Volume 18, Issue 1, March 2023, p.

40-46
http://dx.doi.org/10.20473/jn.v18i1.43704

ORIGINAL ARTICLE OPEN ACCESS

Determinant factors of anemia in pregnancy

based on health belief model: a correlational
study
Mira Triharini1* , Eka Mishbahatul Mar’ah Has1 , and Gita Nofita1
1 Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
*Correspondence: Mira Triharini. Address: Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. Email: mira-
t@fkp.unair.ac.id
Responsible Editor: Retnayu Pradanie
Received: 26 February 2023 ○ Revised: 29 February 2023 ○ Accepted: 29 February 2023

ABSTRACT
Introduction: Pregnancy anemia is still a big problem worldwide. Health behavior can be influenced by perceptions
of the importance of disease prevention. The theory of the Health Belief Model can study the relationship between
prevention efforts and perceptions. The purpose was to analyze the relationship between perceived susceptibility,
perceived severity, perceived benefit, perceived barrier, self-efficacy and cues to action with anemia prevention
behaviors.

Methods: This study used a correlational design cross-sectional approach. The total samples were 104 pregnant
women selected using purposive sampling. The independent variables in this study were perceived susceptibility,
perceived severity, perceived benefit, perceived barrier, self-efficacy, and cues to action. The dependent variable in
this study was anemia prevention behaviors. Data were collected at one obstetrical polyclinic in hospital and also
home visits were conducted to respondents who did not come to the hospital. The instrument used questionnaires
on perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action and
anemia prevention behaviors.

Results: Perceived susceptibility (p=0.023 r=0.223), and cues to action (p=0.037 r=0.204) had a significant
relationship with anemia prevention behaviors., while there was no relation between perceived severity (p= 0.839),
perceived benefit (p= 0.986), perceived barrier (p= 0.585), and self-efficacy (p=0.399) with anemia prevention
behaviors.

Conclusions: Health workers can increase the susceptibility and cues to action of pregnant women through health
education about anemia prevention.

Keywords: anemia, health promotion, health belief model, maternal health, maternity nursing

Introduction is still high (Ministry of Health RI, 2016). The many

Anemia persists as a health problem for pregnant causes of pregnancy anemia in women are due to
women around the world (Hasan et al., 2022). Anemia differences in socioeconomic conditions, lifestyles, or
not only results in the death of the mother but also the health-seeking behaviors that come from various
fetus; therefore, a serious concern by all relevant parties diverse cultures (Lin et al., 2018).
is needed (Daru et al., 2018). Various efforts to prevent It is estimated that 40% of pregnant women
anemia in pregnant women have been carried out. The worldwide suffer from anemia. The incidence of anemia
Indonesian government has pursued a prevention pregnant women in Southeast Asia is as many as 48.7%
program by providing 90 iron supplements to pregnant or around 202 million people (WHO, 2016). This is also
women, but the incidence of anemia in pregnant women in line with pregnant women who experience anemia in

40 P-ISSN: 1858-3598  E-ISSN: 2502-5791 © 2023 Jurnal Ners. This is an open-access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).
 Jurnal Ners

Indonesia; in 2013 there were 37.1% of pregnant Materials and Methods

women experienced anemia, and this increased in 2018 Research design
to 48.9%. There are still 70-80% of pregnant women in
This study applied a descriptive correlational design
Indonesia who experience anemia during pregnancy
with cross-sectional approach. The population of the
(Kemenkes RI, 2018). The incidence of anemia in
study consisted of pregnant women that visited during
pregnant women in South Kalimantan Province is based
the period from June to December 2020 at the obstetric
on data from the South Kalimantan Provincial Health
polyclinic at Bontang Hospital, East Kalimantan,
Office (2016) as many as 21,141 people (27.43%) (Rizani
Indonesia.
& Yuliastuti, 2020). According to patient registration
data at Bontang Hospital from November 2018 to Research subject
September 2019, there were 1127 pregnant women This study used purposive sampling, namely a
patients, with Hb levels <8gr/dl in 27 (2.3%) cases, Hb sampling technique by selecting samples from the
levels 8-8.9 gr/dl in 69 (6.1%) cases, Hb10-10.9gr/dl in population according to the objectives or problems in
253 (22.4%) cases, Hb>11gr/dl in 611 (54.2%) cases. research (Nursalam, 2016). Sample size was based on
From the above data it can be seen that pregnant Slovin’s formula (Sugiyono, 2015). The sample that met
women with low Hb levels or anemia totaled 349 the criteria was 104 people. Drop out calculation was
(30.8%) cases (RSUD Bontang, 2019). plus 10% of the total sample, w here the drop out
A pregnant woman's belief in her body condition criterion is mothers who cannot complete filling out all
affects her behavior in maintaining health. An individual the research questionnaires given. The inclusion criteria
will take precautions when one is considered susceptible used were the following: pregnant women with the
to conditions that have serious consequences (Bazargani ability to read and write, and able to communicate well
et al., 2022). Many factors influence the behavior of and pregnant women in the 1-3 trimesters that received
pregnant women in preventing anemia, one of the iron supplements.
examples is the perception that anemia is naturally The exclusion criteria used were pregnant women
experienced by women during pregnancy (Klankhajhon who were in a state of sickness (experiencing mental
et al., 2021), as well as dietary restrictions during disorders, complications of imminent abortion,
pregnancy which affect the dieting behavior of pregnant preeclampsia, ectopic pregnancy, hyperemesis
women (Mariana et al., 2018). The perception and gravidarum, antepartum hemorrhage, placenta previa,
behavior of pregnant women in preventing anemia can complications of endocrine disease. The mothers who
be seen from the theory of the Health Belief Model. At left the study during the research process were used as
present, the factors related to the behavior of pregnant a dropout criterion.
women in preventing anemia have not been resolved.
Instruments
Providing health information to pregnant women or
those preparing for pregnancy is very important so that The instruments for collecting this data were in the
the women will understand more about anemia as well form of a behavior questionnaire to prevent anemia in
as nutritional benefits during pregnancy to prevent pregnant women by Rahmawaty (2019) which had its
anemia (Triharini et al., 2018a). validity and reliability tested and a questionnaire that
The Health Belief Model theory as a nursing theory the researchers compiled themselves based on the
can be used as a basic theory to assist patients’ behavior opinions of experts and the conceptual framework of
to improve their health status. The advantage of the the Health Belief Model theory. The questionnaires used
Health Belief Model theory is to describe individual included the perceived susceptibility (4 items of
beliefs about carrying out healthy living behaviors. The confidentiality), perceived severity (5 items of
healthy behavior is in the form of preventive behavior statement), perceived benefits (7 items of statements),
and the use of health facilities (Becker et al., 1977). This perceived barriers (5 items of statements), self-efficacy
study aims to analyze the relationship between (3 items of statements), cues to action (6 items of
perceived susceptibility, perceived severity, perceived statements) and anemia prevention behaviors (11
benefit, perceived barrier, self-efficacy, and cues to items) that researchers have tested for validity and
action with anemia prevention behaviors. reliability. The results of the validity test results were all
declared valid, with the value of r count > from the value
of r table, namely the lowest r count value of 0.502; this
value was more than the r table value of 0.444.
Reliability test results obtained Cronbach’s alpha value =

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0.927 which means the questionnaire used is very relationship between the independent and dependent
reliable. variables used Spearmen's rho correlation; is the data
distribution is not normal with a significance level of α ≤
Data collection
0.05, the research hypothesis is accepted, if the
Before conducting the research, researchers significance level is α ≥ 0.05, then the research
conducted preliminary research to determine the hypothesis is rejected.
incidence of anemia in pregnant women and to find out
the problems experienced by clients. The research was Ethical consideration
carried out at the same time as the outpatient polyclinic This research has received an ethical certificate from
service. Because of the current Covid pandemic, the Ethics Commission (KEPK) of Airlangga University,
pregnant women cannot come every month for Faculty of Nursing with No. 2144-KEPK, approval date 13
antenatal care, so researchers make visits to homes January 2021 and expiration date 13 January 2022. At
whose areas can be reached by researchers. Previously the beginning of this study, participants fulfilled
the researchers conducted health checks and conducted informed consent and demographic data. The
Rapid tests / PCR to ensure researchers were in good researchers kept the data of each participant secret by
health. The data obtained from the hospital's medical using a code.
record were managed by the researcher to determine
which respondents were included in the inclusion and Results
exclusion criteria. Collecting data from respondents at Most of the respondents were in the age of 20-29
the obstetrical polyclinic at Taman Husada Bontang years (46.2%). Almost 48 (46%) of respondents had
Hospital was in accordance with the control schedule, graduated from high school/ equivalent. In addition, as
assistance in filling out the questionnaires assisted by many as 63 respondents (65%) had a family income
obstetrical poly workers (officers in obstetrical below the regional minimum wage, and 52 (50%)
polyclinics also follow the applicable health protocols), respondents worked as housewives. The highest
who have received information on the placement of number of children was two children with 47 (45.2%)
attention with researchers. Researchers conducted
Table 1 Demographic characteristics of respondents (N=104)
home visits to respondents who did not come to the Category N %
hospital to check themselves. Before visiting the house, Age
< 20 years 5 4.8
the researcher contacted the respondent via WhatsApp, 20 – 29 48 46.2
and via telephone to ask for permission. At the time of 30 – 39 37 35.6
≥ 40 14 13.5
data collection, the researcher followed the applicable Education Elementary
health protocol. The researcher provided an school 9 8.6
Middle school 13 12.5
explanation, information, advantage or benefit and then High school 48 46
asked for approval through informed consent, ensuring Undergraduate 34 32.6
Income
that the respondent understood the contents of the (Rupiah)
questions by supporting the respondent. This provides < 3.100.000 63 60.5
>3.100.000 41 39.4
opportunity for respondents to ask questions if anything
Occupation
is unclear. During data collection, researchers did not Farmer 4 3.8
Entrepreneur 11 10.5
experience unexpected events such as changes in the
House wife 52 50
respondent's health status, for example increased blood Civil servant 29 27.8
Non 8 7.6
pressure/dizziness/anxiety and so on. Permanent staff
Number of children
Data analysis 1 23 22.1
2 47 45.2
Data analysis used univariate analysis and bivariate 3 26 25.0
analysis. Univariate analysis was carried out on each >3 8 7.6
Pregnancy interval
variable from the research results. In general, this
1 year 26 25
analysis produces the distribution and proportion of 2 years 73 70.2
≥ 3 years 5 4.8
each variable, so that the variation of each variable in
Number of pregnancies
this study is known about the features of the 1 0 0
2 23 22.1
respondents. This analysis is used to see the relationship
>2 81 77.8
of more than two independent variables and the Total 104 100
dependent variable. Statistical test to see the

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respondents, the highest pregnancy interval was two Discussions

years, with 73 (70.2%) respondents. In addition, as Most pregnant mothers feel vulnerable and have
many as 81 respondents (77.8%) had more than two sufficient behavior in preventing anemia and some
pregnancies (Table 1). already have cues to action when considered vulnerable
Based on Table 2, it can be seen that there is a to a condition which has serious consequences.
relationship between perceived susceptibility (p=0.023 Perceived susceptibility is a personal risk perceived by
r=0.223), and cues to action (p=0.037 r=0.204) with individuals, which in this case is related to perceptions
anemia prevention behaviors. While there was no of health conditions (Lennon, 2016). Perceived
relation between perceived severity (p= 0.839), susceptibility includes a person's acceptance and
perceived benefit (p= 0.986), perceived barrier (p= sensitivity to their health conditions. The main findings
0.585), and self-efficacy (p=0.399) with anemia of this research show that perceived susceptibility and
prevention behaviors. cues to action had a significant relationship with
In the perceived susceptibility variable, the highest pregnant mothers’ behavior in preventing anemia.
number is found in respondents with high perceived Respondents with high susceptibility factors tend to
susceptibility and having sufficient anemia prevention have sufficient preventive behavior. However, based on
behaviors, namely 72 respondents (69.3%). In the the results of the study, some respondents also fell into
perceived severity variable, the highest number is found a moderate level of perceived susceptibility but had
in respondents with high perceived severity and having good behavior. In addition, due to the factor of
sufficient anemia prevention behaviors, namely 49 ignorance, the mother was still willing to take preventive
respondents (47.1%). In the perceived benefits variable, behaviors following recommendations from health
the highest number is found in respondents with high workers. Some mothers also had a high perceived
perceived benefits and having sufficient anemia susceptibility but had poor preventive behavior.
prevention behaviors, namely 52 respondents (50%). In Perceived severity of illness or health conditions can
the perceived barriers variable, the highest number is be considered a threat; therefore, the individual is
found in respondents with high perceived barriers and willing to take preventive action, follow the screening,
having sufficient anemia prevention behaviors, namely and control the existing illness (Glanz et al., 2002).
52 respondents (47.1%). In the self-efficacy variable, the Triharini et al. (2018b) revealed that maternal education
highest number is found in respondents with high self- can be an obstacle to maternal compliance in consuming
efficacy and having sufficient anemia prevention nutritional needs during pregnancy.
behaviors, namely 49 respondents (50%). In the cues to Respondents with high perceived severity tend to
action variable, the highest number is found in have sufficient behavior. From a demographic point of
respondents with high cues to action and having view, some respondents already had high levels of
sufficient anemia prevention behaviors, namely 75 education, but low family income made some of the
respondents (72.1%). mothers unable to carry out good behavior and fell into
Table 2 The relationship between the HBM factors and the behavior of pregnant women in preventing anemia (N=104)
The behavior of pregnant women in preventing anemia
Category
Variable Good Sufficient Poor Spearman Rho Test
N % N % N % p r
Perceived susceptibility High 2 1,9 72 69,2 6 5,8 0.023 0.223
Moderate 1 1,0 12 11,5 6 5,8
Low 0 0,0 4 3,8 1 1,0
Perceived severity High 1 1.0 49 47.1 6 5.8 0.839 0.020
Moderate 1 1.0 31 29.8 5 4.8
Low 1 1.0 8 7.7 2 1.9
Perceived benefits High 1 1.0 52 50.0 6 5.8 0.986 0.002
Moderate 1 1.0 23 22.1 6 5.8
Low 1 1.0 13 12.5 1 1.0
Perceived barriers High 1 1.0 49 47.1 6 5.8 0.585 0.054
Moderate 2 1.9 35 33.7 5 4.8
Low 0 0.0 4 3.8 2 1.9
Self-efficacy High 2 1.9 52 50.0 6 5.8 0.399 0.084
Moderate 1 1.0 28 26.9 6 5.8
Low 0 0.0 8 7.7 1 1.0
Cues to action High 2 1.9 75 72.1 7 6.7 0.037 0.204
Moderate 1 1.0 13 12.5 6 5.8
Low 0 0.0 0 0.0 0 0.0

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Triharini, Has, and Nofita (2023) Supremo, Bacason, and Sañosa (2022)

sufficient behavior in maintaining their health. Some prevention behavior, they were unable to prepare a
respondents had low perceived severity and poor balanced diet (Khoramabadi et al., 2015).
behavior, this was due to low educational factors which This is in line with research conducted by Diddana et
led to a lack of understanding regarding the severity of al. (2018) which states that the perceived benefit does
health conditions if mothers are suffering anemia. Some not affect the behavior of pregnant women in
respondents also regarded that pregnancy anemia preventing pregnancy anemia. Whether the benefit
normally occurred in pregnant women, which meant the exists or nonexistent, it does not affect the mother's
severity of anemia did not become a condition that behavior in preventing anemia. According to Glanz et al.
increased maternal awareness. (2002), the perceived barriers are anything that hinders
The perceived severity of the mother related to an individual from making certain behavior changes. The
anemia during pregnancy did not have an impact on HBM theory, explains that everything that hinders can
pregnant women to increase their awareness status be seen in terms of costs, benefits, unsatisfactory and
regarding health condition and the fetus. This was in line pleasant health services, and support from family and
with research conducted by Amir and Djokosujono others. Based on the results of the study, the perceived
(2019) through a literature review study that found the barriers of the mothers were due to the lack of
perceived severity is not related to individual behavior understanding about the benefits of iron supplements,
in preventing anemia. This means the higher the severity nausea felt when consuming iron supplements, and
felt by the mother, the less preventive behavior will be occupied with activities which led to the absence of
carried out. The high perceived severity does not change doing ANC examination, as well as the factor of income
the behavior of the mother in preventing anemia in and support from the husband (family member).
pregnancy; therefore, it does not increase the However, some of these barriers could be overcome by
awareness of the mother to make preventive efforts. mothers so that they were able to carry out preventive
Likewise, if the mother has a low perceived severity, it is efforts in a sufficient way.
not an indication that the mother does not make Respondents with high perceived barrier
preventive efforts. perceptions were dominated by those who had
Pregnant women with a high perceived benefit will sufficient anemia prevention behavior, not too good and
have good anemia prevention behavior. Pregnant not too poor. The respondents did not understand the
women that carry out anemia prevention depend on benefits of preventive behavior, for example, the
their belief in the impact of anemia and the success of consumption of iron supplements regularly and ANC
its prevention efforts. Efforts to prevent anemia can be checks. Barriers can also occur due to demographic
done by having a balanced diet, treating infectious factors such as inadequate family income which causes
diseases that can increase the risk of anemia, and being respondents to be unable to prevent pregnancy anemia,
willing to take iron supplements (Parulian et al., 2016). by consuming balanced nutrition during pregnancy.
Mothers’ belief in the benefits of preventing anemia can Some respondents also had a good level of education
occur by having support from family, social support and high income but did not have sufficient behavior for
(groups of pregnant women), and health workers various reasons, such as not consuming the iron
(Triharini, et al., 2018b). supplements because of the taste. However, it is not in
Efforts to prevent anemia during pregnancy were line with the research conducted by Triharini et al.,
dominated by moderate to high perceived benefits with (2018b) who suggest that the perceived barrier by
the mother's behavior in the sufficient category. pregnant women has a significant correlation with the
Pregnant women understood and felt the impact of behavior of pregnant women in preventing pregnancy
anemia; therefore, some women increased their anemia).
willingness and preventive efforts. Although the According to the social cognitive theory (Bandura,
perceived benefits of the respondents were high, it did 2010), a sense of personal control facilitates changes in
not always lead to good behavior in preventing health behavior. According to the theory, the higher the
pregnancy anemia. On the other hand, if the perceived belief in one's self-efficacy, the better the health
benefits of the respondent low, it did not mean that the behavior is shown. On the contrary, the lower the
respondent would have poor anemia prevention. This confidence in one's own self-efficacy, the change in
can be caused by low family income which was below health behavior would be lower. Therefore, family
the minimum regional wage. Even though the pregnant support is very important for pregnant women to
women already understood the benefits of this anemia increase confidence (Mardhiah & Marlina, 2019). In an
explanation of the results of a study, prevention of

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anemia by providing iron supplements to mothers who Perceived susceptibility has a relationship with
were at high risk of suffering from anemia includes maternal behavior in preventing anemia during
individuals from families with low socioeconomic pregnancy, because mothers who feel high susceptibility
conditions (Abdulsalam & Daniel, 2016). to a hazard will make better prevention efforts,
The absence of a significant relationship in this study especially in behavior to prevent anemia in pregnancy.
was due to the number of respondents who believed in Perceived severity is not related to maternal behavior in
anemia prevention was dominated by the sufficient preventing anemia during pregnancy. Mothers feel that
category, not all the respondents had good pregnancy anemia during pregnancy is a natural thing for mothers
anemia prevention behavior, and on the other hand, not to experience and does not have a serious effect on their
all respondents with low self-efficacy had poor anemia health. Many or at least the perceived benefits by the
prevention behavior. This was probably because the mother during pregnancy are not related to the
pregnant women did not feel confident enough about behavior of pregnant women in preventing anemia.
their own preventive behaviors such as buying and Perceived barriers are also not related to the behavior
consuming healthy food, obeying the consumption of of pregnant women in preventing anemia. The higher
iron supplements, and carrying out routine ANC the perceived barriers, the worse the behavior of
examinations. The low level of education also had an pregnant women in preventing anemia during
impact. Some respondents did not understand the pregnancy. The level of cues to action in a mother is not
benefits of consuming iron supplements. The low- related to her behavior in preventing anemia during
income factor also caused uncertainty for nutritional pregnancy. Cues to action in pregnant women has a
intake during pregnancy. Belief in self-efficacy did not relationship with the mother's behavior in preventing
affect the mother's behavior in preventing pregnancy anemia during pregnancy, meaning that the higher the
anemia. This is not in line with research conducted by desire to act, the better the behavior of pregnant
Cal et al. (2020), which states that self-belief has a direct women in preventing anemia. This can happen because
and significant relationship with the behavior of pregnant women can easily get information from the
pregnant women in preventing anemia. media, as well as health workers.
Cues to action is the perception of an individual's Consistent health counseling provided by health
willingness to take preventive action through workers concerning pregnancy anemia leads to
information from the media, health workers, or families sufficient behavior and willingness to act. Cues to action
who are also influenced by individual sociodemographic have a significant relationship with the behavior of
aspects (Darmawati et al., 2020). Cues to action can be pregnant women in preventing pregnancy anemia. The
obtained from educational information provided by higher the respondent's cues to action, the better the
health workers either directly or through printed, anemia prevention behavior is carried out. Conversely,
electronic, or social media information. In addition, the the lower cues to action, then the lower the anemia
information provided by the family can also increase the prevention behavior of pregnant women (Darmawati et
mother's willingness to increase prevention efforts al., 2020). It is expected to conduct further research by
against anemia (Heru et al., 2012). providing interventions, especially about anemia in
Respondents with high cues to action tend to have pregnancy to improve maternal behavior in preventing
sufficient behavior. The reason was due to the majority anemia during pregnancy, which is based on the Health
of respondents had been provided with information Belief Model. The limitation in this study is purposive
from health workers. The existence of increasingly sampling means the finding cannot be generalized and
sophisticated technology has made accessing the self-reported questionnaire has several limitations
information easier from electronic media and mass to measure behavior.
media. Another explanation is that most of the mothers
were multigravidas. Even so, some respondents had Conclusions
high cues to action but poor behavior caused by Perceived susceptibility and cues to action have a
demographic factors, namely low education and lack of relationship with maternal behavior in preventing
support from their families/ husbands. The results of anemia during pregnancy. Developments in health
this study were in line with research conducted by education should consistently be carried out to increase
Salama (2018), which states that the higher the cues to public awareness concerning good behavior in
action for a pregnant woman, the higher the preventive maintaining health. Providing health education is
behavior that the mother does. important regarding the compliance with routine ANC

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