JURNAL ASUHAN PADA BAYI BALITA DAN ANAK PRA SEKOLAH

Disusun Untuk Memenuhi Tugas Mata Kuliah Asuhan Kebidanan Bayi Balita dan Pra
Sekolah Semester II (Program Alih Kredit/Transfer II)
Dosen Pengampu Christiani Bumi Pangesti, S.SiT., M.Kes

Disusun Oleh :

Rizky Ardika Cahyanti

AB201026

PROGRAM STUDI KEBIDANAN PROGRAM SARJANA

FAKULTAS ILMU KESEHATAN

UNIVERSITAS KUSUMA HUSADA SURAKARTA

TAHUN AKADEMIK 2020/2021

 Jurnal Keperawatan Muhammadiyah 5 (1) 2020

Jurnal Keperawatan Muhammadiyah

Alamat Website: http://journal.um-surabaya.ac.id/index.php/JKM

Pengaruh Anticipatory Guidance Terhadap Pertumbuhan Dan Perkembangan Bayi Usia

0-6 Bulan

Atik Pramesti Wilujeng 1, Desi Trianita 2, Ninis Indriani 3

Program Studi Profesi Ners, Sekolah Tinggi Ilmu Kesehatan Banyuwangi, Banyuwangi
1,3

Program Studi D-3 Kebidanan Sekolah Tinggi Ilmu Kesehatan Banyuwangi, Banyuwangi
2-

INFORMASI A B S T R A C T
Korespondensi: This study aims to analyze the influence of providing Anticipatory Guidance on the
atikpramesti@stikes- growth and development of infants aged 0-6 months. This study uses a quasi experi-
banyuwangi.ac.id mental design with a post test only non equivalent control group design. The respon-
dents involved in this study were 54 mothers who had babies aged 0-6 months who
were taken using a purposive sampling technique which was divided into treatment
and control groups. The results of the Mann-Whitney U test showed that there were
differences in growth in the treatment group with the control group with a value of ρ
= 0.009 while the results of the Mann-Whitney U test on the development variable
showed a difference between the treatment group with the control group with a value
of ρ = 0.021. Assessment of infant growth is carried out by measuring anthropometrics
which include weight (BW), length / height (TB), and head circumference then com-
pared with the WHO-NCHS BB / U index. Assessment of infant development using
KPSP (Kuesioner Pra Skrining Perkembangan). Anticipatory guidance is an educa-
Keywords: tional method provided to provide guidance to parents so that children can grow and
Anticipatory Guidance, develop optimally and aims to improve family independence in maintaining health,
Development, Growths preventing and overcoming child health problems.

11

PENDAHULUAN
Masa balita merupakan periode penting dalam pros-
es tumbuh kembang manusia. Perkembangan dan
pertumbuhan di masa itu menjadi penentu keberhas-
ilan pertumbuhan dan perkembangan anak di peri-
ode salanjutnya (Dosman, Faap, Andrews, & Frcpc,
2012). Pada usia 0-2 tahun merupakan masa tumbuh
kembang yang optimal (golden period) bila terjadi
gangguan pada masa ini akan berpengaruh negatif
pada kualitas generasi penerus (Kesehatan & Indone-
sia, 2017). Pertumbuhan anak yang sehat dipengaruhi
oleh pengasuhan orang tua (Nur & Adriani, 2009).
Diperkirakan 1-3% anak mengalami keterlambatan
perkembangan usia < 5 tahun dengan 5-10% dalam
2 aspek perkembangan. Presentase gizi buruk di Jawa
Timur tahun 2016 sebesar 2,6% sedangkan gizi kurang
sebesar 11% (RI, 2016). Cakupan pemberian ASI Ek-
sklusif tahun 2017 di Banyuwangi sebesar 74% belum
memenuhi target yang telah ditetapkan (77%) ( Jawa
Timur, 2017). Pada tahun 2017 angka balita yang
mengalami gizi buruk di Banyuwangi sebesar 0.55 %.
Berdasarkan laporan Dinas Kesehatan Banyuwangi menun-
jukkan angka kematian bayi tahun 2017 sebanyak 111 setiap
1000 Kelahiran Hidup. Berdasarkan pemeriksaan KPSP
didapatkan data tahun 2015 terdapat 10 anak men-
galami keterlambatan perkembangan (Banyuwangi,
2018). Berdasarkan survei data awal didapatkan data
jumlah persalinan di Ruang Bersalin RSU Blambangan
Banyuwangi Bulan Januari-Juli 2018 terdapat 502 per-
salinan dengan rata-rata 83 persalinan setiap bulan dan
semua ibu yang melahirkan belum pernah diberikan
anticipatory guidance. Kehidupan awal anak dimulai
dari orang tua, sehingga orang tua bertanggung jawab
terhadap masa depan anak (Hasinuddin, 2010). Setiap
orang tua memanfaatkan pendidikan kesehatan untuk
mendapatkan informasi tentang bagaimana mengasuh
anak (Thygesen et al., 2017). Konseling oleh petugas
kesehatan dapat mengurangi perilaku ibu pengena-
lan dini makanan padat pada bayi (< 6 bulan) (Kuo,
Inkelas, Slusser, Maidenberg, & Halfon, 2011). Antici-
patory guidance adalah metode pendidikan yang dise-
diakan untuk memberikan bimbingan kepada orang
tua baru sehingga anak tumbuh dan berkembang opti-
mal. Seorang anak sangat membutuhkan aktivitas ber-
main yang akan mempermudah perkembangan kognisi
anak (Atik Pramesti Wilujeng, Leny Andiyati, 2017).
Sebagai bagian dari tenaga kesehatan profesional, per-
awat mempunyai peran yang penting dalam membantu
memberikan bimbingan dan pengarahan pada orang
tua (Dosman et al., 2012). Keluarga membutuhkan
panduan tentang pentingnya memberikan stimulasi
perkembangan pada anak (Pediatrics, 2016). Dengan
12
Jurnal Keperawatan Muhammadiyah 5 (1) 2020
mengetahui masalah perkembangan sejak dini, anak-
anak dapat diberikan perawatan yang lebih efektif, seh-
ingga defisit perkembangan lebih lanjut dapat dicegah
(Moodie et al., 2014). Banyak data yang menunjukkan
pentingnya bimbingan orang tua dalam mengasuh
anak sampai usia remaja (Partridge, 2014). Pemberian
anticipatory guidance akan efektif apabila diberikan
dalam bentuk pelatihan menggunakan buku panduan.
Pada penelitian ini peneliti menggunakan buku pegan-
gan fasilitator kelas ibu balita serta buku KIA yang di-
miliki oleh ibu.
METODE
Jenis penelitian yang digunakan dalam penelitian ini
adalah quasi experimental dengan pendekatan post
test only non equivalent control group dimana kelom-
pok intervensi dan kelompok kontrol tidak dipilih se-
cara random dan pengukuran dilakukan hanya setelah
selesai diberikan intervensi. Sampel dalam penelitian
ini adalah ibu dengan bayi usia 0-6 bulan memenuhi
kriteria berjumlah 54 yang diambil menggunakan teh-
nik purposive sampling. Variabel bebas penelitian ini
adalah anticipatory guidance. Variabel terikat peneli-
tian ini adalah pertumbuhan dan perkembangan. Pada
kelompok perlakuan dilakukan pemberian anticipatory
guidance selama 5 kali pertemuan menggunakan buku
pegangan fasilitator kelas ibu balita terdiri dari Modul
A1: pemberian ASI, modul A2 : Pemberian Imunisasi,
modul A3 : Pemberian MP-ASI, modul A4 : Tumbuh
kembang bayi dan modul A5 : Penyakit terbanyak pada
bayi. Instrumen yang digunakan untuk menilai status
pertumbuhan bayi adalah lembar observasi penguku-
ran antropometri (BB, PB, LILA, dan LK), sedang-
kan perkembangan bayi diukur dengan Kuesioner Pra
Skrining Perkembangan (KPSP). Analisis bivariat yang
dilakukan pada penelitian ini adalah : Uji statistik U
Mann-Whitney untuk mengetahui apakah ada per-
bedaan penilaian pertumbuhan dan perkembangan
pada kelompok kontrol maupun intervensi.
HASIL
Pengambilan data pada penelitian ini dilakukan di
Ruang Bersalin RSD Blambangan Banyuwangi 2019
ditindaklanjuti dengan melakukan kunjungan ke ru-
mah masing-masing responden.
 Jurnal Keperawatan Muhammadiyah 5 (1) 2020

Tabel 1 Karakterstik responden berdasarkan usia ibu di Tabel 5 Karakteristik responden berdasarkan berat
Ruang Bersalin RSD Blambangan Banyuwangi 2019. badan lahir bayi di Ruang Bersalin RSD Blambangan
Banyuwangi 2019.
No. Usia Ibu dalam tahun n %
1. 20-25 16 30 No. Berat Badan Lahir n %
2. 26-30 21 39 1. < 2500 4 7%
3. 31-35 7 12 2. 2500 – 3500 41 76%
4. 36-40 10 19 3. > 3500 9 17
Total 54 100% Total 54 100%
Sumber : (Data Primer, 2019)
Sumber : (Data Primer, 2019)
Tabel 2 Karakterstik responden berdasarkan pendi- Tabel 6 Karakteristik responden berdasarkan usia gesta-
dikan ibu di Ruang Bersalin RSD Blambangan Banyu- si bayi di Ruang Bersalin RSD Blambangan Banyuwan-
wangi 2019. gi 2019.

No. Pendidikan Ibu n % No. Usia gestasi n %

1. SD 2 4 1. ≤ 37 minggu 38 70%
2. SMP 1 2 2. > 37 minggu 17 30%
3. SMA 49 90 Total 54 100%
4. Perguruan Tinggi 2 4 Sumber : (Data Primer, 2019)
Total 54 100%
Sumber : (Data Primer, 2019) Tabel 7. Distribusi Pertumbuhan bayi usia 0-6 bulan
pada kelompok intervensi di Rumah Sakit Umum
Tabel 3 Karakterstik responden berdasarkan pekerjaan Blambangan Banyuwangi 2019
ibu di Ruang Bersalin RSD Blambangan Banyuwangi
2019. No. Pertumbuhan n %
1. Baik 21 78%
No. Pekerjaan Ibu n % 2. Kurang 5 19%
1. IRT 43 80 3. Buruk 1 4%
2. SWASTA 9 16 Total 27 100%
3. PNS 1 2 Sumber : (Data Primer, 2019)
4. Guru 1 2
Tabel 8 Distribusi Pertumbuhan bayi usia 0-6 bulan
Total 54 100%
pada kelompok kontrol di Rumah Sakit Umum Blam-
Sumber : (Data Primer, 2019)
bangan Banyuwangi 2019
Tabel 4 Karakterstik responden berdasarkan jenis ke- No. Pertumbuhan n %
lamin bayi di Ruang Bersalin RSD Blambangan Banyu- 1. Baik 14 60%
wangi 2019. 2. Kurang 11 33%
3. Buruk 2 7%
No. Jenis kelamin n % Total 27 100%
1. Laki – laki 36 65% Sumber : (Data Primer, 2019)
2. Perempuan 19 35%
Total 54 100%

Sumber : (Data Primer, 2019)

13
 Jurnal Keperawatan Muhammadiyah 5 (1) 2020

Tabel 9. Hasil Uji Normalitas Pertumbuhan bayi usia Tabel 12. Distribusi Perkembangan bayi usia 0-6 bulan
0-6 bulan di Rumah Sakit Umum Blambangan Banyu- pada kelompok kontrol di Rumah Sakit Umum Blam-
wangi 2014 bangan Banyuwangi 2019
Kolmogor- No. Perkembangan n %
Shapiro-Wilk
Kelom- ov-Smirnov 1. Sesuai 15 56%
pok Sta- Sta-
df Sig df Sig 2. Meragukan 11 40%
tistic tistic
3. Penyimpangan 1 4%
Antici- 0,495 27 0,000 0,476 27 0,000
Pertumbuhan

Total 27 100%
patory
Guidance Sumber : (Data Primer, 2019)
Kontrol 0,306 27 0,000 0,752 27 0,000
Tabel 13. Hasil Uji Normalitas Perkembangan bayi usia
0-6 bulan di Rumah Sakit Umum Blambangan Banyu-
Pada tabel 9 di atas menunjukkan bahwa hasil uji nor-
wangi 2019
malitas pada variabel pertumbuhan bayi usia 0-6 bulan
Kolmogor-
menggunakan metode Lilliefors dan Shapiro Wilk. Shapiro-Wilk
Kelompok ov-Smirnov
Nilai Sig (p Value) kedua uji di atas < 0,05 yang be-
Statistic df Sig Statistic df Sig
rarti data tidak berdistribusi normal sehingga peneliti
Anticipa-

0,000

0,000
memilih menggunakan Mann Whitney U Test dari
Perkembangan
tory 0,303 27 0,741 27
pada Independen T Test. Guidance

0,031

0,006
Tabel 10. Perbedaan Pertumbuhan bayi usia 0-6 bulan Kontrol 0,176 27 0,884 27
di Rumah Sakit Umum Blambangan Banyuwangi 2014
Perlakuan Kontrol Tabel 13 di atas adalah hasil uji normalitas pada vari-
Mann Sig able perkembangan bayi usia 0-6 bulan menggunakan
Mean Sum of Mean Sum of (2-tailed) metode Lilliefors dan Shapiro Wilk. Nilai Sig (p Value)
-Whit-
Rank Ranks Rank Ranks kedua uji di atas < 0,05 yang berarti data tidak berdistri-
ney U
busi normal sehingga peneliti memilih menggunakan
Pertumbuhan

Mann Whitney U Test dari pada Independen T Test.

22,81 616,00 238,00 32,19 869,00 0,009
Tabel 14. Perbedaan Perkembangan bayi usia 0-6 bulan
pada kelompok intervensi dengan kelompok control di
Berdasarkan tabel 10 menunjukkan bahwa pada varia- Rumah Sakit Umum Blambangan Banyuwangi
bel penilaian pertumbuhan pada kelompok yang diber-
ikan intervensi anticipatory guidance dan kelompok Perlakuan Kontrol
(2-tailed)

kontrol dengan hasil Sig (2-tailed) 0,009 < 0,05 yang Mann- Mean Sum of
Sig

Mean Sum of Whitney

artinya ada perbedaan nilai pertumbuhan pada bayi Rank Ranks Rank Ranks
U
yang diasuh ibu yang diberikan anticipatory guidance
Perkembangan

dengan bayi yang diasuh ibu tidak diberikan anticipa-

tory guidance.
32,24 870,50 236,500 22,76 614,50 0,021

Tabel 11. Distribusi Perkembangan bayi usia 0-6 bu-

lan pada kelompok intervensi di Rumah Sakit Umum Penilaian perkembangan pada kelompok yang diber-
Blambangan Banyuwangi 2019 ikan intervensi anticipatory guidance dan kelompok
No. Perkembangan n % kontrol menunjukkan hasil Sig (2-tailed) 0,021 < 0,05
1. Sesuai 19 70% yang artinya ada perbedaan nilai perkembangan pada
2. Meragukan 7 26% bayi yang diasuh ibu yang diberikan anticipatory guid-
3. Penyimpangan 1 4% ance dengan bayi yang diasuh ibu tidak diberikan an-
ticipatory guidance.
Total 27 100%
Sumber : (Data Primer, 2019) PEMBAHASAN
Berdasarkan hasil uji statistik dengan menggunakan uji
14

Mann-Whitney U pada variabel pertumbuhan, hasil
nilai p value adalah 0,009 lebih kecil dari 0,05 sedang-
kan hasil uji statistik dengan menggunakan uji
Mann-Whitney U pada variabel perkembangan, hasil
nilai p value adalah 0,02 lebih kecil dari 0,05. Ini berar-
ti bahwa pemberian anticipatory guidance memiliki
pengaruh yang signifikan dengan pertumbuhan bayi
karena nilai p value kurang dari 0,05 adalah 0,009 pada
variabel pertumbuhan dan 0,02 pada variabel perkem-
bangan sehingga dapat dinyatakan satu kesimpulan
bahwa Ha diterima dan H0 ditolak yang berarti ada
pengaruh pemberian anticipatory guidance terhadap
pertumbuhan dan perkembangan bayi usia 0-6 bulan
di Ruang Bersalin RSD Blambangan Banyuwangi
2019. Anak memiliki suatu ciri yang khas yaitu selalu
tumbuh dan berkembang sejak konsepsi sampai bera-
khirnya masa remaja. Anak menunjukkan ciri-ciri per-
tumbuhan dan perkembangan yang sesuai dengan
usianya. Pertumbuhan merupakan peningkatan jum-
lah dan ukuran sel di seluruh bagian tubuh yang secara
kuantitatif dapat diukur dengan ukuran berat (gram,
kilogram) dan ukuran panjang (sentimeter, meter) se-
dangkan perkembangan merupakan bertambahnya ke-
mampuan struktur dan fungsi tubuh yang lebih kom-
pleks dalam pola yang teratur dan dapat diramalkan
sebagai proses pematangan serta pembelajaran (Hock-
enberry dan Wilson, 2009). Pencapaian derajat kese-
hatan yang tinggi bagi anak adalah sebagai satu ba-
gian dari system pelayanan kesehatan di keluarga.
Keluarga sebagai suatu kehidupan yang konstan dan
individu mendukung, menghargai dan meningkat-
kan kekuatan dan kompetensi dalam memberikan
asuhan terhadap anak, sedangkan prinsip keper-
awatan anak harus berfokus pada anak dan keluarga,
untuk memenuhi kebutuhan anak dan keluarga
(Setyawan, 2017). Menurut Kemenkes RI tahun 2016
pertumbuhan terjadi secara simultan dengan perkem-
bangan. Tahun-tahun pertama kehidupan, terutama
periode sejak janin dalam kandungan sampai anak beru-
sia 2 tahun merupakan periode yang sangat penting da-
lam pertumbuhan dan perkembangan anak. Periode ini
merupakan kesempatan emas sekaligus masa-masa yang
rentan terhadap pengaruh negatif. Memiliki bayi yang
baru lahir adalah momen belajar bagi seorang ibu yang
akan merubah pola hidup dan kebiasaan sehari-hari
demi kesehatan bayinya (French et al., 2012). Perkem-
bangan sosial dan emosional pada usia bayi merupakan
pondasi untuk perkembangan ditahap selanjutnya sep-
erti usia todler, pra sekolah dan sekolah. The Center on
the Social Emotional Foundations for Early Learning
(CSEFEL) menyatakan bayi mengekspresikan emosi
ketika berinteraksi sosial dengan cara tersenyum, keta-
Jurnal Keperawatan Muhammadiyah 5 (1) 2020
kutan bahkan menangis ketika ditinggal orang yang
mengasuhnya (Halle & Darling-churchill, 2016). Ke-
majuan terbesar akan terjadi ketika langkah-langkah
perkembangan sosial dan emosional balita dibuat den-
gan jelas ( Jones, Zaslow, Darling-churchill, & Halle,
2016). Kehidupan awal anak dimulai dari orang tua,
sehingga orang tua bertanggung jawab terhadap masa
depan anak (Hasinuddin, 2010). Setiap orang tua me-
manfaatkan pendidikan kesehatan untuk mendapat-
kan informasi tentang bagaimana mengasuh anak
(Thygesen et al., 2017). Konseling oleh petugas keseha-
tan dapat mengurangi perilaku ibu dalam pemberian
makanan dini pada bayi usia kurang dari 6 bulan (Kuo
et al., 2011). Anticipatory guidance adalah metode
pendidikan yang disediakan untuk memberikan bimb-
ingan kepada orang tua baru sehingga anak tumbuh
dan berkembang optimal. Nutrisi yang baik dan cukup,
status kesehatan yang baik, pengasuhan yang benar, dan
stimulasi yang tepat pada periode ini akan membantu
anak untuk tumbuh sehat dan mampu mencapai ke-
mampuan optimalnya sehingga dapat berkontribusi
lebih baik dalam masyarakat. Stimulasi yang tepat akan
merangsang otak balita sehingga perkembangan ke-
mampuan gerak, bicara dan bahasa, sosialisasi dan ke-
mandirian pada balita berlangsung optimal sesuai den-
gan umur anak. Deteksi dini penyimpangan tumbuh
kembang perlu dilakukan untuk dapat mendeteksi secara
dini adanya penyimpangan tumbuh kembang balita ter-
masuk menindaklanjuti setiap keluhan orang tua terha-
dap masalah tumbuh kembang anaknya. Apabila
ditemukan ada penyimpangan, maka dilakukan inter-
vensi dini penyimpangan tumbuh kembang balita di-
mana dalam penelitian ini penelti memberikan stimu-
lasi yang sesuai dengan KPSP selanjutnya dilakukan
evaluasi setelah 2 minggu, hal ini sebagai tindakan ko-
reksi dengan memanfaatkan plastisitas otak anak agar
tumbuh kembangnya kembali normal atau penyimpan-
gannya tidak semakin berat (Kemendikbud, 2012).
Berdasarkan penelitian yang dilakukan oleh (Reich &
Bickman, 2010) menunjukkan bahwa kelompok ibu
yang diberikan buku cara mendidik anak memiliki
pengetahuan yang lebih tinggi dari pada 2 kelompok
yang lain. Sehingga dapat disimpulkan buku yang diba-
ca ibu tampak efektif dalam memberikan bimbingan
antisipatif. Orang tua melaporkan perlunya pelatihan
dan dukungan tambahan untuk membuat bimbingan
antisipatif lebih efektif. Anticipatory guidance yang
terdiri dari informasi yang bermanfaat, untuk member-
ikan dukungan kepada orang tua dalam pengambilan
keputusan sehingga meningkatkan praktik pengasuhan
(Sege, Hatmaker-flanigan, Vos, Levin-goodman, &
Spivak, 2006). Intervensi berbasis masyarakat mem-
15

pengaruhi pertumbuhan anak. (Blake-lamb et al.,
2016). Anticipatory guidance diberikan dengan hara-
pan bahwa orang tua terlibat dalam mendukung per-
ilaku kesehatan anak dan perkembangan awal anak.
Orang tua dapat dengan mudah diajari metode mening-
katkan disiplin dan pencegahan cedera pada anak. Leb-
ih dari 99% orang tua melaporkan kegiatan saat ini
mendukung perkembangan anak mereka (Combs-
orme, Nixon, & Herrod, 2015). AAP merekomen-
dasikan pelatihan pediatrik bagi ibu baru dan calon
pengasuh anak selama 3 bulan (Mccolgan et al., 2010).
Studi secara epidemiologi, sosiologis, dan genetik telah
semakin menunjukkan korelasi antara pola asuh orang
tua dengan kesehatan anak, dan pentingnya family cen-
tered care untuk kesehatan anak. Sering kali informasi
tentang kesehatan anak menjadi efektif apabila disam-
paikan kepada keluarga sehingga keluarga telah menja-
di mitra sejak awal bagi tenaga kesehatan demi tercapa-
inya anak yang sehat (VICTOR C. STRASBURGER,
2010). Pada penelitian ini peneliti mendata ibu yang
melahirkan di Ruang Bersalin RSD Blambangan, se-
lanjutnya peneliti membagi ibu-ibu tersebut menjadi
dua kelompok yaitu 27 orang sebagai kelompok per-
lakuan yang diberikan intervensi anticipatory guidance
dan 27 orang sebagai kelompok control. Selanjutnya
peneliti mendata alamat masing-masing responden dan
mohon bantuan bidan sebagai pembantu lapangan un-
tuk membuat pertemuan dengan ibu-ibu tersebut.
Pada kelompok perlakukan diberikan pendampingan
kelas ibu balita yang terdiri dari 5 modul. Modul A1:
pemberian ASI, modul A2 : Pemberian Imunisasi,
modul A3 : Pemberian MP-ASI, modul A4 : Tumbuh
kembang bayi dan modul A5 : Penyakit terbanyak pada
bayi. Pemberian anticipatory guidance ini peneliti me-
manfaatkan beberapa alat dan bahan pendukung seper-
ti bloknote dan bolpoint untuk responden, buku kelas
ibu balita, buku KIA serta pantom payudara sehingga
diharapkan responden lebih mudah memahami materi
yang disampaikan. Anticipatory guidance disampaikan
dalam bentuk penyuluhan, diskusi dan simulasi. Pem-
berian anticipatory guidance dilakukan di beberapa
rumah bidan dan kader sebagai tempat berkumpulnya
responden. Penyampaian materi masing-masing modul
dilakukan dengan durasi 30 menit dilanjutkan dengan
diskusi. Pada saat sesi tanya jawab diskusi berjalan den-
gan interaktif hal ini tampak dari banyaknya ibu-ibu
yang mengajukan pertanyaan tentang pertumbuhan
dan perkembangan bayi kepada para peneliti. Proses
penyampaian modul dilakukan selama 3 bulan. Pada
bulan pertama dilakukan penyampaian modul pembe-
rian ASI dan modul tumbuh kembang bayi, pada bulan
kedua adalah penyampaian modul imunisasi dan pen-
16
Jurnal Keperawatan Muhammadiyah 5 (1) 2020
yakit terbanyak pada bayi selanjutnya penyampaian
modul pemberian MP-ASI dilakukan pada bulan keti-
ga. Setelah itu peneliti melakukan penilaian pertumbu-
han dan perkembangan bayi dengan menggunakan
buku KIA dan KPSP (Kuesioner Pra Skrining Perkem-
bangan). Adanya perbedaan pertumbuhan dan perkem-
bangan bayi yang diasuh oleh ibu yang telah diberikan
pendampingan anticipatory guidance dibandingkan
dengan ibu yang tidak diberikan anticipatory guidance,
dalam hal ini ibu yang telah diberikan pendampingan
anticipatory guidance telah mendapat informasi yang
lebih jelas mengenai pertumbuhan dan perkembangan
bayi melalui pemberian materi dari 5 modul yang ter-
dapat dalam buku pegangan fasilitator kesehatan ibu
dan balita yang terdiri dari pentingnya pemberian ASI
eksklusif bagi bayi mengingat zat gizi yang terkandung
dalam ASI merupakan komponen zat gizi yang sangat
lengkap dan sesuai dengan pencernaan bayi selain itu
ASI juga mengandung zat anti bodi yang sangat pent-
ing untuk meningkatkan daya tahan tubuh bayi seh-
ingga bayi tidak mudah sakit. Pemberian ASI saja pada
bayi selama 6 bulan pertama bukan merupakan sesuatu
yang mudah bagi ibu-ibu yang belum memahami man-
faat dan pentingnya ASI terutama bagi ibu-ibu yang
bekerja namun pada penelitian ini sebagian besar re-
sponden adalah sebagai ibu rumah tangga sehingga
dengan pendampingan anticipatory guidance tentang
manfaat ASI eksklusif bagi bayi maka ibu-ibu banyak
yang telah berhasil memberikan pemberian ASI saja
pada bayinya sehingga bayi memiliki pertumbuhan
yang baik, sedangkan pada modul pertumbuhan dan
perkembangan bayi menekankan pemahaman menge-
nai pentingnya deteksi dini pertumbuhan bayi melalui
pemeriksaan berat badan dan tinggi badan secara rutin
setiap bulan di posyandu sehingga apabila ada penyim-
pangan pertumbuhan pada bayi dapat segera dilakuan
intervensi. Upaya optimalisasi perkembangan bayi
dapat dilakukan melalui stimulasi, dalam hal ini dibu-
tuhkan pemahaman yang benar bagi ibu-ibu yang
memiliki bayi usia 0-6 bulan mengenai pentingnya
stimulai bagi perkembangan bayi yang dapat dilakukan
melalui permainan dan mempererat tali kasih sayang
antara ibu dan bayi. Hubungan kasih kasih sayang an-
tara ibu dan bayi dapat dilakukan saat proses menyusui
ataupun saat memandikan bayi. Adanya kontak mata
saat menyusui dan sentuhan kasih sayang dari ibu inilah
yang menjadi kunci keberhasilan pertumbuhan dan
perkembangan bayi. Adanya informasi tersebut, me-
mungkinkan pengetahuan responden meningkat seh-
ingga diharapkan ibu-ibu yang memiliki bayi usia 0-6
bulan mampu memberikan nutrisi yang baik melalui
pemberian ASI dan memberikan stimulasi sehingga

bayi mampu mencapai pertumbuhan dan perkemban-
gan yang sesuai dengan tahap usianya. Setelah dilaku-
kan pendampingan anticipatory guidance mengenai
imunisasi maka responden lebih memahami manfaat
imunisasi sebagai upaya pencegahan penyakit bayi serta
ibu-ibu lebih memahami jenis-jenis imunisasi dan jad-
wal imunisasi, responden diharapkan bisa mengubah
persepsinya tentang imunisasi dan efek samping imuni-
sasi. Meskipun salah satu efek samping imunisasi DPT
adalah bayi akan mengalami demam namun dengan
pemahaman ibu yang benar bahwa demam yang terjadi
pada bayi setelah imunisasi adalah hal yang tidak ber-
bahaya maka ibu akan lebih mudah mencari alternative
solusi bukan sebaliknya menimbukan sikap cemas dan
berlebihan. Melalui pendampingan anticipatory guid-
ance tentang penyakit terbanyak pada bayi maka re-
sponden lebih paham tentang penyakit terbanyak pada
bayi dan dapat melakukan tindakan pencegahan dan
penanganan penyakit anak saat di rumah. Anggota kel-
uarga dalam hal ini suami diharapkan memberikan
dukungan serta mendampingi responden dalam mem-
berikan terapi kepada anaknya sehingga responden leb-
ih termotivasi. Sebagaimana yang disebutkan oleh
Friedman (1998) bahwa keluarga bisa memberikan
dukungan berupa pemberian saran, sugesti dan infor-
masi dalam menyelesaikan suatu permasalahan (Wilu-
jeng, 2018). Sebagian besar ibu sebagai ibu rumah
tangga dimana ibu rumah tangga memilki lebih banyak
waktu untuk anaknya, mereka dapat mengatur pola
makan anak dan memberikan ASI lebih banyak seh-
ingga anak anak mereka makan makanan yang sehat
dan bergizi (Mariyana & Kock, 2018). Aktivitas dan
pekerjaan ibu terkadang melupakan peran ibu bahkan
tidak dapat meluangkan sedikit waktu untuk memper-
hatikan anak (Fitri, Chundrayetti, & Semiarty, 2014).
Sebagian besar ibu mempunyai tingkat pendidikan
SMA (90%). Menurut (Fitri et al., 2014) dinyatakan
bahwa pendidikan orang tua merupakan salah satu fak-
tor yang penting dalam tumbuh kembang anak. Karena
pendidikan yang baik, maka orang tua dapat menerima
segala informasi dari luar terutama tentang cara penga-
suhan anak yang baik. Ibu yang memiliki tingkat pen-
didikan yang tinggi cenderung mudah untuk memaha-
mi dan menyerap informasi yang lebih luas dalam
proses pengasuhan anak yang baik, yang nantinya ber-
dampak pada tumbuh kembang anak.
KESIMPULAN
Berdasarkan hasil uji statistik dengan menggunakan
uji Mann-Whitney U pada variabel pertumbuhan, ha-
sil nilai p value adalah 0,009 lebih kecil dari 0,05 se-
dangkan hasil uji statistik dengan menggunakan uji
Jurnal Keperawatan Muhammadiyah 5 (1) 2020
Mann-Whitney U pada variabel perkembangan, hasil
nilai p value adalah 0,02 lebih kecil dari 0,05. Ini be-
rarti bahwa pemberian anticipatory guidance memiliki
pengaruh yang signifikan dengan pertumbuhan bayi
karena nilai p value kurang dari 0,05 adalah 0,009 pada
variabel pertumbuhan dan 0,02 pada variabel perkem-
bangan sehingga dapat dinyatakan satu kesimpulan
bahwa Ha diterima dan H0 ditolak yang berarti ada
pengaruh pemberian anticipatory guidance terhadap
pertumbuhan dan perkembangan bayi usia 0-6 bulan di
Ruang Bersalin RSD Blambangan Banyuwangi 2019.
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18
 Articles

Effects of responsive stimulation and nutrition interventions

on children’s development and growth at age 4 years in
a disadvantaged population in Pakistan: a longitudinal
follow-up of a cluster-randomised factorial effectiveness trial
Aisha K Yousafzai, Jelena Obradović, Muneera A Rasheed, Arjumand Rizvi, Ximena A Portilla, Nicole Tirado-Strayer, Saima Siyal, Uzma Memon

Summary
Background A previous study in Pakistan assessed the effectiveness of delivering responsive stimulation and enhanced Lancet Glob Health 2016;
nutrition interventions to young children. Responsive stimulation significantly improved children’s cognitive, 4: e548–58

language, and motor development at 2 years of age. Both interventions significantly improved parenting skills, with Published Online
June 21, 2016
responsive stimulation showing larger effects. In this follow-up study, we investigated whether interventions had
http://dx.doi.org/10.1016/
benefits on children’s healthy development and care at 4 years of age. S2214-109X(16)30100-0
See Comment page e505
Methods We implemented a follow-up study of the initial, community-based cluster-randomised effectiveness trial, which Department of Paediatrics and
was conducted through the Lady Health Worker programme in Sindh, Pakistan. We re-enrolled 1302 mother–child dyads Child Health, Aga Khan
(87% of the 1489 dyads in the original enrolment) for assessment when the child was 4 years of age. The children were University, Karachi, Pakistan
originally randomised in the following groups: nutrition education and multiple micronutrient powders (enhanced (A K Yousafzai PhD,
M A Rasheed MSc, A Rizvi MSc,
nutrition; n=311), responsive stimulation (n=345), combined responsive stimulation and enhanced nutrition (n=315), and S Siyal MA, U Memon MA); and
routine health and nutrition services (control; n=331). The data collection team were masked to the allocated intervention. Graduate School of Education,
The original enrolment period included children born in the study area between April 1, 2009, and March 31, 2010, if they Stanford University, Stanford,
were up to 2·5 months old without signs of severe impairments. The primary endpoints for children were development CA, USA (J Obradović PhD,
X A Portilla PhD,
and growth at 4 years of age. Interventions were given in monthly group sessions and in home visits. The primary N Tirado-Strayer MSc)
endpoint for mothers was wellbeing and caregiving knowledge, practices, and skills when the child was 4 years of age. Correspondence to:
Analysis was by intention to treat. The original trial is registered with ClinicalTrials.gov, number NCT00715936. Department of Paediatrics and
Child Health, Aga Khan
Findings 1302 mother–child dyads were re-enrolled between Jan 1, 2013, and March 31, 2013, all of whom were followed up University, Karachi 74800,
Pakistan
at 4 years of age. Children who received responsive stimulation (with or without enhanced nutrition) had significantly aisha.yousafzai@aku.edu
higher cognition, language, and motor skills at 4 years of age than children who did not receive responsive stimulation.
For children who received responsive stimulation plus enhanced nutrition, effect sizes (Cohen’s d) were 0·1 for IQ (mean
difference from control 1·2, 95% CI –0·3 to 2·7), 0·3 for executive functioning (0·18, –0·07 to 0·29), 0·5 for pre-academic
skills (7·53, 5·14 to 9·92) and 0·2 for pro-social behaviours (0·08, 0·03 to 0·13). For children who received responsive
stimulation alone, effect sizes were 0·1 for IQ (mean difference with controls 1·7, –0·3 to 3·7), 0·3 for executive
functioning (0·17, 0·07 to 0·27), 0·2 for pre-academic skills (3·86, 1·41 to 6·31), and 0·2 for pro-social behaviours (0·07,
0·02 to 0·12). Enhanced nutrition improved child motor development, with effect size of 0·2 for responsive stimulation
plus enhanced nutrition (0·56, –0·03 to 1·15), and for enhanced nutrition alone (0·82, 0·18 to 1·46). Mothers who
received responsive stimulation (with or without enhanced nutrition) had significantly better responsive caregiving
behaviours at 4 years of child age than those who did not receive intervention. Effect size was 0·3 for responsive stimulation
plus enhanced nutrition (1·95, 0·75 to 3·15) and 0·2 for responsive stimulation (2·01, 0·74 to 3·28). The caregiving
environment had a medium effect size of 0·3 for all interventions (responsive stimulation plus enhanced nutrition 2·99,
1·50 to 4·48; responsive stimulation alone 2·82, 1·21 to 4·43; enhanced nutrition 3·52, 1·70 to 5·34).

Interpretation Responsive stimulation delivered in a community health service can improve child development and
care, 2 years after the end of intervention. Future analyses of these data are needed to identify which children and
families benefit more or less over time.

Funding Grand Challenges Canada.

Copyright © Yousafzai et al. Published by Elsevier Ltd. This is an Open Access article under the CC BY license.

Introduction benefits to children’s early development and growth

Stimulation and nutrition interventions delivered in the outcomes.1–5 A meta-analysis1 of early stimulation and
first 2 years of life in low-income and middle-income nutrition interventions conducted between 2000 and
countries have demonstrated consistent short-term 2013 in low-income and middle-income countries

www.thelancet.com/lancetgh Vol 4 August 2016 e548

 Articles
Research in context
Evidence before this study
We conducted a review of recent systematic reviews for
stimulation or nutrition interventions published since the last
Lancet series on child development in developing countries in
2011 (Jan 1, 2011, to Nov 30, 2015). We searched for reviews on
PubMed and PsycINFO. Key terms used were psychosocial
stimulation, stimulation, parenting, responsive care, nutrition,
supplementation, micronutrients, growth, child development,
early, interventions, longitudinal, follow up. Inclusion criteria
included studies conducted in low-and middle-income countries,
stimulation or nutrition interventions for children younger than
2 years, and outcomes that included a measure of children’s
development. We identified three reviews with meta-analyses of
intervention effect on children’s development or growth. We
found consistent medium-size effects on child development as a
result of stimulation and small-size effects as a result of nutrition
interventions. Nutrition interventions also improved growth and
nutrition status. In the review that specifically analysed integrated
stimulation and nutrition interventions, little evidence was
available to determine additive or synergistic benefits on child
outcomes. Only four studies from Jamaica and Colombia were
identified that had followed up cohorts after the intervention had
ended. The earliest age of follow-up began at 6 years. The two
Colombian studies had high attrition rates (>25%). The Jamaican
cohort showed stimulation intervention showed sustained
benefits in to adulthood, while the effects of nutrition supplement
were not observed after 7 years of age. In summary, there is
limited information on the long-term effects of early stimulation
(with or without nutrition intervention) on later child and adult
outcomes.
Added value of this study
Our results show sustained improvement during the preschool
period as a result of early responsive stimulation (with or
reported that responsive stimulation had a medium
effect (n=21 studies, Cohen’s d=0·42; 95% CI 0·36–0·48)
and nutrition supplementation with or without nutrition
education had a small effect (n=18, 0·09; 0·04–0·14) on
cognitive development at 2 years of age. A systematic
review of combined stimulation and nutrition inter-
ventions reported that stimulation consistently benefited
child development, while nutrition usually improved
nutritional status and growth, and sometimes improved
child development.4 The review found little evidence for
additive benefits on children’s development, although no
significant loss of independent intervention benefits was
reported. Increased attention to combining interventions
is warranted in order to determine potential additive
benefits to outcomes, evaluate cost-effectiveness, and
identify optimal early childhood intervention bundles to
affect many outcomes in children.
Evidence of the enduring effects of interventions that
promote early child development on later life outcomes
and the potential cost-benefits to society from low-income
e549
without enhanced nutrition) on child IQ, executive functions,
pre-academic skills, and pro-social behaviours, while children
who received early enhanced nutrition sustained significant
benefits to motor development. Our study also contributes to
the evidence by investigating sustained benefits to caregiving.
Mothers who were exposed to early responsive stimulation
(with or without enhanced nutrition) showed significant
continued improvement in responsive caregiving behaviours
and in the quality of the caregiving environment, while the
enhanced nutrition exposure showed significant continued
benefit to the quality of the caregiving environment.
This longitudinal follow-up demonstrated that responsive
stimulation delivered in a programme setting in a rural highly
disadvantaged low-income and middle-income population
can sustain benefits on children’s development 2 years after
the end of intervention. However, compared with the
short-term effects at the end of the original intervention,
the effect sizes are reduced.
Implications of all the available evidence
More studies are needed to investigate the independent and
combined effects of early stimulation and nutrition
interventions. These studies should be designed not only to
provide insights into the effectiveness of these interventions,
but also how to optimise integrated implementation. Further,
in contexts such as Pakistan, in which access, retention, and
attainment in future primary education remains extremely
poor, the extent of development protection that early
responsive stimulation might provide in the long term is likely
to be small. Risks that threaten children’s development will
continue to accumulate; therefore strategies to bolster
development along the life course should be explored.
and middle-income countries is scarce.2,3 Only four
cohorts (from Colombia and Jamaica) have been followed
up after the original stimulation interventions were
implemented between 1978 and 2004.6–10 The Jamaica
cohort is the most prominent example of a cohort tracked
into adulthood following exposure to early stimulation
and nutrition interventions.6 In the efficacy randomised
controlled trial, undernourished infants from poor
neighbourhoods of Kingston, Jamaica, were randomly
assigned into four groups to receive stimulation,
nutritional supplementation, combined interventions, or
control (standard health care). After 24 months of inter-
vention exposure, both interventions had independent
and additive benefits on child development and the
nutrition intervention improved early growth. The effects
of the stimulation intervention on cognitive capacity and
behaviour were sustained into adulthood, whereas the
nutrition intervention sustained small cognitive benefits
only up to 7 years of age. Neither intervention had long-
term benefits on growth.11
www.thelancet.com/lancetgh Vol 4 August 2016

Although these data support integration of stimulation
interventions in child nutrition and health services, a
knowledge gap remains in understanding how similar
interventions affect outcomes along the life course for
children growing up in different settings, with varying
risks from physical environments, sociocultural contexts,
political systems, and access to health, nutrition, and
learning.12 Evidence from longitudinal evaluations of
large-scale programmes in high-income countries
suggest that early gains can be threatened if children do
not transition from an early intervention programme to
high quality educational services.13
Between 2009 and 2012, a pragmatic, community-based,
cluster-randomised effectiveness trial was done in an
impoverished rural district of Sindh, Pakistan.14 The trial
was conducted in partnership with the National
Programme for Family Planning and Primary Healthcare
(often referred to as the Lady Health Worker [LHW]
programme). The LHWs delivered either responsive
stimulation or enhanced nutrition interventions to young
children younger than 2 years and their caregivers via
monthly home visits and parenting groups. The results
showed that responsive stimulation significantly improved
children’s cognitive, language, and motor development at
2 years of age, and enhanced nutrition showed modest
benefits on linear growth at 6 and 18 months.14 With
respect to maternal outcomes, responsive stimulation had
larger effect sizes on mother–child interactions, caregiving
environment, and parenting knowledge and practices
compared with enhanced nutrition, and the combined
intervention had a modest effect on decreasing maternal
depressive symptoms over time.15
We aimed to measure the effects of the responsive
stimulation and enhanced nutrition intervention
delivered in Sindh in children now 4 years old. Although
we intend to follow this cohort through schooling years,
the assessment of children’s development and growth at
4 years offers valuable insights. First, it is important to
document longitudinal attenuation in the intervention
effects before children are exposed to variable education
opportunities. Second, the period between 3 and 5 years
of age captures accelerated maturation and function of
the prefrontal cortex, a brain region that supports
development of higher-order cognitive skills such as
regulation of emotions, attention, and behaviour, and
emergent reasoning skills, which are modifiable through
environment and experience.16 These skills are important
markers of school readiness, and are crucial for
successful transition to preschool. Third, competencies
assessed in this age group have been shown to predict
school engagement and longer term academic
attainment.16 Therefore, this longitudinal follow-up com-
prised assessments of verbal and non-verbal intelligence,
executive functions, and pre-academic learning skills in
addition to measures of growth, physical health, and
motor development. For mothers, the most proximal
influence on children’s healthy growth and development,
www.thelancet.com/lancetgh Vol 4 August 2016
Articles
intervention effects on sustained parenting practices
were investigated.
Methods
Study design and participants
The original pragmatic, community-based, cluster-
randomised effectiveness trial with a 2 × 2 factorial design
tested the effectiveness and feasibility of integrating new
interventions with routine services in the LHW
programme to improve child development and growth
outcomes.14 The LHWs delivered responsive stimulation
interventions, enhanced nutrition interventions, or both
in combination to children younger than 2 years or their
caregivers residing in their health catchments (clusters)
through monthly home visits and community group
sessions. The control group received routine health
and nutrition services. The responsive stimulation
intervention was a local adaptation of the Care for Child
Development approach developed by UNICEF and
WHO. This intervention had two goals, to help caregivers
provide a variety of play and communication activities
using everyday household items or homemade toys to
stimulate children’s cognitive, language, motor, and
affective skills, and to use the context of play and
communication activities to strengthen responsive care
by guiding caregivers to observe and respond to their
child’s cues, thereby promoting the quality of the
caregiver–child interactions that support healthy
development. The method of play and communication
counselling encouraged the caregivers to try out an
activity with their child, and receive coaching and
feedback from the LHW. The enhanced nutrition
intervention enriched the existing nutrition education
curriculum of the LHW programme through the addition
of responsive feeding messages (recognising and
responding to early cues of hunger, communication,
encouragement, and patience during feeding, and
independent feeding); distribution of a multiple
micronutrient supplementation (Sprinkles, Genra
Pharmaceuticals, Pakistan) for children aged
6–24 months; guiding LHWs to link nutrition and health
messages; and training LHWs to move away from a
didactic delivery approach to nutrition education to a
counselling approach involving listening, asking
questions, and problem solving.
1489 mother–infant dyads were enrolled into the
original trial, and randomised into one of four groups;
control (n=368), responsive stimulation (n=383),
enhanced nutrition (n=364), and a combination of
responsive stimulation and enhanced nutrition (n=374).
The control group received the routine LHW services,
delivered in monthly home visits and occasional group
meetings, which included health and hygiene advice,
infant and young child feeding recommendations (basic
nutrition education), child growth monitoring, and
immunisations. The responsive stimulation, enhanced
nutrition, and combination groups also received these
e550
 Articles
routine services in addition to their respective enriched
interventions. Mother–infant dyads were followed up
from birth to 2 years of age. The data collection team was
independent of the intervention team and was masked to
intervention assignment.
In this longitudinal follow-up study, we re-enrolled
mother–infant dyads between Jan 1, and March 31, 2013.
Inclusion criteria for re-enrolment were children without
signs of moderate to severe impairments and those who
were resident in Sindh province. We used the Ten
Questions Screen17 to screen for child impairment followed
by a physician or an allied health professional’s
confirmation. We conducted follow-up assessments on
child development and growth, maternal wellbeing, and
parenting practices from April 1, 2013, to March 31, 2014,
within 1 month of the child’s fourth birthday. All mothers
provided written informed consent (or a thumb print for
consent) and could refuse an interview or assessment at
any time. Ethics approval for the longitudinal follow-up
study was obtained from the ethical review committee of
the Aga Khan University, Karachi, Pakistan.
Randomisation and masking
Details of the cluster randomisation are available in the
report on the original trial.14 In brief, a cluster was defined
as the LHW catchment. A two-stage stratified random
sampling strategy was used to sample 80 clusters.
Random assignment of the intervention group was done
independently of the study team. The allocation ratio was
1:20 (ie, 20 LHW catchments per intervention group). In
the longitudinal follow-up study, the data collection team
comprised 12 data collectors and 12 community-based
child development assessors. Among the team, ten
members were new and did not previously work in the
original trial data collection team. The data collection
team was masked to intervention group assignment. To
help with masking, the data collection team was rotated
every 3 months to reduce familiarity with families and
villages; and the team was trained not to ask families
about the interventions they previously received. We
implemented quality assurance strategies to ensure
precision in data collection, including refresher training
sessions every 3 months, daily debriefings and video
reviews, and monthly supervised field observations.
Procedures
All questionnaires and maternal and child assessments
were administered in Sindhi. We followed language and
sociocultural adaptation protocols to ensure that the
conceptual integrity of the original items was retained in
adaptation.18 During the re-enrolment period, we collected
data on household socioeconomic status and food security
using validated protocols implemented previously in this
study district.14 We collected data during a centre-based
and a home-based visit. One centre-based visit, for which
local rooms were rented in eight locations across the study
site to enable privacy and to minimise distractions,
e551
included all direct maternal and child assessments. We
provided mothers and children with a transport service to
visit the centre for approximately 4 h including breaks and
lunch. We piloted the sequence of assessments conducted
in the centre before data collection to ensure feasibility
and reliability with assessments requiring greater con-
centration at the start of the day (eg, cognitive testing) and
assessment requiring less concentration at the end of the
day (eg, weight). The home-based visit included assess-
ments of the caregiving environment and routines. The
field supervisor observed around 10% of assessments for
reporting inter-observer reliability.
We assessed child cognitive capacity using three
different measures. Child IQ was assessed using the
Wechsler Preschool and Primary Scales of Intelligence,
Third Edition.19 Sociocultural modifications were made to
ensure words, concepts, and pictures were relevant to the
study population. We used seven subtests to assess full-
scale IQ, which were block design, information, matrix
reasoning, vocabulary, picture concepts, symbol search,
and word reasoning. Internal consistency was good
(Cronbach’s α=0·91) and inter-observer agreement
between the supervisors and child development assessors
was high for each subtest (Bland Altman test range
n=120–125, R=0·94–0·99; p<0·0001). We followed a
systematic procedure to identify a shortlist of tasks, locally
adapt these tasks, and try out assessments of executive
functions in children. We created a battery of six executive
function tasks, of which fruit Stroop task, knock-tap task,
big-little task, and go/no go task captured children’s
inhibitory control; forward word span captured working
memory; and the Separated Dimensional Change Card
Sort captured cognitive flexibility. We determined the
child’s comprehension of tasks by performance on
practice trials. We created a final executive function
composite score by calculating a mean of test scores
across six executive function tasks for children who
demonstrated comprehension of task rules via
performance on the practice trials. Tests were different to
those used in the original trial because of the difference
in age and developmental stage of the children. In view of
findings that a three-task battery provides a reliable
measure of overall executive function skills, the final
executive function composite includes final scores for
children who passed comprehension criteria for three or
more tasks.20 The executive function composite showed
acceptable internal consistency (Cronbach’s α=0·64) and
the inter-observer agreement was high for each subtest
(Bland Altman test range n=115–123, R=0·922–0·966;
p<0·0001). We measured pre-academic skills using the
Bracken School Readiness Assessment, Third Edition,21
which comprises five subtests for colour recognition,
letter recognition, number and counting, sizes and
comparisons, and shapes. We made modifications to the
assessment, including replacement of the Roman
alphabet and numbers with Sindhi alphabet and
numbers. Following a review of scores, we found the
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 Articles

distribution of subtests for colour recognition, letter

recognition, and numbers and counting were significantly 80 Lady Health Worker clusters

skewed and the majority of individuals scored zero;

therefore, we did not analyse these subtests. Mean scores
were calculated for the remaining two subtests (sizes and 20 clusters: responsive 20 clusters: responsive 20 clusters: enhanced 20 clusters: control
comparisons [Cronbach’s α=0·768, Bland Altman test stimulation and stimulation nutrition
n=119; R=1·000, p<0.0001], and shapes [0·842, n=119; enhanced nutrition

R=0·00, p<0·0001) for use in the outcome analysis.

We assessed social-emotional development in the 374 infants enrolled 383 infants enrolled 364 infants enrolled 368 infants enrolled
children by use of the results of the maternal Strengths
and Difficulties Questionnaire, adapted for the study
344 followed up at 364 followed up at 335 followed up at 348 followed up at
population. Following analysis of data, we retained 2 years 2 years 2 years 2 years
12 items and organised these into subscales with 30 lost to follow-up 19 lost to follow-up 29 lost to follow-up 20 lost to follow-up
moderate internal consistency and good inter-observer 23 deaths 12 deaths 16 deaths 14 deaths
7 others 7 others 13 others 6 others
agreement. Behavioural problems comprised five items
(0·61, n=123; R=0·976, p<0·0001), and pro-social
behaviours comprised seven items (0·60, n=123; 324 re-enrolled 353 re-enrolled 325 re-enrolled 333 re-enrolled
R=0·969, p<0·0001). children children children children

We assessed child motor development using a

composite score of six items identified from the 315 followed up at 345 followed up at 311 followed up at 331 followed up at
Bruininks-Oseretsky Test for Motor Proficiency, 4 years 4 years 4 years 4 years
29 lost to follow-up 19 lost to follow-up 24 lost to follow-up 17 lost to follow-up
Version 2, Brief Form (BOT-2 BF), which were suitable 1 deaths 2 deaths 3 deaths 2 deaths
for assessing fine and gross motor skills in 4-year-olds. 28 others 17 others 21 others 15 others
The six items included were filling a star, drawing a line
through a path, copying overlapping circles, stringing Figure 1: Re-enrolment and assessments at 4 years
blocks, touching nose with index finger and eyes closed, 90% of the original enrolled subjects were re-enrolled for the follow-up study, and assessments at 4 years were
and walking forward heel-to-toe. The BOT-2 BF completed on 87% of the original enrolled subjects. 33 children were not assessed because of loss to follow-up
despite repeated home visits (n=18) or due to moderate-to-severe disability (n=15).
composite showed acceptable internal consistency
(Cronbach’s α=0·60) and good inter-observer reliability
(Bland Altman test n=80–91, R=0·876–1·000; p<0·0001). Responsive Responsive Enhanced Control p value
We measured child height and weight according to stimulation plus stimulation nutrition (n=331)
enhanced nutrition (n=345) (n=311)
standard protocols.22 Height (ShorrBoard, Weigh and (n=315)
Measure LLC, USA) was measured to the nearest 0·1 cm
and weight (Seca 877 Digital Flat Scale, Weigh and Household characteristics

Measure LLC, USA) was measured to the nearest 0·1 kg, Socioeconomic status* 0·1 (2·5) 0·0 (2·4) 0·2 (2·1) –0·1 (2·2) 0·33
and the scales were calibrated each morning before data Food secure households, % 67% (211) 64% (221) 55% (172) 66% (218) 0·02
collection visits with standard weights. The relative Mean number of children 4 (2·5) 4 (1·9) 4 (2·4) 4 (2·6) 0·35
technical error of measurement (TEM) was good for Parent characteristics
anthropometric measures assessed in 133 children Mothers’ years of 3 (6·9) 2 (6·4) 3 (5·5) 2 (4·9) 0·29
(height TEM 1·86%, R=0·99; weight TEM 0·71%, education
R=0·99). To assess anaemia status in children, we Child characteristics
assessed blood haemoglobin by a finger prick assay with Girls, % 46% (145) 44% (152) 51% (159) 44% (146) 0·12
HemoCue machines (HemoCue B-Haemoglobin Mean height-for-age n=312 –0·7 n=308 –1·0 n=308 –0·9 n=329 –0·8 0·29
System, HemoCue AB, Sweden), which were calibrated Z score (1·5) (2·0) (2·3) (1·7)
daily before data collection visits.
Data are mean (SD) or % (n) unless otherwise stated. The analysis is adjusted for clustering by generalised linear model.
Parenting knowledge and practices were assessed by
*Socioeconomic status was measured on a scale of 0–1 by the wealth index, which was created through principal
maternal report of the case child’s current preschool component analysis as an indicator of household socioeconomic position using household assets data and dwelling
exposure and learning opportunities in the home using characteristics (eg, source of drinking water, sanitation facilities, type of material used for flooring).
one item from the early child development module of the
Table 1: Study population characteristics between randomised groups
UNICEF Multiple Cluster Index Surveys (“In the past
three days, did you or any household member over
15 years of age engage in any of the following activities response; therefore, a caregiver might obtain a score
with your child: read books or looked at pictures together, between 0 and 6. Responses were reported separately for
told stories, sang songs, took child outside of the home, mothers, fathers, and other adult caregivers.
played with child, named or counted, or drew thing to or We assessed maternal and child interactions using
with child”).23 The caregiver was asked about each activity the Observation for Mother-Child Interactions (OMCI)
separately and a point was given for every positive measure24 with good internal consistency and inter-

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 Articles

observer reliability (Cronbach’s α=0·807, Bland Altman Statistical analyses

test n=126; R=0·752, p<0·0001). The OMCI is a We adjusted for clustering effects using generalised
measure of sensitive and responsive behaviours linear models. We used Gaussian distribution to model
observed during a 5 min structured activity exploring a continuous coded variables and binomial distribution to
picture book. The assessor scored the frequency of model binary coded variables. Significance was defined
behaviours live, and 10% of the observations were as a p value lower than 0·05 unless stated otherwise. This
videotaped for independent scoring by an expert to was an intention-to-treat analysis. We tested baseline
check for reliability. We assessed the caregiving differences between groups to identify potential
environment using the Home Observation for the confounders that would need to be accounted for in the
Measurement of the Environment, Early Childhood analyses of outcome variables. We then assessed group
version (HOME-EC) with good internal consistency differences across child and maternal outcomes following
and high inter-observer reliability for each subtest the factorial design of the original study, testing
(Cronbach’s α=0·820, Bland Altman test n=126; ranging differences between exposures to the two interventions
per subscale from R=0·751–0·961, p<0·0001). We (responsive stimulation vs no responsive stimulation and
measured maternal depressive symptoms using the enhanced nutrition vs no enhanced nutrition) with
self-reporting questionnaire (SRQ-20) with good generalised equations. In all models we controlled for
internal consistency and high inter-observer reliability the effect of baseline confounding variables (socio-
(0·873, n=92; R=0·988, p<0·0001). In Pakistan, an economic status, household food security, maternal
See Online for appendix SRQ-20 score of 9 or more indicates risk of depression.25 education, number of children, sex of child). We tested
interaction effects between the two interventions
Responsive stimulation Enhanced nutrition p value for (responsive stimulation and enhanced nutrition). A
intervention intervention interaction significant interaction effect denoted that the effect of a
Yes No p value Yes No p value single intervention was different from the effect of the
Cognitive capacity
combined interventions. We then interpreted the type of
interaction effect by analysing the means of the
IQ (FSIQ, WPPSI III) n=633 n=604 0·043 n=589 n=648 0·134 0·974
76·34 74·74 75·09 75·98 independent intervention with the combined inter-
(75·50– (745·22– (74·50– (75·16– vention. Finally, we calculated Cohen’s d effect sizes as
77·18) 75·26) 75·69) 76·80) differences in adjusted means between the intervention
Executive function n=574 n=570 <0·0001 n=545 n=599 0·978 0·882 and control group over the pooled SD. We used Stata
0·05 –0·11 –0·03 –0·02
0·05– to –1·16 to 0·08 to –0·07 to version 12.1 to conduct all statistical analyses. The
10) –0·06) 0·02) –0·02) original trial is registered with ClinicalTrials.gov, number
Pre-academic skills* n=648 n=613 0·0001 n=606 n=655 0·573 0·151 NCT00715936.
24·45 19·45 23·01 21·10
(23·39– (18·28– (21·81– (20·05–
21·15)
Role of the funding source
25·50) 20·62) 24·20)
The funder had no role in study design, data collection,
Social-emotional development (SDQ)
data analysis, data interpretation, or writing of the report.
Pro-social behaviours n=659 n=639 0·014 n=624 n=674 <0·0001 0·002
1·60 1·46 1·50 1·55 The authors of this report had full access to all data in the
(1·57– (1·42– (1·45– (1·53– study. AKY and JO had primary responsibility for the
1·63) 1·52) 1·55) 1·59) decision to submit the manuscript for publication.
Behavioural problems n=659 n=639 0·089 n=624 n=674 0·485 0·095
0·96 0·94 0·95 0·96
(0·92– (0·89– (0·90– (0·91–
Results
1·00) 0·99) 0·99) 1·00) We identified and re-enrolled 1335 mother–child dyads
Motor development (BOT2-BF) and 1302 participated in the assessments of development,
Motor development n=547 n=511 0·095 n=519 n=539 0·024 0·082 growth, and care (87% of 1489 subjects enrolled in the
2·42 2·36 2·52 2·27 original trial [figure 1]). We did not find any significant
(2·18– (2·12– (2·52– (2·04– differences in baseline characteristics between children
2·66) 2·60) 2·78) 2·49)
lost to follow-up and those assessed at 4 years of age,
Data are mean (95% CI) unless otherwise stated. The analysis is adjusted for clustering by generalised linear model and except for in height-for-age Z score, which was poorer in
controlled for several baseline covariates (socioeconomic status, household food security, number of children, maternal the lost to follow-up sample (appendix). Table 1 shows the
education, and sex of child). BOT2 BF=Bruininks-Oseretsky Test for Motor Proficiency, Version 2, Brief Form. FSIQ=Full
Score IQ. SDQ=Strengths and Difficulties Questionnaire. WPPSI III=Wechsler Preschool and Primary Scale of Intelligence,
baseline characteristics of re-enrolled participants across
Third Edition. The number of participants for executive functions is lower than for other outcomes because the analysis the four treatment groups (responsive stimulation plus
only included children who had passed practice trials for three or more executive function tasks. The number of enhanced nutrition, responsive stimulation, enhanced
participants who undertook the motor development assessment is lower than for other outcomes because these data
nutrition, control). Analysis of these variables shows that
were collected towards the end of the centre visit; therefore, if a child was tired or the family did not wish to spend any
longer at the centre the assessment was not taken. *Average score of subscales of sizes and comparisons, and shapes group characteristics were similar, and the only
from the Bracken School Readiness Assessment, Third Edition. significant difference was seen in the proportion of food-
secure households, which was controlled for in sub-
Table 2: Child development outcomes
sequent analyses (appendix).

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Child development outcomes are reported in table 2. Responsive stimulation Enhanced nutrition intervention p value for
Child cognitive outcomes showed that compared with intervention interaction
children who received no responsive stimulation, the Yes No p value Yes No p value
children exposed to responsive stimulation had signi- Anthropometric indices
ficantly higher mean scores for IQ, executive function, Weight-for- n=657 n=638 0·343 n=620 n=675 0·935 0·108
and pre-academic skills. The effect sizes were small for age Z score –0·8 (–0·9 to –0·9 (–0·9 to –0·8 (–0·9 to –0·9 (–1·0 to
IQ (Cohen’s d=0·1 for responsive stimulation plus –0·7) –0·8) –0·7) –0·8)
enhanced nutrition and 0·1 for responsive stimulation), Height-for- n=657 n=637 0·184 n=620 n=674 0·566 0·127
age Z score –0·9 (–1·0 to –0·9 (–1·0 to –0·8 (–1·0 to –0·9 (–1·0 to
medium for executive function (0·3 for responsive –0·8) –0·7) –0·7) –0·8)
stimulation plus enhanced nutrition and 0·3 for Weight-for- n=657 n=637 0·762 n=620 n=674 0·487 0·585
responsive stimulation) and large-to-small for pre- height Z score –0·5 (–0·5 to –0·5 (–0·6 to –0·4 (–0·5 to –0·5 (–0·6 to
academic skills (0·5 for responsive stimulation plus –0·4) –0·4) –0·3) –0·4)
enhanced nutrition and 0·2 for responsive stimulation). Proportion of children moderately-severely undernourished, n (%)
No significant differences in cognitive outcomes were Underweight n=657 n=638 0·076 n=620 n=675 0·414 0·126
observed between children who received enhanced 82 (12%) 64 (10%) 64 (11%) 82 (12%)
nutrition and those were not exposed to enhanced Stunted n=657 n=637 0·247 n=620 n=674 0·892 0·267
113 (17%) 99 (16%) 86 (15%) 126 (18%)
nutrition. Interaction effects between the two inter-
Wasted n=657 n=637 0·464 n=620 n=674 0·908 0·338
ventions were not significant for IQ, executive function, 34 (5%) 31 (5%) 26 (4%) 39 (6%)
or pre-academic skills. Children exposed to responsive Haemoglobin
stimulation had significantly higher mean pro-social
Haemoglobin n=648 n=629 0·010 n=613 n=664 <0·0001 0·007
behaviour scores with a small effect size than did (g/L) 104·9 (10·37 105·5 (10·43 104·0 (10·26 106·3 (10·52
children who received no responsive stimulation (0·2 to 10·61) to 10·68) to 10·54) to 10·75)
for responsive stimulation plus enhanced nutrition and Anaemia n=648 n=629 0·521 n=613 n=664 0·064 0·548
0·2 for and responsive stimulation); and children who (Hb <110 g/L) 381 (58·8%) 363 (57·7%) 374 (61%) 370 (55·7%)
did not receive enhanced nutrition had significantly Data are mean (95% CI), or n (%) unless otherwise stated. The analysis is adjusted for clustering by generalised linear
higher mean pro-social behaviour scores than did model and controlled for several baseline covariates (socioeconomic status, household food security, number of
children who were exposed to enhanced nutrition children, maternal education, and sex of child).

intervention. A significant interaction effect was
observed between the two interventions. Further
analyses suggest an additive effect with a higher mean in
the combined group compared with either responsive
stimulation alone or enhanced nutrition alone (appendix
table C). The two interventions did not affect child
behavioural problems. Mean motor development scores
were significantly higher in children exposed to
enhanced nutrition than in children who did not receive
enhanced nutrition, with a small effect size (Cohen’s
d=0·2 for responsive stimulation plus enhanced
nutrition and 0·2 for enhanced nutrition). No significant
differences were observed in motor development scores
as a function of responsive stimulation exposure. A
significant interaction effect between the two inter-
ventions on motor development was not observed.
Neither responsive stimulation nor enhanced nutrition
affected preschool enrolment rates (responsive
stimulation 172 [26%] of 660 children vs no responsive
stimulation 154 [24%] of 642 children, p=0·9; enhanced
nutrition 181 [29%] of 626 children vs no enhanced
nutrition 142 [21%] of 676 children, p=0·2).
Table 3 shows that mean levels of height-for-age,
weight-for-age, and weight-for-height Z scores or
proportions of moderate to severe undernutrition did not
differ significantly across groups. No significant inter-
action effects were observed between the two inter-
ventions on child growth indicators. Mean haemoglobin
value was significantly higher in children who received
no responsive stimulation than in children who were
Table 3: Child growth and nutritional indicators
exposed to responsive stimulation. Similarly, significantly
higher mean haemoglobin concentrations were observed
in children who received no enhanced nutrition than in
children who were exposed to enhanced nutrition
(table 3). A significant interaction effect was observed
between the two interventions; however, further analyses
suggests a higher mean score in the combined group
compared with either responsive stimulation alone or
enhanced nutrition alone (appendix).
Table 4 reports outcomes at the level of the caregiver.
Children who received responsive stimulation had
significantly higher levels of maternal responsive
behaviours than did children who received no responsive
stimulation, as indicated by the observation of mother–
child interactions with small to medium effect sizes
(Cohen’s d 0·3 for responsive stimulation plus enhanced
nutrition and 0·2 for responsive stimulation) and by the
quality of the caregiving environment indexed by the
HOME-EC with a medium effect size (0·3 for responsive
stimulation plus enhanced nutrition and 0·3 for responsive
stimulation). The mean score for the quality of the
caregiving environment was significantly higher in
children exposed to enhanced nutrition than in children
who did not receive enhanced nutrition, also with a
medium effect size (0·3 for enhanced nutrition). A
significant interaction effect was observed between the two
interventions on the quality of the caregiving environment

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Responsive stimulation intervention Enhanced nutrition intervention p value for

interaction
Yes No p value Yes No p value
Mother–child interactions (observation) n=655 (20·64; n=635 (18·33; <0·0001 n=670 (19·83; n=619 (19·15; 0·136 0·461
20·09–21·19) 17·70–18·96) 19·26–20·39) 18·53–19·78)
Caregiving environment (HOME-EC) n=657 (32·68; n=638 (31·43; <0·0001 n=622 (32·68; n=673 (31·50; <0·0001 0·001
32·07–33·29) 30·79–32·08) 32·03–33·32) 30·89–32·11)
Maternal depressive symptoms (SRQ-20) n=646 (6·60; n=635 (7·44; 0·513 n=614 (6·42; n=667 (7·57; 7·13– 0·184 0·063
6·14–7·06) 7·04–7·84) 5·97–6·87) 8·00)

Data are n (mean; 95%CI) unless otherwise stated. The analysis is adjusted for clustering by generalised linear model and controlled for several baseline covariates
(socioeconomic status, household food security, number of children, maternal education, and sex of child). HOME-EC=Home Observation and Measurement of the
Environment, Early Childhood Version. SRQ-20=Self Reporting Questionnaire.

Table 4: Care and maternal outcomes

Responsive stimulation over 3 days was significantly higher in the no enhanced

80 Responsive stimulation nutrition group than in those families who received
70
No responsive stimulation enhanced nutrition (figure 2). Further details on the
Proportion of family members (%)

treatment effect sizes can be found in the appendix.

60

50 Discussion
40 This study analysed whether enriched interventions
30
(responsive stimulation and enhanced nutrition alone
or in combination) integrated with routine LHW
20
programme services in the first 2 years of life showed
10 sustained benefits on child development and growth at
0 4 years of age. A responsive stimulation intervention
(with or without enhanced nutrition) benefited children’s
Enhanced nutrition cognitive abilities and pro-social behaviours with small to
80 Enhanced nutrition
No enhanced nutrition large effects compared with routine services, whereas
70 the enhanced nutrition intervention benefited motor
Proportion of family members (%)

60 development with a small effect compared with routine

50
40
30
20
10
0
Mother Father
(aged >15 years old)
Figure 2: Proportion of family members who engaged in four or more learning
activities with the case child over 3 days
(A) Responsive stimulation. (B) Enhanced nutrition. No significant differences
were found between responsive stimulation (n=659) compared with no
responsive stimulation (n=639) groups for mothers (p=0·201), fathers (p=0·680),
and other caregivers (p=0·675). There were significant differences between
enhanced nutrition (n=624) compared with no enhanced nutrition (n=674)
groups for mothers (p=0·001), fathers (p<0·0001), and other caregivers
(p<0·0001). A significant interaction effect was found between interventions for
other caregivers (p<0·0001).
score. Further analyses suggest a lower mean in the
combined group compared with either responsive
stimulation alone or enhanced nutrition alone (appendix
table C). The total number of maternal depressive
symptoms did not differ between groups. Figure 2 shows
that the proportion of mothers, fathers, and other adult
caregivers playing four or more games with their children
services. Early nutrition interventions have generally
shown a smaller effect on children’s cognitive develop-
ment in low-income and middle-income countries than
have responsive stimulation interventions,1,4 and more
work is warranted on associations with motor
development.5 Neither intervention made a difference to
preschool enrolment. However, the motivation of
Other caregiver families should be explored further in the context of
variable access and quality to preschool services. Of the
significant interaction effects observed, pro-social
behaviour suggests an additive benefit of the combined
group compared with either responsive stimulation
alone or enhanced nutrition alone. Haemoglobin data
suggest neither responsive stimulation alone nor
enhanced nutrition alone were beneficial, but a
significant interaction effect indicated the combined
group mean effect size was higher; however, these data
should be interpreted with caution. Trial monitoring data
suggested a lower uptake of the micronutrient
supplementation;14 thus these findings could be residual
effects of receiving basic infant and young child dietary
diversity recommendations delivered as part of the
routine LHW programme.
The responsive stimulation intervention had a greater
effect on children’s executive functions than on IQ.

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Research on executive functioning has shown that these
skills are crucial to support children’s school readiness
independent of language and general intelligence.26
Executive functions are a useful measure of cognitive
abilities because assessments can be designed to reduce
measurement biases resulting from lack of formal
education exposure. However, few studies have
implemented these tasks in low-income and middle-
income countries with the exception of a small number of
nutrition intervention studies that assessed child executive
functions in middle childhood,27,28 and focused on only
one aspect of executive function.29,30 In this study, we
intended to employ a more comprehensive measure of
executive function skills for the preschool age group.16 The
executive function findings indicate the potential of early
responsive stimulation to support child executive function
skills during a sensitive period of rapid cognitive growth.
Future studies need to address how early childhood
interventions in low-income and middle-income countries
can promote executive function skills through play
interactions as a way to foster young children’s school
readiness and successful transition to formal education.
In addition to the sustained intervention effects on the
child, both interventions showed significant benefits to
maternal care. Responsive stimulation continued to
improve maternal responsive behaviours, and both
interventions improved the quality of the caregiving
environment as indexed by the HOME-EC. The
responsive stimulation intervention was designed to
focus on the child and caregiver by coaching the caregiver
to strengthen responsive caregiving skills in the play and
communication context rather than adopting an
approach of the LHW directly playing with the child. The
findings (both for responsive stimulation and enhanced
nutrition) indicate that mothers are likely to adapt
learned responsive caregiving skills during infancy and
toddlerhood to the needs of preschool-aged children.
Current evidence suggests a focus on behaviour
modification techniques which support learning-
responsive caregiving skills in early childhood are likely
to benefit children in later years. Landry and colleagues’
study31 in a US population showed that mothers were
able to adapt responsive caregiving skills learned in one
activity to other contexts of care; therefore, in future work
it might also be important to examine whether these
skills transferred to other care practices in our study
population (eg, feeding). Nonetheless, future research
needs to examine how various caregiving practices,
including feeding, might mediate the effect of early
interventions on later child outcomes.
With respect to maternal depressive symptoms, neither
responsive stimulation nor enhanced nutrition inter-
vention was significant. More research is warranted on
the integration of maternal and family mental health
interventions with early child development interventions.
One previous study of children with disabilities32 reported
that participation in a child development programme
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Articles
increased maternal stress, and authors speculated this
might be due to greater knowledge and the responsibility
of new practices in child care; however, the complexities
of maternal mental health and the influence on daily
responsibilities in low-income and middle-income
countries are not well explored.
Compared with the short-term effects at the end of the
original intervention,14,15 the effect sizes were reduced
from medium-to-large to small-to-medium on significant
child and care outcomes. Although investigations of
interventions in high-income countries indicate loss of
impact over time in the general population, beneficial
effects on the most vulnerable children and families
remain.33 Previous longitudinal follow-up of efficacy
studies on early stimulation and nutrition interventions in
low-income and middle-income countries have not
followed children in the preschool age group, making
comparisons with this study difficult.4 However, evidence
from longitudinal evaluations of large-scale programmes
in high-income countries suggest that early gains can be
threatened if children do not transition from an early
intervention programme to high quality educational
services.13 The effect size of the original intervention, the
type of study (efficacy or effectiveness), the child’s level of
risk, continued positive parenting practices, and the
specific health and educational services the child receives
are all factors that need to be better understood. Better
understanding is particularly important when designing
early childhood interventions that are responsive to the
needs of the local population and identifying later sensitive
windows for boosting early effects and supporting a
continuum of healthy development.34 The Jamaican cohort
demonstrated sustained benefits as a result of stimulation
intervention into adulthood.11 Although the effect of early
intervention for schooling and early adulthood is yet to be
followed in this cohort, a lack of early childhood services
might mitigate early intervention benefits, as access,
retention, and attainment in future education programmes
remains extremely poor.35 Therefore, strategies to bolster
development and build on early interventions must be
tested in many delivery platforms in health education and
social protection sectors. Previous intervention studies
have shown benefits by integrating stimulation and
parenting advice in primary health-care services or in
visits with a paediatrician.36,37 However, in low-income and
middle-income countries with weaker primary and
secondary health services, other platforms such as
reaching children through so-called Child Health Days
could also be assessed.
The strengths of this study include a relatively low
attrition rate, a comprehensive battery of child development
and growth assessments, and good reliability of data
collection. However, there are also several limitations.
First, changes in caregiving responsibilities within
households as children transition from infancy to the
preschool age group was not tracked; therefore, while the
assessment of the quality of care focused on the mother, in
e556
 Articles
households with large extended or joint family structures,
the role of elder siblings, grandparents, and other relatives
could have a more significant role. Second, an independent
assessment of whether the LHWs continued to deliver
advice on responsive stimulation and enhanced nutrition
was not undertaken, which might moderate outcomes.
Finally, child behaviour data were collected by maternal
report while other child development measures were
performance-based. A direct observation of children’s
behaviour (eg, interactions with siblings or peers) might
have provided a more objective behavioural measure.
Nevertheless, this longitudinal follow-up demonstrates
that responsive stimulation delivered as part of a
community health service can have sustained benefits on
children’s development 2 years after intervention. These
data might be generalisable to similarly impoverished
rural populations in low-income and middle-income
countries. However, research is needed to investigate
what effect these interventions might have on dis-
advantaged urban populations. Crucially, the inter-
ventions were delivered by community health workers
that might be comparable with similarly qualified and
educated health workers. However, the LHWs are paid
community health workers; therefore, these data are not
generalisable to the many volunteer-based community
health services in low-income and middle-income
countries. Importantly, these data showed benefits to
child executive functions that are crucial to support
school readiness, and showed benefits to care practices
that could be adapted to support later development in
young children. Future analyses of these data need to
identify which children and families benefit more or less
over time, and whether the disparities over the first
4 years of life between groups are reduced or increased.
Contributors
AKY and JO conceptualised the study and planned the analysis. AKY, JO,
and MAR developed the data collection materials with inputs from XAP,
NT-S, SS, and UM. AKY oversaw the study, data analysis, and
interpretation, and drafted the manuscript. MAR, UM, and SS trained the
data collection team and oversaw quality assurance. AR was the
statistician for the study and participated in the study design, data analysis
and interpretation. All authors critically reviewed drafts of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was funded by Grand Challenges Canada (Grant No 0061-03).
Grand Challenges Canada is funded by the Government of Canada and
is dedicated to supporting Bold Ideas with Big Impact in global health.
We thank the mothers and children who gave their valuable time, and
without whom the study would not have been possible, all the study
staff, Amjad Hussain, the data collection research team, and
community-based child development assessors.
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Jurnal Pengabdian Kepada Masyarakat ISSN: 2548-8406 (print)
MEMBANGUN NEGERI ISSN: 2684-8481 (online)
Vol.4 No. 1 April 2020

STIMULASI TUMBUH KEMBANG PADA ANAK USIA PRA SEKOLAH

Apolonia Antonilda Ina dan Bernadeta Novita Septiani1

1
STIKES Santa Elisabeth Semarang

e-mail: apoloniaaina@gmail.com

Abstrak

Kegiatan pengabdian kepada masyarakat ini bertujuan untuk meningkatkan pengetahuan

warga tentang tumbuh kembang pada anak usia pra sekolah, meningkatkan pengetahuan
warga dalam melakukan stimulasi tumbuh kembang pada anak usia prasekolah, serta
optimalisasi tumbuh kembang anak usia pra sekolah. Metode yang digunakan dalam kegiatan
ini yaitu perencanaan, tindakan, observasi dan evaluasi serta refleksi. Perencanaan
dilaksanakan untuk persiapan kegiatan dan sarana. Tindakan yang dilakukan yaitu pemberian
pendidikan kesehatan tentang pertumbuhan dan perkembangan untuk stimulasi pada anak,
mendemonstrasikan cara pembuatan media dari bahan bekas untuk stimulasi tumbuh
kembang pada anak serta optimalisasi tumbuh kembang anak. Observasi dan evaluasi yang
dilakukan yaitu kendala dalam proses pembuatan media stimulasi tumbuh kembang anak
maupun dalam proses pendidikan kesehatan, terkait stimulasi tumbuh kembang anak yang
diberikan kepada warga. Refleksi untuk mengetahui kekurangan atau kelebihan terhadap
kegiatan yang telah dilakukan dalam rangka menetapkan rekomendasi terhadap
keberlangsungan atau pengembangan kegiatan berikutnya. Dengan adanya kegiatan
pengabdian kepada masyarakat dengan judul Stimulasi Tumbuh Kembang pada Anak Usia
Pra Sekolah di Pendidikan Anak Usia Dini (PAUD) Kelurahan Sukorejo, Gunung Pati,
Semarang, dapat meningkatkan pengetahuan warga tentang tumbuh kembang pada anak usia
pra sekolah, meningkatkan pengetahuan warga dalam melakukan stimulasi tumbuh kembang
pada anak usia prasekolah serta optimalisasi tumbuh kembang pada anak usia pra sekolah.

Kata Kunci: Stimulasi, Tumbuh Kembang, Pra Sekolah

A. Pendahuluan
Periode dan aspek perkembangan yang berlangsung pada anak balita, maka penting
dipahami beberapa prinsip tentang stimulai tumbuh kembang. Stimulasi tumbuh kembang
pada anak balita merupakan kegiatan merangsang kemampuan dasar anak agar anak tumbuh
kembang secara optimal. Setiap anak perlu mendapat stimulasi rutin sedini mungkin dan
terus menerus pada setiap kesempatan. Stimulasi tumbuh kembang anak dilakukan oleh orang
tua, yang merupakan orang terdekat dengan anak, pengganti ibu atau pengasuh anak, anggota
keluarga lain dan orang dewasa lainnya. Kurangnya stimulasi dapat menyebabkan
penyimpangan tumbuh kembang anak bahkan gangguan yang menetap. Kemampuan dasar
anak yang dirangsang dengan stimulasi terarah adalah kemampuan gerak kasar, kemampuan

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gerak motorik halus, kemampuan bicara dan bahasa serta kemampuan sosialisasi dan
kemandirian.
Faktor resiko balita kurang stimulasi dikarenakan kondisi malnutrisi,
delay/keterlambatan dalam tumbuh dan berkembang seperti contohnya terlambat bicara,
jalan, motorik kasar atau halus ataupun bahasa. Dengan adanya berbagai faktor resiko
keterlambatan tumbuh kembang, maka stimulasi tumbuh kembang pada anak pra sekolah
perlu dilakukan.

B. Masalah
Hasil pengkajian pada masyarakat di wilayah RW 01 Kelurahan Sukorejo Gunung
Pati didapatkan hasil 76 warga adalah balita dimana 38 warga balita perempuan dan 38 warga
balita laki-laki. Dari 76 warga tersebut membutuhkan stimulasi tumbuh kembang guna
mengoptimalkan pertumbuhan dan perkembangan pada anak usia balita. Dimana ada 1 warga
usia balita yang menderita gizi buruk dan retardasi mental. Selain itu minimnya warga
tentang tumbuh kembang pada anak usia pra sekolah dan cara melakukan stimulasi tumbuh
kembang pada anak usia pra sekolah.

C. Metode Pelaksanaan
Lokasi pengabdian kepada masyarakat ini berada di PAUD Kelurahan Sukorejo,
Gunung Pati, Semarang. Kegiatan ini bertujuan untuk meningkatkan pengetahuan warga
tentang tumbuh kembang pada anak usia pra sekolah, cara melakukan stimulasi tumbuh
kembang pada anak usia pra sekolah serta optimalisasi tumbuh kembang anak usia pra
sekolah. Dalam pelaksanaannya berdasarkan rangkaian tahapan sebagai berikut:
1. Perencanaan
Kegiatan-kegiatan yang dilakukan pada tahap perencanaan adalah:
a. Mengajukan ijin ke pihak Ketua RW terkait pelaksanaan pengabdian masyarakat
b. Pembentukan tim pelaksanaan pengabdian masyarakat
c. Sosialisasi program pengabdian dengan mengundang Kepala Kelurahan, Ketua RW,
Ketua RT yang berkenaan dengan program yang akan dilaksanakan
d. Penyusunan program pelatihan dan pendidikan kesehatan tentang stimulasi tumbuh
kembang
2. Tindakan
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Tindakan dalam kegiatan ini berupa implementasi program, yaitu:

a. Pemberian pendidikan kesehatan tentang pertumbuhan dan perkembangan untuk
stimulasi pada anak
b. Mendemonstrasikan cara pembuatan media dari bahan bekas untuk stimulasi tumbuh
kembang pada anak
c. Optimalisasi tumbuh kembang pada anak

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Gambar 1. Kegiatan Stimulasi Tumbuh Kembang Anak Usia Pra Sekolah

3. Observasi dan Evaluasi

Observasi dilakukan terhadap proses pembuatan media stimulasi tumbuh kembang oleh
warga. Instrumen yang digunakan berupa catatan lapangan. Beberapa hal yang di
observasi adalah kendala-kendala, kekurangan dan kelemahan dalam proses pembuatan di
lapangan maupun dalam proses penggunaan di masyarakat serta proses pendidikan
kesehatan terkait stimulasi tumbuh kembang anak yang diberikan kepada warga. Evaluasi
dilakukan terhadap kuantitas dan kualitas produk yang dihasilkan mampu digunakan
sebagai media stimulasi tumbuh kembang.
4. Refleksi
Refleksi dilakukan terhadap kegiatan yang telah dilaksanakan. Hal ini dilakukan semata-
mata untuk mengetahui kekurangan atau kelebihan terhadap kegiatan yang telah dilakukan
dalam rangka menetapkan rekomendasi terhadap keberlangsungan atau pengembangan
kegiatan berikutnya.

D. Pembahasan
Berdasarkan permasalahan yang dihadapi oleh mitra, beberapa alternatif solusi yang
dapat ditawarkan adalah sebagai berikut:
a) Meningkatkan pengetahuan warga tentang tumbuh kembang pada anak usia pra sekolah
b) Meningkatkan pengetahuan warga dalam melakukan stimulasi tumbuh kembang pada
anak usia prasekolah.
c) Optimalisasi tumbuh kembang anak usia pra sekolah
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Kegiatan pengabdian masyarakat yang dilaksanakan pada warga dan anak PAUD
Kelurahan Sukorejo telah berlangsung dengan baik dengan dukungan media kreatif untuk
stimulasi tumbuh kembang pada anak PAUD. Hal ini terlihat dari animo para ibu dan
antusiasme anak PAUD dalam mengikuti kegiatan stimulasi tumbuh kembang ini tinggi,
terbukti dengan kehadiran para ibu dan wali dalam mendampingi anak selama kegiatan ini.
Hal ini mengindikasikan bahwa para warga menyambut positif kegiatan yang telah dilakukan
oleh tim pengabdian masyarakat. Dalam kegiatan ini, para ibu sangat antusias dalam
menerima informasi terkait stimulasi tumbuh kembang anak usia pra sekolah serta anak
PAUD semangat mengikuti kegiatan stimulasi tumbuh kembang dengan media yang kreatif.

E. Kesimpulan
Adanya kegiatan pengabdian kepada masyarakat dengan judul Stimulasi Tumbuh
Kembang pada Anak Usia Pra Sekolah di PAUD Kelurahan Sukorejo, Gunung Pati,
Semarang, dapat meningkatkan pengetahuan warga tentang tumbuh kembang pada anak usia
pra sekolah, meningkatkan pengetahuan warga dalam melakukan stimulasi tumbuh kembang
pada anak usia prasekolah serta optimalisasi tumbuh kembang pada anak usia pra sekolah.

DAFTAR PUSTAKA.

Proborini, A., Maulidha & Larasati, D. (2017). Faktor-faktor yang Mempengaruhi

Keterlambatan Perkembangan Anak Usia 1-3 Tahun di Desa Cangkringsari Kecamatan
Sukodono Kabupaten Sidoarjo. Diakses dari
https://joim.ub.ac.id/index.php/joim/article/view/40

Purwandari, H. (2008). Kebijakan Pemerintah dalam Pelaksanaan deteksi Dini Tumbuh

Kembang. Diakses dari
https://digilib.uns.ac.id/dokumen/download/7867/MjA0NDU=/Kebijakan-pemerintah-
dalam-pelaksanaan-deteksi-dini-tumbuh-kembang-abstrak.pdf

Putra, A.Y., Yudiemawati, A., & Maemunah, N. (2018). Pengaruh Pemberian Stimulasi Oleh
Orang Tua Terhadap Perkembangan Bahasa pada Anak Usia Toodler di PAUD di
PAUD Asparaga Malang. Diakses dari
https://publikasi.unitri.ac.id/index.php/fikes/article/download/828/642

Shabrina dan Sufriani. (2017). Stimulasi dengan Perkembangan Anak Usia Prasekolah.
Diakses dari http://www.jim.unsyiah.ac.id/FKep/article/view/4313

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MEMBANGUN NEGERI ISSN: 2684-8481 (online)
Vol.4 No. 1 April 2020

Sumiyati & Yuliani, (2016). Hubungan Stimulasi dengan Penrkembngan Anak Usia 4-5
Tahun di Desa Karangtengah Kecamatan Baturraden Kabupaten Banyumas. Diakses
dari http://ejournal.poltekkes-smg.ac.id/ojs/index.php/link/article/view/450

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Journal for Research in Public Health, Volume 2, Issue 2, January 2021, pp: 88-94
ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

The Effects of Baby Massage to Sleep Quality in Infant Age 1-7 Months
Heri Saputro*, Choridhatul
Bahiya
Institut Ilmu Kesehatan STRADA
Indonesia
Email:
h.saputro@iik-strada.ac.id
Received: October 12, 2019
Revised: December 24, 2020
Accepted: January 23, 2021
ABSTRACT
Sleep quality is very important for infant’s growth and
development. Poor sleep quality can lead to decreased daily
activity, weakness, anxiety, decreased resistance, so that growth
and development is less than optimal. Baby massage is one way to
relieve tension and anxiety in the infant, so that it becomes calm,
sleep soundly and the power of concentration will be fuller. The
purpose of this research to know the effect of baby massage on
sleep quality of infants aged 1-7 months in BPM NY. Choridatul
Bahiya AMd. Keb Kebonsari Sukun of Malang City. The research
design used Quasy experimental designs with non equivalent
control group design. The population of all infants aged 1 to 7
months was 25 infants with samples meeting the inclusion criteria
of 20 respondents consisting of 10 respondents treatment group
and 10 respondents control and taken by purposive sampling. Data
were collected using questionnaire and analyzed using wilcoxon
match pairs test. The results showed that the quality of infant sleep
in the treatment group before being massaged was mostly 8 (80%)
poor, 2 infants (20%) moderate and in the control group most were
6 (60%) poor, 3 (30%) were poor and 1 infant (10%) is good. Sleep
quality after massaging in the treatment group was mostly 6 (60%)
good, 3 (30%) moderate and 1 (10%) bad, whereas in the control
group without having a baby massage most of the 6 (60%) were
bad, 3 infants (30%) moderate and 1 baby (10%) good. The results
showed that there was influence of infant massage on the quality of
baby sleep with value of 0,006 <α (0,05). The results show that
baby massage can improve the quality of baby sleep, especially for
babies who have poor sleep quality. Therefore health workers
should provide counseling to mothers who have babies about infant
massage, so motivated in learning to do baby massage
independently.

Keywords: Baby Massage, Sleep Quality, Infant

INTRODUCTION

Infancy is the golden age for growth and development of children, so it needs special attention. One of
the factors that affect the development of a baby is the quality of sleep. Sleep is a top priority for a
baby's life, because during sleep approximately 75% of growth hormone is produced, therefore the
quality of sleep is very important and main for the growth and development of babies, because during
sleep it produces three times more growth hormone than when awakened. On the other hand, poor
sleep quality results in a decrease in daily activities, tiredness, weakness, anxiety, poor neuromuscular
coordination, slow healing and decreased immune system, causing less optimal growth and
development (Widyanti, 2008).
In Indonesia, babies who experience sleep problems are quite high, namely around 44.2% of babies
experience sleep disorders such as often waking up at night. However, more than 72% of parents think
sleep disturbance in babies is not a problem or just a minor problem. The results of Damayanti's
research in 2004-2005 which were carried out in five major cities in Indonesia Jakarta, Bandung,
Medan, Palembang and Batam with 385 respondents, obtained data that 51.3% of babies had sleep
problems, 42% of the night's sleep was less than 9. hours, waking at night more than 3 times and long
waking at night more than 1 hour (Handayani, 2015).

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ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

Poor sleep quality disturbs the physiological and psychological balance. Physiological effects include
decreased daily activities, fatigue, weakness, poor neuromuscular coordination, slow healing process
and decreased immune system. While the psychological impact includes more unstable emotions,
anxiety, lack of concentration, cognitive abilities and lower levels of combined experiences. Given the
importance of sleep time for babies, the quality of sleep must really be fulfilled so that it doesn't
adversely affect their growth and development. One of the non-pharmacological therapies to
overcome infant sleep problems is baby massage (Prasetyo, 2013).
Baby massage is a slow and gentle rubbing motion on the baby's entire body starting from the baby's
feet, stomach, chest, face, hands and back. Gentle massage will help relieve muscle tension so that the
baby is calm and sleeps. Baby massage is a fun way to relieve tension and feelings of anxiety in
babies. Gentle massage will help relax the muscles so that the baby is calm, sleeps soundly and when
he wakes up his concentration will be fuller. This is due to an increase in the levels of serotonin
secretion produced during massage. Serotonin is the main transmitter substance that accompanies
sleep formation by suppressing the activity of the reticular activation system and other brain activities
(Roesli, 2013).
The results of Sundari's (2015) study state that there is a significant relationship between infant
massage and the quality of sleep for babies aged 6-12 months at BPM Atika in Madiun Regency in
2015. With this massage makes babies more relaxed and calm so that it can increase the effectiveness
of their sleep. Gentle massage helps the body release oxytocin and endorphins which can help
overcome discomfort, increase the baby's concentration, generally babies who are massaged will fall
asleep more soundly so that when they wake up the concentration will be better.
Preliminary study at BPM Ny. Choridatul Bahiya, AMd. Kebonsari Kelurahan Kebonsari, Malang
City on 12-17 November 2017 by interviewing 5 parents of babies aged 1-7 months, it was found that
4 babies (80%) said the babies had difficulty sleeping at night, often woke up at night, the amount of
sleep per day was less than 13 hours, the next day often cried and fussy. Based on the data above, it
shows that there are still babies who have poor sleep quality. As for the handling that has been done so
far when the baby is fussy, the baby is only carried and cradled and breastfed, but in this way the baby
is still fussy and falls asleep due to fatigue.
The above phenomenon shows that there are many problems that parents often complain about having
trouble sleeping, are often fussy, especially at night, even though sometimes their babies feel full, are
not defecating, but babies still can't sleep well. . In connection with this, the researcher wants to
provide a solution to parents who complain that their baby has difficulty sleeping, namely by way of
baby massage. Babies who are massaged will be able to sleep soundly, while when they wake up their
concentration will be fuller. If the research is carried out it provides benefits for both the respondent
and the institution. Therefore, researchers are interested in conducting research on the effect of infant
massage on sleep quality in infants aged 1-7 months at BPM NY. Choridatul Bahiya AMd. Kebonsari
Village, Sukun District, Malang City.

RESEARCH METHODS
Materials in this study for infant massage consistency include foam mattresses covered in soft cloth,
towels or rags, diapers and changing clothes, telon oil for massaging, water and washcloths.
The research design used Quasy experimental designs with Non equivalent control group design. The
research instrument used a baby sleep quality questionnaire. Data analysis used the Wilcoxon match
pairs test statistical test.

RESEARCH RESULT
Case 1, Mr. "S", aged 28 year old male complained of pain in postoperative wounds, the client
said that the pain increased when moving, the client said that the pain was stabbing and the client
complained of nausea. The pain that is felt is intermittent with a duration of more than 5 minutes, the
client grimaces, there is a vertical surgical wound with 14 stitches and a drain attached, the client
holds the abdominal area when the pain appears.
The nursing diagnosis that is established is acute pain associated with physical (postoperative)
agents. In nursing intervention, one of the non-pharmacological measures is determined, namely the
progressive relaxation technique of muscel relaxation. The outcome to be achieved is that pain is

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ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

reported from moderate (3) to non-existent (5). Facial expression from the sendang scale (3) to absent
(5).
The implementation that is done is by providing a progressive relaxation technique of muscel
relaxation. This implementation is done once a day. The implementation is still considering the
patient's analgesic drug administration schedule, namely by providing a progressive relaxation
technique of muscel relaxation 1 hour before the drug administration schedule.
Evaluation of nursing care for 3 days of giving implementation found that acute pain was resolved
according to the determined outcome.
Case 2, Mrs. "S" aged 45 years complained of postoperative wound pain in the abdomen. The
client said he had never had surgery before, the client said the pain increased when moving. The client
said that the pain was felt like prickling, the client also said that the pain was getting worse with
movement, the pain was felt continuously. The client's face looks grimacing, pain scale 5 (moderate)
there is a horizontal surgical wound with 16 stitches and a drain attached. There is an increase in blood
pressure of 160/90 mmHg.
The nursing diagnosis is established, namely acute pain associated with physical (post-surgical)
agents. In nursing intervention, one of the non-pharmacological measures is determined, namely the
progressive relaxation technique of muscel relaxation. The outcome to be achieved is that pain is
reported from moderate (3) to non-existent (5). Facial expression from the sendang scale (3) to absent
(5).
The implementation that is done is by providing a progressive relaxation technique of muscel
relaxation. This implementation is done once a day. The implementation is still considering the
patient's analgesic drug administration schedule, namely by providing a progressive relaxation
technique of muscel relaxation 1 hour before the drug administration schedule.
Evaluation of nursing care for 3 days of giving implementation found that acute pain was resolved
according to the determined outcome.
Case 3, Mr. "A", aged 35-year-old man complained of pain in postoperative wounds, the client
said the pain increased when moving, the client said the pain was stabbing, the client said he was
worried about the pain he experienced because this was his first experience of undergoing surgery .
The pain that is felt is intermittent with a duration of 5-10 minutes, the client grimaces, there is an
operation wound and a drain is attached, the client holds the abdominal area when the pain appears.
The nursing diagnosis that is established is acute pain associated with physical (postoperative)
agents. In nursing intervention, one of the non-pharmacological measures is determined, namely the
progressive relaxation technique of muscel relaxation. The outcome to be achieved is that pain is
reported from moderate (3) to non-existent (5). Facial expression from the sendang scale (3) to absent
(5).
The implementation that is done is by providing a progressive relaxation technique of muscel
relaxation. This implementation is done once a day. The implementation is still considering the
patient's analgesic drug administration schedule, namely by providing a progressive relaxation
technique of muscel relaxation 1 hour before the drug administration schedule.
Evaluation of nursing care for 3 days of giving implementation found that acute pain was resolved
according to the determined outcome.
Case 4, Mr. "K", aged 32 year old man, complained of pain in the postoperative wound radiating
to the buttocks, the client said the pain increased when he moved a lot, the client said the pain was like
a cut. The pain that is felt is intermittent with a duration of 5-10 minutes, the client grimaces with a
pain scale of 5 (moderate), there is an operation wound on the abdomen and a drain is attached, the
client holds the abdominal area when the pain appears.
The nursing diagnosis that is established is acute pain associated with physical (postoperative)
agents. In nursing intervention, one of the non-pharmacological measures is determined, namely the
progressive relaxation technique of muscel relaxation. The outcome to be achieved is that pain is
reported from moderate (3) to non-existent (5). Facial expression from the sendang scale (3) to absent
(5).
The implementation that is done is by providing a progressive relaxation technique of muscel
relaxation. This implementation is done once a day. The implementation is still considering the
patient's analgesic drug administration schedule, namely by providing a progressive relaxation
technique of muscel relaxation 1 hour before the drug administration schedule.

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Journal for Research in Public Health, Volume 2, Issue 2, January 2021, pp: 88-94
ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

Evaluation of nursing care for 3 days of giving implementation found that acute pain was resolved
according to the determined outcome.

Case 5, Ms. “M” aged 20 years old complained of postoperative wound pain in the abdomen. The
client said this was the client's first experience of undergoing surgery so he felt anxious with the
healing process of the wound, the client says the pain increases with movement. The client said that
the pain felt like being stabbed, the client also said that the pain was getting worse when moving, the
pain was felt continuously and there was an increase in blood pressure when the TTV was examined,
namely 160/80 mmHg. The client's face looks grimaced, pain scale 5 (moderate) there is a horizontal
surgical wound with 14 stitches and a drain attached.
The nursing diagnosis is established, namely acute pain associated with physical (post-surgical)
agents. According to Wilkinson (2016), nursing diagnoses are enforced based on characteristic
limitations, namely subjective: reporting pain with cues (using a pain scale), reporting pain while
objective data: autonomic response, distraction behavior, expressive behavior, face mask and
protective attitudes. In nursing intervention, one of the non-pharmacological measures is determined,
namely the progressive relaxation technique of muscel relaxation. The outcome to be achieved is that
pain is reported from moderate (3) to non-existent (5). Facial expression from the sendang scale (3) to
absent (5).
The implementation that is done is by providing a progressive relaxation technique of muscel
relaxation. This implementation is done once a day. The implementation is still considering the
patient's analgesic drug administration schedule, namely by providing a progressive relaxation
technique of muscel relaxation 1 hour before the drug administration schedule.
Evaluation of nursing care for 3 days of giving implementation found that acute pain was resolved
according to the determined outcome.

DISCUSSION
Sleep Quality for Infants Ages 1-7 Months Before Massage
The results showed that the quality of sleep of infants at the age of 1-7 months before the baby
massage in the treatment group was mostly 8 babies (80%) in bad category and in the control group
most of them 6 babies (60%) were in bad category. Shows that most of the babies in BPM NY.
Choridatul Bahiya AMd.Keb Kelurahan Kebonsari, Sukun District, Malang City has poor sleep
quality. Sleep quality is a certain physiological quality or state obtained during sleep that restores
bodily processes that occur at waking time. The quality of a baby's sleep not only affects physical
development, but also his attitude the next day (Maryunani, 2010).
Babies with poor sleep quality show drowsiness during daytime activities, lack of enthusiasm or
attention, sleep throughout the day, fatigue, depression, distress, and decreased ability to do activities.
and the number of hours of sleep at night is less than 9 hours and the length of sleep during the day is
less than 8 hours, however, most parents think this is no problem for the quality of their baby's sleep.
This is because based on the complaints reported by the respondent's parents with different
complaints. Some have reported frequently waking up when sleeping at night because during the day
they do too much light play, such as learning to crawl and trying to sit up.
Some things that cause poor sleep quality for babies can be due to fatigue due to activities carried out
for 24 hours and unfavorable environmental conditions such as lots of mosquitoes, crowds and others.
Babies who experience physical exhaustion will have difficulty sleeping and will easily fuss if they
are going to sleep and in their sleep the baby cannot soundly and wake up easily. Inadequate sleep and
poor sleep quality can cause physiological and psychological balance disorders. Babies who
experience physical exhaustion will have difficulty sleeping and will easily fuss if they are going to
sleep and in their sleep the baby cannot soundly and wake up easily. Inadequate sleep and poor sleep
quality can cause physiological and psychological balance disorders (Sofa, 2013).
Poor sleep quality before the baby massage is also caused by fatigue, so that his body is not ready to
sleep. When babies are fussy because they are too tired, stress hormones such as cortisol and
adrenaline flood the baby's bloodstream making it more difficult for the baby to relax and calm down.
This will be a cycle in the baby, the more tired the baby is, the harder it will be for him to relax and
fall asleep. This situation makes baby fatigue worse. He will be even more restless and can only cry.
These fussy babies usually wake up when they are supposed to take a nap and when they should be

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ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

sleeping at night. When the baby is tired, the baby will have difficulty sleeping or make him sleep
deprived. In addition, babies will also wake up more often and become fussy, this is what makes the
baby's sleep quality worse.

Sleep Quality for Babies 1-7 Months After Massage

The results showed that the quality of baby sleep after massage the baby in the treatment group was
mostly 6 babies (60%) in good category and only 1 baby (10%) had poor sleep quality, in the case
before the massage there were 8 babies (80%). who have poor sleep quality. Shows that there is an
increase in the quality of sleep between before and after the massage. Whereas in the control group,
that was without massage intervention, most of the 6 babies (60%) were in the bad category, as at the
time of the first observation. This means that in the control group there was no improvement in the
quality of baby sleep.
The results of this study suggest that an increase in the quality of baby sleep is associated with infant
massage. The increase in sleep quality in infants who are given massage is due to an increase in the
level of serotonin secretion produced during massage, the effect that occurs on the baby's body is
calm, comfortable and reduces the frequency of crying (Roesli, 2013).
The quality of the baby's sleep got better after the massage showed that baby massage was strongly
suspected to affect the quality of the baby's sleep. Baby massage causes better quality sleep because
massage makes babies more relaxed and calm so that it can increase the effectiveness of their sleep.
Baby massage helps the body release oxytocin and endorphins which help deal with discomfort,
increase the baby's concentration, generally babies who are massaged will fall asleep more soundly so
that when they wake up the concentration will be better. In addition, the quality of sleep which is
better is thought to be due to an increase in the level of serotonin secretion produced during massage.
Seretonin has a role in sleep and makes you sleep longer and more soundly at night.

Effect of Infant Massage on Sleep Quality for Infants aged 1-7 Months
The results showed that the treatment group obtained a value of 0.006 <α (0.05), it was concluded that
there was a difference in the quality of baby sleep between before (pretest) and after (postest),
meaning that there was an increase in the quality of baby sleep after baby massage, So it can be
concluded that baby massage affects the quality of sleep for babies at the age of 1-7 months. Whereas
in the control group without infant massage, the p-value was 0.414> α (0.05), it was concluded that
there was no difference in sleep quality for infants aged 1-7 months between pretest and postest or in
other words, there was no improvement in the quality of baby sleep between the observations first
(pretest) and second observation after two weeks (postest). Thus, it can be concluded that infant
massage intervention has a significant effect on the quality of sleep for infants aged 1-7 months.
The results of this study are in accordance with Sundari (2015) which found that there was a
significant relationship between infant massage and the quality of sleep for infants aged 1-7 months.
With massage makes babies more relaxed and calm so that it can increase the effectiveness of their
sleep. Gentle massage helps the body release oxytocin and endorphins that help deal with discomfort,
generally babies who are massaged will fall asleep more soundly so that when they wake up their
concentration will be better. In addition, the increase in the quality of the massage is caused by an
increase in the level of serotonin secretion produced during the massage. Seretonin has a role in sleep
and makes you sleep longer and more soundly at night.
The results of this study are also in accordance with Arista's research (2013) in Tirtomoyo Village,
Ampelgading District, Malang Regency, which states that there is an increase in sleep duration in
infants aged 0-3 months between before and after the massage. Before the baby massage was done,
the baby looked restless and fussy after the baby massage. Besides the baby's sleep duration increased,
the baby also seemed calmer and less fussy. The average duration of sleep for babies before the infant
massage was 15.27 hours a day, while the average after infant massage was 16.67 hours a day.
The results obtained that there were significant differences in sleep quality between infants in the
control group and infants in the treatment group showing better results in the quality of sleep. Baby
massage also has many benefits including making the baby calmer, increasing the effectiveness of
baby rest (baby sleep), increasing growth, improving baby concentration, helping to relieve discomfort
in digestion and emotional stress, stimulating brain and nervous system development, increasing
peristaltic motion for digestion, stimulates the activity of the Vagus Nerve for improved respiration,

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ISSN: 2685-5283 (print), ISSN: 2685-5275 (online)
DOI: 10.30994/jrph.v2i2.32

strengthens the immune system, teaches babies early on about body parts and increases the flow of
oxygen and nutrients to cells.
This is in accordance with the opinion of Roesli (2013) that massage can increase serotonin levels
which will produce melatonin which plays a role in sleep and makes sleep longer and more soundly at
night. Serotonin will also increase the capacity of receptor cells that function to bind glucocorticoids
(adrenaline, a stress hormone). This process causes a decrease in levels of adrenaline (stress hormone)
so that babies who are given massage will appear calmer and less fussy. Massage also increases the
absorption mechanism of food by the vagus nerve so that the baby's appetite also increases.
In this study, there were also babies who did not get baby massage but had moderate and good sleep
quality, this could be influenced by several factors, namely environmental factors, nutrition, disease
and stimuli, such as the habit of drinking milk before bed which could affect the quality of their sleep.
The habit of drinking milk before bed will also affect the quantity and quality of baby sleep. The
results of this study that some of the control group infants had the habit of drinking milk before bed.
Babies who drink milk before bedtime will sleep better and last longer than those who don't drink
milk before bedtime. In the treatment group, even though they had received infant massage, there was
still 1 baby (10%) who had poor sleep quality. From the results of interviews with infant mothers who
had poor sleep quality, the baby's mother said that the factor affecting the quality of her baby's sleep
was a busy and unfavorable environment. Because conditions are safe and comfortable for babies to
accelerate the sleep process. The physical environment in which a baby sleeps has an important effect
on the ability to fall asleep and stay asleep. A crowded and non-conducive environment can make the
baby's sleep quality less than optimal.

CONCLUSION
The quality of sleep for infants before the treatment group was mostly (80%) poor and in the control
group (60%) was poor. The quality of sleep for babies after baby massage in the treatment group was
mostly (60%) good and most of the control group (60%) was in the bad category. There is an effect of
infant massage on the quality of sleep for infants aged 1-7 months with value 0.006 <α (0.05).

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