ISSN: 2347-467X, Vol. 08, No. (2) 2020, Pg.

489-495

Current Research in Nutrition and Food Science

Implementing Precede-Proceed Model toward the

Mothers’ Perception on the Importance of Feeding of
Home-Made Complementary Food to Wasting and
Stunting Toddlers
FITRIANI1*, TEUNGKU NIH FARISNI1, VENI NELLA
SYAHPUTRI2, LILY ARSANTY LESTARY3 and SITI HELMYATI3

1
Department of Public Health Science, Faculty of Public
Health Universitas Teuku Umar, Meulaboh -23615, Indonesia.
1
Department of Public Health Science, Faculty of Public
Health Universitas Teuku Umar, Meulaboh -23615, Indonesia.
2
Department of Public Administration, Faculty of Social and Politic Science
Universitas Teuku Umar, Meulaboh-23615, Indonesia.
3
Department of Health Nutrition, Faculty of Medicine, Public Health and
Nursing Universitas Gadjah Mada, Yogyakarta - 55281, Indonesia.

Abstract
The aim of the study was to modify the PRECEDE-PROCEED models
to use them as a basis for planning of weaning food interventions
for home-made weaning food on wasting and stunting toddlers. Article History
This study used the method of an observational cross sectional with
one group pretest posttest design. The total population in this study Received: 27 September
2019
was 1,520 toddlers under two years old. The samples in this study Accepted: 04 June 2020
were 63 mothers. The data collection was done through distributing
the questionnaire to the mothers. Then, the data analysis was using a Keywords
sample t-paired test. The results of the study show that the application
Complementary Food;
of the PRECEDE-PROCEED models included knowledge (p=0.03), PRECEDE-PROCEED
attitudes (p=0.01), actions (p=0.005), family support (p=0.004), health Model;
worker supports (p=0.004), and cultural support (p=0.0001). Thus, it Stunting Toddlers;
Wasting Toddlers.
can be concluded that there is the increase in the respondents’
knowledge, attitude, actions, family support, health worker supports,
and cultural support after the implementation of PRECEDE-
PROCEED models in concern to the importance of weaning food
providence.

CONTACT Fitriani [email protected] Department of Public Health Science, Faculty of Public Health Universitas
Teuku Umar, Meulaboh -23615, Indonesia.

© 2020 The Author(s). Published by Enviro Research Publishers.

This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-
BY). Doi: http://dx.doi.org/10.12944/CRNFSJ.8.2.14
 FITRIANI et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(2) 489-495 2
(2020)
Introduction
Globally, the problem that occurs is the lack
The effort to increase the nutritional status in
of awareness and knowledge of mothers in
children 0-24 months old can be done by
processing homemade weaning food which are
upgrading the public attitudes in feeding weaning
available in abundant commodities and sources
food to children. It is an inseparable premise from
around the neighborhood. Therefore, the role of
the holistic efforts to improve nutrition. However,
the mother in giving home-made weaning food
there is still amounts of limited knowledge
is profoundly significant, 9 so it is necessary to
regarding how to feed infants— especially
empower the community with the aim of mothers
toddlers. Even worse, some mothers can give food
with toddlers under two years old to always be
which can be detrimental to their children’s health.
selective and creative in making homemade
This condition—directly or indirectly—can
weaning food.8 Meanwhile in Indonesia,
manifest as the key factor in malnutrition in
educational and organizational background is the
children, especially in the age range under 2
primary cause of nutritional problems. It covers 3
years.1
important phases, they are predisposing,
reinforcing, and enabling. The similar case also
An effort that can be carried on as a solution to
applies to the local area where this study was
reduce nutritional cases is through community
conducted. Hence, based on the elaborations
movements in the form of nutrition-conscious
above, the authors are interested in studying
mothers program. This starts from nutritious,
scientifically the PRECEDE-PROCEED model as
diverse and balanced food consumption patterns
the basic guidance in giving the home- made
and special attention to sanitation and
weaning food to children under two years old who
environmental health.2 Improvements in the
are suffered from wasting and stunting in the West
nutritional status of children under two years old
Aceh Regency, Indonesia.
can be achieved through the provision of weaning
food containing proper nutrients which is given to
Health behavior is influenced by individual factors
infants or children aged 6-24 month (under two-
and the environment. Therefore it has two different
year-old babies). Weaning food is a food transition
parts, namely the First PRECEDE (Predisposing,
from breast milk to family food. It is given through
Reinforcing, Enabling, Constructs in, Educational/
some certain stages according to the age of the
Ecological, Diagnosis, Evaluation) and PROCEED
child, starting from pulverized texture, moist
(Policy, Regulatory, Organizational, Constructs in,
texture, and by and by it is served in the regular
Educational, Environmental, Development). One
family texture until the child becomes accustomed
of the best for planning, implementing and
to family food. This is also a means for shaping
evaluating health promotion programs is the
the eating pattern so that it forms future eating
PRECEDE- PROCEED model. Precede part of
habits.3,4
the phase (1- 4) focuses on program planning,
and the Proceed phase section (5-8) focuses on
In general, there are two types of weaning food.
implementation and evaluation.10 Eight phases of
First, it is the food which is the result of processing
the model guide in creating health promotion
factories or commercial complementary food,
programs, starting with more general moving to
and the other one is the weaning food that is
more specific results. Gradually, the process
processed at home named home-made weaning
leads to the creation of a program, program
food. Indonesian Health Department recommends
distribution, and program evaluation.11
giving weaning food that can be obtained from
cheap and easily processed commodities
To be more specific, complementary food is an
available in the local area.6 This kind of weaning
additional food given to babies since a baby aged
food has a positive impact, including improving
6 to 24 months old. So, in addition to
maternal skills and knowledge in designing
complementary food for breast milk, breast milk
foodstuffs, increasing health care-line activities,
must also be given to infants at least until the age
increasing community income, and becoming a
of 24 months. The role of complementary food is
means of education or nutrition counseling. In
not to replace breast milk but only to supplement
recent years, developing countries have carried
breast milk so in this case complementary breast
out campaigns related to the preferences toward
milk is different from weaning
homemade weaning food rather than buying
ready-made weaning food, especially for low-
income families.7
 FITRIANI et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(2) 489-495 3
(2020)
food given when babies no longer consume breast
and minerals, and fat. The staple food is the main
milk after they reach 2 years old.12 Complementary
food ingredient and is a source of carbohydrates,
food is additional food given to babies after the
more preferably cereals or rice. Then, vegetable
age of 6 months. If complementary food for breast
and animal protein is also good nutrients which
milk is given too early (before the age of 6
can be obtained from beef, chicken, fish, eggs and
months), it will reduce the consumption of
nuts. Then, source of vitamins and minerals in the
breast milk and the baby can experience
form of colored vegetables and fruits, especially
indigestion. On the other hand, if complementary
green and orange fruits. And last, it is additional
breastfeeding food is given too late it will cause
energy from fat, oil, and sugar.14 A double mixture
the baby to be malnourished once it occurs in a
can be also provided in the food square. In food
long time. Complementary food standards must
squares, breast milk is positioned in the middle of
be considered seriously concerning to the number
a rectangle precisely because it is the most
of nutritional adequacy recommended by the age
complete food for babies.15 In each corner of the
group and food texture according to the baby’s
quadrilateral is placed staple food, protein,
age development.5
vitamins, and this can act as a complete meal for
the baby.
In providing complementary food, the food should
meet the criteria that it is suitable for eating, it
Materials and Methods
does not cause disease, and it is healthy.5 Other
This study carried out the quantitative approach
additional criteria are including: 1. It is well-coked;
with one group pretest posttest design. The whole
2. It is free from contamination when storing and
population in this study was 725 mothers who
serving the food until consumed by the baby; 3. It
have toddlers under two years old in the area of
is free from physical changes, hazardous
Meureubo and Johan Pahlawan, West Aceh,
chemistry, influence of enzymes, microbial
Indonesia. These two areas are cosnidered as the
activity, rodents, insects, parasites, and damage
location of this study because they have the
due to pressure, cooking and drying; 4. It is free
highest stunting children percentage. After
from microorganisms and parasites that cause
implementing both inclusion and exclusion criteria,
food-borne diseases; 5. It must contain enough
the samples chosen for the study were 63 mothers
calories and vitamins; and 6. It has to be easy to
who have two-year-old toddler(s). These mother
digest by infant digestion. Concerning the home-
met the inclusive criteria which are that the
made complementary food, it is made at home
mothers are residents of the areas; they agreed to
from the ingredients that are often found around
follow the procedures, and they were willing to
the house so that the price is affordable. I n 2 0
sign the agreement. Meanwhile others are not
05, UNICEF recommended giving
able to fulfill these criteria and they were taken
complementary food ingredients which are derived
into the exclusive criteria and did not participate in
from local ingredients.13 Home-made complementary
this study. The dependent variable in this study is
food has the same nutritional content and is more
feeding the home-made weaning food, meanwhile
economical than that of factory-made
the independent variable is PRECEDE-PROCEED
complementary food. A mother must pay attention
model which consist of the following stages, they
to the variety and texture of food made according
are: predisposing (knowledge, attitude, and
to the child's ability to get accustomed to the
action), enabling (family and health workers
eating pattern.
supports), and reinforcing (cultural supports). The
samples were treated using the PRECEDE-
In preparing the complementary food for babies,
PROCEED model in order to increase their
it is very important to pay attention to baby-safe
perception toward the feeding of weaning food to
food ingredients and how to mix these ingredients.
their toddlers. So that, initially the pretest was
The mixture of MP-ASI ingredients consists of two
administered on March 18th, 2019. Later, the
types, namely basic mix and double mix. Basic mix
intervention was done using PRECEDE-
consists of cereals, peanuts, and beans. This
PROCEED model during 3 months; besides, the
mixture does not meet the complete nutrition so
supervisions were also given fortnightly.
that it still requires additional nutrients such as
Afterward, the post-test was administered on June
vitamins and minerals. While double mix or multi
3rd, 2019. Finally, the data obtained form the
mix consists of four groups of foodstuffs such as
pretest and the post-test were analyzed using t-
carbohydrate, protein, vitamins
paired sample test.
 FITRIANI et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(2) 489-495 4
(2020)
Just to mention, this study does not work on the
actions, family support, health worker support, and
feeding process for the stunting children, rather on
cultural support during the pre-test and post-test
giving the educational programs for the mothers
increased after the intervention with PRECEDE-
who have stunting children using the PRECEDE-
PROCEED models.
PROCEED model.
Results
The respondents’ characteristics which are
Test results of the sample t-paired test obtained
considered are concerning to age, educational
the value of the statistical test p-value (0.001)
background, and income. In analyzing the data,
<0.05, there were differences in the use of the
this research used paired sample t-test to see the
PRECEDE-PROCEED models before and after
difference between proceed and preceed that
the administration of home-made complementary
have been given to the respondents. In average,
food in West Aceh District.
the respondents aged between 32.1 ± 7.1 years
old; their average educational background is high-
The average increase is clearly shown in the table
school; and their average income is below regional
below.
minimum wage. The average score of knowledge,
attitudes,

Table. 1: Average Distribution of Each variable

Variable N Pre-test Post-test P-Value

Knowledge 63 5.9±1.231 8.21±1.472 0.003

Attitude 63 4.6±1.023 6.81±327 0.01
Action 63 5.4±1.023 7.2±1.521 0.005
Family support 63 6.1±1.467 7.91±582 0.004
Health workers support 63 6.5±1.467 7.91±582 0.004
Cultural support 63 5.9±1.167 8.7±1.631 0.0001

The table shows that, first, there is a difference in

Second, there are differences in attitude averages
the average knowledge before and after applying
before and after and after applying the
the PRECEDE-PROCEED model obtained within
PRECEDE- PROCEED model obtained in p-
p-value 0.003 at n = 63. The results of this study
value 0.01 at n = 63. The attitude of the mother
illustrate that the mothers of children under two
is a very important domain for giving home-made
years old have poor knowledge before the
complementary food. This research is in line with
implementation of the PRECEDE-PROCEED
research suggesting that a person's attitude is
model. After the implementation of the precede-
related to giving baby’s complementary food.
procedural model, the knowledge of the mothers
Specific attitudes that can influence behavior are
experienced a significant increase. The average
social attitudes expressed in a repetitive manner
addition of knowledge scores is 2.31 ± 0.24.
in activities that are commonly called habits.
Knowledge of nutrition of the mothers is very
Then, motive drives the desires which originate
influential on the provision of home-made
from within. Values in a person are subjective
complementary food in toddlers who are suffered
norms while driving forces and restraining power is
from wasting and stunting. This finding is
in the form of advice or information from other
supported by Folasade et al., as they suggest that
people. These motives then become the practice
there is significant influence between mothers’
of preparing proper complementary food for their
knowledge and educational background and the
babies.18
provision of the provision of home-made
complementary food. It is not only limited to the
Third, there is a difference in the average of
knowledge but also to practice. Low knowledge
actions before and after applying the PRECEDE-
manifests in poor practice of preparing
PROCEED model obtained in p-value 0.005 at n
complementary food for their children.16, 17
= 63. This
 FITRIANI et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(2) 489-495 5
(2020)
study describes the actions the mothers about
to serious problem because the elderly are usually
home-made complementary food increased with
the ones who influences and leads child feeding
the addition of a score of 1.8 ± 0.429. the result
practices in the family.25, 26
is supported by other similar research suggesting
that actions or practices have a profound effect
Fifth, there is a difference in the average health
on the administration of complementary food. An
worker support before and after applying the
attitude does not automatically manifest in an
PRECEDE-PROCEED model obtained in p-value
action. In order an attitude to be a real act,
0.004 at n = 63. The results of this study illustrate
supporting factors or conditions that are possible
that there is an increase in the average health
include facilities are necessary. Besides the
worker support after applying home-made
facilities factor, a support factor from other parties
complementary food with the addition of a support
is needed in realizing the action or practice.19
from health worker is 2.2 ± 0.4. Health worker
Besides, There is a requirement for medical
support gives physical and psychological
services to encourage the home-made weaning
comfort, attention, appreciation, and other forms
food preparation practice, family mediations and
of assistance received by individuals from health
supports, and general wellbeing instruction to
workers. The support of health workers can be in
advance ideal weaning food provision, particularly
the form of emotional support, appreciation,
for less educated mothers.20
instrumental, and information. Health workers are
sources of social support from other individuals
Fourth, there are differences in the average family
who very rarely provide support and have a very
support before and after and after applying the
fast-changing role. Support for mothers is an
PRECEDE-PROCEED model obtained in p-value
important factor in giving complementary food. The
0.004 at n = 63. The results of this study illustrate
help of health workers is significant before birth,
that there is an increase in family support after
yet in addition after conveyance in puerperal stage
applying the PRECEDE-PROCEED application
around about a month and a half after birth. The
with the addition of an average family support
job of health workers since they can share basic
score of
information about breastfeeding as well as the
1.8 ± 0.11. Family support is a form of
complementary food during breastfeeding. The
interpersonal relationship that protects a person
mother will increase her awareness understand
from bad stressful effects.21 Family support is an
that both are useful for her infant.27
attitude, an act of family acceptance of family
members, in the form of informational support,
Last, there are differences in cultural support
assessment support, instrumental support and
averages before and after and after applying the
emotional support.22, 23 So family support is a form
PRECEDE-PROCEED model obtained in p-value
of interpersonal relations that includes attitudes,
0,0001 at n = 63. The results of this study illustrate
actions and acceptance of family members, so
that there is an increase in cultural support scores
that family members feel someone is paying
after the application of precede procedural models
attention. Family social support refers to social
to the provision of home-made complementary
supports that are seen by family members as
food with the addition of a score of 2.8 ± 0.464.
something that can be accessed or held for
Culture is a way of life that develops and is shared
families who are always ready to provide help and
by a group of people and passed down from
assistance if needed.24 This is supported by a
generation to generation. Culture is formed from
research that suggests that there is a relationship
many complex elements, including religious and
between family support and the provision of
political systems, customs, languages, tools,
complementary food. Family support is considered
clothing style, buildings, and works of art. The
as a vital aspect in practicing complementary food
portrayal of the cultural belief on breastfeeding
for babies. This has been found very limited in
and complementary feeding practice will be a
many countries. Mostly, the mothers are
significant advance in encouraging the plan of
misleadingly directed by other family members
intercessions to increase the provision of well-
who also have lack knowledge about nutrition in
fulfilled food for babies.28 Social practices and
complementary food. Furthermore, the inadequate
cultural belief impacted on complementary feeding
knowledge and misperceptions among older
practice for children under 2 years old. The
persons in the family, especially mothers or
impacts
mother-in-law. This can lead
 FITRIANI et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(2) 489-495 6
(2020)
sustaining this process were the statistic attributes
Lastly, home-made weaning food can also be used
from level of training of caregiver, the weight of
as a viable effort to support the family economy.
burden of the caregivers. The social elements
were the convictions related with specific food,
Acknowledgement
sustenance taboos/restrictions.29
The authors are thankful for those who have
contributed to the fulfillment of this paper, they are
Conclusion
Indonesian Ministry of Research and Technology,
Based on the results shown above, there are
the faculty of Public Health of Universitas Teuku
three conclusions that can be drawn. Initially,
Umar, to Dr. Lili Arsanti Lestari and Dr. Siti
knowledge and understanding of the mothers,
Helmyati as the research partners from
attitude, actions, family support, health worker
Universitas Gadjah Mada, Yogyakarta, Indonesia
supports, and cultural supports about stunting and
and also to all members who cannot be mentioned
home-made weaning food did grow better after the
individually.
experimentation process using the PRECEDE-
PROCEED model application. Later, the
Funding
mentioned variables concerning to knowledge,
Indonesian Ministry of Research and Technology
attitude, actions, family support, health worker
with the number: 035/UN59.7/TL/2019.
supports, and cultural supports towards stunting
and home-made weaning food are vital to mothers
Conflict of Interest
and to workers at integrated healthcare servicein
This topic has no conflict of interest.
preventing stunting in toddlers.

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