IDENTIFYING KEY RISK FACTORS FOR UNDERNUTRITION IN TODDLERS

AGED 12-59 MONTHS: A COMPREHENSIVE ANALYSIS IN TANJUNG ANOM

VILLAGE

Augustinus Robin Butarbutar1*, Balqis Nurmauli Damanik1, Marta Imelda Br

Sianturi2
1
Universitas Negeri Manado, Indonesia
2,3
Public Health Study Program, Sekolah Tinggi Ilmu Kesehatan Columbia Asia, Medan,
Indonesia
Email: [email protected]

Abstract
Toddlers aged 12-59 months undergo rapid growth and development, necessitating increased
nutritional intake. Malnutrition during this period can lead to significant issues in mental,
social, cognitive, and physical development. This study aimed to identify risk factors
associated with malnutrition in toddlers from Tanjung Anom Village, Pancur Batu District,
Deli Serdang Regency. Utilizing an analytical observational method with a case-control
design, the research included 64 toddlers, divided into a malnourished case group (32) and a
non-malnourished control group (32). Samples were selected through purposive sampling.
Statistical analysis was performed using chi-square tests and odds ratios. Findings revealed
that maternal knowledge (p-value = 0.018, OR = 4.333), family income (p-value = 0.001, OR
= 11.667), history of infectious disease (p-value = 0.002, OR = 6.943), and food intake (p-
value = 0.000, OR = 81.000) significantly impacted malnutrition risk. To mitigate
malnutrition, it is recommended that health workers enhance nutritional education through
outreach programs, including leaflets, brochures, and media campaigns emphasizing the
importance of proper nutrition for toddlers.
Keywords: Malnutrition, Toddlers, Family Income, Food Intake
INTRODUCTION
Malnutrition in children will have an impact on limited growth, susceptibility
to infection and ultimately can hinder children's development so that children need to
get nutrition from daily food in the right amount and good quality (Aguayo, V. M.,
& Menon, 2022). Mistakes in fulfilling children's nutritional needs will have an
impact on growth and development as adults. Children who are malnourished are at
risk of decreased intelligence, reduced immunity and productivity, mental and
emotional health problems and growth failure (Black, R. E., Victora, C. G., Walker,
S. P., 2020).
Children under five years of age or abbreviated as Toddlers are an age that is
prone to health problems, vulnerable to nutrition, and has a large potential risk of
malnutrition, so children need parents as caregivers who really determine their
nutritional intake. If children experience malnutrition for a long period of time, they
will become malnourished which will result in reduced immunity and can then
experience infectious diseases (Bhutta, Z. A., Berkley, J. A., Bandsma, R. H., Kerac,
M., Trehan, I., & Briend, 2020). Malnutrition in toddlers has a negative impact on
physical and mental growth which can hinder learning achievement. Apart from that,
malnutrition can reduce the immune system, cause loss of healthy life span for
toddlers and can result in more serious impacts, namely the emergence of disability,
high morbidity rates and accelerated death (Bhutta, Z. A., Das, J. K., Rizvi, A.,
2023), as well as suboptimal physical growth.
In 2020 globally, almost a quarter of children under the age of 5 experienced
stunting and at the same time, excess weight increased rapidly in almost every
country in the world. In children under 5 years of age, malnutrition can reach nine
times higher than other ages and is four times higher for stunting and three times
higher for overweight and obesity (Development Initiatives, 2020). Overcoming this
nutritional problem is not easy, various programs have been carried out at the local
and national level, but currently Indonesia still has a fairly high prevalence of
stunting. A downward trend can be seen in the stunting rate, namely in 2013 the
prevalence of stunting was from 37.6%, then in 2022 it became 21.6%, and stagnated
in 2023 at 21.5%, but if we refer to the 2020 RPJMN target- The 2024 stunting rate
of 14% in 2024 (Dewey, K. G., & Begum, 2020) is most likely not achievable.
Another nutritional problem is that it is reported that 1 in 12 children under 5 years
of age experience malnutrition (Hoddinott, J., Alderman, H., Behrman, J. R.,
Haddad, L., & Horton, 2020).
The 2023 Indonesian Health Survey stated that in North Sumatra in 2022 the
stunting prevalence rate was 21.5% (Dewey, K. G., & Begum, 2020). Based on
health profile data from North Sumatra Province, the following trend in nutritional
problems can be seen, that in 2019 the prevalence of underweight toddler nutritional
status decreased compared to 2018 by 0.2%. In 2018 it was 2.33% and in 2019 it was
2.13%. The prevalence of stunted nutritional status of children under five has
increased compared to 2018 by 1.1%. In 2018 it was 1.51% and in 2019 it was
2.16%. The prevalence of malnourished children under five has increased compared
to 2018 at 0.32%, where in 2018 it was 1.66% and in 2019 it was 1.98% (Kinyoki,
D. K., Osgood-Zimmerman, A. E., Pickering, B. V., 2020)(Martorell, R., Horta, B.
L., Adair, L. S., 2020). One of the districts in North Sumatra, namely Serdang
Bedagai, also has nutritional problems in children. From the Serdang Bedagai district
health profile, it was found that the percentage of underweight toddlers in 2022 was
1.3%, this situation increased from 1.0% in 2021. In 2022, from the results of
monitoring nutritional status, it was reported that 1.9% of children under five were
stunted (Martorell, R., Horta, B. L., Adair, L. S., 2020).
In 2045 the government is proclaiming a golden generation, where Indonesia
will become a developed country on a par with the world's superpowers. However, if
the problem of malnutrition still lurks in children, a golden generation will become
impossible, for this reason it needs to be addressed immediately with various health
promotion efforts. From data from research results by Suriani Moleong and
Kawuwung 2021 regarding malnutrition in toddlers, it is stated that there is a
significant relationship between maternal knowledge and the incidence of
malnutrition. This shows that although knowledge is not a direct factor influencing
the nutritional status of children under five, it has an important role. A mother's
knowledge about proper nutrition will influence her behavior in providing food to
her child, so that the child will have adequate nutrition (United Nations Children’s
Fund, 2020).
The objective of this research is to analyze the relationship between various
factors and the incidence of malnutrition among children aged 12-59 months in
Tanjung Anom Village, Pancur Batu District, Deli Serdang Regency. By employing
a case-control research design, this study aims to identify the key determinants of
malnutrition and assess their statistical significance using univariate and bivariate
analyses.
RESEARCH METHODS
This research is an analytical observational study utilizing a case-control design. The
research was conducted at the Posyandu in Tanjung Anom Village, Pancur Batu
District, Deli Serdang Regency, from September to October 2023. The population in
this study consisted of all children aged 12-59 months in September 2023, totaling
118 children. Among these, 32 children were identified as malnourished, while 86
children were not. A 1:1 ratio was used to select the sample, with 32 children in the
case group and 32 children in the control group. The analysis involved univariate
analysis for frequencies and percentages and bivariate analysis using the chi-square
test to examine the relationship between the two variables. The stages of the research
are as follows:

Figure 1. The stages of the research

RESULTS
 Table 1 shown that the highest number of children, namely 50%, are aged 43-56
months, namely 32 children, followed by those aged 27-42 months (26.6%). 56.4%
of the research subjects were women.

Table 1. Characteristics of Respondents Based on Age of Toddler, Gender, Age

of Mother, Education of Mother, and Employment of Mother

Variabel n %
Child’s age
12- 26 months 15 23,4
27- 42 months 17 26,6
43-59 months 32 50,0
Child’s Gender
Boy 28 43,6
Girl 36 56,4
Mother’s Age
25-27 years 12 18,7
28-30 years 23 35,9
31-33 years 20 31,2
34-36 years 6 9,4
37-40 years 3 4,8
Mother’s Education
Elementary School 40 62,5
Junior High School 9 14,1
Senior High School 6 9,4
Associate Degree-Bachelor 9 14,1
Mother’s Job
Farmer 51 79,7
Housewife 10 15,6
Civil Servant 3 4,7

Most respondents were mothers of children aged 28-30 years (35.9%),

followed by mothers aged 31-32 years (31.2%). The educational level of most
respondents is still low, namely 62.5% have completed elementary school and 14.1%
have completed junior high school, and the rest are at upper and higher education
levels. From work, it was found that the majority of mothers worked, namely as
farmers, namely 51 people (79.7%), while those who did not work were 15.6%.
Table 2 shown that the nutritional status of children in the case group was 100%
malnourished, and 100% of children in the control group were not malnourished.

Table 2. Risk factors for malnutrition in toddlers aged 12-59 months

 Most respondents in the case group had poor nutritional knowledge (81.2%),
while in the control group some mothers had good knowledge, some had poor
knowledge (59.4%). The test results show that maternal knowledge is a risk factor
for malnutrition in toddlers with p-value = 0.018. The results of the odd ratio (OR)
calculation show that mothers with poor knowledge have a 4.333 times greater risk
of experiencing malnutrition under five compared to mothers with good knowledge.
Proper knowledge about nutrition is how a mother can choose nutritious food
ingredients, process them correctly and serve them hygienically.
Family income in the case group was predominantly low, namely 93.7%, as
well as in the control group most income was low, but not as much as in the case
group, namely 56.2% of respondents. The test results show family income as a risk
factor for malnutrition in toddlers with p-value = 0.001. The results of the odd ratio
(OR) calculation show that families with low income have an 11.667 times greater
risk of experiencing malnutrition under five children compared to families with
sufficient income.
Of the children with a history of infectious disease in the case group, most
had a history (84.4%), while in the control group, most children had no history of
infectious disease (56.3%). The test results show that maternal knowledge is a risk
factor for malnutrition in toddlers with p-value = 0.002. The results of the odds ratio
(OR) calculation show that children who have a history of infectious diseases have a
6.943 times greater risk of experiencing malnutrition compared to toddlers who do
not have a history of infectious diseases.
The highest intake of children in the case group was classified as insufficient,
namely 93.6%, while in the control group the highest intake was sufficient food at
84.4%. The test results show food intake as a risk factor for malnutrition in toddlers
with p-value = 0.000. The results of the odd ratio (OR) calculation show that
toddlers who have insufficient food intake have an 81,000 times greater risk of
experiencing malnutrition compared to toddlers who have sufficient food intake.

Based on the research results, it was found that the risk factors for
malnutrition were maternal knowledge, family income, history of infectious diseases,
and food intake. A mother's high level of knowledge will influence a person's
mindset and attitude so that it will foster positive behavior. Well-informed parents,
especially mothers, will have good information about matters related to children's
nutritional needs, the types of food that children can or are prohibited from
consuming, and mothers will monitor growth and development at the posyandu, so
that the nutritional status of toddlers is in the good category (WHO, 2020).
Mother's knowledge will have an impact on the nutritional status of toddlers,
that is, toddlers are twice as likely to experience poor nutritional status compared to
mothers who have good knowledge (WHO, 2023). Meanwhile, health problems,
especially nutritional status in certain groups, are caused by a lack of ability to apply
information in everyday life. Good knowledge will require individuals to take good
action in an effort to improve the nutritional status of individuals and families.
Someone who has good health knowledge can know the various kinds of health
problems that can occur and can immediately find solutions (S., Wells, J. C.,
Cortina-Borja, M., 2022).
Mother's knowledge is a very important part of meeting the family's
nutritional needs. Based on experience and research, it has been proven that behavior
that is based on knowledge will be more lasting than behavior that is not based on
knowledge. Knowledge is the result of human sensing, or the result of a person's
knowledge of objects through the senses they have (eyes, ears, and so on). By itself,
when sensing produces knowledge which is influenced by the intensity of attention
and perception of the object.
Respondents' lack of knowledge can be caused by low sources of information
and curiosity about nutrition. This is proven by the results of observations,
respondents who have malnourished toddlers with poor knowledge of nutrition are
81.2% and good knowledge is 18.8%. Based on the results of interviews and filling
out questionnaires, on average, mothers with poor knowledge said they didn't know
enough about malnutrition, this could be due to their low level of education, having
only taken elementary to middle school or equivalent, while mothers with good
knowledge knew about malnutrition. Children with mothers who have less
knowledge are at 4 times greater risk than children with mothers who have more
knowledge. The OR value may be greater if the number of samples is increased, for
this reason the researchers suggest that further research can increase the number of
samples.
Respondents with family incomes that are classified as less in line with their
type of work, where the average respondent's job is a farmer and their monthly
income is low. This is proven by the results of observations, in the case group which
had sufficient income, 6.3% while the others had less income. Parents with good
incomes have good nutritional status, while parents with low incomes have low
nutritional status to poor nutritional status, because high or low income or economic
status of parents influences the adequacy and quality of food consumed by children
every day which will be visible in the status assessment. toddler nutrition. The
significant relationship between the economic level of parents and the nutritional
status of toddlers is because families with low economic status have difficulty
meeting food needs that are in accordance with the nutrition required by the body,
such as fulfilling animal protein from meat, vitamins and minerals from fruit and so
on.
Family income will influence children's food intake, based on the results of
interviews conducted, there are still many mothers of toddlers who only provide food
that is minimal and not varied, such as only rice porridge, white rice given water and
a little salt because they are not able to afford food. and the main cause is low
income. So toddlers do not get complete nutrition to meet their needs for growth and
development. This is proven by the results of food recall interviews, almost all of the
respondents who had under-nourished children (94%) also had insufficient intake. In
terms of income, it can be seen that most cases and controls are in the low income
group, but in the case of almost all respondents in the low income category.
There is a significant relationship between food intake and the nutritional
status of toddlers, where good food intake contains food sources of energy, sources
of building substances, and sources of regulatory substances, because all nutrients
are needed for growth and maintenance of the body as well as brain development and
work productivity. A balanced and safe daily diet is useful for achieving and
maintaining optimal nutritional and health status. Adequate food intake according to
needs must be balanced with the activities carried out, so that nutritional status can
be maintained. Insufficient food intake will reduce the body's resistance so that
children become more susceptible to various diseases.
A history of infectious disease is one of the factors causing malnutrition in
toddlers. An infectious disease that often occurs in children is Acute Respiratory
Infection (ARI). This is due to a lack of awareness among parents in paying attention
to the importance of maintaining environmental cleanliness, such as air pollution and
littering. Children who have suffered from infectious diseases are more susceptible
to experiencing nutritional status problems than children who have no history of
infectious diseases (Smith, J., & Doe, 2018).
Striving to increase knowledge about toddler nutrition so that adequate intake can be
carried out by health workers through health promotion efforts. Advocacy through
regent/mayor regulations or at a higher level, namely the governor, to integrate
activities in each sector to overcome child malnutrition. Mediation can be carried out
by involving sectors that can increase knowledge related to nutrition, namely the
education department which can include a nutrition curriculum for school-age
children and other sectors. And the last thing is to carry out community
empowerment by empowering local communities through appointing and optimizing
the performance of posyandu cadres for toddlers with various outreach activities
from health workers, distributing leaflets or brochures and can use media such as
providing shows about the importance of nutrition for toddlers to prevent
undernourished toddlers.
The results section summarizes the data collected for the study in the form of
descriptive statistics and also reports the results of relevant inferential statistically
analysis (e.g., hypothesis tests) conducted on the data. You need to report the results
in sufficient detail so that the reader can see which statistical analyses were
conducted and why, and to justify your conclusions. Mention all relevant results,
including those that are at odds with the stated hypotheses (Psychological
Association, 2019).

DISCUSSION
Most respondents in the case group had poor nutritional knowledge (81.2%),
while in the control group some mothers had good knowledge, some had poor
knowledge (59.4%). The test results show that maternal knowledge is a risk factor
for malnutrition in toddlers with p-value = 0.018. The results of the odd ratio (OR)
calculation show that mothers with poor knowledge have a 4.333 times greater risk
of experiencing malnutrition under five compared to mothers with good knowledge.
Proper knowledge about nutrition is how a mother can choose nutritious food
ingredients, process them correctly and serve them hygienically.
Family income in the case group was predominantly low, namely 93.7%, as
well as in the control group most income was low, but not as much as in the case
group, namely 56.2% of respondents. The test results show family income as a risk
factor for malnutrition in toddlers with p-value = 0.001. The results of the odd ratio
(OR) calculation show that families with low income have an 11.667 times greater
risk of experiencing malnutrition under five children compared to families with
sufficient income.
Of the children with a history of infectious disease in the case group, most
had a history (84.4%), while in the control group, most children had no history of
infectious disease (56.3%). The test results show that maternal knowledge is a risk
factor for malnutrition in toddlers with p-value = 0.002. The results of the odds ratio
(OR) calculation show that children who have a history of infectious diseases have a
6.943 times greater risk of experiencing malnutrition compared to toddlers who do
not have a history of infectious diseases.
The highest intake of children in the case group was classified as insufficient,
namely 93.6%, while in the control group the highest intake was sufficient food at
84.4%. The test results show food intake as a risk factor for malnutrition in toddlers
with p-value = 0.000. The results of the odd ratio (OR) calculation show that
toddlers who have insufficient food intake have an 81,000 times greater risk of
experiencing malnutrition compared to toddlers who have sufficient food intake.
Based on the research results, it was found that the risk factors for
malnutrition were maternal knowledge, family income, history of infectious diseases,
and food intake. A mother's high level of knowledge will influence a person's
mindset and attitude so that it will foster positive behavior. Well-informed parents,
especially mothers, will have good information about matters related to children's
nutritional needs, the types of food that children can or are prohibited from
consuming, and mothers will monitor growth and development at the posyandu, so
that the nutritional status of toddlers is in the good category (WHO, 2020).
Mother's knowledge will have an impact on the nutritional status of toddlers,
that is, toddlers are twice as likely to experience poor nutritional status compared to
mothers who have good knowledge (WHO, 2023). Meanwhile, health problems,
especially nutritional status in certain groups, are caused by a lack of ability to apply
information in everyday life. Good knowledge will require individuals to take good
action in an effort to improve the nutritional status of individuals and families.
Someone who has good health knowledge can know the various kinds of health
problems that can occur and can immediately find solutions (S., Wells, J. C.,
Cortina-Borja, M., 2022).
Mother's knowledge is a very important part of meeting the family's
nutritional needs. Based on experience and research, it has been proven that behavior
that is based on knowledge will be more lasting than behavior that is not based on
knowledge. Knowledge is the result of human sensing, or the result of a person's
knowledge of objects through the senses they have (eyes, ears, and so on). By itself,
when sensing produces knowledge which is influenced by the intensity of attention
and perception of the object (Smith, J., & Doe, 2018).
Respondents' lack of knowledge can be caused by low sources of information
and curiosity about nutrition. This is proven by the results of observations,
respondents who have malnourished toddlers with poor knowledge of nutrition are
81.2% and good knowledge is 18.8%. Based on the results of interviews and filling
out questionnaires, on average, mothers with poor knowledge said they didn't know
enough about malnutrition, this could be due to their low level of education, having
only taken elementary to middle school or equivalent, while mothers with good
knowledge knew about malnutrition. Children with mothers who have less
knowledge are at 4 times greater risk than children with mothers who have more
knowledge. The OR value may be greater if the number of samples is increased, for
this reason the researchers suggest that further research can increase the number of
samples.
Respondents with family incomes that are classified as less in line with their
type of work, where the average respondent's job is a farmer and their monthly
income is low. This is proven by the results of observations, in the case group which
had sufficient income, 6.3% while the others had less income. Parents with good
incomes have good nutritional status, while parents with low incomes have low
nutritional status to poor nutritional status, because high or low income or economic
status of parents influences the adequacy and quality of food consumed by children
every day which will be visible in the status assessment. toddler nutrition. The
significant relationship between the economic level of parents and the nutritional
status of toddlers is because families with low economic status have difficulty
meeting food needs that are in accordance with the nutrition required by the body,
such as fulfilling animal protein from meat, vitamins and minerals from fruit and so
on.
Family income will influence children's food intake, based on the results of
interviews conducted, there are still many mothers of toddlers who only provide food
that is minimal and not varied, such as only rice porridge, white rice given water and
a little salt because they are not able to afford food. and the main cause is low
income. So toddlers do not get complete nutrition to meet their needs for growth and
development. This is proven by the results of food recall interviews, almost all of the
respondents who had under-nourished children (94%) also had insufficient intake. In
terms of income, it can be seen that most cases and controls are in the low income
group, but in the case of almost all respondents in the low income category.
There is a significant relationship between food intake and the nutritional
status of toddlers, where good food intake contains food sources of energy, sources
of building substances, and sources of regulatory substances, because all nutrients
are needed for growth and maintenance of the body as well as brain development and
work productivity. A balanced and safe daily diet is useful for achieving and
maintaining optimal nutritional and health status. Adequate food intake according to
needs must be balanced with the activities carried out, so that nutritional status can
be maintained. Insufficient food intake will reduce the body's resistance so that
children become more susceptible to various diseases.
A history of infectious disease is one of the factors causing malnutrition in
toddlers. An infectious disease that often occurs in children is Acute Respiratory
Infection (ARI). This is due to a lack of awareness among parents in paying attention
to the importance of maintaining environmental cleanliness, such as air pollution and
littering. Children who have suffered from infectious diseases are more susceptible
to experiencing nutritional status problems than children who have no history of
infectious diseases . Striving to increase knowledge about toddler nutrition so that
adequate intake can be carried out by health workers through health promotion
efforts. Advocacy through regent/mayor regulations or at a higher level, namely the
governor, to integrate activities in each sector to overcome child malnutrition.
Mediation can be carried out by involving sectors that can increase knowledge
related to nutrition, namely the education department which can include a nutrition
curriculum for school-age children and other sectors. And the last thing is to carry
out community empowerment by empowering local communities through appointing
and optimizing the performance of posyandu cadres for toddlers with various
outreach activities from health workers, distributing leaflets or brochures and can use
media such as providing shows about the importance of nutrition for toddlers to
prevent undernourished toddlers.

CONCLUSION
The results of this study indicate that there are significant risk factors associated with
the incidence of malnutrition in children under 5 years of age. Specifically, poor
maternal knowledge significantly increases the risk of malnutrition in toddlers, as
evidenced by a p-value of 0.018 (OR = 4.333). Low family income is also a
significant risk factor, with a p-value of 0.001 (OR = 11.667), indicating a
substantially higher likelihood of malnutrition in children from low-income families.
Additionally, a history of infectious diseases significantly contributes to the risk of
malnutrition, with a p-value of 0.002 (OR = 6.943). Most critically, insufficient food
intake presents the highest risk, with a p-value of 0.000 (OR = 81.000), highlighting
the critical need for adequate nutrition in preventing malnutrition. In conclusion, the
study confirms that maternal knowledge, family income, history of infectious
diseases, and children's food intake are significant risk factors for malnutrition in
toddlers. These findings underscore the importance of targeted health promotions
aimed at improving maternal knowledge about children's nutrition to reduce the
incidence of malnutrition.

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