Mother's Perspective and Trust Toward Integrated Services Post (Posyandu) in Indonesia

3.1. Mother's Knowledge

Twelve questions were administered to assess mothers' knowledge regarding ISP. The majority of mothers (>98%) responded correctly to inquiries about whether children should continue to be weighed after one year, the initial time for weighing a child, the definition of ISP, and the advantages of weighing children at ISP. Over 70% of mothers provided accurate responses concerning ISP schedules, the age at which children should be weighed, the Health Card (HC), known in Indonesia as Kartu Menuju Sehat, appropriate actions for underweight children, the first immunization given to infants, and vitamin A administration schedules. While mothers demonstrated accurate knowledge in most areas, when asked about appropriate measures for severely wasted children, 57.8% of mothers provided incorrect responses. Detailed results are presented in Fig. (1).

3.2. Mother's Behavior and Trust in ISP

Mothers' behavior toward the ISP was assessed and categorized into positive and negative behaviors. The majority exhibited positive behavior, with most respondents selecting “strongly agree” or “agree” for statements indicating trust and approval of ISP services. For instance, 89.1% of mothers strongly agreed that ISP provides essential health services for babies, mothers, and children. Similarly, 88.0% strongly agreed, and 7.1% agreed that ISP is beneficial due to the provision of free vitamin A for children. Furthermore, 69.8% strongly agreed, and 18.7% agreed that ISP contributes positively to the health of mothers and children. Responses were more varied for the statement, “If toddlers need health services, mothers only need to visit ISP and not other health facilities,” with 30.9% strongly disagreeing and 25.8% strongly agreeing, indicating some diversity in reliance on ISP as a sole health resource. Overall, mothers recognized ISP’s role in monitoring child growth, educating mothers on health, and supporting pregnant, postpartum, and breastfeeding women. For statements reflecting negative behaviors, the majority of mothers responded with “strongly disagree” across all nine items. However, some mothers indicated negative behavior by selecting “strongly agree” or “agree” for statements such as, “mothers only bring the youngest child to ISP if they have more than two children” and “mothers no longer bring children to ISP once immunizations are complete.” Further response details are presented in Table 2.

The behavioral assessment revealed that mothers demonstrated a strong belief in the ISP, as evidenced by a high percentage of agreement (89%) regarding the ISP as a source of more accessible health services. Additionally, a significant proportion of mothers (86.1%) considered the ISP a reliable venue for monitoring the growth and development of children.

3.3. Family Support

In addition to knowledge and behavior, family support was also evaluated. The majority of mothers (87-91%) received various forms of family support, including reminders of ISP schedules, information about ISP benefits, motivation to attend ISP sessions, intervention when mothers failed to attend ISP, support for immunization, and assistance in transporting mothers/children to ISP. Notably, 53.8% of mothers reported receiving admonishment from their husbands or family members for not visiting the ISP. Nonetheless, 4.2% of mothers reported being prohibited by family members from attending ISP due to opposition to immunization. Additionally, 8.1% of families expressed reluctance to accompany mothers and children to ISP, and 12.5% did not provide assistance in bringing children to ISP when the mothers were unable to attend, as illustrated in Fig. (2).

The analysis revealed significant patterns in mothers' knowledge, trust, and family support concerning Posyandu services. An overwhelming majority of mothers exhibited a comprehensive understanding of Posyandu, with over 98% accurately responding to inquiries about its fundamental functions and advantages. This extensive knowledge was accompanied by robust trust in the program, as 88.5% of mothers strongly believed in Posyandu's capacity to enhance maternal and child health. Furthermore, the study found that a substantial proportion of mothers (87-91%) reported receiving familial support for Posyandu participation. These findings suggest that interventions focusing on both knowledge enhancement and family engagement could potentially yield effective results in improving Posyandu utilization and outcomes.

4.1. Mother's Knowledge

In general, mothers demonstrated substantial knowledge about ISP, although certain areas showed gaps in knowledge. This finding aligns with a previous study by Susanti in Purwakarta regency, which revealed that the majority of mothers aged 20-35 years possessed sufficient knowledge regarding ISP (9]. Mothers with adequate ISP knowledge may indicate active participation and effective utilization of these services. A study conducted in Jantho demonstrated a correlation between ISP use and child nutritional status [9, 10]. However, another study suggested that maternal participation was not associated with toddlers' nutritional status, potentially due to mothers' insufficient knowledge about toddlers' nutritional requirements [11].

The assessment of maternal knowledge revealed that, despite mothers answering correctly on most questions, more than half of the mothers in this study still harbored misconceptions regarding the management of severely wasted children. This discrepancy may be attributed to the fact that the management of severely wasted children is typically conducted in primary health care services rather than in ISP, although preventive measures could be implemented through ISP activities [12].

Although our findings indicate that mothers generally possess adequate knowledge about Posyandu, this understanding does not consistently correlate with high visit frequency across all respondents. This discrepancy suggests that knowledge alone may be insufficient to ensure regular Posyandu attendance. Additional factors, such as accessibility, time constraints, or perceived necessity, may influence visit frequency. Further research is warranted to investigate these potential barriers to attendance despite the presence of sufficient knowledge.

4.2. Mother's Behavior and Trust in ISP

The behavior assessment revealed that mothers in this study predominantly exhibited positive attitudes toward ISP and believed that ISP facilitated community access to health services, indicating high trust in ISP. However, this finding contrasts with a previous study conducted in 'Posyandu Melati', sub-district Wajo, Makassar city, which demonstrated that mothers' knowledge and behavior regarding ISP were insufficient. The previous study also indicated that mothers lacked the initiative to visit ISP, with some only willing to attend for vitamin A, supplementary food, and medicine. Work commitments also hindered mothers' attendance, resulting in a limited understanding of ISP systems due to infrequent visits [13]. Reasons identified in previous studies for why some mothers do not attend ISP were also observed in this study, although a relatively small percentage of participants represented them. The disparity in mothers' behavior toward ISP between this study and the previous one could be attributed to socio-demographic factors and maternal characteristics. Different locations may have distinct cultures and health approaches, while varying maternal backgrounds, such as workload and education level, could influence behavior regarding ISP. A study in Aceh demonstrated that husbands' perspectives, family, and social environment were factors affecting mothers' trust in ISP, with maternal knowledge playing a vital role in awareness and willingness to visit ISP [14]. Another study conducted during COVID-19 revealed that community attitudes and social circumstances were associated with maternal anxiety. During the COVID-19 pandemic, mothers reported feeling anxious about visiting ISP due to fears of exposure, especially as some visitors might not comply with recommended health protocols [15]. This finding suggests that external conditions and the behavior of others can substantially impact mothers' willingness to engage with ISP services. Additionally, the range of services available at ISP varies by location, influencing attendance; for instance, rural ISPs typically offer a broader array of activities compared with their urban counterparts [16]. Minimal service offerings at some ISP occurred due to challenges such as financial barriers, medicine and equipment shortages, and location constraints. ISP situated far from mothers' homes often deterred attendance. Additional factors contributing to mothers' reluctance included perceptions that child weight monitoring was less valuable than receiving supple- mentary food or medicine, lack of knowledge, absence of spousal support, and work commitments [14, 16].

4.3. Family Support

The majority of mothers in this study reported having supportive husbands or family members. However, 4% of mothers indicated that their husbands or families opposed immunization and, as a result, prevented them from attending ISP. A study conducted in Blora reported similar findings, with most families demonstrating strong support for mothers concerning ISP visits. Additionally, research has shown a significant correlation between family support and toddlers' compliance with ISP visits [17]. A study in Aceh also identified negative family perspectives that hindered mothers from attending ISPs, such as husbands scolding their wives and negative views on immunization due to post-vaccination fever in children [14]. Several studies have reported negative attitudes toward immunization from families or mothers. Research at the Public Health Center Culamega revealed that 45% of mothers lacked parental support or were prohibited by their husbands and parents from immunizing their children [18]. A study in Semarang identified a lack of support from parents, husbands, friends, cadres, and religious leaders regarding basic immunization. Mothers obtained information from unreliable sources claiming that immunization was forbidden, leading them to incomplete basic immunization for their children [19]. A 2021 study demonstrated that the majority of mothers had low perceived susceptibility to health issues and consequently did not immunize their children. Furthermore, 55% of mothers had low perceived severity and were unaware of the potential consequences of illnesses without basic immunization, thus considering immunization unimportant [18].

Husbands' support can significantly influence mothers' behaviors regarding ISP attendance, as husbands often hold greater decision-making authority within households, including decisions about whether mothers and children visit ISP [20]. A supportive family environment can also positively impact mothers' attitudes toward ISP. Research conducted in Sukabumi demonstrated an association between family support and children's ISP attendance [21]. Similarly, a study in Pemalang revealed significant differences in family support and ISP visit frequency between stunted and non-stunted children, with non-stunted toddlers receiving better family support and attending ISP more frequently than their stunted counterparts [22]. Additionally, midwives may play a crucial role in educating mothers, thus potentially influencing maternal perspectives on ISP [23].

While our study offers a comprehensive overview of maternal perspectives and behaviors regarding Posyandu across Indonesia, it is important to acknowledge that potential regional variations were not specifically examined in this research. Indonesia's diverse geographical and cultural landscape suggests that there may be disparities in Posyandu utilization and effectiveness across different areas. Future studies could investigate these potential variations to inform more tailored approaches to Posyandu promotion and service delivery throughout Indonesia's diverse regions. Such research could contribute to the development of strategies that are sensitive to local contexts and needs, potentially enhancing the overall effectiveness of the Posyandu program nationwide.

Further research should investigate the underlying reasons for families opposing immunization, potentially employing qualitative methods to gain deeper insights into their concerns and beliefs. Moreover, further research is required to examine the specific barriers encountered by mothers with limited family support and to design targeted interventions that effectively mitigate these obstacles. Longitudinal studies tracking changes in mothers' perspectives and Posyandu utilization over time would also prove valuable in assessing the long-term impact of educational initiatives and policy changes.

The online survey method employed in this study may introduce a potential selection bias, potentially under- representing mothers lacking internet access or those less comfortable with digital platforms. Furthermore, to address this limitation, concerted efforts were made to reach diverse populations through various channels and community networks. However, this constraint should be considered when interpreting the results. Despite these limitations, our methodology aimed to provide a comprehensive and nuanced understanding of mothers' perspectives, knowledge, behavior, and family support regarding Posyandu services across Indonesia.