EMPOWERING CAREGIVERS TO IMPROVE QUALITY OF LIFE OF ELDERLY IN A SOCIAL INSTITUTION IN LAMPUNG PROVINCE, INDONESIA

Elderly Quality of life is a crucial issue for the aging population in developing countries like Indonesia. Studies found that institutionalized elderly have a lower quality of life than in the community. The caregiver’s role in the social institution could be important as social support to enhance the quality of life of the elderly. This study is to empower the caregivers to improve the quality of life of the elderly in a social institution. A mixed methods exploratory sequential design was used in this study.The WHO-QOL Old questionnaire was used to examine the quality of life and Duke Social Support for social support. Sample for qualitative were seven participants who had experiences that could be explored in detail about their living in a social institution, and 72 participants for quantitative measures. The qualitative findings found four main themes that related to elderly experience living in social institutions, support from caregivers, and facility theme was strongly discussed. As for quantitative findings, after the four-month intervention, the score of elderly quality of life before intervention was 45,97 and after intervention 51,54 (p value>0,00), it means empowerment of caregivers significantly improves the quality of life in a social institution. The empowerment of caregivers as social support for the elderly in social institutions has been proven to improve the quality of life of the elderly in social institutions. However, recommendations are suggested including monitoring systems and policy from the management of social institutions need to maintain sustainability programs. caregiver


INTRODUCTION
Indonesia is in the category of an aging population, this is because the percentage of the elderly population in Indonesia, according to the National Socioeconomic Survey (2016), amounts to 8.69% of the Indonesian population (Risandini & Silvi, 2021). From the data, 49.77% have health complaints, with the morbidity rate in 2016 being 27.46%, meaning that from every 100 older adults, there are 27 of them experience illness (Elgar et al., 2021). (RI, 2015), this is could have happened to the elderly who live in a social institution. However, social institutions that take care of the elderly are supposed to have a program for the elderly to avoid them from being ill, including medication, activity programs, and caregiver support. But, most programs cannot provide complete services, causing a lack of financial support and lack of knowledge and skills of their caregiver. That is why the empowerment of other elderly residents and caregivers becomes important, we need support participation among the elderly and the entire component to improve the quality of life of the elderly Gunawan Irianto 1 , Mohamad Hussain Habil 2 , Farida Hashim 3 Empowering Caregivers To Improve Quality Of Life Of Elderly In A Social Institution In Lampung Province, Indonesia in a social institution (Tebb, 1995). This study's aim was to improve the quality of life of the elderly in the social institution by empowering the caregiver

METHOD
The research design used a mixed-method with an exploratory sequential design (Subedi, 2016). The design of quasi-experimental implemented in this study was a time-series design, In timeseries designs, several assessments (or measurements) are obtained from the treatment group which occurs prior to and after the application of the treatment. In this study, the experience the of elderly while their living in social institutions had been explored and continued with measuring the quality of life and social support for the elderly before and after the intervention. Intervention for the elderly had been held for four months by a social support model from a caregiver (Thompson Jr et al., 1993). Before giving an intervention caregivers had been trained for one month to improve their knowledge and skill for taking care of the elderly. Caregivers also had been taught to use an application online based name 'Gerocare' to assist them and made a daily report while they interacted with the elderly in social institutions

RESULTS AND DISCUSSION A. Qualitative Phase
A qualitative study had been done to know the theme of living experience that correlated to the quality of life of elderly who lived in a social institution. As seen in the table. 1 there are Distribution frequencies of 4 (four) themes that have been discussed as living experiences of the elderly in a social institution.

Table 1. Distribution Of Theme Of Living Experience In A Social Institution
As shown in table 1 main themes that have been the elderly experience in social institutions namely activity, facilities, other resident support, and support from caregivers. It shows that facilities theme have been discussed as same as other resident support (30%). Meanwhile, support from caregivers has been discussed next (26.09%).
To know the main themes that have a strong relation to elderly experience in the social institution could be seen in this table 2.

Table 2. Relationship Of Themes On Elderly Experience In Social Institution
As seen on this table 2, could be seen that support from caregivers and facilities have strong relationship. It mean that elderly have strong experience on support from caregivers and facilities that they recived in social institution.

B. Quantitative Phase
Quality of life of elderly before (pre) and after (post) intervention with 4 (four) times measurement (timelines) can be seen in table 3 below. As seen in Table 3, the impact of the intervention on the quality of life of elderly in social institutions significantly improved p-value 0,00 (p<0,05), mean score before intervention was 45,97 and it has been improved to 51,54.
We could also known the correlation between intervention and quality of life of elderly as seen in table below. As seen in table 4 correlation between Intervention (empowerment of caregiver) and quality of life for the elderly had a strong correlation, with r = 0.959 or strongly correlated. It means empowering the caregivers affected the quality of life of the elderly in a social institution (p-value = 0.00).

C. Support From Caregivers
Based on the qualitative findings of this research, support from caregivers was strongly correlated wiyh elderly experience in social institution. Most of the respondents said that their caregiver rarely visit them in Wisma, so they couldn't talk and get what they need from their caregiver. Other respondents said that they didn't know what they have supposed to do when they got sick, they just get basic medicine from the clinic but rarely meet the Doctor and just the nurse.
This condition made the elderly in social institutions not observe well and impact the lowering of the physical health status of the elderly (Morrow-Howell et al., 2003). A study showed by (Triantos, 2005), found in his research that the institutionalized elderly were more medically complicated and, 15 times more likely to have depression than non-institutionalized. Similar to this finding, the health status of the elderly in Indonesia also showed that elderly who lived in the social institution have worse general health status than those who lived in their family (Maulana. et.al, 2020) Most caregivers in Social institutions did not have a health education background, especially for taking care of the elderly (Scharlach et al., 2000). In this research, all of their educational backgrounds were from junior or senior high school (PSLU, 2020). Even they had been working as caregivers for more than 2 years but they do not have the knowledge or skill to take care of the elderly. Nevertheless, it could be improved by delivering knowledge and skill to the caregiver about caring to the elderly by educating activity.
Improving knowledge and skill to take care elderly by educating like training program could be effective (McPherson et al., 2001). In this research, the result showed that giving education to the caregiver with training program by using the handbook to caring elderly for the caregiver in knowledge and skill aspect on the aging process, communication, helping self-care, helping daily activity, the mental health of elderly and helping on common health problem on elderly has been improved effectively with P-value 0,00 (P<0,05).
In line with this result lt, a study from (Navarro et al., 2021), by using module training and SSFQ (Star Staf Feedback Quessionaire) showed that caregivers in the treatment group believed the program modules were useful, giving it a mean score of 4.86 (SD = 0.378) on an ordinal scale of 0 to 5 and mentioning that their participation in the program had been a very positive experience and had contributed to increasing their professional knowledge, satisfaction and confidence.
Lack of support from caregivers to the elderly not only because of deficiency of knowledge of caregiver to take care of elderly in the social institution but also due to the lack of supervision from social institution management on the performance of its employees, in this case, are the caregivers. A study on caregivers or nursing assistance in the nursing home showed Gunawan Irianto 1 , Mohamad Hussain Habil 2 , Farida Hashim 3 Empowering Caregivers To Improve Quality Of Life Of Elderly In A Social Institution In Lampung Province, Indonesia that A frequent complaint and source of stress voiced by nursing assistants or caregivers is the lack of supervision and feedback on their performance of task activities (Burgio & Scilley, 1994).
Therefore, in this study, the researcher has been developed a system to make the performance of caregivers could be controlled and supervised by the management of social institutions by using an application android -base, namely GEROCARE (see. Appendix 15). This application also could be a tool for the caregivers to took care of more easily cause they could see what they should do to the elderly based on the condition of the elderly. A previous study from Efendi et.al (2021) empowering the caregivers to take care elderly by using a smartphone has shown that it improves the knowledge of caregivers and can be used as a guide for family/caregivers in carrying out care in the elderly.
As a result showed, applying the application of GEROCARE to assist caregivers in their work improved daily performance, cause they know what should they do with the elderly, and being supervised by management and the nurse also impact their clients, which are the elderly. Showed from 2 main indicators of this study were quality of life and social support of the elderly improved significantly.

D. Impact of Empowerment of Caregivers to The Quality of Life of Elderly in Social Institution
The effectiveness of the implementation of empowering the caregivers using the social support model which was carried out for 4 months on the quality of life of the elderly in the nursing home was quite effective, the results showed that there was a difference in the average value of the quality of life of the elderly before and after the implementation of this model with a p-value of 0.00 (p < 0.005), meaning that there is a significant difference in the quality of life of the elderly before and after the application of this method. This condition is in line with previous research from (Sahar et al., 2019), explained that there were significant changes in the quality of life and function in the elderly in nursing homes after the implementation of the Miradasia nursing model in elderly social institutions in Jakarta.
In this study, the implementation of empowerment caregivers using social support model can improve the quality of life of the elderly by implementing a partnership between nurses, the elderly, and caregivers. However, improving the quality of life of the elderly does not mean that it is always accompanied by an increase in the health and functional status of the elderly in nursing homes, because this is because the elderly experience a decrease in body function along with increasing age (Farage et al., 2012). There is 78 elderly at the Natar Social Institution for the Elderly and 30 of them are admitted to the treatment room with various health problems, such as hypertension, gout, diabetes to dementia (PSLU, 2021).
The quality of life of the elderly in nursing homes can be influenced by several factors, namely physical, social, psychological, environmental factors with psychological factors that are the most dominant influencing the quality of life of the elderly in nursing homes (Rohmah & Bariyah, 2012). Psychological problems in the elderly in social institutions are very important to pay attention to, this is considering that the elderly in social institutions are the elderly who are neglected or homeless, do not have a family, and do not have a job, which are factors that trigger mental problems in the elderly in the social institution (Sahar et al., 2019).
For this reason, this model as a form of partnership between nurses, the elderly, and caregivers is a comprehensive solution to improve the quality of life for the elderly, where every party in the social institution can work together and optimize their respective roles (Ekwall et al., 2004).

CONCLUSION
The quality of life of the elderly in social institution tend to be lower because they do not have any support from other family members, this condition could stimulate health problem for the elderly. The nearest support system for the elderly in social institutions would be from their peer or other elderly who live in the same social institution and also the caregivers who take care of them while they're living in a social institution. Therefore, it is necessary to develop a social support system that could stimulate social participation for the elderly, empowering the caregiver by giving their training to improve their knowledge and skill in taking care elderly would be a strategic intervention to achieve a better quality of life of elderly in a social institution