Health Cadre Mentoring Model in Stunting Prevention Programs: A Systematic Literature Review

Introduction

Stunting remains an urgent public health issue in Indonesia, particularly during the first 1000 days of life (from conception to a child’s second birthday). This condition is characterized by impaired physical growth in children (height below the age-standard) and has long-term impacts on cognitive development, metabolic health, and productivity in adulthood.^1–3 Globally, approximately 22% of children under five years old experience stunting, equivalent to more than 149 million children.^4,5 The prevalence of stunting in Indonesia has declined from 24.4% in 2021 to 21.5% in 2023; however, this remains above the WHO threshold (<20%) and national targets.^6,7

Various efforts have been implemented to address stunting, including nutrition supplementation, breastfeeding promotion, and community-based interventions. One key strategy is a family-based approach involving health cadres (community health workers/CHWs), who provide mentoring to families at risk of stunting across the life cycle. Cadres play a central role due to their close social relationships with the community.^8–11 The effectiveness of cadres in performing their roles is strongly influenced by the mentoring models applied. Well-designed mentoring can enhance cadre competencies, strengthen motivation, and improve program continuity and community acceptance.^12,13

In this review, mentoring models are defined as structured approaches that include training, supervision, feedback mechanisms, and community-based interactions such as home visits and participatory activities. Previous studies have highlighted the importance of continuous support for cadres, including training, supervision, and appropriate educational tools, in improving child feeding practices and service delivery.¹⁴ However, these studies are often fragmented and context-specific. Although the role of health cadres in stunting prevention is well recognized, there remains a lack of systematic evidence comparing different mentoring models. Most existing studies are descriptive and focus on local program implementation, without providing comprehensive analysis of mentoring structures, key components, and their relative effectiveness across settings.

Furthermore, the literature synthesizing essential elements of mentoring models such as training approaches, supervision mechanisms, communication strategies, and sustainability remains limited. This gap hinders the development of scalable and evidence-based mentoring frameworks.

Therefore, a systematic literature review (SLR) is needed to identify, evaluate, and synthesize health cadre mentoring models in stunting prevention programs. This review aims to provide a comprehensive understanding of existing approaches, highlight their strengths and limitations, and inform the development of more effective, adaptive, and sustainable interventions.

Based on this rationale, the present review addresses the following research questions:

1. What types of cadre mentoring interventions have been implemented to prevent stunting?
2. What behavioral change components (knowledge, skills, attitudes, motivation, advocacy, and communication) are addressed in these interventions?
3. How do these interventions align with behavior change theories in influencing family practices such as exclusive breastfeeding, complementary feeding, and health service utilization?

This review further maps intervention components to behavior change constructs (knowledge, skills, attitudes, motivation, communication, and advocacy) using established theories, including the Theory of Planned Behavior, Social Cognitive Theory, and the Health Belief Model, to better understand the mechanisms underlying mentoring effectiveness.

Materials and Methods

Study Design

This study is a systematic literature review conducted in accordance with the PRISMA 2020 guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).¹⁵ The review aims to identify, evaluate, and synthesize current evidence on health cadre mentoring models in stunting prevention programs.

Eligibility Criteria

The research questions were formulated using the PICCO framework (Population, Intervention, Context, Comparison, and Outcome). The detailed PICCO components, along with the inclusion and exclusion criteria, are presented in Table 1.

Table 1 The PICCO Framework, Inclussion and Exclussion Criteria

Selection Process

A systematic search was conducted across five electronic databases: PubMed, Scopus, ScienceDirect, SpringerLink, and Google Scholar. The search covered publications from 2014 to 2025. The search strategy combined keywords and MeSH terms related to stunting, community health workers, and mentoring. An example of the search string used was: (“stunting” OR “child malnutrition”) AND (“health cadres” OR “community health workers”) AND (“mentoring” OR “training” OR “capacity building”). The search strategy was adapted for each database. In addition to database searching, supplementary searches were conducted through manual searching and snowballing of reference lists from relevant articles.

All retrieved records were exported and screened using Rayyan web-based systematic review software (Rayyan QCRI) to facilitate blinded screening. Title and abstract screening, followed by full-text assessment, were conducted independently by two reviewers. Discrepancies between reviewers were resolved through discussion and consensus. The study selection process is presented in a PRISMA 2020 flow diagram.

Quality Appraisal and Risk of Bias Management

The results of this process were presented in a PRISMA 2020 flow diagram (Figure 1). The methodological quality of the included studies was assessed using the JBI Critical Appraisal Tools, with adjustments made according to each study design (quantitative, qualitative, or mixed-methods). This appraisal ensured that only studies with sufficient methodological rigor were considered reliable for inclusion in the synthesis. No studies were excluded solely based on quality assessment; instead, studies were categorized according to their methodological quality and this was taken into account during data interpretation to maintain the validity and credibility of the review findings.¹⁶ Data from the selected studies were systematically extracted, including authors, year, study location, research design, participant characteristics, type of intervention, and main outcomes. Data analysis was conducted using a thematic synthesis approach, allowing grouping of data according to key themes such as mentoring forms, training media, the role of cadres in stunting prevention, and the intervention’s impact on child nutritional status.¹⁷ Visualization of the synthesis results could include thematic tables, inter-theme relationship matrices, or word clouds using software such as NVivo.¹⁸

Figure 1 Prisma Flow Diagram.

In addition to thematic grouping, the extracted findings were further mapped onto established behavior change theories to analyze how mentoring interventions address components such as knowledge, skills, attitudes, motivation, advocacy, and communication. Theoretical lenses applied in this review included the Theory of Planned Behavior (Ajzen, 1991), Social Cognitive Theory (Bandura, 1986), and the Health Belief Model (Rosenstock, 1974). This step enabled a structured interpretation of the behavioral mechanisms underlying cadre mentoring models, ensuring that the synthesis not only describes interventions but also explains how they align with behavior change frameworks.

In addition to presenting a data synthesis, this review also identifies research gaps, such as the absence of mentoring models specifically designed for rural communities with limited resources, and the lack of longitudinal studies measuring the sustained impact of interventions. The theoretical contribution of this review lies in expanding the understanding of evidence-based cadre capacity-building models, while its practical contribution provides recommendations for policies aimed at improving cadre quality to support stunting prevention programs at the community level.

To reduce bias, we adopted several strategies: (1) using two independent reviewers for screening, data extraction, and coding; (2) applying the JBI appraisal tools and recording study quality within the synthesis; (3) conducting sensitivity analyses by excluding low-quality studies to test the robustness of the findings; (4) triangulating evidence across multiple outcomes (knowledge, practice, anthropometry) rather than relying on single indicators; and (5) explicitly addressing potential language and publication bias in the limitations section.

Results

A total of 52 studies were included in this review. The characteristics of the included studies are summarized in Table 2. The studies were identified from multiple electronic databases, including PubMed, ScienceDirect, and Google Scholar, the latter of which enabled the inclusion of relevant Indonesian-language studies indexed in SINTA. Articles indexed in SINTA are provided in Table S1. The studies were conducted across various low and middle-income countries and employed diverse designs, including quasi-experimental, randomized controlled trials, qualitative, and mixed-methods approaches. The study populations primarily involved health cadres or community health workers, as well as target groups such as pregnant women and mothers of young children.

Table 2 Characteristics Study

The interventions identified were heterogeneous, encompassing training, home visits, group education, and digital-based approaches, with durations ranging from single-session activities to long-term programs. Most studies implemented structured training interventions, often combined with home visits or supportive supervision. The outcomes assessed across studies included improvements in cadre capacity, maternal health practices, and child nutritional status. The majority of studies reported improvements in cadre knowledge, skills, and engagement, while only a smaller proportion reported direct effects on child nutritional outcomes such as stunting reduction or anthropometric improvements.

The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools, with the results presented in Table 3. Overall, most studies were classified as moderate quality, while a substantial proportion achieved high quality. Randomized controlled trials generally demonstrated higher methodological rigor, whereas quasi-experimental and descriptive studies tended to show moderate quality due to limitations such as the absence of control groups, shorter intervention duration, and incomplete reporting of follow-up or attrition. No studies were excluded based on quality assessment, as all met the minimum inclusion criteria.

Table 3 Quality Assessment of Included Studies (JBI)

The findings were further synthesized using a thematic approach to identify key patterns in mentoring interventions for stunting prevention. This synthesis generated five major themes: forms of mentoring, training media, duration of intervention, roles of health cadres, and impact on outcomes. The summary of this thematic synthesis is presented in Table 4. Interventions that incorporated participatory approaches and continuous supervision were more frequently associated with positive outcomes compared to short-term or one-time interventions.

Table 4 Thematic Synthesis of Findings

Importantly, the identified themes also highlight the influence of social and cultural contexts in shaping the implementation and effectiveness of mentoring interventions. Variations in community engagement, local beliefs, and resource availability were found to affect how mentoring strategies were delivered and adopted, indicating the need for a context-sensitive mentoring model for stunting prevention. Several studies reported that culturally adapted and community-based approaches were associated with better acceptance and sustainability of interventions.

Discussion

The findings of this review indicate that mentoring interventions for health cadres generally show positive effects on cadre capacity and family-level practices. Most of the included studies reported improvements in cadre knowledge, skills, and engagement, indicating consistent positive effects at the individual level. However, the results across studies are mixed and context dependent, particularly when considering variations in study design, intervention characteristics, and outcome measures.

Most studies consistently reported improvements in cadres’ knowledge, skills, and engagement following training and mentoring interventions. Training and home visits appear to play complementary roles, where training provides foundational competencies and home visits facilitate practical application and closer interaction with families. A substantial number of studies implemented structured training, often combined with supervision or home visits, suggesting that multi-component interventions are more effective. Nevertheless, the effectiveness of these approaches is influenced by how they are implemented. Participatory^1,67 and experience-based methods²⁴ tend to produce better engagement and learning outcomes compared to one-way instructional approaches.

Despite these positive findings, not all studies demonstrated significant effects, particularly on child nutritional outcomes. Only a smaller proportion of studies reported measurable improvements in child nutritional outcomes, such as stunting reduction or anthropometric indicators. Some large-scale or multisectoral interventions reported no significant impact on stunting reduction, suggesting that improvements in cadre capacity do not always directly translate into measurable child health outcomes. In addition, several studies indicated that the effectiveness of interventions depends on contextual factors, such as the consistency of home visits^46,63,64,66 and duration of the program. For example, interventions were more effective when implemented continuously and supported by regular supervision, while short-term or less intensive programs showed more limited and less sustainable effects. Furthermore, we found that the majority of mentoring programs were short-term, lasting less than six months. Some were even conducted in a single training session without adequate follow-up, as shown in the studies by Mediani et al and Etrawati et al.^11,19 Only a small number of studies have medium- to long-term interventions (≥6 months), carried out in a phased and sustained manner, such as those by Onah et al, Rockers et al, and Juarez et al.^27,40

This discrepancy may be explained by the imbalance in intervention focus. Most mentoring programs primarily targeted knowledge and skill development, while fewer interventions explicitly addressed behavioral determinants such as motivation, social norms, and environmental constraints. When mapped to behavior change theories, most interventions aligned with constructs from the Social Cognitive Theory and Theory of Planned Behavior, particularly in improving knowledge and self-efficacy, while components of the Health Belief Model were less frequently addressed.

This review also highlights differences in outcomes across levels. While improvements in intermediate outcomes, such as cadre knowledge and family practices, were frequently observed, evidence on long-term outcomes, including child nutritional status, remains limited and inconsistent. This suggests that strengthening cadre capacity alone may not be sufficient without broader system support and sustained implementation.

Variations in findings may also be influenced by differences in study design and methodological quality. Studies with more rigorous designs, such as randomized controlled trials^{25,27,28,32,34,35,39,40,43,47,51,53,57,58,69} tended to provide more robust evidence, whereas studies with simpler designs often reported improvements primarily in short-term or self-reported outcomes. This underscores the importance of interpreting the findings cautiously in light of the overall quality of evidence.

In addition, contextual and cultural factors play an important role in determining intervention effectiveness. Most mentoring models identified in this review were relatively generic and not specifically tailored to local cultural contexts, which may limit their relevance and long-term sustainability. Several studies highlighted the importance of culturally adapted and community-based approaches in improving intervention acceptance and sustainability.^49,66 Interventions that incorporated culturally adapted approaches and community engagement strategies tended to show more meaningful and contextually appropriate outcomes.

Limitation

This review has several limitations. The heterogeneity of study designs, intervention types, and outcome measures precluded a quantitative synthesis. In addition, many studies focused on short-term outcomes, with limited evidence on long-term impacts. Although this review included studies published in both English and Indonesian, differences in language and database indexing may still introduce potential bias.

Conclusion

This systematic literature review synthesizes evidence from 52 studies on health cadre mentoring models for stunting prevention. The findings indicate that most mentoring interventions are effective in improving cadre knowledge, skills, and engagement; however, only a smaller proportion of studies demonstrate direct effects on child nutritional outcomes. Mentoring approaches that combine structured training, supervision, and community-based activities appear to be more effective, particularly when implemented continuously rather than as short-term interventions. Participatory and culturally adapted approaches were also associated with better acceptance and sustainability of interventions.

Despite these positive findings, the limited impact on child nutritional outcomes suggests that strengthening cadre capacity alone may not be sufficient. Future interventions should integrate behavior change theory more explicitly and address broader determinants such as motivation, social norms, and environmental factors to achieve sustained improvements. Overall, health cadre mentoring models have strong potential to support stunting prevention programs; however, their effectiveness depends on implementation quality, contextual adaptation, and long-term system support. Further research is needed to develop and evaluate sustainable, context-sensitive, and theory-informed mentoring models.