ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 REGIONAL DISPARITIES OF STUNTED TODDLER IN ,

Agung Dwi Laksono1, Ratna Dwi Wulandari2, Ina Kusrini3

1 Research and Development Center of Humanities and Health Management, National Institute of Health Research and Development, the Indonesian Ministry of Health, Jakarta, Indonesia 2 Faculty of Public Health, Universitas Airlangga, , Indonesia. 3 Unit of Health Research and Development Magelang, National Institute of Health Research and Development, the Indonesian Ministry of Health, Center , Indonesia

Email: [email protected]

Received: 14 April 2020 Revised and Accepted: 8 August 2020

ABSTRACT: Health status in Madura Island has not changed over time, always at the bottom in the Province. The study was aimed to analyze stunted toddlers and regional disparities in Madura Island. The study was conducted by utilizing the 2017 Nutrition Status Monitoring (PSG/Pemantauan Status Gizi) data. The 2017 PSG was a survey in the control and responsibility of the Directorate of Community Nutrition, Ministry of Health, Republic of Indonesia. By multistage cluster random sampling, 1,160 toddlers were sampled. The dependent variable analyzed was the nutritional status of under five. The independent variables analyzed consisted of region, place of residence, toddler’s age, mother's age, marital, education, and employment. Binary Logistic Regression Test was carried out for the final stage determination. The results show that toddlers in the Region of had 0.513 times the possibility of toddlers in the Region of to experience stunting. The Region of Sumenep has 0.696 times more likely than toddlers in the Region of Bangkalan to experience stunting. While toddlers in the Region proved to have no significant differences compared to toddlers in the Region Bangkalan experienced stunting. Other variables that were proven to be determinants are the toddler’s age, the educational level of the mother, and the employment status of the mother. It concluded that there was a regional disparity in Madura Island. Toddlers in Sampang and Sumenep have a lower likelihood of experiencing stunting than toddlers in the Bangkalan and Pamekasan.

KEYWORDS: stunting, Madurese, nutritional status, community nutrition

I. BACKGROUND Stunting is a chronic nutritional problem that is characterized by z scores of height according to age below minus 2 standard deviations compared to WHO standards. Globally, around 162 million children under five are still stunted. It is expected that in 2025 a stunted toddler prevalence will decrease by 40% from the current prevalence [1]. In Indonesia, Basic Health Survey (Riskesdas) data for 2007; 2013; 2018 shows the successive stunting rate of 36.8%; 27.2%; 30.6% [2]–[4]. Based on data from the Indonesian Toddler Nutrition Status Survey (SSGBI) in 2019, the percentage of stunted toddlers changed to 27.67%. Although the number of stunted toddlers has decreased, stunted toddlers are still a public health problem, because there are still more than a fifth of toddlers in Indonesia stunted. This means that 2 out of 10 toddlers experience chronic nutritional disorders in the first 1000 days of life [5]. Stunting has a long-term effect on the lives of individuals and society. Stunting toddlers will experience disruption to physical growth, cognitive decline [6], [7]. Stunting sufferers in adulthood will experience decreased productivity and an increased risk of developing degenerative diseases/metabolic disorders such as diabetes [8]–[10]. In the life cycle nutrition, children with nutritional problems such as malnutrition/stunting will grow into adults who have nutritional problems (malnutrition). If there is no improvement, malnourished adult women who are in a condition of pregnancy will potentially give birth to babies with low birth weight (LBW) or low body length. While previous studies have identified that babies with LBW have a greater risk of experiencing growth retardation. Besides, LBW babies are vulnerable to infections that affect their health status. This condition is continuously like a cycle that keeps repeating [11]–[13]. Another study informs that chronic undernutrition (stunting) is detrimental to academic performance among primary schools of adolescent children [14]. Stunting is a nutritional problem caused by multifactor. Interventions carried out by only the health sector have a 30% contribution to the successful handling of stunting. While the role of other sectors outside of health has a greater contribution, which is 70%. Referring to the conceptual framework of the determinants of child undernutrition developed by Unicef, there are indirect contributions from other factors that affect children's growth [15], [16]. Parenting behavior, which is inseparable from knowledge and also the level of education

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 plays a very strong role. On the other hand, the condition of the surrounding environment, both physical and mental also influences. Specifically, physical environmental conditions such as environmental sanitation affect the child's susceptibility to infection which is closely related to the nutritional status of children [11], [17]. More broadly, it is also related to socioeconomic and welfare levels, as well as community security. Including socio- cultural factors and socioeconomic status also play a role [18]–[20]. The four regencies on Madura Island always have a health status that ranks lower in East Java Province over time. Based on the Public Health Development Index released by the Indonesian Ministry of Health in 2013, out of 38 regencies/cities in East Java Province, four districts on Madura Island ranked 33 (Sampang), 36 (Bangkalan), 37 (Sumenep), and 38 (Pamekasan)[21]. In 2018 the Ministry of Health released the Public Health Development Index again, and ranked fourth in the on Madura Island has not experienced a significant shift. Noted ranks 31, ranks 33, ranks 35, and ranks 36 [22]. Madura Island, which is predominantly inhabited by Madurese, is known to have a unique culture, which is generally different from other regions or districts in East Java Province on Java Island as the mother island. The Madurese have characteristics of large family size, with many children [23], [24]. General perspective puts people on Madura Island as if they are trapped in a vicious circle that continues to spin. A vicious cycle between poverty, low education, and low health status [25]. Based on the background description, this study aimed to analyze stunted toddlers and regional disparities in Madura Island. The purpose of this study is considered important for policymakers in four districts on Madura Island to evaluate the achievement of community nutrition programs. The results of this evaluation at the same time guide to determine the precise and specific stunting program policy objectives.

II. METHODS The study was carried out using the 2017 Nutrition Status Monitoring (PSG/Pemantauan Status Gizi) data. The 2017 PSG was a survey in the control and responsibility of the Directorate of Community Nutrition, Ministry of Health, Republic of Indonesia. The unit of analysis in this study was toddlers (0-59 months). The national scale survey was conducted with a multistage cluster random sampling so that a sample of 1,160 toddlers was obtained. The 2017 PSG received ethical clearance from the national ethics committee (No. LB.02.01/2/KE.244/2017). Toddler’s nutritional status was assessed based on height per age. This nutritional status was the main variable (the dependent variable). Toddler's nutritional status was determined based on the z-score indication. The score was the standard deviation from the normal height of a toddler according to WHO growth standards. The limits on the nutritional status category of children under five according to the height per age index according to WHO standards were [26]: - Stunted : < - 2,0 standard deviation - Normal : ≥ - 2 standard deviation The independent variable analyzed for the determination of disparity was regions on Madura Island. Region determination was based on district administrative boundaries. There were 4 regencies on Madura Island, namely Bangkalan, Sampang, Pamekasan, and Sumenep [27]. Other independent variables analyzed consisted of the type of residence (urban/rural), toddler’s age, mother’s age, marital status of the mother, education level of the mother, and employment status of the mother. The first stage of variable selection was carried out through the Chi-square test for dichotomous variables. While continuous variables were carried out through the t-test. The third or final stage was the Binary Logistic Regression test. The final test was conducted to determine the predictors or determinants of stunted toddlers on Madura Island.

III. RESULTS Table 1 displays descriptive statistical information from children under five in four regions on Madura Island. It can be seen that in four regions on Madura Island, it is dominated by toddlers who do not experience stunting.

Table 1. Descriptive Statistics of Nutritional Status of Toddler on Madura Island and Related Variables (n=1.160) Regions (Regencies) Variables Bangkalan Sampang Pamekasan Sumenep P n % n % n % n % Nutritional status ***<

0.001 ● Normal 167 57.0 207 72.6 168 56.9 198 69.0 % % % %

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 ● Stunted 126 43.0 78 27.4 127 43.1 89 31.0 % % % % Type of residence 0.127 ● Urban 12 4.1% 10 3.5% 10 3.4% 20 7.0% ● Rural 281 95.9 275 96.5 285 96.6 267 93.0 % % % % Age of toddler (in month/s; ***< 293 24.70 285 23.87 295 25.87 287 21.90 mean) 0.001 Age of mother (in years; ***< 293 29.78 285 30.76 295 29.51 287 30.33 mean) 0.001 Marital status of the mother 0.449 ● Single/Widowed/ 4 1.4% 3 1.1% 3 1.0% 7 2.4% Divorced ● Married 289 98.6 282 98.9 292 99.0 280 97.6 % % % % The education level of the ***< mother 0.001 ● ≤ Primary school 197 67.2 223 78.2 137 46.4 132 46.0 % % % % ● Junior high school 54 18.4 25 8.8% 62 21.0 59 20.6 % % % ● Senior high school 29 9.9% 21 7.4% 60 20.3 64 22.3 % % ● College 13 4.4% 16 5.6% 36 12.2 32 11.1 % % Employment status of the ***< mother 0.001 ● Not employed 160 54.6 193 67.7 215 72.9 187 65.2 % % % % ● Employed 133 45.4 92 32.3 80 27.1 100 34.8 % % % %

Note: Chi-Square is used to test dichotomous variables, and t-test to test continuous variables; *p<0.05, **p<0.01, ***p<0.001. Based on the category of residence’s type, children under five in four regencies are dominated by children living in rural areas. Table 1 shows that the average toddler in Region/Regency of Pamekasan is slightly older than the other three regencies. While based on the age of the mother of children under five, the average age of mothers of children under five in the Region/Regency of Sampang is slightly older than the age of mothers of children under five in three other regencies. Based on the marital status of the mother, all four regions/regencies are dominated by mothers who are married or have a partner. Meanwhile, based on the level of education of mothers, the four regions/regencies are dominated by mothers who have primary school education levels and below. Furthermore, based on the employment status of mothers, the four regions/regencies are dominated by mothers who are not employed. Table 2 displays information on the results of binary logistic regression tests. In this binary logistic regression test, the category used as a reference was the nutritional status of children under five in the category of "normal". Table 2 shows that toddlers in the Sampang Region/Regency have 0.513 times more likely than toddlers in the Bangkalan Region/Regency to experience stunting (OR 0.513; 95% CI 0.355-0.740). Region/Regency of Sumenep has 0.696 times more likely than toddlers in Bangkalan Region/Regency to experience stunting (OR 0.696; 95% CI 0.484-0.999). While toddlers in Region/Regency of Pamekasan proved to have no significant differences compared to toddlers in Region/Regency of Bangkalan to experience stunting. The results of the analysis inform that toddlers in Region/Regency of Sampang and Region/Regency Sumenep have a lower likelihood of experiencing stunting compared to the other two regions/regencies.

Table 2. Result of Binary Logistic Regression Test on Stunted Toddlers on Madura Island (n=1.160) Stunted Predictors Sig. OR Batas Bawah Batas Atas Region: Bangkalan - - - - Region: Sampang ***<0.001 0.513 0.355 0.740 Region: Pamekasan 0.601 1.098 0.774 1.558

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 Region: Sumenep *0.049 0.696 0.484 0.999 Toddler’s age ***<0.001 1.036 1.028 1.045 Mother’s age 0.888 1.001 0.982 1.021 Education level: ≤ Primary school - - - - Education level: Junior high school 0.953 1.011 0.707 1.446 Education level: Senior high school 0.641 0.912 0.620 10.342 Education level: College **0.004 0.466 0.278 0.780 Employment status: Not employed **0.009 0.687 0.519 0.910 Employment status: Employed - - - -

Note: Confidence interval OR 95%; *p<0.05, **p<0.01, ***p<0.001. The research result informs that toddler's age is a determinant of a stunted toddler. Meanwhile, mothers who had a college education level were 0.466 times more likely to have stunted toddlers than mothers who had an elementary school education level and below (OR 0.466; 95% CI 0.278-0.780). Furthermore, mothers of toddlers with junior and senior high school education levels did not have a significant difference with mothers of toddlers who had elementary school level education and below to have a stunted toddler. The results of this analysis inform that toddlers who have mothers with a college education level are less likely to experience stunting. Finally, toddlers who have not employed mothers are 0.687 times more likely than toddlers with employed mothers to experience stunting (OR 0.687; 95% CI 0.519-0.910). It can be interpreted that toddlers who have employed mothers are more likely to experience stunting.

IV. DISCUSSION The results of the analysis found that toddlers in the Bangkalan and Pamekasan had a higher likelihood of experiencing stunting compared to the Sampang and Sumenep. The disparity in the nutritional status of children between regions is possible due to different ecological resources and the environment. This is also reflected in disparities in community access to health services as a result of the availability of different health and environmental services [28]–[30]. The results of the study inform that toddler’s age is one of the determinants of stunted toddlers on Madura Island. While the age of the mother was not proven significantly as one of the determinants of stunting in infants on Madura Island. The finding of toddler’s age as a determinant of the incidence of stunting was also found in several studies in Ethiopia [31], Sub-Sahara Afrika [18], Vietnam [32], Bangladesh [33], dan Tanzania [34]. A study in Northwest Ethiopia informed findings that age was also found to be a predictor of stunting in school-aged children (5-15 years old)[35]. While other research in the Eastern Region of Ethiopia and Bangladesh informs that age is found to influence the incidence of stunting in children aged 6-12 years old in rural areas [36]. Toddlers in Madura who have mothers with higher education have a lower likelihood of experiencing stunting. The findings in this study are in line with the results of research in several countries, including Bangladesh [37], Ethiopia [38], Tanzania [39], Pakistan [40], dan Uganda [41]. Education owned by parents is closely related to their capacity in conducting care [42]. The higher education a mother has, the better the child's growth is expected. Mothers who have a good education, automatically have better knowledge in meeting the needs of children [43]. This applies physically, mentally, and socially, because parenting practices are also influenced by the mental health of the caregiver or his parents [44], [45]. In previous studies, education has often been found to be a positive determinant of health program output [46]–[48], meanwhile low levels of education are informed as barriers to health program output [49], [50]. The results of this analysis inform that toddlers in Madura with employed mothers have a higher likelihood of experiencing stunting. It can be assumed that this is because mothers of toddlers who do not employ have more time to pay attention to their children. The findings in this study are in line with the results of other studies in Indonesia at the national level [51]. Other studies that are in line are also informed in a study in India. The study investigated workload factors and the availability of parents' time to care for children. Mothers who do not work tend to have a lower chance of having stunting [52]. Limitations of this study are due to superficial analysis results. This is because the secondary data that is processed is quantitative so that it can only capture surface phenomena. Qualitative studies are needed to capture the reasons or explanations behind each phenomenon [53] so that explanations related to Madura's cultural distinctiveness can be revealed.

V. CONCLUSIONS Based on the results of the analysis it could be concluded that the disparity between regions in Madura Island. Toddlers in Sampang and Sumenep have a lower likelihood of experiencing stunting than toddlers in Bangkalan

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 and Pamekasan. Other variables also found as predictors of the incidence of the stunted toddler on Madura Island were toddler’s age, education level of the mother, and the employment status of the mother. Based on these conclusions, the author recommends the government of Bangkalan and Pamekasan regencies to benchmark Sampang or Sumenep regencies regarding stunting control policies for toddlers. This benchmark is worth doing because in addition to having relatively the same culture, the chance of stunting in Sampang and Sumenep regencies is almost half of the other two regions.

Acknowledgments The author would like to thank the Directorate of Community Nutrition of the Ministry of Health of the Republic of Indonesia for allowing to data processing of the 2017 Nutritional Status Monitoring.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

VI. REFERENCES

[1] WHO, “World Health Assembly Global Nutrition Targets 2025. Stunting Policy Brief.,” 2015. [2] Ministry of Health of the Republic of Indonesia, “The 2007 Indonesia Basic Health Survey (Riskesdas): National Report,” Jakarta, 2008. [3] National Institute of Health Research and Development of Ministry of Health of the Republic of Indonesia and National Institute of Health Research and Development of The Indonesia Ministry of Health, “The 2013 Indonesia Basic Health Survey (Riskesdas): National Report,” Jakarta, 2014. [4] National Institute of Health Research and Development of The Indonesia Ministry of Health, “The 2018 Indonesia Basic Health Survey (Riskesdas): National Report,” Jakarta, 2019. [5] D. Izwardy, “Studi Status Gizi Balita Terintegrasi Susenas 2019,” Jakarta, 2020. [6] G. Engidaye, M. Melku, A. Yalew, Z. Getaneh, F. Asrie, and B. Enawgaw, “Under nutrition, maternal anemia and household food insecurity are risk factors of anemia among preschool aged children in Menz Gera Midir district, Eastern Amhara, Ethiopia: A community based cross-sectional study,” BMC Public Health, vol. 19, no. 1, p. Article number 968, 2019. [7] C. Li et al., “Growth in early life and physical and intellectual development at school age: A cohort study,” Br. J. Nutr., vol. 121, no. 8, pp. 866–876, 2019. [8] E. D. L. Rolfe et al., “Associations of stunting in early childhood with cardiometabolic risk factors in adulthood,” PLoS One, vol. 13, no. 4, p. Article number e0192196, 2018. [9] H. F. L. Muhammad, “Obesity as the Sequel of Childhood Stunting: Ghrelin and GHSR Gene Polymorphism Explained,” Acta Med. Indones., vol. 50, no. 2, pp. 159–164, 2018. [10] A. Singhal, “Long-Term Adverse Effects of Early Growth Acceleration or Catch-Up Growth,” Ann Nutr Metab, vol. 70, no. 3, pp. 236–240, 2017. [11] A. Imdad, Z. Lassi, R. Salaam, and Z. A. Bhutta, “Prenatal Nutrition and Nutrition in Pregnancy: Effects on Long-Term Growth and Development,” in Early Nutrition and Long-Term Health: Mechanisms, Consequences, and Opportunities, J. Saavedra and A. Dattilo, Eds. Woodhead Publishing, 2016, pp. 3– 24. [12] G. Agbota et al., “Poor maternal anthropometric status before conception is associated with a deleterious infant growth during the first year of life: a longitudinal preconceptional cohort,” Pediatr. Obes., vol. 15, no. 1, p. Article number e12573, 2020. [13] B. Nahar et al., “Early childhood development and stunting: Findings from the MAL-ED birth cohort study in Bangladesh,” Matern. Child Nutr., vol. 16, no. 1, p. Article number e12864, 2020. [14] T. Wolde and T. Belachew, “Chronic undernutrition (stunting) is detrimental to academic performance among primary schools of adolescent children: A randomized cross sectional survey in Southern Ethiopia,” BMC Res. Notes, vol. 12, no. 1, p. Article number 142, 2019. [15] United Nations Children’s Fund, “A Unicef Policy Review: Strategy for Improved Nutrition of Children and Women in Developing Countries,” New York, 1990. [16] United Nations Children’s Fund, “UNICEF’s approach to scaling up nutrition for mothers and their children,” New York, 2015. [17] B. F. Sunguya, S. Zhu, R. Mpembeni, and J. Huang, “Trends in prevalence and determinants of stunting in Tanzania: An analysis of Tanzania demographic health surveys (1991-2016),” Nutr. J., vol. 18, no. 1, p. Article number 85, 2019. [18] L. R. Buisman, E. Van de Poel, O. O’Donnell, and E. K. A. van Doorslaer, “What explains the fall in

6119

ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 child stunting in Sub-Saharan Africa?,” SSM - Popul. Heal., vol. 8, p. Article number 100384, 2019. [19] S. Khan, S. Zaheer, and N. F. F. Safdar, “Determinants of stunting, underweight and wasting among children {\textless} 5 years of age: Evidence from 2012-2013 Pakistan demographic and health survey,” BMC Public Health, vol. 19, no. 1, p. Article number 358, 2019. [20] A. D. Laksono and I. Kusrini, “Ecological Analysis of Stunted Toddler in Indonesia,” Indian J. Forensic Med. Toxicol., vol. 14, no. 4, pp. 1–7, 2020. [21] National Institute of Health Research and Development, The 2013 Public Health Development Index (Indeks Pembangunan Kesehatan Masyarakat Tahun 2013). Jakarta: The Ministry of Health of Indonesia, 2014. [22] National Institute of Health Research and Development of Ministry of Health of the Republic of Indonesia, “The 2018 Public Health Development Index (Indeks Pembangunan Kesehatan Masyarakat),” Jakarta, 2019. [23] R. Widyasari, I. D. Sari, A. L. Maghfiroh, S. Haryanto, and M. S. Pramono, The 2012 Maternal and Child Health Ethnographic Series, Madura Ethnic Jrangoan Village, Omben District Sampang Regency, East Java Province (Buku Seri Etnografi Kesehatan Ibu dan Anak 2012, Etnik Madura Desa Jrangoan, Kecamatan Omben Kabupaten Sampang, Pro. Jakarta: Badan Penelitian dan Pengembangan Kesehatan, Kementerian Kesehatan RI, 2012. [24] B. Imanhadi, D. I. Saragih, and S. Pranata, Childcare: on the earth of “Adi Poday” Sapudi Island (Pengasuhan Anak di Bumi “Adi Poday”). Surabaya: Unesa University Press, 2016. [25] A. D. Laksono, S. Pranata, and W. D. Astuti, Positioning for Shaman (Positioning Bayi). Yogyakarta: PT Kanisius, 2014. [26] Directorate of Community Nutrition of The Ministry of Health of The Republic of Indonesia, “the 2017 Indonesia Nutritional Status Monitoring (Pemantauan Status Gizi 2017),” Jakarta, 2017. [27] A. D. Laksono and R. D. Wulandari, “Determinant of the Puskesmas Utilization in Madura Island,” Indian J. Public Heal. Res. Dev., vol. 10, no. 11, pp. 576–581, 2019. [28] A. D. Laksono, R. D. Wulandari, and O. Soedirham, “Regional Disparities of Health Center Utilization in Rural Indonesia,” Malaysian J. Public Heal. Med., vol. 19, no. 1, 2019. [29] A. D. Laksono, R. Rukmini, and R. D. Wulandari, “Regional disparities in antenatal care utilization in Indonesia,” PLoS One, vol. 15, no. 2, p. e0224006, 2020. [30] I. Kusrini and A. D. Laksono, “Regional disparities of stunted toddler in indonesia,” Indian J. Forensic Med. Toxicol., vol. 14, no. 3, pp. 1685–1691, 2020. [31] H. M. Fenta, D. L. Workie, D. T. Zike, B. W. Taye, and P. K. Swain, “Determinants of stunting among under-five years children in Ethiopia from the 2016 Ethiopia demographic and Health Survey: Application of ordinal logistic regression model using complex sampling designs,” Clin. Epidemiol. Glob. Heal., pp. 1–22, 2019. [32] T. Beal et al., “Child stunting is associated with child, maternal, and environmental factors in Vietnam,” Matern. Child Nutr., vol. 15, no. 4, p. Article number e12826, 2019. [33] R. Akram, M. Sultana, N. Ali, N. Sheikh, and A. R. Sarker, “Prevalence and Determinants of Stunting Among Preschool Children and Its Urban–Rural Disparities in Bangladesh,” Food Nutr. Bull., vol. 39, no. 4, pp. 521–535, 2018. [34] H. A. Mbwana, J. Kinabo, C. Lambert, and H. K. Biesalski, “Factors influencing stunting among children in rural Tanzania: an agro-climatic zone perspective,” Food Secur., vol. 9, no. 6, pp. 1157–1171, 2017. [35] A. Lisanu Mazengia and G. Andargie Biks, “Predictors of stunting among school-age children in Northwestern Ethiopia,” J. Nutr. Metab., vol. 2018, p. Article number 7521751, 2018. [36] T. Y. Bogale, E. T. Bala, M. Tadesse, and B. O. Asamoah, “Prevalence and associated factors for stunting among 6-12 years old school age children from rural community of Humbo district, Southern Ethiopia,” BMC Public Health, vol. 18, no. 1, p. Article number 653, 2018. [37] A. Talukder, S. R. Razu, and M. Z. Hossain, “Factors affecting stunting among children under five years of age in Bangladesh,” Fam. Med. Prim. Care Rev., vol. 20, no. 4, pp. 356–362, 2018. [38] A. K. Tekile, A. A. Woya, and G. W. Basha, “Prevalence of malnutrition and associated factors among under-five children in Ethiopia: Evidence from the 2016 Ethiopia Demographic and Health Survey,” BMC Res. Notes, vol. 12, no. 1, p. Article number 391, 2019. [39] L. Chirande et al., “Determinants of stunting and severe stunting among under-fives in Tanzania: Evidence from the 2010 cross-sectional household survey,” BMC Pediatr., vol. 15, no. 1, p. Article number 165, 2015. [40] S. Khan, S. Zaheer, and N. F. Safdar, “Determinants of stunting, underweight and wasting among children < 5 years of age: Evidence from 2012-2013 Pakistan demographic and health survey,” BMC Public Health, vol. 19, no. 1, p. Article number 358, 2019. [41] Y. Y. Yang et al., “Trends and determinants of stunting among under-5s: Evidence from the 1995, 2001, 2006 and 2011 Uganda Demographic and Health Surveys,” Public Health Nutr., vol. 21, no. 16, pp.

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 2915–2928, 2018. [42] I. R. Nirmala, J. Februhartanty, and L. A. A. Wiradnyani, “Maternal attributes are positively associated with feeding practices of children aged 2-5 years in West Java, Indonesia,” Malays. J. Nutr., vol. 22, no. 2, pp. 191–205, 2016. [43] A. Wemakor and K. A. Mensah, “Association between maternal depression and child stunting in Northern Ghana: A cross-sectional study,” BMC Public Health, vol. 16, no. 1, p. Article number 0163558z, 2016. [44] Z. R. Han, M. M. Gao, J. Yan, X. Hu, and W. Zhou, “Correlates of Parent-Child Physiological Synchrony and Emotional Parenting: Differential Associations in Varying Interactive Contexts,” J. Child Fam. Stud., vol. 28, no. 4, pp. 1116–1123, 2019. [45] L. A. Daniels, “Feeding Practices and Parenting: A Pathway to Child Health and Family Happiness,” Ann. Nutr. Metab., vol. 74, no. Suppl2, pp. 29–42, 2019. [46] R. D. Wulandari and A. D. Laksono, “Education as predictor of the knowledge of pregnancy danger signs in Rural Indonesia,” Int. J. Innov. Creat. Chang., vol. 13, no. 1, pp. 1037–1051, 2020. [47] R. D. Wulandari and A. D. Laksono, “Determinants of knowledge of pregnancy danger signs in Indonesia,” PLoS One, vol. 15, no. 5, p. Article number e0232550, 2020. [48] M. Ipa, M. Widawati, A. D. Laksono, I. Kusrini, and P. W. Dhewantara, “Variation of preventive practices and its association with malaria infection in eastern Indonesia: Findings from community-based survey,” PLoS One, vol. 15, no. 5, p. e0232909, 2020. [49] N. Rohmah et al., “Determinants of teenage pregnancy in Indonesia,” Indian J. Forensic Med. Toxicol., vol. 14, no. 3, pp. 2080–2085, 2020. [50] A. D. Laksono and R. D. Wulandari, “The Barrier to Maternity Care in Rural Indonesia,” J Public Heal. From Theory to Pract., p. Online First, 2020. [51] A. D. Laksono, M. Ibad, A. Mursita, I. Kusrini, and R. D. Wulandari, “Characteristics of mother as predictors of stunting in toddler,” Pakistan J. Nutr., vol. 18, no. 12, pp. 1101–1106, 2019. [52] S. Chaturvedi et al., “Time-constrained mother and expanding market: Emerging model of under- nutrition in India,” BMC Public Health, vol. 16, no. 1, p. Article number 632, 2016. [53] N. Kusumawardani, R. Soerachman, A. D. Laksono, L. Indrawati, P. S. Hidayangsih, and A. Paramita, Qualitative Methods for Health Research (Penelitian Kualitatif di Bidang Kesehatan). Yogyakarta: PT Kanisius, 2015.

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