Cadres’ role in Posyandu revitalization as stunting early detection in Babakan Madang Sub-District, Bogor District

Stunting, the inability to reach one's full potential, still remains common in Indonesia. As a result of stunting’s intergenerational consequences, many strategies have been conducted by both government and non-government organizations to tackle this issue, including nutrition-specific and sensitive interventions, with Integrated Health Service Post (Posyandu) revitalization as one of the key measures to provide valid, reliable, and up-to-date data to establish the early detection and management of stunting. Unfortunately, this role is sub-optimally performed due to the limited competence of the health volunteers (cadres) that correlates with the suppressed parents’ motivation to visit a Posyandu. Moreover, their difficulties are exaggerated by the weak reporting and supervising system. This study aimed to evaluate the cadres’ knowledge and practice change after a sequence of training to revitalize the Posyandu’s role. This quasiexperimental study involved treatment and control villages located in Babakan Madang Sub-District, Bogor District, from which 41 and 37 cadres participated, respectively: between August and November 2019. The treatment group received three consecutive months of structured training, which comprised different learning methods, namely, group discussions, role plays, games, and seminars about Posyandu and stunting management, maternal and child health, and nutritional assessment. The control group was only visited for observational activities. Changes in cadres’ knowledge and practices were collected using structured quantitative questionnaires and analysed using the Wilcoxon test. Both groups shared a considerably similar practice of Posyandu management, but a significant improvement in cadres’ knowledge was found in the intervention group after the training (p < 0.001) compared with the control group. Longer duration is needed to observe any behaviour change, as indicated by their practice of Posyandu management.


Introduction
One of the biggest nutritional problems that remains unsolved in Indonesia is the high prevalence of stunting (measured by the length/height-for-age that is lower than −2 SD based on the median standard of the WHO growth chart for children) (WHO, 2018). Apart from the massive health programs that have been implemented by the government, the prevalence of stunting remains high and exceeds the WHO's recommendation (<20%); the prevalence rates of stunting were 36. 8%, 37.2%, and 30.8% in 2007, 2013, respectively (Ministry of Health Republic of Indonesia, 20072013;. Stunting is a chronic malnutrition status related to food intake, infectious disease, maternal nutrition status, breastfeeding practice, socioeconomic (education and income) status, and hygiene and sanitation that impact the children in their later life (Black et al., 2008;WHO, 2018).
Stunted children tend to have lower cognitive achievement, which corresponds to future lower income and higher fertility level; as parents, they potentially perform inappropriate parenting.
This cycle is then responsible for the intergenerational transmission of poverty (Grantham-McGregor et al., 2007). This is disadvantageous not only for the individual but also the family and the nation for the productivity loss and human resource quality (reduction of future income by 20% and gross domestic product loss by 11% (The National Team for the Acceleration of Poverty Reduction (TNP2K), 2018). It will also be exaggerated by the high cost of treatment for any health complications and long-term effects of malnutrition, e.g., infection and noncommunicable diseases (catastrophic diseases) or even deaths that will significantly increase the health care cost by the implementation of National Health Insurance (JKN) (Vorster & Kruger, 2007).
As one of the national priority sites for stunting management, Babakan Madang Sub-District, Bogor District, has a high prevalence of stunting (31.7%) compared with the national prevalence (30.8%) (Atin, 2018). Related to the stunting prevalence, most of the under-5 children in this area demonstrate inadequate energy intake (67.2%), unexclusively breastfed (61.9%), suffer from infectious diseases in the last 2 weeks (69.4%), and have mothers with low educational level (junior high school/secondary school or lower) (Yustika, 2019). Therefore, stunting management is an urgent agenda because it is highly related to the human resource quality in the future.
To tackle this issue, Indonesia, represented by the TNP2K, started both specific (health sector, focused on the first 1000 days of life) and sensitive (non-health sector; e.g., sanitation, education, and food safety) nutritional intervention in 2018 (The National Team for the Acceleration of Poverty Reduction (TNP2K), 2018). However, this measure is still considered ineffective in managing stunting, because it has a poor figure of its risk factors in the same period, such as worsened immunization profile (reduction of complete immunization proportion in 12-23-month-old babies from 59.2% to 57.9% and rise in reluctance from 8.7% to 9.2%), escalation of low birth weight babies (<2500 g) from 5.7% to 6.2%, and increase in anemia proportion among pregnant women from 37.1% to 48.9% (Ministry of Health Republic of Indonesia, 2018).
Ideally, Posyandu is the frontline for public health services with volunteer-staffed village health workers, or kaders (or cadres), as the main actors, health information providers, and examples of changes in healthy living behavior (Ministry of Health Republic of Indonesia, 2011).
Posyandu holds a strategic position to assess the magnitude of stunting problems in the community, including early detection of the most important determinants of stunting, such as nutritional intake of mothers and children, parenting, hygiene and sanitation, and many more (Rokx, Subandoro, & Gallagher, 2018).
Unfortunately, based on the report of the Undergraduate Student of Nutrition Science Department Internship in 2018, the Posyandu's performance is sub-optimal, indicated by the lack of cadres serving each Posyandu (<5 people), no permanent building to facilitate the activities, and irregular opening hours of Posyandu. Moreover, the Posyandu's meager performance is due to the impact of the low participation (less than 65%) of mothers to visit Trainings conducted by Zainafree and Mardiana on Posyandu management, anthropometry, nutrition counseling in Tambakrejo Village, Blitar, suggested an increasing motivation and performance of cadres in Posyandu recording and reporting. Cadres' skills in anthropometric measurements also improved after training (Zainafree & Mardiana, 2015). This is critical because cadres who are already experts in anthropometric measurements can assess the nutritional status of infants and toddlers to detect the risk of malnutrition in them. In addition, cadres can provide counseling to pregnant and lactating women regarding the prevention of stunting in the first 1000 days of a child's life, which has been missing or has not been a concern in the community.
Considering this situation, we (authors and local stakeholders) agreed that the main problem of Babakan Madang Village was the lack of cadre skills in the comprehensive implementation of the five Posyandu posts. This problem resulted in the lack of visits and knowledge of mothers of under-five about the importance of exclusive breastfeeding and appropriate complementary feeding (MP-ASI), as well as the prevention of diarrhea and infections. Thus, this program is expected to revive the Posyandu's function as the main driver of health services for the community (Community Health Efforts / UKM) so that the community can become even closer to the Posyandu. In the end, if the Posyandu becomes an important part of the community, stunting can be more easily and quickly detected, so it will be handled earlier as well.
This study employed the structured Training of Trainers (ToT) concept, which consisted of seminars, small group discussions, and simulation or role play using prepared education media to optimize information acceptability and retention among the total population of cadres in Sumur Batu Village, Babakan Madang District. This work has not been conducted before in these areas or even in the national level. We understand that most of the trainings to the Posyandu cadres are provided to only few of them or to their representatives in the village, so knowledge transfer is urgently needed. Unfortunately, in most cases, knowledge transfers never occurred, or information may be missing. Batu has the highest prevalence of stunting (20.6%), limited number of nutrition intervention programs by any institution, and poor implementation of Posyandu (Putri, 2019). All the activities were conducted from August to November 2019. The list of variables observed in this study is shown in Table 1. Posyandu revitalization was carried out by optimizing the implementation of five Posyandu tables, including 1) registration, 2) anthropometric measurement, 3) Kartu Menuju Sehat recording, and 4) nutritional counseling through various trainings to empower the cadres, considering that Post 5 (health care services, such as immunization and supplementation) is conducted by health care professionals. The training material provided is related to the implementation of the five Posyandu tables (including anthropometric measurements), as well as nutritional education related to critical life cycle (e.g., maternal and child health), so that cadres can provide this information to pregnant, lactating, and infant-toddler mothers after they receive their training. To maximize the acceptability and retention of information cadres receive, the team employed different methods of trainings, including seminars, small group discussions, and simulations or role plays using educational media prepared in advance (Luca & Heal, 2006). The results of the small group discussions were then presented by one of the members to all cadres and clarified by the midwife and expert team.

This work is a quasi-experimental study (approved by The
The ToT method was employed to enhance basic nutritional knowledge to enable the cadres to provide counseling on nutrition to pregnant women, breastfeeding mothers, and infanttoddler mothers without any need to rely on visits from midwives or nutritionists from the Puskesmas, as well as to improve data integration and recording (Positive Deviance Resource Centre (PDRC), 2015). The trainings were conducted once every month for three consecutive months, starting from August to October 2019.
Based on field experience, we identified several constraints and lessons learned from the methods employed. There were two main constraints, namely, challenges of having the same participants in the subsequent training sessions and having all the important stakeholders be fully involved in the training, especially the village midwife due to her packed schedule and a huge age range of cadres that will influence their ability to accept and retain the health information given. However, we also observed several notable findings from this study, including 1) the enthusiasm of cadres toward various methods of learning, including simulations/role plays and games that keep them focused on the materials delivered (type, content, and systematic structure), 2) delivering health information using their own local language and relevant examples to their context and situation was believed to improve their acceptance on the information, and 3) individual approach to cadres will increase their motivation to continue coming to subsequent sessions because this work was a pre-and posttest study that required persistent attendance.
Univariate analysis was performed to describe the frequency distribution of the cadres' characteristics. Bivariate analysis was employed to determine whether the Wilcoxon test was used to determine any significant changes (p < 0.05) in cadres' knowledge and practices in the intervention group compared with the control group as the data were not normally distributed.

Results and Discussion
This study involved 78 cadres, which consisted of 41 and 37 cadres in the intervention and control areas, respectively. The characteristics of the cadres are shown in Table 2 and 3.   Table 3 illustrates that both groups mostly shared similar occupations, educational levels, marital status, and motivation to be a cadre. Moreover, they were mainly household mothers with low educational background, married, and working voluntary to help the community.
More appreciation was obtained among cadres in the control group, which might be related to the longer time they spent as cadres compared with those in the intervention group.
In the baseline level (pre-test), no difference was found between the control and intervention groups in both knowledge and practical skills among cadres, indicating that they were eligible for further comparison (Table 4). However, by the end of the study, compared with the control group, there was a significant enhancement (p <0.001) of knowledge among cadres in the intervention group, despite having a slight improvement in practices; a high score represents low Posyandu management quality. In terms of practices, both the intervention and control groups did not show any improvement. Indeed, the control group showed a few slopes of both knowledge and practice, although the differences were not significant (Table 4). No significant result was found in their practices in managing Posyandu, so the analysis then focused on the significant changes in knowledge based on each question answered by the intervention group. The questions were on the following topics: the importance of referring the under-five children who did not gain weight for two consecutive months to the Puskesmas, suggested period of complete immunization, frequency of complementary feeding for 9-12 months that was supposed to be 3-4 big meals and 1-2 snacks, skin-to-skin contact as the requirement of initial breastfeeding, benefits of exclusive breastfeeding to naturally postpone another pregnancy, treating fever with warm instead of cold wipes, as well as hygiene and sanitation as the determinants of stunting (p < 0.05; Table 5). The results revealed that most of the cadres had limited knowledge about health and nutrition, including initial breastfeeding, exclusive breastfeeding, complementary feeding, child care, immunization, and stunting, despite dedicating themselves as cadres for a long time period (approximately 5-10 years) (Mudjianto et al., 2003). This finding was unfortunate, because inappropriate knowledge of cadres regarding these issue potentially affects both mothers' knowledge and practices on breastfeeding and child feeding (Abebe, Haki, & Baye, 2016). In addition, inadequate awareness of immunization is considered a direct cause of stunting or malnutrition (Müller & Krawinkel, 2005) and a direct, immediate cause, not an underlying indirect cause, of death (Habicht, 2008). Most of them were assumed to run the Posyandu as a routine activity without focusing on the health content and the important mission of the Posyandu as the front line of health care, especially early detection of stunting. Undernutrition and infection are sub-optimally discovered even from the grass root (Hoko, Kurniawati, & Maryanti, 2019). This issue is exaggerated by the limited support from the local government in terms of capacity to build programs for the cadres, as well as appropriate remuneration to encourage cadres' performance, despite the high demand subjected to them (Iswarawanti, 2010).
However, this study showed significant improvements in knowledge among cadres in the intervention group. This finding was believed to be the result of the trainings they received with several modified methods designed to increase their knowledge and confidence in delivering health information, specifically about maternal health and stunting, with longer retention (Kosasih, Purba, & Sriati, 2018;Luca & Heal, 2006;Megawati & Wiramihardja, 2019;Tumbelaka et al., 2018). Similar studies conducted in four villages in Ciranjang Sub-District showed that participatory trainings, including role play and interactive discussion, boosted cadres' knowledge, skills, and confidence in health promotion; therefore, community participation (D/S) can be improved as an aftereffect, and it can even increase cadres' motivation in performing well (Tumbelaka et al., 2018).
Unfortunately, trainings that were given for 3 months within the duration of this study were unable to capture further significant changes of their practices in managing the Posyandu. Thus, a longer time is needed to stimulate and educate stakeholders to eventually improve their practice and behavior. Someone needs around 12 months to start the stages of change model from "pre-contemplation" (no intention to take actions that can potentially change by increasing awareness of the need to change and internalizing related information) to "action" stage (Parmar & Taylor, 2010). However, Table 4 shows a slight shift in practice in the intervention group toward a better score (2 points of improvements), while the control group showed a decline (1 point). This is expected to be observed further along with the longer duration of the study. A previous study showed that post-training observation on cadres' practices needs to be conducted for at least three consecutive months to be able to show any qualitative changes in a larger population (46 Posyandu's) (Tumbelaka et al., 2018).
Nonetheless, attitude, motivation, and counseling performance might not be significantly different between the intervention and control groups during the timeframe of the study, due to their reliance to social learning and established knowledge, which was regrettably found to be subprime in this study population (Rahmawati, Madanijah, Anwar, & Kolopaking, 2019).
Interestingly, the control group showed a similar score of practice in managing the Posyandu compared with the intervention group, despite having no health promotion of training in this study. This result was presumably related to the high educational background and appreciation received, namely, periodic incentives, uniforms, and free medication, which were considered to build their commitment and be a strong motivation for them to perform well (Bidayati, 2017).
Nevertheless, apart from the limited time, this study showed that a simple health promotion, in the form of sequence trainings that employ modified methods, including interactive seminars and small group discussions, can potentially increase cadres' knowledge; this change is expected to influence their behavior and performance as the front line of health care in Indonesia (The Health Foundation, 2012). This study also emphasized the importance of more comprehensive health information related to the first 1000 days of life, stunting detection, and child care compared with previous studies (Megawati & Wiramihardja, 2019;Tumbelaka et al., 2018). However, further observations on whether or not this intervention can effectively change cadres' practices is critical as behavior change is the heart of health promotion without neglecting the social and cultural context and allows the decision makers to better understand the best strategy in revitalizing Posyandu and manage stunting even better (Van Den Broucke, 2014).

Conclusion
In summary, this study suggested that the increase in cadres' knowledge about maternal health, childcare, and stunting is related to the trainings delivered, yet further observations need to be conducted to ensure that this intervention is effective tool in changing their behaviour and managing Posyandu even better. This is considered critical in the early detection of any health care problems in the household level, including stunting in the community. This study can support the government to better understand the real problem and tackle it effectively and efficiently. This study can also be a reference for the general community to develop structured, attractive, and effective trainings that aim to improve certain important stakeholders' knowledge, apart from usual focus group discussions. Further studies should capture the changes in cadres' practices and behaviour with longer observation and intervention duration.