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Abstract

Background:

Alternative early prevention of stunting in toddlers has been engaged by implementing the cadre’s educational approach, particularly a digital learning method to advise mothers effectively regarding toddler nutrition and maternal health practices during the critical first 1000 days of life. In this study, we developed a smart digital education model, namely ‘RoSi’, that is in the form of a module and website platform.

Design and methods:

This study used a mixed-method experimental design. The data were collected by questionnaires, interviews, and observations of health cadres. This study involved 84 cadres at a Public Health Office. The cadre’s knowledge, attitude, and skills have been observed before and after the implementation of the RoSi model, and validated by experts. The data were analysed by univariate, bivariate, and multivariate analysis by using multiple logistic regression tests (α = 0.05).

Results:

RoSi was then applied through speech, discussion, and demonstration. Results showed improvements in cadres’ skills after the accomplishment of the RoSi model. The knowledge was enhanced from 42.9% to 65.5% (p = 0.003), attitude was improved from 36.9% to 63.1% (p = 0.037), and skills increased from 36.9% to 64.3% (p = 0.004). Although the implementation faced technical and motivation challenges among cadres, the digital model proved accessible and effective.

Conclusion:

The RoSi model has shown effective improvement on cadres’ knowledge, attitude and skills in order to prevent stunting in toddlers. This study suggested that the government and stakeholders implement the smart digital education model in the near future.

Keywords

smart model stunting cadres knowledge attitude skills

Introduction

Linear growth failure is the most common form of malnutrition, which manifests as stunting cases globally. Stunting has been identified as a major public health priority. WHO data has confirmed that 142.9 million children under 5 years of age were too short for their age (stunting), 45.4 million were too thin for their height (wasting) and 38.9 million were too heavy for their height (overweight) in 2020.¹ It is projected to be 127 million in 2025 with a sustainable programmes on reducing stunting worldwide describes the short-term impact of stunting such as increasing mortality, morbidity, and health expenses as well as decreasing cognitive, motoric, morbidity and language development. Long-term impacts would be a short stature, increasing risk of obesity and its co-morbidities, decreasing reproductive health, learn, and work capacity.²

Various intervention programmes have been conducted in relation to make some efforts on early stunting prevention in various countries. For example, in Brazil, the Food and Nutrition Surveillance System was applied for the continuous monitoring of the nutritional status of the determinant population.¹ In Africa, some countries have made some efforts to overcome stunting based on the UNICEF framework.³ In Indonesia, there was a national programme named as Scaling Up Nutrition (SUN) programme, which promotes the human right to consume food and nutrition. The SUN programme has been derived from the family hope’s programme (PKH), and the first 1000 days of birth programme. Fulfilment of nutritional intake in the golden period is very important to overcome the nutritional problems and prevent stunting in children. Early on PKH programme was implemented by giving incentives to beneficiary families, but pregnant women need to visit a Public Health Centre and pre-school children will be monitored and given nutritional supplements.^4,5 As a result, the PKH programme has only reduced stunting by about 2.7%.⁶ However, it might be considered as unsophisticated results because the total number of stunting cases is still elevated, and the more sustainable advanced programmes must emerge. A study reported in 2022 in the Journal of Public Health Research, showed that behaviour in fulfilling nutritional need is related to culture, family support, and mothers knowledge.⁷ Therefore, the most recent programme launched by Ministry of Health in 2023 was the specific interventions which focussing in the pregnant or pre-natal phase and the post-natal phase, primarily in infants aged 0–24 months. At this point, empowering the health cadres who interact directly with mothers is highly crucial and urgently needed.⁵

Recent literature emphasises the need for innovative training approaches to enhance health cadres’ ability to deliver nutritional guidance during the critical first 1000 days of life, addressing previous shortcomings in traditional methods.^8–15 The research gap addressed by this study lies in the insufficient literature on the effectiveness of digital training methods in equipping health cadres with the essential knowledge and skills needed for providing accurate nutritional guidance to mothers during the critical first 1000 days of life.

The initial interviews with health cadres at the Public Health Centre of Medan Tembung and Medan Deli Districts have revealed that health cadres were not optimal in carrying out the HPK programme, including during the pre-pregnancy period, pregnancy period, exclusive breastfeeding period, and toddlerhood. On-site observations revealed that the health cadres only fill in data on the healthy card, body weight, and provide additional food to toddlers. Measurements of the height or body length of toddlers and babies are carried out every 3 or 6 months, except for routine monthly weight. Even though cadres sometimes did not measure the baby’s body length, height and head circumference. The preliminary interviews revealed that all cadres had already taken part in training, namely training on five tables, how to weigh and recording on a healthy card. However, special training on efforts to prevent early stunting by implementing the HPK programme and techniques for measuring the length or height of babies and toddlers at 180 and 540 days had never been implemented. By the fact that health cadres need to be empowered by training and mentorship, a previous study demonstrated that there were significant differences in the knowledge and actions of cadres before and after training.¹⁶ Though our previous report demonstrated that cadres’ skills were associated with self-awareness and encouragement.¹⁷ Furthermore, a prior study that was published in the Journal of Public Health Research highlighted the importance of developing preventative programmes and mental health promotion to shield stunted toddlers from maternal depression.¹⁸

In this study, we developed a specific model designed to prevent early stunting in toddlers through empowering cadres. The use of digital education models enhances learning by providing interactive, up-to-date training that significantly improves health workers’ knowledge and skills to effectively advise mothers on nutrition and health practices. This addresses the lack of engagement and understanding observed in traditional training methods. The digital intelligent education model, named as RoSi, provides education to cadres through lectures, discussions, and website demonstrations. The lecture material relates to the efforts to prevent early stunting in toddlers. The discussion was held to give the cadres the opportunity to ask questions about the content of the lecture given. The interactive demonstration of the RoSi application was available via an accessible website. The RoSi model was guided by the Health Belief Model, emphasising perceived susceptibility and benefits to motivate cadres’ behaviour change.¹⁹ By addressing knowledge gaps and enhancing self-efficacy through interactive learning, the model aimed to influence health actions, supporting its design rationale and enhancing replicability across similar community-based health interventions.

The specific objectives of this study were to: (1) develop the ‘RoSi’ smart digital education model comprising a module and website platform; (2) implement the model through lecture, discussion, and demonstration; and (3) evaluate the effectiveness of the model by measuring changes in health cadres’ knowledge, attitudes, and skills regarding early stunting prevention before and after the intervention.

Methods

The combination of qualitative and quantitative approaches in exploratory and quasi-experimental research design has been applied. The study was conducted at Public Health Centre Medan Tembung and Public Health Centre Medan Deli, North Sumatra Province, Indonesia, from October 1 to October 31 2022. The study population consisted of 520 active health cadres registered in the working areas of the Public Health Centres. The sample size of 84 cadres was calculated using Slovin’s formula ( $n = N / (1 + N e^{2})$ ) with a population ( $N$ ) of 520 and a margin of error ( $e$ ) of 10% (0.10). Participants were selected using simple random sampling (lottery method) to ensure an equal probability of selection. This study is a pre-post test with no control. Inclusion criteria for the subjects were: (1) registered as active health cadres at the study sites, (2) ownership of a smartphone to access the digital application, and (3) willingness to participate in the full duration of the study. Exclusion criteria included cadres who were sick or absent during the data collection period.

The study adopts Lawrence Green’s Precede-Proceed Model, which identifies three factors influencing behaviour: predisposing factors (knowledge, attitudes), enabling factors (skills, availability of the RoSi digital tool), and reinforcing factors (support from health workers). The ‘RoSi’ model was designed to intervene in these factors to enhance cadre performance in the 1000 First Days of Life (HPK) movement. The health cadre improvements were observed for knowledge, attitude, and skills before and after the implementation of the RoSi model. The data were collected by questionnaires, interviews, and observations of cadres. Interviews were conducted in person with selected cadres using a semi-structured guide focussed on their experiences before and after using the RoSi model. Interviews were audio-recorded, transcribed verbatim, and analysed thematically to identify patterns in behaviour change, knowledge application, and challenges. For long-term follow-up, no extended monitoring was conducted beyond post-intervention assessment, limiting insights into sustained skill retention or behaviour change over time.

Primary data were collected through the distribution of questionnaires containing questions as independent variables: knowledge (20 items), attitude (20 items), and skills (12 items). The results of the answers to the knowledge variables were categorised into good (score 31–40) and less good (score 20–30), the alternative answers to the Guttmann scale were true and false. Attitudes were categorised into positive (score 31–40) and negative (20–30), the Guttmann scale was agree and disagree. Skills were categorised as good (score 19–24) and poor (score 12–18); the measurement was on an ordinal scale.²⁰ The data obtained were then analysed by using multiple logistic regression tests (α = 0.05).

Data were collected using a structured questionnaire assessing knowledge, attitudes, and skills. The instrument underwent validity and reliability testing before use. Validity tests showed that all items were valid ( $r_{c o u n t} > r_{t a b l e} o f 0.361)$ . Reliability was confirmed using Cronbach’s Alpha, indicating high internal consistency for the variables measured. This is an appropriate approach since knowledge, attitude, and skills are measured in binary categories. Data analysis included univariate analysis to describe variable distributions and bivariate analysis to assess the effect of the intervention. Cohen’s Kappa was used to measure agreement/consistency in behaviour, and statistical significance tests (at α = 0.05) were employed to compare pre- and post-intervention scores for knowledge, attitude, and skills.

The RoSi application contained materials of lectures, discussions and demonstrations at https://rosistunting.com/stunting/index.php. The applications could be accessed via smartphones by cadres at the Public Health Centre activity with a specific user login. The RoSi application model was developed according to expert suggestions, material expert validation, and module expert validation.²¹ This study was approved by the Ethical Review Board Committee of Institut Kesehatan Medistra Lubuk Pakam, Number: 004.D/KEP-MLP/II/202. Written informed consent was obtained from all participating subjects before study initiation, ensuring they understood the study’s purpose and their rights. We acknowledge the need to address potential digital divide issues and data privacy risks. In future applications, we will ensure informed digital consent, secure data handling, and equitable access, especially for cadres in low-connectivity areas, to uphold ethical standards in digital health interventions.

Results

The distribution of cadres’ knowledge, attitude and skills before and after the application of the RoSi digital smart education model was presented in Tables 1 –3 below, respectively.

Table 1.

Knowledge of Cadres before and after the application of the RoSi digital smart education model.

No.	Knowledge	Before the application of RoSi model		After the application of RoSi model
No.	Knowledge	Total (n)	Percentage (%)	Total (n)	Percentage (%)	p-Value	h-Value
1.	Less good	48	57.1	29	34.5	0.003	0.486
2.	Good	36	42.9	55	65.5	0.003	0.486
Total		84	100	84	100

Table 2.

Attitude of Cadres before and after the application of the RoSi digital smart education model.

No.	Attitude	Before the application of RoSi model		After the application of RoSi model
No.	Attitude	Total (n)	Percentage (%)	Total (n)	Percentage (%)	p-Value	h-Value
1.	Negative	53	63.1	31	36.9	0.037	0.596
2.	Positive	31	36.9	53	63.1	0.037	0.596
Total		84	100	84	100

Table 3.

Skills of Cadres before and after the application of the RoSi digital smart education model.

No.	Skills	Before the application of RoSi model		After the application of RoSi model
No.	Skills	Total (n)	Percentage (%)	Total (n)	Percentage (%)	p-Value	h-Value
1.	Poor	53	63.1	31	36.9	0.037	0.596
2.	Good	31	36.9	53	63.1	0.037	0.596
Total		84	100	84	100

The RoSi application model resulted a highly feasible criteria based on material expert validation (87.50%), language expert validation (84.62%), and module expert validation (91.67%). The validity and reliability tests obtained the lowest R value of 0.498 and the highest 0.930 > from the R table (0.361). The lowest calculated Cronbach alpha value of 0.939 and the highest 0.964 > 0.600, so it is assumed that the question items on the questionnaire are valid and reliable. The Cohen’s h-value showed the medium effect of size for knowledge, meanwhile the medium to large effect for attitude and skills.

Discussion

Cadres’ knowledge about early prevention of stunting in toddlers during the programme of the first 1000 days of birth at before application of the RoSi digital smart education model showed that the majority of cadres’ knowledge were less good.²² Cadres did not understand the early prevention of stunting in toddlers during the programme of the first 1000 days of birth including the definition of stunting, the impact of stunting on toddlers, stunting indicators in terms of nutritional status and balanced nutrition.²³ After applying the RoSi model, the cadres’ knowledge was increased on basic nutrition, such as balanced nutrition, stunting indicators in terms of nutritional status, toddler height measurements, causes, prevention, and their impact.²⁴ The knowledge improvement has helped cadres for better communication and made it easier to deliver information to mothers with stunted toddlers.²⁵ Evidence from Cohen’s Kappa test shows a p-value of 0.003 that there are significant differences in cadre knowledge before and after the application of the RoSi digital smart education model. In line with previous studies, there is a relationship between knowledge, motivation, infrastructure, funds and supervision systems with the performance of implementing officers.²⁶ The study also showed that cadre knowledge has a significant relationship with early prevention of stunting in toddlers.²⁷

The attitude of cadres before the use of the RoSi model was mostly negative. Cadres felt that Public Health Centre activities were not organised seriously in weighing and providing counselling to pregnant women and mothers of toddlers.²⁸ At that time, cadres felt that it was not important to remind mothers to control their diet; to eat little but often, to consume additional food during pregnancy to prevent chronic energy deficiency, to supplement breastfeeding according to the age of the baby, and to encourage mothers to bring their toddlers to the Public Health Centre every month. Cadres have negative attitudes due to a lack of motivation from health workers and a lack of supervision. Based on observations, there was a tendency for health workers, such as the immunisation team, to focus only on the task of serving immunisation and to be less concerned about the implementation of cadres’ tasks during activities at the Public Health Centre.²⁹ After the RoSi model was applied, the cadres’ attitudes changed in terms of the importance of providing basic nutrition counselling to pregnant women and mothers of toddlers. Cadres reminded mothers to take Fe tablets (90 tablets) regularly, and the importance of breast care in preparation for breastfeeding. Cadres also encouraged mothers to choose delivery assisted by a health worker such as a midwife or doctor at a health facility, encouraged mothers to give exclusive breastfeeding to toddlers and continue until the toddler is 2 years old, reminded mothers to routinely go to the Public Health Center to measure the weight and height of toddlers, and obtained some additional food for pregnant women and toddlers.³⁰ The results of the Cohen’s Kappa test showed a p-value of 0.037, meaning that there were differences in the attitudes of cadres before and after the application of the RoSi model. After the application of education, cadres increased their response to the need to provide counselling to pregnant women about the programme of the first 1000 days of birth and its benefits for mothers and toddlers.³¹

The response of cadres also increased to their duties related to early prevention of stunting in toddlersthrough the programme of the first 1000 days of birth, including: reminding mothers to get tetanus toxoid immunisation, to do breast care, and to have delivery assisted by a doctor or midwife, to exclusively breastfeed infants up to 6 months of age, and advising mothers to bring infants for immunisation to health facilities.³¹ The cadres respond to the task of measuring the length and height of infants and toddlers, as well as head circumference at each Public Health Centre visit and recording the results of measuring the length, height, and weight of infants and toddlers, as well as head circumference. Our research showed that the attitude of cadres has a significant relationship with early prevention of stunting in toddlers. Therefore, it is hoped that cadres will remain consistent in implementing the stunting website to facilitate tasks in efforts to prevent early mothers at risk of giving birth to stunted toddlers or not through the programme of the first 1000 days of birth.³²

To prevent stunting in toddlers is not only the responsibility of cadres or health workers, but it is hoped that the support of the community, especially pregnant women, mothers giving birth, and mothers of toddlers as objects that will be targeted to know and accept the RoSi Model as an effort to prevent early stunting in toddlers.³³ It is hoped that this model can help them to behave better in improving health and reducing the impact of their behaviour so far, then they can change their attitudes and positive behaviour will increase.³⁴

The skills of cadres on early prevention of stunting in toddlers through the programme of the first 1000 days of birth, before the use of the RoSi model, showed that the majority were poor. Cadres are less skilled in explaining the programme of the first 1000 days of birth, less skilled in providing nutrition counselling, and less skilled in measuring the height of toddlers and recording the measurement results in the MCH book. This lack of skill may be due to the cadres’ lack of knowledge about their duties. Cadres tend to feel that health counselling is more appropriate for health workers.³⁵ After applying the RoSi digital smart education model, the skills of cadres who were previously the majority of poor changed to the majority of good skills. Cohen’s Kappa test showed a p-value of 0.004, meaning that there was a difference in cadre actions before and after the application of the RoSi digital smart education model. The RoSi application effectively enhanced cadre skills due to its smartphone accessibility, interactive features such as lectures and demonstrations, and expert-validated content. Digital health education tools improve learning outcomes by increasing engagement, accessibility, and retention of knowledge.

After the application of education, cadres increased their skills in carrying out tasks related to the programme of the first 1000 days of birth, including cadres are more skilled in conveying or informing information about health during pregnancy to pregnant women, skilled in measuring the upper arm circumference of pregnant women, skilled in measuring the head circumference of toddlers, skilled in measuring the height of pregnant women and toddlers.³⁶ Cadres were skilled in finding solutions when measuring or weighing toddlers was difficult or when children were crying or unwilling. Cadres are more skilled at explaining the importance of good maternal behaviour during the programme of the first 1000 days after birth.¹⁸ The improvement in cadres’ skills was demonstrated by the observation that cadres were more skilled in carrying out their tasks than before. Cadres were more skilled in communicating information to pregnant women and mothers of toddlers who visited the Public Health Centre. Cadres also conduct dialogue with pregnant women and mothers of toddlers who visit the Public Health Centre. Cadres were more skilled at measuring and weighing. This study showed that cadre skills have a significant correlation with the early prevention of stunting in toddlers.³⁷ Another study showed that there was an increase in the average score of cadres’ actions after being given training.¹⁶ There was an increase in the average action score of 1.071 points after attending the training. Cohen’s Kappa test obtained significant differences in cadre actions before and after attending training on monitoring the growth of toddlers. This means that there was an effect of training on cadres’ actions in assessing and monitoring the growth of toddlers.²⁴ Another similar study explained that skilled cadres were accompanied by a high level of knowledge.^38–40

Our study highlighted that there was a relationship between the level of knowledge of cadres about anthropometric measurements and skills in measuring the growth of toddlers (p < 0.05). Although the evaluation results showed that the RoSi model has weaknesses and strengths, it was able to change the behaviour of cadres in an effort to prevent early stunting in toddlers. However, this study is limited by the absence of a control group, which restricts causal inference. Potential selection bias may exist despite random sampling. Findings may not be generalisable beyond the study sites, as results reflect specific contexts of two Public Health Centres in North Sumatra with unique cadre characteristics.

Scalability and sustainability

The RoSi model demonstrates high feasibility for scale-up due to its digital accessibility via smartphones. To ensure sustainability, we recommend that local governments integrate this model into the Posyandu system through Mayoral Regulations (Perwal), eventually elevating it to Regional Regulations (Perda). This would mandate the use of digital tools for all cadres, ensuring standardised stunting prevention training across the region.

Limitations

A primary limitation of this study is the use of a quasi-experimental design without a concurrent control group for the cadre intervention. Consequently, observed improvements cannot be solely attributed to the RoSi model with absolute certainty, as external factors may have contributed. Future studies should employ a randomised controlled trial (RCT) design to strengthen causal inferences.

Conclusion

The novelty of this study lies in the integration of a digitally accessible, expert-validated smart education model (RoSi) into community-based health systems, which significantly improved knowledge, attitudes, and practical skills of cadres in early stunting prevention during the first 1000 days of life—a digital innovation not previously applied at the Posyandu level. The application of the RoSi digital smart education model is carried out through lectures, discussions, and demonstrations of the stunting website module for Public Health Centre cadres can improve the behaviour of cadres in efforts to prevent early stunting in toddlers. There are changes in the behaviour of cadres in efforts to prevent early stunting in toddlers after the application of the RoSi digital smart education model as evidenced by the percentage of cadre knowledge previously the majority was less good (57.1%) turned into a majority of good (66.7%), the percentage of attitudes previously the majority was negative (53.6%) turned into a majority of positive (63.1%) and the percentage of cadre skills previously the majority was poor (63.1%) turned into a majority of good (56%). It is hoped that the Public Health Centre will encourage cadres to apply the RoSi Model and the stunting website to detect and prevent early stunting in toddlers and prevent mothers at risk of giving birth to stunted toddlers. Future research should include controlled trials to strengthen causal claims and explore long-term impacts of RoSi on child health outcomes.

Supplemental Material

sj-docx-1-phj-10.1177_22799036261423665 – Supplemental material for Smart Digital Education model of cadres empowerment for early stunting prevention

Supplemental material, sj-docx-1-phj-10.1177_22799036261423665 for Smart Digital Education model of cadres empowerment for early stunting prevention by Rotua Sumihar Sitorus, Rahmad Gurusinga, Samsider Sitorus, Megawati Sinambela and Reni Aprinawaty Sirait in Journal of Public Health Research

Supplemental Material

sj-docx-2-phj-10.1177_22799036261423665 – Supplemental material for Smart Digital Education model of cadres empowerment for early stunting prevention

Supplemental material, sj-docx-2-phj-10.1177_22799036261423665 for Smart Digital Education model of cadres empowerment for early stunting prevention by Rotua Sumihar Sitorus, Rahmad Gurusinga, Samsider Sitorus, Megawati Sinambela and Reni Aprinawaty Sirait in Journal of Public Health Research

Footnotes

Acknowledgements

Author thanks to all contributors involved in this study. Author also thanks to Public Health Center Medan Tembung and Public Health Center Medan Deli, North Sumatra Province, Indonesia that have supported with facilities, infrastructures, and human resources.

ORCID iDs

Rotua Sumihar Sitorus

Rahmad Gurusinga

Samsider Sitorus

Megawati Sinambela

Reni Aprinawaty Sirait

Ethical considerations

The research has been given ethical approval by Ethical Review Board Committee of Institut Kesehatan Medistra Lubuk Pakam, Number: 004.D/KEP-MLP/II/2024. All respondents have signed informed consent. Furthermore, all contributing authors declare no conflicts of interest in this research.

Author contributions

Concept and Study Design (R.S.S., R.G., S.S.,), Materials (R.G., M.S.), Data Collection (R.S.S., R.A.S.), Data Analysis and Interpretation (R.S.S., R.G., S.S., M.S., R.A.S.), Literature Review (R.S.S.), Paper Writing (R.S.S.), Critical Review and Editing (R.G., S.S., M.S., R.A.S.), Final approval of the manuscript (R.S.S., R.G., S.S).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online at .

Significance for public health

A smart digital education model, namely ‘RoSi’, has been developed in the form of a website platform in order to increase the cadres’ ability to detect mothers at risk for stunted birth and stunted growth toddlers. This study exhibited that the RoSi model was effective in improving cadres’ knowledge, attitude and skills in order to prevent stunting in toddlers. Furthermore, this study suggested that the government and stakeholders implement the smart digital education model in the near future.

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