counseling materials carried out at the integrated health post and the existence of the Mother Support Group / Kelompok Pendukung Ibu (KP Ibu).
Gilingan Public Health Center's officers have tried to improve the health of babies by influencing the behavior of mothers on exclusive breastfeeding. The socialization program on exclusive breastfeeding that has been implemented by the Gilingan Public Health Center was counseling and individual counseling. Exclusive breastfeeding counseling was carried out at the integrated health post according to the schedule of visits by Public Health Center officers, while individual counseling is carried out at the integrated health post, client's house and Public Health Center.
Individual counseling regarding infant nutrition was needed because it affects the knowledge and attitudes of breastfeeding mothers (Waits et al., 2018). Research by Masthalina & Agustina (2018) stated that there were significant differences before and after nutritional counseling interventions were given to breastfeeding mothers (p=0.000). Counseling was carried out on an incentive and scheduled basis, then breastfeeding mothers practice independently. Raissian & Su, (2018) stated in his research that mother who intend to breast-feed have a knowledge more about breastfeeding and like to seek for sources of information about nutrition and diet than women who did not intend to breastfeed so one counseling intervention is required to improve the mother's intention to breastfeed.
This breastfeeding counseling was an effective public health intervention to increase coverage of exclusive breastfeeding. Interventions should be done face-to-face, but can also be provided by telephone. This counseling was carried out starting from antenatal and postnatal, because information about exclusive breastfeeding needed since pregnant women are able to prepare for breastfeeding needs and can provide a full 6 months (McFadden et al., 2019;Susiloretni et al., 2019).
Public Health Center officers provide encouragement in providing exclusive breastfeeding by protecting and enhancing the behavior of mothers who breastfeed exclusively or to breastfeed their babies for up to 2 years. Public Health Center officers also help mothers solve barriers and problems about breastfeeding such as not smooth breastfeeding, stress control and management of expressed breast milk by giving approaches to problem mothers and encouraging breastfeeding by fostering mother's trust.
The results of the interview stated that the evaluation was carried out with breastfeeding motivators and the UKM meeting was based on the results of data collection on breastfeeding coverage conducted by the cadres.
However, there were obstacles in the application of this method, such as the absence of mothers during counseling and the number of mothers who do not apply exclusive breastfeeding due to stress so that the milk is not smooth and the mother works so that the baby is given formula milk.
Evaluation needed so that officers know the impact of each program implemented. Breastfeeding counseling, exclusive breastfeeding counseling is needed because it has an effect on the duration of breastfeeding (Pemo et al., 2020). Breastfeeding mothers needed intensive information and positive exposure so that the mindset about exclusive breastfeeding can be well formed (Kannaiah, 2019).
The socialization program by the Gilingan Public Health Center's officer is quite good because the socialization program has been implemented but has not been optimal, such as there was no definite schedule because it is only based on integrated health post visits, individual counseling carried out at the client's home is only carried out by breastfeeding motivators in each RW even though breastfeeding mothers need more attention of Public Health Center officers.

Education in Exclusive Breastfeeding Program
The education program that has been implemented by the Gilingan Public Health Center was in the form of pregnant women classes, toddler classes and breastfeeding motivator training. The target of the educational program in increasing the coverage of exclusive breastfeeding was pregnant women and lactating women. The role of the Gilingan Public Health Center officers in education was as counselors, facilitators, moti-vators and communicators. In the education program, responsible officers are nutritionists, health promotion officers and midwives (Pemo et al., 2020;Zhang et al., 2018).
An understanding of the knowledge of breastfeeding as a staple in the exposure of health communities (Little et al., 2019). The duration of breastfeeding itself can be achieved through programs that improve the process of breastfeeding behavior, such as the presence of pregnancy classes (Susiloretni et al., 2019).
Pregnant women class can grow the mother's intention to provide exclusive breastfeeding. The intention to provide exclusive breastfeeding needed to be strengthened by a delivery service policy by implementing exclusive breastfeeding at every birth, and supported by every midwife at the Public Health Center (Ismiati et al., 2019) .
The response of mothers who take part in educational programs such as pregnancy classes, toddler classes and breastfeeding motivator training also good. The following is the answer of IT 1 "... using a tancep screen, miss , with direct practice ... good sis, everyone is entertained, it will be easy ..." ("...menggunakan layar tancep gitu mbak, sama praktik langsung...bagus mbak, semua terhibur jadinya ya mudeng...") and IT 2 added "... yo nice sis, everything is compact, it's clear so that the given material (obviously the time to deliver the material) ... " ("...yo apik mbak, semuanya kompak, jelas ngono nek memberi materi (jelas waktu penyampaian materi)...") The educational program that has been implemented by the Gilingan Public Health Center has a weakness, namely the absence of an indicator of program success. The instrument to assess the success rate of the program was only carried out in the toddler class after 6 months (one period) was completed. The instrument filled by companion cadres who follow the toddler class. The instrument is related to the delivery of the material, the material raised, the media used and the pretest and post-test of the material presented during one period. This instrument is an evaluation tool for Gilingan Public Health Center officers about the programs that have been implemented.
Researchers gave the question of the role of health centers in providing education officer linked exclusively breastfed in the form of education and training has been maxima l . According to IU 1 "... it is adjusted to the counselor and facilitator but I think so ..." ("...disesuaikan dengan konselor dan failitator tapi ya saya rasa sudah..."). Meanwhile, IU 2 answered in contrast "... yes, we still have to keep improving, right? So far, the coverage is still lacking, right ..." ("...ya kita tetep harus memperbaiki terus sih, kan selama ini cakupannya juga masih kurang kan...").
According to Gavine et al (2017) there was not much evidence that education and training for pregnant and breastfeeding mothers can increase the achievement of exclusive breastfeeding. This study supports that education and training conducted by health workers can make mothers breastfeed as early as possible (implementing breastfeeding early initiation (IMD) as the first step in exclusive breastfeeding).
The researcher also asked about the media used in education and training. According to IU 2, "... the most interesting media were IMD videos and breast massage, maybe other materials could follow these media and methods ..." ("...media yang paling menarik yang waktu video IMD dan breast massage, mungkin materi yang lain bisa mengikuti media dan metode tersebut..."). IU 1 added her complaint regarding the existing media, "... maybe just reproduce it, the number is minimal. So it is used interchangeably at the time of practice ... ", ("...mungkin lebih diperbanyak aja, memang minim jumlahnya. Jadi digunakan bergantian pada saat praktiknya...") The media played an important role in increasing the knowledge and positive attitudes of mothers regarding exclusive breastfeeding (Permatasari et al., 2018). Health education using audio-visual media was more effective in increasing the knowledge and attitudes of breastfeeding mothers. Mother pays attention by using two senses at once, the senses of hearing and sight. These senses function very effectively in digesting the messages conveyed (Wijayanti, 2019).
Based on analysis of interviews, it needed for increased monitoring of the mothers who breastfeed by breastfeeding motivator. This related to the low coverage of exclusive breastfeeding in the working area of the Gilingan Public Health Center. Monitoring breastfeeding mothers accompanied by health center officers is planned so that exclusive breastfeeding coverage can increase next year.

Exclusive Breastfeeding Program Campaign
Communication of social and behavioral changes can have a major impact on behaviors related to child survival and optimal nutritional status (Fox & Obrego, 2014). The approach that often taken was interpersonal communication and some have a mass media component. The advantages of using mass media include reach and frequency, control over message content and delivery, consistency, and relatively low costs per person exposed (Nguyen et al., 2017).
Campaign according to Kotler (2013) mean a form of communication action that can cover the entire process and phenomena of campaign practices that occur in the field. The campaign has clear characteristics, among others; clear sources, there were those who are initiators, designers, transmitters and even those in charge of a campaign product (campaign makers), as well as any individual receiving the campaign message can identify and evaluate the credibility of the source of the message at any time.
Campaigns can be implemented through social media by creating groups of breastfeeding mothers because social media groups can positively influence attitudes, knowledge and behavior and lead to longer breastfeeding duration (Skelton et al., 2018). Mass media campaigns led to greater changes in exclusive breastfeeding behavior. The campaign refers to the geographic location of the intervention to be carried out so that the mass media has influence through the social diffusion process (Naugle, 2016).
Researchers give questions about the form of exclusive breastfeeding campaigns that have been implemented. IU 1 replied, "... for the mass campaign rich in banners it has not been ..." ("... untuk kampanye massal kaya spanduk itu belum...") and IU 2 clearly stated, "... there is not yet ...""(... belum ada..."). This is reinforced from the answer to IT 1, "... Whoa, never miss, never know me sis, not yet ..." "...Waah, nggak pernah mbak, belum pernah tau saya mbak, belum ada...". An exclusive breastfeeding campaign needed because it acts as a platform that provides information to a heterogeneous audience and more profitable because it also reaches prospective mothers (already pregnant or not). This campaign also has an impact on families and husbands who can access this information service (Chuckwu-Okoronkwo et al., 2019). Campaigns with general targets can also be carried out on social media, Marcon et al., (2018) stated that social media is used to network, promote , and further support breastfeeding widely in its large and diverse global online community .
Related to the role of health center officers in health campaigns to increase the coverage of exclusive breastfeeding . IU 1 answered, "... following representatives from the city level with a parade of breastfeeding counselors ..." ("...mengikuti perwakilan dari tingkat kota dengan parade konselor ASI..."), while IU 2 answered, "... until now they are still nutrition officers, health promotion officers have not been involved ...", ("...sampai saat ini masih petugas gizi saja, petugas promkes belum dilibatkan...)" and IU 2 added "... if for example it is needed, it can be done by making MMT World Breastfeeding Week ..." ("...kalo misal dibutuhkan sih ya bisa dilakukan dengan pembuatan MMT Pekan ASI Sedunia...") According to Basri, (2016) the message characteristic factors (message content and delivery) in a health campaign can change the target attitude in health habituation . This mean that the initiator of a campaign product must be expert in creating campaign messages with clear sources and in accordance with the desired target audience (Kim et al., 2018). This also related to campaign objectives that are always clear, specific and measurable (Kim et al., 2018) Future exclusive breastfeeding promotion interventions should target four factors, namely breastfeeding knowledge, attitudes, subjective norms and practice control. Among these four factors, knowledge about breastfeeding was a factor that contributes to exclusive breastfeeding so that the main target was to increase the knowledge of prospective mothers so that good subjective attitudes and norms about breastfeeding will emerge (Zhang et al., 2018).
The role of Gilingan Public Health Center officers in the campaign has not been realized because planning and coordinators are held by nutrition officers as breastfeeding counselors at Gilingan Public Health Center, while health promotion officers have not been involved in planning health campaigns. Based on the results of the interview which stated that the officer in charge of planning and executing the health campaign was a nutrition counselor who, in fact, came from nutrition officers and midwives who were not in accordance with the field of knowledge they had lived.
The Gilingan Public Health Center can include health promotion officers in breastfeeding counselor training held by the Surakarta Health Office so that health promotion officers can make plans according to the characteristics of a health campaign that can attract audiences to change their behavior.

CONCLUSION
Based on the results of the study, it could be concluded that the public health center officers had just shown an active role in 2 programs, the socialization and education of the exclusive breastfeeding program. The exclusive breastfeeding program campaign has not been carried out completely.
To support the achievement of exclusive breastfeeding, then it was recommended to be in the planning program of exclusive breastfeeding campaign involved not only the nutritional officer, but it need to be involvement in the field of health promotion and across other sectors. .