Rindang Ekawati1, Laili Rahayuwati2, Ikeu Nurhidayah2, Evalina Hutasoit3, Habsyah Saparidah Agustina2
1Indonesia Family Planning and Population Board, Jl. Sederhana no 1, Kota Bandung.
2Faculty of Nursing Universitas Padjajaran, Jl. Raya Bandung Sumedang km 21, Jatinangor.
3 Indonesia Family Planning and Population Board, Jl. Sederhana no 1, Kota Bandung.
Corresponding author: Rindang Ekawati, Indonesia Family Planning and Population Board, Jl. Sederhana no 1, Kota Bandung. Email: firstname.lastname@example.org, Telephone: +62 222033117, +6281809918997
Nationally, there are around 40 percent of children under two years old who experience stunting. There are several factors that influence the incidence of stunting, including: maternal factors, the First 1000 Days of Birth (Hari Pertama Kelahiran/HPK), nutritional fulfilment, parenting patterns, and the environment. In West Java, there have not been many studies on family resilience factors and stunting. Therefore, the purpose of this study was to determine the contribution of socioeconomic and family resilience factors, namely: demographics (age, education), socio-economic (household expenditure and number of children), family resilience (knowledge, actions, the use of contraception, BKB participation) with stunting. This cross-sectional study was conducted in six districts / cities in West Java. The respondents were 350 women aged 15-49 years old who were pregnant and or had children under five. The analysis was performed by comparing two groups of stunting and not stunting, using the Chi Square Test. The results showed that mother’s age, mother’s education, household expenditure, knowledge, and BKB participation contributed to reducing stunting. The conclusion is important to increase the knowledge of mothers, to improve the ability to manage household expenditure, and to escalate the participation of mothers in BKB program in reducing the incidence of stunting.
Keywords: stunting, knowledge, education, household expenditure, BKB participation.
The national stunting prevalence reached 37.2 per cent, an increase from 2010 (35.6%) and 2007 (36.8%). This means that stunting is suffered by around 8.9 million Indonesian children, or one in three Indonesian children. The prevalence of stunting in Indonesia is higher than other countries in Southeast Asia, such as Myanmar (35%), Vietnam (23%), and Thailand (MCA Indonesia, 2013).
Stunting illustrates the chronic malnutrition status during growth and development since early life (WHO, 2010). In fact, nutrition problems, especially stunting during the first 1000 days of life can obstruct children’s development, with negative impacts that will take place in the next stage of life, such as intellectual decline, susceptibility to degenerative and non-infectious diseases, decreased productivity resulting in poverty and the risk of giving birth to low birth weight infants (UNICEF, 2012; WHO, 2010).
Indonesia is the fifth largest country in the world for stunting prevalence. According to Bappenas (2013), the incidence of short toddlers is related to low-birth-weight problems (weight at birth <2500 grams). Around 37% of nearly 9,000,000 toddlers in Indonesia are stunted (RISKESDAS, 2013). On a national scale, toddlers’ age, especially under two years old (0-24 months) is the highest age groups to experience stunting, with a percentage of 18.5% in the short category and 23.0% in the very short category (Kemenkes RI, 2013).
West Java is the province with the largest population in Indonesia and with the biggest stunting problems in Indonesia (Bappenas, 2014). Of the 27 districts / cities, there are 13 districts / cities (49%) with the biggest stunting problems and become the priority districts / cities as the target of national stunting intervention. Those cities / districts include Bogor City, Sukabumi District, Cianjur District, Bandung District, Garut District, Tasikmalaya District, Kuningan District, Cirebon District, Sumedang District, Indramayu District, Subang District, Karawang District, and West Bandung District.
There are several factors that contribute to stunting. The determining factor is the importance of maintaining health for the first 1000 days of life (HPK), which accounts from the period of pregnancy until the infants reach 2 years of age. This period is a very sensitive period to the environment, so more attention is needed especially the adequacy of nutrition (Kurniasih, 2010). The nutritional status of pregnant and nursing mothers, good health status and nutritional intake are important factors for the growth and development of physical and cognitive abilities of children which can reduce the risk of morbidity in infants and mothers. Pregnant women with poor nutritional status will cause fetal growth disturbance, the main cause of stunting and it can increase the risk of obesity and degenerative diseases in adulthood (The Lancet, 2013; USAID, 2014). Apart from maternal factors, the nutrition of children in the first two years of life also needs to be considered; for example, by initiating early breastfeeding and giving vitamin A supplementation, which are the two factors that influence the incidence of stunting (Simanjuntak et al., 2018). Considering the importance of nutrition for 1000 HPK, the prevention and intervention of stunting in 1000 HPK is a top priority to improve the quality of life of future generations (Bappenas RI, 2012).
Factors other than 1000 HPK are maternal factors which include demographics (age, education), socio-economic (household expenditure, family endurance (participation of Bina Keluarga Balita or BKB, mother’s knowledge and actions). Household expenditure is one of the factors related to stunting or child health (Clement et al., 2019; Pells, 2011). According to Indrastuti and Pujiyanto (2014), toddler’s stunting incidence has a correlation with the family’s economic status. This socio-economic level is mainly reflected in household expenditure used to meet the needs of food through food security efforts (Fadzila & Tertiyus, 2019) Therefore, aspects of household expenditure incurred to fulfil food compliance are very important in preventing stunting.
Family resilience is the main pillar in stunting prevention and treatment. This will reduce the failure of growth and development in children. Law No. 52 of 2009 defines family resilience as a condition of a family that has tenacity and resilience and contains physical and material abilities to live independently and develop themselves and their families to live in harmony in increasing physical and spiritual happiness. Furthermore, family resilience is defined as the ability to gain access to income, resources including basic needs for clean water, adequate food, educational opportunities, housing and health services.
Toddler family development program (Bina Keluarga Balita/BKB) is a program that aims to improve the knowledge, attitudes, behavior and skills of parents and other family members in caring for and fostering growth and development of toddlers through physical, intellectual, emotional, social and spiritual stimulation through effective interaction between parents and children. The BKB movement is the collaboration between the government and the community in maintaining health in children, improving children’s development, early detecting of health problems, preventing disability, and preparing children under five to be able to interact with other children, and is one of the programs in building family security.
The Toddler Family Development Program (Bina Keluarga Balita/BKB) is one of the programs that has been launched by the National Population and Family Planning Agency (BKKBN) since 1981 and the implementation itself began in 1984 (BKKBN, 1992). However, the impact on children growth and development, including its role in preventing health problems such as stunting in children, is still not measurable (Directorate of Toddler and Children Development BKKBN, 2015). So far, the BKB program has only focused on the output of how many toddlers, BKBs, and BKB cadres are registered (Directorate of Toddler and Children Development BKKBN, 2015). Therefore, studies on family resilience program are still needed, especially the BKB program and its role in preventing stunting in children in Indonesia.
Based on the study of maternal variables and environmental factors which are thought to influence the incidence of stunting, the purpose of this study was to obtain data on the contribution of maternal characteristics variables: demographics (age, education), socio-economic (household expenditure and number of children), family resilience (the use of contraception, BKB participation, mother’s knowledge and actions at 1000 HPK) to stunting.
This cross sectional study was carried out simultaneously in six (6) districts and cities from 13 prioritized districts and cities for stunting interventions in West Java Province in August until November 2018. City districts as research samples were selected based on the highest incidence of stunting in West Java (Bappenas, 2017) namely Bandung City, Bandung District, Garut District, West Bandung District, Subang District, Sumedang District.
The sampling technique was done by using cluster sampling from 6 districts / cities consisting of 6 villages with KB villages, so that each village was represented by a sample of 135 respondents per village. The population in this study was the Fertile Age Couple (Pasangan Usia Subur/PUS) with the criteria of pregnant women (trimester one to trimester three) and or mothers with children under the age of five (toddlers). The total population of the six districts was 534,652 people, and the total sample was 810 respondents with 735 respondents of toddlers and toddler mothers (89.3%), pregnant women (8.2%) or 67 people, and pregnant women with toddlers (2.5%) or 20 people. Of the 810 respondents, there were 175 stunting toddlers, then 175 non-stunting toddlers were compared.
Stunting condition in infants was measured by the anthropometric method, namely body weight, body height / body length. Determinant data was measured using a questionnaire of social, economic and demographic factors, consisting of age, knowledge, level of education, family expenses, BKB participation.
The analysis was performed using comparative analysis to see the contribution of maternal characteristics to stunting. Statistical analysis was using the Chi Square test. This research had been through an ethical study from the Research Ethics Committee of Padjadjaran University, with letter number: 1206 / UN6 / KEP / EC / 2018. The following is the Concept Framework Scheme presented in this Research:
Results and Discussion
Univariate and bivariate analysis of the age of the mother, the mother’s level of education, household expenditure, number of children, the use of contraception, BKB participation related to stunting can be seen in Table 1 and Table 2.
Table 1. Demographic, Socioeconomic and Family Resilience Factors and Stunting
|Education||Below Junior High||55||30||85|
|Above Senior High||120||145||265|
|Social Economy||Household Expenditure||Below 1.500.000||68||89||157|
|Number of children||2 or less||130||130||260|
|3 or more||45||45||90|
|Family Resilience||The Use of Contraception||No||19||17||36|
Table 1 shows more than half of respondents aged 35 years and under, and more than seventy per cent of respondents with high school education and above. From the socio-economic factor, more than half of respondents had a family income of 1,500,000 and above. In terms of number of children, most of the respondents had less than 2 or 2 children. For BKB participation, there were only a small proportion of respondents, but almost all respondents use contraception. Lastly, the majority of respondents had knowledge of 1000 HPK and the action was good.
Table 2. The significance correlation between demographic, socioeconomic and family resilience factors and stunting
|Stunting and Mother’s Age||1.643||0.025 (*)|
|Stunting and Mother’s Education||2.215||0.002 (*)|
|Stunting and Household Expenditure||0.614||0.024 (*)|
|Stunting and Number of Children||1||1|
|Stunting and The Use of Contraception||1.132||0.725|
|Stunting and BKB Participation||2.488||0.001 (*)|
|Stunting and Mother’s Knowledge||9.434||0.034 (*)|
|Stunting and Mother’s Action||3.035||0.338|
Based on table 2, the Chi Square test results, there are several significant variables, namely: mother’s age, mother’s education, household expenditure, BKB participation and knowledge of 1000 HPK contributing to the stunting event.
Table 3. Multivariate Analysis on Factors Most Impactful to Stunting
|Variables||B||SE||Wald||OR (95% CI)||p-value|
|Use of Contraception||-0,365||0,327||1,245||0,694||0.264|
|Number of Children||0,139||0,270||0,266||1,149||0,606|
Based on table 3, the multivariate logistic regression test, out of the seven factors that contributed to the incidence of children’s stunting in West Java, maternal education was the most influential factor.
In terms of demographic factors, mothers under 35 years old tend to have stunting children. The test results show that mothers under 35 years old have a risk of having a stunting child by 1.6 times compared to mothers over 35 years old. It is suspected that this is not related to the biological age of the mother, but towards the maturity of the mother in providing child care for growth and development, so there is a lack of knowledge about meeting the nutritional needs of children.
The maternal education factor shows that mothers with high school education and above tend to have non-stunting children. In the Chi Square test, mothers with high school education and above have 2.2 times the chance of stunting prevention compared to mothers with below high school education. This is supported by a number of studies which show that maternal education is a determining factor in children’s health (Briones Alonso, Cockx, & Swinnen, 2018; Smith & Frankenberger, 2018). One of them is Rahayu and Khairiyati’s (2014) study stating that mothers with low education are 5.1 times more likely to have stunted children.
This research proves that household expenditure is divided into two categories, namely above Rp1,500,000 and below Rp.1,500,000. Even though it has a significant correlation, it needs to be reviewed because the situation that is clearly recorded from this research is that category, especially if it is associated with regional minimum wage (UMR margin) that is suitable for families, both of which are grouped under the UMR. It is suspected that even though the amount of expenditure is small, there is a need for further review of the proportion of expenditure on food, nutrition, and health, compared to secondary and tertiary needs because research shows that higher household expenditure has a 0.6 times chance of stunting to families with household expenditure below Rp.1,500,000. Whereas some research in developing countries like India shows that good economic conditions can improve the health status of children and toddlers (Carneiro, Meghir, & Parey, 2013; Pells, 2011).
Few groups of respondents who actively participated in the BKB program experienced stunting. Supported by the two variable test results, those who participated in BKB had a 2.5 times chance of not stunting compared to families who did not participate in BKB. This is reinforced by the importance of government programs on family resilience, where family resilience can be said to prevent stunting in the community. One of the programs in building resilience is the Toddler Family Development Program (BKB). The BKB program aims to increase knowledge, attitudes, behaviors and skills as parents and other family members to nurture and foster the development of toddlers, through physical, social intelligence, emotional, spiritual stimulation through parent and child interaction (MCA Indonesia, 2013).
Mothers with good knowledge of 1000 HPK have a tendency to have non-stunting children. This is strengthened by a comparison test of 2 variables which show that good knowledge of 1000 HPK has a 9 times chance to prevent stunting compared to poor knowledge. This is also supported by many studies which show a strong correlation between good knowledge and the quality of children’s health. As research by Kusumawati et al. (2015) states that poor mother’s knowledge is one of the risk factors for stunting. Another study by Simanjuntak et al., (2019) saying that maternal knowledge about nutrition is related to actions in reducing the incidence of stunting. Although this research is in the area of nutritional knowledge, it can support this research, that about 1000 HPK knowledge can reduce the risk of stunting.
The results of this study indicate that maternal education has a significant relationship with the incidence of stunting (p <0.008) and is the most significant factor of the seven other factors (contraceptive use, maternal participation in the BKB program, household expenditure, maternal knowledge about nutrition, maternal actions in nutrition, number of children and maternal age). Mother’s education is fundamental to the achievement of good children nutrition, this is related to its role most in the formation of children’s eating habits because it is the mother who prepares food starts to arrange menus, shop, cook, prepare food, and distribute food. The level of education of the mother is related to the ease of the mother in receiving information about nutrition and health from information sources available outside. Mothers with higher levels of education will more easily accept the information obtained compared to mothers who have lower levels of education who will be more difficult to receive and understand information (Ni’mah & Muniroh, 2015).
In this study, it was found that the higher the education of mothers, will provide an opportunity of 2,113 times to prevent the occurrence of stunting in children. According to Rahayu and Khairiyati (2014) mothers whose higher education tends to be better in parenting as well as better in the choice of children’s food. This is because mothers with higher education have greater opportunities in accessing information about the nutritional status and health of children so that their knowledge increases. Then the information is practiced in the process of child care which will impact on the nutritional status and better health of children.
According to research in Mexico that if maternal education levels are low, improvement in socioeconomic status must be accompanied by changes in behavior and effective communication to prevent stunting in children and to protect mothers from weight imbalances (Leroy JF, Habicht, de Cossío, & Ruel, 2014). In line with the results of a study in Mexico, the results of a Monteiro study (2010) in Brazil and Peru also found that mothers who had a high level of education could reduce the prevalence of stunting in children. This research was also supported by Rahayu and Khairiyati’s (2014) study which stated that mothers with low levels of education had a 5.1 times greater risk of having stunted children.
Although there are other studies that have different results from this study, including research Astuti and Taurina (2012) and Anindita research (2012). Both studies show there is no relationship between maternal education level with the nutritional status of preschool children and elementary schools. This is possible because in the two studies most of the respondents were mothers from poor families, so they have economic limitations to continue their education at a higher level.
The most important long-term approach to breaking the chain of stunting is to improve the formal education of prospective mothers, because education is the most strategic way for mothers to more easily absorb and understand health information, including on preventing stunting in children, for later practicing childcare.
There is still a need to strengthen family resilience including programs to improve the level of mother and family education to prevent and manage stunting in children. The other effort that can be made to overcome that problem is by increasing mother and family participation, especially in West Java Province, which is the province with the largest population in Indonesia, so that it will reflect problems in Indonesia as a whole (Datamikro & Statistics, 2014 ).
Conclusions and Recommendations
There is a significant correlation on the variables of maternal age, maternal education, household expenditure, BKB participation, and knowledge of 1000 HPK to stunting, with the most dominant factor is mother’s education level. As a form of practical recommendation for government and non-government institutions, it can be suggested that the BKB program is a priority for finding solutions in stunting prevention, besides that, the most important thing is to prepare quality mothers-to-be by increasing education programs for adolescent girls and women, so that they are ready to provide good care in preventing stunting in children.
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