Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11964 The efficacy of implementing family-centered care in child feeding practices Annif Munjidah, Elly Dwi Masita, Hinda Novianti, Uke Maharani Dewi Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Surabaya, Indonesia Abstract Nutrition is a basic need for a child to grow optimally. Improper child feeding practices are still found in the community, leading to malnutrition. The incidence of malnutrition has increased sharply in children aged 6 to 18 months in various coun- tries, primarily due to ignorance and/or an inability to prepare food. The family plays a crucial role in the prevention and treat- ment of child nutrition problems. Families can provide education and practical supervision in addressing nutrition-related issues, including promoting healthy lifestyle patterns. The objective of this study was to determine the effectiveness of implementing family-centered care in changing child feeding practices. The research design employed was true experimental analysis with a pre-posttest group design. The population consisted of 130 respondents, infants aged 6 to 23 months, selected using a proba- bility sampling technique with purposive random sampling. The research was conducted in Wonokromo, Surabaya, Indonesia, from March to June 2023. The measuring instrument utilized was a family-centered care-based child feeding guide. The indepen- dent variable in the study was family care, while the dependent variable was the change in the child’s feeding practices. Test anal- ysis was performed using the Mann-Whitney test. The results of the Mann-Whitney test indicated a significant difference in feed- ing practices before and after counseling with the family-centered care approach (p=0.043). Thus, family-centered care was found to be effective in changing child feeding practices. Introduction Nutrition is essential for a child to grow optimally.1 Providing correct nutrition during the first 1000 days of life will determine both short-term and long-term quality of life for a human.2 Healthy eating habits are essential for improving nutritional status and strengthening immunity against diseases.3 Still, a lot of inap- propriate feeding practices are found among children in societies, which is a reason for malnutrition. Stunting among children nega- tively impacts their health and overall development.4 Indonesia is facing nutritional problems, one of which is malnutrition.5 The incidence of malnutrition increases sharply in the 6 to 18-month period in various countries, either due to ignorance and/or inabil- ity to prepare complementary foods.6 The health and nutritional status of children are very dependent on the care of the mother from the time in the womb until the child is born, grows, and develops.7 In Indonesia, the anthropometric index is recorded on a Card Towards Health called Kartu Menuju Sehat or KMS, which refers to WHO–2005 Standard Growth Charts (WHO–2005 SGC).8 Based on the 2018 Basic Health Research, the prevalence of being underweight, stunting, and wasting is 17.8 percent, 30.8 percent, and 10.24 percent, respectively.9 Exclusive breastfeeding is one of the important indicators in addressing nutritional problems in children.10 Feeding practices typically commence with exclusive breastfeeding during the first 0-6 months, followed by the introduction of solids from 6-24 months. Complementary feeding (CF) plays a crucial role in meet- ing the nutritional needs of children that cannot be solely satisfied by breastfeeding alone.11 CF begins when breast milk alone is no longer sufficient to meet infants’ nutritional requirements, neces- sitating the introduction of other foods and liquids alongside Correspondence: Annif Munjidah, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Surabaya, Indonesia. E-mail: annifmunjidah@unusa.ac.id Key word: child, efficacy, family, feeding, practice. Contributions: AM, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; EDM, conceptualization, investigation, methodology, vali- dation, and writing – original draft; HN, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and edit- ing; UMD, resources, investigation, and writing –review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the Ethical Committee of Nursing and Midwifery Faculty, Universitas Nahdlatul Ulama, Indonesia, has certified that this research is ethical. The ethical certifica- tion number is 035/016/V/EC/KEP/LCBL/2023 May, 16 2023. 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 did not receive external funding. 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 LPPM Universitas Nahdlatul Ulama Surabaya, Indonesia for funding this research and pro- viding motivation, facilities for researchers so that this research can be carried out smoothly. The authors would like to thank all respondent who were cooperative and assisted in this research process. Received: 13 October 2023. Accepted: 11 March 2024. Early access: 29 March 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11964 doi:10.4081/hls.2024.11964 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, 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 2024;12:11964] [page 453] Non -co mmerc ial us e o nly breast milk. Thus, the transition from exclusive breastfeeding to family foods is termed complementary feeding. Consequently, the period from birth to two years of age has been recognized as the optimal time for fostering healthy dietary habits.12 One of the pri- mary challenges in developing countries is the provision of low- quality complementary foods, resulting in failure to thrive during the complementary feeding period.4 According to the 2021 Indonesian Nutritional Status Survey (INSS), exclusive breast- feeding rates stand at 42%, while the introduction of semi-solid and solid foods to children is at 69%. However, only 52.5% of chil- dren aged 6-23 months have diverse dietary intake. The frequency of appropriate complementary foods, as per WHO recommenda- tions, is 53%, and only 19% of children receive food of minimum quality. These figures fall short of evidence-based feeding prac- tices recommended for infants and toddlers in Indonesia to prevent child malnutrition. To address this issue, it is crucial to identify the causes of incorrect feeding practices and undertake efforts to recti- fy them. Researchers have identified several studies on factors influenc- ing feeding practices. Zulfikar et al. (2020) analyzed the role of culture and maternal knowledge in feeding children.13 Agus Sri Banowo (2020) discovered that nutrition education programs serve as flagship initiatives to improve family feeding practices and combat stunting.14 Andi Tenri Abeng et al. (2018) found that train- ing integrated healthcare center cadres significantly influences maternal practices in providing complementary foods.15 Diah Estingtias (2019) found that family involvement plays a crucial role in maternal practices regarding the provision of complemen- tary foods.16 Shloim (2015) revealed that parental approaches, par- enting styles, eating styles, and feeding practices greatly impact children’s eating habits and growth.17 Wa Ode Syahrani H. (2016) also found that personal health education significantly enhances maternal efficacy and feeding behaviors in children with poor nutrition. Asmare et al. (2020) conducted a study on the prevalence and factors associated with child feeding practices.12 Researchers assessed the success of feeding practices influenced by child fac- tors, environmental factors, and food factors. In previous studies, researchers have investigated the effect of education on maternal literacy regarding the provision of complementary foods.18 the effect of feeding rules on children’s feeding difficulties19 massage interventions to improve children’s chewing ability20 and weight gain21 and use of card media22 as well as the effect of adding onion and garlic to complementary foods.23 Research shows that moth- ers, as primary caregivers, are greatly influenced by the support of close relatives such as husbands and family members in their household.1 This support is key in helping families, the smallest societal unit, in preventing and treating child nutrition issues.They can provide education and practical supervision to prevent and address nutrition-related problems, including through the promo- tion of healthy lifestyle patterns. Therefore, efforts to empower families are essential.24 Moreover, it is evident that alternative methods involving dif- ferent respondents are still highly necessary. This research propos- es a new method employing the family-centered care approach because researchers are interested in studying the implementation of family-centered care to change children’s feeding practices. Materials and Methods Research design The research design employed in this study was True Experimental analysis with a pre-group design - posttest. This research investigates the influence of family-centered care on changes in child feeding practices. Study participants The population of this study consisted of 130 respondents, namely babies aged 6 months to 23 months in the sub-district of Wonokromo, Surabaya City, Indonesia. The babies included both boys and girls aged 6-23 months, who were not currently ill or suf- fering from congenital defects, and belonged to Muslim, Javanese, and Madurese families. They were selected during health activities in villages known as integrated service posts conducted monthly. The sampling technique employed was probability-based purpo- sive random sampling, with the research conducted in the Wonokromo sub-district of Surabaya. The research period spanned from March to June 2023. Variables, instruments and data collection The independent variable in this research is family-centered care, and the dependent variable is child feeding practices. The oper- ational definition of family-centered care is the role of the family in the care process. Meanwhile, the operational definition of feeding encompasses the implementation of feeding children, including scheduling, menu selection, processing methods, and methods of feeding. The measuring tool used to assess feeding practices is a checklist derived from the 0-1 year old infant care guide11and evi- dence-based child feeding recommendations.6 Data analysis utilized the Mann-Whitney test. Data collection was conducted directly after the researchers received an ethics approval letter from the Brahmanda Lentera Indonesia (Candle) Ethics Institute. The research team then obtained permission for the study and submitted it to the Chairman of the sub-district RW Wonokromo in the city of Surabaya. Subsequently, the research team coordinated with village midwives and child health cadres. Once the research timeline was agreed upon, the team formed a field team comprising 12 midwifery students. These students received assignment letters from Nahdlatul Ulama University Surabaya and were provided with daily food and transportation incentives. The field team, consisting of 12 midwifery students, conducted data collection at the beginning of each week. Additionally, they provided assistance to 65 families, with each stu- dent accompanying 5-6 families. Counseling sessions about the role of the family in providing complementary breastfeeding were con- ducted for the treatment group three times a week, specifically on Mondays, Wednesdays, and Saturdays, each lasting for 60 minutes. In the second week, the research team administered a questionnaire about feeding practices to children. Data analysis Data were collected and analyzed using bivariate analysis after being directly obtained as primary data. The Mann-Whitney test was used for data analysis. The recognized level of significance was p=0.05. Using SPSS version 20, all data were examined. Ethical clearance The Ethical Committee of Nursing and Midwifery Faculty, Universitas Nahdlatul Ulama, Indonesia, has certified that this research is ethical. The ethical certification number is 035/016/V/EC/KEP/LCBL/2023 May, 16 2023. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 454] [Healthcare in Low-resource Settings 2024;12:11964] Non -co mmerc ial us e o nly Results The results of the research on feeding practices in 130 respon- dents yielded the following general data. According to Table 1, it was observed that 66.9% of respondents were aged between 20 and 44 years, 36.1% had a high school education, 28.8% were employed, 55.4% had an income of more than 3 million, 62.3% had more than three family members, and 60% had more than two children. Based on Table 2, it is evident that the average score of feeding practices in the treatment group is higher (38.58%) than in the control group (29.7%). The provision of family-centered care- based education can enhance children’s feeding practices, as indi- cated by the higher average score in the intervention group com- pared to the control group. Based on Table 3, it is evident that in the intervention group, after receiving treatment, the majority (52.3%) of respondents exhibited good feeding practices, while almost half (32.3%) demonstrated poor practices, with a smaller proportion (15.4%) showing sufficiency. Conversely, in the control group post-treatment, nearly all respondents (84.6%) displayed poor feeding practices, with only a small proportion (15.4%) achieving sufficiency. The results of the Mann-Whitney test con- ducted using SPSS for Windows, with a significance level of α = 0.05, yielded a P-value of 0.043 (0.043 < 0.05), indicating signifi- cant differences in feeding practices between the intervention and control groups. Discussion The study results revealed significant differences in feeding practices following the implementation of the family-centered care model treatment. This model of care involves educating family members residing in the same household. The research demon- strated the effectiveness of the family-centered care educational approach in rectifying previously incorrect child feeding practices. Traditionally, childcare predominantly focused on the mother and child relationship; however, this study incorporated family involvement, including the husband and other household members. Based on the overall research results, a significant difference in the practice of feeding children in the treatment group before and after receiving family-centered care model education can be observed. Moreover, changes in child feeding practices after receiving family-centered care model education predominantly shifted in a positive direction.25 This indicates the positive role of the family in child rearing, aligning with the theory that family- centered care can be applied across various healthcare settings and age groups.26 The core tenets of family-centered care include mutual respect, information exchange, participation, and coopera- tion.27 The philosophy of family-centered care originates from an environment where families are empowered to support their men- tal health and contribute significantly to life enhancement. However, family-centered services may lead to undesirable out- comes if families make uninformed decisions while caring for their members, underscoring the importance of clear communication Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents in May-June 2023. Characteristics of respondents Frequency Percentage (%) Age <20 24 18,4 20-44 87 66,9 >44 19 14,6 Education Primary School 28 21,5 Middle School 30 23 High School 47 36,1 College 25 19,2 Work Not working 31 23,8 Student 7 5,3 Private 29 22,3 Entrepreneur 26 20 Labor 37 28,4 Family income <3.000.000 58 44,6 >3.000.000 72 55,4 Family members 1-3 49 37,6 > 3 81 62,3 Number of children 1-2 52 40 >2 78 60 Primary Data: June 2023 Table 2. Results of data analysis in the treatment group and control group before and after treatment. Feeding practice Group Control Intervention Pre Post Pre Post Mean 26.7 29.7 27.2 38.58 Primary Data: June 2023 Table 3. Distribution of feeding practice after treatment with family centered care. Feeding practice Group Intervention Control Frequency Percentage (%) Frequency Percentage (%) Poor 21 32.3 55 84.6 Enough 34 52.3 10 15.4 Well 10 15.4 0 0 Total 65 100 65 100 Statistical test with Mann Whitney Test Exact Sig (2-tailed) = 0.043 Primary Data: June 2023 [Healthcare in Low-resource Settings 2024;12:11964] [page 455] Non -co mmerc ial us e o nly from healthcare professionals. The implementation of the family- centered care philosophy necessitates collaboration from all stake- holders, emphasizing the role of healthcare providers in fostering information exchange and fostering cooperative relationships.28 Feeding practices encompass various elements, including the mother’s organization of eating schedules, food menus, ingredi- ents,29 processing methods, serving methods, and administration methods,30 as well as handling distractions and the mother’s atti- tude when the child refuses to eat.31 Families implementing the family-centered care method will not only understand,14 but also actively engage in child feeding practices. The practical signifi- cance of the research results is twofold: i) the adoption of the fam- ily-centered care method will serve as a guideline for midwives, nurses, and health cadres, highlighting the importance of family involvement in child care; ii) the family-centered care method can serve as an effective approach to modifying child feeding prac- tices. limitation of this study is that respondents may not have pro- vided accurate information about their children’s feeding practices due to social desirability bias. Data collection techniques involving questionnaires require mothers to recall their children’s feeding practices from previous periods, which may lead to forgetting, potentially influencing current feeding practices. It is suggested that future research on feeding practices employ direct observation methods to obtain a more accurate understanding of children’s feeding practices. This research demonstrates that the child care model involving the family has been effective in improving child feeding practices, consistent with previous findings linking family involvement to the provision of complementary foods.16 Methods of care or other interventions aimed at improving and enhancing children’s feeding practices should be explored further to ensure children’s nutritional needs are met and to prevent stunting.6 Conclusions The development of family-centered care methods has proven effective in changing children’s feeding practices. Differences in feeding practices between the intervention group and the control group were observed. Family-centered care methods have the potential to alter children’s feeding practices. The more families are involved in the parenting process, the better children’s needs are met. Health workers, midwives, or nurses should educate not only mothers or caregivers but also husbands or other family mem- bers within a household about child feeding practices. Family- based educational activities can be implemented before children reach 6 months of age. Midwives, nurses, or health cadres in the village should provide facilities to mothers experiencing difficul- ties with feeding practices through WhatsApp or during counseling events in the village. References 1. Marah Has EM, Efendi F, Wahyuni SD, et al. Women’s Empowerment and Sociodemographic Characteristics as Determinant of Infant and Young Child Feeding Practice in Indonesia. Curr Res Nutr Food Sci 2022;10:607–19. 2. Indriyani D, Yunitasari E, Efendi F, et al. the Analysis of Maternal Characteristics and Regulation of Antenatal Care on Pregnancy Risk Status Based on the Independent Family Health Evaluation. Asia Pacific J Heal Manag 2023;18:1–10. 3. Kishino M, Hida A, Chadeka EA, et al. Association between diet quality and risk of stunting among school-aged children in Schistosoma mansoni endemic area of western Kenya: a cross- sectional study. Trop Med Health 2024;52:12. 4. Maulina R, Qomaruddin MB, Prasetyo B, et al. The Effect of Stunting on the Cognitive Development in Children: A Systematic Review and Meta-analysis. Stud Ethno-Medicine 2023;17:19–27. 5. Ibad M, Lutfiya I, Herdiani N, et al. Determinants of stunting events in Indonesia using path analysis. AIP Conf Proc 2023;2595(1). 6. IDAI. Rekomendasi Praktik Pemberian Makan Berbasis Bukti pada Bayi dan Batita di Indonesia untuk Mencegah Malnutrisi. UKK Nutr dan Penyakit Metab Ikat Dr Anak Indones. 2015. 7. Umijati S, Andajani S. The Model of Mothers’ Caregiving Risk Factors on Keeping Nutritional Status of Children Aged 0-6 Months. Univers J Public Heal 2023;11:146–54. 8. Chamidah N, Zaman B, Muniroh L, Lestari B. Multiresponse semiparametric regression model approach to standard growth charts design for assessing nutritional status of East Java tod- dlers. Comm Math Biol Neurosci 2023;2023:30. 9. Putri DUP, Mahmudiono T, Indriani D, Lisatriana B. The rela- tionship between the competence and performance of family planning instructors in family assistance at risk of stunting in Lampung province. J Public Health Africa 2023;14:2544. 10. Kapti RE, Arief YS, Azizah N. Mother’s knowledge as a dom- inant factor for the success of exclusive breastfeeding in Indonesia. PAGEPress Publications. 2023. 11. Meta H. Mommyclopedia, panduan lengkap merawat Bayi 0-1 tahun. Jakarta: Gramedia Pustakan Utama; 2016. 12. Asmare LD, Kassaw MW, Abebe AM, et al. Prevalence and Factors Associated with Child Feeding Practice Among Mothers of Woldia Town, Northeast Ethiopia. Nutr Diet Suppl 2020;12:205–13. 13. Fariqi MZ Al, Yunika RP. Pengaruh Budaya dan Pengetahuan Ibu terhadap Praktik Pemberian Makan pada Bayi di Wilayah Kerja Puskesmas Narmada Lombok Barat. Nutr J Pangan, Gizi, Kesehatan 2021;2:77–81. 14. Banowo AS, Hidayat Y. Pengaruh Edukasi Gizi terhadap Praktik Pemberian Makan Pada Baduta Stunting di Kabupaten Bengkulu Utara. J Ilm Univ Batanghari Jambi 2021;21:765. 15. Abeng AT, Hardiyanti L. Pengaruh Pelatihan Oleh Kader Posyandu Terhadap Praktek Ibu Dalam Pemberian Makanan Pendamping Asi (Mp-Asi). Bina Gener J Kesehat 2019;11:1– 7. 16. Estingtias D, Susanto T, Nur KRM. Hubungan Peran Keluarga Dengan Praktek Pemberian Makanan Pendamping Asi Pada Bayi Umur 6-24 Bulan Di Kabupaten Jember [Correlation Between Family of Roles and Complementary Breast Feeding Practices Among Children Aged 6-24 Months in Jember]. Penelit Gizi dan Makanan 2019;42:57–64. 17. Shloim N, Edelson LR, Martin N, Hetherington MM. Parenting styles, feeding styles, feeding practices, and weight status in 4-12 year-old children: A systematic review of the lit- erature. Front Psychol 2015;6. 18. Munjidah A, Putra NE, Nahdlatul U, Surabaya U. Edukasi meningkatkan literasi ibu dalam. 2023;319–30. 19. Munjidah A, Rahayu E. Pengaruh Penerapan Feeding Rules Sebagai Upaya Mengatasi Kesulitan Makan Pada Anak (Picky Eater, Selective Eater Dan Small Eater). J Kesehat Masy 2020;8:29–35. 20. Munjidah A, Anggraini FD. The effects of tui na massage on Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 456] [Healthcare in Low-resource Settings 2024;12:11964] Non -co mmerc ial us e o nly the growth status of children under five years of age with KMS T status (Low weight gain). J Public Health Africa 2019;10:127–30. 21. Munjidah A, Rukmana EE, Nisa F, et al. Feeding Complementary Foods with complete Menu Correlated with Babies Weight. Jurnal Ners dan Kebidanan 2023;202–9. 22. Anggraini FD, Nisa F, Hasina SN, Munjidah A. The effect of nutritional education using cognitive approaches and psy- chomotor approaches on fruit and vegetable consumption behavior in children. Open Access Maced J Med Sci 2021;9:1161–5. 23. Munjidah A, Masita ED. Pengaruh Penggunaan Allium Cepa Dan Allium Sativum Dalam Mpasi Sebagai Upaya Perbaikan Makan Pada Anak. J Keperawatan dan Kesehat Masy Cendekia Utama 2021;10:135. 24. Gayatri M. Pencegahan Stunting dengan Pendekatan Keluarga: Sebuah Tinjauan Literatur. In: Best Practice Memerangi Stunting: Implementasi Kampus Merdeka Berbasis Agro and Marine Industry (pp.35-46). Publisher: Percetakan Bandar di Lamgugob Banda Aceh. 2022. 25. Syam A, Musni M, Amin AN, Iskandar I. Potential Loss among Infant Feeding Options. J Ners 2021;16:74–80. 26. Susan AM. Patient Family – Centered Care ini the Ambulatory Surgery Setting. Journal of PeriAnesthesia Nursing 2013;24:244-6. 27. McGuire SL, Eigsti DG. Family-Centered Approach to Community Health Nursing Practice. In: Comprehensive Community Health Nursing, Family, Aggregate, & Community Practice. Ed.V (hal.158 – 232) Missouri: Mosby.; 2013. 28. Community Research P and ET. Putting Family-Centered Care Philosophy into Practice. Centre for Addiction and Mental Health.; 2014. 29. Campoy C, Campos D, Cerdó T, et al. Complementary feeding in developed countries: The 3 Ws (When, what, and why?). Ann Nutr Metab 2018;73:27–36. 30. Boswell N. Complementary feeding methods—a review of the benefits and risks. Int J Environ Res Public Health 2021;18(13). 31. Benjasuwantep B, Chaithirayanon S, Eiamudomkan M. Feeding Problems in Healthy Young Children: Prevalence, Related Factors and Feeding Practices. Pediatr Rep 2013;5:38. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11964] [page 457] Non -co mmerc ial us e o nly