Health Belief Model of Pregnant Women in Samarinda’s Free Nutritious Meal Program: The Role of Predisposing, Reinforcing, and Enabling Factors in Self-Efficacy
Abstract
Introduction: Stunting remains a national health priority in Indonesia due to its long-term impact on human capital. One flagship government intervention under the National Strategy for Stunting Reduction 2018–2024 is the provision of free nutritious meals for pregnant women to improve maternal nutritional status and prevent stunting. However, adherence to this program varies widely, and previous studies have rarely examined psychosocial determinants based on behavioural health theories.
Objective: This study aimed to analyse factors within the Health Belief Model (HBM), including perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy, alongside predisposing, reinforcing, and enabling factors that influence the self-efficacy of pregnant women participating in the free nutritious meal program in Samarinda City.
Methods: A quantitative cross-sectional design was applied to 203 pregnant women enrolled in the free nutritious meal program between March and August 2024. Participants were selected purposively to ensure representation of diverse educational backgrounds, parity, and gestational ages according to predefined inclusion criteria. Data were collected using a structured questionnaire based on HBM dimensions, perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy, that had been validated and tested for reliability. Partial Least Squares–Structural Equation Modeling (PLS-SEM) was employed due to its suitability for analyzing complex latent constructs and small-to-moderate sample sizes, enabling simultaneous estimation of measurement and structural models.
Results: Predisposing factors showed a strong effect on the HBM construct (? = 0.556). Reinforcing factors exerted a greater influence on self-efficacy (? = 0.228) compared with enabling factors (? = 0.142). The HBM construct itself contributed positively to the enhancement of self-efficacy (? = 0.244). The model demonstrated an SRMR of 0.074 (< 0.08), indicating acceptable model fit.
Conclusion: Predisposing factors (knowledge, attitudes, and motivation) form the foundation of maternal health perceptions, while social support (reinforcing factors) plays a more dominant role than enabling factors in improving pregnant women’s self-efficacy. This first comprehensive application of the HBM to a free nutritious meal program in Samarinda provides new empirical evidence to guide the design of theory-based maternal nutrition interventions and supports Indonesia’s national stunting reduction efforts. Theoretically, the findings extend the HBM by demonstrating how contextual predisposing and reinforcing factors interact to strengthen self-efficacy within community-based nutrition programs. Practically, policymakers should integrate behavioral counseling and family involvement components into the free meal program to enhance motivation and sustained adherence among pregnant women. Future research should use longitudinal designs to assess long-term program effects and explore contextual factors influencing self-efficacy.
References
Kementerian Kesehatan RI. Laporan Baseline Program Percepatan Pencegahan Stunting 2018–2024. Jakarta: Kemenkes; 2019.
Sekretariat Negara RI. Presiden targetkan angka stunting di Indonesia turun hingga 14 persen pada 2024. Jakarta, Indonesia: Sekretariat Negara Republik Indonesia.; 2023.
Kementerian Kesehatan Republik Indonesia. Laporan Nasional Riskesdas 2018. Jakarta: Badan Penelitian dan Pengembangan Kesehatan, Kementerian Kesehatan RI; 2019.
Badan Penelitian dan Pengembangan Kesehatan. Laporan Nasional Riset Kesehatan Dasar. Jakarta: Kemenkes; 2018.
Demilew YM, Alene GD, Belachew T. Effects of guided counseling during pregnancy on birth weight of newborns in West Gojjam Zone, Ethiopia: A cluster-randomized controlled trial. BMC Pediatr. 2020;20(1):1–12.
Kumalasari I. Mothers’ Knowledge, Attitudes, and Support from Health Workers Influencing The Maternal and Child Health (MCH) Handbook Utilization for Maternal and Child Health in Palembang. J Appl Nurs Heal. 2024;6(2):24–35.
Bayked EM, Yimer EM, Gelaw T, Mohammed AS, Mekonen NA. Dietary knowledge, attitude, practice, and associated factors among pregnant mothers in Ethiopia: a systematic review and meta-analysis. Front Public Heal. 2024;12 Septemb.
Olloqui-Mundet M, Cavia M del M, Alonso-Torre S, Carrillo C. Dietary Habits and Nutritional Knowledge of Pregnant Women: The Importance of Nutrition Education. Foods. 2024;13(19):319.
Riazi S, Ghavami V, Sobhani SR, Shoorab NJ, Mirzakhani K. The effect of nutrition education based on the Health Belief Model (HBM) on food intake in pregnant Afghan immigrant women: a semi-experimental study. BMC Pregnancy Childbirth. 2024;24(1).
Maringka NX, Hamzah AN, Marcellin C, Satria O, Nainggolan JDL. Knowledge, Attitude, Practice of Pregnant Women and Husband’s Support on the Implementation of Pregnancy Exercise. Indones J Obstet Gynecol. 2024;12(1):5–8.
Eidan AT, Shawq AH. Effect of a Nutritional Education Program on Mother Knowledge Regarding Their Children Nutritional Status. J Obstet Gynecol Cancer Res. 2024;9(5):522–531.
Hatamzadeh N, Shakerinejad G, Navak T, Haghi M, Haghighizadeh MH, Baumann SL. The Efficiency of the Health Belief Model in Predicting the Preventive Behaviors of Pregnant Women During the COVID-19 Pandemic in Iran. Nurs Sci Q. 2024;37(1):76–80.
Huang J, Xu L, Xu Z, Luo Y, Liao B, Li Y, et al. The relationship among pregnancy-related anxiety, perceived social support, family function and resilience in Chinese pregnant women: a structural equation modeling analysis. BMC Women’s Heal. 2022;22(1):1–11.
Balis LE, Yaroch A, Palmer S, Shaw E, Lima Dos Santos P, Byker Shanks C. Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study. J Acad Nutr Diet. 2024;124(10):1255–1265.
Shrestha P, Afsana K, Weerasinghe MC, Perry HB, Joshi H, Rana N. Strengthening primary health care through community health workers in South Asia. Lancet Reg Heal - Southeast Asia. 2024;28:1–14.
Beressa G, Whiting SJ, Belachew T. Effect of nutrition education integrating the health belief model and theory of planned behavior on dietary diversity of pregnant women in Southeast Ethiopia: a cluster randomized controlled trial. Nutr J. 2024;23(3).
Candra MA, Laenggeng AH, Lestari A. Relationship of Knowledge, Energy Intake and Family Income with Nutritional Status of the Elderly in Lambara Village, Tawaeli District, Palu City. J Public Heal Pharm. 2022;2(3):50–4.
Widyawaty, Lestari A. An Analysis of Macro Nutrition in Red Dragon Fruit (Hylocereus Polurhizus) Peel Dodol. J Public Heal Pharm. 2022;2(2):37–40.
Yaturramadhan H, Syahdat A. Processing of Red Ginger Powder Drink to Improve the Immune System During the Covid-19 Pandemic. J Public Heal Pharm. 2021;1(3):46–8.
Jang W, Kim M, Ha E, Kim H. Maternal Diet Quality Assessed Using the Korean Healthy Eating Index and Risk of Small-for-Gestational-Age Infants: Findings from the Mothers and Children’s Environmental Health (MOCEH. Study Nutr. 2025;17(19):3056.
Kabahenda MK, Stoecker BJ. Associations between maternal dietary intake and nutritional status with fetal growth at 14 to 26 weeks gestation: a cross- sectional study. BMC Nutr. 2024;10:77.
Dinas Kesehatan Provinsi Kalimantan Timur. Laporan prevalensi stunting tahun 2023. Samarinda: Dinkes Kaltim; 2023.
Deviatin NS, Feriyanti A, Devy SR, Sulistyowati M, Ratnawati LY, Andayani Q. Determinants that Contributes to Stunting Prevention Behavior in Pregnant Woman in Indonesia. Media Gizi Indones. 2022;7(1SP):168–174.
Soetjiatie L, Utomo B, Suprihatin K, Intiyati A. Nutrition Education for Pregnant Women Using Community-Based Approach for Stunting Prevention and Maternal and Child Health in Bulak Village, Surabaya City. Front Community Serv Empower. 2025;4(1):175–82.
Setiawan E. Metodologi Penelitian Kesehatan. Jakarta: EGC; 2021.
Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 6th ed. Los Angeles: Sage; 2023.
Hair JF, Hult GTM, Ringle CM, Sarstedt M. A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). 3rd ed. Sage Publishing; 2022.
Shmueli G, Sarstedt M, Hair JF, Cheah JH, Hiram Ting SV, Ringle CM. Predictive model assessment in PLS-SEM: guidelines for using PLSpredict. Eur J Mark. 2019;53(11):2322–2347.
Wong KKY. Partial least squares structural equation modeling (PLS-SEM) techniques using SmartPLS. Mark Bull. 2013;24(1):1–32.
Charron-Prochownik D, Sereika SM, Becker D. Long-term effects of the booster-enhanced READY-Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes. Diabetes Care. 2013;36(12):3870-4.
Hair JF, Sarstedt M, Ringle CM, Gudergan SP. Advanced Issues in Partial Least Squares Structural Equation Modeling. Thousand Oaks: Sage; 2018.
Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175–183.
Champion VL, Skinner CS. The Health Belief Model. In: Glanz K, Rimer BK, Viswanath K, editors. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. Jossey-Bass; 2008. p. 45–65.
Nastiti AA, Triharini M, Sari NW, Armini NKA, Nursalam N, Poddar S. Nutritional fulfillment behavior of pregnant women based on the health belief model theory in Indonesia. Nutr Hosp. 2025;42(1):73–9.
Rahmawati W, Pligt P van der, Willcox JC, Worsley AF. Sources of nutrition information for Indonesian women during pregnancy: how is information sought and provided? Public Heal Nutr. 2021;24(12):3859–69.
Triharini M, Nursalam N, Sulistyono A, Adriani M, Hsieh PL. Perceived Benefits and Intakes of Protein, Vitamin C and Iron in Preventing Anemia among Pregnant Women. J Ners. 2019;13(56):156–61.
Arifah I, Bachtiar EY, Ibrahim DS, Aulia DA, Firmansyah, Werdani KE, et al. Health Program and Nutritional Determinants of Pregnancy Anemia in Boyolali District, Central Java, Indonesia: A Case-Control Study. Natl J Community Med. 2025;16(4):351–9.
Riyadi S, Marmi M, Madury S Al, Farid M. Smoking Cessation Behavior Among Madurese Adolescents: The Role of Social Capital and the Theory of Planned Behavior. Media Publ Promosi Kesehat Indones. 2025;8(9):971–80.
Lukiana D, Sugiatini TE. The Influence Of Preconceptional Nutrition Counseling On Knowledge And Attitude Of Women Of Reproductive Age. Int J Med Heal. 2022;1(4).
Hadi H, Nurunniyah S, Gittelsohn J, Alfiana RD, Fatimatasari, Lewis EC, et al. Preconception Maternal Mentoring for Improved Fetal Growth among Indonesian Women: Results from a Cluster Randomized Controlled Trial. Nutrients. 2023;15(21):4579.
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