Understanding Cough Ethics and Changes of Behavior of Kindergarten Teachers in the Work Area of Puskesmas Sedayu I: Community-Based Health Efforts

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INTRODUCTION
One of the Puskesmas activities according to the Ministry of Health Regulation No. 75 of 2014, is Community-Based Health Efforts/Upaya Kesehatan Berbasis Masyarakat (UKBM), which is more focused on promoting and preventive efforts by involving all levels of society, including kindergarten teachers 1 .One of the preventive promotive efforts in UKBM is the prevention and control of infectious diseases.Transmission of infectious diseases such as the common cold in schoolchildren is very easy.The common cold disease does not happen seasonally and can be experienced by anyone throughout the year.Common cold, influenza, and pharyngitis can be experienced by anyone whose immune system is decreasing 2 .This disease can easily attack people with low endurance and in some circumstances only by resting and eating a balanced diet, can sufferers improve 3 .The number of common cold sufferers in pre-school age children in Puskesmas Sedayu I tended to increase from 2013, 2014, and 2015, specifically 674, 628, and 715 cases.Common cold and acute pharyngitis have always been counted in the 10 most diseases over the past 3 years for all ages 4,5,6 .
Coughing is a symptom of a disease caused either by infection or non-infection.Infectious disease is one caused by germs in the form of bacteria, viruses, fungi, parasites, and not caused by physical factors (burns) or chemicals (poisoning).Mode of transmission of disease can occur through direct media on the surface of the skin of people to people or air media directly in the form of droplets or saliva splashes or indirectly through water borne 7 .Direct transmission usually occurs through sneezing or coughing.Coughing also occurs in people with GERD, chronic lung conditions such as asthma, COPD, pulmonary fibrosis, and lung tissue disease, and can also be due to embolism, or heart failure congestion 8  The most common behavior is not wearing personal protective equipment such as masks and CTPS.Compliance in washing hands with soap and water together is recommended because it reduces the incidence of illness that comes from the environment compared to washing hands with an alcohol-based liquid 10 .Fulfillment of proper infrastructure is also needed to minimize cough transmission, especially in the school environment.The application of standard precautions in health care facilities starts with health workers serving in health services, applied in daily activities, especially when on duty 11 .When there are no tissues, you can use your inner side of elbow arm when coughing or sneezing, and if there is fluid coming out through the nose, use tissue or discharge sputum into the toilet or in a special place filled with antiseptic fluid 12,13 .This study aimed to provide an understanding of Cough Ethics and behavior change using narrative in action by kindergarten teachers so that teachers can be an example and healthy role model of Cough Ethics for kindergarten children.

RESEARCH METHODS
This research was descriptive-analytic study with a qualitative approach.This research used narrative in action with 6 steps of activities consisting of dialogue, motivation, education, persuasion, promotion, and empowerment.Each step consists of questions: (1)  Descriptive research is conducted to describe, interpret, and explain social situations.Descriptions are in the form of phenomena found, risk factors, and effects or results.Subjects were divided into 3 groups due to the busy schedule of the teachers so that the grouping was based on the similarity of time the subjects had when they were going to be observed.

Table 1. Research variable
The method of data analysis used audio-visual recordings from the observation, interview and demonstration stages as pre-narrative in action activities, including the narrative in action recorded sounds, post narrative in action recorded audiovisuals, and finally finished with analyzing pre and post engagements by simple coding.

RESULTS AND DISCUSSION
Screening several videos about cough ethics is a way to attract attention early in the activity.The results of the narrative in action can be seen in appendix 1.The dialogue activities of the respondents could be directed more by referring to the video watched, and reactions from the three dialogue groups developed according to the participants' understanding.Almost all participants actively said they were in the habit of closing their noses when coughing or sneezing and using a handkerchief, tissue, mask, or inner elbow.The question of why use a mask was appropriately answered by fellow respondents.The question about the effectiveness of using the inner side of elbow arm in group 3 was raised by one of the respondents.Dialogue about correct CTPS was also inserted into the health promotion.
Motivating activities according to Sulaksana tend to be done in 2 directions 14 , so also in this activity motivating respondents to use tissues, masks, and the inner side of elbow arm when coughing or sneezing in each group.The goal was motivating to want to wear the right mask, how to get rid of tissues, masks, the right reaction, and how to CTPS sequentially.In group 3 respondents were found motivated to the use of the inner elbow when coughing or sneezing.
Educational and promotional activities tended to be one-way from the Researchers and also in answering respondents' questions.Some respondents in each group were enthusiastic about asking why it is safer to wear a disposable mask, about the causes of coughing, and why use the inner side of elbow arm.
The persuasion step was done with respondents who still use a handkerchief urging them to pay attention to how to treat a handkerchief after use.Also, respondents who still use their hands to cover their nose and mouth when coughing or sneezing were urged to do the correct CTPS as soon as possible.It was explained that the effect of not closing the nose-mouth when coughing will spread airborne diseases such as common cold 15 .But the activities did not appear to show there was a good promotional effort.However, at the end of the activity, there were empowerment efforts by concluding together, agreeing, asking for willingness to become a role model, and conveying the correct Cough Ethics.
The results of the initial and final observations after the narrative in action can be seen in Table 3 below.Pre and post narrative in action activities were used to assess understanding and behavior changes after exposure to the narrative in action.
The initial stage was done by observing, visiting a kindergarten, seeing and talking with kindergarten students as well as teachers.The results of initial observations found 100% of students and teachers do not know the correct steps of CTPS.
Final observation after 3 months of the last narrative in action activity, namely in April week III, showed there was significant change in all teachers and students who now already know the 7-step hand washing song with 93.33% of kindergarten.The PHBS (Clean and Healthy Life Behavior) poster increased by 100% from 5 schools to 10 schools.Kindergarten schools that are being renovated are using water taps for ablution in the mosque next to the location.
Solid or liquid soap already exists near the water tap, and there were an additional 12 locations up from 20% to 100%.Tissues or napkins were already available around the place to wash hands.Most sites had closed trash bins and several begin to have dry and wet waste sorting with a change from 33.33% to 73.33% having closed trash.All kindergarten schools already have well-maintained bathrooms.Some children who are coughing still use their arms to cover their nose and mouth.

CONCLUSIONS
The activity that begins with watching the video makes it easier to implement steps in the narrative in action.Cough Ethics can also be socialized with narrative in action.When coughing or sneezing, closing your mouth to the bottom of the nose with the forearm to the elbow is more practical than using a tissue or mask.Steps to wash hands with soap are easy to remember by singing.Removing phlegm or nasal discharge is better in the bathroom.In patients with the chronic or old disease tissues can be disposed temporarily in a lodong.In the room, there should be a closed trash bin.The results of the final observation after 3 months of narrative in action, found a significant change in doing the Cough Ethics properly.
The population were kindergarten teachers in the working area of the Puskesmas Sedayu 1.The sampling technique was purposive snowball sampling in 15 kindergartens and 36 teachers.Inclusion criteria were: (1) Kindergarten teachers who work in the work area of Puskesmas Sedayu 1; (2) Willing to be a respondent; (3) Not yet retired in the next 5 years; and (4) Not being treated by a doctor.Exclusion criteria: (1) Kindergarten teachers who do not live in the District of Sedayu; and (2) Not a kindergarten teacher.Sistia Utami et al. │ Understanding Cough Ethics and Changes of Behavior of... │ Research Article What do you do when you cough or sneeze?; (2) If you don't wear a mask or tissue, what do you do ?; (3) If your hands get wet with coughing or sneezing splashes, what do you do ?; and (4) If you cough and there is phlegm, where do you get rid of the phlegm?