Enfermería Clínica 31 (2021) S296---S300

www.elsevier.es/enfermeriaclinica

The contribution of family functions, knowledge

and attitudes in children under five with stunting夽
Praba Diyan Rachmawati ∗ , Mira Triharini, Putri Dewi Suciningtyas

Faculty of Nursing, Universitas Airlangga, Surabaya, East Java, Indonesia

Received 15 September 2020; accepted 21 September 2020

KEYWORDS Abstract The objective of study is to analyze the relationship between the function, knowl-
Family functions; edge and attitude of families with the nutritional status of stunted children. The design of this
Knowledge; study was a cross-sectional. The population was the mothers of children under five with stunting.
Attitudes; The sample consisted of 129 respondents selected through purposive sampling. The indepen-
Stunting; dent variables were family function, knowledge and attitude, while the dependent was the
Under five children nutritional status. The data was collected using a questionnaire and analyzed using the Spear-
man rho with ˛ < 0.05. The results show that there was no relationship between family function
with the nutritional status (p = 0.553, r = 0.053), however knowledge (p = 0.004, r = 0.249) and
attitude (p = 0.000, r = 0.637) had a relationship with the nutritional status. Family knowledge
and attitude determine the nutritional status of stunting children. It is important for nurses to
develop education for families to prevent stunting.
© 2020 Elsevier España, S.L.U. All rights reserved.

Introduction Stunting can hurt children under five due to interference

One of the nutritional problems that has not yet been
resolved in Indonesia is stunting.1 Stunting shows that there
has been long-term (chronic) nutritional insufficiency that
starts before pregnancy, during pregnancy and after birth.
夽 Peer-review under responsibility of the scientific committee of
the 4th International Conference for Global Health (ICGH) in con-
junction with the 7th Asian International Conference in Humanized
Health Care (AIC-HHC). Full-text and the content of it is under
responsibility of authors of the article.
∗ Corresponding author.
E-mail address: praba-d-r@fkp.unair.ac.id (P.D. Rachmawati).
such as low intelligence, decreased immunity and delayed
growth and development. This will have an impact on these
children when they are adults.2,3
The prevalence of stunting in Indonesia is higher than in
other countries in Southeast Asia, such as Myanmar (35%),
Vietnam (23%) and Thailand (16%). Indonesia is ranked 17th
out of 117 countries that have complex nutritional prob-
lems including malnutrition (19.6%) and stunting (37.2%).4
Indonesia is included in the 14 countries with the largest
rate of stunting in children under five and it ranks 5th after
India, Nigeria, Pakistan and China.5 The incidence of stunt-
ing in East Java Increased from 2007 to 2010, the results of
the study stated the incidence of stunting in East Java was
39.4%.6

https://doi.org/10.1016/j.enfcli.2020.12.035
1130-8621/© 2020 Elsevier España, S.L.U. All rights reserved.
 Enfermería Clínica 31 (2021) S296---S300
Several research studies into the factors that correlate
with the background of stunting have been carried out such
as those looking at feeding patterns and lifestyle.7 Another
important factor is family function. The family functions can
influence the presence of a healthy lifestyle in the family,
including meeting the nutritional needs that are appropriate
for the child.8 A good family function will affect the mother
when she is providing care for her child.9 The mothers play
a role in providing nutrition to their children.10 There is a
relationship between maternal attitude and the husband’s
support of nutritional practices.11 The mother’s behavior
related to providing nutrition to her child is very important
for the child’s growth and development. Achieving an age of
growth potential in the first 2 years of life makes it is very
important that the child is given proper nutrition.12 Fulfill-
ing the proper nutrition during pregnancy can also affect the
child’s nutritional status. Pregnant women must get ade-
quate nutrition through nutritional supplementation (iron
tablets or Fe) and health monitoring.13
Efforts to reduce the prevalence of stunting have been
carried out to support the achievement of the health devel-
opment targets following the 2015---2019 Strategic Plan. The
family area focuses on the approach used for implementing
a healthy Indonesia program.5 However, children under-five
has still been found with stunting. Besides the role and func-
tion of the family, the knowledge and attitude of the mother
is still a fundamental problem affecting childcare. This study
aims to analyze the influence of family function, knowledge,
and attitude related to children under five with stunting.
Method
Design
The design of this study used a cross-sectional approach.
Population and study setting
The population in this study consisted of all families with
stunted children aged under five. The criteria for determin-
ing the sample was through purposive sampling. The total
sample consisted of 129 respondents who met the inclusion
criteria, which was where the mother lived together with
her child and took care of the child directly.
Variables
The independent variables in this study were family func-
tion, knowledge and attitude in relation to caring for
children under five. The dependent variable in this study was
the nutritional status of stunted children under five years
old.
Data collection
The instrument used in the collection of the family function
data was a questionnaire modified from the Family Function-
ing Device (FAD) consisting of 60 questions. These items were
used to measure family function and they were developed by
Epstein et al. (1983).14 The measurement of family knowl-
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edge and attitude was done using a questionnaire prepared
by the researchers through the different stages of discus-
sion with experts. It was tested for validity and reliability
and declared to be a valid and reliable questionnaire.
The research questionnaire was given to the mothers in
the Integrated Service Post (POSYANDU). Before the respon-
dent filled out the questionnaire in order to participate in
this study, the researcher explained the study first and then
the respondent signed an informed consent sheet.
Data analysis
The analysis of the data was done using the Spearman Rho
statistical test ˛ ≤ 0.05.
Ethical aspects
This study has been approved by the Health Research Ethics
Committee Faculty of Nursing of Universitas Airlangga
Results
Most of the respondents (79.1%) were 18---35 years old. More
than half of the respondents (59.7%) had an elementary
school level of education. The largest percentage did not
work (48.1%). The majority of the respondents in this study
had a family income in the low category (99.2%). The largest
percentage were in the age category of 4---5 years for as
many as 59 of the respondents (45.7%). The category of giv-
ing exclusive breast feeding was in the category ‘not giving
as much’ at 58.1% (Table 1).
The biggest value was for effective family function,
where the children in the stunted category totalled as many
as 72 (55.8%) respondents. In this study, it was found that
there was no significant relationship between family func-
tion and the nutritional status of stunted children with a
value of p = 0.553. The total number of respondents who had
good knowledge and children in the category of stunted was
52 (40.3%). Knowledge is significantly related to the nutri-
tional status of stunting children with p = 0.004 and r = 0.249.
The highest number for the mother’s attitude was where
the respondents had a positive attitude and children in the
stunted category (50.4%, n = 65). This study shows that atti-
tude has a significant effect on children with a stunted
nutritional status as indicated by p = 0.001 and r = 0.637
(Table 2).
The mean score obtained from the 7 sub-variables of fam-
ily function shows the lowest average value was effective
responsive with an average score of 11.40 and the highest
average score is the General Function 29.07 (Table 3).
Discussion
The majority of respondents have effective family func-
tions and family function is not related to the nutritional
status. This result is in line with the previous studies.15 Fam-
ily function is one of the factors that influence a child’s
health status. Families must do so in a mutual, supportive
and respectful manner to increase their strength and com-
petence. Previous studies show that good parenting from
 P.D. Rachmawati, M. Triharini and P.D. Suciningtyas

Table 1 Characteristics of the respondents (n = 129).

Characteristics Category n %
Age 18---35 years old 103 79.8
36---50 years old 24 18.6
>50 years old 2 1.6
Education Elementary school 92 71.3
Junior high school 22 17.1
Senior high school 14 10.9
High education 1 0.8
Family income Low income 128 99.2
High income 1 0.8
Child age <2 years old 42 32.6
2---5 years old 87 67.4
Exclusive breast feeding Given 54 41.9
Not given 75 58.1

Table 2 Factors influencing the nutritional status of stunted toddlers (n = 129).

Variable Nutrition status n % p r

Severely stunting Stunting

n % n %
Family function
Effective 20 16.3 72 55.8 93 27.9 0.553 0.053
Ineffective 16 12.4 21 15.5 36 72.1
Knowledge
Less 9 7 12 9.3 21 16.3 0.004 0.249
Enough 16 12.4 29 22.5 45 34.9
Good 11 8.5 52 40.3 63 48.8
Attitude
Negative 35 27.1 28 21.7 63 48.8 0.001 0.637
Positive 1 0.8 65 50.4 66 51.2

family has a close relationship with the nutritional status of responsiveness was because of the large number of family
children, because parents will provide protection and care members. The impact that arises here is a lack of affection
for the child lovingly.16 and family attention. In addition, a possible cause is still
The results show that the majority of respondents have found early marriage in families. This is where there is psy-
effective family functions. The highest value is indicated chological unpreparedness related to building a household.
for General Function and the lowest for affective respon- The value of general function includes the family being
siveness. The possible cause of the low value of affective able to fully provide the food intake that a child need. Worry
and a fear of poor growth and development are felt by many
families, especially the mothers when caring for their chil-
Table 3 Family functions related to children under five dren. There is often a person to them who they always talk to
with stunting (n = 129). about the development and growth of their children. In addi-
tion, the high value for general function is that the majority
Parameter Mean SD
of mothers in the Galis Puskesmas are mothers who do not
Problem solving 11.44 1.96 work. The mothers are directly involved in childcare, where
Communication 15.84 3.26 the time spent with their children is longer than that of
Roles 21.64 4.27 working mothers.
Affective responsiveness 11.40 2.15 The family function tends to be how the family pro-
Affective involvement 15.03 3.09 vides support and its role in fulfilling the child’s nutrition. In
Behavior control 17.28 2.73 Indonesia, the influence of culture, habits and daily lifestyle
General function 29.07 4.08 is very influential on how the family care for children under
five. Research says that the influence of culture and lifestyle

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 Enfermería Clínica 31 (2021) S296---S300
contributes greatly to the nutritional status of children.7
Daily habits that are hereditary tend to apply an unhealthy
culture in the context of childcare. A lack of knowledge
about nutrition in large families who live with both mothers
and children will also have an impact on maternal feed-
ing practices.7 In addition the family economic factors, also
have an influence on the nutritional status of children.17
In this study the majority of the families had an income
that was in the low category. Family function parameters in
solving problems are lacking in this study, so families have
toddlers with stunting nutritional status.
The better the mother’s knowledge, the better the nutri-
tional status of the child. The attitude of the mother and the
child’s stunted nutritional status also has a strong relation-
ship in this study, where positive values indicate a better
level of attitude. A better the nutritional status of the
children under five will result. A person’s attitude can be
influenced by several factors including age, occupation, edu-
cation and parity.7 Some of the mothers in this study have a
negative attitude. Their actions and behaviors will be nega-
tive. This has caused nutritional problems in children before.
More than half of the mothers in this study have good
knowledge. However, they still have stunted children. They
have good knowledge, they cannot use their knowledge
appropriately.7 Mothers tend to follow the culture in the
community, they live. The majority of the respondents were
of a low economic level in society. This can be one of the
reasons why good maternal knowledge cannot be applied
appropriately.18 In addition, the majority of mothers do not
know that their child’s nutritional status does not only have
to focus on body weight, but also on height status. The
majority of mothers do not know the dangers of stunting.
Unhealthy feeding habits in the family will have an impact
on the child’s eating habits. Children prefer unhealthy foods
compared to healthy foods.
The family function has no relationship with the nutri-
tional status of stunted toddlers, while the mother’s
knowledge and attitude do influence nutritional status. The
majority of respondents had an effectively functioning fam-
ily. Although the family function in this study was mostly
effective, if it is not supported by good knowledge and the
influence of unhealthy daily living habits, then it will not
be able to meet the standards for good quality nutrition in
children under five.
Conclusion
Family function, knowledge and attitudes are very impor-
tant for the nutritional status of the child. These three items
have a relationship with each other, so the counseling about
nutrition is not only given to the mother. It also involves the
extended family where the children and mother lives and
are cared for together.
Conflict of interest
The authors declare no conflict of interest.
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Acknowledgments
We would like to thank the respondents who participated in
this study.
References
1. Vaozia S, Nuryanto N. Faktor risiko kejadian stunting pada
anak usia 1---3 tahun (studi di Desa Meduran Kecamatan
Brati Kabupaten Grobogan). J Nutr College. 2017;5:314---20,
http://dx.doi.org/10.14710/jnc.v5i4.16426. Bahasa Indonesia.
2. de Onis M, Blössner M, Borghi E. Prevalence and
trends of stunting among pre-school children,
1990---2020. Public Health Nutr. 2012;15:142---8,
http://dx.doi.org/10.1017/S1368980011001315.
3. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter
L, et al. Maternal and child undernutrition: consequences for
adult health and human capital. Lancet. 2008;371:340---57,
http://dx.doi.org/10.1016/S0140-6736(07)61692-4.
4. Haddad L, Achadi E, Ag Bendech M, Ahuja A, Bhatia K, Bhutta
Z, et al. The global nutrition report 2014: actions and account-
ability to accelerate the world’s progress on nutrition. J Nutr.
2015;145:663---71, http://dx.doi.org/10.3945/jn.114.206078.
5. Pusat data dan informasi Kementerian Kesehatan RI: situasi
balita pendek [Internet]. Jakarta: Kementerian Kesehatan
Republik Indonesia; 2016. Available from: https://www.
kemkes.go.id/resources/download/pusdatin/infodatin/situasi-
balita-pendek-2016.pdf [cited 09.08.19].
6. Mahmudiono T, Sumarmi S, Rosenkranz RR. House-
hold dietary diversity and child stunting in East Java,
Indonesia. Asia Pac J Clin Nutr. 2017;26:317---25,
http://dx.doi.org/10.6133/apjcn.0120.16.01.
7. Yuarnistira, Nursalam N, Rachmawati PD, Efendi F,
Pradanie R, Hidayati L. Factors influencing the feed-
ing pattern of under-five children in coastal areas.
IOP Conf Ser Earth Environ Sci. 2019;246:12008,
http://dx.doi.org/10.1088/1755-1315/246/1/012008.
8. Weatherspoon DD, Miller S, Ngabitsinze JC, Weatherspoon
LJ, Oehmke JF. Stunting, food security, markets and
food policy in Rwanda. BMC Public Health. 2019;19:882,
http://dx.doi.org/10.1186/s12889-019-7208-0.
9. Green LW, Kreuter MW. Health promotion planning: an edu-
cational and ecological approach 3rd ed. Mountain View CA:
Mayfield Publishing Co; 1999.
10. Rahman MM, Saima U, Goni MA. Impact of maternal house-
hold decision-making autonomy on child nutritional status
in Bangladesh. Asia Pac J Public Health. 2015;27:509---20,
http://dx.doi.org/10.1177/1010539514568710.
11. Vollmer RL, Adamsons K, Foster JS, Mobley AR. Asso-
ciation of fathers’ feeding practices and feeding style
on preschool age children’s diet quality, eating behav-
ior and body mass index. Appetite. 2015;89:274---81,
http://dx.doi.org/10.1016/j.appet.2015.02.021.
12. Romero-Velarde E, Villalpando-Carrión S, Pérez-Lizaur AB,
Iracheta-Gerez MDLL, Alonso-Rivera CG, López-Navarrete GE,
et al. Guidelines for complementary feeding in healthy
infants. Bol Med Hosp Infant Mex (English Ed). 2016;73:338---56,
http://dx.doi.org/10.1016/j.bmhime.2017.11.007.
13. Yunitasari E, Rachmawati PD, Lestari DIN. Effort to pre-
vent anaemia during menstruation among female ado-
lescent in islamic boarding school. J Ners. 2019;14:28,
http://dx.doi.org/10.20473/jn.v14i1.9928.
14. Epstein NB, Baldwin LM, Bishop DS. The McMaster Fam-
ily assessment device. J Marital Fam Ther. 1983;9:171---80,
http://dx.doi.org/10.1111/j.1752-0606.1983.tb01497.x.
 P.D. Rachmawati, M. Triharini and P.D. Suciningtyas

15. Hanifah UA, Arisanti N, Agustian D, Hilmanto D. Hubungan 17. Sud S, Tamayo NC, Faith MS, Keller KL. Increased restric-
fungsi keluarga dengan status gizi anak di Kecamatan Soreang tive feeding practices are associated with reduced energy
Kabupaten Bandung pada tahun 2016. Jurnal Sistem Kesehatan. density in 4-6-year-old, multi-ethnic children at ad libi-
2017;2:200---6, http://dx.doi.org/10.24198/jsk.v2i4.12498. tum laboratory test-meals. Appetite. 2010;55:201---7,
Bahasa Indonesia. http://dx.doi.org/10.1016/j.appet.2010.05.089.
16. Cislak A, Safron M, Pratt M, Gaspar T, Luszczynska A. 18. McLeod ER, Campbell KJ, Hesketh KD. Nutrition
Family-related predictors of body weight and weight-related knowledge: a mediator between socioeconomic
behaviours among children and adolescents: a systematic position and diet quality in Australian first-time
umbrella review. Child Care Health Dev. 2012;38:321---31, mothers. J Am Diet Assoc. 2011;111:696---704,
http://dx.doi.org/10.1111/j.1365-2214.2011.01285.x. http://dx.doi.org/10.1016/j.jada.2011.02.011.

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