Community-Based Stunting Intervention Strategies: Literature Review

Nursing Department, Faculty of Health and Sciences, Universitas Jenderal Soedirman, Purwokerto, Indonesia Nursing Department, Faculty of Medicine and Health Sciences, Alauddin State Islamic University, Makassar, Indonesia Faculty of Nursing, Universitas Indonesia, Depok, Indonesia Nursing Department, Health Polytechnic of Minsitry of Health, Semarang, Indonesia Primary Health Services Department, Universitas Indonesia Hospital, Depok, Indonesia


BACKGROUND
Nutrition problems in Indonesia affect the quality of human resources. The threat of stunting to the quality of Indonesia's human resources is increasingly alarming. Basic Health Research (Riskesdas) in 2018 shows that as many as 30.8% of Indonesian children under five are stunted (1). This figure decreased by 6.4%, compared to Riskesdas five years before (2). Although the number of children with very short postures decreased by 6.4% compared to Riskesdas in 2013 at 18.0%, an increase in this proportion should not be careless (3). Because actually the number of short-bodied children actually has increased. Stunting is an indicator of chronic malnutrition caused by poor interaction of various risk factors that have taken place at least in the first 1000 days of life (4) At present, the number of children under five in Indonesia is around 22.4 million and 5.2 million women in Indonesia are pregnant (5). The average number of babies born every year is 4.9 million children. Three out of 10 toddlers in Indonesia are stunted or have a lower height than the standard age (6). Not only short stature, the domino effect on toddlers who experience stunting is more complex. In addition to physical problems and cognitive development, stunting toddlers also have the potential to face other problems beyond that. Stunting does not mean that malnutrition is characterized by the condition of a child's body that is so thin (7). What often happens, children who experience stunting are not very visible physically. Stunting children or toddlers generally look normal and healthy (8). However, if examined further there are other aspects that actually become a problem. Not only cognitive or physical, stunted children tend to have a body metabolism system that is not optimal. For example, if another child can grow up, he actually grows to the side. This then has the risk of non-communicable diseases in Indonesia such as diabetes or obesity (9).
Nutrition becomes a very important thing related to stunting. Fulfillment of malnutrition to chronic is influenced by maternal nutrition during pregnancy, socioeconomic conditions, diseases affecting infants, and malnutrition in infants (10). LBW affects 20% of the occurrence of stunting. In addition to LBW, the age of giving birth to babies who are too young can also cause babies born vulnerable to stunting (11). Fulfillment of adequate nutrition when the baby is very influential on the growth and development of the baby and stunting. Exclusive breastfeeding is also one way to meet the nutrition of the baby. In addition to exclusive breastfeeding, fulfillment of food nutrition must also pay attention to quantitative, qualitative, and food security provided (12).
The government and development partners working in the health sector need to change understanding of stunting. This can be done by conducting health promotion about what is stunting, stunting risk factors, the impact of stunting on children's health now and in the long term (13). The implementation of the stunting prevention program is expected to involve the entire community, including adolescents, parents and health cadres (14). In addition, health workers play a very important role in preventing and managing stunting. Prevention and handling of stunting can be done with good nutrition education to adolescents, parents, health cadres. Education is a part that is closely related to the knowledge, attitudes and health behaviors of adolescents, parents and health cadres. Knowledge and awareness are very necessary for the fulfillment of nutrition when the baby is in the womb so that the baby's birth weight is fulfilled (15). Nutrition fulfillment can be done by health workers by means of four Community Nursing strategies including health education, empowerment, group processes, and partnerships (14). Health workers also play a role in intensively monitoring adolescents and especially pregnant women who are prone to lack of adequate nutrition. The main factor influencing adequate nutrition is financial. Low standard of living tends to have poor nutrition (16). This is very vulnerable to stunting. Therefore, special attention needs to be paid to pregnant women who have a low standard of living. The implication of this research for the development of nursing science is to add reference sources related to various community-based stunting handling interventions, so nurses can play a role in providing appropriate interventions to deal with stunting problems experienced by clients, especially with community-based strategies.

METHODS
This study used the literature review method of relevant studies, with the inclusion criteria of articles taken as a reference source, which are published and indexed international Scopus articles for the period 2015-2019 in English, and can be accessed in full text. The articles used were taken by Science Direct, ProQuest, SAGE, Scopus, EBSCO, and Taylor and Francis within community-based, management strategies, stunting. Research articles obtained as many as 15 articles and analyzed through several stages, namely, first the researcher chose the article to be examined by reading the title of the research article, followed by reading the abstract. If the title and abstract match the reference criteria required by the researcher, then the article continues to be analyzed as a whole.The inclusion criteria are articles published 2015-2019, original research, literature or systematic review were included. The exclusion criteria are duplicated and abstract only.Articles with substance that fit the criteria needed by researchers are taken as a source of reference (the article selection process flow and the analysis table attached). (Figure 1) (Table 1) Stunting is a chronic malnutrition in the form of growth failure characterized by linear growth retardationin children so, the child is shorter than a normal child his age and has a delay in thinking (10). Nutritional deficiencies that occur in the womb and early in life cause the fetus to make adjustments to reactions including slowing growth by reducing the number and development of body cells including brain cells and organs such as the heart, liver, pancreas, muscles, and kidneys (17).

RESULTS AND DISCUSSIONS
Stunting in children is influenced by a history of maternal nutritional status and during pregnancy can affect the growth of the fetus being conceived. Maternal nutritional status during pregnancy is characterized by weight gain during pregnancy, mothers suffering from KEK (Chronic Energy Deficiency), anemia and other nutritional deficiencies or experiencing infectious diseases such as malaria during pregnancy (18). History of maternal nutritional status and history of the disease will affect fetal growth, causing intrauterine growth retardation (IUGR) and affect babies born, such as the weight and length of the baby's body potentially experiencing nutritional and health problems in the next age period (19). Stunting can also be caused by indirect determinants such as access to health care, availability and access to food, care patterns, family characteristics, education, urbanization, socioeconomic, political stability, environmental sanitation and clean water, population density and social support (20).
Stunting prevention is carried out through integrated nutrition interventions, including specific nutrition interventions and sensitive nutrition (15). Specific interventions relate to health interventions such as providing supplementation and supplementary food. Specific interventions have been carried out in various countries aimed at changing feeding practices, supplementation with folic acid, calcium, zinc, vitamin A, balanced protein-energy supplementation, breastfeeding and complementary feeding, handling acute and severe malnutrition (9). Sensitive interventions include non-health interventions, improved family economics, access and use of clean water, sanitation (especially latrines and safe septic tanks), which are urgently needed to support personal and environmental hygiene behavior. (8). Through combining specific and sensitive nutrition interventions in the fields of health, food, environmental sanitation, economy, education and infrastructure shows a reduction in stunting from 36% to 28%(9).
The strategy for implementing the Hone, Asih and Foster program interventions consists of: increasing the capacity of cooperation between stakeholders to accelerate evidence-based nutrition improvement activities, increasing the capacity to facilitate cooperation between stakeholders, increasing the capacity to implement mutually beneficial cooperation among various stakeholders, increase the capacity to monitor and evaluate joint performance to achieve nutritional improvement targets, increase the capacity for identification by sharing experiences or interventions related to the model to increase understanding of achieving goals, and increase advocacy capacity in the context of increasing political commitment and mobilizing resources and technical assistance (21).
Stunting prevention interventions are more effective by involving public health cadres. Optimization of health cadres in the implementation of the stunting treatment program is able to motivate mothers to participate in the handling and prevention of stunting. Community-based interventions effectively optimize optimal breastfeeding and other infant feeding practices (22). Cadre training is needed to improve the knowledge and skills related to nutrition of mothers, infants and toddlers. The importance of breastfeeding and the promotion of optimal infant feeding in the survival of children is largely determined by the knowledge and skills of the mother (9). Kang, Suh, Debele, Juon, & Christian also explained community-based participatory nutrition promotion (CPNP) can increase the growth of children by involving all components of the community, especially health cadres (23  Kang Y, et al (23) 2.

2016
A randomized trial cluster Mothers in the intervention group showed higher scores than those in the control group regarding eating frequency, composite feeding score; addition score from current breastfeeding, feeding frequency and diversity of food) and composite feeding score.
2017 A systematic review Fourteen programs, which were demonstrated to reduce stunting, were identified from 19 low and middle income countries. The most implemented interventions are sensitive and specific nutrition interventions including nutrition education and counseling, monitoring and promotion of growth, immunization, water, sanitation and hygiene, and social safety nets. A program is considered to have an effective stunting reduction. Successful interventions are characterized by a combination of political commitment, multi-sectoral collaboration, community involvement, community-based service delivery platforms, and wider program coverage and compliance

LIMITATIONS
This study has limitations including reference sources that examine stunting prevention and treatment, still limited research related to specific stunting issues, as well as published articles and international indexed related to open access stunting issues.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest

CONCLUSION
Conclusions from this studystunting management strategies can be carried out through specific nutrition interventions, the implementation of a sharpening, fostering and fostering program carried out by taking into account human resource indicators in the form of local regulations.Nutrition services need to be supported with basic commodities to provide complete services. the involvement of all health cadres at the sub-district, district and community level and community-based cadres, and the involvement of health facility managers, policy makers, and partners are key nutrition services. the dissemination of all new policies and policies and field guides to a lower level will be very important. national and sub-national levels must increase data validation activities through regular monitoring and coordination.It is necessary to increase the capacity of cross-sectoral cooperation to accelerate the improvement of nutrition in Indonesia in handling stunting.