Prevalence and Determinants of Stunting Risk Factors among Children Under Five Years Old: An Analysis of the Indonesian Secondary Database

doi:10.21203/rs.3.rs-3019263/v1

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Research Article

Prevalence and Determinants of Stunting Risk Factors among Children Under Five Years Old: An Analysis of the Indonesian Secondary Database

https://doi.org/10.21203/rs.3.rs-3019263/v1

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Background

Stunting among children under five remains a global health problem. Indonesia is no exception, as its stunting reduction rate has not yet reached the expected target. Regencies/cities in the West Sumatra province in Indonesia still show a stark disparity of achievement following the implementation of their various stunting prevention policies and programs.

Methods

Cross-sectional study based on 2018 Riskesdas and 2021 SSGI. Nineteen regencies/cities in West Sumatra province. Families with children under five years involved 3,380 subjects from the 2018 Riskesdas and 4,662 subjects from the 2021 SSGI.

Results

The results showed that the stunting prevalence decreased from 31.2% in 2018 to 23.3% in 2021. Stunting risk factors include male gender, low birth weight, mothers over 35 years, upper respiratory tract infection, lack of vitamin A consumption, and parents’ low education. The rate of stunting reduction varies significantly between cities or regencies in the West Sumatra province due to non-exclusive breastfeeding, lack of growth monitoring, poor water quality, and working mothers.

Conclusions

Most stunting occurs before the age of two. Stunting is significantly influenced by various infectious diseases, dietary intake, and parents' socioeconomic status. The related city/regency governments should develop intervention strategies and specific programs to reach the expected target.

Determinants

Indonesia

risk factors

stunting

under five years

Stunting indicates impaired growth and development due to poor nutrition, repeated infection, and inadequate psychosocial stimulation. Stunting is indicated by height for age less than two standard deviations below the median set by the World Health Organization (WHO).⁽¹⁾ In 2014, 159 million children under five suffered stunting worldwide. By 2018, the figure fell to 149 million. More than half of stunted children under five live in Asia (57%).⁽²⁾ WHO has recognized stunting as a global priority and has set a target to reduce the number of stunted children worldwide by 40% in 2025.⁽³⁾ In the context of Indonesia, it has only recently reduced the prevalence of stunting by around 1.5% per year, from 36.6% in 2013 to 24.4% in 2021.^(4,5) Globally, Indonesia ranks fifth in the number of stunting cases⁽⁵⁾ and is grouped as one of the countries that contribute to the 90% of stunting cases worldwide.⁽⁶⁾

Stunting has wide-ranging consequences, including high morbidity and mortality, less exploratory behavioral displays, higher anxiety, depression, poor health, adult short stature, chronic diseases in later life, poor intellectual quotient (IQ) level, poor cognitive function, and poor academic achievements.⁽⁷⁾ The most crucial time to meet the nutritional requirement of children is in the first 1,000 days from conception to their second birthday. During this period, children experience increasing nutritional requirements to support rapid growth and development, become more susceptible to infections, have high sensitivity to biological programming, and depend totally on others for nutrition, care, and social interactions.⁽⁸⁾

The Indonesian government has struggled to reduce the prevalence of stunting in accordance with the National Medium-Term Development Plan target. It has set its goals to curb the prevalence of stunting by 14% in 2024 or reduce it by around 3-4% per year. In 2017, stunting was put in the spotlight, and since then, it has attracted the attention of the nation's top leaders. Efforts to accelerate stunting reduction are cross-sectoral, involving stakeholders: the central government, regional governments, business sectors, the general public, and others. Although various programs related to stunting prevention are available, they have not been implemented effectively and have not been run on an adequate scale.⁽⁹⁾ The reports released by the 2018 Riskesdas (Riset Kesehatan Dasar [The Basic Health Survey]) (henceforth referred to as Riskesdas) of West Sumatra Province and by the 2021 SSGI (Studi Status Gizi Indonesia [Indonesian Nutrition Survey]) (henceforth referred to as SSGI) show that regencies and cities in the province have not been evenly distributed their efforts to reduce stunting cases.^(4,5)

While the obstacles to stunting prevention nationwide have been identified, the situation remains complex. The fundamental problem is the implementation of specific and sensitive nutrition interventions, which are not yet integrated. This is shown by many aspects, including planning and budgeting, implementation, monitoring, and evaluation. The obstacles also take place in the field (village level), where various stunting-related activities are not integrated, both in setting targets, and planning activities, roles, and tasks among relevant parties.⁽¹⁰⁾ This suggests that the success of stunting prevention highly depends on the implementation of policies from the central government at the top-level right to the villagers at the bottom. Therefore, policy studies are necessary as they allow us to monitor the management of stunting prevention acceleration programs and identify local wisdom and innovations, ranging from the central government to villages and households, the ultimate targets of specific and sensitive interventions.

The present study used a cross-sectional study based on two national health surveys: the 2018 Riskesdas and the 2021 SSGI. This study passed the ethical review organized by the Research Ethics Commission of the Faculty of Medicine, Andalas University, Padang, Indonesia (No 616/UN.16.2/KEP-FK/2022).

The research sample was taken from nineteen regencies/cities in West Sumatra province included in the 2018 Riskesdas and 2021 SSGI. The research subjects were families with children aged 0-59 months and involved 3,380 subjects from the 2018 Riskesdas and 4,662 subjects from the 2021 SSGI. A two-stage stratified household sample was used for the 2018 Riskesdas and the 2021 SSGI. Both are nationally representative and include strata for rural and urban areas. The 2018 Riskesdas and 2021 SSGI reports include detailed information on survey sampling and the methods for data collection.

The study criteria consisted of families with children aged 0-59 months and with complete data for all research variables. The exclusion criteria were available data from outside the West Sumatra province.

The study used data and available variables in the 2018 Riskesdas and the 2021 SSGI. The outcome variable was the incidence of stunting as seen from the Z-score of length or height according to age. The determinant variables included the child's characteristics (age, sex, birth weight, and length), maternal characteristics (age and number of births), and the incidence of infection (diarrhea, ARI, and pneumonia). The variables related to nutritional intake were not measured in both surveys and, therefore, were not analyzed.

The indirect causal variables available for quantitative analysis included dietary patterns, such as Infant and Young Child Feeding Practices (PMBA), breastfeeding patterns (Early Breastfeeding Initiation/IMD), exclusive breastfeeding, duration of breastfeeding), and complementary feeding (MPASI). Access to health services with relevant variables was also taken into account, such as KIA (Mother-child Health Monitoring)/MCH books, health insurance/JKN, complete basic immunization, supplementary feeding for undernourished, growth monitoring, places and midwives/delivery assistant, administration of high-dose vitamin A capsules, blood-booster tablets for pregnant women, and the use of contraceptives.

The outcome variables, determinants, and indirect causes above were arranged in Table 3 (Operational Definition of Quantitative Data), based on the Guidelines for Filling the 2018 Riskesdas and the 2021 SSGI questionnaires. All data from these variables were requested from the Litbangkes (Penelitian dan Pengembangan Kesehatan [Research and Development on Health]) office for further analysis.

The data were checked for completeness, edited, coded, and entered into the Stata version 14.2 for analysis. Bivariate analysis (Chi-square test) and binary logistic regression test were used to calculate the adjusted. The odds ratio (OR) and confidence interval (CI) were estimated using a binary logistic regression test to find the determinants of stunting risk factors. All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant.

Figure 1 presents the estimated prevalence of stunting among children under five by cities/regencies in West Sumatra province. The results showed that the prevalence of stunting decreased from 31.2% in 2018 to 23.3% in 2021. Based on the 2018 Riskesdas, Solok had the highest level (41.0%), followed by Pasaman (40.56%), Lima Puluh Kota (4.13%), and Pasaman Barat (38.6%). In contrast, Pariaman and Payakumbuh showed the lowest levels, 17.7%, and 20.1%, respectively.

Figure 2 shows the estimates of stunting prevalence among children under five by cities/regencies in West Sumatra province based on the 2021 SSGI. Solok showed the highest level (39.4%), followed by Solok Selatan (34.5%) and Sijunjung (29.1%). Sawahlunto was the lowest (13.6%), followed by Payakumbuh (14.2%), Dharmasraya (15.1%), and Pariaman (16.0%).

Figure 1 and Figure 2 show differences in the rate of stunting reduction between cities/regencies in West Sumatra. Lima Puluh Kota and Pasaman Barat regencies succeeded in reducing the prevalence rate by 11.9% and 11.1%, respectively, while Padang Pariaman Regency and Pariaman City failed to do so. The two areas even showed a rise in stunting cases.

Table 1 presents the descriptive characteristics of children and their parents. In 2021, most cases had normal birth weight (89.2%) and birth length. The table also shows that more than half cases did not receive early breastfeeding initiation either in 2018 or 2020. However, nearly all of these groups received exclusive breastfeeding. The majority of cases did not complete basic immunizations. Moreover, almost all case groups did not experience infectious disease. The data also shows that most mothers were between 20 and 35 years old and around one-third of the cases were over 35 years old. The table also shows that more than half of the mothers in the case group did not have formal education. In this study, mothers who gave birth to children with low birth weight and length, who did not get iron supplementation, those aged over 35 years old, and those with low education levels were responsible for stunting.

Table 1 Descriptive characteristics of children and parents

Variables

Riskesdas 2018

SSGI 2021

Group (n=3,380)

Group (n=4,662)

Case = 984

f (%)

Control = 2,396

f (%)

Case = 1,144

f (%)

Control = 3,518

f (%)

Sex

Male

Female

540 (54.9)

444 (45.1)

1,202 (50.2)

1,194 (49.8)

650 (56.8)

494 (43.2)

1,772 (50.4)

1,746 (49.6)

Birth weight (kg)

<2,500

≥2,500

Nil

123 (10.8)

1,021 (89.2)

154 (4.4)

3,364 (95.6)

Birth length (cm)

<48

≥48

9 (0.9)

975 (99.1)

4 (0.2)

2,392 (99.8)

231 (20.2)

913 (79.8)

507 (14.4)

3,011 (85.6)

Early initiation of breastfeeding

Yes

219 (61.3)

138 (38.7)

560 (59.5)

381 (40.5)

192 (53.6)

154 (43.0)

783 (53.4)

661 (45.1)

Exclusive breastfeeding

Yes

84 (23.9)

267 (76.1)

146 (15.6)

788 (84.4)

20 (1.7)

1,124 (98.3)

130 (3.7)

3,388 (96.3)

Age of supplementary infant feeding

< 6 months

≥ 6 months

190 (55.2)

154 (44.8)

599 (65.1)

321 (34.9)

163 (45.5)

169 (47.2)

651 (44.4)

557 (38.0)

Diarrhea

Yes

133 (13.5)

851 (86.5)

281 (11.7)

2,115 (88.3)

114 (10.0)

1,030 (90.0)

290 (8.2)

3,228 (91.8)

Upper respiratory tract infection

Yes

86 (8.7)

898 (91.3)

161 (6.7)

2,251 (93.3)

101 (8.8)

1,043 (91.2)

241 (6.9)

3,277 (93.1)

Pneumonia

Yes

15 (1.5)

969 (98.5)

37 (1.5)

2,359 (98.5)

5 (0.7)

749 (99.3)

7 (0.3)

2,430 (99.7)

Complete basic immunization

Yes

294 (69.7)

128 (30.3)

601 (57.6)

443 (42.4)

150 (89.8)

17 (10.2)

713 (92.7)

56 (7.3)

Fe tablet consumption

Yes

65 (8.1)

736 (91.9)

601 (57.6)

443 (42.4)

61 (5.4)

1,070 (94.6)

194 (5.6)

3,293 (94.4)

High dose of Vitamin A

Yes

Nil

143 (19.0)

611 (81.0)

651 (26.7)

1,786 (73.3)

Decent drinking water

Not good

Good

221 (21.7)

796 (78.3)

373 (15.5)

2,039 (84.5)

75 (6.6)

1,069 (93.4)

190 (5.4)

3,328 (94.6)

Source of water for other purposes

Not good

Good

324 (31.9)

693 (68.1)

554 (23.0)

1,858 (77.0)

495 (43.3)

649 (56.7)

1,545 (43.9)

1,973 (56.1)

Mother’s age (years)

<20

20-35

>35

8 (0.8)

674 (66.3)

335 (32.9)

28 (1.2)

1,661 (68.9)

723 (30.0)

9 (0.8)

784 (68.5)

351 (30.7)

21 (0.6)

2,363 (67.2)

1,134 (32.2)

Mother’s education

Low

High

513 (51.6)

482 (48.4)

932 (39.7)

1,414 (60.3)

1,022 (90.0)

113 (10.0)

2,937 (84.0)

558 (16.0)

The disparity of stunting prevalence based on levels of maternal education and residential areas

The prevalence of stunting decreased in all maternal education groups between 2018 and 2021. In Figure 3, the disparity was found in as many as 46% of uneducated mothers and 20% of mothers with high educational levels in 2018. In 2021, the figure decreased in those mothers with no education to 38%, while mothers with a higher education level fell to 18%.

Residential areas are divided into two groups: urban and rural. In Figure 4, stunting was found that stunting was higher in rural areas in the 2018 and 2021 data. Interestingly, the stunting rates declined slightly between rural and urban areas in West Sumatra from 2018 to 2021.

Determinant factors of stunting among children under five in West Sumatra

Table 2 presents the determinant factors of stunting in West Sumatra. In the multivariate logistic regression analysis, several factors were closely associated with stunting (p-value ≤ 0.05). Gender and birth weight below 2,500 grams played a significant role in the risk factors of stunting. The male gender had a 1.2 to 1.3 times higher risk of suffering from stunting, and children under two years had a lower risk of stunting (AOR = 0.63; 95%CI = 0.54-0.73). In addition, children under two years enjoyed a protective factor from suffering from stunting by 0.6 times. However, the figure was insignificant, following interactions with confounding factors. Low birth weight was significantly higher in the case group, with adjusted odds ratios ranging from 2.6 to 2.8. Mothers over 35 years old significantly increased the prevalence of stunting compared to those under 20 years old (AOR =1.10; 95%CI = 1.02-1.79).

A history of upper respiratory tract infection posed another risk factor associated with stunting. Both surveys found this statistically significant (AOR = 1.56, 1.51; 95%CI = 1.23-1.98, 1.11-2.06).

The study found no significant association between all feeding practices, health services, environmental quality, and incidence of stunting. Mothers’ low education risk was 1.3 to 1.5 times higher, while fathers’ low education risk was 1.2 to 1.7 times higher in experiencing stunting. Working mothers posed a lower risk than those who did not work by 0.6 to 0.7.

Table 2 Adjusted odds ratio and unadjusted odds ratio of determinant factors for stunting in West Sumatra

Characteristics	*Riskesdas* 2018		SGGI 2021
Characteristics	Unadjusted OR (95% CI)	Adjusted OR* (95% CI)	Unadjusted OR (95% CI)	Adjusted OR* (95% CI)
Child
Sex
Male	1.201 (1.119-1.541)*	1.310 (1.220-1.671)*	1.296 (1.133-1.483)*	1.317 (1.149-1.509)*
Female	Ref	Ref	Ref	Ref
Age (months)
0-23	0.514 (0.413-0.432)	0.781 (0.552-0.817)	0.637 (0.553-0.734)	0.628 (0.544-0.726)*
24-59	Ref	Ref	Ref	Ref
Birth weight (kg)
< 2,500	Nil	Nil	2.632 (2.055-3.369)*	2.787 (2.169-3.580)*
≥ 2,500	Ref	Ref	Ref	Ref
Birth length	0.87 (0.615-0.817)	0.89 (0.567-0.917)	1.009 (1.005-1.013)*	1.008 (1.004-1.012)*
Maternal
Age (years)
< 20	0.99 (0.892-1.246)	1.02 (0.989-1.324)	1.292 (0.589-2.832)	1.339 (0.599-2.993)
20-35	Ref	Ref	Ref	Ref
> 35	1.112 (1.109-1.655)*	1.104 (1.023-1.798)*	0.933 (0.807-1.078)	0.864 (0.746-1.002)
Infectious disease
Diarrhea
Yes	1.312 (0.994-1.628)	1.291 (0.978-1.769)	1.232 (0.981-1.547)	1.235 (0.948-1.610)
No	Ref	Ref	Ref	Ref
Upper respiratory tract infection
Yes	1.423 (1.115-1.789)*	1.567 (1.234-1.985)*	1.317 (1.033-1.678)*	1.516 (1.111-2.069)*
No	Ref	Ref	Ref	Ref
Pneumonia
Yes	1.746 (0.918-1.890)	1.98 (0.876-1.890)	2.317 (0.733-7.323)	1.772 (0.547-5.740)
No	Ref	Ref	Ref	Ref
Infant and child feeding
Early initiation of breastfeeding
Yes	Ref	Ref	Ref	Ref
No	0.98 (0.891-1.251)	0.88 (0.543-1.327)	1.086 (0.860-1.372)	0.839 (0.452-1.558)
Exclusive breastfeeding
Yes	Ref	Ref	Ref	Ref
No	0.578 (0.312-0.871)	0.754 (0.342-2.375)	0.464 (0.288-0.746)	0.938 (0.293-3.001)
Age of complementary feeding (months) < 6 ≥ 6 Unknown	0.989 (0.543-1.146) Ref 0.221 (0.132-0.674)	1.134 (0.467-1.983) Ref 0.314 (0.918-0.765)	0.825 (0.647-1.052) Ref 0.331 (0.213-0.513)	1.228 (0.563-2.681) Ref 0.303 (0.201-0.543)
Duration of breastfeeding	Nil	Nil	1.045 (1.002-1.090)	1.046 (0.975-1.123)
Access to health services
Ownership of MCH books
Yes	Ref	Ref	Ref	Ref
No	1.252 (0.781-1.611)	1.119 (0.876-1.341)	1.353 (0.870-2.102)	1.291 (0.781-2.562)
Complete basis immunizations
Complete	Ref	Ref	Ref	Ref
Incomplete	0.543 (0.234-0.785)	0.816 (0.345-1.899)	0.693 (0.392-1.226)	0.952 (0.420-2.159)
Growth monitoring
Yes	Ref	Ref	Ref	Ref
No	0.871 (0.652-0.919)	0.993 (0.326-1.011)	0.920 (0.780-1.085)	0.733 (0.490-1.095)
Fe tablets consumption
Yes	Ref	Ref	Ref	Ref
No	0.765 (0.342-0.989)	0.998 (0.764-0.985)	0.968 (0.720-1.301)	1.129 (0.455-2.798)
High dose of Vitamin A
Yes	Ref	Ref	Ref	Ref
No	Nil	Nil	0.642 (0.524-0.787)	0.625 (0.418-0.936)*
Birth attendant
Health workers	Ref	Ref	Ref	Ref
Not health workers	0.987 (0.768-0.987)	0.874 (0.345-0.876)	1.468 (0.728-2.961)	0.724 (0.113-4.629)
Delivery in health facilities
Yes	Ref	Ref	Ref	Ref
No	0.893 (0.325-1.095)	1.202 (0.897-1.345)	1.143 (0.695-1.880)	1.071 (0.353-3.254)
Environmental quality
Source of drinking water
Good	Ref	Ref	Ref	Ref
Not good	1.123 (0.956-1.453)	1.218 (0.878-1.514)	1.229 (0.932-1.620)	1.225 (0.925-1.621)
Source of water for other purposes
Good	Ref	Ref	Ref	Ref
Not good	0.871 (0.564-1.092)	0.985 (0.765-0.987)	0.974 (0.851-1.114)	0.990 (0.864-1.136)
Parent’s socioeconomic
Mother’s education
Low	1.555 (1.235-1.895)*	1.576 (1.102-1.874)*	1.718 (1.387-2.129)*	1.399 (1.029-1.902)*
High	Ref	Ref	Ref	Ref
Father’s education
Low	1.238 (1.125-1.986)*	1.132 (1.015-2.013)*	1.793 (1.358-2.368)*	1.681 (1.294-2.251)*
High	Ref	Ref	Ref	Ref
Mother’s work
Not working	Ref	Ref	Ref	Ref
Working	0.654 (0.234-0.781)	0.732 (0.245-0.984)	0.754 (0.650-0.875)	0.638 (0.138-2.961)

* = p value < 0.05

Differences in stunting reduction rates between cities or regencies in West Sumatra

Table 3 presents the differences in stunting reduction rates between cities and regencies in West Sumatra. The analysis of the determinant factors for stunting showed that there was a significant difference in the rate of stunting reduction and several factors responsible for this include male gender, low birth weight, age under two years, maternal age over 35 years, exclusive breastfeeding, ownership of MCH books, growth monitoring, administration of high doses of vitamin A, water source, education level of parents, and mother's employment status.

Low birth weight was associated with both success and failure in reducing the rate of stunting as many as 3.21 times, which could reduce the rate of stunting by more than 10%, and, in reverse, 2.54 times had the chance to increase the rate of stunting. Maternal age over 35 years was significantly associated with the rate of stunting reduction, which the chance of reducing stunting was >10% as much as 1.2 times. There was a significant difference in the incidence of stunting for children who were not exclusively breastfed, and the change to reducing the stunting rate >10% was 1.2 times and 1.15 times less than 10%.

Children who did not receive growth monitoring were significantly associated with a more than 10% reduction in stunting rates. This suggests that the absence of growth monitoring resulted in a higher reduction in stunting rates. Likewise, children who did not receive high doses of vitamin A showed a significant difference in the rate of stunting reduction, with a chance of 1.5 times. The feasibility of drinking water and water source also served as a determinant factor of stunting.

Furthermore, mothers’ education had significant effects on the rate of stunting. It was found that mothers with low education had a risk of 2.01 times to increase the incidence of stunting. Fathers with low education affected the stunting rate significantly, that is, a 2.8 times higher chance of reducing the stunting rate by >10%. Working mothers also decreased and increased the incidence of stunting by up to a 1.78 times risk of failing the reduction of stunting.

Table 3 The difference in the rate of stunting reduction between cities or regencies of West Sumatra

Characteristics	OR (95% CI)
Characteristics	>10%	<10%	Failed (increased rate)
Child
Sex
Male	1.373 (1.040-1.812)*	1.315 (1.105-1.565)*	1.140 (0.821-1.583)
Female	Ref	Ref	Ref
Age (months)
0-23	0.573 (0.426-0.771)*	0.665 (0.554-0.798)*	0.625 (0.440-0.888)*
24-59	Ref	Ref	Ref
Birth weight (g)
< 2,500	3.211 (1.963-5.253)*	2.450 (1.768-3.395)*	2.541 (1.402-4.608)*
≥ 2,500	Ref	Ref	Ref
Birth length (cm)	0.851 (0.722-0.875)	0.880 (0.668-0.867)	0.740 (0.512-0.768)
Maternal
Age (years)
< 20	0.99 (0.892-1.246)	1.02 (0.989-1.324)	0.875 (0.716-1.345)
20-35	Ref	Ref	Ref
> 35 years	1.224 (1.114-1.784)*	1.112 (1.055-1.625)*	1.121 (0.925-1.787)*
Infectious disease
Diarrhea
Yes	1.137 (0.673-1.920)	1.248 (0.940-1.655)	1.188 (0.668-2.114)
No	Ref	Ref	Ref
Upper respiratory tract infection
Yes	1.217 (0.756-1.959)	1.323 (0.983-1.780)	1.390 (0.532-3.635)
No	Ref	Ref	Ref
Pneumonia
Yes	n/a	2.077 (0.656-6.578)	n/a
No	Ref	Ref	Ref
Infant and child feeding
Early initiation of breastfeeding
Yes	Ref	Ref	Ref
No	0.838 (0.513-1.369)	0.945 (0.699-1.277)	1.110 (0.623-1.980)
Exclusive breastfeeding
Yes	Ref	Ref	Ref
No	1.225 (1.128-1.332)*	1.154 (1.048-1.270)*	1.066 (0.908-1.251)
Duration of breastfeeding (months)	0.712 (0.625-0.975)*	0.783 (0.718-1.267)	0.89 (0.625-0.868)
Age of complementary feeding
< 6 months	0.989 (0.543-1.146)	1.134 (0.467-1.983)	0.915 (0.651-1.217)
≥ 6 months	Ref	Ref	Ref
Unknown	0.221 (0.132-0.674)	0.314 (0.198-0.765)	0.523 (0.217-0.812)
Access to health services
Ownership of MCH books
Yes	Ref	Ref	Ref
No	1.073 (0.862-1.335)*	1.176 (0.930-1.486)*	1.007 (0.827-1.227)*
Complete basis immunizations
Complete	Ref	Ref	Ref
Incomplete	0.570 (0.227-1.430)	0.759 (0.360-1.599)	n/a
Growth monitoring
Yes	Ref	Ref	Ref
No	1.460 (1.040-2.049)*	0.988 (0.795-1.228)	0.840 (0.561-1.257)
Fe tablets consumption
Yes	Ref	Ref	Ref
No	1.647 (0.631-4.298)	1.097 (0.769-1.566)	0.728 (0.375-1.413)
High dose of vitamin A
Yes	Ref	Ref	Ref
No	1.577 (1.030-2.416)*	1.590 (1.220-2.072)*	1.513 (0.939-2.436)
Birth attendant
Health workers	Ref	Ref	Ref
Not health workers	0.627 (0.125-3.154)	0.630 (0.284-1.399)	n/a
Delivery in health facilities
Yes	Ref	Ref	Ref
No	0.696 (0.188-2.575)	0.852 (0.492-1.477)	n/a
Environmental quality
Decent drinking water
Good	Ref	Ref	Ref
Not good	1.033 (0.617-1.731)	1.114 (1.097-1.246)*	2.935 (0.373-23.075)
Source of water for other purposes
Good	Ref	Ref	Ref
Not good	1.439 (1.092-1.895)*	0.930 (0.778-1.112)	0.731 (0.525-1.018)
Parent’s socioeconomic
Mother’s education
Low	2.179 (1.286-3.694)*	1.577 (1.213-2.051)*	2.010 (1.171-3.451)*
High	Ref	Ref	Ref
Father’s education
Low	2.808 (1.336-5.903)*	1.780 (1.252-2.532)*	1.307 (0.726-2.353)
High	Ref	Ref	Ref
Mother’s work
Not working	Ref	Ref	Ref
Working	1.633 (1.161-2.296)*	1.225 (1.020-1.472)*	1.780 (1.165-2.721)*
Father’s work
Not working	n/a	3.524 (0.219-56.628)	0.693 (0.149-3.212)
Working	Ref	Ref	Ref

This study found that boys were at a higher risk of suffering from stunting compared to girls. This finding is consistent with other studies in Rwanda and sub-Saharan Africa.^(11,12) The fact that boys are expected to grow slightly faster than girls and that their growth is more easily affected by nutritional deficiencies or other diseases or exposures might be responsible for this.⁽¹³⁾

Children aged 0–23 months were at lower risk of stunting than those in the older age group of 24–59 months. Other studies have reported similar findings.⁽¹⁴⁾ This might be due to the high rates of exclusive breastfeeding during the first six months of children in West Sumatra, which can prevent stunting at early ages.^(4,5)

Maternal age was found to be associated with child stunting. Children whose mothers were over 35 years old were more likely to suffer from stunting than those whose mothers were younger (under 20 years). This finding contradicts other studies arguing that younger maternal age was a risk factor for stunting. A previous study in Ghana reported that children of teenage mothers were eight times more likely to experience stunting than those of adult mothers and that the risk of child malnutrition increased with the age of the young mother.⁽¹⁵⁾

In addition, upper respiratory tract infection in children was found to be a risk factor for stunting, while diarrhea was not. The finding was similar to previous studies conducted in Surabaya, where acute respiratory tract infection was the main factor causing underweight, but diarrhea was the main risk factor for stunting. This suggests a strong relationship between diarrhea and respiratory infection in causing stunting.^(16,17)

Acknowledgements: We are also grateful for the collaborative work between the Universitas Andalas, the Health Ministry Polytechnic of Padang, and the Indonesian National Health Research and Development Board. Data described in the manuscript, code book, and analytic code will be made available upon request pending (availability of data should be contact the corresponding author).

Funding: This study was funded by the Asian Development Bank and the Indonesian National Health and Research Development Board (grant number: No.037/MADEP-ADB/KONTRAK/III/2022).

Conflict of Interest: None of the authors has a personal or financial conflict of interest.

Authorship:

Asrawati contributed to study conceptualisation, draft, review, and editing the article.
Masrul contributed to study conceptualisation, draft and review the article, and mentor.
Gusnedi contributed to co-principal investigator the research and article, study conceptualisation, draft, and review the article.
Hermita Bus Umar contributed to data analyses, study conceptualisation, draft, and review the article.
Idral Purnakarya contributed to data holder, study conceptualisation, draft, and review the article.
Syafrawati contrubuted to study conceptualisation, draft, and review the article.
Andrafikar contrubuted to study conceptualisation, draft, and review the article.
Novianti contrubuted to study conceptualisation, draft, and review the article.
Andi Susilowati contrubuted to study conceptualisation, draft, and review the article.
Ricvan Dana Nindrea contrubuted to study conceptualisation, draft, review, and editing the article.
Nur Indrawaty Lipoeto contributed to principal investigator the research and article, study conceptualisation, draft, and review the article.

Ethical Standards Disclosure: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Research Ethics Commission of the Faculty of Medicine, Universitas Andalas, Padang, Indonesia (No 616/UN.16.2/KEP-FK/2022).

Availability of Data and Materials: Not applicable.

AUTHOR DISCLOSURE

None of the authors has a personal or financial conflict of interest.

Data sharing: no additional data available.

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No competing interests reported.

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Prevalence and Determinants of Stunting Risk Factors among Children Under Five Years Old: An Analysis of the Indonesian Secondary Database

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