Evaluation Of Programs For Stunting Prevention Management At Tajinan Public Health Center

Received: September, 4, 2020 Revised: February, 18, 2021 Available online: May 2021 East Java is one of the provinces that has a high prevalence of stunting. The government is committed to reducing stunting rates through several health policies. The Indonesian Ministry of Health recommend programs for stunting prevention management. The purpose of this study was to evaluate the programs for stunting prevention in toddlers through elements of input, process, and output. This research was qualitative. It took place at Tajinan Public Health Center (PHC). The purposive sampling technique determined the initial informants. The data collection method was in-depth interviews, observation, and documentation of 6 initial informants consisting of the head of the PHC, the coordinator midwife for children and maternal health, the nutrition coordinator, the village midwife, the cadres, and some target mothers. Two triangulation informants were the family health coordinator and the nutrition coordinator at the District Department of Health Office. The results showed that the health workers involved still needed additional at the input stage. There were no nutrition workers. There were well-implemented programs with the family approach through home visits by the cadres in the process element. The taburia administration was a program that need development. In the output element, the coverage of the prevalence of stunting at TajinanPHC, Malang Regency, in 2018 was 17.24%.


INTRODUCTION
Stunting in children is a severe problem because it can cause morbidity and mortality, obesity and noncommunicable diseases in the future, short adults, poor cognitive development, and low productivity and income (Fikawati, 2017). Currently, around 162 million stunted children under the age of five. When this trend continues, by 2025, 127 million children under five years of age will be stunted. According to the United Nations, Children's Emergency Fund (UNICEF), more than half of the children are stunted, or 56% live in Asia, and more than a third or 37% live in Africa (Supariasa, 2011).
Indonesia is a country with many stunted children. 32 out of 34 provinces had numbers of stunting above 20% based on the stunting rate limit from the World Health Organization (WHO). Based on Basic Health Research (from now on, it is named with Riskesdas), in 2018, the stunting rate in Indonesia for toddlers reached 30.8%, consisting of 11.5% severely stunted children and 19.3% short children. Indonesia's stunting rate decreased compared to the 2013 Riskesdas data, which reached 37.2%, consisting of 18% severely stunted toddlers and 19.2% short children under five (Kemenkes RI, 2018) Based on the results of Riskesdas, East Java is one of the provinces that has a high prevalence of stunting.
The number of toddlers with stunting in East Java in 2018 reached 25.2%. Malang Regency was the 100 priority districts with a stunting rate of 20% spread over six priority villages ( birth weight is less than 2,500 grams (Sistiarani, 2008). LBW has a high risk of neonatal death, child growth disorders, including the risk of stunting when it is not appropriately handled. It is in line with research conducted by (Tiwari et al., 2014), which stated that children with a history of LBW were at risk of suffering from stunting compared with no LBW. A study conducted in Nigeria also reported that children with LBW were at risk of suffering from stunting (Akombi et al., 2017).
The education level affects stunting incidence. Children born to educated parents are less likely to be stunted than children born to parents with low education levels. Research conducted in Nepal also showed that children born to well-educated parents had a lower potential to suffer from stunting. This study is in line with research conducted by Haile et al., (2016). The study reported that children born to parents with higher education tend to receive health education more easily during pregnancy, for example, health education in the importance of meeting nutritional needs during pregnancy and exclusive breastfeeding (Haile et al., 2016).
The problem of stunting is an intergenerational nutritional problem. Stunted women will give birth to babies with LBW, which contributes to the cycle of malnutrition in life (Haile et al., 2016). Mothers with a height less than 150 cm tended to give birth to stunted babies (42.2%) than the group mothers with standard tall (36%). A study conducted in Ghana, with a sample of children under five years, showed that children with mothers who were shorter than 150 centimeters were at risk of suffering from stunting (Ali et al., 2017) Exclusive breastfeeding for less than six months is a factor that inhibits stunting. A study conducted in Nepal reported that children aged 0-23 months had a significantly lower risk of stunting than children aged > 23 months because of breast milk protection (Tiwari et al., 2014 mothers to nursing mothers, until the child reaches 24 months of age or two years old. The critical 1,000 periods effectively prevent stunting because it is a period that determines the quality of lifethe child's growth will be rapid in the "Golden Period". Therefore, nutritional coverage must be fulfilled starting from 270 days during pregnancy and the first 730 days after the baby is born. However, prevention of stunting does not only begin at the first 1,000 days but begins in adolescence by improving nutrition (World Health Organization, 2014). Stunting prevention starts with improving the nutrition of pregnant women.
Nutritional improvement is giving Fe supplementation at least 90 tablets during pregnancy. Also, mothers who experience chronic energy deficiency (CED) need to get additional food to improve the nutrition (World Health Organization, 2014). Increased breastfeeding practice is also one of the measures to prevent stunting. Early initiation of breastfeeding and exclusive breastfeeding for six months can protect against gastrointestinal infections. It is in line with research conducted by Tiwari, which reported that children with exclusively breastfed were less likely to suffer from stunting compared to children who were not nutrition (World Health Organization, 2014).
The factors that cause stunting from the mother are the mother's education level and nutritional status.
Factors causing stunting in infants are Fetal growth restriction (FGR), LBW, gender, and exclusive breastfeeding. This study aims to evaluate the management of the nutritional status in children under five with stunting at Tajinan PHC, through system elements (input, process, and output) including programs: 1) health program for pregnant women, 2) exclusive breastfeeding for infants 0-6 months, 3) infant growth and development monitoring, 4) supplementary food, 5) vitamin A supplements to toddlers, 6) taburia (multivitamins and mineral supplement for children age 6-59 months) administration.

METHOD
It was a qualitative study at Tajinan PHC, Malang Regency. The purposive sampling technique determined the initial informants. The data collection method was in-depth interviews, observation, and documentation of 6 initial informants consisting of the head of the PHC, the coordinator midwife for Child and Mother Health, the nutrition coordinator, the village midwife, cadres, and target mothers who have a baby. The data validity used two triangulation informants: the coordinator of family health and the nutrition coordinator in the Malang District Department of Health Office. The data analysis technique was reducing, displaying, and drawing conclusions.  (Sattu, 2014).

RESULT
A study on pregnant mothers who visited health professionals and gave birth at Banyumas Hospital in 2012 reported that LBW babies incidence correlated 5.85 times with poor quality antenatal compared with good quality antenatal. LBW is a factor that plays a role in the incidence of stunting (Sistiarani, 2008).
Output: The stunting prevalence decreased to 17.24% in 2018. It was much less than in 2017 and 2016, which reached up to 30% or more. The prevalence reduction because of stunting prevention management, including the health program for pregnant women, exclusive breastfeeding, growth monitoring, supplementary feeding, vitamin A supplementation, and taburia administration.

DISCUSSION
The health program for pregnant women is a part of managing the nutritional status of stunted toddlers at Research revealed that several factors predisposed stunted toddlers, one of them was ANC visit. ANC visits can detect earlier risks in pregnancy in mothers, especially those related to nutritional problems (Putri, 2015). A study found that babies whose mothers did ANC visits only once (less than the minimum standard) had a 2.4 times risk of stunting than four times ANC visit Najahah et al., (2013). The exclusive breastfeeding program in the management of stunted toddlers in the Tajinan PHC was not conducive because health workers were not following their primary duties and functions. Some health workers didn't receive training on lactation counsellors, so they had lack confidence when providing health education to patients. The health worker is the key to successful breastfeeding education for the mothers. This opinion is in line with former research that concluded that health workers' support was related to the mothers' exclusive breastfeeding behavior. Health workers are the key to success in exclusive breastfeeding education (Rosita, 2014).
Based on an interview with the head of PHC, exclusive breastfeeding program for infants aged 0-6 months at the Tajinan PHC consist of: a) Skin to skin contact between mother and baby immediately after giving birth b) Breastfeeding in the first 60 minutes c) Giving colostrum d) Emptying one breast before transferring the baby to the other breast e) Not giving any other food including plain water, sugar water or other food until six months old f) On-demand breastfeeding, according to the baby's wishes day and night at least eight times per day. All health workers at the Tajinan PHC must know the existing policies to provide health education related to standardized exclusive breastfeeding. Thus, the implementation process had been integrated following the guidelines of the Tajinan PHC, although it was not yet optimal. The coverage of the exclusive breastfeeding program as the output of the program at the Tajinan PHC in 2018 was 89.3%. It means that exclusive breastfeeding significantly affects the stunting prevalence.
Every month, the village midwife as the implementer, with the help of cadres, carried outweighing and measuring the babies during the posyandu activities. There was a lack of anthropometric measuring tools.
The Tajinan  A study related to consumption patterns, health status, and its correlation with nutritional status and development of toddlers reported that nutrition in toddlers was essential. It is the foundation for health, strength, and intellectual abilities. The study also revealed that toddlers had a more excellent average developmental value of 71.60 ± 11.91 than preschool-aged subjects of 68.08 ± 15.54 (Lampung et al., 2018). Monitoring children's growth and development should be attention because it will affect the nutritional status, one of which is stunting. It is following the policy standards of the Tajinan PHC. However, there should be a concern in the quality and quantity of additional food so that children health status, especially nutritional status, can be optimal.
Research on risk factors for underweight children aged 7-59 months stated that parenting played a significant role and dramatically affected the nutritional status of children, one of which was stunting. One of the critical aspects of food parenting is compiling and giving complementary foods, namely in additional food (Septiana et al., 2014). The practice can include colostrum administration, exclusive breastfeeding, and weaning practices (Doloksaribu et al., 2016). Research on vitamin A and zinc deficiency as a risk factor for stunting revealed that vitamin A deficiency affected protein synthesis, affecting cell growth. For this reason, children who suffer from vitamin A deficiency will experience growth failure and lack of micronutrients (Vitamin A and Zinc). It is one of the factors that influence the stunting incidence.
The taburia administration program in managing the nutritional status of stunting toddlers at the Tajinan PHC was not effective. The coordinator, who were also nutrition coordinators, did not know the main task and function in procuring taburia. The District Department of Health Office subsidized the procurement of taburia. Simultaneously, the PHC only plans taburia needs and distributes it to target children based on projection calculations from Statistics Indonesia. The policy of giving taburia at the Tajinan PHC in terms of duties and implementation teams did not integrate, especially in managing the provision of taburia, which included planning needs, provision, storage, distribution, recording and reporting, monitoring, and evaluation. Based on interviews and documentation, the taburia administration program output coverage for children under five was 0% in 2018. This coverage does not have a positive effect on reducing the prevalence of stunting under five.
Based on the evaluation of the taburia administration program, the organizing must be coordinated. This program involves other sectors of the sub-district in disseminating taburia to the public. The handbook on https://doi.org/10.33086/jhs.v14i2.1754 Rifzul Maulina -Evaluation Of Programs For Stunting Prevention Management At Tajinan Public Health Center the management of taburia administration program states that socialization is an essential part of increasing the coverage of taburia giving. Socialization can mobilize all levels of society to support the activity of giving taburia as a micronutrient to prevent stunting (Alim et al., 2011).

CONCLUSION
The health program for pregnant women, development monitoring program for toddlers, supplementary feeding program, vitamin A administration, correlates with the reduction of stunting toddler's incidence at Tajinan PHC. However, the taburia administration program is not effective yet.