Factors Associated to The Occurrence of Stunting at The Primary Health Center in Madiun City, Indonesia

Stunting, a common nutritional problem characterized by a child's shorter stature due to growth failure, affects 11.5% of toddlers at Demangan Primary Health Center in Madiun, Indonesia. This research aimed to analyze factors linked to toddler stunting, using an observational analytical cross-sectional design. All toddlers visiting Demangan Primary Health Center's Integrated Health Post in Madiun were involved in the study sample. Maternal pre-pregnancy BMI, maternal upper arm circumference (LILA), maternal weight gain during pregnancy, inter-birth interval, low birth weight, per capita income, parental education, maternal knowledge on toddler's nutrition and parenting patterns of feeding were factors collected through questionnaires, Maternal and Child Health books, and primary health center records. Univariate and bivariate analysis results were tested using the Chi-Square or Fisher Exact test. In this study, 156 samples were obtained, consisting of 18 stunted toddlers (11.5%) and 138 normal toddlers (88.5%). Stunting associated with maternal pre-pregnancy BMI showed p=0.020, maternal upper arm circumference p=0.008, maternal weight gain during pregnancy p≤0.001, low birth weight p=0.001, per capita income p=0.007, and maternal knowledge on toddler's nutrition had p=0.011. In conclusion, pre-pregnancy conditions significantly influence stunting. So, enhancing interventions for maternal health during pre-pregnancy is crucial for maximizing impact.

INTRODUCTION

One of the five stages in building a more productive and competitive Indonesia, with high flexibility to face changes in the world, is the development of human resources. Human resource development can begin by ensuring the health of pregnant women, infants, toddlers, and school-age children¹¹. The primary focus during this phase is addressing malnutrition in the early stages of life, as it can significantly impact the quality of human resources and hinder optimal growth attainment²². There is a term known as the First 1,000 Days of Life, considered crucial in determining a person’s future quality of life¹.Therefore, proper nutrition fulfillment during this period is essential to prevent the emergence of nutritional problems, especially in toddlers. Stunting is one of the numerous nutritional issues observed in Indonesia. It occurs when a child’s posture is too short for their age due to growth failure. According to the child growth standards established by the World Health Organization (WHO), stunting is defined as a condition where a child’s height is more than 2 standard deviations (SD) below WHO standards compared to the average growth of other children³³.De Onis and Branca (2016) also emphasized that stunting is defined as a state of malnutrition characterized by a decrease in child nutrition up to -2SD from length/height according to age⁴⁴.

WHO recommends a stunting prevalence target of 20% for a region⁵⁵. However, Indonesia still has not reached this target. When observed over the past decade, the incidence of stunting remains high to date even at the national level reaching a percentage of 37%⁶⁶. The incidence of stunting nationally has decreased, from 37.2% in 2013 to 30.8% in 2018⁷⁷. Furthermore, based on Teja’s study (2019), the national stunting prevalence rate in 2019 decreased again, which was 27.67%⁵⁵.East Java, with a prevalence of 26.86% according to the Susenas Integration Implementation Report in March 2019 and the SSGBI 2019, remains above the WHO target, necessitating special attention for successful government programs in human resource development. The city of Madiun contributed to stunting cases in East Java with a prevalence of 17.44%⁸⁸. Among its primary health centers, Demangan Primary Health Center has the highest prevalence at 11.4%. Although this is below the national figures and WHO targets, there is a concern as new cases are frequently reported, as discovered through interviews with health center staff. Further efforts are needed to address this issue and prevent the recurrence of new cases.

The high prevalence of stunting not only impacts the country’s progress but also hinders the overall quality of individuals. Stunting can have detrimental effects on physical, mental, intellectual, and cognitive development in the long run⁹⁹. These factors influence children’s academic achievements, and later in life, impede daily productivity, making it challenging for individuals to develop into high-quality human beings. Moreover, stunting is linked to various diseases, increasing morbidity and mortality rates. According to the WHO conceptual framework, stunting is caused by household and family factors, including inadequate breastfeeding, insufficient food, the presence of infectious diseases, and home environment factors. Additionally, community and social factors such as social, economic, cultural, political, educational, health services, water sanitation, environment, food systems, and agriculture contribute to stunting¹⁰¹⁰. This suggests that stunting is a multifactorial condition. This study focuses on identifying factors contributing to stunting in toddlers.

MATERIALS AND METHODS

The research employed an observational analytical approach with a cross-sectional design. The participants included all toddlers from three Integrated Health Post (Posyandu) with the highest stunting prevalence, located at Demangan Primary Health Center in Madiun, Indonesia known for having the highest stunting prevalence. Sampling was carried out using a total sampling technique. It was conducted by considering the inclusion and exclusion criteria. Toddlers born at term, possessing a Maternal and Child Health book, and whose parents were willing to participate met all the inclusion criteria. Toddlers with a history of congenital diseases and/or severe infectious illnesses, as well as those with incomplete data, were excluded from the study. The study received approval from the Ethical Health Research Committee of Faculty Medicine Universitas Airlangga Surabaya, Indonesia, with ethics approval number 17/EC/KEPK/FKUA/2023 on 19 January 2023.

In this study, the variables used were stunting, maternal pre-pregnancy BMI, maternal upper arm circumference (LILA), maternal weight gain during pregnancy, inter-birth interval, low birth weight, per capita income, parental education, maternal knowledge on toddler’s nutrition and parenting patterns of feeding. Data were collected through questionnaires as primary data and secondary data from Maternal and Child Health books and primary health care records. The data collected from this study were examined through either a Chi-Square or Fisher’s Exact test.

RESULTS

In this research, 156 samples were acquired, comprising 18 cases of stunting (11.5%) and 138 normal toddlers (88.5%). These samples were gathered from three Integrated Health Posts in Demangan Primary Health Center, Madiun. The subsequent section presents the findings from the data analysis conducted in this study.

Characteristics	n	%
Gender of toddlers
Boys	100	64.1
Girls	56	35.9
Toddlers’ age (months)
0 – 11	29	18.6
12 – 23	25	16.0
24 – 35	26	16.7
36 – 47	36	23.1
48 – 59	40	25.6
Mothers’ age (years)
21 – 30	51	32.7
31 – 40	89