This study was approved by the UPN Veteran Jakarta Ethical Clearance Committee (Protocol number: 352/VI/2021/KEPK) after due consultation, consent letters had been provided by the researchers and written informed consent had been obtained from all respondents.

This study was a cross-sectional observational analysis conducted in Tanara District, Serang Regency, Banten Province in September 2020. The target population consists of mothers with children aged 6–24 months; using consecutive sampling, we have collected 40 samples from nine subdistricts in the Tanara District that met the inclusion and exclusion criteria. The variables studied were the mother’s knowledge of complementary feeding of breastfed infants, family income, exclusive breastfeeding, time and frequency of complementary feeding, knowledge of intestinal worms, attitudes toward a healthy life, healthy living behavior, environmental hygiene and sanitation, and history of infectious diseases (e.g., diarrhea, tuberculosis, and worm infection). Meanwhile, the dependent variable is infants/toddlers with stunting, which was determined by microtoize. Some independent variables were developed from respondent characteristics, whereas others were adapted from prior studies and collected by our questionnaires following validity and reliability tests. Chi-squared analysis and multivariate (adjusted) analysis, instead of bivariate (crude) analyses, were used to examine associations between variables. The interpretation of results are presented in the discussion section. Odd ratio (OR) in statistics is obtained from a measure of association between an exposure (independent variable) and outcome (dependent variable). Meanwhile, OR in logistic regression is defined as the ratio of the probability of success to the probability of failure. A 95% confidence interval (CI) is the range of lower and upper values within which the true population values lie.

Twenty-one children aged 6–24 months were found to be stunted (52.5%). On average, 75% of the family income is <2,542,539 rupiah (US$1 = Rp 14,537.00), and the majority (85%) has good knowledge about environmental sanitation hygiene. Moreover, 55% of the respondents have a history of infectious diseases, 62.5% have poor knowledge of intestinal worms, 60% have a poor healthy attitude, and 62.5% have poor health behavior. Regarding the frequency of complementary feeding of a breastfed infant, up to 57.5% give <3 times/day, with 70% provide complementary feeding for ≤6 months, 65% exclusively breastfeed their children for ≤6 months, and 65% have knowledge about complementary feeding ( Table 1). A relationship exists between the incidence of stunting and the following: a history of infectious disease (OR = 4.55; 95% CI = 1.18 to 17.52; p = 0.025), lack of knowledge of complementary feeding (OR = 5.87; 95% CI = 1.31–26.33); p = 0.02), and a lack of attitude of healthy living (OR = 1.23 to 20.30; p = 0.02) ( Table 2).

According to the Basic Health Research reports data, the average prevalence of stunting under five years old in Indonesia was 37.2 % in 2013, whereas it was 30.8% in 2018. ² The Integrated Toddler Nutrition Status Study 2019 reported 27.67% of stunted toddlers, ⁹ whereas the stunting rate in 2022 decreased to 21.6%. ² Our study in the Tanara subdistrict stated that the prevalence of stunting in children aged 6–24 months was 21 (52.5%). Generally, economic factors, lack of health services, false beliefs, lack of food security, poor sanitation and hygiene, maternal nutrition during pregnancy and breastfeeding, parenting, inadequate breastfeeding, not giving exclusive breastfeeding, and infectious diseases are all causes of stunting. ⁴ Infectious diseases, a lack of knowledge about complementary feeding, and an unhealthy lifestyle were found to influence the incidence of stunting in children aged 6–24 months in this study.

The multivariate analysis reveals that the most prevalent factors influencing the incidence in stunting of children under five were a history of infectious disease (OR = 6.62; 1.13–38.90; p = 0.04) and an attitude toward a healthy life (OR = 6.21; 1.02 to 37.71; p = 0.05) ( Table 3).

In this study, a significant correlation was found between infectious diseases and the incidence of stunting. Moreover, following Desyanti, ¹⁰ we found that a more frequent history of diarrhea can increase the risk of stunting in children. A 10-year longitudinal study conducted in Guatemala found that repeated infections can result in stunted growth and malnutrition. Additionally, malnutrition can increase the frequency, duration, and severity of infectious diseases. ¹¹ Clinical and subclinical infections that increase the risk of stunting include gastrointestinal infections, respiratory infections, malaria, decreased appetite due to infection, and inflammation. Diarrhea is the most common infectious disease, especially in poor hygiene and sanitation conditions. The incidence of diarrhea among 24-month-old toddlers will increase the incidence of stunting several times. Moreover, the number of diarrhea episodes equal to five times can increase the risk of stunting by 25%. ¹¹ Also significantly associated with stunted children in Indonesia ¹² are reported illnesses, a lack of parental education, and a low socioeconomic status. Similar to the findings of Prendergast AJ and Humphrey JA, the present study also found a history of infectious diseases, such as diarrhea and tuberculosis, among children, but no children had worm infection. According to Vonaesch, P., et al. (2017), even children in developing countries are susceptible to helminth infections, so it is surprising that no helminths were found in the stool samples given the prevalence of chronic malnutrition. This observation may be attributable to UNICEF’s widespread use of mebendazole to treat helminths. ¹³

The bivariate analysis reveals a significant relationship between mothers’ lack of knowledge of complementary feeding and the incidence of stunting in children aged 6–24 months in the Tanara subdistrict. These results are consistent with the findings of Boro RM, who found that the level of maternal nutrition knowledge significantly correlates with the nutritional status of children aged 6–24 months. Knowledge will affect the mothers’ practice of providing complementary feedings to their children. On the basis of weight/age and height/age indicators, the pattern of complementary feeding will affect the nutritional status of children. The lack of maternal nutrition knowledge and the incorrect pattern of complementary feeding in the long term will increase the risk of stunting in children aged 6–24 months. ¹⁴ Babies require complementary foods after six months (26 weeks, not before 17 weeks) to meet their nutritional needs for growth. As the amounts of complementary foods gradually reduce with the increases in variety of foods, breast milk or infant formula should continue. Health professionals need to be aware of the key nutrients and food because every infant’s needs are different. ¹⁵ UNICEF stipulates that infant aged 6–23 months must receive adequate complementary foods if they can consume at least four or more than seven different types of food, including cereals/tubers, nuts, dairy products, eggs, other protein sources, vegetables, fruits rich in vitamin A, and other vegetables and fruits, which is the minimum dietary diversity. In addition, it has been considered that infants must meet the minimum meal frequency requirements: that is, 6-to-23-month-old children who are breastfed or not and have received complementary feeding (soft food/solid food) should be given at a specific rate. The frequency of complementary feeding for breastfed children (6–24 months old) is 2–3 times or more. Infants not breastfed can be given four times a day or more. ¹⁶ Complementary feeding is important in infants’ and toddlers’ growth and cognitive development. The lack of complementary feeding will cause malnutrition. Moreover, mother’s knowledge has a big role in complementary feeding. ¹⁷

This study found a significant relationship between healthy lifestyle attitudes and the incidence of stunting in children aged 6–24 months in the Tanara subdistrict. Purwanto ¹⁸ showed that one of the factors influencing the incidence of stunting is healthy living behavior. Poor hygiene can cause an increase in the incidence of infectious diseases, especially fecal–oral infections, such as diarrhea. This will disrupt nutrient absorption and increase the risk of stunting in children. ¹⁹ The meta-analysis study also shows that the water, sanitation, and hygiene (WASH) intervention is significantly associated with an increase in the average height/age in children under five. The intervention is in the form of one or a combination of improving the microbiological quality of drinking water, reducing fecal–oral contamination either directly or indirectly, and promoting hand washing habits after defecation or before touching food. The study also explained that the WASH intervention was effective in improving the nutritional status of the children. ²⁰

According to the Maternal and Child Nutrition Study Group, the nutrition-sensitive program focused on the following sectors to influence the determinants of nutrition: agriculture, health, social protection, early child development, education, water, and sanitation. Agriculture encompasses food provision (increases household availability and access to food), means of subsistence, and income. Because food supply is essential for long-term reductions in poverty, hunger, and malnutrition, and because women play a role in access to nutritious and diverse foods, increasing agricultural productivity improves their decision-making power regarding intra-household allocation of food, health, and care. Social safety nets program will increase the income of vulnerable groups by distributing cash transfers to low-income households. This program also reduces poverty but needs to be strengthened because it requires more advantages for maternal, child nutrition, and child development. Stunting had similar risk factors with impaired cognitive development, such as protein, energy, micronutrient deficiency, intrauterine growth retardation, social economic condition of the family, depression on mother, and poverty, especially during the first 1000 days of life. Therefore, some nutrition-sensitive intervention programs highlight that several factors, such as knowledge of complementary feeding, a healthy lifestyle, and maternal education, can assist children in overcoming risk factors. ²¹ Along with undernutrition, which affects intrauterine growth retardation, stunting, wasting, vitamin A and zinc deficiencies, improper breastfeeding, maternal overnutrition, and obesity have also increased maternal morbidity and infant mortality. ²²

Specific nutrition intervention programs that we had conducted were complementary feeding for the infant, exclusive breastfeeding, education for pregnant women, and the family, including triggering free open defecation. Meanwhile, nutrition-sensitive intervention programs focused on the provision of water sanitation, hygiene, control of infectious disease, family income, attitudes toward a healthy life, and healthy living behavior. This study found that the factors affecting the incidence of stunting in children 6–24 months were infectious diseases and lack of a healthy lifestyle. Mostly, there are nutrition-sensitive intervention programs and lack of knowledge of complementary feeding, requiring a specific intervention program. Those are in line with the result of the qualitative research by Rosha et al., ²³ who determined that as the closest person to infants and toddlers, mothers should also receive an intervention to change their knowledge and behavior in parenting their children, especially about complementary feeding in a better direction. For example, mothers, whether they are mothers of infants/toddlers or pregnant women, can obtain through learning classes. In the nutrition-sensitive intervention program, improvement activities of environmental hygiene must be encouraged. The local government, in this case, the head of every village, has a routine program to create a clean and healthy environment.

The weakness of the cross-sectional research design was that it only examined the retrieved data once. Therefore, this research should be conducted using a different design, such as a case-control or cohort study, in order to assess the factors that contribute to the incidence of stunting more thoroughly. Alternatively, one must develop the research area to collect more research samples.

A history of infectious diseases and an unhealthy lifestyle negatively impact the incidence of stunting in children under the age of five. Further developments in stunted children under five will have both short- and long-term effects. Therefore, the government must repair the WASH facilities and optimally manage the health of children, particularly in the Stunting Locus Area, through specific and sensitive nutrition intervention programs. However, more innovation is required to reach the 14% stunting incidence target by 2024 with the precision of interventions carried out and the balance of quality between specific and sensitive interventions.