Strengthening capacity of Posyandu cadres to educate mothers: A program evaluation of emotional demonstration for cadres in Bantul Regency

ABSTRACT


INTRODUCTION
Based on the Indonesian Nutrition Status Survey in 2021, 24.4% of children under 5 years old are stunted. 1 Stunting is impaired growth and development due to chronic malnutrition and repeated infections. Children with stunting have height/ length-for-age more than two standard deviations (<-2SD) below the WHO Child Growths Standards median. Stunting that is not treated immediately can cause a decrease in cognitive function and lost productivity in the future. 2 Inadequate dietary patterns, parenting, and sanitation can cause stunting. Dietary patterns involve food availability and family access to food with balanced nutrition during pregnancy until the child is 2 years old. Parenting that affects the nutritional status is about parenting behavior related to Infant and Young Children Feeding (IYCF) practices. 3 Parents are responsible for what food they serve to the children and when and where they serve it. 4 The mother's level of knowledge related to nutrition plays an important role in meeting the nutritional needs of children. 5 Mothers are expected to have good nutritional knowledge to determine the type of quality food, feeding schedule, and adequate amount of food to meet the needs that children need to grow and develop optimally. 5, 6 Mothers with low education levels tend to have poor nutritional knowledge due to poor access to accurate information. 7 Mothers with low education levels also had a 3.3 times higher risk of having a stunted child. 8 Based on research conducted by Ningtias in 2020, there are differences in the feeding pattern between children with stunting and normal children. Children who receive inadequate nutrition are six times more likely to be stunted than children who receive balanced nutrition from their parents. These conditions cause children to lose weight and affect their nutritional status. 9 Food intake that is not varied, not eating enough, or foods that lack growth-promoting nutrients are direct causes of stunting. 10 The Integrated Healthcare Center (Posyandu), as a source of basic health services for mothers and children in the passively listen. Emo-Demo is developed in various games played with props for 15-20 minutes.
In every Emo-Demo game, there are one or two messages related to nutrition that are conveyed simply. Health messages are conveyed by creating moments that involve emotional feelings in mothers. To facilitate the Emo-Demo's game, the cadres need to master good communication skills consisting of open questions with affirmations and appreciation; actively listening and reflecting; and summarizing or concluding so that the delivery of messages can be carried out optimally and can touch the emotional feeling of mothers. 15

METHODS
The evaluation aimed to assess the effectiveness of Emo-Demo roleplay for cadres in the Bantul Regency. This study used a descriptive analysis approach. The study was conducted in Bantul, the regency with the second-highest prevalence of stunting in Daerah Istimewa Yogyakarta in 2021. The research in the paper has obtained permission from the relevant institution.
Data were collected from 126 cadres from 5 villages: 1) Triharjo, 2) Wijirejo, 3) Gilangharjo, 4) Caturharjo, and 5) Trimurti in Srandakan subdistrict. The cadres participated in the Emo-Demo program, which was held in August 2022. The cadres were divided into 4 groups with different Emo-Demo games. The cadres did role plays to give instructions, explain the game's rules, and convey key messages regarding each game. Data collection was done by participatory observations, interviews, and a feedback form. Observers assessed the ability of cadres to do a roleplay of the Emo-Demo game based on the completeness sheet of roleplay facilitation done by the cadres during the participatory observation. There was one observer in each group.
The data were analyzed with the Easy Evaluation method, which emphasizes the importance of valuing tradition in evaluation. 16 An Easy Evaluation assessment was determined for each criterion, among others: 1) Practice the roleplay according to the order of the emotional demonstration programs; 2) Apply communication skills according to the PAMM technique (Pertanyaan Terbuka; Afirmasi dan Apresiasi; Mendengarkan dan Merefleksikan; dan Menyimpulkan); 3) Delivery key message and 4) Apply effective time management. These criteria are assessed based on a rubric with the values categories made by the researchers. The observers entered the data from the observations of the Emo-Demo roleplay conducted by the cadres based on the assessment criteria into Ms. Excel. The average of the assessment results was categorized based on the rate in the rubric evaluation.

Participant characteristics
The cadres that were involved in the assessment were 126 female cadres. The age range was 25-60 years. The cadres were from Triharjo, Wijirejo, Gilangharjo, Caturharjo, and Trimurti, Srandakan subdistrict. Most cadres had not received training on Infant and Young Children Feeding (IYCF) practices.

Easy evaluation assessment
Based on the Easy Evaluation assessment, the overall results obtained are shown in Table 1. There were two criteria: practice the roleplay according to the order of the Emo-Demo programs and deliver key message to get a rate as Very Good while criteria of applying communication skills and effective time management were rated as Good.

Practice the roleplay according to the order of the Emo-Demo programs
The practice of the roleplay according to the order of the Emo-Demo is assessed based on the following aspects: 1) Prepare game equipment thoroughly; 2) Greeting; 3) Greet the participant; 4) Convey the purpose of the forum; 5) Delivering game objectives; 6) Guiding Rumpi Sehat chants; and 7) Practice the game in sequence. community, plays an important role in monitoring parenting, including providing education about proper feeding practices for infants and children. In providing education about parenting, cadres can also conduct consultations, counseling, group discussion, and demonstrations with parents or children's families. The role of skilled cadres in delivering education greatly influences the success of IYCF practices. Counseling by cadres for mothers with children aged 6-24 months can improve the practice of providing adequate complementary feeding, especially regarding the consumption of animal protein, food texture, and food variety. 11,12, 13 Based on Widaryanti's research in 2019, education on the practice of feeding infants and children in Posyandu has not been adequately implemented. 11 Our preliminary survey showed that 38.7% of mothers did not receive education and counseling from Posyandu cadres. Several reasons cause cadres to not provide education and counseling at Posyandu, including low self-efficacy among cadres to carry out education or counseling, cadres' confusion about abundant educational materials, and cadres' perception that young mothers were busy workers, among others. Low self-efficacy among cadres is caused by lower education and knowledge related to child nutrition compared to mothers with higher education. Even though the knowledge of IYCF of mothers is good because of better access to information related to nutrition, it is necessary to increase and strengthen information related to early initiation of breastfeeding, exclusive breastfeeding, and complementary feeding from health workers and cadres to combat hoaxes. 14 But it should be noted the teaching methods should involve educational methods that interest mothers nowadays.
One of the education methods that cadres find interesting and quite easy to do is Emotional Demonstration (Emo-Demo). Emo-Demo is an activity guide that aims to change nutrition-related behavior to reduce child stunting in the target group (pregnant women and mothers of children less than 5 years old), which is done in an interactive and participatory way so mothers do not just ORIGINAL ARTICLE     Based on the completeness sheet of the roleplay facilitation assessment, 77.0% of the cadres practice the roleplay according to the order of the Emo-Demo programs. Based on the rubric evaluation in Table 2, practicing the roleplay according to the order of the emotional demonstration programs was rated as Very Good. In the assessment sheet, assessments related to communication skills that need to be done by the cadres include: 1) Dig for information with an open-ended question; 2) Affirmation and appreciation after participants have an opinion; 3) Active listening to participant's opinions carefully (did not do other activities); 4) Repeat participants' answers/opinions to ensure that cadres and participants have the same perspective; and 5) Summarized the important points that must be conveyed; and 6) Involve all participants to participate in the game actively.

Apply communication skills
About 60.35% of cadres applied communication skills according to the PAMM technique. Based on the rubric evaluation in Table 3, applying communication skills among cadres was rated as Good.
Deliver key messages There are several aspects to assessing key message delivery, including: 1) Deliver the key message clearly and simply; 2) Use clear language and volume; and 3) Use the right expression and intonation according to the moment.
There 84.9% of the cadres delivered a clear key message. Based on the rubric evaluation in Table 4, the delivery of a key message was rated as Very Good.

Applying effective time management
Applying effective time management was assessed based on the duration of cadres doing the roleplay in the Emo-Demo. Based on the Emo-Demo guide, each game is played for no more than 20 minutes.
There 77.5% of cadres applied effective time management. Based on the rubric evaluation in Table 5, effective time management was rated as Good.

DISCUSSION
Communication skills are an important part of health education that needs to be mastered by cadres. Cadres are expected to apply effective communication in conducting education and counseling with mothers. 17 The findings in this study showed that some cadres practice communication skills with the PAMM technique but not as well as expected. Although the communication skills were rated as Good, many cadres are still not good at practicing these communication skills, especially in the Appreciation, Affirmation, and Reflecting techniques. Appreciation is an act of recognizing or understanding that the opinion of participants is valuable and important. Affirmation is a sentence that is conveyed after participants make an opinion. Based on observations, most cadres did not give appreciation statements after the participants gave their opinions but immediately confirmed or refused the participant's opinions. Reflecting is a way of repeating what the participants said to ensure that the cadres understand the participant's intentions.
This result matches the results of Erny's research in 2014, which showed that the communication skills of Posyandu cadres were poor before the communication skills training. Mothers also complained about how cadres communicated and that the information conveyed was difficult to understand. 18 Based on our preliminary survey before conducting the Emo-Demo training, it can be seen that some mothers dislike the way Posyandu cadres communicate. They said that there were cadres who were less friendly, and they often judged the mothers. This follows Imansari's research in 2021 which stated that only 33.3% of cadres avoided judgmental sentences during counseling at Posyandu. 19 Following Dewi's research in 2018 that was based on direct observations, some cadres perform services that are not pleasant, for example, reprimanding mothers with a high-pitched voice. 20 Difficulty creating a cozy and conducive atmosphere when educating or counseling the mothers can cause the education and counseling implementation not optimal. 13 Lack of communication skills also affects time management during the roleplay. Cadres who do not actively involve participants are usually not good enough at managing their time because they talk too much alone. They also have not been able to compose sentences effectively. 21 Whereas participants tend to feel more satisfied when cadres provide opportunities for participants to speak, and express their opinions, and cadres give time to listen to the mothers actively. 22 One-way communication can make participants bored and disinterested in the educational content. 23 Communication in education and counseling that is less effective can affect the messages. If the cadres communicate ineffectively, the message is unclear and can cause misunderstandings between cadres and mothers, so the message cannot change the mothers' behavior. Accordingly, the routine training in communication skills is needed to improve cadres' capacity. 13

CONCLUSIONS
The Emo-Demo program was done effectively, feasible to be continued and applied to all cadres in Bantul. However, some aspects need to be improved, such as the implementation of Emo-Demo program needs to emphasize better and effective communication skills among cadres. Education regarding communication skills needs to be done repeatedly so cadres become more proficient.