Beyond personal factors: Multilevel determinants of childhood stunting in Indonesia

Determinants of concurrent wasting and stunting among children 6 to 23 mo in Indonesia

OBJECTIVES

Concurrent wasting and stunting (WaSt) in a child is a health problem that leads to detrimental effects. However, to our knowledge, there is limited research regarding the prevalence and determinants of WaSt, including in Indonesia. The aim of this study was to analyze the prevalence and determinants of WaSt in children 6 to 23 mo of age.

METHODS

This cross-sectional study was conducted with data sets from the Indonesia Nutritional Status Survey (INSS). Data was collected between January and December 2021. About 15 641 children, ages 23 mo, were included. A χ2 analysis examined the association between the dependent and independent variables. A multivariate test analyzed the risk for the independent variable to the dependent, seen through the adjusted odds ratio (aOR).

RESULTS

The prevalence of WaSt was 2.4%. Higher odds for WaSt were seen in the following: • Boys: 2.15 times (95% confidence interval [CI], 1.72-2.68); • Children ages 12 to 23 mo 3.15 times (95% CI, 2.33-4.25); • Those with low birth weight 3.11 times (95% CI, 2.33-4.15) • Those with small birth size: 2 times (95% CI, 1.59-2.54) • Babies born from mothers >35 y of age: 1.5 times (95% CI, 1.19-1.89); • Children who experienced infection: 1.43 times (95% CI, 1.16-1.76); • Children not using the Integrated Health and Nutrition Services (Posyandu): 1.17 times (95% CI; 1.29-2.27); • Children from middle- income families:2.54 times higher odds (95% CI, 1.75-3.7); and • Children from rural areas: 1.37 times (95% CI, 1.1-1.71).

CONCLUSION

WaSt is associated with multiple factors in Indonesia. Hence, policymakers need to address this problem comprehensively.

Examining determinants of stunting in Urban and Rural Indonesian: a multilevel analysis using the population-based Indonesian family life survey (IFLS)

BACKGROUND

In Indonesia, chronic malnutrition leading to stunted growth in children represents a significant issue within the public health domain. The prevalence of stunting varies between urban and rural areas, reflecting disparities in access to nutrition, healthcare, and other socioeconomic factors. Understanding these disparities is crucial for developing targeted interventions to address the issue.

METHODS

The study used data from the fifth wave of the Indonesian Family Life Survey (IFLS), which is a national cross-sectional population-based survey conducted across approximately 13 provinces in Indonesia in 2014-2015. Multivariate and Multilevel logistic regression models were utilized in the analysis to determine the factors associated with the prevalence of stunting in Indonesian children.

RESULTS

The multivariate logistic regression analysis indicated that among children aged 24-59 months in Indonesia, stunting was associated with the age of the child, birth weight, maternal nutritional status, and residence. Subsequently, the multilevel logistic regression analysis revealed that in rural areas, the age of the child and birth weight exhibited significant associations with stunting. Conversely, in urban areas, stunted children were influenced by 7 factors, including the child's age (months), age of weaning, birth weight (kg), mother and father's age, place of birth, and maternal nutritional status.

CONCLUSIONS

Variations in childhood stunting between urban and rural regions in Indonesia were observed, indicating a differential prevalence. The study's findings suggests the importance of age-appropriate nutritional support, healthcare interventions, and growth monitoring. Focused interventions are vital, potentially encompassing initiatives such as improving access to maternal and child healthcare services, promoting adequate nutrition during pregnancy and infancy, and facilitate greater parental engagement in childcare responsibilities.

Socioeconomic determinants of the double burden of malnutrition among women of reproductive age in sub-Saharan Africa: A cross-sectional study

Background and Aim

The positioning of eliminating all forms of malnutrition within the spirit of the Sustainable Development Goals and the adoption of the United Nations resolution for a Decade of Action on Nutrition are a testament to strong global commitment to combat the double burden of malnutrition (DBM). Yet, there is a knowledge gap in sub-Saharan Africa (SSA) regarding the influence of socioeconomic status on DBM. We investigated the associative effect of socioeconomic status on DBM in SSA.

Methods

Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of 29 countries in SSA conducted from 2010 to 2020. Bivariate and multivariate logistic regression models were fitted to examine the association between socioeconomic status and DBM. The results were presented using adjusted odds ratio (aOR) and 95% confidence interval (CI).

Results

Children of obese mothers were less likely to be stunted compared to those born to mothers who were not overweight/obese [aOR = 0.70; 95% CI = 0.66-0.77]. The odds of stunting increased with wealth index, with children born to poorest mothers having the highest odds compared to those born to richest mother [aOR = 1.79; 95% CI = 1.64-1.95]. The odds of stunting among children was highest among those born to mothers with no formal education compared to those whose mothers had higher education [aOR = 2.73; 95% CI = 2.34-3.18].

Conclusion

DBM among children in SSA is predicted by maternal level of education, and wealth status. These results underscore the urgency of tailored interventions and policies that address DBM among women of reproductive age, with a particular focus on the socioeconomic disparities in SSA. To effectively combat this pressing public health issue, it is imperative to direct efforts towards empowering women to attain higher levels of education and to implement strategies that consider the specific needs of women across varying socioeconomic statuses.

Effectiveness of ERKADUTA model to increase stunting prevention behaviors among mothers with toddlers in Indonesia: A quasi-experiment

Stunting, a persistent nutritional issue arising from prolonged inadequate nutrient intake, poses substantial risks such as heightened morbidity, mortality, and compromised cognitive, psychomotor, and verbal development. In Indonesia, addressing stunting in children under two necessitates urgent community empowerment, given its multifaceted nature. The aim of this study was to assess the effects of an intervention targeting mothers of toddlers, called RT kawal baduta (ERKADUTA) model, a local community-based assistance for babies under two years old. A quasi-experiment using pre-test and post-test with a control group design was conducted. Employing a quantitative analytic approach with 112 respondents, the effectiveness of ERKADUTA model to improve the knowledge, attitude, and practice of stunting prevention among mothers with child under two years old was assessed. ERKADUTA program was run for three months. The Wilcoxon test was used to determine score changes before and after program in both groups, while the Mann-Whitney test was used to analyze the score differences of knowledge, attitude and practice between intervention and control groups. Our data indicated that there were changes in knowledge, attitudes, and practices in preventing stunting in both the intervention and control groups. There are significant differences in knowledge (p<0.001, effect size=-0.855), attitude (p<0.001, effect size=-0.864), and practice score (p<0.001, effect size=-0.924) between the intervention and control groups after the intervention. This study highlights that the ERKADUTA model emerged as a potent catalyst in improving stunting prevention behaviors among mothers with toddlers and this model holds promise for addressing the complexities of stunting in Indonesia.

Gut microbiota differences in stunted and normal-lenght children aged 36-45 months in East Nusa Tenggara, Indonesia

The role of the gut microbiota in energy metabolism of the host has been established, both in overweight/obesity, as well as in undernutrition/stunting. Dysbiosis of the gut microbiota may predispose to stunting. The aim of this study was to compare the gut microbiota composition of stunted Indonesian children and non-stunted children between 36 and 45 months from two sites on the East Nusa Tenggara (ENT) islands. Fecal samples were collected from 100 stunted children and 100 non-stunted children in Kupang and North Kodi. The gut microbiota composition was determined by sequencing amplicons of the V3-V4 region of the 16S rRNA gene. Moreover, fecal SCFA concentrations were analyzed. The microbiota composition was correlated to anthropometric parameters and fecal metabolites. The phyla Bacteroidetes (Bacteroidota; q = 0.014) and Cyanobacteria (q = 0.049) were significantly higher in stunted children. Three taxa at genus levels were consistently significantly higher in stunted children at both sampling sites, namely Lachnoclostridium, Faecalibacterium and Veillonella (q < 7 * 10-4). These and 9 other taxa positively correlated to the z-score length-for-age (zlen), while 11 taxa negatively correlated with zlen. Several taxa also correlated with sanitary parameters, some of which were also significantly different between the two groups. All three fecal SCFA concentrations (acetate, propionate and butyrate) and their total were lower in stunted children compared to non-stunted children, although not significant for butyrate, indicating lower energy-extraction by the gut microbiota. Also, since SCFA have been shown to be involved in gut barrier function, barrier integrity may be affected in the stunted children. It remains to be seen if the three taxa are involved in stunting, or are changed due to e.g. differences in diet, hygiene status, or other factors. The observed differences in this study do not agree with our previous observations in children on Java, Indonesia. There are differences in infrastructure facilities such as clean water and sanitation on ENT and Java, which may contribute to the differences observed. The role of the gut microbiota in stunting therefore requires more in depth studies. Trial registration: the trial was registered at ClinicalTrials.gov with identifier number NCT05119218.

Family economic trajectories and body mass index in Indonesia: Evidence from the Indonesian Family Life Surveys 2 to 5

Indonesia faces the double burdens of childhood obesity and malnutrition. A family's socioeconomic status has been suggested to be one of the most influential factors contributing to childhood nutritional problems. This study aimed to: 1) identify the distinct trajectories of family economics; and 2) assess whether a family's economic trajectory influences children's body mass index (BMI). We analyzed trajectory patterns of family economic levels from 1997 to 2015 among 846 children aged under 3 years in 1997 using data from Indonesian Family Life Surveys. Trajectory patterns were identified with Group-Based Trajectory Modeling using the traj plug-in in STATA software. The BMI was classified according to 2007 World Health Organization growth standards. Adjusted relative risk ratios (aRRRs) of family economic level trajectories and children's BMI were calculated using multinomial logistic regressions. We identified three distinct trajectories of family economic level: stable poorest, stable middle, and increasing richest. In the total sample, there were no significant relationships between a family's income trajectory and children's BMI in the adjusted models. A significant relationship existed for male children, but not for female children, of compared to the poorest family trajectory group, male children in the increasing richest trajectory group were more likely to be overweight/obese (aRRR 6.1, 95% confidence interval: 1.22-30.62) after adjusting for age and BMI. The present results highlight the importance of early interventions to minimize the potential adverse impacts of excessive BMI later in adulthood.

Sociodemographic and Healthcare Factors Associated with Stunting in Children Aged 6-59 Months in the Urban Area of Bali Province, Indonesia 2018

Stunting is a worldwide public health concern, including in Indonesia. Even when living in an urban area with urban characteristics, it is still possible for children to be at risk of stunting. The aim of this study was to determine the sociodemographic and healthcare factors associated with stunting in a province experiencing tourism growth, namely, Bali. Cross-sectional data on Bali Province from the Indonesian Basic Health Research Survey (Riskesdas, 2018) were used as the basis for the research analysis. A total of 846 respondents under five years of age were analyzed, indicating a stunting prevalence of 19.0%. Multivariate logistic regression demonstrated low maternal educational attainment (adjustedOR = 1.92; 95% Confidence Interval = 1.24-2.97), the inadequate consumption of iron tablets during pregnancy (adjustedOR = 1.56; 95% Confidence Interval = 1.08-2.24), and no extended family (adjustedOR = 1.55; 95% Confidence Interval = 1.07-2.26) as being significantly associated with stunting. According to these findings, sociodemographic and healthcare factors are associated with stunting in urban Bali. Improving women's education, ensuring sufficient iron tablets are consumed during pregnancy, and encouraging the involvement of the extended family in childcare are recommended.

Determinants of stunting in children under five years old in South Sulawesi and West Sulawesi Province: 2013 and 2018 Indonesian Basic Health Survey

BACKGROUND

The prevalence of stunting in South Sulawesi and West Sulawesi Province is relatively high. Studies reveal various household, parental, and child factors are associated with stunting. This paper aimed to determine the determinants of stunting among children under five in South and West Sulawesi Province using the 2013 and 2018 Indonesia Basic Health Survey.

METHODS

This study was a secondary data analysis using the 2013 and 2018 Indonesian Basic Health Surveys. The unit of analysis was children under five years, and the study obtained 3641 and 4423 children in South Sulawesi Province from the 2013 and 2018 Indonesia Basic Health Survey, respectively, and 804 and 1059 children from the 2013 and 2018 Indonesia Basic Health Survey in West Sulawesi Province, respectively. The multivariable poisson regression model was conducted to determine the determinants of stunting.

RESULTS

The results showed that the mean age of children in South Sulawesi and West Sulawesi Province was 31.1 months and 30.8 months, respectively, on 2013 survey compare to 29.6 months and 29.1 months on the 2018 survey. The determinants of stunting in children under five in South Sulawesi Province in 2013 survey were household with two children under five (APR:1.24; 95% CI: 1.1-1.3; p-value = 0.006), maternal BMI (APR: 1.1; 95% CI: 1.03-1.1; p-value = <0.001), maternal weight (APR: 0.9; 95% CI: 0.94-0.97; p-value = <0.001), children aged 12-23 months (APR: 2.2; 95% CI: 1.7-2.7; p-value = <0.001), children aged 24-59 months (APR: 2.2; 95% CI: 1.8-2.7; p-value = <0.001), birthweight (APR: 1.9; 95% CI: 1.5-2.5; p-value = <0.001). In the 2018 survey, the determinants were maternal weight (APR: 0.9; 95% CI: 0.98-0.99; p-value = 0.005), mothers with no education or with education in primary school (APR: 1.5; 95% CI: 1.3-1.9; p-value = <0.001), mothers with education in middle school (APR: 1.3; 95% CI: 1.1-1.6; p-value = 0.014), mothers with a height less than 151 cm (APR: 1.3; 95% CI: 1.5-3.1; p-value = <0.001), mothers with a height of 151-160 cm (APR: 1.3; 95% CI: 1.1-1.6; p-value = 0.014), children aged 12-23 months (APR: 2.2; 95% CI: 1.7-2.8; p-value = <0.001), children aged 24-59 months (APR: 2.5; 95% CI: 2.0-3.2; p-value = <0.001)., birthweight (APR: 1.5; 95% CI: 1.2-1.9; p-value = <0.001). The determinants of stunting in children under five in West Sulawesi Province in 2013 survey were children under five years living in poor households (APR: 1.9; 95% CI: 1.1-3.3; p-value = 0.021), children under five who lived in a household with three or more children under five (APR:1.8; 95% CI: 1.2-2.7; p-value = 0.002), children aged 12-23 months (APR: 1.8; 95% CI: 1.2-2.6; p-value = 0.006), children aged 24-59 months (APR: 1.9; 95% CI: 1.3-2.7; p-value = 0.001). On the 2018 survey, the determinants were maternal BMI (APR: 1.02; 95% CI: 1.01-1.03; p-value = 0.004), maternal weight (APR: 0.9; 95% CI: 0.95-0.98; p-value = <0.001), mothers with no education or with education in primary school (APR: 1.9; 95% CI: 1.3-2.7; p-value = 0.001), mothers with education in middle school (APR: 1.9; 95% CI: 1.3-2.7; p-value = 0.001), mothers with education in high school (APR: 1.8; 95% CI: 1.2-2.6; p-value = 0.004), children aged 12-23 months (APR: 2.1; 95% CI: 1.4-3.0; p-value = <0.001), children aged 24-59 months (APR: 2.6; 95% CI: 1.9-3.6; p-value = <0.001), male (APR: 1.2; 95% CI: 1.01-1.4; p-value = 0.035), and acute respiratory infection (ARI) (APR: 1.6; 95% CI: 1.04-2.5; p-value = 0.030).

CONCLUSIONS

The determinants of stunting in children under five in South Sulawesi Province are number of children under five in the household, maternal education, maternal weight, maternal height, maternal BMI, child's age, and birthweight. Meanwhile, the determinants of stunting in children under five in West Sulawesi were wealth, maternal education, maternal weight, maternal BMI,, child's age, child's sex, and history of acute respiratory infection. Hence, intervention on household and child levels as well as maternal sociodemographic factors need to be addressed.

Determinants of length for age Z scores among children aged 6-23 months in Central Java, Indonesia: a path analysis

Introduction

Length for Age Z (LAZ) score determinants are complex and vary among different areas, but it is important for designing effective and efficient strategies to decrease stunting prevalence among children under 2 years. This study aimed to investigate the determinants of LAZ scores among children under 2 years in Central Java, Indonesia.

Methods

This study was conducted on the 2021 Indonesian Nutritional Status Study (INSS) dataset, which was a cross-sectional survey. Data on 3,430 children aged 6-23 months from Central Java province were derived from the 2021 INSS data. After missing data elimination, 3,238 subjects were included in the analysis. Determinant factors included direct and indirect factors. Direct factors were the mother's age, birth weight Z score (BWZ), birth length Z score (BLZ), exclusively breastfed history, dietary diversity scores (DDS), empty calorie drink consumption, unhealthy snacks consumption, and infections. Indirect factors were early initiation of breastfeeding (EIBF) and posyandu (integrated health post) utilization. Underlying factors were socioeconomic status (SES) and the mother's education. Bivariate analyses and multiple linear regressions were conducted. A path analysis with a hypothesized model based on the UNICEF conceptual framework was also performed.

Results

Stunting, wasting and underweight proportions among the subjects were 19.1%, 7.6% and 12.3%, respectively. The mean LAZ scores were -0.95 ± 1.22; the mother's age was 29.7 ± 5.95 years; BWZ was -0.47 ± 0.97; BLZ was -0.55 ± 1.05; and DDS was 4.45 ± 1.51. The infection proportion among the subjects was 28%. BWZ and BLZ were positively correlated to LAZ scores, with r = 0.267 (p < 0.01) and r = 0.260 (p < 0.01), respectively. The mother's age was negatively correlated to LAZ scores with r = -0.041 (p < 0.05). Maternal education was positively correlated to SES but had no direct effect on LAZ scores. LAZ score determinants of BLZ (p < 0.001) and SES (p < 0.001) showed positive direct associations with LAZ scores, but the mother's age (p = 0.039), exclusively breastfed history (p < 0.001), and empty calorie drinks consumption (p < 0.001) had negative associations with LAZ scores.

Conclusion

To prevent stunting among children aged 6-23 months in Central Java, Indonesia, intervention programs to increase the nutritional status of women at child-bearing age and nutrition education on child feeding practices should be conducted more efficiently and effectively.

Spatial and Machine Learning Approach to Model Childhood Stunting in Pakistan: Role of Socio-Economic and Environmental Factors

This study presents the determinants of childhood stunting as the consequence of child malnutrition. We checked two groups of factors-the socio-economic situation and climate vulnerability-using disaggregated sub-regional data in the spatial context. Data related to the percentage of stunted children in Pakistan for 2017 were retrieved from MICS 2017-18 along with other features. We used three quantitative models: ordinary least squares regression (OLS) to examine the linear relationships among the selected features, spatial regression (SDEM) to identify and capture the spatial spillover effect, and the Extreme Gradient Boosting machine learning algorithm (XGBoost) to analyse the importance of spatial lag and generate predictions. The results showed a high degree of spatial clustering in childhood stunting at the sub-regional level. We found that a 1 percentage point (p.p.) increase in multi-dimensional poverty may translate into a 0.18 p.p. increase in childhood stunting. Furthermore, high climate vulnerability and common marriages before age 15 each exacerbated childhood stunting by another 1 p.p. On the contrary, high female literacy and their high exposure to mass media, together with low climate vulnerability, may reduce childhood stunting. Model diagnostics showed that the SDEM outperformed the OLS model, as AIC_OLS = 766 > AIC_SDEM = 760. Furthermore, XGBoost generated the most accurate predictions in comparison to OLS and SDEM, having the lowest root-mean-square error (RMSE).

Stunting among kindergarten children in China in the context of COVID-19: A cross-sectional study

BACKGROUND

The impact of COVID-19 has most likely increased the prevalence of stunting. The study aimed to determine the prevalence of stunting among kindergarten children in the context of coronavirus disease 2019 (COVID-19) in Longgang District, Shenzhen, China, and its risk factors.

METHODS

A cross-sectional study was conducted to identify children from 11 sub districts of 481 kindergartens in the Longgang District of Shenzhen City from May to July 2021. In the context of COVID-19, an online survey was conducted to gather demographic information, height, birth information, and lifestyle. The prevalence of stunting was calculated, and the risk factors were analyzed using binary logistic regression with three stepwise models.

RESULTS

A total of 118,404 subjects were included from May to July 2021, with a response and questionnaire effective rates of 85.75% and 95.03%, respectively. The prevalence of stunting and severe stunting were 3.3% and 0.8%, respectively. Model 3 showed that risk factors for stunting were male sex [odds ratio (OR) = 1.07], low birth weight (OR = 2.02), insufficient sleep time (OR = 1.08), less food intake than their peers (OR = 1.66), slower eating than their peers (OR = 1.16), accompanied by grandparents alone or non-lineal relatives (reference: parents accompanying) (OR = 1.23, 1.51), and children induced to eat (OR = 1.17). Protective factors included only-child status (OR = 0.66), reported high activity (OR = 0.37, 0.26, 0.23), parents with high education levels (father: OR = 0.87, 0.69; mother: OR = 0.69, 0.58), high monthly income per capita of the family (OR = 0.88, 0.74, 0.68), and allowing children to make food choices (OR = 0.82).

CONCLUSION

The stunting rate of children in kindergartens in Longgang District is 3.3%, close to the level of developed countries but higher than the average level of developed cities in China. The relatively high stunting rate in children under 3 years old in 2021 may be associated with the influence of COVID-19. Appropriate policies should be formulated for individuals and families with children to help children establish good living habits and reduce stunting.