Health Education and Health Promotion

Effect of Stunting Prevention Education Program Through Instagram on Literacy and Attitude of Pre-Marital Couples

Document Type : Original Research

Authors

T. Huriah 1
R. Az-Zahra 2
F.A. Yuniarti 3
S. Abdul Hamid 4

1 Community Nursing Department, School of Nursing, Muhammadiyah University of Yogyakarta, Yogyakarta, Indonesia

2 Faculty of Medicine and Health Sciences, Muhammadiyah University of Yogyakarta, Yogyakarta, Indonesia

3 Pediatric Nursing Department, School of Nursing, Muhammadiyah University of Yogyakarta, Yogyakarta, Indonesia

4 International Islamic University of Malaysia, Kuala Lumpur, Malaysia

https://doi.org/10.58209/hehp.11.3.419
Abstract
Amis: Interconnected factors can cause increased stunting cases. One of the risk factors for stunting is adolescents’ lack of knowledge and attitudes. Various media, including Instagram, can be the reason behind the issue. This study aimed to determine the effect of providing the pre-marital education program through Instagram to increase the literacy and attitude of pre-marital couples regarding stunting prevention.

Materials & Methods: This quasi-experimental research with a pre-test and post-test design with a control group was conducted in pre-marital couples in the Gunung Kidul Regency from December 2021 to January 2022. The instruments were questionnaires (Google Forms) and educational media such as posters and videos via Instagram. Data were analyzed using the Wilcoxon and Mann-Whitney tests.

Findings: After receiving the pre-marital education program through Instagram, pre-marital couples were stunted in both the intervention and control groups. There was an increase in attitude in the intervention group after the intervention. The literacy and attitudes about stunting prevention were increased in pre-marital couples of the intervention compared to the control groups after being given pre-marital education through Instagram.

Conclusion: The pre-marital education program improves the literacy and attitudes about stunting prevention in pre-marital couples.

Keywords

Stunting
Toddler
Education
Social Media
Knowledge
Subjects
Introduction
The stunting issue is still common, especially in poor and developing countries. Globally, 149 million children, or 21.9% of children under five, were stunted in 2018, half of which are in Asia. Data from the World Health Organization (WHO) showed that Indonesia is among the third countries with the highest prevalence in the Southeast Asia/Southeast Asia Regional (SEAR) region, with an average prevalence of stunting in children of 36.4 after India at 38.4% and Timor Leste at 50.2% in 2005-2017 [1].
Indonesia Health Office stated that the prevalence of very short and short toddlers in 2018 was 11.5% and 19.3% [2]. This condition increased from the previous year. The prevalence of very short toddlers was 9.8%, and 19.8% of short toddlers. A basic health survey in Indonesia reported that the prevalence of stunting in the Special Region of Yogyakarta was 16.21% [3]. The highest stunting prevalence in toddlers was in Gunung Kidul Regency at 27.20%, and the lowest was in Sleman Regency at 16.69%. The prevalence of stunting in Yogyakarta was 24.22%, Kulon Progo Regency was 20.92%, and Bantul Regency was 19.05%. Interconnected factors can cause a high incidence of stunting in Indonesia.
Inadequate intake of energy and nutrients, as well as infectious diseases, are factors that significantly contribute to the problem of stunting [4]. Other factors that cause stunting are poor nutritional status of the mother during pregnancy, maternal stature which is also short, spacing of children who are too close, lack of knowledge about stunting, food insecurity, premature or low birth weight births, exclusive breastfeeding, management of complementary foods for children, sanitation environment, low socioeconomic status of the family, poor parenting, especially in the behavior and practice of feeding children [5-9].
Ignorance regarding nutrition information can lead to a lack of quality or nutritional quality of family food, especially that toddlers consume. The level of the mother's knowledge about nutrition influences the mother's knowledge and attitude in choosing food ingredients that will affect family nutrition. Mother's knowledge about food and various kinds of processed fish will help her find alternatives and variations of appropriate and liked by toddlers so that food is nutritious [10-12]. A mother with good nutritional knowledge will consume balanced, nourishing food [13, 14]. Margawati et al. (2018) found a relationship between maternal parenting styles and stunting. A mother's nutritional knowledge is one factor that significantly influences the incidence of stunting [15]. Efforts to prevent stunting are changing people’s behavior through providing health education and community empowerment Hamzah et al. and health education to increase public literacy about stunting since knowledge or cognition is a critical domain in shaping one’s action [16-18].
Young and mature women ready for childbearing should be prepared for their pregnancy and the child’s first 1000 days of life (HPK). Stunting prevention will help mothers to improve their nutritional status during pregnancy. A mother’s knowledge affects the mother’s health status, the fetus in the womb, and the quality of the baby. So far, efforts to improve nutrition have been carried out when the mother is pregnant, even though nutrition education would be better done when the mother is not pregnant to prepare for pregnancy [19].
Pre-marital couples can increase literacy related to stunting through various media, including online media. Fauziatin et al. showed increased literacy in prospective brides after being given an education; also proven by statistical tests that there are differences in knowledge and attitudes of the future bride and groom before and after the intervention using the media [19]. Hamimah Hamimah & Azinar showed differences in mothers’ knowledge about stunting before and after health education through video media [17]. In Indonesia, the use of social media for health education, particularly targeting teenagers, is still restricted. Based on the background described, the researchers were interested in knowing how much influence the Pre-Marital Education (PME) program had through the online media Instagram to increase literacy and attitudes regarding stunting prevention.

Materials and Methods
This study used a quantitative research method with a quasi-experimental design. The population was pre-marital couples in the rural area of Yogyakarta Province (Gunung Kidul Regency area) who registered at the Office of Religious Affairs (KUA) from December 2021 to January 2022, as well as late adolescents who had entered the age of marriage. This rural area had the highest number of stunting cases in Gunung Kidul Regency. Sampling was done by purposive sampling technique. The sample was calculated based on the sample formula for two independent groups, and the number of samples was 19 pairs of respondents for each group (n=76). The inclusion criteria were registering at KUA, having personal smartphones, using social media, having Instagram accounts, and participating in the intervention until it was completed. Those who did not participate to the end of the program were excluded.
The research instrument was a literacy and attitude questionnaire distributed via Google Forms to make it easier for respondents to fill out and for researchers to collect data from respondents. The instrument adopted the research questionnaire by Yunitasari & Hanifah, which had gone through validity and reliability tests to be directly used as a research instrument to determine the literacy of pre-marital couples regarding stunting prevention [20]. Researchers also used tools such as posters and video media to provide education.
Researchers shared posters and educational videos on Instagram. Health education was provided twice a week for a month (a total of eight health education postings, with one post containing two different health education items), with the content offered at the first and second meetings related to the characteristics of teenagers. The material presented at sessions 3-5 is related to stunting, whereas the material provided at meetings 6-8 is about patterns of healthy living behavior. Follow-up is done once a week via chat on the WhatsApp Group application.
Bivariate analysis used the Wilcoxon test to determine differences in pre-test and post-test in each group. It used the Mann-Whitney test to compare the values of the intervention and control groups. The results were declared significant if the p-value was <0.05.

Findings
The mean age of the intervention (24.21±3.22 years) and control (21.97±1.95 years) groups was significantly different (p<0.001). There were no significant differences in gender, education level, and occupation between the intervention and control groups (Table 1).

Table 1. Frequency distribution of respondent characteristics by gender, education, occupation, and age (n=76)


After receiving the PME program through Instagram, pre-marital couples stunted in both the intervention and control groups. There was an increase in attitude in the intervention group after the intervention (Table 2).

Table 2. Comparing the frequency (Wilcoxon test) of literacy and attitudes about stunting prevention in the intervention and control group at KUA Tepus (n=76)


The literacy and attitudes about stunting prevention were increased in pre-marital couples of the intervention compared to the control groups after being given PME through Instagram (Table 3).

Table 3. Comparing the frequency (Mann-Whitney test) of literacy and attitudes in pre-marital couples after intervention between the groups (n=76)


Discussion
The analysis showed that the literacy category of respondents in both the intervention and control groups was 55.3% good before the intervention. Hence, the respondents had good initial literacy related to stunting prevention in toddlers. Oka & Annisa, and Rahmawati et al. found that the level of education is significantly associated with a mother's knowledge about stunting [21, 22]. Education helps shape parental understanding of stunting [22]. In the control and intervention groups, most of whom were high school graduates. Parents with high school education find it easier to understand the information they get than those with junior high school education [22].
Rahmawati et al. also found that other factors related to parental knowledge about stunting in toddlers are age and information, the variables most related to parental knowledge. The average age of respondents in this study was 24 years old, with a maximum of 32 years. According to the Ministry of Health, the age between 26 and 35 is in early adulthood. Compared to adolescence, early adulthood allows parents to be more concerned with their child's development so that they are more interested in and better able to absorb information about stunting. Fujiyanto et al. said that a person’s memory or memory is influenced by age, where a person’s comprehension and mindset are more mature with age so that the knowledge gained is also getting better [23]. Widyaningrum et al. strengthened Fujiyanto’s statement that adult mothers better understand feeding toddlers than teenagers [24].
Rahmawati et al. stated that information is the variable most significantly related to the mother’s knowledge about stunting [22]. Parents who have received information about stunting must have understood, interpreted, and remembered the messages conveyed from the information obtained to form good knowledge. The information factor is the most dominant, so it can change one's understanding even though other factors that affect learning are not changed. Providing information about stunting can be the leading solution to increase parental knowledge.
The knowledge between the intervention and control groups after being given the PME intervention increased equally due to homogeneous characteristics between the control and intervention groups. Factors such as age, level of education, and information can influence the knowledge of the control group so that even though they are not given treatment, the ability of the control group also increases.
Mann-Whitney Test results showed differences in the knowledge of pre-marital couples in the intervention group and the control group after being given PME. The Pre-Marital Education program is aimed at couples getting married and preparing the bride and groom for life after marriage, including preparing for pregnancy by providing knowledge about healthy reproduction for the bride and groom [25].
This study reinforced previous research, stating that the Pre-Marital Education Program can increase knowledge [26-28]. The pre-marital phase is the proper phase to prepare oneself physically, psychologically, and socially. Pre-marital couples must prepare their physiology and psychology to understand the world of marriage, including all possibilities when building a household. Pre-marital education plays an essential role in increasing the knowledge of the prospective bride and groom regarding pre-marital health because, with a sufficient understanding of pre-marital health, the future bride and groom can lead a safe and healthy married life. Government must provide prospective brides with adequate knowledge about pre-marital health and rights to be better prepared to become a mother and a father [29].
The results showed that after the intervention, all respondents in the intervention group had a positive attitude, while the control group had the same ratio of positive and negative attitudes. The Mann-Whitney U test analysis showed differences in the attitudes of pre-marital couples in the intervention and control groups after receiving pre-marital education.
The pre-marital education program is carried out through social media. Along with technological developments, social media can support the search and communication of health information. Social media as an educational medium is becoming an option because it can facilitate the dissemination of information and access to health information management and reach many targets that are not limited by space and time. Submitting information through social media has also proven to increase one's knowledge. Zaki et al. also showed that social media is quite widespread in various circles, not only limited to cities but also quite familiar in rural areas [30]. One useful social media is Instagram.
Instagram is one of the most widely used social media to find health information [31]. One of the health information effectively provided is information about stunting prevention [32]. Rusdi et al. revealed that using Instagram as an educational medium has proven effective in increasing nutrition knowledge, attitudes, and behavior compared to other social media because Instagram has better and more interactive features than other social media. Instagram is also more accessible for users to use and enjoy [33].
An Instagram account can provide various health information about stunting. This information can be presented in attractive posters and videos by adding captions as descriptions. Information shared with frequent intensity and in multiple ways can make the account a helpful health information media account for followers. It will support fulfilling one's knowledge about balanced nutritional patterns and good health behavior to form a good attitude toward stunting prevention. Stunting information provided through this Instagram account is credible, supports one's beliefs, and ultimately influences attitudes toward stunting prevention [31].
These posters and videos can be used as educational media so that the public can access health promotion materials more efficiently [34]. Poster media has advantages and attractiveness, namely attracting attention by highlighting the power of messages, attractive images, and colors. Video media is one of the latest media that shows advances in science and technology, including visual and audio media. Using video to convey information can make it more exciting and motivating. Data is transferred more efficiently because images can move and communicate quickly, accelerating understanding more comprehensively. Using posters and video media can encourage changes in knowledge, attitudes, and behavior [35].
The researchers concluded that health education provided through posters and videos using online media proved effective in increasing knowledge and changing attitudes for the better in efforts to prevent stunting. Prasetyanti et al. found an influence between health education on the attitude of pre-marital couples regarding stunting prevention efforts. This study revealed that all respondents were positive (100%) toward stunting prevention efforts after education because they gained new knowledge [36].
A positive attitude cannot be separated from the knowledge and information obtained [37]. Researchers understand that there is a change in attitude for the better because they are given education through posters and videos containing explicit material about stunting prevention so that pre-marital couples can receive messages or information. In addition, researchers also facilitate questions and answers about stunting so that researchers can answer any information they need and increase their knowledge. Increasing one's knowledge can affect growth in positive attitudes [38].
Researchers also understand that an increase in positive attitudes can be caused by information when providing education through online media, which carries a suggestive message that stunting prevention is essential and must be carried out by pre-marital couples before entering pregnancy. Pre-wedding couples will do their best to prepare their child's First 1000 Days of Life (HPK) with good information and attitude. The study's weakness is that not all respondents used their personal Instagram accounts to view the Instagram link. Several couples used one Instagram account for two people when participating in study activities.
The limitations of this study are the different characteristics of the control and intervention groups, where the intervention group is pre-married couples who have registered with the Office of Religious Affairs, and the control group is teenagers who are ready to marry but have not yet registered with the Office of Religious Affairs. Pre-marital couples need to improve literacy by seeking information from various media that are trusted and mutually supportive of reducing stunting in children.

Conclusion
The pre-marital education program improves the literacy and attitudes about stunting prevention in pre-marital couples.

Acknowledgment: We thank the Office of Religious Affairs in Gunung Kidul Regency, Yogyakarta, for the research facilities. We also thank the Research and Innovation Centre at Universitas Muhammadiyah Yogyakarta for financing research activities.
Ethical Permissions: This study was approved by the Faculty and Health Sciences Universitas Muhammadiyah Yogyakarta health research ethics committee under the number 300/EC-KEPK FKIK UMY/XI/2021.
Conflicts of Interests: Nothing to be reported
Author Contribution: Huriah T (First Author), Methodologist/Discussion Writer (25%); Az-Zahra R (Second Author), Introduction Writer/Main Researcher (25%); Yuniarti FA (Third Author), Assistant Researcher/Statistical Analyst (25%); Abdul Hamid SHB (Fourth Author), Assistant Researcher/Statistical Analyst (25%)
Funding/Support: Universitas Muhammadiyah Yogyakarta partially funds this research in the scheme of the Sabbatical Leave Program.
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Health Education and Health Promotion
Volume 11, Issue 3
Autumn 2023
Pages 419-424