Professor of Nutrition and Health Sciences at the Faculty of Mathematics and Natural Sciences, Semarang State University (UNNES)
Introduction
Stunting, or in simpler terms, “shortness” – although these two terms are technically different – is a condition in which a child experiences growth impairment, resulting in their height not being appropriate for their age, as a result of chronic nutritional problems, namely long-term insufficient nutrient intake. Stunting poses a threat to the nation as the failure to grow in children, especially during the first 1,000 days of life due to chronic malnutrition, can affect brain growth and development, thus negatively impacting a child’s intelligence and increasing their risk of non-communicable diseases such as diabetes mellitus, cancer, and coronary heart disease in adulthood (Ministry of Health, 2018).
In 2017, the World Bank reported that Indonesia ranked fourth in the world in terms of the highest number of stunted children, slightly lower than India, Pakistan, and Nigeria. According to the data on the prevalence of stunting among children collected by the World Health Organization (WHO), Indonesia is among the top three countries with the highest prevalence in the South-East Asia Regional (SEAR) region.
Nutrition Status Study in Indonesia (SSGI) by the Ministry of Health (Kemenkes) reported that the prevalence of stunting among children in Indonesia was 24.4% in 2021. This means that nearly a quarter of children in the country experienced stunting in the past year. The government aims to reduce the prevalence of stunting in Indonesia to below 14% by 2024. Therefore, the target for reducing the prevalence of stunting each year should be around 2.7%. Data from the Indonesian Nutrition Status Survey (SSGI) in 2021 showed that the prevalence of stunting in Central Java was 27.7% in 2020 and decreased to 20.9% in 2022. However, when this percentage is multiplied by the number of mothers giving birth in Central Java, which averages 551,000 per year, the stunting rate in Central Java is still relatively high.
The issue of stunting is complex, and some regions are reluctant to accept that their region has many stunted children. Almost 60% of parents refuse to acknowledge if their child is classified as stunted. Moreover, many people comment that a significant amount of funds has been used to address stunting, a problem that they believe does not exist and has no solution.
Based on Presidential Regulation Number 72 of 2021 on the Acceleration of Stunting Reduction, the target groups for accelerating stunting reduction include adolescents, prospective brides and grooms, pregnant women, lactating mothers, and children aged 0 to 59 months. The handling of stunting reduction is focused on areas with high prevalence rates and areas with a high number of stunted children through more intensive interventions, consolidated and integrated funding, to make the efforts more effective and efficient. It also involves various sectors, such as the local government, universities, stakeholders, and others.
According to the Nutrition Status Monitoring (PSG) data in Central Java, the prevalence of stunting among children in Central Java from 2015 to 2017 was also above 20%, with 24.8% in 2015, 23.9% in 2016, and an increase to 28.5% in 2017. Based on the 2018 Basic Health Research (Riskesdas), Rembang Regency had a stunting prevalence of 26%, with a total of 425 cases of stunted infants born from January to October 2020. Based on the results of a workshop on the Reduction of Malnutrition and Stunting in commemoration of the 55th National Health Day at Fave Hotel Rembang on Thursday, October 17, 2019, the Rembang Regency Government through the Health Office targeted to reduce the stunting rate to below 20 percent. Currently, based on nutrition status monitoring data (PSG), the prevalence of stunting is higher compared to other nutrition problems such as undernutrition, thinness, and overweight.
The prevalence of stunting in Rembang Regency in 2021, amidst the Covid-19 pandemic, increased to 24.97%, placing Rembang Regency as the third-highest stunting rate in Central Java Province. The number of stunting cases in the August 2021 weighing month reached 5,566 cases from 17 health centers in Rembang Regency. Various efforts have been made to prevent and address the issue of stunting in Rembang Regency, such as the “Gemari” campaign (encouraging fish consumption), stunting meetings (Rembuk stunting), and cross-sectoral nutrition interventions. Several factors have contributed to the increase in stunting, including the Covid-19 pandemic. During the pandemic, services requiring visits to integrated health posts (posyandu) had to undergo rapid testing, resulting in a participation rate of around 50%. There is a high disparity in variations between different health centers. Not all national and private institutions have designated spaces for breastfeeding. Early marriage is still prevalent, and the patterns of care and nurturing are not yet optimal. Addressing stunting requires the support of various stakeholders and cannot be solely burdened by the Health Office alone.
Responsibility for reducing the prevalence of stunting nationally requires active engagement from multiple sectors in its activities. Convergence is the approach adopted in implementing programs from the central level to the village level. The elements within it support each other so that national and regional targets can be more effectively achieved. The concept of the “penta helix” contains a similar understanding to convergence. The concept of “penta helix” development involves the participation of five elements: the government, communities, academia, business, and media in national development. Addressing the issue of stunting, which is a national priority, also requires the involvement of these elements in efforts to reduce the national prevalence.
Stunting Support Activities
Many current activities are linked to stunting. There is the “Stop Stunting” campaign by nutrition alumni in stunting hotspot villages, thematic community service programs by university students in remote areas, and foster parent programs for families at risk of stunting. There are also initiatives such as planting moringa trees and producing moringa-based food for children under two years old (infants and toddlers). Additionally, eggs are distributed at integrated health posts (Posyandu) for families with toddlers. Stunting has become a flagship program in various regions, particularly rural areas. The acceleration program for reducing stunting is fundamentally policy-based. In Indonesia, Presidential Regulation (Perpres) No. 72 of 2021 on Accelerating the Reduction of Stunting has been issued, replacing Presidential Regulation No. 42 of 2013 on the National Movement for Accelerating Nutrition Improvement. This new regulation emphasizes a family-based program, whereas previously it targeted specific groups such as pregnant women, breastfeeding mothers, or infants and toddlers. Through the role of the National Population and Family Planning Board (BKKBN) as the coordinator, it is expected that this family-based approach to tackling stunting will be successful. Attention to the nutritional status of pregnant women during the early stages of pregnancy is crucial, as it affects fetal growth, including bone length. That’s why attention to this period is essential.
Attention to the nutritional needs of children from birth to 2 years old is crucial. From birth to 6 months, infants only need breast milk, and after that, they should be given complementary foods, known as complementary feeding (MP-ASI). This food should be a mixture of various food ingredients, including vegetables, eggs, fish, or meat. Unfortunately, in rural areas or families with low education levels or limited socio-economic conditions, the quality of complementary foods is often low. Moreover, there are myths surrounding the introduction of eggs, fish, and meat to children. Intensive support is needed to ensure the quality of the food provided to children up to the age of two.
RAN PASTI stands for the National Action Plan for Accelerating the Reduction of Stunting, which is regulated under BKKBN Regulation No. 12 of 2021. It serves as the operational foundation for accelerating the reduction of stunting from the national level down to the village level from 2021 to 2024. Various activities related to accelerating the reduction of stunting are presented comprehensively and systematically in this regulation. With this regulation, the target of achieving a 14% national stunting prevalence rate by 2024 is expected to be met. “Empat PASTI” (Four Certainties) is an effort that can be used as a guideline to ensure that the target groups receive optimal services. Firstly, ensure that all target groups are included in the program. Secondly, ensure that all target groups can access the available services. Thirdly, ensure that the target groups receive the program at the service location. Fourthly, ensure that the implemented programs are recorded and reported. It may seem trivial, but the implementation of these Four Certainties can only be achieved if all personnel perform their duties well and optimally. Smart work and sincere work are certainly prerequisites.
The Role of Higher Education Institutions in Accelerating the Reduction of Stunting
In order to accelerate the reduction of stunting prevalence, serious prevention and reduction efforts from provincial and district/city governments are needed. However, initiatives to accelerate the reduction of stunting prevalence should not come solely from local governments. Initiatives can also emerge from higher education institutions. In this regard, higher education institutions play an important role in accelerating the reduction of stunting prevalence. Higher education institutions can fulfill a strategic role through community service activities, which is one of the components of the three pillars of higher education. They can also participate together with community members in community service activities through direct socialization, education, training, and workshops for the wider community. The socialization and education provided, for example, can include informing the benefits of meeting the nutritional needs of toddlers in preventing stunting, educating about the risks and dangers of stunting in toddlers, or addressing other prevention and reduction themes related to stunting.
Higher education institutions or academicians should have a crucial role in reducing the prevalence and supporting the implementation of stunting programs. They can contribute by maintaining the sustainability of stunting reduction programs, providing scientific evidence to program implementers, strengthening the capacity of district/city governments, and providing assistance in the development of effective intervention models, as well as serving as a source of good practice learning.
According to a statement issued by the Directorate General of Higher Education (Ditjen Dikti), Ditjen Dikti supports the stunting intervention program initiated by the Ministry of Health (Kemenkes). This support is manifested through the Campus Preparedness program and the Healthy Living Community Movement (GERMAS), in collaboration with the Indonesian Nutritionist Association (PERSAGI) and the Association of Higher Education Institutions in the Nutrition Field (AIPGI). The program aims to mobilize higher education institutions to encourage students in 8 Merdeka Campus activities conducted off-campus to assist in stunting intervention. Higher education also plays a role in providing recommendations based on studies or research in addressing stunting. Equally important is the implementation of accelerated stunting reduction practices at the regional level through education and promotion to the community, utilizing a family-centered approach through cooperation between higher education institutions and relevant institutions, as part of the higher education policy.
The role of higher education institutions is crucial in convincing local leaders that stunting is not just a health issue. Additionally, they help educate the public about nutrition issues and concerns, and through community service, higher education institutions can help collect comprehensive and integrated data on existing cases. Higher education institutions must play a significant role, particularly in the field of nutrition, to improve Indonesia’s reputation in addressing nutrition issues, especially anemia among adolescents and stunting. This can be achieved through education and outreach to the community regarding stunting, particularly among the impoverished population.
Good Practices of UNNES in Combating Stunting
As part of the Tri Dharma of Higher Education and as a form of participation in accelerating the reduction of stunting prevalence, academics and students from UNNES (Semarang State University) actively participate in the Acceleration Action for Stunting Reduction in Rembang District through applied research programs and thematic Community Service (KKN) through UNNES GIAT with a theme of Stunting. The research activities on stunted children focused on accelerating the reduction of stunting prevalence are funded by the Directorate General of Higher Education (Ditjen Dikti) through the Kedaireka program. The Kedaireka Matching Fund Program is a funding program from Ditjen Dikti that involves higher education institutions, the business and industry sector, local governments, and other institutions. In this program, academics collaborate with the local government to implement activities for accelerating the reduction of stunting in Rembang District. The activities conducted include focus group discussions (FGD), socialization, education/training/workshops, national seminars, and competitions. Education/training and workshops are conducted through community empowerment based on local assets, local natural resources, and community participation.
The implementation of the intervention program for stunting prevention adopts the Participatory Action Research (PAR) and Asset-Based Community Development (ABCD) approaches. Participatory Action Research is a research method that actively involves all relevant parties in studying ongoing actions (where their own experiences are the issues) in order to bring about change and improvement towards a better direction. It is a process in which researchers and participants work together systematically to identify and solve problems. The researchers involve the community in identifying and analyzing problems, and then take action to solve them. On the other hand, the ABCD approach is a community development approach based on the local assets available in an area. These assets are developed to address the problems in the area. Assets can include individuals, institutions, associations, organizations, as well as natural resources. Therefore, this locally based program is a community-based program that plays a crucial role in all stages of the social and behavioral change process. When the community is engaged in a process of change, actively involved, and becomes independent agents of change, they will adopt the new behaviors and agree to new social norms to promote wider behavioral change. This also encourages community acceptance of behavioral change and the sustainability of activities to support effective change and improvement of good practices in stunting prevention.
Stunting prevention also involves food interventions for infants and young children. Provision of supplementary feeding (PMT) and complementary feeding (MP-ASI) are interventions that can be implemented to address stunting. Often, PMT and MP-ASI are made from ingredients that are difficult for the community to access, causing parents or caregivers to hesitate in providing high-nutrition foods due to economic limitations. However, in reality, many local food resources have high nutritional content in the vicinity of the children’s residence who are stunted. The lack of knowledge about food sources and processing methods is one of the obstacles preventing the optimal utilization of available natural resources. It is unfortunate that parents cannot utilize the existing and affordable local food resources to help their children overcome stunting.
Rembang District has rich local food resources that can be utilized as supplementary feeding for toddlers. Two examples of local food resources are moringa leaves (kelor) and sea fish. Moringa leaves can be used as a vegetable when they are young. However, people rarely utilize moringa leaves as a vegetable due to myths that it can remove charms or ward off evil spirits. In reality, moringa leaves have excellent health benefits, especially for children. Moringa leaves are reported to contain protein (19-29%), fiber (16-24%), fats, carbohydrates, minerals, calcium, magnesium, phosphorus, iron, sulfur, oxalic acid, vitamin A, vitamin B (choline), vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3, vitamin C, and vitamin E. Adequate fiber content is also beneficial for children’s digestion. Moringa plants are easy to grow and can be found in lowland and highland areas. They can be propagated generatively (from seeds) or vegetatively (stem cuttings), making it convenient for the community to cultivate them.
As for sea fish, it contains numerous essential nutrients for children. Sea fish is one of the foods with a variety of nutrients needed by the body, including protein, omega-3 fatty acids, vitamins, and minerals such as B-complex vitamins, vitamin D, iron, calcium, selenium, and zinc. For coastal communities like Rembang District, it is easy to access sea fish. The market price of sea fish is also affordable for the community due to its proximity to the coastline. The processing of sea fish can be diverse, not limited to frying alone. Similar to adults, children also have saturation points with certain foods. Therefore, parents or caregivers need to provide variety to ensure that children’s nutritional needs are met.
Moringa leaves and sea fish can be suitable choices for improving nutritional intake in children as part of efforts to address stunting. The abundance of available resources, affordable prices, and ease of processing provide convenience for parents and caregivers in promoting the health and optimal growth of their children.
Conclusion:
The good practices carried out by academics and students from UNNES aim to enhance the knowledge and awareness of the community regarding stunting and its prevention and mitigation methods. In the implementation of these activities, UNNES collaborates with the Regency Government of Rembang, the National Population and Family Planning Board (BKKBN), the Rembang District Health Office, health centers, and other community elements. This collaboration is key to the success of these activities. Through holistic and integrated intervention activities based on local wisdom in Rembang District, it is hoped that the community will gain knowledge about stunting and be motivated to actively participate in early prevention efforts in their surroundings. Additionally, it is expected that stunted children can gradually recover and grow up healthy, just like their peers.
We express our gratitude to the Directorate General of Higher Education (Ditjen Dikti) for funding the holistic and integrated intervention activities based on local wisdom in Rembang District through the 2022 Kedaireka Matching Fund Program. We thank the LP2M team for assisting in the administrative process. Our heartfelt thanks go to the Dean of the Faculty of Mathematics and Natural Sciences, UNNES, for their full support of the holistic and integrated intervention activities under the Kedaireka program. We extend our gratitude to the Vice Regent of Rembang, as the head of the Stunting Acceleration Team, the Head of the Rembang District Health Office, and their respective teams for their willingness to collaborate and wholehearted support of the Kedaireka activities. Our boundless appreciation goes to our fellow lecturers in the 2022 Kedaireka Matching Fund team, who have accompanied us with unwavering enthusiasm and shared the joys and challenges in our efforts to accelerate stunting reduction in Rembang District. They are: Prof. Dr. drh. R. Susanti, MP, Prof. Dr. Noor Aini Habibah, M.Si, Dr. Dewi Mustikaningtyas, M.Si.Med, dr. RR. Sri Ratna Rahayu, M.Kes, Ph.D, Ervi Rachma Dewi, S.K.M, M.Kes, dr. Yanuarita Tursinawati, M.Si.Med, Kholiq Budiman, S.Pd, M.Pd. We apologize if there were any unintended mistakes in our words or actions, and we humbly ask for forgiveness and understanding. May our efforts to accelerate stunting reduction be realized as hoped. Amen, O Lord of all the worlds.
Bibliography:
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Prof. Dr. Ari Yuniastuti, M.Kes is a professor in the field of Nutrition and Health. She has a educational background in Bachelor of Nutrition and Animal Feed, followed by Master’s and Doctoral degrees in Basic Medical Sciences and Health. She teaches courses such as Nutrition and Health, Nutritional Biochemistry, Biochemistry, Organic Chemistry, and Biostatistics. Her research focus is on Nutrigenomics and Functional Foods.
