ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 REGIONAL DISPARITIES OF STUNTED TODDLER IN MADURA ISLAND, INDONESIA 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, Surabaya, Indonesia. 3 Unit of Health Research and Development Magelang, National Institute of Health Research and Development, the Indonesian Ministry of Health, Center Java, 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 East Java 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 Sampang had 0.513 times the possibility of toddlers in the Region of Bangkalan 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 Pamekasan 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 6115 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 Regency on Madura Island has not experienced a significant shift. Noted Sumenep Regency ranks 31, Sampang Regency ranks 33, Pamekasan Regency ranks 35, and Bangkalan Regency 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 % % % % 6116 ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 ● Stunted 126 43.0 78 27.4 127 43.1 89 31.0