The Effectiveness Of Video And E-Booklet Media In Health Education On Improving The Knowledge Of Pregnant Women About The Pregnancy Danger Signs At Jetis 1 Public Health Center Of Bantul Regency

Background: Danger signs of pregnancy before causing complications can be detected early independently through learning media such as videos and e-booklets. The purpose of this study was to determine the effectiveness of video and ebooklet media in improving the knowledge of pregnant women about the danger signs of pregnancy Methods: This study was conducted in December 2020-January 2021 at Jetis 1 Public Health Center, Bantul Regency and used the type of quasi-experimental research and pretest-posttest with control group design. The research subjects were pregnant women in the first, second and third trimesters as many as 24 people for each group. Sampling was collected using purposive sampling technique on respondents with the criteria of being willing to follow the research rules, there is no trouble in seeing/speaking/hearing, being capable to read and write. Respondents who resigned during the study, did not complete the questionnaire until the end and worked as health workers were not taken as research respondents. The measuring instrument used is a questionnaire that has been tested for validity and reliability. The data analysis used Wilcoxon test and Mann Whitney test Results: The results of the analysis show that the two media have an effect on increasing the knowledge of pregnant women with p-value 0,000 for videos and p-value 0,000 for e-booklet Conclusion: Video is more effective than e-booklet in improving the knowledge of pregnant women (p-value 0,031). Thus the video made by researchers can be used to provide health education about the danger signs of pregnancy ARTICLE HISTORY Received : April 30 th , 2021 Accepted : June 18 th , 2021


INTRODUCTION
Changes of body during pregnancy, it allows for common complaints that usually go away on their own. However, it does not rule out the possibility of complaints that need to be watched out for so-called danger signs of pregnancy such as not eating, excessive nausea, vomiting, high fever, insufficient movement of the fetus in the womb, swelling of several parts of the body, bleeding and premature rupture of the membranes. This danger sign if not detected will result in death (Kementerian Kesehatan Republik Indonesia, 2019).
Indonesian Health Profile in 2019 said that the Maternal Mortality Rate (MMR) generally decreased during the 1991-2015 period from 390 to 305 per 100.000 live births. However, the data on maternal mortality rate for 2015, which amounted to 305, still failed to meet the 2015 MDGs target of 102 maternal deaths per 100.000 live births (Kementerian Kesehatan RI, 2020).
Based on Yogyakarta Health Profile data in 2019, the maternal mortality rate rose sharply by 39 cases in 2016 and fell back slightly to 34 cases in 2017, but rose again in 2018 to 36 cases and in 2019 it remained at 36 cases. The highest number of maternal deaths occurred in Bantul Regency with 13 cases and the lowest in Yogyakarta City with 4 cases (Dinas Kesehatan Provinsi, 2020). On the map of the distribution of maternal mortality cases in Bantul Regency, Jetis 1 Public Health Center is in the red zone area with ≥ 2 cases of maternal death (Dinkes Bantul, 2020).
To prevent complications in pregnancy, every pregnant woman must know and recognize the danger signs of pregnancy so that the family can immediately take the mother to a health facility if the complaint arises and the mother will not be late for help. Efforts to enable pregnant women to be able to carry out early detection of pregnancy danger signs is through health education by health personnel about pregnancy danger signs. Therefore, education is needed to increase the knowledge of pregnant women through easy-to-understand media.
Based on a preliminary study at Jetis 1 Public Health Center, it is known that health education for pregnant women is carried out through classes for pregnant women using the KIA book (Maternal and Child Health Book) and videos. However, the video played only covers the process of getting pregnant and how to bathe the baby, in which there is no video about pregnancy danger signs and e-booklet has never been used at all. The perceived obstacle is the lack of pregnant women's attention to read KIA books due to various underlying factors.
To facilitate the educational process so that there is an increase in knowledge, media that is tailored to the target is needed. Basically the media is divided into 3, namely print media, electronic media and board media (Notoatmodjo, 2014b). Examples of printed media include booklets, leaflets, flyers, flip charts and rubrics (Susilowati, 2016). The form of a booklet can be modified into an e-booklet (electronic booklet), which is a simple form of an e-book (electronic book) which is produced as an electronic document and can be read using the appropriate software on a computer, laptop, tablet, or smartphone (French, 2013). E-booklets are classified as electronic learning media and because they are also an amalgamation of printed media, e-booklets are considered more practical to carry anywhere by presenting structured, attractive and highly interactive information (Sulistina, 2016). The quasi-experimental research in 2015 showed that the use of e-booklet media provided a statistically significant increase in knowledge (Setyawati & Herlambang, 2015).
Examples of electronic media include television, radio, film, cassettes, CDs, and VCDs (Susilowati, 2016). Video is an electronic medium for electronically displaying moving scenes into vibrant multimedia applications (Simarmata, 2020). The advantage of video is that it saves time with a large number of viewers being able to obtain information because the recording can be played back (Switri, 2019). Quasi experimental research in 2020 shows that video media is an effective health education medium in increasing knowledge and attitudes compared to leaflet media (Pawestri, 2020).
The use of video media and e-booklets can be compared to determine their effectiveness in providing information because through these various health education media, knowledge, namely everything that is known and obtained from the touch of the five senses to certain objects from the results of seeing, hearing, feeling and thinking is one goal to be achieved in improving perceptions and healthy lifestyles (Makhmudah, 2018).
According to the the opinion of Wiroatmojo and Sasonohardjo (2002) in a literature study in 2019, it was stated that the percentage of vision absorption was 82%, hearing 11%, touch 3.50%, taste 2.50% and smell 1%. This shows that the senses with the highest absorption ability of the information received are the sense of sight followed by the sense of hearing, where video and e-booklets are a form of media that utilize the sense of sight and hearing (Khotimah et al., 2019).
Research in 2018 states that in addition to increasing knowledge, the use of media can also improve the attitudes of pregnant women towards pregnancy danger signs, where combined media (booklet and audiovisual) are in the first place, then booklet comes second and audiovisual comes third (Senja Atika Sari & Suhendra Sulaeman, 2018). This study has the advantage of comparing the use of booklet and audiovisual media separately or in combination, but the subjects taken are too few for the three intervention groups and there is no exposure to the characteristics of the information presented and the p-value is not known for significant differences between the characteristics of the respondents so that it is not yet certain whether the media presented is effective in increasing pregnant women's knowledge and attitudes towards pregnancy danger signs or this is due to differences in respondent characteristics.
Based on the facts above, it is known that there are various forms of educational media that have been studied, each with their respective levels of effectiveness. So this study was conducted to further optimize the knowledge of pregnant women in all trimesters, especially regarding the danger signs of pregnancy per trimester as an early step for early detection using easy-to-understand media. Although this study only presented two media, namely video and e-booklet, for comparison, a larger number of respondents was taken for the two groups and analyzed to determine whether there are significant different characteristics in these groups. The characteristics of media exposure are also considered in order to ensure the participation of the media that will be given, so that it can be seen whether the video media and e-booklets provided are effective in increasing pregnant women's knowledge.
The aim was to determine the increase in pregnant women's knowledge before and after being given health education about pregnancy danger signs using video and ebooklet media so that the differences in the effectiveness of video and e-booklet media are known to increase pregnant women's knowledge about pregnancy danger signs.
Hopefully the results of this study can enrich empirical evidence and broaden readers' insights regarding the effectiveness of video and e-booklets media in health education about pregnancy danger signs and provide practical benefits for pregnant women to be able to detect pregnancy danger signs in all trimesters and for midwives to conduct education pregnancy danger signs using video or e-booklets media. Then for further researchers, they can create other media innovations that are much better.

MATERIALS AND METHOD
This type of research is a quasi-experimental with a pretest-posttest design with a control group. The research subjects were divided into two groups, namely the treatment group and the control group. The treatment group was given counseling with video media while in the control group, it was given counseling using e-booklet media. The two groups were carried out a pretest before being given counseling then after the counseling would be carried out immediately posttest. Researchers measured knowledge through posttest immediately after being given treatment in both groups. Each group only had one intervention. The results of increasing knowledge is obtained from the difference in the value of posttest minus pretest. The population of this study were all pregnant women who visited the obstetric clinic at Jetis 1 Public Health Center, Bantul Regency, with a sample size of 24 people for the treatment group and 24 people for the control group. Sampling was collected using purposive sampling technique on respondents with the criteria of being willing to follow the research rules, there is no trouble in seeing/speaking/hearing, being capable to read and write. Respondents who resigned during the study, did not complete the questionnaire until the end and worked as health workers were not taken as research respondents. After the research respondents were determined according to the inclusion-exclusion criteria, the distribution of the treatment group and the control group was divided into odd-even distribution. Odd numbers as the treatment group and even numbers as the control group.
This research was conducted in December 2020-January 2021 in the obstetric clinic at Jetis 1 Public Health Center, Bantul Regency. The independent variable of this research is health education media, namely video and e-booklet media. The dependent variable of this study is an increase in knowledge about the danger signs of pregnancy. With other variables observed, namely age, latest education, occupation, parity and information. This type of data is primary data obtained directly from respondents. The instrument for measuring knowledge uses a closed questionnaire about the danger signs of pregnancy in the first, second and third trimesters which have been tested for their validity and reliability at Jetis 2 Public Health Center, Bantul Regency in November 2020. The research material used two animated videos dimensions and e-booklets were both designed by researchers and made by video and design grapher and media validity tests were carried out using the opinion of material experts and media experts. Both media have also registered for Intellectual Property Rights and received Registration Certificates. The research procedure starts from the preparation stage, the implementation stage and the completion stage. Data management starts from editing, scoring, coding, data entry, cleaning and tabulation. Data analysis consisted of univariate analysis to explain the characteristics of respondents and bivariate analysis using the Shapiro Wilk normality test, with the results of the data distribution not being normally distributed so that the Wilcoxon test and the Mann Whitney test were used. Bivariate analysis to determine whether there were significant differences in the age characteristics of the mean data used the independent t test, while the characteristics of the latest education, occupation, parity and information used the chi square test. This research has received a certificate of ethics worthy statement from the Health Research Ethics Commission of Poltekkes Kemenkes Yogyakarta on November 30, 2020 with a number e-KEPK/POLKESYO/0648/X/2020. In terms of age characteristics, it is known that the average age of respondents in the video group is 26.29 (±5.393) years, while the average age of respondents in the ebooklet group is 29.21 (±5.831) years. Most of the respondents had less than the mean age of 54.2% for the video group and 62.5% for the e-booklet group and a p-value of 0.079 so that there was no significant difference in age in the two groups (p> 0.05). In the latest educational characteristics, it is known that most of the respondents have secondary education (SMA / MA / SMK) with a percentage of 54.2% for the video group and 62.5% for the e-booklet group and a p-value of 0.540 so that there is no significant difference in the latest education at both groups (p> 0.05). In terms of job characteristics, it is known that most respondents do not work with a percentage of 58.3% for the video group and 62.5% for the e-booklet group and a p-value of 0.768 so that there is no significant difference in work in the two groups (p> 0.05). In terms of parity characteristics, it is known that most respondents are nulliparous with a percentage of 70.8% for the video group and 45.8% for the e-booklet group and p-value 0.196 so that there is no significant difference in parity in the two groups (p> 0.05). In the information characteristics, it is known that most respondents have received information with a percentage of 75% for the video group and 66.7% for the e-booklet group and a p-value of 0.525 so that there is no significant difference in information between the two groups (p> 0.05). The difference in increasing knowledge before and after counseling in the video group and the e-booklet group: In the video group there was an increase before and after counseling from an average of 78.504 (±14.5353) to 90.375 (±9.4305). Statistically there was a significant difference in the increase in knowledge in the video group with a p-value of 0.000 (<0.05). In the e-booklet group there was also an increase in knowledge before and after counseling from an average of 77.546 (±16.6644) to 83.792 (±15.1845). Statistically there was also a significant difference in increasing knowledge in the e-booklet group with a p-value of 0.000 (<0.05). Comparison of the mean increase in knowledge between the video group compared to the e-booklet group: The average increase in knowledge in the video group was 28.67 and 8.34 higher than the average in the e-booklet group, namely 20.33. Statistically there was a significant difference in the increase in knowledge in the video group compared to the e-booklet group with a p-value of 0.031 (<0.05) where counseling using video was more influential in increasing the knowledge of pregnant women compared to counseling using e-booklets.

DISCUSSION
As a cognitive domain, knowledge has a role in shaping a person's actions which are obtained from the process of knowing and after feeling an object (Notoatmodjo, 2014b). This knowledge is obtained from the learning process which can be taken by memorizing/remembering and exercising which is influenced by various factors (Purwanto, 2017). Based on age, both groups were less than the mean. Age is one of the predisposing factors and the organism (individual) includes the maturity/growth factor that affects learning success (Purwanto, 2017 andNotoatmodjo, 2014a) As a person grows older, knowledge will also increase through improvement power of perspective and mindset (Rosa, 2019). This is in line with previous research in 2017 and 2018 which stated that age as a factor affecting a person's level of knowledge, seen from a person's maturity level affects their cognitive abilities (Negara &Prabowo, 2018 andSuwaryo &Yuwono, 2017).
Based on education, most of the respondents have secondary education (SMA/MA/SMK). Education begins with basic education (SD/MI/SMP) and continues to secondary education (SMA/MA/SMK) and higher education (college). Education as a predisposing factor and a self-organism (individual) is an effort to develop abilities and influence a person's level of knowledge (Purwanto, 2017 andNotoatmodjo, 2014a). The higher the level of education, the more knowledge is obtained and vice versa, the less the level of education will hinder the acceptance of newly recognized values (Rosa, 2019 andArini, 2018). This is in line with the research in 2020 which states that there is a relationship between the level of education and the level of knowledge, but it is not in accordance with the 2018 research that there is no influence between education and knowledge (Negara &Prabowo, 2018 andIswara, 2020).
Based on occupation, most of the respondents did not work. Work as a predisposing factor and a self-organism (individual) is a way of earning a living to meet the needs of himself and his family (Purwanto, 2017, Notoatmodjo, 2014aand Arini, 2018. The work environment provides direct or indirect experience and knowledge that can affect a person's level of knowledge (Notoatmodjo, 2014a andRosa, 2019). This is in line with research in 2015 which states that there is a relationship between work and knowledge but it is not in accordance with research in 2018 that there is no relationship between work and knowledge level (Yeni, 2015 andCahyaningrum, 2018).
Based on parity, most respondents are nulliparous, that is, they have never given birth before. Parity as a predisposing factor and a self-organism (individual) is an experience where a person will get a source of knowledge by repeating the knowledge obtained to solve problems. The experience in going through the period of pregnancy will have an impact on the mindset in the next pregnancy (Notoatmodjo, 2014a andRosa, 2019). Research in 2018 shows that parity is related to a mother's level of knowledge of pregnancy danger signs (Budiarti et al., 2018).
Based on information, most of the respondents had received information about pregnancy danger signs. Information as predisposing factors and factors outside the individual (social) in the form of tools used to influence learning success obtained from formal/informal education or mass/non-mass sources (Purwanto, 2017, Notoatmodjo, 2014aand Rosa, 2019. Research in 2018 states that there is a relationship between information and the level of knowledge (Cahyaningrum, 2018).
There was an increase in knowledge before counseling and after counseling both in the video and e-booklet groups. After doing the average comparison, the video group had a higher average than the e-booklet group. Statistically (p-value 0.031) shows that counseling using video media is more effective in increasing the knowledge of pregnant women compared to counseling using e-booklets. Quasi experimental research in 2020 also states that compared to leaflet, video media is more effective in increasing knowledge (Pawestri, 2020). Previous quasi experimental research in 2017 also stated that video was more effective in increasing pregnant women's knowledge, attitudes and behavior compared to booklet media (Selvia et al., 2017). Subsequent research in 2021 also states that the use of videos increases the effectiveness of self-efficacy in understanding pregnancy danger signs compared to the KIA book (Herinawati et al., 2021). When compared with other studies, the opposite is shown by 2019 study which states that there is no significant different in the use of video media and leaflets (Nuradhawiyah, 2019). This also seems to be in line with previous research in 2017 which stated that leaflets were more effective than videos (Kasman et al., 2017).
When viewed from the contact with the five senses, the sense of sight has high absorption capacity at 82% followed by the sense of hearing with 11% absorption, all of which are on video media with animated images and sound to explain the danger signs of pregnancy in the first, second and third trimesters (Khotimah et al., 2019). Video as a mass health education media is a didactic (one-way) method to communicate health messages to the public at large in order to raise awareness of health, especially the danger signs of pregnancy (Notoatmodjo, 2014b andNurmala, 2018). According to Edgar Dale's The Cone of Experience, video is a fifth order health education aid included in the television category, where this category presents abstract learning experiences that are better when compared to verbal words or symbols (Notoatmodjo, 2014b andGuslinda, 2018). By type, video is an electronic media that is conveyed through electronic aids. The advantages of video include easy to understand, more interesting, include all five senses, the presentation can be controlled and repeated and the loudness of the voice can be adjusted (Susilowati, 2016 andSimarmata, 2020). So that in health education for pregnant women, video media is more useful and easy to use to provide health information, especially about pregnancy, such as pregnancy danger signs. Video media that includes the senses of sight and hearing will be easier to understand and can increase pregnant women's knowledge compared to e-booklets that only include the sense of sight.

CONCLUSION
The conclusion of this study is that there is an increase in the knowledge of pregnant women about the danger signs of pregnancy after being given counseling using media made by researchers, namely videos and e-booklets, where the video group further increases the knowledge of pregnant women. Counseling using video media made by researchers was more effective in increasing the knowledge of pregnant women about the danger signs of pregnancy compared to counseling using e-booklets which were also made by researchers.