Stunting is a growth problem occurred in child aged under 5 years old. Its defined as length/height-for-age. Results that show <-2 SD are categorized as stunting based on WHO antropometric standard. Stunting is caused by chronic malnutrition since pregnancy and continue throughout early age of childhood. Which includes inadequate intakes of nutrition, psychosocial economic factors and repeated exposure to infections. stunting can make child motoric, cognitive and verbal development delayed. While in the long term stunting can lead to increased risk of degenerative disease, reduced work capacity and productivities as an adult.

Stunting is the biggest nutritional problem in Indonesia, especially in children under 5 years old. In 2018, there were 30,8% prevalence of stunted child in Indonesia. East Java ranked seventh nationally with prevalence 33,6%. Malang regency has 2711% prevalence of stunted child in 2020 and Gondanglegi sub-district was ranked first in term of total stunted children.

Factors that are considered to have high contribution to stunting are exposed to infection (diarrhea and ARI) and nutritional intake. Sufficient nutritional intake supports optimal growth and development of children. Disposing colostrum, did not breastfeed exclusively, inappropriate complementary foods and inadequate nutritional intake can lead to stunting [1-3]. Exposure to infection such as diarrhea and ARI tend to cause stunting if not treated immediately. Batiro et al., [2], stated that there were significant correlation between exposure to diarrhea to malnutrition. Socio-economic, demographic and environmental factors also play a big role in stunted children. Socio-economic are related to the type of occupation, income, access to healthy food and health facilities. Environmental factors plays role in stunting if the family and kids did not practice healthy living behavior demographic factors will likely affect parenting, access of food and health care facilities [1,2].

Other study showed that kids characteristics such as birth weight and length, age, gender, protein and calories intake affect the incidence of stunting in Indonesia [4,5]. Maternal nutritional status and utilization of health care facilities also associated with stunting. Parental education status has a big role to determine the occupation and family income. A higher family income means stability of food supply and access to health care facilities [6].

Based on 2018 basic health research, Malang regency has prevalence of stunted children approximately at 27,1%. In 2020, the prevalence of stunted children was 12% or 17.000 stunting cases. Gondanglegi is the subdistrict with the highest prevalence of stunting, namely 34,5% or equivalent to 932 children which divided into two work areas, Gondanglegi and Ketawang Health Center.

Hence, this study was conducted to determine factors that associated with stunting in children under five years.

This study was an observational analytic study using quantitative approach with case-control design. The study was held on October – November 2021 in two Health Center in Gondanglegi sub district, namely Gondanglegi and Ketawang Public Health Care. The subjects of this study were children aged 6 – 59 months, with total sample of 136, divided ito two equal groups, cases (stunting) and control (normal). Respondents were from 3 villages, Gondanglegi Kulon, Putat Lor and Ganjaran, which obtained using purposive sampling technique.

Dependent variables in this study were stunting while the independent variables including child, maternal, family and household, socio-economic, location of residence and utilization of public health center. Data obtained by measuring height and weight, questionnaire based interview, 24-hour food recall and Mother and Child Health Had book. 

Before filling in the data, respondents were informed about the aim of the study and asked for their permission to be respondent. Respondent were asked to sign an informed consent papers. This research was approved by Ethics Research Commission Brawijaya University (No.286 / EC / KEPK – S2 / 09 / 2021).

Data from 136 respondents were successfully collected. The results showed that stunting were likely occurred in children who weigh less than 2500 grams (30,8%) and length less than 48 cm (30,8%), age ranged from 6-35 moths (69,2%), stunting was common in boys (51,4%), exposure to infection in the past month is likely has relation to stunting, inadequate intake of protein and calori was commonly found (64,7%).

Based on maternal nutritional status, there were 27 mothers who from chronic energy deficiency. Based on household characteristics stunting was common from family who had not enough food security (55,9%), had poor sanitation (55,9%), gave a poor feeding practice (58,9%), had large family member (54,4%) and birth sape was more than two years (70,6%).

Based on socio-economic characters, father’s education in stunted children was low, but it’s statistically not significant. While mother’s educational status was statistically significant (70,5%). Both father and mother were work on informal sector (69,1% and 72,1%), stunted children were likely coming from low income family (55,9%). Based on residence location living in rural was probably stunting predictor (47,1%) and poor utilization of health care center tend to lead to stunting (38,2%) (Table 1).

Table 1: Distribution of Characteristics Between Case and Control Groups

*Statisticaly significant at p-value <,0,05

Then, seventeen variables were analyze using multiple logistic regression. The results showed that factors associated with stunting were protein intake (AOR = 35,308), calorie intake (AOR = 9,563) and exposure to infection (AOR=5,168) (Table 2). Children with protein intake less than recommendation had thirty-five times greater risk of stunting than those with sufficient protein intake. Children whose calorie intake was inadequate had 9 times greater risk for stunting than children who got adequate calorie intake. Children who exposed to infection (diarrhea and/or ARI) in the past month was 5 times greater risks for stunting than child who did not get infection in the past month.

Table 2: Multivariate Analysis Result

* Statisticaly significant at p-value <,0,05

In term of child characteristic, the two groups were relatively different. Significant difference were found in birth weight and length, child’s age, exposure of infection, calorie and protein intake. These results were similar to other studies in Indonesia and Ethiopia, which reported that stunted children has history of low birth weight and short length at birth, it caused by malnutrition throughout pregnancy. Child under three years old were prone to stunting, it caused by at the time there was transition from breast milk to solid food which can lead to eating problems, hence low intake of calories and protein intake can interfere growth rate [1,7], maternal characteristic marked with arm circumference were different between two groups. The stunted children has come from mater with UAC more than 23,5 cm, but in this research did not measure mother height and BMI to ensure mother nutritional status. Mother with UAC less than 23,5 cm was tend to has stunted children because undergoing malnutrition and at risk to give birth to low birth weight baby. In term of household characteristics, food securities, household sanitation, feeding practice and total family members were significantly affecting stunting. families with more than 4 members and has low income tend to has limited food resources, especially meat based food. Feeding practice including breastfeeding exclusively, a good complementary feeding could prevent children from stunting, hence complementary food must bee full of nutrients to supports child growth and development. Household sanitation plays an important role to prevent children from infection that lead to wasting and stunting [1,2,8,9]. Birth spacing were not statistically significate it might be caused by as the mother getting older it was likely to be more risk to give birth a low birth weight baby [10].

In term of socio economy characteristics there were no difference between fathers’s educational status and parent’s occupation in two groups with stunting. there were significant difference between mother’s education and family income. These results were similar to other studies which reported that low educated mother has limited knowledge in child feeding, seeking health practices, food choices that contribute to stunting. Low income family was associated with food securities and utilization of health facilities [4]. 

Children who lived in rural area were associated with high risk of being stunting. Living in rural area were prone to difficult access to food, education and health facilities. Low rate of utilization of health facilities may cause children being stunting. mother who attended less than 4 times to get ANC from health worker were at risk of giving birth to stunted kid. During pregnancy, mother’s would be taken care of by midwife, if mother did not attend as much as 4 times it will caused problem during pregnancy, birth and kid’s childhood. Children who did not attend integrated service post (Posyandu) were prone to stunting, because they growth and development were not monitored. It was known that parent of stunted children feel ashamed to go to Posyandu caused by their child condition. Basic immunization for toddler were important to prevent them from infection that can led to stunting. Parent’s low education status were associated with this behavior, hence they didn’t know how it will affect their kid in the future [2,4,6,11].

Results of this study indicated that children with low intake of protein and calorie have thirty-five and nine times greater risk of stunting than children whose protein intake were sufficient (AOR = 35,308; CI = 6,559–190,077). These results are in line with other study which stated that children who takes energy and protein less than recommendation were six and four-time greater risk than children who get sufficient intake of protein. The low level of meat consumption causes children to lack protein so they are more at risk of being exposed to stunting. As we know, energy and protein is an important substance to our body, lack of protein, energy and carbohydrate can cause DNA methylation which DNA methylation were found in stunted children [2,12].

Recurrent infections in children under five, mainly diarrhea and ARI have an effect on the incidence of stunting in children under five in Gondanglegi District, Malang Regency. These results are in line with the finding in Ethiopia where diarrhea and ARI in children under five had a significant effect on stunting (AOR = 3.04; 95% CI = 13.35). Toddlers who have ARI are more susceptible to nutritional problems because in the respiratory tract and digestive tract there are Lactobacilli and Bifido bacteria which are usually found in breast milk, these two microbiota act as an immune barrier and help the reabsorption process in the digestive tract in toddlers. If the child has repeated infections such as diarrhea and ARI, it will affect the normal flora and the child will be more susceptible to infection and lose the ability to reabsorb in the intestines [2].

The results showed that protein and calorie intake and exposure to infection were factors associated with stunting among children under five years old in Gondanglegi sub-district, Malang, Indonesia. Children whose protein and calorie intake were below recommendation had thirty-five and nine times higher risk than whose get sufficient protein intake and calorie. Children who exposed to reccurent infection of diarrhea and ARI were five times higher risk than children who did not get reccurent infection. Hence, macronutrients and prevention of infection are important and should be prevented to reduce stunting prevalence in Gondanglegi sub-district.

Acknowledgment

The author thanks the board of supervisior for criticism and suggestions, respondents, lecturer and staff and family for the support so this research was successfully held.

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