CADRES OF THE INTEGRATED HEALTH POST FOR ELDERLY AND THEIR SATISFACTION: HERZBERG THEORY APPROACH

Integrated health post (posbindu) is a place for the elderly to obtain various health services to improve their quality of life. The satisfaction of the health care volunteers (cadres) has an important role in the success of the posbindu. The higher the cadre’s satisfaction, the higher the performance in managing the posbindu. According to Herzberg, two factors that contributed to the work satisfaction, namely motivator factor and hygiene factor. Identifying these factors is important, so that cadres can remain active and satisfy in doing their work in the posbindu. The purpose of this study was to explore the components of cadres’ satisfaction in providing health services in the posbindu based on Herzberg’s factors A qualitative phenomenological study was conducted on 12 active and 6 inactive cadres in 16 posbindu, Bandung City, West Java, Indonesia. A purposive sampling was performed to select the posbindu and the cadres. Data collection was carried out by an in-depth interview to explore the work satisfaction factors based on the concept of the Herzberg theory. Triangulation was based on the result of active and inactive cadres interviews, as well as observation of the activities during the posbindu. This study discovered practicing religious teachings and social relations as two new components that can influence satisfaction


INTRODUCTION
It is estimated that Indonesia faced a rapid increase in the proportion of the elderly population (≥65 years old) from 5.0% in 2010 to 10.6% in 2035 (Jones, 2010). This increase proportion will cause the increase of noncommunicable diseases such as hypertension, heart disease, diabetes mellitus, stroke, and osteoarthritis (Hussain et al., 2015). Declaration of Alma-Ata (1978) stated that the primary health care emphasized the importance of community to participate in health programs (Rifkin, 2018), one of which is to participate in the non-communicable disease prevention programs. The Indonesian government encourages the establishment of an integrated health post for the elderly (posbindu) which is formed by the community, managed by the community, and allocated for the community (Maulida et al., 2015). The purpose of the posbindu is to conduct early detection of diseases and provide promotive and preventive healthcare (Pratono & Maharani, 2018). The forms of health services conducted in the posbindu are examination of daily-life activities, mental status, nutritional status, blood pressure, sugar in urine, counseling, home visit, and physical activity (Ministry of Health, 2010).
The success of the posbindu relies on the role of the healthcare volunteers (cadres). The cadres are chosen from their community and expected to have more knowledge and skills to manage the posbindu compare to other community members (Maulida et al., 2015). Cadres play an important role as a bridge between first-level health facilities and the community (Spencer et al., 2010). The role of cadres is realized by providing various services such as simple health screening, health counseling, and invite the elderly to attend and participate in the activities of the posbindu (Ministry of Health, 2010).
The cadres' satisfaction becomes an important factor to drive the enhancement of the quality of the posbindu (Hastuti, 2018). A study by Rachmati et. al. stated that the cadres in an integrated health post for children were satisfied with their jobs (Rahmawati et al., 2016). Work satisfaction is a pleasant emotional feeling that makes a person loves his/her work. It is characterized by working with high motivation and happy doing their job (Rahmawati et al., 2016). Herzberg described two factors that affected work satisfaction, namely motivator factor and hygiene factor (Bohm, 2012;Herzberg, 1968). The identification of these factors is important to ensure cadres remain active and satisfy in doing their work. The identification of factors contribute to satisfaction of cadres from the posbindu had never been carried out. The purpose of this study was to explore the factors creating cadres' satisfaction in providing health services in the posbindu based on Herzberg's theory.

METHOD
A qualitative study with a phenomenology approach was performed so that it could explore the opinions, thoughts, experiences, and feelings of the informants. The selection of posbindu was carried out using multistage sampling by initially selecting 16 of 80 Public Health Centers (Pusat Kesehatan Masyarakat, puskesmas) in Bandung City, West Java, Indonesia through simple random sampling using a computer. One posbindu, where had the most numbers of cadres was selected from each puskesmas. From each posbindu, 1-2 cadres were selected using purposive sampling, with the following inclusion criteria: became a cadre more than ≥ 1 year (active cadre), not active as cadre ≥ 1 month, could communicate fluently (no physical or mental disability hampering communication). This study was conducted from July to December 2019.
Before conducting interviews, interview protocol was developed using concepts from Herzberg's theory with no limitations on the emerging of new concepts. The protocol consisted of two parts. The first part consisted of general questions about the characteristics of the informants, namely age and education of the cadres, how long she had been as a cadre, and was she satisfy with the work as a cadre.
The second part consisted of open-ended questions consisted of the motivator and hygiene factors concept as follows: motivator factor consisted of 5 concepts: 1) achievement: the success in cadre work; 2) recognition: obtaining an appreciation for the achievement of the work as cadre; 3) the work itself: an activity or a task that gives a positive or negative feeling; 4) possibility for growth: opportunities to develop themselves and improve knowledge/skills/expertise; and 5) responsibilities: the obligation to carry out the work. Hygiene factor consisted of 8 concepts: 1) policies and administration work from the puskesmas and local government: policies or rules and administrative system that were given by puskesmas and local government to cadres in providing services in the posbindu; 2) supervision: supervising and guiding the cadre in providing service in the posbindu; 3) interpersonal relationships: the bond or communication among cadres and with the supervisors from puskesmas and local government; 5) incentives: wages or salaries given to the cadre; 6) personal life: the condition of the personal life of cadres affecting their works as cadres; 7) working conditions: an environment affecting cadres in providing services in the posbindu, and 8) status: cadre position in the community.
Permission to do the study was obtained from three institutions, namely the Bandung City Mayor Office, Bandung City Health Office, and the selected puskesmas. This study had received the ethical clearance from the Ethics Committee of Universitas Padjadjaran Bandung, Indonesia under the ethical clearance 338/UN6. KEP/ EC/2019.
In-depth interviews were conducted in the posbindu for the active cadres and at home for the inactive cadres. The in-depth interviews were audiotape-recorded with the cadres' consent and were fully transcribed. All expressed views would be anonymous and their participation would be kept confidential. A combination of individual interviews and observation of cadres behavior, expression, and communication during the activity conducted in the posbindu was employed to facilitate the widest range of collaborative constructions of meaning around the topic of work satisfaction as a triangulation process. Throughout the interview, the interviewer started by asking the general questions, followed by other questions regarding motivator-hygiene factor. The interviewer also allowed the informants to suggest a new concept as long as it was in coherence with the concepts. Responses were checked during the interview process by restating the information given by the informants to determine the accuracy of it. The interview was conducted in 30 minutes.
After the recorded interviews and results of observation were transcripted, it was systematically marked and assigned based on the literature review. In the next step, the researchers examined it carefully and a content analysis was conducted. The core categories (determined and emerging) were elaborated as an initial assessment by the researchers who reached a consensus agreement for these categories. The categories then organized into substantial subthemes.

RESULTS AND DISCUSSION
Posbindu is a form of community-based health effort (Upaya Kesehatan Bersumber Masyarakat, UKBM), established based on the community needs. The posbindu aim is to improve the health and quality of life of the elderly (Ministry of Health, 2010).
The cadres play important roles in running the posbindu. They are members of the community derived and chosen by the community where they live (Chatio & Akweongo, 2017;Rahman et al., 2010). They are trained by health care personnel from the puskesmas to manage, provide simple health services, and motivate the elderly to participate in the activities at the posbindu (Ministry of Health, 2010. They are assisted and supervised by puskesmas and local government (Ministry of Health, 2010). Cadres who are active, trained, and highly motivated, have a potential role in strengthening posbindu (Chatio & Akweongo, 2017;Rahman et al., 2010).
The informants in the study consisted of 18 cadres; 12 active cadres and 6 inactive cadres. All informants are women. Most active cadres aged between 43-69 years, while there were a young (25 years) and very old (81 years) inactive cadres. Most of the informants were high school graduates, and few informants graduated from higher education. They have been cadres for more than 2 years (See Table 1).
Herzberg's theory describes that one's satisfaction is influenced by two factors, namely motivator and hygiene factors. Motivator factors are intrinsic factors that raise job satisfaction and high motivation, but if they are not present, they do not cause dissatisfaction (Alshmemri et al., 2017;Bohm, 2012). Motivator factors consist of achievement, recognition, the work itself, responsibility, advancement, and the possibility for growth (Herzberg, 1968). A study in Palu, Indonesia indicated that the higher the motivation, the higher the quality of health services provided by the health personnels (Mustainah, 2012). Hygiene factors are extrinsic or environmental factors, where when present, they do not increase satisfaction and its absence will increase dissatisfaction (Alshmemri et al., 2017;Bohm, 2012;Herzberg, 1968). Hygiene factors consist of company policy and administration, supervision, interpersonal relationships, working conditions, salary, personal life, and status (Herzberg, 1968). Hygiene factors contribute to 69% and motivator factors contribute 31% to dissatisfaction in the workplace, on the other hand, hygiene factors contribute to 19% and motivator factors contribute to 81% to satisfaction in the workplace (Herzberg, 1968). Work satisfaction has an indirect effect on performance. Job satisfaction leads a person to commit to carrying out his/her duties and ultimately improve performance (Hastuti, 2018). Herzberg's theory is very helpful for a manager to decide in developing a motivated workplace. If work dissatisfaction is seen as a major problem, the hygiene factor should be improved. To improve work satisfaction, the motivator factor needs to be intervened in changing the nature of work to be more challenging and more rewarding (Andjarwati, 2015).

Motivator Factor.
This study discovered that cadres felt satisfied when many elderly were present during the activities at the posbindu and became healthy. They also mentioned that they were very proud when their posbindu had been promoted to enter a competition and became an example/ model for other posbindu. The need for achievement is a reflection of the drive for responsibility and the courage to take risks, as well as the need to do the work better than before (Yanuarini & Triwahyuningsih, 2016). Achievement contributes about 40% to satisfaction (Herzberg, 1968).
Posbindu is a volunteering work, however, the results showed that there were two different opinions regarding recognition. Some of the cadres did not expect any award, the expression of gratitude from the elderly, made them feel appreciated, on the other hand, they feel motivated if there was a recognition in the form of material from the puskesmas or local government. Recognition is the second rank after achievement that has a meaningful contribution of 30% to the intrinsic motivational factors (Herzberg, 1968). The desired recognition is in the form of respect, recognition of achievement, compliment, gain power, and award in various forms (Djuhaeni et al., 2009). Recognition could make them more motivated to work as cadres (Yanuarini & Triwahyuningsih, 2016). Enjoyment in the work is a contributor to the motivator factors (Rahman et al., 2010). This study discovered that working as a cadre was an enjoyable work and a job to be proud of, however, most of the inactive cadres stated that being a cadre was exhausting, burdensome, and unpleasant since there were too many activities to be done, and reports to be made. One of the factors contributing to attrition was workload (Rahman et al., 2010).
Personal growth is formed by one's chances of developing his/herself, in terms of knowledge, skills, and experience. Some cadres mentioned that being cadres allowed them in enhancing their knowledge and skills, especially in the simple health measurement of height, weighing, and blood pressure of the elderly. They frequently participated in various trainings or seminars conducted by the puskesmas. This study also revealed that being a cadre could implement their skills and experiences in organizing something and could help their community. Increased knowledge and skills provide increased attitude and positive behavior to the activities of posbindu (Maulida et al., 2015). Training conducted with direct settings in the community can improve the performance of 4.76 times better, compared to those trained in the health facility setting (Chung et al., 2017). Moreover, a cadre stated that being a cadre, made her smarter compare to any other member of the community. The other benefit as a cadre was she could prevent the occurrence of dementia, because she always socialized with the community. To be well-trusted cadres can make their life better in the sense that they can make a positive difference in another person's life, increasing their sense of self-worth, and increasing their overall well being (McDonald et al., 2013). (see Table 2.) "Alhamdulillah (thank God), yesterday, we participated in the district level, but there is no announcement yet. It makes me excited. In the level of the subdistrict, we won, now hopefully in the district level" (informant 14, 67 years old; inactive cadre) 2 Recognition 5 Expression of gratitude "The community is most grateful of our work" (informant 1; 49 years old; active cadre) 6 Do not expect for appreciation "As cadres, we do not expect any appreciation from the community. If there is one, it is our fortune, if not, means it is not our fortune, that's it" (informant 4; 49 years old; active cadre) 7 Material things given as recognition " as I mentioned before, we do not expect any appreciation, but we are thankful if every year the puskesmas or the local government could give us uniforms. It makes us more motivated to do our work (informant 4; 49 years old; active cadre) 3 Work itself 8 Enjoy and proud work "Alhamdulillah (thank God), I am happy and proud to help the community" (informant 6; 49 years old; active cadre) 9 Exhausting work " I don't like the work, make me tired. We have to do many tasks, weighing, height measurement, fill the forms, and make many reports. Also many programs that we have to conduct" (informant 17; 36 years old; inactive cadre) 4 Personal Growth Responsibility is interpreted as gain satisfaction from being given the responsibility and freedom to make decisions (Alshmemri et al., 2017;Lisnawati, 2015;Rahmawati et al., 2016). This study discovered that during the posbindu, there were several elderly who were absent. The cadres were eager to come to the homes of the elderly door to door and fetch them to the posbindu. Moreover, each cadre knew her specific tasks and duties, such as measuring weight and height, administrative tasks, etc. They mentioned that these activities were the responsibility to be cadres. This study also found that the cadres felt that their responsibility to help the community to become healthy. Most of the long-serving health volunteers mentioned good health and the desire to help their community members as motivation for them to continue engaging in health intervention activities (Chatio & Akweongo, 2017).
This study found that practicing religious teachings was a new concept of the motivator factor. All of the cadres were Moslems. Several cadres stated that they worked as cadres sincerely (ikhlas), believing that by becoming a cadre was worship (ibadah), and made this work as a saving for the afterlife (akhirat). Helping a person not merely because of her duty as a cadre, but because of a sense of humanity and an obligation as a Moslem. Helping others is part of worship and she does not feel burdened by it (Anoraga, 2015;Herawati, 2019). Religion is an inseparable part of everyday human life and is a way of life. The way of life is the rules, values, and norms that govern human life. It grows and develops along with the growing and developing of human life, society, and culture that build a system of religious, social, cultural life (Baihaqi, 2015). Samsari as quoted in Baihaqi defines religiosity as a level of faith in one's life and practice of the religious teachings. Religiosity is generally associated with the cognitive aspects (knowledge and religious beliefs) that affect what is done with emotional attachment or emotional feelings about religion, and behavior. Religiosity leads to the quality of the passion and attitude of one's life based on the religious values he believes and emphasizes more on the substance of religious noble values (Baihaqi, 2015). Religiosity is significant in increasing the capacity of the organization (Sulistyo, 2011). The higher the level of a person's religiosity, the higher the person's satisfaction in the workplace (Sulistyo, 2011).

Hygiene Factor
Policy and administration systems are rules and administrative works provided by puskesmas and local government to run a posbindu. Some cadres mentioned policies and administrative reports were not burdensome for them, on the other hand, there were still cadres who complained about the large numbers of tasks to be carried out, and sometimes there was suddenly instruction from the local government to do some tasks and had to be completed in a short time. Policy and administration are extrinsic factors that can make cadres feel dissatisfied (Rahmawati et al., 2016). This factor is the highest factor that can cause dissatisfaction that is equal to 35% (Herzberg, 1968).
Supervision consists of the process of monitoring and guiding the health services and administrative works in the posbindu, carried out by the puskesmas and local government. Forms of supervision include mentoring during posbindu, training or seminars held by the puskesmas and local government. This study discovered that not all of the cadres were supervised by the puskesmas and local government. Supervision is an important factor to demonstrate better performance, however, it is often neglected (Chung et al., 2017). Local government (lurah/ RW/RT) who always provides support for every posbindu activity causes the performance and sustainability of the posbindu to be better compared to other posbindu where does not have any support. The support can be in the form of giving tasks that are monitored and supervised periodically, telling what is right and what is wrong, considering the ability of cadres before giving tasks, and always present at the posbindu, as well as the provision of training or seminars by the supervisors (Profita, 2018). According to Mathis and Jackson quoted from Hok et.al, training is a process by which people gain the ability to help achieving the organizational goals (Hok et al., 2014). Combination of on the job training, off the job training and on-line training should be developed (Hok et al., 2014). Supervision is the second highest factor that can cause dissatisfaction after policies and administration systems as equal to 20% (Herzberg, 1968).
An organization is a group of people consists of leaders, subordinates, and work partners who work together to achieve a certain goal (Obakpolo, 2015). Interpersonal relationships are important because they have a direct effect on organizational sustainability. Many conflicts and misunderstandings influence organizational outcomes (Obakpolo, 2015). In this study, interpersonal relationships with superiors are reflected as relationships with puskesmas and local government. Some cadres suggested a good relationship with the puskesmas as evidenced by the familiarity with the name of the health providers from the puskesmas, and the good support during the posbindu activities. Without the support from the puskesmas, the cadres felt they could not do their work smoothly. On the other hand, interpersonal relations with the local government were unfavorable, due to lack of attention and support given to the posbindu program. The cadres stated that the local government only gave a lot of tasks and ordered them in short notice which made the cadres less comfortable and dissatisfied. Work as a team, togetherness at work, comfortable with each other, close relationship, and good communication were components of the cadres perception when asked about the concept of the interpersonal relationships among work partners. They worked together as a team in doing their tasks eagerly. Every problem was always discussed and solved together. They supported each other. They were familiar with each other's character so that they were very comfortable with themselves and their working environment. Interviews with inactive cadres proved different results. One of the reasons why they stopped being cadres were the poor relations with some cadres, which made them uncomfortable. Interpersonal relationships have significant effects on job satisfaction of both coworkers and supervisors that regardless of the employee's position in an organization (Lodisso, 2019). In addition, there is a significant positive relationship between the role of interpersonal relationships and job performance. This implies that the employees' productivity depends on their interpersonal relationships (Muhammad et al., 2018).
This study discovered that there was no incentive in any form (wage and operational costs) provided to the cadres for operating the posbindu. Some cadres mentioned that they frequently raised some money from themselves or the community. They mentioned that becoming a cadre was not to get money or incentives, but they did it sincerely (ikhlas) to achieve the social and environmental welfare of their respective community they served. They stated that work as a cadre is worship (ibadah) to get savings for the afterlife (akhirat). However, some cadres felt that they would more motivated, if incentives were provided. A study by Djuhaeni et al, discovered a similar result. Incentives were not the main things to motivate the cadres (Djuhaeni et al., 2009). On the other hand, incentives attract people to do their tasks and one of the reasons they retain as cadres. r (Chatio & Akweongo, 2017;Yanuarini & Triwahyuningsih, 2016).
Personal life issues can cause dissatisfaction and factors in attrition. Interviews with active and inactive cadres discovered that support from their family was the main reason they retain as cadres. Support can come from mothers, husbands, and children. Another personal life issue that emerged from the interviews with active cadres was they could fill their spare times with many activities, because their children were already adults. Some causes of attrition were their health conditions such as getting pregnant and giving birth so that they had to take care of their babies themselves, and they had some health problems. They felt that they were getting older and they allowed the younger person to take over as a cadre. Financial problems that forced them to get a job and preoccupied with household things were other factors in attrition. Family support is a very important factor (Lisnawati, 2015;Rahman et al., 2010). Family support is an effective force in motivating a person to participate in his/her environment, even though it demands time and responsibility. (Lisnawati, 2015). A study by Maulida discovered that as many as 43.3% of cadres stated that their families supported them as cadres (Maulida et al., 2015). Burdensome "The report we have to make is not a burden to us, we always distribute it among us, so we work together to get it done" (informant 5; 49 years old; active cadre). "The programs should not be pilling up, the programs were changed whenever the leader was replaced, it was confusing. The format should be clear, do not keep changing" (informant 11, 61 years old; active cadre) 2 Supervision 2 Supervision by the puskesmas ""Yes the health provider from the puskesmas is always present, and he/she always explains things that we did not understand or confuse. He/she also guides us so that our tasks are carried out well ( Work conditions can affect work dissatisfaction. The posbindu operates only once a month, they did not have to come to it every day. This schedule made them comfortable in doing their task and obligation. On the other hand, most of the cadres stated that there was a lack of facilities to operate the posbindu, however they still devoted to their work. The work conditions have a direct influence on someone who carries out their duties. Comfortable work conditions can improve performance, conversely, an inadequate work conditions will reduce performance (Yanuarini & Triwahyuningsih, 2016).
Status in the community becomes one of the hygiene factors based on Herzberg's theory (Alshmemri et al., 2017;Herzberg, 1968). Some cadres said that as a cadre made them better known and more trusted by the community and became part of the community leaders. Someone's status showed the existence of trust and recognition regarding one's abilities in experience, skills, and knowledge. It leads to high work satisfaction and increase work productivity (Ola, 2019).
Social relations emerged as a new category of Herzberg's theory. This study discovered that most of the cadres stated that as cadres, they had more opportunities to meet their community. They also stated, that they knew their community better and made new friends. They were very happy if they could help others, so that one day if they needed help, the community could help them as well. Humans as social beings tend to need other people and want to live in groups. They want to be accepted by their environment. The posbindu is a place where they could interact and socialize with the community, and exchange opinions and experiences to solve their problems (Djuhaeni et al., 2009). The need for affiliation is a desire for a kind and close relationships. Generally, individuals who have high affiliation needs, succeed in their work that requires high social interaction (Lisnawati, 2015;Yanuarini & Triwahyuningsih, 2016).
This study has limitations. During interviews, the cadres were interrupted by other cadres who were on duty. This happened because the interviews were conducted at the same time as the posbindu activities. Some of the cadres had difficulties to understand the meaning behind the questions, because they had low education and old age. The researchers had to explain the questions repeatedly until they understood.

CONCLUSION
Despite the limitations, this study provides findings on the factors of work satisfaction based on Herzberg's theory. Practicing religious teachings and social relations are new factors that emerge in this study and lead to work satisfaction or dissatisfaction. To improve work satisfaction, the motivator factor, namely achievement, recognition, the work itself, the possibility for growth, responsibilities, and practicing religious teachings need to be intervened in changing the nature of work to be more motivated. To minimize dissatisfaction, the hygiene factor such as policies and administration work from the puskesmas and local government should be developed as simple as possible so that it will not be a burden for the healthcare cadres. Moreover, supervision by the puskesmas and local government should be carried out frequently so that they can monitor the work of the cadres and if there is a problem, it can be solved right away.