Perceptions of Internship Doctors on Promotive and Preventive Health Services in Puskesmas ( Community and Primary Health Care Center )

Background: Health care services are any efforts that are self-administered or done jointly within an organization to maintain and improve health, prevent and cure diseases and restore the health of individuals, families, groups and/ or communities. Promotional and preventive services are conducted by individuals or groups in improving health and preventing the occurrence of outcomes unwanted by the community. Community Primary Health Care Centers (Puskesmas) are primary health care centers for the community which serve as the location of the new family doctors internship program in Indonesia. Objectives: The purpose of this study is to investigate the perception of internship doctors on the promotion and preventive services at the Puskesmas where they are placed for internship. Methods: This research is a quantitative analytical study with cross-sectional research design through the distribution of a questionnaire in the form of a Google survey form to all internship doctors in 571 Puskesmas in Indonesia. The questionnaire contains a list of questions that have been categorized according to the parent theory used, namely the Lawrence Green theory. The samples obtained in this study included 218 internship doctors. Results: From this study it was found that as many as 130 people (59.6%) of intern doctors who conducted promotive and preventive health services at Puskesmas came from State Universities. As many as 86 people (39.4%) of interns who conducted promotive and preventive health services at Puskesmas were 25 years old, with 143 (65.6%) females and 184 people (84.4%) unmarried. From the results of logistic regression analysis of Awareness Level, Knowledge Level, Time, Potential Revenue and Government Support, all factors have significant influence on the internship doctors’ perceptions on the promotive and preventive health care services (p<0.05). Conclusion: In this research, there are profiles and factors that significantly influence the internship doctor’s perceptions on health promotion and preventive services at Puskesmas.


BACKGROUND
Health care services are any efforts that are done individually or jointly within an organization to maintain and improve health, prevent and cure diseases and restore the health of individuals, families, groups and or the community 1 .In addition, based on RI Law no.23 of 1992 article 1, paragraph 2 (2002: 2) the definition of health services is "any activity to maintain and improve the health of the government and society 2 .In our society many people still live below the poverty line and desperately need better health services, especially in rural and urban areas.This health development is expected to help the community in obtaining better and equitable health services which are affordable, especially in low-income communities, so the goals of health development in Indonesia can be achieved.
The purpose of health services is to meet the needs of individuals or communities to overcome, neutralize or normalize all health problems or deviations that exist in the community 1 .This is in accordance with the DEPKES RI 3 .Quality health services provided to the patients are one of the benchmarks for the success of health services and various businesses activities 1 .Its role is greater and decisive if carried out as effectively as possible by always referring to predetermined interventions.In general, when a service is running effectively then the higher the quality of health services achieved.
Health promotion and prevention services is an effort made by individuals or groups in preventing the occurrence of something that is not desirable by the person or community.Prevention is etymologically derived from the Latin verb, prevenire which means, come before or anticipate or prevent something to happen.In a very broad sense, prevention is defined as a deliberate attempt to prevent disturbance, damage, or harm to a person or society.Prevention measures aim to prevent the occurrence of disease and health disorders of individuals, families, groups and communities 4,5 .
Health promotion and prevention services will be most effective if they become a priority in every health service that is provided either in the hospital or in the health center as the promoter of health services.The research by Luquis and Paz 5 in 2014 found that the majority of participants (99%) performed promotion and prevention health services, and most participants agreed that promotion and prevention health was the responsibility of the primary health care center called Puskesmas (74%).
Internship is an independence-based professional training in primary care community centers to develop competence, improve performance, and apply professional standards to medical practice after completion of doctor's education and competency tests 6 .The purpose of the internship is to provide opportunities for physicians who have just graduated from medical education to develop the competence gained during their education into primary care with a family medicine approach.Health promotion and prevention services are aspects that should become a habit done by the internship doctor because promotion and prevention should be the primary goals of the future doctors.
Puskesmas is one of the places of doctors' internship program implementation and also a place to give community health services 7 .Accordingly, to see the perceptions of internship doctors about health services is very good to be done at Puskesmas.According to Lawrence Green (1980) there are 3 main factors that can affect a person's response to situations, namely: predisposing factors, enabling factors, and reinforcing factors 7 .
Based on the phenomenon that occurs in the case of the implementation of health promotion and prevention services, the researcher was interested to conduct research on health promotion and prevention services conducted by internship doctors.Since the impact of these health promotion and prevention services in health development for the people of Indonesia is very important, the researcher surveyed the perceptions of internship doctors at primary care centers.

RESEARCH METHODS
This research is a quantitative analytical research with cross-sectional research design through the distribution of questionnaires in the form of google survey form to all internship doctors in 571 Puskesmas in Indonesia.The questionnaire contains a list of questions that have been categorized according to the parent theory used, called the Lawrence Green theory.The samples obtained in this study were 218 internship doctors.The data used in this study is the primary data.The data collection method used in this research was a survey questionnaire.The dependent variable in this study was the perceptions of Internship Doctors about health promotion and prevention services in Puskesmas and the independent variables in this study are factors that influence the perceptions of internship doctors on health promotion and prevention services at Puskesmas.The profile of internship doctors, predisposing factors, enabling factors, and reinforcing factors are discussed in detail.This study used univariate, bivariate, and multivariate analysis using SPSS.

RESULTS AND DISCUSSIONS
This study aimed to determine the perceptions of internship doctors on health promotion and prevention services in Puskesmas.The profile seen in this study included 4 characteristics: university origin, gender, marital status, and age.In addition, there were also factors that can affect a person's response in regard to a specific situation.In this study the researcher applied the basic theory of perceptions developed in the Lawrence Green theory that reveals three factors that can affect a person's perceptions of a specific situation: predisposing factors, enabling factors, and reinforcing factors.In this study there are 4 predisposing factors, 2 enabling factors, and 2 reinforcing factors.

Characteristic description
This study was conducted at Puskesmas in Indonesia with a total sample of 218 people.
Table 1 shows that 130 participating (59.6%) internship doctors who do health promotion and prevention services at Puskesmas came from a State University.As many as 86 people (39.4%) were 25 years old, with females numbering 143 people (65.6%) and 184 people unmarried were (84.4%).The internship doctors' responses on their perceptions about the promotion and prevention health services at the Puskesmas in this study are very diverse.For the level of awareness as many as 118 people (54%) internship doctors strongly agree that health promotion and prevention services are important for the patients.A total of 111 people (50.9%) of internship doctors agree promotion and prevention health is the primary responsibility of a doctor and as many as 117 people (53.7%) of internship doctors strongly agree that promotion and prevention health is the primary responsibility of the whole health service team.
As many as 147 people (67.4%) of internship doctors agree that in prioritizing, a doctor should make health promotion and prevention as a priority and a primary part of the medical practice.For the level of knowledge of internship doctors, 112 people (51.4%) did not agree that there was any lack of doctor knowledge about the health of promotion and prevention in communities.A total of 132 people (60.6%) of the internship doctor agreed that there is a lack of guidance on promotion and prevention health services, and as many as 98 people (45%) agreed that some doctors lack the knowledge, competence and skill of doctors about promotion and prevention health.
For the time factor, as many as 145 people (66.5%) of the internship doctor agreed that a doctor should spend more time on promotion and prevention activities and as many as 127 people (58.3%) of the internship doctors agree that the more time spent on health services for curative and rehabilitative services results in a lack of time for promotion and prevention services.According to the survey results as many as 94 (43.1%) of the internship doctors agreed that the there is a lack of incentives when doing promotion and prevention health services.
As many as 99 people (45.4%) and 98 (45%) of internship doctors agree that there is government support in providing promotion and prevention health services.Each of the questionnaires when summed up became total values to be grouped into good and bad perceptions.The normality test was done and the mean or median was measured.
When the data were above the median, the data were categorized as good perceptions whereas if the data were below the median value then they were categorized as not good.From these results, the perceptions of 89 internship doctors were categorized as bad and the perceptions of 129 internship doctors were categorized as good.

Relationship level awareness (X1) in response to perceptions of internship doctors on promotion and prevention health services at Puskesmas
The results of bivariate analysis on the relationship of awareness level (x1) to the behavior of internship doctors to health promotion and preventive services at Puskesmas in this research were obtained from 129 internship doctors who have good perceptions about health promotion and preventive service at health center.As many as 79 (64%) of them stated they strongly agree that promotional and preventive health services are important to the patients, and no one disagreed about the statement.All agreed promotional and preventive health is the primary   9 .This awareness will also be in line with the experience, skill and knowledge possessed 9,10 .Such awareness also appears to be related to the risks of the illness experienced by the patient, and the compilation if promotion and prevention services are not performed and whether the promotion and prevention actions performed have a good effect on the patient 9 .Most of the doctors realized that health promotion and prevention are very important to do and its application is appropriate at Puskesmas 9 .Lambe and Collins in their research also stated that most doctors consider that Puskesmas is the right place to do promotion and prevention services and it is the responsibility of doctors and the health care team 9,10,11,12 .

Preferred priority relation (X2) on internship doctor perceptions about promotion and prevention health services at Puskesmas
Most internship doctors agree that a doctor should make promotive and preventive health services a priority (67.4%) and they are part of medical practice services.
The results of bivariate analysis showed some associations with prioritized programs (x2) to internship doctor perceptions on health promotion and preventive services at Puskesmas.The priority is to prioritize a program or prioritize something else 8 .In this study the priority of a program had no relation with the internship physician's perception on health promotion and preventive services at the Puskesmas (p = 0.107).According to Fairhurst et al. doctors often prioritize healing diseases compared with providing promotive and preventive services at Puskesmas 13,14 .According to Maria et al. doctors who have such perceptions tend to make the implementation of promotion and prevention to be less important 9,14 .

Relationship of knowledge level (X3) in response to perceptions of internship doctors on promotion and prevention health services at Puskesmas
Some internship doctors less agree about the lack of knowledge of doctors concerning the health of promotive and preventive services by 51%.However, some of them agree that there is a lack of guidance on promotive and preventive health services with 60.6% and 47% who believe that there is a lack of knowledge, competence and expertise of doctors regarding promotive and preventive health.The results of bivariate analysis on knowledge level (x3) to internship doctor's perception in health promotion and preventive services at Puskesmas is described as follows: The level of knowledge is everything that is known 8 , including all the aspects that doctors know about health promotion and preventive services at the Puskesmas.In this research, the level of knowledge has correlations with the perception of internship doctors about health promotion and preventive services at Puskesmas (p = 0.000, and 0.001).Maria et al. mentions the fact that it will also be in line with experience, expertise and knowledge possessed 9,10 .In influencing perception, a doctor must have enough knowledge to transfer them to the society 15 .
In addition, the expertise in promotion and preventive health programs is also required by a doctor and they should be given subject matter since at the university and have continuous training so that health promotion and preventive services can run well 13 .Albert D Fortin et al. also mentioned that the curriculum at the university also influences the implementation of promotive and preventive services.Lack of training and skills will be a barrier to make health promotion and prevention services run well 15 .

Relationship level stress (X4) in response to perceptions of internship doctors on promotion and prevention health services at Puskesmas
As many as 45% of internship doctors agree that too much of the workload is carried by doctors in running medical practices causing doctors to not provide proper health care and preventive services.The results of bivariate analysis indicated associations of stress level (x4) to the perception of internship doctors about health promotion and preventive services at Puskesmas is described as follows: The level of stress in this study is a level that states a quality or condition higher or lower with the workload of internship doctors in performing health services while working at the health centers.In this research, the stress level has correlations with the perception of internship doctors about health promotion and preventive services at Puskesmas (p = 0.000).According to Lambe and Collins, too much workload in Puskesmas affects promotive and prevention health care 10,12 , and according to Maria et al.
Puskesmas staff should create a well-coordinated working team so that all members know and understand their respective work roles 9 .

Relationship of time (X5) in response to perceptions of internship doctors on promotion and prevention health service at Puskesmas
Spending more time to do promotive and preventive activities is what most internship doctors agree on by 66.5%.The majority of internship doctors feel that the time of health services is more widely used for curative and rehabilitative services so that the time for promotive and preventive services is less.
Results of bivariate time relationship analysis (x5) to internship doctor behavior in health promotion and preventive services at Puskesmas showed time taken by someone to do something was as follows: All internship doctors agreed that the lack of time in doing promotive and preventive services was the result of doing curative and rehabilitative services.In this study the obtained time results related to the behavior of internship doctors in health promotion and preventive services in Puskesmas (p = 0.001).Wytske et al. found that there is a lack of time that a doctor discusses about promotive and preventive programs at Puskesmas 11,13 .Luquis and Paz mention doctors are more curative-oriented and rehabilitative than promotion and prevention oriented 5,9 .When doctors provide promotive and preventive services and it has a positive impact on the patient then the doctor will give more time to the patient.According to Carlos et al. promotion and prevention services have very effective impact if done done one to one, but the weakness is that providing health promotion and prevention is time-consuming 10,12 .

Relationship potential revenue (X6) in response to perceptions of internship doctors on promotion and prevention health services at Puskesmas
As many as 43% of internship doctors agree that there is the lack of incentives when doing promotive and preventive health services.The results of bivariate analysis on the correlation of earnings potential to (X6) internship doctor behavior in health promotion and preventive services at Puskesmas were as follows: Potential income was considered as a means of motivating material, which is given as a deliberate incentive to health care workers (Khairinisa, 2017).In this research, the earning potential is related to the behavior of internship doctors in health promotion and preventive services at Puskesmas (p = 0.000).According to Maria et al. high income potential is one factor that can influence the behavior of internship doctors in health promotion and preventive services in Puskesmas 9,14 .On the other hand, the encouragement of drug companies brought more benefit for doctors in prescribing drugs compared with recommending lifestyle changes 9,12,16 .

Relationship of institutional support (X7) in response to perceptions of internship doctors on promotion and prevention health services at Puskesmas
From the total of 218 internship doctors there was 454% who agreed in response to institutional support in the provision of promotive and preventive health services.The results of bivariate analysis of the association of institutional support (x7) to the behavior of internship doctors about health promotion and preventive services at Puskesmas were as follows: There was some support provided by the institution to the internship doctors in carrying out promotive and preventive health service programs in Puskesmas.In this study we found support from institutions was associated with the behavior of internship doctors in promotive and preventive health services at Puskesmas (p = 0.000).According to research conducted by Luquis and Paz, institutional support is necessary in promotive and preventive health services in Puskesmas 5,9 .

Relationship of government support (X8) to internship doctors' perceptions on promotion and prevention health services at Puskesmas
From the total of 218 internship doctors there were 45% who agreed in response to the existence of government support in the provision of promotive and preventive health services.The results of bivariate analysis of the relationship of government support (X7) to the behavior of internship doctors in health promotion and preventive services at Puskesmas were as follows: There was some support provided by the government to the internship doctors in conducting promotion and prevention health service programs at the Puskesmas.In this study the bivariate analysis results showed government support was associated with the perceptions of internship doctors on promotion and prevention health services in Puskesmas health centers (p = 0.000) According to research conducted by Luquis and Paz government support is needed in health promotion and prevention services in Puskesmas 5,9 .

Results of multivariate analysis of logistic regression between independent variables to internship doctors' perception on promotive and preventive health services at Puskesmas
The Table 2 below shows that the Awareness (X1), Knowledge (X3), Time (X5), Income Potential (X6) and Government Support (X8) variables together influence the perception of internship doctors about health promotion and prevention services.
In the results of multivariate logistic regression analysis, it is found that Awareness Level (X1

DISCUSSION
The results of univariate analysis based on sociodemographic consisting of age, sex, university origin, and marital status found that internship doctors mostly come from public universities with about equal number of women who do promotion and prevention services in Puskesmas with men, and their status is largely unmarried, with the doctors' average age is <25 years old.
In addition to sociodemographic data, univariate analysis was also conducted on the factors that are suspected to influence internship doctors' perceptions in this study.The analysis results obtained in this study are very diverse.
For the level of awareness most of the internship doctors agreed that the service promotion and prevention health are important for the patients, promotion and prevention health programs are the primary responsibility of a physician and also the primary responsibility of the entire health care team.A large number of internship doctors agree that a doctor should make promotion and prevention health a priority and consider it as an essential part of the medical practice.At the level of knowledge some internship doctors disagree that doctors lack knowledge of promotion and prevention community health, but they agree that there is a lack of guidance on promotion and prevention health care and lack of knowledge, competence and skill of some doctors on promotion and prevention health.The internship doctors also feel that the workloads that doctors carry in practicing medicine makes doctors to not provide promotion and prevention health services.A large number of internship doctors agree that a physician should spend more time on promotion and prevention activities and they agree that at the time of medical service time more health services are used for curative and rehabilitative services resulting in a lack of time for promotion and prevention services.Some of the internship doctors agree on the lack of incentives when doing promotion and prevention health services.Internship doctors who do promotion and prevention services largely agree that there is some support of government and institutions in the provision of promotion and prevention health services.
In bivariate analysis, there was a significant correlation between level of awareness and perceptions of internship doctors on health promotion and prevention services.Internship doctors strongly agree that promotive and prevention health services are important for patients, and promotive and prevention health is the primary responsibility of a doctor and health care team.However, this is contrary to the second analysis.In the second analysis of the priorities, that a doctor should make health promotion and prevention service as a priority and a main part of the medical practice service had no significant relationship with the perceptions of internship doctors on health promotion and prevention services.According to Fairhurst et al. doctors still prioritize the healing of disease more compared with providing promotive and prevention services in Puskesmas 13,14 .According to Maria et al. doctors who have such perceptions tend to make the implementation of promotive and preventive to be less 9,14 .
In multivariate analysis, the level of awareness, level of knowledge, time, potential revenue and government support together influence the internship doctor's perceptions about health promotion and prevention services.This finding is in line with the research of Luquis and Paz which found that the higher level of awareness and the level of knowledge of internship doctors about health promotion and prevention services will affect the doctor's perceptions in the providing the promotion and prevention services 5,9 .The short time in doing medical practice as well as the doctors being more oriented on curative and rehabilitation also make health promotion and prevention services to be not running properly 9 .The existence of government support and high incentives also affect the perceptions of doctors in providing health promotive and prevention services 9 .
In the future, the researcher hopes that another research will be able to analyze with other epidemiology study designs, having longer research time, and more variation among respondents because there are many predisposing factors, enabling factors, and reinforcing factors which can be used as variables of the research.

CONCLUSION
Factors that have a relationship to the perceptions of internship doctors on health promotion and prevention services in health centers are Predisposing Factors: Awareness Level (X 1 ), Stress Level (X 4 ); Enabling factors: time (X 5 ) and Revenue Potential (X 6 ); and Reinforcing factors: institutional support (X 7 ) and Government Support (X 8 ).These factors collectively affect the perceptions of internship doctor on promotion and prevention health services in Puskesmas.

Fadillah
and Latifah │ Perceptions of Internship Doctors on Promotive and Preventive Health Services in Puskesmas │ Research Article

Table 1 .
8requency distribution based on characteristics responsibility of a doctor and just over half indicated it was the health care team with 50.9%.Level of awareness is a deep understanding of the person or group of people embodied in thoughts, and perceptions that support the development of the environment8.In this study, it is measured as a deep understanding of internship doctors about health promotion and prevention services at Puskesmas.From the results of this research, the level of awareness has correlations with the perceptions of internship doctors about health promotion and prevention services at Puskesmas (p = 0.13, 0.014, and 0.002).This result is in line with research conducted by Maria et al. on the awareness of doctors about the need for health promotion and prevention

Table 2 :
Multivariate analysis results logistic regression between independent variables and the perceptions of internship doctors on health promotion and preventive services at PuskesmasFadillah and Latifah │ Perceptions of Internship Doctors on Promotive and Preventive Health Services in Puskesmas │ Research Article