THE IMPLEMENTATION OF SCHOOL HEALTH UNITS BASED ON WORK TEAM AND TRIAS UKS IN THE PRIMARY SCHOOLS

Background: The proper management of School Health Units (in Indonesian abbreviation as “UKS”) in educational institutions has the ability to sustain health behavior and optimize student growth and development. As evaluation of the program is a reliable process to measure efficiency and effectiveness of their activities, we aimed to report the evaluation of development the UKS work team and the Three Main Programs of Schools Health Units (TRIAS UKS) in Ngawen Subdistrict, Blora Regency as an indicators’ for Indonesia health research networks and programs. Methods: This is a quantitative descriptive research with data obtained from principals of 30 Primary Schools by using purposive sampling. The evaluation using the work team form and TRIAS UKS form indicators, including health education, health services and healthy school environments, is designed to profile the development of school health program. Results: Based on those indicators, the UKS work team still had problems in showing the decree on the organization of UKS team. In terms of health education, many of the schools hd lack of media to promote health. The schools also had difficulties in doing some consultation for mental health for students and some of schools were unsuccessful developing the healthy canteen. Conclusion: Research evaluation the UKS work team and TRIAS UKS are important elements in the success of the School Health Units (UKS). Thus, it creates constructive positive learning process and provides an overview of the limitations and challenges which can be used for better planning and promotion of the health research system nationally and globally.


INTRODUCTION
Students are the next generation of a nation. A productive and competitive nation is largely determined by the health and quality of student life. Primary school children are vulnerable during the period of growth and development, therefore they need to be introduced to health behaviour and made them understand at an early age, in order to develop a Clean and Healthy behaviour for their well-being [1].
The School Health Units (UKS) is health education program in primary school to ensure the sustainability of health behavior and evaluate of health status of the school children that conducted in the school environment and directly provided by all the primary schools in Indonesia. It was pioneered in 1976 and strengthened in 1984 with the issuance of a decree from 4 ministers, namely the Minister of Education, the Minister of Religion, the Minister of Health and the Minister of Home Affairs which was renewed in 2003 [2]. It is legally decided that schools are the closest place to engage the health behaviour to the children and become the safest place to evaluate health status of them. Moreover, according to the Basic Development and Guidance Policy in accordance, for the successful of the program it has been given the legal Board Team established by the government to supervise the implementation of UKS itself.UKS has three main programs known as the TRIAS UKS which includes Health Education, Health Services and Fostering a Healthy School Environment [3] which later become the indicators to evaluate in this study.
Health education is aiming the health knowledge of the school children regarding healthy way of life. For instance, they can understand the important of washing hands, brush teeth, physical activity, consume healthy food and vitamins. This program might be used some media like a poster, leaflet and some slide presentation from teacher or volunteers among the students.
Health education also require any competition that will motivate the children to think creative towards creating the healthy environment. Health service in UKS is provided as a first stage of children to have some curative program experience. With UKS, children who feels any discomfort or ill can be treated as a first aid before referred to proper health services if needed, including dental caries. School cooperated with primary health service in the same area to check any dental caries, report and will be followed by treatment from the dentist. By that, school can have some health profile of their own children that can be reported to local health services. Lastly, school requires to provide healthy environment, since it is the most important place beside children's home, so it will enlighten the children about the necessity of health. It can be supported by the providing the healthy canteen, physical activity room, UKS room and no smoking environment.
The implementation of UKS in Public Primary Schools in Central Java Province has not been functioning optimally. This is proven by the data obtained from the Provincial Health Office in 2018 that happened in one of the health service's program called dental check-up for the students. It is found that there was a decrease in 2018(41%) when compared to 2017(44%), regarding the follow-up treatment for the dental caries detected in school and another decline was detected in 2018(38.1%) compared to 2017 (43.3%) in terms of nutrition status reported for in Blora District, thus it has been changed from the treatment into the reporting only. The observations and interviews conducted on students and teachers showed that many scholars had not benefitted optimally from the services rendered by the UKS in their school. For instance, children were still lack of knowledge regarding health risk behaviour and for the teacher, they happened to find many difficulties especially in managing the time, due to many others responsibilities in school. Furthermore, the health risk behaviours were still remain seen among most of the school children in that schools such as not washing their hands properly, not eating healthy food, less physical activity and it is somehow increased the number of obesity among the schools children. Based on these problems, this research is aimed to evaluating the UKS Work Team and the implementation of the TRIAS UKS in schools by employing all necessary indicators to evaluate the programs to enhance the implementation of school education program in order to develop quality of life of the school age children

METHODS
The study population consist of the principals of 30 Public Primary Schools located in Ngawen Sub district in Blora Regency. This research is a quantitative study with descriptive analysis following the cross sectional studies using the Work Team form and TRIAS UKS form including all the indicators (Health Education, Health Services and Healthy environment) of success to describe all the obstacles found in the field. These forms are reliable and valid to measure the efficiency and effectiveness of the performance of the school health units because it developed by the outcomes expected from the UKS program in Indonesia and these instruments have been developed and validated by Ministry of Education Indonesia. It is called "UKS Work Team form" This form evaluating the implementation of Work Team that should appointed by the schools as committee, the decree of the team, the involvement of teachers and public health centres, the coordination, time schedule, the visiting and monitoring from the board. All of those indicators are written by the government to ensure the implementation of the UKS in schools.

UKS TRIAS form
These forms include the health education to estimate the availability of counselling, the health services implemented with a check routine, measurement height and weight, and evaluate the cleanliness and the property provided by schools for healthy environment. Ethical approval Ethics approval for this study was obtained from Research Ethics Committee of Universitas Esa Unggul.

UKS Work Team
The results from the table 1 showed that no school (0%) fulfilled the principal's indicators of issuing a Decree (SK) for the organization of the UKS team, while one school (3.3%) had pointed the UKS team. There were also found that no regular internal meeting and no coordination meetings and counselling with the Board Team conducted in all schools. All participants admitted that school were unsuccessful to create a work-program and making report to Board team. It was also discovered that only 4 school (13.3%) involved teachers, public health services, students and parents to the UKS implementation program .Moreover, 100% of the schools were observed have been included the elements of cleanliness, beauty, comfort and safety as an indicator in enhancing the facilities in their schools.

TRIAS UKS-Health Education
The results from Table 2

TRIAS UKS-Health Services
The results from Table 3 showed that all 30 schools (100%) carried out early disease detection by observing the health status of the students, there were also students' screening by the Board Team, regular health checkups for students who have illness, immunization programs together with the basic health services nearby and made referrals to the nearest public health centre or hospital for those required intensive care, such as dental caries that have been detected every year in school. However, only 4 Schools (13.3%) provided counselling services for mental health of the students.

TRIAS UKS-Healthy School Environment
The results from Table 4 showed that all 30 schools (100%) already have toilets or latrines for students, a non-smoking area, a field or hall for physical education, sewerage and temporary landfills. Subsequently, 14 schools (46.7%) have UKS rooms, while 12 schools (40%) had actualized healthy canteens, and 27 schools (90%) have a washbasin with tap water.

DISCUSSION
The aim of this study was to evaluate the implementation of UKS according Team Work and TRIAS UKS. Health education is become priority for the health behaviours problem we are facing recently [4,5] especially for the school age children who are at risk for embracing the unhealthy habit toward their social and environment. Indonesia like other countries are contribute to make some efforts to decrease the number of those health risk behaviour by developing some health education programs such as school health units (UKS). School health Units as one foundation to work closely to the school age children, thus they able to access the information, the services and as one step to fulfil their interest of living healthy [6,7]. Therefore, preparing the successful school health units, there are some require indicators should be conducted by the schools observed, including Work Team and TRIAS UKS that can be learned and studied to developed a comprehensive health program that build up in primary school for quality of school children.

The Implementation of the UKS Work Team
The results from this research showed that all the 30 schools had implemented indicator number 9 [have been included the elements of cleanliness, beauty, comfort and safety as an indicator in enhancing the facilities in their schools].This is important to build the characters of the students which expectantly followed by the healthy living attitude. It has to be conducted by the schools to obtain the objective of the UKS program itself.
UKS Program also has The UKS Central Board Team, who responsible as a form of organization that coaches and manages UKS in an integrated and coordinated manner. Therefore, the Work Team of each UKS program could arrange the following tasks such as implementing the three main programs (TRIAS UKS) which consists of health education, health services, and healthy school environment development. Work team is also responsible in establishing cooperation between parents, school committees, other agencies and the community in carrying out UKS activities, organizing programs, conducting assessment/evaluation, preparing reports and completing the administration of the UKS [8].
The results found that all of the schools were unsuccessful to receive some coaching, monitoring and coordinating from the Board Team which expectedly leads to the defective program. This may give some good suggestion for the implementation of the afterward health education program. It is necessary to assign Board member to supervise the UKS program.
Furthermore, the importance of formulating a decree (SK) has an impact on the responsibilities of the team members. Work programs and routine coordination are also needed to ensure that the activity schedule of the UKS does not interfere with the main function of the school as an educational facility. Therefore, these results are useful to encourage the school to fulfil the Work Team indicators for sustainability of the school health units. Additionally, the optimization of the School Health Work Team tends to affect education and health services in the school because it functions as an entity while the implementation of UKS is based on priority and policies set by the Sub district Health Development Team [9,10].

The Implementation of TRIAS UKS-School Health Education
The results from this research stated that all the schools have successfully conducted the counselling program and voluntary work (100%).
These two programs are vital to educate the students regarding health behavior and give the experience as health educators and health workers for the students. According to the Ministry of Education and Culture Indonesia, Health Education is important because it prepares students to grow and develop normally, properly, and healthy in all aspects of physical, mental, social and environmental through activities such as guidance and counselling, that required for their current and future roles [11,12]. However, delaying those exposures to students it tends to affect their knowledge of health, including lifestyles such as Clean and Healthy Behaviour in the future.
TRIAS UKS-Health education is also including activities such as, weight and height measurements, classroom cleanliness competitions and there were around 26% and 30% schools were not able to conduct those programs. The measurements and the competition have the similar objectives for exposing the students with all healthy living style. It is easy to conduct, spend low cost and work effectively to aim quality of school age children [13]. Therefore, UKS is not only a curative tool it also serves as a preventive and promotion measure. These functions are useful in avoiding risk health behaviours in the future.
According to the data obtained, one indicator that conducted with the least number (16.7%) of schools was qualified with adequate property/media of health education. It is clearly become obstacles to optimize the health education program. It is definitely more understandable if the education completed with the visual properties such as leaflet, poster and also video animation if possible.
Therefore, it was concluded that the implementation of School Health Education was not 100% successful because there were some indicators have not fulfilled by the schools. However, this obstacles could have suggest the government to prior some problems such as, providing more property for health education to simplify the school work, for instance, some digital height and weight measurements, posters, and some replicas of the human body [14,15].

The Implementation of TRIAS UKS-School Health Services
It was showed from the results that most of the indicators in this TRIAS were successfully applied by all the schools, including health checks, early detection/screening, and immunization program and give some referral treatment to other health services. Those activities are important to provide health services at school. School health unit is also designed to detect health problem for all the students. It is deliberate as one of the accessible health services for them to escalate the health awareness among them. According to the Ministry of Education and Culture (2014), health services in school health unit includes promotive, preventive, treatment (curative), and recovery (rehabilitative) aimed for students and their environment [15].These objectives are to prevents the occurrence of diseases, disorders, disabilities and also health symptoms as early as possible. It ideally boost the health status of students and all school residents, conversely its lack has an impact on the students' health. Services ,such as health screening help schools and parents to detect health problems in children, for example malnutrition, dental problem, vision and hearing issues.
However, only 4 schools (13.3%) who able to organize the counselling program. As one of the indicator for health services, it is essential to provide services regarding student counselling, which is very important in understanding students' mental health situations. Mental health situation is related with some health issues of the school age children [16]. Thus, some schools required to facilitate these services in order to enhancing the teachers' understanding of mental health issues of students. This may take several intakes to the development of school health units. The lack of understanding on how significant is the counselling program from the teachers might become the cause of the problem. Therefore, UKS Board members are compulsory to provide the pre-clinic and give some training for the UKS Work Team so they can ensure the counselling program for students.

The Implementation of TRIAS UKS-Healthy School Environment
Based on the results, 100% of the schools have been provided with toilet, hall for physical activity, wastewater sewer, and temporary landfill. Additionally, those schools have implemented the-Non-smoking area. The healthy school environment is one of the TRIAS that concerns with the facilities and area of school that effected to the healthy life. According to the Ministry of Education and Culture [2], school environment is a place for educational activities. A healthy school environment is defined as the condition of the premises to support the optimal growth and development of students, practice healthy living behaviours and avoid negative influences. It is an important element in fostering schools, to improve the health of students, teachers and staff, as well as increasing the effectiveness of pupils during the learning process [17].
Subsequently, Healthy school environment is also required other facilities, such as wash bin with running water, healthy canteen and UKS room. The data showed that 10%, 53.3% and 60% of the school have not equipped with those facilities. The importance of the UKS room is to implement an optimal routine health program. The constraints on this element occurred due to limited land and lack of guidance by the Education and Health Office. This problem is moderately challenging to be solved. Regarding healthy canteen, it is significant movement to change the consumptive habit of children in buying the unhealthy snack that affected to obesity [18]. With the proper facilities, school health unit will constructively contribute to create quality of the school age children with the understanding of health risk behaviour.

CONCLUSION
Results show an advanced necessity for more awareness in the assessment of evaluation of health education program in primary schools. The more attention to program performance is essential in solving health problem especially among school age children such as health risk behaviours. The evaluation was based on the Work Team and TRIAS UKS form as an indicator for the successful of the program.It is necessary to encourage school to optimize the item in Work Team and the TRIAS of UKS in order to beneficiate more the program of school health unit. The measurements of these indicators are capable in profiling the effectiveness of the program and very useful to design another health education program in Indonesia and in the whole world that facing the same health problem in school age children. Further research is needed on complementary methods of evaluation and practical recommendation on the performance of UKS in Indonesia.

ETHICAL CONSIDERATIONS
Ethical issues (Including plagiarism, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.