Factors Related to The Utilization of Integration Health Program (Posbindu) Among Older Adults in Indonesia: A Scoping Review

Background

The number of elderly individuals in Indonesia has significantly increased, posing challenges for health services. This demographic shift is partly due to higher life expectancy, which was 69.59 years for men and 73.46 years for women in 2020.¹ The elderly population, constituting 9.6% (25.64 million people) in 2019, is projected to reach 63.71 million by 2045.² In the world, the elderly population has exceeded 7%, thus entering the era of the aging population.³ Globally, Indonesia is among the countries experiencing the highest increase in its elderly population.⁴

The rise in elderly numbers is an indicator of human development success.⁴ Elderly who are healthy and remain productive make a good contribution, but the elderly are one of the vulnerable groups in the family that require special attention. However, this group often faces physical and psychological health challenges, with 48.14% experiencing complaints and a 24.35% morbidity rate dominated by non-communicable diseases.⁵ These conditions necessitate comprehensive health interventions, highlighting the importance of primary health services.⁶

The importance of health control for the elderly, especially those who are sick, so that the elderly family as the main support system and caregiver for the elderly must pay good attention to the condition of the elderly,⁷ but the elderly often rely on family support for care, but not all families have the resources or knowledge to provide adequate assistance,⁸ which is particularly crucial for elderly populations who often require ongoing support and education to manage their health effectively.⁹ So, there is a need for a community approach with community empowerment in the health sector.

Hence, community-based health initiatives, such as the integration health program (Posbindu), play a vital role in promoting health and preventing disease in elderly. This involves health improvement, disease prevention and treatment, and health restoration, which are carried out routinely every month. The Posbindu program offers integrated health services and self-development activities to enhance the quality of life for the elderly.¹⁰

The Posbindu program is considered effective in enhancing the elderly’s ability to independently detect degenerative diseases and increasing their awareness of healthier living practices.^11,12 Beyond the health benefits, Posbindu also fosters social care within the community and among the elderly.¹³ Moreover, elderly individuals who actively participate in Posbindu activities experience a higher quality of life compared to those who do not participate.¹⁴ The program’s effectiveness heavily relies on the active participation of the elderly.¹⁵

Participation can be in the form of participating as Posbindu administrators or cadres, it can also be by making good use of the program as an active member.¹⁶ The target for the participation of the elderly as active members set by the Ministry of Health is 80%, while the participation of the elderly is still very low, namely 41.76%.¹⁵ This coverage target can be different; in another article, it is stated that elderly participation is said to be sufficient when it reaches 75%, but only 4.4% of the elderly actively participate in Posyandu.¹⁷

The lack of participation of the elderly in the use of the Posbindu program can be influenced by various factors. Data collection and publication of articles regarding factors related to the utilization of the Posbindu have been carried out, a literature review of the article has been carried out, focusing on factors of elderly knowledge, family support, and the role of cadres, with the result that all three are related to the utilization of the Posbindu.¹⁸ Another literature analysis was published, which analyzed the relationship between perceived need factors in the utilization of the Posbindu.¹⁹ The study stated that chronic conditions, self-rated health, subjective health complaints, perceptions of benefit matter and limitations in data imitation in daily activities have a relationship with the participation of the elderly in utilizing the Posbindu.¹⁹ Data regarding the utilization of Posbindu can be seen in the Indonesia Family Life Survey conducted in 2014, secondary data analysis was carried out by Ridzkyanto, who concluded that ownership of health insurance and the distance of Posbindu have a close relationship with the activity of the elderly attending the Posbindu.²⁰

The difference with these studies is that this research does not limit the particular factors analyzed but groups them into predisposition, enabling, and reinforcement factors based on the stages of behavioural diagnosis or educational and ecological assessment on the PRECEDE-PROCEED model. This model was chosen because it can be practically applied to community empowerment-based health programs, including analysis of behavioral factors.²¹

This model from Green & Kreuter can be applied in planning health services, including community empowerment, advocacy, atmosphere building, and partnerships. This theory helps to understand the characteristics of the community that will be the target of health services.²² This model divides the factors that influence individual behavior and lifestyle into three domains: predisposing factors, enabling factors, and reinforcing factors.²³ A study was conducted that aims to analyze the factors related to the utilization of the Posbindu in Indonesia.

Method

Scoping review follows the JBI methodology, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist as a writing guide.²⁴ A literature search was conducted on Google Scholar, Pubmed, ProQuest, and Researchgate databases.

This review uses PCC with the context:

Population: Elderly (based on WHO, ie, pre-elderly, age ≥45 years) or families with elderly family members.

Concept: Predisposition, Enabling, and Reinforcing factors.

Context: Utilization of Posbindu

The keywords used in the search for articles in English included: “Factors” OR “Determinant” OR “Cause” AND “Utilization” OR “Utilization” OR “Correlation” OR “Related” OR “Participation” AND “Posyandu” OR “Posyandu Elderly” AND “Elderly”. The Indonesian keywords included: “Faktor” OR “Determinant” AND “Pemanfaatan” OR “Utilisasi” OR “Kunjungan” OR “Partisipasi” OR “Hubungan” AND “Posyandu Lansia” OR “Posbindu”. Boolean operators AND and OR were used in the search strategy. Articles were searched in the ProQuest, Google Scholar, PubMed, and ResearchGate databases.

Screening of search results articles using the PRISMA-ScR guidelines, along with the inclusion and exclusion criteria in Figure 1.

Figure 1 PRISMA Scoping review. Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021:372:n71. Creative Commons.22

Result

Table 1 describes the population and sampling technique. All articles have the same research design, namely, the correlative quantitative method with a cross-sectional approach, which has the following characteristics.

Table 1 Population and Sampling Technique

Table 2 describes the characteristics of the respondents. Five of the nine selected articles described the characteristics of the respondents who were included in their research in the form of gender, education, occupation, income, and/or knowledge, as follows in Table 2.

Table 2 Characteristic Respondent

Table 3 about the view of the use of the Posbindu. It describes the percentage of elderly who participate actively in the activities of the Posbindu, as well as their achievement of targets based on articles, as follows in Table 3. This table describes about use of the Posbindu. The data above shows that the percentage of utilization of the Posbindu has an average value of 47.51%, with the lowest score of only 11.69% and the highest percentage of 71.9% still not reaching the target set. The low participation of the elderly in Posbindu is related to various factors.

Table 3 Use of the Posbindu

Table 4 summarizes factors associated with the utilization of the Posbindu. The smaller the p-value produced by the two variables, the closer the relationship between them. A p-value less than 0.03 is categorized as having a very close relationship, values 0.03–0.05 are in the closely related category, values 0.05–0.1 can be said to be weakly related, and ≥ 0.1 is not related.³⁴

Table 4 Factors Associated with the Utilization of the Posbindu

From the results of the table above, several factors have p-values that interpret the results differently, but there are also factors that are consistently closely related to the utilization of the Posbindu.

Discussion

The utilization of the Posbindu is influenced by various things, based on the articles analyzed, the following are the factors related to the utilization of the Posbindu, using the PRE-factors approach, as follows:

Predisposing Factors

Predisposing variables are what set off a behavior, or in this case, what draws the elderly to Posbindu. Knowledge, attitudes, intentions, and sociodemographic circumstances are a few of them. However, while previous study assert that there is a very close association between knowledge and use of the Posbindu.^28,31 Other study contend that there is no correlation between the elderly’s knowledge and their use of the Posbindu.^27,32 This discrepancy in results makes sense because predisposing factors have no effect on health behavior, but their absence has an impact on healthcare delays.³⁵ Older adults with good health knowledge can decide whether or not to visit Posbindu, but those with poor health knowledge do not consider doing so.

The second component is the strong correlation between elderly visits to Posyandu and attitude.^25,26,32 Regression analysis indicates that elderly visit activity is influenced by attitude.³⁰ The congruence of these findings with Triandis’s Theory of Attitude and Behavior suggests that an individual’s behavior is strongly associated with their attitude on what actions to take; a person who has a positive attitude about health is more likely to visit a health facility.³⁶

Intentionality is another factor that is directly linked to older people’s visits to Posbindu.²⁵ Perceived behavioral control and attitudes toward behavior are two examples of factors that can impact intentions directly.³⁰ As stated by previous study, in a group setting, tales can be shared to inspire others.³⁷ Although each person’s motivation for taking action might vary greatly based on their personal experiences, values, and other factors.

According to previous research, perceptions of illness are not related to behavior, which may explain the difference in behavior.³² The elderly in the area tend to visit the clinic, primary care facility, or hospital right away when they have complaints, making Posbindu less appealing. Rosenstock found that perceptions about health affect health service utilization behavior.³⁸ Similar to subjective norms, previous research indicates that these variables are unrelated to the use of Posbindu; study participants believe that taking part in the Posbindu program is beneficial, but they may not plan to do so.³⁰ The other program, Chronic Disease Management Program Activities (Prolanis)in the previous study reported that positive attitudes towards health and the perceived benefits of regular health check-ups play a significant role in participant engagement.³⁹ Both are critical in enhancing the health outcomes of older adults in Indonesia.

Sociocultural elements play a role in how people behave when it comes to health; how they react physically and mentally to sickness depends on the culture of their surroundings.⁴⁰ The research conducted by Simbolon indicates that tradition and belief are closely associated with the elderly’s engagement in Posbindu.²⁷ Health professionals need to understand the customs and culture of the communities they work with.³¹ If a tradition is good, it should be upheld; if it is not, a better one should be substituted without sacrificing its core values.⁴¹

A person’s position inside a group might affect their behavior. Socio-demographic factors are the social and demographic circumstances of each individual within a population.⁴² There are conflicting findings, though. Melita and Nadjib’s study revealed no correlation between education and Posbindu attendance,³¹ while Intarti and Khoriah’s reported a weak correlation²⁹ and Rahayu’s piece demonstrated a strong correlation.³² The observed discrepancy suggests that an individual’s behavior in accessing healthcare services is not solely influenced by their educational background.

Variations in the gender component also show up in the results. Gender and the use of Posbindu is associated, according to Intarti and Khoriah, while it is unrelated, according to Melita and Nadjib research and Rahayu research.^29,31,32 As reported by Hart, an individual’s behavior is more influenced by their feminine-masculine level, regardless of their gender.⁴³

Age represents the last sociodemographic factor. It is thought to have no significant relationship with elderly visits to Posbindu, but there is still a weak relationship: those in the pre-elderly age group visit Posbindu more frequently because they engage in other social activities, such as social gatherings, and because Posbindu is a topic of conversation at other events, encouraging each other to attend.³¹ There was no examination of other sociodemographic parameters.

Enabling Factors

Things like accessibility or distance to health facilities are examples of reinforcing factors—things that make it easier for someone to receive health services. Previous study claims that there is a correlation between the elderly’s use of Posbindu and the distance between their home and the app,³² but three other studies have found no such correlation.^26,29,31 This is because accessibility serves as a reinforcement, and in the absence of motivating factors, an individual’s behavior cannot be formed.

According to Penchansky and Thomas’ theory, access to health services encompasses not only physical distance but also factors such as availability, acceptability, affordability, and adequate service, as well as implementation and evaluation.⁴⁴ As a result, one accessibility factor is Posbindu’s quality, and member participation is said to be closely correlated with it.²⁹

According to Saurman, communication and information—both about programs and community literacy in relation to health—are included in the dimensions of access.⁴⁴ This is consistent with Ariani’s finding that older people’s arrival at the Posbindu is correlated with their access to information;²⁵ the more comprehensive the information regarding the events scheduled, the more probable it is that the elderly will attend.

Reinforcing aspects include economic issues; WHO highlights that higher income and social status are directly linked to better health.¹⁰ There is a correlation between the work and income of the elderly and the use of the Posbindu.²⁹ But according to another study, income and employment had little bearing on how actively the Posbindu participated.^27,31,32 This is likely because the Posbindu, as a health unit built on community empowerment, does not require a large amount of funding.

Reinforcing Factors

The component that causes the behavior to persist over time and be consistently engaged in is known as the driving factor. The primary motivator is the intricate network of support that includes the government, the community, the family, and health care providers.⁴⁵ In order to effectively support and remind the elderly to regularly attend and participate in activities, family support and Posbindu cadres are closely linked to the use of Posbindu.^{26,28,29,31–33}

Friedman asserts that the family serves a variety of purposes in terms of support, including informational exchange, monitoring behavior through assessment and evaluation, actual, instrumental assistance, and emotional support that encourages someone to engage in a behavior. According to previous study, families provide the most comfortable environment for older individuals to live out their remaining years and serve as their primary support network for maintaining their health.⁷

A Posbindu health voluntary is a person with the capacity and willingness to assist health workers in managing the Posbindu voluntarily. They can accomplish this by serving as a coordinator, energizing the community, promoting health, encouraging and monitoring the elderly and their family to continue taking part in Posbindu events, and supplying documentation. They received training on how to assess the elderly, measure height and weight, and provide health education from the community nurse. As part of this job, health voluntary must be evaluated and assisted in gaining more knowledge and expertise on health-related topics.⁴⁶ The active engagement of the Posbindu is highly associated with social support.²⁵ It can come in the form of direct help, knowledge sharing, emotional support, affirmation and gratitude, and encouragement of helping others in need.⁴⁷ Apart from providing support, the information factor encompasses rewarding positive behavior or success in abstaining from negative behavior. It also includes the option of punishment for negative behavior or deviation from routine tasks.⁴⁸ The other study about Prolanis, reported that the program considered to be good, but the participants still feel some obstacles in following the program, such as the lack of collaboration of health workers and family support to participate in this program.⁴⁹

Conclusion

Many aspects of the Posbindu’s use are covered in this scoping review, including intention, knowledge, attitudes, education, employment, income, traditions, and beliefs; access to information; control over actions; and the quality of the Posbindu. Gender, age, distance, subjective norm, and pain perception are the unrelated elements. It is desired that community nurses, families, and Posbindu health voluntary will fully encourage the elderly in using the Posbindu, as this has been shown to be most closely associated with the presence of the elderly.