Evaluation of Getar Thala Innovation Program (Gerakan Tanggulangi Anemia Remaja dan Thalassemia) during the Covid-19 Pandemic

Background: The GetarThala innovation program was doing by the Sleman District Health Office even during the Covid-19 pandemic. The coverage of the blood-added tablets for adolescent girls in 2019 was 81%, dropping to 37% in 2020. The research objective was to evaluate the implementation of the Getar Thala innovation program during the Covid-19 Pandemic in Sleman Regency. Methods: Qualitative research design with an embedded single case study. The selection of participants was using purposive sampling and the number of participants was 19 participants. Then, data collection used in-depth interviews from May to July 2022 and the analysis of data used thematic analysis. Results: There are 3 themes, namely input, process, and output indicators. Input indicators are human resources, program implementation facilities during the Covid-19 pandemic, structure of authority and responsibility for program implementers, financial resources and adolescent management. While the process indicators are program implementation, the blood-added tablets supplementation procedures, the obstacles to the blood-added tablets supplementation and program management during the Covid-19 pandemic. Then, the output indicators consist of the distribution coverage the blood-added tablets and the anemia rate of female adolescents. Conclusion: The implementation strategy was carried out by changing the target of female adolescents, changing the procedure for distributing the blood-added tablets, and obtaining an increase in the coverage of the blood-added tablets.

The policies related to implementing the anemia prevention program for female adolescents have to be adjusted to the policies of the Regional Government even during the Covid-19 pandemic which refers to the guidebook for administering the blood-added tablets during the Covid-19 Pandemic Emergency Response (Kemenkes, 2020). The anemia prevention program for female adolescents during the Covid-19 pandemic was carried out by optimizing the use of anemia educational media online (Wahdah & Sulistyaningsih, 2021). The success of the anemia-free future movement is highly dependent on the success of the bloodadded tablets program (Ray, 2020). The modification, distribution, and promotion of blood-added tablets can increase female adolescent compliance in consuming the blood-added tablets (Gosdin et al., 2020). Information and motivation are essential parts of the blood-added tablets program (Singh et al., 2020). A study on the evaluation of the implementation of the blood-added tablets program showed that there was a distribution mismatch and a lack of monitoring of the blood-added tablets program. The monitoring system for female students was not optimal (Yudina & Fayasari, 2020).
The Sleman District Health Office, Special Region of Yogyakarta, has implemented an anemia management program for female adolescents through the Getar Thala innovation program. The Getar Thala program was able to increase the coverage of the blood-added tablets in Sleman Regency from 28% in 2018 to 81% in 2019. Whether in 2020 the blood-added tablets declined with a coverage of only 36% because of the disruption of distribution of the blood-added tablets in schools during the Covid-19 pandemic. Based on the graphic of the blood-added tablets in 2019 and 2020 it is important to evaluate the program as in the coverage of blood supplement tablets that have decreased drastically in 2019 and 2020, it is important to evaluate program implementation as a strategic implementation during covid-19. The purpose of this study was to evaluate the implementation of the "Getar Thala" Innovation Program during the Covid-19 Pandemic in Sleman Regency.

Participant characteristics and research design
This study is a qualitative research method with an embedded single case study approach (Yin, 2018). This research is Getar Thala Program during the Covid-19 Pandemic in Sleman Regency. The research context is the implementation of Getar Thala program, it is focused on evaluating the implementation of innovation programs during the Covid-19 pandemic.

Sampling procedures
The researchers used depth interviews and documentation for data collection techniques. The instruments used were interview and documentation study guidelines. Interview trials were implemented with content validity through pilot interviews with 1 participant who is a practitioner of Puskesmas and 1 female adolescent participant who had the same characteristics as the research participant. The interviews duration are 20-35 minutes.
Sample size, power, and precision The objects of analysis are program managers, program management teachers in high schools, and female adolescents. The location of this research is in the Sleman District Health Office area which has implemented the Getar Thala Innovation Program during the Covid-19 Pandemic, which are 6 health centers and 6 high schools. The selection of participants used a purposive sampling technique of heterogeneous sampling that met the inclusion and exclusion criteria (Moser & Korstjens, 2018). The participants of this study were 1) public health staff at the Sleman District Health Office; 2) Program implementers at the Ngemplak 1 Health Center, Gamping 2 Health Center, Mlati 1 Health Center, Ngaglik 1 Health Center, Depok 3 Health Center, Prambanan Sleman Health Center; 3) Program implementing teachers at SMK Bina Tama, SMK Bina Harapan, SMKN 2 Depok, SMAN 1 Ngemplak, SMAN 1 Gamping, SMA Muhammadiyah 1 Prambanan; 4) Female adolescents in the Sleman Regency area. The recruitment of female adolescent participants was implemented by snowball sampling.

Measures and covariates
In-depth interviews and documentation studies are all used to collect data. The rigor to demonstrate credibility, transferability, dependability, and confirmability (Lochmiller, 2022) was implemented through source triangulation, method triangulation, audit trail, field notes, and verbatim transcription.

Data analysis
Thematic analysis is used in research data analysis techniques such as creating codes, coding, and pattern codes (Stufflebeam, 2017).

RESULTS AND DISCUSSION
The participants of this study consisted of policymaker, service providers, and female adolescent. The characteristics of the participants group in this study are as follows: Based on the results of depth interview and documentation with the thematic analysis presented in the matrix as follows:

Input indicators
Type of human resources implementing the program at the Puskesmas consists of 3 nutrition programmers and 2 health promotion officers who collaborate in implementing the program as stated by participant P.2: "...three nutrition programmers and two health promotion programs are usually collaborating because the activities of nutritionists are the blood added tablets distribution and supervision…" (P.2 Service provider) The parties involved in implementing the Getar Thala innovation program according to participant P.4: "…across-sectoral approach, at the sub-district level, so we don't only come from health officials, but also from the education office, KUA, Polsek, BLKB, sub-district, and PKK..." (P.4 service provider ) In the implementation of the Getar Thala innovation program during the Covid-19 pandemic, program facilities related to the availability of TTD supplies were ensured by planning the amount of supply TTD through the mechanism of providing TTD which is implemented by planning the need for nutritional drugs by calculating the target number, then multiplied by 52 tablets added with a buffer stock 10%. The decision is based on the guidebook for the prevention and control of adolescent anemia to ensure the availability of TTD, the total amount of TTD must be added by 10% of the total TTD as a buffer stock. The mechanism for providing TTD was conveyed by participant A.1 as follows: "...If the mechanism for providing TTD is to hold a plan at the end of each year, planning for the need for nutritional medicine, one of that is TTD, so we calculate the number of targets, we multiply that by 52 tablets because in one year there are 52 weeks once a week, so we add our 10% buffer stock. We at the health officials have their own UPT to procure drugs like that, sis, there are drug supplies and medical devices at POAK…" (A.1 Policymaker) The implementation of the Getar Thala innovation program comes from several calculations consisting of BOK, APBD, and BLUD as mentioned by participant P.1 namely: "...The funding sources for the puskesmas consist of 3 sources, such as BOK, APBD and Regional Income…" (P.1 Service provider) In the management of adolescents by providing education to female adolescents in the Sleman Regency area, the program implementers always invited female adolescents to consume TTD by an approach to encourage female adolescents to consume TTD as stated by participant P.1: "...inviting the students to take TTD, let's remind them to drink, so at that time we happened to propose at the Islamic boarding school at that time there were already around 2 or 3 young women who were the coordinators to overcome this obstacle and thank God, it works..." (P.1 Service provider) The formation of youth cadres or the Getar Thala task force was also implemented to optimize the management of female adolescents who act as counselors and assist UKS coordinators in distributing iron tablets and motivating their peers to consume iron tablets. The active role of the Getar Thala task force is an effort to increase the functional role of schools in overcoming adolescent anemia as explained by participant P.1: "...We had some time ago the health office once formed cadres. At that time, he got a vest as a healthcare, that was teenage cadre, there was an appointment for the school to represent or send student representatives to be appointed as cadres..." (P.1 Service provider) Many people are involved in the implementation of the Getar Thala program to ensure the smooth and continuous activity of taking TTD in all schools, considering the multisectoral coalition in preventing adolescent anemia during the Covid-19 pandemic requires coordination between institutions by the SKB 4 Ministerial Policy (Lestyoningsih et al., 2021).
The facilities used by health workers during the Covid-19 pandemic included means of transportation for the distribution of TTD to schools that were far away and difficult to reach. The facilities used by health workers in providing education and information about anemia to female adolescents are presentation tools for counseling such as the use of power points, leaflets, and banners. The program implementers always invite female adolescents to consume TTD. Based on the technical instructions for implementing the program that program implementers in schools must motivate female adolescents to regularly consume TTD once a week or by the recommendations of health workers. The formation of youth cadres Gartha Thala task force was also implemented as an effort to increase the active role of schools in tackling adolescent anemia. Through the Getar Thala task force, education is carried out by a peer counselor who will motivate peers to consume TTD regularly. The importance of peer support research conducted by (ansari et al., 2021) peer support plays an important role in student acceptability in consuming TTD.

Process Indicator
The plan was developed as a strategy for implementing an innovation program during the Covid-19 pandemic as an effort to optimize the implementation of the Getar Thala innovation program during the Covid-19 pandemic in Sleman Regency, Health Office appealed to female adolescents to continue consuming TTD at home according to the information given by participant A.1: "...we have made a Circular letter …" (A.1 Policy stakeholder) The procedure for supplementing TTD during the Covid-19 pandemic was a drive-thru at school as an effort to continue distributing TTD during the Covid-19 pandemic as explained by participant S.1: "... we distributed them to female adolescents even though they were riding motorbikes, the children don't go down, then I give TTD as well during a pandemic, sometimes I give it when I submit the results of the test work..." (S.1 Service provider) In the implementation of TTD supplementation during the pandemic, the main obstacle to implementing this program was the Covid-19 Pandemic itself. The coordination was constrained between program implementers due to the implementation of PPKM which is no teaching and learning activities in schools, then the activities of TTD at schools was temporarily suspended, as stated by participant P.3: "...Yes, it's a pandemic, the implementation of PPKM. Then, offline meetings are a bit difficult, this is an obstacle during a pandemic, it means the pandemic is a problem.. ." (P.3 Service provider) The Health Office organized to improve the quality of implementing the Getar Thala innovation program by providing technical guidance to all ATLM in the Sleman regency and examining thalassemia. This is in accordance with the statement of participant A.1: "... BIMTEK for taking the blood sample to ATLM, so we have BIMTEK for all ATLM in the Sleman regency, how do to take the sample, then what about when blood is taken..." (A. 1 Policy stakeholder) Various health efforts and health innovations have been made to continue providing health services during the Covid-19 pandemic (Lestyoningsih et al., 2021), one of which is by optimizing the use of educational media to prevent anemia online (Wahdah & Sulistyaningsih, 2021). The effort to implement the Getar Thala innovation program in distributing TTD is to change the target of the program to become female adolescents in the village through cadres at Posyandu. This is supported by research conducted by (Sulistyawati & Setiyaningsih, 2021) that distribution through Posyandu is an effective alternative for TTD distribution during the Covid-19 pandemic. Although the change in program targets for female adolescents in schools to female adolescents in the village are an aspect of incompatibility when compared with the technical instructions for implementing the Getar Thala innovation program in Sleman Regency because it should be implemented at school and consumed together every Friday (Manik et al., 2020).
Monitoring of female adolescents taking TTD at school was monitored directly by the UKS teacher, but during the Covid-19 pandemic monitoring of female adolescents consuming TTD was implemented by health cadres in the village. Monitoring female adolescents consuming TTD at home tends to be difficult compared to monitoring done at school by drinking TTD together on Fridays. This topic is similar to research conducted by (Jayadi et al., 2021) that monitoring in TTD and white program during the pandemic was still lacking due to female adolescents taking TTD at home. Then, there was a possibility of falsifying information, and the self-monitoring system for female adolescents was not optimal. Supplementation of TTD during the pandemic was still distributed to adolescents in schools with a drivethru, such as adolescents taking TTD at school using private vehicles and did not get off the vehicle. During the Covid-19 pandemic, TTD remained available with sufficient supply and there was never a shortage of supply.
Coordination and collaboration require joint action considering this involves agreeing on common goals through bilateral multisectoral (Castañer & Oliveira, 2020). Collaboration in implementing the Getar Thala innovation program is implemented by program implementers in collaboration with relevant health workers if there are crucial cases that must be handled together with other health workers. The health workers also coordinate according to their respective duties which have been written in the technical instructions for implementing the program. Then, all program implementers know the duties and responsibilities, and authorities of each implementer in implementing the Getar Thala innovation program.

The output indicators
Output or program results in the output indicators consist of 2 categories, such as the trend of decreasing TTD coverage during the Covid-19 pandemic and the trend of increasing anemia rates for female adolescents in 2020, such as 10.22% to 15.33% in 2021. Coverage of TTD content distribution during the Covid-19 pandemic in 2020 decreased significantly from the previous year with a decrease of 44%. The decrease in the coverage of TTD is similar to the research conducted by (Nurcahyanti et al., 2022) which found that there was a decrease in the coverage of TTD in Wakatobi Regency due to the cessation of program implementation for 4 months due to being in the red zone during the Covid-19 pandemic.
The prevalence of anemia in female adolescents tends to increase in 2021, namely 15.33% compared to 2020, which is around 10.22%, which means there is an increase in the prevalence of anemia in female adolescents by 5.11% in the Sleman Regency area. The increase in the prevalence of anemia among female adolescents during the Covid-19 pandemic was in line with research conducted by (Djogo et al., 2021) which found that the prevalence of anemia among female adolescents in Kupang City was 65.5%, which was in the high category on a national scale, namely 20% during the pandemic Covid-19.
The limitations of this study were that some of the required documentation was not available in several schools because program documentation was not implemented. The research was conducted during the school semester holidays so 6 participants were interviewed online so that researchers could not analyze the expressions and gestures of participants when providing information, then, taking conclusions only based on the intonation of the participant's voice.

LIMITATION OF THE STUDY
The limitation of this research is that the research location is only limited to Sleman Regency CONCLUSIONS AND SUGGESTIONS Evaluation of the input indicators showed that there has been a change in the program's target which is the program's implementation strategy during the Covid-19 pandemic. The targets should have been female adolescents in schools were changed to female adolescents in the village. Evaluation of process indicators showed that there was a new procedure for the distribution of TTD through drive-thru and distribution by village cadres. Evaluation of the output indicators showed an increase in the coverage of TTD content distribution after a change in the TTD target distribution strategy. The prevalence of anemia for female adolescents in Sleman Regency has increased from 10.22% in 2020 to 15.33% in 2021.
Program implementers in schools are advised to monitor the distribution of TTD to female adolescents and monitor their consumption of TTD on an ongoing basis in accordance with the policies of implementing the program during the Covid-19 pandemic. Future research is needed to further evaluate the role of health cadres in distributing TTD in the village and monitoring TTD consumption in an effort to prevent anemia in female adolescents during the Covid-19 pandemic.