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TAHUNAJARAN2023/
2024
 Jurnal Keperawatan
Volume 14 Nomor S4, Desember 2022
e-ISSN 2549-8118; p-ISSN 2085-1049
http://journal.stikeskendal.ac.id/index.php/Keperawatan

ANALISIS SITUASI (FISHBONE) DALAM ASUHAN KEPERAWATAN

KOMUNITAS PADA ANAK SEKOLAH DENGAN MASALAH RISIKO
KEKERASAN SEKSUAL: STUDI KASUS
Erna Handayani1*, Nurul Laili1, Dodik Hartono1, Deny Prasetyanto2, Siti Nur Hasina3
1
STIKES Hafshawaty Pesantren Zainul Hasan Probolinggo, Gerojokan, Karangbong, Pajarakan, Probolinggo,
Jawa Timur 67281, Indonesia
2
Sekolah Tinggi Ilmu Kesehatan Fatmawati Jakarta, Jl. H. Beden No.25, Pd. Labu, Cilandak, Jakarta Selatan,
Jakarta 12430, Indonesia
3
Universitas Nahdlatul Ulama Surabaya, Jl. Smea No.57, Wonokromo, Wonokromo, Surabaya, Jawa Timur
60243, Indonesia
*Ernayani.06@gmail.com

Kekerasan seksual merupakan keterlibatan anak dalam aktivitas seksual dengan orang dewasa atau
dengan anak kecil lainnya yang anak tidak memahami sepenuhnya , tidak mampu memberikan
persetujuan untuk melakukan dan kegiatan ini melanggar hukum atau tabu sosial masyarakat. diagram
Fishbone sebagai alat (tool) yang menggambarkan sebuah cara yang lebih sistematis dalam melihat
berbagai masalah merupakan salah satu pendekatan yang digunakan untuk mengidentifikasi prilaku
kekerasan dalam penerapan asuhan keperawatan komunitas. Penelitian ini merupakan studi kasus,
sampel penelitian ini adalah di anak sekolah dasar yang berisiko terjadi kekerasan seksual. Pengumpulan
data dilakukan dengan menggunakan wawancara, observasi dan telaah data puskesmas setempat. Hasil
analisis situasi Fishbone didapat diangnosa keperawatan terkait masalah risiko kekerasan seksual pada
anak sekolah yaitu masalah ketidakefektifan pemeliharaan kesehatan tentang pencegahan kekerasan
seksual pada agregat anak usia sekolah berhubungan dengan isufisiensi sumber social dan pengetahuan.

Kata kunci: asuhan keperawatan; fishbone; kekerasan; komunitas; perilaku

ANALYSIS OF THE SITUATION (FISHBONE) IN COMMUNITY NURSING

CARE IN SCHOOLCHILDREN WITH THE PROBLEM OF RISK OF SEXUAL
JERKING: A CASE STUDY

ABSTRACT
Sexual violence is the involvement of children in sexual activities with adults or with other small children
which the child does not fully understand, is unable to give consent to do and this activity violates the
law or social taboos of society. Fishbone diagram as a tool that describes a more systematic way of
looking at various problems is one approach used to identify violent behavior in the application of
community nursing care. This research is a case study, the sample of this research is elementary school
children who are at risk of sexual violence. Data collection was carried out using interviews,
observations and data analysis of local health centers. The results of the Fishbone situation analysis
obtained a nursing diagnosis related to the problem of the risk of sexual violence in school children,
namely the problem of ineffective health care regarding the prevention of sexual violence in the
aggregate of school-age children related to the inefficiency of social resources and knowledge.

Keywords: behavior; community; fishbone; nursing care; violence

PENDAHULUAN
Pelecehan kekerasan seksual anak merupakan masalah kesehatan masyarakat yang utama
dengan perkiraan prevalensi global yang mengungkapkan bahwa antara 8% hingga 31% anak
perempuan dan 3% hingga 17% anak laki-laki telah menjadi korban pelecehan seksual anak
sebelum usia 18 tahun(Hébert et al., 2019). Fenomena ini memiliki dampak yang luar biasa
pada anak-anak dan keluarga mereka dan menimbulkan tantangan unik bagi para praktisi

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Kesehatan terutama pada masa Covid-19 (Tener et al., 2021). Kekerasan terhadap anak tetap
menjadi perhatian global. Memahami sumber dukungan untuk hukuman fisik dalam budaya,
dan potensi penularan penganiayaan anak antargenerasi, sangat penting untuk pengembangan
kebijakan dan keterlibatan masyarakat untuk melindungi anak-anak (Goodman, 2020).
Pelecehan seksual terhadap anak merupakan hal yang tabu di sebagian besar komunitas Muslim
termasuk Indonesia (Alzoubi et al., 2018). Dalam kebanyakan kasus, orang tua Muslim akan
minimal membahas masalah terkait seks dengan anak-anak mereka. Dalam beberapa kasus,
orang tua meminta anak-anak mereka untuk menarik diri dari pendidikan seks atau program TV
yang membahas masalah seksual. Orang tua percaya bahwa mengekspos anak-anak mereka ke
pendidikan seks dapat memicu mereka untuk berlatih seks pada tahap awal dan untuk menarik
perhatian mereka pada masalah seksualitas. Akibatnya, anak-anak tidak memiliki pengetahuan
yang cukup dan tidak memiliki kepercayaan diri untuk mengungkapkan pelecehan seksual yang
mereka alami karena stigma sosial(Alzoubi et al., 2018; Solehati et al., 2022a). Dalam beberapa
kasus, pelakunya adalah anggota keluarga atau teman dekat; membuat pengungkapan lebih
sulit. Anak-anak sering tidak percaya dalam kasus pengungkapan kecuali ada bukti yang jelas.
Akibatnya, anak akan menderita kerugian fisik dan psikologis yang signifikan (Alzoubi et al.,
2018; Wismayanti et al., 2021). Remaja dan anak yang memiliki pengalaman kekerasan seksual
berisiko untuk depresi berat, pascatrauma gangguan stres, penggunaan zat terlarang, gangguan
makan, dan kekerasan seksual(Murchison et al., 2019) .Sekolah juga mempunyai peranan
dalam sex education untuk anak. Sehingga perlu adanya Pendidikan yang tepat baik dalam
bentuk kebijakan dan program terstruktur bagi anak disekolah dalam hal sex education. Sesuai
penjelasan tersebut penelitian melakukan studi kasus dengan tujuan memberikan asuhan
keperawatan komunitas pada anak sekolah dengan masalah risiko kekerasan seksual.

METODE
Penelitian ini merupakan studi kasus, sampel penelitian ini adalah di anak sekolah dasar
Kelurahan Gedawang yang berisiko terjadi kekerasan seksual. Jumlah samnpel penelitian 40
orang. Pengumpulan data dilakukan dengan menggunakan wawancara, observasi dan telaah
data puskesmas setempat.

HASIL
13th 6 th
12th 7th
Usia Anak 2% 3%
2% 12% 8th
12%
11th
27%

22 9th
% 22%

Diagram 1. Distribusi Responden Berdasarkan Usia

Berdasarkan Diagram 1 didapatkan bahwa usia terbanyak adalah usia 11 tahun sebanyak 11
anak (27%) dan duduk dikelas 5 dan 6, usia 9 tahun sebanyak 8 (22%) anak dan duduk di kelas
3 – 5, usia 10 tahun sebanyak 8 (22%) anak duduk di kelas 5 dan 4.
Distribusi Responden Berdasarkan Jenis Kelamin

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Jenis Kelamin

Perem Laki-
puan laki
50% 50%

Diagram 2. Distribusi Jenis Kelamin Responden

Status Orang tua Bekerja

Ayah
dan Ibu
43% Ayah
57%

Ibu
0%

Diagram 3. Distribusi Responden status orang tua bekerja

Kejadian disentuh / berciuman

bibir
Disentuh /
berciuman
bibir…

Tidak
70%
Diagram 4. Distribusi Responden Berdasarkan Morbiditas ( Angka kejadian)

Kejadian Disentuh
Pada Daerah Dada
Disentu
h Dada
25%

Tidak
75%

Diagram 5. Proporsi responden berdasarkan angka kejadian disentuh daerah dada

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Kejadian Disentuh pada Daerah

0% Kemaluan Disentuh
Kemaluan
25%
Tidak
75%

Diagram 6. Proporsi responden berdasarkan angka kejadian disentuh daerah kemaluan

Kejadian Disentuh Pada Daerah

Pantat
Tidah
28%

Disentuh
Dipantat
72%
Diagram 7. Proporsi responden berdasarkan angka kejadian disentuh Pantat

Melihat gambar/ film yang tidak senonoh

0%
0%

Ya
20%

Tidak
80%

Diagram 8. Proporsi responden berdasarkan angka kejadian melih hatgambar/ film tidak
senonoh

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Analisis situasi (fishbone)Belum pernah mendapatkan penyuluhan tentang kekerasan seksual pada anak

Edukasi dan Organisasi Perilaku dan lingkungan Epidemologi

12,5% anak pernah

53% anak masih tidur mendapatkan sentuh
85% anak suka melihat
Tingkat pengetahuan dengan orang tua dikemaluannya
sinetron remaja
anak, 35% baik, 35%
cukup dan 30% kurang Petugas kesehatan menyatakan belum adanya
40% anak mengunakan kegiatan penyuluhan tentang kekerasaan
Belum pernah internet utk mencari seksual dan tersedianya sumber dukungan
mendapatkan gambar atau film berupa poster, buku rapor kesehatanku
penyuluhan tentang KSA

Belum tersedianya (20%) anak pernah ( 12,5%) anak

kader/ kelompok peduli melihat gambar dan film pernah mengalami
KSA Belum ada dewasa, disentuh dan
1. Ketidakefektifan pemeliharaan
pemberdayaan berciuman bibirnya
kesehatan tentang pencegahan
masyarakat untuk 32,5% anak masih kekerasan seksual pada agregat
pencegahan KSA menggunakan pakaian anak usia sekolah di RW 03
yang ketat adan pendek Kelurahan Gedawang
tanpa dilarang orang Banyumanik Kota Semarang
tuannya
2. Defisiensi kesehatan
43% orang tua memiliki sikap kurang di komunitas tentang pencegahan
karenakan orang tua merasa tabu dan bingung kekerasan seksual pada agregat
menggunakan bahasa yang sesuai bagi anak. anak usia sekolah di RW 03
Kelurahan Gedawang
Banyumanik Kota Semarang

Paraved Barrier

PEMBAHASAN
Masa anak merupakan kondisi yang sangat rentan terhadap pengaruh dari luar, terutama
tehnologi yang sabgat mempengaruhi mental. Kajian ini menemukan bahwa pengetahuan
tentang kekerasan seksual di Indonesia masih terbatas. Tabu membahas masalah seksual
diidentifikasi sebagai faktor yang menghambat pelaporan. Kemiskinan juga menyebabkan
meningkatnya risiko pelecehan seksual pada anak. Ada sedikit perhatian pada pelecehan
seksual pada anak yang terjadi dalam konteks keluarga dan fokus lebih pada kemunculannya di
luar keluarga (Boothby & Stark, 2011; Solehati et al., 2022b; Wismayanti et al., 2021).
Kekerasan seksual adalah sebagai keterlibatan seorang anak dalam aktivitas seksual yang tidak
sepenuhnya dipahaminya dan untuk itu persetujuan tidak dapat diberikan. Selain itu, anak tidak
siap secara perkembangan untuk perilaku tersebut, dan perilaku itu sendiri melanggar hukum
atau melanggar tabu sosial(Solehati et al., 2022b).

Penelitian yang dilakukan di Tanzania oleh Abeid et al. menemukan bahwa jenis kelamin, usia,
dan pendidikan tinggi berhubungan dengan pengetahuan tentang pelecehan seksual. Perempuan
kurang beruntung dibandingkan dengan laki-laki dalam hal pendidikan, yang dapat
menyebabkan kurangnya pemahaman mereka tentang konsekuensi kesehatan dari pelecehan
seksual (Abeid et al. 2015). Di sisi lain, penelitian di Indonesia mengenai faktor-faktor yang
berkontribusi terhadap pengetahuan CSA belum komprehensif dan masih belum jelas.

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Perempuan dan laki-laki memiliki tingkat keterpaparan yang berbeda terhadap berbagai sumber
informasi, yang mempengaruhi pengetahuan kesehatan seksual mereka. Perempuan, terutama
di Timur Tengah, lebih berisiko karena lebih sedikit akses informasi di luar rumah mereka.
Perempuan menerima informasi melalui ibu, teman, atau saudara mereka (AlQuaiz et al. 2013).
Bertambahnya usia dan pendidikan tinggi dikaitkan dengan pengetahuan yang lebih baik
tentang pelecehan seksual (Abeid et al. 2015). Anak-anak kelas bawah yang lebih muda
memiliki pengetahuan yang lebih sedikit tentang bagian tubuh seksual dan pencegahan
pelecehan daripada anak-anak kelas menengah dan atas, sementara orang tua kelas bawah
melaporkan kurang memberikan pendidikan seks untuk anak-anak mereka (Gordon et al. 1990).

Usia anak sekolah merupakankondisi yang risiko dan rentan terhadap kekerasan seksual. Hal
ini dikarenakan orang tua belum memberikan pendidikan seksual sesuai dengan usia anak
dan masihmerasa tabu. Oleh karena itu, tenaga kesehatan khususnya perawat diPusksmas
sebagai pemberi pelayanan kesehatan bagi anak sekolah harus berperan aktif dalam kegiatan
UKS. Pengkajian keperawatan yang dilakukan berdasarkan pengembangan model PRECEDE-
PROCEED (Predisposing, Reinforcing and Enabling Causes in Eductional Diagnosis and
Evaluation)-( Policy, Regulatory, Organizational construct in Educational and Enviromental
Development) dan HBM (Health Belief Model).

Pendekatan ke dua model tersebut sangat cocok diterapkan untuk mengkaji perilaku yang akan
menyebabkan terjadinya kekerasan seksual pada anak usia sekolah. Model PRECEDE-
PROCEED memiliki konsep bahwa perilaku kesehatan dipengaruhi oleh faktor individu dan
lingkungan. Model ini berisi 9 fase yang akan memandu proses keperawatan komunitas mulai
dari diagnosis sosial, diagnosis epidemiologi, diagnosis perilaku dan lingkungan, diagnosis
pendidikan dan organisasi, diagnosis administrasi kebijakan, implementasi, evaluasi proses,
evaluasi dampak, sampai dengan evaluasi hasil (Green and Kreuter, 2005). Health Belief Model
(HBM) sendiri merupakan model kepercayaan kesehatan yang menjelaskan pertimbangan
seseorang sebelum mereka berperilaku sehat dengan 6 komponen utama yang meliputi
perceived susceptibility, perceived severity, perceived benefit, perceived barriers, cues to
action, dan self efficacy (Taylor, 2012). Teori ini tuk mengkaji sejauhmana orang tua digunakan
Kombinasi ke dua model ini menjadi panduan pengkajian yang tercantum dalam angket,
pedoman wawancara, dan pedoman observasi. Pengkajian menggunakan model Precede-
Proceed bertujuan untuk mengkaji pada variable kesehatan, perilaku, lingkungan, administrasi
dan kebijakan yang ada di Kelurahan Gedawang RW.03 KecamatanBanyumanik Kota
Semarang. Untuk model pengkajian Health Belief Model (HBM) memiliki fungsi sebagai
model pencegahan preventif melalui promosikepada masyarakatuntuk merubah prilaku dalam
pencegahan kekerasan seksual pada anak usia sekolah.

Diagnosa prioritas utama pada risiko kekerasan seksual pada anak sekolah di Kelurahan
Gedawang RW. 03 KecamatanBanyumanik Kota Semarang yaitu ketidakefektifan
pemeliharaan kesehatan tentang pencegahan kekerasan seksual pada agregat anak usia sekolah
di RW 03 kelurahan Gedawang Banymanik Kota Semarang berhubungan dengan isufisiensi
sumber social dan pengetahuan. Munculnya masalah tersebut didasari adanya data 40 anak yang
telah mengisi angket :Tingkat pengetahuan anak tentang bagian tubuh yang tidak boleh di
sentuh oleh orang lain 35%anak baik, 35% anak cukup dan 30% anak kurang. Prilaku anak
yang beisiko 85% anak suka melihat sinitron remaja, 40% anak menggunakan internet untuk
mencari gambar atau film, 32,5% anak masih menggunakan pakaian ketat dan pendek
tanpadilarang orang tuanya, 53% anak masih tidur dengan orang tuanya. 20% anak pernah
melihat gambar dan film dewasa.12,5% anak pernah mengalami disentuh dan berciuman bibir.
12,5% anak pernah mendapatkan senthan dan 1 diantaranya menyentuh/ dipegang secar

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langsung didarah kemaluanya. 43% orang tua memiliki sikap kurang dikarenakan merasa tabu
dan bingung menggunakan bahasa yang sesuai bagi anak dalam memberikan pendidikan
seksual. 100% anak belum pernah mendapat peyuluhan tentang kekrasan seksual pada anak.
Definisi ketidakefektifan pemeliharaan kesehatan adalah ketidak mampuan mengatur dan atau
mencari pertolongan dalam upaya meningkatkan kesehatan (Herdman &Kamitsuru, ,2014)

Intervensi dalam menyelesaikan masalah ketidakefektifan pemeliharaan kesehatan tentang

pencegahan kekerasan seksual pada agregat anak usia sekolah di RW 03 kelurahan Gedawang
Banymanik Kota Semarang berhubungan dengan isufisiensi sumber social dan pengetahuan
adalah dengan pendidikan kesehatan (5510). Konsep pendidikan kesehatan dalam kegiatan
program lebih pada upaya mengubah perilaku agrgat agar berperilaku sehat terutama dari segi
kognitif, yaitu pengetahuan agregat ( Nasution, 2004). Pendidikan kesehatan merupakan salah
satu strategi itervensi dalam keperawatan komunitas selain kemitraan ( partnership),
pemberdayaan masyarakat, dan proses kelompok ( Helvi, 1998). Pendidikan kesehatan
merupakan sebuah kegiatan dalam upaya pencegahan dalam bentuk promotif dan preventif
dengan menyebarkan inforasi serta menngkatkan motivasi masyarakat untuk berperilaku sehat.
Pendidikan kesehatan mrupakan salah satu alat yang digunakan untuk berinteraksi dengan
rentan risiko ( Stanhope& Lahcaster, 2004). Anak dibawah usia 18 tahun sangat rentan oleh
tindakan kekerasan seksual dan rentan sebagai pelaku kekerasan seksual untuk saat ini. Oleh
sebab itu pendidikan kesehatan pada anak usia sekolah sangat berperan penting dalam merubah,
memperbaiki dan mempertahankan perilaku kesehatan. Pendidikan kesehatan sangatlah
berpran penting dalam peningkata pengetahuan, perubahan perilaku dan sikap dalam mncegah
terjadinya kekerasan seksual pada anak usia sekolah ( Edelman& Mandle, 2010).

Pelaksanaan pendidikan kesehatan ini mempunyai sasaran anak dan orang tua yang memiliki
anak usia sekolah. Pendidikan kesehatan yang mempunyai tujuan untuk memotivasi orang tua
dan anak melalui penerapan kartu ABIJARI diharapkan orang tua mampu memberika
pendidikan seksual dan mengajarkan kepada anak bagaimana mereka bisa menjaga diri sendiri
supaya terhindar dari kekerasan seksual. Kartu ABIJARI ( deteksi ) disini digunakan oleh orang
tua untuk mendeteksi kemungkinan terjadi kekerasan seksual pada anak dan dapat juga
digunakan sebagai media untuk mengtahui pelaku kekerasan seksual tersebut. Pengunaan
media edukatif lebih mempermudah dalam penyampaian informasi pada anak( Andika, Puji &
Realita, 2016). Hasil yang didapatkan peningkatan pengetahuan baik dari 35% menjadi 67,5%
hal ini menujukkan bahwa anak sudah memahami cara mencegah terjadinya kekerasan seksual.
Metode pendidikan kesehatan dengan menggunakan media edukatif mampu merubah perilaku
dari anak dan orang tua sesuai dengan hasil penelitian dari Puji Hidayat et. all tahun 2016.
Dalam penelitian mengunakan tehnik analaisa kulitatif-kuantitatif terdapat perubahan perilaku
anak sebelum dan sesudah menggunakan kuku pesek, serta orang tua lebih mengenal
pengetahuan pendidikan seksual bagi anaknya.

Diagnosa keperawatan kedua pada risiko kekerasan seksual pada anak sekolah di Kelurahan
Gedawang RW. 03 KecamatanBanyumanik Kota Semarang adalah defisiensi kesehatan
komunitas b.d ketidakadekuatan dukungan social program kesehatan. Diagnosa keperawatan
tersebut muncul karena adanya data yang diperoleh dari Serta hasil wawancara cara dengan
pemegang program mengatakan “Data kejadian untuk kekerasan seksual pada anak tidak ada
secara terlapor. Pernah ada yang datang kesini untuk periksa pada tahun 2015, bukan dari
wilayah puskesmas Pudak Payung. Namun keluarga tidak mau dimasukkan kedalam laporan
dan di sesaikan secara baik-baikdan kekeluargaan. Pelaksanaan kegiatan penyuluhan
kekerasan seksual pada anak belum pernah terlaksanakan Untuk sarana pendukung, poster
tetang kekerasanseksual belum ada. Dikarenakan tidak ada pendistribusian dari Dinas

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Kesahatan”.Belum ada pemberdayaan masyarakat untuk pencegahan KSA. Data hasil angket:
20% anak pernah melihat gambar dan film dewasa, 12,5% anak pernah mengalami disentuh
dan berciuman bibirnya 12,5% anak mendapatkan sentuh dikemaluannya dan 1 diantaranya
menyentuh secara langsung pada kemaluanya. Defisiensi kesehatan komunitas adalah adanya
masalah kesehatan atau fartor yang menghambat kesehatan atau menikatnya faktor risiko
masalah kesehtan yang dirasakan oleh agregat (Herdman &Kamitsuru, 2014)

Intervensi pada diagnosa ini adalah pengembangan program (8700). Program yang dibentuk
pada intevensi ini adalah memberdayakan masyarakat dalam kelompok peduli GEPAKS (
Gerakan Peduli Anak dari Kekerasan Seksual). GEPAKS ini merupakan sebuah gerakan yang
diprakarsai oleh kelompok peduli dan mereka akan membuat kegiatan dimana masyarakat,
orang tua dan anak mengetahui cara mencegah terjadinya kekerasan seksual pada anak.
Pemberdayaan memiliki arti Menurut Carlzon &Macauley pemberdayaan adalah
:“Membebaskan seseorang dari kendaliyang kaku, dan memberi orang tersebutkebebasan untuk
bertanggung jawab terhadap ide-idenya, keputusan-keputusannya dan tindakan-tindakannya.

Pelaksanaan program GEPAKS merupakam bentuk strategi intervnsi keperwatan komunitas

yaitu pemberdayaan. Pemberdayaan merupaka sebuah proses aktif dimana individu, kelompok
dan komunitasbergerak maju untuk menikatkan kontrol terhadap individu dan komunitas,
politis, meningkatan kualitas hidup komunitas dan kebijakan social (Diem & Moyer ,2005).
Tujuan dari pemberdayaan adalah membentuk atau komunitas dalam memperoleh kemampuan
untuk menganbil sebuah keputusan untuk menentukan tindakan yang akan dilakukan untuk
menolong diri sendiri ( notoatmojo, 2010).

Program GEPAKS memiliki tujuan meningkatkan kemampuan anak, orang tua dan masyarakat
dalam mencegah terjadinya kekerasan seksual pada anak. Setelah 2 minggu intervensi
didapatkan hasilpeningkatan pengetahuan anak tetang pencegahan kekerasan seksual pada
anak. Sebelum diintervensi anak yang memiliki pengetahuan baik sejumlah 14 anak (35%).
Dan setelah di berikan intrvensi pengetahuan anak mengalami peningkatan sejumlah 27 anak
(67,5%). Dan Menunjukan penurunan angka prilaku berisiko kejadian kekerasan seksual pada
anak sebelum intervensi anak menunjukkan prilaku suka menonton sinetron remaja 34 anak
(85%), penggunaan internet untuk mencari gambar dan film 16 anak (40%), 21 anak ( 53%)
masih tidur dengan orang tua. Setelah dilakukan intervensi prilaku suka menonton sinetron
remaja 15 anak (37,5%), penggunaan internet untuk mencari gambar dan film 4 anak (10%),
10 anak ( 25%) masih tidur dengan orang tua. Hasil tersebut didukung oleh penelitian yang
dilakukan oleh Hariyanto (2009) yang menyatakan bahwa tingkat pengetahuan seseorang
sebelum menerima penyuluhan kurang, namun setelah menerima penyuluhan kesehatan
terdapat peningkatan pengetahuan.

SIMPULAN
Hasil analisis situasi dengan menggunakan fishbone didapat 2 diangnosa keperawatan terkait
masalah risiko kekerasan seksual pada anak sekolah di RW 03 Kelurahan Gedawang yaitu
masalah ketidakefektifan pemeliharaan kesehatan tentang pencegahan kekerasan seksual pada
agregat anak usia sekolah di RW 03 kelurahan Gedawang Banymanik Kota Semarang
berhubungan dengan isufisiensi sumber social dan pengetahuan, dan defisiensi kesehatan
komunitas b.d ketidakadekuatan dukungan social program kesehatan.

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DAFTAR PUSTAKA
Alzoubi, F. A., Ali, R. A., Flah, I. H., & Alnatour, A. (2018). Mothers’ knowledge & perception
about child sexual abuse in Jordan. Child Abuse & Neglect, 75, 149–158.
https://doi.org/10.1016/J.CHIABU.2017.06.006
Boothby, N., & Stark, L. (2011). Data surveillance in child protection systems development:
An Indonesian case study. Child Abuse and Neglect, 35(12), 993–1001.
https://doi.org/10.1016/j.chiabu.2011.09.004
Goodman, M. L. , H. A. , K. P. H. , G. S. , A. P. K. , & R. B. G. (2020). Neglect, Sexual Abuse,
and Witnessing Intimate Partner Violence During Childhood Predicts Later Life Violent
Attitudes Against Children Among Kenyan Women: Evidence of Intergenerational Risk
Transmission From Cross-Sectional Data. Journal of Interpersonal Violence. Journal of
Interpersonal Violence.
Hébert, M., Amédée, L. M., Blais, M., & Gauthier-Duchesne, A. (2019). Child Sexual Abuse
among a Representative Sample of Quebec High School Students: Prevalence and
Association with Mental Health Problems and Health-Risk Behaviors. Canadian Journal
of Psychiatry, 64(12), 846–854. https://doi.org/10.1177/0706743719861387
Murchison, G. R., Agénor, M., Reisner, S. L., & Watson, R. J. (2019). School restroom and
locker room restrictions and sexual assault risk among transgender youth. Pediatrics,
143(6). https://doi.org/10.1542/peds.2018-2902
Solehati, T., Pramukti, I., Kosasih, C. E., Hermayanti, Y., & Mediani, H. S. (2022a).
Determinants of Sexual Abuse Prevention Knowledge among Children’s Schools in West
Java Indonesia: A Cross-Sectional Study. Social Sciences, 11(8).
https://doi.org/10.3390/SOCSCI11080337
Solehati, T., Pramukti, I., Kosasih, C. E., Hermayanti, Y., & Mediani, H. S. (2022b).
Determinants of Sexual Abuse Prevention Knowledge among Children’s Schools in West
Java Indonesia: A Cross-Sectional Study. Social Sciences, 11(8).
https://doi.org/10.3390/SOCSCI11080337
Tener, D., Marmor, A., Katz, C., Newman, A., Silovsky, J. F., Shields, J., & Taylor, E. (2021).
How does COVID-19 impact intrafamilial child sexual abuse? Comparison analysis of
reports by practitioners in Israel and the US. Child Abuse and Neglect, 116.
https://doi.org/10.1016/j.chiabu.2020.104779
Wismayanti, Y. F., O’Leary, P., Tilbury, C., & Tjoe, Y. (2021). The problematization of child
sexual abuse in policy and law: The Indonesian example. Child Abuse and Neglect, 118.
https://doi.org/10.1016/j.chiabu.2021.105157
Riskesdas. (2018). Hasil Utama Riset Kesehatan Dasar. Kementrian Kesehatan Republik
Indonesia, 1–100. https://doi.org/https://doi.org/10.1088/1751-8113/44/8/085201
Kementrian Kesehatan RI. (2014). Profil kesehatan Indonesia tahun 2013. Jakarta. Epub ahead
of print 2014. DOI: 10.1088/0305-4470/14/8/037.
World Health Organization. (2019). Health education. World Health Organization,
https://www.who.int/topics/health_education/en/ (accessed 5 July 2019).

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World Health Organization. (2006). Background paper to the UN secretary-general’s study on

violence against children : Global estimates of health consequences due to violence
against children. Switzerland: World Health Organization.
Notoadmodjo S. (2007). Promosi kesehatan dan ilmu prilaku. Jakarta: Rineka Cipta.

1010
 available online at: http://journal.jptranstech.or.id/index.php/ACHNR

Asian Community Health

Nursing Research
ACHNR
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16

Family Nursing as an Improvement Strategy of

Family Health Index in Indonesia: A Literature
Review
Andy Nuriyanto1 and Laili Rahayuwati2,*
1 Community Nursing Department, Nursing Faculty of Padjadjaran University; nuriyantoandy@yahoo.co.id
2 Community Nursing Department, Nursing Faculty of Padjadjaran University; lailira2002@yahoo.com
* Correspondence: nuriyantoandy@yahoo.co.id; Tel.: +6281347544054
Literature Review
Received: August 5, 2019; Accepted: September 15, 2019 ; Published: October 15, 2019
https://doi.org/10.29253/achnr.2019.1721

Abstract: The occurrence of health issues in the family affected by the ability of the family itself to carry
out the role and task of family health care. Family nursing has been developed in various countries as a
solution to solve individual, family, and community health issues in a region. The family health status in
Indonesia is measured by the Family Health Index (FHI) value, comprising the category of unhealthy
families (FHI < 0.50), pre-healthy families (FHI value of 0.50 to 0.80), and healthy families (FHI > 0.8).
This study aims to generate a literature review on strategies that can be used to improve the Family
Health Index. The search database includes CINAHL, MEDLINE, and Google Scholar with several
keywords: 'family nursing', 'family health', and 'family health status'. 102 articles published between
the year of 2000 until 2019 have been obtained. The results of the literature review indicate that family
nursing is an innovative and efficient strategy to achieve a preferable health status as well as a better
quality of human life. Family nursing has a positive correlation with the increased ability of families to
carry out their task in maintaining, preventing and overcoming family health issues independently.
Research on the families' ability to carry out health care tasks to improve the health status by measuring
FHI has never been done previously. Future research is required to discuss the relationship of families'
ability in carrying out the five health care tasks to improve FHI independently in Indonesia.

Keywords: family health nursing; family health index; family health status

1. Introduction
The increase in population, economic needs, technological advancements, as well as requirements
and changes in health services have encouraged governments in several developed and developing
countries to find cost-effective innovations for family-based health care throughout the world. Curative
health service delivery in the current health service unit is not sufficient to meet future health demands.
As a result, WHO in Europe has recommended a family-oriented health program since the period of 1998
through the provision of family health nurses. Through such family nursing, multidimensional activities
are carried out not only for individuals but also for families, groups and populations. Family nursing
innovation activities aim to promote health, protect humans throughout life, and proactively prevent
disease and disability to maintain the health status of individuals in the family and community structure
(Obbia, 2014).
Copyright© 2019 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons
Attribution (CC BY) license.
8 Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16

Family-oriented nursing is the right solution to solve health problems. Family nursing in Europe
began to be applied in several developed and developing countries by maximizing promotive and
preventive efforts through family empowerment. The family nursing program is a unified intact between
the family and the nurse in order to establish relationships through the ideal communication principles
in achieving family health status (Dorell, Östlund, & Sundin, 2016). Family nursing is also applied in
several states in America as an effective solution to health problems. The goal is for families to be involved
as partners in planning, service and system development, enhancing nursing effectiveness research and
providing policy feedback on family health nursing practice (Spencer, Blau, & Mallery, 2010).
Through family nursing, the existence of family becomes highly crucial in managing the incidence of
the disease and maintain its health status. This is because every family health problem can affect the role
of other family members (Effendy, 1998). The family nursing approach can also be applied in efforts to
solve health problems at the community level (Dorell et al., 2016). This is in line with the main target of
the implemented health program, which is the family itself. Family is the smallest organizational unit of
society consisting of heads and family members who gather and live under one roof and have
interdependence to one another (Kemenkumham, 2009). In addition, the family also has an important
role as a provider of human resources, material, financial and social objectives, and health care for family
members (Irinoye, Ogunfowokan, & Olaogun, 2006). As a result, it can be concluded that, where families
with good health status are gathered in a community, they can support the development of a community
with good health status.
Family nursing is also a prominent part of the community health care program (known as
Perkesmas) in first-level health facilities, particularly with the existence of Healthy Indonesia Program
through Family Approach (Program Indonesia Sehat dengan Pendekatan Keluarga, abbreviated as: PIS-
PK). PIS-PK is an innovation in the health sector which is on the agenda of the National Long-Term
Development Plan in the health sector for the period between 2005 and 2025 in order to realize a better
quality of life for Indonesian people. The objective of the integrated family nursing program in PIS-PK is
to improve the ability of families to carry out their tasks to solve health problems they face independently
(Siti, Nursalam, Adriani, Ahsan, & Tantut, 2018). Hence, with the existence of PIS-PK, it is expected that
families can face and solve family health problems independently by empowering the ability of the family.
The ability of families to carry out family care duties independently in solving health problems is an
important factor in achieving family health status. The task of family care consists of five main
interconnected tasks, namely: 1) recognizing health problems, 2) deciding on health measures, 3)
conducting the nursing process, 4) modifying the environment, and 5) accessing health facilities
(Ratnawati, 2018). The ability of the family to carry out the five family tasks illustrates the role and
function of the family in health care through coaching and mentoring by nurses (Agrina & Zulfitri, 2013).
By carrying out family coaching and mentoring in health care units as well as through home visits, it is
expected that families can be more cooperative and are capable to prevent and overcome health
problems faced independently (Siti et al., 2018). Therefore, with coaching and mentoring in health care,
families can improve their abilities independently to maintain, overcome and prevent family health
problems.
The process of achieving family health status through the PIS-PK program carried out at each
community health center begins with planning and preparation in each working area. The ultimate goal
of this program is to collect family health data based on 12 indicators of family health. The data collection
and implementation of the program is carried out by competent health workers and can carry out
activities in accordance with the technical guidelines with the output data in the form of a Family Health
Index as a description of the family's health status. Family Health Index is divided into three levels,
namely: 1) Family Health Index value of < 50.00% = unhealthy, 2) Family Health Index value of 50.00%
to 80.00% = pre-healthy, and 3) Family Health Index value of > 80% = healthy (Kemenkes, 2016a). Family
Health Index can also be used in the assessment of health indices at the tier level starting from the family
level, community level (Sub-district, District, Regional level), up to the national level to describe the
Indonesian Health Index.
As what has been explained in the background of the study, it is necessary to conduct a literature
review on family nursing strategies to improve health status that can be applied according to the
situation in Indonesia. This literature review aims to identify the implementation of family nursing
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16 9

systems to maintain, improve health status, and resolve health problems that occur in families
independently with a Family Health Index assessment

2. Methods
The literature review method has been used in the research. Search for supporting articles is
conducted through the CINAHL, MEDLINE, and Google Scholar databases. This literature review uses
keywords in Indonesian and English language (bilingual). In Indonesian language, the keywords used
are: 'pendekatan keluarga', 'keperawatan keluarga', and 'kesehatan keluarga'. Whereas in English
language, the keywords used are: 'family health approach', 'family nursing', and 'family health'. There is
a total of 102 suitable articles found using these keywords with a total synthesis of 9 articles published
from the period between 2000 and 2019. The articles are then evaluated according to criteria regarding
the nursing concept implementation with a family approach to achieve family health status and then a
review is conducted. Moreover, government theory and policy are also used in this literature review to
analyze these papers comparatively and to strengthen the reasons for the literature being studied.

3. Results (or Results and Discussion)

Nine articles were synthesized for analysis with the main orientation of family nursing on general
family health problems. Research that has been conducted qualitatively and quantitatively in the realm
of education and practice of family health nursing with the orientation of the role of nursing staff in
realizing good family nursing care along with the impact on families who obtain the intervention.

Table 1: Family Nursing Implementation to Improve Family Health Status

Author and Research Title Conclusions

Murray (2004)
“Family Health Nursing: the education
programme for the WHO European Scottish
Pilot”
Family nursing program is a solution for families to
overcome health problems they deal with. Family nurses
must carry out their roles and functions in accordance
with the education curriculum in collaboration with other
community health care teams. The most prominent role of
a nurse in family nursing is to establish a propitious
communication with the family.

Irinoye et al. (2006) Graduate nursing education curriculum in Nigeria shows

“Family Nursing Education and Family
Nursing Practice in Nigeria”
that nurses with master and doctoral degrees as well as
community nursing specialist degrees already have basic
theories about family nursing. However, many nurses in
Nigeria with such degree are not directly involved in
clinical practice of family nursing. They put more effort in
the direction of developing specialization and view that
nursing with family orientation has a further scope than
public health nursing.

Parfitt and Cornish (2007)
“Implementing Family Health Nursing in
Tajikistan: From policy to practice in
primary health care reform”
Nurses were initially considered inferior to doctors. In this
research, family nurses were considered to have greater
clinical responsibility than doctors because nurses have a
direct communication with families by taking the
responsibility for disease prevention and treatment,
making independent decisions and working with a team of
doctors and all family members they cared for.
The main inhibiting factor for family nurses is the friction
in the differences of nurses' salaries and other health
workers, so that the success of family health care is not
met due to an uneven financing system. In other words, the
10
Author and Research Title
Spencer et al. (2010)
“Family-Driven Care in America: More Than
a Good Idea”
Häggman-Laitila, Tanninen, and Pietilä
(2010)
“Effectiveness of resource-enhancing
family-oriented intervention”
Agrina and Zulfitri (2013)
“Efektifitas Asuhan Keperawatan Keluarga
Terhadap Tingkat Kemandirian Keluarga
Mengatasi Masalah Kesehatan di Keluarga”
Obbia (2014)
“Introducing the family health nurse in
Italy”
Marwati, Aisya, and Alifariani (2018)
“Promkes untuk Mendukung PIS-PK
Indikator Hipertensi dan KB di Desa
Combongan”
Siti et al. (2018)
“Structural Model for Public Health Nurses’
Performance in the Implementation of
Family Nursing Based on Nursing
Relational Capital”
In the curriculum of nursing education in Europe, the family nursing program requires the role
of every nurse to provide solutions in solving family health problems. Nurses must be able to carry out
their roles and functions in accordance with the educational curriculum that they have taken and work
with other community health care teams. The most important role of nurses in family nursing is to
establish good communication with the target performance to improve the health status of the family
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16
Conclusions
issue of nurse salaries caused serious problems for nurses
as health workers, this was due to the cultural heritage of
the former colony of the Soviet Union.
The critical success factor for this family nursing program
is the enthusiasm of the nurse itself and the acceptance of
the presence of the nurse by the service user.
Nurses as implementers of family nursing are expected to
facilitate the ability of families as partners in planning,
developing services and care systems, implementing and
improving care research, and feedback on nursing policies
and practices.
Empirical knowledge about nurses' performance on family
nursing is still minimal related to methods, reciprocal
relationships, and increased family resources that can
affect family health status. Family nurses are needed to
support the family in: 1) improving the role of parents, 2)
strengthening family social relationships, and 3)
increasing family resources to manage family tasks
towards family members, especially children.
There is a significant effect in providing family nursing
care to the level of family independence overcoming
health problems (p value = 0.00).
WHO-EU recommended Family Health Nursing program
with the target of palliative care services, case
management, family nurse partnerships, nursing clinics,
community nursing, home visits, etc. The need for
recognition of Family Health Nursing as an integrated
form of nursing.
The goal of Healthy Indonesia Program through Family
Approach is to improve health status through health
efforts and community empowerment with a family
approach.
Factors that affect the Performance of Nurses and Family
Independence include 1) structural capital of nursing, 2)
human resources of nursing, 3) client factors, 4) family
factors, 5) factors of nursing relationships.
An ideal nurse performance in family nursing care can
increase family independence in caring for sick family
members.
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16 11

(Murray, 2004). Nurses with master and doctoral academic degrees or community nursing specialists
are considered to have strong basic theories about family nursing, but many nurses in Nigeria with these
degrees are not directly involved in the clinical practice of family nursing. They put more effort in the
direction of developing specialization and view that nursing with family orientation has a further scope
than public health nursing (Irinoye et al., 2006).
Qualitative research conducted by Häggman-Laitila et al. (2010) explained that empirical
knowledge about nurses' performance on family nursing is still limited when it comes to methods,
reciprocal relationships, and increased family resources that can affect family health status. The results
of the study stated that the presence of nurses is needed to support families in: 1) improving the role of
parents, 2) strengthening family social relationships, and 3) increasing family resources to manage family
tasks towards family members, especially to children. In addition, research conducted by Agrina and
Zulfitri (2013) stated that there is a significant effect on the provision of family nursing care to increase
the level of family independence to overcome the health problems experienced. This study concluded
that the level of family independence increased after good family nursing care was carried out in
accordance with the prescribed instructions.
The level of family independence can be achieved well, and this can be clearly seen from the ability
of families to understand and carry out five family health care tasks. The ability to understand and carry
out these tasks is highly dependent on the role of nurses in providing nursing care. As explained in the
results of a previous study conducted by Agrina and Zulfitri (2013), the one-group pretest-posttest
design resulted in a p-value of 0,000 which concluded that family nursing care can increase family
independence to overcome health problems. In implementing the intended family nursing program, the
family is expected to get coaching and mentoring efforts to carry out five family health care tasks by
nurses in solving health problems experienced by the family independently Agrina and Zulfitri (2013).
In Italy, family nursing is also a program recommended by WHO-Europe with the target of palliative
care, case management, family nurse partnerships, nursing clinics, community nursing, home visits, etc.
which are directly carried out by nurses (Obbia, 2014). The implementation of this program requires
nurses to be more active in managing their target families. Although nurses were initially considered
inferior to doctors, in a study conducted by Parfitt and Cornish (2007), nurses had greater clinical
responsibility than doctors. This is because nurses make direct contact with the family and take full
responsibility for disease prevention and treatment, make independent decisions, and work closely with
the team of doctors and family members as a whole. Hence, doctors may assess and assume that nurses
have a direct positive impact on improving health in the family (Obbia, 2014).
Inhibiting and supporting factors of the implementation of family nursing programs need to be
known and acted upon by each policymaker in a country. The most important inhibiting factor for family
nurses in carrying out family nursing, as stated on a research conducted by Parfitt and Cornish (2007) in
Tajikistan, is the difference in salary of nurses with other health workers. This is considered to make the
success of the family care program being unachieved properly due to an uneven operational financing
system. The issue of nurses' salaries has become a serious issue as a health worker, which is a
contributing factor to the culture of having a negative view of nurses as a legacy for the former colony of
the Soviet Union. Thus, supporting factors for the success of family nursing are the enthusiasm of the
nurse itself and the existence of the nurse in the eyes of users of nursing services as interconnected
subjects during the family care process.
The interrelationship of the mutual relationship between nurses and family is a factor that can be
developed to support the success of the family nursing program. In family nursing research entitled
"Family-Driven Care in America: More Than a Good Idea" suggests that the ability of family’s needs to be
developed as partners in planning, developing care services and systems, implementing and improving
care research, and nursing policy and practice feedback (Spencer et al., 2010). As such, the reciprocal
relationship between nurses and family can be used as a support to strengthen the family's view of the
policy from the point of view of the family itself as well as the government's point of view regarding
family nursing that is carried out to realize better health status.
In accordance with Law 36 of 2009 concerning Health Chapter II article 3 states that the purpose of
health development is to increase awareness, willingness and ability to live healthy for everyone in order
to realize the highest degree of public health (SekretarisNegara, 2009). Achieving health status, as stated
on the research by (Marwati et al., 2018) concerning public health, states that the goal of Healthy
12 Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16

Indonesia Program through Family Approach is to increase health status through health efforts and
community empowerment with family orientation. Community health centers are at the forefront of
determining the success of this program in each of its working areas. Efforts that can be maximized are
promotive efforts through health education to the community to strengthen the realization of health
development (Marwati et al., 2018). Practically in the 2018 Health Profile of Indonesia, it is stated that
the Human Development Index (HDI) increased 4.86 points, from 66.53 in 2010 to 71.39 in 2018.
However, when observing the Family Health Index data that can be accessed through the
keluargasehat.kemkes.go.id website, states that the national Family Health Index is still in the value of
0.18 or in an unhealthy range. The lowest Family Health Index value is on the seventh indicator, namely
hypertension patients undergoing regular treatment at 24.39% of the national target (Kemenkes, 2019).

4. Discussion
The concept of family nursing emerged from the World Health Organization's initiative to develop
health practitioners' competencies with family goals as the focus of organizing practices (WHO, 2000).
The main object of family nursing is the family itself and is in line with Healthy Indonesia Program
through Family Approach to improve the ability of families to carry out family care duties in order to
create good health status (Kemenkes, 2017a). The principle of the family approach to Healthy Indonesia
Program through Family Approach is also in line with the curriculum of family nursing education to
encourage nurses to act as providers of nursing services, case decision makers, communicators, and
managers (Murray, 2004). This is supported by nurses being able to carry out their roles at each stage of
Healthy Indonesia Program through Family Approach activities as managers for work goals and other
teams when preparing activities, caregiver providers and case finding during data collection and
intervention, and communicators and educator (liaison and education provider) at the time of the follow-
up activities (Virdasari, Arso, & Fatmasari, 2018).
Healthy Indonesia Program through Family Approach encourages families to be able to improve and
maintain their health status independently. Improving family health status is conducted through the
implementation of family care tasks by increasing: 1) the ability of families to recognize problems, 2) the
ability of families to make decisions, 3) the ability of families to take care of one another, 4) the ability of
families to modify the environment, and 5) the ability of families to access health facilities (Parellangi,
2018). Through these five family health care tasks, family independence to solve problems and create
good health status can be improved by implementing family nursing care (Agrina & Zulfitri, 2013). This
shows that the better implementation of family nursing care has positive implications for increasing
family independence to solve problems and maintain their health status independently.
In accordance with the mandate set out in Law Number 23 of 2014 concerning Regional Government
which is also in line with the Law 36 of 2009 concerning Health, it is stated that family development is an
effort in order to create a family that has a quality of life in a healthy environment (SekretarisNegara,
2014). These efforts can be maximized by empowering through the implementation of the family health
nursing function. There are five family functions (the health care function), especially in the maintenance
or family health nursing function. The function of the family aims to maintain the state of health in all
family members so as to have high productivity on an ongoing basis. The intended family health function
is developed into a family task in the health field (Friedman, Bowden, & Jones, 2010) with the
participation of each family member to maintain health conditions in the family.
The role of families in achieving optimal family care tasks is a comprehensive and independent
solution to family health problems (Murray, 2004). This shows that the relationship between nurses and
family members with each other is highly influential in every health problem they deal with. In carrying
out family care tasks, a comprehensive nursing model with a family-oriented curriculum is needed
(Irinoye et al., 2006). It aims to create positive reciprocity as a strength for nurses to create family health
status and the existence of family nursing as an effort to create a better family health status.
In addition to the role of the family as the main support to achieve good health status, the role of the
nurse is also needed to facilitate the role of the family. The role of nurses as providers of nursing services
carried out by a nurse, especially in the assessment and examination of the history of the disease that can
occur in cases of maternal and child health, hypertension (measurement of blood pressure), tuberculosis,
mental disorders, and a history of smokers in the family. The role of nurses as communicators and
educators and community leaders in data collection activities is to conduct counseling, health education,
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16 13

and provide positive feedback when health problems are found in accordance with the indicators
assessed. The role of decision-makers and case finding for nurses is that nurses can determine the
assessment of a healthy family index and provide suggestions and solutions related to family health
problems using the family education information package (referred to as Pinkesga) (Kemenkes, 2016c).
In addition to this role, nurses also have the ability and the amount of human resources that can be
relied upon in activities to improve health status with orientation to the family. For example, as an
implementer of Healthy Indonesia Program through Family Approach, nurses can collect data, manage
data, analyze data, formulate interventions, carry out interventions by conducting nursing services, and
make reports on community health center information systems (Kemenkes, 2016c). In addition, the
composition of nurses is the most dominant health worker in First-Level Health Facilities throughout
Indonesia, amounting to 49% of the total 1,000,780 health workers (Kemenkes, 2017b). This illustrates
that nurses become an important part in successfully improving health status with a family approach.
The family approach in realizing a Healthy Indonesia must be absolutely accompanied by family and
community empowerment in health development (Kemenkes, 2016a). This is evidenced by the positive
change in Basic Health Research data since 2013. Data showed the proportion of stunting babies born
(body length < 48 cm) at 20.2% in the period, and data also reveal that 37.2% of toddler groups is also
suffering from stunting. To cope with stunting, detection and health intervention must be done as early
as possible by monitoring the growth of infants and toddlers through weighing at the Integrated Service
Post (referred to as Posyandu) regularly. In 2007, the proportion of children under five visiting the
Integrated Service Post in the last six months was only 25.5% and increased in 2013 to 34.3% (Riskesdas,
2013). If growth monitoring is an important matter to do for infants and toddlers in the Integrated
Service Post, then infants and toddlers who do not come should have a home visit to follow up on the
problems found. Coming to the Integrated Service Post or home visits in such cases requires good
collaboration between health workers, health leaders and families. This shows that the family approach
and community empowerment is an absolute thing to do in realizing the prevention of stunting as a
health problem in the family.
In addition, family health monitoring can also be done on families with non-communicable diseases
such as hypertension. It is known that the prevalence of hypertension in 2013 was 25.8% or a total of
42.1 million people. Of this amount, only 36.8% of hypertension sufferers made contact with health
workers, the remaining approximately 2/3 of hypertension cases did not realize that they were suffering
from hypertension (Riskesdas, 2013). The data shows that if there is no family approach by home visit,
2/3 or 28 million people with hypertension may never be monitored and handled. Coming to Integrated
Development Post (referred to as Posbindu) or community health centers or home visits in such cases
also requires good coordination between health workers, health leaders and families. It also reinforces
that an absolute family approach controls non-communicable diseases.
Based on the Family Health Index data that can be accessed through keluargasehat.kemkes.go.id
website, it is known that the national IKS is 0.18 or in the unhealthy range (Kemenkes, 2019). This
illustrates that the health program with a family approach in Indonesia has not been implemented well.
When viewed from the perspective of family nursing, the current family approach strategy does not
maximize the role of the nurse. Therefore, health advocacy during data collection and role as case finding,
and communicator and educator are not conducted properly because the data collection is not from the
nursing profession. Supposedly after the data collection, problems and health plans have been recorded
and the family has the motivation to improve the ability to overcome problems independently. In
addition, a resurvey of Family Health Index is rarely conducted to reassess its changes and to improve
family data in the work area of each health centers.
An indicator of hypertension patients undergoing regular treatment which is also still low at 24.39%
of the national target (Kemenkes, 2019), also gives meaning that the family approach is not going well.
Health workers should conduct home visits to monitor families with hypertension health problems.
However, because data collection is not carried out by competent health workers, blood pressure is
usually obtained through interview information without measurement. Therefore, the follow-up of the
Community Health Nursing Services program was also not carried out properly due to incomplete
information. This is the main point that family nursing is a strategy that can be implemented in Indonesia.
Considering the family nursing curriculum and the dominance of the number of nurses in Indonesia of
14 Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16

49% of the total 1,000,780 health workers (Kemenkes, 2017b), nurses are very likely to be the main
implementers and pilot projects of the Family Health Index improvement strategy in Indonesia.

Diagram 1: The flow of nursing implementation to improve health status with a family
approach

Diagram 1 above discussing the flow of nursing implementation to improve health status with a
family approach is a general description of nursing strategies to improve Family Health Index in
Indonesia. The government has an important role to provide human resources, health resources and
infrastructure which are the main capital to realize health status and better quality of human life. In
addition, there is a need for government policy support in the academic and clinical spheres as well as
community empowerment as a regulatory basis for realizing the program. Thus, the inhibiting factors of
nurses in family nursing related to differences in nurse salaries or operational financing which are the
main issues, may not occur. This can increase the enthusiasm of nurses to increase their presence in the
eyes of users of nursing services so that it will increase supporting factors to achieve the ultimate goal of
family nursing (Parfitt & Cornish, 2007).
As a form of implementing health services to improve the ability of family care independently,
nurses must carry out their role with the aim of maximizing five family care tasks. The roles of nurses in
question include being a case finder, nursing service provider, communicator, health information
provider, group planner/coordinator, and decision-maker. This role aims to provide positive changes to
the independence of the family in carrying out five family care tasks as a determinant of family health
status that can be assessed with Family Health Index. So that the final goal in the form of good family
health status can be achieved independently.
As what has been explained on the review of the scientific articles, it was concluded that to achieve
good family health status five elements are needed. The five elements are: 1) human resources as targets,
2) health workforce resources as implementers, 3) facilities and infrastructure as supporters, 4)
government policies as regulations, and 5) family/community participation in health services. The five
main points become the basis of the role of nurses in a dependent, independent and interdependent
manner that has a direct impact on the independence of the family carrying out five family care tasks to
achieve health status independently by Family Health Index assessment. A good Family Health Index
Asian Comm. Health Nurs. Res. 2019, 1(3), 7–16 15

score is directly expected to have a positive impact on family health status and the quality of human life
(Diagram 1).
As a strategy to improve Family Health Index, family nursing must place a position in every
supporting element of the family health status. The first element is human resources/health workers as
the target and program implementers in accordance with the concept of nursing, namely the target family
by maximizing the role of the family nurse. Second, the facilities and infrastructure as program proponent
that can be fulfilled through the evaluation element of community health center accreditation by meeting
the service standards and infrastructure available at the community health center (Kemenkes, 2014).
The fourth element is the government policy which is the basis of implementing a program to improve
family health status, namely the existence of regulations on nursing and the Healthy Indonesia Program
with a Family Approach (Kemenkes, 2016b). The fifth element is a form of community and family
empowerment based on the Indonesian mutual cooperation culture and empowerment programs that
can be maximized through the function of the community health center. Therefore, it can be concluded
that family nursing has the potential to be applied as a strategy to increase Family Health Index in
Indonesia

5. Conclusions and Suggestions

Based on the literature review that has been carried out, it can be concluded that family nursing is
a form of a social approach which observes family as a unit that provides mutual reciprocity between
nurses and all family members to achieve optimal family health status. The implementation of family
nursing by carrying out the role of nurse has positive implications for increasing the independence of the
family in achieving its health status. Family nursing can be used as a strategy to increase Family Health
Index in Indonesia. However, in relation to the literature review, no qualitative or quantitative articles
has been found regarding the direct relationship or effect of the family's ability to carry out five family
care tasks to Family Health Index as a description of the family's health status.

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