QUALITATIVE STUDY OF LOCAL CULTURAL WISDOM AND HEALTH SERVICES ON STUNTING EVENTS

: Preliminary. Stunting is a condition of chronic malnutrition accompanied by complications of the disease. The prevalence of stunting in children under five in Indonesia and the province of Lampung is still high and the highest is in rural areas. Stunting occurs from the initial nutritional status of the mother before pregnancy, during pregnancy and this condition is thought to be influenced by local habits in attitudes and behavior in the care of pregnant women with their babies. Cipadang village is one of the villages formed from immigration from Java to Sumatra, which makes this village inhabited by the majority of the population of Javanese ethnicity with their cultural style. Socio-cultural conditions in general affect the health of mothers during pregnancy and the pattern of child rearing when they are under 2 years old. The purpose of this study is to explain the state of local culture and health services on the incidence of stunting. Method. This study uses a qualitative approach, to explore in depth the socio-cultural and health services related to the incidence of stunting. Sources of information came from informants, 17 people through focus group discussions. Results and Discussion. The research location village is inhabited by the majority of the population of Javanese ethnicity with its cultural style, with an agricultural livelihood. The characteristics consist of 14 mothers of toddlers and 2 posyandu cadres in Cipadang village, 1 community leader with an age range of informants between 21 to 45 years with the most education level being Elementary School. The community pays special attention to the period of pregnancy, and there are habits in the care of babies, pregnant women and postpartum mothers with ancestral traditions. However, this habit has begun to shift to health care services. Knowledge of general informants is good but behavior is not in accordance with health standards. Conclusion. Some cultures still have an influence, there are habits in caring for babies, pregnant women and postpartum mothers. Good knowledge has not been able to describe the desired behavior.


INTRODUCTION
Stunting is a condition of chronic malnutrition accompanied by disease complications (Khoeroh and Indriyanti, 2015). The prevalence of stunting in children under five in Indonesia is 29.9% and Lampung province is 27.4% and the highest is in rural areas. The condition of stunting prevalence in Lampung is below the national figure but still above 20% (WHO target is less than 20%). Stunting prevalence below 20% is only in Metro City (19.52%) and Pringsewu District (10.55%) and the highest is in Way Kanan District (36.07%) and Pesawaran District (27.49%) (Balitbangkes RI, 2018), this figure has not met the WHO target, so it is necessary to study the determinants of stunting.
Stunting has a negative impact, both in the short and long term. In the short term, children will be at risk and susceptible to infectious diseases, while in the long term, in adulthood they are at risk of suffering from chronic diseases (Nurbaiti et al., 2014;Prendergast and Humphrey, 2014;Safitri and Nindya, 2017).
Stunting occurs from the initial nutritional status of the mother before pregnancy, during pregnancy (World Health Organization, 2013) and this condition is thought to be influenced by local habits in attitudes and behavior in the care of pregnant women with their babies. Likewise, infectious diseases are directly or indirectly related to the habit of seeking health services (Dangour et al., 2013). With these considerations that attitudes and behavior in seeking health services can affect the incidence of stunting. Maternal socioeconomic status does not only affect the growth of the fetus and baby born but also on good self-care behavior and children (Vir, 2016).
Low income can affect household nutrition (Michaelsen et al., 2015). The incidence of stunting is inseparable from the habits, cultural beliefs, knowledge, and perceptions of local communities in terms of fulfilling family nutrition, these beliefs affect child care (Michaelsen et al., 2015). Women in Indonesia strongly believe that eating fish will make their breast milk smell and taste bad (Agus, Horiuchi and Porter, 2012;Withers, Kharazmi and Lim, 2018). Asian women always practice various cultures and traditional practices during pregnancy, childbirth and during childbirth (Withers, Kharazmi and Lim, 2018). Services using traditional birth attendants (shamans) are related to the ability of economic status, beliefs, traditions, and easy access (Titaley et al., 2010;Agus, Horiuchi and Porter, 2012).
Cipadang village is one of the villages that was formed since the Dutch colonialism immigrated from Java to Sumatra, which made this village inhabited by the majority of the population of Javanese ethnicity with their cultural style. In his daily life, he upholds the cultural norms of his ancestors, both in government life and in the health sector. Problems in the health sector in particular, namely the incidence of stunting as many as 43 out of 205 toddlers (20.9% prevalence) (Bidan Desa, 2020). Socio-cultural conditions in general affect the health of mothers during pregnancy and the pattern of child rearing when they are under 2 years old. Likewise, traditional birth attendants have an important role in assisting in childbirth and postpartum maternal care and infant care during the puerperium. Births carried out by mothers themselves or assisted by traditional birth attendants occur because of the strong role of customs and community culture in several regions in Indonesia (Lestari and Auliyati, 2018).
Stunting is one of the outcomes of the efforts to provide maternal and child health services that are not optimal. One of the reasons is the lack of synergy between existing programs and the culture or habits that exist in the community. There are several errors in maternal and child health services related to culture. One of its components is the ability of health workers to carry out early detection of risks to pregnant women and their babies to be born (Arman et al., 2021). When the early stages of risk detection and risk management are not good, it can have a negative impact on the nutritional status and condition of the mother and baby.
The results of several studies show that people with different ethnic and cultural backgrounds have different understandings regarding childbirth. The view of competent health workers also influences the decision where the mother will give birth at the health worker (Lestari and Auliyati, 2018). From the description above, it is necessary to conduct a qualitative study of the determinants of socio-cultural habits related to the health of pregnant women and children under five with stunting. This study analyzes qualitatively about local wisdom with the incidence of stunting. How is the relationship between local cultural wisdom and maternal and child health services to the incidence of stunting in Cipadang Village, Pesawaran Regency. The purpose of this study is to explain the state of local culture and health services on the incidence of stunting.

RESEARCH METHODS
This study uses a qualitative approach, to explore in depth the socio-cultural and health services related to the incidence of stunting in the research location (Cipadang village, Gedong Tataan District, Pesawaran Regency, Lampung Province).
Sources of information came from informants, pregnant women, mothers of toddlers, village officials, community leaders, health workers and traditional birth attendants with a total of 17 informants. Techniques for determining informants by coordinating and recommending village officials.
Technical data collection, interviews with sources of information (informants), using open-ended questions as an interview guide by means of focus group discussions. Then the researcher used a tape recorder, a mobile phone camera, and a video camera to record the results of the interviews, to make it easier to transcribe the results of the interviews into text.

RESULTS AND DISCUSSIONS
Cipadang village is one of the villages that was formed since the Dutch colonialism immigrated from Java to Sumatra island, which makes this village inhabited by the majority of the population of Javanese ethnicity with its cultural style. The lives of the residents of Cipadang Village as an agricultural village are generally rubber trees, cocoa, and a small part of cultivation of secondary crops. In his daily life, he upholds the cultural norms of his ancestors, both in government life and in the health sector. The sociocultural situation in general has a background of immigrants from the island of Java (West Java and West Java).

Characteristics of Informants
The characteristics consist of 14 mothers of toddlers and 2 posyandu cadres in Cipadang village, 1 community leader. The activity of conducting indepth interview research with health cadres and mothers of children under five was carried out at the Hamlet Hall, Sumber Sari Hamlet, Cipadang Village. The identity of the mother of the toddler as an informant in table 1.

No Initial Age
Educat ion The age range of the informants is between 21 to 45 years with the highest education level being Elementary School and the highest education level being Junior High School. Mothers of toddlers, informants are mostly elementary school education, and education, this situation can affect a person's behavior, increase an active role in behaving, acting, and acting to encourage health behavior (Malelak and Taneo, 2021).

The cultural state of the community
From observations during the research location, the livelihoods of the residents of Cipadang village in general are farmers, with seasonal crop commodities, such as rice, corn and others and work in plantation businesses such as coffee, pepper, rubber, and oil palm plantations, and state-owned enterprises. (PTPN), as well as the private sector. Some people are Muslim, but there are still those who use the customs that were taught by their ancestors, there are still such as birth ceremonies, in which the ceremony is carried out by installing lights which symbolize that the baby at the time in the womb did not see the slightest light, scissors and brave iron to keep the baby from being disturbed by spirits. Then bathe the baby after 40 days, and there are things that are added to the baby's bathing water, in the form of salt, rice and sugar, each of which is added a little, then this bath is read prayers. Seeing the culture of these ancestors when viewed from the health care of babies, there are habits that are not in accordance with the principles of personal hygiene. Other personal hygiene practices are in the form of bathing in a day using clean water and bath soap (Aisah, Ngaisyah and Rahmuniyati, 2019), The concept of personal hygiene in everyday life is very important and must be considered because the concept of personal hygiene will affect a person's health (Rahmayani, 2018).
Society pays special attention to the period of pregnancy, and there are rituals that must be carried out which signify that pregnancy is an extraordinary event, not only in the life of the pregnant woman herself but also her husband and family. There has been a shift in culture during pregnancy and childbirth in some areas, but in others it is still maintained. To ensure the health and safety of the mother and baby, the people of Cipadang Village check their pregnancy with the midwife, however they still use traditional birth attendants to check pregnancy, lead four-monthly and seven-monthly ritual ceremonies and also provide suggestions for the safety of themselves and their babies. Comprehensive efforts (services by the government and the community) can improve the quality of maternal and child health services, as well as prevent stunting (Arman et al., 2021). The influence of the family on pregnant women in general is still strong and this is shown by the strong role of the family (not only the husband) in making decisions for antenatal care and delivery decisions. However, the people of Cipadang Village still follow the government's policy in using the MCH handbook which is implemented by the family in determining the selection of health facilities for delivery. The MCH handbook contains information and materials on maternal health during pregnancy, childbirth and family planning as well as children's health materials on care for newborns to toddlers, daily care for children under five, care for sick children, how to feed children and make MP-ASI, giving complete basic immunizations, cards for pregnant women, Cards for Health (KMS) for toddlers and records of maternal and child health services. (Subiyatun, 2017).

Mother Toddler Knowledge
Knowledge of Stunting, it was shown from the results of group discussions that mothers of toddlers in general have heard the term Stunting, but some comments from mothers of toddlers related to the notion of stunting have an incorrect understanding. MP's mother thinks "stunting is failure to grow, small body, poor scales and failure to grow and speak slowly. Then if you often sleep at school, you often get sick".
Then the US mother, argues "The child does not gain weight, lacks length, also lacks growth" The low level of hygiene and sanitation practices is not due to lack of knowledge but due to personal habits and responses of a person, especially someone who is used to processing food or food handlers (Aisah, Ngaisyah and Rahmuniyati, 2019). From the opinion of the two information, it is known that the knowledge of mothers of children under five about stunting is still inaccurate, because comments about stunting are characterized by low body weight and thinness. Basically knowledge is the basis for someone to do something. Starting from knowing someone will want to do something and then being able to do it. It can be seen that the knowledge of mothers in Indonesia about MP-ASI is still very lacking so that there is a phenomenon of giving MP-ASI to infants under the age of 6 months. (Nurzeza, 2013). The level of knowledge of posyandu cadres is getting better, it is hoped that the cadres can apply this knowledge better so that the assessment of the nutritional status of toddlers will increase (Nomlenia, Nahak and Goa, 2021).
Furthermore, for knowledge about the causes of stunting are: Mom AND opinion "penyebab stunting, makan ibunya waktu hamil itu ya sama kurang gizi terus makan, kurang sayur itu juga kurang yang waktu anaknya udah melahirkan udah dikasih makan belum 6 bulan"; (the cause of stunting, eating the mother while pregnant is the same as being malnourished and continuing to eat, lack of vegetables is also lacking which when the child has given birth has not been fed for 6 months); IQ mother thinks that "anak tidak dikasih ASI, dikasih makanan bubur, dan kurang makan sayur". (the child is not breastfed, given porridge, and does not eat vegetables).
From the information above, mothers of toddlers know the direct causes of stunting, so it can be estimated that their children are stunted not because of their knowledge but because of their inappropriate behavior, it can also be caused by low social and economic conditions. Socio-economic factors that affect nutritional status begin with the type of work that is influenced by the level of education so that the level of education is low and the type of work that is not suitable will directly affect family income (Wulanta, Amisi and Punuh, 2019). Then the knowledge about the signs and characteristics of stunting on the commenting informants, is: SR's mother thinks "berat badannya tidak naik, kurus, kecil badannya"(not gaining weight, thin, small), then Ms mother thinks "pendek dan kecil badannya, dibiarin kasih makan yang tak kasih sayuran" (short and small in body, let him feed those who don't give vegetables).
In general, mothers of children under five already know the characteristics and signs of stunting, so that stunting prevention by the government is easier. Furthermore, the informant mother of toddlers is of the opinion of how to prevent stunting.

SM's mother thinks
"Do you continue to give us nutritious food, we give milk, how do we do it, we have to go to the Posyandu regularly so that we can keep the child's height measured, we give nutritious food, additional food for up to 2 years after exclusive breastfeeding." TKH mother continued "mother always breastfeeds early, so that the baby is healthy, how do we breastfeed when the newborn is just born we breastfeed until the age of 2 years".
In general, mothers of toddlers already know how to prevent stunting comprehensively, in feeding children and visiting posyandu.
Knowledge can be obtained from experience either oneself or others, while trust is often received from parents, grandmothers, grandfathers and so on, trust is accepted based on belief without prior proof. (Risa, 2015). The level of education can affect a person's mindset and digestibility. The higher the information that can be absorbed and the higher the information absorbed affects their knowledge, people with higher education are more concerned about health problems (Azzahra, Bujawati and Mallapiang, 2015).
Then comments about the experience of informants related to the practice of early initiation of breastfeeding (IMD) and breastfeeding for their children, can be found in the following interview. EF's mother shared her experience "my experiences are not discussed, no ……. As far as I know, IMD is breastfeeding when we are just giving birth, breastfeeding is placed on the chest here so that the baby looks for the nipple itself, so that the baby's immune system can get it and yes, give it exclusively, from 0 months to 6 months we give milk, we don't give anything to eat, we give extra is it just breast milk" Next, Mrs. SNT shared her experience "If the month is 0 months to 6 months to 2 years, the mother of a newborn, we give milk. Until later, yes, but be careful, until 6 months, after 6 months, we give additional food, porridge, given vegetables, there are carrots, there are potatoes." From the experience above, their child should be stunted, seeing this phenomenon there is a possibility due to other factors that are not directly known to the mother of the toddler. To be able to achieve nutritional balance, everyone, including pregnant women, must consume at least one type of food from each food class, namely carbohydrates, animal and vegetable protein, vegetables, fruit and milk. (Lestari, Sulistiawati and Naelasari, 2021 From the experience of several mothers of toddlers, they have obtained some information from the condition of intake and the influence of the behavior of those around them during pregnancy. It turns out that the experience of mothers during pregnancy is influenced by the people around them, especially when they are still with their parents and in-laws. From the experiences of these mothers, existing cultural habits still do not support the improvement of nutrition for pregnant women in order to prevent stunting. Chronic energy deficiency (CED) is a lack of energy intake in mothers that lasts for a long time, one of the most common causes found in pregnant women, due to picky eating habits (Lestari, Sulistiawati and Naelasari, 2021 From the description of the experience, the level of health services provided by the posyandu has been carried out well. Information from these 2 (two) cadres, it can be explained that the PSoyandu activities are running normally, in the form of recording posynadu participants, detecting growth and development (measuring weight and height), providing additional food for toddlers aged over 6 months and counseling is carried out by cadres regularly. personal. The frequency of visits to posyandu is the most dominant factor in the incidence of stunting. (Destiadi, Susila and Sumarmi, 2013). The role of the community in providing health services independently by optimizing the resources and potential available in the community (Susanto, Claramita and Handayani, 2017). Posyandu is a community-based health effort that makes it easy for the community to get basic health services for posyandu, nutrition recovery, and immunization. It aims to increase the improvement of nutritional status (Destiadi, Susila and Sumarmi, 2013).
According to Destiadi, Susila and Sumarmi, 2013, Low public education causes most people to be open to health information and still adhere to customary/cultural values in community groups which often do not support health behavior (Destiadi, Susila and Sumarmi, 2013). The most dominant factor in the incidence of stunting is the frequency of posyandu visits to the posyandu, which has a low risk of 3.1 times to grow stunting when compared to children who regularly attend the posyandu (Destiadi, Susila and Sumarmi, 2013).
The results of in-depth interviews with the civil servant, the condition of village government activities in participating in stunting prevention. From the description of the village officials, it can be illustrated that the condition of the Cipadang village is very active in government activities in development programs to improve the economy of the residents in the form of various farmer groups and social gatherings for self-help development, indirectly playing a role in preventing stunting. Implementation of integrated interventions with priority target groups in stunting locations is the key to successful nutrition improvement, child development and stunting prevention (Sekretariat Wakil Presiden Republik Indonesia, 2018).

Conclusion
Mothers of toddlers during pregnancy are influenced by the people around them, especially when they are still with their parents and in-laws. From the experience of mothers of children under five, existing cultural habits still do not support the improvement of nutrition for pregnant women in order to prevent stunting. Psoyandu activities run normally, in the form of recording posynadu participants, detecting growth and development (measuring weight and height), providing additional food for toddlers aged over 6 months and personal counseling.

Suggestion
Integrated counseling in improving family nutrition food, through cross-programs (convergence). Provision of stimulants for family nutritional food security through the use of house yards.
The posyandu program in service must receive support from the local government so that the posyandu functions as a health service activity at the village level, has an important role in the prevention and reduction of stunting. .