Study area and period
Bogor Regency is a buffer zone for the national capital, namely DKI Jakarta Province. The population in Bogor Regency based on data from the Central Statistics Agency (CSA) is 5,427,068 people in 2019, the most in West Java Province, even in Indonesia. In 2019 the population growth rate of Bogor Regency was 2.13%, but during the COVID-19 pandemic, the population in this region decreased by around 500 thousand people since the COVID-19 pandemic. The population pyramid in Bogor Regency shows a pyramid of youth. Of the total population in this region, as many as 9.68% children aged 0-4 years in 2019. This number decreased from 2016-2019. conversely, the Infant Mortality Rate and Toddler Mortality Rate in Bogor Regency is high (29).
Bogor Regency is included in the 100 priority areas for stunting interventions in Indonesia (5). The prevalence of stunted children in this region reached 32.9% until 2018, where this number is included in the category of high prevalence based on the WHO category (30-39%) (30). Likewise, malnutrition and underweight are still the focus of serious handling in this region. This district has 101 health centers spread over 40 sub-districts, where several sub-districts are included in the category of nutrient-prone areas. Sub-districts located in the lowlands, namely in urban areas, have developed into industrial areas. Meanwhile, the sub-districts in the highlands developed as agricultural areas. Resident alternatives to obtain quality drinking water sources vary widely. Most urban communities have used the services of Regional Drinking Water Companies to meet the needs of drinking water sources. In rural, people are relatively more varied, ranging from those using protected wells, dug wells, hand pumping wells, protected springs, rainwater reservoirs to those using water bodies such as lakes and rivers to meet their drinking water needs. The population in general works as factory workers, farmers, entrepreneurs, and a small part as government employees. More than half of the population has low education. More women have less education than men. They generally marry in their teens (less than 18 years). They become housewives and act as the primary caregivers for their children (31).
Design and samples
A cross-sectional study was conducted from February-May 2019 in rural areas, in Bogor District, West Java Province, Indonesia. A total of 330 pairs of mother’s and children under five years participated in this study. Participants came from two community health center working areas in one sub-district as a nutrient-prone area in Bogor Regency. Four out of ten villages that became pockets of undernutrition were selected as locations in this study. Participants who met the inclusion criteria and exclusion criteria were selected from the four villages by systematic random sampling.
Inclusion and exclusion criteria
Participants in this study are mother’s who have children aged 0-59 months, who have lived for at least six months or more in the village, to obtain homogeneous exposure to people's lifestyles, access to information, and health services in rural areas. Other inclusion criteria are children who are not undergoing intensive health care or suffering from serious illnesses that affect their nutritional status. The exclusion criteria were children who had congenital abnormalities from birth.
Sample size determination
The sample was calculated using the one-sample test of proportions with a two-sided alternative hypothesis using the following assumptions: 5% level of significance, 90% power, 48.5% undernutrition among rural children (P0) based on a previous study (27), and Pa 10% smaller than P0, and 10% contingency for loss to follow-up. Therefore, the calculated sample size was 330 for pairs mother-child (32).
Sampling technique and procedure
Four villages as pockets of undernutrition were selected from two working areas of the community health center in Bogor District. Eligible participants were selected using a systematic random sampling technique (Figure 1).
Data collection and measurements
Anthropometric measurements
Anthropometric measurements were performed using conventional indices, namely weight-for-age, length/height-for-age, and weight-for-length/height. In addition, measurements were used using the CIAF, which is an anthropometric index that combines the three indices of weight-for-age, length/height-for-age, and weight-for-length/height to determine the nutritional status of children under five years. Age was obtained from the information provided by the mother, namely the date, month, and year the child was born. Then the child's age is calculated in months.
Weight
Bodyweight measurements were carried out by trained midwives, namely for children less than two years of age, measured with a calibrated SECA digital infant scale. Before weighing, ensure the infant is not wearing any clothes and remove the diaper before measuring the weight. The weight should be measured to the nearest 0.01 kg. For children older than 24 months, an electronic floor scale that has been calibrated to an accuracy of 0.01 kg is used. The children were weighed twice and the results were averaged. The results of the first and second measurements should not be much different, and then the results of the two measurements are averaged and recorded.
Length/Height
Measurement of length/height, namely for children under the age of 2 years or who cannot stand, use a length board or infantometer. Infantometer placed on a table or flat surface, placing the baby on his back, and making sure the baby does not use hat/headgear and footwear. When measuring, the baby's feet must be close together, the baby's knees pressed until they are straight, and the feet are straightened. For babies who are more than 2 years old or can stand up, the height measurement was done using a stadiometer. The child should stand up straight, with buttocks, shoulder blades, and heels together touching the back of the stadiometer. The feet should face outward at a 60-degree angle. Their arms should be loosely hanging at the sides with palms facing the thighs. The horizontal bar of the stadiometer should be lowered until the hair is compressed to the crown of the head. The stadiometer accuracy is 0.1 cm. Measurements were carried out twice, to obtain two readings within 0.2 cm. The average of the two closest measurements should be recorded.
Z-Score
To assess nutritional status, the anthropometric index measurements of weight-for-age, length/height-for-age, and weight-for-length/height refer to the child growth standards according to WHO (12). The results of anthropometric measurements were analyzed using the WHO Anthro software to obtain the z-score value.
Composite Index of Anthropometric Failure (CIAF)
Assessment of nutritional status based on failure to thrive in children using the CIAF index is an alternative indicator of malnutrition by referring to the Handbook of Anthropometry: Physical Measures of Human Form in Health and Disease (21). The CIAF identified seven groups of children including those who did not experience anthropometric failure (Table 1). The seven groups are A) without anthropometric failure, B) wasting only, C) wasting and underweight, D) wasting, underweight, and stunting, E) underweight and stunting, F) stunting only, and F) underweight only. The sum of groups B, C, D, E, F, and Y gives the total amount of malnutrition. At the same time, the CIAF index can be used in detecting some anthropometric failures.
Mother and Child Characteristics
Mother and Child characteristics were measured by direct interviews using a structured questionnaire. Mother's age is categorized based on the mean age of the mother, namely 1) < 25 years, and 2) 25 years. Mother's height is categorized based on the mean value, namely 1) short if the height is less than 150 cm, and 2) tall if more than equal to 150 cm. Mother's education is categorized into 1) low if you have never attended school and have a primary school education, and 2) high if you have primary high school education and above. Mother's employment status is grouped into 1) not working, and 2) working. The level of family income is how much income is received by the family in one month. Then, its grouped based on the regional minimum wage in Bogor District (3.800.000 IDR), that is 1) low income, if < the regional minimum wage, and 2) high income, if the regional minimum wage. Parity is the number of children born to the mother, grouped into 1) primipara, if the mother gives birth to one child, 2) multipara, if the mother has given birth to 2-4 children, and 3) grand multipara if the mother has given birth to more than 4 children. The primary caregiver is the person who takes care of the day-to-day children. These variables are categorized into 1) being raised by someone other than the mother, and 2) mother as a primary caregiver. Data regarding the mother's knowledge was measured by asking questions about a balanced diet consisting of 20 questions. Each correct answer was given a score of 1, and 0 if wrong. The total score obtained is divided by the number of questions multiplied by 100 percent (correct answer score/20 x 100 percent). It is categorized based on the mean score, 1) knowledge is not good if the value is less than 70, and 2) knowledge is good if the value is more than equal to 70.
Characteristics of children (sex, age, immunization history, and early initiation of breastfeeding) were measured using a structured questionnaire. The sex of the children is categorized into 1) boy and 2) girl. Immunization history is the provision of complete basic immunizations that must be given to infants from birth to 9 months of age and categorized into 1) ungiven, if the baby from the beginning of birth to the age of 9 months was not given any immunizations at all, 2) incomplete, if the baby had not been fully immunized and was not even 9 months old, and 3) complete if the baby was given complete all types of immunization from birth to 9 months of age. Early Initiation of Breastfeeding (EIB) is categorized into 1) No, if the baby was not given breast milk immediately after birth for the first 1 hour, and 2) Yes if the baby was breastfed immediately after birth until the first hour after birth.
Data regarding the frequency of consumption of food sources of energy and the frequency of consumption of food sources of protein in children were measured by the A Food Frequency Questionnaire (FFQ). The mother fills out a limited checklist on how often her child consumes food sources of energy and food per day (times/day) in the last six months. For food consumption of energy sources based on the analysis, results are categorized: 1) low consumption if the consumption frequency is < 3x/day, and 2) high consumption if the consumption frequency is 3x/day. Meanwhile, protein source food consumption is categorized into 1) low consumption, if the consumption frequency is < 3x/day, and 2) high consumption if the consumption frequency is 3x/day.
Environment sanitation and Clean Living Behavior
Measurements of environmental sanitation include indoor air temperature and relative humidity, while measurements of clean living behavior include sources of drinking water, hand washing habits, and bowel habits. Environmental sanitation measurements were not measured for every house because there were considerations that not every participant allowed data collectors to enter the house. In general, the participants gave reasons that the condition of their house was not suitable and stated that they were disturbed.
Measurement of room temperature and humidity using an environment meter with the code KW0600291. This tool can measure air temperature in the range of -20oC~200oC, with accuracy or resolution of 0.1oC. Room temperature is measured by placing the instrument at chest level, waiting for 5 minutes to measure the temperature steadily. It was measured twice, and the results were averaged and recorded. The measurement results are then categorized based on SNI T-14-1993-037 into 1) uncomfortable, if the room is at a temperature of <20.5°C and >27.2°C, and 2) comfortable if the room is at a temperature of 20.5-27.2°C.
The relative humidity is measured by the environment meter. This tool can measure air relative humidity in the range of 35%RH~95%, resolution 0.1%RH, with an accuracy level (%rdg+digits) of ±5%RH at 25°C. Measurement of relative humidity of the air is done by placing the instrument at chest level, waiting for 5 minutes to measure the temperature steadily. It was measured twice, and the results were averaged and recorded. These results, then categorized based on SNI 03-6572-2001 into 1) uncomfortable, if the humidity is <40% and >70%, and 2) comfortable if the humidity is in the range of 40-70%.
Sources of cooking water were categorized into 1) unprotected springs and 2) protected springs. Handwashing habits are divided into 2 categories, 1) not good if washing hands do not use running water and soap, 2) good, if washing hands do not use running water and soap. Also, the habit of defecating is divided into 1) open place and 2) toilet.
Quality Assurance of Data Collection
Four nutritionists served as data collectors in this study. They lived during the data collection period in each village because access to the area was quite difficult to reach. Data collection was carried out directly by face-to-face interviews through home visits by data collectors accompanied by posyandu cadres in every village, and periodic supervision to ensure the accuracy of data collection. All instruments used in this study were calibrated before use. All data collectors have been given direction and trained to have skills in the use of these tools. Supervision was carried out by two practitioners with a master's degree in public health nutrition and who had experience in research. The questionnaire used was reviewed by experts and tested previously on 10% of the total participants in other villages who have similar characteristics to the study area. After the data is collected, it is verified and checked for completeness by the data collector before being submitted to the supervisor.
Data processing and analysis
All items in the questionnaire were checked for missing values, including mother and child characteristics and environment sanitation. Furthermore, it was coded and input in statistics software using SPSS version 22.0. Descriptive statistics consisting of the mean, standard deviation, and percentage analyzed by univariate analysis. Bivariate analysis using the chi-square test, where the variables are categorical data. A 95% confidence level and a value of P < 0.05 were used to assess the statistical significance. Binary logistic regression analysis were used to analyze the dominant factors associated with malnutrition based on underweight, stunting, wasting, and CIAF.
Ethical approval and consent to participate
Ethics Commission of Health Research of the Faculty of Medicine and Health in Universitas Muhammadiyah Jakarta acceded to this study with approval number 01A/PE/KE/FKK-UMJ/2019. The Government and The Health Office of Bogor District, and two community health centers as the study area also granted permission. The comfort of the mother and childer while participating in the data collection process was prioritized, and the confidentiality of their identity was well guarded. The authors confirmed that all methods were carried out following the relevant guidelines and regulations (Helsinki Declaration).