Analysis of Factors Affecting Pregnant Mothers in Performing VCT Examinations at the Arjasa Public Health Center, Sumenep Regency

HIV/AIDS is a frightening phenomenon for the Indonesian people today, so that people with HIV/AIDS often get very bad stigma and discrimination.The purpose of this study was to analyze the effect of attitudes, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. The design of this research is an observational quantitative study with a cross sectional approach with the focus of the research directed at analyzing the influence of attitudes, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. The total population is 159 respondents and a sample of 108 respondents is taken by the Accidental Sampling technique. In the study it was found that halmost half of the respondents have attitude enough category as many as 47 respondents (43.52%). Most respondents have adequate family support category as many as 49 respondents (45.37%). Most of the respondents have sufficient service quality category as many as 50 respondents (46.30%). Most of the respondents carried out the VCT test as many as 71 respondents (65.74%). Based on the results of the Logistics Regression analysis showed that the p-value <0.05 then H1 was accepted so it was concluded that there was an influence of attitude, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Health Center, Sumenep Regency. It is expected for pregnant women to routinely check the womb in order to maintain the health of the mother and fetus so that the baby is born healthy and the mother is safe.


ABSTRACT
HIV/AIDS is a frightening phenomenon for the Indonesian people today, so that people with HIV/AIDS often get very bad stigma and discrimination.The purpose of this study was to analyze the effect of attitudes, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. The design of this research is an observational quantitative study with a cross sectional approach with the focus of the research directed at analyzing the influence of attitudes, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. The total population is 159 respondents and a sample of 108 respondents is taken by the Accidental Sampling technique. In the study it was found that halmost half of the respondents have attitude enough category as many as 47 respondents (43.52%).
Most respondents have adequate family support category as many as 49 respondents (45.37%). Most of the respondents have sufficient service quality category as many as 50 respondents (46.30%). Most of the respondents carried out the VCT test as many as 71 respondents (65.74%). Based on the results of the Logistics Regression analysis showed that the p-value <0.05 then H1 was accepted so it was concluded that there was an influence of attitude, family support and service quality on the implementation

METHODS
In this study, the researcher used an observational quantitative design with a cross sectional approach, which is a study to study the dynamics of the correlation between risk factors and effects, by approaching, observing or collecting data all at once (point time approach), that is, each subject The study was observed only once and measurements were made on the status of the character or variable of the subject at the time of examination. This does not mean that all research subjects are observed at the same time . This research will analyzethe influence of attitudes, family support and service quality on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. The total population is 159 respondents and a sample of 108 respondents is taken by the Accidental Sampling technique. Data analysis using Logistic Regression test. This research has gone through an ethical test with the number SK: 2314/KEPK/III/2021. 1. Attitude towards VCT Implementation Based on the results of the Logistics Regression analysis shows that the p-value 0.000 <0.05 then H1 is accepted so it can be concluded that there is the influence of attitudes on the implementation of VCT examinations in pregnant women at the Arjasa Public Health Center, Sumenep Regency 2. Family Support for the Implementation of VCT Based on the results of the Logistics Regression analysis shows that the p-value is 0.003 <0.05 then H1 is accepted so it can be concluded that there is the effect of family support on the implementation of VCT examinations for pregnant women at the Arjasa Health Center, Sumenep Regency 3. Service Quality on the Implementation of VCT Based on the results of the Logistics Regression analysis shows that the p-value is 0.005 <0.05 then H1 is accepted so it can be concluded that there is The influence of service quality attitudes on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency.

A. Attitude of Pregnant Women in Conducting VCT Examination at Arjasa Health Center, Sumenep Regency
The results showed that almost half of the respondents had a moderate category attitude as many as 47 respondents (43.52%). In addition, a number of 36 respondents (33.33%) have an attitude of less category. Meanwhile, a number of 25 respondents (23.15%) had a good attitude category.
Attitude is a reaction or response of someone who is still closed to a stimulus or object. The manifestation of that attitude cannot be directly seen, but can only be interpreted beforehand from closed behavior. According to Randi in Imam (2011), attitude is a general evaluation made by humans against themselves or others for reactions or responses to stimuli (objects) that cause feelings accompanied by actions that are in accordance with the object.
According to Notoatmodjo (2010) that the level of knowledge is a domain for someone to take someone's actions to the level of understanding shown through interpreting the material correctly so that further application is real, which means that respondents are able to view HIV/AIDS correctly. Knowledge can influence a person's attitude to take an action, in this case the attitude of pregnant women to HIV/AIDS. This is in accordance with the research of Oberhelman, et al. (2015) providing comprehensive and appropriate information also has an influence on knowledge which will ultimately affect attitudes. This is supported by the research of Taha, et al (2016), which shows that knowledge is positively correlated with attitudes. This proves the importance of education to increase one's knowledge which will ultimately shape that person's attitude. And supported by research Yasemin, et al (2010) which explains that increasing one's knowledge can change one's attitude towards a problem and it is beneficial for the development of one's self-awareness.
According to the researcher, to be able to form the basis for attitude formation, personal experience must leave a strong impression. Therefore, attitudes will be more easily formed if the personal experience occurs in situations that involve emotional factors. In general, individuals tend to have an attitude that is conformist or in line with the attitude of people who are considered important. This tendency is motivated, among others, by the desire for affiliation and the desire to avoid conflict with the person who is considered important. Based on the results of the study, it was found that half of the respondents had a moderate category attitude where this was due to the respondents wanting to do the best for themselves and their families.

B. Support of Pregnant Families in Conducting VCT Examinations at Arjasa Health Center, Sumenep Regency
The results showed that most of the respondents had adequate family support as many as 49 respondents (45.37%). In addition, 38 respondents (35.19%) had family support in the category of less. Meanwhile, a number of 21 respondents (19.44%) had good family support.
According to Friedman (2014) family support is the attitude, action and acceptance of the family towards its members. Family members are seen as an inseparable part of the family environment. The family also functions as a support system for its members and family members view that people who are supportive are always ready to provide help with assistance if needed.
Kane in Friedman (2017) defines family support as a relationship process between the family and the social environment. According to Kuncoro (2017) family support is verbal and nonverbal communication, advice, real help or behavior provided by people who are familiar with the subject in their social environment or in the form of presence and things that can provide emotional benefits or influence. on the behavior of the recipient, in this case the person who feels emotionally supported feels relieved because he is noticed, gets advice or a pleasant impression on him.
Family and community support have a big role in increasing compliance, namely by supervision and giving encouragement to someone. The advantage of family support is that they live in the same house or close to home with mothers and toddlers so that monitoring is more optimal and there is no direct need for transportation costs (Becher, 2014). Families are aware of the importance of obedience in carrying out an activity, especially regarding the visit of mothers and toddlers at the posyandu, it is very necessary to monitor the growth and development of toddlers to become healthy adults.

C. Quality of VCT Services for Pregnant Women at Arjasa Public Health Center, Sumenep Regency
The results showed that most of the respondents had sufficient service quality category as many as 50 respondents (46.30%). In addition, a number of 32 respondents (29.63%) have poor service quality category. While a number of 26 respondents (24.07%) have good service quality category.
Quality is something that is decided by the customer. Quality is based on the actual experience of the customer or consumer towards the product or service which is measured based on these requirements (Mongkaren, 2013). Service quality can be interpreted as an effort to fulfill consumer needs and desires as well as the accuracy of delivery in balancing consumer expectations (Amrizal, 2014).
Service quality (service quality) can be known by comparing the perceptions of consumers on the services they receive with the services they actually expect on the service attributes of a company. Service quality is perceived as good and satisfactory if the service received or perceived is as expected, if the service received exceeds consumer expectations, then the service quality is perceived as very good and of high quality. Service quality is perceived as bad if the service received is lower than expected (Amrizal, 2014). The quality of health services refers to the level of perfection in the appearance of health services that can satisfy every user of health services in accordance with the level of satisfaction of the average population.
Service is an activity or a series of tools that are invisible (cannot be touched), which occur due to interactions between consumers and employees or other things provided by service providers that are intended to solve consumer problems (Gronroos, 2011 in Ratminto andWinarsih, 2015).
People as consumers certainly want quality services. Service quality is defined as the level of excellence expected and control over the level of excellence to meet customer desires (Tjiptono, 2008, in Dimas andOktafani, 2014). Service quality can be interpreted as an effort to fulfill consumer needs and desires as well as the accuracy of delivery in balancing consumer expectations (Dimas and Oktafani, 2014).
One of the services that is widely used by the community is health services. According to Azwar (2014) the use of health services is the use of service facilities provided either in the form of outpatient care, inpatient care, home visits by health workers or other forms of activity from the use of these services based on the availability and continuity of services, public acceptance and fairness, easy to use. accessible to the public, affordable and of good quality.

D. Implementation of VCT Examination for Pregnant Women at Arjasa Health Center, Sumenep Regency
The results showed that most of the respondents carried out the VCT test as many as 71 respondents (65.74%). Meanwhile, 37 respondents (34.26%) did not carry out the VCT test.
The Ministry of Health has made efforts to prevent mother-to-child transmission of HIV/AIDS in accordance with WHO recommendations (2009)  Ariningtyas' research (2017) states that the implementation of PPIA in maternal and child health services can reduce maternal mortality with HIV. The Independent Practice Midwife Service is one of the maternal and child health service facilities in Indonesia.
The VCT examination program as a mother-to-child HIV prevention program is mostly carried out by midwives. Midwives can provide counseling and support to women who are not infected with HIV or who are already infected with HIV. Midwives know about HIV and AIDS socialization to pregnant women from the training and socialization they have attended. Midwives who have received PPIA training are required to socialize to midwives who have not had the opportunity for training, this is done so that all midwives gain knowledge and can disseminate HIV and AIDS as well to every pregnant woman who comes (Widiyasari et al., 2014).
The VCT screening program aims to control HIV/AIDS transmission, reduce HIV cases as low as possible, reduce stigma and discrimination, and reduce AIDS deaths (Getting to Zero). This program can be implemented in an integrated manner at every level of health care and can be implemented by public health center and their staff, hospitals, and independent practice midwives. In this case, midwives have a very important role, where midwives are at the forefront of maternal and child health services. The increasing transmission of HIV from mother to child causes the PPIA program to be implemented immediately.
According to the researcher, the VCT examination program must be implemented immediately in all health services so that HIV transmission from mother to child can be prevented from an early age. The VCT examination program is integrated into MCH services, so it is part of the midwife's duties in MCH services. One of the MCH service providers is the Independent Practice Midwife (BPM) but the VCT examination has not been carried out at the Independent Practicing Midwife because there is no standard procedure that regulates the implementation of VCT in the Independent Practice Midwife and it must be at the Public health center. Based on the results of the study, it was found that there were some respondents who were not willing to do the VCT test in the program to prevent mother-to-child transmission of HIV at the Arjasa Health Center, Sumenep Regency, which was due to the respondent's ignorance of this program so that respondents were still afraid.

E. The Influence of Attitudes on the Implementation of VCT Examination in Pregnant Women at the Arjasa Health Center, Sumenep Regency
Based on the results of the Logistics Regression analysis shows that the p-value 0.000 <0.05 then H1 is accepted so it can be concluded that there is the influence of attitudes on the implementation of VCT examination in pregnant women at the Arjasa Health Center, Sumenep Regency.
Various comprehensive efforts related to the prevention of transmission from mother to baby have been carried out by health facilities. However, not all health services in districts/cities can provide HIV/AIDS services, including PMTCT services. Most of the health services located in districts/cities that are unable to handle female HIV patients until major actions such as giving birth to HIV mothers are immediately referred to the nearest referral hospital. This is the reason why HIV women, especially those who are pregnant or have toddlers, are not optimal in accessing PMTCT services. Especially without the support of the closest people such as spouse or husband and family (Gangga, 2012).
The most appropriate strategy to prevent vertical transmission is to prohibit HIV-infected mothers from getting pregnant, and to terminate pregnancy for HIV-infected mothers. However, this is not possible because everyone wants offspring. Pregnancy and having children are the rights of every human being. People with HIV also have the same right to marry and continue their offspring. Therefore, so that babies are not infected with HIV, a prevention strategy is carried out, namely PMTCT (Damania, 2016). PMTCT is a program to prevent the transmission of HIV/AIDS from mother to baby. The basic concept is to reduce the Viral Load as low as possible. Minimize exposure of the fetus/infant to HIV positive body fluids. Then optimize the health of babies from HIV positive mothers.
Pregnant women are a group at risk of contracting HIV, and every year it always increases. This happens because of the increasing number of men who have unsafe sex, so that they will transmit HIV to their sexual partners and have an impact on the baby they are carrying. Transmission of HIV from mother to baby is the end of the chain of HIV transmission. Mother-tochild transmission of HIV reaches up to 90% of cases10. Efforts to prevent mother-to-child transmission of HIV are carried out comprehensively and effectively in health care facilities with the Prevention of Mother-to-Child HIV Transmission (PPIA) program. PPIA services can be carried out in various health facilities (hospitals, health centers) with the proportion of services in accordance with the availability of facilities and personnel/staff who understand and are able to carry out this program.
So far, the implementation of the program to prevent mother-to-child transmission of HIV-AIDS has faced many obstacles since it was announced by the government in 2004. Constraints experienced include inadequate health facilities, not all health facilities are able to provide PMTCT services. The coverage of K1 antenatal care is quite high, namely 92.7%, but the coverage of K4 antenatal care (quality) has only reached 61.4%, meaning that there are still many pregnant women who have not received quality services, which is to prevent and detect early problems/diseases that they suffer. pregnant women and their fetuses, including HIV in pregnant women. This makes another obstacle, namely the delay in knowing the HIV status of pregnant women which will have an impact on the behavior of the mother in preventing the transmission of HIV/AIDS to the baby.
Wudineh (2016) stated that the prevention of HIV transmission from mother to child is a program that is increasingly becoming a concern along with the increasing incidence of HIV in mothers and children. With good intervention, the risk of HIV transmission from mother to baby by 25% to 45% can be reduced to less than 2%. Implementation of PPIA in maternal and child health services can reduce maternal mortality with HIV. The Independent Practice Midwife Service is one of the maternal and child health service facilities in Indonesia. The Independent Practice Midwife is a basic service center that is the first line of early detection of complications in pregnancy, including HIV.
According to researchers, midwives play a role in referring pregnant women to get integrated ANC at the public health center. Counseling and offering HIV testing to all pregnant women can reduce stigma and discrimination in society. The implementation of the PPIA examination as a mother-to-child HIV prevention program can mostly be done at the Public health center. A good attitude to pregnant women can encourage a person to be more open and willing to accept the situation no matter what. So it can be concluded that there is an influence of attitude towards the implementation of VCT examination in pregnant women at the Arjasa Health Center, Sumenep Regency.

F. The Effect of Family Support on the Implementation of VCT Examinations for Pregnant Women at the Arjasa Health Center, Sumenep Regency
Based on the results of the Logistics Regression analysis shows that the p-value is 0.003 <0.05 then H1 is accepted so it can be concluded that there is the effect of family support on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency. Support is information from other people that someone is loved and cared for, has selfesteem and is valued and is part of a communication network and shared obligations, while what is meant by a husband is a form of interaction in which there is a relationship of mutual giving and receiving. individuals who are involved in the social system which in the end will be able to give love, attention and a sense of attachment to both social families and partners (Ingela, 2009).
Instrumental support or facilities are the highest form of support that mothers get because this form of support involves direct assistance, for example in the form of financial assistance or assistance in carrying out certain tasks (Sarafino, 2014).
HIV counseling and testing behavior for pregnant women in Indonesia is still considered low, pregnant women consider HIV taboo which is a lifelong disease and has a bad stigma, mothers have never carried out risky behaviors such as changing partners that can transmit HIV, and do not feel the symptoms of HIV so that HIV testing does not need to be carried out voluntarily, besides that pregnant women are also afraid of the results obtained because it can affect the psychology of the mother and the fetus they are carrying when the test results are positive. The impact that can be caused by the unwillingness of pregnant women to take an HIV test is that HIV-positive mothers are not detected and are at risk of giving birth to HIV-positive babies, thereby increasing the HIV prevalence rate (Depkes RI, 2013).
The results of this study are supported by Nurhayati's research on the factors related to the participation of pregnant women in voluntary HIV counseling and testing at the Bukittinggi City Health Center which shows that husband's support is one of the factors that significantly influences HIV counseling and testing voluntarily with a value significance of 0.016. (Nurhayati, 2016).
The results of this study are also supported by research by Tyan Ferdiana Hikmah in 2016 Factors that influence pregnant women to screen for HIV/AIDS through the PMTCT program in the work area of the Kretek Health Center Bantul Yogyakarta. The results showed that there was a significant relationship between husband's support and the behavior of pregnant women to screen HIV/AIDS with a significance value of p = 0.027.

G. The Effect of Service Quality on the Implementation of VCT Examinations for Pregnant Women at Arjasa Health Center, Sumenep Regency
Based on the results of the Logistics Regression analysis shows that the p-value is 0.005 <0.05 then H1 is accepted so it can be concluded that there is The influence of service quality attitudes on the implementation of VCT examinations for pregnant women at the Arjasa Public Health Center, Sumenep Regency.
Good services are health services that are available to the community (acceptable) and sustainable (sustainable). This means that all types of health services needed by the community are found and their presence in the community is available at any time of need. Health services must be reasonable (appropriate) and acceptable (acceptable) by the community. This means that the health service can overcome the health problems faced, does not conflict with customs, culture, beliefs and beliefs of the community, and is unnatural, is not a condition of good health services.
The location angle is easily accessible by the community, so the distribution of health facilities is very important. Coverage of auxiliary facilities to determine effective demand. If the facility is easily accessible by using the available means of transportation, this facility will be widely used. Past user levels and trends are the best indicators of short and long term changes in future demand.
The services provided are affordable (affordable) by the community, where the cost of these services is sought in accordance with the economic capacity of the community. Expensive health services may only be enjoyed by some people. And shows the level of perfection of the