Implications

134 QOL model (Bakas et al., 2012).

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In Indonesia, ‘CERDIK’ behaviors (i.e. health check-up, non-smoking, physical activity, healthy diet, rest, stress management) are recommended in order to prevent NCDs and promote health (Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan, Kementerian Kesehatan Republik Indonesia, 2013). However, there are issues in community health activities in Indonesia for the prevention of NCDs and

promotion of health. These are: limited implementation of NCDs prevention programs and activities (Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan, Kementerian Kesehatan Republik Indonesia, 2012); and health promotion for NCDs is not integrated into primary health care programs (Kementerian Kesehatan Republik Indonesia, 2011).

As a primary health care program, it is important to provide health education focusing on salt reduction at community settings like Puskesmas (community health center) and Posbindu (community health post).This is because there is evidence that salt reduction decreases blood pressure (Graudal et al., 2011; He et al., 2013; Hooper et al., 2004). This is also because our study indicated seeking health information is a key for salt reduction, which is similar to a literature review conducted in low- and middle-income countries that health education focusing on salt reduction was a key element for controlling hypertension (van de Vijver, Oti, Addo, de Graft-Aikins, & Agyemang, 2012). Heath professionals who work at Puskesmas and Posbindu should provide the community people with concrete information about salt reduction and hypertension e.g. relation of salt and raised blood pressure, the amount of salt in food in the district, choosing food by checking nutritional label, and choosing food that can be a substitution for salty food.

2) Supporting core health behaviors to promote necessary health behaviors for NCDs prevention and health promotion in collaboration with social and religious leaders.

It is important for people to seek health information with support from the Kader (health volunteer). This study indicated that the Kader supported people in seeking health information. This result is similar to an existing randomized control trial which showed that community health workers supported salt reduction of Mexican American people

(Balcazar, Byrd, Ortiz, Tondapu, & Chavez, 2009). Thus, it is necessary for community

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health nurses to work with the Kader for NCDs prevention and health promotion in community settings.

It is also important for the people to be supported by social and religious leaders. Our study indicated that fulfilling obligation to God, one of the core health behaviors, was influenced by Islamic spiritual support. The district’s health professionals pointed out that unhealthy behavior like smoking was influenced by social role models like religious leaders. Indonesian Ministry of Health regarded the importance of increasing awareness and participation of religious leaders for health promotion (Kementerian Kesehatan Republik Indonesia, 2011). In Indonesian within the Muslim women’s community, female preachers provide not only religious advice but also family counseling, education, care for the poor, and medical services (van Doorn-Harder, 2006). Moreover, there is a project in which ulama (Islamic religious leaders) work as mediators and discuss HIV/AIDS problem with Muslims at mosques, schools and community centers to increase awareness of people’s attitudes towards HIV/AIDS issues (Wagener, 2006). Therefore, it is important for community health nurses to work with social and religious leaders to provide health care program for people for NCDs prevention and health promotion at community settings.

3) Creating healthy environment to reduce salt intake.

The study results indicated that reducing salty food was influenced by environmental barriers to practice healthy eating. Actually, during the author’s stay in the district, it was difficult to find salt-reduced food or sugar-reduced drinks at stores and restaurants in the district. It is important not only to provide health information for individuals but also to create a healthy environment for people to choose healthy behaviors. Existing studies found that salt reduction of food had effect in reduction of blood pressure (Ferrante et al., 2011;

Nakamura, Aoki, Yamada, & Kubo, 2003; Peng, 2014) and is a cost-effective intervention (Wang & Labarthe, 2011). Because restriction of salt can impact people who are not interested in their health and healthy eating, a broader public health approach should be taken and therefore it is important for health sector to cooperate with industry and food sector to provide people accessibility to healthier food.

2. Strengthening nursing education to improve the health program of NCDs prevention and health promotion.

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Nurses play an important role for NCDs prevention and health promotion at community settings. For example, there is evidence that nurses contributed to smoking cessation and health promotion in community settings (World Health Organization, 2012a). In order to improve health programs for NCDs prevention and health promotion in the district, competence of nurses should be strengthened. The author explains implications as follows:

1) Including noncommunicable disease as a national standard of the role for community health.

In Indonesia, NCDs prevention and control are not clearly included in the national standards of the six community health programs. The six programs include: health promotion, maternal and child health, nutrition, communicable diseases, healthy environment, and treatment (Kementerian Kesehatan Republik Indonesia, 2006a).

Therefore, it is necessary to integrate NCDs into the national standard of community health programs.

2) Including adult nursing, nursing for noncommunicable diseases and interprofessional education into the district’s basic nursing curriculum.

Globally and nationally, health care with a life-course perspective is important for NCDs prevention and health promotion (Kementerian Kesehatan Republik Indonesia, 2011; World Health Organization, 2013c). Consistent with other countries, risk for NCDs increase with people aged over 40 years in Indonesia (Kementerian Kesehatan Republik Indonesia, Politeknik Kesehatan Palembang & Prodi Keperawatan Lubuklinggau Palembang, 2012).

Thus, it is important to provide health education for adults especially middle-aged people.

However, there is no subject addressing adult nursing in the national standard of basic nursing education curriculum (Departmen Kesehatan Badan Pengembangan dan Pemberdayaan Sumber Dana Manusia Kesehatan, 2006). The subject of medical surgical nursing includes nursing care for people with diseases. Therefore, it is important to include adult nursing into the basic nursing curriculum which provides education such as stages of human development, NCDs prevention and health promotion, and andragogy to provide health education for an adult population.

Moreover, the district’s basic nursing education curriculum should include nursing care for the specific district’s health needs in order for nurses to address the district’s own health

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needs. In Indonesia, in addition to the national standard of subject and credits, there are 14-24 credits that can be added by each institution (Departmen Kesehatan Badan Pengembangan dan Pemberdayaan Sumber Dana Manusia Kesehatan, 2006). Thus, it is important to include nursing care for the emerging district health needs i.e. NCDs into the additional credits.

Further, recently, there is an increasing necessity of interprofessional collaboration to work together with community to provide the highest quality of care (World Health Organization, 2010b; World Health Organization Country Office for Indonesia, 2013). As aforementioned, it is important to work collaboratively with the Kader and social and religious leaders. Community health nurses in West Java also regarded that collaboration with other health professionals were key for effective community health activities (Personal interviews with community health nurses at Bandung, West Java during internship at WHO-Indonesia, June 2013). In Indonesia, University of Indonesia began implementing interprofessional education in 2013 (World Health Organization Country Office for Indonesia, 2013).

Subsequently, other universities have also started to integrate interprofessional education to bachelor’s program in nursing (Personal interviews with nursing faculties at Padjadjaran University and Muhammadiyah University Yogyakarta, June & December, 2014). The bachelor’s program in nursing in this district also needs to include the education in order for nursing students to prepare to work together with health professionals at community settings.

3) Including nursing for noncommunicable diseases at community setting and nursing research into the district’s advanced-level nursing curriculum.

Although NCDs are an increasing health issue, community health nurses in West Java perceived a limited opportunity to learn about NCDs (Personal interviews with community health nurses at Bandung, West Java during internship at WHO-Indonesia, June 2013).

Compared to the previous national basic nursing curriculum (Kementerian Pendidikan dan Kebudayaan Republik Indonesia, 1999), credits for community nursing have decreased in the current national basic nursing curriculum (Departmen Kesehatan Badan Pengembangan dan Pemberdayaan Sumber Dana Manusia Kesehatan, 2006). The World Health Organization (2013a) recommends, practicing a population-based approach, community-wide changes in unhealthy behaviors targeting community, and a focus on the

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worksite to reduce hypertension. Therefore, it is necessary for community health nurses to be competent not only in case management of risk groups but also in NCDs prevention and health promotion for the whole community. Continuous education such as the burden of NCDs, behavioral counseling, NCDs prevention and health promotion in community settings should be provided at an advanced-level of nursing education.

In addition, the district’s health professionals pointed out that there were limited surveys regarding health behaviors related to NCDs (Tashiro et al., 2014). Globally, it is necessary for nurses to conduct surveys on risky health behaviors, evaluation of current practice, and best strategies to address NCDs (World Health Organization, 2012a).

Therefore, it is important for nurses in the district or province to have competence in nursing research at advanced-level of nursing education.