The Effectiveness of Integrated Counseling on Pregnant Mothers to Improve Knowledge on Pregnant Mothers in Pematangsiantar City

Indonesia has a pretty severe nutritional problem which is marked by the number of cases of malnutrition in children under five, the age of going to school both in men and women. Nutrition problems at school age can cause low levels of education, high absenteeism and high dropout rates. Every individual must experience the stages of development. Developmental stages that will be passed from the phase of infants, children, adolescents, adults and the elderly. The phase that must be passed by individuals to be good, it must be considered growth and development since the womb, infants and toddlers (WHO, 2006). Stunting is a picture of stunted growth as a result of lack of nutrient intake for a long time. According to the WHO Child Growth Standard stunting is based on the body length index compared to age (PB / U) or height compared to age (TB / U) with a limit (-score) of less than minus 2 elementary schools (Ministry of Health Republic of Indonesia, 2015). The problem of stunting in Indonesia has become the focus of the government in the field of health nutrition. The results of the Nutrition Status Monitoring in 2017 show that stunting for toddlers is as high as 29.6 percent in Indonesia, and this result is higher than that of stunts with 20.1 percent (PSG, 2017). The impact of this stunting is decreased intelligence, stunted growth, unproductive and economic decline and increased poverty. Disruption of this child's growth will be a decline in Human Resources (HR) in the coming year. Because brain growth is decreasing so that the quality of health is also low and the cost of living for health will increase then poverty will Abstract


I. Introduction
Indonesia has a pretty severe nutritional problem which is marked by the number of cases of malnutrition in children under five, the age of going to school both in men and women. Nutrition problems at school age can cause low levels of education, high absenteeism and high dropout rates. Every individual must experience the stages of development. Developmental stages that will be passed from the phase of infants, children, adolescents, adults and the elderly. The phase that must be passed by individuals to be good, it must be considered growth and development since the womb, infants and toddlers (WHO, 2006).
Stunting is a picture of stunted growth as a result of lack of nutrient intake for a long time. According to the WHO Child Growth Standard stunting is based on the body length index compared to age (PB / U) or height compared to age (TB / U) with a limit (-score) of less than minus 2 elementary schools (Ministry of Health Republic of Indonesia, 2015).
The problem of stunting in Indonesia has become the focus of the government in the field of health nutrition. The results of the Nutrition Status Monitoring in 2017 show that stunting for toddlers is as high as 29.6 percent in Indonesia, and this result is higher than that of stunts with 20.1 percent (PSG, 2017).
The impact of this stunting is decreased intelligence, stunted growth, unproductive and economic decline and increased poverty. Disruption of this child's growth will be a decline in Human Resources (HR) in the coming year. Because brain growth is decreasing so that the quality of health is also low and the cost of living for health will increase then poverty will Abstract Integrated counseling through lectures and booklets is an effort to increase knowledge on pregnant women in Pematangsiantar City. Second trimester pregnant women are the target to prevent children from starting in the womb as early as possible. The purpose of this study was to analyze the effectiveness of integrated lectures on pregnant women in increasing maternal knowledge. occur in Indonesia will increase. Because the impact of stunting is very broad, the government has made stunting a focus to reduce the number in Indonesia.
The main problems of government failure in reducing stunting are poverty and low levels of parental knowledge. The lack of parental knowledge about children's nutrition makes parents less prepared for the child's growth and development well. The low level of parental knowledge is evidenced by the high number of low levels of education in Indonesia (Ministry of Health, 2018).
Efforts made by the Pematangsiantar City Health Office through Puskesmas in each Sub-district related to stunting prevention have been carried out, one of which is the class of pregnant women. This class of pregnant women is a program that is carried out at the puskesmas to prepare mothers in the process of pregnancy until delivery. Pregnant women are also the intended target in stunting prevention. The class activities of pregnant women in preventing stunting in the form of lectures 1000 HPK with lecture method using flipchart media, supplementary feeding, blood tests, and questions and answers about lecture material but there are still stunting children in Pematangsiantar City.
Based on the results of interviews with the health center, they said it might be better knowledge of pregnant women if also accompanied by a booklet-type book containing pictures and information about stunting so that pregnant women can read it at home when relaxed. therefore, researchers feel it is important to give integrated lectures so that information about stunting is conveyed to pregnant women.
Based on the description above that the problem is "the lack of knowledge and attitudes of mothers to prevent their children from stunting so that researchers want to examine The Effectiveness of integrated counseling on pregnant mothers to improve knowledge on pregnant mothers in Pematangsiantar City".

Effectiveness
Effectiveness is basically the level of achievement of the objectives of an activity carried out. This effectiveness assesses how good or bad is done and how the benefits derived from its activities by looking at the time, energy and other things that include good goals.
According to Sondang (2014), in his book said that effectiveness is the utilization of resources, facilities and infrastructure in certain levels that have become the provisions to produce the activities or programs implemented. Effectiveness provides information on the success of the program that has been done, the closer to the target program, the more effective a program is run.

Counseling
Counseling is one way to change someone's behavior with an educational approach. The educational approach is a series of activities carried out in a planned and systematic manner taking into account the local socio-cultural conditions as well as creating an active role from a group of people to participate. Therefore, health education is an activity carried out to a group of people with an educational approach to foster public awareness in improving and maintaining their health status (Suhardjo, 2013).
Counseling aims to understand the goals we understand and willing to do well and correctly in accordance with what we heal which is then done with awareness and willingness to apply new ideas in his life. Counseling is done in a directed, planned and continuous manner, the target is to continue to do the things that we are guiding continually and there is a change in behavior. Changes made by the community are expected not only to increase knowledge, but there are good changes in actions to do it in everyday life (Lucie, 2005).
Extension methods. According to Notoadmojo (2014) that the method in public health counseling based on the type of target is divided into individual counseling methods, group counseling methods, and mass counseling methods.
Methods of health education can be classified based on communication techniques, the targets achieved and the senses of the recipient of the promotional targets (MOH, 2008).

Knowledge
Definition of Knowledge. Health knowledge is a form of observation of a person's senses that are influenced by the intensity of attention and perception of something.
Knowledge level. According to Notoadmojo (2014) that a person has different levels of knowledge. There are 6 cognitive domains, namely: Know can also be understood as remembering material that has previously been studied or can also be said to recall (recall) that has been learned or given by sensory stimulation. Tofu is the lowest level of knowledge.
Understanding. Understanding is the ability of a person to explain correctly about the object being seen and be able to explain by mentioning good examples and inferring the object's object.
Application. Application is a person's ability to use an object appropriately, for example, using formulas, appropriate methods.
Analysis. Analysis is the ability to describe the material of a particular object and be able to distinguish, separate and classify properly.
Synthesis. Synthesis is the ability to construct new formations of observed objects and plan and adjust to an existing theory.
Evaluation. Evaluation is the ability to judge an object that is valued based on our own assessment indicators (Notoadmojo, 2014).
Factors affecting knowledge. Knowledge can be measured through interviews and questionnaires. According to Notoadmojo (2014), that a person's knowledge is influenced by several factors, namely: Education. Education is one of the factors why a person has low knowledge or high knowledge. Education is one way to obtain information. The higher a person's education, the more information he gets and vice versa if a person's education is low then his knowledge is also low.
Information. Information affects a person's knowledge to change people's lifestyles for the better. The more information that is received by the community, the higher the knowledge gained to guide the healthy life in the community.
Socio-culture. Socio-culture is very close in the pattern of people's behavior to change. The social culture of the community shapes the attitude of the community to action. People only gain knowledge because of their culture.
Experience. Experience, the events experienced by someone in his life both from within himself and the environment that can influence someone to increase their knowledge.

Attitude
Attitude is a form of response from something that is influenced by experience and knowledge and can directly or indirectly influence practice (Notoadmojo, 2014).
Attitude is a response from the stimulus that is given both the response of receiving or not receiving the stimulus. Attitude is a preparation to act on a given stimulus (Notoadmojo, 2014).
New Comb, one of the experts in social psychology, said that the attitude was a readiness or a willingness to act and not an implementation of certain motives. Attitude is not yet an action or activity but it is a predisposition to a behavior, that attitude is still a closed reaction, not an open reaction or an open behavior, attitude is a readiness to react to objects in certain environments as an appreciation of the object ( Notoadmojo, 2014).
Factors affecting attitude. According to Saifuddin Azwar (2013), that attitude formation is influenced by: Personal experience. Personal experience becomes an attitude formation factor if the experience experienced by a person is memorable in his life.
Other people's influences are considered important. The influence of other people who are considered important, can affect a person's attitude if that person is one of the important people in his life. For example her husband, her parents.
Culture. Local culture, is a habit that is inherent in a person's daily life becomes an influencing factor in the formation of attitudes whether he can change his attitude.
Mass media. The mass media can provide information that will change a person's attitude. The information obtained will change a person's behavior patterns.
Educational institutions and religious institutions. Educational institutions and religious institutions, can provide knowledge and information can open someone's insight to change attitudes. Religious institutions can also change a person's attitude because of one's religious beliefs.
Emotional factors. Emotional factors, this affects a person's emotions can also affect his attitude because of the form of frustration or other things that affect his psychic.

Pregnant mother
According to Arysha (2020) Women are one important element in a family or community. Therefore, women's health, especially their reproductive health, is one of the important health problems. Differences in knowledge and attitudes of pregnant women before and after the implementation of counseling using the lecture method. There are several forms of methods that can make participants (hearings) more active in the implementation of health counseling besides lecture methods including group discussions, FGD (focus group discussions), buzz groups, role play and simulations. All the methods above are expected to be able to increase the knowledge and attitudes of participants over those that only have oneway communication (Notoatmodjo in Purnamasari, 2020).
Pregnant women are women who conceive starting from conception until the birth of the fetus (Prawirohardjo, 2014). Pregnancy is an event that occurs in a woman, starting from the process of fertilization (conception) until the birth of a baby. The period of pregnancy starts from the end of the menstrual period until the birth of the baby, about 266 to 280 days or 37 to 40 weeks, which consists of three trimesters. The period of development of pregnancy consists of three stages. The first stage, the development of zygotes, namely cell formation, cell division into blastocytes, and implantation. The second stage, embryonic development, which is from differentiation to organogenesis. The third stage is the development of the fetus (fetus) or the growth of the baby (Hardinsyah and Supariasa, 2016). Pregnant mother's nutrition. Nutritional needs are the main needs for pregnant women. Significant physical and hormonal changes in pregnant women are normal. One of them decreases the function of the kidneys in reabsorbing food no longer the same as before pregnancy and the placenta which functions to supply food to infants in the womb (Tuty, 2016).

III. Research Methods
This type of research is quasi-experimental (quasi-experimental) with the design approach "pre-post test group design". The groups studied in this design were not taken randomly but were deliberately chosen by the researcher as a group to be compared.
This study used two groups, namely groups that were given integrated counseling treatment in the form of lectures along with booklets and groups that were given integrated counseling treatment through lectures and flipchart media in pregnant mothers class programs.
The location of the study was carried out in Pematangsiantar City which consisted of 8 puskesmas working areas and selected 2 puskesmas working areas that had the same characteristics, namely the accredited puskesmas working area and received an intermediate predicate. As for those in accordance with these characteristics, the working area of the Bah Biak and Bah Kapul Puskesmas Timing of the study begins with the submission of the research title, bibliography research, preparation of the research proposal, designing a questionnaire, which starts from October 2018 and is expected to be completed in June 2019.

IV. Result and Discussion
Based on the results of research conducted known that there is an increase in knowledge of pregnant women in the prevention of stunting after given lectures and booklets as well as lectures and turning sheets. Based on the results of the study it is also known that there are differences in the increase in knowledge of pregnant women in the prevention of stunting after being given lectures and booklets as well as lectures and turning sheets. The results showed that the group given the lecture intervention and the respondent's booklet were not able to answer the questions correctly but there were some questions that were answered well. From the questions given, all respondents can correctly answer that routine pregnancy check is a way to keep the fetus in the womb so that the situation is good as many as twenty people (100%). Another question that can be answered correctly by all respondents is that food contains sources of energy, regulating substances and building substances is the notion of balanced nutrition as many as twenty people (100%). The purpose of feeding children is to be full and sleep well. The results of the study explained that in the group given lecture and booklet intervention after being given an intervention or posttest the respondent answered the question well. There are seven questions that were answered entirely by respondents. The questions are: exclusive breastfeeding is given for up to six months without milk or other food, food containing energy sources, regulating substances and builders is the understanding of balanced nutrition, first milk comes out called Colostrum, Routine checking for pregnancy is a way to keep the fetus in content to be in good condition, children need to be given a variety of foods according to balanced nutrition guidelines to meet their nutritional needs, the benefit of KMS is to find out the growth of the child, how to improve the child's appetite is to replace the child's meal.
Questions children need to be given a variety of foods according to the guidelines for balanced nutrition in order to meet the nutritional needs of the response can answer correctly as many as twenty people (100%).
This research also shows that there are some questions that have not been perfectly answered but after being given an intervention their knowledge increases. The fruit question is not good for children because it can cause diarrhea as many as thirteen respondents (65%) answer correctly. The question of the growth of children under five years late due to heredity as many as twelve people (60%) who answered correctly. The question of the purpose of feeding children to be full and sleep well 12 respondents (60%) answered correctly. Attitude Variable. Attitude variables in this study there are ten statements with alternative answers strongly disagree, disagree, doubt, agree and strongly agree. The measurement is by giving 10 statements consisting of 4 negative statements (2,5,8,10) and positive statements (1,3,4,6,7,9).
This study explains that before giving lectures and booklets half of the respondents answered agree that during pregnancy it is important to be full without knowing the source of food as many as ten people answered agree (50%) and two people (10%) who answered strongly agreed. Another statement also eleven people (55%) answered agree with the statement in giving food to children who are important children are full and as many as five people (25%) answered strongly agree. Another statement that examined my pregnancy at the beginning of the pregnancy and when I was about to give birth was answered very much agreeing by eleven people (55%) answered agree as many as three people (15%) and answered strongly disagreeing none.
Based on the results of the study note that all items of knowledge questions have increased, where before giving the intervention of the mirror and booklet some respondents have sufficient knowledge. Before being given the intervention of the mirror and the booklet there were still respondents answering wrong on all the question items.
Another question that answered incorrectly before giving lecture and booklet interventions was the question that the growth of children under five who were late due to heredity was still answered incorrectly by thirteen respondents (65%). Late child growth is not due to hereditary factors but due to lack of nutritional intake for a long period of time and starting from the period in the womb until infancy (Setiawan, 2011), it is expected that respondents know that the growth of children is delayed not because of heredity but because of a lack of long-term nutrition. After lecture and booklet interventions, the number of respondents who answered correctly increased to sixteen people (80%) and those who answered wrongly declined to four people (20%).

V. Conclusion
As for completeness in this study, there was an increase in knowledge from less, enough and good to enough and good so that there was no more lack of knowledge. Likewise with attitudes towards pregnant women from lack of attitude, good enough and good enough and good and no more lacking attitude. From the results before and after the intervention was given both through lectures and booklets or lectures and turning sheets there was an increase in knowledge and attitudes in preventing stunting.
Improved knowledge and better attitudes can be seen from the results of lecture and booklet interventions compared to lectures and flipcharts in preventing stunting because pregnant women can directly read the booklet given.