The Effect of Health Promotion Using Emo Demo Video on the Selection of Food Contains Iron for Anemia Prevention in Adolescents: Study at Islamic Senior High School in Yogyakarta

Background. Emotional Demonstration (Emo Demo) is a technique to educate the public through the latest approach from the theory of Behavior Center Design as a reference. This strategy can be an alternative to help young women in choosing food ingredients to prevent anemia. Given the adverse effects of anemia, it is necessary to overcome them. Objective. This study aims to assess the effect of health promotion through Emo Demo video media on the selection of foods containing iron for the prevention of anemia in adolescent girls. Method. The research design was a pre-post test with a control group design, and quasi-experimental design. The research design used in this research is “Control Group Design”. In this study, there were 2 groups, namely the intervention group using the Emo Demo video method and the control group using e-leaflets. Results. Emo Demo video promotion has a positive effect on knowledge (p value 0.000), attitudes (p value 0.000), and behavior (p value 0.000) in adolescent girls to prevent anemia compared to e-leaflets. Conclusion. Emo Demo video as a learning media is more effective in increasing knowledge, attitudes, and behavior in choosing foods high in iron in adolescent girls than in the group using e-leaflets. It is important to provide continuous Emo Demo videos and do the monitoring of adolescent girls to prevent anemia.


INTRODUCTION
Adolescent girls have a higher risk of anemia than young men. The first reason is that every month young women experience menstruation. The volume of blood lost during menstruation ranges from 25-30 cc per month. This amount reflects an iron loss of 12.5-15 mg per month or 0.4-0.5 mg per day for 28 days. The second reason is that young women often take care of their appearance, they want to stay slim or thin, so they end up on a diet and reduce food portions. A diet not balanced with the body's nutritional needs will cause a lack of essential nutrients, such as iron. 1 Lack of behavior in preventing anemia is protecting against risks, including the consumption of Fe tablets and how to take vitamin C in addition to supplementation along with Fe tablets.
Anemia in adolescent girls has an impact on growth and development, resistance to infectious diseases, activity, concentration, and intelligence as well as capture power. As a mother-to-be, adolescent girls need more iron so that deficiency does not occur before pregnancy. If these needs are not met, it will have an impact on the birth of the baby, including premature birth, abnormal birth, low birth weight, and even maternal mortality. 2 Therefore, the problem of anemia must be prevented and overcome since teenagers because they will become pregnant women later. 3 The prevalence of anemia in Special Region of Yogyakarta Province with a target of 1500 young women in 5 regencies and city showed that 19.3 percent of young women have anemia (Haemoglobin level below 12 g/ dl). They are at risk of chronic energy deficiency (CED) with mid upper arm circumference (MUAC) values in Indonesia under 23.5 cm as much as 46 percent. 4 Based on the Decree of the Minister of Health of the Republic of Indonesia (PERMENKES) in 2010 the roles of professional midwives include providing services for adolescents, namely providing counseling and informing about reproductive health. This activity was carried out with the aim of adding insight along with education in the health sector as well as counseling about anemia experienced by adolescents.
Extension media have various types, where in the determination, adjustments should be made to the audience criteria so that the things that will be conveyed can be obtained with full effectiveness. 5 Research and counseling in improving knowledge, attitudes, and behavior have been carried out. Emotional Demonstration (Emo Demo) is a technique to educate the public through the latest approach with reference to the theory of Behavior Center Design (BCD). The theory has the principle that behavior can only be changed into a response to something new, challenging, surprising or there is interest in it. This method uses various methods that are provocative and imaginative in order to achieve changing behavior in terms of public health. 6 In addition, e-leaflet media is used as a medium for health education because it is good for the community, especially students, who almost all of them use technology. The goal is that the media is adjusted and learned independently by the user, they can find out the contents while relaxing, the information can be shared with friends and family, provide more detailed information that cannot be given verbally or minimize the need for recording. 7 Research conducted by Anifah 8 on the Effect of Health Education through Video Media on Knowledge about Anemia in Young Women found that there was an increase in knowledge from 7 to 17 respondents after being given health education through videos. There is a statistical difference in the average level of knowledge of respondents before and after being given health education through video. In addition, another study results showed 9 that there was an increase in the average score of knowledge and attitudes of adolescents about anemia before counseling with video media and without media.
This strategy aims to provide health promotion related to anemia prevention with the Emo Demo video media to provide knowledge and change the behavior and attitudes of teenagers. This health promotion is expected to be an effective method for teenagers so it can improve the teenagers' health status.

METHODS
The research design was a pre-post test with a control group design and a quasi-experimental design. The variables in this study were Emo Demo video media and e-leaflet media as independent variables, and knowledge, attitude, behavior as dependent variable. In this study, there were two groups, namely the intervention group with the Emo Demo video method and the control group using e-leaflet. These two groups lived in different dormitories so there was very little possibility of interaction. The study began with an initial test (pre-test) regarding attitudes, behavior, and knowledge of anemia which was given to two groups, before being given treatment for one month. After the treatment, the two groups were given a final test (post-test) regarding attitudes, behavior, and knowledge of anemia.
The study was conducted at Madrasah Aliyah Ali Maksum as an intervention group and SMA Ali Maksum as a control group which was carried out from August-November 2021. The choice of research location was supported by previous research which stated that 65 percent of the female students of House's Q Pondok Pesantren Ali Maksum Al Munawir Krapyak were anemic. In the preliminary study, it was found that two female students already knew about anemia, while 8 of them did not have knowledge about anemia. 10 The population of this study was all female students at Madrasah Aliyah Ali Maksum. A total of 90 students participated in this study, divided into 45 students in the intervention group and 45 students in the control group. The sample was selected using purposive sampling. Inclusion criteria are students of class XI MA and SMA Ali Maksum who are willing to be respondents, get permission from parents or guardians, and students watch the Emo Demo video for 5-7 minutes duration until it's finished. Exclusion criteria are the respondent withdrew and they do not watch the Emo Demo video or do not read e-leaflet about choosing the right food ingredients for anemia prevention. The students who are sick or absent will automatically be disqualified from this study. This research has received ethical approval from the Ethics Commission of the Faculty of Medicine, Public Health, and Nursing Universitas of Gadjah Mada with the number: KE/FK/1001/ EC. Each respondent and their guardian were asked to sign an informed consent as an agreement to follow the research procedure. The age category of adolescents studied in this study was 15-18 years old. The age difference for the students of Madrasah Ali Maksum class XI is because at the time of admission, they accept students of various ages. Opportunities to take education at this school are more open, as long as students can follow the lessons. The average age that can be accepted by Madrasah Ali Maksum is 13-14 years old for class X.
Before the intervention, the two groups were asked to fill out a questionnaire containing knowledge, attitudes, and behavior. After that, on the same day the intervention group was asked to watch an Emo Demo video which lasted 5-6 minutes. The Emo Demo video is based on the Emo Demo module and the anemia prevention material was adopted from the material compiled by the Indonesian Ministry of Health regarding adolescent anemia. This health education method uses two-way communication in the form of simulations or games that can invite respondents to be able to participate and interact in the process.
The Emo Demo method is given in direct or face-to-face form so in this study, it was modified by using video media as a medium for delivering health promotion. Videos related to choosing food ingredients to prevent adolescent anemia as much as 1 video with a duration of about 5-6 minutes. The video was made by female student cadres who have been selected by caregivers, who are students of Madrasah Aliyah Ali Maksum Krapyak regarding adolescent anemia and e-leaflet that can be accessed via a link that will be sent to the class group. The attitude, behavior, and knowledge of adolescent anemia questionnaires have been validated with a value of r greater than r table of 0.312 for the three questionnaires. The reliability value using a computer program of knowledge questionnaires about anemia is known to have a classical estimation value with the Cronbach alpha equation of 0.74, the reliability of the attitude instrument about anemia in high criteria. 11 After the first video screening, the sample in the intervention group was given a video file for independent playback. A month from the screening of the first video, an assessment of knowledge, attitudes, and behavior was held.
For the operational definition of knowledge using an interval scale, the value obtained by students in answering questions about knowledge of anemia, diet, and risk of anemia with the measurement results of the correct answer getting a value of 1 and the wrong answer getting a value of 0. In the operational definition of attitudes and behavior using an ordinal scale, namely statements of feelings, assumptions, beliefs of students about the image of body weight, diet, risk of anemia and student actions to consume animal sources of iron, sources of vegetable protein, sources of vitamin C. The measurement results are measured using a 5-point Likert scale, namely strongly agree, agree, doubt, disagree, and strongly disagree. Unlike the intervention group, the control group was only asked to read the e-leaflet and a month later an assessment of knowledge, attitudes, and behavior was carried out.
Knowledge, attitude, and behavior data before and one month after video playback was calculated based on the score. The data were then analyzed using IBM Statistical Package for the Social Science Software (SPSS) version 25 was used for statistical analysis. Data analysis was tested using the Wilcoxon and Mann-Whitney tests because the data were not normally distributed.

RESULT
The activity begins with a pre-test for Madrasah students at Islamic Boarding Schools. Students are trained related to anemia prevention material. Then after the counseling, they do the post-test. The result is as Table 1 below:

Characteristics of Respondents
Characteristics of respondents include age and sources of information that have been obtained by respondents outside this study. The age of respondents is 15-18 years old and 93.35 percent total of respondents from intervention and control group have received information related to health. The sources of information that respondents often get are friends, print media, television, or radio.

The Effect of Emo Demo Video on Knowledge Improvement
The results of statistical analysis showed a significant difference in the intervention group, namely an increase in the knowledge score of the respondents indicated by a p-value of 0.000 (p<0.05). The results of the analysis in the control group showed a p-value of 0.003 (p<0.05) so there was a difference between the pre-test and post-test scores in the control group. The results of the statistical analysis of the comparison of the pre-test knowledge values of the two groups before treatment showed a p-value of 0.103 (p>0.05) so there was no difference between the two groups before treatment. The p-value of the two groups for the post-test p<0.001 (p<0.05), and the results of statistical tests on the comparison knowledge of the control group and the intervention group are worth -4.719 (Z score), there was a significant difference so that it could be concluded that health promotion with Emo Demo video media was effective in increasing respondents' knowledge. The results of the analysis can be seen from Table  2.

Before and After Intervention
The  The results of the statistical analysis comparison of the two groups after intervention showed a p<0.001 (p<0.05) so it can be concluded that there was a significant difference with an increase in attitude scores. The results of statistical tests on the comparison attitudes of the control group and the intervention group are worth -5.230 (Z score), this shows that the Emo Demo video can improve the attitude of the respondents to choose foods that are high in iron to prevent anemia. When compared to the difference in attitude, values in the intervention group were 8.46 while for the control group were 3.78. So it can be concluded that increasing attitudes with Emo Demo video increased the attitude value higher than the provision of e-leaflet alone. The results of the analysis can be seen from Table 3.

The Effect of Emo Demo Video on Behavior Improvement
The results of the statistical analysis can be seen in Table 4. The Wilcoxon test showed the p-value of the intervention group was 0.000 (p<0.05) while the control group was 0.000 (p<0.05). This shows that in the intervention group and the control group there is a statistically significant increase in behavior in the selection of foods that are high in iron for consumption.
The results of statistical analysis between the two groups before intervention showed a p-value of 0.106 (p>0.05), which means that there was no difference in the pre-test value in the two groups. After the intervention was carried out on the respondents and the post-test scores of the two groups showed that the p-value was 0.000 (p<0.05). The results of statistical tests on the comparison behavior of the control group and the intervention group are worth -3.739 (Z score), this shows that there is a significant difference in the post-test scores between the two groups so it can be concluded that health promotion with Emo Demo video is better than e-leaflet alone in improving respondent behavior in a better direction towards healthier behavior. In this case the selection of foods that are high in iron to prevent anemia.

Intervention Group
Control Group p-value intra group* p-value between group** n=45 n=45 Min

The Effect of Emo Demo Video on Knowledge Improvement
Health education is a planned effort to influence and provide learning experiences for individuals, families, and communities to apply healthy ways of living as expected by education or health promotion actors. 12 Knowledge is the most important factor for someone to take action or behavior. The more people know and understand about health knowledge, it is expected that behavior or actions will lead to positive things. This is what the researchers applied in research on the effect of health promotion through Emo Demo video on the selection of foods containing iron for the prevention of anemia in adolescent girls.
Most of the young women have inadequate knowledge about anemia, the causes of anemia, prevention, and how to overcome it. Low knowledge about adolescent anemia results in adolescent girls experiencing anemia. 13 A study conducted in Ethiopia said that adolescents who did not know about anemia had a 60 percent higher risk of suffering from anemia compared to adolescents who were aware of anemia. 14 In the pre-test score assessor, it is known that the average value obtained in both groups is 81. Even though the assessment has been categorized as a good value, but the score is not evenly distributed. Some of the other children still get a lower score of knowledge about adolescent anemia. The study explains that the lack of knowledge of female students about iron deficiency anemia makes them at risk of three times greater incidence of anemia. 15 The results of the value of knowledge in pre-post knowledge increased both in the intervention group and the control group after being given health promotion with modified Emo Demo video about anemia prevention. The results of this study confirm that health promotion education through Emo Demo video on the selection of foods containing iron for the prevention of anemia in adolescent girls can provide information that is much better understood by adolescents than just e-leaflet. From the results of the mean rank between the intervention group and the control group, it is known that the mean values are 58.17 and 32.83. So that the value before and after being given education increased. Research conducted by Muthia 16 stated that conducting counseling with an Emo Demo video about tuberculosis was more effective than e-leaflet. In line with the research conducted by Syakir 17 which explains that the use of Emo Demo video is very effective in educating adolescents who do not understand anemia. The use of Emo Demo video in the study was proven to be more effective than e-leaflet in increasing respondents' knowledge.
The results of the post-test knowledge that were carried out after the intervention increased. The knowledge post-test value of the intervention group was higher than the control group. Health education is an effort to influence and provide learning experiences for individuals to apply a healthy way of life as expected by health educators or health promotion. 12 High curiosity due to exposure to signs and symptoms of disease causes high curiosity about what happened to her and what the consequences for her future. It is proven in Table 2  The risk of anemia that occurs in the long term will have a bad impact on the lives of adolescents in the future. It is described in a study conducted by Ababa 21

The Effect of Emo Demo Video on Attitudes
Attitude is a reaction or response that is still closed from a person to a stimulus or individual awareness in determining steps and real behavior and behaviors that may occur, or readiness to respond that is positive or negative. 23 The mean value of attitudes in the intervention group and control group increased. It can be seen in Table   2

Improvement
There is an increase in the mean value of behavior. The mean value of the behavior of the intervention group was higher than that of the control group. Health promotion with emo demo video is effective in increasing respondent behavior compared to only e-leaflets. Research reveals that there is a weak correlation between knowledge and behavior. 26 That study revealed that there is a low positive correlation between knowledge and behavior. This is understandable because behavior change cannot be done in a short time, it takes 18-66 days to make changes in behavior. 27 The more often the behavior is repeated, the faster the behavior change will occur. However, strong knowledge will direct better behavior in preventing nutritional deficiency anemia. 13 Behavior that is lacking in preventing anemia is seen in the questionnaire, namely behavior in protecting against risk, namely the consumption of Fe tablets and how to take vitamin C in addition to supplementation with Fe tablets. Inadequate behavior is due to poor knowledge, attitude, and evaluation of supervision from related parts. The provision of nutrition education was significant in increasing knowledge but not on behavior even though 38 hours of nutrition education had been given. 28 This shows that to meet the goal of changing behavior, it is advisable to nutrition education consistently and in the long term. Planned and sustainable nutrition education at the secondary and higher education levels. In addition, the involvement of parents or guardians of students plays an important role in the knowledge, attitudes, and behavior of adolescents. Parenting patterns and access to healthy food that is provided play a big role. Rules and invitations to consume healthy food that are applied to families or schools indirectly become early education related to food in adolescents will automatically affect the eating patterns of adolescents. 29 This research contains an update on the Emo Demo video. Previously, the Emo Demo video was carried out directly to the target, but this study tried to carry out the Emo Demo video through video packaging so that it is more friendly for teenagers. In practice, researchers are faced with several technical problems such as the lack of access for students to be able to access videos independently. Students are not allowed to bring electronic devices such as cellphones, laptops, and so on so that access to videos independently uses the shared television provided in the dormitory but can only be accessed every holiday so students cannot access it optimally. In addition, the purpose of the Emo Demo video is to increase knowledge, attitudes, and behavior in choosing foods high in iron in adolescent girls to prevent anemia.
However, there needs to be regular monitoring from the dormitory to support the prevention of anemia in adolescents in Islamic boarding schools.

The conclusion of this study is that Emo
Demo video is effective as a learning media and more effective in increasing knowledge, attitudes, and behavior in choosing high iron foods in adolescent girls to prevent anemia.
The use of Emo Demo video is more effective compared to e-leaflet media.

SUGGESTION
This media can be used as a reference as material for making health promotion media or counseling. Students can be consistent in consuming a balanced nutritional intake, improve the right diet, and can disseminate this information or knowledge from Emo Demo video to prevent adolescent anemia to other peers. In addition, parents or guardians of students can use multimedia educational media related to the prevention of adolescent anemia as learning for students, providing support, and monitoring students in consuming a balanced nutritional intake. So that the anemia prevalence decreases and increase the quality of parents' human resources to produce children as successors of a great nation in national development later.