Marni Marni*
| Andi Zulkifli | Ridwan Mochtar Thaha | Healthy Hidayanty | Stang Stang | Muhammad Syafar | Amran Razak | Aloysius Liliweri | Ria Rezeki Sudarmin | Intje Picauly
© 2023 IIETA. This article is published by IIETA and is licensed under the CC BY 4.0 license (http://creativecommons.org/licenses/by/4.0/).
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This study aims to determine mothers' level of awareness, motivation, and intentions in preventing stunting in dry areas that tend to be food insecure. The type of research used was qualitative, using a phenomenological approach through interviews, forum group discussions, and observations. The informants involved were 20 mothers with babies 0-23 months and 3 health workers responsible for the Kupang Regency stunting program. The mother's awareness regarding stunting prevention efforts could be seen from the mother's knowledge, action cues, and risk perception. In-depth interviews were conducted with informants regarding the mother's motivation, reflected in the mother's attitude and self-confidence in carrying out stunting prevention efforts. The results of FGDs and in-depth interviews with mothers revealed that they knew nothing about stunting and had never even heard of the term. This was similar to what health workers stated; people generally did not know the term stunting. Actions to prevent stunting in the form of breastfeeding revealed that they act to provide breast milk to children which is part of efforts to prevent stunting due to encouragement from health workers and also families. The mother's intention to make efforts to prevent stunting properly is by doing a number of things, including providing nutritious food, routinely checking children at the Puskesmas and taking good care of them. The conclusion is mother's awareness regarding stunting prevention efforts, judging from the variety of mothers' knowledge, some have never heard of the term stunting, some know the term stunting but don't know what it means. Their cues to act were obtained from health workers and their families. Perceptions of risks related to stunting in children, mothers consider it not a problem.
stunting, awareness, motivation, intention, prevention, dry area
Malnutrition is a public health problem that is a global health burden and a cause of premature death and childhood morbidity. The problem of malnutrition suffered by some children causes stunting, which indicates a failure to reach the genetic potential of the child's height [1]. The long term will cause wasting (thin) and stunting children and is supported by research results which show that the heightened risks of potentially irreversible loss of growth and cognitive functions and increased morbidities and mortalities associated with stunting demand further work on the etiology, prevention, and early treatment of children with stunting [2].Stunting reflects chronic malnutrition and can have long-term impacts, including stunted growth, decreased cognitive and mental abilities, susceptibility to disease, low economic productivity, and low quality of reproductive output.
Data from the WHO (World Health Organization), Unicef, and the World Bank Group in mapping the health problems of children under five years old in 2020 shows that Indonesia is included in a very high level of stunting, which is 30% [3]. The reduction in stunting rates on a national scale in Indonesia differs from the conditions in the Province of East Nusa Tenggara. The prevalence of stunting in the Province of East Nusa Tenggara is the highest prevalence among 34 provinces that have a stunting prevalence above the Indonesian national prevalence of 24.4% [4]. Based on SSGI, the prevalence of stunting in East Nusa Tenggara is still in the red area, with the prevalence of stunting in children at 37.8% [4]. Of the entire area in NTT, Kupang Regency is a district that has a relatively high prevalence of stunting, namely 33.9% from 8,859 children under five in 2019 and continues to increase to 40.4% [5], and one of the sub-districts in East Nusa Tenggara. Kupang Regency has a prevalence above the national standard, Kupang Timur District, at 27.2%, or as many as 1,015 toddlers who experience stunting.
Kupang Regency, East Nusa Tenggara (NTT) Province, especially in East Kupang District, is a dry land area. Dry land is a stretch of land that is never flooded or flooded most of the time of the year [6]. The climate conditions in East Nusa Tenggara are semi-arid, with rainy periods lasting 3-4 months and dry periods 8-9 months. The consequences are, among others: drought, crop failure, crop failure, flooding, and severe pests and plant diseases [5]. These climatic conditions greatly affect agriculture. Research conducted by PIKUL shows that uncertain climatic conditions and low rainfall in Kupang Regency impact crop failure for farmers and family food insufficiency [7]. Regency Kupang, located in the Nusa Tenggara region, is classified as very food insecure at 14.5%, meaning that the fulfillment of energy is less than 70% of the recommended needs for a healthy life [8]. Of course, this vulnerable condition greatly affects the nutritional needs of families, especially children.
This study aims to determine mothers' awareness, motivation, and intentions in preventing stunting in dry areas that tend to be food insecure, Kupang Regency, East Nusa Tenggara.
2.1 Research type and location
The type of research used was qualitative, using a phenomenological approach to find behavioral phenomena related to maternal awareness, motivation, and intentions in stunting prevention efforts. This research was conducted in East Kupang District, Kupang Regency, East Nusa Tenggara Province, in May 2021.
2.2 Research instruments
This research involved instruments in the form of the researchers using interview guidelines, FGD guidelines, and observation guidelines, as well as tools that help researchers record and document all interviews with informants in the field in the form of a tape recorder, cellphone camera, pens, and notebooks. Then, the informants involved were 20 mothers with babies 0-23 months and 3 health workers responsible for the Kupang Regency stunting program. The main informant (mother) was determined by purposive sampling with the following criteria; willing to be an informant residing in the East Kupang District, Kupang Regency, and has a baby 0-23 months.
2.3 Data collection
The data collected was carried out by observing the COVID-19 prevention health protocol. This data was obtained through in-depth interviews, questionnaires, FGD (Focus Group Discussion), and observation. In-depth direct interviews with informants were in the form of individual dialogues using questions so that the informants express knowledge, attitudes, motivations, and intentions of mothers related to parenting and feeding their children. In the awareness variable, information was studied: knowledge, action cues, and perceptions of risk for mothers with babies 0-23 months and health workers. Motivation variables included attitude, the influence of norms, and the self-confidence of mothers who have babies 0-23 months. Then, the intention variable included the mother's intention in feeding and parenting related to stunting prevention in mothers with babies 0-23 months.
2.4 Data analysis
At the analysis stage, the data was obtained from the results of in-depth interviews, FGDs with several informants, then made a transcript of the results. Then, the data was reduced by including it in the interview matrix and determining the themes of each finding. From this matrix, the researcher then interprets the data and concludes.
2.5 Research ethics
This study proposed ethical considerations from the Research Ethics Commission of the Faculty of Public Health, Hasanuddin University, number of recommendation letter for ethical approval 3105/UN4.14.1/TP.02.02/2021 and protocol number 15421043005, and obtained permits and recommendations from the Government of East Nusa Tenggara Province and the Government of Kupang Regency.
3.1 Characteristics of informants
The main informants' characteristics were 20 mothers, 18 people who did not work, and 2 working as teachers. The most recent education was 9 people who graduated from high school, 5 graduated from elementary school, 4 graduated from junior high school, and only 2 graduated with bachelor's degrees. Judging from their religion, 7 mothers were Catholic, 8 mothers were Protestant Christians, and 5 mothers were Muslim (Table 1). Characteristics of key informants consisted of 3 Health Officers. The last education of health workers was 1 person graduated from high school, 1 person graduated with an associated degree (DIII), and 1 person graduated with a bachelor's degree.
Table 1. Characteristics of informants
|
Characteristics |
n |
% |
|
Job status |
|
|
|
Work Doesn't work |
5 18 |
10 90 |
|
Education |
|
|
|
Bachelor's degrees Senior high school Junior high school Elementary school |
2 9 4 5 |
10 45 20 25 |
|
Religion |
|
|
|
Catholic Protestant Christians Muslim |
7 8 5 |
35 40 25 |
|
Total |
20 |
100 |
3.2 Mother's awareness regarding stunting problems
The mother's awareness of stunting prevention efforts was seen from knowledge, action cues, and risk perception.
3.2.1 Knowledge
The results of interviews with mothers in East Kupang related to knowledge about stunting; it was found that their knowledge level was divided into three categories, namely, not knowing the term stunting at all, only knowing the term stunting and understanding about stunting.
Do not know the term stunting at all
The results of FGDs and in-depth interviews with mothers revealed that they knew nothing about stunting and had never even heard of the term. This was similar to what health workers stated; people generally did not know the term stunting. Although health workers acknowledge that they continued to socialize with mothers when they went to the Integrated Healthcare Center (in Indonesia: Posyandu), the information was not maximally conveyed.
Furthermore, in in-depth interviews, researchers conducted probing related to short children. Although some mothers did not understand the term stunting, they knew it when researchers mentioned the word, short child. Mothers said they know the term short child; they call it a dwarf child "unyil." The mothers revealed that the causes of children becoming short were lack of food or malnutrition and the lack of attention parents gave to their children. Furthermore, the informant revealed that the short child was not only caused by lack of food and malnutrition; it was also caused by heredity, children with short families are at risk of becoming short children.
The prevention that can be done to prevent children from becoming short, expressed by the informant, is by consuming various foods such as vegetables, nuts, and fruits, as well as drinking milk. This information was basic and known to all informants. Furthermore, when asked about exclusive breastfeeding, mothers knew the term. However, this knowledge was considered unrelated to the problem of short children. Then, the health workers asked the mothers who had given birth to give their first milk, the medical term is colostrum, and the mothers also followed every suggestion from the health workers.
Know about stunting
In-depth interviews with the TNI (36 years old) stated that the term stunting had been heard before, but they did not know the explanation about stunting. A mother's knowledge about stunting was only up to the knowledge level. Informants had heard of the term stunting; however, the explanation of stunting was not understood well.
Mothers who know the term stunting think that stunting is another word for short children whose prevention methods include exercise, consuming vegetables, maintaining personal and environmental hygiene, getting adequate rest, and measuring height at the Integrated Health Centre. Because stunting was considered a short child, the informants understand that for children to be tall, they must be diligent in exercising.
In-depth interviews with health workers revealed that the Communication, Information, and Education intervention was still running at the Integrated Health Centre, but the health workers could not explain this to mothers. However, during the 2 years of the COVID period, education on stunting did not run very well because the rules not to allow crowds to gather made health workers and cadres unable to convey information about stunting more regularly.
Good understanding of stunting
FGDs and in-depth interviews with mothers related to stunting found that some mothers already understood stunting. As an informant who understands stunting, Mother gets information from various sources. They know the term stunting from information obtained when visiting the Integrated Health Centre or other health facilities and reading the Mother Child Health book.
In contrast to informants who did not know about stunting, informants who understood stunting were mothers who diligently visited health facilities so that they were familiar with the term stunting and had a better understanding of stunting in terms of its definition, causes, and ways to prevent it. Mothers revealed that stunting was a condition in which children's height did not match their age due to malnourished children, which they call short or stunted children. The various informants' knowledge of stunting could not be separated from the informants' experiences who have directly experienced stunting conditions.
DNA (31 years old) knows about stunting based on his experience, namely as an inappropriate weight or, in other words, stunting is considered a condition of malnutrition. Various informants expressed knowledge related to the causes of stunting. Several informants revealed two reasons why children become stunted; firstly, because of heredity, starting with pregnant women with short families, and second, because children are malnourished. The way to prevent children from experiencing stunting was expressed by several mothers, namely by providing nutritious food. Other stunting prevention efforts were revealed by EST (30 years old), who works as a housewife by maintaining cleanliness, consuming good food, and having a good diet. In contrast to other informants, YLI (36 years old), who works as a teacher, provided limits for stunting prevention, which could only be done when the mother is pregnant by consuming nutritious food.
3.2.2 Action cues
The results of interviews with mothers related to reasons for acting or cues to prevent stunting in the form of breastfeeding revealed that they acted to provide breast milk to children who are part of stunting prevention efforts due to encouragement from health workers and also families.
SNT (22 years) and EST (30 years) stated that they gave breast milk to their children because the midwife told them not to throw away the first milk and breastfeed their children when they were at the Community Health Center (in Indonesia: Puskesmas). Likewise, mothers who gave birth in the hospital also received information from doctors who encouraged them to continue breastfeeding their children. In addition to getting information from midwives and doctors, encouragement to breastfeed children was also obtained from the family. DNA (31 years old), who works as a teacher, stated that she gave breast milk to her child because, from the results of the examination at the Community Health Center, her child was in the category of malnutrition. So doctors recommend switching from formula to breast milk to improve child nutrition. Informants' information on breastfeeding in children was obtained from the mother-in-law, and counseling activities were carried out by health workers, in this case, midwives at the Integrated Health Center. This was similar to interviews conducted with health workers in that they provided counseling during Integrated Health Center activities and provided information and advice to mothers who visited health facilities related to exclusive breastfeeding, maintaining personal and environmental hygiene, and consuming nutritious food.
3.2.3 Perception of risk
In interviews conducted with mothers related to awareness, researchers conducted probing to find out how to assess the risks that will be experienced by a child when suffering from stunting or malnutrition. The results of the interview obtained two categories, namely: the mother considers that the short condition experienced by the child is normal and has no effect on health; the condition of the child's short body is considered not something that affects health problems but is considered a natural thing because of heredity. The second category was the mother's assessment that the stunting condition experienced by the child would affect health; stunting has an impact on health problems such as children who get sick easily, are sluggish or not enthusiastic, and their growth is not good. Another assessment of the risks experienced by children when suffering from stunting is slow to think and has an impact on the child's IQ so that it will ultimately determine the child's personal quality.
3.3 Mother's motivation regarding efforts to prevent stunting in children
In-depth interviews were conducted with informants related to the mother's motivation for stunting prevention efforts in children seen from the mother's attitude and self-confidence in carrying out stunting prevention efforts.
3.3.1 Attitude
Interviews with informants related to mothers' attitudes in preventing stunting found three categories: mother's attitude related to exclusive breastfeeding, mother's attitude related to child care, and mother's attitude related to providing nutritious food to children.
Mother's attitudes regarding exclusive breastfeeding for children
The informant was firm by refusing everything related to children's consumption before 6 months other than breast milk. Mothers give exclusive breastfeeding because they think that exclusive breastfeeding provides good benefits for children's growth and development. The mother's fear of health problems when giving children food other than breast milk before the age of six months encourages mothers to take action to refuse.
Mother's attitude regarding child care
The informant considered the mother's attitude regarding child care to be something important. The interviews with informants found that mothers should carry out parenting so that the inner bond between mothers and children improves. The informant considered parenting to be able to devote all his full attention compared to if the child was cared for by his grandmother.
Mother's attitude regarding the nutrient intake for children
The results of in-depth interviews with informants found that in addition to exclusive breastfeeding, child care and consumption of nutritious food were also considered important. This is also supported by the experience of informants with poor nutritional status.
3.3.2 Self-confidence
The results of in-depth interviews showed that the informants' self-confidence was divided into four categories: related to personal hygiene in children, related providing nutritious food to children, related to providing immunizations to children, and related to childcare efforts. Self-confidence related to efforts to maintain personal hygiene in children. The interviews with informants showed that the efforts related to maintaining personal hygiene in children by bathing twice a day and washing children's hands when they wanted to eat believed the informants to be correct. Self-confidence related to efforts to provide nutritious food to children. The in-depth interviews with informants found that mothers were still unsure about giving their children nutritious food. SNT (22 years old), a housewife, explained that efforts to provide nutritious food to children were still considered insufficient. This is because the condition of the availability of side dishes at home in the form of fish, meat, tofu, and tempeh is sometimes not available, so children are only given porridge. Health workers confirmed that one of the obstacles is the economic factor; sometimes, people want to provide nutritious and more varied food to their children, but it is just not possible to buy it, so the food is prepared according to financial ability.
Another case was stated by DRL (36 years old), who also works as a housewife. Informants considered that the provision of nutritious food to children was still lacking due to the busy work of mothers at home, so they paid less attention to the food given to children. Health workers and community cadres expressed the same thing that mothers who are busy working in the garden do not have time to pay attention and arrange children's food, so that time to prepare food for family members sometimes does not have time this is because almost all day mother's time is spent working in the garden. However, mothers strongly believe that exclusive breastfeeding is the best food for children aged 0-6 months.
Self-confidence related to efforts to give immunizations to children
One of the efforts that can be made to prevent stunting is to provide complete immunization to children. The results of an in-depth interview with DNA (31 years old) revealed that, by immunizing their children, their immunity would be better, and they would avoid various diseases. The problem of stunting is currently the government's concern. The results of in-depth interviews with health workers revealed that the health programs implemented to deal with the stunting problem were the provision of blood-boosting supplements, supplementary feeding for pregnant women and the poor, promotion and counseling, Kindergarten screening, and integrated management of sick toddlers and many others.
Self-confidence regarding parenting
Informants expressed their belief in the care given to their children. For some informants, child care was a very priority for them because, for them, children are the most valuable asset. They took good care of their children without having to entrust the child to someone else. The same was explained by health workers who pay attention to child-rearing behavior. The health officer explained that in the community in Kupang Regency, especially in East Kupang Subdistrict, when the child is still in infancy until the age of 2 years, the child will be cared for by the mother without being entrusted and given good care. Later the child is 2 years old, and the mother leaves the child when she is working.
3.4 Mother's intention to prevent stunting in children
Based on the results of interviews and FGDs conducted with mothers regarding the intentions of efforts to prevent stunting in children, two categories were obtained, namely wanting to make stunting prevention efforts well, wanting to take stunting prevention efforts but having obstacles.
Want to take good stunting prevention efforts
In-depth interviews with mothers were related to their intention to carry out stunting prevention efforts properly, namely by doing several things, including providing nutritious food, routinely checking children at the Integrated Health Center and taking good care of them.
EST (30 years), OMK (43 years), and DNA (31 years) stated that to prevent stunting in children, they strive to meet the nutritional needs of children even though the nutritional requirements of 4 healthy 5 perfect are applied, but they still provide nutritional intake with good food and take good care of their children, not only that, also routinely carry out child health checks at the Integrated Health Center.
Want to make efforts to prevent stunting in children, but there are obstacles
The results of interviews with several mothers regarding their intentions in preventing stunting in children stated that they wanted to take steps to prevent stunting, but several obstacles prevented them from doing so. SNT (22 years old) and DRL (35 years old) stated that they wanted to provide nutritious food, but they were constrained by the problem of the family's ability to prepare the nutritional intake needs of their children, then rely on practically available food.
The health officer confirmed the informant's statement, and even the health worker added that mothers sometimes give food to their children without paying attention to the nutrition of the food. In addition, there are economic factors and their parents' busyness, so they cannot pay attention and prepare good food for their children.
4.1 Mother's awareness regarding stunting problems
The results of this study explain that maternal awareness regarding stunting in children is influenced by three basic aspects: knowledge, action cues, and risk perception. Mother's knowledge related to stunting is still diverse. Starting from those who do not know at all, know the term but do not understand the meaning, to those who understand the term and its meaning. This certainly cannot be separated from the differences in the informants' education. Low education limits mothers in understanding information about stunting. It is just that higher education does not guarantee that mothers will have a good understanding of stunting [9]. In this study, informants' knowledge related to stunting was influenced by several factors. Some received information from health workers, and some received information from their families. Families have a strategic position in providing information and support for behavior change. This is inseparable from a tendency for people to trust those closest to them more easily [10].
Furthermore, the act of cue factor affects the mother's awareness regarding the problem of stunting. Signals for action can be internal or external [11]. These cues for action include exposure to information obtained by the mother from health workers during visits to the Public Health Center and the unsanitary health condition of the child, which makes the mother switch from formula feeding to breastfeeding.
The last thing that affects maternal awareness regarding the problem of stunting is the perception of risk. Based on the results of in-depth interviews that have been conducted, the researchers obtained information that there are two different perceptions. Some informants think stunting is natural and does not affect health. The researcher sees that the informants' perception of the term stunting has not fully led to the truth. This is evidenced by the informant's statement that stunting is a natural thing and a hereditary factor. This could be triggered by the lack of information about stunting circulating among the public, so wrong perceptions and conclusions are formed about the term stunting [12]. Perception is influenced by the repetition of health workers' information and the family's support [13].
4.2 Mother's motivation regarding efforts to prevent stunting in children
This study examines the mother's motivation regarding stunting prevention efforts based on the mother's attitude and self-confidence in carrying out stunting prevention efforts.
Informants in this study have a good attitude regarding breastfeeding because breastfeeding benefits children's health and development. In addition, the fear factor of the emergence of health problems in children if the mother provides food other than breast milk before the age of 6 months also strengthens the mother's attitude to continue to give exclusive breastfeeding to her child. Mothers who became informants also agreed that parenting should be carried out directly by the mother because it would strengthen the inner bond with the child, and of course, the attention given would be much more leverage than other people. Based on research conducted by Nurdin and Hartati that errors in parenting are one of the factors that cause stunting in Goroantalo [14]. Quamme and Iversen said that maternal parenting and environmental quality were the main factors in the incidence of stunting in Saharan Africa [15]. Parenting must be considered and cannot be ignored to improve nutritional status, especially for toddlers, to prevent stunting [16]. Factors that are not good parenting in the family are one of the causes of nutritional problems, including stunting.
Self-confidence is the most effective predictor in assessing changes in a person's behavior. Self-confidence is an essential element that supports maternal awareness in taking stunting prevention actions. The results of this study indicate that the informants believe that efforts related to maintaining personal hygiene in children in the form of bathing twice a day and washing children's hands when they want to eat are important. Then, the informants are also not sure if the efforts related to providing nutritious food have been fully carried out properly. Providing nutritional intake, in this case, breastfeeding and complementary foods, is very influential on the incidence of stunting [17]. Therefore, mothers need to make efforts to fulfill nutrition for their children even while they are still in the womb [18].
This study also shows that the informants believe immunization will increase the child's immune level. This is in line with research conducted by Miranti and Hasnunidah that children with a low immunization history tend to be stunted [19]. In addition to being related to nutritional deficiencies (macronutrients and micronutrients), it is known from several research results that infection can cause stunting. One of the steps in preventing infectious diseases in children can be done by giving immunizations. Immunization is an effort to cause/increase a person's active immunity against disease [20].
Many things can influence a mother's beliefs about parenting. It starts from the mother's education level to the parenting pattern in the family sphere [21]. The results of this study indicate that the informants believe that child care is a very priority because children are their most valuable assets, so they take good care of their children without entrusting them to someone else. Research conducted Apriliana related to child care in urban and rural areas found that parenting patterns in the family sphere also affect the growth and development of toddlers [22].
4.3 Mother's intention to prevent stunting in children
The results of this study indicate that the mother's intention to prevent stunting in children is divided into categories. Some intend to make the best possible prevention efforts, such as providing nutritious food intake, routinely carrying out child health checks, and taking good care of children. Based on research carried out by Fitroh and Oktavianingsih [23], health literacy is needed to increase mothers' awareness, intention, and belief in parenting through a parenting education program [23]. In essence, to strengthen the mother's intention in child care, it is necessary first to strengthen the knowledge aspect. According to research conducted by Aridiyah et al. [24] the level of a mother's knowledge about nutrition is one of the factors that can affect the occurrence of stunting in children under five in both rural and urban areas. Knowledge about nutrition is the initial process of changing behavior to improve nutritional status, so knowledge is an internal factor influencing behavior change. A mother's knowledge about nutrition will determine the mother's behavior in providing food for her children. Mothers with good nutritional knowledge can provide food with the right type and amount to support the growth and development of toddlers.
Mother's awareness regarding stunting prevention efforts, judging from the varied knowledge of mothers, some have never heard of the term stunting, some know the term stunting but do not know its meaning, and some do. Their cues for action were obtained from health workers and their families. Moreover, related to the perception of risk related to stunting in children, mothers think it is not a problem, and some consider that stunting conditions can interfere with children's health.
Motivation is seen in the mother's firm attitude in refusing actions such as feeding children under 6 months for fear of the child experiencing health problems. In addition, it is also seen in the mother's self-confidence. Some mothers are sure that the efforts are good, but some are not convinced because of financial constraints and busy mothers preparing nutritious food for their children.
Mothers' intentions related to efforts to prevent stunting in children; some mothers want to take good stunting prevention efforts such as providing nutritious food and routinely checking the growth and development of children in health facilities. Some mothers want to make efforts to prevent stunting in children, but there are obstacles such as economic problems and mother busyness.
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