Journal of Maternal and Child Health (2017), 2(1): 30-41 https://doi.org/10.26911/thejmch.2017.02.01.04
Path Analysis on Gestational Socio-economic Determinants of Nutritional Status in Children Under Five in Purworejo Regency, Central Java
Ika Yuli Ayuningrum1), Harsono Salimo2), Yulia Lanti Retno Dewi3)
1) Masters Program in Public Health, Sebelas Maret University, Surakarta 2) Department of Maternal and Child Health, Dr. Moewardi Hospital, Surakarta 3) Faculty of Medicine, Sebelas Maret University, Surakarta
ABSTRACT
Background: Undernutrition by height-for-age standard starts during pregnancy and continues to the first two years of life. Linear growth disorders among children under five years are associated with morbidity, mortality, loss of physical growth potential, reduced neurological development, reduced cognitive functions, and increased risks of adulthood chronic diseases. In 2015, the number of undernourished children under five (height-for-age) reached 156 million globally. Purworejo regency was an area with the second highest undernutrition cases in Central Java in 2014. This study aimed to analyze the life-course epidemiology perspectives on the socio-economic factors contributing to the nutritional status of the children aged two to five years in Purworejo regency, Central Java. Subjects and Method: This was an observational analytical study with case control design. This study was conducted in Purworejo, Kaligesing, and Bruno sub-districts, Purworejo Regency, Central Java in February to March 2017. A total sample 160 children aged two to five years and their mothers were selected by fixed disease sampling. There were 37 children in the case groups, and 113 children in the control groups. The independent variables included family income, maternal age, maternal nutritional status (mid upper arm circumference), birth length, exclusive breastfeeding and the children‘s history of illness. The dependent variable was the children‘s nutritional status (height-for-age/HAZ). Data on the children‘s height were collected using microtoise. Other data were collected by maternal and children health (MCH) books and a set of questionnaires. The data were analyzed using path analysis. Results: Nutritional status of children under five (height-for-age/HAZ) was affected by family income (x Rp 100,000) (b=0.03; SE=0.24; p<0.001), maternal age (years) (b=0.02; SE=0.02; p=0.160), maternal nutritional status/MUAC (cm) (b=0.08; SE=0.05; p=0.066), birth length (cm) (b=0.22; SE=0.05; p<0.001), exclusive breastfeeding (b= 0.03; SE=0.16; p=0.080), and the absence of illness (b=0.39; SE=0.14; p=0.007). Conclusion: Nutritional status of the children under five (height-for-age/HAZ) is affected by family income, birth length, exclusive breastfeeding, maternal age, maternal nutritional status, and the absence of illness.
Keywords: nutritional status, children under five, life-course epidemiology, socio-economic
Correspondence: Ika Yuli Ayuningrum. Magister of Public Health Program, Sebelas Maret University, Surakarta. Email: [email protected]. Mobile: +6285729407360.
BACKGROUND are born (Semba, 2008). Therefore, the Undernutrition among the children under nutritional status measurement by height- five years by height-for-age standard is for-age is able to indicate bad environment caused by long-term chronic nutrition or factors which restrict the children‘s long- insufficiency and frequency of the children term growth. This height-for-age measure- being exposed to diseases even before they ment is also able to demonstrate the
30 e-ISSN: 2549-0257 (online)
Ayuningrum et al./ Path Analysis on Gestational Socio-economic Determinants
children‘s well-being and it is an accurate cence, and adulthood. Undernutrition does reflection on social inequalities (de Onis not only affect the individual but it also dan Branca, 2016). The nutrition status impacts the future generations. Undernutri- (height-for-age) commonly occurs among tion in childhood, adolescence, and preg- children under two years and its impact is nant women may bring negative impacts to massive and irreversible (UNICEF, 2013; fetal growth and babies‘ weight. Fetus with WHO, 2010a). insufficient nutrition intakes will suffer The nutrition status by height-for-age from intra-urine growth retardation/ (HAZ) often does not receive the same IUGR), as a result they will be born with attention as weight-for-height (WHZ), or low birth weight. If the infants with IUGR weight-for age (WAZ) from health workers. or low birth weight survive, they will Moreover, height is not measured regularly experience restriction their optimal growth as part of a community health program. and suffer from various developmental Family and health workers often fail to disorders. Stunted female children will recognize short children because short grow as stunted women, and they are more stature is common in communities, so that likely to give birth stunted children these children are viewed normal. Family, (Martorell dan Zongrone, 2012). health workers, and policy makers are not Determinants of the nutritional status aware of the consequences of the short of the children under five years (height-for- stature in children and its effects in age) in this study were identified using life- adulthood; thus it is not considered as a of the socio-economic factors. The life- public health issue (Dewey dan Begum, course epidemiological perspectives have 2011; de Onis et dan Branca, 2016). implications to the biological factors and WHO (2010b) based on World Health social events that occur in each life stage, Statistics Data in 2010 showed that 40% of even since gestation. The biological factors the children under five in Indonesia were and social events in each stage of age may stunted. Indonesia‘s Basic Health Research bring long-term effects to health condition (Riset Kesehatan Dasar /RISKESDAS) in in the next stages of life. The life-course 2013 found that the prevalence of under- epidemiological perspectives synchronize nutrition by height-for-age (HAZ) among paradigms of the eco-social determinants of the children under five in Indonesia was health, that health is not only affected by 37.2%. Purworejo regency was an area with biological factors, but also socio-economic the second highest prevalence of under- and environment. nutrition cases among the children under This study aimed to analyze the life- five in Central Java in 2014 (Central Java course epidemiology perspectives of the Health Office, 2014). socio-economic determinants of the nutri- The life-course epidemiology perspec- tional status of the children aged two to five tive provides a strong framework to des- years in Purworejo regency using path cribe issues related to human nutrition. analysis. People‘s nutritional status goes on over their life-course (Martorell dan Zongrone, SUBJECTS AND METHOD 2012). Study Design Undernutrition seems to start since This was an observational analysis study the children are in uterus and it affects their with case control design. The study was nutritional status in childhood, adoles- conducted in Purworejo, Kaligesing, and e-ISSN: 2549-0257 (online) 31
Journal of Maternal and Child Health (2017), 2(1): 30-41 https://doi.org/10.26911/thejmch.2017.02.01.04
Bruno sub-district in Purworejo regency, Birth length variable was defined as Central Java in in February to March 2017. size of children body length that measured Population and Sample at the time of birth and registered on Population of this study was children aged maternal and children health (MCH) books. two to five years old in Purworejo Regency, Exclusive breastfeeding was defined Central Java. A total of 160 children aged as the infant only received breast milk, no two to five years and their mothers were other liquids or solids are given (not even selected by fixed disease sampling. There water) with the exception of oral rehy- were 37 stunted children (height-for-age/ dration solution, drops/syrups of vitamins, HAZ)) in the case groups and 113 well- minerals or medicines from birth to six nourished children (height-for-age/HAZ) in years old. the control groups. History of child illness was presence Variable or absence children who was suffered from The independent variables were family infectious disease (e.g diarrhea, non pneu- income, maternal age, maternal nutritional monia cough, etc) in three months latest. status, birth length, exclusive breastfeeding, Instrument Data Collection and children‘s history of illness. The depen- The current children‘s height was measured dent variable was nutritional status (height using microtoise. The data on the children‘s for age) of children aged 2 to 5 years old. date of birth, birth length, maternal age, Exogenous variables were maternal and the maternal nutritional status (MUAC) age, maternal nutritional status, birth were collected through MCH books. Infor- length and family income. Endogenous va- mation on breastfeeding history and the riables were exclusive breastfeeding, history children‘s history of illness were collected of illness and children‘s nutritional status by a set of questionnaires. (height for age). Data Analysis Operational Definition The data were collected during children Children nutritional status in this study was health examination in integrated health the condition of nutritional status (height posts (posyandu), toddler class, and home for age/ HAZ) of children aged two to five visits. The categorical data of the study years old based on WHO Child Growth subject‘s characteristic were described in Standard Refference. frequency (n) and percentage (%). Univariat Current family income was average analysis were described in mean, standard number of fixed and side income from deviation (SD), minimum and maximum father, mother and other family members in value. Bivariat analysis were analyzed using last a month. Pearson correlation test. Maternal age was the total number of Multivariate analysis were analyzed time units (in years) which measured based using path analysis by IBM SPSS AMOS 22 on the year of mother was born until she version, following steps: pregnant her children who is currently 1. Model specification being the study subject. 2. Model identification Maternal nutritional status was the 3. Model fit nutritional status of pregnant women which 4. Estimation measured by mid upper arm circumferrence 5. Model respesification (MUAC) size and recorded in maternal and children health (MCH) books.
32 e-ISSN: 2549-0257 (online)
Ayuningrum et al./ Path Analysis on Gestational Socio-economic Determinants
Ethical Approval RESULTS The aim of ethical approval is to protect the 1. Characteristics of the study subjects study subjects. They are a valuable part of The characteristics of the study subjects the research process and not merely a were presented in Table 1. Table 1 showed means of accessing data. that the number of female children under This study has received ethics appro- five was higher (53.1%). Most mothers were val from the Ethics Health Research Com- graduated ≥senior high schools (34.4%), yet mission of Dr. Moewardi Hospital/ School seven mothers did not complete primary of Medicine, Sebelas Maret University, school. Most of the mothers were house- Surakarta, No: 79/II/HREC/2017, dated on wives (71.9%). February 16, 2017. Table 1. Characteristics of the study subjects Characteristics Criteria n % Children‘s sex Male 75 46.9 Female 85 53.1 Mothers‘ education Did not complete primary school 7 4.4 Primary school 45 28.1 Junior high school 48 30.0 Senior high school 55 34.4 Diploma 3 1.9 Bachelor 2 1.3 Mothers‘ occupation Housewife 113 70.6 Labor 1 0.6 Farmer 21 13.1 Trader 16 10.0 Teacher 1 0.6 Government officer 3 1.9 Private employee 2 1.3 Business owner 3 1.9
2. Univariate Analysis healthy reproductive age (20-35 years). As a. Frequency Distribution many as 74.4% of the mothers had good The univariate analysis was conducted to nutritional status at pregnancy (MUAC identify the frequency distribution and ≥23.5 cm). Percentage of the children percentage of the variables on the nutri- under five with normal birth length (≥48 tional status (height-for-age) of the child- cm) was 85%, respectively. ren aged two to five years old, current The categorical data of the study family income, maternal age, birth length, subject‘s characteristic were described in exclusive breastfeeding, and children‘s frequency (n) and percentage (%). This history of illness. was presented on Table 3. Table 3 showed Table 2 showed the frequency distri- frequency distribution of the variables on bution of the study variables on family breastfeeding and history of illness. Most income, maternal age, and birth length. of the study subjects (66.3%) received The majority of the children (60%) were exclusive breastfeeding. Most of the from low-income family (