Analysis of Maternal Behavior in the Prevention of Pneumonia in
Children Using WHO Behavioral Determinant Approach
Ilya Krisnana, Ika Nur Pratiwi, and Ni Kadek Dwi Kristiani
Faculty of Nursing Universitas Airlangga. Kampus C Unair Jalan Mulyorejo Surabaya 60115
Keywords: Pneumonia, infant, behavior, WHO, prevention.
Abstract: Pneumonia in children under five years is a health problem in Indonesia related to the high morbidity and
mortality. Therefore this study aims to analyze the mother's behavioral factors in the prevention of
pneumonia in children with WHO determinants of behavior approach. The samples were 100 mothers taken
by using cluster sampling. The independent variables were thought and feeling (knowledge, attitudes,
perceptions, and belief) personal references (health workers and posyandu cadres), resources (floor and air
ventilation) and cultures. The dependent variable was pneumonia prevention behavior. Data were collected
using questionnaires, observation form and analyzed by Spearman’s rho with α=0.05. The result showed a
significant correlation between variables thought and feeling: knowledge (p=0.020), attitude (p= 0.005),
perception (p=0.007) and belief (p=0.030), resources: house floor and air vents (p=0.006) and cultures
(p=0.001) with the prevention behavior of pneumonia, but there’s no correlation between personal
reference: health workers and health cadres (p=0.737) with the prevention of pneumonia. Discussion:The
factors associated with the mother’s prevention behavior are thought and feeling: knowledge, attitudes,
perception, and belief, resources: floor and air ventilation, and cultures. Further research needs to explore
more about the personal reference variable.
1 INTRODUCTION
One of the infectious diseases that pose a threat to
toddlers is pneumonia. Pneumonia in infants is a
health problem in Indonesia, this is associated with
high morbidity and mortality due to pneumonia.
Pneumonia is the second leading cause of death in
infants in Indonesia after diarrhea (Kementerian
Kesehatan Republik Indonesia, 2010) Various
factors that can affect the increase of pneumonia
incidence in infants, both from individual aspects of
children, parent behavior (mother), and
environment. Maternal behavior such as
immunization and clean and healthy lifestyle have
an important role in the prevention of pneumonia in
infants. Negative mood behaviors such as rarely
cleaning houses, poor feeding and poor toddler care
may affect the incidence of pneumonia (Muchlis, R.,
& Sherli, 2009).
According (WHO, 2016) Pneumonia is one of
the most common causes of death infections in
children worldwide. Pneumonia is the cause of 15%
of underfive deaths in Indonesia, estimated at
922,000 underfives in 2015 with an estimated
national pneumonia cases of 3.55% (Kementerian
Kesehatan Republik Indonesia, 2016). Based on data
of Indonesia Health Profile in 2015, East Java
Province was ranked 7th with the discovery of
pneumonia case as much as 4.45%. And in 2015
found as many as 4,018 cases of pneumonia in
toddlers in the city of Surabaya (Dinas Kesehatan
Kota Surabaya, 2015). Sememi community health
center has third rank of pneumonia cases in infants.
This is evidenced by data of Sememi community
health center which showed an increase in cases of
pneumonia toddlers in 2015 as much as 128 cases
and increased to 316 cases in 2016 and based on the
data visit of patients on maternal and child health in
Sememi community health center during the period
January 2017 to March 2017 found 43 cases of
pneumonia in toddler
The government has made various efforts to
prevent pneumonia through MDGs 4 (Millennium
Development Goals) program aimed at reducing
child mortality from pneumonia such as providing
health education through KIA poly to maintain clean
environment condition, giving immunization and
exclusive breastfeeding for 6 months. However, in
the last 3 years cases of pneumonia in infants are
still high (Kementerian Kesehatan Republik
Krisnana, I., Pratiwi, I. and Kristiani, N.
Analysis of Maternal Behavior in the Prevention of Pneumonia in Children Using WHO Behavioral Determinant Approach.
In Proceedings of the 2nd International Conference on Sports Science, Health and Physical Education (ICSSHPE 2017) - Volume 1, pages 65-70
ISBN: 978-989-758-317-9
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
65

Indonesia, 2016). Behavior of a person is influenced
by several factors, among others: (1) Thought and
feeling: knowledge, attitude, perception and belief,
(2) Personal reference or reference of a trusted
person such as religious leaders, community leaders,
(3) Resource or infrastructure that supports one's
behavior can be facilities, money, time and energy,
(4) Culture or local culture generated and passed
down by a group of people from generation to
generation (Notoatmodjo, 2010). Therefore the
researcher was interested in using behavioral
determinant approach according to WHO to analyze
mother's behavior factor because based on
preliminary study result, mother's behavior in
prevention of pneumonia is influenced by various
factors so that approach of WHO's behavior theory
can be used to analyze these factors.
2 METHODS
This research used descriptive analytic design with
cross-sectional approach. The target population in
this study were all mothers with children (0-5 years
old) and were enrolled in Sememi Baru Posyandu,
Gunung Agung A, Merbabu and Rinjani as many as
513 people. Sampling using cluster sampling
technique. The sample consisted of 100 mothers.
Independent Variables in this research were 1)
thought and feeling: knowledge, attitude, perception
and belief of mother about prevention of pneumonia,
2) personal referrer: health officer and posyandu
cadre as reference, 3) resource: facility in mother's
house (floor and ventilation air) and 4) cultures.
Dependent variable in this research was behavior of
prevention of pneumonia. The data collected by
using questionnaires and observation sheets.
The first step in this research was to test the
validity and reliability of the instrument used in the
form of questionnaires. All questionnaires used are
valid and reliable. The next step done by the
researcher was to conduct ethical review of research
proposal to Research Ethics Commission of Health
Faculty of Nursing University of Airlangga and has
been declared ethical based on ethical certificate
number 382-KEPK. This research was conducted on
14-17 June 2017 at 4 Posyandu Balita at Sememi
Surabaya Public Health Center. Data collection to
respondents together with activities of Posyandu
Toddlers attended by mother who brought Toddler.
Before the questionnaire was given, the mothers
were given an explanation of the implementation of
the research to obtain information about the research
before signing the informed consent. Furthermore,
the researchers convey to the respondents that in the
next period researchers will visit the respondent's
home to make observations about the resources
owned by the respondents. This observation activity
is assisted by posyandu cadres in the local area. Data
from questionnaire and observation were analyzed
using Spearman's rho statistic test with degree of
significance α=0,05.
3 RESULTS
Table 1: Distribution of research variables.
Variables Percentages (%)
Knowledge :
Good
Moderate
Low
Total
86
12
2
100
Attitude :
Positive
Negative
Total
50
50
100
Perception :
Positive
Negative
Total
57
43
100
Belief :
Weak
Strong
Total
52
48
Personal references:
Good
Moderate
Low
Total
71
10
19
100
Cultures:
Positive
Negative
Total
63
37
100
Prevention behaviour :
Good
Moderate
Low
Total
94
6
0
100
Table 2: Analysis between Variables.
Variables assosiate Statistical test with
S
p
earman Rho
Knowledge with
b
ehaviour
p = 0,020; r = 0,232
Attitude with behaviour
p
= 0,005; r = 0,279
Perception with
b
ehaviour
p = 0,007; r = 0,270
Belief with behavior
p
= 0,030; r = -0,238
Personal references with
p
= 0,737; r = -0,034
ICSSHPE 2017 - 2nd International Conference on Sports Science, Health and Physical Education
66

b
ehavior
Resources with behavior
p
= 0,006; r = 0,506
Cultures with behavio
r
p
= 0,001; r = 0,336
The results showed that mother's knowledge
about pneumonia and its prevention was good
(86%). The role of health workers is considered
positive by most mothers (96%). Positive cultures in
supporting the prevention behavior of pneumonia
are also largely positive resulting in preventive
behaviors against maternal pneumonia in either 96%
(see Table 1).
Among the 7 variables there were 6 variables
related to the prevention behavior of Pneumonia in
Toddlers, whereas there is one variable that is
personal references not related to the prevention
behavior of pneumonia done by the mother in
Toddler (see table 2).
4 RESULT AND DISCUSSION
4.1 The relationship between though
and feeling factors: Mother
Knowledge with Pneumonia
Prevention Behavior
The results showed that there was a correlation
between mother knowledge with behavior of
prevention of pneumonia in under fives with weak
correlation correlation. Respondents with good
knowledge tend to exhibit good pneumonia
prevention behavior, whereas respondents with
sufficient knowledge and less tend to exhibit
adequate pneumonia prevention behavior.
Knowledge is related to the prevention behavior of
Peneumonia (Keter, 2015). Mother's knowledge of
pneumonia, mother's perception of the cause of
pneumonia and her ability to recognize signs and
symptoms of pneumonia will help mothers in
shaping better behaviors to prevent pneumonia in
infants.
Knowledge is a very important domain for the
formation of a person's behavior (action). The better
a person's knowledge the better his behavior will be
(Notoatmodjo, 2011). The above is also reinforced
by the determinants of behavior according to WHO
(1984) that one of the reasons people behave are
thoughts and feelings (thoughts and feelings) in the
form of knowledge, attitudes, perceptions and
beliefs to the object of health (Notoatmodjo, 2010).
Mothers who have a good knowledge of
pneumonia prevention will be easier in carrying out
what he knows in the prevention of pneumonia so
that will cause the behavior of prevention
pneumonianya be better. Mother's lack of knowledge
about respiratory diseases affects mother's delay in
doing disease prevention and is a contributing factor
in the high mortality (Malik, A.Y. & Iqbal, 2012).
Early recognition of maternal pneumonia symptoms
and its participation in effective cases of pneumonia
can reduce mortality rates in children (Memon,
2013).
4.2 The relationship between thought
and feeling factors: Mother's
attitude with Pneumonia
Prevention Behavior
The results showed that there was a relationship
between maternal attitudes with prevention behavior
of pneumonia in under fives with weak correlation
correlation. The attitude of mother toddler about
prevention of pneumonia related to behavior of
prevention of pneumonia (Rahim, 2013). Attitude is
a person's closed response to a particular stimulus or
object, involving the factors of opinion and emotion
in question (Notoatmodjo, 2010). Attitude is not yet
an action or activity, but it is still a predisposition to
the action of a behavior. Factors that influence the
formation of attitudes are personal experience,
culture, other important people, mass media,
institutions or educational institutions and religious
institutions and emotional factors in individuals
(Azwar, 2009). A person's attitude will affect health
behavior, positive attitude of a person will produce a
positive health behavior as well, while a negative
attitude will result in negative health behavior as
well (Alfaqinisa, 2015). A positive attitude is an
important factor that can affect decision making by
parents in taking precautions pneumonia (Ridda, I.,
Lindley, L.R., McIntyree, P., MaacIntryee, 2008).
4.3 The relationship between thought
and feeling factors: Mother
Perceptions with Pneumonia
Prevention Behavior
The results showed that there was a relationship
between maternal perceptions with prevention
behavior of pneumonia in infants with weak
relationship strength. Maternal perception is
associated with preventive behavior against
pneumonia (Abusaad, El Sayeed F., Hashem, 2014).
Perception is a process that involves the entry of
messages or information in the human brain
continuously establish relationships with its
Analysis of Maternal Behavior in the Prevention of Pneumonia in Children Using WHO Behavioral Determinant Approach
67

environment through its senses. One important
reason of perception is in the interpretation of the
circumstances around us that each of them do the
perception of an object differently. Perception is a
process that is almost automatic and works in a
similar way to each individual, but nevertheless
typically produces different perceptions (Slamento,
2010).
Based on the results of the study, almost half of
the respondents had negative perceptions but had
good prevention behavior and some respondents had
a negative perception of having sufficient
pneumonia prevention behavior. The emergence of
negative perceptions possessed by the mother can
arise because of the dissatisfaction of the object that
the source of his perception, the existence of
individual ignorance and the lack of individual
experience of the perceived object and vice versa.
The level of education of the mother has a
significant relationship with the mother's perception
of pneumonia (Pradhan SM, Rao AP, Pattanshetty
SM, 2016). The level of maternal education may
affect the mother's perception of the child's health
and relate to inappropriate hygiene behavior
(Shibata, T., 2014).
4.4 Relationship between thought and
feeling factor: Mother belief with
Pneumonia Prevention Behavior
The results showed that there was a relationship
between maternal belief with the prevention
behavior of pneumonia in infants with correlation
and negative relationship direction. Based on the
research results can be seen that the respondents
who have strong and weak trust can both have good
and adequate pneumonia prevention behavior. This
indicates that, respondents with weak trust have
good prevention behavior.
A region with different tribes has different
customs, customs, and beliefs. Every individual has
a different social structure, lifestyle and ultimately
has differences in doing a health behavior
(Notoatmodjo, 2010).
The result of the research shows that the majority
of Javanese still have strong belief in information
obtained from generation to generation from parent,
grandparent or without proven in advance. One of
the main reasons (determinants) of a person
behaving is a factor of thought and feeling that
includes knowledge, attitudes, perceptions and
beliefs. Trust is obtained from parents or
grandparents. A person accepts trust based on belief
and without any proof (Notoatmodjo, 2010).
In relation to the belief there are respondents
who have a strong belief about suwuk, change the
name and belief that the child will recover if brought
to the shaman infant or dipijet. The condition is
caused by limited information obtained by Mother.
Information obtained is limited to statements
submitted by parents, grandparents or grandparents
4.5 Relationship between personal
factors references: Health workers
and Posyandu Cadres with
Pneumonia Prevention Behavior
The results showed that there was no relationship
between personal references with preventive
behavior of pneumonia in children. Reference from
the important person (personal reference) is one of
the factors that influence the behavior of one's
health. If a person is important to us then anything
done and said tends to be our example. Other people
who are considered important can influence the
formation of individual attitudes and tend to have a
unidirectional attitude with the attitudes of people
who are considered important (Nursalam, 2013)
The results showed that there are some
respondents who have a positive personal reference
but the prevention behavior is sufficient, this is
because in addition there are personal reference
factors, there is also a factor of thought and feeling
is the knowledge and attitude factors that are
personal factors of the respondents who are
important domains for the formation of a person's
behavior. Formation of behavior is not only
influenced by others who are considered important
but also influenced by several factors one of which
is the attitude and personal experience (Maulana,
2013).
4.6 Relationship between the resources
factor: Facilities in the Home
Environment with Pneumonia
Prevention Behavior
Resources in the mother's home environment (home
floor and ventilation) are strongly linked to
pneumonia prevention behaviors. Conditions that are
not eligible home at risk 4.65 times exposed to
pneumonia compared with toddlers whose home
conditions meet the requirements (Budiati, E. &
Duarsa, 2012). A poor dwelling density increases the
risk of pneumonia in infants by 1.38 (Anwar, A. &
ICSSHPE 2017 - 2nd International Conference on Sports Science, Health and Physical Education
68

Dharmayanti, 2014). Densely populated homes can
have a chance of getting pneumonia 2.20 times.
Densely populated homes may contribute to
bacterial transmission, pneumonia-causing viruses
by breathing from one home to another easily and
quickly (Hartati, 2011).
Based on the observation of the house, all
respondent households use ceramic type floor and
clean house floor condition although there are still
some respondents with less clean house floor
condition. Type of floor at risk of the incidence of
pneumonia in infants because basically toddlers
more often play on the floor. The condition of the
floor of the house is a risk factor because the
condition of the house floor is closely related to the
type of floor of the house.
Most respondents have air ventilation in their
homes and some respondents do not have air vents.
Most of the respondents had a window in the house
with varying numbers, but there were two
respondents who did not have a window at home.
Homes that do not have air ventilation 6.44 times
risk of experiencing pneumonia compared to
toddlers who have home ventilation (Sugihartono &
Nurjazuli, 2012).
In addition, family members who smoke in the
house have a major influence in indoor air pollution.
Based on demographic data it is known that most
respondents have family members who smoke.) Said
that exposure to cigarette smoke is a factor that can
increase the risk of pneumonia in infants. Research
conducted by also that indoor air pollution increases
the risk of under-five mortality due to pneumonia 3
times greater (Sugihartono & Nurjazuli, 2012)
4.7 Relationship between cultures with
Pneumonia Prevention
Most respondents have a positive culture and almost
half of respondents have a negative culture.
Negative cultures of respondents include the habit of
not closing the mouth when coughing near the child,
not wearing a mask while coughing, not wearing a
mask when in contact with sick children and not
washing hands after contact with the nose and mouth
when coughing. Toddlers have 4.72 times the
possibility of pneumonia if the mother washes hands
without using soap after coughing (Shibata, T.,
2014).
Culture is the plural of the word mind and power
which means love, taste and intention. Culture is all
the work, taste, and creation of society (Setiadi,
2008). So that culture or culture concerning all
aspects of human life both material and non material
Culture is a pattern of life produced by normal
behavior, habits, values and procurement of
resources within a community (Notoatmodjo, 2010).
Culture in the community is a factor that affects
health behavior of the behavior of prevention of
pneumonia in infants. In addition, cultural values
and knowledge of mothers about health helps
motivate mothers in making decisions about health
behaviors (Miller, 2011). In addition to the culture in
which a person lives and is raised has a great
influence on the formation of one's attitude. Attitude
is an important domain for forming an action or
health behavior (Notoatmodjo, 2010).
5 CONCLUSION
Preventive behavior against pneumonia in the
mother associated with thought and feeling
(knowledge, attitude, perception and trust),
resources and culture. The better the knowledge
about the prevention of pneumonia owned by the
mother, the better the prevention behavior of
pneumonia done by the mother. The more positive
the perception of the mother the better the mother's
behavior in the prevention of pneumonia. While the
personal reference factor is not directly related to the
prevention behavior. The formation of behavior is
not only influenced by the reference of others who
are considered important, but also influenced by
several factors one of which attitude and personal
experience.
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