Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11728 The effect of pregnant mother assistance on stunting prevention behavior Nursyahid Siregar, Evy Nurachma, Siti Raihanah Department of Midwifery, Politeknik Kesehatan Kemenkes Kalimantan Timur, Indonesia Abstract Stunting, a consequence of prolonged inadequate nutrition, often due to improper feeding practices, was a significant health issue. This study aimed to investigate the impact of maternal assis- tance on behaviors aimed at preventing stunting. The research employed a pre-experimental design with a one-group pre-test and post-test for 32 pregnant women attending a Samarinda health center. Data collection utilized structured questionnaires evaluat- ing knowledge, attitudes, and actions. The result of the study revealed that most participants were aged 18-25, had a high level of education, and were housewives. A majority had an income exceeding 2,868,081 units, were primigravida, and lived in nuclear families. Notably, maternal assistance significantly improved stunting prevention behaviors, as evidenced by a p- value of 0.005. This study emphasizes the positive impact of pro- viding comprehensive support, including education and counsel- ing, to pregnant women. Such assistance could enhance knowl- edge, attitudes, and actions related to stunting prevention. Health professionals should prioritize this support to reduce the risk of stunting among children and promote maternal and child health. Introduction Stunting is a chronic malnutrition problem caused by pro- longed insufficient nutritional intake, often resulting from inade- quate feeding practices that do not align with nutritional needs.1,2 It’s worth noting that stunting can manifest from fetal develop- ment and becomes evident in children around the age of two.3,4 Short stature in toddlers, commonly referred to as stunting, is a widespread nutritional issue affecting children worldwide.5 Inadequate nutrition during pregnancy and the first year of life can have lasting effects on brain development. The prenatal period is marked by rapid brain development, which continues into early childhood.6 Research reveals that newborns possess approximate- ly one hundred billion brain cells, and the maturation and forma- tion of neurological connections occur progressively from birth to early childhood. Insufficient nutrition during this critical period can lead to neurological abnormalities, developmental disorders, and impact motor, cognitive, language, socio-emotional abilities, and even result in mental retardation.7 Motor function decline in stunted children without congenital abnormalities is associated with the underdevelopment of the triceps surae muscle, hampering their motor abilities.8 In 2017, approximately 22.2% of the global toddler popula- tion, roughly 150.8 million children, experienced stunting. However, this figure represents an improvement compared to the stunting rate in 2000, which stood at 32.6%.8,9 Indonesia, in par- ticular, faces a high prevalence of stunted children, with national data from Riskesdas in 2018 indicating a prevalence of 30.8%. This represents a decline from 37.2% in 2013 to 30.8% in 2018.10 While Indonesia has made progress, the prevalence remains rela- tively high compared to the World Health Organization’s (WHO) benchmark of less than 20%, highlighting the need for continued attention.9 In East Borneo, the prevalence of stunting, as per data from the East Borneo Health Office in 2017, stands at 30.6% among toddlers. Although this percentage is below the national Correspondence: Nursyahid Siregar, Department of Midwifery, Politeknik Kesehatan Kemenkes Kalimantan Timur, Indonesia E-mail: siregarnursyahid@yahoo.co.id Key words: assistance; pregnant; prevention; behavior; stunting Contributions: NS, Conceptualization, Investigation, Data Curation, Formal Analysis, Methodology, Validation, Writing – Original Draft, Review & Editing; EN, Conceptualization, Methodology, Validation, and Writing – Original Draft, Review & Editing; SR, Conceptualization, Methodology, Formal Analysis, Validation, and Writing – Original Draft, Review & Editing;. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Commission, Poltekkes Kaltim, based on ethical certificate LB.02.01/7/ 2068/2021. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research was supported by a research grant from Poltekeks Kaltim with contract number PP.03.01/1.1/32997/2020. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: we would like to thankful to all parties involved in this research Received: 9 September 2023. Accepted: 11 October 2023. Early access: 23 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11728 doi:10.4081/hls.2023.11728 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2023; 11:11728] [page 51] Non -co mmerc ial us e o nly average, it still exceeds the WHO standard of 20%, making it a sig- nificant health concern.11 Assistance for pregnant women encompasses activities such as education, nutrition guidance, and health counseling designed specifically for pregnant women.12 This support also extends to services and assistance, all aimed at preventing stunting through individual and group approaches.13 Assistance involves various actions, including paying attention, delivering messages, encour- agement, providing advice or solutions, offering services, refer- ring, mobilizing, and collaborating to empower pregnant women. Consequently, this research seeks to examine the impact of Pregnant mother assistance on stunting prevention behavior within a health center in Samarinda. Previous studies offer valuable insights into the potential ben- efits of nutrition education and counseling for pregnant women. For instance, research in the West Gojjam Zone, Ethiopia, demon- strated that pregnant women who received nutrition education were 2.02 times more likely to improve their dietary practices compared to those who did not receive such education.13 Another study in Katenga-Kauda indicated that knowledge about nutrition and consumption of diverse foods increased in both study groups but was notably higher in the intervention group.14 Furthermore, a study by Yurni revealed that two weeks of balanced nutrition edu- cation in two sessions increased respondents’ practice of selecting a balanced menu by 7.7 percent.15 Intensive nutritional counseling, employing leaflet media, has proven to be an effective method for enhancing pregnant mothers’ knowledge.16 This research aimed to assess the influence of pregnant mother assistance on stunting pre- vention behavior within a health center in Samarinda. By building on previous studies and addressing the critical issue of stunting in toddlers, this research endeavors to contribute to the broader efforts aimed at improving maternal and child health outcomes. Materials and Methods Design The research design employed in this study follows a pre- experimental approach, specifically utilizing a one-group pre-test and post-test design. This design entails conducting an initial assessment (pre-test) before the intervention or treatment and then a follow-up assessment (post-test) after the intervention. Sample The study employed consecutive sampling, selecting pregnant women in their first to third trimesters who met the criteria for nor- mal pregnancies and completed all questionnaire items related to stunting prevention at both pre-test and post-test stages. A total of 32 participants comprised the study’s sample size. Regarding the intervention procedure, pregnant women received assistance through direct education using visual aids such as flip sheets and informative leaflets during their visits to health- care facilities. This educational and counseling approach aimed at stunting prevention involved two-way communication, fostering an interactive dialogue to enhance knowledge. This process served as the initial step in facilitating behavioral change towards stunting prevention. Instruments The study utilized a questionnaire to assess the attitude and behaviour of pregnant women. In order to analyze the data descrip- tively, we established a measurement scale using attitude and behavioural instruments. Attitudes Participants responded to statements related to stunting during pregnancy, with 20 items in the questionnaire. Half of these items (1, 5, 6, 7, 10, 11, 12, 17, and 18) were framed positively (+), while the remaining half (2, 3, 4, 8, 9, 13, 14, 15, 16, 19, and 20) were framed negatively (-). We employed a Likert-Scale rubric to assign scores, where for negative statements: Extremely Agree (EA) was scored as 0, Agree (A) as 1, Doubt (D) as 2, less agree (LA) as 3, and extremely disagree (EDis) as 4. Conversely, for positive state- ments, the scoring was the opposite: Extremely Agree (EA) was scored as 4, Agree (A) as 3, Doubt (D) as 2, Less agree (LA) as 1, and extremely disagree (EDis) as 0. All individual scores were then summed, and the total scores were classified as ‘good’ (>65) or ‘poor’ (<65). Behavior Behavior refers to actions taken by pregnant women both dur- ing and after childbirth related to stunting prevention. It was indi- cated by various factors such as pregnancy examination visits, bal- anced nutritional consumption, iron tablet intake, early breastfeed- ing initiation, and exclusive breastfeeding. Each participant’s behavior was rated on a scale of 0 to 5 based on a combination of these five indicators. ‘Good’ behavior was defined as scoring 2 or higher, representing adherence to at least four of these indicators, while ‘poor’ behavior was assigned to those scoring 1, indicating adherence to fewer than four indicators. Analysis The paired t test was used to analyze the data. The level of sig- nificance used in this test is a p-value of  0.05 at 95% confidence. The variables measured are the knowledge, attitudes, and actions of pregnant women in preventing stunting. The measuring tool used is a questionnaire. Measuring behavioral changes (knowl- edge, attitudes, and actions) in efforts to prevent stunting with questionnaires measurement results using ratio data. All questions have valid status because the value of r-count (Corrected Item- Total Correlation) is greater than table >0,468. Ethical clearance Ethical test at the Poltekkes Kaltim ethics committee with number LB.02.01/7/2068/2021. After obtaining prospective research respondents, the researcher first explained research infor- mation and ethics in research to the subject regarding the benefits and objectives of the research, time, and research procedures. The researcher also explained to the subjects who were willing to be respondents to sign the consent form; if they did not sign, they would not be used as research respondents. Researchers also explained that the subject has the right to withdraw as a research subject and not be given any sanctions or treatment. Results Frequency distribution of demography characteristics of all variables. Table 1 provides a comprehensive overview of the demograph- ic characteristics of the pregnant women participating in this study. It reveals that a substantial proportion of the participants fell with- in the 18–25 age bracket, with 14 individuals (43.7%) belonging to [page 52] [Healthcare in Low-resource Settings 2023; 11:11728] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly this age group. Moreover, a notable percentage, consisting of 14 participants (43.8%), possessed a higher level of education, while a majority of 18 individuals (56.3%) identified as housewives. The economic profile of the participants was also noteworthy, with a significant 25 families (78.1%) reporting an income exceeding 2,868,081 rupiahs. Additionally, 15 respondents (46.9%) were experiencing their first pregnancy (primigravida), and the family structure of 17 families (53.1%) adhered to a nuclear family arrangement. These demographic insights provide a valuable con- text for understanding the characteristics of the study’s participants and their potential influence on stunting prevention behaviors. Table 2 provides a clear picture of the changes observed in pregnant women’s knowledge, attitudes, and actions before and after receiving assistance. Prior to assistance, the mean knowledge score was 9.59±4.89, which increased significantly to 12.8±2.88 after assistance. Similarly, the mean attitude score also showed a noteworthy improvement, rising from 7.91±2.84 before assistance to 10±0.00 after assistance. In terms of actions related to stunting prevention, the mean score before assistance was 7.84±2.61, and it slightly increased to 8.19 ± 2.38 after receiving assistance. To assess the impact of pregnant mother assistance on stunting pre- vention behavior, the paired t-test was employed with a signifi- cance level of 5% (0.05). The results revealed that for knowledge (p=0.00) and attitude (p=0.00), there was a highly significant effect of pregnant mother assistance. Moreover, for stunting prevention actions, the p-value was 0.014, indicating a statistically significant influence of the assistance on these behaviors. This suggests that the provided assistance had a positive and statistically significant impact on enhancing knowledge, attitudes, and actions related to stunting prevention among pregnant women. Discussion Stunting prevention behavior prior to and follow- ing pregnancy assistance The result showed that knowledge, attitudes, and actions of pregnant women have shown significant improvement both before and after receiving assistance. In summary, pregnant mother knowledge, attitudes, and actions regarding stunting prevention have significantly enhanced. These findings align with research conducted in Pulang Pisau District, which indicates that pocket- book treatment is notably effective in improving pregnant women’s attitudes towards preventing stunting.17 Similarly, the results of this study are consistent with the research conducted by Wisma et al.,which demonstrates a significant difference (p<0.001) in healthy food consumption practices among pregnant women who received nutrition education in the intervention group compared to the control group.18 The mentoring intervention provided to pregnant women in this study successfully increased their average knowledge, indicat- ing a solid knowledge base. The enhancement in pregnant women’s knowledge can be attributed to the educational and coun- seling assistance they received regarding stunting prevention. This two-way communication activity serves as the initial step in the process of behavior change for prevention.19 Counseling plays a pivotal role in establishing productive cooperation and communi- cation between counselors, creating a comfortable atmosphere. Moreover, counseling and education aimed at stunting prevention in mothers correlate with reduced stunting prevalence and improved feeding practices during early childhood, as demonstrat- ed in the research by Mistry et al. Counselors have the ability to gauge the extent of the counselee’s knowledge and build upon it. The repetition of information during counseling sessions also con- tributes to the enhancement of knowledge.20 [Healthcare in Low-resource Settings 2023; 11:11728] [page 53] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. The frequency distribution of respondent characteristics. Characteristics of respondents Frequency Percentage Age < 18 Years 1 3.1 18-25 Years 14 43.7 26-30 Years 6 18.8 >30 Years 11 34.4 Education Primary Education 5 15.6 Secondary Education 13 40.6 Higher Education 14 43.8 Occupation Housewife 18 56.3 Self-employed 3 9.4 Private Employee 10 31.3 Government Employees 1 3 Income < IDR 2.868.081 7 21.9 > IDR 2.868.081 25 78.1 Number of Children Primigravida 15 46.9 Secondary gravida 5 15.6 Multi gravida 12 37.5 Family Structure Nuclear Family 17 53.1 Extended Family 15 46.9 Non -co mmerc ial us e o nly The findings of Waswa’s research in 2015 further substantiate the effectiveness of nutrition education in improving knowledge and practices related to complementary feeding, with significantly higher average nutritional knowledge observed in the intervention group.21 In summary, the results of this study underscore the effec- tiveness of assisting pregnant women in enhancing their knowl- edge, attitudes, and actions concerning stunting prevention during pregnancy. Pregnant mother assistance has positively influenced the attitudes of pregnant women toward stunting prevention, as reflected in the increased average value. This highlights the capac- ity of Pregnant mother assistance to instigate favorable changes in mothers’ attitudes and behaviors regarding stunting prevention. Muluye’s research also supports this notion, demonstrating that nutrition education leads to improved practices and knowledge related to appropriate complementary foods.22 It is crucial to acknowledge that stunting is the result of multifaceted factors and not solely attributable to malnutrition experienced by pregnant women and children under the age of five. To effectively reduce the prevalence of stunting, interventions must focus on the first 1,000 days of life. Changes in stunting prevention behavior before and after mentoring Based on the statistical test results presented in Table 2, it is evident that pregnant mother assistance has a significant impact on stunting prevention behavior. This signifies that pregnant mother assistance plays a crucial role in influencing stunting prevention behavior. According to the study’s findings, after pregnant women received assistance, their average knowledge, attitudes, and prac- tices related to stunting prevention significantly improved. These results are consistent with research conducted in the West Gojjam Zone, Ethiopia, which found that pregnant women who received nutrition education were 2.02 times more likely to enhance their dietary practices compared to those who did not receive such education. Counseling based on the health belief model and the theory of planned behavior emerges as an effective approach to increasing the proportion of pregnant women who adopt appropriate dietary habits.23 Likewise, the outcomes of this study align with the findings from Katenga-Kauda, where nutrition knowledge and diverse food consumption behaviors improved in both study groups but showed greater improvement in the inter- vention group. Enhanced nutritional knowledge has a notable impact on improving nutritional perceptions and behaviors.14 Stunting prevention primarily focuses on improving nutrition during the first thousand days of life, spanning from pregnancy until the child reaches two years of age. This approach can con- tribute to the optimal growth and development of millions of chil- dren, with far-reaching economic benefits in the long term.24 Nutrition during the first 1000 days is recognized as pivotal, with significant implications for both maternal and offspring health. Inadequate or inappropriate nutrition during this period elevates the risk of premature birth and low birth weight.25 Conversely, pregnant women who experience excessive weight gain during pregnancy are at risk of giving birth to larger babies. The First 1000 Days of Life Program highlights that changes in risk factors for obesity during pregnancy correlate with shifts in maternal behavior towards healthier food consumption.26 Consequently, nutrition education aimed at fostering long-term healthy eating habits represents a strategic intervention. The assis- tance provided to pregnant women in this study demonstrates a substantial impact on behavior change regarding stunting preven- tion, moving in a positive direction. This is also corroborated by research in Bangladesh, revealing that counseling mothers using the Essential Health Care (EHC) framework can enhance knowl- edge and dietary practices related to child feeding, effectively reducing the prevalence of stunting.27,28 The study’s outcomes also align with Monitz et al.’s, indicat- ing that pregnant women who received preventive health promo- tion text messages displayed increased belief and expected behav- iors. This suggests that text messages can effectively promote health during pregnancy.29 A mother’s knowledge profoundly influences her decision-making and behavior. Mothers equipped with comprehensive knowledge about preventing stunting are more likely to implement effective prevention practices. This con- cept is further supported by the results of research by Yurni and Sinaga, demonstrating that a two-week balanced nutrition educa- tion program with two meetings led to a 7.7 percent increase in respondents’ practice of selecting a balanced menu.15 Intensive nutrition counseling, utilizing leaflet media, emerges as an effective alternative for enhancing the knowledge of pregnant women.16 Moreover, the observed behavioral changes in the sub- jects of this study can be attributed to an increase in knowledge regarding stunting. These findings collectively contribute to the growing body of evidence highlighting the positive impact of edu- cating and counseling pregnant women during pregnancy on improving their knowledge, attitudes, and practices related to stunting prevention.30 This intervention can be efficiently adminis- tered through healthcare workers who possess a high potential to enhance maternal and child health, particularly in hard-to-reach rural areas.30,31 These studies underscore the scientific evidence that nutrition and reproductive health education during pregnancy enhance Pregnant mother knowledge, attitudes, and practices, thereby contributing to improved maternal and infant health and reduced childhood stunting.18 Mother’s level of nutritional knowl- edge significantly influences her nutritional status, as sound knowledge is closely linked to the selection of a balanced menu.32 Knowledge is a pivotal factor predisposing individuals to adopt positive behaviors. By increasing knowledge, people’s behavior can be positively influenced to prevent stunting at an early age. While stunting may have genetic factors, it can also result from poor sanitation and inadequate nutritional intake during pregnancy. Genetics or heredity accounts for 26% of the risk fac- tors.33 The tendency to attribute a child’s short stature to genetics can sometimes lead to inaction, when in fact, the condition may be [page 54] [Healthcare in Low-resource Settings 2023; 11:11728] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. The effect of pregnant mother assistance on stunting prevention behavior. Behavioral Domain Mean ± SD p Pre Post Knowledge 9.59 ± 4.89 12.8±2.88 0.00* Attitude 7.91 ± 2.84 10±0.00 0.00* Action 7.84±2.61 8.19±2.38 0.014* *p<0.05. Non -co mmerc ial us e o nly stunting, which necessitates intensive medical intervention. Early prevention of stunting, even during pregnancy, can be achieved by meeting nutritional needs from pregnancy until the child reaches two years old (the first 1000 days of life) while monitoring their growth. The maternal nutritional status during pregnancy directly affects the growth and development of the fetus, with food utiliza- tion, absorption, and utilization impacting the outcome.34,35 Maternal nutrition is a critical factor during pregnancy, with healthy pregnant women who do not experience nutritional disor- ders before or during pregnancy giving birth to larger and healthier babies compared to those with nutritional disorders. Chronic undernutrition contributes to the birth of stunted children.36 Researcher asserts that providing assistance to pregnant women can indeed lead to changes in mothers’ behaviors regarding stunt- ing prevention from pregnancy onwards. Specific nutrition inter- ventions, such as micronutrient supplementation and additional food for pregnant women, alongside counseling and education on regular pregnancy checks and the consumption of healthy and nutritious foods, represent effective strategies in this regard. Conclusions In summary, this study underscores the significant impact of mentoring on pregnant women’s knowledge, attitudes, and actions in preventing stunting. It aligns with existing evidence highlighting the vital role of education, counseling, and support in promoting positive maternal behaviors related to stunting prevention, starting during pregnancy. In essence, this research illuminates a path toward healthier futures for both mothers and their children. 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