Addressing chronic energy deficiency among Indonesian pregnant women: A social cognitive theory perspective

Chronic Energy Deficiency (CED) during pregnancy remains a major public health concern in Indonesia, contributing to adverse maternal and neonatal outcomes. This study applied Social Cognitive Theory (SCT) to examine how psychosocial and structural determinants influence CED among pregnant women on Madura Island. A cross-sectional study was conducted between December 2024 and January 2025 among 400 pregnant women, selected using combined fixed disease and proportional random sampling from the Sumenep Maternal and Child Health Registry (n = 15,464). Participants represented all trimesters, with a mean age of 27.6 years (SD = 5.8); education levels were primary (46 %), secondary (39 %), and tertiary (15 %). CED status was assessed by mid-upper arm circumference (MUAC), while SCT constructs (observational learning, outcome expectations, self-efficacy, reinforcement, knowledge, attitude) and contextual factors (decision-making autonomy, food availability, parity, distance to health centers, residence) were measured via structured interviews. Path analysis tested 25 hypothesized relationships (H1–H25). CED prevalence was 10.8 %. Attitude was the strongest predictor of preventive behaviors (β = 0.46), followed by self-efficacy (β = 0.10), which was shaped by knowledge, reinforcement, outcome expectations, and observational learning. Decision-making autonomy improved MUAC both directly (β = 0.10) and indirectly through preventive behavior, while distance to health centers negatively influenced both outcomes. Unexpectedly, higher parity was positively associated with MUAC, reflecting possible sociocultural protective factors. The SCT-based model explained nearly 70 % of variance in nutritional status, demonstrating strong theoretical and contextual fit. Findings support multi-level strategies that combine behavior change communication with structural interventions to improve food security, healthcare access, and women's empowerment in similar low-resource settings. • Multi-faceted approach prioritizing psycho-social and environmental factors is key to CED prevention. • SCT-based model can be used to help combat CED by promoting healthy behaviors and autonomy pregnant women. • Key drivers of CED prevention: observational learning, knowledge, attitude, self-efficacy, and reinforcement.