Prevalence of malnutrition and stunting among under-five children: A cross-sectional study family of quality of life in agricultural areas of Indonesia

Abstract

BACKGROUND:

Family quality of life (F-QOL) is necessarily issued for in fulfilling nutrition among under-five children that influenced their growth and development.

OBJECTIVE:

To examine the prevalence of malnutrition and stunting among under-five children and their correlation of F-QOL in agricultural areas of Jember regency, Indonesia

METHOD:

A cross-sectional study through a family based-survey was conducted among 424 family farmers in Jember regency of Indonesia November to December 2019 using a self-administered questionnaire consisted the characteristics of parents and children, quality of family life, family welfare, family awareness, and measurements of children’s age, height, and weight to identify stunting and malnutrition. T-tests of independence and the One Way ANOVA test was used to correlate the categorical and continuous variables, respectively. Furthermore, to determine the correlation among constant variables, we used a Product Moment test.

RESULTS:

Prevalence of wasted, stunted, and malnutrition among under-five children in agricultural areas were 3%, 18.9%, and 5%. There was a significant correlation between ethnic of family and type of family with HAZ (p = 0.007), respectively. Meanwhile, there was a significant correlation between WAZ and age of children (r = 0.106; p < 0.05). Furthermore, there were significantly correlation between FQOL and WAZ (r = 0.260; p < 0.01) and HAZ FQOL (r = 0.209; p < 0.01), respectively.

CONCLUSION:

Malnutrition and stunting are the biggest problems of nutritional status in Indonesia’s agricultural areas correlated with ethnicity and type of family. Meanwhile, the F-QOL is main correlated with stunting and malnutrition among under-five children in agrarian areas.

Keywords

Malnutrition stunting under-five children agricultural

1 Introduction

The prevalence of malnutrition among children in Indonesia is 3.9% [1]. Nutritional problems and stunting among children are strongly influenced by carbohydrate intake and a high percentage of food expenditure [2], sanitation and hygiene [3], and food security [4]. Meanwhile, several factors of family, such as the socioeconomic status of the family [5], working mothers [6], family parenting [7], and family awareness of nutritional [8]. Therefore, it is necessary to pay attention to the level of quality of life and family welfare and family awareness in meeting children’s nutritional needs in the family.

The 2nd Sustainable Development Goal’s (SDG’s) achievement for hunger and malnutrition should below 40%. The family has an essential function in meeting the needs of family [7]. Parents are expected to provide adequate parenting for under-five children to facilitate growth stages, both physically, mentally, and psychologically [9]. Parents must know how the right activities in providing care and protection to children [5]. Therefore, it is necessary to increase family awareness concerning the quality of life and family welfare problems with malnutrition and stunting in children under five to achieve the SDG framework.

The family’s economic pattern in rural areas is generally the middle to lower economy related to family welfare [10]. The success of fulfilling nutrition assesses from nutritional status by balancing the amount of nutrient intake and the amount needed by the body used to carry out biological functions such as physical growth and development of activitied to maintain health [11]. Meanwhile, the prevalence of malnutrition among infants in India is high when it connects with the health care mothers give for their children [12]. Furthermore, the effectiveness of mother’s role as a caregiver for her child in family conditions without the father affects the nutritional status [13].

Meanwhile, there are still many problems with stunting and malnutrition in rural areas of Indonesia. A previous study showed that the issue of stunting and malnutrition in the treatment and control groups by 22.2% vs. 37.5% and 9.7% vs. 4.2% in Indonesia [7], where family functions play an essential role in fulfilling nutrition among under-five children [10]. Furthermore, the quality of family life is determined by the fulfillment of all needs, one of which is the fulfillment of adequate nutrition. Physical well-being and quality of life are promosing [14]. Therefore, identification is needed related to the quality of life and welfare and family awareness in fulfilling toddler nutrition to prevent malnutrition and stunting in toddlers. Furthermore, this study aims want to examine the prevalence of malnutrition and stunting among under-five children and their correlation of the family quality of life in agricultural areas of Jember regency, Indonesia.

2 Methods

2.1 Design and participants

A cross-sectional study through a family based-survey was conducted among 424 family farmers in Indonesia’s Jember Regency from November to December 2019. This study’s inclusion criteria were as follows: (i) Parents who have children aged 0–60 months; (ii) Parents who live with under-five children. Meanwhile, the exclusion criteria were: (i) The parents stated that they rejected the research; (ii) Under-five children in unhealthy conditions such as infectious diseases; (iii) Parents are not able to communicate verbally; (iv) Under-five children with a history of low birth weight; and (v) When the research was carried out the parents were not present.

The population of the study is 4,607 families with under-five children who live in Jember Regency. The sample size was calculated using formula $n = z_{1 - \infty / 2}^{2} \sum_{h - 1}^{L} \frac{N_{h}^{2} P_{h} (1 - P_{h})}{W_{h}} / [N^{2} d^{2} {+ z}_{1 - \infty / 2}^{2} \sum_{h - 1}^{L} N_{h} P_{h} (1 - P_{h})]$ (1)

The study (N = 4607) used a 95% confidence interval and total error rate (0.1), so this study’s sample size was 680 families. The sample screening process identified 680 under-five children, of which 58 had passed the Posyandu, eight families refused to become participants, and 2 of under-five children had moved to live, and 35 of under-five children had a history of low birth weight. Therefore, this study’s final sample size was determined by consecutive sampling, namely 424 families with under-five children.

2.2 Instruments

A self-administered questionnaire was used in this study (see in Appendix 1). This questionnaire consisted of parent’s and children’s characteristics, quality of family life, family welfare, family awareness, and measurements of children’s age, height, and weight to identify stunting and malnutrition. The questionnaire was used to contain data on the characteristics of parents, including: name, age, gender, education level, ethnicity, type of work, income, and kind of family. The characteristics of the child was included age, sex, current weight, and height.

The Family Quality of Life Scale Questionnaire (FQOL) questionnaire was used to performed family quality of life using 25 items of the question with Linkert (very not satisfied = 1; very satisfied = 5) [15], which included five domain (FQOL-1 family interaction = 6; FQOL-2 parenting = 6; FQOL-3 emotional welfare = 4; FQOL-4 physical welfare = 5; and FQOL-5 family support = 4). A family welfare instrument was made by the National Population and Family Planning Agency of Indonesia (BKKBN) was used to measure family welfare using 21 items questions with dichotomous (No = 0; Yes = 1) [16]. Then, the Nutritional Awareness of Mother Questionnaire (NAMQ) questionnaire was adapted from [8] to performed family awareness of nutrition using 60 items with Likert (Not agree = 0; Agree = 2).

Calculation of nutritional status was assessed using anthropometry based on body weight for age (WAZ) consisting of malnutrition, severely under-weight, normal, and obese, based on height for age (HAZ) consisting of severely stunting, stunting, and normal, based on body weight for height (BAZ) consisting of malnutrition, severely under-weight, normal, and obese with Z-score interpretation. Researchers measured body weight and height directly on under-five children. Tools for measuring body weight use digital scales that have been calibrated, while height uses a length board or microtoise. A length board for children was used to calculate age under 12 months to 24 months, while microtise for children aged 24 to 60 months. The final results of weight and height calculations were converted into Z-score assessments using the Anthroplus WHO-2018 software tool [17 –19].

2.3 Data collection

The data collection process was carried out through surveys of families with children under five. Each family received an explanation regarding the aims and objectives of the study. Families who volunteered to be research subjects signed the informed consent form. In the first stage, researchers measured height and weight in under-five children. After that, the researchers explained how to fill out a questionnaire to families or parents of under-five children. Participants fill out a questionnaire sheet and are accompanied by the researcher as a facilitator. The researcher then examined the questionnaire’s completeness, including the demographic questionnaire data, the F-QOLS questionnaire, weight and height data for children under five, and an informed consent sheet.

2.4 Ethical consideration

The study was approved by the Ethical Committee Review Board of Indonesia of the Faculty of Dentistry, University of Jember No. 980/UN25.8/KEPK/DL/2020.

2.5 Data analyses

All data were analyzed using the IBM Statistical Package for Social Sciences software program, version 22.0. Statistic descriptive was used to determine participant’s characteristics, with mean and standard deviation (for numeric data) and percentage (for categorical data). T-tests of independence and One Way ANOVA test were used to correlate the categorical and continuous variables, respectively. Furthermore, to determine the correlation among continuous variables, we used a Product Moment test. A p-value <0.05 was considered statistically significant.

3 Results

Characteristic of participants (Table 1) showed the mean age of parent and children were 27±5.95 years and 34±14.22 months, with 92.9% of parents of male and 50.7% of the male of children, respectively. The majority of participants were 65.6% of Madura ethnic, with 79.7% of nuclear family. Majority 38.7% of parent was educated elementary school with 80.7% % of mother household. The mean score of FQOL, NAMQ, and family welfare were 94.63±13.54, 71.56±26.28, and 14.19±4.93, respectively.

Table 1
Characteristic of participants, FQOL, NAMQ, and family welfare among parent (n = 424)

Variable n (%)

Age of parents (year)

M±SD 27±5.95

Age of children (month)

M±SD 34±14.22

Gender of parent

Male 30 (7.1)

Female 394 (92.9)

Gender of children

Male 215 (50.7)

Female 209 (49.3)

Ethnic of family

Madura 278 (65.6)

Jawa 139 (32.8)

Mixed 7 (1.7)

Type of family

Nuclear family 338 (79.7)

Extended family 86 (20.3)

Education

Not attending school 3 (0.7)

Elementary school 164 (38.7)

Junior high school 135 (31.8)

Senior high school 112 (26.4)

Bachelor degree 10 (2.4)

Occupation

Mother household 342 (80.7)

Farmer 26 (6,1)

Employer 22 (5,2)

Seller 27 (6,4)

Entrepreneur 6 (1,4)

Fisher 1 (0.2)

Salary per month (IDR)

Lower than 5,000,000 27 (6.4)

500,000 – 1,000,000 145 (34.2)

1,000,000 – 1,500,000 184 (43.4)

1,500,000 – 2,000,000 54 (12.7)

More than 2,000,000 14 (3.3)

Total FQOL

M±SD 94.63±13.54

NAMQ

M±SD 71.56±26.28

Family welfare

M±SD 14.19±4.93

Variable		n (%)
Age of parents (year)
	M±SD	27±5.95
Age of children (month)
	M±SD	34±14.22
Gender of parent
	Male	30 (7.1)
	Female	394 (92.9)
Gender of children
	Male	215 (50.7)
	Female	209 (49.3)
Ethnic of family
	Madura	278 (65.6)
	Jawa	139 (32.8)
	Mixed	7 (1.7)
Type of family
	Nuclear family	338 (79.7)
	Extended family	86 (20.3)
Education
	Not attending school	3 (0.7)
	Elementary school	164 (38.7)
	Junior high school	135 (31.8)
	Senior high school	112 (26.4)
	Bachelor degree	10 (2.4)
Occupation
	Mother household	342 (80.7)
	Farmer	26 (6,1)
	Employer	22 (5,2)
	Seller	27 (6,4)
	Entrepreneur	6 (1,4)
	Fisher	1 (0.2)
Salary per month (IDR)
	Lower than 5,000,000	27 (6.4)
	500,000 – 1,000,000	145 (34.2)
	1,000,000 – 1,500,000	184 (43.4)
	1,500,000 – 2,000,000	54 (12.7)
	More than 2,000,000	14 (3.3)
Total FQOL
	M±SD	94.63±13.54
NAMQ
	M±SD	71.56±26.28
Family welfare
	M±SD	14.19±4.93

Nutritional status among under-five children (Table 2) showed that the mean score of WAZ was – 1.24±1.35, with the prevalence of 5% of malnutrition, 22.2% of severely under-weight, and 1.5% of obese. Meanwhile, the mean score of HAZ was – 1.79±1.65, with the prevalence of 18.9% of severely stunting and 27.8% of stunting. Furthermore, the mean score of BAZ was – 0.98±13.65, with the prevalence of 3% of malnutrition, 9% of severely under-weight, and 7% of obese.

Table 2

Nutritional status among under-five children (n = 424)

Nutritional status		n (%)
WAZ	M±SD	–1.24±1.35
	Malnutrition	21 (5.0)
	Severely under-weight	94 (22.2)
	Normal	303 (71.5)
	Obese	6 (1.5)
HAZ	M±SD	–1.79±1.65
	Severely stunting	80 (18.9)
	Stunting	118 (27.8)
	Normal	226 (53.3)
BAZ	M±SD	–0.98±13.65
	Malnutrition	15 (3.0)
	Severely under-weight	37 (9.0)
	Normal	344 (81.0)
	Obese	28 (7.0)

Table 3 showed that there were significant correlation between ethnic of family and HAZ (p = 0.007). Meanwhile, there were significant correlation between type of family and BAZ (p = 0.030). Furthermore, Table 4 figured that there were significantly correlation between WAZ and age of children (r = 0.106; p < 0.05), and FQOL (r = 0.260; p < 0.01), in particularly FQOL-1 (r = 0.277); FQOL-2 (r = 0.234); FQOL-3 (r = 0.248); FQOL-4 (0.207), and FQOL-5 (r = 0.181), respectively. Meanwhile, there were significantly correlation between HAZ and FQOL (r = 0.209; p < 0.01), in particularly FQOL-1 (r = 0.203); FQOL-2 (r = 0.175); FQOL-3 (r = 0.193); FQOL-4 (0.216), and FQOL-5 (r = 0.136), respectively.

Table 3

Correlation characteristic of participants and WAZ, HAZ, and BAZ (n = 424)

Variable		WAZ			HAZ			BAZ
		M	SD	p-value	M	SD	p-value	M	SD	p-value
Gender of parent^†
	Male	–1.185	1.30	0.769	–1.73	1.72	0.820	–0.31	1.37	0.779
	Female	–1.260	1.35		–1.80	1.64		–1.03	14.16
Gender of children^†
	Male	–1.33	1.46	0.245	–1.78	1.67	0.864	–0.30	2.26	0.297
	Female	–1.18	1.22		–1.81	1.63		–1.68	19.31
Ethnic of family^‡
	Madura	–1.27	1.33	0.705	–1.62	1.65	0.007	–1.48	16.60	0.578
	Jawa	–1.20	1.40		–2.15	1.63		0.01	4.10
	Mixed	–1.62	1.06	–1.87	1.04	–0.77	1.57
Type of family^†
	Nuclear family	–1.21	1.40	0.234	–1.82	1.67	0.580	–0.25	2.89	0.030
	Extended family	–1.41	1.11		–1.71	1.58		–3.83	29.74
Education^‡
	Not attending school	–0.77	2.12	0.299	0.14	1.55	0.241	–1.27	2.06	0.849
	Elementary school	–1.33	1.61		–1.73	1.89		–1.95	21.62
	Junior high school	–1.36	1.14		–1.91	1.37		–0.41	1.41
	Senior high school	–1.06	1.15		–1.84	1.60		–0.31	4.34
	Undergraduate	–0.85	0.94		–1.48	1.65		–0.13	1.41

Note. Significance finding in bold. Determined using t-independence test^† and One Way ANOVA test^‡.

Table 4

Correlation between age of parent and children, FQOL, NAMQ, family welfare and nutritional status (n = 424)

	Age of parent	Age of child	FQOL	FQOL-1	FQOL-2	FQOL-3	FQOL-4	FQOL-5	NAMQ	Family wellness	WAZ	HAZ	BAZ
	r	r	r	r	r	r	r	r	r	r	r	r	r
Age of parent	1	0.101^*	0.022	0.035	0.006	0.035	0.047	–0.032	–0.068	–0.079	0.07	0.049	0.079
Age of child	0.101^*	1	–0.009	–0.019	0.054	–0.058	–0.016	–0.008	–0.057	0.013	–0.106^*	0.038	0.027
FQOL	0.022	–0.009	1	0.905^**	0.942^**	0.873^**	0.906^**	0.813^**	–0.011	–0.042	0.260^**	0.209^**	0.064
FQOL-1	0.035	–0.019	0.905^**	1	0.809^**	0.713^**	0.796^**	0.676^**	0.02	–0.022	0.277^**	0.203^**	0.065
FQOL-2	0.006	0.054	0.942^**	0.809^**	1	0.801^**	0.798^**	0.761^**	–0.017	–0.019	0.234^**	0.175^**	0.076
FQOL-3	0.035	–0.058	0.873^**	0.713^**	0.801^**	1	0.766^**	0.595^**	–0.032	–0.02	0.248^**	0.193^**	0.067
FQOL-4	0.047	–0.016	0.906^**	0.796^**	0.798^**	0.766^**	1	0.643^**	–0.026	–0.102^*	0.207^**	0.216^**	0.013
FQOL-5	–0.032	–0.008	0.813^**	0.676^**	0.761^**	0.595^**	0.643^**	1	0.007	–0.02	0.181^**	0.136^**	0.067
NAMQ	–0.068	–0.057	–0.011	0.020	–0.017	–0.032	–0.026	0.007	1	–0.05	–0.027	–0.048	0.072
Family welfare	–0.079	0.013	–0.042	–0.022	–0.019	–0.02	–0.102^*	–0.02	–0.05	1	–0.018	–0.055	0.035
WAZ	0.070	–0.106^*	0.260^**	0.277^**	0.234^**	0.248^**	0.207^**	0.181^**	–0.027	–0.018	1	0.527^**	0.04
HAZ	0.049	0.038	0.209^**	0.203^**	0.175^**	0.193^**	0.216^**	0.136^**	–0.048	–0.055	0.527^**	1	–0.165^**
BAZ	0.079	0.027	0.064	0.065	0.076	0.067	0.013	0.067	0.072	0.035	0.040	–0.165^**	1

Note. ^*p < 0.05; ^**p < 0.01; ^***p < 0.001. Determined using Product Moment test.

4 Discussion

Our findings showed that the F-QOL was related to children’s nutritional status under-five children, especially the WAZ and HAZ indicators. However, there is no relationship between F-QOL and BAZ. This is probably because the F-QOL with its characteristics is related to children’s nutritional status among under-five children, especially in the development of children’s age, family ethnicity, and family type in agricultural areas in Indonesia.

4.1 Prevalence of malnutrition and stunting among under-five children

Regarding WAZ, our finding identified that the prevalence of malnutrition and severely under-weight among under-five children were 5% and 22.2%, respectively. These findings were higher compared National Basic of Research of Indonesia in 2018 (3.9% and 13.8) [1]. This is probably due to the characteristics of agricultural areas in Indonesia [20], which are generally located in rural areas, which are socially and economically limited in meeting the nutritional needs of the family. Reduced food production, increasing food prices, and the global financial crisis may worsen the childhood malnutrition burden of [21] among family farmers. Meanwhile, the prevalence of obesity among under-five children were 1.5% which is lower compared the previous study (12%) [22]. This may be caused by food consumption among family farmers are limited in rural areas [23]. Therefore, fulfilling the nutritional needs of under-five children in farming families is necessary to support the fulfillment of optimal growth and development. Optimizing community empowerment through village nutrition posts can significantly help facilitate additional food for children, especially for low-income families in rural areas.

Furthermore, based on HAZ, we found that the prevalence of severely stunting and stunting among under-five children were 18.9% and 27.8%, respectively. These findings were higher compared previous studies with 12% [22], although lower compared earlier studies with 36.7% [24]. This situation contributed to several factors, including socio-economic and demographic factors like house-hold’s poverty, income, residence, occupation, education, maternal age, and family size [25]. Therefore, monitoring and supporting parenting program in the community [7] and providing complementary feeding [26] could help family farmers reduce stunting among under-five children.

4.2 Family of quality of life correlated with nutritional status among under-five children

Our results identified that family’s ethnicity was correlated with stunting which is consistent with a previous study [25]. This is because children’s growth rate is very different between ethnic [27] and the height very much determines the child’s height in their ethnic [28]. Meanwhile, the type of family was correlated with malnutrition among under-five children which consistent with previous study [29]. This is possible because the existence of the kind of family will be related to the number of family members. The greater the number of family members [16] contributed, children’s nutritional needs are not fulfilled, resulting in malnutrition [25]. Furthermore, maternal and child health service programs that pay attention to aspects of local culture and family planning are needed in overcoming the problem of child malnutrition in the family.

Finally, we examined that F-QOL was correlated with malnutrition and stunting among under-five children in agricultural areas. The family has an essential role in fulfilling children’s nutrition [30]. Besides, the family’s economic status also influences the fulfillment of the food consumed by the family. Therefore, good quality of family life is critical to improving children’s nutritional status. Quality of life is defined as a view of an individual’s life in society, including culture and value systems in life-related to goals, expectations, standards, and concerns [31]. In contrast, the quality of family life is a dynamic view of family welfare in meeting all family members [32]. Improving the family’s quality of life needs to be considered in improving the nutritional status of under-five children in the family. The national government program currently being carried out is the healthy living community movement, where one of the main goals is adequate nutritional intake in fulfilling the nutritional status of the community and children who are in the process of growth and development [10].

Furthermore, the results showed that family life quality in family interactions was the highest indicator domains. This is possible because, on average, mothers who only work as housewives have the full time to interact with their toddlers, so that a mother, in this case, is more focused on childcare [33]. Family interaction is shown by families who enjoy time together, are open to each other among family members, solve problems together, support one another, show caring attitudes, and overcome issues that exist in the family [34]. Therefore, the family life quality can also be improved by frequent interaction of family members with one another.

On the indicator domain of emotional well-being, it was found that in families in agricultural areas, families expressed satisfaction with the support they received from other family members and friends around them. In this case, well-being is a past life assessed with dignity, while subjective experience about the present can be assessed by the level of happiness [10]. Based on indicators of emotional well-being, families in agricultural areas have an adequate level of emotional well-being, where the family can provide support to overcome existing problems. This follows the notion of welfare, namely that a person can realize his abilities, overcome life stress problems, work productively, and contribute to his surroundings [10].

The study results also identified that the support indicators also showed a low value, less supportive among family members. This was evidenced by the presence of under-fives children, who still had less nutritional status. It meant that the average nutritional status of under-five children could be concluded above standards. This indicates that the area is still nutrient-prone, with many malnutrition and excess nutrition that exceeds usual standards. This shows that this situation still requires attention from all parties, not just families. Under-five children who have demonstrated a malnutrition status must immediately take action. Government programs should be implemented, namely the providing complementary feeding, which is only applied as additional food, not a substitute for eating. Besides that, it is also vital to carry out family therapy or activities to train families to provide support between them: family members, especially those indicated as less supportive families.

We concluded that the prevalence of wasted, stunted, and malnutrition among under-five children in agricultural areas are 3%, 18.9%, and 5%, respectively. These are indicated that stunting is the biggest problem of nutritional status in Indonesia’s agrarian regions correlated with ethnicity and type of family. Meanwhile, the family quality of life is main correlated with stunting and malnutrition among under-five children in agricultural areas. In this case, the family is expected to improve the quality of life by seeking information from health services or health workers to improve the nutritional status of under-five children and their quality of family life.

Furthermore, health workers are expected to provide health education/counseling on the importance of the family life quality and provide information on improving the quality of family life, such as how to process family finances and health services that are easily accessible. However, it should be noted that health programs that are used to improve the quality of family life must also periodically screen the nutritional status of under-five children. Besides, this research can be used as a reference in writing a Maternal-Child Handbook. The determination of nutritional status should use the three anthropometric indices, including HAZ, WAZ, and BAZ because they are interrelated.

Footnotes

Acknowledgment

We would like to thank the Department of Research and Community Engagement, Universitas Jember, for funding research to Research Group of Family and Health Care Studies.

Funding

Department of Research and Community Engagement, Universitas Jember for funding research to Research Group of Family and Health Care Studies for grand research 2020.

Conflict of interest

We declare no conflict of interest.

Appendix 1. Questionnaire

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