Influential Factors of Fertile Age Couples (PUS) in the Selection of Long- Term Contraception Methods (MKJP) in the Work Area of the Medan Community Health Center

Efforts to reduce population growth are carried out by controlling births through family planning. The contraceptive method recommended by the government is the Long Term Contraception Method (MKJP) because it is more efficient, safe, and effective. Data at the state, provincial, district / city level, as well as data from the Community Health Center, the use of non-MKJP (73.4%) is more desirable than the Long-Term Contraception Method (MKJP) (26.6%). Many factors cause someone to choose to use MKJP based on Green's theory. The purpose of this study was to analyze the factors that influence EFA in the selection of the Long-Term Contraception Method (MKJP). This type of research is an analytic survey with a cross sectional design. The research was conducted in the working area of ​​the Medan Teladan Community Health Center. The population of PUS mothers was 2,897 people, and the sample was obtained 110 people. Data analysis was univariate, bivariate using chi-square and multivariate using multiple logistic regression at the 95% confidence level ( = 0.05). The results showed that the variables that had an effect on the selection of MKJP in the Medan Teladan Community Health Center were knowledge (p = 0.002), family / husband support (p = 0.038), and the role of cadres (p = 0.001). The variables that had no effect were attitude (p = 0.153), accessibility (p = 0.061), and peer support (p = 0.098). The most dominant factor was the role of the cadre variable with a value of Exp (B) / OR = 8.819, which means that respondents who stated that the role of cadres was supportive had the opportunity to choose MKJP by 8.8 times higher than stating that the role of cadres was not supportive. The conclusion of this study is that the selection of MKJP by Fertile Age Couples (PUS) is influenced by knowledge, family / husband support, and the role of cadres. It is recommended that KB cadres increase counseling to husbands and wives about MKJP by offline (face to face, leaflets, brochures, etc.) and online (internet) during the Covid-19 period. 
 


Introduction
Family planning (KB) programs are women's rights and cannot be separated from reproductive health (Nopiantini et al., 2016). Universal family planning is part of the reproductive health and reproductive rights approach in planning or postponing pregnancy, and the use of contraceptives according to one's self so that it can reduce population growth (Purwoko, 2017).
Efforts to reduce population growth are carried out by controlling births with the contraceptive method. The type of contraceptive method recommended by the government is the Long-Term Contraception Method (MKJP) consisting of an intrauterine device (IUD) or an intra-uterine device (IUD), the mother's operational method (MOW) or tubectomy, the male operational method (MOP) and contraceptives. Under Skin (AKBK) / Implant / Implant. The MKJP contraceptive method has advantages over non-MKJP contraception, it is considered more efficient because it can be used for a long time and is safer and more effective (2019 BKKBN) Data on the use of contraceptives in North Sumatra Province shows that there are fewer active family planning acceptors using MKJP compared to non-MKJP users (2019 North Sumatra Provincial Health Office). The percentage of acceptors using MKJP was 32.44% and those using non MKJP were 67.56%. Likewise, the data from Medan City shows that the number of MKJP usage is 18.6%, while those who use non-MKJP are 81.4% (Medan City Health Office, 2019). Data from the Medan Teladan Community Health Center, the acceptors for KB MKJP users in 2019 were 26.6% and non-MKJP users were 73.4%. Based on the aforementioned data, it shows that at the state, provincial, district / city level, as well as puskesmas data, it can be seen that the use of non-MKJP contraceptives is more in demand and family planning acceptors are chosen compared to MKJP.
The selection of MKJP is a form of health behavior. According to Laurence W. Green's behavior theory quoted by Notoatmodjo, a person's behavior is influenced by 3 main factors, namely: predisposing factors consisting of knowledge, belief, value, attitude, belief, will; Supporting factors (enabling factors) in the form of availability and accessibility of health resources, government priorities and commitments, skills of health workers, and reinforcing factors, namely family support, especially husbands, friends, educators, service providers, community leaders, regulations, and laws. -invited (Notoatmodjo, 2015).
Many factors cause a person to choose to use or not use contraceptives such as MKJP. A couple of reproductive age (husband and wife) in choosing a family planning program are influenced by factors of effectiveness, safety, frequency of use, side effects, age of provision, information, and support from their husbands. In addition, consideration is also based on the cost and role of religion and culture regarding contraception. Another factor is the frequency of sexual intercourse. The impact of using the FP method includes slight menstruation, spotting or no menstruation at all, erratic bleeding due to the influence of hormones. Other factors, namely the role and support of husbands, parents (mothers / in-laws) recommend non-MKJP, the roles of health workers and community leaders have not been optimal (Setiawati et al., 2017).

Methods
This research is an analytical survey research using a cross sectional design. This research was conducted in the working area of the Medan Teladan Community Health Center. The population in this study were all family planning acceptors for the period of December 2019 as many as 2,897 PUS mothers. Samples were obtained as many as 110 people.
The research instrument uses a questionnaire that has been tested for validity and reliability. The data used are primary, secondary, and tertiary data. Data analysis was performed univariate, bivariate with Chi-Square test, and multivariate using multiple logistic regression tests with a confidence level of 95% ( = 0.05).

Respondent Characteristics
Based on the results of the study showed that most of the respondents were 21-35 years old (69.1%), a small proportion of respondents were> 35 years old (30.9%). Respondents have high school education (55.5%), a small proportion of respondents have junior high school education (11.8%). Most of the respondents did not work (56.4%), a small proportion of the respondents worked (43.6%). Most of the respondents with parity of 2 people (40.9%), a small proportion of respondents with parity of 4 people (7.3%). Derived from the Malay ethnicity (25.5%), a small proportion of the respondent's ethnicity was Chinese (10.0%). Respondents who stated that accessibility was good (53.6%), stated that it was not good (53.6%). Respondents who stated that their family / husband was not supportive (68.2%) stated that they were supportive (31.8%). Respondents who stated that the role of cadres was supportive (57.3%), a small proportion said they were not (42.7%). Respondents who stated that their friends did not support using MKJP (59.1%), who stated that their friends supported (40.9%).

Bivariate Analysis
Based on the research, it shows that the results of the chi-square test show that the p-value of the variable relationship with MKJP selection is knowledge (p = 0.000), attitude (p = 0.000), accessibility (p = 0.010), family / husband support (p = 0.000), the role of cadres (p = 0.000), and support from friends (p = 0.000). This shows that all variables become candidate models in the multiple logistic regression test because they have a p value <0.25.

Multivariate
The results of multiple logistic regression tests using the forward conditional method found that there were 3 variables that influenced the selection of MKJP, namely knowledge, family / husband support and the role of cadres. The most dominant variable influencing the selection of MKJP was that the role of cadres had a value of Exp (B) / OR = 8.819, meaning that respondents who stated that the role of cadres was supportive had the opportunity to choose a long-term contraceptive method of 8.8 times higher than respondents who stated that the role of cadres was not supportive. .
The knowledge variable has a value of Exp (B) / OR = 5.208, which means that respondents who have good knowledge of MKJP, have the opportunity to choose a long-term contraceptive method of 5.2 times higher than respondents with poor knowledge.
The variable of family / husband support has a value of Exp (B) / OR = 3.080, meaning that respondents who receive support from their family / husband have a 3 times higher chance of choosing a long-term contraceptive method than respondents who do not receive support from their family / husband. Based on the results of the multiple logistic regression test, it also shows that the variables that have no effect on the choice of long-term contraceptive methods because it has a significant value> 0.05 are the variables of attitude (p = 0.153), accessibility (p = 0.061), and peer support (p = 0.135. ). Details can be seen in the following table.  (Setiasih et al., 2016).
The results of Widyami and Dhewi's research in the work area of Puskesmas Paramasan showed that 60% of the respondents had sufficient knowledge. One of the reasons for insufficient knowledge is that in the knowledge questionnaire there are several questions about family planning in general and MJKP specific family planning, which is easy to understand even though in general the knowledge is sufficient (Widyami & Dhewi 2018). Siregar's research in the Work Area of Medan Sunggal Subdistrict in 2015 explained that the majority of Non-MKJP respondents had poor knowledge, meaning that the higher the mother's knowledge of MKJP, the higher the possibility of mothers using MKJP (Siregar, 2015).
Knowledge as a result of knowing after a person has sensed a certain object through the senses of sight, hearing, smell, feeling, and touch. Knowledge can also be defined as a collection of updated information obtained from the learning process during life and can be used at any time as a means of adjustment both to oneself or the environment. There are several factors that can affect a person's knowledge, including knowledge, information, age, experience, and those closest to him (Notoatmodjo, 2012).
According to researchers, the selection of MKJP by PUS in the working area of the Medan Teladan Community Health Center was influenced by the knowledge of the mother. The better the mother's knowledge, the greater the tendency to choose the long-term contraceptive method (MKJP), on the other hand, mothers with less knowledge tend to choose non-MKJP contraceptive methods. This study found that most of the mothers had poor knowledge of MKJP because the MKJP program had not yet provided maximum outreach to the community in the working area of Puskesmas Teladan Medan, especially for fertile age couples (PUS). Some mothers do not get enough information about MKJP so that many do not understand well about long-term contraceptive methods. There are still mothers who are less knowledgeable, so they do not know the purpose of long-term contraceptive use.
Based on this research, it is also seen that there are 31.8% of respondents who have good knowledge about MKJP, which means that the knowledge of mothers in choosing long-term contraceptive methods is also not good. All mothers should have good knowledge about the use of long-term contraceptives so that mothers can get the desired birth, adjust the interval between births, control the time at birth in relation to the age of the husband and wife, and determine the number of children in the family.
Based on the respondent's answer to the question of the knowledge variable, the most answered answer is correct, namely about implant contraceptives that can be used for a long time, and statements about the effective use of implants for 3-5 years. This is because some respondents have already received information about implant contraceptives from health workers or by reading from health books and special books on family planning, so when asked about implant problems, many answered correctly.
The most incorrect answer from respondents was that the statement about the IUD / spiral should only be inserted by trained health workers. This is because some respondents think that all health workers can attach IUD or spiral contraceptives, even though trained health workers are a prerequisite for inserting an IUD or spiral contraceptive device. Knowledge of contraceptives, especially MKJP, is important for all people to know, especially PUS who plan a small and happy family. Apart from the lack of information, the mother's lack of knowledge could be due to the mother's education level, where some respondents (11.8%) still had junior high school education.

Family / Husband Support for PUS Mother Influences the Election of MKJP
Family / husband support for PUS mothers influences the selection of MKJP at the Teladan Community Health Center in Medan. The OR value of the family / husband support variable was 3.080, meaning that the respondent whose family / husband was supportive had the opportunity to choose a long-term contraceptive method by 3 times higher than the respondent whose family / husband was not supportive.
Ningrum's research in 2018 on couples of childbearing age in the Batang Hari Community Health Center, East Lampung Regency, concluded that there was a relationship between family / husband support and the choice of MKJP contraception (Ningrum, 2018). Suryanti's research in 2019 at Puskesmas Paal V Jambi City concluded that the results of the study were that there was a relationship between husband's participation and the use of MKJP with a p-value (0,000) <0.05 (Suryanti, 2019). In contrast to Febriani's research in 2018 in Pasir Kuda, West Bogor, the study concluded that there was no relationship between husband's support and use of MKJP contraceptives (Febriani et al., 2018).
Husband's support for the family in reproductive health, especially in family planning, greatly affects health. Husband's support for his family can be in the form of motivators in the form of encouragement or enthusiasm for using family planning and wanting to do family planning if the wife is not possible to use it. The role of the educator is to provide support for decision making and provide information on when to check health, encourage family care, participate in control and so on. The facilitator's message is to provide all the needs of the wife when examining her reproductive health problems (Taslim, 2015).
According to researchers, family support, especially husbands, is very important in choosing a long-term contraceptive method (MKJP). It is evident that the selection of MKJP by PUS in the working area of Puskesmas Teladan Medan is influenced by the knowledge of mothers. Based on this research, it can be seen that mothers who get support from their husbands tend to choose the long-term contraceptive method (MKJP) while mothers who do not get support from their husbands do not choose to use long-term contraception (MKJP) but prefer to use non-MKJP. This indicates that the husband's support has an influence on the selection of MKJP in improving the welfare of mothers and children and creating a happy and prosperous small family.
In this study, it was found that some mothers received support from their husbands but did not choose the long-term contraceptive method (MKJP), this was because mothers felt they were incompatible with long-term contraceptives such as implants, IUDs or MOWs and mothers preferred to use non-MKJP contraceptives. such as pills, and injections. This study also found that some PUS did not get support from their families and husbands but chose a long-term contraceptive method. This was because the mother understood and understood the long-term contraceptive method (MKJP), so even though her husband did not support using MKJP, she felt that she was suitable so that she decided to use the MKJP contraceptive which is more efficient than the non-MKJP contraception.
In general, husbands who do not provide support to their wives because their husbands also do not understand about MKJP contraceptives so that husbands do not know how to provide correct and appropriate support for their wives to use MKJP. Another reason, because some husbands are less concerned about the use of contraceptives by their wives, where the husbands leave the decision to use contraceptives to their own wives. The desire to have more children in the near future makes wives also prefer non-MKJP contraceptives, because if they use the MKJP contraception, it will take longer.
Based on the answers per item on the family / husband support variable, it shows that some respondents stated that their husband / family gave permission to use MKJP. However, respondents also stated that their husbands / families did not praise or encourage using MKJP. This is because usually wives ask permission from their husbands to use contraceptives but husbands do not give praise to their wives after using the MKJP contraceptives. Because according to him it is normal. In addition, most husbands rarely give praise to their wives.

The Role of Cadres Influences the Election of MKJP
The role of cadres influences the selection of MKJP by women of PUS in the working area of Puskesmas Teladan Medan. The OR value of the cadre role variable was 8.819, meaning that respondents who stated that the cadre's role was supportive, had the opportunity to choose a long-term contraceptive method of 8.8 times higher than respondents who stated that the role of cadres was not supportive. The role of cadres is the most dominant variable influencing the selection of MKJP by PUS in the working area of the Medan Teladan Community Health Center.
The results of this study are in line with Setiasih's research in 2016 on mothers of fertile age couples (PUS) in Kendal Regency. It is concluded that there is a relationship between the role of family planning cadres and the choice of contraceptive methods (Setiasih et al., 2016). Triyanto's research in East Java Province concluded that the variable role of family planning cadres influences fertile age mothers in the use of the long-term contraceptive method (MKJP) (Triyanto & Indriani, 2018).
The role of cadres as providers can be in the form of communicator, informator and motivator. The role of cadres in carrying out health tasks affects maternal health. The role of health cadres is to provide support and appeal to the community to be present on time for posyandu activities. The low attractiveness of the posyandu and the low awareness of the mother herself, which is likely to make community participation to come to the posyandu low (Sihombing et al., 2016).
According to researchers, support for the role of cadres in mothers in the selection of MKJP in the working area of Puskesmas Teladan Medan is very large because getting support from the role of cadres of mothers is motivated to choose MKJP. For some PUS, family planning cadres have an important role in providing information about MKJP contraceptives because the duties of family planning cadres are implementing / managing, mobilizing, empowering and mobilizing and developing partnerships with various parties in implementing family planning programs with rural or urban community institutions at the village level or sub-district. One of the duties of family planning cadres is to make visits / approaches to the community such as PUS, WUS, formal / informal figures in the context of socializing family planning programs.
This study found that some respondents who received support from the role of cadres but did not choose the long-term contraceptive method (MKJP) because mothers prefer to use other contraceptives such as injection or pill contraception. This study also found that some mothers stated that the role of cadres was not supportive but chose the long-term contraceptive method (MKJP), this was because the mother understood and understood the long-term contraceptive method (MKJP) so that without being told by the family planning cadres, the mother herself was the one who chose to use MKJP contraceptives such as IUDs, implants, or MOWs because they are more efficient than non-MKJP contraceptives.
Health workers or family planning cadres are considered to have a very important role in the final stages of choosing a contraceptive device. Prospective acceptors who are still in doubt in choosing a contraceptive device can be convinced by health workers. This is also supported by the position of health workers who are still considered role models in society, so that recommendations or decisions made will be carried out by the community, as well as regarding the use of contraceptives (Simanungkalit 2017). It will be easier for mothers to accept and follow the recommendations of health workers or cadres because they are considered to have better understanding of problems, especially in the use of MKJP contraceptives.

The Attitude of PUS Women Has No Effect on the Selection of MKJP
The attitude of PUS mothers has no effect on the selection of MKJP in the work area of the Medan Teladan Community Health Center in 2020. This result is different from the research results of Safitri et al. at the Puskesmas Pemurus Dalam, Puskesmas Cempaka Putih and Puskesmas 9 November Banjarmasin in 2019 that got the results that the attitudes in the MKJP group were mostly good attitudes 80% and the most non MKJP groups with 50% bad attitudes. The conclusion of this study is that there is a relationship between the level of attitude and the use of MKJP (Safitri et al., 2019). Likewise, Wahyuningrum's 2014 research on post partum patients at Kudus Hospital found that there was a relationship between the level of knowledge and attitudes towards the choice of KB MKJP (Wahyuningrum et al., 2014).
Attitude is an assessment of something related to public health behavior. The form of assessment, if desired, is a desire to do so (Green et al., 1980). The formation of attitudes is influenced by various internal and external factors. Internal factors in the form of personal experiences and emotional states. Experience with an object that gives a pleasant or good impression will form a positive attitude, an unpleasant experience will form a negative attitude. Emotional factors, more on the psychological condition of an individual, feelings of attraction, pleasure, and feelings of need will form a positive attitude, while feelings of hatred, indifference, and disbelief will form negative attitudes.
Meanwhile, external factors that form attitudes include the influence of communication, group interaction, and cultural influences (Saifuddin, 1995). Mother's attitude about KB MKJP is influenced by several factors, including personal experience, influence of people who are considered important, cultural influences and the mass media. The experience received by mothers, especially regarding the attitude of using KB MKJP is one of the sources or references in addressing the use of KB MKJP (Widyami & Dhewi, 2018) According to the researcher, the results of this study prove that the selection of MKJP in the working area of the Medan Teladan Community Health Center was not influenced by the attitude of PUS. The negative attitude towards PUS arises because of the issues that develop in the community about long-term contraceptive methods such as the IUD that can move from the mother's womb to other parts of the body such as the heart and brain, using long-term contraception methods become infertile mothers after being removed even though using a longterm contraceptive method such as an IUD or implant but still being able to get pregnant, using an IUD makes a husband and wife relationship uncomfortable, for women who put implants should not work hard and carry heavy lifting, and others.
The results of the study by Styavada and Adamchak from Nepal showed that one of the difficulties found by acceptors who would use contraceptives was having to travel to health care facilities that were quite far away and encountered many difficulties (Satyavada & Adamchak 2000). Access to services is one of the factors influencing the use of contraceptive methods, including MKJP. Improvements in family planning services and provision of easy access can increase the use of contraceptive methods (Hadie 2015).
The availability of family planning services includes infrastructure, distance and equipment. If the facilities and infrastructure are comfortable and the equipment is complete, sterile and various, there will also be a lot of public interest in using Non-Hormonal MKJP. There is no obstacle to the distance to the family planning service, it's just that MOW / MOP has to be sent to a hospital that is far from home (Setiasih et al., 2016). The availability of health services is about the completeness of contraceptives, rooms, and transportation to health facilities (infrastructure) used to provide health services, making it easier or more convincing for patients to seek treatment or consultation (Satrianegara & Saleha, 2019).
According to the researcher, the results of this study indicate that accessibility does not affect the selection of MKJP in the working area of the Teladan Community Health Center in Medan. This is due to respondents who say that the distance between their house and health facilities that provide family planning services is close, and who say that there is no difference in using long-term contraceptive methods (MKJP). Most of them prefer to use non-MKJP contraceptives such as pills or injections.
So, the two groups have no real differences. Likewise, those who said that the accessibility was good and less good were fewer who chose the long-term contraceptive method (MKJP), so there was no difference in data distribution. Mothers who were respondents did not make the accessibility of contraceptive services a factor that influenced them to use the MKJP contraceptive method.

Friend Support Has No Effect on MKJP Election
Support from friends has no effect on the selection of MKJP by women of PUS in the working area of Puskesmas Teladan Medan. In contrast to the results of Febriani's research in 2018 which examined Muslim WUS in Pasir Kuda, it was concluded that there was a relationship between friend support and the use of contraceptives, with an OR value of 6,058 (95% Cl = 1,742-21,065), meaning that WUS getting support from friends has odds. 6.05 times higher to use contraceptives than WUS who do not receive support (Febriani et al., 2018).
Friends are the closest people who can influence a person's health behavior. Usually friends easily influence their friends to follow what they want because of their sense of trust and often they have desires and perceptions that are not much different in seeing things (Green et al., 1980). Lack of peer support for MKJP acceptors can be caused by several considerations or decisions and conditions of family planning acceptors. Consideration can be obtained by a person from past experiences of himself or others around him. Environmental support can influence family planning acceptors using the type of family planning (Alifah 2015).
According to the researcher, the results of this study prove that the selection of MKJP by PUS in the working area of Puskesmas Teladan Medan was not influenced by peer support. This is because some respondents who stated that their friends provided support and those who stated that they did not provide more support chose to use non-MKJP contraceptives so that there was no difference in the two groups.
Likewise, fewer respondents who stated that they received support from friends and did not get support from places, were less likely to use the long-term contraceptive method so that there was no difference in data distribution between the two groups. Indeed, some people usually follow what their closest people do, such as friends, but in this study more of their friends supported using non-MKJP contraceptives so that more respondents also used non-MKJP than those who used long-term contraceptive methods.

Conclusion
This study concluded that the variables that influenced the selection of MKJP were knowledge, family / husband support, and the role of cadres. Meanwhile, attitudes, accessibility and peer support had no effect. The most dominant factor affecting women of PUS in choosing MKJP in the work area of Puskesmas Teladan Medan is the role of cadres with a value of Exp (B) / OR = 8.819, mothers of PUS who claim to be supported by cadres, have the opportunity to choose a long-term contraceptive method of 8.8 times higher compared to PUS mothers who stated that their cadres were less supportive.