Path Analysis and Health Belief Model on the Association between Education and Cadre Performance in Tuberculosis Control at Baki Community Health Center, Sukoharjo, Indonesia

Abstract

Background: The new cases of tuberculosis in 2014 as many as 9.6 million. There are 6 million
cases reported findings. The efforts to increase the number of case finding through cooperate
community and community health workers. This study aimed to analyze the association of
education and health belief model with a performance of cadres in tuberculosis control.
Subjects and Method: This was an observational analytic with a cross sectional design. This was
conducted in community health center of Baki, Sukoharjo, Indonesia, in April 2016. A total of
sample was 90 subjects were selected by random sampling. The data collection used questionnaire.
The data were analyzed using path analysis.
Results: There was no relationship between education and the performance of cadres in
tuberculosis control cases through the perception of vulnerability, perceived seriousness, perceived
benefit, perceived barriers and self-efficacy. There was a direct positive relationship between the
perception of vulnerability to the performance of cadres in tuberculosis control cases (b = 3.35;
95% CI= 1.43 to 5.27; p=0.001), seriousness (b=2.21; 95% CI=0.43 to 3.9; p = 0.015), benefits (b=
2.11; 95% CI= 0.42 to 3.80; p = 0.014), self-efficacy (b = 2.04; 95% CI= -0.01 to 4.09; p = 0.051),
the impulse to act (b = 1.64; 95% CI= 0.06 to 3.22; p= 0.042) with the performance of cadres in the
control of tuberculosis cases. There was a direct negative relationship between perceptions of
barriers to the performance of cadres in tuberculosis control (b=-4.54; 95% CI= -7.56 to - 1.52); p =
0.003).
Conclusion: There is indirect relationship between education and performance of cadres in
tuberculosis control cases through the perception of vulnerability, seriousness, benefits, barrier
and self-efficacy. There is a direct relationship between construct of health belief model with the
performance of cadres in tuberculosis control cases.
Keywords: path analysis, education, health belief model, the performance of cadres, tuberculosis
Correspondences :
Dhian Nurayni. Sulistyo Ningrum. Faculty of Public Health, Sebelas Maret University, Surakarta.
Email: dhiannuraynis@gmail.com

Full text

Journal of Health Policy and Management (2016), 1(1): 38-43
https://doi.org/10.26911/thejhpm.2016.01.01.06
38 e-ISSN: 2549-0281 (online)
Path Analysis and Health Belief Model on the Association between
Education and Cadre Performance in Tuberculosis Control
at Baki Community Health Center, Sukoharjo, Indonesia
Dhian Nurayni Sulistyo Ningrum1), Bhisma Murti2), Ruben Dharmawan3)
1)Faculty of Public Health, Sebelas Maret University, Surakarta
2)Medicine Faculty of Sebelas Maret University, Surakarta
ABSTRACT
Background: The new cases of tuberculosis in 2014 as many as 9.6 million. There are 6 million
cases reported findings. The efforts to increase the number of case finding through cooperate
community and community health workers. This study aimed to analyze the association of
education and health belief model with a performance of cadres in tuberculosis control.
Subjects and Method: This was an observational analytic with a cross sectional design. This was
conducted in community health center of Baki, Sukoharjo, Indonesia, in April 2016. A total of
sample was 90 subjects were selected by random sampling. The data collection used questionnaire.
The data were analyzed using path analysis.
Results: There was no relationship between education and the performance of cadres in
tuberculosis control cases through the perception of vulnerability, perceived seriousness, perceived
benefit, perceived barriers and self-efficacy. There was a direct positive relationship between the
perception of vulnerability to the performance of cadres in tuberculosis control cases (b = 3.35;
95% CI= 1.43 to 5.27; p=0.001), seriousness (b=2.21; 95% CI=0.43 to 3.9; p = 0.015), benefits (b=
2.11; 95% CI= 0.42 to 3.80; p = 0.014), self-efficacy (b = 2.04; 95% CI= -0.01 to 4.09; p = 0.051),
the impulse to act (b = 1.64; 95% CI= 0.06 to 3.22; p= 0.042) with the performance of cadres in the
control of tuberculosis cases. There was a direct negative relationship between perceptions of
barriers to the performance of cadres in tuberculosis control (b=-4.54; 95% CI= -7.56 to - 1.52); p =
0.003).
Conclusion: There is indirect relationship between education and performance of cadres in
tuberculosis control cases through the perception of vulnerability, seriousness, benefits, barrier
and self-efficacy. There is a direct relationship between construct of health belief model with the
performance of cadres in tuberculosis control cases.
Keywords: path analysis, education, health belief model, the performance of cadres, tuberculosis
Correspondences :
Dhian Nurayni. Sulistyo Ningrum. Faculty of Public Health, Sebelas Maret University, Surakarta.
Email: dhiannuraynis@gmail.com
BACKGROUND
Tuberculosis (TB) is one of the main
problems that occur in global health. TB
being the second leading cause of death in
the world after HIV. Mortality with TB in
2014 reaches 1,500,000 inhabitants and of
which 140,000 are older children. WHO in
2014 estimates as much as 9,600,000 new
TB cases with 5,400,000 are men and
women are 3,200,000 and children are
1,000,000. Based on these estimates about
6,000,000 TB cases are reported. When
compared to the estimated figure 9.6
million new TB cases, reports of such cases
only amounted to 63%. Thus in the world
there are 37% of new TB cases are undiag-
nosed or not reported. Indonesia is the
second country from the five countries with
the largest number of incidence of TB cases
in the year 2014, namely India (2.0 to 2.3
million), Indonesia (0.7 to 1.4), China (0.8
to 1.0), Nigeria (0.34 to 0.87) and Pakistan

Ningrum et al./ Path Analysis and Health Belief Model on the Association
e-ISSN: 2549-0281 (online) 39
(0.37 to 0.65). The estimated incidence of
TB in Indonesia is 1 million per year (WHO,
2000).
Tuberculosis is an infectious disease
caused by the bacteria Mycobacterium
tuberculosis can invade a variety of organs
and tissues of other organs, but more often
is stricken with lung (Steingart et al., 2001;
Kemenkes, 2015). TB has a characteristic
way of easy transmission over the air,
namely sprinkling droplets or phlegm.
Control of TB transmission is done by the
strategy of Directly Observed Treatment
Short-course (DOTS) in accordance with
the recommendations of the World Health
Organization (WHO) in 1994. This strategy
consists of top five pillars, namely: 1)
Commitment of political decision makers,
2) Diagnosis and examination of micro-
scopic sputum sufferers, 3) Guarantees the
availability of the drug and its distribution
lines, 4) direct Supervisors taking medi-
cation (PMO) and 5) using a recording of
reporting in facilitating monitoring and
coaching (Kemkes, 2013; Maryun, 2007).
The discovery of TB sufferers suspect on
strategy of DOTS using passive case
finding, namely that networking is only
done on sufferers who came for a visit at
the health service center which in this case
is the health centers. Networking in this
way cannot crawl suspek TB that is not
visited on the health service center, so some
sources of transmission cannot be pre-
vented early (Wahyudi, 2010).
The World Health Assembly (WHA)
declared the achievement of success strate-
gies DOTS in the detection of new cases of
SMEAR-positive 70%, and the healing of
85% of the cases in 2000 (WHO, 2009).
Another strategy introduced the WHO
in 2006 was the stop TB partnership which
aims to intensify the response to TB and
reach out to all patients. The stop TB
partnership strategy has six components,
namely: 1) expansion and enhancement of
high-quality DOTS, 2) addressing TB/HIV,
MDR-TB and other challenges, 3) health
systems strengthening, 4) involvement of
all health care givers, 5) empowerment of
patients and communities, 6) encourage
and enhance research (WHO, 2006). The
second strategy that run either DOTS or
stop TB partnership cannot realize the
targets of the MDGs in lowering the
prevalence and mortality with TB quickly
up to half by 2015 (Dyeet et al., cit Murti,
2005).
The indicator is seen in the success of
TB control include product Case Detection
Rate (CDR), Case Notification Rate (CNR),
the proportion of children TB patients, the
number of TB treatment success and
patient TB treatment proportion RR/MDR
TB. CDR indicator is used to describe the
scope of the invention of new TB patients
with SMEAR positive. The tendency or the
trend of CDR that happened in Indonesia
has decreased from 60% in 2013 be 46% in
2014. The decline also occurred in the CDR
product Sukoharjo Regency i.e. from 33%
in 2013 to 30% in 2014. The case at one of
the clinics in the region namely Sukoharjo
Regency Health Center Tray, close to CDR
2014 decreased compared to 2013 from
25.6% to 23.78%. This means that at the
national level as well as in areas close to the
CDR is still far from the target of 70% that
is declared by the WHO (Kemkes, 2015;
DKK Sukoharjo, 2014).
Research conducted Murti et al.,
(2015) in Sukoharjo note that CDR product
failure factors, among others: 1 CDR's
discovery) rely more on passive case finding
(PCF) and have yet to optimize active case
finding (ACF), 2) has not been optimal
participation of communities and social
capital, 3) networking suspect TB sufferers
are too loose (too sensitive) because many
suspek who netted although it doesn't meet

Journal of Health Policy and Management (2016), 1(1): 38-43
https://doi.org/10.26911/thejhpm.2016.01.01.06
40 e-ISSN: 2549-0281 (online)
the criteria, 4) quality of phlegm. Similar to
the research dilakukn by Awusi et al.,
(2009) that identifies that networking
suspect, service IEC (Information, Educa-
tion, Communication) and training DOTS
officer influential positive clinics at the
discovery of TB cases and can increase
CDR. The low discovery TB cases that occur
will result in increasing morbidity, disabi-
lity, mortality and transmission.
SUBJECTS AND METHOD
This was an analytic observational study
with cross sectional design. This was
conducted in community health center of
Baki, Sukoharjo, Indonesia in April 2016. A
total sample of 90 subjects was selected by
random sampling. The independent vari-
ables were education, perception, percep-
tion of the seriousness of the vulnerability,
the perception of the benefits, barriers, self-
efficacy perception and encouragement Act.
The dependent variable was the perform-
ance of cadres in controlling TB cases. The
data analysis was used Path Analysis.
RESULTS
The characteristics of the subjects in the
study were age and employment status. The
category of age (50 years < 67.8%) and age
≥ 50 years (32.2%). Subject categories that
do not work (55.6%) and subject to the
status of work (44.4%).Relationship in
multivariate describes the relationship of
more than one independent variable on
education, vulnerability perception, percep-
tion of the seriousness of the benefit,
barriers, self-efficacy perception and
encouragement Act. The method used is the
path analysis using STATA program 13.
Table 4.3. Result of path analysis associated education and invalid construct
belief model with the performance of cadres in controlling tuberculosis cases at
Baki community health center
Variables
Path coef
CI (95%)
p
Lower
Upper
Indirect Effect
Vulnerability
Education
1.32
0.33
2.30
0.009
Seriousness
1.08
0.08
2.07
0.033
Benefit
0.78
-0.11
1.69
0.089
Barriers
-1.23
-2.15
-0.32
0.008
Self-efficacy
0.45
-0.46
1.37
0.329
Direct Effect
Performance
Vulnerability
3.35
1.43
5.27
0.001
Seriousness
2.21
0.43
3.99
0.015
Benefit
2.11
0.42
3.80
0.014
Barriers
-4.54
-7.56
-1.52
0.003
Self-efficacy
2.04
-0.01
4.09
0.051
Encouragement Act
1.64
0.06
3.22
0.042
Likelihood Ratio =
-296.54
DISCUSSION
There is an indirect relationship between
education and the performance of cadres
on controlling tuberculosis cases between
education and the perception of vulnera-
bility (b= 1.32; CI 95%= 0.33 to 30; p=
355), continued from the perception of
vulnerability to the performance of cadres
on controlling tuberculosis (case b=3.4;

Ningrum et al./ Path Analysis and Health Belief Model on the Association
e-ISSN: 2549-0281 (online) 41
95% CI= 1.43 to 5.27; p=0.001). Then
between education and perceptions of
seriousness (b=1.08; CI95%=0.08 to 2.07;
p= 0.033), continued from the perception
of seriousness to the performance of cadres
on controlling tuberculosis (case b= 2.21;
CI 95%= 0.43 to 3.9; p= 0.015).
The relationship between education
with the perception of benefits (b=0.78;
95% CI=-0.11 to 1.69; p=0.089), continued
from the perception of benefit to the perfor-
mance of cadres on controlling tuberculosis
(case b=2.11; 95% CI=0.42 to 3.80; p=
0.014). Then between education and per-
ceptions of barriers (b=-1.23; 95% CI=-2.15
to -0.32; p = 0.008), continued from the
perception of obstacles to the performance
of cadres on controlling tuberculosis cases
(b =-4.54; 95% CI 95%=-7.56 to -1.52;
p=0.003). The relationship between edu-
cation and self-efficacy (b= 0.45; CI 95%=-
0.46-1.37; p=0.329), proceed from self-
efficacy to the performance of cadres on
controlling tuberculosis (case b= 2.04; 95%
CI=-0.01 to 4.09; p= 0.051).
Education affects the way a person's
point of view against themselves and the
environment as well as human leads to
action. Education cadres affect control of
tuberculosis cases primarily in the process
of granting material in extension and
capability discovery suspect tuberculosis.
This research fits with research (Trisnawati,
2008) that education plays a major role in
productivity, if the higher education then
the level of productivity in doing a better
job. In line with this, the results of similar
studies also suggested that high levels of
education produce good performance
(Khayati, 2012).The performance of cadres
is the work of cadres in performing a health
behavior in this case is the control of
tuberculosis cases of the disease.
Education is the process of learning
both formal or informal that complement
each other to enrich their knowledge. Social
cognitive theory by Bandura (1986) that
most of the knowledge and behavior driven
from the neighborhood and thought pro-
cesses to information received. The deri-
vative of this theory includes self-efficacy.
Self-efficacy is expressed as one's belief that
he can run the task on a certain level that
affects private activities toward the achieve-
ment of the tasks (Bandura, 1986).
Research results showed that the
relationship of education and self-efficacy is
positive 0.45 which means that a subject
with a high education have a smaller
average 0.45 to have a good self-efficacy.
The results of this study are in line with the
results of Biological Research (2010)
stating that a person can accomplish tasks
that are outside of its ability just solely with
the belief that he is capable of (self-efficacy)
but rather in need of harmony between the
confidence on the one hand and its own
merits as well as the knowledge he had
gained from the learning process.
Based on the Health Belief Model
(Taylor, 2003; Glanz, 2002) health beha-
viors indirectly influenced from individual
characteristics include demographic, psy-
chosocial variables and structural. Sosio-
demografic factors in detail especially edu-
cation is believed to have indirect effects on
health behaviors are influenced by the
perception or the understanding of vulnera-
bility, seriousness, benefits and barriers in
the Health Act or behaviour in order to
prevent and treat a disease (Dwijayanti,
2011).
There is a direct relationship between
positive perception of vulnerability and the
performance of cadres on controlling tuber-
culosis cases. The value of the coefficient on
line on this relationship mean cadres with
the perception of vulnerability to experien-
cing a high tuberculosis disease have score
logic performance cadres on controlling

Journal of Health Policy and Management (2016), 1(1): 38-43
https://doi.org/10.26911/thejhpm.2016.01.01.06
42 e-ISSN: 2549-0281 (online)
tuberculosis cases 3.4 units higher than the
perception of low vulnerability (b=3.4; 95%
CI= 1.43 to 5.27; p = 0.001).
The performance was heavily influen-
ced by various factors such as variable
factor is psychological variables consists of
sub variables namely perception, attitude,
and personality (Maryun, 2007).
The results of this study in accordance
with the theory of the Health Belief Model
(Rosenstock, 1982), which states that a
person has the perception of vulnerability
(perceived susceptibility) of individuals
affected any possibility of a disease will
affect their behavior in particular to do
prevention or looking for treatment. Those
who feel the disease affected will sooner
feel threatened. Someone will act to prevent
the disease when she felt that quite possibly
exposed to the illness. A vulnerability where
each individual differ depending on the risk
by individuals at a particular.
REFERENCES
Amiruddin F, Ibnu IF, Rahman MA (2012).
Implementasi Strategi AKMS dalam
Penanggulangan TB Paru oleh ‘Aisyi-
yah Muhammadiyah di Kota Maka-
sar’. Fakultas Universitas Hasanudin
Makasar.
Ary D, Arsyad DS, Rismayanti (2014).
Pemanfaatan Imunisasi di Kelurahan
Pampang Kecamatan Panakkukang
Kota Makassar (Pendekatan Health
Belief Model). Bagian Epidemiologi
Fakultas Kesehatan Masyarakat Uni-
versitas Hasanudin Makassar.
Awusi RYE, Saleh YD, Hadiwijoyo D
(2009). Faktor-faktor yang Mem-
pengaruhi Penemuan Penderita TB
Paru di Kota Palu Provinsi Sulawesi
Tengah. Berita Kedokteran Masyara-
kat. 25 (2): 59-68 .
Bandura A (1986). Social Foundation of
Thought and Action: A Social Cog-
nitive Theory. New Jersey: Practice-
H.
Deci E, Ryan R (2008). Facilitating Optimal
Motivation and Psychological Well
Being Across Life’s Domain. Can
Psychol, 14-23.
Depkes RI (2009). Buku Saku Kader Pro-
gram Penaggulangan TB. Jakarta:
Direktorat Jenderal Pengendalian Pe-
nyakit dan Penyehatan Lingkungan.
Dwijayanti YR, Herdiana I (2011). Perilaku
Seksual Anak Jalanan Ditinjau de-
ngan Teori Health Belief Model
(HBM). Fakultas Psikologi Univer-
sitas Airlangga.
Glanz K, Rimer BK, Lewis FM
(2002). Health Behavior and Health
Education. Theory, Research and
Practice. San Fransisco: Wiley & Sons.
Has EMM (2012). Perilaku Ibu dalam
Pemenuhan Gizi Anak Usia Praseko-
lah Berbasis Integrasi Health Promo-
tion Model dan Self Regulation
Theory. Surabaya: Universitas Air-
langga.
Hayati M (2010). Hubungan Kemampuan
Metakognitif dan Efikasi Diri dengan
Prestasi Ketrampilan Laboratorium
Kimia Analitik Mahasiswa Analis
Kesehatan. Tesis Magister Kedokter-
an Keluarga Pascasarjana UNS.
Kemkes RI (2015). Infodatin TB 2015.
_____ (2013). Pedoman Nasional Pelayan-
an Kedokteran Tata Laksana Tuber-
kulosis. 1-110.
Khayati, Nur (2012). Beberapa Faktor yang
Berhubungan dengan Pelaksanaan
Surveilans Epidemiologi Malaria
Tingkat Puskesmas di Kabupaten
Purworejo. Jurnal Kesehatan Mas-
yarakat.
Kurniawati C, Sulistyowati M (2014). Apli-
kasi Teori Health Belief Model dalam
Pencegahan Keputihan Patologis. Jur-
nal Promkes. 2(2): 117-127.

Ningrum et al./ Path Analysis and Health Belief Model on the Association
e-ISSN: 2549-0281 (online) 43
Maryun Y (2007). Beberapa Faktor yang
Berhubungan dengan Kinerja Petugas
Program TB Paru terhadap Cakupan
Penemuan Kasus BTA (+) di Kota
Tasikmalaya Tahun 2006.1–125.
Rosenstock (1982). Historical Origins of
The Health Belief Model. In: Becker,
Marshall H. Eds. The Health Belief
Model and Personal Health Behavior.
Charles B. Slack Inc, Thorofare, New
Jersey.
Steingart KR (2014). Xpert® MTB/ RIF
Assay for Pulmonary Tuberculosis
and Rifampicin Resistance in Adults.
The Cochrane Database of Systematic
Reviews, 1(1):CD00959.
Subagiyo AAA (2014). Health Belief Model
sebagai Pembentuk Perilaku Sehat.
Trisnawati G (2008). Pelatihan Peningkat-
an Kemampuan Kader dalam Pe-
nanganan Tuberkulosis (TBC) di
Wilayah Kerja Puskesmas Gemolong
II Sragen. Jurnal Warta. 11(2): 150-
158.
Wahyudi E (2010). Hubungan Pengetahu-
an, Sikap dan Motivasi Kader dengan
Penemuan Suspek Tuberkulosis Paru
di Puskesmas Sanankulon.
WHO (2006). The Stop TB Strategy. World
Health Organization.