FACTORS THAT AFFECT THE INCIDENCE OF STUNTING IN TOODDLERS AGED 6-59 MONTHS

Based on WHO data (2018), the average prevalence of stunting under five in Indonesia in the 2005-2017 range is 36.4%. Indonesian Toddler Nutritional Status Survey (SSGBI) in 2019 shows the prevalence of stunting under five in Aceh province is 33.6%. Meanwhile, for West Aceh district, the prevalence of stunting under five is quite high, at 40.4%. The high prevalence of stunting in West Aceh is still an important health problem to overcome because children are the nation's assets in the future. Objective: to determine the factors that influence the incidence of stunting in Kaway XVI sub-district. Methods: Quantitative research with Cross Sectional Study approach. The population in this study were all toddlers aged 0-59 months totaling 126 toddlers and the research sample was toddlers aged 6-59 months, with the sampling method using purposive sampling technique with a total of 117 samples. Results: The results showed that there was no significant effect between exclusive breastfeeding (p: 0.683), feeding patterns (p: 0.376), and mother's knowledge (p: 0.483) on the incidence of stunting, and there was a significant effect between maternal education (p: 0.018) on the incidence of stunting in toddlers aged 6-59 months in Kaway XVI sub-district.


INTRODUCTION
Stunting (short toddlers) is one of the nutritional problems due to chronic malnutrition, especially in the 1,000 HPK (First Day of Life) experienced by toddlers which refers to the condition of the child's height being shorter than children his age. In addition, the process of stunting coincides with the process of inhibition of growth and development of other organs, including the brain (Sri, A, et al, 2018).
Stunting is a chronic nutritional problem experienced by toddlers around the world. Stunting is still a serious problem in every poor and developing country. Based on world data in 2017 around 150.8 million (22.2%) children under five in the world experienced stunting, although this figure has decreased compared to 2000, which was 32.6%. As many as 55% of stunting toddlers in the world come from the Asian region (Data and Information Center of the Indonesian Ministry of Health, 2018).
The prevalence of stunting in developing countries is quite high, one of which is Indonesia. Based on WHO data (2018), Indonesia is included in the third country with the highest prevalence in Southeast Asia, where the average prevalence of stunting under five in Indonesia in the 2005-2017 range is 36.4%. This shows that more than a third of children under five in Indonesia or around 8.8 million children under five experience nutritional problems where the child's height is shorter than children his age or commonly known as stunting (WHO, 2018).
Riskesdas data in 2018 showed the prevalence of stunting under five was 30.8% and decreased in 2019 by 27.7%, although the prevalence of stunting under five showed a decline, this prevalence was still relatively high from the target to be achieved (Kemenkes RI, 2019 Indonesian Toddler Nutrition Status Survey (SSGBI) in 2019, the prevalence of stunting under five in Aceh province is 33.6%. Meanwhile, for West Aceh district, the prevalence of stunting under five is quite high, at 40.4%. Based on these data, it shows that the prevalence of stunting is above the threshold set by WHO, which is 20%. Of course, this is a very urgent problem and it is very important the role of the government and related parties in determining policies as an effort to overcome the stunting problem in Indonesia, especially West Aceh (SSGBI, 2019) Anthropometric index assessment is the most frequently used way to see the nutritional status of children under five. Some anthropometric indices that are often used to see the nutritional status of toddlers are weight for age (BB/U), height for age (TB/U), weight for height (BB/TB) which is expressed as a standard deviation of units z. (Z-score). Stunting in toddlers can be diagnosed through the anthropometric index of height according to age (TB/U) (Kemenkes RI, 2017).
Many factors influence the incidence of stunting in toddlers. Among these factors, maternal nutrition before and during pregnancy is an indirect cause of fetal growth and development. Pregnant women with poor nutrition can cause the fetus to experience a lack of nutrition and nutrition which has an impact on the growth and development of the fetus so that when the baby is born, the baby has low birth weight. In addition, recurrent infectious diseases and exclusive breastfeeding are factors that contribute to the growth retardation experienced by toddlers. This situation makes it more difficult to overcome growth disorders so that there is a high chance of stunting (Germas, 2018).
Several studies related to factors related to stunting, including the research conducted by Hermawati Hamalding in 2020 on the analysis of determinants of stunting in Taraweang village, Labakkang district, Pangkep district, showed that there was a relationship between maternal nutritional knowledge (p = 0.003), diet (p=0.010), history of breastfeeding (p=0.000), and history of disease (p=0.003) on the incidence of stunting (Hamalding et al, 2020). In addition, research conducted by Komalasari (2020) showed a relationship between exclusive breastfeeding status (p = 0.000), maternal nutritional status (p = 0.048), and maternal education (p = 0.046) with the incidence of stunting, while LBW (p = 0.743) is not related to the incidence of stunting (Komalasari, 2020).
Based on the description above, it is known that stunting is still a serious nutritional problem where the stunting rate in West Aceh is still high, especially in Kaway XVI sub-district. Therefore, the authors are interested in conducting research on the factors that influence the incidence of stunting in Kaway XVI sub-district.

IMPLEMENTATION METHOD
This research was conducted in the District of Kaway XVI with the locus in 4 villages, namely Tanjong Bungong Village, Puuk Village, Pungkie Village, and Keude Tanjong Village. This research is a quantitative research with a Cross Sectional Study approach. The population in the study were all toddlers aged 0-59 months in the 4 villages, totaling 126 toddlers. The sampling technique in this study used purposive sampling where the sampling was based on certain considerations in accordance with the criteria determined by the researcher and obtained a sample of 117 samples. The inclusion criteria are: 1) Mothers who have children under five aged 6-59 months, 2) mothers who are willing to participate in this study. While the exclusion criteria are: 1) Mothers who have toddlers aged 0-5 months, 2) Mothers and toddlers who were not present at the time of data collection and also not present at the posyandu, 3) Mothers who were not willing to participate in this study. Data collection activities will be carried out in October 2021.
The instruments used in this research are: 1. Microtoice, measuring the height of children under five who can stand up is done with an accuracy of 0.1 cm. 2. Digital weighing scale to measure the weight of toddlers. 3. The questionnaire was used as an interview guide to determine the identity of the respondents, the identity of children under five and data about children under five needed. Data collection was obtained in two ways, primary data and secondary data. Primary data is data that researchers obtained directly by interview using a questionnaire. Secondary data in the form of data on the number of children under five and the nutritional status of children under five which the researchers obtained from posyandu cadres and KPM cadres. The variables that will be measured in this study are mother's knowledge, mother's education, exclusive breastfeeding, and toddler feeding patterns.
Analysis of the data obtained was carried out by univariate and bivariate. Univariate analysis was carried out to determine the distribution of each variable, while bivariate analysis was used to see the relationship between the independent variables and the dependent variable, namely mother's knowledge, mother's education, exclusive breastfeeding, and feeding patterns of toddlers to the incidence of stunting in toddlers using the Chi-square test with 95% significance level. Based on Table 1 shows that of the 117 toddlers who were sampled in this study 44 (37.6%) of them experienced stunting. Most of the toddlers are in the age range of 24-59 months, as many as 72 toddlers (61.5%) while the toddlers who are in the age range of 6-23 months are 45 toddlers (38.5%). There are more female gender, namely 61 toddlers (52.1%) than male gender, namely 56 toddlers (47.9%). For exclusive breastfeeding, it is known that most of them do not get exclusive breastfeeding, namely 69 toddlers (59%) while those who get exclusive breastfeeding are 48 toddlers (41%). In the practice of feeding patterns, it is known that poor feeding is greater, namely 62 toddlers (53%) compared to good feeding patterns, namely 55 toddlers (47%). The majority of mothers are in the secondary education category with 61 (52.1%) while mothers with higher education are 37 (31.6%) and mothers with low education are 19 (16.2%). Mothers who have good knowledge are 66 people (56.4%) while mothers with less knowledge are 51 people (43.6%).  Table 2 shows that, stunting cases were more prevalent in the group of toddlers who did not receive exclusive breastfeeding, namely 27 toddlers (61.4%) compared to toddlers who received exclusive breastfeeding, which was 17 toddlers (38.6%). Statistical analysis test with Chi-square obtained p-value = 0.683 greater than (0.05), based on these results it can be concluded that Ho is accepted and Ha is rejected, which means that there is no significant effect between infants receiving exclusive breastfeeding and the incidence of stunting. Further analysis obtained PR value = 0.905 (95% CI: 0.397-1.831), where the prevalence ratio is <1 so it can be concluded that exclusive breastfeeding is not a risk factor for stunting in toddlers aged 6-59 months. In table 3, it is known that the toddlers with a good feeding pattern category were also larger in the group of toddlers who did not experience stunting, namely 32 toddlers (43.8%), compared to the group of toddlers who experienced stunting, namely 23 toddlers (52.3%). Meanwhile, toddlers with poor feeding patterns were more in the group of toddlers who did not experience stunting, namely 41 toddlers (56.2%), compared to the group of toddlers who experienced stunting, namely 21 toddlers (47.7). Statistical analysis test with Chi-square obtained p-value = 0.376 > 0.05, based on these results it can be concluded that there is no significant effect between feeding patterns in toddlers and the incidence of stunting. Further analysis obtained the value of PR = 1,236 (95% CI: 0.662-2,973), where the prevalence ratio > 1 which means that feeding patterns are a risk factor for stunting, namely toddlers whose diet is not good has a risk of stunting 1,236 times greater than toddlers who eat a good diet. In table 4 it is known that, stunting cases were more prevalent in the group of mothers with secondary education category, namely 23 mothers (53.3%), compared to the group of mothers with low education category, namely 12 mothers (27.3%) and the group of mothers with higher education category, namely 9 mothers (20.5%). Statistical analysis test with Chi-square obtained pvalue = 0.018 smaller than (0.05), based on these results it can be concluded that Ho is rejected and Ha is accepted, which means that there is a significant effect between maternal education and the incidence of stunting. In table 5, it is known that stunting cases were more prevalent in the group of mothers who had good knowledge, namely 23 mothers (52.3%) compared to mothers who had less knowledge, namely 21 mothers (47.7%). Statistical analysis test with Chi-square obtained p-value = 0.483 greater than (0.05), based on these results it can be concluded that Ho is accepted and Ha is rejected, which means that there is no significant effect between mother's knowledge on the incidence of stunting. Further analysis obtained PR value = 1.181 (95% CI: 0.616-2.779) where the prevalence ratio is > 1 which means that mother's knowledge is a risk factor for stunting, namely toddlers with less maternal knowledge have a risk of experiencing stunting 1.181 times greater than toddlers mother's knowledge is good.

The Effect of Exclusive Breastfeeding on Stunting Incidence
The results of statistical tests obtained p value > 0.05 which indicates that there is no significant effect between the factor of exclusive breastfeeding and the incidence of stunting in toddlers aged 6-59 months. This research is in line with research conducted by Daming (2019) at the Salo Public Health Center, Pinrang Regency in 2019 with a p value of 0.351, where there is no significant effect between exclusive breastfeeding and the incidence of stunting at the Salo Public Health Center, Pinrang Regency, and research conducted by Anshori. (2013) which states that exclusive breastfeeding has no effect on the incidence of stunting. However, the results of this study are not in line with research conducted by Sativa, et al (2020) in South Bangka district which showed a relationship between exclusive breastfeeding and stunting with a p value = 0. 004 where toddlers who don't get exclusive breastfeeding have a 3 times tendency to experience stunting compared to toddlers who get exclusive breastfeeding. The results of Komalasari's research (2020) on the factors that cause stunting in toddlers with the result that there is a relationship between exclusive breastfeeding and stunting (p value: 0.000 and OR:11.111) which means that toddlers who do not receive exclusive breastfeeding have a risk of 11.111 times more have a higher incidence of stunting compared to toddlers who receive exclusive breastfeeding.
The results of in-depth interviews with mothers of children under five, it is known that most mothers also give formula milk at the same time as breast milk, this is due to the production of breast milk that is not smooth and also mothers who work. Breastfeeding combined with formula milk can indeed meet the nutritional needs of toddlers to support their growth and development, but the content in formula milk is not as good as the content of breast milk.

The Effect of Feeding Patterns on Stunting Incidence
Statistical analysis test with Chi-square showed p-value > 0.05 (p = 376), so it can be concluded that there is no significant effect between feeding patterns on the incidence of stunting in toddlers. The same results were also shown in a study conducted by Ibrahim, IA. (2019) which shows that there is no relationship between the practice of feeding children under five and the nutritional status of stunting in children aged 12-36 months in Bontongan Village. Nursanti's research (2013) in Cibatok stated that there was no relationship between feeding and the incidence of stunting with p>0.05. The availability of food in the community is sufficient to meet daily needs, although some people have low income because most of the residents of Kaway XVI sub-district work as farmers and own their own land so that they can meet adequate nutrition for their children. However, this study is not in line with the research conducted by Hamalding, et al (2020) which stated that there was a relationship between diet and the incidence of stunting (p = 0.010).
In a study conducted by Loya (2017), it was stated that the pattern of feeding according to the type of food, the amount of food and the feeding schedule for children is the right feeding pattern and of course it must also be adjusted to the age of toddlers because toddlers are a group that is vulnerable to nutrition so that the type of food given must be in accordance with the needs of the body and the child's digestibility. Furthermore, Manggabarani (2018) in his research suggests that every mother needs to learn and understand that uncontrolled eating patterns such as the habits of children who like to snack and consume snacks must be wary of because they can have a negative impact on children's health and growth.

The Effect of Mother's Education on Stunting Incidence
Statistical test results obtained p value = 0.018 (p <0.05), based on these results indicate that there is a significant relationship between maternal education and the incidence of stunting in toddlers aged 6-59 months. This study is in line with the research conducted by Dayyana (2015) which showed that there was an influence between mother's education and the incidence of stunting. Ni'mah's research (2015) also shows a similarity, namely the relationship between mother's education and the incidence of stunting (p = 0.029). Komalasari's research (2020) on the factors that cause stunting in toddlers shows that the statistical test results obtained a p value = 0.046 where the p value <0.05 which means there is a relationship between mother's education and stunting. There is a relationship between mother's education and the incidence of stunting in accordance with the theory which states that the level of education plays a very important role in changing positive attitudes and behavior, as stated by Notoatmodjo (2012) that interventions for behavior change can be done through education. However, this study is not in line with research conducted by Maynarti (2021) which showed p value = 0.645, which means that there is no relationship between maternal education and the incidence of stunting. Research conducted by Wanimbo, et al (2020) showed that there was no relationship between the mother's education level and the incidence of stunting (p = 0.203).

The Effect of Mother's Knowledge on Stunting Incidents
The results of statistical tests showed that there was no relationship between mother's knowledge and the incidence of stunting in toddlers aged 6-59 months, where statistical analysis with Chi-square showed p-value = 0.483 (p> 0.05). This study is in line with research conducted by Kustanto, et al (2016) in Koto Rojo, Pasaman district which stated that there was no relationship between knowledge and the incidence of stunting in toddlers, and research conducted by Daming (2019) at the Salo Public Health Center, Pinrang Regency in 2019 with a score of p = 0.351, where there is no significant effect between mother's knowledge and the incidence of stunting at the Salo Public Health Center, Pinrang Regency. However, this study is not in line with the research conducted by Olsa et al. (2017) which showed a p value = 0.000 (p <0.05), which means that there is a significant relationship between mother's knowledge and the incidence of stunting, and research conducted by Hasnawati, et al in 2021 which stated that there was a relationship between mother's knowledge and the incidence of stunting (p = 0.02), where mother's knowledge can affect the health and welfare of children . Mother's knowledge is an indicator that helps achieve good nutritional status of children.

CONCLUSION
The results obtained in 4 villages located in the Kaway XVI sub-district, West Aceh Regency, namely: 1. There is no effect between exclusive breastfeeding and the incidence of stunting in toddlers aged 6-59 months (p value: 0.683). 2. There is no effect between feeding patterns and the incidence of stunting in toddlers aged 6-59 months (p value: 0.376).