Factors Associated with Utilization Triple Elimination Examination by Pregnant Women In Indonesia: Scoping Review

Introduction: The prevalence of HIV, Syphilis and Hepatitis B infections among pregnant women in Indonesia has reached 0.3%, 1.7% and 2.5%, respectively. The risk of transmission from mother to child respectively 20%-45%, 69-80% and more than 90%. Transmission of these three diseases from pregnant women to babies during pregnancy, childbirth and breastfeeding cause disabilities in children and even death. The government stipulates that all pregnant women are required to HIV/AIDS, Syphilis and Hepatitis B screening (Triple elimination examination) at integrated antenatal services. The target set is that early detection of HIV, syphilis and hepatitis B in pregnant women must reach 100% through examinations at First Level Health Facilities and Referral Health Facilities by 2022. However, in 2021 the achievements were only 50.8%, 16.4% and 60.3% for HIV, syphilis and hepatitis B. Objective: This study aims to determine the factors associated with the utilization of triple elimination examinations by pregnant women. Method: This study uses a scoping review method. Article collected from online databases including scopus, science direct, proquest, EBSCO, PupMed and Google Scholar with keywords "Related" AND "Pregnant Women" OR "Pregnancy" AND "Triple Elimination Examination". Article selection conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Result: The results showed 8 articles that met the inclusion criteria. The research showed factors that associated with the utilization of the triple elimination examination are sources of information, the role of health workers, use of classes for pregnant women, family support, and age of pregnant women. Conclusion: This study concluded that the utilization of triple elimination examinations by pregnant women associated with external factors around pregnant women.


METHOD
This research uses a scoping review method.Scoping review is a method used to identify literature comprehensively through various sources with various research methods and is related to the research topic.The steps of this research conducted through (1) identifying research questions, (2) determining keywords, (3) determining inclusion and exclusion criteria, (4) articles collection and studies selection, (5) article and data mapping.

Stage 1: Identifying Research Questions
At this stage, the researcher identifies research questions based on the PICO framework (population, intervention/exposure, comparison and outcome).The population) is Pregnant women, the exposure is associated factor, the comparison is no comparison and the outcome is triple elimination examination utilization.Based on determined population, exposure, comparison and outcome above the question in this research is "what factors are associated with the utilization of Triple Elimination examination in pregnant women?"

Stage 2: Determining keywords
Keywords are determined based on PICO, so the keywords used are "Related" AND "Pregnant Women" OR "Pregnancy" AND "Triple Elimination Examination".

Stage 3: Determining inclusion and exclusion criteria
The inclusion and exclusion criteria determined in the table 1.

Table 1. Inclusion and Exclusion Criteria Inclusion criteria
Exclusion criteria 1. Articles published in English and Indonesia 2. Articles published in 2019-2023 (last 5 years).

Picture 1. PRISMA Flowchart
The results of article collection based on keywords in online databases including scopus, science direct, proquest, EBSCO, PupMed and Google Scholar were 491 articles.After duplicates were removed, 253 articles obtained.After that, researchers filtered articles based on title and obtained 137 articles with relevant titles.Then, the researchers identified articles based on the predetermined inclusion criteria and obtained 103 articles, but 95 articles did not match the research objectives, and leaving 8 articles remaining.These 8 articles fulfilled the requirements for extraction and article quality assessment which will then be included in the charting data.The Critical Appraisal Tool used in this scoping review is Appraisal tool for Cross-Sectional Studies (AXIS).This tool evaluates the quality of the included studies via 20 items with a two-point Likert, including yes (score of 1) and no (score of 0).This tool assesses report quality (7 items), study design quality (7 items), and the possible introduction of biases (6 items).Finally, AXIS rates the quality of studies at three levels: high (70 to 100%), fair (60 to 69.9%), and low (0 to 59.9%).Two researchers separately extracted information and evaluated the quality of the studies.The articles included in the study are listed in the table 2. Stage 5: Article and data mapping After the articles were selected, the information in the articles was summarized regarding factors related to the utilization of triple elimination examinations by pregnant women.

RESULTS
8 articles were identified based on PRISMA based as listed in the table 2. These 8 articles discuss factors related to the utilization of triple elimination examination by pregnant women based on primary research conducted by researchers.6 articles in Indonesian and 2 articles in English published in 2022 and 2023.All articles are research conducted in various regions in Indonesia using cross-sectional methods.The selected articles have been evaluated using the Critical Appraisal Tool for Cross-Sectional Studies (AXIS) with the results as shown in table 3. Was the study design appropriate for the stated aim(s)?
Was the sample size justified?
Was the target/reference population clearly defined?
Was the sample frame taken from an appropriate population base so that were representative of the target/reference population under investigation?
Was the selection process likely to select subject/participant that were representative of the target/reference population under investigation?
Were measures undertaken to address and categorise nonresponders?
Were the risk factor and outcome variable measured appropriate to the aims of the study?
Were the risk factor and outcome variables measured correctly using instruments that had been trialled, piloted or published previously?After the articles were selected, the information in the articles was summarized regarding factors related to the utilization of triple elimination examinations by pregnant women as table 5. Based on the mapping results in the table 5, there are several factors related to the utilization of triple elimination examinations by pregnant women, including sources of information, the role of health workers, use of classes for pregnant women, family support, and age of pregnant women.

DISCUSSION Factor 1: Sources of Information
Information about triple elimination examination given to pregnant women to undergo blood tests in the laboratory during pregnancy.The more information received, the more knowledge gain, including knowledge about the triple elimination examination (15).Exposure to health information for individuals will encourage health behavior.Information support about how HIV, Syphilis, Hepatitis B is transmitted and its prevention is an important factor that supports the use of triple elimination examinations in pregnant women (16).
Information sources are media or channel tools to obtain information and to facilitate the reception of messages for the public or recipients of the messages (17).The source of information is very important because it relates to the level of knowledge which will influence a person's awareness in making health efforts (18).Sources of information encourage someone to act and make decisions and influence someone's attitude.Research about relationship between information sources, peer support and young women's attitudes towards breast self-examination behavior shows that there is a significant relationship between information sources and health behavior.Pregnant women who get information from sources they trust will easily accept the information they receive.Print media (newspapers, magazines), electronic media (television, radio, internet), and health worker activities such as training are possible sources of information.Information from health workers is good and clear information (19).The result of research about relationship between perceptions, sources of information and behavior of pregnant women on the triple elimination examination states that after obtaining information from health workers, especially doctors or midwives, it will be easier for pregnant women to immediately carry out triple elimination examinations.Pregnant women who obtain information from health workers, especially from midwives or doctors where they carry out pregnancy checks, will be more receptive to the information given (20).

Factor 2: Role of Health Workers
Health workers are a very important factor in accelerating health development, because all efforts made to fulfill customers' desires for services are carried out by service providers, namely health worker (21).Health workers play an important role in stopping the transmission of HIV, syphilis and hepatitis B from mother to baby (22).In the triple elimination program, health workers according to their competence and authority are expected to be able to stop the transmission of HIV, Syphilis and Hepatitis B from mother to child and reduce morbidity, disability and death rates due to HIV, Syphilis and Hepatitis B in mothers and children.This is aimed at achieving 0 elimination of HIV Syphilis and Hepatitis B by 2030 (23).
The role pattern of health workers greatly influences the compliance of pregnant women in the triple elimination examination (24).A good role in providing information and counseling regarding triple elimination can increase pregnant women's motivation to comply with the examination.The role of health workers, especially in the form of information support and providing motivation to the community to carry out voluntary triple elimination examinations, is an important factor that has an impact on the use of examinations by pregnant women (16).Health workers can not only provide interventions to pregnant women directly, but also through the environment around pregnant women.
The result of research about determinants of triple elimination examination of pregnant women in sukaresmi village, megamendung district in 2021 states that the educational approach by village midwives to the husbands of pregnant women by involving village heads and community leaders through social activities such as recitations and minilok which are held every quarter, can increase the role of husbands or families in providing support to pregnant Publisher: Fakultas Kesehatan Masyarakat, Universitas Muhammadiyah Palu women such as, accompany, remind pregnant women to have their pregnancy checked, and ask for the result s of their pregnancy check.

Factor 3 Use of classes for pregnant women
Classes for pregnant women is an activity to prepare pregnant women to carry out a normal and healthy pregnancy, to face a comfortable and safe birth (25).Pregnant women's classes have a role in increasing the standard of minimum ANC visits for pregnant women, especially in triple elimination examinations.Participating in classes for pregnant women can increase pregnant women's knowledge of the importance of triple elimination examinations in pregnancy and can recognize danger signs in pregnancy.Pregnant women's classes have an influence on knowledge of early detection of danger signs for pregnant women (26).In the pregnant women's class, midwives always explain to mothers how to carry out triple elimination examinations so that they can screen for HIV/AIDS, Syphilis, Hepatitis B to the community, especially pregnant women, so that the health condition of the mother and fetus is maintained and prevents early transmission of HIV/AIDS from mother to fetus (15).

Factor 4 Family support
High motivation in pregnant women will increase the scope of triple elimination examinations (19).The motivation that pregnant women have to carry out triple elimination examinations is influenced by external parties, namely family support.Husband and family support plays a very important role because he is the closest family member and can be trusted (16).Family support is assistance that is emotionally beneficial and provides a positive influence in the form of information, instrumental assistance, emotions and assessments provided by family members consisting of husband, parents, parents-in-law and other relatives.The pattern of family support is in the form of instrumental support, where the family is a source of concrete and practical help, as well as informational support, where the family functions as a disseminator (desiminator), and finally support in the form of emotional support.Families who support pregnant women in carrying out triple elimination examinations will increase the motivation of pregnant women to comply with triple elimination examinations, compared to pregnant women who receive less support from the family regarding carrying out triple elimination examinations (24).

Factor 5: Age
Age will greatly influence the ability to grasp so that the gained knowledge will be better.The older someone get, the more experience and knowledge a person will gain, thereby increasing mental and intellectual maturity.The result of research about determinants of implementing triple elimination examinations for pregnant women in the Wanajaya Cibitung Bekasi community health center area stated that there is a relationship between age and triple elimination examinations in pregnant women where younger people tend to quickly gain access to information and this affects the level of ability and maturity in thinking and receiving better information (27).

CONCLUSIONS
There are several factors associated the utilization of triple elimination examination by pregnant women in Indonesia, namely sources of information, the role of health workers, use of classes for pregnant women, family support, and age of pregnant women.

SUGGESTION
To achieve the determined target related to 0 transmition of HIV, syphilis and hepatitis B from pregnant women to baby, government need to optimalize the support of health worker, pregnant women's family as an external factor that significantly influence the utilization of triple elimination examination.
3. Original Research 4. Qualitative and quantitative design 5. Free full-text available 6.The research subjects were pregnant women 7. Articles state the research results in the form of factors related to the Triple Elimination Examination in pregnant women 1.Not published in a journal 2. The result was not factors related to the Triple Elimination Examination in pregnant women 3. The article is a review of existing research 4. Full text not available Stage 4: Articles collection and studies selection Article searches were carried out through online databases, namely Science Direct, Scopus, Proquest and Google Scholar.Article selection was carried out based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) gideline.The result of this stage provided in picture 1.

Table 2 . Article selected Author and year Title Method Sample Size Associated factor Code
Publisher: Fakultas Kesehatan Masyarakat, Universitas Muhammadiyah Palu Examination in Puskesmas Kuala Bangka Kab.Labuhan Batu Utara

Table 3 .
Results of Critical Appraisal Cross Sectional Study

Table 4 .
Mapping associated factors