Factor Affecting the Utilization of Family Planning Program Services for Women in the Working Area of the Pasie Raya Community Health Center

Factor Affecting the Utilization of Family Planning Program Services for Women in the Working Area of the Pasie Raya Community Health Center Melda Andriani, Megawati, Asriwati Amirah, Lucia Lastiur Student of Public Health Science Master Program, Faculty of Public Health, Helvetia Institute of Health, Indonesia Lecturer at the Masters Program in Public Health Sciences, Faculty of Public Health, Helvetia Institute of Health, Indonesia


Introduction
Population problems in Indonesia, which can be seen from the very low quality of life of the population, where the population is out of control from an increasing number. Based on the projections of the National Development Planning Agency, Indonesia's population in 2019 will reach 268 million, for the population in the productive age category (14-64 years) 179.13 million people (67.6%) and the elderly population 65 and over as many as 85 , 89 million people (5.8%). From this projection, the number of births this year reached 4.81 million, while the number of deaths was 1.72 million. The ratio of the dependency rate (productive age to non-productive age) was 47.9%, lower than the previous year at 48.1% and also down from the position that reached 50.5% and will reach its peak in 2026.
One of the government policies to improve quality families, the Government utilizes the BKKBN (National Population and Family Planning Agency) which is an agency that specifically handles family planning (family planning) issues by formulating the direction of family planning program policies and strategies towards the vision of "Quality Families" where Based on WHO (World Health Organization) data on Monitoring Health for SDGs 2018, it is estimated that 77% of women of reproductive age who are married or in association have family planning needs with modern contraceptive methods. The need for family planning programs that are fulfilled by modern contraceptive methods for couples of reproductive age in Sub-Saharan Africa is very small 45% compared to WHO regions such as America 80%, Asia 72% and Europe 70%.
Based on World Population Day (WPD) 2017 data on "Family Planning: Empowering people, Developing Nations" that ± 214 million women in the world who want to avoid pregnancy but do not use safe and effective family planning methods, where ± 155 million women do not use contraception and ± 59 million who still rely on traditional methods due to minimal access to information / services and lack of support from their partners / communities. The majority of women with minimal access to contraceptive services are in 69 developing and poor countries (39% in the African continent and the South Asian region). As for the 5 countries with the largest population in 2017, the first was China with 1.38 billion, the second was India at 1.34 billion, the third was the United States at 326 million, the fourth was Indonesia with 263 billion Million and the last country Brazil is 211 million.
Substantively, WUS (women of childbearing age) are expected to use MKJP after childbirth to avoid the risk of four too, especially to maintain a safe and healthy distance between pregnancies or subsequent births, as well as to reduce the risk of too many children.
Family planning services are a form of individual promotive and preventive health efforts (Gavin et al., 2014;Cleland et al., 2006). The implementation of the life cycle approach and the principle of continuum of care in family planning services can be seen from the types of services and targets intended. Family planning services have begun to be provided to adolescents in the form of providing information about reproductive health that is integrated in adolescent care health service (PKPR).
For prospective brides, family planning services are provided in the form of providing information as part of reproductive health services. Family planning services for pregnant women are provided integrated with antenatal services in the form of postpartum family planning counseling, use of the MCH Handbook, delivery planning programs and complications prevention (P4K), as well as providing information in classes for pregnant women. If after childbirth a mother has not used contraception, at the time of providing postnatal care, the health worker can provide postpartum FP counseling and postpartum family planning services. For women who are not pregnant, family planning services are provided in the form of counseling and family planning services with the aim of planning and space or limit pregnancy In Indonesia itself, the implementation of the family planning (family planning) program has unresolved constraints, such as the high population growth rate, inadequate access to and quality of family planning services for the community, and the high number of unmet needs. the number of wus (women of childbearing age) who wish to postpone pregnancy or do not want additional children but do not use the contraceptive method of family planning (family planning). Other obstacles that cause the low coverage of the family planning program are the inadequate provision of contraceptives, the minimum number of field family planning officers, and different government policies in each region (Azzahra, 2018).
Family planning (KB) is an effort to space out or plan the number and distance of pregnancies using contraception. The aim is to improve the welfare of mothers and children and to realize the norms of a happy and prosperous small family which are the basis for the realization of a prosperous society with birth control and population growth (Hartanto, 2004).
The Aceh National Population and Family Planning Board (BKKBN) noted that up to November 2017, Aceh province's family planning participants reached 101,598 wus (women of childbearing age). The number of registered family planning (family planning) participants was only 94% more than the target. The target for family planning (family planning) participants in 2017 was set at 108,023 pairs. Meanwhile, the number of WUS (women of childbearing age) in Aceh Jaya Regency in 2018 was 14,896 couples. In 2019 the period from January to May there were 14,896 WUSs. Data on WUS at Pasie Raya Puskesmas in 2018 were 1,125 WUS, in 2019 the January-June period the number of PUS (fertile age couples) was 1,253WUS. So far, many information related to contraceptives have not received the correct information and there are still wrong assumptions about contraceptives. So there is a need for counseling about contraceptives that are easy to use and the safest to use such as the IUD. The IUD does not affect the body in the long term unlike injections and pills that affect the body, but because the IUD is inserted in the uterus, many female partners are reluctant to have it inserted because there is still a culture of shame in society. Even though the IUD is the safest contraceptive tool and has no impact on the body. In addition, community participation in the family planning program is also low so that it can affect the population. This of course will have an impact on other sectors of life. The lack of information obtained causes them to be still afraid to use contraception (Bongaarts & Bruce, 1995). Some of them still believe in a culture that states "many children have a lot of sustenance".
The unmet need for family planning services varies according to age group. Married women aged 35-49 years tend to have a greater need for contraceptive services than young women aged 15-34 years. The fulfillment of family planning service needs does not differ between urban women and rural women, but the need for family planning services in urban areas is to limit births, while rural women are more for spacing births (Bawah et al., 1999). The family as the smallest unit in social life is expected to receive the Small Family Norm Happy and prosperous (NKKBS) which is oriented towards "Catur Warga" means a mother and father with two children. One thing that supports the implementation of planning in Indonesia is that almost the technical methods of family planning announced by the government can be accepted by the community.
A person's behavior towards health is influenced by 3 factors, namely predisposing factors (knowledge, attitudes, age, education, economy, perceptions, beliefs, values, culture, traditions, which are related to individual or group motivation to take an action), enabling factors (availability of health infrastructure, facilities and information), reinforcing factors (family support, behavior of community leaders, religious leaders, commitment of government and health workers). Health behavior is inseparable from the social, economic, and demographic characteristics of humans themselves (Edberg, 2007;Becker et al., 1972). Meanwhile, the other 2 women said they had used contraceptives because they thought that culture did not influence them not to use contraception, they also stated that they always received information and knew the importance of using contraceptives to sparse pregnancy and children. The aim of this study was to analyze the factors that influence utilization of family planning program services for women of childbearing age in the work area of the Pasie Raya Community Health Center, Aceh Jaya Regency in 2019.

Methods
This research uses a qualitative research type with a narrative approach on the grounds that this approach is deemed appropriate to describe the problems of human subjects who are generally disobedient, change and have individual subjectivity, have emotions, etc. This study aims to capture an overview of city government policies towards exclusive breastfeeding for working mothers in Langsa City, Aceh Province in 2019. This research was conducted in Langsa City. The informants in the qualitative research were 5 people, namely 1 key informant, namely the Special Staff of Aceh Specialties and the Welfare of the Langsa City Government and 4 supporting informants, namely 1 Kasie, Family Health and Nutrition, Langsa City Health Office, 1 IBI Langsa City Secretariat and 1 Person Head of government agencies and 1 head of private agencies.

Respondents Characteristics
In this study, age is the length of time a person lives from birth to the present, calculated in years. Based on the results of the research presented in table 4.1, it is known that the age of the most respondents was in the age range of 20-35 years, namely as many as 61 respondents (67.8%) and the age of the respondents at least in the age range ≤ 20 years, namely as many as 6 respondents (6.7%). Table 4.2 shows that there are 2 informants in the age range of 20-35 years, which are 1 key informant and 1 main informant. While in the age range ≥ 35 years there are 3 people, namely 1 person is the key informant, 1 person is the main informant and 1 other person is the supporting informant.
From informant 1 is a key informant, is an informant who uses the services of the Kb Program in the Pasie Raya Puskesmas area in 2019 with a high school education background (high school), is 25 years old and is an IRT (Housewife). Informant 2 is also a key informant of the research, with a 36 year old high school education background, occupation is a health cadre in the village informant 3, informant 4 is the main informant with a 36 year old S1 Nursing educational background who has worked in Pasie Raya Puskesmas for more than 5 years, while informant 4 has a 28-year-old Diploma 3 educational background who is a cadre of BKLB (Family Planning) for 3 years. Informant 5 is a research support informant with an educational background of S1 Economics, who is 38 years old and is one of the community leaders in the work area of the Pasie Raya Community Health Center in 2019.
Whereas in the education group, the largest number of respondents who took advantage of family planning (family planning) program services were in the high school education level (high school), which amounted to 51 respondents (56.7%), 20 people in the diploma / tertiary education group ), in the junior high school (SMP) group as many as 14 people (15.6%) and the smallest group in the use of family planning program services (Large Families) were in the Elementary School (SD) group of 5 people or (5.5%). Table 4.2 Informant characteristics can be seen, namely 2 informants are a group of high school education level (high school), 3 informants are a diploma / college group.
Age is one of the factors that influence a person's behavior, including in the choice of contraceptives, those with old age have a smaller chance of using contraceptives compared to younger people. Hartanto in Neari Zebuka's intention states that the basic pattern of rational contraceptive use at the age of 20-30 years is contraception that has high reversibility because at that age couples of childbearing age still want to have children. Whereas at the age> 30 years the recommended contraception is that which has high effectiveness and can be used for the long term. It can be seen from the results of the research on the job criteria presented in table 4.1 it can also be seen that most respondents are in the IRT group / do not work as many as 62 respondents (68.9%), self-employed group as many as 16 respondents (17.8%), and in the civil servant group as many as 10 people (11.1%) and the smallest group of 2 respondents (2.2%) are in the student group. In table 4.2 the characteristics of the informants, it can be seen that 2 informants are IRT / do not work, 1 person is a civil servant and 2 other informants are in the self-employed group.
Knowledge, Information Sources, Culture, Family Support, and Healthcare Support Based on the results of research from the aspect of knowledge about family planning services, it shows that the respondent's knowledge is quite good, this is in line with the responses of informants 1 and informants 2 about the knowledge of Kb services, which Kb (Family Planning) service is meant as a form of health effort. Individual promotive and preventive. The implementation of the life cycle approach and the principle of continuum of care in family planning services can be seen from the types of services and targets aimed. Family planning services have started to be provided to adolescents in the form of providing information about reproductive health that is integrated into youth care health services (PKPR).
For prospective brides, services Family planning is provided in the form of providing information as part of reproductive health services. Family planning services for pregnant women are provided integrated with antenatal services in the form of postpartum family planning counseling, use of the MCH Handbook, delivery planning programs and complications prevention (P4K), as well as providing information in classes for pregnant women. If after childbirth a mother has not used contraception, at the time of providing postnatal care, the health worker can provide postpartum FP counseling and postpartum family planning services. For women who are not pregnant, family planning services are provided in the form of counseling and family planning services with the aim of planning and space or limit pregnancy.
For prospective brides, family planning services are provided in the form of providing information as part of reproductive health services. Family planning services for pregnant women are provided integrated with antenatal services in the form of postpartum family planning counseling, use of the MCH Handbook, delivery planning programs and complications prevention (P4K), as well as providing information in classes for pregnant women. If after childbirth a mother has not used contraception, at the time of providing postnatal care, the health worker can provide postpartum FP counseling and postpartum family planning services. For women who are not pregnant, family planning services are provided in the form of counseling and family planning services with the aim of planning and space or limit pregnancy.
From the results of research and interviews conducted by researchers, it shows that respondents and informants have received information about Kb, where the source of information is the basis used in delivering the message, which is used in order to strengthen the message itself. Information is providing information and then communication can draw its own conclusions. From the results of interviews with informants, it can also be seen that there is a cultural influence in the community in the use of family planning program services in the community where culture is a multiple development of cultivation, which means the power of mind so that it is distinguished between culture which means the power of mind in the form of creativity, initiative, and taste. And culture which means the result of the creativity, initiative and feeling.
Culture or civilization contains a broad meaning covering the understanding, feelings of a complex nation including knowledge, beliefs, arts, morals, laws, customs (habits) and other traits obtained from members of society.
Where information is a part of service that is very influential for prospective acceptors and user acceptors, knowing whether the chosen contraceptive is in accordance with the health condition and in accordance with the acceptors' goals in using the contraception. Information really determines the choice of contraception chosen, so that complete information about contraception is needed in order to decide which method of contraception to use.
Whereas the effect of family support on the use of the Kb program can be seen that the majority of respondents get family support and take more advantage of the Kb program services than respondents who do not get support and take advantage of family planning services The results of this study indicate that there is an influence between family support on the use of family planning program services where p value = 0.001 (<0.005). This is also in line with the results of in-depth interviews where the supporting informants answered that there is a form of family support, in this case the husband, in the use of Kb program services such as accompanying his wife or accompanying the wife to the health center to get family planning services.
From the results of interviews with informants, it can also be seen that there is a cultural influence in the community in the use of family planning program services in the community where culture is a multiple development of cultivation, which means the power of mind so that it is distinguished between culture which means the power of mind in the form of creativity, initiative, and taste. and culture which means the result of the creativity, initiative and feeling. Culture or civilization contains a broad meaning covering the understanding, feelings of a complex nation including knowledge, beliefs, arts, morals, laws, customs (habits) and other traits obtained from members of society.
In an effort to realize the handling of family planning side effects on injection family planning acceptors, good participation from local health workers is needed. This can be done through promotional activities, namely through counseling, counseling in the mother's class, as well as couples of childbearing age in health services. In preventive activities, the side effects of family planning can be overcome by taking action in accordance with the complaints that are felt. If the kb acceptor experiences nausea and vomiting, inform him that this is a common thing and will disappear in the near future.

Qualitative Analysis
Knowledge A person's education level is closely related to the knowledge and information obtained, so that the higher the level of one's knowledge, the higher the insight and the easier it will be to receive information. Education is a process where human potentials are easily influenced by habits so that they can be perfected by good habits by means (media) that are arranged in such a way and are managed by humans to help others or themselves to achieve the stated goals.
One of the factors that influence knowledge is the educational guidance that a person gives towards the development of others towards certain ideals that define humans to act and fill life to achieve safety and happiness. Education is needed to get information, for example things that support health so that it can improve the quality of life.
Based on the results of in-depth interview research conducted with key informants in the working area of the Pasie Raya Community Health Center, it is known that the level of knowledge of most women of childbearing age in the working area of the Pasie Raya Community Health Center is at the middle and high levels. So this is a factor that causes WUS behavior in using contraceptives or behavior in utilizing family planning (family planning) services. The results of the study show that most of the informants have a high level of education. This explains that with high knowledge, efforts to seek information It will be broader, because people who have basic secondary and tertiary education are easier to understand and understand the information they receive. It can be seen from the answers of informants about the knowledge of types of contraception and the use of Kb when compared to women of childbearing age who have less education. Meanwhile, based on the level of education where the better the respondent's knowledge of using contraceptives, the higher the interest in using contraceptives, the higher the level of education of the respondents will support accelerating the acceptance of KB information on couples of childbearing age. This research is supported by research of Airlangga University Postgraduate Students that the educational factor is related to the utilization of puskesmas services. The higher a person's education, the higher the desire and the more selective he is in choosing health services.
Based on the results of interviews with key informants, it was found that high-educated fertile women tended to take more advantage of the Kb Program services.

Source Of Information
Based on the results of interviews with key informants and supporting informants in the working area of the Pasie Raya Community Health Center, it can be concluded that WUSs get information about contraception or family planning from mass media, electronics and health workers. In terms of contraceptive use, it can be explained that women who receive information sources tend to use contraception, whereas women who do not receive information tend to not Use Contraception This is in accordance which states that there is a significant relationship between sources of information on fertile age couples (PUS) and contraceptive use in Merak village, Tangerang district. It is known that the information source has a relationship to contraceptive use. This explains the relationship between sources of information on fertile age couples (PUS) and contraceptive use.

Culture
Socio-culture according to Koentjaraningrat is a system of ideas, actions and human work in people's lives that are born from humans through the learning process. Socio-cultural factors cannot be avoided and play an important role in community behavior. This aspect makes people think or as a basis for consideration for accept something in change. For example, in running the family planning program it is recommended to use contraception.
According to the theory, it states that the strong socio-culture that binds the community greatly influences individual behavior in making decisions including in determining the contraceptive device to be used, the socio-cultural environment regarding the perceptions that exist in society that is still less profitable, where family planning and reproductive welfare in assume it is a woman's affair and responsibility, so that men are more likely to be passive.
However, according to the assumptions of the results of in-depth interview research conducted on key informants and supporting informants, it can be seen that the existing culture in the community does not influence the decision to utilize the Kb service program in the form of contraceptive use. Although there are some people who reject the kb program, according to informants the Kb service carried out at the Pasie Raya Puskesmas does not violate Islamic law where services are carried out in a closed room separate from other rooms so that it does not Based on the results of interviews with key informants and supporting informants, it is stated that there is support from the family in the use of family planning program services, in which the husband and mother or in-laws play a role in making decisions about contraceptive choice, the husband is also willing to take his wife to family planning services available at the Pasie Health Center Kingdom. From the results of interviews with informants, it can also be seen that there is a cultural influence in the community in the use of family planning program services in the community where culture is a multiple development of cultivation, which means the power of mind so that it is distinguished between culture which means the power of mind in the form of creativity, initiative, and taste. and culture which means the result of the creativity, initiative and feeling. Culture or civilization contains a broad meaning covering the understanding, feelings of a complex nation including knowledge, beliefs, arts, morals, laws, customs (habits) and other traits obtained from members of society. This is in accordance theory which states that the benefit of informational support is that it can withstand the emergence of a stressor because the information provided can contribute specific suggestions to individuals. The aspects of this support are advice / direction, suggestions, suggestions or input, guidance, and provide important information that is needed by patients.

Health Worker Support
The role of officers in the socialization of family planning is limited to women who want to use contraceptives, the assumption of this interview is that the role of officers is minimal due to the lack of counseling provided while counseling is a strategic activity in helping clients to be able to make their own decisions to take part in the FP program and reproductive health use a type of contraception and a method of delivering information that is not mastered by the officer.

Output Aspects
The program can be said to be running well, so it is necessary to study how the form of socialization and the benefits that have been felt by program recipients related to the family planning program (family planning), the family planning program (KB) which is realized in the use of contraception also has direct or indirect benefits for health mother, infant and child, family health and reproductive and sexual life, and family welfare and resilience.
The existence of counseling and counseling regarding family planning is also a strategic way to increase the coverage of family planning program services. Promotional activities carried out intensively affect community decisions in family planning. Sari's research results (2010) state that statistically there is a very significant relationship between family planning counseling and the decision-making of fertile age couples (PUS) in the use of contraceptives.
The results of the study were based on interviews, although women who were in the Pasie Raya Puskesmas work area had used the Kb service program, most of the WUS did not understand and understand the benefits that were obtained from the family planning program, most of them only followed suggestions or recommendations from their families regarding the choice of contraceptives. This will be used because of the lack of socialization and counseling carried out by health workers and related parties. However, different facts are shown from the results of this study, namely the lack of support from health workers in the family planning program, supporting informants stated that officers rarely provide counseling about contraception, while supporting informants who participate in family planning programs state that officers have provided complete information about family planning services, both types. The choice of birth control method as well as the side effects of the birth control method.
So that the role of officers in the socialization of family planning is limited to women who want to use contraceptives, the assumption of this interview is that the role of officers is minimal due to the lack of counseling provided while counseling is a strategic activity in helping clients to be able to confidently make their own decisions to participate in the FP program and reproductive health. by using a type of contraception and a method of delivering information that has not been mastered by officers.

Conclusion
From the factors that influence the utilization of family planning program services at Puskesmas Pasie Raya including respondent's knowledge, information sources, culture, family support and health worker support, the variable support for health workers has the greatest influence on the utilization of family planning program services. Based on the results of the study, it was stated that the ability of officers at the Pasie Raya Community Health Center in carrying out services was as expected, but there are a number of things that must be improved, such as the ability of officers to install implant contraceptives. The ability of health workers plays a very important role in the final stage of selecting and using contraceptives, because prospective acceptors who were still hesitant about using contraceptives finally decided to use contraceptives after receiving encouragement from health workers because health workers were the ones who took part in the final stages of the process of selecting and using contraception. The technical ability of officers can be improved by attending seminars and attending competency improvement training held by related parties. As well as the ability of health workers in conveying information about KB services to innovate more with methods other than lecture methods such as screening films related to family planning so as to assist women in the decision-making process through various objective considerations.