Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13185 Health literacy based on the Health Promotion Model to improve maternal behaviors in preventing the risk of stunting in children Emmy Putri Wahyuni,1,2 Nyimas Heny Purwati,1 Anita Apriliawati1 1Faculty of Nursing, Universitas Muhammadiyah Jakarta; 2Department of Nursing, Poltekkes Kemenkes Kalimantan Timur, Samarinda, Indonesia Abstract Health literacy is a key component of health promotion aimed at modifying lifestyle behaviors and increasing awareness of how health determinants influence quality of life (QOL). This moti- vates individuals and families to proactively address health-relat- ed challenges. This study aimed to examine the effect of health lit- eracy on parental behavior in preventing the risk of stunting in children. A quasi-experimental design was employed, utilizing a pre-test and post-test non-equivalent control-group approach. The participants were mothers of children aged 0-23 months selected through purposive sampling, with a total of 58 respondents. They were divided into intervention and control groups. The results showed significant differences in maternal behaviors related to preventing stunting between the intervention and control groups, as evidenced by pre- and post-test comparisons (p<0.05). Specifically, health literacy had a statistically significant effect on maternal behavior in preventing stunting (p=0.001). Based on these findings, it is recommended that primary healthcare services enhance their efforts to prevent stunting by incorporating health literacy interventions such as educational modules and mentoring programs targeted at mothers and their families. Introduction Chronic malnutrition can begin as early as the prenatal period and continue until the child reaches two years of age. Therefore, the first 1,000 days of life represent a critical window that war- rants special attention, as this period significantly influences a child’s physical growth, cognitive development, and future pro- ductivity.1 Stunting remains a major global challenge and a promi- nent nutritional concern.2 Globally, the prevalence of stunting among children under five years of age has decreased from 33.1% to 22%, with the number of affected children declining from 203.6 million to 149.2 million.3,4 According to the 2023 Indonesian Nutritional Status Study conducted by the Health Development Policy Agency of the Ministry of Health of the Republic of Indonesia, the prevalence of stunting in East Kalimantan is 22.8%.5 In Samarinda City, the capital of East Kalimantan Province, the prevalence of stunting in 2025 reached 18.14%, based on data from 32.63% of measured toddlers.6 Stunting is caused by the complex interplay of multidimen- sional factors.7 A 2021 study conducted in India reported that chil- dren who practice open defecation are born to mothers with low levels of education and live in poor households, and are at a sig- nificantly higher risk of stunting.8 In Ethiopia, 60.6% of infants do not receive exclusive breastfeeding, 68.8% of children are given complementary foods that lack vegetables, and 68.1% lack ani- mal-source foods in their diets.9 In Indonesia, available data indi- cate that 60% of children aged 0-6 months do not receive exclu- sive breastfeeding, and two out of every three children aged 0-24 months do not receive appropriate complementary feeding.10,11 Poor parenting practices, including mothers’ lack of knowl- edge about their child’s health and nutrition, are important factors that cause stunting, especially in children aged 0-23 months.12-14 The study found that parents’ parenting style in providing food to their children significantly affects their children’s nutritional sta- tus.15-17 Parents’ limitations greatly influence incorrect parenting practices when finding information sources.18 Therefore, an appropriate program is needed to overcome these problems, including fulfilling the information needs of parents, especially in Correspondence: Emmy Putri Wahyuni, Faculty of Nursing, Universitas Muhammadiyah Jakarta, Jakarta, Indonesia. E-mail: emmyputri.wahyu@gmail.com Key words: attitude; health literacy; knowledge; psychomotor; stunting. Contributions: EPW, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; NHP, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; AA, conceptualization, investigation, methodology, validation, and writing – original draft. Conflict of interest: the authors have no conflict of interest to declare. Ethics approval and consent to participate: the Health Research Ethics Commission, Faculty of Nursing, Universitas Muhammadiyah Jakarta, approved the study based on ethical certificate 0938/F.9-UMJ/VI/2023. During the study, the researcher emphasized the ethical principles of informed consent, respect for human rights, beneficence, and non-malef- icence. Consent for publication: written informed consent was obtained from all patients included in this study. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Funding: this research was supported by a grant from BLU Poltekkes Kemenkes Kalimantan Timur with contract number: GM.03.01/4.3/ 09517/2023. Received: 13 January 2025. Accepted: 26 May 2025. Early view: 20 August 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13185 doi:10.4081/hls.2025.13185 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 prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 86] [Healthcare in Low-resource Settings 2025;13(s2):13185] preventing stunting risks. Health literacy is an emerging focus within the field of health promotion and is increasingly being recognized as a critical issue in contemporary public health discourse.19-21 This approach seeks not only to modify lifestyle behaviors, but also to foster awareness of the importance of health-related factors in determining quality of life, thereby motivating individuals and families to address their health challenges proactively.5,22 A systematic review reported that health literacy interventions led to significant improvements in knowledge across ten studies.23 Health promotion plays a central role in influencing parental behavior, particularly in efforts to pre- vent stunting in children.24 Accordingly, this study aimed to deter- mine the influence of health literacy on maternal behavior to pre- vent the risk of stunting among children. Materials and Methods This study employed a quasi-experimental design using a pretest-posttest approach with a nonequivalent control group. Study participants The population comprises mothers with children in the Palaran District Health Center working area in Samarinda City (Indonesia), with a total of 1,377 children. The sample consisted of 58 respon- dents using non-probability sampling techniques with purposive sampling methods, comprising 29 intervention and 29 control group samples. The sample formula used was a hypothesis test with two different proportions. The proportion of the occurrence of the effect in the trial group (anticipated population proportion 1) and the proportion of the occurrence of the effect in the control/standard group (anticipated population 2) were obtained from previous research, namely, research conducted by Sirajuddin et al. (2021) entitled “The Intervention of Maternal Nutrition Literacy Has the Potential to Prevent Childhood Stunting: Randomized Control Trials”.25 The inclusion criteria consisted of mothers with children aged 0-23 months, those who possessed mother-child health books, and mothers who were able to read and write. Exclusion criteria included mothers of children aged 0-23 months who were identified as stunted or had chronic comorbidi- ties such as congenital heart disease, Down syndrome, or other similar conditions. Variable, instrument, and data collection The independent variable was the effect of health literacy, and the dependent variable was behavior, including mothers’ knowl- edge, attitudes, and psychomotor skills in preventing stunting. This study used the Health Literacy Survey - European Union, 16 items (HLS-EU-Q16) questionnaire, adopted from the Asian Health Literacy Association Indonesia as the questionnaire license holder, to assess maternal knowledge of stunting risk prevention. The HLS-EU-Q16 questionnaire consists of 16 modified items with several subdomains: i) seeking health information, four items (Q1, Q2, Q3, Q4); ii) understanding health information, three items (Q5, Q6, Q7); iii) assessing health information, four items (Q8, Q9, Q10, Q11); and iv) applying health information, two questions (Q12 and Q13). Each question was assessed on a 4-point Likert scale, where the answer choices were 1=tough, 2=quite challenging, 3=complex, and 4=very easy. An attitude question- naire on stunting risk prevention was created based on positive and negative attitude statements. Both aspects were measured using 15 closed statements, consisting of nine positive attitude statements (numbers 1, 2, 3, 4, 7, 9, 12, 13, and 15) and six negative attitude statements (numbers 5, 6, 8, 10, 11, and 14). Psychomotor skills were measured using a skills checklist adopted from the Specific Nutrition Intervention by the Indonesian Ministry of Health, with components assessing breastfeeding skills, complementary feeding practices, growth measurement, and hand washing. If the respon- dent could perform the skills at each stage, they were given a score of 1; if they could not, they were given a score of 0. The validity test of the knowledge questionnaire yielded a cal- culated r-value greater than the r-table value of 0.361 (r=0.402- 0.674), indicating that all questionnaire items were valid. By con- trast, the reliability test obtained a Cronbach’s alpha value for the knowledge questionnaire of 0.760>0.60, indicating reliability. The validity test of the attitude questionnaire showed that the calculat- ed r-values ranged from 0.364 to 0.645, all exceeding the r-table value of 0.361. As a result, 13 items were deemed valid, while items 4 and 5 were found to be invalid. The reliability test pro- duced a Cronbach’s alpha coefficient of 0.760, which is greater than the acceptable threshold of 0.60, indicating that the attitude questionnaire was reliable. The intervention provided was health literacy through educa- tion and stunting prevention simulation, following specific nutri- tional interventions for the intervention group through online media and modules. In contrast, the control group received health education according to the Health Center Program. Furthermore, the intervention group was provided assistance for one month, which was divided into three phases: the intensive phase from the first day to the seventh day, the strengthening phase from the eighth day to the fifteenth day, and the independent phase from the sixteenth day to the last day. Data analysis Univariate and bivariate analyses were also performed. Bivariate analysis used a paired t-test and an independent t-test for variable knowledge. In contrast, for attitude and psychomotor vari- ables, the Wilcoxon and Mann-Whitney tests were used, as the data were not normally distributed. Ethical clearance This study was approved by the Health Research Ethics Commission of the Faculty of Nursing, Universitas Muhammadiyah Jakarta, under ethical certificate number 0938/F.9-UMJ/VI/2023. Ethical principles were upheld throughout the research process, including obtaining informed consent, respecting human rights, and ensuring beneficence and non-malef- icence. Results Table 1 presents the demographic characteristics of mothers and children in the intervention and control groups. The average age of the mothers in the intervention group was 32.66 years, com- pared to 31.59 years in the control group. The average age of the toddlers in the intervention group was 12.93 months, while that in the control group was 12.31 months. Furthermore, the average weight of the toddlers in the intervention group was 8,948.28 grams, compared to 8,715.52 grams in the control group. The aver- age body length of toddlers in the intervention group was 71.81 cm, whereas that of the control group was 72.56 cm. Table 2 pre- sents the characteristics of the mothers based on education, employment status, and monthly family income, as well as the gender distribution of the children. The majority of the mothers in both the intervention and control groups had a high level of educa- Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13185] [page 87] tion. In terms of employment, nearly all mothers in both groups were unemployed. Regarding monthly family income, most moth- ers in the intervention group reported incomes equal to or above the regional minimum wage (IDR 3,329,199), whereas the major- ity of mothers in the control group reported incomes below this threshold. Additionally, the gender distribution of the children in both groups indicated that the majority were female. Based on the data presented in Table 3, the average knowledge score in the intervention group was 31.76, compared to 34.31 in the control group. The average attitude score was 47.03 in the intervention group and 48.84 in the control group. In contrast, the average psychomotor score was higher in the intervention group (9.69) than that in the control group (8.76). Based on Table 4, the average behavior of parents in preventing the risk of stunting in the intervention group for 21 days following the intervention showed an increase in the knowledge variable by 7.62, in attitude by 4.17, and in psychomotor skills by 1.65. The average knowledge, atti- tude, and psychomotor variables in the control group increased, but were still lacking. The results of statistical tests for knowledge, attitude, and psychomotor skills obtained a p-value of 0.001 (p<0.05). Therefore, it can be concluded that there was a difference in the knowledge, attitude, and psychomotor skills of parents in preventing stunting in toddlers before and after receiving a health literacy intervention in the intervention group. Table 4 shows that, also in the control group, which did not receive health literacy intervention, there was an increase in knowledge, attitude, and psychomotor skills before and after the study. The statistical test results revealed a p-value of 0.001 (<0.05) for the knowledge and psychomotor variables, indicating a significant difference in knowledge and psychomotor skills related to the prevention of stunting risk in children before and after the intervention. For the attitude variable, the p-value was 0.070 (>0.05), suggesting no significant difference in parents’ attitudes toward preventing stunting risk in children before and after the educational intervention. Table 5 illustrates that the average difference in knowledge in the intervention group was 34.05, and in the control group was 24.95, with p=0.039 (<0.05), indicating that there was a significant difference in the average knowledge of mothers in preventing stunting risk between the intervention group and the control group. Furthermore, the mean rank value of attitudes in the intervention group was 53.4, while in the control group it was 48.83, with p=0.006 (<0.05), indicating a significant difference between the average attitude of mothers in the intervention group and the con- trol group in preventing stunting. The mean rank of psychomotor skills in the intervention group was 37.32, and 21.69 in the control group, with p=0.001 (<0.05), indicating a significant difference between the average psychomotor skills of the parents in the inter- vention and control groups in preventing stunting in children. Based on Table 5, it can be concluded that there were differ- Pathways of Change, Part II Table 1. Characteristics of the respondents, including maternal age, child’s age, child’s weight, and child’s length. Variable n Mean SD Min-Max Mother’s age (years) Intervention group 29 32.66 5.76 22-42 Control group 29 31.59 5.93 20-46 Child’s age (months) Intervention group 29 12.93 6.27 01-23 Control group 29 12.31 7.59 01-23 Child’s weight (grams) Intervention group 29 8948.28 1724.94 4300-12000 Control group 29 8715.52 2287.35 3800-13300 Child’s body length (centimeters) Intervention group 29 71.814 7.81 55.5-88.0 Control group 29 72.555 103.632 52.0-88.0 SD, standard deviation. Table 2. Characteristics of the respondents, including maternal education, employment status, family income, and child’s gender. Variable Intervention group Control group (n=29) (n=29) n % n % Education Low Education 7 24.1 7 24.1 Higher Education 22 75.9 22 75.9 Work Doesn’t work 21 72.4 25 86.2 Work 8 27.6 4 13.8 Family income