Validity and Reliability of Indonesian Public Health Nursing Competencies in Achieving Indonesian Healthy Program with a Family Approach: A Pilot Study

Corresponding Author: Tantut Susanto Department of Community, Family & Geriatric Nursing, Faculty of Nursing, Universitas Jember, Indonesia Email: tantut_s.psik@unej.ac.id Background: Indonesia has the Indonesian Healthy Program with a Family Approach (IHP-FA) to solve various health problems in the country. The public health providers in Indonesia play a very vital role in realizing this program. There have not been clear reference standards regarding the Indonesian Public Health Nursing (IPHN) competencies. This condition causes the provision of nursing services in public health centers (PHCs) to be suboptimal. Purpose: This study aimed to identify the validity and reliability of the core competencies of IPHN standards in a practice setting to achieve the IHP-FA. Methods: A pilot study using a descriptive correlational study was conducted among 55 coordinators of public health nursing (PHN) program from 50 PHCs in Jember, Indonesia. The IPHN practices were accessed using the five PHN core competencies (including activities in PHCs and nursing care for follow-up patients, family, special needs group in the community, and community). The IHP-FA was measured using 12 indicators. Content Validity Index (CVI) was used to examine the validity of core competencies. Internal consistency was explored using Cronbach’ α coefficient. Construct validity using the known-groups technique was explored to measure the correlational between IPHN competencies and indicator of IHP-FA. Results: The CVI indicated adequate content validity (0.80-0.10) and high reliability (Cronbach’s alpha coefficient=0.81). There was a significant correlation between five core IPHN competencies and achievement of IHP-FA (safe birth delivery, immunization, growth and development, management of tuberculosis, smoking, and access to clean water). Conclusion: IPHN competencies contain valid, reliable, and psychometrically robust measures. However, some programs in IHP-FA could not be achieved with five IPHN core competencies, demonstrating the need for developing the IPHN competencies in the future.


Introduction
Family health nursing, as a primary form of family service in the community, can facilitate healthy family development through the preservation of healthy values in family institutions and family dynamics based on the family structure and function (Susanto et al., 2018). The government of Indonesia designed the Indonesian Healthy Program through Family approach (IHP-FA) (Ministry of Health Republic of Indonesia, 2016a). This program is realized through the fifth agenda of the 10 Indonesia's president agenda (called in Bahasa Indonesia: Nawa

Setting and sample
This study was conducted in May 2019 in Jember regency, East Java, Indonesia. Fifty-five coordinators of PHN program from 50 PHCs in Jember were recruited, involving at least 1 PHN from each PHCs. The data from the Department of Public Health of Jember reported that the achievement of PHN services was only 44.87% of caring for community groups from 50 PHCs (Susanto et al., 2019). Therefore, all coordinators of PHN program from 50 PHCs were included to do an assessment on their competencies. The inclusion criteria in this study were the coordinator of PHN program, length of duties as the coordinator of PHN program was at least 3 months, and had a license of coordinator of PHN program.

Measurement and data collection 2.3.1 Tools development
The core competencies of PHN in this study were developed based on the five core IPHN competencies (including activities in PHCs and nursing care for follow-up patients, family, special needs group in the community, and community) with regard to the regulation from the Ministry of Health of Indonesia in 2006 (Ministry of Health Republic of Indonesia, 2006). These competencies consist of 35 items that are divided into five core competencies, including activities in PHCs (9 items), nursing care for follow-up patients (7 items), nursing care for family (7 items), nursing care for special needs group in the community (5 items), and nursing care for community (6 items). For developing the tool in this study, the IPHN competencies were accessed using a Likert scale (always=4; often=3; sometimes=2; and never=1). Then, all of the items from the questionnaire were summed to obtain the total score of IPHN and the overall score of five cores of IPHN, respectively.

Measurement
A self-administered questionnaire was used to measure the sociodemographic data of the coordinators of PHN program (including age, gender, educational background, profession status, length of becoming of the coordinator of PHN program, occupation status, PHN training program, and experience of working in a hospital). The IPHN competencies were measured using the PHN competencies developed by the researchers as described in the previous section (tool development).
For the IHP-FA program, we used the IHP-FA from the Ministry of Health of Indonesia in 2016 (Ministry of Health Republic of Indonesia, 2016a). The IHP-FA was measured using 12 indicators (including family planning, safe birth delivery, immunization, exclusive breastfeeding, growth and development, management of tuberculosis, management of hypertension, rehabilitation mental illness, smoking, coverage health insurance, access to clean water, and healthy sanitary). The secondary data of the IHP-FA report were also accessed in this study as reported by PHNs monthly to the Department of Public Health of Jember regency from 50 PHCs.
For the purpose of data collection, 55 coordinators of PHN program from 50 PHCs were invited to attend this study in the Department of Public Health of Jember Regency. These participants were informed of the aim and procedures of this study. They signed informed consent for their participation.

Data analysis
This study used descriptive and correlational data analyses. Descriptive statistics included frequencies and percentages for summarizing categorical measures. Then, median and standard deviation were used for summarizing continuous measures.
Content Validity Index (CVI) was employed to determine item validity (Polit & Beck, 2017). Three experts of community and family health nurses were asked to rate each of the 35 items of IPHN competencies based on relevance and clarity for measuring the PHNs duties for PHN services to achieve healthy programs in the PHCs. The questions rated employed a four-point Likert scale with a score of 1 meaning not relevant, a score of 2 meaning somewhat relevant, a score of 3 meaning quite relevant, and a score of 4 meaning highly relevant. The survey's internal consistency was assessed using Cronbach's alpha. In reliability analysis, means and standard deviations of the items were examined to measure the item difficulty for judgment and Nurse Media Journal of Nursing, 11(1), 2021, 74 Copyright © 2021, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 endorsement purposes, while the item-total correlation was employed to examine item discrimination (Susanto et al., 2018).
Finally, construct validity using the known-groups technique was performed to refer to an instrument's ability to differentiate between the coordinators of PHN program competencies on the achievement of IHP-FA. A Pearson's product moment was used to measure the correlational between coordinators of PHN program competencies and indicator of IHP-FA. To determine the statistical significance based on the assumption of the appropriate test was performed using a two-tailed significance level of 0.05.

Ethical considerations
This study was approved by the Institutional Review Boards (IRB) of the Faculty of Dentistry, Universitas Jember, Indonesia (reference number 189/UN25.8/KEPK/DL/2018). All participants signed informed consent for their participation. Table 1 shows that the mean age of the participants was 37.1 years, and the mean of length of becoming PHN coordinator was 10.9 months. The majority of the participants were males (60%) and hold Diploma 3 of nursing/midwifery (60%). Regarding the core competencies for IPHN standard from three expert panels, the content validity index indicated adequate content validity (0.80-0.10).  Table 2 indicates that the core competencies of IPHN standards had high reliability (Cronbach's alpha coefficient=0.814), including activities in PHCs (Cronbach's alpha=0.961), nursing care for follow-up patient (Cronbach's alpha=0.946), nursing care for family (Cronbach's alpha=0.974), nursing care for special needs group in community (Cronbach's alpha=0.963), and nursing care for community (Cronbach's alpha=0.966). In Figure 1 (see Appendix 1), from 12 indicators of IHP-FA, the top three achievements of PHN activities were 89.6% for health care of mental illness patients, 86.1% for family planning with contraceptives and 82.7% for birth delivery with midwifery. Table 3 indicates that there was a significant correlation between the five core IPHN competencies (for activities in PHCs, nursing care for follow-up patient, nursing care for family, nursing care for special needs group in the community, and nursing care for the community) and the achievement of IHP-FA (p<0.05). However, there was no correlation between the total score of five core IPHN competencies and the achievement of IHP-FA (p>0.05). The core competencies of PHN for activities in PHCs were correlated with safe birth delivery with midwifery, basic immunization for under-five children, and monitoring growth and development of under-five children. Meanwhile, core competencies of public health professionals for nursing care for follow-up patients were correlated with safe birth delivery with midwifery, basic immunization for under-five children, monitoring growth and development of under-five children, management of tuberculosis patients, and access to clean water. Then, core competencies for nursing care for family and nursing care for the community were correlated with safe birth delivery with midwifery and stopping smoking habit in the family. Furthermore, the core competencies of PHN for nursing care for special needs groups in the community was only correlated with stopping smoking habits in the family.

Discussion
The IPHN competencies are a valid and reliable instrument for measuring the coordinators of PHN program' duties and PHN services to achieve healthy programs in the PHCs and predict the achievement of IHP-FA. The competencies contained 35 items with five core competencies (including activities in PHCs, nursing care for follow-up patient, nursing care for family, nursing care for special needs group in the community, and nursing care for a community) with adequate content validity (0.8-0.10), and high reliability (overall Cronbach's alpha=0.84). The five core competencies of IPHN are correlated with the achievement of IHP-FA, although some of the core competencies are not predictable for the achievement of IHP-FA.
The IPHN competencies that contained 35 items with five core competencies are valid and reliable, although the items are different from the Quad Council Practice Competencies (QCPC) for PHN (Swider et al., 2013). QCPC for PHN consisted of eight core competencies with a total 79 of items (including analytic and assessment skills, policy development/program planning skills, communication skills, cultural competency skill, the community of dimensions of practice skills, public of health sciences skills, financial management and planning skills, and leadership and systems thinking skills) and ten domains competencies of primary health care professional (professional values, communication, teamwork, management, community-oriented, health promotion, problem-solving, health care, and education and basic public health sciences) (Witt & de Almeida, 2008). Whereas in this study, the IPHN competencies include five core competencies with 35 items, such as activities in PHCs, nursing care for follow-up patient, nursing care for family, nursing care for special needs group in the community, and nursing care for community (Ministry of Health Republic of Indonesia, 2006). However, a previous study reduced the QCPC for PHN to six factors that integrated important concepts of both the nursing process and the intervention wheel (Reckinger et al., 2013). The differences in this competencies may be explained that IPHN competencies are just focused on the duties of coordinators of PHN program for their activities in PHN services. The five core competencies of IPHN are included in both of the core competencies of the QCPC for PHN (including analytic and assessment skills and community of dimensions of practice skills) (Widyarani et al., 2020). Therefore, the IPHN competencies should be developed that used confirmatory factor analysis with QCPC for PHN.    Our finding indicated that the core competencies of coordinators of PHN program for activities in PHCs were correlated with safety birth delivery with midwifery, basic immunization for under-five children, and monitoring growth and development of under-five children. It is similar with a previous study that the overall level of competency of QCPC was most strongly associated with the duration of professional experience in rural areas (Bigbee et al., 2010). This situation shows that the majority of IPHNs work in rural areas, in which the major health problems are maternal and child health care (Susanto, 2018). Therefore, the IPHC competencies could be implemented for PHNs to perform their activities of PHN services in rural areas.
Meanwhile, the core competencies for nursing care for follow-up patients were correlated with safety birth delivery with midwifery, basic immunization for under-five children, monitoring growth and development of under-five children, management of tuberculosis patients, and access to clean water. This indicates that so far, the health services provided by the coordinators of PHN program have focused on completing Indonesia's national agenda in reducing maternal and child mortality (Ministry of Health of Republic Indonesia, 2016a), although several infectious diseases in Indonesia have yet to finish the program (Ministry of Health of Republic Indonesia 2018), and clean and healthy living behavior in Indonesia still low (Susanto et al., 2016). This is likely because the case finding and prevention of some infectious diseases have not been optimal (Susanti et al., 2018). Thus, the tools of competencies of IPHN should be sensitive to measure their activities for preventing communicable diseases.
Then, the core competencies for nursing care for family and nursing care for the community were correlated with safe birth delivery with midwifery and stopping smoking habits in the family. These results are relevant to the previous study that the core competencies model of PHN could predict the family planning program (Hewitt et al., 2014). However, some negative behavior, such as smoking, has begun to be identified as the cause of health problems (Susanto & Widayati, 2018). This indicates that coordinators of PHN program need to conduct regular and continuous home visits in providing nursing care services to reach the level of family independence in solving their health problems. The level of family independence is the main goal of providing family nursing care in facilitating the continuity of family functions (Ministry of Health of Republic Indonesia, 2006). Therefore, family empowerment needs to be carried out optimally by coordinators of PHN program to solve the health problems of fostered families.
Furthermore, the core competencies for nursing care for special needs groups in the community was only correlated with stopping smoking habits in the family. This result is similar with previous studies that chronic diseases and non-communicable diseases is a health problem in the rural area as a state of health transition related to smoking behavior (Low et al., 2015;Ng, 2006). However, smoking regulation needs appropriate bargaining through the government institutions, as previous research indicated that the competence of coordinators of PHN program is required for the management of policies and organizations (Polivka & Chaudry, 2015). Therefore, skills in negotiation and organizational planning need to be developed in PHN services.

Implication and limitation
The IPHN competency instrument developed in this study can be used as a reference in measuring the performance of PHNs in Indonesia. The results of this pilot study could be used by the government, especially the health office, in developing the competencies of coordinators of PHN program in PHCs. This tool could also be used for evaluating the performance of the coordinators of PHN program in carrying out the HIP-FA. However, it can only estimate the tasks and obligations that must be performed at PHCs. In order to be able to measure more broadly, the competency standard of PHN in Indonesia needs to be developed again related to other dimensions by referring to the QCPC for PHN. Therefore, the achievement of IHP-FA can be accelerated in its completion.
This study has some limitations. First, PHN competencies developed in this study only used the IPHN competencies, so the results cannot be generalized. For this reason, further research can conduct explanatory and confirmatory factor analysis between IPHN competencies and QCPC for PHN. Second, the research is only conducted in one region in Indonesia; therefore, it needs to be conducted in a larger population in order to measure the achievement of IHP-FA.

Conclusion
The IPHN competencies contain valid, reliable, and psychometrically robust measures. However, some programs in IHP-FA could not be achieved with the five core competencies of IPHN, demonstrating the need for developing the IPHN competencies in the future. The IPHN competencies are very important to be a standard for achieving the 12 indicators of IHP-FA. Therefore, developing the PHN core competencies of IPHN should be standardized in the Indonesian setting. Subsequent research to focus more on confirmatory and explanatory factor analysis between the IPHN and QCPC for PHN is necessary; therefore, IPHN competences can measure PHN services in PHCs in achieving the IHP-FA.