Knowledge, Attitude and Behavior of Methodist 2 Palembang High School Student towards Clean and Healthy Lifestyle (PHBS)

Background: Clean and Healthy Lifestyle or namely PHBS (Perilaku Hidup Bersih dan Sehat) in Indonesia is a program from the Indonesian Ministry of Health that has been implemented since 1996. PHBS in school settings is very important to be realized in order to create a clean and healthy school environment so that the learning and teaching process can run effectively. Aims: This study aims to describe the knowledge, attitudes and behavior of Methodist 2 High School students towards PHBS. In addition, this study also aims to see the relationship between PHBS knowledge and attitudes towards PHBS behavior in Methodist 2 Palembang High school students Methods: This study uses a cross-sectional study involving 216 students obtained by calculating unpaired categorical analytic samples. Samples were taken using purposive sampling technique. Data was collected using a questionnaire distributed online via google form. The data obtained were processed using Chi Square through the SPSS 25. Result: There were 216 respondents who met the inclusion and exclusion criteria of this study. The sample consisting of female (n=124 (57.4%)) and male (n=92 (42.6%)) and distributed evenly from 1st grade to 3rd grade (1 st grade n=65 (30.1%), 2nd grade n=75 (34.7%), 3rd grade n=76 (35.2%)). Using average value as cut off point (12.7), most of the students of Methodist 2 Palembang high school had a sufficient knowledge of PHBS (n=132 (61%) and the rest of it had insufficient knowledge of PHBS (n=84 (38,9%)). With median value (57.6) as the cut-off point, it showed that most of the students had a sufficient PHBS attitude (n=118 (54.6%)) and the rest of it had insufficient attitude of PHBS (n=98 (45,5%)). With average value (13.2) as cut off point, most of the students had insufficient PHBS behavior (n=102 (52.8%)) and the rest of it had sufficient behavior of PHBS (n=102 (42,7%)). The results of the analysis found that there was no significant relationship between knowledge and PHBS behavior among Methodist 2 Palembang high school students (p value = 0.744) and there was a significant relationship between PHBS attitudes towards PHBS behavior among Methodist 2 Palembang high school students (p value = <0.001)


Introduction
Clean and Healthy Lifestyle or more commonly known as PHBS (Perilaku Hidup Bersih dan Sehat) in Indonesian is one of the Ministry of Health of the Republic of Indonesia programs that has been implemented since 1996. 1,2 PHBS defined by the Indonesia Health Ministry as a collection of behaviors that are practiced on the basis of personal awareness as a result of learning, which makes a person, family, group or community able to help themselves independently in the health sector and play an active role in realizing public health. 1 Healthy living behavior stated by Hitchock, et al. in 2004 covering physical and emotional health care, not smoking, and not using narcotics. 3 in 2001 Nies, et al. also stated that a good healthy lifestyle includes adequate sleep (7-8 hours a day), eating nutritious foods, not drinking alcohol, and doing regular physical activity. 4 PBHS has five arrangements, namely PBHS in households, schools, workplaces, health facilities and public places. 1,2 PHBS arrangements in schools have eight indicators, namely: washing hands with clean water and soap before and after eating, consuming healthy snacks, using healthy latrines, exercising regularly, eliminating mosquito larvae, not smoking in the school area, throwing garbage in its place, and not consuming narcotics, alcohol, psychotropics and other addictive substances. 2,5 PHBS in the school setting aims to empower all school members (students, teachers and the school community) to implement a healthy lifestyle in order to create a clean and healthy school environment. 1,6 Schools with a clean and healthy environment strongly support the learning and teaching process. 1,2,6 There are several factors that can affect the implementation of PHBS in schools, which are: 7 comprehension, application, analysis, synthesis and evaluation. [8][9][10][11] Attitude is a closed response that a person gives to a stimulus or object. The meaning of a closed response is that the reaction has not been realized into an open behavior or in other words, attitude is a predisposition of a behavior. 8 Behavior is all activities carried out by humans, where these activities can be observed directly or indirectly by outsiders. 8,10,11 In 2018 Riset Kesehatan Dasar (RISKESDAS) or basic health research in Indonesia stated that some of the PHBS indicators did not show a positive increase from the 2013 RISKESDAS results. The indicators were: smoking prevalence aged 10-18 years, lack of physical activity at the age of 10 years. 12 Another survey done by the Depok Public Health Office during 2013 and 2014 found a decrease in the percentage for implementing PHBS in school settings. 13,14 The decrease in percentage occurred in indicators: consuming healthy snacks from 67.96% to 54%, throwing garbage in its place from 75.08% to 47.5% and several other indicators such as washing hands with clean water, using clean latrines, eradicating mosquito larvae. 13,14 in 2017 Prautami conducted a study on high school students in a school in Palembang regarding PHBS behavior (smoking behavior), and found as many as 63.3% of high school students who smoke. 15 In addition to smoking, in Palembang itself there are also problems in terms of drug use behavior. The National Narcotics Agency or Badan Narkotika Nasional (BNN) of South Sumatra in 2019 stated that there were more than 96,000 cases of drug use, where most of the users were teenagers.

Objectives
This study is conducted with the aim of knowing the description and relationship between the knowledge, attitudes, and behavior of Methodist 2 High School students regarding PHBS.

Participants
This study involved all students from all levels at SMA Methodist 2 Palembang. There were 216 respondents out of 242 who met the inclusion criteria and exclusion criteria. A total of 26 respondents were excluded because they did not answer the questionnaire completely.

Study design
This study used a cross-sectional study design and this study was conducted from January 2021 to February 2021. The sampling in this study used a purposive sampling technique and by calculating the unpaired categorical analytical study formula, the minimum required sample was 216 samples. This research was approved by the ethics committee of the Faculty of Medicine, Pelita Harapan University.

Research Instrument
Data were collected using several questionnaires that were distributed to respondents using a google form. The questionnaires contain questions and statements regarding knowledge, attitudes and behavior towards PHBS. In addition, there are also questionnaires containing socio-demographic data of the respondents (name, gender and grade) and questionnaires regarding PHBS facilities.

Statistical Analysis
Data analysis was carried out using Microsoft Excel and IBM SPSS Statistics 25. The data obtained were processed using Chi square to determine the relationship between knowledge and attitudes towards PHBS behavior in Methodist 2 Palembang High School students. It is said to be significant if the p value is <0.05. Research on the knowledge, attitudes and behavior of clean and healthy living involved all students from all levels in Methodist 2 Palembang Highschool. There were 216 respondents who met the inclusion and exclusion criteria. Most of the respondents were women (57.4%) and the respondents were evenly distributed from 1 st grade to 3 rd grade. Initially the assessment of the questionnaire was divided into sufficient and insufficient knowledge of PHBS using the median value (7) as the cut-off point. It was found that all respondents had sufficient knowledge of PHBS (100%). Therefore, the cut value for knowledge is changed to the average value (12.7) so that in the Chi square calculation (the relationship between knowledge and behavior) there will be no cells with a value of 0. With knowledge, using the cutoff point of the average value (12.7) found that more than half of the respondents (61.1%) had sufficient knowledge of PHBS.

Knowledge, Attitude and Behavior towards PHBS
For the calculation of attitude assessment using the average value (57.6) as the cut-off point and it was found that the majority had a sufficient attitude towards PHBS (54.6%).
The initial behavioral assessment used the median value (8) as the cut-off point, and it was found that all respondents (100%) had sufficient PHBS behavior. Therefore, the cut-off point for PHBS behavior was changed to the average value (13.2) so that in the Chi square calculation there were no cells with a value of 0. With behavior, using the mean value cut-off point (13.2) found that the majority of respondents had insufficient PHBS behavior (52.8%).

Facilities of PHBS
Methodist 2 Palembang High School has all the facilities that support the implementation of PHBS. The facilities in question are clean and healthy latrines, clean water and soap are always available at school toilets, smoking bans in schools, activities to eradicate mosquitoes, activities to clean the school environment, good waste disposal sites, scales are in good condition and functioning well in the school health unit.

Relationship between PHBS knowledge and PHBS behavior in Methodist 2 Palembang high school students
The results of the analysis of the relationship between PHBS knowledge and behavior towards PHBS in Methodist 2 Palembang High School students who used chi squared obtained a p value of 0.744. Because the p value > 0.05, it can be stated that there is no significant relationship between PHBS knowledge and behavior towards PHBS in Methodist 2 Palembang High School students.
This study is not in line with research conducted by Zubaidah in 2014. 14 Zubaidah conducted a study entitled "The Relationship of Demographic Characteristics, Knowledge and Attitudes with PHBS of Depok City Elementary School Students". 14 Zubaidah's research stated that there was a significant relationship between PHBS knowledge and PHBS behavior. 14 This research is also not in line with research conducted by Prautami in 2017. Prautami conducted a study entitled "The Relationship of Knowledge and Attitudes with Smoking Behavior in Adolescents at PGRI 2 Palembang High School." In his research, he found a significant relationship between PHBS knowledge and PHBS behavior. 15 In this study, it was found that there was no significant relationship between PHBS knowledge and PHBS behavior. The reason for this is because behavior is not only influenced by knowledge, but also by attitudes. 14 In other words, a behavior arises because of stimuli from inside and outside the body (knowledge/cognitive), but the behavior itself is also determined by the feelings towards the stimulus (attitude/affective). 8,14,16 In addition, the insignificant results in this study can also be influenced by the sample selection method. The sample selection method in this study is purposive sampling where the sampling is determined or adjusted to the research objectives so that the sample does not represent the general population. Meanwhile, in the research conducted by Zubaidah and Prautami, both of them used a sample selection method that could better represent the general population, namely simple random sampling.

Relationship between PHBS attitude and PHBS behavior in Methodist 2 Palembang high school students
In this study, it was found that the attitudes of Methodist  This research is in line with several studies that have been conducted previously. Attitude itself is a predisposing factor in the occurrence of a behavior according to Green's theory in 1980 which was presented by Zubaidah in 2014. 14 One of the three behavioral domains is affective where affective is focused on a feeling, emotion or can also be referred to as the level of acceptance or rejection. This affective itself is also often referred to as attitude. Zubaidah in 2014 also emphasized that the attitude involves thoughts, attention and other psychological matters or in other words the attitude is a collection of symptoms that respond to a stimulus or object. 14

Conclusion
The conclusion of this study is:

Limitation
This study was conducted using a selfreport questionnaire which could lead to a risk of bias. The bias could be due to the respondent in filling the questionnaires.