DOI Number: 10.5958/0976-5506.2019.03114.

Factors Affecting the Occurrence of Stunting in Indonesia

Nailul Izza1,2, Windhu Purnomo3, Mahmudah3

1
Student Master of Public Health at Airlangga University Surabaya, Indonesia; 2Research Center for
Humanities and Health Management, Ministry of Health, Indonesia; 3Departement of Biostatistics,
Faculty of Public Health, Airlangga University Surabaya, Indonesia

ABSTRACT
Stunting is an indicator of children’s welfare and a reflection of social inequality. The stunting prevalence
in Indonesia ranks fifth in the world, in 2018 it is still above the national target of 30,8%. The scope of
the causes of stunting is wide ranging from toddlers themselves, households to the community. This study
aims to determine the factors that influence the occurrence of stunting in Indonesia. This research is a non-
reactive study because it only carries out secondary data collection obtained from the 2017 Nutritional
Status Monitoring (PSG) and Socio-Economic Survey (Susenas) research data. The analysis shows that the
factors that influence stunting are household factors that have access to proper sanitation (p value = 0,037).
Exclusive ASI variable, toddler weighing> 4 times, energy adequacy, protein sufficiency and poverty did
not affect stunting. The factors that influence stunting are the percentage of households that have access to
proper sanitation, but are only able to explain 37,2% for stunting. The cause of multifactor stunting, the need
to involve other causes such as infection, cases of diarrhea in this analysis that can arise due to low access
to proper sanitation.

Keywords: stunting; toddler; sanitation.

Introduction is still above the national target (<30%), which in

Childhood stunting is an indicator of children’s
welfare and a reflection of social inequality.(1) Stunting
is a condition of failure to thrive in children under five
(infants under five years old) due to chronic malnutrition
so children are too short for their age. Malnutrition
occurs since the baby is in the womb and in the early
days after the baby is born but the stunting condition only
appears after the baby is 2 years old.(2) Toddlers are short
(stunted) and very short (severely stunted) are toddlers
with body length (PB/U) or height (TB/U) according
to their age compared to WHO-MGRS standard of less
than -2 SD.(3,4)
The prevalence of stunting in Indonesia ranks fifth
in the world,(5) in addition, the prevalence of stunting
2013 was 37.2 percent and for 2018 it was 30,8% in
addition, the prevalence of stunting is still above the
national target (<30%), which in 2013 was 37,2% and
for 2018 it was 30,8%.(6) Based on data from the 2014
Global Nutrition Report that Indonesia is included in 17
countries experiencing a double burden of nutritional
problems and as many as 159 million stunting children
worldwide 9 million of them from Indonesia.(2) The data
from the research shows that Indonesia is a country that
still has public health problems, in accordance with a
statement from WHO to set limits on nutrition problems
of no more than 20%.(7,8) Regions with low stunting
prevalence (<30%) based on 2018 Riskesdas data is in
Bali, while the highest prevalence is in the East Nusa
Tenggara Region.(6)

The cause of stunting according to a modified concept

Corresponding Author: of UNICEF’s “Logical framework of the Nutritional
Windhu Purnomo Problems” 2013 happens because it is multifactorial,
Departement of Biostatistics, which is the direct, indirect and main problem.(9,10)
Faculty of Public Health, Direct causes of stunting include breastfeeding factors
Airlangga University Surabaya, Indonesia, 60115 which are considered very important in addition to
Email: windhu-p@fkm.unair.ac.id supplementary feeding.(1) According to the National
 1846 Indian Journal of Public Health Research & Development, October 2019, Vol.10, No. 10

Team for the Acceleration of Poverty Reduction that Method

60% of children aged 0-6 months do not get breast milk
exclusively.(5,11) The results of Anisa’s research that low
protein nutrient intake has a chance of stunting 5.775
times compared to toddlers in Kalibaru Sub-district
whose protein intake is sufficient.(12)
Parenting factors are an indirect cause of stunting.
One form of parenting is to weigh the toddler’s weight
regularly (weigh more than 4 times) to be able to
monitor growth.(13) Stunting is often not recognized in a
community where short stature is so common that it is
considered normal. Visual identification is quite difficult
and the lack of regular assessment of linear growth in
primary health care services contributes to stunting.(8)
The availability of proper sanitation is one of the
environmental factors needed to nurture mothers and
children because it can be an indirect cause of stunting.
(8,10)
Poor sanitation facilities can increase the incidence
of infectious diseases because the energy for growth is
diverted to resistance to infection so that nutrients cannot
be absorbed properly and inhibit growth.(13) The lack of
fulfillment of nutrient intake in the family itself is also
due to lack of food availability in households that are
affected by low family income.
The scope of the causes of stunting is wide ranging
from toddlers themselves, households to the community.
Based on the description of the background, this
study aims to determine the factors that influence the
occurrence of stunting in Indonesia.
This research data uses secondary data obtained from
research data “Nutritional Status Monitoring (PSG)” in
2017 by the Directorate of Community Nutrition of the
Ministry of Health of the Republic of Indonesia(4) and
the Central Bureau of Statistics through 2017 socio-
economic survey (Susenas).(14,15) The unit of analysis of
this study is the provinces in Indonesia, which number
34 provinces.
Data were analyzed using the multiple linear
regression method enter. The multiple linear regression
function to determine the effect of independent variables
on the dependent variable, besides that it can model the
state of the variable that is affected and the variables that
influence it. The equation for multiple linear regression
models is:
Y = β0 + β1X1 + β2X2 + ... + βkXk
Description: Y = independent variable; X = independent
variable (bound) (i = 1,2,3, ..., k); β0 = intercept; β1 =
regression coefficient (i = 1,2,3, ..., k).
Results
Bali Province is the province with the lowest
stunting prevalence of 19,1%, while East Nusa Tenggara
Province is the province with the highest stunting
prevalence of 40,3%.

Figure 1: Stunting prevalence by province in Indonesia, 2017(4)

Table 1 shows the percentage of poverty is the variable with the lowest average value, while the variable with the
highest average value is the variable weighing under five more than 4 times (X2).
 Indian Journal of Public Health Research & Development, October 2019, Vol.10, No. 10 1847

Table 1: Overview of Stunting and Suspected Affecting Factors

Variable Min Maks Mean Standard deviation

Stunting (Y) 19,10 40,30 30,29 5,55
exclusive breastfeeding (X1) 10,70 61,40 33,23 10,41
Weigh> 4 times (X2) 54,90 88,00 72,97 8,86
Energy Sufficiency (X3) 17,10 43,50 29,04 6,89
Protein Adequacy (X4) 36,10 66,20 55,08 6,69
Poverty (X5) 0,18 1,20 0,48 0,25
Sanitation Access (x6) 33,06 91,13 65,75 13,65

The results of multiple linear regression analysis in table 2 show that only significant value of sanitation access
variables (X6), while exclusive breastfeeding variables, toddler weighing> 4 times, energy adequacy, protein
adequacy, and poverty did not affect stunting. As for the T test the regression equation was obtained, namely:

Y = 38,760 - 0,208 access to proper sanitation

The value of households that have access to proper sanitation of 0,208 means that if a household that has access
to proper sanitation increases by 1 point, then the prevalence of stunting will decrease by 0,208.

Table 2: Results of Stunting Regression Analysis on Factors Influence of Stunting in Indonesia

Unstandardized coefficients
Model t Sig.
B Std. error
Constant (stunting) 38,760 12,149 3,191 0,004
Breastfeeding -0,057 0,108 -0.533 0,599
Weigh> 4 times 0,045 0,121 0,370 0,714
Energy Sufficiency -0,136 0,186 -0,729 0,472
Protein Adequacy 0,123 0,212 0,581 0,566
Poverty 2,103 4,347 0,484 0,632
Decent sanitation access -0,208 0,98 -2,116 0,044

Table 3 on the results of the F test shows that the dependent variable, namely the prevalence of stunting
percentage of households that have access to proper is only 37,2%, while the remaining 62,8% is explained
sanitation (X6) together (simultaneously) has a positive by other variables not included in the equation of the
and significant effect on the occurrence of stunting in variable under study.
Indonesia with a p value = 0,037.
Table 4: Stunting Determination Coefficient Test Results
Table 3: Stunting F Test Results
R Adjusted R Std.
Sum of Mean Model R
df F Sig. Square Square error
squares Square
1 0,610 0,372 0,232 4,86
Regression 378,789 6 63,132 2,663 0,037
Residual 640,100 27 23,707 Discussion
Total 1018,890 33
Provinces that have a stunting prevalence below
Table 4 shows the R2 value of 0,372, which means the national prevalence rate (29,6%) are only one-third
the ability of independent variables to influence is the of the provinces in Indonesia in 2017. The number of
percentage of households that have access to proper provinces with stunting prevalence is still above the
sanitation to explain the magnitude of variation in the national level making the region included in the category
 1848 Indian Journal of Public Health Research & Development, October 2019, Vol.10, No. 10
of experiencing chronic acute health problems. Based on
the category of community nutrition problems by WHO
in 1997 stated that a region is said to experience acute
acute nutritional problems if the prevalence of under-
fives is short 20 percent or more and the prevalence of
under-fives is thin 5 percent or more.(4) WHO set limits
on nutritional problems no more than 20%.(7,8)
The lowest stunting prevalence was in Bali Province
(19,10%) while the highest province was the prevalence
of stunting in NTT Province (40,30%), the magnitude
of the gap that occurred indicated an unequal imbalance
and development.(16) Handling the problem of stunting
seems very slow, globally the percentage of children
who are stunted has decreased only 0,6% per year since
1990. WHO proposes a global target of decreasing the
incidence of stunting in children under 40 percent by
2025, but predicted only 25-36 countries who are able to
meet these targets.(17)
The results of multiple linear regression analysis
indicate that the factors that influence stunting are
household factors that have access to proper sanitation
(p = 0,037) with the equation model:
Y = 38,760 - 0,208 access to proper sanitation
Exclusive ASI variable, toddler weighing> 4 times,
energy adequacy, protein adequacy and poverty level
did not affect the occurrence of stunting in Indonesia.
The percentage of households that have access to proper
sanitation increases by 1 point, then the prevalence of
stunting will decrease by 0,208. This is reinforced by
the results of the analysis of R2 value of 0,372, which
means the percentage of households that have access to
proper sanitation is only able to explain the magnitude of
variation in stunting by only 37,2%, while the remaining
62,8% is explained by other variables not included in the
equation variable studied.
The results of this study are not in line with the
research conducted in the Kalibaru Sub-district of
Depok that the low intake of protein nutrients has the
opportunity to stunting 5,775 times compared to toddlers
with sufficient protein intake.(12) The results of research
conducted by Aridiyah et al (2015) in the Patrang
and Mangli Jember Community Health Center work
areas that in rural areas protein and calcium adequacy
are associated with stunting, but not in urban areas.
(18)
Research conducted by Setiawan, et al (2018) said
that the low level of energy intake had an effect on the
occurrence of stunting (p = 0,001).(19)
The results of the research conducted by Setiawan,
et al (2018) that exclusive breastfeeding status did not
affect stunting (p = 0,464).(19) However, it is different
from the results of Aridiyah’s research (2015) that
exclusive breastfeeding is related to the incidence of
stunting in infants in both rural and urban areas (p value
<0,05).(18)
Based on the WHO concept that lack of available
water and sanitation infrastructure is one of the factors
causing stunting at the community level.(1) Lack of access
to clean water and sanitation. Data obtained in the field
shows that 1 in 5 households in Indonesia still defecate
in open spaces, and 1 in 3 households do not yet have
access to clean drinking water.(5,11) One form of activity
that can contribute to stunting reduction through Specific
Nutrition Interventions is providing and ensuring access
to clean water and access to sanitation.
Olaf Muller (2005) reported that the condition of
environmental sanitation in developing countries was
in a bad category.(20) Poor sanitation conditions increase
the incidence of infectious diseases, leading to a high
prevalence of malnutrition. Households with the ability
to be able to access proper sanitation will certainly be
able to minimize the attacks of various diseases such
as ARI, diarrhea and other infectious diseases. The
results of the research conducted by Mustikaningrum
A, et.al (2016) showed that the incidence of diarrhea
was a determinant of the incidence of stunting, in
which infants with diarrhea were at a risk of 2,14 times
stunting compared to those without diarrhea.(21) The
average prevalence of diarrhea increases with increasing
disparity in the prevalence of stunting (p = 0,000).(22)
The factors that cause stunting are very complex,
therefore the intervention efforts undertaken also involve
various sectors, both the health sector and the non-
health sector. Stunting is caused by multi-dimensional
factors and is not only caused by malnutrition factors
experienced by pregnant women and children under five.
Results of discussions conducted by Aryastami (2017)
efforts to reduce nutrition problems must be handled
cross-sectorally in all lines, strengthening the system so
that the 1000 First Days of Life (HPK) become part of
the culture and social life in the community.(7)
 Indian Journal of Public Health Research & Development, October 2019, Vol.10, No. 10
The results of the literature review conducted by
Mitra that the reduction in stunting was focused on
Scaling Up Nutrition (SUN) or the national nutrition
awareness movement carried out on the first 1000 days
of life.(17) The principle of the Scaling Up Nutrition
movement is that everyone has the right to good food
and nutrition. The results of the research conducted by
Kusudaryati, et.al (2017) said that the adequacy of Zn
had a significant effect on changes in the Z score of TB/U
(p = 0,042), so that the presence of sufficient Zn intake
would help deal with the occurrence of stunting.(23)
Conclusion
Factors that can influence stunting are households
that have access to proper sanitation. Whereas, exclusive
breastfeeding variable, toddler weighing> 4 times,
energy sufficiency, protein sufficiency, insignificant
poverty. The percentage of households that have access
to proper sanitation is only able to explain 37,2 percent
for stunting. So the causes of stunting are 62,8 percent of
which are caused by many other factors.
Suggestion
The cause of multifactor stunting, the need to
involve other causes such as infection, cases of diarrhea
in the analysis that can arise due to low access to proper
sanitation.
Acknowledgement
On this occasion the author would like to thank the
Ministry of Health.
Conflict of Interest: The author states that there is no
conflict of interest regarding the publication of this article.
Source of Funding: PPSDM of the Ministry of Health.
Ethical Clearance: This study was approved by Ethical
Commission of Health Research, number 92/EA/
KEPK/2019, Faculty of Public Health, University of
Airlangga, Surabaya.
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