The Relationship between The Attitude of Mothers of Children under Five Years and Utilization of Maternal and Child Health (MCH) Handbook

The Maternal and Child Health (MCH) handbook is a program by the Indonesian government since 1993 which is intended to provide information regarding the maintenance and care of maternal and child health. This is one of the programs proposed by the government to reduce MMR and IMR. However, the utilization of the MCH handbook is still low due to the absence of mothers ’ attitudes toward the significance of the manual's contents. This study aims to determine the relationship between the attitude of mothers of children under five years and the utilization of the MCH handbook. This research is an observational analytic study with a cross-sectional approach. The sampling technique used was multistage sampling. The respondents were selected using a systematic random sampling technique, which included 45 mothers of children under five years. Furthermore, the data analysis was done using the Fisher exact test. The results of this study reported that 28 people (62.2%) had used the MCH handbook properly, while 17 people (37.8%) had not used the MCH handbook properly. Moreover, 34 people (75.6%) had a positive attitude toward using the MCH handbook, while 11 people had a negative attitude (24.4%) in using the MCH handbook. With an R-value of 0.730, there

The Maternal and Child Health (MCH) handbook is a program by the Indonesian government since 1993 which is intended to provide information regarding the maintenance and care of maternal and child health. This is one of the programs proposed by the government to reduce MMR and IMR. However, the utilization of the MCH handbook is still low due to the absence of mothers' attitudes toward the significance of the manual's contents. This study aims to determine the relationship between the attitude of mothers of children under five years and the utilization of the MCH handbook. This research is an observational analytic study with a cross-sectional approach. The sampling technique used was multistage sampling. The respondents were selected using a systematic random sampling technique, which included 45 mothers of children under five years. Furthermore, the data analysis was done using the Fisher exact test. The results of this study reported that 28 people (62.2%) had used the MCH handbook properly, while 17 people (37.8%) had not used the MCH handbook properly. Moreover, 34 people (75.6%) had a positive attitude toward using the MCH handbook, while 11 people had a negative attitude (24.4%) in using the MCH handbook. With an R-value of 0.730, there is a significant relationship between the attitude of mothers of children under five years and the utilization of the MCH handbook. It is expected that the participation of health professionals and community leaders will synergize to support mothers in taking care of their health and the health of their children, by continuing to add insight into knowledge through the use of the MCH handbook.
The implementation of the Maternal and Child Health (MCH) handbook program in Indonesia is also supported by JICA (Japan International Cooperation Agency) (Departemen Kesehatan Republik Indonesia, 2009). This handbook contains various information regarding the maintenance and care of mothers and child health (Kemenkes RI, 2015;Sistiarani et al., 2014). The MCH handbook is intended for 1 pregnant woman. Based on Indonesia Basic Health Research (RISKESDAS) data in 2013, it shows that 80% of mothers have the MCH handbook. However, during the inspection, only 40.4% could show the MCH handbook, and the other 19.2% did not have it. This behavior becomes one of the factors of the low utilization of the MCH handbook. The attitude of the mother toward the significance of understanding the information in the MCH handbook determines the behavior of utilizing the Maternal and Child Health (MCH) handbook (Nasir, 2008).
Several factors influence the use of the MCH handbook as proposed by Lawrence Green, namely the predisposing factors (knowledge, attitudes, beliefs, values and culture). The MCH handbook is still being used to a limited extent, which contributes to mothers' lack of knowledge and attitudes. Most mothers also mistakenly assume that the MCH handbook is merely an exam book, thus they are incapable of comprehending its contents. The second factor is the enabling factor (physical environment, funding, health facilities and infrastructure). This includes things that have a big influence on utilizing health services in the sense of using the MCH handbook, such as the availability of transportation and the availability of health facilities. The third factor is reinforcement or driving factors (attitudes and behavior of health workers) This is in line with research conducted by (Hanum Rina, 2018). demonstrating that mothers' positive attitudes encourage expectant women to use the maternal and child health handbook. As a result, this condition prompts them to bring books whenever they visit a medical facility, read the MCH handbook, and implement it in daily life. In contrast, mothers who have a negative attitude tend to ignore the MCH handbook. This is proved by the mother's intention to not carry the MCH handbook when visiting health facilities, to not read it, and even to lose the MCH handbook. Some mothers assumed that regardless of whether they brought the MCH handbook or not, they would still be checked and that staff members at the medical facility would keep records of the results of the examination.
Based on the background above, the researcher is interested in examining how the attitude of the mothers of children under five relates to the usage of the MCH handbook.

Participant characteristics and research design
This research is an observational analytic study with a cross-sectional approach. The purpose of this study is to determine the attitude of mothers of children under five in a maternal and child health handbook toward a mother of children under five at one of the Community Health Centers in North Sumatra Province.

Sampling procedures
The informants in this study were all mothers of children under five. The sampling technique in this research was multistage sampling. Respondents were selected using a systematic random sampling technique. Sampling was carried out at the integrated health service post (Posyandu).

Sample size, power, and precision
The samples in this study were all mothers of children under five who lived in the working area of the Community Health Center-45 people in total.

Data analysis
Data analysis used were univariate and bivariate analysis. The bivariate analysis was performed using statistical fisher's exact test.

RESULTS AND DISCUSSION
The data was collected through questionnaires. Data collection started from April-June 2022.  Table 1 shows that 23 people make up more than half of the distribution of children with one child (51.1%). The distribution of respondents with basic education was 19 people (42.2%). More than half of mothers, or 30 people (66.7%), were housewives, according to the distribution of their jobs.  Table 2 shows that 28 people (62.2%) had used the MCH handbook properly and 17 people (37.8%) had not used MCH handbook properly. This information shows how useful the MCH handbook is at the Community Health Center.  Table 3 shows that 34 people (75.6%) had a positive attitude in using the MCH handbook and 11 people had a negative attitude (24.4%) in using the MCH handbook.  Table 4 shows that more than half of those who have an effective MCH handbook utilization system are optimistic. This was shown by 28 people (62.2%) who supported the MCH handbook program (positive attitude). Meanwhile, less than 17 people (37.8%) received the MCH handbook, less than 6 people (13.3%) did not receive the MCH handbook, and 11 people (24.4%) had a negative attitude towards the MCH handbook.
With a p-value (0.000-0.05) and a 95% level of confidence, it can be concluded that there is a significant relationship between the use of the MCH handbook and the mother's attitude towards the use of the MCH handbook (Ho rejected). The r-value is 0.730, which shows that the relationship between variables is strong, indicating the strength of the correlation. In the research results, the direction of the correlation is positive (+), indicating that the more the utilization of the MCH handbook, the better the maternal attitudes regarding the use of the MCH handbook.
This is in line with the previous research conducted by (rahmi et al., 2018), which found that there were 53.5% of mothers who did not use the MCH handbook properly. This occurred as a result of lack of awareness and sensitivity of mothers in utilizing the MCH handbook as a source of knowledge. On the other hand, using and applying the MCH handbook properly and correctly has a significant effect on increasing the knowledge of mothers and families, concern for the health of mothers and children, and being able to mobilize and empower the community to create a healthy living environment (Syari et al., 2021). Utilization of the MCH handbook makes a positive contribution in improving behavior and attitudes in order to be cooperative and concerned about their health and the health of their children (Mintarsih, 2018). According to (Rahayu et al., 2018), the reasons behind the low use of the MCH handbook are the mothers' lack of knowledge and attitudes about the benefits of the MCH handbook, and the assumption that the handbook is just an examination record book.
The mother's positive attitude is closely related to the midwife's support in providing education on the importance of applying the MCH handbook in everyday life. Based on the research from (Simanullang & Dioso, 2020), the competencies of midwives include the knowledge, skills, and behavior to produce quality, safe, and quality services. To transform the mindset and attitudes of mothers implementing the MCH handbook for mothers of children under five and child health, it is important to emphasize the clear and accurate delivery of information and education regarding the advantages of the MCH handbook for mothers of toddlers.

CONCLUSIONS AND SUGGESTIONS
From the results and discussion of the study on the relationship between the use of the MCH handbook and mothers' attitudes, it can be concluded that mothers' attitude towards the use of the MCH handbook shows a positive attitude. Moreover, it shows that there is a relationship between the use of the MCH handbook and mothers' attitudes. By continuing to contribute information through the usage of the MCH handbook, it is anticipated that the participation of health professionals and community leaders would work in harmony to help mothers in caring for their own health and the health of their children.