Analysis of Knowledge and Skills of Cadres in Early Detection of Stunting Toddler Development in Soppeng Regency, Indonesia

Background: About 16% of Indonesian toddlers experience neuro developmental and brain disorders ranging from mild to severe, every two days 1,000 babies experience motor development disorders. The prevalence of stunting in South Sulawesi is in the 20th lowest ranking, namely 27.4% based on the provincial level in 2021. Objective: Recognizing the increased knowledge and skill of cadre and mothers and toddlers in early development detection of stunted infants using a Developmental Pre-Screening Questionnaire (DPQ) in the working area of the Panincong Health Center, Soppeng Regency. Method: This study used a quasi-experimental design with a pretest-posttest control group involving 30 cadres and 30 mothers with 15 children in each group selected by systematic random sampling. Data were analyzed using paired t-tests and Independent t-tests. Results: The results showed that there were differences in knowledge (p=0.000) in the intervention group and differences in knowledge levels in the control group (p=0.044). The level of knowledge after treatment was greater in the intervention group (11.8%), while the knowledge after treatment in the control group was only (2.9%). There was a difference in the skills of the cadres (p=0.000) after being given the Android-based DPQ intervention. There was a difference in the knowledge (p=0.000) and skills of toddler mothers (p=0.000) after being given the Android-based DPQ intervention applied by the cadres. Conclusion: Android-based DPQ is effective as an educational medium and as an alternative to cadres and parents in monitoring or early detection of child development using Android-based DPQ. Key words : Stunting, Development Disorders, Cadre, Survey, Questionnaire.


INTRODUCTION
One group that is at risk of experiencing health problems is the toddler group which is a golden period for human survival.In 2020, globally it is also explained that as many as 149.2 million (22%) children under 5 years are stunted.The prevalence of stunting globally decreased from 33.1% to 22%, and the number of children affected fell from 203.6 million to 149.2 million. 1The 2018 Basic Health Research (Riskesdas) shows that the prevalence of stunting in toddlers in Indonesia is 30.8% or around 7 million toddlers. 2uth Sulawesi is in the 20th lowest ranking, namely 27.4%. 3Based on data from the Supping District Health Office, there were 433 (26.1%) stunted toddlers, the most in Marmora District including the Panincong Health Center 202 (26.3%) stunted toddlers and also there were 344 stunted toddlers and 186 stunted toddlers. 4fancy-related chronic malnutrition, which affects infants for the first 1,000 days of life (HPK) and lasts for a very long time, results in stunting and delays in brain and child development.The child's brain develops quickly during the prenatal mass and continues to do so after birth until early childhood.250 million children, or 43% of children worldwide, are thought to be living in developing nations in 2016. 1 In Indonesia, 16% of toddlers have mild to severe neurodevelopmental and brain disorders, 1,000 babies have motor development problems every two days, 3-6 out of 1,000 babies have hearing loss, and 1 in 100 children have lower IQs and speech delays.The literacy score for toddlers aged 36 to months in 2018 is 64.6%, followed by scores in the physical (97%), social-emotional (69.9%), learning (95.2%), and overall index (88.3%). 2 The government and society are responsible for a portion of public health, which includes monitoring children's growth and development through screening.Monitoring growth and development is one step that can be taken to ensure sustainable growth and development.This will allow for the early detection of deviations and the proper course of action.To identify abnormalities in a child's development early on, the government works with the community, including through the Developmental Pre-Screening Questionnaire (DPQ) program. 5 order to prevent stunting, the role of integrated healthcare center cadres is urgently needed.The Indonesian Ministry of Health has established instruments for early detection and intervention on child growth and development to continue until preschool age, one of the activities being the conduct of coaching using instruments on integrated healthcare center cadres. 6e effect of parental education on child care is one of the causes of problems with child growth and development, with this it is hoped that parents can be active in providing stimulation and routinely checking the growth and development of toddlers at the integrated healthcare center to prevent irregularities in child growth and development.
Based on the direction and policy, the 2020-2024 RPJMN strategy is to improve health services towards universal health coverage, especially strengthening primary health care services by encouraging increased promotive and preventive efforts supported by innovation and the use of technology.Early detection of toddler growth and development is one of the efforts to improve the quality of children and is one of the programs from the Indonesian Ministry of Health.The President of the Republic of Indonesia has launched the National Movement for Monitoring the Growth and Development of Children.Monitoring the child's development can be done using DPQ. 8sed on the results of interviews with the Nutrition Manager at the Panincong Health Center who stated that before the COVID-19 pandemic, monitoring of toddler growth and development was carried out at the integrated healthcare center using Maternal and Child Health Book Instruments/Tools (KIA), while during the COVID-19 pandemic until 2021 monitoring growth and development of toddlers cannot be done directly because of the policies in force.This has an impact on mothers of toddlers and even health workers who do not routinely carry out screening for the growth and development of toddlers because it takes a long time to carry out and prepare DPQ sheets.In this regard, respondents need an instrument/tool that can be used to monitor developments independently through assistance from health workers including integrated healthcare center cadres.
Since the use of this Android-based DPQ is not constrained by space or time, preparation and execution time can be reduced.Promotive and monitoring applications for monitoring toddler development with the DPQ method have been developed to facilitate monitoring without using sheets of paper any longer.

Design studies
In this study, a control group participated in a pretest-posttest quasiexperimental design.This study is being conducted in the Panincong Health Center's operational area.

Participant study and sampling
There are 95 integrated healthcare center health cadres identified at the Panincong health center, as well as 186 parents of toddlers with stunting, made up the study's population.The sample for this study consisted of 30 cadres and 30 mothers of toddlers, with 15 individuals in each group for the intervention group and the control group.While the control group received only a standard DPQ assessment sheet, the intervention group received treatment using the Android-based DPQ for the early detection of stunting toddler development.

Data selection
Developmental Pre Screening Questionnaire (DPQ), observation sheets, and a questionnaire were all used in the data collection process.The control group only received traditional DPQ sheet media for the purpose of early toddler development while the intervention group received training and an introduction to the use of Android-based DPQ.

Android-based DPQ in early detection of stunting toddler development
The most significant aspect of this application is the early detection of toddler development using the DPQ method, which has become the basis for evaluations from the Ministry of Health.The application uses an Android-based DPQ that contains several promotional media, both articles and educational videos for users, both parents of toddlers and the community, related to stunting, the stages of toddler development, and the most important thing in this application is the early detection of toddler development using the DPQ method.

Data analysis
Using SPSS statistics version 26 by using a univariate test to assess the frequency of respondents and a bivariate test using the Paired Sample T-Test analysis which aims to assess or examine the effectiveness of the treatment which is indicated by the difference in the average before and the average after being given treatment (knowledge and skills) of cadres and mothers of toddlers between the intervention group and the control group, 9 while the Independent Sample T-Test analysis aims to be able to compare the average level of knowledge and skills of cadres and mothers of toddlers from the two groups that are not related to each other. 10

Ethical considerations
The research was conducted after obtaining written consent from each respondent after being given an explanation regarding the purpose of the research.Ethical approval was obtained from the Hasanuddin University Health Research Ethics Committee with ethical approval recommendation number 15004/UN4.14.1/TP.01.02/2022.

Univariate analysis/respondent characteristics
The frequency distribution of the characteristics of cadre respondents and mothers of toddlers can be seen in Table 1 which shows that the age of the most cadres is more than 35 years in the intervention group of 9 people (60%) and there are 12 people (80%) in the control group.The average cadre with the last education was high school, with 10 people (66.7%) in the intervention group and 8 people (53.3%) in the control group.The distribution of cadres based on training frequency in the intervention group was 8 people (53.3%) and cadres who had never attended training were 7 people (46.7%), while in the control group cadres who had never attended training were 9 people (60%) more than the cadres who had attended training, only 6 people (40%).
The age of the toddler mothers was in the widest age range, namely 20-35 years in the intervention group with 12 people (80%) and there were 11 people (73.3%) in the control group.The average mother of toddlers with the last education was high school and college, there were 6 people (40%) in the intervention group and the control group with the last education was high school, there were 10 people (66.7%).Meanwhile, there were 6 mothers (40%) who worked in each group and 9 mothers who did not work (60%) in both the intervention and control groups.The average parity of toddler mothers in this study was that mothers who had 2 children or better in the intervention group were 9 mothers (60%) while in the control group there were 8 mothers (53.3%).
It is known that the characteristics of each group of stunting toddlers are in the age range of 24-35 months in both the intervention group of 7 toddlers (46.7%) and the control group of 8 toddlers (53.3%).The average gender of toddlers in this study was male (53.3%) in both the intervention and control groups, while the female gender was 7 toddlers (46.7%) in each group.
Bivariate analysis to find out whether there are differences in the treatment of using Android-based DPQ in the intervention group and conventional DPQ in the control group given to cadres and mothers of toddlers.
Table 2 shows that there was an increase in cadre knowledge after treatment in both the intervention group (p=0.000) and the control group (p=0.044).However, the increase in knowledge was greater in the intervention group, namely 11.8%, while in the control group it was only 2.9%.The results of statistical tests showed that there was no difference in knowledge between the intervention group and the control group before treatment (p=0.827) and after treatment there was a significant difference (p=0.012) between the intervention group and the control group.
Table 3 shows that there was an increase in cadre skills after treatment in the intervention group (p = 0.000), whereas, in the control group, there was no increase in cadre skills (p= 0.083).The results of statistical tests showed that there was no difference in skills between the intervention group and the control group before treatment (p=0.103) and after treatment, there was a significant difference (p=0.000).So, it can be concluded that the Android-based DPQ contained in the E-PROKASI application effectively improves the skills of cadres in carrying out early detection of development in toddlers, especially stunting toddlers.Table 4 shows that there was an increase in the knowledge of toddler mothers after treatment in the intervention group (p = 0.000), whereas, in the control group, there was no increase in knowledge of toddler mothers (p = 0.111).The results of statistical tests showed that there was no difference in knowledge between the intervention group and the control group before treatment (p=0.783) and after treatment, there was a significant difference (p=0.013).
Table 4 shows that there was an increase in the skills of toddler mothers after treatment in the intervention group (p = 0.000), while in the control group, there was no increase in the skills of toddler mothers (p = 0.078).The results of statistical tests showed that there was no difference in skills between the intervention group and the control group before treatment (p=0.983) and after treatment, there was a significant difference (p=0.013).It concluded that the Androidbased DPQ contained in the E-PROKASI application was effective in increasing the skills of toddler mothers in carrying out early detection of stunting toddler development.

Feasibility of Android-based DPQ based on expert validation test
The android operating system is currently primarily used in health application development.The development of Android-based DPQ is part of the development of advances in information technology in the world of health because the use of the Android system makes it easier to access, operate, and quickly learn information.This is in line with research which states that the Stimulation Early Detection and Intervention Growth and Development mobile application can also  provide information about stimuli that parents can give their children to support the growth and development process so that growth and development delays can be prevented. 11Android-based DPQ specifically designed to assist health workers and parents in carrying out early detection of development in children which aims to find out whether there are developmental deviations in children.
After conducting research, the use of this application greatly facilitated respondents, especially young parents or primipara mothers, in increasing knowledge and skills, especially the importance of stimulation for children because after this research most parents were aware that the importance of stimulation in children and continued with monitoring developments using DPQ could help the sensory and motor development of children better according to the growth of the child's age.Pediatric health nurses must keep up with the latest technological advances and position themselves as users who can provide valuable feedback in society.As the main caregiver who is entrusted with looking after the welfare of children in the health care environment, child health care cannot simply create new technology, but instead has the wisdom to distinguish its advantages and disadvantages. 12Monitoring growth and development is very important to do, but many parents ignore the monitoring of growth and development.This is in line with research which states that toddlers who do not routinely monitor their growth and development have a 2.4 times greater risk of stunting than those who monitor their growth and development. 13

Respondent characteristics
Age: The average age of cadre respondents was more than 35 years in both the intervention group and the control group, while the majority of toddler mothers' respondents were in the age range of 20 years to 35 years in both the intervention and control groups.At this age, cadres can make it easier to understand the material presented during training and are classified as productive in carrying out integrated healthcare center activities.In this study, age has an influence on the skills of cadres.This is in line with research which suggests that age affects the knowledge and skills of cadres in carrying out early detection of developments using DPQ. 14anwhile, the age of the mother who is less than 20 years is associated with the unpreparedness of the reproductive organs which are still in the growth phase to reproduce.At the age of more than 20 years, the mother is psychologically ready to care for children.Meanwhile, an age of more than 35 years is associated with the decline of reproductive organs and the risks posed by pregnancy.Supported by research that states that a history of pregnancy, birth, and perinatal complications is identified as a substantial risk factor for developmental disorders in preschool children. 15The age that is considered ideal is in the range of 20-35 years which is classified as productive and reproductive organs and will be easier to receive knowledge compared to adulthood because in adulthood a mother has had many experiences that shape her mindset.
Education: Based on education, the majority of respondents, both cadres and toddler mothers, were high school students.Education is a strong and consistent predictor of a person's attitudes, values, and behavior for the future.The education of integrated healthcare center cadres with the most educational history was the high school in both the intervention group (66.7%) and the control group (53.3%).Meanwhile, mothers with senior high school education and tertiary education were in the intervention group (40%) and the control group with high school education (66.7%).
Based on the characteristics of cadres and parents with their educational history, they have the potential to generate ideas and skills in the early detection of development in toddlers.Knowledge obtained through education is improved by a person's level of education in comparison to a person with low education. 16Parents with low education influence the parenting style given to children.This is in line with research which states that the level of primary school education of parents is related to the child's height according to age (stunting). 15 line with research which states that there is an effect of health education on the ability of cadres to use DPQ in Balung Kidul Village, Jember district (p = 0.000). 17In addition, this study is in line with research showing that mother's education is a risk factor for child development with an OR of 7,250, (CI) 95%. 18Mother's education level has a positive impact on child development because a high level of education will make it easier for mothers to find and understand information related to child development and be able to apply early detection of development in children.
Training frequency: Based on the frequency of training, it is known that 60% of cadres have never participated in training on using DPQ in carrying out early detection of development in children.This is in line with research which states that there is a significant effect between DPQ training on increasing the knowledge and skills of integrated helathcare center cadres. 19casion: From the characteristics of the occassion, it is known that 90% of parents are housewives.As housewives, respondents will have sufficient time to carry out activities in raising children because they are not tied to formal work, so motor stimulation activities and early detection of development in children can be carried out more optimally.According to the results of the study, it was concluded that there was no difference in the proportion of the DPQ rating level between respondents who did not work and who worked or there was no significant relationship between work and DPQ assessments at PMB E Serpong in 2021. 17The results of the analysis obtained OR = 1.23, meaning that mothers who don't work have 1.23 times the opportunity to evaluate the appropriate DPQ compared to working mothers. in the process of growth and development of children.Supported by research which explains that work stress affects a person's productivity with a value of p = 0.001 (<0.05). 20kewise, between working and non-working mothers there is no significant relationship with the DPQ assessment.According to Handayani (2003), there is a difference in the time spent together between working and non-working mothers with their children.This means that it is not absolutely guaranteed that a mother who is at home (not working) will guarantee the development of a toddler according to age.The reason is that many mothers do not work and stay at home all day, but their relationship with their children's education is not good.This happens because, physically, the mother is with the child, but she is not involved in the stimulation process with the toddler.Based on this, it means that the most important thing for child development is the quality of care, sufficient (quality) time with children in play, and providing adequate stimuli to help the development of children in both working and non-working mothers. 18 Parity: In general, mothers who have more than one child tend to share their attention.When viewed from the perspective of time and energy, mothers with more than one child will feel overwhelmed and find it difficult to arrange a time to come to the integrated healthcare center because they have to take care of the household and their children.However, in terms of experience and insight, mothers will be more experienced and can make the best use of the integrated healthcare center program because they take lessons from previous children.
In this study, the parity of respondents were mostly 50% who had children ≥ 2. Of course, more and more children make parents more understanding and have personal experience with growth and development and motor stimulation in children, so they are more adept at detecting early development in children.This is in line with research which shows that there is a relationship between mother's education and parity with the development of children under five aged 3-4 years. 21n addition, the results of other studies state that there is a relationship between the history of pregnancy examinations and the incidence of stunting in children aged 6-59 months. 22However, this study is not in line with research which states that there is no significant relationship between parity and maternal participation. 23Primipara mothers are 3.4 times more likely to be less active in visiting the integrated healthcare center program than multiparous mothers.However, having family members is certainly not a determining factor in children's welfare, this is supported by research which states that there is no relationship between the number of family members and stunting in children aged 6 months-59 months. 22fferences in knowledge and skills of cadres before and after training Health education is an application in education in the health sector with activities to provide and improve knowledge, attitudes, and practices to individuals, groups, and communities in promotive and preventive efforts, 24 based on Table 4 after an assessment of the level of knowledge (pre-post test) on cadres integrated healthcare center with the results of the intervention group (0.000 <0.05) and the control group (0.044 <0.05) which showed that there was an increase in knowledge in each group after being given training regarding the use of DPQ.
After that, this research was continued on an ongoing basis to improve the ability and skills of cadres in carrying out early detection of development in children so that integrated healthcare center cadres are able to assist health workers in carrying out early detection of deviations in child development.Based on the statistical test results in Table 3, it is explained that there was an increase in skills after training using the Android-based DPQ in the intervention group (0.000 <0.05).This shows that the Android-based DPQ is effective for increasing the skills of cadres in carrying out early detection of development in toddlers, especially in stunted toddlers.Whereas in the control group applying early detection of toddler development using conventional DPQ with results (0.103 > 0.05), this shows that conventional DPQ is less effective in improving the skills of cadres in implementing early detection of toddler development.

Differences in knowledge and skills of toddler mothers before and after training
After being given training to cadres in both the intervention group and the control group, the cadres assisted mother o toddlers in implementing DPQ for early detection of toddler development.The statistical test results in Table 7 show that there was an increase in the knowledge of toddler mothers in the intervention group (0.000 <0.05), while in the control group (0.783 > 0.05) meaning that only applying conventional DPQ did not help toddler mothers increase their knowledge about the importance of early detection of developmental toddler.
This research is in line with research that shows that there are significant differences in the acquisition of scores before and after using the Android-based Pekke Madising application with a p-value of 0.000 <0.05, so this study explains that the Pekke Madising application can significantly increase the knowledge of toddler mothers. 27In addition, it is supported by research that states that the use of media in health education is aimed at getting attention to a problem and recalling information that has been conveyed so that changes in knowledge are obtained. 28e results of the research statistical tests in Table 8 show that there was an increase in the skills of toddler mothers in the intervention group (0.000 <0.05) after treatment with the use of Android-based DPQ in carrying out early detection of toddler development.While the results of statistical tests showed no increase in the skills of toddler mothers in the control group (0.078 > 0.05) after treatment with conventional DPQ.Supported research by Probosiwi et al. in Kalasan showed that there was a relationship between stunting nutritional status and toddler development with an OR of 3.9 (95% CI; 1,678,90).This is in line with research that states that the early detection application developed can detect child growth and development disorders using the DPQ instrument by automatically calculating the number of answers from application users regarding child development .In addition, it was explained that there were three results of application trials that had been carried out by child development experts (81%), health medical teams (89%), and parents (81%).The three groups stated that applications could be categorized as educational tools.][31][32] Supported by research that states that there is a relationship between a mother's knowledge and the growth and development of toddlers. 33

Research limitations
The sample coverage used in the study was only one working are of the public health center.
In this study the use of Android-based DPQ can only be used in areas that are covered by the internet network.

CONCLUSION
There is an increase in the knowledge of cadres in carrying out early detection of development in toddlers, especially in stunting toddlers, as evidenced by the treatment given to the intervention group related to the use of Android-based DPQ.
There is an increase in the skills of cadres in carrying out early detection of development in toddlers, especially stunting toddlers, as evidenced by the treatment given to the intervention group related to the use of Android-based DPQ.
This research was continued with cadre assistance for toddler mothers, and the results showed that there was an increase in the knowledge and skills of toddler mothers in the intervention group after implementing early detection of toddler development using an Android-based DPQ.

SUGGESTION
For health services: It is recommended that health workers support the development of Android-based DPQ, which is used as an alternative to facilitate monitoring and early detection of developments using Androidbased DPQ.It is also recommended to routinely involve integrated healthcare center cadres in monitoring developments in toddlers.
For society: It is suggested that parents increase their knowledge related to child growth and development as well as their motivation to carry out independent monitoring regarding child development, which can be applied through the Android-based DPQ.
For further researchers: For future researchers, if they wish to continue or conduct similar research, it is recommended to add to the Visibility Test (TDL) and Hearing Test (TDD) screenings, as well as to examine in more depth the factors that influence parents' motivation in routinely monitoring children's development.

Table 2 : Average knowledge of cadres before (pre-test) and after (post- test) treatment in the intervention group and the control group.
a: Paired Sample T-Test b: Independent Sample T-Test