Simanjutak et al. Kesmas: National Public Health Journal.

2019; 14 (2): 58-

64 DOI: 10.21109/kesmas.v14i2.2712 Kesmas: National Public Health
Journal

Maternal Knowledge, Attitude, and Practices about

Traditional Food Feeding with Stunting and Wasting of
Toddlers in Farmer Families

Betty Yosephin Simanjuntak1*, Miratul Haya1, Desri Suryani1, Ali Khomsan2, Che An Ahmad3

1Nutrition Department, Politeknik Kesehatan Kementerian Kesehatan Bengkulu, Indonesia, 2Department of

Community Nutrition, Faculty of Human Ecology, Bogor Agricultural University, Indonesia, 3Faculty of Nursing
Mahsa University, Kuala Lumpur, Malaysia

Abstract
Traditional foods are foods consumed by a certain ethnic group in a specific region. The habit of consuming traditional foods is usually inherited by the
family members, including toddlers, of a respective generation. The study aimed to determine relationship of maternal knowledge, attitude, and practices in
traditional food feeding with stunting and wasting of toddlers in the farmer families of the Central Bengkulu District. This study employed a cross-sectional
design with a sample of mothers with children aged 12–59 months. The sample included a total of 115 farmer families. Data on nutritional knowledge,
attitude, practices about traditional food, sex of children, and the number of family members were collected via interviews conducted with the mothers;
stunting and wasting status data were collected via height and weight measurements. Data were analyzed bivariately using the chi-square test. Multivariate
logistic regression analysis was also used in this study. It was found that there was a relationship between nutritional knowledge of traditional food and
nutritional status of weight-for-age (p-value = 0.031), and there was a correlation between nutritional practices of traditional food and wasting incidence (p-
value = 0.012). According to the height-for-age index, the nutritional status was related to the maternal knowledge of traditional food, whereas the maternal
nutritional practice with traditional food had a significant relationship with the weight-for-age index.
Keywords: Knowledge, practice, stunting, traditional food, wasting

Introduction main ingredient of unique foods, especially in the

Traditional food is formed as an evolutionary result coastal community. Dewi et al.,1 reported that examples
of experiences that have been inherited for years, even of tra-ditional fish-based food in Bengkulu are Pendap,
centuries, and served in daily dishes consumed by Pais, Lemea, Bagar hiu, Gulai kemba'ang, and
fami- lies. The existence of traditional food is Tempoyak (fermented durian). These traditional foods
increasingly scarce owing to the complexity of the have nutri-tional values and more specific tastes
making of food and its limited knowledge by a certain because the ingre-dients are obtained from local food
group of people. Moreover, the main ingredients used sources, and the taste is relatively acceptable to the
in traditional foods are extremely likely to be people of Bengkulu.
determined by the location where they are found. 1 Failure of growth and development can affect an in-
However, the tendency of con- suming traditional fant’s life in adulthood. Nutritional status is a child de-
foods in families is often during wed- ding ceremonies velopment factor affected by eating habits. Healthy eat-
of the Bengkulu people. This tradition is still ing habits are mandatory for children who need to grow
maintained and followed owing to their fondness, and solve acute dietary problems in children. 2
preference, and the ease to obtain the foods. Besides, as Furthermore, Sharif et al.,3 stated that the process of
a coastal area, Bengkulu is rich in the diversity of transforming knowledge of the Malay traditional food
typical fish food. This increases the wide usage of fish among generations is from mothers to their daughters
as the Correspondence*: Betty Yosephin Simanjuntak, Department of Nutrition,
Poltekkes Kemenkes Bengkulu, Padang Harapan, Bengkulu, Indonesia, E-
mail: patricknmom@yahoo.co.id, Phone: +62-736-341212
How to Cite: Simanjutak BY, Haya M, Suryani D, Khomsan A, Ahmad CA. Received : October 24th 2018
Maternal knowledge, attitude, and practices about traditional food feeding Revised : May 9th 2019
with stunting and wasting of toddlers in farmer families. Kesmas: Public Accepted : July 15th 2019
Health Journal. 2019; 14 (2): 58-64. (doi:10.21109/kesmas.v14i2.2712)

Copyright @ 2019, Kesmas: National Public Health Journal, p-ISSN: 1907-7505, e-ISSN: 2460-0601, Accreditation Number: 30/E/KPT/2018, http://journal.fkm.ui.ac.id/kesmas
 Simanjuntak et al, Maternal Knowledge, Attitude and Practices about Traditional Food Feeding with Stunting and Wasting of Toddlers

with an explanation of the used ingredients, cooking

ers in the agricultural areas who had children aged 12–
methods, used equipment, and cooking skills. It is also
59 months at Jambu, Renah Semanek and Pagar Jati
assumed that mothers with a good nutritional
sub- districts with a total of 137 people. The total
knowledge prefer to prepare foods for their families.
number of mothers in the study sample was 115.
Another study found that attitude scores and maternal
Samples were se- lected using a purposive sampling
dietary under- standing were positively associated with
technique. Exclusion criteria were non-farmer family
the toddler's diet scores.4
heads and the children who were not able to stand
Most people in the Bengkulu Province still depend
upright.
on the agricultural sector. Farmer families usually
The independent variables were maternal
consume foods derived from the agricultural products.
knowledge, attitudes, and practices related to the
Therefore, research studies on the diversity of
traditional food consumption in farmer families are traditional food as collected by using a questionnaire
still rarely carried out. The latest study by Oly- consisting of 15 questions about definition, benefit,
serving habits, role of traditional food for toddler.
Alawuba and Iheidioha in Nigeria, 5 shows that
Knowledge was catego- rized into three categories
stunting in children aged 2 - 5 years at 6.4% in the
farming community. This is in contrast with the study including low (below 60%), medium (60% - 80%), and
high (over 80%) of all cor- rect answers. Nutritional
by Cruz et al.,6 which states that the children living in
attitudes were categorized into “disagree” with a score
urban areas are significantly at a lower risk of stunting
cut-off point of less than 80 and “agree” with a score of
as compared with the children in rural areas, who
greater than 80. Practices are categorized into seldom
belong the farmer families.6
and often.
Balanced nutrition is essential to maintain a good
The dependent variable was the nutritional status of
health and prevent malnutrition in infants, including
toddlers that was measured based on the body length
stunting, wasting, and obesity. The anthropometric
or height-for-age (Length/Age or Height/Age). Body
com- posite index is an anthropometric index that
mass was measured by using a digital scale, and the
combines the three indexes, namely weight-for-age
height was measured using microtoise. To assess the
(WAZ), height- for-age (HAZ), and weight-for-height child’s nutri- tional status, the weight and height of
(WHZ), to deter- mine the nutritional status of a each toddler is converted into a standardized value (Z-
toddler. A study in Bengkulu showed underweight score) by using the 2005 WHO anthropometric
toddlers at 11.9%, stunting at 28.09%, and wasting at
standards.10 A total of 10 categories of the WAZ score
10.46% were mostly aged 13 - 59 months.7 included being under- weight if the Z-score was
Mothers are the first caregiver of toddlers in aim to between −3.0 and −2.0 stan- dard deviations (SD), and
mainly avoid nutritional problems in children and normal if Z-score was between
achieve an optimal growth. Maternal knowledge, atti-
−2.0 and 2.0 SD. Categories of the HAZ scores
tudes, and practices affect the change of the children’s
included stunting if the Z-score was over -2.0 SD, and
diet. Mothers with a good knowledge will implement a
normal if the Z-score was below -2.0 SD. Categories of
good feeding practice; hence, their children will be free
the WHZ scores included wasting if the Z-score was
from malnutrition; in turn, this can help the children
between -3.0 SD and -2.0 SD, and normal if the Z-
have a good health while following better dietary prac-
score was between
tices. Subsequently, this will help the mothers in chang-
-2.0 SD and 2.0 SD.
ing their family’s eating behavior and practices. 8 A Editing, coding, cleaning and entry data were
study by Saaka,9 concluded that there is a significant employed on the collected data. Univariate data
relation-ship between maternal knowledge and HAZ analysis included maternal knowledge, attitudes, and
index, but it does not have a relationship with the practices about the traditional food, nutritional status
WHZ index nutritional status. The aim of this study (WAZ, HAZ, and WHZ), sex of children, and the
was to analyze the relationship of maternal nutritional number of family. Inter-group comparison was
knowledge and practices of traditional foods with the performed with bivariate analysis by using the
stunting and wasting of children (12 - 59 months) chi-square test. Multivariate logistic regression
incidences in farming families in the Central Bengkulu analysis was also carried out in this study. A p-value of
District. less than 0.05 criterion was taken to determine the
statistical significance.
Method
This study applied a cross-sectional study design Results
pri- marily in the Central Bengkulu District from April The data of 115 farming families, specifically
to July 2017, with a local ethical committee of Public mothers and their children, were analyzed in this
Health Faculty, Diponegoro University No. study. Questions addressed to the mothers included
31/EC/FKM/2017. The population in this study mainly their nutritional knowledge, attitude, and practices
comprised all moth- about the traditional food, sex of children, and the
number of family members; whereas, the children
samples were only measured for their body height and
weight. Traditional foods examined

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Kesmas: National Public Health Journal, 2019; 14 (2): 58-64

in this study consisted of snacks, side dishes, and

housewives, have a high knowledge of traditional food.
vegeta- bles. Traditional snacks often consumed were
In terms of maternal attitude on traditional foods,
tart cakes, Kembang goyang, Koja sponge, and Lemang
most of the mothers (69.6%) showed the ‘agree’
tapai. Types of side dishes were Pais fish, Bagar
attitude, but only 19.1% of them were practicing
chicken, Lemea fish curry, and Tempoyak ikan
traditional foods often in their families. According to
mungkus. Vegetables con- sumed by toddlers were
the Z-score, the WAZ index is categorized into two
sweet and sour bamboo shoots, sweet cane egg curry,
groups, namely underweight and normal. There are
and stir-fried pucuk lumai.
still 19.1% of tod- dlers with underweight nutritional
Table 1 shows that out of 115 farming families,
status; whereas based on the HAZ index, 29.6% of the
only 33.9% of mothers, who were working as farmers
toddlers are stunted, and 11.3% of them have wasting
and
based on the WHZ index.
Table 1. Distribution of Maternal Knowledge, Attitude, and Practices
about Traditional Foods in Farmers
Table 2 describes the distribution of maternal know-
ledge on traditional food. In general, mothers know the
Variable Category n % meaning of traditional foods, that is useful, but there
Maternal knowledge of traditional food Low 11 9.6 are still mothers (65.2%) who do not understand the
Medium 65 56.6
High 39 33.9
danger of using coconut milk, and 60.0% do not know
Maternal attitude to traditional food Disagree 35 30.4 that traditional foods contain fiber.
Agree 80 69.6 As shown in Table 3, the five variables related to the
Maternal practice about traditional food Seldom 94 80.9
Often 21 19.1 WAZ index are maternal nutritional practices on tradi-
WAZ Index Underweight 22 19.1 tional food (p-value = 0.012); whereas, the variables
Normal 93 80.9
HAZ Index Stunting 34 29.6
that have no significant association with the WAZ index
Normal 81 70.4 are maternal knowledge and attitude about traditional
WHZ Index Wasting 13 11.3 food, sex of children, and the number of family
Normal 102 88.7
members.
Notes: n = the number of samples, % = percentage, WAZ = Weight-for-Age Z- The results of chi-square test (Table 4) showed that
score, HAZ = Height-for-Age Z-score, WHZ = Weight-for-Height Z-score

Table 2. Distribution of Maternal Knowledge Based on Correct Answers

Question n %

Definition of traditional food 109 94.8

Benefits of traditional food 109 94.8
The danger of using coconut milk in traditional food 75 65.2
Traditional food serving habits 105 91.3
Traditional food from fresh food 104 90.4
Traditional food are usually consumed only for adults 73 63.5
The important role of traditional food for the growth of toddlers 98 85.2
Nutrition in traditional food 105 91.3
Eating traditional foods causes diarrhea 77 67.0
Traditional food causes obesity 66 57.4
Fiber content in traditional food 69 60.0
Traditional food takes a long processing time 94 81.7
Traditional food contains a source of protein that is useful for children's intelligence 70 60.9
Traditional food in the form of snacks do not contain artificial dyes and preservatives 88 76.5
Traditional snacks can be filling 103 89.6

Table 3. Relationship between Maternal Knowledge, Attitudes, and Practices on Traditional Food with the Weight-for-Age Z-score Index

WAZ Index

Variable Category Underweight (n = 22) Normal (n = 93) Total (n =115) p-Value OR (95% CI)

N % N %

Maternal knowledge of traditional food Low 1 9.09 10 90.91 11 0.608 -

Medium 14 21.54 51 78.46 65
High 7 17.95 32 82.05 39
Maternal attitude to traditional food Disagree 5 14.29 30 85.71 35 0.382 0.618 (0.208–1.833)
Agree 17 21.25 63 78.75 80
Maternal practices about traditional food Seldom 1 4.76 20 95.24 21 0.012 4.308 (1.168–1.460)
Often 22 23.40 72 76.60 94
Sex of children Male 13 20.63 50 79.37 63 0.073 2.143 (0.925–4.966)
Female 9 17.31 43 82.69 52
The number of family member Big 14 16.28 72 83.72 86 0.287 0.510 (0.189–1.381)
Small 8 27.59 21 72.41 29

Notes: n = number of sample, OR = Odds Ratio, CI = Confidence Interval, WAZ = Weight-for-Age Z-score

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 Simanjuntak et al, Maternal Knowledge, Attitude and Practices about Traditional Food Feeding with Stunting and Wasting of Toddlers

Table 4. Relationship of Maternal Knowledge, Attitude, and Practices about Traditional Foods with the Height-for-Age Z-score Index

HAZ Index

Variable Category Stunting (n = 34) Normal (n = 81) Total (n =115) p-Value OR (95% CI)

N % N %

Maternal knowledge of traditional foods Low 7 63.64 4 36.36 11 0.031 -

Medium 16 24.62 49 75.38 65
High 11 28.21 28 71.79 39
Maternal attitude to traditional foods Disagree 12 34.29 23 65.71 35 0.436 1.375 (0.568-3.229)
Agree 22 27.50 58 72.50 80
Maternal practices about traditional food Seldom 5 23.81 16 76.19 21 0.523 0.700 (0.32-2.095)
Often 29 30.85 65 69.15 94
Sex of children Male 23 36.51 40 63.49 63 0.112 2.143 (0.923-4.966)
Female 11 21.15 41 78.85 52
The number of family member Big 19 23.46 62 76.54 81 0.663 0.735 (0.299-11.807)
Small 10 29.41 24 70.59 34

Notes: n = number of sample, OR = Odds Ratio, CI = Confidence Interval, HAZ = Height-for-Age Z-score

Table 5. Relationship of Maternal Knowledge, Attitude, and Practices on Traditional Foods with the Weight-for-Height Z-score Index

WHZ Index

Variable Category Wasting (n = 13) Normal (n = 102) Total (n =115) p-Value OR (95% CI)

N % N %

Maternal knowledge of traditional food Low 1 9.09 10 90.91 11 0.613 -

Medium 9 13.85 56 86.15 65
High 3 7.69 36 92.31 39
Maternal attitude to traditional foods Disagree 2 5.71 33 94.29 35 0.201 0.380 (0.080–1.814)
Agree 11 13.75 69 86.25 80
Maternal practices about traditional food Seldom 1 4.76 20 95.24 21 0.07 0.7 (0.234–2.095)
Often 13 13.83 81 86.17 94
Sex of children Male 7 11.11 56 88.89 63 0.943 0.958 (0.301–3.05)
Female 6 11.54 46 88.46 52
The number of family member Big 14 16.28 72 83.72 86 0.407 0.492 (0.147–1.647)
Small 8 27.59 21 72.41 29

Notes: WHZ = Weight-for-Height Z-score

Table 6. Final Variables of Multivariate Analysis

95% CI
Anthropometric Index Variable p-Value OR
Lower Upper

WAZ Maternal nutritional practice 0.001 2.757 7.002 1.085

HAZ Sex 0.040 2.143 4.966 0.925
WHZ Maternal nutritional practice 0.045 3.071 9.593 1.018

Note: WAZ = Weight-for-Age Z-score, HAZ = Height-for-Age Z-score, WHZ = Weight-for-height Z-score

maternal nutritional knowledge (p-value = 0.031) was

who showed practices on traditional foods. It was found
related to the HAZ index. Many of the mothers with a
that stunting was higher in boys (36.51%) than girls
higher nutritional knowledge level were having
(21.15%). Based on the HAZ index, 23.6% of stunted
children with a normal body weight. Due to the low
children came from the families with the ‘big’ number of
maternal knowledge of traditional food, stunting was
family members which did not show much difference
observed in 63.64% of the toddlers. There was no
from families with the ‘small’ family members (29.41%).
relationship between maternal attitude to traditional
As shown in Table 5, all the variables (maternal
foods and the toddlers’ HAZ index (p-value = 0.436).
nutritional knowledge, attitude, practices, sex of chil-
There were 34.29% mothers with ‘disagree’ attitude on
dren, and the number of family members) are not
traditional foods toward the HAZ index. There was no
related to the WHZ index. Most of mothers with low
relationship between maternal practices about
knowledge had normal WHZ index at 90.91%.
traditional foods and the toddlers’ HAZ index (p-value
Mothers with ‘disagree’ attitude (94.29%) on the
= 0.523). There were rarely stunted toddlers (23.81%)
traditional food had children with the normal (WHZ)
among the 21 mothers,
index. In this study,

61
Kesmas: National Public Health Journal, 2019; 14 (2): 58-64

mothers with “seldom” nutritional practices had

status.14 In line with the study by Alawuba,5 there was a
95.24% were normal.
relationship of knowledge of nutritional education with
Table 6 shows that the p-value of the WAZ index was
the WHZ (p-value = 0.018), HAZ (p-value = 0.012),
0.001 (p-value < 0.05 with OR = 2.757) and WHZ was
WAZ indexes (p-value = 0.026).
0.045 (p-value < 0.05 with OR = 3.071). It means that
This study showed that there was a relationship of
mothers who seldom practiced traditional food feeding maternal nutritional practices with the WAZ index (p-
to their children had 2.757 times higher risk of having value = 0.012). It can be seen that most mothers with a
underweight (WAZ) index than mothers who often did. high level of nutritional knowledge could practice how
In the WHZ index, the mothers who seldom practice to supply their food, so that their nutritional needs are
traditional food feeding to their children had 3.071 fulfilled. In line with the study by Yabanci et al.,4
times higher risk of having wasting (WHZ) index as finding that many mothers have higher levels of
compared with the mothers who often did. nutritional practices and their children have normal
weights. The study by Saaka,9 showed that maternal
Discussion knowledge is correlated with HAZ, but not with WHZ
This study showed that the HAZ index was index. The nutritional knowledge of traditional foods
influenced by nutritional knowledge (p-value = 0.031), will affect mothers’ ability to provide both in terms of
and maternal nutritional practices were related to the quantity and quality to affect the food consumed by
WAZ index (p- value = 0.012). Also, this study found no children.9 The variety of food ingredients in the family
relationship of maternal knowledge, attitude, and will increase the intakes of energy and other
practices with the WAZ index. This is likely due to
nutrients. The study by Adnan and Muniandy,15 found
other factors. Several factors influencing the nutritional
that the maternal know -ledge level influences the
status included sex, the number of family members, practice of feeding children and, ultimately,
income, father's education, family income, education, determines the nutritional status of children.
and maternal employment.6 Galgamuwa et al.,11 stated Maternal nutritional knowledge has an im -portant
that being underweight is more common in the low- role in improving the nutritional status of their
income households than in the high-income children. Mothers who
households. It is similar to a study in India showing provide the proper nutritious food can help the
that children from low-income group have a high level children meet the needs for a better growth and
of unaffordability to buy foods. It shows that poverty is nutritional status.16
not the only factor responsible for malnutrition but The most common problem of malnutrition in
inadequate food intake, poor hygienic habits, and toddlers is stunting. Stunting is a major public health
environment along with low education level also can problem in developing countries such as Indonesia as
contribute to child malnutrition among the low-income compared with underweight and wasting. The HAZ-
groups.11 based nutritional status showed stunting to be
This study showed that the WHZ-based nutritional prevalent in 6.1% of the toddlers. 2 Stunting is resulted
status of farmer families was not influenced by from a complex interaction of household,
nutritional knowledge and attitude, but influenced by environmental, socio- econo mic, and cultural
nutritional practices. There was a relationship between influences that are described in the WHO Conceptual
maternal understanding of dietary and WAZ (p-value = Framework on Childhood Stunting.17 This study is
0.031). Saaka,9 stated that an increase in maternal child almost the same with the study by Alawuba in Nigeria, 5
care knowledge may contribute significantly to the which found that stunting in children aged 2-5 years is
child’s nutritional status in Ghana. In another study, 6.4%. However, a study on fisherman families in the
the score of maternal nutritional attitude and Philippines found 30.3% stunting incidence in
knowledge was positively related to the child’s diet
children aged 0–60 months, 18 which is in contrast to
score.12 Maternal knowledge was not only obtained
the study by Cruz et al.,6 stating that children living in
from the level of edu- cation, but also received from
urban area have a significantly lower risk of stunting
mass media such as television. Stunting, caused by
than children in rural areas, with a p-value < 0.001. A
experiences of chronic nutritional deprivation, affects
study by Sarma et al.,19 showed that the prevalence of
approximately 25% of child under-five. There is a
stunting was found at around 41% among children
relationship between stunting and child development in
under 60 months of age, and higher in rural area than
the low- and middle-income countries.13 It is estimated
in urban area (43% versus 36%).
that the level of expertise of maternal nutrition can be Traditional food is a cultural phenomenon as they
useful for feeding toddlers, so that the nutritional status are consumed by a certain ethnic group in a specific
of children is normal. Previous studies have region. Traditional foods have the potential to be a
demonstrated a significant influence between source of nutrients that is sustainable, economically,
maternal knowledge and children’s nutritional culturally acceptable and diverse, but not yet
continuously used to prevent malnutrition through the
62 diversification of tradi-
 Simanjuntak et al, Maternal Knowledge, Attitude and Practices about Traditional Food Feeding with Stunting and Wasting of Toddlers

tional food-based foods.3 In fact, the traditional source over this century due to the knowledge of traditional
of food can be used for elevating the strategy of im- foods is low, so that the available local nutrient sources
proving the nutrition for family with a traditional food are not used optimally. The loss of traditional food
base. Micronutrients in forms of iron, vitamin A, and consumption will lead to a decrease in the diversity of
vi- tamin C are mostly available in traditional di- et in each tribe, and a changing lifestyle causes
foods. 20 Besides, an optimization of the use of local people to choose to buy fast food.5
food means that it is easily obtained and the price is
relatively afford- able.4,8 Conclusion
Lifestyle and dietary changes lead to the increased There is a relationship of maternal nutritional
occurrence of obesity and chronic diseases. The rapid practices with the nutritional status of toddlers (12–59
nutrition transition in this region may be due, instead, months) based on the WAZ and WHZ indexes in
to the increasing food availability and food farmer families in the Central Bengkulu District.
purchasing po wer, rather than to a shift in food
While, the sex of children has a substantial
preferences toward modern Western foods.21 As a relationship with the HAZ index, it is necessary to
result, the micronutrient intake becomes low. Another improve the maternal under- standing of traditional
consequence is the increase in energy, carbohydrate, food, so that the mothers of the toddlers can practice
and fat consumption. the feeding in order to improve the child’s nutritional
Results of this study highlighted that traditional
status. The traditional source of food can be used for
foods in Central Bengkulu included vegetable groups
elevating the strategy of improving the nutrition for
with traditional food ingredients mostly obtained from
family with a traditional food base. Micronutrients
rice fields such as unji, lumai, kambas, lemea, umbut,
including iron, vitamin A, and vitamin C are mostly
round purple eggplant, ferns, white mushrooms, taro
available in traditional foods. On the other hand, an
leaves, and young papaya.1 The vegetable is processed optimization of local food means that it is easily
by saute- ing or making chili sauce. Vegetable food obtained and the price is relatively affordable.
ingredients which are usually processed into the sauce
are unji, young papaya, lumai fruit, and lemea. By Acknowledgment
judging from these types of traditional foods, mothers The authors would like to thank the Neys-van
usually only provided vegetable soup to their toddlers, Hoogstraten Foundation for funding this study.
or serve it in a small size. Traditional foods in the study Appreciation is addressed to the Director of Health
location rarely used fish because the site of this study is Polytechnic of Bengkulu, the Dean of Faculty of
located in an agricultural area, so that the source of the Human Ecology, Bogor Agricultural University.
animal protein generally comes from the livestock
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