Training program to support posbindu cadre knowledge and community health centre staff in the Geriatric Nutrition Service

The geriatric minimal service standard (SPM) coverage in Depok has steadily decreased from 37.53% in 2013 to 11.8% in 2018. One factor affecting the problem is a lack of patient participation and the inability of posbindu (integrated service post for older people) cadres to perform their tasks. To increase the coverage of older people visiting posbindu, it is necessary to raise the knowledge and skill levels of posbindu cadres and community health centre staff in Depok. The skills include performing nutritional status assessment (NSA) and screening, early detection of dementia, independence assessment, and elderly nutrition counselling. This is a case-based article focusing on geriatric nutrition training for posbindu cadres and community health service staffs. We undertook training for 35 subjects (22 posbindu cadres and 13 community health centre staff). At the end of the training, the mean score of the elderly nutrition knowledge had increased to 52.5 points. The score before training significantly differed with post-training (p = 0.001). The knowledge of subjects who have the previous training was also significantly different from those who did not have the previous training (p = 0.017). The knowledge of posbindu cadres and community health centre staffs can be improved through elderly nutrition training. Technical assistance and monitoring performed three months after the training measured their ability to perform the geriatric nutrition services. They should be able to demonstrate how to educate older people in the diabetes mellitus nutrition campaign, metabolic syndrome, nutrition-balanced diet, and gout; also, how to conduct predicted height measurements using the knee-height predictor, and how to fill MNA, MMSE, BADL, and IADL instruments. We suggest the geriatric nutrition training program will increase SPM coverage at Depok City.

utilized, including the participation of the integrated service post for elderly (posbindu) cadres, the leading role in the implementation of older people health programs in the community (Ministry of Health, 2010).
The scope of older people visiting Depok to receive healthcare in posbindu and the community health centre from 2013 to 2016 decreased drastically over that time to 25.73% (Depok District Health Office, 2018). In 2017, the minimum service standard (SPM) of 100% elderly health service in Depok had not been achieved (Depok District Health Office, 2017).
In fact, only 54% were achieved within the last year. However, a community health centre at Government Regulation, 2018 states that the minimum service standard (SPM) is a provision regarding the type and quality of basic services, a compulsory governmental privilege to which every citizen is entitled. The Health SPM is included at the provincial health and district/city levels (Peraturan Pemerintah Republik Indonesia, 2018). One type of basic health service at the provincial and district/city levels is elderly health service. The purpose of those services is to improve the quality-of-service delivery, responsiveness to needs in performing services, financing for service development, and quantity and expansion of user outreach. After the SPM is implemented properly, it will have an impact on service user satisfaction and independence in service delivery. Therefore, SPM plays an important role in improving the quality of health service facilities, including posbindu.
Posbindu is a form of community-based health efforts geared to controlling risk factors for non-communicable diseases under the gUniversitas Indonesiadance of the community health centre. Posbindu was bUniversitas Indonesialt based on the joint commitment of all elements of society who care about the threat of non-communicable diseases. It specializes in early detection and monitoring of risk factors for non-communicable diseases, carried out in an integrated, routine, and periodic manner (Ministry of Health, 2019). Elderly people in Depok often suffer from hypertension (19.6%), diabetes mellitus (7%), and obesity (12%).
The possibility of their contracting these conditions can increase in the proportion of these diseases if not immediately anticipated early by nutritional screening (Depok District Health Office, 2018). The coverage of health services for elderly people in 2013 was 37.53%, 23.62% (2014), 69.34% (2015), and 11.8% (2016). The trend shows a decline in the proportion of health services coverage over the past five years. Several studies have shown that one of the factors associated with elderly visits to posbindu was the participation of posbindu cadres.
One of the determining factors for increased coverage of elderly visits to posbindu is the participation and capability of cadres to serve them. As the spearhead of posbindu in the community, cadres are assigned several tasks, assisting community health centre workers to serve older people in posbindu. Cadres have a big role in the implementation of posbindu monthly activities such as preparing places, tools, and materials; measuring height and weight; conducting individual counselling based on a health test (questions regarding a clean and healthy way of life), elderly nutrition and health, and others. In fact, cadres have difficulty taking health and nutrition education to older people due to a lack of confidence and lack of extension media. Low cadre performance certainly affects the quality of health and nutrition of elderly people in their area. Therefore, it is necessary to improve the skills of posbindu cadres and community health centre staff in Depok City by training them in elderly patients' health services management (Ministry of Health, 2003;2004). Improving posbindu cadre skills will increase the proportion of elderly people visits to posbindu. Finally, it will hopefully increase SPM percentage of Depok City from 53.9% in 2019 to 100% in 2025.
Elderly patients' health services include health and nutritional screening services by midwives, nurses, nutritionists, and posbindu cadres. The scope of the screening includes checks for hypertension (blood pressure), diabetes (blood glucose), blood cholesterol level, nutritional status assessment (NSA) through weight and height measurement, and early detection of dementia through Mini Mental Status Examination (MMSE) and Geriatric Depression Scale (GDS) (Ministry of Health, 2014;. Other elderly health services that posbindu cadres can perform are height and weight measurement, early detection of malnutrition using Mini Nutritional Assessment (MNA) tools, and elderly people independence assessment using Barthel (BADL) and IADL Activity Daily Living Index (Robin, 2019). The Mini-Nutritional Assessment Short-Form (MNA®-SF) is a screening tool used to identify older adults (>65 years) who are malnourished or at risk of malnutrition.
Malnutrition in older people is associated with premature death and complications. The progression to malnutrition is often insidious and undetected by older people (Soysal et al., 2019).
Mini Mental State Examination (MMSE) is a screening test/tool to detect the potential risk of dementia in older people. Dementia is a brain syndrome that causes gradual deterioration of brain function, cognitive skills, and ability to perform everyday tasks (e.g., washing, cooking, bathing, and dressing). Creavin et al. (2016)  Height measurement of older people is difficult to perform due to changes in body posture caused by aging, spine abnormalities due to osteoporosis, kyphosis, or the necessity to sit on a wheelchair or bed. To anticipate this difficulty, height predictors such as arm span, knee height, and sitting height can be used to obtain predicted height in older people. Afterwards, the results of both indicators can be converted to Body Mass Index (BMI) in older people with an NSA (Nutritional Status Assessment) card (Fatmah, 2013). In 2013, a training of NSA card usage and elderly anthropometry measurement practice -knee height, arm span, and sitting height predictors-was conducted on cadres from several chosen posbindu in Depok.
However, the implementation on the field has not been performed since 2013 due to limited eqUniversitas Indonesiapment provided by the UNIVERSITAS INDONESIA team at the time.
Therefore, the socialization and application practice of this technology should be reconducted through a training of practical application skills of posbindu cadres and community health centre staffs/older people coordinators. In addition, one strategy that increases elderly peoples' posbindu coverage is to improve their knowledge in geriatric nutrition service at posbindu through training (Indarjo et al., 2018). The objective of the study was to assess the effect of geriatric health services training of posbindu cadres and their knowledge levels at the end of the training.
The novelty of this study came from providing geriatric nutrition service training for the participants, which differed from the previous study. The first study focused on the nutritional status assessment, using knee height, arm span, and sitting height predictors, and the NSA card (Fatmah, 2013). Geriatric nutrition services consisted of malnourished risk assessment (using MNA instrument), dementia early detection (using MMSE instrument), and independent level risk assessment of older people (using BADl and IADL instruments).
In addition, we developed some IEC (information, education, and communication) materials on diabetes mellitus, metabolic syndrome, gout, and balanced nutritional gUniversitas Indonesiadelines in the form of a leaflet, flipchart, and poster to increase the knowledge level of participants in geriatric nutrition and health.

Study design
This is a quasi-experimental one group pre-test-post-test design (Ariawan, 1998 Pre-and post-tests were given to all participants to assess their improving knowledge on geriatric nutrition service. After the training, a Universitas Indonesia team conducted technical assistance and accompaniment of posbindu cadres through monitoring and visiting for 3 months. The objective of the activity was to observe the ability and skill of posbindu cadres (training participants) in taking geriatric nutrition service to their posbindu (how to conduct a geriatric nutrition campaign; how to measure knee height as a height predictor for older people; and how to fill out the forms of MNA, MMSE, BADL, and IADL Index Barthel). The training materials included the theory of predicted height from knee height predictor, the practice of using the MNA instrument for early screening of older people at risk of malnutrition, practice of using a MMSE instrument for early detection of older people at risk of dementia, the practice of older people independent assessment using BADL and IADL, and older people nutritional counselling practice, including balanced nutrition for older people, the degenerative disease of hyperuricemia, diabetes, and metabolic syndrome. Theory and practice of the use of knee height measurement, MMSE, MNA, BADL, and IADL instruments were provided on the first day of training. The second day of training was filled with nutritional counselling practice by interviewees with the help of two nutrition students from the Faculty of Public Health, Universitas Indonesia, followed by role play performed by the participants.

Study subject and location
Data were analysed using SPSS for Windows version 20, which included univariate analysis to obtain frequency distribution and proportion of minimum, mean, and maximum values. Data were presented descriptively in a table. Bivariate analysis was performed using dependent T-test to determine the average difference in knowledge before and after training.
Analysis using independent T-test and ANOVA were also performed to assess the changes in knowledge after training according to participants' characteristics, e.g., age, education, duration of employment as posbindu cadre and community health centre staff, employment status, and attendance at prior trainings before this older people nutrition training. The study was carried out over a period of 5months, starting from reproduction of the NSA card, knee height measurement; MNA, MMSE, BADL BARTHEL, IADL forms; geriatric nutrition campaign materials, and geriatric nutrition service training implementation, until monitoring and evaluation of posbindu cadres training of participants' skill in geriatric nutrition service.

Evaluation of training and posbindu cadres monitoring
Pre-and post-test were used to evaluate the improving knowledge of participants before and after the training (Figure 2). While the monitoring and technical assistance of all training participants were undertaken by filling the observation instrument of participants' skill on the geriatric nutrition service in posbindu (Figure 3).

Fg. 2 Geriatric nutrition service training
Fg. 3 Role play of cadres on nutrition counselling There were 10 questions asked in the pre-and post-test questionnaires which was answered correctly by all the participants as described in This may be due to almost all participants had knowledge of DM symptoms before training.

Results and Discussion
The description is consistent with other studies stating that most posbindu cadres had good knowledge of diabetes mellitus (Sengkey et al., 2015). Meanwhile, the proportion of participants with correct answers to macronutrition suggestions for older people is like the answers to the question about clean and healthy living for older people (each contributed 20%).
The proportion of participants with correct answers to the metabolic syndrome risk factor at the end of training increased two-fold. Even the question regarding predicting older people's height predictor was correctly answered by all participants. The question of hyperuricemia criteria was correctly answered by more than three-quarters of participants at the end of the training compared to before training. Increasing knowledge of participant scores at the end compared to before the training was indeed not large (4.45 points). It might be based on the same backgrounds of all participants, both posbindu cadres and community health centre staffs of nutrition officers/older people program coordinators. The training strengthens or refreshes what they already know.
The mean test score differences before and after training according to participants' characteristics are presented in Table 3. The pre-test scores significantly differed with posttest scores (p = 0.001). Likewise, previous participation in health and nutrition training also significantly differed before and after training (p = 0.017). The findings of the study are consistent with other studies that assessed the knowledge of cadres who have never had training with the knowledge level of the integrated health service post (posyandu) revitalization strategy (Wahyuni et al, 2017). However, this is not the case for employment status, education, duration of work as posbindu cadre, or community health centre staff, and age. Although insignificant, the participants who were employed had a slightly higher score mean difference compared to participants who were unemployed.
Participants who graduated from Academy /Bachelor's degree had higher score differences than participants who graduated from high school and junior high school. It is consistent with what has been observed in other studies (Diaz-QUniversitas Indonesiajano et al., 2018;Rakhma et al., 2017). The higher the educational level of person, the easier she or he will be to open to information (Kromydas, 2017). The tendency cannot be found in age and working duration as posbindu cadres and community health centre staff. It might be due to the similar proportions of participants in the three groups of working duration (Table 2). Meanwhile, the largest proportion of age is in the 40-49 group whose vision and hearing functions may start to decrease, affecting their information absorption (Wardani et al, 2014). However, the findings are inconsistent with other studies that proved the association between both variables and knowledge level (Dharmawati & Nyoman, 2016).
All participants were asked to lie down on the floor using the Knee Height Caliper tool.
Participants did well according to the facilitator's instructions. Likewise, during the simulation practice of older people's nutrition counselling on the topics of gout, diabetes mellitus, metabolic syndrome, and balanced nutrition, they could do it appropriately. MMSE, MNA, BADL, and IADL instruments could not be filled out correctly because there were still some errors in counting the value of each activity in these instruments. They almost never fill the forms in their daily activities because their tasks focus on taking height and weight; nutrition supplementation; and taking blood pressure, uric acid, blood glucose level, and cholesterol for older people (Ministry of Health, 2019). Therefore, the resource person must gUniversitas Indonesiade all participants several times slowly until they understand. The training methods used simulation/role play and two-way communication discussion by the resource person to the training participants. The simulation method and the use of extension media tools such as the leaflet and the flipchart are qUniversitas Indonesiate effective in increasing human knowledge. The nutrition counselling pamphlet is printed teaching material designed to be studied independently by trainees, while the discussion method is learning through two-way communication so that it is easier for participants to understand (Fitriana et al., 2015;Weheba & Maher, 2007).
Several studies showed that the eye is one of the body's senses delivering the most knowledge into the brain (75-87%). The remaining 13-25% is channelled through the other five senses, namely the ears and hands. More knowledge is absorbed with greater clarity when more senses are used to receive knowledge (Hutmacher, 2019). The training material provided is in accordance with the posbindu cadre's task in the field as a companion to community health centre staffs and field counsellors. Exposure to information and knowledge frequently and repeatedly can increase individual knowledge both from one's self and others' experiences. Individual knowledge is also influenced by education, work, and length of work. Knowledge is the basis for someone to take an action (Manly et al, 2018 Post-test scores of participants with diploma/bachelor's degree were slightly higher compared to junior high school and high school/vocational high school graduates. This finding was in accordance with four studies conducted to posbindu cadres (Fatmah, 2013;Fatmah & Yusran, 2012;Pratiwi, 2012;Yuyun, 2017 Printed media produced better understanding than digital media for people to increase their knowledge (Delgado et al., 2018).
Posbindu cadres were elderly people reform agents, increasing nutritional and health status through efforts in the community movement, older people nutrition counselling, early screening for malnutrition, early detection of dementia in the older people, and older people independence assessment. The function of posbindu cadres is to motivate the community, providing counselling, and monitoring (MOH, 2010). The services given by posbindu cadres every month related to knowledge given in this training were daily activity assessments (activities of daily living) using BADL and IADL, dementia mental status assessment using MMSE, NSA using height and weight measurement and MNA form, and health and nutritional counselling (Burman et al., 2015;Devi, 2018;Julieta & Eneida, 2017;Li-Chin & Alan, 2015;Torbahn et al., 2020;Yang et al., 2016). The four skills were reqUniversitas Indonesiared by posbindu cadres to perform their duties as posbindu cadres. Therefore, the improving knowledge of posbindu cadres in elderly people nutrition services is expected to increase the total number of older people visits to be able to increase the minimal service standard value in Depok City.
The study had several limitations, i.e., 1) there was no comparison/control group that could affect data accuracy, 2) the authors were unable to control external influence, both from mass media (printed and audio-visual) and other sources that may influence the knowledge and skills of cadre and community health care staff regarding elderly people's nutrition, and 3) the assessor of cadre's technical skills in counselling older people in posbindu were the authors themselves, thus cannot rule out respondent evaluation. To overcome respondent evaluation, the assessment can be performed by individuals/group outside of the authors using a double-blind method, whereas the assessor and the assessed had no knowledge of each other. Control group can be incorporated in a similar study in other places to increased data accuracy to compare knowledge changes.

Conclusion
Elderly people's nutrition training program can increase the knowledge of posbindu cadres and community health centre staff in Depok with an increase of 50 points post training. There was a significant difference of post-test score compared to pre-test score.
This increase in scores is caused by trainings previously attended by participants, including anemia TOT, positive deviance, caregiver, toddler growth monitoring, PMBA, solid foods for babies, lactation, PHBS, malnutrition management, and growth monitoring. Technical accompaniment and evaluation of monitored visits by posbindu cadres and community health centre staff were undertaken three times after three months post-training. The aim of the activity was to observe the ability and skills of posbindu cadres in performing geriatric nutrition services in posbindu. Thus, the improvement of their skills with elder people nutrition service can be expected to increase the coverage of older people visiting posbindu.
It will ultimately increase the percentage of SPM in Depok to 100%.