Model of Behavioral Change of Dental Health Social Workers on Community Dental Health Effort Program (UKGM): a qualitative study

. Objectives: to analyze behavioral changes in dental health social workers at the Community Dental Health Effort Program (UKGM) in Semarang Regency, Central Java, Indonesia. Background: The dental health social workers are driving figures in the community, are expected to be able to play a role and provide examples in behavioral change in the field of dental health. Design and Methods: This research is a qualitative study with a phenomenological approach. The sampling method was purposive sampling from urban and rural areas. As a participant is : 5 people as dental health social workers from urban areas and 5 people from rural areas, 1 person in charge of the program at the district health office, 2 people from dental health workers at Public Health Center. Data analysis was carried out by holistic analysis of all cases. Results: The level of perceived susceptibility is quite good, the perception of the severity of dental and oral disease has been positive, there are no perceived barriers, there are benefits that are felt after doing self-care, the level of confidence after doing self-care is relatively good. Conclusion: the behavior of dental health social workers in self-care in the field of dental health is not optimal.


Introduction
The existence of a global policy in the SDGs (Sustainable Development Goals) in accordance with what is mandated in Constitution no. 36 of 2009 concerning Health, which explains that health development aims to increase awareness, willingness, and ability to live healthy for everyone in order to realize the highest degree of public health, as an investment for the development of socially and economically productive human resources [1].
The most common dental and oral health problems were cases of dental cavities (dental caries) with a prevalence of 88.8%. with an average of 7.1 teeth damaged per resident (Kemenkes-RI, 2019). Personal hygiene behavior in dental and oral health by brushing their teeth every day does show a fairly high number, namely 94.7%, but those who brush their teeth in the right way according to program recommendations, namely after breakfast and before going to bed at night only 2.8% [2].
The existence of this condition indicates that the behavior in performing self -care in the field of dental health carried out by the community has not been able to create a better condition. Behavior is one of the determinants of health, influencing disease incidence as a measure of health outcomes, or positive aspects of health (such as quality of life, life skills, or health expectations), and health-related behaviors and actions by individuals. It is further explained that lifestyle is a way of life based on behavioral patterns that can be identified by influencing influences, among the interactions of individual persona l characteristics, social interactions, and socio-economic and environmental conditions of life [3].
In addition to behavioral factors, in improving the degree of dental and oral health, the participation of all parties is also needed. The obligation of the need for community participation in creating optimal dental health conditions has been regulated in Constitution no. 36 of 2009 concerning Health, paragraph (1) reads: "Everyone is obliged to participate in realizing, maintaining, and improving the highest degree of public health" [1].
Community participation is a concrete form and the core form of community empowerment. In the context of health described by WHO in the Health promotion glossary, what is meant by health empowerment in health promotion is the process by which people gain greater control over decisions and actions that affect their health [4].
The condition of community participation in the field of dental and oral health carried out by health social workers dental health is not optimal. The results that Pratiwi conducted in 2004 in the Pasuruan area were 18.5% of health social workers dental health who were not active in conducting coaching. This study also found that promotive is one of the dimensions and indicators of health behavior possessed by social workers dental health [5].
The model of community empowerment in the health sector in Indonesia is applied through UKBM (Community Based Health Efforts). One form of UKBM is UKGM (Community Dental Health Efforts), which is an educational approach that aims to increase the ability and participation of the community in maintaining dental health, by integrating promotive, preventive, and dental health efforts in various UKBMs based on the approach Primary Health Care. This approach is known globally as the Primary Oral Health Care Approach [6].
Conditions that occur in the field, it is found that the performance of the UKGM program is not optimal, so far what can be monitored is activities through Posyandu whose coverage until the latest data in 1998 only reached 29.86% of villages and 24.76% of Posyandu. The results of RISFASKES (Health facility research) in 2011 data that can be seen are the number of Public Health Centers nationally that provide dental health services plus UKGS (school dental health program) plus UKGM by 50.8%, for Puskesmas that provide dental health services and UKGM by 7.1%, while Puskesmas that only provide UKGM services. of 7.1%, although the condition of the data like this can at least give us an idea that not all Puskesmas have been able to provide UKGM guidance [6]. Empowerment can be seen from different levels, namely at the individual, organizational and community levels. Theories and models of health promotion at the individual level include the Health Belief Model [7]. According to Glanz, Health Belief Model (HBM) contains several key concepts that predict why people will take action to prevent, screen, or control disease conditions; these include susceptibility, seriousness, benefits and barriers to behavior, triggers for action, and most recently, self-efficacy [8].
Empowerment conditions that have not been optimal in the field of dental health through the UKGM program, occurred in Semarang Regency, obtained data from previous research regarding the results of coaching, namely the frequency of coaching 2 times per year only 53 villages (28.5%), and those being fostered 3 times per year. as many as 18 villages (9.7%), so that the overall achievement of the frequency of coaching that reaches the target (2 and 3 times) is 38.2%. In addition, there are still a number of villages with a coaching frequency of only 1 time in 1 year with a fairly large proportion, almost equal to the number of villages that could achieve the target of 67 villages (36%) [9]. In addition to the problem of empowerment that has not been optimal, the results of a preliminary study of 14 social workers dental health who had received UKGM training on dental health showed that 4 people (28%) had not brushed their teeth before going to bed regularly, 12 people (85%) did not. regular dental check-ups every 6 months and not cleaning tartar in the last 6 months.
To be able to realize optimal community empowerment, there are four domains of community empowerment organizations formed based on the opinions and perceptions of Rapla community members, namely: (i) community activation; (ii) community competence in solving their own problems; (iii) program management skills and (iv) creating a supportive environment [10].
Social workers dental health is expected to act as innovators for their groups, to be able to play a maximum role, it is hoped that individual social workers dental health has a sufficient foundation for positive dental health behavior. Apart from being referred to as an agent of change, in a new innovation an agent is often referred to as an assistant from a professional to his clients. An assistant in order to increase trust in his client needs to show a success that has been made by an innovator. Direct experience experienced by Repetto, a surveyor vasectomy in India, to implement the success of a vasectomy, a surveyor must also be able to show the success he experienced [11].
The need for the presence of social workers in the health sector as agents of change as described in the theory of social change is the "agent" theory, that social change is caused by various agents. In the beginning, individual roles have very little power, but collectively will have great power. interdependence between actors and systems [12].
The need for the presence of health workers who in this case are social workers in the health sector considering that the pattern of life that occurs in the community is a pattern of interdependence with one another. The life of biological organisms with social structures has similarities in terms of order and balance as a system, so that society is a collection of interconnected and dependent social systems [13].
The construction of HBM is based on three essential factors, namely: 1) individual readiness to change behavior in order to avoid a disease or minimize health risks; 2) there is an encouragement in the individual's environment that motivates to change behavior, and: 3) the behavior itself. In 1988, the HBM building was revised by Rosenstock, Streaker and Bekecker. In the revision then HBM is constructed in: (a). Background, which is a socio demographic factor such as education, age, gender, ethnicity, ethnicity; (b) Perception, including (i) threat, namely perceived susceptibility or receiving a diagnosis, and perceived severity of health and illness; (ii) Expectations include: perceived benefits or benefits (perceived benefits of action), (perceived barriers to action perceived barriers to action), and perceived take action (self-efficacy to self-efficacy to performance action); (c) triggers for action (cues to action), such as the media, influence personal and reminder, and (d) Behavior to reduce threat based on expectation [3].
Looking at the results of a preliminary study on dental health social workers dental health in Semarang Regency, there are still problems in personal hygiene behavior which is run by social workers dental health still needs attention. As an agent of change, dental health social workers dental health is expected to have basic protective behavior better self-esteem as a provision to set an example for the community in their area. Based on the background above, it shows that health promotion and empowerment in the UKGM program have not been running as they should. Researchers are interested in seeing the factors that influence changes in personal hygiene behavior in the field of oral health.
The purpose of this study was to obtain an overview of the factors that influence changes in personal hygiene behavior in the field of dental and oral health from dental health social workers.

Design and methods
It is qualitative research with a phenomenological approach. The subjects in this study were dental health social workers who were members of the Community Dental Health Efforts (UKGM) in Semarang Regency who came from urban and rural groups. The criteria for categorizing rural and urban areas are taken based on the Ministry of Home Affairs regulations. The dental health social workers in urban areas are cadres who come from areas whose leadership in the area is led by civil servant officials appointed by the government, while rural areas are areas whose leaders are taken from elements of the local community who are elected by the community itself and are not civil servants who are called heads village.
The sampling method was purposive sampling with the criteria taken from the community groups represented, that were from urban and rural areas. The inclusion variables in this study were dental health social workers who had attended training and were actively carrying out their duties as dental health social workers. Based on these provisions, the participants who were used as informants consisted of: 7 dental health social workers from urban areas and 7 people from rural areas.
Testing the validity and reliability in this study was carried out using the Credibility test, this technique was carried out by triangulation of sources and triangulation of techniques. Triangulation is carried out through checking data from various sources other than the main informant source, then from the data obtained, crosschecking with other sources is also carried out, namely: 1 person in charge of the program at the district health office, 2 people from dental health workers at public health centers (Puskesmas) in urban and rural areas, and 2 people from regional leaders from rural and urban areas. In addition, technical triangulation was also carried out to explore data using two different techniques, namely the technique of giving direct questions to the informant and the same question being repeated with a different technique, which is continued by collecting data with discussion techniques together through focus group discussions (FGD).
Data was collected by using in depth interview and forum group discussion (FGD). At the initial data mining stage, personal indept interviews were carried out with 7 main informants from rural areas and 7 informants from urban areas. Furthermore, in order to clarify the truth of the data, triangulation of sources was carried out to informants, 1 district health office officer, 2 puskesmas officers, and 2 rural and urban area leaders. To complete the data as well as clarify the data, data mining techniques were also carried out with focus group discussions (FGD) on all informants simultaneously as many as 19 informants. Table 1. Operational definitions of independent variables from the dependent No Variables Operational Definition Perceived Susceptibility feelings possessed by respondents from the point of view of responding to any conditions that make a person susceptible to dental and oral diseases from the point of view of the target and the physical condition of the oral cavity. Perceived Severity subjective assessment of the severity of the incidence of dental and oral disease regarding the complications caused, the possibility of activity disturbances, the threat of job opportunities. Benefits to action This is the condition that respondents want for the benefits of carrying out personal hygiene, namely the benefits after carrying out specific protection, and the benefits of conducting an early examination (diagnosis and from treatment). Perceived barriers to action possible barriers that occur as a result of performing personal hygiene from the dimensions of financing, side effects, conditions accepted by society, feelings experienced, and time required Self-efficacy increases self-confidence as a result of performing personal hygiene, including: self-confidence not to be easily affected by dental disease due to prevention, self-confidence in the association Cues to Action there are aspects that provide encouragement, both from oneself, and those closest to them to perform personal hygiene including: from oneself, cadre friends, close family, health workers care Behavior to maintain personal hygiene regarding dental and oral health is the behavior of dental health social workers dental health in daily life covering aspects of knowledge, attitudes, and actions in terms of brushing teeth, controlling and checking teeth, and regulating eating patterns from the knowledge dimension, attitudes, and actions Data analysis was conducted by using holistic analysis of all cases. The steps were: data reduction, data presentation, and drawing conclusions. Data collection activities were carried out by in-depth interviews with each informant. Data analysis was carried out by holistic analysis of all cases. The steps taken: data reduction, data presentation, and drawing conclusions.
The independent variables in the study included perceived susceptibility, perceived severity; perceived benefits of action, perceived barriers to action, selfefficacy; and variables cues to actions. The dependent variable in this study is self-maintenance behavior in dental and oral health.

Description of the Informant's Condition
The description of the condition of the informants in this study as seen from the dimensions of gender, education level, and length of work, can be seen from the Table 2.

The results of interviews with informants
The results of in-depth interviews conducted with informants of dental health social workers dental health, program managers, village obtained the Table 3.

Perceived susceptibility
The results of the research on the perceived susceptibility found that the informants have the assumption that the target group is susceptible to dental disease and mouth are the general public, children and pregnant women, age group 30 years and over. The existence of this condition shows that dental health social workers already have a fairly good understanding of the dimensions of the target group. Anyone can be affected by dental and oral disease, even social workers dental health from urban areas can already mention that the target group of children and pregnant women is a vulnerable group that is easily affected by disease. teeth, especially cavities. Respondents were able to explain and give reasons why the group of pregnant women became vulnerable, but for the target children they could not provide further explanations. In general, the susceptibility felt by respondents from the target dimension was quite good.
Likewise, for the susceptibility of the dimensions of the condition of the dental tissue which is easily affected by dental and oral diseases, the informants already understood that the condition of the tooth layer, namely enamel, will play a very important role in the occurrence of dental disease, lack of teeth. Calcium can have an impact on being susceptible to dental disease. With this assumption, the respondent's understanding of the susceptibility aspect of the dimensions of the dental condition itself is sufficient.
The existence of a perceived susceptibility has positive value, but has not been able to make behavior change optimally, so it is not in accordance with previous research by Chen and Land, which stated that there was a reciprocal causal relationship between health beliefs and preventive dental visits. The individual's higher perceived susceptibility level increases his or her likelihood of having a dental examination. But the act of visiting the dentist led to a decrease in the level of perceived susceptibility. Without having regular dental check-ups, individuals become unsure about the health status of their teeth and, as a result, feel vulnerable to dental problems. On the other hand, by visiting the dentist regularly, the individual learns the status of his teeth and his confidence in his dental situation increases. As a result, she feels less susceptible to dental disease [14].

Perception of severity.
The results showed that the severity felt by respondents that the presence of dental and oral disease disorders would have an impact on being absent from work, and being unable to work in certain occupational professions, such as the soldier and police. The existence of this perception of severity will make a positive condition for the respondent to feel it is important to prevent dental and oral disease. Another condition conveyed by the respondent is the complications that arise as a result of dental disease, the respondent can explain that headaches and kidney disease are an impact or complications of dental disease. Even more amazing and encouraging is the perception that dental disease can cause death, this finding is an advancement of understanding in the community, because so far, most people still think that dental and oral disease cannot cause death. This means that most of the respondents already have a positive perception that the condition of damage or the occurrence of dental disease and as something painful so that prevention is necessary. So, it is clear that the perception of severity that respondents have is related to indicators of work disturbances and indicators of lost job opportunities. The influence of perceived severity of the respondent is in accordance with the results of previous research by Rosenstock, the perceived severity/seriousness of feelings about the seriousness of contracting the disease or leaving it untreated including evaluation of medical and clinical consequences (e.g, death, disability, and pain) and possible social consequences (such as the effect of the condition on work, family life, and social relationships). The combination of susceptibility and severity has been labeled as a perceived threat [8].
The existence of a threat condition that is felt by a person, but has not been able to fully provide behavior change shows that there is no overall conformity with Bandura's theory, who explains that for behavior change to be successful, people must feel threatened by their current behavior patterns (perceived susceptibility and severity) [15] , [16].

Variables
Quotations from informants' statements Perceived susceptibility The target group that is easily affected by dental disease is the general public, children and pregnant women, the age group of 30 years and older From the aspect of the condition of the condition of the teeth that are susceptible to disease is the tooth layer, where tooth enamel from one person to another varies. Pregnant women who are deficient in calcium may be at risk for toothache. Severity felt.
There is an assumption that dental and oral diseases are important to overcome. It can have an impact on complications of headaches and kidneys, but the complications to the heart is unknown. In addition, there is already an assumption that tooth disease could lead to death. Toothache can have an impact on work interruptions. Decayed teeth affects the difficulty to get a certain jobs (military, police force).

Barriers to action
Generally social workers dental health feel there is never a barrier from the time, cost, side effects, there is no feeling depressed Ever the uncomfortable feeling a sense of aching in the root area of the teeth, due to the wrong brushing technique. Benefits to action Using a toothbrush, it can eliminate bacteria in the oral cavity, it can prevent dental disease. Check can detect if there is tooth decay, and immediate action can be taken.

Self-efficacy
After doing a dental examination and brushing teeth can make teeth clean and healthy so that it creates a sense of confidence in getting along with other people who Cues to action There is support from the family reminding you if you haven't brushed your teeth at night, reminding and ordering to fill cavities There is a desire from yourself to keep your teeth clean and healthy mouth There is support from friends social workers dental health There is support from puskesmas officers, most often from the midwife. The role of officers in conducting coaching and contact with social workers dental health is still minimal, which is only done once a year. The Behavior to maintain personal hygiene regarding dental and oral health of dental health social workers Behavior of social workers dental health from rural areas in brushing their teeth at the right time shows that in the morning they have not done it when they have finished brushing their teeth. breakfast, but at the same time as bath time. The social workers dental health from urban areas have been doing it at the right time every day. The behavior of social workers dental health from rural areas in terms of tooth brushing technique has not done the correct brushing technique, they are still using thebrushing technique vertical. Social workers dental health who come from urban areas have done it with the right technique. Dental check-ups have been carried out, but the respondent has not done routine dental check-ups at the time. Social workers dental health from rural areas have never cleaned tartar, there are social workers dental health who have never cleaned tartar. For social workers dental health from urban areas, they have cleaned but not regularly at the right time. Respondents already know the types of food that are beneficial in maintaining dental health, namely the types of fruits and badgers such as eggs and fish, but the frequency of consuming these foods cannot be ascertained with certainty. Respondents also already know the types of food that need to be avoided, namely types of sweet and easily attached foods such as candy, chocolate

Barriers to action
The perceived barriers to action on self-maintenance behavior (personal hygiene) in the field of dental and oral health. The indicator of perceived barriers that play a role in this study is the obstacle in the aspect of whether there is a sense of comfort when doing personal hygiene. The results showed that the more a person perceives that there are no significant obstacles, especially in making personal hygiene efforts to feel comfortable, it will make the person behave more positively, and vice versa the more a person has a negative assumption, he feels uncomfortable in making efforts to do personal hygiene will make selfmaintenance behavior in a low condition. The existence of the perceived influence of barriers on a person's behavior proves that the existence of an aspect of obstacles in a person is an obstacle to acting in carrying out behavior. This is as stated by Rosenstock, the potential negative aspect of certain health actions is the perceived barrier that can act as an obstacle to carrying out the recommended behavior. One of them is not realized, for example in the cost benefit analysis that occurs where individuals weigh the expected benefits of the action against the perceived barriers. There is a possibility that the financing aspect can be helpful but may be perceived as expensive, have negative side effects, be unpleasant, uncomfortable, or time-consuming [8].
In the field of dental health in this study, it was found that respondents felt that there were no longer barriers to comfort, no more barriers to fees, but apparently this condition did not fully enable respondents to brush their teeth at the right time. So that in research there are no obstacles but sometimes even contribute negatively to the occurrence of behavior change. This is in accordance with previous research which stated that there was a negative and statistically significant relationship between maternal behavior towards oral health and perceived barriers [17].

Benefits of action
There are benefits of action felt by the informant, which in this study was explored that by taking care of yourself by brushing your teeth can eliminate bacteria in the oral cavity, it can prevent dental disease. Apart from that, the informant also felt that having a dental check-up can detect if there is tooth decay, and immediate action can be taken. The existence of this condition also shows that a person's positive assessment of the perceived benefits in carrying out personal hygiene efforts will increase a person's attitude. The benefits of the action to carry out personal hygiene owned by someone who has given a positive assumption will be realized in action, even though the conditions that occur in the informant in terms of the actions taken have not been maximized. Indicators of actions that have not been carried out optimally are in terms of actions taken by social workers in the field of dental health from rural areas in the proper brushing time, indicating that in the morning they have not done so after breakfast, but at the same time as bath time. The social workers dental health from urban areas have been doing it at the right time every day. In addition, what has not been maximized is the behavior of social workers dental health from rural areas in terms of tooth brushing techniques, they have not done the correct brushing technique, they are still brushing their teeth with a vertical movement. Social workers dental health who come from urban areas have done it with the right technique.
The existence of this condition indicates that the benefits of action that a person has in good condition cannot fully create a positive behavior condition in maintaining dental health. This condition is not in accordance with what was conveyed by Rosenstock [18], who stated that a person's behavior is considered dependent on how useful he believes various alternatives will exist in his case.

Self-efficacy
In terms of the effect of self-efficacy, the results of the study obtained data that after doing a dental check-up and brushing teeth can make teeth clean and healthy so as to create a sense of confidence in getting along with other people. The existence of a good self-confidence then the condition of the person's attitude is also high. Positive attitude shown in terms of the right time to brush your teeth. Another positive attitude that exists is the attitude to keep reducing sweet and sticky foods such as bread and biscuits even though we brush our teeth regularly.
Unfortunately, this good attitude is not fully realized in the form of optimal action, where not all informants brush their teeth at the right time. In addition, from the aspect of the technique used, the technique of brushing teeth is still obtained with a vertical movement of the technique. Even though the social workers dental health who come from urban areas have done it with the correct technique. Dental check-ups have been carried out, but the respondent has not done routine dental check-ups at the time.
The existence of self-efficacy conditions owned by the informant is in good condition, but has not fully made the behavior conditions optimal, considering that the efficacy cell does not stand alone in making behavior change, but is strongly influenced by the perceived obstacle variable. Dental and oral hygiene can be improved by reducing perceived barriers and increasing self-efficacy of oral and dental hygiene [19].
The results of the study are also not fully in accordance with previous research conducted by [17] which showed that there was a positive and significant relationship between maternal behavior towards dental and oral health with perceived benefits and self-efficacy.

Cues to action
Due to the influence of the precipitating factor of the action, the results showed that there was support from the family, reminding them that they had not brushed their teeth at night, reminding them and ordering them to fill cavities. There is a desire from yourself to keep your teeth and mouth clean. Informants also feel that they often get support from their fellow social workers in the field of dental health. For support from Publich Health Centers officers, the most often received is support from village midwives, while support from dental health workers is still very minimal, even so far on average it is only done once a year.
The condition of support from health workers that is not optimal is in accordance with the results of previous research which stated that the frequency of coaching 2 times per year was only 53 villages (28.5%), and 18 villages were trained 3 times per year (9.7 %), so that the overall achievement of the coaching frequency that reaches the target (2 and 3 times) is 38.2%. In addition, there are still a number of villages with a frequency of coaching which is only once a year with a fairly large proportion, almost equal to the number of villages that can achieve the target of 67 villages (36%) [9].
The existence of conditions that triggered the action that came from themselves and fellow cadre friends who were already positive, but could not completely create a positive behavior condition because the conditions that triggered the action that occurred were not fully perceived by the respondents as positive. In addition to the occurrence of behavior change, the triggering factor for the action will not stand alone but is also supported by other factors, namely susceptibility and benefits, although in this study the perceived vulnerabilities and benefits were quite good, but there are other factors that were not examined in this study. this. In accordance with previous research conducted by [20] that action triggers will work effectively when there is a perception of susceptibility and the perceived benefit can only be reinforced by other factors, especially by cues to incite action, such as bodily events or by environmental events. such as media publications, but he did not study the role of cues empirically. Action triggers are also not studied systematically, although the concept of cues as trigger mechanisms is interesting but triggers are difficult to study in explanatory surveys. Cues can be fleeting competing or barely conscious poster perceptions.
In addition, there are conditions that trigger actions that actually already exist in health social workers, but cannot make behavior change optimally, most likely due to other factors that play a role in a person not examined in this study, namely the presence of psychological characteristics. Most likely the psychological characteristics of the respondents have not been maximized so that the impact on behavior change is also not maximized. The influence of psychological characteristics factors on behavior change as stated in previous research which explains that psychological characteristics are one of the factors that need to be taken into account in designing multiple behavior change interventions for adults [21].

Conclusion
The susceptibility factor, the perceived severity is a form of threat perception owned by the informant. The existence of a perceived threat (susceptibility and severity) that exists indicates that the condition is already good, but the condition of the presence of this threat perception does not fully have an impact on behavior change. Some behaviors that still need attention are when brushing teeth, and brushing techniques. For the variables of perceived benefits, perceived barriers, and self-efficacy are fully in good condition. The presence of this condition will lead to some positive behaviors that occur in social workers dental health, where social workers dental health is able to explain the importance of dental check-ups as an effort for early detection, besides that informants are also able to identify types of food that play a role in helping healthy teeth, and the need to avoid the types of foods that make them unhealthy. The condition of the teeth is susceptible to cavities.