Stunting Risk Factors And Knowledge, Attitudes, And

Behavior Of Mothers With Stunted Children In Indonesia

Tri pitara1, Titiek hidayati2*, Indrayanti3, Dewi Yuniasih4, Mei-Ling Tsai5

1, 2, 3
Faculty of Medicine and Health Science, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia.
4
Medical Faculty, Universitas Ahmad Dahlan.
5
College of Medicine, National Cheng Kung University, Tainan, Republic of China (ROC), Taiwan.
Email: 2 hidayatifkumy@yahoo.co.id

*Corresponding Author: Titiek hidayati

Faculty of Medicine and Health Science, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia.
DOI: 10.47750/pnr.2022.13.S10.572

Stunting, also known as short stature in children, is a chronic malnutrition condition that occurs in toddlers during the growth and development
phase of their lives. Risk Mothers' knowledge, attitudes, and behavior are strongly linked to their children's risk of stunting. Stunting is a
global issue that is closely linked to nutritional issues, particularly in poor and developing countries. This study aimed to determine risk
factors for stunting, the knowledge, attitudes, and conduct of mothers with stunted and non-stunted children, and what knowledge, attitudes,
and behavior must be changed in Indonesia. The study design was case control analytics group. As a result, Low birth weight, intrauterine
growth restriction, poor ante natal care/ANC adherence, low parental education, inadequate immunization, non-exclusive breastfeeding, and
low stunting knowledge and attitudes are risk factors for children. Stunted children's mothers have less information, attitudes, and behaviors.
From a child's first 1000 days, chronic disorders like diabetes and stunting must be averted. Mothers of stunted children must improve their
prenatal care/ANC exam habits. Stunted children showed lower hemoglobin, erythrocytes, monocytes, and lymphocytes. As conclusion,
stunting risk factors include mother's knowledge, attitudes, and actions. Increasing awareness, attitudes, and behavior around adult chronic
illness risk, stunting prevention, and routine ANC behavior. The stunted and non-stunted groups had similar test results.
Index Terms— Stunting, Knowledge, Attitude, Blood laboratory examination.

INTRODUCTION
Toddler stunting or stunted growth is still a major issue, particularly in emergent nations such as Indonesia. According to
UNICEF data from 2019, 2 out of every 5 toddlers worldwide have stunted growth [1]. According to the WHO, stunting is
considered a public health hazard if the prevalence is 20% or greater. In comparison, Indonesia has a relatively high frequency
of stunting in children under the age of five, compared to Myanmar (35%), Vietnam (23%), Malaysia (17%), Thailand (16%),
and Singapore (4%).. Indonesia grades 17th out of 117 countries in terms of three nutritional issues: stunting (37.2%), wasting
(12.1%), and being overweight (11.9%). [3].

Stunting has a long-term impact on toddlers' physical, mental, intellectual, and cognitive development. This condition can also
persist into adulthood, increasing the risk of having low birth weight/ LBW children [4]. Given the magnitude of the stunting
problem, it is critical to understand susceptibility factors that can lead to stunting [1].

Parents with a higher education are more likely to understand nutritional needs, development, and growth and can provide better
care for their children [2]. This explanation is supported by WHO's Conceptual Framework, which states that low caregiver
education and poor parenting can result in toddler stunting. Furthermore, known risk factors for stunting include low family
income, low birth weight, not being exclusively breastfed, one parent being short, poor parenting, and MP-ASI occurring at an
early age [5].

Blood and bone marrow tests are used to diagnose some blood illnesses (anemia, leukemia, porphyria disorders, abnormal
bleeding, and clotting), inflammation, infection, and hereditary disorders of red blood cells, white blood cells, and platelets.
Specimens can be obtained through capillary blood (fingertip, toe, or heel), dried blood samples, arterial or venous samples, or
bone marrow aspiration.

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Capillary blood is utilized for peripheral blood smears and other hematological examinations. Blood capillary mockups from
adults are taken at the fingertip. For infants under one year of age and neonates, the big toe or heel side is the best sampling
location. Based on the background above, the purpose of this study was to obtain risk factors for stunting, to find out the
knowledge, attitudes and behavior of mothers with stunted and non-stunted children and what types of knowledge, attitudes
and behavior must be improved in Indonesia.

RESULTS
A. The table 1 results from univariate variables as a determinant factor are give birth methods, birth weight, pregnancy age,
immunization status, medical history, breast milk, mother education.
Table 1. Analysis Univariate Determinant factors
Determinant Factor Stunting Non stunting
Give birth methods N % N %
Normal 17 85 14 70
Caesar 3 15 6 30
Birth weight
low 6 30 1 5
enough 14 70 19 95
Pregnancy age
Less month 3 15 3 15
Enough month 17 85 17 85
Immunization status
Complete 17 85 19 95
Incomplete 3 15 1 5
Mother medical ante natal
care/ ANC history
Yes 16 80 18 90
No 4 20 2 10
Breast milk
exclusive 13 65 19 95
Non-exclusive 7 35 1 5
Mother’s education
Primary school 3 15 1 5
Middle school 10 50 6 30
Secondary school 4 20 11 55
University 3 15 2 10
According to table 1, The percentage of children with stunting who have low birth weight is higher than the percentage of
children who do not have stunting. Furthermore, the number of women with low gestational age, a history of poor ANC
compliance, and low education was higher than the percentage of moms whose children were not stunted. Stunted children had
a higher percentage of inadequate immunizations and a history of non-exclusive nursing than non-stunted children.

B. The table 2 results are percentage of Total correct knowledge, attitude, and behavior variables stunting and non-stunting
groups.

According to table two, the knowledge of mothers with stunted and non-stunted children is still lacking. Lack of knowledge
there are 2 things, namely the first " Stunted children have a risk of developing diabetes as adults.” and the second " The
changes that occur in the first 1000 days of life are permanent.”

Attitudes regarding the prevention and treatment of stunting among mothers with stunted children are lower than those of
mothers with non-stunted children. There are two things that need to be improved, namely " Stunting coincides with inhibiting
the growth and development of all organs, such as the brain, heart, kidney, and pancreas” and " in my opinion, stunting can
occur due to low access to ANC services (prenatal checks) during pregnancy”.

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Table 2. Percentage of Total Correct Knowledge, Attitude, and Behavior Variables in the Pretest Stunting and Non-Stunting
Groups
Percentage of people who
Characteristic Questionnaire questions answered correctly (%)
Stunting Non-stunting
Knowledge Stunting marks kids shorter or taller than their chronological 96,36 66,66
age.
Stunting causes physical changes and does not affect the child's 67,27 83,33
intelligence.
Lack of maternal nutrition during pregnancy does not cause 56,36 83,33
stunting in children.
Child stunting is caused by deprived sanitation and water. 58,18 83,33
Stunted children have a risk of developing diabetes as adults. 43,63 33,33
The changes that occur in the first 1000 Days of life are 63,63 16,66
permanent.
Attitude
Stunting coincides with inhibiting the growth and development 65,45 66,66
of all organs, such as the brain, heart, kidney, and pancreas.
in my opinion, stunting can occur due to low access to ANC 50 72,72
services (prenatal checks) during pregnancy

Behaviour In my opinion, stunting can occur due to low access to ANC 38,18 33,33
services (prenatal checks) during pregnancy
I think giving children a lot to eat is enough to prevent stunting 54,54 66,60
My child rarely eats milk and bread supplements 66,66 84,45
The behavior that is still lacking in mothers with stunted children is carrying out ante-natal care checks during pregnancy.

3. Table three result of Average Lab Results between Stunting and Non-Stunting Groups.

Routine blood laboratory tests are done on stunted and non-stunted children at primary care centers to determine the child's
hematological condition.
Table 3. Average laboratory results for the stunting and non-stunting categories
Laboratory average results Stunting group Non-stunting group P value
Hemoglobin/Hb 10.7 ± 0.89 11.2 ± 1.30 0.283
Leukosit 9379 ± 25297 8322 ± 21411 0.237
Eusinofil 0.20 ± 0.40 0.22 ± 0.44 0.914
Eritrosit 4.43 ± 0.54 4.22 ± 0.39 0.259
Platelets 394.8 ± 101.44 428.4 ± 89.79 0.350
Limfosit 52.19 ± 8.73 56.33 ± 6.76 0.177
Monosit 0.7 ± 0.48 1.1 ± 0.33 0.060

Based on table 3 above regarding the average laboratory results between the stunting group and not stunting. Examination was
carried out on blood components, namely Hb, Leukocytes, Eosinophils, Erythrocytes, Platelets, Lymphocytes, Monocytes. The
findings revealed a substantial value in blood laboratory testing, particularly monocytes.

DISCUSSION
Toddlers who lack disease immunity will quickly lose body energy as a result of infectious diseases, as a reaction is a decrease
in the child's appetite, and the child will refuse to eat. Food refusal reduces nutrient intake in the child's body. Children are at
risk of fail to thrive if their nutritional intake is inadequate, and they suffer from recurring infections. Children's growth and

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development can be hampered by recurring infections. Recurrent infections can impede children's growth and enlargement,
making them more vulnerable to disease.. Illness offers negative feedback on nutritional status and, if protracted, can raise the
menace of stunting. Immunization can upshot in the production of antibodies or immunity that effectively prevents the spread
of certain diseases. Every baby is required to be fully immunized by the government. The concept of complete basic
immunization was changed by the Ministry of Health to complete routine immunization. Basic and advanced immunization are
required for complete routine immunization. Basic immunization is given to babies as young as 24 hours old and continues
until they reach the age of 9 months. Immunization seeks to lower the risk of morbidity and mortality from avoidable diseases
in children. Children's immunization status indicates contact with health services [6].

Risna's findings that vaccination status is associated to the occurrence of stunting in kids aged 2 to 5 years are supported by this
study. According to other research, basic immunization is one of the chance influences for stunting, with OR (2.9), which means
that toddlers with incomplete immunization have twice the risk of experiencing stunting. Immunization is a risk factor for
stunting; tots with insufficient basic immunization are three spells more likely to be stunted. Stunting is associated with a lack
of immunization. This hypothesis is also consistent with the findings of Swathma et al, who discovered that toddlers who did
not obtain complete basic immunization 2.9 times (CI 1.37-11.84) were more likely to suffer from stunting.. Meanwhile, several
previous studies found no link between immunization status and the prevalence of stunting (p = 0.056) [7].

A. Birth weight
Low birth weight/ LBW (2.5 kg) is associated with stunting in toddlers (p=0.001), with an OR of 3.82 (95% CI 2.29-6.37). The
stunting and malnutrition opportunities reported in LBW newborns are reliable with research steered in other means-limited
African and Asian countries. [9]..

In Cebu, Philippines, LBW predicted stunting for two years. LBW increased the jeopardy of stunting at 6 and 12 months,
according to Metro Cebu research. In Indonesia, LBW is linked to stunting in children under 5 (p<0.05) [9].

Children with LBW who also have insufficient food consumption, insufficient health care, and frequent infections during
infancy will continue to have stunted growth and produce stunted children [12],

Infants who experience growth failure (growth faltering) at a young age are more likely to experience growth failure later in
life. Stunting caused by slowing growth and insufficient catch-up cyst echoes an failure to triumph optimum development.
However, with proper nutrition, the normal growth pattern can be resumed. Birth length, along with birth weight, is used to
assess the health of the fetus in the womb.

B. Breast milk
Breast milk supports growth and development in children. Breast milk antibodies seldom make children sick. 46 (59%) of 25-
59-month-old non-wholly breastfed infants were stunted, according to studies. The chi-square test results showed a p-value of
0.01 by OR = 2.43 (95% CI 1.276-4.624), indicating that a history of nursing affects the occurrence of stunting in kids matured
25-59 months, with a risk of stunting 2.429 times higher in toddlers with a past of non-exclusive breastfeeding than exclusive
breastfeeding.

Tots who have a antiquity of non-exclusive nursing are four times more likely to have stunting than toddlers who have a history
of exclusive breastfeeding, with a p-value significant. In terms of weight/age and PB/age indices, the lower the breastfeeding
rate, the greater the child's growth rate in the malnutrition category. Breast milk is required to supply the nutritional needs of
newborns during their growing stage [10].

C. Medical history
Both the stunting and non-stunting nursery groups were in poor health. The history of sickness and stunting are linked [11]
[13], who exposed a tie between a past of illness and the prevalence of stunting. According to the theory, toddlers with a history
of illness disrupt children's nutritional status, ranging from malnutrition to stunting. The link between stunting and infectious
and non-infectious illnesses has an impact on growth by reducing appetite, impairing absorption in the gastrointestinal tract,
and increasing energy requirements for disease healing [8].

The toddler stage is when infants are most vulnerable to various health problems. When the baby is sick, the risk of recurrent
infections is high.

D. Mother’s education

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The level of parental education has an impact on low-income families and less-than-optimal child care and attention. Another
factor is that the level of ability to receive information makes it easier to consult people with higher education. The mother's
education level history reveals that the proportion of toddlers aged 25-59 months with a junior high/lower education level of 10
toddlers (50%) is stunted. Stunting has a positive and significant relationship with LBW, low education of mothers and fathers,
short mother height, and history of exclusive breastfeeding [14] [10]. The verdicts of this lessons are supported by preceding
seek [10], which found that low maternal education is 3.38 times more likely to cause stunting in toddlers than high maternal
education, thru a p-rate of 0.029.

The mater's primary role is to shape her children's eating habits, beginning with menu planning, grocery shopping, cooking,
preparing, and distributing food. Furthermore, mothers with a junior high school education are better at parenting and selecting
food for their children. This is because mothers with a junior high school education have more access to information about their
children's nutritional status and health, so their knowledge grows. The information is then applied in the childcare process,
which has an crash the youth's nourishing prestige and overall health. The findings revealed that mothers with stunted children
had less knowledge, attitudes, and behavior regarding stunting than mothers with non-stunted children

In this investigation, stunted and non-stunted children had similar test results. (sig > 0.05). However, there was a difference in
the average test site results between the stunting and non-stunting groups, with the small group having a higher average number
of Hb, leukocytes, and erythrocytes than the non-stunting children. The average Hb level in stunted children was 11.2 g/dl,
while the average Hb level in non-stunted children was 10.7 gl/dl. According to these findings, the average Hb in impeded was
higher than in non-impeded kids. These findings contradict previous research [16], which claims that anemia is the most mutual
hematological ailment in malnourished children.

Stunted children had a lower average eosinophil count, but the difference was not statistically significant. Blood eosinophilia
is caused by helminthiasis. Although eosinophilia and increased serum IgE levels are indicators of allergy and helminthiasis,
eosinophilia is the primary immune mechanism against helminthiasis. Allergies and helminthiasis are linked to elevated IgE
and eosinophil counts. [19]

High eosinophil counts were found in worm patients, particularly those from tropical countries [15],. Children who test positive
for helminthiasis but have good nutritional status or nutritional state are more likely to be influenced by the child's body's
response to worm infection. If a child gets worms, the body activates Th-2 cells, which activate eosinophils, basophils, and
mast cells to release inflammatory mediators to limit parasite activity and kill worms. [20].

The average platelet count in stunted children was 394,000, while the average platelet count in non-stunted children was
428,000. The results show that stunted children have fewer platelets than non-stunted children. In terms of lymphocytes, the
average lymphocyte count in stunted children was 52.19%, while it was 56.33% in non-stunted children. According to the
findings, stunted children have a lower average number of lymphocytes than non-stunted children. These findings support
previous research [17], which found a link between malnutrition and TLC 1,200 cells/mm3 in gaunt inpatients. The mechanism
of lymphocyte reduction in malnutrition is unknown, but it is most likely linked to thymic atrophy and interleukins. [17]

The results revealed that the middling number of monocytes in stunted broods was 0.7%, while the typical number of
lymphocytes in non-stunted children was 1.1%. According to the findings, stunted children have a lower average number of
monocytes than non-stunted children. Monocytes play a key role in innate immunity due to their great ability to phagocytize,
digest, process, and deliver antigens to lymphocytes. Monocytes can be differentiated phenotypically into CD14 and CD16
expressions. Master scavenger cells are classical monocytes (CD14hiCD16-). Their key function in fighting infection is
phagocytosis and the generation of large quantities of anti-inflammatory cytokine (IL-10). [21] Stunted children had lower
monocyte numbers than non-stunted children between the ages of 2 and 5 years, which is consistent with their low percentage
of effector helper T cells [21].

CONCLUSION
Babies born with low birth weight, Intrauterine Growth Restriction, a history of poor adherence to antenatal care/ANC, low
parental education, inadequate immunization, a history of non-exclusive breastfeeding, and mothers' lack of knowledge and
attitudes about stunting are all risk factors for stunting in children. Mothers of stunted children appear to have less knowledge,
attitudes, and behaviors related to stunting than mothers of non-stunted children.

Increased knowledge is needed concerning the risk of chronic diseases such as diabetes mellitus in adulthood, as well as the
prevention of stunting or failure to thrive, which must begin within the first 1000 days of a child's life. Antenatal care/ANC
exams during pregnancy are attitudes and practices that need to be improved in moms with stunted children. The average

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condition of regular blood laboratory findings was not statistically different between the stunted and non-stunted groups, but
hemoglobin levels, the number of erythrocytes, monocytes, and lymphocytes were lower in the stunted group than in the non-
stunted group.

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