The Role of Leadership and its Relationship with the Performance of Community Health Volunteer: A Survey in Rural Indonesia

Background: Community Health Volunteers (CHVs) are the manifestation of community participation to solve health issues of the community, which is reflected through Integrated Services Post or known as Posyandu activities. Therefore, CHVs selection criteria need to be upgraded to support their performance in delivering community health services. This research aimed at identifying the relationship between the role of leadership and their performance in Posyandu activities. Method: This was a cross-sectional study conducted in Purwomartani village, Sleman, with a total of 68 respondents. Data were collected using validated questionnaires to evaluate the leadership and performance of healthy volunteers. The data were analyzed using Spearman's rank correlation. Results: The respondents comprised 100% females, 71.3% were aged above 41, and 82.4% were housewives, and 83.3% completed their education up to senior high school. The study revealed that 57.4% of respondents showed excellent performance before, during, and after the Posyandu activities. Bivariate analysis revealed that the role of leadership has a significant relationship with the performance of health volunteers (p<0.05). Conclusion: Training on leadership and effective communication is needed to support the role of CHVs to motivate the community to use the facilities for better health status.


Introduction
Indonesia's health development aims to improve the community's health status and nutritional status through health endeavors and community empowerment. One of governments' efforts to encourage the community to achieve health development is through Village Public Health Development (VPHD) program by establishing Integrated Services Post or known as Posyandu, in the community. Posyandu activities are organized and implemented by Community Health Volunteers (CHVs) who have got training and education by Public Health Center (PHC) [1].
CHVs are a manifestation of community participation in the effort of solving health problems in their environment. Thus, CHVs have a vital role in fair and equitable national health. CHVs are demanded to participate actively and be responsible for implementing Posyandu activities. If the CHVs are not actively implementing the activities, it will undoubtedly impact the ineffectiveness of Posyandu, affecting the community health status in their area. The performance of CHVs becomes a parameter to the successful Posyandu activity programs in the community [2].
A community health volunteer has to fulfill the criteria to carry out her role and function, such as: being able to read and write, being cooperative, knows tradition and customs in the community, and lives in the neighborhood of the Posyandu area [3]. Based on a study on the utilization of Posyandu in Palembang, Indonesia, 54.0% of mothers have not used Posyandu optimally [4]. Further, another study revealed that 23.4% of mothers did not regularly access their children at Posyandu in Teling Atas, Manado, Indonesia [2]. In addition, based on Indonesia health data and information in 2016 indicated the several Posyandu activities were not achieving the expected target, such as the average vitamin A coverage was 90.1% and weight measurement (for four times or more) of a child under five years old only 72.4% [5]. Unfortunately, in 2018 these situations could not be handled successfully in several provinces, such as Yogyakarta.
Yogyakarta is one of Indonesia's provinces which recorded has a large number of active Posyandu. However, this province has children's nutritional status issues that need more attention. Data on health information revealed an increase in the prevalence of undernutrition and stunting from 2017 to 2018. In 2017, the prevalence of children with undernutrition was 10.20%, where 2018 became 13.705 and stunting from 14.70% to 15.10% [6]. A study revealed that 31.2% of children under five years old in the working area of Puskesmas Umbulhardjo were undernutrition [7]. This data indicated that the CHVs role and performance were inadequate.
One of the factors concerning community empowerment in health is internal factors such as leadership [8]. Community leadership is reflected through several activities, including role modeling, inspiring, working in a team, trusting and developing, showing motivation and respect [9]. A study conducted found that leadership had a significant impact on CHVs' performance [10]. Therefore, to improve CHVs' participation in community health endeavors, it is necessary to identify possible factors affecting CHVs' performance that can be used as study material to improve the quality of community participation in the health sector.

Method
This study used an analytic correlation design with cross-sectional as its approach. The study was conducted in Purwomartani Village, Kalasan, Sleman, Yogyakarta. The village belongs to the PHC of the Kalasan working area. Samples of the study have chosen using the purposive sampling technique based on the data of active CHVs in the village. The sample size was calculated using a formula of correlation samples by predicting that α was 0.05 and β was 0.20, while the correlation coefficient was set to 0.35, resulting in 68 participants. Data was collected directly by gathering the participants based on the CHVs meeting schedule during September-October 2019.
The study evaluated CHVs performance as a dependent variable while leadership skills as an independent variable using validated questionnaires based on CVI results (1.00). The questionnaire of CHVs performance had 30 items using a 5-point Likert scale developed by the researcher with reliability result was α 0.940. While the leadership questionnaires had 12 items using a 5-point Likert scale, Cronbach's alpha's reliability test on the leadership questionnaire was α 0.623. The researcher newly developed the leadership questionnaire; thus, its value of α 0.623 was regarded as reliable to evaluate the role of CHVs' leadership. Bivariate data analysis was used as a study technique using the Spearman correlation formula utilizing SPSS software.

Characteristics of Respondent
A total of 68 respondents participated in this study with a mean age of 45.9 years (SD ± 9.4). The study revealed that 100% of participants were female, and most of them were housewives. 83.3% completed their education up to senior high school and worked as CHVs for more than five years. The majority stated that they had not got training to support their function and roles as CHVs in the community. More details can be seen in Table 1. The role of leadership of CHVs was identified based on 4 (four) competencies; transformational competence, political competence, trans-organizational competence, and team building competence. Among the competencies, transformational and team building had the highest mean value, 4.1. The CHVs performance was assessed based on five working domains: cooperation, attendance rate, time management, work quality, and work quantity. Based on the CHVs performance, the attendance rate and time management aspects had the lowest mean value compared to other domains (x 4.2). However, based on the cooperation evaluation, CHVs could work cooperatively with society and other team members during Posyandu activities (x 4.6). More details are shown in Table 2.

Relationship between Role of Leadership and CHVs Performance
The study revealed a correlation between the role of leadership and the performance of CHVs y (PR = 2.307; 95% CI = 1.586 -12.457; p <0.05). The better the role of leading a community health volunteer, the higher her performance (see Table 3).

. Discussion
Leadership in health service is defined as the individual ability to influence other people to reach personal, group, or organization goals [11,12]. CHVs are community members who are willing to manage and actuate the Posyandu voluntarily [13,14]. A CHVs with good leadership are expected to motivate and encourage the community to be independently healthy [15]. The study found that 35 of CHVs in Purwomartani Village have got a good role in leadership. This finding is consistent with other studies, identifying that most CHVs (65.7%) have good leadership with a democratic leadership style, which is frequently performed by the CHVs [16].
The study revealed that transformational competency and team building had better mean value (x4.1) than other competencies. This value indicated that CHVs have been able to motivate and be role models to other members and also be able to work cooperatively and give support to other people. Transformational leadership competence played a vital role in building strategy, motivating, and inspiring members through transformation of attitude, trust, value, and behavior to reach better goals because this style focused more on the personal relationships among individuals [17,18]. On the contrary, the political competence of CHVs was less satisfactory. They considered they had less knowledge about the bureaucratic system and government policies regarding health, felt less knowledgeable, and lacked understanding of marketing and health promotion media. Meanwhile, regarding trans-organizational competence, there was still minimum understanding shown by the community toward resource utilization (x 3.9).
The study result showed that 39 of CHVs (57.4%) in Purwomartani Village had a high level of performance. The majority of the CHVs were considered able to work together with the community and colleagues. In addition, the CHVs were considered to be able to finish their tasks and helped each other when conducting the activities, gave health service to the community, and were pretty responsive toward problems that the members of Posyandu were having. On the other hand, a study also found similar findings that most CHVs had good performance (74%), in which the performance was evaluated through 3-month observations according to CHVs' job description before and during the Posyandu activities [19].
Community health volunteers are responsible for pre-activity, during-activity, and postactivity when a Posyandu is conducted [20,21]. The pre-activity included preparing facilities and information sharing about when Posyandu would be held in their neighborhood, which was expected to increase the community's number of visits and utilization toward the Posyandu facility. Further, Posyandu day focused on health services for pregnant mothers, toddlers, and couples of childbearing ages, such as weight measurement, supplementary food provision, and training. Meanwhile, the post-activity focused on home visits and Posyandu activities report after the Posyandu day.
Based on the CHVs performance, attendance and time management had the lowest mean value compared to other domains (x 4.2). This value indicated that community health volunteers had not got high commitment to attend each activity to support Posyandu activities. Furthermore, home visits were less popular activities that performed by the CHVs. Home visits after Posyandu day was a less-paid attention activity by CHVs, with a mean value of 3.6. A home visit is an activity conducted to toddlers who did not attend to Posyandu, children with malnutrition, or children with other problems to monitor and give health counseling [22]. However, the level of CHVs' active participation in this study can be affected by their work status, primarily housewives. The occupation was one of the predisposing factors that influenced CHVs behavior [23,24]. The CHVs who did not work had less income This study revealed that the role of leadership was associated with CHVs performance with a risk of 2.3 times. In other words, good leadership competence is closely related to the improvement of the CHVs performance. This finding is in line with the previous study, which explained that leadership is one of contributing factors to influence the performance of CHVs on Posyandu activities [16]. Good CHVs performance might influence the utilization of health facilities by the community. When a health volunteer performed her role by promoting the Posyandu day, it would improve the community's awareness and understanding of its benefits, affecting community participation. The previous study also revealed that the CHVs' roles could influence the mother's motivation to use the healthcare facilities, especially on Posyandu activities for toddlers [26,27].
This study also reported that CHVs who had a good leadership role tended to have a high level of performance (74.3%) and vice versa. One of the competencies that a community health volunteer must have is communicational competence [28]. Effective communication in the study was identified as one of the transformational competencies. Through effective communications, CHVs are expected to build good interpersonal relationships to move the community to the desired goals [29,30]. A good leader can create conditions and not only give directions. Hence, a CHV's leadership role will influence her performance level that can impact the success of the Posyandu program and its utilization by the community in the area.
The cross-tabulation test result also identified that there were CHVs who had a good leadership role but with poor performance (25.7%). This value could happen due to contributing factors to the CHVs' performance. A study argued that incentives such as operational and transport fees could positively impact CHVs motivation to do their job optimally [3].

Conclusion
According to the study results, CHVs were reported to have good leadership roles with a high level of performance. The CHVs who have good leadership competencies will increase their performance on Posyandu activities. The role of CHVs as the mediator to strengthen promotive and preventive strategies is essential. Thus, the PHC and local government officials are obliged to monitor and evaluate CHVs' performance periodically. Training on leadership and effective communication are also needed to improve their skills in motivating and influencing the community to use the healthcare facilities to improve community health status.