2476 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 Major Stunting Determinants in Infants: A Prevention Model

Teungku Nih Farisni1, Yarmaliza1, Fitriani1, Dewi Susanna2, Fitrah Reynaldi1, Zakiyuddin1, Safrizal S.A.1

1Lecturer, Department of Public Health, , , -23615, 2Lecturer, Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Indonesia-16424

Abstract The number of stunting cases in West increases every year. This study was an observational study with case-control design exexamine the dominant stunting factors among toddlers in West Aceh Regency amine the dominant stunting factors among toddlers in West Aceh Regency. This study was conducted from February 10 to June 30, 2018, in Johan Pahlawan District of West Aceh Regency of Aceh Province. The location was chosen through a purposive sampling technique by observing the highest number of children under five experiencing stunting in West Aceh Regency. The number of samples in this study was192 children. The results of this study showed that there was a significant relationship between the occurrence of stunting in children under five and the number of family members; parental height; Socioeconomic status (SES); low birth weight (LBW); nutritional knowledge; and food intake, where the p-value < 0.05.

Keywords: Dominant factor, stunting, toddler, number of family members, socio-economic status.

Introduction feeding practice that does not meet the nourishing needs. Indonesia positioned on the fifth for the In 2012, the World Health Assembly Resolution children with stunting conditions. More than 33% of 65.6 embraced a Comprehensive implementation Indonesian children under five years in Indonesia are plan on maternal, infant and young child nutrition1 underneath average height. The National Medium Term which indicated six worldwide nourishment targets for Development Plan or ‘Rencana Pembangunan Jangka 2025.2 This policy briefly achieves the first objective Menengah Nasional’ (RPJM) and Strategic Plan or of a 40% stunting decrease in children under five years ‘Rencana Strategis’ (RENSTRA) 2015-2019 has set the old1. Stunting during childhood is one of the massive goal to decrease stunting in children under five years obstacles to human improvement internationally old by 9.5%. Meanwhile, in 2013, the stunting rate is influencing around 162 million children under five years 37% implies that there is a 28.5% decrease in monetary old. Stunting, or being unreasonably short for one’s decline, and this should urgently be solved shortly.3 age, is characterized as a height that is in two standard deviations underneath the World Health Organization The Nutrition in the First 1,000 Days State of (WHO) child growth standards.1 the World’s Mothers (2012) elicits that the condition influenced the causes during 1000 days of a child’s life Stunting is an issue of perpetual malnourished beginning from the womb until their two years of age.4 health which is brought about by a long-time absence Specifically, the predominance of stunted children in of supplement consumption because of mistaken Aceh in Aceh area in 2016 was 41.5%, increasing from 2017, which was 37.2%.5 One of the indirect reasons for stunting cases is the number of members in the family. Corresponding Author: This number of a family is under recent research results Teungku Nih Farisni which have reasoned that the aspects influencing the Lecturer, Department of Public Health, Teuku Umar stunting case incorporated with the number of family University, Meulaboh, Indonesia-23615 members,6-7 parents’ height,8Socio-economic status 9 10 e-mail: [email protected] (SES), and history of LowBirth Weight (LBW). Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 2477 In deliberation of the depiction narrated above, the was a 24-hour diet recall. A body length according to age objective of this study was to examine the dominant with a Z-score less than -2 SD was to determine stunting stunting factors among toddlers in West Aceh Regency. in children.11 The data analysis performed by univariate and bivariate analysis using the chi-square test. The test Materials and Method used the confidence intervals (95% CI) and significance This study is an observational study with a case- level p <0.05. The multivariate analysis was carried out control design. This study was conducted from February by a logistic regression test.The sample of this study was 10 to 30 June 2018 in Johan Pahlawan District of West 182 children who divided into two groups; 96 children Aceh Regency of Aceh Province. The location was chosen for the control group and 96 children for the case group. through a purposive sampling technique by observing Results the highest number of children under five experiencing stunting in West Aceh Regency. The number of samples Table 1 below explains that the food intake in this study was 192 children. The instrument used to and parental height (paternal and maternal) differed measure the variables was a structured questionnaire for significantly between the case group and the control interviews; to measure height was a height meter with group. a precision level of 0.1 cm, and to measure food intake

Table 1. Frequency of Variable Distribution

Cases (n=96) Control (n=96) Variable n % n %

Number of Family Member a. >Three persons 73 76.56 30 31.25 b. Three persons 23 23.44 66 68.75 c. ≤ Three persons

Paternal Height a. 155 cm 25 26.56 90 93.75 b. ≤ 155 cm 71 73.44 6 6.25

Maternal Height a. >145 cm 23 23.44 80 83.37 b. ≤ 145 cm 73 76.56 16 16.63

Socio-economic (SES) a. High (> UMP) 24 25 69 71.88 b. Low (< UMP) 74 75 27 28.12

Low Birth Weight (LBW) a. LBW 80 83.38 30 31.25 b. Normal 16 16.62 66 68.75

Nutritional Knowledge a. Good 32 33 63 65.62 b. Not Good 64 67 33 34.38

Food Intake a. Good 17 17.7 72 74.94 b. Not Good 79 82.3 24 25.06

* significant p < 0,05, PMW = Province Minimum Wage or UMP (Upah Minimum Provinsi) 2478 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 Table 1 explains that there was a significant relationship between the occurrence of stunting and the food intake; parental height; nutritional knowledge; SES; the history of LBW; and the number of family members. The highest OR found in food intake, with 8.09, which indicated that children who had poor food intake had an opportunity for 8.09 for stunting. It followed by maternal height (6.12), paternal height (5.43), nutritional knowledge (4.93), SES (4.79), LBW (3.78), and the number of family members (3.56).

Table 2. Bivariate Analysis of Variables

Toddler Height OR Variable Stunting Normal p-Value (95% CI) n % n % Number of Family Member a. >Three pesons 73 76.56 30 31.25 3.56 b. Three persons 23 23.44 66 68.75 0.03 (1.4-2.78) c. ≤ Three persons Paternal Heigh a. > 155 cm 25 26.56 90 93.75 5.43 0.002 b. ≤ 155 cm 71 73.44 6 6.25 (1.6-3.36) Maternal Heigh a. >145 cm 23 23.44 80 83.37 6.12 0.001 b. ≤ 145 cm 73 76.56 16 16.63 (1.03-7.23) Socio-economic (SES) a. High (>PMW) 24 25 69 71.88 4.79 0.007 b. Low (

*Significantp< 0,05, PMW=Province Minimum WageorUMP (Upah Minimum Provinsi) Table 3. Logistic regression analysis

Model 1 Model 2 Model 3 Model 4 Model 5 Variable OR OR OR OR OR 95% CI 95% CI 95% CI 95% CI 95% CI Number of Family Member a. >three persons 2.77 2.04 3.02 2.67 3.19 b. ≤ 3 people (0.22-7.98) (0.33-7.82) (0.68-10.05) (0.43-7.56) (0.95-10.98) High of Father a. > 155 cm 5.60 4.73 4.54 5.54 4.83 b. ≤ 155 cm (1.03-12.96) (0.98-10.86) (0.84-10.95) (1.08-12.76) (1.30-12.01) High of Mother a. >145 cm 6.70 5.73 4.03 6.54 5.83 b. ≤ 145 cm (1.53-13.96) (1.09-12.86 (0.64-11.94 (1.48-13.85) (1.10-12.31) Socio-economic a. high (>PMW) 3.88 3.57 4.05 3.57 4.85 b. Low (< PMW) (0.53-10.97) (0.68-9.86) (0.98-11.65) (0.73-11.56) (0.91-11.91) Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 2479

Model 1 Model 2 Model 3 Model 4 Model 5 Variable OR OR OR OR OR 95% CI 95% CI 95% CI 95% CI 95% CI Birth Weight a. LBW 3.65 2.84 3.25 2.97 4.19 b. Normal (0.72-9.98) (0.38-8.82) (0.78-11.05) (0.43-8.56) (0.95-11.98) Nutritional Comprehension a. Good 4.78 3.57 4.95 3.59 4.45 b. Not Good (0.93-11.96) (0.68-9.86) (0.94-11.05) (0.78-11.76) (0.71-11.01) Food Supply a. Good 7.15 7.98 8.32 6.65 9.87 b. Not Good (2.97-17.07) (2.99-20.87) (3.18-22.15) (2.87-18.01) (3.57-26.64) R2 (%) 0.23 0.27 0.19 0.18 0.34 n 182 182 182 182 182

*PMW=Province Minimum Wage or UMP (Upah Minimum Provinsi)

This study used multivariate logistic regression altogether identified with the occurrence of stunting analysis where this test would describe the most (p-value<0.05), which can be found in Table 2. The appropriate model to be used to explain the relationship parents’ height can be incorporated into multivariate between independent variables and dependent variables. analysis since its result of a bivariate analysis indicated The bivariate test results of all independent variables p < 0.25, and it was discovered that the paternal height in this study can be included in multivariate analysis of <150 cm had 4.83 occasions the risk of getting a because all of their p-values were <0.25. stunted child (OR = 4.83) (Table 3). Another research recommends that being born from short parents is also Discussion a factor for stunting.15-16. The other study also suggests Further, the information about these research results that parental height is altogether related to the occurrence 17 provided. The relationship between the occurrence of of stunting. stunting and the numbers of a family member, parental Third, the result of this study demonstrated that height, SES, BLW, parents’ nutritional knowledge, and there was a critical connection among SES and the food intake examined carefully, and the discussion is as occurrence of stunting in children under five years old in the following. (p-value<0.05), which can be found in Table 2. Another First, there is a relationship between the number investigation likewise proposes that SES identified with of family members and the occurrence of stunting. The the occurrence of stunting in children under five years old 18 result of bivariate analysis demonstrated that there was a five. It further expressed that SES is the predominant noteworthy connection between the number of families factor in stunting case caused by the arrangement of 19 and the stunting case (Table 2). The variable number of nutritious food is unfulfilled. SES is related to parents’ relatives incorporated into multivariate analysis since salary to address family needs so that SES impacts the the value of bivariate analysis demonstrated p <0.25 capacity of families to meet the healthful nutritional or value of 3.16. This result implies that families with needs of children under five years old and different sorts more than four individuals had 3.19 occasions the of supplementary nourishment. danger of having a stunted child compared to families Fourth, the result of this study further demonstrated with under four individuals (Table 3). This outcome is that there was a significant connection between LBW following an investigation that recommends that there and the occurrence of stunting in children under five is a connection between the number of family members years old (p-value<0.05), which can be found in Table 12-14 and the occurrence of stunting. 2. Children with a background marked by LBW had Second, the result of this study also demonstrated 4.19 occasions the risk of stunting. This result supported that parents’ height (both father’s and mother’s) by a study about the prevalence and determinants of 2480 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 malnourished children and stunting in the area of Brazil Conclusion which expresses that there is a noteworthy connection In conclusion,the results obtained in this study between children with LBW (<2,500 gr) and stunting showed that there was a significant relationship between occurrence.20 A few studies demonstrate that children the occurrence of stunting in children under five and the with LBW are at a high risk to experience neurological number of family members; parental height; SES, LBW, abnormalities and deferred growth and development in nutritional knowledge; and food intake with p-value the long periods of life.21 Consequently, it influences <0.05. The results of multivariate analysis obtained R2 the development of their height. Another study likewise in the fifth model which indicated that the variable of the demonstrates that children with a weight of <2,500 gr number of family members, parental height, SES, LBW, connected to the occurrence of stunting.22 nutritional knowledge and food intake contributed Fifth, the results of the bivariate analysis 34%to the occurrence of stunting in West Aceh Regency demonstrated that there was a significant connection of Aceh Province. between nourishing knowledge and the occurrence of List of Abbreviations: ES: Socioeconomic status; stunting. It indicated that parents who had poor dietary LBW: low birth weight; RENSTRA: Rencana Strategis; knowledge had 4.93 occasions higher risk to have their RPJMN: Rencana Pembangunan Jangka Menengah children experience a lack of healthy food compared Nasional’; PMW: Province Minimum Wag; UMP to children whose parents are well-informed about (Upah Minimum Provinci). nourishment in food. On the contrary, the individuals who have inadequate information will give their Ethics approval and consent to participate: children unseemly vitality and protein consumption Informed written consent and permission were obtained and not as needs be to children’s healthful needs. This from each individual. finding is following a study that proposes that nutritional knowledge of parents identified with the occurrence of Competing Interests: The authors declare that they stunting.23-25 Also, a study suggests that the woman’s have no competing interests. knowledge about health, in general, brings about Source of Funding: The authors have no support to having more beneficial effects on their children as it can conduct this research. minimize the occurrence of stunting.26 The absence of nutritional knowledge of mothers in West Aceh regency References caused a high pace of stunting in children under five years old. 1. World Health Organization. Standards for improving the quality of care for children and Finally, the result of this study demonstrated that young adolescents in health facilities. Geneva: food intake is also related to the stunting occurrence. World Health Organization; 2018. This information can be seen in Table 2, where the 2. World Health Organization. Child growth standards p-esteem is 0.00001 as well as OR value= 8.09, which and the identification of severe acute malnutrition demonstrated that children under five years old with in infants and children. A joint statement. Geneva: inadequate food intake had 8.09 occasions the risk of World Health Organization; 2009. stunting. There was a suggestion that there is a connection 3. Kemenkes Republik Indonesia. Riset Kesehatan between food intake and the occurrence of stunting.27 Dasar (Basic Health Research). Jakarta: Nourishment security in families is essential toward the Kementerian Kesehatan Republik Indonesia; 2018. appearance of stunting in children under five years old. Pregnant mothers who consume low supplement food 4. Millennium Challenge Account. Stunting dan Masa intake and experience infectious diseases will deliver Depan Indonesia (Stunting and Indonesian future). birth to babies with LBW and underneath standard body Jakarta: MCA Indonesia; 2015. length. The factor of good condition, particularly toward 5. Dinas Kesehatan Aceh Barat. Angka Kejadian the fantastic start of a child, can augment the genetic Stunting pada Balita (Stunting Incidence Rate potential so that they can come to their ideal height.26 in Toddlers). Aceh Barat: Dinas kesehatan Aceh Further, Wondimagegn states that it is important to Barat; 2017. enhance people’s cultural beliefs and cultural realities to 6. Meilyasari F. Faktor Risiko Kejadian Stunting decline the stunting rate.27 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 2481 Pada Balita Usia 12 Bulan Di Desa Purwokerto in children living in conditions of extreme poverty: Kecamatan Patebon Kabupaten Kendal (Risk a case-control study. BMC Public Health. 2004. Factors for Stunting Incidence in Toddlers at 12 17. Willey B.A. Socio-economic predictors of stunting Months in Purwokerto Village, Patebon District, in preschool children-a population-based study Kendal Regency). Journal of Nutrition College. from Johannesburg and Soweto Barbara A Willey, 2013; 3(2). Noel Cameron, Shane A Norris, John M Pettifor, 7. Fikadu, et. al.. Factor Associated With Stunting Paula L Griffiths. SAMJ; June 2009, Vol. 99, No. 6. Among Children Age 24 To 59 Months In Meskan 18. Ngaisyah, RD. Hubungan Sosial Ekonomi Dengan District, Gurage Zone. South Ethiopia; 2014. Kejadian Stunting Pada Balita Di Desa Kanigoro, 8. Johnson, M, Inc and Brookstone. Nutrition in The Saptosari, Gunung Kidul (Socio-Economic First 1000 Days State Of The World’s Mother Relationship With Stunting In Toddlers In Kanigoro 2012. Save The Children. 2012 Village, Saptosari, Gunung Kidul). Jurnal medika 9. Kusuma, K.E, Nuryanto. Faktor Risiko Kejadian respati. 2015; 10(4). Stunting Pada Anak Usia 2-3 Tahun (Studi di 19. Correia, LL. Prevalence and determinants of child Kecamatan Semarang Timur) (Risk Factors for undernutrition and stunting in the semiarid region Stunting Occurrence in Children Aged 2-3 Years of Brazil. Rev Saude Publica.2014; 48(1):19-28 (Study in East Semarang District).). Unpublished 20. Dalimunthe, SM. Gambaran Faktor-Faktor bachelor thesis. Universitas Diponegoro: Semarang; Kejadian Stunting Pada Balita Usia 24- 59 Bulan 2013. Di Provinsi Nusa Tenggara Barat Tahun 2010 10. Rosha, BC. Determinant Analysis Of Stunting (Overview of Factors for Stunting Occurrence Children Aged 0-23 Months In Poor Areas In in Toddlers Age 24-59 Months in West Nusa Central And East Java.Penelitian Gizi Makan. Tenggara Province, 2010). Unpublished bachelor 2012; 35(1): 34-41. thesis. Syarif Hidayatullah Islamic University, 11. World Health Organization. Global targets 2025. Jakarta; 2015. To improve maternal, infant and young child 21. Kusumawati, E. Model of Stunting Risk Factor nutrition. 2015 Control among Children under Three Years Old, 12. Oktarina, Z. Risk Factors of Stunting among Jurnal Kesehatan Masyarakat Nasional. 2015;9(3). Children [24—59 months] in Sumatera. Jurnal Gizi 22. Ibrahim IA, Faramida R. Hubungan Faktor Sosial dan Pangan November.2013; 8(3): 175—180. Ekonomi Keluarga dengan Kejadian Stunting Anak 13. Jesmin, A. Prevalence and determinants of Usia 24-59 Bulan di Wilayah Kerja Puskesmas chronic malnutrition among preschool children: a Barombong Kota Makassar Tahun 2014 cross-sectional study in Dhaka city, Bangladesh. (Relationship between Family Socio-Economic International Centre for Diarrhoeal Disease Factors and Stunting Occurrence of Children 24-59 Research, Bangladesh. Health and Popular Months in the Work Area of the City of Barombong Nutrition. 2011; 29(5):494-499 Health Center Makassar City in 2014). Public Health Science Journal. 2014; 6(2). 14. Kleynhans, IC. Stunting among young black children and the socio-economic and health status 23. Ni’mah K., Nadhiroh SR. Faktor yang berhubungan of their mothers/caregivers in poor areas of rural dengan kejadian Stunting pada balita (Factors Limpopo and urban Gauteng–the NutriGro Study. related to the incidence of Stunting in infants). SAJCN. 2006; 19(4). Media Gizi Indonesia. 2015; 10(1): 13–19. 15. Lestari, W. Faktor risiko stunting pada anak 24. Abebe Z. Health Extension Workers’ Knowledge umur 6-24 bulan di kecamatan Penanggalan kota and Knowledge-Sharing Effectiveness of Optimal provinsi Aceh (Risk factors for Infant and Young Child Feeding Are Associated stunting in children aged 6-24 months in the sub- With Mothers’ Knowledge and Child Stunting in district of Penanggalan, Subulussalam, Aceh Rural Ethiopia. Food and Nutrition Bulletin. 2016; Province). Jurnal Gizi Indonaresia. 2014;3(1): 37(3): 353-363. 37‑45. 25. Kementerian PPN/Bapenas. Pedoman Pelaksanaan 16. Reyes, H. The family as a determinant of stunting Intervensi Penurunan Terintegrasi Kabupaten/kota 2482 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 (Ministry of PPN/BAPPENASs. Guidelines for 27. Wondimagegn, Z.T. Magnitude and determinant Implementing District/City Integrated Decrease of stunting among children in Africa: A systematic Interventions). Jakarta; 2018. review. Current Research in Nutrition and Food 26. De onis M, Ssner M.B dan Borghi, P. Prevalence Science. 2014; 2(2): 88-93. and trends of stunting among pre-school children. Public Health Nutrition. 2011; 15(1): 142–148.