Dampak Stimulasi Kognitif Berbasis Pengasuhan disertai Pemberian Garam Beriodium Terkontrol pada Kemampuan Kognitif Anak Prasekolah di Daerah Endemik GAKI

LENY LATIFAH, S.PSI., PSI., MPH, Prof. dr. Djauhar Ismail, Sp.A(K), MPH, Ph.D.

2015 | Tesis | S3 Ilmu Kedokteran

Latar Belakang: Setiap tahun lebih dari 200 juta anak di bawah lima tahun gagal mencapai potensi perkembangannya. International Child Development Steering Group menyebutkan stimulasi kognitif yang tidak memadai dan GAKI (Gangguan Akibat Kekurangan Iodium) sebagai dua dari empat faktor risiko utama kegagalan perkembangan bagi anak di negara berkembang. Anak di daerah endemik GAKI memiliki risiko lebih tinggi untuk mengalami hambatan kemampuan kognitif, atau disebut sebagai endemik mental defisiensi di daerah endemik GAKI. Belum diketahui dampak kombinasi intervensi mikronutrien iodium dan stimulasi berbasis pengasuhan terhadap Kemampuan Kognitif anak. Tujuan: Mengukur dampak stimulasi kognitif berbasis pengasuhan disertai dengan pemberian garam beriodium terkontrol terhadap peningkatan indikator-indikator pengasuhan ibu, status iodium dan fungsi tiroid anak, serta kemampuan kognitif anak. Metode: Penelitian ini menggunakan rancangan kuasi eksperimental pretest posttestwith control group design. Penelitian dilakukan di Kecamatan Pituruh, Kabupaten Purworejo terhadap 78 anak prasekolah usia 4-5 tahun beserta ibunya. Intervensi stimulasi kognitif berbasis pengasuhan berupa serangkaian program pendidikan dan pendampingan orang tua dalam pengasuhan yang menstimulasi perkembangan anak, mengacu pada teori kemampuan kognitif Piaget, teori sosiokultural Vygotsky diperkaya pemikiran Ki Hajar Dewantara, juga memasukkan kearifan lokal. Health Action Process Approach (HAPA) menjadi teori acuan untuk disain perubahan perilaku. Intervensi garam beriodium berupa pemberian garam yang diproduksi khusus mengandung 30 ppm kalium iodat (KIO3). Evaluasi dilakukan bulan ketiga dan keenam. Data indikator pengasuhan ibu berupa efikasi dan perencanaan diukur dengan kuesioner self report, kemampuan mediasi kemampuan kognitif anak (MKA) dengan Mother Child Picture Talk Task (MCPTT),serta data kualitas lingkungan pengasuhan dengan HOME (Home Observation for Measurement of the Environment). Status gizi iodium diukur dengan indikator ekskresi iodium urin (EIU), fungsi tiroid diukur dengan kadar thyroid stimulating hormone (TSH), dan thyroxine bebas (fT4). Kemampuan kognitif anak diukur dengan WPPSI (Weschler Primary and Preschool Scale of Intelligent). Data dianalisis dengan Anova Repeated Measure Mixed Design untuk mengukur dampak intervensi pada indikator-indikator pengasuhan ibu, status gizi iodium, dan kemampuan kognitif anak. Paired sampel t test dananalisis regresi linear digunakan untuk mengukur perubahan fungsi tiroid serta faktor yang berpengaruh terhadap perubahan fungsi tiroid sesudah intervensi garam beriodium 6 bulan. Hasil: Kelompok intervensi menunjukkan pola perubahan efikasi (F= 16.56; p=0.000) dan perencanaan pengasuhan (F= 11.73; p=0.000) lebih baik daripada kelompok kontrol. Peningkatan efikasi terlihat sejak bulan ketiga (p < 0.01) dan perencanaan pada bulan keenam (p < 0.01). Intervensi juga secara signifikan (F= 4.64; p=0.034) meningkatkan kemampuan ibu melakukan mediasi kemampuan kognitif anak (MKA) secara verbal, sejak bulan ketiga (p < 0.05). Pada bulan keenam pengukuran, terjadi peningkatan signifikan pada level deskriptif (p < 0.05) dan elaboratif (p < 0.01). Kelompok intervensi secara signifikan menunjukkan perbaikan kualitas lingkungan pengasuhan yang lebih baik daripada kelompok kontrol (F=10.252; p=0.002), sejak bulan ketiga (p < 0.05). Terjadi perubahan status iodium dan fungsi tiroid pada anak sesudah intervensi garam beriodium 30ppm. Nilai EIU meningkat signifikan (p < 0.01) dari rata-rata lebih (268±193) μg/L menjadi ke arah ekses (361.08 ± 158). Kedua kelompok menunjukkan pola perubahan kadar EIU yang sama dari waktu ke waktu (F= 0.187; p=0.830). Anak dengan status iodium awal yang defisien menunjukkan kenaikan nilai iodium paling tinggi (F= 12.82; p=0.000). Hasil lain menunjukkan bahwa proporsi anak dengan anemia 44.7%, defisit energi berat 42.9%, dan defisit protein berat 37.86%.Hasil analisa regresi menunjukkan, nilai EIU di awal dan akhir penelitian, serta kadar iodium garam rumah tangga sebelum penelitian berpengaruh negatif terhadap perubahan status TSH. Intervensi stimulasi kognitif berbasis pengasuhan, signifikan meningkatkan kemampuan kognitif anak, baik aspek kognitif umum (F=7.945; p=0.006) maupun non verbal (F= 19.03; p=0.006), yang terlihat sejak evaluasi bulan ketiga. Peningkatan kemampuan kognitif verbal kelompok intervensi secara signifikan lebih baik daripada kelompok kontrol (p < 0.01) pada bulan keenam. Peningkatan pada kelompok intervensi lebih baik 8.4 poin pada aspek kemampuan kognitif non verbal, 8.1 poin pada kemampuan kognitif verbal, dan 10.3 poin pada kemampuan kognitif umum dibandingkan kelompok kontrol. Kesimpulan: Ibu yang mendapatkan intervensi menunjukkan peningkatan signifikan dalam efikasi dan perencanaan pengasuhan, kemampuan melakukan mediasi kemampuan kognitif pada anak, serta kualitas lingkungan pengasuhan. Intervensistimulasi kognitif berbasis pengasuhan meningkatkan aspek-aspek kualitas pengasuhan ibu yang relevan dengan peningkatan kemampuan kognitif anak pra sekolah di daerah endemik GAKI. Sesudah intervensi dengan garam beriodium 30ppm, status UIE anak meningkat, tetapi fungsi tiroid menunjukkan arah yang berbeda, yaitu menurunnya kadar fT4 dan meningkatnya kadar TSH. Proporsi anak dengan anemia disertai proporsi tingkat defisiensi energi dan protein yang tinggi mungkin menyebabkan kecukupan asupan iodium belum disertai dengan perbaikan fungsi tiroid. Intervensi stimulasi kognitif berbasis pengasuhan disertai pemberian garam beriodium dosis terkontrol meningkatkan kemampuan kognitif umum dan non verbal anak sejak bulan ketiga, dan kemampuan kognitif verbal anak sesudah bulan keenam intervensi.

Background: Each year more than 200 million under 5 years children failed to reach their development potential. International Child Development Steering Group identify inadequate cognitive stimulation and IDD (Iodine Deficiency Disorders) as two of the four major risk factors for the developmental failure of children in developing countries. Children in IDD endemic areas have a higher risk for cognitive abilities delayed,entitled asendemic mental deficiency in IDD endemic areas. There still lack of evidence on the combination of iodine and cognitive stimulation intervention effectiveness for optimizing child cognitive abilities. Purpose: Measuring the impact of parenting based cognitive stimulationcalong with the administration of controlled dose iodized salt in enhancing indicators of maternal quality of care, iodine status and thyroid function of children, and cognitive abilities of the children. Methods: This was a quasi-experimental design pre-test post-test with control group design. The study was conducted in Pituruh, Purworedjo district. The subjects were 78 pre-school children 4-5 years age and their mothers. Parenting cognitive stimulation intervention was a series of educational and supporting programs on parenting for stimulating children development. The theoritical framework used were cognitive abilities theory from Piaget, socio-cultural theory from Vygotsky, enriched with thought of wisdom from Ki Hajar Dewantara. Health Action Process Approach (HAPA) used as theoritical framework for behavioral change. Iodized salt with controlled dose were distributed for household usage, produced in particular for this research, with 30 ppm potassium iodate (KIO3). Evaluation was conducted in the third and sixth month. Maternal quality of care measures with several indicators. Parenting efficacy and planning were measured with selfreport questionnaires, maternal ability in mediating child cognitive abilities (MCCD) with Mother Child Talk Picture Task (MCPTT), and quality of home care with HOME scale (Home Observation for Measurement of the Environment). Iodine nutritional status measured by Urinary Iodine Excretion (UIE) level, thyroid function measured with thyroid stimulating hormone (TSH) and free thyroxine (fT4) level. Child cognitive abilities measured with WPPSI (Weschler Preschool and Primary Scale of Intelligent). The data were analized using ANOVA Repeated Measure Mixed Design to measure the impact of the interventions on maternal quality of care indicators, iodine nutritional status, and cognitive abilities. Paired samples t-test and linear regression analysis is used to measure changes in thyroid function and the factors that influence thyroid function changes after 6 months of iodized salt intervention. Results: The intervention group showed better patterns of change in efficacy (F = 16:56, p = 0.000) and the planning of care (F = 11.73, p = 0.000) than the control group. Improved efficacy seen since the third month (p <0.01) and in the sixth months for the planning of care (p <0:01). The intervention also significantly (F = 4.64, p = 0.034) increase maternal ability in mediating child cognitive abilities (MCCD) verbally, since the third month (P <0.05) for elaborative talking. In the sixth months evaluation, significant increase found in the descriptive (P <0.05) and elaborative (p <0:01) talking. The intervention group showed significant improvement of the home quality of care better than the control group (F = 10,252, p = 0.002), since the third month (P <0.05). There is a change in iodine status and thyroid function in children after 30ppm iodized salt intervention. UIE values increased significantly (p <0.01) from more than average (268 ± 193ug / L) to excess level (361.08 ± 158). Both groups showed the same pattern of change in UIE levels over time (F = 0.187, p = 0.830). Children with initial status of iodine deficient showed the highest increase in UIE odine value (F = 12.82, p = 0.000). TSH level increase significantly and fT4 level decreased significantly after 6 months of 30 ppm iodized salt intervention. Regression analysis showed that the UIE values at the beginning and end of the study, also the iodine content in household salt before the study, affect TSH status change negatively. Other results showed: the proportion of children with anemia were 44.7%, severe energy deficiency found in 42.9% children, and severe protein deficiency in 37.86% Parenting based cognitive stimulation interventions, significantly increase cognitive abilities, both in general (F = 7,945, p = 0.006) and non-verbal (F = 19:03, p = 0.006) cognitive abilities, which is visible from the third month evaluation. Verbal cognitive ability increases in the intervention group were significantly better than the control group (p <0.05) in sixth month evaluation. The increase in the intervention group were 8.4 points better in non-verbal cognitive ability, 8.1 points better in verbal cognitive ability, and 10.3 better points in general cognitive ability than the control group. Conclusion: Mothers who received parenting based cognitive stimulation intervention showed significant improvement in parenting efficacy and planning, the ability for mediating child cognitive abilities in children, also the home quality of care. Therefore the interventions could improve maternal quality of care aspects which were relevant with the enhancement of cognitive abilities in pre-school children. After intervention with 30ppm iodized salt, UIE status of children increased, but thyroid function show a different direction, showed significantly decreased of fT4 levels and increased of TSH levels. The high proportion of children with anemia,severe energy deficiency and severe protein deficiency intake, may cause sufficiency or even excessive iodine intake level had not been accompanied by improved thyroid function. Parenting based cognitive stimulation accompanied with iodine intervention could enhance preschool child cognitive development living in IDD endemic areas, indicated with the increasing points of child general and nonverbal cognitive abilities after three months intervention, and verbal cognitive abilities after sixth monthintervention.

Kata Kunci : stimulasi kognitif, pengasuhan, mediasi kemampuan kognitif, garam beriodium, endemik GAKI, anak prasekolah