Factors influencing mother’s participation in Posyandu for improving nutritional status of children under-five in Aceh Utara district, Aceh province, Indonesia

Under-nutrition is the outcome of insufficient food intake and repeated infectious diseases. It is a major public health problem that needs more attention because it leads to the loss of a generation. This contributes to the deaths of approximately 5.6 million children under five in the developing world each year. It triggers poor school performance and dropout, decreased productivity, threatens the ability of girls to bear healthy children in the future and perpetuates a vicious cycle [1].

According to the Indonesian Basic Health Survey, the prevalence of children under five in Indonesia who suffered from being underweight (weight for age is below -2 standard deviations of the WHO Child Growth Standard median) was 19.6 %. The wasting (weight for height is under -2 standard deviations of the WHO Child Growth Standard median) was 12.1 % and the stunting (height for age is below -2 standard deviations of the WHO Child Growth Standard median) was 37.2 % in 2013, and these values have not changed greatly from 2007 [2, 3]; much greater than the WHO targets of, less than 10 % underweight, 5 % wasting, and 20 % stunting [2‐4]. In Aceh were 26.6, 16.8, and 43.3 %, respectively [2‐4].

In 1975, the Indonesian government established the Development of Village Community Health (PKMD, Pembangungan Kesehatan Masyarakat Desa). PKMD is a health development strategy that applies the principles of mutual work and non-governmental organizations. It preceded an international agreement on a similar concept; known as the Primary Health Care (PHC), as stated in the Alma Ata Declaration in 1978. Nevertheless, PKMD activities were compartmentalized [5], nutrition improvement, diarrhea prevention, immunization and family planning were managed by different sectors. These compartmentalization caused difficulties in coordinating programs, resource inefficiencies, and were a disadvantage of PKMD [5]. To address these problems, in 1984, the Indonesian government merged these activities into an integrated service program called Posyandu (pos pelayanan terpadu).

Posyandu (Health and Nutrition Integrated Service Center) aim to provide basic health services such as family planning, mother and child health, nutrition (growth monitoring, supplemental feeding, vitamin and mineral supplementation and nutrition education), immunization, and disease control (diarrhea prevention) [6]. Posyandu is supported by Ministry of Health (act as the leading sector), Family Planning Board, and Ministry of Internal Affairs. However, considering Posyandu is a community-based effort, it has to be carried out by, from, and for the community, thus community participation is essentials to implement the basic health effort. In order to function, Posyandu need the village health post volunteers called Cadres. They are voluntarily selected from community members to organize the acitivies of Posyandu. Puskesmas (Primary Health center; as the sub-district representative of Ministry of health) will train the cadres until they are able to provide basic health care services required. The medical doctor or midwife from Puskesmas also has to help cadre held every activities, as written in law about Puskesmas (Indonesian Health Ministry Regulation No. 75 Year 2014). Community leader also has to support by conducting a fund raising and encourage the community to actively participate in the implementation of Posyandu. The community is encouraged to run the Posyandu once a month in every village.

Levels of Posyandu are divided into 4 levels. First level is Posyandu Pratama, this Posyandu has limited cadres (less than 5 cadres) and the activities are not conducted monthly. Second level is Posyandu Madya which has carried out the activities more than 8 times per year and have 5 cadres or more. The coverage of 5 activities is still low, under 50 %. Third level is Posyandu Purnama, its’ criteria are same with Posyandu Madya. However, it has independent fund managed by community itself. The participants involving in are less than 50 %. Posyandu mandiri is the last level. It has as same criteria as Posyandu Purnama, yet it has 50 % or more of participants [7].

Community participation is the active involvement of people from communities in health activities [8]. In Indonesia, the participation percentage of mothers to Posyandu was about 45 % [2‐4], far below the national target of 100 %. In Aceh Province, the percentage was even lower (34 % in 2013) (Fig. 1) [4]. Therefore this study aimed to investigate the factors influencing mother’s participation in Posyandu for improving the nutritional status of children under five in the Aceh Utara District of Aceh Province.

We found that the household income had a significant association with the mothers’ participation frequencies, and mothers of higher household income groups showed lower participation. The mothers of high household income is more likely to be working outside home rather than being a housewives, therefore more difficult to manage time to attend Posyandu every month [12]. Also, they are financially capable of bringing their children to other health facilities such as Puskesmas, general practitioneurs, or midwives to receive the same services at their convenient. In the study on effectiveness of Vitamin A capsule distribution program in Indonesia, one of the services provided by Posyandu, mothers gave ‘usually take child to another health facility’ (13.8 %) and ‘too busy’ (2.9 %) as reasons not taking children to the Posyandu [13]. However, considering 85 % of respondents of this study were in household income ≤1 million IDR group, the activities provided at free of charge in Posyandu is of great significance as all the children can receive much benefit.

This study showed that mothers with positive attitude towards Posyandu, satisfied with Posyandu service, and/or had intention to attend showed high attendance. In addition, these variables were associated with each other. The results of multivariate analysis showed that satisfaction affect more on the participation of the mothers than intention or attitude. This indicates that interventions that would increase mothers’ satisfaction would promote their attendance to Posyandu.

Improving the quality of services is one way and probably the most significant way to increase mother’s satisfaction on Posyandu services. Even though Posyandu is conducted and nutritional advice is given to the mothers every month, prevalence of malnutrition children remain high in Indonesia and even higher in Aceh. This clearly indicates that current approach is ineffective. In spite of worldwide use of growth monitoring especially in the developing countries, many reports point out that growth monitoring alone would not reduce children’s growth faltering, and ‘good nutrition counselling is paramount for growth promotion and is often done badly’ [14]. Posyandu in is unexceptional. Training of cadres is too brief and not practice-oriented, result in cadres have neither the knowledge nor skills to communicate effectively with caregivers [14]. Even cadres themselves feel that counseling is necessary to be improved [15]. Advices provided by cadres are often inappropriate or superficial. For example, mothers of a child with low body weight are advised to give more food to the child, but it is impractical for the poor family. It is clear that adequate and periodic training of cadres is definitely needed so that all the cadres meet certain standards, especially they are volunteers with various levels of educational background. But it is not as easy in practice since the Posyandu activities are carried out by the community, and the community must secured the financial resources for cadres’ training.

The leading reason for the mothers to attend Posyandu was children’s growth monitoring, far more frequent (41.6 %) than other reasons. Yet prevalence of underweight, wasting, stunning of children under 5 in Ache is higher than Indonesia’s national level, indicating suitable care is not provided to the children at risk of malnutrition. To reduce children with under-nutrition or growth faltering, such children must be identified first without oversight, then specific counseling and efficacious advices should be given by health professionals, and special support to high-risk children such as extra follow-up, food, frequent counseling sessions, and weekly weighing should be provided. The appropriate allocation of roles between cadres and health professionals in this process may be necessary for more effective intervention. Cadres should be trained to accurately take measurements and plot on the chart and judge whether the child is maintaining good growth. In case they detect growth faltering, cadres should refer the mothers to a midwife who is also present at Posyandu for special feeding and nutrition advices. Improvement of child’s nutritional status by detecting children at risk and providing appropriate advices by health professionals would enhance the quality of services, therefore increasing mother’s satisfaction.

Besides capacity building of cadres, education of mothers is also important. Growth charts can make children’s growth visible to caregivers and it can be used as educational tool, but mothers must have ability to understand the growth curve. Understand what growth curve is denoting would promote mothers’ interests in their children’s nutrition and the way they care their children. In the implementation of community-based growth monitoring project in South Africa, caregivers were pleased that they understood the link between appropriate weight gain, nutrition and their children’s health, and gained sense of empowerment through better understanding of what made their children health and how to check this [16]. Prior to the project, only 3 % of infants were taken to the clinic specifically for growth monitoring; the mothers were not motivated because the rationale was never explained to them. Studies in Indonesia showed lack of caregiver’s knowledge about the benefit of vitamin A is associated with the low rates of participation in the national vitamin A capsule program [17, 18]. These studies indicate that advancement in mothers’ knowledge and understanding would increase their interest in the nutritional conditions of their children and would motivate their attendance to community health programs such as Posyandu.

The health care system in Indonesia emphasizes community empowerment, and organization of Posyandu activities are responsible of village community. Therefore, the support from heads of the village and village health committees are essential for the success of Posyandu activities. Research on close-to-community (CTC) services in Indonesia reported the villages performing well (in terms of utilization of services) had much more supportive and active village heads and other stakeholders than those performing less well [19]. The village heads, community leaders, and religious leaders are influential in the community and useful in raising the community’s awareness of the importance of Posyandu activities. Community leaders and health sector collaborators should disseminate information through media campaigns and village meetings. In addition, they have authority to allocate funding to provide appropriate facilities and instruments for Posyandu. Holding leadership workshops for the community leader for good governance or stewardship may be another possible intervention to promote active participation of the community, and in turn child health promotion of the area.

About one third of the mothers had unfavorable impression towards Posyandu, and their reasons for attending Posyandu were ‘closeness to home’ and ‘free of charge’ of the Posyandu services. Many studies reported the distance to the health facilities are the barriers to accessing health services [20‐22]. Our findings showed that closeness in distance prompt the attendance to Posyandu; the mothers who are not satisfied and not motivated would attend Posyandu if it is close to home. Holding Posyandu at the village-level is indispensable in child health because being readily accessible would increase chance for the undernourished children to be detected, and would be opportunities to provide information or advice to mothers. Indonesia has already established community-based health care delivery system (Posyandu) that is remain an issue to many developing countries. Increasing quality of services of Posyandu is the challenges for the future. Improvement of coordination and referral system of health providers (midwives, cadres, and Puskesmas staffs), implementation of formal and regular training of cadres are potential areas for remediation.

The limitation of this study is that the study sample may not represent the population of mothers of children under five living in the Aceh Utara District. Additionally, a deeper exploration of the influencing factors of participation through the combination of quantitative and qualitative studies is needed.

In our study, household income, mothers’ attitude towards the benefits of Posyandu, satisfaction with Posyandu services, and intention to attend Posyandu significantly affected participation frequency of the mothers. In addition, growth monitoring of children under five was the reason respondents attended Posyandu. Hence, improving the quality of Posyandu services and providing qualified resources can promote the participation of mothers.