Determinant of Smoking Behavior at Home as a Clean and Healthy Life Behavior Effort in Puskesmas Nanjungmekar in 2019 1

PHBS Household itself is an effort so that families know, want and be able to maintain their own health in the health sector so as to avoid various risks of disease. The purpose of this study was to determine the determinants of smoking behavior in the home as an effort to clean and healthy behavior in the household setting in the working area of Nanjungmekar Health Center. The study design uses descriptive correlational with Cross Sectional approach. Sampling used Multistage Sampling as many as 96 households. The measuring instrument is a questionnaire with Chi-square analysis. The results showed that the majority (54.2%) of family heads behaved in the house smoking. There is a relationship of knowledge, attitudes, and the role of cadres with smoking behavior and there is no relationship between motivation and smoking behavior. So it is necessary to disseminate PHBS evenly throughout the work area of the puskesmas through increasing the performance of cadres in order to be more competent in carrying out their duties in order to increase the coverage of household PHBS in the work area of the Nanjungmekar Puskesmas.


Introduction
Sustainable Development Goal (SDG's) is a sustainable development program containing a set of transformative goals that are agreed upon and applicable to the entire nation without exception. Obtaining health and well-being is the 3rd message from 17 SDG's goals which are at the same time one of the development priorities for the Indonesian State (Bappenas, 2019). Disease prevention and reducing unhealthy behaviors are targets for achieving optimal health and well-being. These efforts can be realized by implementing the clean and healthy behavior program (Bappenas, 2018).
The number of households in West Java in 2017 was 14,147,170 households, which were monitored by the attitude of PHBS behavior, namely 8027,722 families. From this monitoring it was found that 4,309,125 families behaved in PHBS with 57.80% coverage. The coverage figure has increased from the previous year which was 5.3%. This shows that the efforts to improve the degree of public health are quite successful even though there are still many households that have not PHBS (Dinkes, 2017a) (Dinkes, 2017b).
In 2017 Bandung Regency was ranked 19th with the lowest increase in coverage of 27 districts and cities in West Java, amounting to 53.60%. The increase in the number of coverage in the last two years was only 0.5%, which shows that the increase that occurred is still far from the target set by the Bandung Regency Office, which is 75%. The acquisition of coverage over the past two years shows that there are still many households in the Bandung Regency region who have not implemented clean and healthy behavior (Dinkes, 2017a).
Smoking behavior itself is one of the behaviors influenced by several factors as explained in the L Green theory that health behavior is influenced by several factors, where predisposing factors which include knowledge, attitudes, keyism, values and traditions/culture. Then proceed with enabling factors which include things like, health facilities, supporting infrastructure, and distance to health services. Then followed by reinforcing factors that determine health actions that can support the running of an activity such as community leaders, the role of health workers (Notoatmodjo, 2018;Yarmaliza & Farisni, 2018;Syahputri et al., 2019) Nanjungmekar Health Center is one of the health centers that reviewed household PHBS that has not yet reached the specified target coverage. In 2018 the coverage of PHBS household in Nanjungmekar Health Center only received 16% coverage with a decrease in coverage of 41.1%. Household PHBS reviewed by Nanjungmekar Health Center includes 10 indicators including childbirth by health workers 99.1%, exclusive breastfeeding 63.7%, weighing toddlers 87%, using clean water 83.6%, washing hands with clean water and soap 79, 3%, using healthy latrines 71.4%, eradicate larvae 83.4%, eating fruits and vegetables every day 73.6%, and the last indicator is no smoking in the house 22.1%.
Based on the results of interviews conducted with community members of the community health work area among them stated that smoking in the house had become a habit and considered the activity a natural thing that would not cause any effect. Therefore, most people in the working area of Nanjungmekar Health Center still consider smoking inside the house as a normal behavior and will not cause significant problems. The community behavior occurs due to lack of counseling and the absence of appropriate interventions so that the smoking rate in the home is always high. The purpose of this study was to determine the determinants of smoking behavior in the home as an effort to clean and healthy behavior in the household setting in the working area of Nanjungmekar Health Center.

Materials and Methods
This research uses quantitative methods with cross sectional research design. By way of approach, observation or data collection at one time (point time approach) (Notoatmodjo, 2014). The independent variables examined are (knowledge, attitudes, motivation and the role of cadres) while the dependent variable under study is (smoking behavior in the home).
The population in this study is the head of the family in the working area of Nanjungmekar Community Health Center in 2019, amounting to 13,652 households. The sample in this study was 96 families. Research instruments are tools used for data collection (Notoatmodjo, 2014). The instrument used in this study was in the form of a questionnaire. Based on the way to obtain data, the types of data collected in this study were primary and secondary data and if there is an error can be suppressed as little as possible, and with the help of a computer. In analyzing the data, the authors used univariate analysis and bivariate analysis methods. Chi square test results obtained p value of 0.004 (P value < 0.05), which means there is a significant relationship between knowledge of the head of the family with smoking behavior in the home in the working area of Nanjungmekar Health Center in 2019 as shown in Table 1.

Results
The results showed that, a small portion of the community who lacked knowledge due to the lack of effective dissemination of information that was only given in certain times and the implementation of counseling was only done inside the Puskesmas building while out-building counseling was rarely done. While half of the community has good knowledge but still smoking because of lack of individual awareness and consider smoking in the house is a reasonable activity to do. Based on the results of the answers is a leisure activity as shown in Table 2.
Chi square test results obtained P value of 0.015 (P value <0.05), which means there is a significant relationship between the attitude of the head of the family with smoking behavior in the house. The results of the Prevalence Odds Ratio (POR) = 3.039 which means the head of the family those who have the attitude of not supporting the opportunity to behave smoking 3 times in the house compared to the head of the family who has a supportive attitude.
The results showed that, the majority of family heads have unsupportive attitudes towards smoking behavior in the home. This is seen from the response of the head of the family that the head of the family ignored the prohibition of smoking in the house because he felt it was useless and applying the prohibition of not smoking in the house was a compulsion.

Discussion
Knowledge can directly produce actions (open responses) and attitudes can also be preceded (closed responses) then actions (open responses). Therefore, in the context of healthy behavior, people need to be given correct and complete knowledge or information about illness and health services. Trust that is not based on true and complete knowledge, will cause mistakes to act (Lena & Eko, 2015). This study is strengthened by the research of Lena & Eko (2015) which is almost similar, stating that knowledge is related to the prevention of smoking behavior. Knowledge of people with the importance of personal and environmental health to prevent contracting a disease (Nurbaya, 2014). This is in line with previously study that there are 9 people or 13.2% of household heads who have less knowledge. This could be due to the low education factor of the head of the household and lack of information about PHBS problems so that the knowledge of the head of the household about PHBS in the household category was lacking (Trisnowati & Suryatno, 2017).
The level of education will affect the way someone thinks in behavior and a behavior will last with the education of a person. With education will help someone think and apply PHBS well (Notoatmodjo, 2011). This relates to one's knowledge because education is a basic thing that can shape one's mindset so that it affects one's knowledge and attitudes in daily life (Wulandini & Saputra, 2018).
According to Azwar (2013), factors that influenced attitudes included: personal experience, influence of others who are considered important, cultural influences, mass media, educational institutions and religious institutions and emotional factors. Notoatmodjo (2018) explained that attitudes are not certain to be realized in an action (over behavior) that is real or in the form of activity, but rather a predisposition of behavior (closed reaction). To realize the attitude to be a real action in certain conditions, such as when individuals behave not smoking in the house.
The results of the above study were also strengthened by the research of Alamsyah & Agus (2017) in which the results showed a significant relationship between attitude and smoking behavior with a P Value of 0.00. Most students agree that smoking is a negative action, but there are students who have a negative attitude towards smoking which is 38.9%. This shows that there are some students who tend to want to be given the freedom to smoke (Alamsyah & Agus, 2017). Another supporting research showed that negative attitudes toward smoking will risk smoking behavior compared to positive ones (Rachmat et al., 2013).
According to Aryani in 2010, attitude is a very important thing related to smoking behavior, because in essence the attitude will determine a person behaves towards an object whether realized or not realized that attitude is influenced by knowledge, beliefs and emotions (Alamsyah & Agus, 2017).
Chi square test results obtained P Value of 0.112 P Value> 0.05 which means that Ho was received with a statistical test showed there was no significant relationship between motivation of family heads with smoking behavior in the home. Prevalence Odds Ratio (POR) 2.105 which means the head of the family those who have poor motivation have a 2.1 times chance of smoking behavior in the home compared to family heads who have good motivation.
The results of this study indicate that the majority of family heads have poor motivation, people often behave in smoking in the house because they feel accustomed to and consider things to be done. This is seen from the response of the head of the family that smoking behavior in the house is a habit that has long been done by the head of the family.
Motivation is an effort to increase activities in achieving a goal. Motivation is needed as an activator in an individual to do something. Intrinsic motivation is more important than extrinsic motivation because intrinsic motivation arises from within the individual himself without any external stimulation. Intrinsic motivation is more pure and lasting and does not depend on the encouragement or influence of others (Wulandini & Saputra, 2018).
Habits in society that have long been done to make people think of it as something that is not dangerous. Where the habit of smoking in the house has been done by previous generations. Previously research also states that the factors that influence a person's behavior are reinforcing factors, where social support is included (Khairunnisa & Nurlaella, 2015) Chi square test results obtained P Value of 0.004 (P value <0.05) then Ho is rejected, which means there is a significant relationship between the role of health cadres with smoking behavior in the home. The results of the Prevalence Odds Ratio (POR) = 3.722 which means the head families who gave a value did not support the role of cadres with 3.7 times more likely to behave smoking in the home than the head of the family who gave support values to the role of cadres. Half the head of the family gave an unsupportive assessment of the role of the health center. This can be seen from the answers to the cadre's assessment statement that the cadres only did PHBS data collection without giving counseling especially indicators of not smoking in the house This study was also strengthened by Surhayanta's almost similar research that the results of the correlation analysis of knowing between each independent variable, can be seen from the significant value (P) <0.010 or 0.000 <0.010 which means H0 is rejected and Ha is accepted, there is an influence between the role of health workers by preventing smoking behavior (Suharyanta & Widiyaningsih, 2018).
According to Charles the role of health workers is needed to change people's behavior, therefore health workers must be able to provide conditions that can affect positive behavior towards health, one of them is the application of PHBS in the household, especially indicators of not smoking in the home (Sukowati & Shinta, 2003). This influence depends on persuasive communication aimed at the community, where it can include attention, understanding, recipient's memory and behavior change (Kurniawati et al., 2018) This is phenomenon which states that a person will be more motivated to perform a health behavior when he gets social support from people around him either informationally, instrumentally, or just approval. Based on this, it can be concluded that social support is an important thing that needs attention and is formed in mobilizing PHBS in the Household. Therefore, optimization of health promotion efforts is needed on secondary targets, namely husbands, family members, community leaders, and cadres, health workers (Khairunnisa & Nurlaella, 2015).

Conclusion
Based on the results of the study concluded that there is a relationship between knowledge, attitudes, motivation and the role of cadres with smoking behavior in the home. Researchers suggest that Nanjungmekar Health Center can provide appropriate interventions such as conducting routine cadre training, holding regular counseling in all health centers, and of course providing optimal services for the community in order to achieve the clean and healthy lifestyle behavior targets in the Nanjungmekar Health Center.

Acknowledgement
Thanks to the District Health Office of Bandung, Head of the Nanjungmekar Health Center and staff, cadres who have provided assistance to researchers. To the University of Bhakti Kencana, especially the Faculty of Health Sciences which has given permission to carry out this research. To all those who could not be mentioned one by one who had provided assistance so that the implementation of this research was carried out smoothly.

Author Contribution and Competing Interest
The author's contribution in this article is Ratna as the main contributor who is responsible for the formulation or approval of the research goals and objectives. Bintang as a contributor who is responsible for the development or design and evaluations as well as conducting experiments or collecting data.