Copyright © 2021 by Author/s and Licensed by Modestum. This is an open access article distributed under the Creative Commons Attribution License which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Electronic Journal of General Medicine
2021, 18(6), em324
https://www.e jgm.co.uk/ Original Article OPEN ACCESS
Empowering Mothers through Mentoring on 6-60 Months Children’s
Nutrition Care: An Effort to Prevent Child Malnutrition
Sri Umijati 1,2*, Sri Kardjati 1,2, Ismudijanto 1,2, Sunarjo 1,2
1 Universitas Airlangga, Surabaya, INDONESIA
2 Dr. Soetomo Hos pital, Surabaya, INDONESIA
*Corresponding Author: sri-u@fk .unair.ac.id
Citation: Umijati S, Kardjati S, Ismudijanto, Sunarjo. Empowering Mothers through Mentoring on 6-60 Months Children’s Nutrition Care: An Effort
to Prevent Child Malnutrition. Electron J Gen Med. 2021;18(6):em324. https://doi.org/10.29333/ejgm/11311
Received: 8 Sep. 2021
16 Oct. 2021
The prevalence of malnutrition in Indonesia in the last 20 years remains high. This shows that management
curative aspects is not enough. A new strategy is needed to solve the problem as well as to overcome
factors. The root cause of malnutrition in Indonesia is the lack of maternal knowledge and power towards
status. This study aims to determine the mentoring that To do through a tutorial module on
factors. This expects to empower mothers on caring for 6-60 months old children. This research is a two
experimental study with controls. Respondents were mothers who had children aged 6-60 months. A
39 mothers choose a control group and 38 mothers as a treatment group. The mentoring method was given
treatment group while providing counseling to the control group: multivariate ANOVA and independent t-
show maternal empowerment. Mentoring on caregiving was very effective in increasing mothers’ abilities
for their children’s nutrition (p <0.05). Hence, the mentoring method could empower mothers to care for
(p = 0.005). It took six months to empower 13.2% of mothers with a minimum knowledge score of 2.5
of 3.1 times, respectively, much higher than the counseling method. Mothers who are
will be aware of any deviation in their children’s nutritional status.
Keywords: caregiving, children, mentoring, mother empowerment, risk factors
In Indonesia, the government is against malnutrition in
curative aspects, either through maternal skills in feeding
children, or high economy, or infection. The same with the
opinion , the district is being prominent in the district with
malnutrition-related to the mother’s nutritional status and
maternal independence. Inadequate nutrition is born nutrients
were lack of energy, protein, or other micronutrients due to its
adverse effects on the problem and function of tissues and
clinical results . Curative control cannot be practical to the
mother in the environment (including children’s frogs), bound
to happen [3,4]. In Indonesia, the prevalence of childhood
malnutrition was unchanged from 2003 to 2013, about 19% [5,
6], although slightly decreased in 2018 by 17.7% .
Malnutrition incidence in children under five years old in
Surabaya, East Java, Indonesia in 2005 remained high at 28.9%
, sustainable development goals (SDGs) in 2025 (22.3%) .
These figures show that the problem has not changed in the
past two decades. Malnutrition is one of the primary victims of
death in toddlers and one of the most common factors that
pose a threat to children’s life and health . malnutrition has
a mortality rate of about 45% in children under five, despite
concerted efforts in malnutrition . For malnutrition of
origin, the factors causing it are still present and diking .
New strategies are needed to control malnutrition in children
to the root of the problem and at the same time to address risk
factors . Factors that influence include maternal
knowledge, household socio-economic conditions, and
distance . Therefore, the prevention aspect can consider as
an alternative approach.
The root cause of malnutrition in Indonesia is the lack of
maternal skills to care for their child’s nutritional status (p =
0.02) . The role of mothers is the most crucial factor in
alleviating the negative impact of dietary problems through
their care. Concerning risk factors related to malnourished
children in Indonesia are nutrition and health care,
breastfeeding, feeding, and environmental management .
Child nutrition care consists of the mother’s ability to recognize
the signs of malnutrition beforehand and monitor the child’s
growth. Watching a child’s development is essential for a
health assessment. Energy intake adjusts to energy needs to
achieve normal body weight and height for age . The
recommended growth graph for use in evaluating children’s
growth by the World Health Organization (WHO) is compiled
based on National Center for Health Statistics (NCHS) data .
The parenting risk approach is a new strategy in addressing
the problem of malnourished children. Child health and
nutritional care are essential for their survival and growth.
Children’s development reflects their nutritional status [18-20].
Malnutrition can cause physical problems and decrease the
quality of life . Mothers should be sensitive in detecting risk
factors in parenting that can lead to child malnutrition. That
2 / 6 Umijati et al. / ELECTRON J GEN MED, 2021;18(6):em324
way, mothers can make plans to control children’s nutrition
and addressing problems that may arise [19,22]. The
importance of meeting the needs of balanced nutrition is to
prevent the disease in the future, especially chronic diseases
among the disease Focus on child health work .
Malnutrition information is a significant challenge for
mothers. It encourages women’s empowerment to build family
and community support to increase knowledge and eliminate
misinformation about diet to improve health and nutrition .
Do an assignment with mentoring. This includes individual
learning through mentoring on parenting risks in the Parenting
Skills Training Course Module and natural parenting learning
[22,25]. Do the teaching well through social media and direct
knowledge . Nutrition assistance is currently emphasizing
counseling, where role models and partnerships are still
needed to solve existing problems rather than on society’s
potential. Based on the explanation, this study aims to
determine that mentoring through a tutorial module based on
parenting risk factors can empower mothers in caring for
children aged 6-60 months.
MATERIALS AND METHODS
This was a two-sample experimental study with controls.
There were treatment and control groups divided into four
subgroups based on respondents’ education level and
occupation. The story of education impacts the knowledge that
someone has . The mentoring method was provided to the
treatment group, while the control group received the
Both groups received learning material consisting of
caregiving risk factors related to child malnutrition. The risk
factors were general caregiving, growth monitoring, body
weight and height measurement, child’s nutrition
maintenance, breastfeeding, feeding, recognizing the early
signs of illness, and maintaining hygiene as well as
Risk factor learning in mentoring was provided through the
module tutorial strategy, while in the control group by
counseling. The mentoring group was also given caregiving
skill training and learning in the field. Skill training materials
were done by measuring weight and height, growth
monitoring, feeding, and recognizing early signs of illness in the
child. Indicators of the success of intervention were caregiving
empowerment, which includes increased knowledge,
attitudes, and practices of mothers to care for their children.
This study was conducted in three poor sub-districts of
Surabaya, East Java, Indonesia. Based on the sample size
formula experimental design. The proportion of maternal
empowerment from each group before the treatment was
12.9% (the USAID WVI 2005 Surabaya survey results showed
that only 12.9% of mothers received good care). The expected
proportion reached 45%, with α 0.05 and β 0.2 after the
treatment. It was found that 38 mothers in the treatment group
and 39 mothers in the control group. The inclusion criteria were
non-broken families, poor, urban families, having one
physically average child and the mothers as the primary
caregiver, having formal education diplomas, and participating
in mentoring for six months.
The sampling technique was random cluster sampling. One
Public Health Centre (PHC) was selected from each sub-district,
then 3 Integrated Health Centre (IHC) were chosen from each
PHC. Ten mothers who met the inclusion criteria were selected
from each IHC. Furthermore, they were divided into treatment
or control groups.
The dependent variable of this study was the
empowerment of mothers in child nutrition care, and the
independent variable was the mentoring of caregiving.
Multivariate ANOVA and independent-two-sample t-tests were
used to determine maternal assignment in caregiving their
child . Before the intervention, the respondents have
explained the treatment. Afterward, respondents were asked
to sign an agreement to participate in this study.
This study collected 39 mothers as a control group and 38
mothers as a treatment group from three poor subdistricts of
Table 1 showed that respondents’ age, education level,
and occupation do not differ in both groups (p> 0.05). Likewise,
their ability to care for sick children was not different before
treatment, and the data had normal distribution (p> 0.05).
Descriptively, the difference in the average value of the
mentoring group was higher than that of the control group. The
result of empowerment is better for the mentoring group.
Based on standard deviation values, both groups showed
significant variations in learning outcomes. In the mentoring
group, significant variations showed the results of the
individual teaching applied. Differences in the average value of
Distribution of frequency for respondents’ characteristic of treatment and control groups with proportion value of t-test
Total Independent t-test between treatment and control groups
Low educational level was described as less than or equal to 9-year formal education.
2. High educational level was described as more than or equal to 10-year formal education
Umijati et al. / ELECTRON J GEN MED, 2021;18(6):em324 3 / 6
knowledge and practice in the two groups (p <0.005) can be
seen in Table 2.
Mentoring using child caregiving module learning
effectively increased mothers’ caregiving abilities related to
their child’s nutrition (p <0.05). The slightest difference
between the two groups (2.5 times) occurred in the mothers’
knowledge about measuring the child’s weight and height.
52.5% of mothers had this ability for more than 70%, so it took
11.4 months for all mothers to understand this care properly.
In the treatment group, changes in the average value of
caregiving practices that were more than 100 (like measuring
child weight and height, maintaining their hygiene and
sanitation, recognizing signs of a sick child) are shown as
results of mothers’ training activities. Thus, it can be concluded
that behavior change with repeated training showed more
tremendous activity changes.
Descriptively Table 3 shows that those who receive
mentoring may improve their ability to care for sick children.
A few mothers who managed at the end of the mentoring
correctly showed that the care provided was new to the
mother. Conversely, more than 50% of mothers who had the
ability at the end of the mentoring showed that caregiving’s
theme was often done in their daily lives or could be caused by
provided training during mentoring.
The tutorial module learning resulted in better
empowerment efforts compared to counseling (p <0.005). The
module tutorial gave a difference in mean caregiving
knowledge at least 2.5 times higher than counseling. In
contrast, the average difference in caregiving practices was at
least 3.1 times higher. The intermediate parenting practice is
higher than the mother’s knowledge due to skills training or
parenting norms that mothers often carry out. The more senses
are used in influencing behavior change, the easier the
behavior change occurs.
Mentoring is better than counseling because of the
following reasons. Tutorial learning is individualized, while
counseling is done together . It presents an explanation
that builds actual events that exist as a problem and can
explore mothers’ experiences as students in similar cases that
need to be discussed. Thus, various issues that exist and the
potential of each participant can be used by other participants
Mean difference, standard deviation, and probability value of the T and multivariate
Caregiving for children
aged 6-60 month
Measuring body’s weight
Maintaining good hygiene
Recognizing early signs of
a sick child
Table 3. Frequency distribution in percent of mothers who have the ability of caregiving based on treatment group
Treatment group, n=38
Control Group, n=39
Caregiving for child aged 6-60 month
Maintaining child’s growth
Measuring body’s weight and height
Maintaining child’s nutrition
Maintaining good hygiene and environmental sanitation
Recognizing early signs of a illness or sickness
Note: Assessment of mothers’ caregiving abilities is calculated at more than 70%
4 / 6 Umijati et al. / ELECTRON J GEN MED, 2021;18(6):em324
as experience to be known as a process that must be done in
solving problems. Negative experiences often leave a deep
impression on the participants. If the occasion is appropriately
discussed, it can lead to a lasting positive outlook. Every
mother becomes a rich source of learning, and at the same
time, she provides a broad base for learning something new.
Factors of the level of intelligence, self-confidence, and
controlled feelings must be recognized as individual personal
rights. The decisions participants make do not have to be
always the same.
The tutorial learning involves all participants in learning
activities and giving ideas, not only from the theory presented
by the supervisor, thus enabling the optimal development of
each individual. They feel valuable and had self-respect in front
of their peers, having confidence in themselves. Togetherness
in groups does not always have to be the same because it
acknowledges one truth without criticism that shows the
differences, including the differences in their potential.
Learning with modules aims to make students become
themselves, understand life’s necessities, and carry out their
social role assignments. Empowerment does not dominate
class groups much and seeks to find alternatives to develop
participants’ personalities based on their potential and
experience. Tutorials can form intensive communication of
existing problems because of the guaranteed closeness of the
mother and empowerment, increasing the mother’s sensitivity
to aspects of life that affect health according to the individual’s
Learning is not a self-adjustment imposed by others as
counseling but needs to deal with life problems that are always
dynamic in line with risk factors for caregiving skills. Learning
together by tutorial helps mothers deal with the dynamics of
behavior change that will produce long-lasting positive
behavior [30,31]. Resilience to this positive behavior is formed
based on personal experience adjusted by the awareness of the
potential risks with consequences. Furthermore, they
simultaneously respond and act according to their potential,
leading to new stimuli adapted to other new concepts based
on existing experience. Thus, this process continues and
develops to form self-improvement efforts. In counseling,
forced behavior changes will not last long and cannot follow
Learning about a child’s weight and height measurements
increases mothers’ empowerment to monitor a child’s growth.
Growth indicators are dynamic which can be followed from
time to time when the weight deviation occurs. The application
of mentoring to the nutrition prevention program can
significantly improve the child’s nutritional status. Policy in
several countries in ASEAN applies the nutritional status of
children as an indicator of the progress of the people’s welfare,
not by the average supply or consumption of energy and
protein . Adequate food supply does not guarantee every
household member to get adequate food and good nutritional
status, so it is necessary to understand that it is very important
to reduce malnourished and micronutrient people deficiency
. Adequate food supply does not guarantee that every
household member gets sufficient food and good nutritional
status. Many other factors can interfere with the process of
establishing a good nutritional status, including clean water,
environmental hygiene, and essential health services.
Likewise, the application of the module to maintain a
child’s hygiene and sanitation and to recognize the early signs
of the sick child in a nutrition improvement program can
support a child’s nutrition status. Changes in the environment
and incidence of a sick child can indicate a dynamic on a child’s
health and interfere with a child’s nutrition status. The success
of the nutrition program will be more quickly achieved by
improving the environment.
Only 13.2% of mothers have the caregiving ability after
mentoring for six months. Thus, it took at least 46 months to
empower all mothers to care for children with a minimum
capability of 70%. The empowerment of caregiving must be
carried out as early as possible before the mother is pregnant
for the first time or when the mother is still a teenager.
Generally, mothers have the initial concept that caring for
children is natural; mothers are obliged to keep children alive.
Likewise, to maintain children’s growth, children are
miniatures of adults so that in caring for children, mothers care
for children as they care for adults. Mothers are not aware of
the differences in life needed for children from adult life,
including children’s growth. The new concept is that mothers
must be caregivers according to the child’s growth and
Changing behavior in something new takes a long time,
especially at the stage of contemplation. Mothers begin to
realize the importance of caregiving their children and
maintaining their growth. With the consideration of mothers’
potential, there is a strong sense of ambivalence about
changing behavior in a better direction—conversely,
behavioral changes in things that have been done as a habit.
Mothers have been in the maintenance stage; it does not
require a long time to change the behavior.
Mentoring can be used as a new effort in solving child
nutrition problems. This effort uses an integrative risk care
approach based on community potential, uses indicators of
child growth dynamics, and pays attention to the risks of
environmental hygiene and children’s hygiene. Mothers who
had already been empowered will be aware of any deviation in
their children’s nutritional status. Moreover, the success of the
nutrition program will be more quickly achieved by
empowering mothers. This study suggests that health
policymakers and clinicians prioritize empowering mothers as
one of the solutions to prevent child malnutrition.
Author contributions: All authors have sufficiently contributed to the
study, and agreed with the results and conclusions.
Funding: This research was supported by the Faculty of Medicine,
Universitas Airlangga, and the Government of the Republic of Indonesia
c.q. Minister of Education and Culture through Post-Sarar Education
Scholarship (BPPS). Thank the Faculty of Medicine of Universitas
Airlangga’s ethics research committee that gave ethical clearance no.
Declaration of interest: No conflict of interest is declared by authors.
1. Boah M, Azupogo F, Amporfro DA, Abada LA. The
epidemiology of undernutrition and its determinants in
children under five years in Ghana. Plos One. 2019 Jul
0219665 PMid:31365528 PMCid:PMC6668784
Umijati et al. / ELECTRON J GEN MED, 2021;18(6):em324 5 / 6
2. Pulgar IH, Campayo ES, Valero ML. Desnutrición. Medicine-
Programa de Formación Médica Continuada Acreditado.
2020 Jun 1;13(14):787-92. https://doi.org/10.1016/
3. Lourenco F, Casey BJ. Adjusting behavior to changing
environmental demands with development. Neurosci
Biobehav Rev. 2013 Nov 1;37(9):2233-42.
4. Wong B, Candolin U. Behavioral responses to changing
environments. Behav Ecol. 2015 May 1;26(3):665-73.
5. RI K. Riset kesehatan dasar [Basic health research].
Republic of Indonesia: Ministry of Health. 2013.
6. Statistics Indonesia. Balita (0-59 Bulan) Menurut Status
Gizi, Tahun 1998-2005 (%) / Nutrition State in Under five-
children from 1998 to 2005 (%). 2009.
7. Ministry of Health. Riset Kesehatan Dasar / Basic Health
8. Umijati S. Data analysis assessment of basic data on the
nutrition situation of under 5 child and mothers in
Surabaya in 2005. 2006.
9. Anung. Kesehatan dalam Kerangka Sustainable
Development Goals (SDGs) / Health in SDGs Framework. In
Rakorpop Kementerian Kesehatan RI 2015. (Issue 97).
10. Mohseni M, Aryankhesal A, Kalantari N. Prevention of
malnutrition among children under 5 years old in Iran: A
policy analysis. PloS One. 2019 Mar 7;14(3):e0213136.
11. Rabaoarisoa CR, Rakotoarison R, Rakotonirainy NH, et al.
The importance of public health, poverty reduction
programs and women’s empowerment in the reduction of
child stunting in rural areas of Moramanga and Morondava,
Madagascar. PloS One. 2017 Oct 18;12(10):e0186493.
12. Mohseni M, Aryankhesal A. Developing a model for
prevention of malnutrition among children under 5 years
old. BMC Health Ser Res. 2020 Dec;20(1):1-9.
13. UNICEF. Improving Child Nutrition: The Achievable
Imperative for Global Progress. 2013.
14. Rahman MS, Howlader T, Masud MS, Rahman ML.
Association of low-birth weight with malnutrition in
children under five years in Bangladesh: do mother’s
education, socio-economic status, and birth interval
matter?. PloS One. 2016 Jun 29;11(6):e0157814.
15. Umijati S, Kardjati S. Under fives nutritional rearing model
based on risk factors approach. JBP 2012;14(1):30-9.
16. Turck D, Braegger CP, Colombo C, Declercq D, Morton A,
Pancheva R, Robberecht E, Stern M, Strandvik B, Wolfe S,
Schneider SM. ESPEN-ESPGHAN-ECFS guidelines on
nutrition care for infants, children, and adults with cystic
fibrosis. Clin Nutr. 2016 Jun 1;35(3):557-77.
17. Abedzadeh Zavareh MS, Hasani M, Darabi M, Mirzaei A,
Khorshidi A, Saeidi A, Momeni K, Jalilian M. Growth
indicators and nutritional supplement evaluation in 6-12
months year old children's: A perspective From Ilam.
Electron J Gen Med. 2018 May 1;15(3):em17.
18. Elder JP, Pequegnat W, Ahmed S, Bachman G, Bullock M,
Carlo WA, Chandra-Mouli V, Fox NA, Harkness S, Huebner G,
Lombardi J. Caregiver behavior change for child survival
and development in low-and middle-income countries: an
examination of the evidence. J Health Comm. 2014 May
940477 PMid:25207447 PMCid:PMC4263266
19. UNICEF & WHO. Nurturing Care for Early Childhood
Development: A Global Framework for Action and Results.
2018. (Issue May).
20. WHO. Nutrition Landacape Information System Country
Profile Indicators: Interpretation Guide. Department of
Nutrition for Health and Development World Health
Organization 20 Avenue Appia 1211 Geneva 27 Switzerland.
In Nutrition Landacape Information System. 2010.
21. Mejia CR, Sulca PA, Hernani-Salazar L, Ricaldi-Asto L, Rojas
MA, Hernández-Arriaga G, Tovani-Palone MR, Bueso-
Pineda L. Association of nutritional status and anemia with
multi-micronutrient supplementation in young children in
Peru. Electron J Gen Med. 2019 Sep 1;16(5):em163.
22. Laverack G. Public health: power, empowerment and
professional practice. Macmillan Int Higher Edu; 2019.
23. Turck D, Braegger CP, Colombo C, Declercq D, Morton A,
Pancheva R, Robberecht E, Stern M, Strandvik B, Wolfe S,
Schneider SM. ESPEN-ESPGHAN-ECFS guidelines on
nutrition care for infants, children, and adults with cystic
fibrosis. Clin Nut. 2016 Jun 1;35(3):557-77.
24. Bhanbhro S, Kamal T, Diyo RW, Lipoeto NI, Soltani H.
Factors affecting maternal nutrition and health: A
qualitative study in a matrilineal community in Indonesia.
Plos One. 2020 Jun 16;15(6):e0234545.
25. Okafor M, Sarpong DF, Ferguson A, Satcher D. Improving
health outcomes of children through effective parenting:
model and methods. Int J Env Res Pub Health. 2014
296 PMid:24366048 PMCid:PMC3924445
26. Indarto MR, Sunardi J, Retnowati ND, Sawitri S. Increasing
Understanding of General Knowledge of Plastics with
Video-based Learning. Universal J Edu Res. 2020;8(11B):
27. Bin Nordin MN, Mustafa MZ, Razzaq AR. Regression
between Headmaster Leadership, Task Load and Job
Satisfaction of Special Education Integration Program
Teacher. Universal J Edu Res. 2020;8(4):1356-62.
28. O'Brien RG, Kaiser MK. MANOVA method for analyzing
repeated measures designs: an extensive primer. Psychol
Bull. 1985 Mar;97(2):316. https://doi.org/10.1037/0033-
29. Notoatmodjo S. (2012). Health Promotion and Behaviour.
PT. Rineka Cipta.
6 / 6 Umijati et al. / ELECTRON J GEN MED, 2021;18(6):em324
30. Center for Health Leadership and Practice. Mentoring
Guide: A Guide for Mentors. In the Center for Health
Leadership & Practice, 2003. Public Health Institute.
31. Woolf SH, Aron L. Panel on Understanding Cross-National
Health Differences Among High-Income Countries.
Committee on Population. 2013.
32. Beal T, Massiot E, Arsenault JE, Smith MR, Hijmans RJ.
Global trends in dietary micronutrient supplies and
estimated prevalence of inadequate intakes. PloS One.
2017 Apr 11;12(4):e0175554. https://doi.org/10.1371/
journal.pone.0175554 PMid:28399168 PMCid:PMC5388500