34 JNK JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk E-Learing of Health Protocols Improving School-Age Children's Skills Facing Offline Learning Kili Astarani1, Fidiana Kurniawati2 1,2Nursing Department, STIKes RS. Baptis Kediri, Indonesia Article Information Abstract The surge in confirmed cases of Covid-19, especially in children aged 6-18 years, on March 3, 2021, showed 9.2% of children in Indonesia were exposed to Covid-19 virus. This makes the government advises the public to implement health protocols and have clean and healthy living behaviors, especially in terms of washing hands. This study aimed to analyze the effect of E-learning of Health Protocols on the Skills of School-Age Children Facing Offline Learning at Pelita Bangsa Elementary School, Surabaya. The design of the study used pre-experimental using one-group pre-test post-test design method. The population in this study was 59 students at Pelita Bangsa Elementary School in Surabaya. There were 59 school-age children met the inclusion criteria using the total sampling technique. The inclusion criteria in this study were children aged 7-12 years, children who came to school during data collection, and children who were willing to be examined. The instrument used a hand washing checklist sheet. The data analysis used Wilcoxon. Before being given E- Learning of Health Protocols the unskilled category in washing hands with soap with a total of 51 respondents (86.4%), there was a significant difference in hand washing skills between before health education with E-Learning Media and after health education with a significant value of 0.000 (p < 0.05). E- Learning of Health Protocols affects the skills of school-age children to face offline learning at Pelita Bangsa Elementary School Surabaya History Article: Received, 11/02/2022 Accepted, 23/03/2022 Published, 15/04/2022 Keywords: e-learning of health protocols, skills, hand washing © 2022 Journal of Ners and Midwifery Correspondence Address: STIKes RS. Baptis Kediri – East Java, Indonesia P-ISSN : 2355-052X Email: astaranikili79@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v9i1.ART.p034-042 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) http://jnk.phb.ac.id/index.php/jnk mailto:astaranikili79@gmail.com https://doi.org/10.26699/jnk.v9i1.ART.p034-042 Kili Astarani1, Fidiana Kurniawati2, E-Learing of Health Protocols Improving School-Age … 35 INTRODUCTION At the beginning of 2020, Indonesia was shocked by the entry of the Covid-19 virus which had previously spread in the Huanan market area, Wuhan in December 2019. The emergence of the Jakarta cluster on February 14, 2020, became the initial cluster for the spread of the Covid-19 virus in Indonesia. The initial emergence of this cluster occurred when an event was held in the Kemang area, South Jakarta where it was found that a Japanese Foreign Citizen (WNA) who had a domicile in Malaysia was confirmed as positive for the Covid-19 virus after attending the event (Anies, 2020). With the continued increase in confirmed cases of Covid-19, especially in children aged 6-18 years, on March 3, 2021, it was found that 9.2% of children throughout Indonesia were exposed to the Covid-19 virus. This makes the Government advise the public to implement health protocols and have clean and healthy lifestyles, especially in terms of washing hands (Anies, 2020). There is still a lack of awareness in carrying out clean and healthy living behavior, especially in children, it can be seen from the children's habits when holding objects around them which without realizing it there are various germs or bacteria that can cause disease and also children's penchant for buying food outside and eating it. without washing their hands first (Wantiyah et al., 2015). In situations and conditions like this, hand washing behavior in children needs to be improved so that children can avoid various kinds of diseases or viruses, especially the Covid-19 virus which is currently spreading and suppresses the increase in the addition of Covid-19 cases in children. For the percentage of hand washing according to the results of the 2013 Riskesdas, the proportion of those aged 10 years who washed their hands properly was 46.7%. The Directorate General of Disease Control and Environmental Health of the Indonesian Ministry of Health (2013) stated that only 18.5% of Indonesians washed their hands with soap at five important times. (Natsir, 2018). For the national average, the proportion of hand washing behavior in East Java residents in 2013 who behaved correctly in washing their hands was only 48.1%. Based on the results of the pre-research conducted by researchers on 10 children in the Pojok Village area, precisely in the RT 06 area on 23-24 January 2021 for the proportion of hand washing in children aged 7-12 years, it was found that as many as 50% of children did not know about the method or steps. good and correct hand washing and in the habit of washing hands 60% of children said they only used water without using soap. Besides this, 70% of children stated that if their hands were clean, there was no need to wash their hands properly and 60% of children only washed their hands when they wanted to eat. Other results obtained by researchers, 80% of children said that when washing their hands, their fingertips and nails did not need to be washed. The Health Protocol is an effort to be able to prevent the risk of transmission of Covid-19, with the implementation of the health protocol, it is intended that people can still carry out their daily activities safely and do not endanger their health or the health of others (Suryaningsih & Poerwati, 2020). However, in reality, the implementation of health protocols is still not fully implemented by the community, a simple example is washing hands with soap which is an important activity in preventing and controlling infection transmission. (Suryaningsih & Poerwati, 2020). Washing hands is often considered a trivial thing in various elements of society, not only children, teenagers, but also parents. Whereas hand washing can contribute to improving health status (Wantiyah et al., 2015). Various diseases such as diarrhea, ARI, typhoid, bird flu, intestinal worms, and also a new virus that is currently endemic, namely Covid-19, will emerge if the habit of washing hands with soap is ignored and ignored. (Natsir, 2018). Seeing the phenomenon that is happening where the world is currently being bothered by an outbreak of a disease, namely Corona Virus Disease 19 or commonly referred to as Covid-19. Covid-19 is an infectious disease that is transmitted zoonically or between animals and humans. This virus can cause mild to severe symptoms, infection from SARS- CoV-2 in humans can cause symptoms in the form of acute respiratory disorders such as fever, cough, and shortness of breath. And if in cases with severe symptoms this disease can cause pneumonia, acute respiratory syndrome, kidney failure, and also cause death. Symptoms of this disease can appear within 2-14 days after exposure (Kementerian Kesehatan RI, 2020) in (Moudy & Syakurah, 2020). Preventive efforts to prevent an increase in the number of Covid-19 cases in various countries have implemented several systems, namely the city lockdown system to suppress the spread of the Covid-19 virus, as implemented in Wuhan, China, 36 Journal of Ners and Midwifery, Volume 9, Issue 1, April 2022, page 34-42 and several cities in Italy. However, some other countries do not participate in implementing the lockdown system, only the implementation of physical distancing and wearing masks. In South Korea, efforts are being made to do massive tests on people who are vulnerable or at risk of being exposed to this virus. WHO explains that whatever the local government decides, every community is obliged to be able to participate in preventing the spread of this virus by complying with the recommended health protocols. (Anies, 2020). Prevention of the spread of Covid-19 that has been carried out and introduced by many countries by following WHO instructions and washing hands is the dominant thing that many do to avoid and break the chain of transmission of various diseases including Covid-19 (Anies, 2020). This action is taken because basically, the hands are one of the agents that carry pathogenic germs that can be transferred from one person to another. Hand washing is very important not only for adults but also for children to avoid infections that can endanger them. Therefore it is necessary to educate children to always wash their hands before and after doing activities (Setiawan et al., 2017). Washing hands is one of the actions contained in the health protocol issued by the WHO to break the chain of the spread of the Covid-19 virus, this must be accustomed from an early age because children at elementary school age will find it easier to instill the value of knowledge will be useful in daily life (Mahdalena & Handayani, 2019). To provide learning experiences and foster children's interest in improving their health status during this pandemic, it is necessary to provide health education, one of which is by socializing health education using video media. Video media is a medium that is often used in research in elementary schools or equivalent for the reason that it is more effective in stimulating understanding and can provoke children's imagination in interpreting messages through video media. The second reason is that videos can be used to explain the flow of activity and processes related to the correct steps for washing hands with soap and the third reason is that videos can be used repeatedly (Heru Iskandar, 2014). Therefore, to improve hand washing skills in school-age children, it can be done by using video media as a tool in stimulating the senses of sight, hearing and other senses so that it will be accepted by respondents more quickly (Heru Iskandar, 2014). Based on the above background, the researcher was interested in researching the Effect of E-learning of Health Protocols on the Skills of School-Age Children Facing Offline Learning at Pelita Bangsa Elementary School, Surabaya. METHOD The research design used in this study was Pre Experiment using the one-group pre-test post- test design method. The population in this study was 59 students at Pelita Bangsa Elementary School in Surabaya. There were 59 school-age children met the inclusion criteria using the total sampling technique. The inclusion criteria in this study were children aged 7-12 years, children who came to school during data collection, and children who were willing to be examined. Health education in this study used video media through e-learning which contained 11 steps on how to wash hands with soap. Collecting data using a handwashing checklist sheet. Respondents were asked to wash their hands before and after being given health education. The hand washing steps used sources from (Ministry of Health of the Republic of Indonesia, 2020), with an assessment that if the respondent did not do it, the score was 0 (zero) if the respondent did but was not perfect, the score was 1 (one) and if the respondent did it perfectly, the score was 2 (two). Respondents were said to be skilled if they had a value range of 12 - 22, and if the respondent had a value of 0 - 11 then it was said to be unskilled. The data analysis used is Wilcoxon. RESULT Table 1: Characteristics of respondents at Pelita Bangsa Elementary School Surabaya from April 30, 2021, to June 30, 2021 (n=59) No Characteristics Child Data Total (%) 1 Gender Man 30 50.8 Woman 29 49.2 Total 59 100 Kili Astarani1, Fidiana Kurniawati2, E-Learing of Health Protocols Improving School-Age … 37 No Characteristics Child Data Total (%) 2 Age 7 years 7 11.9 8 years 7 11.9 9 years 17 28.8 10 years 7 11.9 11 years 14 23.7 12 years 7 11.9 Total 59 100 3 Kelas Class 1 7 11.9 Class 2 7 11.9 Class 3 17 28.8 Class 4 7 11.9 Class 5 14 23.7 Class 6 7 11.9 Total 59 100 Table 2: Category of hand washing skills with soap before E-Learning of Health Protocols at Pelita Bangsa Elementary School Surabaya on April 30, 2021, to June 30, 2021 (n=59) No. Hand washing skills with soap F % 1. Unskilled 51 86.4 2. Skilled 8 13.6 Total 59 100.0 Table 3: Category of hand washing skills with soap after E-Learning of Health Protocols at Pelita Bangsa Elementary School Surabaya on 30 April, 2021 to 30 June 2021 (n=59) No Hand washing skills with soap F % 1 Unskilled 2 3.4 2 Skilled 57 96.6 Total 59 100.0 Table 4: The category of hand washing skills with soap at Pelita Bangsa Elementary School Surabaya from April 30, 2021, to June 30, 2021 (n=59) No Handwashing skill category with soap F % Before After Before After 1 Unskilled 51 2 86.4 3.4 2 Skilled 8 57 13.6 96.6 Total 59 59 100 100 Statistic test Wilcoxon Signed Rank Test p = 0,000 Z = -6.498 Table 5: Wilcoxon Statistical Test at Pelita Bangsa Elementary School Surabaya on 30 April 2021 to 30 June 2021 Hand washing skills with soap Ranks Wilcoxon Signed Rank Test N Mean Rank Sum Of Ranks Child skills before – Child skills after Negative Rank 1 17.50 17.50 Positive Rank 57 29.71 1693.5 Ties 1 TOTAL 59 38 Journal of Ners and Midwifery, Volume 9, Issue 1, April 2022, page 34-42 Test Statistics Child skills before – Child skills after Z -6.498b Asymp. Sig. (2-tailed) .000 DISCUSSION School-Age Children Skills in Facing Offline Learning Before and After Health Education Using E-Learning of Health Protocols Media at Pelita Bangsa Elementary School Surabaya Based on the results of research related to the skills of school-age children (hand washing skills with soap) facing offline learning, as many as 59 respondents it was known that the results of data recapitulation, before providing health education with E-Learning of Health Protocols, almost all respondents were included in the unskilled category with a total of 51 respondents (86.4%) while after the provision of health education with E-Learning of Health Protocols showed that almost all respondents were in the skilled category with a total of 57 respondents (96.6%). Skills are defined as aspects of behavior that are related to the ability to move the body's muscles. However, skills are not only limited by physical aspects, skills are the ability to complete tasks both physically and mentally. Come on in the book (Subaris, 2016). Skills can also be defined as the human ability to perform a task or a job by involving the limbs and equipment that has been provided. Skills are personal so that every human being will have a different skill level from one individual to another depending on their knowledge, abilities, and experience. This was in line with proprietary research (Wijayati, 2020) which explains that skills are a continuation of individual learning outcomes cognitively in understanding something and affectively or seen from their behavior. Measurement of skills can be done in two ways, namely directly and indirectly. Direct measurement is a measurement by observing (observation), namely observing an action from the subject in maintaining his health (Subaris, 2016). The results of Setiawan et al., (2017) explained that the skills seen were skills in washing hands with soap. Washing hands with soap is an effort to maintain hand hygiene to prevent or break the chain of disease transmission. We as adults as well as children need to be able to wash our hands in the right way to prevent ourselves or others from various diseases. (Setiawan et al., 2017). Before being given health education with E- Learning of Health Protocols related to proper hand washing with soap, almost all respondents were included in the unskilled category with a total of 51 respondents (86.4%) this was evidenced by the fact that respondents still did not take proper washing steps hands with the right soap. Several steps were not taken such as not rubbing the back of the hand and between the fingers, not rubbing the palms and between the fingers in an interlocked position, not rubbing the backs of the fingers against the palms with interlocked fingers, not grasping and washing the mother. fingers in a circular position, did not rub the tips of the fingers into the palms of the hands so that the nails could be exposed to soap, and did not clean the faucet spinner with a disposable cloth/tissue after washing hands. At Pelita Bangsa Elementary School Surabaya, there were facilities or hand washing tools to support respondents to be able to practice how to wash their hands in the right steps. According to the researcher, 51 respondents (86.4%) were unskilled because these respondents had not received information about how to wash their hands with soap in the right way even though there was already a brochure containing instructions for washing hands next to the existing sink. This respondent's unskilledness could be caused by several things, starting from the lack of children's curiosity about how to wash their hands in the right way, less exposure of children to hand washing information, lack of habit of reading brochures next to the sink, and habituation in washing hands with soap in the right steps and lack of awareness about clean and healthy behavior. This was in line with what was revealed by Chrisnawati, 2018 in her research that in addition to this, there are other things, namely the lack of information provided by health workers regarding PHBS, the lack of support from health workers as evidenced by the statement of the Principal of SDI Darul Mu'minin Banjarmasin, where PHBS health education activities in schools have never been held (Mulyadi et al., 2018). In this study, it appeared that respondents already had sufficient knowledge from various sources, both from parents, schools, and hospitals. However, in reality, Kili Astarani1, Fidiana Kurniawati2, E-Learing of Health Protocols Improving School-Age … 39 these respondents have not been able to carry out handwashing with the correct steps according to the 2020 Ministry of Health manual. At the time of the study, there were still children who washed their hands using only water without using soap. This could be seen in the observation sheet according to the 2020 Ministry of Health Handwashing Handbook with Soap in step number 2 which required using sufficient soap when washing hands. From the results of interviews conducted by researchers to respondents, it was found that several children had obtained information from various sources including television and their playmates, but were said to be unskilled because they could not remember the steps that had been taught and they forgot a little even though they had been given because it was not repeated every day. The Effect of E-Learning of Health Protocols on the Skills of School-Age Children in Facing Offline Learning in School-Age Children at Pelita Bangsa Elementary School Surabaya Based on the results of research related to the Effect of E-Learning of Health Protocols on the Skills of School-Age Children Facing Offline Learning in School-Age Children at Pelita Bangsa Elementary School, Surabaya, as many as 59 respondents were known for skills after being given health education with video media, almost entirely increased, namely 57 respondents (96, 6%). And a small part of the 2 respondents (3.4%) were still in the unskilled category. In detail, it coulld be explained that almost all of the 59 respondents, namely 57 respondents, experienced an increase from previously unskilled to skilled in washing hands with soap. Then a small percentage of 1 respondent was included in the fixed category which can be described as follows as much as 1 respondent before the provision of health education with video media was given into the unskilled category and after the provision of health education with video, media remained in the unskilled category. While 1 other respondent from before giving health education with video media was given into the skilled category then after being given health education with video media remained in the category accompanied by an increase in score with a p-value of 0.000 < 0.05. The Health Protocol is an effort to be able to prevent the risk of transmission of Covid-19, with the implementation of the health protocol, it is intended that people can still carry out their daily activities safely and do not endanger their health or the health of others. (Suryaningsih & Poerwati, 2020). However, in reality, the implementation of health protocols is still not fully implemented by the community, a simple example is washing hands with soap which is an important activity in preventing and controlling infection transmission. (Suryaningsih & Poerwati, 2020). One of the things that students are ready to receive offline learning at school is being able to apply health protocols appropriately. Prevention of the spread of Covid-19 that has been carried out and introduced by many countries by following WHO instructions and washing hands is the dominant thing that many do to avoid and break the chain of transmission of various diseases including Covid- 19 (Anies, 2020). This action was taken because basically, the hands are one of the agents that carry pathogenic germs that can be transferred from one person to another, and this can be done by children. Therefore, it is necessary to educate school-age children to always wash their hands before and after doing activities (Setiawan et al., 2017). Washing hands is one of the actions contained in the health protocol issued by the WHO to break the chain of the spread of the Covid-19 virus, this must be accustomed from an early age because children at elementary school age will find it easier to instill the value of knowledge will be useful in daily life (Mahdalena & Handayani, 2019). This can support providing learning experiences and without ignoring the principle of improving their health status during a pandemic. Washing hands is often considered a trivial thing in various elements of society, not only children, teenagers, but also parents. Whereas hand washing can contribute to improving health status (Wantiyah et al., 2015). Seeing the phenomenon that currently affects all sectors, including in the field of education. The learning process that should be carried out offline / face-to-face, is currently being carried out online to break the chain of Corona Virus Disease 19. The situation of the outbreak of Corona Virus Disease 19 or commonly referred to as Covid-19, Covid-19 is an infectious disease whose transmission occurs zoonotic or between animals and humans. This virus can cause mild to severe symptoms, infection from SARS- CoV-2 in humans can cause symptoms in the form of acute respiratory disorders such as fever, cough, and shortness of breath. And if in cases with severe symptoms this disease can cause pneumonia, acute 40 Journal of Ners and Midwifery, Volume 9, Issue 1, April 2022, page 34-42 respiratory syndrome, kidney failure, and also cause death. Symptoms of this disease can appear within 2-14 days after exposure (Kementerian Kesehatan RI, 2020) (Moudy & Syakurah, 2020). Health education can be defined as a process that is obtained from several experiences that influence both the habits, attitudes, and knowledge of an individual regarding health (Induniasih & Ratna, 2017). The provision of health education can also be explained as an effort to provide information and skills to individuals and groups related to health (Induniasih & Ratna, 2017). As support in providing health education, media is needed as a tool to facilitate the presenters in applying the material to be conveyed so that what is the goal in research can be achieved (Putra et al., 2020). Health education in this study related to how to wash hands with soap in the right way, using possible media, namely video through e- learning. E-learning using video has the advantage that students can access it wherever they are and at any time. E-learning with video media was chosen by researchers because it was considered quite interesting and practical to give to children, this was in line with research (Heru et al., 2014) which states that the function of using video media modeling is to display more practical hand washing movements. and easy. Video media can be used as an alternative to providing health education because it can stimulate several senses in children such as the sense of sight and hearing which makes information given to children more quickly accepted so that the results obtained are more optimal (Putra et al., 2020). In this case, the provision of health education on the correct steps for handwashing could be accessed, accepted, studied, and applied to respondents with school- age levels. The intervention to the respondents, namely the provision of health education through E- learning through the video steps for washing hands with soap, influenced this study, as evidenced by the increase in the skill scores before and after the respondents. So that after health education with video media was given, there was an increase in handwashing skills with soap for school-age children at Pelita Bangsa Elementary School, Surabaya. The results of this study were in line with research (Heru et al., 2014) which states that there is an increase in the ability to wash hands in 4th-grade students, it can be seen from the student's average handwashing ability score which was previously 12.78 after being given video media modeling. to 21.64 means that the handwashing ability score has increased. Also in line with proprietary research (Qurrotul Aeni & Warsito, 2015) which said that handwashing skills health counseling activities increased by 73.3%. So, it could be concluded that there was an effect of health education using video media. This research was also in line with research (Rachmawati & Putr, 2016) The Effect of Counseling on hand washing with video media on the application of hand washing practices at SDN Nogotirto Yogyakarta. The study used a one-group pre-test post-test design which resulted in the effect of counseling on hand washing with video media on the application of handwashing practice, namely based on the results of data analysis, the average pre-test value was 52.33 and the average value post-test 58.62 with an average difference of 6.29 and p-value 0.02 <0.05 then Ha was accepted and Ho was rejected. This means that there is an influence of E-Learning of Health Protocols on the Skills of School-Age Children in facing offline learning, namely the application of hand washing practices. The provision of education using E- Learning of Health Protocols video media was good for school-age children because it was interesting for children to be able to understand the messages conveyed easily and to some extent could change the behavior of washing hands with soap. In addition, it could increase children's knowledge about how to wash their hands with soap, as well as recall children's memories if they could not remember well the steps they have previously received from these various sources. This was in line with proprietary research (Setiawan et al., 2017) the use of video media is very effective given to school-age children because using video media will increase children's interest in learning and children can absorb the information conveyed by the presenters through images and sounds that can be watched during a few minutes and can be directly followed by students while watching videos related to the lessons delivered. In the results of this study, there were still 2 respondents who were not skilled. The researcher argued that this could be due to the attitude of not paying attention when presenting the video about washing hands, it was proven that the respondent several times turned his attention to his friends who were playing around him so that the respondent did not understand the content of the video presented. This was in line with proprietary research (Livana, 2020) which explains that Kili Astarani1, Fidiana Kurniawati2, E-Learing of Health Protocols Improving School-Age … 41 students who have a negative attitude have an opportunity to behave poorly in CTPS by 2 times compared to students who have a positive attitude. The researcher argued that the attitudes of respondents in the Mesuji Regency had not formed behavior because their attitudes were still influenced by external circumstances and conditions when they wanted to do CTPS correctly. Therefore, health promotion interventions that could be carried out were formulating forms, methods, and health promotion strategies that refered to three psychological domains, namely cognitive changes, affective changes, and psychomotor changes. Respondents carried out for the benefit of the health of themselves and their families. Skills in washing hands with soap were an indicator of the readiness of school-age students to take offline learning, adjusting government policies in the field of education in response to Covid-19 cases. CONCLUSION The skills of school-age children facing offline learning at Pelita Bangsa Elementary School in Surabaya before the provision of E- Learning of Health Protocols, almost all of the respondents have been in the unskilled category. E-Learning of Health Protocols have affected the skills of school-age children to face offline learning at Pelita Bangsa Elementary School Surabaya SUGGESTION Based on this research, it is hoped that it can increase knowledge and information regarding the behavior of washing hands with soap through the E-Learning of Health Protocols media and is expected to change the behavior and motivation of elementary school-aged children to be able to wash their hands with soap properly and correctly so that children have readiness in implementing offline learning. ACKNOWLEDGMENT I thank God Almighty for His grace so that the research activity report with the title "E- Learning of Health Protocols Improving Skills of School-Age Children Facing Offline Learning". It can be solved in the best way. I hereby express my deepest gratitude to. Mrs. Selvia David Richard, S.Kep., Ns., M.Kep as the Head of STIKES Baptist Hospital in Kediri who has given permission, opportunities, and facilities to carry out the Tri Dharma of Higher Education activities. The Principal of SD Pelita Bangsa Surabaya as the Principal who has given permission and the opportunity to do community service. All teachers and students of SD Pelita Bangsa Surabaya who participated in this activity. The entire research team at STIKES RS. Baptist Kediri who have participated in the completion of community service reports that I cannot mention one by one. God Almighty repays the kindness of all those who have helped, prayed for, provided input, and was enthusiastic in completing this journal. The author realizes that the preparation of this journal still has many shortcomings and weaknesses. Therefore, the writer expects corrections in the form of criticism and suggestions that are beneficial. 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