Factors influencing the implementation of ‘Four Pillars of Balanced Nutrition’ in a retired health cadre program for the elderly in BTPN Salatiga

Elderly people are at risk in overnutrition or undernutrition, and thus leading to cause multiple diseases. Responding to this, ‘Four Pillars of Balanced Nutrition’ is recommended to promote health status, particularly in Integrated Service Post for Retired People (Posyandu lansia). However, there is limited evidence regarding factors influencing the implementation of ‘Four Pillars of Balanced Nutrition’. Retired Health Cadre is a BTPN bank-funded program which provides similar facilities to regular Integrated Service Post with several adjustments including time, services and the usage of peer counseling. Therefore, this cross sectional study was aimed to investigate the correlation of the frequency of participant attendance, gender, education level and income of elderly people in Retired Health Cadre Program to implement ‘Four Pillars of Balanced Nutrition’. This research was conducted in BTPN Salatiga branch offices with forty-four participants aged 60-74 years, enrolled by consecutive sampling method. Data collected include general characteristics, single 24-hour recall, level of physical activity and questionnaire of implementation clean and healthy lifestyle. The participants' weight and height were measured to calculate BMI. Statistical analysis included univariate analysis, bivariate analysis using chi-square and multivariate analysis using logistic regression. Bivariate analysis showed no correlation between the program attendance frequency with Dietary Diversity Score (DDS) (p=0.1000), physical activity (p=0.383), clean and healthy lifestyle implementation (p=0.357) and nutrition status (p=0.068). However, the multivariate analysis showed that the level of education affects food diversity more than the frequency of attendance (p=0.019) and frequency of attendance is the factor that affects nutritional status most (p=0.037) compared to others. In conclusion, there was no correlation between participant attendance frequency toward dietary diversity, physical activity, clean and healthy lifestyle implementation and nutrition status among elderly participants of Retired Health Cadre Program in BTPN Salatiga. However, dietary diversity was affected by education level while the nutrition status was affected by the frequency of attending.


Introduction
Elderly people are more prone to have both undernutrition and overweight for several reasons. These conditions related to many factors like problems in chewing and digestion, or lack of appetite which contribute to loss of weight. In contrast, sedentary lifestyle, being physically inactive, imbalance intake, or hormonal change could cause overweight (Boscatto et al., 2013). Moreover, overweight raises the risk of mortality to suffer from diabetes, hypertension, and cardiovascular diseases (Ahmed and Haboubi, 2010).
Recently the data shows that adults above 75 years old by far have the highest prevalence in developing hypertension and cardiovascular disease with 69.5% and 4.7% respectively (Kementerian Kesehatan Republik Indonesia, 2018). While type 2 diabetes mostly occurred on the elderly aged 55-64 years with 6.3% (Kementerian Kesehatan Republik Indonesia, 2018). Thus, the provider caring for the elderly must take this data into consideration due to the number of elderly are predicted to rise in the future, especially when setting the program aim. Several methods are established in order to decrease this number including to apply the principle of balanced eISSN: 2550-2166 © 2020 The Authors. Published by Rynnye Lyan Resources nutrition.
Balanced nutrition consists of four main pillars basically a series of efforts to balance between nutrients intake and uptake by monitoring body weight regularly (Kementerian Kesehatan Republik Indonesia, 2014). The four pillars involve food diversity, physical activity, implementation of clean and healthy lifestyle, and also monitoring and maintaining normal body weight (Kementerian Kesehatan Republik Indonesia, 2014). Previous research shows the higher the food diversity score, the healthier and better their cognitive function (Clausen and Holmboe-Ottesen, 2005). Other studies describe physical activity such as Tera Gymnastics improves their heart and lung fitness (Parwati et al., 2013). Moreover, the implementation of clean and healthy lifestyle has a strong correlation with preventing infectious diseases that lead to malnutrition (Kemenkes, 2011). In general, applying 'Four Pillars of Balanced Nutrition' helps the elderly to adapt during their ageing process. Delivering this information becomes mandatory for everyone. Government, as well as the private sector, has provided information to the application of 'Four Pillars of Balanced Nutrition'. For instance, government launch Communication, Information, and Education (IEC) for elderly people by encouraging local people through Integrated Service Post (posyandu) as the closest basic health care facility in the community, which services are delivered by the women at the society. It is considered as a place for basic health services that focused on prevent and promote without ignoring curative and rehabilitative (Khofifah, 2016). The main purpose of the program is to improve the health status of the elderly in order to achieve a happy and more beneficial in the family and community (Khofifah, 2016). However, the implementation of Integrated Service Post for elderly needs the role of community in long term care services. Integrated service post for the elderly is difficult to succeed without adequate government support. It is also necessary to improve services with creativity and culturally acceptable activities (Pratono and Maharani, 2018).
Few studies on the participation of the elderly in Integrated Service Post revealed that older adult who attends in the program have a strong impact in the ability to detect malnutrition earlier (Utami and Palupi, 2017), better nutrition status (Sam and Asnindari, 2014) and have a better quality of life (Karohmah, 2016). Although the information on health status, food pattern, and lifestyle are accessible for the elderly, frequency of attendance in these programs is quite low, some factors including lack of knowledge about the program, difficult access, lower level of family support, cadre services, and physical condition (Pertiwi, 2013;Alhidayati, 2014;Ginting and Etalia, 2019).
In the private sector, BTPN in collaboration with Universitas Diponegoro released a Retired Health Cadre Program for their retirement customer. This program adopts the elderly Integrated Service Post with several modifications including the time of implementation, provided service, and counseling methods to deliver message especially 'Four Pillars of Balanced Nutrition' to boost their attendance in the program. First, the access to this program is high since retired customer of BTPN bank withdraws their retirement payment at the beginning of the month for 2 until 4 days. While waiting to be called by the teller or after taking their money, they could get benefits of this program (Wijayanti et al., 2019). Secondly, it provides services such as height and weight measurement, nutritional status, blood pressure and additional services for measuring body composition. Body composition especially body fat and visceral fat are important indicators in the early detection of cardiovascular disease and diabetes mellitus type 2 (Chang et al., 2018). Thirdly, participants also receive nutrition and health counseling from cadres using peer counseling methods. The counseling process helps the elderly to acknowledge and to deal with their individual nutrition and health problems (Waryana, 2016). Furthermore, during counseling, participants sharing experiences occurs in order to help the elderly in making decisions related to self-management, especially a healthy lifestyle (Officer and Beard, 2015).
This program attracts elderly to participate, to check and to monitor their health status repeatedly, therefore the message delivers continuously. Previous research presented that elderly who were actively attended on Integrated Service Post more than six times have a better quality of life than older people who are not active (Latifah, 2013). The result of other studies also showed that active leisure activities, such as club/organization or volunteering, homemaking/maintenance and traveling, were significant predictors of life satisfaction for older adults (Dongwook et al., 2017). The evidence about the effectiveness of Integrated Service Post for elderly people, particularly in implementing balanced nutrition is still limited. Provision of information on an ongoing basis will increase knowledge that will be the basis for forming behavior in accordance with the knowledge possessed (Notoadmodjo, 2014). Hence, this study aimed to analyze the association between which factors that affect the implementation of 'Four Pillars of Balanced Nutrition' most at Retired Health Cadre Program for the elderly in BTPN bank Salatiga.

Research design
A cross sectional study design with forty-four elderly people bank customers aged 60 to 74 years old was selected using consecutive sampling in BTPN Salatiga. Location selection was based on a large number of elderly people around 21.396 (11.6%), high prevalence of non-communicable disease like hypertension (74%) and DMT2 (8.8%) (Dinkes, 2015), and also high client participation. Subjects were qualified if participated in the program at least twice from June until November 2018 and able to communicate with others.

Data collected 2.2.1 General characteristics
General characteristics including name, date of birth, address, occupation, income, level education, residence status and housing status and history of disease.

Frequency of attendance
Attending frequency data was collected using attendance book which categorized based on the median, <4x and ≥4x of attendance.

Dietary diversity
A single 24-hour recall was performed to measure Dietary Diversity Score (DDS) with 9 food group according to the guidelines by FAO (2013). DDS was categorized into minimal dietary diversity (<4 food group) and adequate dietary diversity (≥4x food group) (Krawinkel, 2017).

Clean and healthy lifestyle
Implementation of Clean and Healthy Lifestyle (Perilaku Hidup Bersih Sehat/PHBS) was recorded based on the Indonesia Ministry of Health Guideline (Kemenkes, 2011). This research used 5 points individual PHBS which categorized into two categories: do not implement if it less than 5 points and implemented if it meets 5 points required.

Statistical analysis
Statistical analysis includes univariate analysis, bivariate analysis using chi-square and multivariate analysis using logistic regression. This research was approved by the Health Research Ethics Committee Faculty of Medicine of Universitas Diponegoro Number 142/EC/KEPK/FKUNDIP/V/2019, and signed informed consent was obtained from all participants.

Results and discussion
In this research, elderly men and women have the same amount to participate in the Retired Health Cadre Program in BTPN Salatiga as seen in Table 1. This result was not in line with previous research that showed more elderly women took part in the Elderly Integrated Service Post (Posyandu Lansia) than elderly men (Latifah, 2013). A factor that might affect the interest in attendance in this research is the level of education. Most of the participants in this program were elderly with high education. The level of education will affect attitude development toward new value (Notoadmodjo, 2014). Previous research shows a positive correlation between the level of education toward the interest in attending of Integrated Service Post (Sari, 2009). This means that the level of education will be followed by a high level of interest in attending of Integrated Service Post (Sari, 2009). High interest can be seen from the attendance frequency in a certain period of time.
Based on attendance book, 52.3% subject had attended the program more than equal four times, a larger number compared with subjects who had attended the program less than four times (47.7% subject) as depicted in Table 2 was appropriate with previous research that showed the elderly were more motivated to attend the integrated service post if they were sick or had a health problem (Lestari et al., 2018). On the other hand, a long time client's reasoned to attend this program to know their health condition and make a conversation with Cadre. Other research showed that good services and Cadre attitude will lead participants attendance continuously (Alhidayati, 2014).
Elderly who attend continuously will get regular and ongoing counseling. During counseling, subjects were given information about 'Four Pillar of Balanced Nutrition' in general and health problem solution in specific. The provision of sustainable health information will increase knowledge about it (Notoadmodjo, 2014). Furthermore, with the knowledge they build, it will lead to the awareness that ultimately makes a person behave according to the knowledge he had (Notoadmodjo, 2014). Previous research showed that counseling intervention was effective in improving elderly knowledge and changing their attitudes to be more positive, which led to improve their dietary practice (Mohamed et al., 2013). Table 3 showed that there is no correlation between attendance frequency towards the dietary diversity score in the elderly participants of Retired Health Cadre Program in BTPN bank Salatiga with p=0.1000 (p>0.05). Apparently, the frequency of attendance is not a direct factor that affects the subject's dietary diversity. Based on the result of multivariate analysis, the level of education had more effect on the subject's food diversity than the frequency of attendance (p=0.019). Some subjects claimed not to tell their wife or family about health information during counseling process. As a result, there was a barrier to the process of delivering information into behavior. In addition, the elderly usually have oral problem (Otsuka et al., 2016) and subjects tend to choose foods based on appetite without considering adequate nutrition (Whitelock and Ensaff, 2018).

The statistical analysis in
In general, subjects with minimal and adequate dietary diversity have the same amount as much as 22 people (50%). Minimal dietary diversity (less than 4 food group) associated with inadequate nutrient intake. Previous research showed a positive association between DDS and probability of nutrition adequacy (Rathnayake et al., 2012;Tavakoli et al., 2016). In this research, most subjects do not consume food groups including organ meat, dairy product and egg because a high level of fat and cholesterol. Besides, dairy products had a strong correlation with the probability of adequacy of vitamin B2, vitamin B12, calcium, magnesium, protein and energy intakes (Tavakoli et al., 2016). Calcium plays essential roles in various metabolic and physiological pathways (Tavakoli et al., 2016). In contrast, starch/ grains were consumed by all subjects, while dark green leafy vegetables; fruits and vegetable source vitamin A; meat, poultry, fish; legumes and seeds; also other fruits and vegetables were consumed by most participants. DDS of the grains group was correlated with the probability of adequacy in vitamin B2, vitamin B3, protein and energy intake (Tavakoli et al., 2016). Dietary pattern with relatively high amounts of vegetables, whole grains fruits, poultry, fish and low-fat dairy products may be associated with superior nutrition status, quality of life and survival in older adults (Anderson et al., 2013 (Tavakoli et al., 2016). Other research shows that higher DDS associated with lower prevalence abdominal and regular obesity (Abris et al., 2018).
Statistical analysis showed that there is no correlation between attendance frequency toward the physical activity of elderly participants of Retired Health Cadre Program in BTPN Salatiga with a p-value of 0.383 (p> 0.05) as shown in Table 4. This is because most of the subject have adequate physical activity even before participating in this program. Moderate physical activity like daily household chores, while vigorous physical activity including farming, raising livestock, gardening, and carpentering which is conducted 3-5 days a week. Subject's physical activity in this research was appropriate with the physical activity recommended for the elderly people by WHO (WHO, 2010b.) Adequate physical activities for the elderly should be associated to reduce cardiovascular disease, hypertension, diabetes mellitus type 2, osteoporosis, obesity and cancer (Chodzko-Zajkoet al., 2009). In addition, most of the subjects had exercises like walking, aerobic, and static cycling with duration 15-30 minutes/3-5x/week for walking, and 60 minutes/2x/week for aerobic. Exercising can increase body fitness, muscle strength, flexibility and balanced (Chodzko-Zajkoet al., 2009). Besides, physical activity in the elderly is good for maintaining cognitive function and prevent depression (WHO, 2010b). Table 5 displays that there is no correlation between the attendance frequency toward the implementation of Clean and Healthy Lifestyle in elderly participants of Retired Health Cadre in BTPN Salatiga with a p-value of 0.357 (p>0.05). Based on cross-tabulation, elderly with the frequency of attendance more than four times tend to implement PHBS. This study uses 5 individual PHBS points including washing hands with soap, using a latrine, consuming fruits and vegetables, doing physical activities and not smoking (Kemenkes, 2011). It categorized to implement PHBS if all points qualified. In general, 52.3% subjects did not implement PHBS. The PHBS point which is not implemented the most is washing hands with soap. Based on interviews, subjects carried out the practice of washing hands but did not use soap. This result appropriate with Riskesdas (2018) that states prevalence washing hand in the right way among the population aged ≥10 years old as much 49.8% (Kementerian Kesehatan Republik Indonesia, 2018). Another point that is also often not implemented is the consumption of fruits and vegetables and smoking behavior. Poor consumption of fruits and vegetable prevalence in the elderly population as much 97.2% (Hermina and Prihatini, 2016) and 28.8% population was smoking (Kementerian Kesehatan, 2018). Most subjects said that consumption of fruits and vegetables depends on availability and appetite, while for smoking the subjects admitted that it was still difficult to stop because it was a habit since they were young.
No correlation was found between the attendance frequency toward body mass index in elderly participants of Retired Health Cadre program in BTPN Salatiga as seen in Table 6 with a p-value of 0.068 (p>0.05). However, based on the multivariate analysis result, attendance frequency is the factor that most affects nutritional status (p=0.037) compared to other factors such as gender, education level and income. In this FULL PAPER In general, the result of bivariate analysis showed that there is no correlation between attendance frequency toward the implementation of the 'Four Pillars of Balanced Nutrition' in elderly participants of Retired Health Cadre Program in BTPN Salatiga. This is because the knowledge of the subjects is limited to information that does not encourage them to implement 'Four Pillars of Balanced Nutrition'. However, based on multivariate analysis as seen in Table 7, attendance frequency is the most influencing factor toward nutritional status compared to other factors with a risk of 0.232. In addition, multivariate analysis in Table 8 also showed that level of education is the most influencing factor toward dietary diversity with a risk of 0.218. This result was in line with previous research which stated that participants with a lower level of education were higher expected risk of having a low DDS (Taruvinga et al., 2013).
Based on SOR (Stimulus, Organism, Responses) theory, behavior can change if the stimulus exceeds the original stimulus (Notoadmodjo, 2014). In this study, stimulus is in the form of providing health information through peer counseling. If the stimulus is received by the organism means there is attention, understanding and acceptance from individual. After that, the organism processed the stimulus provided. Finally, with the encouragement of the surrounding, the stimulus has an action effect. The results or changes in behavior in this way require a long time and other supporting factors like family support as a reinforcing factor (Notoadmodjo, 2014). In addition, a barrier in information transfers to the subject's family and short-term memory may be a factor that can impact the implementation of 'Four Pillar of Balanced Nutrition'.

Conclusion
There was no correlation between attendance frequency toward Four Pillar of Balanced Nutrition (dietary diversity, physical activity, clean and healthy lifestyle implementation and nutrition status). However, there was a tendency that older people with more frequency of attendance have better physical activity, better clean and healthy lifestyle implementation and normal body weight. In addition, multivariate analysis result shows that dietary diversity affected by education level while nutrition status affected by frequency of attendance. For further research is recommended to use a cohort study design with larger sample size.

Conflict of Interest
There is no conflict of interest in this study.