Exploring the relationship between maternal education, parenting practice, and stunting among children under five: Findings from a cross-sectional study in Indonesia

Ethics statement

The research presented in this manuscript has been approved by the Ethics Committee at the Research Ethics Commission of Padjadjaran University with letter number 1206/UN6/KEP/EC/2018. Written informed consent was obtained from all participants included in this study. Participants were informed about the nature of the study, its purpose, the procedures involved, and their rights as research participants. They were also assured of their anonymity and confidentiality.

Study design

This study used a cross-sectional design. The population in this study were couples of childbearing age with the criteria of pregnant women (first trimester to third trimester) or those with children under the age of five, conducted in six rural areas in West Java province, including Bandung Regency, Bandung City, Garut Regency, West Bandung Regency, Subang Regency, and Sumedang Regency. Based on data from Indonesia’s Ministry of National Development Planning in 2017, the districts and cities are chosen based on where there are the most stunting children in West Java. This research was conducted in October-December 2018.

Recruiting and sampling

In this study, the final sample used was 801 respondents. The minimum sample size is based on the total population according to the Isaac and Michael sampling table,¹³ with a significance level of 1% for a population of 550,000. With a total population of 534,652 respondents, a minimum sample size of 665-810 respondents was obtained. A number of these respondents in this study applied the cluster sampling technique from six regencies or cities consisting of six villages with a KB. The inclusion criteria were children aged 0-5 years whose mothers willingly participated in the study by providing accurate and complete information about themselves and their children, and whose children had height-for-age Z-score below the 2nd percentile according to the WHO Child Growth Standards. Additionally, participants were recruited from communities in the areas of focus for the study, using notifications from healthcare workers. Additionally, potential participants who met specific criteria were identified based on information from databases, before the study began. Researchers clearly explained the study purpose and requirements, both orally and in writing. Participants were asked to sign a consent form, which detailed the study’s purpose and the rights and responsibilities of participants. Participants who agreed to participate signed this form. All information provided by participants was kept confidential and used only for research purposes. Hence, 135 respondents represented each village involved. Of the 801 samples involved, as many as 733 respondents were involved in the research because they met the criteria of this study (see Figure 1).

Figure 1. STROBE diagram.

Data collection

Data was collected using a questionnaire with measurements around social demographic factors such as the mother’s education level and occupation that has been validated by a previous study.¹⁴ In addition, the questionnaire measured mother’s knowledge of stunting and behavior toward parenting practice. Data collection was also carried out based on medical records sourced from the Maternal and Child Health Book (KIA) to examine stunting as part of the health status of mothers and children. Physical observations were also carried out with anthropometric measurements to observe stunting in toddlers. There is no data collection that refers to the need to recall respondents for each variable assessed. The study was carried out in regions of West Java with the highest number of stunting cases, which include Bandung Regency, Bandung City, Garut Regency, West Bandung Regency, Subang Regency, and Sumedang Regency.

Statistical analysis

The collected data were then exported to Jamovi for further analysis. Jamovi analyses related demographic data, as well as the relationship between variables as a factor that influences the incidence of stunting in toddlers. Descriptive statistics were generated to summarize the characteristic including the mother’s educational background, mother’s knowledge of stunting, mother’s behavior toward parenting practice, and the nutrition status of toddlers based on body height. The analysis was performed using Spearman rank for the relation between stunting and the variables, and logistic regression was also performed to analyze the predictors of stunting. Our decision was to incorporate statistical significance by utilizing a two-tailed p-value of 0.05.

Characteristics of included respondents

Table 1 showed the characteristics of participants and the health condition of their children. A total of 733 participants were included in this study. The results showed that 40.1% of participants had middle school for their educational background, 62.8% had a good knowledge of stunting and 57.2% participants had good behavior toward parenting practice. Therefore, the results showed that based on the body height indicator, most of the children (72.9%) had a normal body height, with a total of 24% children with short and very short body heights.

Study outcomes

Association between stunting and mothers’ demographic and parenting practice

Table 2 shows a bivariate analysis regarding the relationship between each variable and stunting. Education is divided into high and low levels based on Indonesia’s law that everyone must go to school for at least 9 years. Thus, the low category refers to middle school and under. The mothers’ knowledge and behavior are categorized into poor and good. The results of the analysis show that education levels, knowledge about stunting, and mothers’ behavior toward parenting practice are not significantly related to stunting. These results can be seen by the significance value obtained, namely p-value>0.05.

Principal findings

This present study investigated stunting among children under five and its relationship with maternal education and parenting practice in West Java, Indonesia. We discovered that 24.01% of these children were stunted, indicating a significant prevalence of stunting. This cross-sectional study demonstrated that mothers’ education level, knowledge, and attitude are not determinants of predicting stunting.

The education level of mothers is one of the demographic factors that have become a major focus. Education is important; it indirectly affects nutrition because it changes how parents raise their children. A previous study concluded a correlation between lower maternal education and an increased incidence of stunting. Previous studies in Indonesia also found a correlation between maternal education and child stunting. However, these studies could not indicate the stronger correlation.¹⁵ This difference could be due to varied factors. However, this study found that education level is not correlated with stunting. First, there are differences in sample size and research setting; this research was only conducted on less than 1000 samples and was limited to several cities in West Java, while previous research was conducted based on a national demographic survey. Second, compared to other provinces, West Java has easier access to healthcare and supporting infrastructure, such as roads that reduce travel time to health centers.¹⁶ Therefore, the region or province may be more correlated than the education level in West Java to determine stunting among children under five. Third, based on our observations, there is a tendency that the higher educated mothers do not provide direct care to their children. Moreover, this study also confirmed that mothers’ knowledge regarding stunting was also not correlated with stunting under five.

Another factor related to education and knowledge is a mother’s attitude toward stunting. A mother’s knowledge and attitude are associated with feeding her child during the first two years of life.^17,18 According to Behroozeh et al., attitude is one of the variables that should be addressed because it affects food security.¹⁹ They contended that the way one feels about the influence that food has on one’s health as well as the concept of taking pleasure in one’s diet are connected to one’s level of food security. In contrast to our expectations, this present study showed that mothers’ attitude is not correlated with stunting among children under five. This could be owing to the fact that our research was conducted at a time when stunting preventive programs, such as new parenting and mothers’ education-related stunting, were flourishing.

As primary caregivers, mothers have full authority over healthy eating practices, including childcare.^20,21 Despite this, the present study is contrary to previous studies, but we still consider the important role of mothers’ education in preventing stunting in Indonesia. Mothers with a higher degree of education and good knowledge have a stronger awareness of their children’s health, as it is known that mothers with a better education have nutrition knowledge; this can be advantageous for healthy feeding habits.^22–24 Mothers with superior education will utilize health facilities to address the healthcare needs of their children and their nutritional needs, especially complementary feeding. Furthermore, a mother’s inappropriate complementary feeding behavior as a result of a lack of nutrition, knowledge on optimal feeding practices, insufficient awareness of the frequency of feeding and the amount of food to be fed to the child, as well as what constitutes a balanced diet and cultural beliefs, are modifiable factors that can contribute to a child’s nutritional status deterioration.²⁵ Therefore, besides formal education, informal education for mothers regarding parenting to prevent stunting is much needed. Moreover, the WHO recommends nutritional education as well as increased daily calorie and protein consumption for malnourished pregnant women to reduce the risk of low-birth-weight infants. Women who aren’t getting enough food can avoid bad prenatal outcomes by taking balanced energy and protein supplements. About 25% of the total energy supplement can come from proteins.²⁶

Strengths and limitations

The study is focused on associating the maternal education and parenting practice factor with stunting among children under five, which is the strength of this study. However, our study is not in line with expectations and previous studies that suggest a correlation between stunting and maternal education. Thus, further research needs to be done to confirm, the same thing, the association between stunting and maternal education, considering that health promotion regarding stunting has currently been carried out by governments in whole areas, especially key stunting areas. However, this study was conducted in an earlier national stunting program and this must be acknowledged as a limitation. Second, the present study cannot be associated with other factors due to its sole concern in a scope variable. Thus, we cannot demonstrate which variable is strongly associated. Third, we cannot explain the influence of cultural variables that are still quite influential in Indonesia, particularly in rural regions. Finally, this study cannot demonstrate the effect of a maternal education intervention on stunting prevention, thus, further studies using clinical trials regarding effective mothers’ education related to preventing stunting are needed.

Implications for practice and further research

The results of the study suggest that there is no significant association between maternal education, knowledge of stunting, and behavior toward parenting practice with stunting among children under five. This finding has important implications for practice, as it suggests that simply increasing maternal education or knowledge of stunting may not necessarily lead to a reduction in stunting among children. Instead, interventions that focus on improving parenting practices may be more effective in reducing the prevalence of stunting. Further research is needed to identify specific parenting practices that are most strongly associated with stunting, and to develop targeted interventions that can help parents improve these practices. Additionally, future studies may benefit from exploring the relationship between other factors, such as household income and access to healthcare, and stunting among children under five. By identifying the most important factors associated with stunting, researchers and practitioners can develop more effective strategies for addressing this important public health issue.