E:\IBUK\NERS DESEMBER 2021\6--j 301Agustina, Ayuningtyas, Noviasari, Pathway Analysis of Behavioral Determinants in ... Pathway Analysis of Behavioral Determinants in Preventing Genital Infections of Santri Putri Pondok Pesantren : Application of The Integrated Behavior Model Ika Agustina1, Kanthi Devi Ayuningtyas2, Ita Noviasari3 123Midwifery Department, STIKes Patria Husada Blitar, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 20/09/2021 Accepted, 22/11/2021 Published, 15/12/2021 Keywords: Prevention of Genital Infection, Fe- male Students, Integrated Behavior Model, Path Analysis Article Information Abstract Female students who live in Islamic boarding schools are a population at risk for genital infections. The practice of personal/vaginal hygiene or menstrual hygiene is a form of maintaining reproductive health by preventing genital infections. Some bad behavior related to vaginal hygiene is a trigger factor for female genital infections. This study aimed to examine the factors behind the behavior of preventing genital infection in female students in the Islamic boarding school environment. This study was a quantitative study with a cross-sectional design. The population in this study was all female stu- dents. Determination of the sample in this study was carried out randomly with the number of subjects determined based on the rule-of-thumb sample size for path analysis, namely a minimum of 100 subjects, a minimum of 5 subjects per parameter, and a minimum of 10 subjects per variable. So that a sample of 150 female students was determined. The independent variable in this study was the behavior of preventing genital infection, while the depen- dent variables was: (1) behavioral intentions, (2) correct knowledge about behavior, (3) perception of the meaning of behavior, (4) environmental barri- ers, (5) experiential attitudes, (6) instrumental attitudes, (7) injunctive norms, (8) descriptive norms, (9) perceived behavioral control, (10) self-efficacy. This study indicated that infection prevention behavior can be determined by the behavior of female students prevention of genital infection is not influenced by the behavior of environmental barriers. Good knowledge and skills did not affect female students in taking measures to prevent genital infections; therefore, it was necessary to develop a more heterogeneous number of respondents and a questionnaire that can be understood by re- spondents so that an integrated behavioral model can become a reference to change behavior, and use methods that can improve their behavior. © 2021 Journal of Ners and Midwifery 301 Correspondence Address: STIKes Patria Husada Blitar – East Java, Indonesia P-ISSN : 2355-052X Email: ikapatria45@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i3.ART.p301–308 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://doi.org/10.26699/jnk.v8i3.ART.p301-308 https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i3.ART.p301-308&domain=pdf&date_stamp=2021-12-26 302 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 301–308 INTRODUCTION East Java is the province with the largest num- ber of mukim students in Indonesia. In Blitar Re- gency in particular, there are 132 Islamic boarding schools with a total of 4,208 mukim students (Min- istry of Religion of the Republic of Indonesia, 2019). As a place to live, a place to study and a place to interact for many students who come from various regions and have different behavioral habits, coupled with less than optimal environmental man- agement, Islamic boarding schools become places that are at risk for causing various health problems. One of the health problems that arise among stu- dents is genital infection. Especially in the female santri community, is- sues regarding female organs and reproductive health are still often neglected. This is related to the negative public perception of the discussion about these matters. There is an assumption that women should not talk about their femininity to other people, often making female students not getting proper treatment when they are exposed to genital infec- tions.. Many female students start living in the pesantren environment before experiencing me- narche, so the practice of managing menstruation is only obtained from seniors or their coaches based on environmental habits. Menstruation is a natural process, but if the process is not managed properly, it will create humidity in the genital area which in- creases the risk of germs entering the reproductive tract and triggering infectioni(Rizky Amelia, Irvani Dewi and Karim, 2013). The practice of personal/ vaginal hygiene or menstrual hygiene is a form of maintaining reproductive health by preventing genital infections. Some bad behaviors are related to vagi- nal hygiene when defecating or urinating, such as perfect cleaning of the genitals (unclean or wrong), using soap when cleaning the vagina, not washing hands before touching the vagina, wearing tight underwear and made from non-absorbent sweat, rarely changing underwear or pads, is a trigger fac- tor for female genital infections(Pudiastuti, 2010). A study conducted by Sevil, et al in 2013 also re- vealed the results that the frequency of genital in- fections was more common in female students who had poor hygiene behavior (Sevil et al., 2013). A preliminary study at the Al Mawaddah Is- lamic Islamic Boarding School 2 Jiwut, Nglegok, Blitar produced several findings related to genital infections in female students. (1) Based on a ran- dom survey of 30 female students, 75% stated that they had experienced vaginal itching and/or exces- sive vaginal discharge, but only 10% had complained to their supervisor and tried to deal with complaints appropriately. (2) There was no health clinics or specially trained officers to provide reproductive health services to female students. (3) The habit of female students wearing sarongs or skirts with double trousers, taking turns using towels or pant- ies, wearing inappropriate sanitary napkins, rarely changing underwear or sanitary napkins during menstruation. (4) There are differences in the level of hygiene behavior in female students. On aver- age, older female students (Aliyah level – equiva- lent to senior high school) had better hygiene be- havior than younger female students (Tsanawiyah level – equivalent to junior high school). Based on these findings, the researcher assumes that hygiene behavior as a form of prevention against genital in- fections is influenced by many factors. Therefore, researchers are interested in conducting research to examine the factors behind the behavior of pre- venting genital infections in female students in the Islamic boarding school environment. Through this research, researchers will find the dominant factor so that they can choose the right intervention steps to overcome the problem of female students’ geni- tal infection. METHOD The research to be conducted is a quantitative study with a cross-sectional design. The research will be conducted at the Al Mawaddah Islamic Boarding School 2 Jiwut, Nglegok District, Blitar Regency. The population in this study were all fe- male students with the source population being fe- male students who had lived for at least 6 months, which were 385 people. Determination of the sample in this study was carried out randomly with the number of subjects determined based on the rule-of-thumb sample size for path analysis, namely a minimum of 100 subjects, a minimum of 5 sub- jects per parameter, and a minimum of 10 subjects per variable. So that a sample of 150 female stu- dents was determined. The variables that will be used in this study consist of two types, namely the independent vari- able and the dependent variable. All research vari- ables come from the constructs that make up the integrated behavior model. The independent vari- able in this study is the behavior of preventing geni- 303Agustina, Ayuningtyas, Noviasari, Pathway Analysis of Behavioral Determinants in ... tal infection, while the dependent variables are: (1) behavioral intentions, (2) correct knowledge about behavior, (3) perception of the meaning of behav- ior, (4) environmental barriers, (5) experiential atti- tudes, (6) instrumental attitudes, (7) injunctive norms, (8) descriptive norms, (9) perceived behavioral con- trol, (10) self-efficacy. The habit variable is excluded because it has the same meaning with behavior. Related to the data analysis method that will be used in this study, the research variables are also divided into two types, namely exogenous variables and endogenous variables. Included in the types of exogenous variables are experiential attitudes, in- strumental attitudes, injunctive norms, descriptive norms, perceptions of behavioral control, self-effi- cacy, correct knowledge of behavior, perceptions of the meaning of behavior, and environmental bar- riers. Included in the type of endogenous variable is the behavior of preventing genital infection. The data in this study will be collected using a questionnaire developed by the researcher himself. Before the instrument is used to collect data, the researcher will first test the instrument on a popu- lation that has the same characteristics as the re- search subject. It aims to obtain a valid and reliable instrumentThe research data that will be obtained by the researchers will be numerical data with a continuous scale. Furthermore, for the purposes of data analysis, the researcher will use the mean or median value of each variable as a cut of point to convert the data into a categorical measurement scale. Data analysis will be carried out in three stages (univariate, bivariate, and multivariate) using the STATA 13 program. Univariate analysis uses de- scriptive statistical tests to determine the frequency distribution of each variable. Meanwhile, to find out the relationship between each independent variable and the dependent variable in the bivariate analy- sis, the chi-square test with odds ratio and p-value will be used. The last stage of analysis will use the path analysis method to determine the magnitude of the influence of the independent variable on the dependent variable, either directly or indirectly. The size of the relationship used to determine the mag- nitude of the influence in this analysis is called the path coefficient. It is assumed that the greater the path coefficient, the stronger the relationship be- tween variables or the greater the influence of one variable on other variables. Ethical Clearance in this study was obtained from the Health Research Ethics Commission of the University of Muhammadiyah Lamongan No. 082/EC/KEPK-S2/06/2001 RESULT Variable Category Frekuension % Genital infection prevention behavior Bad 75 46.88 Good 85 53.13 Perception of the meaning of behavior Bad 76 47.50 Good 84 52.50 Injunctive norm Bad 75 46.88 Good 85 53.13 Descriptive norm Bad 79 49.38 Good 81 50.63 Subjective attitude (affect) Negativ 73 45.63 Positiv 87 54.38 Instrumental attitude Negativ 69 43.13 Positiv 91 56.88 Self efficacy Low 76 47.50 High 84 52.50 Behavioral control perception Low 75 46.88 High 85 53.13 Intention to behave Low 56 35.00 High 104 65.00 Table 1 Variable Frequency Distribution 304 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 301–308 From the Table 1 above, it is explained that the respondents who live in the female Islamic board- ing school Al Mawaddah 2, the majority of female students’ genital infection prevention behaviors are good as many as 85 respondents (53.13%), the majority of the perception of the meaning of fe- male students’ behavior is good as many as 84 re- spondents (52.50%), the majority of the norms in- junctive female students as many as 85 respondents (53.13%), the majority of descriptive norms for fe- male students were good as many as 81 respon- dents (50.63%), the majority of subjective attitudes (affect) of female students were negative as many as 87 respondents (54.38%), the majority of instru- mental attitudes of female students were positive as many as 91 respondents (56.88%), the majority of female students’ self-efficacy is high as many as 84 respondents (52.50%), the majority of female students’ behavior control perceptions are 85 re- spondents (53.13%), the majority of female stu- dents’ behavioral intentions are high as much as 104 (65.00%), the majority of female students’ knowledge and skills were low as many as 88 re- spondents (55.00%), the majority of female stu- dents’ environmental barriers were high as many as 91 respondents onden (56.88%). dik_behav binomial logit -1.9 dik_salience binomial logit dik_intent binomial logit -.36 dik_desc_norm binomial logit dik_knows binomial logit dik_inst_att binomial logit dik_affect binomial logit dik_pbc binomial logit dik_self_efc binomial logit dik_ij_norm binomial logit dik_envbar binomial logit 1.5 1.4 .38 .25 -.75 -2.3 1.8 1.1 1.2 1.4 Knowledge and skills Low 88 55.00 High 72 45.00 Environmental barriers Low 69 43.13 High 91 56.88 Picture 1 Path Analysis Chart 305Agustina, Ayuningtyas, Noviasari, Pathway Analysis of Behavioral Determinants in ... The behavior of preventing genital infection is directly and significantly influenced by the percep- tion of the meaning of the behavior and the inten- tion to behave. Someone who has a good perception of the meaning of behavior has a log odds of carrying out genital infection prevention behavior of 1.49 units better than someone who has a bad perception of the meaning of behavior (b = 1.49, 95% CI = 0.75 to 2.24, p = <0.001). Someone with a high behavioral intention had a log odds of doing a genital infection prevention behavior of 1.39 units better than someone with a low behavioral intention (b= 1.39, 95%CI= - 0.60 to 2.18, p= 0.001). Genital infection prevention behavior is indi- rectly influenced by subjective attitudes, instrumen- tal attitudes and injunctive norms, through behav- ioral intentions. DISCUSSION The results of this study indicated that behav- ior in preventing genital infection with adolescents’ perceptions of the meaning of behavior was 0.0001. This is in line with research from (Agustina, Murti and Demartoto, 2016), that there is a close rela- tionship between perception and behavior to pre- vent sexually transmitted infections. Perceived be- havioral control refers to a person’s perception of the difficulty of carrying out the desired behavior, related to the belief that the resources and opportu- nities needed to realize certain behaviors will be available by reflecting past experiences and antici- pation of obstacles and obstacles (Ajzen, 1991 dalam Mihartinah and Coryanata, 2019). An individual’s past experience of a behavior can be influenced by information that can be ob- tained from others, Ajzen explained that a person’s behavior is not only controlled by himself, but also Dependen variable Independen variable b 95% CI pUpper Lower limit limit Direct Effect Genital infection prevention behavior  Perception of the meaning of behavior 1.49 0.75 2.24 < 0.001 Genital infection prevention behavior  Behavioral knowledge and skills 0.37 - 0.58 1.33 0.45 Genital infection prevention behavior  Intention of behave 1.39 0.60 2.18 0.001 Genital infection prevention behavior  Environmental barriers 0.25 - 0.69 1.19 0.61 Indirect Effect Intention to behave  Subjective attitude 1.78 0.51 3.05 0.01 Intention to behave  Instrumental attitude - 2.32 - 4.05 - 0.60 0.01 Intention to behave  Injunctive norm 1.39 0.04 2.74 0.04 Intention to behave  Descriptive norm - 0.75 - 2.21 0.71 0.32 Intention to behave  Self efficacy 1.18 - 0.29 2.66 0.12 Intention to behave  Behavioral control perception 1.08 - 0.14 2.29 0.08 N Observasi = 160 Log Likelihood = - 169.99 df = 45 AIC = 363.98 BIC = 400.88 Table 2 Path Analysis Results 306 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 301–308 requires control. Perceived behavioral control has two aspects, namely how much a person has con- trol over the behavior and how a person feels con- fident about the ability to perform or not perform the behavior. The genital infection prevention be- havior carried out by the young women of the Pondok is in accordance with the Theory of Rea- soned action model that the existence of such be- havior is based on the perception of past experi- ences. If the youth of the cottage are menstruating, the sanitary napkins used are cloth that can be washed again. Perception of behavioral control or also called behavioral control is a person’s feelings about the ease or difficulty of realizing a certain behavior, (Ajzen, 2005 in Naratama and Nurcaya, 2016)). Ajzen explains the feelings related to con- trol behavior by distinguishing it from the locus of control or control center proposed by Rotter’s. Control center relates to a person’s belief that is relatively stable in all situations. Perceptions of be- havioral control may change depending on the situ- ation and the type of behavior to be performed. The control center is concerned with the individual’s belief that his success in doing anything depends on his efforts. According to Fishbein dan Ajzen (1975) that in order to understand the area of Attitude, it is nec- essary to distinguish between Attitude, Belief, Be- havioral Intention and Behavior. One form of dis- tinction that has been used for a long time is the classic trilogy between emotion or feeling, cogni- tion and conation. Emotions refer to a person’s feel- ings and evaluation of an object, person, problem, or event. Cognition which is knowledge, opinions, beliefs, and experiences about objects. Conation is nothing but the intention of behavior. Knowledge of something is a representation of the cognitive as- pect so that adolescent knowledge related to the prevention of genital infections which in theory has an influence on Attitudes Towards Behavior The results showed that there was no relation- ship between genital infection prevention behavior with knowledge and behavioral skills. Skiner in Notoatmodjo (2010), a psychologist, formulated that behavior is a person’s response or reaction to a stimulus (stimulus from outside). But in reality, the stimulus received by the organism is not always able to produce behavior, there are several other fac- tors that play a role in the emergence of behavior, one of which is the intention to behave in a certain way from an individual. Intention itself will also not a ppea r without a n influencing deter mina nt (Mahyarni, 2013). Several studies have shown that the object which is a representation of cognitive factors has been described in TRA as one of the factors that can influence behavioral intentions through attitudes (Hidayat, 2018). The results of this study indicate that the be- havior of preventing genital infection is influenced by the behavioral intentions of female students, ex- plained from the results of data analysis that stu- dents with high behavioral intentions have a log odds of carrying out genital infection prevention behav- ior of 1.39 units better than someone who has low behavioral intentions (b = 1.39, 95%CI= - 0.60 to 2.18, p= 0.001). According to Papahan, M et all (2021) the theory described from Theory of Rea- soned Action (TRA) which explains that behavior is the result of intention. The behavior of prevent- ing genital infection is also indirectly influenced by subjective attitudes, instrumental attitudes and in- junctive norms, through behavioral intentions. Based on the data obtained, female students with subjec- tive attitudes were mostly positive attitudes as many as 87 respondents (54.38%), students with instru- mental attitudes were mostly positive attitudes as many as 91 respondents (56.88%) and students had mostly good injunctive norms as many as 85 re- spondents. (53.13%). It was found that the subjec- tive attitude was obtained p = 0.01, the instrumen- tal attitude was obtained p = 0.01, and the injunc- tive norm was obtained p = 0.04. Respondents have a subjective attitude based on what is experienced during their stay in the Is- lamic boarding school, female students can adjust the place to avoid genital diseases. The instrumen- tal attitude or basic attitude of the santri has been obtained before living in the cottage so that it be- comes a good habit. As for the injunctive norms of students, it can be known from how students pre- vent the occurrence of genital infections in the Is- lamic boarding school environment. The behavior of students in preventing infection includes clean- ing the genitals, most of them are good, the under- wear used is appropriate, Another factor that influences infection pre- vention behavior is self-efficacy. Confidence from students in infection prevention behavior was ob- tained from the results of the questionnaire, the majority of students with high self-efficacy were 84 respondents (52.50%). With high self-efficacy, students believe that what they do can prevent in- 307Agustina, Ayuningtyas, Noviasari, Pathway Analysis of Behavioral Determinants in ... fection in the genitals by washing their hands be- fore and after cleaning the genitals, wearing loose underwear that absorbs sweat, and changing sani- tary napkins 3-4 times a day. Descriptive norm is one of the factors that in- fluence infection prevention, obtained from the re- sults of the questionnaire, most of the students with good descriptive norms were 81 respondents (50.63%). Most of the students did the same thing as some of their friends in preventing infection. Avoid sharing towels with friends when drying the genitals. In this study the perception of behavioral con- trol is also a factor in preventing infection. most of the students’ behavior control perceptions were high as many as 85 respondents (53.13%). Santri who experience genital problems rarely discuss their complaints with other people, they are more confi- dent in expressing what they experience with people they trust, for example parents, trusted cottage com- panions and health workers who come to the cot- tage. The results of the research on the prevention of genital infection behavior were not influenced by environmental barriers, explained from the re- sults of data analysis p 0.61. One of the behaviors is influenced by environmental factors. In general, environmental factors are determinants of human behavior. Environmental factors will affect when the human has started to enter and interact with the environment. So, the environment is the land for the development of behavior (Notoatmodjo, 2010). The environment in Islamic boarding schools that is supportive in matters relating to genital in- fection prevention behavior includes the availability of clean water or water flowing directly from the faucet, the availability of a poskestren (Islamic boarding school health post) that can facilitate fe- male students if there are complaints or problems related to the genital area. . As well as the avail- ability of adequate health workers, so that female students feel comfortable to check the complaints they are experiencing. So that environmental barri- ers do not affect the behavior of preventing genital infections in Islamic boarding schools CONCLUSION The results of this study indicate that behavior in preventing genital infection with adolescents’ perceptions of the meaning of behavior is 0.0001, there is no relationship between genital infection prevention behavior with knowledge and behavioral skills. The results of this study indicate that infec- tion prevention behavior can be determined by the behavior of female students prevention of genital infection is not influenced by the behavior of envi- ronmental barriers. SUGGESTION Good knowledge and skills do not affect fe- male students in taking measures to prevent genital infections, therefore, it is necessary to develop a more heterogeneous number of respondents and a questionnaire that can be understood by respondents so that an integrated behavioral model can be a ref- erence. REFFERENCE Abrori, Qurbaniah M. Infeksi Menular Seksual. 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