Analysis of traditional feeding practices and stunting among children aged 6 to 59 months in Karanganyar District, Central Java Province, Indonesia

Stunting is a major public health issue in the Southeast Asia region [1]. According to a joint report by UNICEF, WHO, and the World Bank in 2020, approximately 24.1% of children aged under 5 years in the Southeast Asia region experienced stunting [2]. Stunting is primarily caused by chronic undernutrition and infection during pregnancy through the second year of life and continues until the age of 5 years [3, 4]. The short-term negative consequences of stunting include a low immune system, diminished physical development, and impaired cognitive function in children aged under 5 years [5, 6]. The long-term negative consequences of stunting include decreased school performance in childhood and an increased risk of chronic diseases in adulthood [6, 7]. In addition, stunting can be genetic in women. This means that women who experienced stunting can have stunted offspring [8, 9].

Among Southeast Asian countries, Indonesia has a persistently higher prevalence of stunting. In 2020, approximately 31.8% of children aged under 5 years were stunted, which was the second highest rate in the region after East Timor, with a rate of approximately 48.8% [2]. The government has tried to reduce the prevalence of stunting by including it in the national public health agenda since 2017 [10]; however, the reduction has been relatively slower than the government’s expectation [11]. From 2012 to 2020, the reduction in Indonesia was approximately 2.7 percentage points, from 34.5% to 31.8%. This decline was lower than that in Southeast Asia, which was approximately 3.6 percentage points, and far lower than that of 5 target countries (Lao PDR, Cambodia, Philippines, Myanmar, and Vietnam), which was approximately 5.8 percentage points for the same time period [2].

Factors related to stunting have been examined in numerous previous studies [4, 12‐23]. Various socioeconomic conditions were shown to be associated with stunting, including household income level, maternal education and health status, and child birth weight, age and sex [4, 12, 13, 22, 23]. Optimal feeding practices, including exclusive breastfeeding, early initiation of breastfeeding within one hour after birth, and timely introduction of complementary foods, could lower the risk of stunting [14‐17]. Furthermore, infections, including recurrent child infections, and vaccination, as well as environmental factors, including access to safe drinking water and sanitary conditions, were found to be determinants of stunting in children [18‐21].

In Indonesia, traditional feeding practices are widespread among mothers due to culture and religion. According to field experts, certain practices are inappropriate for children and lead to stunting. For instance, some mothers perform prelacteal feeding by applying honey or sugar on their babies’ lips, as they believe that applying something sweet will bring good fortune to the babies in the future. Some mothers are also known to give rice water to their babies because they believe that its white color and thick texture have benefits similar to those of breast milk. In addition, an incomplete vaccination status, which puts children at higher risk of stunting, seems to be related to certain religious beliefs, since some Muslim mothers are doubtful of the impermissible ingredients (i.e., porcine-derived products) used in vaccines. Traditional feeding practices in this study refer to belief-driven feeding practices.

To the best of our knowledge, traditional feeding practices and incomplete vaccination have been relatively understudied in Indonesia because most previous studies conducted in Indonesia used secondary nationwide survey data sources [24‐26]. Therefore, this study aimed to add to the body of knowledge on factors related to stunting among children aged 6 to 59 months. Specifically, along with the general factors evaluated in previous studies, we analyzed whether traditional feeding practices commonly used among Indonesian mothers are related to stunting and explored the reasons for these practices. Additionally, reasons for incomplete vaccination were explored.

The results showed that low sociodemographic status (child age, child size, preceding birth interval, and household income level), inappropriate feeding practices (early initiation of breastfeeding, exclusive breastfeeding, duration of breastfeeding, and feeding frequency), traditional feeding practices (food restrictions during pregnancy, food restrictions for the child, and prelacteal feeding), incomplete basic vaccination, and residence in rural areas were related to stunting.

Traditional feeding practices and incomplete basic vaccination were based on cultural and religious beliefs. The study findings revealed that these practices were higher among children with stunting than among children without stunting. For example, mothers believed that red meat could cause high blood pressure; thus, it could trigger miscarriage or bleeding during delivery. A similar pattern was observed for the vaccination status. Most mothers believed that vaccines were harmful to their children due to their general side effects, such as fever. Another reason was hesitancy in vaccines among mothers due to its ingredients which are not permitted by their religion.

Based on the findings, we emphasize the importance of education for mothers to correct misconceptions of traditional behaviors. The government has recommended that all PHCUs offer counseling to educate mothers about appropriate feeding practices and vaccination. However, PHCUs have to cover all community members within subdistricts, and there are a large number of patients visiting every day; hence, the waiting time is long due to the shortage of health care professionals [36, 37]. Consequently, counseling sessions to educate mothers are often short, and services are limited to a basic physical examination. Therefore, the government should consider gradually improving resources as a long-term strategy to prevent stunting.

As a short-term strategy, the government can utilize local health cadres to monitor traditional feeding practices among mothers and provide education to correct misconceptions. In addition, public relations should continue to improve knowledge and attitudes on appropriate feeding practices and vaccination through mass media or internet-based social media networks. This practice should also be targeted at other family members, particularly grandmothers, as senior family members significantly influence the traditional behavior of mothers in Indonesia [38, 39].

This study focused on inappropriate traditional feeding practices related to stunting. The government should also explore traditional feeding practices that may have benefits in reducing stunting. For example, most pregnant mothers believed that eating Moringa oleifera leaves, which are known to contain minerals and micronutrients beneficial for the health of mothers, could prevent LBW [40]. Therefore, through national investigation, a list of inappropriate and appropriate feeding practices can be developed to provide a better understanding of stunting prevention in Indonesia.

In addition, in terms of sociodemographic factors, this study found that children aged 6–11 months were less likely to have stunting than those aged 36–59 months. This could be because the children did not receive adequate feeding to meet their nutritional needs as they aged [23]. Furthermore, studies mentioned that increasing child age was also associated with susceptibility to recurrent infections, which led to an increased risk of stunting [41‐43]. The risk of stunting with increased age was reported in previous studies conducted in Tanzania, Madagascar, and Nepal [13, 44, 45].

Our study showed that children with LBW had a higher risk of stunting. Similar studies found that the birth weight of children was significantly associated with stunting [18, 46, 47]. This can be explained by the fact that children with LBW are born with low vital growth nutrients and therefore cannot reach a normal size during childhood [20, 48]. In addition, a previous study in Indonesia revealed children with LBW are more vulnerable to infections, such as diarrhea and acute respiratory infection, which puts them at a higher risk of stunting [12]. This finding reflects the importance of enhancing mothers' knowledge of maternal nutrition during pregnancy to prevent children from having LBW.

We found that children born with a birth interval < 24 months were at high risk of stunting. This could be because short birth intervals negatively affect children’s nutritional needs due to the inability of mothers to provide optimal feeding (e.g., shorter duration of breastfeeding), competition for available food resources, and limited time for mothers to care for each child [49, 50]. This finding was consistent with previous studies conducted in Ethiopia, Congo, and Indonesia [16, 17, 51]. Therefore, family planning interventions are important to prevent stunting.

The study showed that children in low-income households had a higher probability of stunting. This may be attributed to the fact that poor households are likely to have less financial ability to purchase nutritious foods, insufficient food intake, and poor sanitation, which leads to a higher risk of infection, as well as a lack of access to and utilization of health care services [52‐54]. In addition, mothers in poor households tend to have a lower level of education, which has been associated with a lack of knowledge on child nutrition [47, 55]. Similarly, the association between household income inequalities and stunting has been observed in numerous studies [13, 56, 57]. This finding highlights the importance of poverty reduction interventions for the long-term prevention of stunting by improving food security and access to basic health services for poor households. Special attention should be given to the education of mothers and the improvement of household income levels.

In addition, in terms of feeding practices, this study found that children for whom breastfeeding was initiated within one hour after birth were less likely to have stunting than those for whom breastfeeding initiation was delayed. This is attributed to early breastfeeding initiation practices to ensure that newborns receive colostrum or ‘first milk’, which is considered the first natural immunization for newborns due to it being rich in vitamins and antibodies [16, 19]. In addition, studies have shown that early initiation of breastfeeding positively impacts milk production and the duration of exclusive breastfeeding [19, 58, 59]. Several studies have also reported that early breastfeeding initiation protects children against stunting [17, 19, 60].

Exclusive breastfeeding has been identified as one of the determinants of stunting in children [15]. This study found that children with nonexclusive breastfeeding were more likely to have stunting than their counterparts with exclusive breastfeeding. This could be because exclusive breastfeeding provides all essential nutrients needed for children's growth and immunity during the first six months of life, thus protecting them from stunting. In addition, studies in Bangladesh reported that exclusive breastfeeding eliminates the risk of contamination from the unhygienic preparation of baby formula milk [61, 62]. Similar findings were reported in cross-sectional studies conducted in Ethiopia [20] and Uganda [34], which revealed a higher prevalence of stunting among children with nonexclusive breastfeeding.

In this study, the duration of breastfeeding was found to be significantly associated with stunting. Children with a breastfeeding duration of < 23 months were more likely to have stunting than children with a breastfeeding duration of up to 23 months. This could be because continuing breastfeeding in the second year of life contributes significantly to the intake of key nutrients that are lacking in low-quality complementary foods. This is consistent with studies conducted in Ethiopia [15, 16]. These findings regarding feeding practices demonstrate that there is a need for a continued effort to educate mothers on the importance and benefits of optimal breastfeeding (i.e., early breastfeeding initiation within one hour after birth, exclusive breastfeeding, and continued breastfeeding up to 23 months).

Our study found that the probability of stunting was higher among children with inadequate feeding frequency than among children with adequate feeding frequency. Feeding frequency is a proxy of energy intake [63]. Therefore, adequate feeding frequency is required to meet the necessary level of energy and nutritional needs and prevent deficiencies that could lead to stunting. This finding was consistent with other studies in Ecuador, Tanzania, and Indonesia, which showed that inadequate feeding frequency was significantly associated with stunting in children [64‐66].

In terms of vaccination, this study found that children with complete basic vaccination were less likely to have stunting than children with incomplete basic vaccination. This is probably because incomplete vaccination increases the risk of preventable infectious diseases (e.g., pneumonia, measles, diarrhea), which affect children's general health, including their nutritional status. Specifically, a study in South Ethiopia found that recurrent diarrhea reduced appetite and nutrition absorption, resulting in loss of nutrition for children [67]. Thus, a lack of nutrients could expose children to stunting. This finding was consistent with a previous study conducted in Indonesia, Ethiopia, and Madagascar [12, 19, 45].

Regarding the community factor, our study revealed that children living in rural areas were more likely to have stunting than their counterparts living in urban areas. Other studies have similarly found that children living in rural areas were at higher risk of stunting [23, 50]. In the study area, mothers in rural areas mainly work as farmers. Studies found that mothers working as farmers had less time to care for and properly feed their children than nonfarming mothers such as housewives [68, 69]. Therefore, suboptimal breastfeeding and inappropriate complementary feeding were higher among mothers who worked as farmers [15]. In addition, studies have reported that rural areas are likely to have low household income levels [22, 45], poor sanitation [70], and culture-based lifestyles [54, 68]. Therefore, further research is required for stunting prevention interventions in rural areas.

This study has some limitations that need to be addressed. First, the study area only covered Karanganyar District, which is located in Central Java Province and is dominated by Javanese ethnicity. In Indonesia, there are more than one thousand ethnic groups with different cultures and traditional practices. Therefore, larger-scale studies are required to verify whether the findings of this study on traditional behavior can be generalizable to the entire nation of Indonesia. Second, due to the time gap between collecting medical records from the PHCUs (April 2021) and conducting interviews with the mothers (May 2021), there may have been some changes in the knowledge and practices related to feeding practices among the mothers. Although we cross-checked the data with the maternal and child health handbook, particularly for exclusive breastfeeding and vaccination status, the potential changes should be taken into account in future studies.

Third, this study did not standardize anthropometric measures across the PHCUs. Although all PHCUs used the same anthropometric equipment along with the WHO child growth standard guideline manual, the lack of standardization may cause some undetected errors in the results of this study, which must be considered by future studies. Fourth, the difference between the COR and AOR results indicated confounding effects among the independent variables. Future studies should consider potential interactions between independent variables to obtain more precise socioeconomic patterns of stunting. Fifth, the use of a cross-sectional design in this study without balancing sociodemographic characteristics between the children with stunting and children without stunting groups may not precisely capture the association between traditional feeding practices and stunting. The main analysis of this study was performed adjusting for the sociodemographic factors. This adjustment could minimize the bias associated with less comparable characteristics between children with stunting and children without stunting. However, the reliability of the study findings should be further assessed by future studies using a case–control design with a sociodemographically matched sample between the two groups.

Last, this study did not consider calculating the sample size for data collection because the sample population for this study was all children with stunting aged 6 to 59 months in nine subdistricts and an equivalent number of children without stunting in the same subdistricts. That is, the sample size for this study depended on the number of children with stunting aged 6 to 59 months in nine subdistricts. Nevertheless, the sufficiency of this study’s sample size was assessed using the following formula: n = (1.96² × p × q) ÷ d² [71]. In this formula, n is the minimal sample size, p is the prevalence of stunting in the study area (28%), q is 1–p, and d is the tolerated error margin of 5%. The formula suggested a minimum of 310 children, which was far less than the total sample size of this study (706 children). However, having a larger sample size than the suggested sample size may over or underestimate the results. Accordingly, the results must be interpreted with caution.

The present study highlighted that inappropriate traditional feeding practices, including food restrictions during pregnancy, food restrictions for children, and prelacteal feeding, were associated with stunting. In addition, there are multiple determinants of stunting. Children aged 36 to 59 months, children with LBW, children with a short birth interval of < 24 months, children living in low-income households, children for whom breastfeeding initiation was delayed, children with nonexclusive breastfeeding, children with a duration of breastfeeding < 23 months, children with an incomplete basic vaccination status, and children living in rural areas had a higher prevalence of stunting. The findings reflect the importance of education for mothers to correct misconceptions of traditional feeding practices. Local health cadres can be utilized to correct misconceptions of traditional feeding practices. Moreover, gradually increasing the number of health care professionals at PHCUs in every subdistrict can be considered to strengthen counseling services to improve knowledge and attitudes on the appropriate feeding practices of mothers. Additionally, public relations practices through the mass media should continue for family members, especially senior family members, as they influence mothers’ autonomy in decision-making regarding feeding practices in Indonesia.