Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13697 Health education and interprofessional collaboration to improve maternal knowledge on stunting prevention Dwi Indah Lestari,1 Superzeki Zaidatul Fadilah,2 Nurul Arifah,2 Abdul Aziz Azari,1 Ishana Balaputra1 1Bachelor of Nursing Department, Bhakti Al Qodiri School of Health Sciences, Jember; 2Faculty of Nursing, University of Jember, Indonesia Abstract Stunting is characterized by growth failure due to chronic mal- nutrition. A health education initiative utilizing an interprofession- al collaboration approach is needed to decrease incidents of stunt- ing. This study aimed to analyze the impact of health education with interprofessional collaboration on mothers’ knowledge about stunting. It used a quasi-experimental design with a pretest- posttest control design. The research was conducted at a public health center, involving 230 mothers with children aged 0-24 months. Data analysis was performed using the Wilcoxon test. According to the findings, the majority of mothers lacked knowl- edge before the IPC intervention, accounting for 83.5%. However, this improved significantly afterward, with 70.4% demonstrating good knowledge. Statistical analysis revealed a significant increase in maternal knowledge (p=0.000). The IPC program pos- itively influenced maternal knowledge about stunting. It is hoped that policymakers will collaborate with health workers through IPC programs to reduce the prevalence of stunting. Introduction Stunting remains a significant global health issue due to chronic undernutrition.1,2 It is associated with poor maternal health and nutrition, poor socioeconomic conditions, frequent illnesses, and inappropriate child feeding in early life.2 Stunting is estimated to affect 155 million toddlers worldwide. Children who experi- ence stunting face a higher risk of mortality and suffer from impaired cognitive, verbal, and physical abilities, placing a greater financial burden on their parents due to higher care costs.3 Stunting is a critical indicator among the various factors that influ- ence a child’s growth and development.4 The early years of life, particularly from birth to 2 years old, are crucial, as stunting can negatively impact a child’s physical and cognitive development as they grow older.5-7 The consequences of stunting are both short- and long-term, leading to increased morbidity and mortality, poor child development and learning capacity, higher risk of infection and non-communicable diseases in adulthood, and reduced pro- ductivity and economic potential.8,9 According to the World Health Organization (WHO), the global prevalence of stunting in 2022 reached 149 million children under the age of 5.10 In Indonesia, the prevalence of stunting has increased significantly from 28.5% in 2017 to 30.8% in 2018.11 According to the 2022 Indonesian Nutritional Status Survey (SSGI), East Java had the highest stunting prevalence among all provinces in Indonesia, with a rate of 34.9%.12 Nationally, the overall stunting rate was 21.6%. Within East Java, Jember Regency reported a stunting prevalence of 19.6%. Appropriate prevention and intervention are essential and should involve mul- tiple sectors and disciplines.13 Indonesia has implemented national strategies to reduce stunt- ing by accelerating the learning process and improving mecha- nisms for sharing knowledge and innovation.7 The WHO also emphasizes the importance of various stakeholders in preventing and addressing stunting. Effective prevention and management of stunting requires interprofessional collaboration and coordination among multiple disciplines.8 Stunting is a complex issue that impacts many aspects of health.14 The responsibility for prevent- ing and managing stunting can be shared across various profes- sions through Interprofessional Collaboration (IPC).15 The IPC Correspondence: Dwi Indah Lestari, Bachelor of Nursing Department, Bhakti Al Qodiri School of Health Sciences, Jember, Indonesia E-mail: dwiindah343@gmail.com Key words: children, health education, interprofessional education, stunting. Contributions: DIL, SZF, conceptualization, data curation, formal analy- sis, study design, validation, visualization, writing – original draft, review & editing; NA, AAA, IB, data analysis, supervision, draft. All authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. Conflict of interest: the authors have no conflict of interest to declare. Ethics approval and consent to participate: this research was conducted after obtaining ethical approval from the KEPK of the Faculty of Health Sciences, Muhammadiyah University Jember, on 19th July 2024 (approval number 0196/KEPK/FIKES/XII/2024). All respondents pro- vided informed consent before the study. Consent for publication: written informed consent for the publication of anonymized patient information was obtained from each participant. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: this research was funded by the Ministry of Education, Culture, Research, and Technology of Indonesia, under the PDP scheme. Acknowledgments: we thank the Ministry of Education, Culture, Research, and Technology for providing us with the opportunity to qual- ify for the PDP scheme. We also extend our gratitude to the organizations that supported us in recruiting participants and disseminating the survey for this study. Received: 4 February 2025. Accepted: 14 April 2025. Early view: 26 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):13697 doi:10.4081/hls.2025.13697 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 130] [Healthcare in Low-resource Settings 2025;13(s2):13697] approach to lowering the risk of stunting emphasizes knowledge sharing and health education promotion.16 It is considered a poten- tial solution to help reduce stunting in toddlers while also encour- aging relevant agencies and institutions to provide maximum sup- port.16,17 Previous research has demonstrated that cross-sector col- laboration decreases stunting rates. A moderate increase in toddler height and knowledge was observed among mothers who partici- pated in nutrition classes using the IPC approach.17,18 IPC can pro- vide significant benefits to team members, allowing them to achieve better results than they would individually.16,19 Collaborative teamwork is essential for healthcare providers, as it can reduce workload and enhance job performance satisfaction.20 IPC enhances knowledge, attitudes, and behaviors related to nutri- tion among mothers and their stunted toddlers.21 Research on stunting prevention has been conducted world- wide, focusing not only on nutritional issues but also on supporting factors, such as parenting patterns, socioeconomic status, educa- tion, and sanitation.22-25 A critical factor closely associated with stunting is the influence of policymakers in a specific area.9 Policymakers can implement direct interventions to effectively address stunting. Therefore, collaboration through health educa- tion with interprofessional collaboration (HEI collab) is aligned with the government’s efforts. This study aimed to analyze the effect of the HEI collab on mothers’ knowledge of stunting in tod- dlers. The HEI collab program involves a collaborative health team that includes nurses, midwives, nutritionists, pharmacists, and san- itarians. Materials and Methods Study design This study employed a quasi-experimental research design fea- turing a pretest-posttest control group methodology. This approach allows for the comparison of outcomes between the treatment and control groups before and after the intervention. Sample This study was conducted at a public health center with a pop- ulation of 383 stunted toddlers. We employed a stratified random sampling technique, which involved selecting samples based on specific strata within the population, according to the inclusion and exclusion criteria. The final sample consisted of 230 respondents, with 115 assigned to the intervention group and 115 assigned to the control group. The inclusion criteria for this study were as follows: i) mothers with children aged 0-24 months; ii) complete respon- dent data; and iii) willingness to participate. Children were exclud- ed from the study if they had any pathological conditions such as Down syndrome, Marfan syndrome, bone disorders, or Turner syn- drome. Instruments and data collection This study employed the Stunting-Related Knowledge ques- tionnaire, which consists of 10 questions that have been validated and proven reliable to assess the level of knowledge of respon- dents.26 The questionnaire focused on mothers’ understanding of stunting prevention, covering topics such as the definition of stunt- ing, its causes, risk factors, signs and symptoms, impacts, and pre- vention strategies. Scores were assigned based on the following responses: a correct answer received a score of 1, whereas an incorrect answer received a score of 0. The assessment results were categorized as follows: “good” for scores of 76-100% (score 8-10), “fair” for scores of 56-75% (score 7), and “poor” for scores below 55% (score <6). The experimental group participated in an IPC program, which involved a multidisciplinary team comprising nurses, midwives, nutritionists, and sanitarians. This program con- sisted of three meetings: the first focused on assessing the partici- pants’ initial knowledge, the second on delivering educational con- Pathways of Change, Part II Table 1. Characteristics of respondents. Respondent’s characteristic Category Intervention group Control group n % n % Mother’s age 17-25 years 17 14.8 3 2.6 26-35 years 77 67 96 83.5 36-45 years 21 18.3 16 13.9 Toddler’s age 0-6 Months 3 2.6 0 0 7-11 Months 18 15.7 33 28.7 12-23 Months 42 36.5 39 33.9 24-59 Months 52 45.2 43 37.4 Number of children 1-2 89 77.4 92 80 >2 26 22.6 23 20 Education Elementary school 45 39.1 52 45.2 Junior high school 17 14.8 18 15.7 Senior high school 48 41.7 40 34.8 Vocation degree 2 1.7 1 0.9 Bachelor’s degree 3 2.6 4 3.5 Occupation Housewives 93 80.9 94 81.7 Farmer 13 11.3 11 9.6 Merchant 5 4.3 4 3.5 Entrepreneur 3 2.6 4 3.5 Teacher 1 0.9 2 1.7 Ethnic Madurese 70 60.9 71 61.7 Javanese 45 39.1 44 38.3 Religion Islam 115 100 115 100 [Healthcare in Low-resource Settings 2025;13(s2):13697] [page 131] tent, and the third on evaluating the outcomes of the education. During the meetings, the nurses provided information on parenting and nutrition for children, while midwives discussed topics related to child growth and development as well as proper nutrition for mothers and children. Sanitation experts educated the participants about environmental sanitation practices to prevent stunting. In contrast, the control group did not receive the IPC program and continued their usual activities. Data analysis The collected data were analyzed using the Wilcoxon test. Data coding, collection, cleaning, editing, tabulation, and analysis were performed using SPSS version 25.0. Prior to data analysis, the Kolmogorov-Smirnov test was conducted to assess the distribution of data in each group. Ethical clearance This study was conducted after obtaining ethical approval from the KEPK of the Faculty of Health Sciences, Muhammadiyah University, Jember, on July 19, 2024 (No. 0196/KEPK/FIKES/XII/2024). Written informed consent was obtained from each participant prior to the study. Results In the intervention group, the majority of respondents were aged 26-35 years (67%), housewives (80.9%), Madurese (60.9%), and Muslim (100%). The respondents’ education level was primar- ily senior high school at 41.7%, and they had children under five years old (45.2%). The majority had 1-2 children (77.4%). In the control group, most of the respondents were aged 26-35 (83.5%). Most mothers had children under 5 years of age (37.4%), with the majority having 1-2 children (80%). The education level in the control group was mostly elementary school (45.2%), and the par- ticipants were housewives (81.7%), Madurese (61.7%), and Muslims (100%) (Table 1). As shown in Table 2, the majority of mothers in the interven- tion group had poor knowledge before the IPC intervention (83.5%), which improved significantly afterward, with 70.4% demonstrating good knowledge. In contrast, most mothers in the control group, who received only leaflets, had less knowledge before the intervention (77.7%). After the intervention, 71 respon- dents (61.4%) were categorized as having a low level of knowl- edge, while 37 (32.2%) had a moderate level of knowledge. Statistical analysis revealed a significant increase in maternal knowledge from pretest to posttest, with a p-value of 0.000. Discussion This finding demonstrated that IPC intervention had a positive impact on maternal knowledge about stunting. This aligns with previous research showing that the effectiveness of IPC in reduc- ing community stunting rates is supported by collaborative tech- niques, including each professional’s ability to understand both individual and team roles, share knowledge, and promote preven- tive behaviors, particularly among families during the crucial first 1,000 days of a child’s life.27,28 IPC in stunting prevention programs involves the active partic- ipation of nurses, doctors, midwives, nutritionists, and sanitarians. Therefore, implementing the right strategies is essential to enhance the knowledge, attitudes, and behaviors of mothers with toddlers in efforts to prevent stunting. Research suggests that this collabora- tive approach can serve as the most effective model to reduce stunting cases in the community and represents one of the most impactful efforts in preventing stunting.21,29-32 Midwives play a crucial role in preventing stunting, beginning from the first 1,000 days of life. They are actively involved both upstream, by safeguarding the health of prospective brides, preg- nant women, and postpartum mothers, and downstream, by sup- porting the growth and development of toddlers.33,34 Based on the study results, the role of midwives in preventing stunting involves providing information, encouragement, facilities, and empowering women to actively address the issue of stunting in their children.35 Other roles of the midwife profession in prevent- ing stunting are related to reproductive health education in schools, healthy marriage education, providing blood tablets for adoles- cents, implementing standard antenatal care interventions, provid- ing additional food for pregnant women with Chronic Energy Deficiency (CED), and scheduling special visits for CED.36 Nurses also played an active role in preventing stunting. The results of the review from a previous study showed that nurses act as supportive educators, including nutrition educators, health ser- vice providers with improved nutrition, family supporters, and facilitators of interprofessional collaboration in preventing stunt- ing.37 This finding is in line with the results of this study, which stated that nurses play a role as educators and community motiva- tors in families with stunted children.38,39 According to the WHO, environmental sanitation involves efforts to control all aspects of the human physical environment and can impact physical development, health, and human endurance. Sanitation is an overlooked aspect of life, even though it can be a source of diseases.40 Improper sanitation can contribute to infections, and infectious diseases in infants can result from lack of access to clean water sources and poor sanitation facilities. This causes the energy required for growth to be diverted to fight infec- tion, disrupting the process of nutrient absorption and leading to Pathways of Change, Part II Table 2. Knowledge level of intervention and control groups. Category Intervention groupControl group Pretest Posttest Pretest Posttest n % n % n % n % Good knowledge 5 4.3 81 70.4 10 9.1 7 6.1 Fair knowledge 14 12.2 31 27 16 13.2 37 32.2 Poor knowledge 96 83.5 3 2.6 89 77.7 71 61.7 Total 115 100 115 100 115 100 115 100 Wilcoxon signed-rank test p=0.000 p=0.000 [page 132] [Healthcare in Low-resource Settings 2025;13(s2):13697] stunted growth.41,42 Research conducted in developing countries has shown that poor sanitation facilities and contaminated drinking water are often combined, leading to stunting. Children’s health must be prioritized from an early stage, par- ticularly during the “window of opportunity”, also known as the golden period of child development, which spans from conception through the first two years of life, or the first 1,000 days.43 Nutritional fulfillment must be considered during pregnancy because it requires more essential nutrients.44 In addition to meet- ing the mother’s own needs, nutrition during pregnancy is also needed for the growth and development of the fetus in her womb. Growth disorders in the womb can cause low birth weight, which increases the risk of stunting.45,46 Research on children aged 3-24 months with low birth weight and low maternal body mass index shows a high risk of stunting. Besides the pregnancy process, pro- viding complementary feeding is crucial for preventing stunting. Complementary feeding is the transition from an initial intake of only breast milk to semi-solid foods. Complementary feeding should be introduced after the baby is 6 months old in stages, con- sidering the time and type of food, to meet their energy need.47 Therefore, providing breast milk and complementary feeding has a critical impact on stunting.44,48 Conclusions Implementing interprofessional collaboration interventions has been shown to positively impact maternal knowledge of stunting. Practical stunting prevention and intervention efforts require col- laboration across various sectors and interdisciplinary fields. IPC involves the participation of various professionals, including mid- wives, nurses, hygienists, and nutritionists, who work together to deliver comprehensive care. Policymakers can use the IPC approach to develop health promotion programs that integrate mul- tiple disciplines, ultimately enhancing maternal knowledge and contributing to the prevention of stunting in children. References 1. Has EMM, Krisnana I, Efendi F. 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Pathways of Change, Part II [page 134] [Healthcare in Low-resource Settings 2025;13(s2):13697]