Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13424 Development of a health promotion model for parents to promote healthy diet to prevent cancer in adolescents: a cross-sectional study in East Java Indonesia Ilya Krisnana,1,2 Praba Diyan Rachmawati,1 Iqlima Dwi Kurnia,1 Pratuma Rithpho3 1Faculty of Nursing Universitas Airlangga, Surabaya, East Java, Indonesia; 2Pediatric Nursing Research Group Universitas Airlangga, Surabaya, East Java, Indonesia; 3Faculty of Nursing, Naresuan University, Tha Pho, Phitsanulok, Thailand Abstract A healthy diet has been proven to reduce mortality risk. However, the number of people consuming unhealthy diets is increasing, especially among adolescents. Parents are responsible for promoting a healthy lifestyle for adolescents. This research aims to develop a health promotion model for parents of adoles- cents regarding a healthy diet to prevent cancer. The study used a cross-sectional design with an explanatory survey. The population were 148 parents of junior high school students in Surabaya and East Java, Indonesia, who accessed online form over four months. The sample was determined based on the following inclusion cri- teria: parents of adolescents aged 13-16 years, parents of adoles- cents registered at junior high schools in Surabaya, parents capa- ble of completing the form, and parents willing to participate in the research. Convenience sampling was used. Data was collected via a Google Forms questionnaire and analysed using Partial Least Square with T=1.96. There were nine questionnaires used (demo- graphic, perceived benefits and barriers, the self-efficacy for exer- cise, the Physical Activity Enjoyment Scale - PACES, environ- mental support, knowledge, participation, the shortened Committed Action Questionnaire, and Health-Promoting Lifestyle Profile - HPLP II). The study included 148 parents of adolescents. Parental characteristics influenced cognition and affect (T=3.4) and environmental support (T=4.2). Environmental support influ- enced parental empowerment (T=2.9). Similarly, cognition and affect influenced empowerment (T=4.189). Parental empower- ment influenced commitment (T=3.3), which in turn influenced health promotion behaviour regarding a healthy diet (T=3.3). The health promotion model was developed through efforts to empow- er parents and strengthen their commitment to implementing a healthy diet for adolescents, even in challenging situations. Introduction Cancer is the leading cause of death in children and adoles- cents worldwide (WHO, 2021). Indonesia has the highest inci- dence of childhood cancer in the Southeast Asia Region, with 8,677 children suffering from cancer and a death rate of 3,292.1 The increasing prevalence of cancer in Indonesia may be attribut- ed to a shift in food consumption patterns from traditional to mod- ern processing, such as fast food.2 Consuming healthy snacks after main meals has been proven to reduce mortality risk and prevent diseases, including cancer.3 Parents play a crucial role in prevent- ing health risk behaviour in children and adolescents.4 Efforts to increase preventive behaviour in parents can be achieved through health promotion initiatives.5 While health promotion theory has been widely used to improve the health status of children and ado- lescents, its application to increase parental preventive behaviour in promoting healthy snack consumption to prevent cancer remains limited. According to data from the Ministry of Agriculture, fast food currently accounts for 28% of all calories consumed by urban res- idents, with children and adolescents being the largest consumers.6 Research in Lampung shows that more than 50% of adolescents consume fast food 3-5 times a week.7 The higher the frequency of Correspondence: Ilya Krisnana, Faculty of Nursing Universitas Airlangga, Mulyorejo Campus C Universitas Airlangga Surabaya, East Java, Indonesia. Tel.: 62.85648230221; Fax: 62.315913257 E-mail: ilya-k@fkp.unair.ac.id Key words: adolescents, cancer, diet, healthy diet, health promotion. Conflict of interest: there is no potential conflict of interest. Contributions: KI, principal investigator, conceptualised and designed the study; RPD, ethical clearance, collecting data, analysis; KID, writing manuscript, translating, proofreading; RP, reviewed the manuscript. Informed consent: all participants in this study agreed to be respondents through a statement of agreement contained in the online form. Patient consent for publication: this article does not mention the names and identities of respondents (anonymity). Ethics approval: the study design and protocols were reviewed and approved by the Health Research Ethics Commission of Faculty of Nursing Universitas Airlangga, which issued an ethical feasibility certifi- cate (number 2823-KEPK). Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: the author thanks all respondents and Airlangga University for funding the research. Received: 25 November 2024. Accepted: 3 June 2025. Early access: 16 June 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; 13:13424 doi:10.4081/hls.2025.13424 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. [page 190] [Healthcare in Low-resource Settings 2025;13:13424] fast food consumption, the greater the risk of cancer.8 While fast food does not directly cause cancer, its content can trigger cancer development.9 A healthy diet is a solution to prevent increased fast- food consumption and reduce cancer risk.3 Pender’s Health Promotion Model (HPM) is widely used to change unhealthy behaviour and improve health.10 The HPM explores characteristics and previous experiences, cognition and affect, commitment, and preventive behaviour implemented by parents, in this case, regarding healthy snacks. The greater the commitment to a specific action plan, the more likely health-pro- moting behaviour is maintained over time.11 The objective of this study was to develop a health promotion model for parents of ado- lescents regarding a healthy diet to prevent cancer. Materials and Methods Design This study employed a cross-sectional design with an explana- tory survey method. This research design was chosen to explore and explain the causal relationships between independent and dependent variables within the phenomenon under investigation. Population, samples, and sampling The population of this study were all parents of junior high school students in East Java who accessed the online form from June to September 2023. The sample was determined based on the following inclusion criteria: i) parents of adolescents aged 13-16 years, ii) parents of adolescents registered in junior high school in East Java, iii) parents who completed the online form, and iv) par- ents who signed informed consent for the research. Convenience sampling was used over four months. The final sample size was 148 parents. Variables The independent variables in this study were previous parental characteristics: father’s education, mother’s education, age, father’s occupation and mother’s occupation, cognition and affect (perceived benefits and barriers, self-efficacy and affect), environ- mental support, empowerment (knowledge and participation), and commitment. The dependent variable was health promotion behaviour related to a healthy diet. Instruments Parent characteristics The parent characteristics questionnaire is a checklist that cap- tures respondents’ demographic information, including education, age, and occupation. Perceived benefits and barriers The perceived benefits instrument was adopted from the exer- cise benefits questionnaire.12 The instrument measuring the bene- fits of healthy diet behaviour consists of four subscales: i) physical appearance, ii) psychological aspects, iii) social interactions, and iv) preventive health. The instrument measuring the benefits of healthy diet behaviour consists of four subscales: i) environmental conditions, ii) time spent, iii) drained energy, and iv) family disap- pointment. Responses are recorded on a 4-point Likert scale: 4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree. Self-efficacy The self-efficacy measurement instrument is based on the Self- Efficacy for Exercise (SEE) scale questionnaire,13 modified to focus on healthy diet behaviour instead of exercise. The question- naire consists of nine items assessing parents’ confidence in pro- viding a healthy diet. Responses range from 0 (not confident) to 10 (very confident). Affect The affect assessment uses the Physical Activity Enjoyment Scale (PACES),14 consisting of 10 items rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The total score is calculated by summing all responses. Environmental support The environmental support questionnaire focuses on the non- physical environment, precisely information sources. These sources include health workers, family members, and others in the respondents’ social circle. Responses are scored as follows: always = 3, sometimes = 2, never = 1. The maximum possible score is 9, and the minimum is 3. Knowledge The knowledge questionnaire consists of five true/false ques- tions covering i) the definition of a healthy diet, ii) types of healthy diets, iii) food sources of protein, iv) food sources of saturated fat, and v) iodized salt. Correct answers receive 1 point, while incor- rect answers receive 0 points. The maximum possible score is 5. Participation The participation questionnaire was adopted from Pengpid & Peltzer16 and consists of five items measuring parental involve- ment in preparing a healthy diet. The questions cover: i) involving children in determining the daily meal menu, ii) involving children to help cook food, iii) involving children in preparing the dining table, iv) involving children in serving food, and v) involving chil- dren in cleaning the dining table. Responses are scored on a 5- point scale: always = 5, often = 4, rarely = 3, once = 2, never = 1. The maximum possible score is 25, and the minimum is 5. Commitment The commitment questionnaire used the shortened Committed Action Questionnaire,17 adapted to focus on healthy dietary behaviour in parents of adolescents. It consists of eight items with the following response options: 0 = never, 1 = very rarely, 2 = rarely, 3 = sometimes, 4 = often, 5 = almost always, and 6 = always. Health promotion The Health Promotion Questionnaire on a healthy diet was adapted from the Health-Promoting Lifestyle Profile [HPLP II] (Adult Version) questionnaire.18 It consists of nine items with four response options: 4 = always, 3 = often, 2 = sometimes, 1 = never. The maximum possible score is 36, and the minimum is 9. Data collection Data was collected through Google Forms distributed to the target group using various methods, including: i) sending to col- leagues with adolescents attending junior high school in Surabaya, ii) sharing links with colleagues or professional associations of Pediatric Nurses in the East Java region via group messages, iii) publishing the questionnaire link on the researchers’ social media Article [Healthcare in Low-resource Settings 2025;13:13424] [page 191] status. Before completing the questionnaire, potential respondents were provided information about the research title, research team, objectives, benefits, risks, and compensation. Consent was obtained by having respondents click an «agree» button. To vali- date that respondents were parents of junior high school students, they were required to provide the name and location of their child’s school. Data analysis The collected data was analysed using Smart Partial Least Square (PLS) SmartPLS version 4.0.9.5 (Oststeinbek, Germany).19 An indicator was considered valid if it had an outer loading value above 0.5 and a T-statistic value above 1.96. Hypothesis testing was conducted using the t-statistical test. Ethical clearance This study involved human subjects, specifically parents of adolescents. The research team strictly adhered to ethical princi- ples throughout the study. These principles included: i) informed consent: potential participants were provided with a full explana- tion of the study before agreeing to participate; ii) anonymity: respondents’ names were not collected or included in the study data; iii) confidentiality: all data collected from the questionnaires was kept confidential; iv) autonomy: participants were allowed to withdraw from the study if they felt uncomfortable at any point during the questionnaire completion process; v) compensation: to ensure equitable participation, respondents were provided with internet data allowances commensurate with the online question- naire completion requirements. The study design and protocols were reviewed and approved by the Health Research Ethics Commission of Faculty of Nursing Universitas Airlangga, which issued an ethical feasibility certificate (number 2823-KEPK). Results Table 1 shows that over 50% of parents in this study had the last education at senior high school, with the largest employment category being employees in the private sector, both fathers and mothers. Table 2 indicates that parents’ cognition and affect regarding the benefits of a healthy diet had a mean score of 13.7 (SD = 2.0). The primary benefit perceived was that a healthy diet that prevents cancer could make adolescents more attentive to their health. However, parents reported obstacles in maintaining health and providing a healthy diet at home, with the most significant challenge being a lack of time due to work commitments. Parental self-efficacy had the highest average score of 63.6 (SD = 21.0), indicating that many parents felt capable of providing the best care for their children, including a healthy diet, even in difficult situa- tions. On average, all mothers reported positive affect when main- taining health and a healthy diet for their adolescents. Table 3 reveals that parents obtained most of their information from family and close associates, with a minimum score of envi- ronmental support of 3 and a maximum score of 9. Parental knowl- edge about healthy diets for adolescents ranged from a minimum score of 1 to a maximum of 5. The question most frequently answered correctly concerned the definition of a healthy diet, while the question most often answered incorrectly related to types of food containing animal protein. Parental participation scores ranged from 5 to 25, with involving adolescents in preparing healthy diet menus being the highest form of participation and involving them in cooking being the lowest. Parents showed the strongest commitment to maintaining a healthy diet for adolescents even in challenging conditions, while their lowest commitment level was in their ability to change methods rather than abandon healthy diet practices. No parents reported never providing a healthy diet to adolescents, and some always did so. The most commonly implemented healthy diet practice was limiting sugar consumption, while the least common was serving 6-11 portions of bread or cereal daily. Table 4 presents the results of hypothesis testing for the influ- ence of exogenous variables on endogenous variables. The test cri- teria state that the relationship is significant if the T-statistic value ≥ T-table (1.96). All exogenous variables showed significant rela- tionships with endogenous variables, except for the relationship between parent characteristics and health promotion behaviour (T=0.2; p=0.772). Figure 1 illustrates the final (fit) model for developing a health promotion model for parents of adolescents regarding a healthy diet. The model shows that parent characteris- tics do not directly influence health promotion behaviour for a healthy diet, but can indirectly influence it through cognition and affect as well as environmental support. This represents a novel finding from this research. Furthermore, both empowerment and commitment variables positively influence the formation of healthy diet behaviour in adolescents to prevent cancer. Discussion Based on data from WHO, it is estimated that 400,000 children and adolescents aged 0–19 years suffer from cancer every year.20 Parents have a very important role in preventing disease in adoles- cents. Disease prevention carried out by parents can start by pro- viding healthy and nutritious food for adolescents. Several person- al factors of parents are related to preventing health-risk behaviour, including preventing disease.21 The study found that parental char- acteristics, including work and education, influence cognition and affect. This aligns with Pender’s theory that individual characteris- tics influence cognition and affect.22 Higher individual characteris- Article Table 1. General characteristics of the participants (n=148). Characteristics n % Father’s education Elementary school 21 14.2 Junior high school 24 16.2 Senior high school 77 52.0 Higher education (University) 26 17.6 Occupation (father) Farmer 4 2.7 Employee 70 47.3 Entrepreneurs 56 37.8 Civil Servant 8 5.4 Military 7 4.7 Fisher 3 2.0 Mother’s education Elementary school 19 12.8 Junior high school 26 17.6 Senior high school 76 51.4 Higher education (University) 27 18.2 Occupation (mother) Farmer 9 6.1 Employee 71 48.0 Entrepreneurs 54 36.5 Civil Servant 14 9.5 [page 192] [Healthcare in Low-resource Settings 2025;13:13424] tics produce higher cognition and affect, determining subsequent actions.23 Parental characteristics in this context include previous experiences, which are a source of knowledge and a way to obtain the truth of knowledge.24 Most respondents were parents of adoles- cents who understood the importance of a healthy diet in prevent- ing cancer, indicating prior experience in maintaining their chil- dren’s diet. More than half of the parents had permanent jobs in the private sector, suggesting they could afford to buy healthy food for their children. However, some parents struggled to prepare food according to a healthy diet, possibly due to a lack of understanding about what constitutes a healthy diet menu for adolescents. The health promotion model emphasizes that each person has unique personal characteristics and experiences that can influence subse- quent actions.25 In terms of health care for adolescents to prevent cancer, parents need to pay attention to their children’s eating pat- terns both at home and outside. The facilitation process aims to increase parents’ potential to act better and more innovatively.26 Environmental support is greatly influenced by individual characteristics.27 In this study, the greatest support for healthy dietary behaviour came from family or people close to the adoles- cent’s parents. The family plays a significant role in solving health problems.28 Parents need reinforcement and support from family members to carry out health promotion behaviour, specifically pro- viding a healthy diet for adolescents to prevent cancer. Parents who have knowledge and participate in providing a healthy diet can feel empowered to support their adolescent children’s health.29 Cognition and affect are built from perceived benefits, barriers, and self-efficacy. More than half of the parents felt high benefits in maintaining their teenage children’s health to prevent cancer. The most significant benefit perceived by parents was that maintaining a healthy diet increased their attention to their children’s health. The biggest obstacle reported was a lack of time to provide a healthy diet regularly. All parents reported a positive effect towards maintaining their children’s healthy diet. Routine and reg- ular healthy diet behaviour in adolescents is a way to prevent can- cer.30 Parents need self-efficacy to be able to carry out their role in preventing disease in adolescents properly.4 Self-efficacy is also a necessity for parents in preventing disease in toddlers.31 Self-effi- cacy can also encourage parents to behave well in carrying out pre- vention without experiencing boredom. Commitment directly influences healthy dietary behaviour carried out by parents. Article [Healthcare in Low-resource Settings 2025;13:13424] [page 193] Table 2. Cognition and affect indicators about a healthy diet in adolescents. Indicators Minimum Maximum Mean ± SD Perceived benefits 9 16 13.7±2.0 Perceived barriers 4 16 11.0±2.7 Self-efficacy 9 90 63.6±21.0 Affect 23 50 40.8±8.4 Table 3. Distribution of variables of environmental support, empowerment, and health promotion behaviour of healthy diet among adolescents. Indicators Minimum Maximum Mean ± SD Environmental support 3 9 6.1±1.8 Knowledge 1 5 3.0±1.0 Participation 5 25 18.7±3.9 Commitment 10 40 23.5±6.0 Health promotion behaviour 13 36 25.1±5.6 Table 4. Hypothesis testing of the health promotion model regard- ing a healthy diet to prevent cancer. T Statistics p Characteristics -> environmental support 4.2 <0.001* Characteristics -> cognition and affect 3.4 0.001* Environmental support-> empowerment 2.9 0.004* Cognition -> empowerment 4.1 <0.001* Empowerment -> commitment 3.3 0.001* Characteristics -> health promotion behaviour 0.2 0.772 Commitment -> health promotion behaviour 3.3 0.001* * (p≤0.05) Figure 1. Model fit development of a health promotion model for parents of adolescents regarding a healthy diet to prevent cancer. Parents’ commitment fosters greater attention in their teenage chil- dren to maintain health through a healthy diet. Preventive behaviour based on a commitment will last a long time so that goals can be achieved. One factor that can influence the formation of commitment is the existence of a collaborating team.32 Empowerment has a direct effect on commitment. Parental empowerment is one of the factors that must be carried out to form a disease prevention program through adequate information about nutrition.33 Parents’ lack of knowledge about cancer can negatively affect their daily behaviour. Forming commitment requires several continuous processes and stages, and cannot happen quickly.34 The health promotion model about a healthy diet for adoles- cents in preventing cancer is very much determined by the educa- tion of parents, both mothers and fathers. Parental education is the basis for the formation of cognition and affect. Parents who have higher education can minimise the perceived obstacles and strengthen the perceived benefits. The health promotion model about a healthy diet for adolescents in preventing cancer is very much determined by parental education, both the mother’s and the father’s. Parental education is the basis for the formation of cogni- tion and affect. Parents who have higher education can minimise perceived obstacles and strengthen perceived benefits. Parents with a good level of education have strong self-efficacy and posi- tive affect to provide a healthy diet to adolescents. The existence of adequate environmental support for parents can create empow- erment so as to foster commitment in implementing health promo- tion in providing diet to adolescents. Without commitment from parents, health promotion behaviour in a healthy diet for adoles- cents cannot be formed. Conclusions The health promotion model for healthy diet behaviour applied by parents to adolescents can be formed through strengthening characteristic factors, cognition and affect, environmental support, empowerment, and commitment. Parental education is a signifi- cant factor in shaping cognition, affect, and environmental support. The benefits, obstacles, self-efficacy, and affect experienced by parents can foster a sense of empowerment, which is strengthened by family support. The sense of empowerment experienced by par- ents will foster commitment through a determination to continue providing healthy diets to adolescents, even in difficult situations. Behaviour formed through strong commitment is likely to be more sustainable. References 1. WHO. Childhood Cancer. World Health Organization. 2021. 2. WHO. Estimated number of incident cases and deaths all cancers, both sexes, ages 0-14. 2022. Available from: h t t p s : / / g c o . i a r c . f r / t o d a y / o n l i n e - a n a l y s i s - m u l t i - bars?v=2020&mode=population&mode_population=coun- tries&population=900&populations=900&key=total&sex=0& cancer=39&type=0&statistic=5&prevalence=0&population_g roup=11&ages_group%5B%5D=0&ages_group%5B%5D=2 &nb_ite 3. Gondhowiardjo SA. Pedoman Strategi & Langkah Aksi Penerapan Perilaku Diet Sehat. Komite Penanggulangan Kanker Nasional (KPKN); 2019. 1–67 p. 4. Krisnana I, Rachmawati PD, Kurnia ID. Self-efficacy and parental commitment to prevent health risk behavior among adolescents in East Java. Enferm Clin 2022;32:S20–3. 5. Kurnia ID, Krisnana I, Rachmawati PD, et al. The increased interaction of parents can prevent smoking behavior and alco- hol consumption of adolescents in Indonesia. In: Proceedings ofthe 9th International Nursing Conference (INC 2018). SCITEPRESS – Science and Technology Publications; 2019. p. 274–9. 6. De Vet E, Stok FM, De Wit JBF, De Ridder DTD. The habitual nature of unhealthy snacking: How powerful are habits in ado- lescence? Appetite 2015;95:182–7. 7. Reza Miranda A, Arief Budi Y, Ajeng Kartika S. Gambaran Aktivitas Fisik dan Pola Makan Selama Pandemi COVID-19 Pada Remaja di SMA Negeri 4 Metro Lampung. Bandung Conf Ser Med Sci 2022;2:21–6. 8. Tayyem RF, Bawadi HA, Shehadah I, et al. Fast foods, sweets and beverage consumption and risk of colorectal cancer: A case-control study in Jordan. Asian Pacific J Cancer Prev 2018;19:261–9. 9. Credihealth Team. Fast Food & Cancer – Is there a relation? Credi Health. 2022. Available from: https://www.credihealth. com/blog/fast-food-and-cancer-relation/#:~:text=It has been generally linked,fast food and cancer relation. 10. Khodaveisi M, Omidi A, Farokhi S, Soltanian AR. The effect of pender’s health promotion model in improving the nutrition- al behavior of overweight and obese women. Int J Community Based Nurs Midwifery 2017;5:165–74. 11. Pender NJ. Health promoting model manual. Chicago: University of Michigan; 2011. 12. Lovell GP, Ansari W El, Parker JK. Perceived exercise benefits and barriers of non-exercising female University Students in the United Kingdom. Int J Environ Res Public Health 2010;7:784-98. 13. Estrada M. University Students’ Involvement in a Health Promoting Lifestyle : Influencing Factors of the Health Promotion Model. 2016. Pittsburg State University, Thesis. Available from: https://digitalcommons.pittstate.edu/etd/232/ 14. Motl RW, Dishman RK, Saunders R, et al. Measuring enjoy- ment of physical activity in adolescent girls. Am J Prev Med 2001;21:110–7. 15. Pengpid S, Peltzer K. Parental involvement and health risk behaviours among school-going adolescents in six African countries. J Psychol Africa 2018;28:212–7. 16. Pengpid S, Peltzer K. Parental involvement and health risk behaviours among school-going adolescents in six African countries. J Psychol Africa 2018;28:212–7. 17. Mccracken LM, Chilcot J, Norton S. Further development in the assessment of psychological flexibility: A shortened Committed Action Questionnaire (CAQ-8). Eur J Pain 2014;19:677-85. 18. Susan N, Karen R, Nola J. Health Promotion model - instru- ments to measure health promoting lifestyle: Health- Promoting Lifestyle Profile [HPLP II] (Adult Version). 1995;42–3. 19. Ringle CS, Wende S, Becker J. Smart PLS4. Oststeinbek: SmartPLS GmbH; 2022. Available from: http://www.smart- pls.com 20. WHO. Childhood Cancer. World Health Organization. 2025. Available from: https://www.who.int/news-room/fact- sheets/detail/cancer-in-children 21. Krisnana I, Rachmawati PD, Kurnia ID, et al. Factors related to parental involvement in the prevention of health risk behav- iors among adolescents: a cross-sectional study in East Java Article [page 194] [Healthcare in Low-resource Settings 2025;13:13424] Indonesia. Open Access Maced J Med Sci 2022;9:371–4. 22. Pender NJ. Health Promotion Model Manual. deepblue.lib.umich.edu. 2011. p. 1–17. Available from: http://deepblue.lib.umich.edu/bitstream/handle/2027.42/85350 /?sequence=1 23. Diananda A. Psikologi Remaja Dan Permasalahannya. J Istighna 2019;1:116–33. 24. Balqis UM, Hartati S, Ayu SA. Penguatan Program Promosi Kesehatan Melalui Komplikasi Hipertensi Pada Pasien Rawat Jalan Puskesmas Karang Tengah - Cianjur. J Mitra Masy 2022;3:23–32. 25. Petiprin A. Health Promotion Model - Nursing Theory. Nursing-Theory.org. 2016. Available from: http://www.nurs- ing-theory.org/theories-and-models/pender-health-promotion- model.php 26. Vistad I, Skorstad M, Demmelmaier I, et al. Lifestyle and Empowerment Techniques in Survivorship of Gynaecologic Oncology (LETSGO study): A study protocol for a multicentre longitudinal interventional study using mobile health technol- ogy and biobanking. BMJ Open 2021;11:e050930. 27. Zhang L, Shi Y, Deng J, et al. The effect of health literacy, self- efficacy, social support and fear of disease progression on the health-related quality of life of patients with cancer in China: a structural equation model. Health Qual Life Outcomes 2023;21:75. 28. Badi’ah A, Mendri NK, Palestin B, et al. Family empowerment psychoeducation on family support caring of children diarrhea. Open Access Maced J Med Sci 2022;9:137–41. 29. Banach M, Iudice J, Conway L, Couse LJ. Family support and empowerment: post autism diagnosis support group for par- ents. Soc Work Groups 2010;33:69–83. 30. Tang H, Wang R, Liu W, et al. The influence of nutrition liter- acy, self-care self-efficacy and social support on the dietary practices of breast cancer patients undergoing chemotherapy: A multicentre study. Eur J Oncol Nurs 2023;64:102344. 31. Zatihulwani EZ, Sukartini T, Krisnana I. Development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddlers. J Ners 2017;12:171. 32. Suryani I. Factors affecting organizational performance. J Manaj Dan Inov 2018;9:14–31. 33. Lovell JL. How parents process child health and nutrition information: A grounded theory model. Appetite 2016;97:138– 45. 34. Bashaw R, Grant E. Exploring the distinctive nature of work commitments: their relationships with personal characteristics, job performance, and propensity to leave. J Pers Sell Sales Manag 2013;14:41–56. Article [Healthcare in Low-resource Settings 2025;13:13424] [page 195]