Effects of family-based nursing interventions on mothers’ knowledge, attitudes, and self-efficacy related to stunting prevention in Indonesia: A quasi-experimental study

Abstract

Objectives

This study aimed to evaluate the effectiveness of family-based nursing interventions in improving mothers’ knowledge, attitudes, and self-efficacy to prevent stunting among children under 2 years of age in Indonesia.

Methods

A quasi-experimental study was conducted from June to December 2024 in Alor District, East Nusa Tenggara, Indonesia. Sixty mothers of children aged 0–24 months were recruited using convenience sampling and assigned to either an intervention group (n = 30) or a control group (n = 30). The intervention group received seven structured sessions of a family-based nursing intervention grounded in Family-Centered Care and Social Cognitive Theory. In contrast, the control group received routine health education from local community health centers. Knowledge, attitudes, and self-efficacy were measured using validated questionnaires at baseline, post-intervention, and a three-month follow-up. Data were analyzed using independent-sample t-tests and a mixed repeated-measures analysis of variance.

Results

All 60 participants completed the study. Independent-sample t-tests revealed no significant differences between the two groups at baseline for knowledge (t = −0.682, P = 0.498), attitudes (t = 0.655, P = 0.515), and self-efficacy (t = 1.671, P = 0.100). A mixed repeated-measures analysis of variance demonstrated significant group, time, and group × time effects on knowledge, attitudes, and self-efficacy (all P < 0.001). Pairwise comparison revealed that the scores at post-intervention and three-month follow-up were significantly higher in the intervention group for all three variables (all P < 0.001).

Conclusions

The family-based nursing intervention effectively enhanced maternal knowledge, attitudes, and self-efficacy regarding stunting prevention. These findings underscore the importance of incorporating structured, family-centered interventions into community-based public health programs to reduce the risk of stunting.

What is known?

• •Stunting remains a major public health problem in many low- and middle-income countries, particularly during the first 1,000 days of life, and is closely associated with inadequate maternal knowledge, suboptimal caregiving practices, and limited family support for optimal child nutrition and health.
• •Maternal knowledge, attitudes, and self-efficacy are consistently associated with caregiving practices that influence child nutrition, health behaviors, and stimulation, thereby playing a critical role in stunting prevention.
• •Family-based interventions, particularly those grounded in nursing and focused on maternal empowerment within the family context, have been shown to improve caregiving practices and contribute to better child health outcomes, including reduced stunting risk.

What is new?

• •We developed a family-centered nursing intervention grounded in Family-Centered Care and Social Cognitive Theory, consisting of structured health education, participatory group discussions, role-plays, practical feeding demonstrations, and family engagement activities tailored to the local cultural context.
• •The intervention significantly improved mothers’ knowledge, attitudes, and self-efficacy with sustained effects three months after program completion.

1. Introduction

Malnutrition encompasses undernutrition (stunting, wasting, and underweight) and the diet-related non-communicable diseases that result from it [1]. In 2022, an estimated 149 million children under the age of five worldwide were stunted (too short for their age) [1]. Child stunting is the best indicator of children’s overall health and a precise reflection of social inequalities. Stunting is the most prevalent form of malnutrition in children [2], particularly in the first 1,000 days from conception to age two [3]. If not addressed promptly, stunting can lead to serious physical and mental consequences, including impaired cognitive and physical development, increased vulnerability to infections, a higher risk of chronic diseases, and elevated mortality rates later in life [1,4,5]. Despite international commitments such as the World Health Assembly’s [6] target to reduce stunting by 2025, many countries, including Indonesia, continue to face challenges in meeting these goals. The 2022 Indonesia Nutritional Status Survey [7] reported a national stunting rate of 21.6 %, down from 24.4 % in 2021. However, this rate remains above the 14 % target set by the National Medium-Term Development Plan for 2020-2024 [8]. Furthermore, East Nusa Tenggara remains one of the provinces with the highest prevalence in Indonesia, with a rate of 35.3 % [7].

In East Nusa Tenggara, cultural norms and extended family decision-making strongly influence infant feeding and caregiving practices. A qualitative study [9] from eastern Indonesia indicates that culturally rooted beliefs and rituals can affect exclusive breastfeeding and contribute to early complementary feeding. Family dynamics, particularly the influence of grandmothers, often shape feeding decisions and caregiving behaviors, increasing the risk of suboptimal nutrition during early childhood [10]. Evidence from Indonesia suggests that family empowerment interventions can improve feeding practices and child growth outcomes [11]. At the same time, broader literature supports culturally sensitive, family-centered approaches that align health messages with local values and social support systems [12,13]. These contextual characteristics underscore the need for family-centered and culturally tailored nursing interventions in high-prevalence settings, such as East Nusa Tenggara.

Some studies [14,15] have identified multiple determinants of stunting, including inadequate maternal knowledge, inappropriate parenting practices, low educational attainment, and poor environmental conditions. A cross-sectional study [16] emphasizes that maternal knowledge, positive attitudes, and self-efficacy are key factors influencing child feeding behaviors and nutritional outcomes. Intervention studies [[17], [18], [19]] in Indonesia have shown that nutrition education programs significantly improve mothers’ knowledge, self-efficacy, and feeding practices, with subsequent benefits for child growth indicators. A community-based caregiver capacity-building program [20] has reported similar improvements in knowledge, attitudes, and efficacy related to stunting prevention. Furthermore, a recent scoping review [21] grounded in Social Cognitive Theory (SCT) highlighted that knowledge, self-efficacy, and social support are essential drivers of maternal feeding behavior and child nutrition. Despite these findings, empirical evidence evaluating structured, theory-driven interventions that explicitly strengthen maternal knowledge, attitudes, and self-efficacy within a family-based nursing framework remains limited, particularly in high-burden regions of Indonesia. Few studies [[22], [23], [24], [25]] have integrated education and family empowerment as core strategies during the first 1,000 days of life. However, family involvement has been shown to support optimal child nutrition and developmental outcomes [26].

Based on these gaps, the present study is theoretically grounded in Family-Centered Care (FCC) and SCT [27,28], which emphasize the role of families as active partners in care and the interaction of cognitive, behavioral, and environmental factors in shaping health behaviors. These theories provide a strong conceptual basis for collaborative and contextually relevant nursing interventions aimed at strengthening mothers’ knowledge, attitudes, and self-efficacy in stunting prevention. Accordingly, this study aimed to examine the effects of a family-based nursing intervention on mothers’ knowledge, attitudes, and self-efficacy related to stunting prevention in Indonesia.

2. Methods

2.1. Study design

A quasi-experimental design was applied in this study, conducted from June to December 2024 in Alor Regency, East Nusa Tenggara, Indonesia. Alor Regency, one of the districts with the highest stunting rates in East Nusa Tenggara as of 2022, includes 21 villages served by a single family-care community health center [7]. This study was reported in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement to ensure methodological rigor and transparency.

2.2. Study participants

The participants were mothers aged 18–49 years, representing women in the active reproductive age who were primary caregivers and decision-makers for infant feeding and caregiving practices, and who had at least one child aged 0–24 months. Infants aged 0–24 months were selected as this period represents the most critical postnatal window within the first 1,000 days of life, during which growth faltering and stunting are most likely to occur. Eligible participants were required to read and communicate in Bahasa Indonesia. Mothers with severe psychiatric disorders or other comorbidities that could hinder participation were excluded, based on self-report and confirmation from community health records. Mothers who were seriously ill or whose children had congenital anomalies requiring specialized care were also excluded.

Participants were recruited through convenience sampling. Group allocation was nonrandom, consistent with the quasi-experimental design, and followed a first-come, first-served approach. The first 30 eligible mothers were assigned to the intervention group and the subsequent 30 to the control group. This nonrandom allocation was adopted due to local logistical constraints, including limited availability of community health workers, and to minimize information contamination between groups within closely connected communities. Although this approach may introduce selection bias and limit comparability, it reflects a feasible and ethically acceptable design consistent with the quasi-experimental nature of the study.

2.3. Sample size calculation

The sample size was calculated using G∗Power software, version 3.1.9.2 [29]. The calculation was based on a two-tailed t-test for independent means, with α = 0.05, statistical power = 0.80, and an effect size of 0.66. This effect size was derived from a prior quasi-experimental study in Indonesia that reported improvements in mothers’ knowledge, attitudes, and self-efficacy related to stunting prevention [20]. In that study, the mean change in self-efficacy scores was 2.62 ± 3.82 in the intervention group and 1.96 ± 3.73 in the control group, yielding a Cohen’s d of 0.66. Based on this calculation, a total of 60 participants was required, equally divided between the intervention (n = 30) and control (n = 30) groups. An attrition rate adjustment was not incorporated into the sample size calculation because the study was conducted in a stable community setting, with close collaboration with community health volunteers (Posyandu cadres), and with planned intensive follow-up throughout the intervention period.

2.4. Interventions

2.4.1. Intervention group

The family-based nursing intervention implemented in this study was a structured program designed and conceptually grounded in two theoretical frameworks: FCC and SCT. The FCC model served as the foundation for engaging families, particularly mothers, as active partners in child-health decision-making, emphasizing mutual respect, partnership, and shared responsibility [30]. In parallel, SCT provided a behavior-change framework highlighting mechanisms such as observational learning, direct experience, and reinforcement of self-efficacy [28].

The intervention content was developed through a multistep process comprising three main stages: 1) a targeted literature review of peer-reviewed studies on maternal empowerment and family-based nursing interventions for stunting prevention, including three empirical studies conducted in Indonesia and one conceptual study on family nursing interventions [19,23,31,32]; 2) an analysis of national stunting-reduction guidelines; and 3) a local needs assessment conducted through focus group discussions (FGDs) with mothers and Posyandu health volunteers. Key reference materials included the Family-Centered Nursing Model [33], the Indonesian Nursing Intervention Standards [34], and the National Guidelines for Integrated Stunting-Reduction Interventions at the District/City Level [35]. The intervention also incorporated the “Five Family Health Tasks for Stunting Prevention” framework proposed by Setiawan et al. [36], emphasizing education, empowerment, behavior change, and the strengthening of family support systems.

The FGDs involved 10 participants: six mothers of children under five and four Posyandu health volunteers with experience in maternal and child health services. These discussions explored local caregiving practices, perceived barriers to optimal nutrition, and community perspectives on stunting prevention to inform the intervention’s contextual adaptation. To ensure content validity, the intervention was reviewed by a panel of five experts: two senior lecturers in community and family nursing, one maternal and child nutritionist with more than 15 years of experience, one pediatric nursing lecturer, and one expert in nursing education. This process followed the Polit and Beck validation framework [37], focusing on relevance, clarity, and cultural alignment. The panel provided constructive feedback, recommending 1) the use of visual educational tools to support mothers with low literacy, 2) inclusion of structured family-communication exercises and joint decision-making components, and 3) strengthening of the home-visit element by observing sanitation practices and promoting the use of the Maternal and Child Health Handbook (KIA book). All recommendations were incorporated into the final intervention.

The final program was administered once per week over seven consecutive weeks and consisted of seven structured sessions facilitated by trained nurse facilitators: 1) program introduction; 2) health education on stunting; 3) supportive parenting; 4) nutrition and feeding; 5) environmental health; 6) access to health services; 7) evaluation and closing. These facilitators were public-health nurses holding Community Nursing Specialist degrees. They had been taught by bilingual nurse researchers (fluent in English and Bahasa Indonesia) from the Community Nursing Department of the Faculty of Nursing at Universitas Indonesia. Each session, conducted in Bahasa Indonesia, included group education, participatory discussions, simulation exercises, and home visits. The 30 mothers in the intervention group were divided into two subgroups of about 15 participants each to promote active participation and effective facilitation. Each session lasted 60-90 min, depending on participant engagement. The first 30 mothers recruited were assigned to the intervention group to ensure logistical feasibility and minimize contamination, as earlier participants might otherwise influence later participants. The detailed structure of the family-based nursing intervention, including session objectives, topics, methods, and expected outcomes, is presented in Appendix A.

Each component of the intervention was explicitly mapped to principles of FCC and SCT. Participatory group discussions and role-play exercises reflected SCT mechanisms of observational learning and reinforcement, allowing mothers to observe and practice positive caregiving behaviors. Family-communication and action-planning sessions operationalized FCC principles by promoting shared decision-making and strengthening the family’s role as a care unit. Home visits and joint monitoring of sanitation and child growth integrated FCC’s partnership model with SCT’s focus on building self-efficacy through direct experience. Overall, the seven-session structure was educational and theoretically coherent, ensuring that improvements in mothers’ knowledge, attitudes, and self-efficacy aligned with behavioral determinants critical to stunting prevention.

2.4.2. Control group

The control group received routine maternal and child health services from local community health centers (Puskesmas), including standard growth monitoring and health education.

2.5. Measures

2.5.1. Demographic data

Demographic data were collected through a self-administered questionnaire developed by the researchers, which captured maternal age, educational level, employment status, distance to the healthcare facility, insurance ownership, family income, and number of children.

2.5.2. Knowledge, attitudes, and self-efficacy instruments

The research team developed the knowledge, attitudes, and self-efficacy instruments based on two primary sources: national guidelines on stunting prevention during the first two years of life [38], which define key domains of recommended maternal practices, and a previously validated study [20] examining maternal knowledge, attitudes, and self-efficacy related to stunting. This combined approach ensured conceptual relevance and comprehensive coverage of core constructs related to stunting prevention. Content validity was evaluated by a panel of 11 local experts who were not involved in the study. The panel consisted of four senior lecturers in community and family nursing (PhD), three maternal and child health nurses holding Master’s degrees, two public health researchers, and two nurse educators with experience in instrument development. They reviewed the questionnaires for relevance, clarity, and cultural appropriateness. The overall scale-level Content Validity Index (S-CVI) was 0.80, and no items were revised or removed after review. A pilot test was conducted with 30 mothers from a similar population who were not included in the main study. They completed the instruments twice: at recruitment and 1 month later to assess item comprehension and test–retest stability. Based on the pilot results, no significant modifications were required. Internal consistency was confirmed with Cronbach’s α coefficients ranging from 0.70 to 0.84, demonstrating acceptable psychometric reliability.

2.5.2.1. Mother’s knowledge of stunting prevention questionnaire

This 11-item questionnaire assessed participants’ knowledge of stunting prevention, covering key domains of definition, risk factors, critical periods of growth, nutrition and feeding practices, infection and sanitation, and long-term consequences. The items included: 1) stunting is a condition of growth failure in children caused by chronic malnutrition; 2) unbalanced nutrition increases the risk of stunting in children; 3) the first 1,000 days of life are a critical period for child growth and development; 4) exclusive breastfeeding for the first six months helps prevent stunting; 5) stunting can be identified by shorter stature compared to children of the same age; 6) micronutrient supplements, such as iron and vitamins, are essential for preventing stunting; 7) infectious diseases, such as diarrhea, contribute to the risk of stunting in children; 8) good sanitation and hygiene help prevent stunting; 9) introducing complementary foods before six months increases the risk of stunting; 10) responsive feeding practices help prevent stunting; 11) stunting can have long-term effects on a child’s health and productivity.

Each item was scored as 1 (correct) or 0 (incorrect), yielding a total score range of 0–11, with higher scores indicating greater knowledge. In this study, the scale’s internal consistency was acceptable (Cronbach’s α coefficient = 0.83).

2.5.2.2. Mother’s attitudes towards stunting prevention questionnaire

This 12-item questionnaire assessed maternal attitudes toward stunting prevention, focusing on beliefs, motivation, responsibility, and family and community support related to child nutrition and caregiving practices. The items included: 1) I believe that providing balanced nutrition is essential for my child’s growth; 2) I am motivated to follow healthcare advice regarding my child’s nutrition; 3) I believe that exclusive breastfeeding is crucial for my child’s health; 4) I am committed to ensuring that my child receives regular health check-ups; 5) I believe that my actions can significantly influence my child’s growth and development; 6) I am willing to learn more about strategies to prevent stunting; 7) I feel responsible for maintaining my child’s nutritional status; 8) I am open to modifying feeding practices to prevent stunting; 9) I believe that good sanitation and hygiene are essential for my child’s health; 10) I believe that maternal education plays a vital role in child health; 11) I am willing to seek support from community resources for stunting prevention; 12) I consider preventing stunting to be a priority for my family.

Responses were rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores ranged from 12 to 60, with higher scores indicating more positive attitudes toward stunting prevention. In this study, the scale’s internal consistency was acceptable (Cronbach’s α coefficient = 0.74).

2.5.2.3. Mother’s self-efficacy in stunting prevention questionnaire

This 13-item questionnaire assessed maternal self-efficacy in performing behaviors related to stunting prevention, including nutrition, feeding practices, hygiene, health service utilization, and disease prevention. The items included: 1) I am confident that I can provide balanced nutrition to my child every day; 2) I am confident that I can provide exclusive breastfeeding to my child for the first six months; 3) I am confident that I can recognize the signs of stunting in my child; 4) I am confident that I can prepare nutritious meals for my child; 5) I am confident that I can ensure my child receives regular health check-ups; 6) I am confident that I can follow healthcare advice related to child nutrition; 7) I am confident that I can maintain good sanitation and hygiene at home; 8) I am confident that I can introduce complementary foods at the appropriate time; 9) I am confident that I can identify and utilize community resources for stunting prevention; 10) I am confident that I can effectively manage my child’s health and nutrition; 11) I am confident that I can prevent infectious diseases in my child; 12) I am confident that I can ensure my child receives necessary micronutrient supplements; 13) I am confident that I can provide responsive feeding practices for my child.

Responses were rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with higher total scores indicating greater self-efficacy. The scale’s internal consistency was acceptable (Cronbach’s α coefficient = 0.84).

2.5.3. Maternal satisfaction questionnaire

Following the intervention, mothers in the intervention group completed a structured maternal satisfaction questionnaire developed by the research team to assess their perceptions of the family-based nursing intervention. The questionnaire content was determined based on the objectives and key components of the intervention program, as well as feedback from the expert panel involved in content validation. The questionnaire evaluated six key domains: material relevance, facilitator competence, practical applicability of the sessions, perceived knowledge improvement, attitudes change, and enhancement of self-confidence in stunting prevention. The responses were strongly disagree, disagree, neutral, agree and strongly agree. This measure was used solely for supportive feedback and was not included as a primary study outcome.

This study did not directly assess child anthropometric outcomes; therefore, the findings are interpreted as behavioral and psychosocial improvements supporting stunting prevention rather than as direct evidence of reduced stunting.

2.6. Data collection

Data were collected using interviewer-assisted structured questionnaires administered by trained enumerators. Enumerators were practicing nurses employed at local community health centers (Puskesmas) and were not involved in delivering the intervention. Following institutional review board approval, eligible mothers were recruited at family-care community centers in Alor Regency, East Nusa Tenggara, during routine child-health visits. Enumerators provided standardized explanations regarding the study objectives, procedures, and the voluntary nature of participation.

Baseline data were collected using interviewer-assisted questionnaires in Bahasa Indonesia to ensure comprehension and consistency. For the intervention group, data were collected at three time points: pre-intervention (baseline), immediately after completion of the seven-session program (post-intervention), and three months after the final session (follow-up). For the control group, data were collected at equivalent time points: baseline, seven weeks after intervention, and three months after the final session. Each data collection session lasted approximately 20–30 min and was conducted in private or semi-private areas within community centers to ensure confidentiality and participant comfort.

2.7. Data analysis

Data were analyzed using IBM SPSS Statistics version 23.0. Descriptive statistics (frequencies, means, and standard deviations) were used to summarize participants’ characteristics. Normality of outcome variables was assessed using the Shapiro–Wilk test, and homogeneity of variances between groups was evaluated using Levene’s test. Baseline comparability between the intervention and control groups was examined using Chi-square tests for categorical variables and independent-sample t-tests for continuous variables. Changes in knowledge, attitudes, and self-efficacy over time were analyzed using mixed repeated-measures analysis of variance, with time (baseline, post-intervention, and three-month follow-up) as the within-subjects factor and group (intervention group vs control group) as the between-subjects factor. This approach was used to evaluate main effects of time, main effects of group, and group × time interaction effects. When the assumption of sphericity was violated, the Greenhouse–Geisser correction was applied. Independent-sample t-test was conducted to explore between-group differences at individual measurement points when appropriate. All analyses were two-tailed, and a P-value < 0.05 was considered statistically significant. Responses to the maternal satisfaction questionnaire were analyzed descriptively using frequencies and proportions.

2.8. Ethical considerations

Ethical approval for this study was obtained from the Nursing Research Ethics Committee, Faculty of Nursing, Universitas Indonesia (Approval No. KET-159/UN2.F12.D1.2.1/PPM. February 00, 2024). All ethical procedures were implemented before and throughout data collection to ensure compliance with international research ethics guidelines. Participants were fully informed about the study’s objectives, methods, potential benefits, and possible risks in a clear and culturally appropriate manner. Written informed consent was obtained from all participants before participation. Participation was entirely voluntary, and participants had the right to withdraw from the study at any time without penalty. Confidentiality and anonymity were strictly maintained, and all data were de-identified and securely stored for research purposes only.

3. Results

3.1. Characteristics of the participants

Appendix B showed the participant flow from recruitment to final analysis according to the TREND guidelines. Of the 60 eligible mothers approached, all consented to participate and were allocated to the intervention group (n = 30) or the control group (n = 30). No participants withdrew during the intervention or follow-up period, and complete data were available for all outcome analyses.

The mean age of mothers was 27.46 ± 6.69 years in the intervention group and 28.33 ± 6.47 years in the control group. Higher education, defined as completion of senior high school or higher, was reported by 50.0 % of the intervention group and 60.0 % of the control group. Most participants were unemployed (90.0 % in the intervention group and 66.7 % in the control group). Regarding distance to healthcare facility, most mothers lived within 4 km (93.3 % in the intervention group and 83.3 % in the control group). Family income below the regional minimum wage was reported by 63.0 % of mothers in the intervention group and 80.0 % in the control group. Slightly more than half of the participants had ≤2 children, while the rest had ≥3. Nearly all mothers had health insurance coverage (93.3 % in the intervention group and 96.7 % in the control group). Chi-square tests and independent-sample t-tests indicated no statistically significant baseline differences between the intervention and control groups across all demographic characteristics (P > 0.05), confirming homogeneity between groups (Table 1).

Table 1.

Comparison of demographic characteristics of the study participants.

Characteristics	Total (n = 60)	Intervention group (n = 30)	Control group (n = 30)	χ2/t	P
Age (years)	27.90 ± 6.55	27.46 ± 6.69	28.33 ± 6.47	0.188a	0.666
Educational level
Senior high school or higher	33 (55.0)	15 (50.0)	18 (60.0)	0.269b	0.604
Junior high school or lower	27 (45.0)	15 (50.0)	12 (40.0)
Employment status
Employed	13 (21.7)	3 (10.0)	10 (33.3)	3.535b	0.060
Unemployed	47 (78.3)	27 (90.0)	20 (66.7)
Distance to healthcare facility
Far (>4 km)	7 (11.7)	2 (6.7)	5 (16.7)	0.647b	0.421
Near (≤4 km)	53 (88.3)	28 (93.3)	25 (83.3)
Family incomec
Above minimum wage	17 (28.3)	11 (36.7)	6 (20.0)	1.313b	0.252
Below minimum wage	43 (71.7)	19 (63.3)	24 (80.0)
Number of children
<2	28 (46.7)	16 (53.3)	12 (40.0)	0.603b	0.438
≥3	32 (53.3)	14 (46.7)	18 (60.0)
Health insurance ownership
Yes	57 (95.0)	28 (93.3)	29 (96.7)	0.000b	1.000
No	3 (5.0)	2 (6.7)	1 (3.3)

Note: Data are n (%) or Mean ± SD.

^aIndependent-sample t-test.

^bChi-square test.

^cFamily income was categorized based on the 2024 Provincial minimum wage (Upah Minimum Provinsi) of East Nusa Tenggara (IDR 2,186,826).

3.2. Intervention effects between two groups

All outcome variables were normally distributed at each measurement point based on the Shapiro–Wilk test (P > 0.05), supporting the use of parametric analyses. Mauchly’s test indicated violations of the sphericity assumption for knowledge (W = 0.863, P = 0.015), attitudes (W = 0.035, P < 0.001), and self-efficacy (W = 0.018, P < 0.001); therefore, Greenhouse–Geisser corrections were applied. Table 2 presents the comparison of knowledge, attitudes, and self-efficacy scores between the intervention and control groups across the three measurement points.

Table 2.

Comparison of knowledge, attitudes, and self-efficacy scores at baseline, post-intervention, and three-month follow-up between the two groups.

Variables	Pre-intervention	Post-intervention	Three-month follow-up	Group effect		Time effect		Group × Time effect
				F	P	F	P	F	P
Knowledge
Intervention group	4.16 ± 1.82	7.26 ± 1.81	7.86 ± 1.83	28.87	<0.001	27.99	<0.001	16.50	<0.001
Control group	4.50 ± 1.96	4.46 ± 1.69	5.26 ± 1.83
t	−0.682	6.167	5.487
P	0.498	<0.001	<0.001
Attitudes
Intervention group	37.06 ± 6.36	48.83 ± 6.59	50.20 ± 6.41	71.96	<0.001	17.53	<0.001	33.91	<0.001
Control group	35.93 ± 7.01	34.10 ± 6.82	33.73 ± 6.88
t	0.655	8.444	9.583
P	0.515	<0.001	<0.001
Self-efficacy
Intervention group	33.26 ± 8.19	49.53 ± 7.09	50.43 ± 7.04	65.65	<0.001	46.79	<0.001	27.92	<0.001
Control group	29.83 ± 7.71	31.96 ± 8.95	32.00 ± 9.08
t	1.671	8.423	8.784
P	0.100	<0.001	<0.001

Note: Data are Mean ± SD.

For knowledge, there was no statistically significant difference between groups at baseline (t = −0.682, P = 0.498). Mixed repeated-measures analysis of variance revealed significant main effects of group (F = 28.87, P < 0.001), time (F = 27.99, P < 0.001), and a significant group × time interaction (F = 16.50, P < 0.001), indicating that changes in knowledge over time differed significantly between the two groups. Pairwise comparison revealed that the intervention group had higher knowledge scores than the control group at both the post-intervention (t = 6.167, P < 0.001) and three-month follow-up (t = 5.487, P < 0.001).

For attitudes, no significant difference was observed between groups at baseline (t = 0.655, P = 0.515). Mixed repeated-measures analysis of variance demonstrated significant main effects of group (F = 71.96, P < 0.001), time (F = 17.53, P < 0.001), and a significant group × time interaction (F = 33.91, P < 0.001), confirming a differential pattern of attitudes change between groups across time. Pairwise comparison revealed that the intervention group showed significantly higher attitudes scores than the control group at post-intervention (t = 8.444, P < 0.001) and three-month follow-up (t = 9.583, P < 0.001).

Regarding self-efficacy, baseline scores were comparable between the intervention and control groups (t = 1.671, P = 0.100). Results of the mixed repeated-measures analysis of variance indicated significant main effects of group (F = 65.65, P < 0.001), time (F = 46.79, P < 0.001), and a significant group × time interaction (F = 27.92, P < 0.001), demonstrating that improvements in self-efficacy over time were significantly greater in the intervention group compared with the control group. Pairwise comparison revealed that the intervention group exhibited significantly higher self-efficacy scores at both the post-intervention (t = 8.423, P < 0.001) and three-month follow-up (t = 8.784, P < 0.001).

3.3. Participant satisfaction with the intervention

Mothers in the intervention group reported high levels of satisfaction across all six domains assessed in the satisfaction questionnaire. Satisfaction rates ranged from 80 % to 94 %, with the highest satisfaction observed for perceived knowledge improvement (94 %) and the lowest for practicality of the material (80 %). These findings indicate that the intervention was perceived as relevant, practical, and empowering, suggesting high acceptability and perceived value among participating mothers. Detailed results are presented in Appendix C.

4. Discussion

This study evaluated the effectiveness of a family-based nursing intervention in improving mothers’ knowledge, attitudes, and self-efficacy regarding stunting prevention. The findings demonstrated significant and sustained improvements across all three domains, with knowledge, attitudes, and self-efficacy levels increasing from baseline to post-intervention and remaining elevated at the three-month follow-up. These results confirm the initial hypothesis and extend previous evidence that family-based, culturally adapted interventions grounded in FCC and SCT are effective in enhancing maternal health behaviors in high-burden settings such as East Nusa Tenggara. A prior study [39] in this region reported limited maternal awareness of the term “stunting,” reflecting the persistent knowledge gap. Improving maternal education has long been linked to better child growth outcomes and reduced stunting prevalence [40]. The sustained improvements found in this study reinforce the importance of structured, theory-driven, and participatory interventions for maternal empowerment.

Several factors likely contributed to the observed increase in maternal knowledge. The structured and participatory nature of the intervention, incorporating group discussions, visual aids, and role-plays, encouraged active learning and engagement. Prior studies [[41], [42], [43]] have demonstrated that such interactive strategies enhance maternal knowledge and feeding practices. The culturally tailored content further facilitated comprehension and acceptance among mothers, consistent with previous findings that contextually relevant education strengthens understanding and retention [44]. Within this framework, SCT explains how observation and imitation in group settings promote social learning, enabling mothers to internalize positive caregiving behaviors modeled by peers. Future research could include qualitative interviews or FGDs to identify which intervention components most effectively influence knowledge and awareness. At the same time, facilitator feedback could guide material refinement and delivery strategies.

Regarding maternal attitudes, significant and sustained improvements were observed immediately after the intervention and at follow-up. These findings are consistent with previous studies [25,45] demonstrating that improvements in maternal attitudes toward child feeding are associated with better nutrition-related practices and enhanced child growth and nutritional outcomes. Through participatory learning and role-play, mothers in this study experienced the benefits of preventive behaviors, reinforcing more favorable attitudes toward adopting these practices. Similar family-based approaches have been shown to foster mothers’ proactive engagement in child health promotion, particularly when interventions emphasize clear, relevant information and peer interaction [42,46].

Consistent with previous findings, mothers in the control group showed no significant improvement, suggesting that routine health services alone may be insufficient to drive behavioral change [17]. Studies from Indonesia and Ethiopia similarly found that structured, participatory interventions produced greater improvements compared with standard care [17,20,25]. This underscores that effective change requires a family-based and culturally sensitive framework supported by community engagement.

As for self-efficacy, mothers in the intervention group demonstrated substantial and sustained gains compared with the control group. Self-efficacy, defined as confidence in one’s ability to perform and sustain desired behaviors, plays a critical role in translating knowledge and attitudes into practice [47,48]. The participatory strategies used in this study, including role-plays and group problem-solving, provided mothers with direct mastery experiences that strengthened their confidence in applying new knowledge. Consistent with previous research [19,23,49], family-based interventions emphasizing maternal empowerment and caregiving competence effectively enhance self-efficacy.

Demographic factors such as education level and number of children may also have influenced the outcomes. Higher education is associated with greater nutritional knowledge and health-seeking behavior [16,50], while having more children may increase caregiving experience and maternal confidence [16]. These findings suggest the need to tailor family-based programs to mothers’ demographic profiles. Additionally, in Indonesian households, grandparents often play influential roles in child-feeding decisions [51]. Future interventions could include grandparents to strengthen family support and create a more enabling environment for sustained behavioral change.

Taken together, the improvements in knowledge, attitudes, and self-efficacy observed in this study can be explained through the interplay of observational learning, participatory practice, and reinforcement within the family context. Comparable mechanisms have been documented in other low and middle-income countries, where family-oriented and culturally sensitive interventions significantly improved maternal behaviors and child nutrition outcomes [17,25]. These findings suggest that family-based nursing interventions can be effectively adapted to similar high-burden contexts by engaging community health workers, ensuring sustainable program delivery, and aligning caregiving practices with local cultural values.

Finally, high participant satisfaction reinforces the acceptability and perceived value of the intervention. This subjective evidence complements the quantitative results and indicates that mothers perceived the intervention as relevant, practical, and empowering. To further strengthen future programs, researchers could incorporate in-depth interviews to capture richer feedback on participant experiences and include objective child health indicators, such as stunting prevalence or growth data, to assess long-term impacts of family-based nursing interventions.

5. Limitations

This study has several limitations. The use of convenience sampling in one district and a nonrandomized quasi-experimental design may have introduced selection bias and limited external validity. The small sample size could also reduce statistical power. A randomized controlled trial would have offered stronger causal inference, but it was not feasible due to ethical and logistical constraints in rural East Nusa Tenggara; therefore, a quasi-experimental design was adopted. Although baseline demographic differences were not significant, they may still have influenced outcomes. In addition, outcome measures focused on maternal knowledge, attitudes, and self-efficacy. They did not include objective indicators of child growth (e.g., height-for-age or weight-for-age), which limits conclusions about the intervention's direct impact on child nutritional status.

The intervention focused solely on mothers and did not include other key caregivers, such as grandparents, who often influence childcare in Indonesia. Although the instruments showed acceptable validity and reliability, further testing in more diverse populations is recommended. The intervention was delivered exclusively by trained community nurses, without collaboration with other health professionals, which may have limited its comprehensiveness. Despite these limitations, the study provides meaningful evidence on the effectiveness of family-based nursing interventions in improving maternal knowledge, attitudes, and self-efficacy for stunting prevention. Future research using larger samples and randomized or mixed-method designs is needed to confirm and expand these findings.

6. Conclusions

This study demonstrated that family-based nursing interventions grounded in the principles of FCC and SCT significantly improved mothers’ knowledge, attitudes, and self-efficacy in preventing stunting among children under 2 years of age. The structured seven-session intervention not only produced immediate improvements in maternal competencies but also sustained these gains at the three-month follow-up. These findings provide empirical support for integrating culturally adapted, family-oriented nursing strategies into community-based stunting prevention programs. The intervention’s emphasis on education, empowerment, and family engagement highlights its potential as a scalable, cost-effective model for strengthening maternal and child health in community settings.

Data availability statement

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Agus Setiawan: Conceptualization, Methodology, Formal analysis, Writing - original draft. Syamikar Baridwan Syamsir: Investigation, Resources, Project administration, Writing - review & editing. Dwi Cahya Rahmadiyah: Data curation, Visualization, Writing - original draft. Astuti: Supervision, Project administration, Writing - review & editing. Lasarus Atamou: Investigation, Data curation, Resources. Randy Talilah: Funding acquisition, Project administration, Writing - review & editing. Shefaly Shorey: Conceptualization, Methodology, Validation, Writing - review & editing.

Funding

This work was supported by a Universitas Indonesia research grant under the PUTI Q1 scheme (Grant No. PENG-001/UN2.RST/PPM.00.00/2024). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Declaration of competing interest

The authors have declared no conflicts of interest.

Appendices. Supplementary data

The following are the Supplementary data to this article: