The Role of Communication, Information and Education in Preventing Stunting among Stakeholders in Abang Village, Karangasem Regency

There are 5 pillars in the Grand Design for Population Development in Indonesia, which have been established and encompass Population quantity control, Improvement of population quality, Population distribution and mobility direction, Quality family development, Population data and information arrangement, and population administration, which must be part of the contents of the Grand Design for Population Development (BKKBN, 2020). One of the pillars related to improving population quality is the issue of stunting. The reduction of stunting prevalence has become a nationally emphasized program, given its impact on the quality of the population, especially the younger generation in the future (Marhaeni et al., 2023). Indonesia aims to become an advanced country with excellent Human Resources (HR) by the year 2045, 100 years after its independence. One of the key focuses is to reduce and prevent stunting prevalence across Indonesia to enhance HR quality and leverage the demographic bonus opportunities in the country.

Stunting is defined as a condition of failed growth due to malnutrition during the first one thousand days of a child’s life, where a child’s height falls below the standards set by the World Health Organization (WHO) (Kemenkes, 2018). Stunting is a severe health problem and a primary government program that needs to be continuously reduced. Nutritional deficiencies experienced by infants in their first one thousand days are a leading cause of stunting. Chronic malnutrition in toddlers limits a child's growth potential due to inadequate nutrient intake. Stunting has negative consequences for the quality of life, including decreased intellectual capacity, susceptibility to diseases, reduced productivity, and increased poverty.

Reducing the national prevalence of stunting must be supported by reductions in stunting prevalence across various regions of Indonesia, with a focus on areas with high stunting prevalence to accelerate the reduction ofstunting nationwide. One of President Joko Widodo's five visions for an advanced Indonesia is the priority of developing HR from the prenatal stage, which can help create excellent HR in Indonesia. Therefore, the most effective targets to achieve this goal are the younger generation, prospective newlyweds, pregnant women, Posyandu cadres, and other related stakeholders, including those in the healthcare sector. To rapidly achieve the goal of reducing and preventing stunting, it requires the collective efforts of various parties, each playing their roles within the community.

Data indicates that stunting prevalence varies significantly among provinces in Indonesia and between regencies/cities in Bali Province. Bali is the Indonesian province with the lowest stunting prevalence in 2021. The province with the highest stunting prevalence is Nusa Tenggara Timur (NTT). Data in Figure 1 illustrates the significant variation in prevalence between provinces with the highest and lowest stunting rates, reflecting considerable differences in economic, social, environmental, and other conditions among provinces in Indonesia.

Source: SSGI, 2021 (Dalam Siti Fathonah, 2022)

The province of Bali, with the lowest prevalence of stunting, is not exempt from the high variation among regencies/cities. Karangasem Regency has the highest stunting prevalence, both in 2021 at 22,9 percent (SSGI, 2021) and in 2022 at 10,40 percent (Ministry of Home Affairs, 2022). Given that Karangasem Regency still holds the highest stunting prevalence, the community service team from the Faculty of Economics and Business at Udayana University conducted activities in Karangasem Regency.

Source: Ditjen Bina Pembangunan Daerah - Kementerian Dalam Negeri, 2022

Considering that the quality of the population is a crucial requirement for achieving Indonesia Maju by 2045 and for leveraging the demographic bonus opportunities to enhance work productivity, activities aimed at reducing and preventing stunting in the community become a top priority. Thus, this community service activity is intended to contribute to the reduction and prevention of stunting in the village of Abang, Abang District, Karangasem Regency.

The objectives of this activity are to enhance the understanding of village officials, the community, PKK (Family Welfare Empowerment) members, and parents about the importance of preventing stunting through good childcare practices so that the next generation can grow and develop well. In detail, the objectives of this activity are as follows: 1) to conduct Communication, Information, and Education (CIE) about good childcare practices to prevent stunting in children; 2) to conduct CIE about the adverse effects of stunting on children; 3) to conduct CIE about demographic bonuses and their relationship with stunting; 4) to conduct CIE for economically capable community members in Abang Village to participate in preventing and addressing stunting through the "Bapak Asuh Stunting" (Stunting Guardian) Program in Abang Village, Abang District, Karangasem Regency.

The benefits of this Community Service activity are expected to increase awareness, understanding, and practices/behaviors regarding stunting prevention in Abang Village, Abang District, Karangasem Regency. With the increased knowledge of the community about stunting, it is expected that the prevalence of stunting in Karangasem Regency, especially in Abang Village, will decrease. The increased awareness of the community about good childcare practices will also have a positive impact on the cognitive, affective, and psychomotor aspects of children. Thus, the demographic bonus envisaged by the government will not turn into a demographic disaster, and the hope of achieving excellent HR by 2045 can be realized by the community.

The community service activity was conducted using the following methods: 1) Identifying and mapping families with potential and those who have experienced stunting cases in their families; 2) Identifying and mapping potential stakeholders in the village who can play a role in addressing stunting, such as newlyweds, pregnant women, families with stunted children, posyandu cadres, PKK cadres, and community leaders; 3) Reaching an agreement with potential families and stakeholders regarding the timing of delivering Communication, Information, and Education (CIE) related to stunting; 4) Providing CIE on the adverse effects of stunting, good childcare practices, demographic bonuses, and the potential for community members in the village to become Stunting Guardians (Bapak Asuh Anak Stunting - BAAS); 5) Evaluating the Knowledge, Attitude, and Practice (KAP) related to the CIE conducted for stakeholders; 6) Conducting descriptive analysis using descriptive statistical tools to process the evaluation data from the community service activities.

The evaluation of the CIE was carried out not only for young people but also for pregnant women, families with stunted children, newlyweds, PKK, Posyandu, and other community members. This activity was conducted separately at different times because the content provided differed, and different speakers were involved.

Several characteristics of the respondents are discussed in this report, including gender, age, education, and the respondents’ primary activities. In the second CIE session, 39 participants were present, but only 36 of them were willing to respond to the evaluation, so the data analysis was conducted with a total of 36 respondents.

The data analysis shows that there were very few male respondents, accounting for approximately 8 percent, while the remaining 92 percent were female respondents. Male respondents present were community leaders, while females included housewives with stunted children, and newlyweds, as evidenced by data on pregnant women, PKK managers, and posyandu, all of whom were female. With this characteristic, it can be confirmed that female respondents significantly outnumber male respondents, as evident in the data analysis results.

The primary activities of the respondents or participants in the socialization were also discussed as one of the participant characteristics. Data processing shows that more participants identified their primary activity as being housewives rather than employment. Sometimes, respondents or socialization participants who work informally at home to generate income are often considered not to be working, resulting in a lower percentage of those considered to be employed. Sometimes, their income-generating work done at home is seen as secondary to their domestic responsibilities, and their primary role is considered that of a homemaker.

Source: Primary data processing results, 2023

Education is a crucial variable that influences various activities, including knowledge and understanding of stunting in the community. In general, education is positively correlated with various knowledge and understanding levels on various topics. The following presents the educational background of socialization participants.

Data in Figure 3 shows that the educational level of socialization participants is high. If we look at those who have completed high school or higher, it’s around 53 percent, and those with education levels below high school (junior high school or lower) make up about 47 percent. The lowest education level observed is completing elementary school, and there are no respondents without elementary school education. With such a high level of education, it can be expected that their understanding and knowledge of stunting are high. Therefore, efforts to prevent and reduce stunting can be more easily achieved.

The role of childcare for children, both after birth and during pregnancy, is crucial in preventing stunting in the community. Childcare manifests in several aspects, including breastfeeding and complementary feeding, psychosocial stimulation, hygiene and envi- ronmental sanitation practices, caring for sick children by providing home-based health care, and seeking professional healthcare services (Bella, Fajar, & Misnaniarti, 2020). Public knowledge about the connection between childcare practices and pregnancy can prevent stunting or address it if it has already occurred within the first 1000 days of a child’s life. Various activities can be carried out by communities and stakeholders to improve public knowledge and awareness of the dangers of stunting in a child’s future.

Before the socialization activity, most participants had already heard about the stunting phenomenon. In the evaluation, the sources of information where they obtained knowledge about stunting were also surveyed. The primary source, based on the highest frequency of responses, is the Posyandu, indicating that Posyandu can serve as an information source for various health-related topics, including stunting. According to Fertman & Allensworth (2016), Posyandu is one of the Community-Based Health Efforts (Upaya Kesehatan Bersumberdaya Masyarakat - UKBM) in the implementation of health development with the aim of empowering the local community, facilitating access to basic health services, monitoring child growth and development, including stunting, and reducing maternal and infant mortality rates. In addition to Posyandu, another significant source of information is socialization activities. This means that participants frequently attend events that have mentioned the stunting phenomenon. Another essential source of information is social media, antenatal classes, and information provided by midwives or Family Welfare Program (PLKB). According to Picauly & Toy (2013), fetal growth disorders during pregnancy can result from maternal malnutrition or food intake. As a result, antenatal classes are considered one of the ways to disseminate information about nutrition and health during pregnancy. If we rank these sources of information, it can be seen in Table 7 below.

Source: Data processing from primary data, 2023

Based on the data in Table 2, it can be observed that there are 7 information sources mentioned by respondents/participants from where they acquired information about stunting before the activity. The data confirms that in Bali, Posyandu activities are the most active in Indonesia. This observation is consistent with the findings from this evaluation, emphasizing the relevance of higher-level institutions supporting the development of Posyandu activities, aiming to enhance both their quality and quantity.

As mentioned earlier, most of the participants had already heard about the stunting phenomenon, but there was a small percentage of respondents who encountered this information for the first time during the socialization. For participants who were already familiar with the topic and those who were introduced to it for the first time, their knowledge after attending the socialization was assessed.

Source: Data processing from primary data, 2023

The data in Table 2 indicates that the conducted activity can be considered successful because it significantly increased the understanding and knowledge of the participants regarding the stunting phenomenon. Approximately 89 percent of the socialization participants reported an improvement in their knowledge or information about stunting after the activity, while about 11 percent did not experience an increase in their knowledge. Those with unchanged knowledge might include individuals already engaged in stunting interventions or who have already served as speakers or educators on the subject, which could account for their already high level of knowledge about the stunting phenomenon. Nevertheless, it is evident that a significant portion of participants stated that their knowledge and information about stunting improved following the socialization. This aligns with the views expressed by Beal et al. (2018) and Efevbera et al. (2017), emphasizing that collaborative efforts in community engagement activities through accompanying target groups (families at risk of stunting and prospective family support personnel) using the Communication, Information, Motivation, and Education (CIME) method can optimize knowledge, attitudes, and self-efficacy to prevent child stunting. This approach acknowledges that stunting is not only related to nutritional intake but also encompasses sanitation and hygiene, early marriage, child-rearing, and accessibility to quality food and healthcare services.

Community knowledge about the impact of child-rearing practices on stunting conditions can be considered the backbone for preventing or treating stunting in the first 1000 days of a child's life. This knowledge was also acquired among the participants of the socialization program, and the results showed that approximately 72 percent affirmed that child-rearing practices could lead to stunting in children. The remaining 28 percent stated that they did not understand or were unaware of the fact that childrearing practices could have an impact on stunting in children. Mothers with good child-rearing practices are more likely to have toddlers with better nutritional status than mothers with inadequate child-rearing practices (Venny, 2018). One of the aspects related to this is the provision of daily meals for children. Insufficiently providing nutritious meals to young children is common in communities, and people often overlook foods that contain essential nutrients for a child's growth and development (Zian, 2018). A child's growth and development depend on the nutritional composition of the foods they consume. It is crucial that the foods are varied, not of the same type each time. The frequency and timing of meals, as well as the types of foods provided, can all be considered part of child-rearing practices. After being educated through competent speakers, all the participants came to understand that child-rearing practices can affect the occurrence of stunting in children. The environmental conditions in which a child grows can also influence the child's health status and potentially affect the occurrence of stunting. Taking care of a child and practicing good child-rearing methods during the first 1000 days of a child's life is a key factor in a child's future success. This knowledge should be imparted to pregnant mothers, expectant mothers, and mothers whose children are already experiencing stunting, enabling them to break free from this condition during the first 1000 days of their child's life. Inadequate child-rearing practices can lead to poor nutritional status in young children. If this occurs during the golden age period, it can hinder optimal brain development, and recovery can be challenging (Novita, 2018). With the socialization provided, it is expected that mothers, expectant mothers, and newlywed mothers will possess knowledge of proper child-rearing practices to prevent or treat stunting in their children. A study by Purwanti et al. (2022) emphasized that support programs for pregnant women can provide motivation, monitor the nutritional and pregnancy status of mothers, and increase their knowledge and commitment to supporting child nutrition and health.

Questions about attitudes and practices of child rearing in the future were also addressed with a question, “After this activity, will you be aware of and practice proper child-rearing for future stunting prevention?” Almost all participants answered “yes” (94 percent), indicating that the disposition and awareness to implement proper childrearing for their children in the future is acceptable and will be executed to prevent stunting and to make efforts for recovery if it has already occurred. Only about 6 percent answered “no.” Upon investigation, it is possible that these respondents do not have an elementary school education. With low levels of education and a lack of employment to secure adequate income to provide proper nutrition for their children, they stated “no.” This is more related to economic incapacity to provide good nutrition as part of child-rearing to enhance the children's health quality.

An evaluation was also conducted to assess the improvement in knowledge, attitudes, and practices regarding proper child-rearing to prevent stunting. Data processing results showed that there has been a very satisfactory increase in knowledge, attitudes, and practices regarding child-rearing to prevent stunting. Details can be seen in Table 3 below.

People are willing to prevent and treat stunting because they understand the adverse effects of stunting. Knowledge of the adverse effects of stunting is essential to motivate individuals to engage in prevention. During the awareness campaign, participants were also asked whether they were already aware of the adverse effects of stunting before the campaign began. The evaluation results showed a higher percentage of people who were aware of the adverse effects of stunting before the awareness campaign compared to those who were not aware. Approximately 78 percent of respondents were already aware of the adverse effects of stunting before the awareness campaign, while only 22 percent were not aware. This data indicates that a significant number of respondents or participants only became informed about the adverse effects of stunting after the awareness campaign was conducted. This implies that the campaign was successful in increasing public knowledge.

Source: Primary data processing results, 2023

The data shows that about 8 percent of respondents from the awareness campaign did not see an improvement in their knowledge of the adverse effects of stunting after the campaign. The remaining 92 percent experienced increased knowledge about the adverse effects of stunting. Considering the educational background of the participants in the awareness campaign varies from elementary school to higher education, it can be assumed that their responses are closely related to their pre-existing knowledge of the stunting phenomenon. There is also the possibility that those whose knowledge did not improve were already well-informed about the topic, so the information presented during the campaign was not new to them.

The occurrence ofstunting is closely related to the demographic bonus, where stunting experienced by children will affect their future when they enter the job market. Stunting reduces the quality of human resources, both in physical and intellectual terms, due to suboptimal growth. Consequently, the potential of the demographic bonus cannot be optimally harnessed by high-quality human resources, resulting in a slower increase in productivity. As part of this awareness campaign, participants were also asked about their knowledge of the demographic bonus. Data processing results are as follows.

Source: Primary data processing results, 2023

The research data indicates that a significant number of respondents or participants had never heard about the demographic bonus before this campaign. Therefore, they only learned about the demographic bonus for the first time during the campaign. The demographic bonus refers to a condition where the dependency ratio (DR) is below 50. The DR is the ratio or comparison between non-productive population and productive population, multiplied by 100 as a constant. If the result is 50 , it means that 100 productive individuals support 50 non-productive individuals, so two productive individuals are supporting one non-productive individual. If the DR is lower than 50 , which means that two productive individuals are supporting less than one nonproductive individual, it signifies a window of opportunity to harness the large workingage population to significantly increase per capita income. When the DR is lower than 50 , the area enters a demographic bonus period, making the quality of the population crucial for the rapid increase of per capita income. Herein lies the connection between stunting and the formation of future human resource quality to achieve rapid per capita income growth. In other words, this window of opportunity can be utilized to increase per capita income, provided there is support from a high-quality population. If the population's quality is low due to stunting, the demographic bonus, which represents an opportunity, cannot be fully utilized to achieve rapid per capita income growth.

Furthermore, about 61 percent of respondents were aware that stunting would affect the realization of benefits from the demographic bonus in the future, with only 39 percent unaware of this fact. Additionally, a higher percentage of respondents or campaign participants, around 89 percent, were aware and understood that stunting would affect the quality of human resources in the future, while only 11 percent did not grasp this concept. With this understanding, it is expected that participants will make efforts to prevent stunting in their families.

The analysis also revealed that approximately 78 percent of respondents were aware and understood that the quality of future human resources would affect the realization of benefits from the demographic bonus, specifically the expectation of increasing per capita income rapidly. Consequently, approximately 22 percent of campaign participants were not aware that the quality of human resources would influence the opportunity to achieve results from the demographic bonus. Through this awareness campaign, the presenters explained that the quality of human resources influenced by stunting is one of the variables determining the potential to harness the demographic bonus opportunity for increasing per capita income rapidly.

In accelerating the reduction of stunting in the community, the government has initiated a program aimed at assisting families with stunted children by providing economic support for three months to improve the nutrition of families with stunted children. This program is expected to help families with stunted children improve the nutrition of their affected child. Economically capable families are expected to become foster parents for stunted children, enabling the community to consciously participate in efforts to reduce stunting in Indonesia. Knowledge of the Foster Parents for Stunted Children (BAAS) program was also evaluated in this activity, with the results showing that approximately 81 percent of the participants were aware of the BAAS program. However, a significant portion, about 19 percent, were not aware of the BAAS program. Although most of the participants were members of Posyandu or PKK, not all of them were familiar with the program. For those who did not understand or were unaware of the BAAS program, it was explained during the evaluation interviews, as well as during the awareness campaign. Furthermore, during the evaluation, participants were asked if they agreed with the BAAS program. All participants expressed their agreement and strong support for the BAAS program because it plays a crucial role in accelerating the reduction of the stunting phenomenon in Indonesia.

As members of the community who have acquired knowledge and understanding of the stunting phenomenon, it is essential for their involvement both within their families and in the broader community. Through educational activities, counseling, and discussions, it is expected that mothers can put into practice the knowledge they have gained and disseminate this information to peers to improve childcare and parenting (Malfasari and Hasanah, 2022). Cadres and mothers understand the causes, effects, and interventions for stunting (Choliq et al., 2020). In this study, participants were also explicitly asked what they would do as a form of contribution to address stunting. Some activities carried out by participants in the awareness campaign to be involved in addressing stunting include the following: 1) Providing support to parents with stunted children; 2) Motivating participation in Posyandu activities; 3) Providing nutritious meals to children; 4) Improving childcare practices for children. 5) Actively participating in the socialization of the dangers of stunting; 6) Sharing information about stunting prevention; 7) Understanding and applying the recommendations of doctors and outreach workers; 8) Complying with the requirements of Posyandu; 9) Regularly checking children's weight at Posyandu and providing them with nutritious food; 10) Ensuring adequate nutrition for babies in the womb; 11) Providing support and encouragement to families with stunted children. From in-depth interviews with participants in the awareness campaign, it is evident that there is a significant variety of activities undertaken by the community to contribute to the prevention and treatment of stunting in the village. This diversity of actions demonstrates the community's commitment to working alongside the government to alleviate stunting in the community, particularly in the village of Abang where the awareness campaign was conducted.

The Community Engagement Activity has been successfully carried out, providing Knowledge, Information, and Education (KIE) to young mothers, housewives with stunted children, pregnant women, Posyandu and PKK managers, and community leaders. The program has run effectively, motivating participants to actively engage in efforts to prevent and treat stunting, both for their own families and others in the community. It has also significantly improved the participants' knowledge, attitudes, and practices related to childcare, the adverse effects of stunting, demographic bonuses associated with stunting, and the role of Stunting Caregivers.

The involved community members are now actively participating in stunting prevention. This program has enhanced their knowledge, attitudes, and behaviors regarding stunting prevention. The Posyandu and PKK activities are running well and are continuing routinely, becoming the primary activities in the village for addressing stunting. With these efforts, it is expected that future cases of stunting can be prevented, and that continuous treatment can be provided for children affected by stunting in their first thousand days of life. Therefore, the hope of making Abang Village the first stunting-free village in Karangasem Regency can be realized.

Based on the analysis, the KIE activities have effectively improved the Knowledge, Attitudes, and Practices (KAP) of the participants, which suggests that similar activities could be conducted in areas with high stunting prevalence. Additionally, there is a need for a deeper understanding of the role of the community as Stunting Caregivers. This way, families with stunted children who are living in poverty can be provided with better nutrition for their children, accelerating their exit from stunted conditions.