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The Effect of Competence on Health Promotors Performance in Central Java Indonesia

Health Promoter is one of the health professionals in all health institutions. Different educational backgrounds, educational levels, competencies and functional positions can affect performance in the field. This study aims to analyze competence and its effect on the performance of health promoters. This type of research is an exploratory survey with a quantitative approach. The research population is health promoters in Central Java. The research sample was 114 people and selected by simple random sampling technique. Data analysis used simple linear regression. The results showed that there was a strong positive correlation between competence and performance (r = 0.712), the coefficient of determination (R square) was 0.507. This explains that 46.3% of performance is influenced by competence.


Introduction
Health Promotion as stated in the Regulation of the Minister of Health Number 1193/Menkes/SK/X/2004 concerning National Health Promotion Policy is an effort to increase community capacity through learning from, by, for, and with the community to help themselves, as well as developing community-based activities. in accordance with the local sociocultural and supported by health oriented public policies. Health promotion is one of the essential health efforts and is a minimal program that must be implemented by every health service unit. The health promotion program is oriented towards improving the community's healthy living behavior through various activities to promote clean and healthy living behavior.
Regulation of the Minister of Health Number 74 of 2015 concerning Efforts to Improve Health and Disease Prevention also motivation are more of a condition for building and realizing competence. Jasmine et al. (2015), explains that performance or work performance is part of human resource management and is an important criterion for the results and success of an organization. Muelleret al. (2013), work performance or performance can be defined as the degree of fulfillment of work demands (activities) in the current workplace (environment). Carlos andRodrigues (2017), defines job performance as a periodic evaluation of the behavior of individuals displayed in their tasks and work, where it is the result of a combination of cognitive abilities, personality and learning experiences that form trust in the organization.
Public health experts have competence as professional public health workers, selfdevelopment abilities, skills in effective communication, and have good self-skills in the field of public health. These competencies are also owned by public health experts with a concentration in the fields of health promotion and behavioral science(C. Jongen et al., 2018). With these competencies, it is hoped that health promotion personnel can carry out their main duties and functions in public health promotion programs both at health centers, hospitals, and health offices. (CS Jongen et al., 2017). Based on this, with the diversity of educational resources, professional positions, and competencies of health workers, it is necessary to conduct research to analyze the public health competencies of health workers in Central Java Province.

Method
This research was designed quantitatively with an exploratory survey method. This research goes through 5 dimensions and indicators of competence. This design is built on a two-variable relationship framework, where public health competence is the independent variable while the performance of health promoters is the dependent variable. The population of this study were all health promotion workers in Central Java Province who had carried out the professional oath of health workers in 2020, which were 643 people. The research sample was 114 people who were number and distribution of health promotion personnel in all regions. In addition, the capacity of health promotion personnel in the regions is still very limited.
Based on the 2019 Health Facility Research Report (RIFASKES), there are 4,144 health promotion workers spread across Puskesmas-Puskesmas in Indonesia. The average health promotion personnel at the Puskesmas was 0.46 per Puskesmas. This data shows that not all Puskesmas have professional health promotion personnel. RIFASKSES data also shows that only 1% of health promotion workers have a health promotion education or training base.
The number of health promotion workers in the province of Central Java is 643 people spread over 35 districts and cities. Of these, only a few have functional health promotion positions. Educational backgrounds are also very diverse, including nurses, midwives, sanitarian workers, and public health nonspecialized in health promotion. This condition greatly affects the quality and ability to carry out their duties as health promoters.
Assessment of the performance of human resources in the health sector is based on knowledge, skills, and attitudes. The knowledge and skills of human resources in the health sector follow their respective expertise. While competence is a specific combination of knowledge, attitudes, and skills needed to perform certain activities. This competency must be understood and possessed by health promotion officers, especially in Puskesmas or Community Health Services.
Competence is a person's underlying characteristics regarding the effectiveness of an individual's performance in their work or individual basic characteristics that are causally related to the criteria for effective performance in a particular workplace or situation. Lin et al., (2012), stated that knowledge, experience, and skills are the basis of one's competence. Competence is an underlying characteristic of people who exhibit a way of behaving or thinking, which generalizes across various situations and persists for long periods of time. Springer & Oleksa (2017), add that competence is treated as a collection of knowledge, skills, and attitudes, while personality traits or selected by simple random sampling technique. The research data was collected by using documentation study techniques for secondary data collection and questionnaires via google form to obtain primary data.

Results and Discussion
The development and quality control of health workers is aimed at improving the quality of health workers in accordance with the competencies expected in supporting the implementation of health services for all Indonesian people. The development and quality control of health workers is carried out through increasing the commitment and coordination of all stakeholders in the development of health workers and legislation, including professional certification, namely through competency tests, registration, licensing, and rights of health workers. (Liang et al., 2019). Frequency distribution of the characteristics of Health Promoter respondents in Central Java Province  Table 2 explains that most of the respondents are female, namely 79.8%. Respondents were dominated by young people, as many as 56 people (49.1%). Almost half of the sample are Civil Servants/PNS, as many as 76 people (66.7%). The highest level of education is Bachelor of Public Health graduates, with 1 to 3 years of service the highest is 50 people (43.9%).
The average tenure of extension workers is relatively young to carry out their duties as agents of change. This can be seen from the time they carry out these tasks in the range of 1-10 years and some even reach a dozen years. Based on table 2, the regression value between the variables of the influence of competence on performance (R Square) is 0.712. These results indicate that 71.2% of competencies affect performance. Based on table 3, it is obtained that the calculated F is 114,346 with a significant level of 0.000 because p <0.05, the regression model can be used to predict the effect of competence on performance. The regression equation Y = 6.932 + 0.762 X means that if the X coefficient is considered zero, then the value of the Y variable is 6.932. The regression coefficient of 0.762 states that for each additional coefficient of the X variable of 1, there will be an additional value of the Y variable of 0.762. The value of t count is 10,693 > 1,658 (t table with df 110). In addition, the coefficient table shows that the significance is 0.000, so the hypothesis is accepted, and the significant regression coefficient means that competence has a significant effect on performance. The results of this study indicate that the performance competence of health promotion personnel is generally quite good. This achievement is closely related to the factors that influence it, namely the professional level, self-development, effective communication, self-skills, and the foundation of public health. Professional Competence Enough with an average score of 5.98, competence. The significance value of the competence and capability variables p-value (0.000) < 0.05 and t count > t table so that H0 is rejected, which means that both variables partially or jointly have a positive and significant effect on the performance variable. Self development is quite good, with an average of 17.36. Effective Communication Competence is quite good with an average of 22.87, self-skill competence is quite good at 13.96.
The results of this study are in line with Jeffrey and Dinata (2017), Hutagalung (2020), which states that competence has a positive and significant effectaffect employee performance. The same thing was stated by Urtasun & Núñez (2012), states that competence can have a positive and significant influence on a person's performance. Within the scope of the organization, this research is also in line with (Vainieri et al, 2019), which states that managerial competence is positively related to organizational performance. Managerial competence is closely related to the process of sharing information that is developed into an organization. In particular, managerial competence plays an important role on overall performance, and the results are mediated by the use of mature information sharing instruments such as benchmarking of performance results.
Employee competence in the quality of health services is highly dependent on the knowledge and skills of health workers. Therefore, health workers need to improve their competence (eg ethics, knowledge, and skills). So that the services provided are of the best quality (Bonesso et al., 2020). Educational facilities for related health workers play an important role in providing education and professional development in health facilities. Health workers hope that the place of education will be a place to gain knowledge, not only in theory but also in practice in the field (Christanti & Juliantini, 2020).
Health promotion workers are health workers who have the competence to study, research, analyze and prioritize health problems, as well as plan behavior change interventions through community empowerment which is strengthened by advocacy and creating a supportive and conducive environment based on the spirit of partnership by using appropriate and targeted media (Nawawi, 2012). Selfdevelopment or the level of respondent's ability is shown by the majority of respondents being able to analyze, determine and decide on actions to overcome health problems in the community through slide projectors, brochures, and posters in counseling once a year. Inviting, involving and using sponsors (company, product, private) for health promotion activities. 1-3 times a year inviting and involving relevant crosssectors (agencies/institutions) for joint health promotion activities and internships for health students at the Puskesmas (Jongen et al., 2017).
Effective communication. The results of the study that describe effective communication show most respondents that a health promotion officer must be humble, polite, and respectful of the audience when conducting counseling. They do not involve personal feelings, need someone or family to help themselves and play an active role in realizing their health (Setyabudi & Dewi, 2017). Proud to be a health promotion worker and continue the counseling by holding back anger and hope that the counseling will end soon when facing an apathetic audience. Carry out advocacy activities, develop an atmosphere and movement for community empowerment, disseminate information, make media designs, conduct studies/research on public health behavior, and plan interventions in developing community behaviors that support health. In addition, public health promoters also have roles, functions, and competencies. Self skills. The skill level of the respondents is still at the limit of mediocrity. Though in general it is quite good. This is illustrated by the number of respondents who have planned and prepared methods and media for counseling to anticipate conditions in the field, only able to make all health promotion media, mastering communication techniques. Skill is the ability to operate a job easily and carefully. Skill is an activity that requires practice or can be interpreted as an implication of the activity. Skills as the capacity needed to carry out several tasks which are the development of the results of training and experience gained. In addition to the training needed to develop skills (Grillich et al., 2016).
Basic public health. The function of public health is to provide Community Health Efforts (UKM) services at the community level. Personnel needed to carry out public health functions in health centers, hospitals, and health services. Public health workers, especially those with competence to carry out health promotion, have been included in the Puskesmas staffing standards (PMK-75/2014). The performance of our respondents can be concluded that the higher the competence, the higher the performance of health promotion personnel. The correlation between competence and performance shows a strong relationship and has a positive pattern (r = 0.712). The coefficient of determination (R square) is 0.507. This explains that 46.3% of performance is influenced by competence and the rest by other factors (Krijgsheld et al., 2022). The performance of public health promoters in the practice of promoting Puskesmas in Puskesmas, Health Offices, and Hospitals. Several things related to performance that respondents did not do were standard operating procedures (SOPs) that were available, written, and complete.
There is no planning and implementation of training for health cadres, formulating problems based on the priority of the main problems. Making media leaflets and posters in planning to formulate interventions to be carried out. Conduct performance evaluations every six months. Conduct an assessment of the resources owned by the community (Bindels et al., 2021).
The education level of respondents with good performance at the Diploma III level is 7%. Meanwhile, 85.1% of respondents holding S1 in Public Health performed well, other S1 holders were 1.8%, Masters in Public Health were 4.4%, and other Masters were 1.8%. The relationship between the respondent's education level and the performance of health workers in health promotion practices. This shows that differences in education levels have a significant effect on the performance of Public Health Extension Officers in Health Promotion Practices. The results are in line with Lawrence Green's theory that a person's level of education is a convenient factor for behavior change. The education level of S1 Public Health achieved can affect the quality of work (Anderson & Green, 2018).

Conclusion
Monitoring and evaluation is carried out periodically to monitor the success of the health promoter itself and as a tool to make further planning. The health promoter's competence in the activity should be reviewed after completion to improve and make it better. Performance evaluation is a continuous process and has targets. Its purpose is to monitor and evaluate competence and performance to see the progress of each activity. Public health workers, especially those with competence to carry out health promotion, have been included in the Puskesmas staffing standard (PMK-75/2014).