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Current Intake and Infection Status were not Good Predictive Factors of
Stunting among Children Aged 6-59 Months in Babakan Madang Sub-District,
Bogor District, West Java, Indonesi...

Article in Indonesian Journal of Public Health Nutrition · April 2022

DOI: 10.7454/ijphn.v2i2.5387

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IJPHN

Current Intake and Infection Status were not Good Predictive Factors of Stunting
among Children Aged 6-59 Months in Babakan Madang Sub-District, Bogor
District, West Java, Indonesia

Ruth Desinta Purnamasari*, Ratu Ayu Dewi Sartika, Trini Sudarti

Public Health Nutrition Faculty of Public Health Universitas Indonesia, F Building 2nd Floor Kampus
Baru UI Depok 16424, Indonesia

*Corresponding Author:
Ruth Desinta Purnamasari
E-mail: ruthdesintap@gmail.com

Abstract
This study aims to discover the prevalence of stunting and determine the associations between the history
of pulmonary tuberculosis disease with the prevalence of stunting among children under five years of age
(6-59 months) in Babakan Madang Sub-District, Bogor District 2019. This study uses a cross-sectional
design with a quantitative approach. The sample in this research was 194 children under five obtained by
cluster sampling. Data collection was conducted through May 2019. The data collection process includes
anthropometric measurements using calibrated microtoise and digital length board, dietary assessment
using 1 x 24-h food recall, and a self-administered questionnaire. Data analyses were performed using the
chi-square test and independent t-test. The result of this study shows that 35.6% of children under five are
being stunted (HAZ ≤ -2.00). The risk factor with a significant correlation with stunting is history of
pulmonary tuberculosis disease (p-value 0.044), although careful interpretation is needed in this result due
to the limited number of observed cases. However, this study recommends pulmonary tuberculosis disease
prevention and improve nutritional education.

Keywords: stunting, children under-five, pulmonary tuberculosis disease

Abstrak
Penelitian ini bertujuan untuk mengetahui besaran prevalensi stunting dan membuktikan hubungan antara
riwayat penyakit TB paru serta faktor lainnya dengan kejadian stunting pada balita umur 6-59 bulan di
Kecamatan Babakan Madang Kabupaten Bogor Tahun 2019. Penelitian ini menggunakan desain studi
cross-sectional dengan pendekatan kuantitatif. Sampel pada penelitian ini berjumlah 194 balita yang
didapat dengan cara cluster sampling. Pengambilan data dilakukan selama bulan Mei 2019. Proses
pengambilan data meliputi pengukuran antropometri menggunakan microtoise dan digital length board
yang telah divalidasi, wawancara food recall 1x 24 jam, dan pengisian kuesioner. Analisis data dilakukan
dengan uji chi-square dan independent-t. Hasil penelitian ini menunjukkan terdapat 35,6% balita stunting
(Z-score PB/U atau TB/U ≤ -2,00). Faktor risiko yang memiliki hubungan signifikan dengan kejadian
stunting adalah riwayat penyakit TB paru, meskipun hasil ini memerlukan kehati-hatian dalam interpretasi
mengingat sangat terbatasnya jumlah kasus TB paru yang diobservasi. Meskipun demikian, studi ini
merekomendasikan upaya pencegahan terhadap penyakit TB paru dan peningkatan edukasi gizi.

Kata kunci: stunting, balita, riwayat TB paru

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
 42

Introduction This study aims to examine the

associations between history of
Stunting, as an indicator of chronic
pulmonary TB disease and other factors
malnutrition, reflects a failure in
with stunting in children aged 6-59
attaining a child’s potential linear growth
months. Regarding the very limited
(1). Stunting has been associated with
previous research on this topic, this study
some serious health and social problems
also aims to give a result that could be
as risks, such as morbidity, deprived
used as a starting reference for further
immune functions, and non-
research on this topic.
communicable diseases (2-4). The
prevalence of stunting in Indonesia in
Methods
2018 showed about 30.8% of children
were being stunted (5). This number is This study was a cross-sectional
considered ‘high’ based on the threshold conducted through May 2019 in
of public health problems for stunting by Babakan Madang Sub-District, Bogor
WHO (6). Regarding this situation, the District. Any children aged 6-59 months
Indonesian government has then made and their mother/caregiver that was
stunting one of the issues to be solved by willing to participate in this study were
prioritizing 100 districts/towns with a selected from 6 of 9 sub-districts using
high burden of stunting to be given the cluster sampling method. The sample
interventions, and Bogor District is one size was calculated using Z-Test
of them (7). difference between 2 proportions
Pulmonary tuberculosis, as an formula. The minimum number of
infectious disease, has a reciprocal samples taken by the researcher is the
relationship with malnutrition in a form highest number of samples from the
of a vicious cycle, which can lead to calculation results (n = 38). The
stunted growth (8). Research on the minimum number of samples is
relation between pulmonary tuberculosis multiplied by two and then by the design
disease in children and stunting is very effect (def) of 2 (two) to increase the
limited. Most studies reported efficiency of the number of samples
malnutrition as a risk factor for TB because the sampling technique used is
disease, yet there are limited studies or cluster sampling. The final sample size
literature investigating TB disease as a obtained was 152 toddlers. 10% of the
risk factor of malnutrition. An overview total amount to anticipate respondents
had highlighted TB as a specific dropping out during data collection was
infection that has a high impact on added to the sample result (n=167).
nutritional status, yet it mentioned that The sample result was 167
more research is needed regarding the respondents. Some of the subject's
relation of this specific infectious disease inclusion criteria were, among others,
with malnutrition (9). Furthermore, a residing in the selected village, each
systematic review on research topics in child from a different family head, and
TB does not mention any single study on being the youngest child. Meanwhile, the
the role of nutrition in the primary exclusion criteria are children who have
prevention of TB (10). Even so, the physical abnormalities that affect body
impact of TB, such as anorexia, length or height. A total of 194
vomiting, cough, fever, and weight loss, respondents participated in this study as
could rationally lead to stunted growth, the actual subject. Length measurement
given the time of TB treatment is 6 data of the children were collected using
months by minimum (9,11). a digital infantometer and microtoise

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
 43

with a precision of 0.1 cm. The data Buku Foto Makanan (Porsimetri) by
collected were later compared with Indonesia Ministry of Health was used as
WHO Child Growth Standards. A child a portion guide to minimize bias related
will be considered stunted when the to food recall. The data categorized was
HAZ is <-2.00 SD. analyzed using SPSS v.22 and WHO
The data collection officer in this Anthro 2005. Chi-square analyses were
study is the researcher herself with the used to find any significant association
help of thirteen students, consisting of between each independent and
four undergraduate students and seven dependent variable.
magister students of the Nutrition Study
Program Faculty of Public Health who Results
participated in the collaborative
This study included 194 children
research. Researchers were divided into
aged 6-59 months in 6 sub-district of
two groups, each containing seven
Babakan Madang Sub-District, Bogor
people. One person is in charge of
District. 30.9% of the children were
screening every mother of toddlers who
within the age group of 12-23 months
come to Posyandu based on the inclusion
old. Most of the children’s families in
and exclusion criteria, two people were
this study received income below
in charge of measuring anthropometry of
Rp3,760,000. Further information on
children (body weight and body length),
demographic characteristics is provided
and the remaining three people were in
in Table 1.
charge of carrying out interview and
Results showed 35.6% of children
recall intake. To minimize the bias of
were stunted, and 1.5% of children had a
measurement done by multiple
history of pulmonary TB disease. 69.6%
operators, the operators were properly
of the children were being insufficient
trained and used standardized and
zinc intake. Further information on
calibrated instruments.
variables is provided in Table 2.
Data on the history of pulmonary TB
Bivariate analyses showed a
disease and other factors (history of
significant association between history
diarrhea disease, history of ARI disease,
of pulmonary TB disease and stunting p-
hand-hygiene practice, vitamin A
value of 0.044 (p-value <0.05). Table 2
supplementation, completion of basic
provides further information on bivariate
vaccinations, and demographic
analyses. Since only one significant
characteristics) were collected through
association was found, multivariable
interviews using questionnaires. Dietary
analyses were not conducted.
assessments to collect the energy,
protein, and zinc intake were collected
using 24-hour food recall (1x24 hours).

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
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Table 1. Frequencies of children aged 6-59 months based on demographic characteristics

n = 194
Variables
n %
Age groups
6-11 45 23.2
12-23 60 30.9
24-35 34 17.5
36-59 55 28.4
Biological sex
Male 105 54.1
Female 89 45.9
Maternal education level
Basic 150 77.3
Middle 43 22.2
High 1 0.5
Paternal education level
Basic 116 59.8
Middle 66 34.0
High 12 6.2
Family income
< Rp3,760,000 128 66.0
≥ Rp3,760,000 66 34.0

Table 2. Bivariate analyses and stunting among children aged 6-35 months
HAZ
Variable Stunted Not stunted p-value
n % n %
History of Pulmonary TB Disease
Yes 3 100.0 0 0.0
0.044*
No 66 34.6 125 65.4
History of Diarrhea Disease
Yes 18 36.0 32 64.0
1.000
No 51 35.4 93 64.6
History of ARI Disease
Yes 37 37.0 63 63.0
No 0.779
32 34.0 62 66.0
Energy intake
Inadequate 43 36.4 75 63.6
0.870
Adequate 26 34.2 50 65.8
Protein intake
Inadequate 41 33.9 80 66.1
0.634
Adequate 28 38.4 45 61.6
Zinc intake
Inadequate 46 34.1 89 65.9
0.621
Adequate 23 39.0 36 61.0
Hand-Hygiene Practice
Not good 29 32.6 60 67.4
Good 0.517
40 38.1 65 61.9

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
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HAZ
Variable Stunted Not stunted p-value
n % n %
Vitamin A Supplementation
Not given 9 28.1 23 71.9
Given 0.447
60 37.0 102 63.0
Completion of Basic Vaccination
Not completed 37 34.3 71 65.7
0.585
Completed 31 39.2 48 60.8
Maternal Education
Basic 53 35.3 97 64.7
Middle 16 15.3 27 62.8 0.739
High 0 0.0 1 100.0
Paternal Education
Basic 44 37.9 72 62.1
Middle 23 34.8 43 65.2 0.338
High 2 16.7 10 83.3
Family Income
< Rp3,760,000 51 39.8 77 60.2
0.115
≥ Rp3,760,000 18 27.3 48 72.7

Discussion infections were not good predictive

factors of stunting in children 6-59
This study showed that 35.6% of months in this study area. Although the
children aged 6-59 months are stunting, history of TB is significantly different
higher than both national and province among stunted and non-stunted children,
prevalence of stunting. Regarding the the data should be carefully interpreted
WHO thresholds for public health because the number of children with
problems, the stunting prevalence of this history of pulmonary TB disease was
population could also be classified as only 3 (three).
‘very high” (≥30%). This very high Pulmonary TB as an infectious
problem magnitude implies the urgency disease has a major influence on
for handling and preventing stunting nutritional status due to decreased
problems in the Babakan Madang Sub- appetite, anorexia, and vomiting. It also
District. It is also associated with poor causes long fever, which lead to an
socio-economic conditions, the increase in the nutritional needs of
possibility of early and repeated children. In addition, the treatment for
exposure to diseases, and improper pulmonary TB is a long process (6
feeding practices in these populations. months by minimum). During this
The prevalence of stunting in this period, a lack of intake in pediatric
population is highest in the age group of pulmonary TB patients will affect their
36-59 months, and males than the body weight and height (9).
counterparts. A similar study by Madanijah and
As we can see from Table 2, Triana (2006) showed a significant
variables like energy intake, protein correlation between the historical
intake, zinc intake, history of ARI did nutritional status of children and the
not give significant results. This means incidence of TB in kindergarten children
current dietary intake and history of

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
 46

(19). The lower the historical nutritional With the association of history of
status of the children (using the pulmonary TB and stunting found in our
anthropometric index of height study, future research could explore
according to age), the greater the risk of more on the possible factors of the
TB compared to children with normal association and propose possible
nutrition. interventions according to it.
One of the possible factors affecting
the result of pulmonary TB association Conclusion
with stunting prevalence is the Current dietary intake and history of
possibility of early and repeated infections were not good predictive factors
exposure to diseases that causes a change of stunting in children 6-59 months in
in body weight and height. Babakan Madang Sub-District, Bogor
According to Crofton, children have District, West Java, Indonesia. With the
immature immune system. Immunity limitation of our cross-sectional study
also decreases if the child suffers from design, hopefully future research could
malnutrition (12). In these children, explore other study design such as cohort to
primary infection can immediately be provide better picture through time.
followed by miliary tuberculosis and TB Meanwhile, our study found history of
meningitis. Of all people infected with pulmonary TB disease to be associated
TB, about 10% will develop TB disease, with stunting in children aged 6-59
depending on the number of TB germs months with precaution. Given the
inhaled and the immune system of the observed associations, prevention of
infected person (a person's resistance). pulmonary TB disease in children should
Initially the patient's defenses can still be a concern. The intervention
control TB. However, after months or programs include detecting TB infection,
years, the defenses may weaken, due to identifying children at high risk of
malnutrition or other diseases, then TB disease progression, implementing
disease begins to spread in the lungs. treatment of infection, and support from
Stunted under-fives can reduce other stakeholders like TB activist and
children's immunity and make children Ministry of Health.
more susceptible to TB germs. Untreated
TB in children can also lead to impaired Ethical Clearance
nutritional growth. Ethical clearance has been reviewed and
Apparently, this association was also released by Ethical Committee of
found in a study in India. India is one of Faculty of Public Health, Universitas
the countries with the highest burden of Indonesia, issued from May 6, 2019 (No.
TB in the world, accounts for 257/UN2/F10/PPM.0002/2019).
approximately one fifth of the global
incidence. Studies point the role of
various social, behavioural, economic Acknowledgment
and environmental factors like The authors would like to thank for
undernutrition, indoor air pollution, the research team and fellow other
smoking and alcohol addiction, friends and partners for helping this
ignorance and poverty as barriers to research. The authors also want to thank
complete elimination of TB (13-17). Of all the respondents who participated in
these, undernutrition is the single most this study and all parties in Babakan
important predisposing factor for TB in Madang Sub-District.
India. It is in line with our study results.

Indonesian Journal of Public Health Nutrition April 2022, Vol. 2 Issue 2 page 41 - 48
 47

9. Krawinkel, M.B. Interaction of

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