Research Article
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THE APPLICATION OF TRANSCULTURAL NURSING MODEL IN PERSPECTIVE OF MADURA CULTURE IMPROVING BREASTFEEDING
MOTHERS BEHAVIOR IN JEMBER
(Penerapan Model Keperawatan Transkultural dalam Perspektif Budaya Madura Meningkatkan Perilaku Ibu Menyusui di Jember)
Awatiful Azza, Cipto Susilo Faculty of Health Sciences University of Muhammadiyah Jember
E-mail: [email protected]
ABSTRAK
Pendahuluan: Menyusui merupakan salah satu tugas perkembangan perempuan setelah melahirkan. Banyak faktor yang dapat mempengaruhi keberhasilan ibu dalam memberikan ASI secara ekslusif, diantaranya adalah dukungan keluarga maupun pengaruh budaya lokal. Tujuan Penelitian ini untuk menerapkan model keperawatan transkultural dalam perspektif budaya Madura pada ibu menyusui. Metode : Penelitian ini dilakukan di desa Suboh wilayah kerja Puskesmas Pakusari, pengumpulan data menggunakan kuesioner, dan fokus group diskusi. Desain penelitian quasi eksperimen post test design with control dengan analisis Paired Samples Test. Selain itu, peneliti juga melakukan analisis kualitatif untuk mengeksplorasi budaya Madura. Sampel yang digunakan adalah ibu menyusui yang mempunyai bayi usia 1-6 bulan sebanyak 50 sampel dan dibagi menjadi 2, yaitu kelompok perlakuan dan kontrol. Selain itu sumberdata lain yang digunakan adalah tenaga kesehatan. Hasil: Hasil penelitian didapatkan bahwa rentang usia ibu antara 15 34 tahun, dengan rata-rata berusia 27 tahun, selain itu rata-rata pendidikan responden tidak tamat SD sebanyak 60%, baik pada kelompok perlakuan maupun kontrol. Hasil analisis tentang modifi kasi budaya didapatkan P value 0,001 yang artinya ada pengaruh penerapan model transcultural nursing dalam Meningkatkan perilaku ibu menyusui. Diskusi: Aplikasi modifi kasi budaya yang dilakukan mampu meningkatkan produksi ASI. Perlu kerjasama yang baik bagi semua komponen masyarakat dalam mensuport ibu menyusui dengan memodifi kasi budaya lokal yang kurang menguntungkan bagi kesehatan.
Key word: transkultural, menyusui, budaya Madura
ABSTRACT
Background and objective : Breastfeeding is one of the development tasks for women after childbirth. Many factors can aff ect mothers success in breastfeeding exclusively, such as family support as well as local cultural infl uences. This research aims to apply the transcultural nursing model in Madura cultural perspective in breastfeeding mothers. Method: This research was conducted in Public Health Centre of Pakusari Suboh Jember. The data were collected using questionnaires, and focus group discusses. The research design was question-experimental research of post test design with control by using Paired Samples Test analysis. In addition, the researchers also performed a qualitative analysis to explore the Maduranese culture. The samples were breastfeeding mothers who had infants aged 1-6 months, and 50 samples were then divided into two, i.e., treatment and control groups. Also, another data source were health professionals. Result: The result showed that the maternal age range between 15-34 years with an average age of 27 years. Besides, the average of the respondents education background was that 60% of them did not pass elementary school, both in treatment group and control group. The results of the analysis on cultural modifi cations were p-value of 0.001, which means that there are the eff ects of applying the transcultural nursing model in improving mother behavior. Conclusion: An application of cultural modifi cations that is able to increase milk production. Therefore, it needs a good cooperation for all the components of society in supporting breastfeeding mothers by modifying less the local culture that becomes favorable for health.
Keywords: transcultural, breastfeeding, Maduranese culture
INTRODUCTION
Breastfeeding is a natural process and is one of the tasks in the health care of children (babies), but in reality, not all mothers can carry out these tasks well, not successfully breastfeed or stop breastfeeding early. This condition does not only affect the health of the
babies but in some women also can interfere with the self-concept as a mother since it cannot be an optimal role in health care to her babies (Study et al. 2010). Breastfeeding plays an important role to maintain the health and survival of infants because breast milk is the best food for babies. Breast milk is the right
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Jurnal INJEC Vol. 2 No. 1 Juni 2017: 916
food choices for babies since breastfed infants will make babies rarely suffer from diseases and avoid malnutrition compared to infants fed other milk (Study et al. 2010) (Some research shows that even though a breastfeeding mother in a state of malnutrition, the breast milk still has enough quality. The differences in maternal nutrition affect only the quantity of breast milk and not on the quality of breast milk. Exclusive breastfeeding in Indonesia is still very alarming, and it needs a lot of attention from all sides. Mother awareness to exclusively breastfeed their babies is still very poor and shows a decline from year to year. In 2008, coverage of exclusive breastfeeding was only 24.3%, in 2009 was 34.3%, in 2010 was only 15.3%, while the target to be achieved should be 80%. The low number of exclusive breastfeeding triggers the low nutritional status of infants and toddlers and can be an indirect cause of infant mortality (Study et al. 2010).
Nigel and Bandari research results in 2016, which was published in the bulletin Lancet reveals breastfeeding can reduce infant mortality by 13 percent, a variety of adverse effects can occur in infants if they do not get breast milk (Study et al. 2010) Other data on lactation research notes that the IQ of premature babies group who were breastfed is 8.5 points higher than those are given formulated milk. While the research conducted in Guatemala argues that the delay of lactation onset became a significant greater risk of doing short-term breastfeeding (Study et al. 2010).
The data on the health of newborns in Jember district is not much different from some places in Indonesia. The data from the Department of Health Jember 2014 shows that infant mortality rate (IMR) increased from the previous year into a range of 398 439 cases each year. Based on the data that there are several causes of infant mortality is 48 per cent due to malnutrition, 15 per cent because of shortness of breath, and 15 percent of other cases (Study et al. 2010). It becomes interesting to study because of Jember as one of the districts in East Java with Madura ethnic population is greatest. Knowingly or not, the factors of trust and cultural knowledge as conceptions about
the various restrictions, the causal relationship between food and health-illness conditions, habits and ignorance, have brought both positive and negative impacts on the health of mothers and children. Breastfeeding success also greatly influenced by many factors both from within his own mother as well as from the surrounding environment. One powerful factor is of social, cultural and environmental factors in the community where they are located. A culture is a form of human adaptation to the environment. Adaptation in the broad sense includes all the behavior and habits and set forth in the mind, knowledge, attitudes, and practices; all intended as a form of reaction to the environment (and amendments thereto) both internally and externally (Nurwidodo. 2006) . Model transcultural nursing is a formula that can be developed to bridge the local culture in order to become a culture which is positive for the health of mothers and babies, and in this case is a nursing mother.
Research objective
I n some t r a d it ional societ ies i n Indonesia, we can see the conception of culture embodied in the daily behavior related to the culture different of postpartum mothers with modern health conception. Socio-culture factors have an important role in understanding the attitudes and behaviors responded to birth and breastfeeding. Most cultural views on these matters have been handed down in the culture of the community. Therefore, even though health officials might find a form of behavior or attitude that proved to be less beneficial for health, but it is often not easy for health professionals to make changes on it, due to having been embedded beliefs underlying attitudes and behaviors in depth in the local culture.
The scope of this research f ield, especially nursing mothers maternity, building on the development of local culture to be able to support successful breastfeeding. The aims of this study are as follows: 1) To analyze the Maduranese culture and
myths developed in the community about breastfeeding through transcultural model approach.
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The Application of Transcultural Nursing Model (Awatiful Azza, Cipto Susilo)
2) To develop a model and tested model of transcultural in Maduranese culture among nursing mothers.
3) To conduct the analysis of cultural modifi cation through the implementation of the transcultural model to be a positive culture for nursing mothers both in treatment group and control group.
Research urgency:
Un it e d Nat ion C h i ld r e ns Fu nd (UNICEF) claims that there are 30,000 infants deaths in Indonesia and 10 million deaths of children under five in the world each year. It could be prevented by breastfeeding (breast milk) exclusively for six months after birth, without providing food or beverage additives in infants. UNICEF also states that infants fed by formula milk are likely to die during the first month of his birth, and the opportunity was 25 times higher than babies who are breastfed by mothers exclusively (Nigel & Bandari, 2016).
Low coverage breastfeeding is due to several factors, such as lack of knowledge, awareness, motivation and low maternal attitudes to breastfeeding, in addition to the strong cultural inf luence also provide a substantial contribution to the failure of exclusive breastfeeding.
A n t h r o p ol o g i c a l s t u d i e s a b o u t pregnancy and birth for women with all good and bad consequences on the health of these need to be considered for health professionals in Indonesia in an effort to increase the success of health care services they apply for both mother and baby.
Maternity nurse as a member of the health team has a very big role in helping improve the health status of the community, especially the health of mothers and children. Maternity nurses should be able to mobilize community participation in particular, with regard to maternal health, maternity, nursing mothers, newborns, teenagers and the elderly. Community involvement in order to care for his health can be implemented; then the health professionals should be able to find the approach to society that the program launched by the government can be successful and at the
same time can reduce infant mortality due to malnutrition.
Models Lininger becomes one of the references to develop the potential of people with a culture of Madura in Jember. The number of cultural rules in society, as well as the myths that developed Jember related nursing mothers, is very detrimental to mother and baby. It has an impact on the high infant mortality rate (IMR) is one of the reasons is the poor nutrition due to poor feeding behavior.
Review Of Related Literature
Culture is one of the embodiments or forms of real interaction as human beings and social creatures. Culture, in the form of norms, becomes a reference of human behavior in life one others. The pattern of life that lasts long in one place, which is always repeated, makes human beings tied up in the process. The sustainability to constantly live a life and last long are the process of internalization of the values that influence the formation of character, thought patterns, the interaction patterns of behavior all of which will have an influence on nursing intervention approaches (cultural nursing approach). Culture has broad influences in lives of an individual. Therefore, it is important for nurses to know the cultural background of the patients (Andrew, M. & Boyle, J. S, 2008). Local wisdom can be formed from a way of thinking and behavior of the community when responding to problems that arise around it (Wahyuningsih, S. 2014). ((PDPI 2011)
Transcult ural nursing is the main direction in nursing which focuses on study and comparative analysis of cultures and sub-cultures in the world and appreciate the behavior of caring, nursing services, values, beliefs about healthy sick, as well as patterns of behavior aimed at developing knowledge the body of scientific and humanistic nursing practice in order to make room for the particular culture and universal culture (Potter, PA & Perry, AG 2009). The transcultural nursing theory emphasizes the importance of the role of nurses in understanding the clients culture.
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A correct understanding of the nurses themselves about the culture of clients, whether individuals, families, groups, and communities can prevent imposition.Cultural culture shock and culture shock occurs when an outside party (nurses) are trying to learn or adapt effectively to specific cultural groups (clients) whereas culture imposition is the tendency of health professionals (nurses), either secretly or blatantly imposing cultural values, beliefs, and habits/behavior on individuals, families, or groups from other cultures because they believe that their culture higher than in the other groups culture (Leininger M and MC Farlan MR, 2002).
There are three things to consider nurses in performing transcultural nursing models, namely:
Culture care preservation/maintenance, i.e., the principles of aid, facilitate, or pay attention to the cultural phenomena in order to form the individual determines the health and lifestyle desired.
Culture care accommodation/negotiation, i.e., the principles of aid, facilitate, or pay attention to the cultural phenomenon, refl ecting the ways to adapt or negotiate or consider the health and lifestyle of the individual or client.
Culture care repatterning/restructuring, i.e.,the principle of reconstruction or change the design to help improve health conditions and lifestyle towards better client (Leininger M and MC Farlan MR, 2002).
When nurses purposively ignore the theoretical basis of nursing practice based on cultural or transcultural nursing, they will undergo a cultural shock. It will be undergone by the client in a condition where nurses are not able to adapt to differences in cultural values and beliefs. this may lead to the emergence of a sense of discomfort, powerlessness, and some will be disoriented. It is important for nurses to understand their own culture before understanding transcultural nursing. In applying transcultural nursing, not only culture that must be considered, but also keeps in mind the nursing paradigm that can be applied in transcultural nursing.
Culture is one of the embodiments or forms of real interaction as human beings and social creatures. Culture in the form of norms, customs become a reference human behavior in life with others. Madura community is known to have a distinct culture, unique, and, it is considered as the cultural identity of the individual ethnic identity of Madura in behavior and Bohemian society. In the Maduranese culture, women were reserved husband is fully under his control. The absolute leadership is in the hands of the husband (male). Men who have a right to determine what is allowed and what should not be done by women for women is hers. Because women are at the center of self-esteem of men, then women are being protected, controlled and owned by men (Putra, J.S. 2012). The weak bargaining position of women seems to have consequences far greater, that women do not have access to health care, even when they are pregnant. Besides the many myths that developed in the Maduranese community about breastfeeding, also contribute to the low achievement of the target of exclusive breastfeeding. Breastfeeding is a natural process and is one of the tasks in the health care of children (babies), but in reality; not all mothers can carry out these tasks well, not successfully breastfeed or stopping breastfeeding early (Rejeki, S. 2014). Breastfeeding mothers need a strong support in order to provide their exclusive breastfeeding for 6 months. Collaborative culture and the latest methods of breastfeeding can increase the overall successful coverage lactation. Hence, the application of the transcultural model is the most appropriate way for Indonesian people who are still highly affected by local cultural.
METHOD
The design used in this research was quantitative with the question-experimental approach of post-test design with control. As for the exploration of the culture of Madura, the researchers also conducted a qualitative approach.
The research was conducted in Pakusari, Jember district, especially in Suboh village.
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The Application of Transcultural Nursing Model (Awatiful Azza, Cipto Susilo)
Samples are nursing mothers who have children aged 1-6 months, with the Madurese people in 4 districts Suboh village Posyandu Pakusari with purposive sampling approach in 50 samples. In addition, researchers also obtained data from couples and families mothers as participants, validate the data on Community Leaders, and Jember District Health Office.
Data were collected by questionnaire, in-depth interview and FGD (focus group discussion). Quantitative data analysis is done by using the data homogeneity test Kolmogorov Smirnov and continued with the analysis Paired Samples Test, while data FGD results presented in qualitative terms.
RESULT
Madurese people are very obedient and submissive to some information given by the community leaders or scholars. The myth that developed in the community about pregnancy, childbirth and postpartum may be inhibiting the achievement of the health program to reduce maternal and child mortality rate. Some cultures are found in pregnant women, childbirth and breastfeeding are very unique, there is positive support also exists negative
health, contrary to health. Some Madurese women have birth to a shaman, to reduce pain during labor the mothers body smeared with hot ash, to reduce the swelling of the vagina after giving birth mothers are given the herb ginger mixed with salt to compress. Other cultures are related to breastfeeding infants were given coconut if the milk has not come out, do a breast care on the river with sand, mothers should not eat fish because milk will be fishy and only recommended to eat vegetables. Some characteristics of nursing mothers in the village Suboh have been identified include:
From the data obtained an average age of nursing mothers in the control group is 26 years old with a minimum age of 16 years while the maximum is 34 years old and the average age in the group treated with the 27-year minimum age 15 years, while the maximum was 34 years old. Data shows that most respondents did not complete primary school either the treatment group or control of 60% and 64%. Breastfeeding mothers behavior to find out the behavior of lactating mothers in the treatment group or the control group then performed Normality Test Data. The results of the analysis using the Kolmogorov Smirnov test: indicates that the
Table1. The age distribution of nursing mothers in Suboh, Pakusari 2016
Statistics The age of treatment group The age of control group
N Valid 25 25 Missing 0 0
Mean 27.4000 26.1600 Median 28.0000 26.0000 Mode 32.00 18.00a Std. Deviation 5.37742 5.79281 Variance 28.917 33.557 Minimum 15.00 16.00 Maximum 34.00 34.00 a. Multiple modes exist. The smallest value is shown
Table 2. Distribution of nursing mothers by giving an education Suboh, Pakusari 2016
Last Education Treatment Group % Control Group % Elementary school/no school 15 60.0 16 64.0 Junior High School 9 36.0 8 32.0 Senior High School 9 4.0 1 4,0 TOTAL 25 100.0 25 100.0
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normal distribution of data, it is shown by the P value in the control group and the treatment group 1.002 0.659 greater than 0.05 The test results obtained using Paired Samples Test P value 0,001 <0,05 so that it can be concluded there is the influence of culture through the modification of the Transcultural nursing model in improving milk production Action Breastfeeding is an activity that is always carried out by mothers in this village, apart from exclusive breastfeeding or not. Nowadays with the advancement of information and the active region midwives, nurses and volunteers have much to change the culture and myths. Model Transcultural nursing is an effort to help people understand their health, through a cultural perspective Table 3. Normality test data by Kolmogorov-Smirnov Test in the treatment group and the control Mother behavior in treatment group Mother behavior in control group N 25 25 Normal Parametersa Mean 46.1200 46.1200 Std. Deviation 17.98685 17.98685 Most Extreme Diff erences Absolute .132 .132 Positive .132 .132 Negative -.073 -.073 Kolmogorov-Smirnov Z 1.002 .659 Asymp. Sig. (2-tailed) .268 .778 a. Test distribution is Normal. Table 4. Analysis of application modifi cations of transcultural model based on Maduranese culture perspective in treatment group and control group. Paired Samples Test Paired Diff erences T df Sig. (2- tailed)Mean Std. Deviation Std. Error Mean 95% Confi dence Interval of the Diff erence Lower Upper P a i r 1 Mother behavior of treatment group Mother beavior of control group -1.79200E1 23.54060 4.70812 -27.63708 -8.20292 -3.806 24 .001 adopted. Model transcultural nursing is an effort to help people understand their health but does not eliminate the existing culture. According to Leininger, 2002, the strategy used in applications such transcultural nursing a) Maintaining culture Maintaining culture is done when the patient is not contrary to the culture of health. Perencanaan and implementation of nursing provided in accordance with the relevant values which have been owned by the client so that the client can improve or maintain their health status. b) Culture negotiation Intervention and implementation of nursing at this stage to help clients adapt to a particular culture more favorable to 15 The Application of Transcultural Nursing Model (Awatiful Azza, Cipto Susilo) health. The nurse helps clients to choose and determine other cultures that favor health improvement. c) Restructuring culture Cultural restructuring is done when the culture of adverse health status. Nurses are working to restructure the clients lifestyle. The pattern of life plan selected is usually more profi table and in accordance with the beliefs held. DISCUSSION Culture is one of real manifestations or forms of interaction as a social human being. Madurese community is known to have a specific culture, unique, and, cultural identity is considered as the individual identity of ethnic Madurese in behaving and in the community (Wulansari , S, Sadewo, dan Raf lizal. 2014). The results of research on Madurese community about breastfeeding are breastfeeding is an activity that is always carried out by mothers in this village, apart from exclusive breastfeeding or not. Nowadays with the advancement of information and the active region midwives, nurses and volunteers have much to change the culture and myths. This study also shows that there is an effect of cultural modification through the transcultural nursing model in increasing milk production Model Transcultural nursing is an effort to help people understand their health, through a cultural perspective adopted. Model transcultural nursing is an effort to help people understand their health but does not eliminate the existing culture. According to Leininger, 2002, the strategy used in applications such transcultural nursing Maintaining culture Maintaining culture is done when the patient is not contrary to the culture of health. Perencanaan and implementation of nursing provided in accordance with the relevant values which have been owned by the client so that the client can improve or maintain their health status. Culture negotiation Intervention and implementation of nursing at this stage to help clients adapt to a particular culture more favorable to health. The nurse helps clients to choose and determine other cultures that favor health improvement. Restructuring culture Cultural restructuring is done when the culture of adverse health status. Nurses are working to restructure the clients lifestyle. The pattern of life plan selected is usually more profitable and in accordance with the beliefs held. CONCLUSION Many cultures did not support exclusive breastfeeding among Madurese people. An application in the form of cultural modifications as made through a trial model of transcultural in Maduranese culture was to allow an education on lactation management using the existing culture, demonstration by developing a culture that is to be adapted to modern techniques associated with the treatment of breast and massage oxytocin. There was the inf luence of cultural modifications to the successful breastfeeding in Suboh, Pakusari, Jember district. Health professionals need to understand the local culture in the community about health. There were three attempts related to culture in the community to support the health of which is to preserve the culture, to negotiate culture and to reconstruct culture. It needs to involve the community and its figures in providing health education related to local culture so that the results can be achieved well. It needs to establish a breastfeeding counselor at health services, both in clinics and health centers with a hope to improve public knowledge regarding exclusive breastfeeding. It needs to improve socialization of exclusive breastfeeding for the implementation so that it can be maximized and perceived by the public. It takes the governments courage in enforcing 16 Jurnal INJEC Vol. 2 No. 1 Juni 2017: 916 regulations on infant formula, i.e., Government Regulation of the Republic of Indonesia No. 39 of 2013 on infant formula, in all maternal and child health services. Community figures among Maduresecommunity become a figure and role model in daily lives. Thus, it needs a good cooperation between health officials and local community figures to actively participate in helping the surrounding community in modifying a negative culture into a positive culture for public health. REFERENCES A nd rew, M. M., & Boyle, J. S (2008) Transcultural Concepts in Nursing Care (6th ed.). 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(2005)The onset time of lactation after delivery, MJIR, vol. 19, no. 2, pp. 135-139, 2005Siegel, J.D. et al., 2007. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. American Journal of Infection Control, 35(10 SUPPL. 2). Study, C.A.Q. et al., 2010. Impact of PRISMA , a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec. , pp.107118. Tanudyaya, F.K. et al., 2010. Prevalence of Sexually Transmitted Infections and Sexual Risk Behavior Among Female Sex Workers in Nine Provinces in. , 41(2), pp.463473. Wahyuningsih, S. 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