RESILIENCE WITH THE LEVEL OF ANXIETY OF PREGNANT WOMEN DURING THE COVID-19 PANDEMIC IN TOURISM DESTINATION AREA IN BULELENG DISTRICT

During the Covid-19 pandemic, many Tourism Destination Areas (DTW) were affected, one of which was a decrease in visits and a decline in the community's economy, causing many psychological problems, especially for groups of pregnant women. The handling of this problem has not been carried out by related parties. The aim is to determine the relationship between resilience and the anxiety level of pregnant women in the tourist destinations of Pemuteran Village and Pejarakan Village. The cross-sectional approach used a sample of 72 pregnant women. Sampling technique with non-probability sampling with purposive sampling. Data collection used a standardized questionnaire measuring anxiety levels Hamilton Anxiety Rating Scale (HARS), and resilience measurement using The Connor-Davidson Resilience questionnaire (CD-RISC). Univariate analysis to determine the characteristics data and demographic data, and bivariate analysis Spearman's Rank test. The results showed that most of the respondents showed an anxiety level in the mild category, 55 people (76.4%). The level of resilience of majority of respondents has a high level of resilience, namely 52 people (72.2%). There is a significant relationship between high resilience associated with decreased anxiety with a p-value of 0.001 <0.05 with a value of r = -606. The higher the resilience, the lower the anxiety level of pregnant women.


INTRODUCTION
So far, research during the Covid 19 Pandemic related to pregnancy has been carried out a lot, only focusing on the physical effects on infected pregnant women, prevention, and management of a transmission. It is very important not to ignore the impact on the psychological condition of pregnant women during the Covid 19 Pandemic, because psychological health can be associated with long-term risks for the mother and her fetus (Arisanti, 2021).
During the Covid-19 pandemic, many tourist destination areas (DTW) were affected, one of which was a decrease in visits and a decline in the community's economy, causing many psychological problems, especially for vulnerable groups, namely pregnant women. Several preliminary studies have reported that women experiencing pregnancy during a pandemic describe low mood  and increased anxiety . In particular, we found substantially increased symptoms of depression and anxiety in a sample of nearly 2,000 pregnant women in Canada, of whom 37% reported clinically relevant depressive symptoms and 57% reported clinically relevant symptoms of anxiety (Lubián López et al., 2021).
Another Canadian survey study of 520 pregnant women reported similar rates; 40.7% of women reported depression above the clinical threshold, and 72% of women reported moderate to high anxiety. Another Turkish study conducted in June and July 2020 found that 64.5% and 56.3% of women reported clinically significant symptoms of anxiety and depression, respectively (Kahyaoglu Sut & Kucukkaya, 2021).
A study explains that the prenatal period is a time of vulnerability for the fetus where the psychological stress of the mother can have a deleterious effect on the developing fetus. Continuing prenatal psychological distress increases the risk of prenatal and postpartum depression, prenatal infection and disease, miscarriage, premature birth, and decreased birth weight. Furthermore, children who were prenatally exposed to maternal psychological distress were more likely to have physical, behavioral, cognitive, and emotional problems than their unexposed peers, and they were at higher risk for physical and mental health problems in later stages (Giesbrecht et al., 2021).
Resilience is an adaptation to life experiences that are felt in the long term and are felt to be hard to go through in terms of mental, emotional, and behavioral aspects. An optimistic attitude during the Covid-19 Pandemic is one of the characteristics of an individual who has high resilience, in particular, this can be seen in the ability to see positive things from the impact of the pandemic. The intellectual level is quite good and able to solve problems is another characteristic of resilience. Individuals who have relatively good resilience will focus on positive things and try to find a way out of the negative impacts of the pandemic so they can avoid stress (Chodijah, 2022). By reducing stress levels, the tendency to feel anxious about a pandemic situation can be increasingly avoided.
Recent studies have focused on social psychological factors such as social support, a history of abuse or domestic violence, adverse life events, and high perceived stress. Several studies have shown that high stress is significantly associated with anxiety and depression in pregnant women. However, there are only a few studies that focus on the impact of resilience on the mental health of pregnant women. Research that assesses resilience, especially in pregnant women, and its impact on SJKP 2022DOI: http://dx.doi.org/10.34310/jskp.v9i2.686 pISSN 2301eISSN 2502-5236 http://stikesyahoedsmg.ac.id/ojs/index.php/sjkp Received October 24, 2022Revised November 14, 2022;Accepted December 2022 139 prenatal anxiety and depression, is lacking (Ma et al., 2019).
Pemuteran Village and Pejarakan Village are one of the DTWs affected by the Covid-19 Pandemic. Pemuteran Village is one of the villages in Gerokgak District. In terms of territoriality, this village has the potential for areas that are mountains/seas and mountains/hills. Such regional conditions constitute a potential arena for the development of various productive businesses in the fields of agriculture, animal husbandry, and services. In its development, even since the 1980s in this village began to develop tourism activities. In early 2000 Pemuteran Village began to develop into a Tourist Destination Area in the West Bali area. Since the world and Bali, in particular, have been hit by the Covid-19 Pandemic the level of tourist visits to tourist areas in Pejarakan Village and Pemuteran Village has declined again, causing a decline in the community's economy. This decline had a huge impact not only on the economy but also on the psychology of the people who had so far depended on the tourism sector for their lives (Mudana, 2015).
The results of the preliminary study found that 10 pregnant women who attended posyandu in Pemuteran Village and Pejarakan Village showed symptoms from measurements using a questionnaire in conditions of low resilience and had mild to moderate levels of anxiety. On average, the results of short interviews with pregnant women said they were worried about current developments, namely uncertainty over the spread of the virus during the Covid 19 Pandemic and the development of the tourism sector as a source of support for the family economy. Almost all husbands of pregnant women who were surveyed during the preliminary study said they had lost their main job. The purpose of this study was to determine the characteristics of pregnant women in tourist destinations, resilience, and anxiety, and to analyze the relationship between resilience and anxiety levels of pregnant women during a pandemic in tourist destinations in Pemuteran Village and Pejarakan Village.

METHOD
The research method used in this research is quantitative with a cross-sectional. The location of this research is the tourist destination area in Buleleng which is taken from the working area of the Gerokgak II Health Center, namely Pejarakan Village and Pemuteran Village. The population of this study was pregnant women in Pejarakan Village and Pemuteran Village with a total of 188 respondents. After calculating the sample size formula, it was found that 72 pregnant women who were respondents in this study were pregnant women with inclusion criteria, pregnant women who were active and participated in posyandu activities. Pregnant women who were willing to be respondents, pregnant women who had never participated in similar research before, and mothers pregnant TM 1-3 who can communicate well and are not currently undergoing psychiatric therapy.
This research has passed the ethical test number 145/EC-KEPK-SB/VII/2022. Data collection used a standard anxiety level questionnaire, namely the Hamilton Anxiety Rating Scale (HARS). This questionnaire contains 14 statement items and the level of resilience is measured by a standardized resilience level questionnaire, namely The Connor-Davidson Resilience (CD-RISC). This questionnaire contains 25 statement items.
Respondents who fit the inclusion criteria (purposive) will be taken as many as 36 pregnant women who take part in the KIA Posyandu in Pejarakan and Pemuteran villages. Pregnant women who are participating in Posyandu will be given an explanation regarding the research to be carried out. Furthermore, after filling out the informed consent, pregnant women were included as respondents and given a questionnaire measuring the level of resilience and anxiety values. Furthermore, after the data is collected, an analysis of the rank spearmen to assess the direction of the relationship and the strength of the relationship of resilience to the anxiety of pregnant women.

RESULTS
In this study, the results of the research sample characteristics were analyzed using univariate and are shown in table 1 below: In table 1 it can be seen that most of the family income during the Covid 19 pandemic was in the less category, and most accessed information during the pandemic from social media, namely respectively 72 people (100%), 58 people (80.6), 57 people (79.2%), 55 people (76.4%), and 54 people (75%) respectively.
Judging from the characteristics of resilience and level of anxiety, it was found that the majority of respondents indicated a level of anxiety in the mild category, 55 people (76.4%). The level of resilience of the respondents showed that the majority had a high level of resilience, namely 52 people(72.2%)

Variable Anxiety
Level Resilience Level r = -606 p<0.001 n = 72 Table 3 shows that resilience has a significant relationship with the level of anxiety with a significance value of p 0.001 <0.05 with a value of r = -606 which means that Ho is rejected, that is, there is a significant relationship between resilience and anxiety levels in pregnant women. Negative results mean that there is an opposite relationship between resilience and the anxiety level of pregnant women. The higher the resilience, the lower the level of anxiety for pregnant women and vice versa. The results of the value of r = 606 can also be concluded that resilience has a relationship with the moderate category with the level of anxiety in pregnant women. Pregnant women in Pemuteran Village Posyandu and Pejarakan Village located in Gerokgak District, Buleleng Regency

Characteristics of Respondents
The Covid-19 pandemic has shown an increase in pregnancies that have occurred due to the fact that many WUS did not make contraceptive visits which ended in baby booms. The results of this study found that the characteristics of the respondents used in the resilience and anxiety research of pregnant women during a pandemic were in the age range of 20-35 years. These results are in line with research conducted at the Minas Health Center where pregnant women who were given questionnaires related to anxiety during pregnancy and during the pandemic were at reproductive age, namely at the age of 20-30 years as much as 50.5% (Alwi, Fitri, & Astari, 2021 ). This indicates that most pregnant women are at a very good reproductive age and not at a pathological age or have a high risk of pregnancy. Pregnant women who are in this age range should have a lot of information about their reproductive organs, even during a pandemic.
These results also found that the mother's marital status was currently married and had a husband because this pregnancy was the fruit of the love of husband and wife. In addition, these results also found that pregnant women who were used as respondents reported that as many as 19.4% had been exposed to Covid either from themselves who were infected or from their families who were infected with Covid-19. This is one of the risks that can increase the anxiety of pregnant women or lead to fear of pregnant women if the future child and themselves are not in good health. Even though currently data has been released regarding the incidence and prevalence of Covid-19 which has started to decline, all of this does not guarantee that you will not be worried about your pregnancy. Pregnant women really need support from their family, environment, partners and especially the government to overcome anxiety that can harm their pregnancy (Yue et al., 2021).

Proportion of Resilience
Resilience is defined as the capacity to adapt to life's adversities and is considered a subjective measure of this response which includes concepts such as inner strength, competence, and flexibility (Alves, Cecatti, & Souza, 2021). As a vulnerable population, pregnant women and their fetuses are considered to be at high risk of SJKP 2022 DOI: http://dx.doi.org/10.34310/jskp.v9i2.686 pISSN 2301-6221; eISSN 2502-5236 http://stikesyahoedsmg.ac.id/ojs/index.php/sjkp Received October 24, 2022;Revised November 14, 2022;Accepted December 2022 contracting infectious diseases during the COVID-19 Pandemic. This condition triggers the emergence of pressure which has a negative effect on psychology and requires pregnant women to be resilient in facing this difficult time. The results of this study found that the majority of pregnant women in Gerokgak District had high resilience, which was 72.2%. These results are in line with previous research that showed that the resilience of mothers during pregnancy through the covid pandemic was very high and this became one of the aids to reduce anxiety (Alves et al., 2021).
However, different results were found in Spain during the Covid-19 pandemic and found that as many as 155 women (30.2%) received a resilience score below the average, meaning a low level of resilience. Lower scores were associated with obsessive and catastrophic thoughts about the pandemic, and with sleep disturbances, so women struggling not to think about illness scored significantly lower. Especially when seen from these results that as many as 79.2% have a family history of having been laid off before, but history does not affect the resilience of pregnant women in depth to be low.
The level of resilience of each individual will be very different according to characteristics according to age, experience in dealing with stressful conditions and the supporting resources that a person has. In a study conducted by (Olajubu, AO, Omoloye, GO, Olajubu, TO, & Olowokere, 2021) found that the resilience level of pregnant adolescents in this study showed that most had low resilience. This finding corroborates previous studies among pregnant adolescents where their resilience rates were found to be low compared to pregnant adults. Resilience during the Covid-19 Pandemic in pregnant women is a defense that can be developed and improved to avoid the negative effects of anxiety on the health and mental development of the mother and fetus. A study found that several efforts that can be made to access resources to be resilient are by using virtual communication platforms, engaging in self-care behaviors (for example, adequate sleep, physical activity, and healthy eating), emotional support for partners, being outside space, gratitude, and following structure and routine (Farewell, Jewell, Walls, & Leiferman, 2020).

Proportion of Anxiety
In pregnant women anxiety can occur especially in the third trimester of pregnancy until delivery, the anxiety felt by pregnant women is for various things such as the normal or abnormal baby at birth, the response to pain that will be felt, so that the closer the delivery schedule is, especially in primigravidas, it's normal for feelings of anxiety or fear to arise due to pregnancy, let alone added to the burden of thoughts with the condition of the Covid 19 Pandemic. Several factors affect an individual's anxiety, namely age, gender, occupation, knowledge and education (Citra Dewi, Nurbaiti, Surahmat, & Putinah , 2021).
The results of this study found that pregnant women had a mild anxiety level of 74.6%. The results of other studies also found the same thing that most pregnant women also experienced mild anxiety during the Covid-19 pandemic, namely as many as 54.1% (Alwi et al., 2021). A research result conducted by (Asmariyah, Novianti, & Suriyanti., 2021) found that most pregnant women respondents spent 20-24 hours per day at home (84.7%), worried about their family members contracting . Poor health status as a result of the Covid 19 pandemic was significantly associated with psychological impacts, including higher levels of stress, anxiety and high depression (p<0.05).
This study concluded that during the initial phase of the spread of Covid-19 in China, more than half of the respondents rated the psychological impact as moderate to severe and about as likely reported moderate to severe levels of anxiety. Psychologically, anxiety in pregnant women will have an impact on the mental health of a prospective mother and also the fetus. A literature review shows the results that there is a significant relationship between prenatal fetal bonding and anxiety during pregnancy (Göbel, Stuhrmann, Harder, Schulte-Markwort, & Mudra, 2018).

The Relationship between Resilience and Anxiety.
The results of this study found that there is a relationship where if the resilience of the mother is high, then the mother's anxiety will automatically become mild and not even experience anxiety. but several summaries regarding the relationship between these two variables have been carried out in several countries. A study in Spain to determine depression, anxiety and also resilience in pregnant women undergoing lockdown as a response to the Covid-19 Pandemic found that 72.8% had been silent <40 days and 27.2% between 41 and 60 days . A total of 182 people (35.4%) in the level of depressive symptoms. This study also found high trait and anxiety scores, with 223 (43.4%) of pregnant women who were on lockdown for <40 days and 227 (44.2%) of pregnant women who were on lockdown for 41 and 60 days.
Resilience is negatively related to anxiety and depression, which means that the higher the resilience, the lower the depression and anxiety levels of pregnant women (Lubián López et al., 2021). In addition, other similar results also found that high resilience greatly affects the anxiety level of pregnant women. So it can be concluded that economic and spiritual problems are one of the factors that can increase resilience (Chodijah, 2022).
The relationship between resilience and mood disorders has been studied in pregnant women. Several studies have shown that individuals with high levels of resilience tend to have fewer depressive symptoms and are more emotionally balanced. Therefore, in pregnancy, an important period of psychosocial adaptation, a high level of resilience will be important to adapt to the changes inherent in the period of pregnancy and childbirth. A study of 531 pregnant women showed that those with high levels of anger tended to have lower levels of resilience, which may be related to the development of higher rates of postpartum depression in this group. The level of resilience in pregnant women can facilitate overcoming difficulties inherent in the period, such as fears related to body changes and adaptations, as well as fears related to childbirth and social problems (Alves et al., 2021).
The Covid-19 pandemic has been going on for a long time, starting in 2020, and until now there is still data related to the incidence of Covid-19, although it is very small compared to before. Mothers are one of the vulnerable groups in society experiencing stress during a pandemic (Chodijah, 2022). This is because there have been changes in lifestyle seen from various aspects and economic adjustments due to the pandemic that has hit.

CONCLUSION
In conclusion, judging from the characteristics of resilience and level of anxiety, it was found that the majority of respondents indicated a level of anxiety in the mild category, 55 people (76.4%). The level of resilience of the respondents showed that the majority had a high level of resilience, namely 52 people (72.2%). Furthermore, there is a statistically significant relationship that the higher the resilience of pregnant women, the lower the anxiety level. It is necessary to develop research that combines the relationship between factors other than resilience and the anxiety level of pregnant women during the pandemic in tourist destinations in Buleleng and Bali Province.