Factors Associated with Stunting in Toddlers Aged 0-59 Months in Bonomerto

Stunting is a health problem that hinders human growth and development globally. It is important to raise awareness about the importance of nutrition during pregnancy and child growth, as well as provide support and education to pregnant women and society in general. Preventive efforts and early intervention can help overcome the problem of stunting and improve children's overall health. This study was designed to determine the factors associated with the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency. This research is quantitative with a cross sectional research design. This research was conducted in June-July 2023. The research was carried out in Bonomerto Village, Suruh District, Semarang Regency. The population in this study was 224 mothers who had toddlers aged 0-59 months in Bonomerto Village, Suruh District, Semarang Regency. The sampling technique used was using the Random Sampling technique, so that the sample in this study was 144 toddlers. The instrument used in this research was a questionnaire. Data analysis in this study was analyzed using the chi-square test. The research results showed that there was a relationship between maternal education (p=0.000), family income (p=0.000), Antenatal Care Visits (p=0.000), baby birth weight (p=0.004) with the incidence of stunting in toddlers aged 0-59 months. It is recommended for mothers to carry out regular antenatal care visits and early detection of the risk of stunting in the fetus at health facilities and for health workers to provide education about the importance of prenatal checks for pregnant women in order to reduce the incidence of stunting risk.


INTRODUCTION
Stunting is a health problem that hinders human growth and development globally.
WHO estimates that the number of stunting cases in the world in 2020 will reach 22% or as many as 149.2 million (WHO, 2021).According to the United Nations Children's Emergency Fund (UNICEF) more than half of stunted children in the world, 56% live in Asia and 37% live in Africa.Of the 83.6 million toddlers with stunting in Asia, South Asia has the highest proportion of stunting at 58.7% and Central Asia has the least proportion of stunting at 0.9% (UNICEF, 2016).
Based on the results of a survey on the nutritional status of Indonesia, it is known that the prevalence of stunting in Indonesia in 2022 is 21.6%.This figure has decreased from 2021 of 24.4%.But even so, there is still a need to reduce the stunting rate by 3.8% per year in order to achieve the target of a stunting rate of 14% in 2024.The province with the highest prevalence of stunting is East Nusa Tenggara at 35.3% and the province with the lowest prevalence namely Bali by 8.0% (SSGI, 2022).
Vol 5 The prevalence of stunting in Central Java Province in 2022 is 20.8%.Central Java only experienced a decrease in the stunting rate of 0.1% from 2021 of 20.9%.The highest prevalence of stunting under five was in Central Java Province, namely Brebes Regency at 29.1% and the lowest stunting prevalence was in Semarang City, namely 10.4% (SSGI, 2022).In 2022 Semarang Regency has a stunting toddler prevalence rate of 18.7%.Semarang Regency ranks 13th in the regencies or cities in Central Java province with the lowest prevalence of stunting (SSGI, 2022).
But even so, stunting is still one of the problems related to public health which is a strategic issue and development priority for Semarang Regency.Stunting is one of the priorities in development in Semarang Regency.The handling of stunting is realized to create healthy and intelligent people (BAPPEDA, 2022).Stunting is an important aspect of development because the incidence of stunting causes a decrease in productivity and cognitive abilities, as well as a greater risk of contracting a disease which can reduce the quality of human resources (Berhe et al., 2019).
Based on a preliminary survey conducted at the Suruh Health Center in Semarang Regency.In 2022, out of 2,834 toddlers, 80 toddlers or around 2.82% will have stunting cases.
This figure is far below the Semarang Regency stunting rate which reached 18.7%.However, it remains a serious problem because of the future impact, namely regarding the retardation of the quality of human resources which causes the community's competitiveness to be very low.
If broken down from the 80 stunting toddlers in the Suruh Health Center area.The highest cases of stunting occurred in the Bonomerto Village Region, namely 15 toddlers (18.75%).
There have been many studies related to the factors that influence the incidence of stunting, but there are still differences of opinion regarding the factors that influence the incidence of stunting.Study Islami (2021) stated that there was no relationship between mother's education, family income, birth weight of toddlers, exclusive breastfeeding with the incidence of stunting in toddlers (Islami et al., 2021).
Then in research Ika (2022) mentioned that there was a relationship between mother's education, family income, birth weight of toddlers, and exclusive breastfeeding to the incidence of stunting.However, there is no relationship between antenatal care visits and the incidence of stunting (Ika et al., 2022).This is different from research Zurhayati (2022) which stated that there was a relationship between antenatal care visits and the incidence of stunting in toddlers.

Vol 5
Based on these problems, the researcher intends to conduct research on factors related to the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency.

METHODS
The type of research used in this research is quantitative with a descriptive observational research design with a Cross Sectional approach.This study was designed to determine the factors associated with the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency.This research was conducted in June-July 2023.The research was conducted in Bonomerto Village, Suruh District, Semarang Regency.In this study, the population of mothers who had toddlers aged 0-59 months in Bonomerto Village, Suruh District, Semarang Regency was known to be 224 toddlers.To determine the number of samples, the researchers used the Slovin formula and found a sample size of 144 respondents.
In this study the sampling technique was carried out by using the Random Sampling technique where samples were taken randomly based on data from mothers under five obtained from the village Posyandu.Sampling was selected according to the inclusion criteria and did not meet the exclusion criteria that had been determined by the researchers, namely mothers who had toddlers aged 0-59 months, lived in Bonomerto Village, Suruh District, Semarang Regency, and were willing to be respondents.Then the exclusion criteria from the researcher were unable to read and write and unable to communicate properly.
Data collection was carried out using a questionnaire that had been tested for validity and reliability.This research uses validity and reliability tests on a questionnaire which contains questions such as giving exclusive breast milk.This research uses a significance level of 95%, so the value is 0.361.The question items from the questionnaire are said to be valid.
Meanwhile, the reliability test using the Cronbach's Alpha method on question items that were valid on the exclusive breastfeeding variable showed reliability with a Cronbach's Alpha value > 0.60, namely 0.864.
The data analysis used in this research is bivariate analysis with the chi-square test.This

RESULTS
The characteristics of the respondents in this study were age, marital status, number of children, and occupation.Based on the results of the bivariate analysis in table 3, the value of p = 0.000 was obtained for the mother's education variable so that it was p <0.000.This means that there is a relationship between mother's education and the incidence of stunting in toddlers aged 0-59 months.In the family income variable, the value of p = 0.000 <0.05 is obtained, which means that there is a relationship between family income and the incidence of stunting in toddlers aged 0-59 months.Then the value of p = 0.000 <0.05 was obtained for the antenatal care visit variable.This means that there is a relationship between antenatal care visits and the incidence of stunting in toddlers aged 0-59 months.Furthermore, for the baby's birth weight variable, the value of p = 0.000 <0.05 is obtained, which means that there is a relationship between the baby's birth weight and the incidence of stunting in toddlers aged 0-59 months.Statistical test results on the ASI variable obtained p = 0.004 <0.05.This means that there is a relationship between breastfeeding and the incidence of stunting in toddlers aged 0-59 months.who have low knowledge regarding stunting.In conclusion, the value of OR = >1 indicates that the mother's education level has an effect on the risk of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency.This shows that the higher the mother's education level, the lower the risk of toddlers aged 0-59 months experiencing stunting.

DISCUSSION
Conversely, the lower the mother's education level, the higher the risk of toddlers aged 0-59 months experiencing stunting.
This research is in line with research conducted by Ika (2022) that mothers with low education have a higher risk of having stunted children than mothers with high education.This is clarified by other research which states that mothers who have a high education tend to influence the mother's decisions in providing food and care to toddlers (Yanti et al., 2020).
Ardian ( 2022) in his research also explained that the nutrition of children with mothers who have a high education will be fulfilled compared to mothers who have a low level of education.
The results of this study are also in accordance with Notoatmodjo's theory that education is something that can bring a person to gain as much insight and knowledge as possible and provide opportunities for someone to receive good information.So, with the information obtained, a mother will consider both the nutritional intake of her baby and the parenting style that is applied (Mkhize et al., 2020).
The research results show that respondents who have a low level of education experience more stunting than respondents who have a higher education.Respondents who have low education and suffer from stunting are caused by a lack of knowledge.The thing that caused the respondents to have less knowledge based on interviews during the research was that some of these respondents were embarrassed to ask midwife cadres even though they participated in integrated service posts almost every month.The embarrassment factor of asking about fulfilling nutrition and providing the right type and amount of food so that the child can grow and develop according to his age is related to the mother's level of trust so she is less likely to seek information about stunting prevention events.

Months
The results of statistical tests that have been carried out show that there is a relationship between maternal education and the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency with an Odds Ratio (OR) = 46.200(95% CI = 5. 833-365.932).This shows that families with high income have a 46,200 times chance of preventing stunting among toddlers aged 0-59 months compared to families with low income.
Vol 5 This means that high or low family income can affect the incidence of stunting in toddlers aged 0-59 months.The higher the income of a family, the lower the rate of stunting in toddlers aged 0-59 months.Conversely, the lower the income level of a family, the higher the rate of stunting in toddlers.High and low family income is related to meeting family needs, in this study related to fulfilling nutrition for toddlers (Agustin et al., 2021).
The results of this study are in accordance with previous research conducted by Wahyudi (2022) that the higher the family income, the greater the family's access to consuming nutritious and varied food.Based on WHO (2018) explained that cases of malnutrition occur in countries with low to middle income.Nursita (2022) in his research stated that poverty in the family can affect cognitive, emotional, social, and behavioral development in children.This is because parents who live in poverty are more likely to suffer from mental health, relationship and financial problems which can have a negative impact on parenting patterns (Gebre et al., 2019).The results of this study are also in accordance with the theory regarding stunting put forward by Notoatmodjo that a lack of nutritional sources which are lacking in the food provided, how to provide food when sick and healthy, and food hygiene can cause toddlers to experience stunting at the age of 0-59 months (Humaira, 2023;Kartika Sari et al., 2023).
In this study, parents had low incomes because many parents had the majority of their employment status as farmers, this resulted in them experiencing health problems and not directly utilizing health facilities due to financial constraints.Thus, the time of exposure to disease becomes longer and can cause nutritional problems.

0-59 Months
Antenatal Care (ANC) is a health service provided to mothers during their pregnancy with the aim of detecting the risk of complications during pregnancy.Antenatal Care (ANC) must be carried out routinely to obtain optimal and quality antenatal care (Hamid dkk., 2021).
Statistical tests showed that ANC visits had a relationship with the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency with an Odds Ratio (OR) = 24.667(95% CI = 6.333-96.072).This means that respondents with a high frequency of antenatal care visits had a 24,667 chance of preventing stunting in toddlers aged 0-59 months.Thus, the level of antenatal care visits made affects the high or low incidence of stunting in toddlers aged 0-59 months.The higher the frequency of antenatal care visits, the lower the risk of stunting in toddlers aged 0-59 months.
Vol 5 Based on research conducted by Hutasoit et al., (2020) antenatal care visits are carried out at least 4 times during pregnancy, this aims to detect early risks of pregnancy, maintain fetal health, monitor the nutritional status of pregnant women to prevent malnutrition in the early stages of the child's life, prepare for the labor process leading to birth, maintain maternal health during pregnancy , minimizing the risk of danger when the mother gave birth.
So, this research is in accordance with the research conducted by Erawati (2022) that antenatal care visits during pregnancy are important, by carrying out antenatal care visits in a complete and regular manner the mother will be better able to detect if there are problems with the nutrition of the mother and fetus.
The results of this study are in accordance with the theory that a history of antenatal care visits is a risk factor for stunting.This is because during pregnancy, many mothers do not regularly make antenatal care visits at health facilities due to the lack of money to carry out pregnancy checks, access to services that is far away and lack of support from husbands and families.Therefore, routine antenatal care visits can detect early pregnancy risks in the mother, especially those related to nutrition and nutrition problems.

Relationship Between Baby's Birth Weight and Stunting Incidence in Toddlers Aged 0-59 Months
Toddler birth weight is closely related to long-term growth and development conditions.In the research conducted by Ika concluded that there was a significant relationship between toddler birth weight and the incidence of stunting (Ika et al., 2022).
This study shows that there is a relationship between birth weight and the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency with an Odds Ratio (OR) = 12.321 (95% CI = 3.814-39.81).These results indicate that the more normal the baby's weight will have a 12.321 chance of preventing stunting in toddlers aged 0-59 months.That is, the more normal the baby's weight, the lower the rate of stunting in toddlers aged 0-59 months.Conversely, the more abnormal the baby's weight, the higher the risk of stunting in toddlers aged 0-59 months.
According to Farmani (2021) The baby's weight at birth can be an indicator of determining whether the baby's growth and development in the womb is good or not.Low Birth Weight (LBW) is classified into two, namely babies born small due to preterm and babies born small with a weight that should be for the gestation period.Thus, this research is in line with research conducted by Ika (2022); Oktavianisya (2021) states that there is a significant Vol 5 relationship between under-five birth weight and the incidence of stunting, which states that a history of low birth weight under-fives has a high risk of causing stunting.

Relationship Between Breastfeeding and Stunting in Toddlers Age 0-59 Months
Mother's Milk indirectly plays role in the psychomotor development of children, because if the child is healthy the child will find it easier to explore and learn in the surrounding environment (Ibrahim et al., 2021).
Based on the results of statistical tests, it was found that there was a relationship between breastfeeding and the incidence of stunting in toddlers aged 0-59 months with an Odds Ratio (OR) = 5.902 (95% CI = 1. .This shows that the higher the frequency of breastfeeding, the greater the chance of preventing stunting in toddlers aged 0-59 months.The more exclusive breastfeeding, the lower the occurrence of stunting in toddlers aged 0-59 months, conversely if exclusive breastfeeding is not given, the higher the rate of stunting in toddlers aged 0-59 months. Exclusive breastfeeding is given to babies from birth to six months of age.Thus, breast milk can meet three-quarters of protein needs in infants aged 6-12 months, because breast milk contains the essential amino acids needed by infants (Budiastutik et al., 2018).This research is in accordance with research conducted by Anita (2022) that toddlers who are not given exclusive breastfeeding have a 61 times chance of experiencing stunting.The results of this study are in accordance with Notoatmodjo's statement that incorrect breastfeeding, late initiation, not giving exclusive breastfeeding to infants, and premature cessation of breastfeeding are among the factors that cause stunting in toddlers aged 0-59 months.
Based on this study, it can be revealed that all factors such as mother's education, family income, antenatal care visits, baby's weight, and breastfeeding have a relationship with the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency.Stunting is of particular concern in Indonesia, seeing that it has a very large impact on children, one of the major impacts that is feared by stunting is the risk of death (Choliq et al., 2020).Thus, it is necessary to pay attention to factors related to the occurrence of stunting, especially in toddlers aged 0-59 months to prevent stunting.

CONCLUSIONS
There is a relationship between mother's education, family income, visits to antenatal care, birth weight of toddlers, and exclusive breastfeeding with the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency.Based on these Vol 5 results it can be concluded that the factors that can influence the incidence of stunting in toddlers aged 0-59 toddlers in Bonomerti Kecamata Suruh Semarang Regency are mother's education, family income, antenatal care visits, toddler birth weight, and exclusive breastfeeding.
It is recommended that mothers attend routine antenatal care visits to detect early the risk of stunting in the fetus.Discuss proper nutritional intake with health workers, including nutritious foods and necessary supplements.Pregnant women are also advised to maintain personal hygiene and health and avoid risk factors that can affect fetal growth.With consistency in antenatal care and attention to nutrition, we can reduce the risk of stunting in children.
research data was processed using the Statistical Package for the Social Sciences (SPSS) version 23 software.This research has received ethical approval by the Health Research Ethics Commission Team of the Faculty of Medicine, Muhammadiyah University of Surakarta number 5009/B.1/KEPK-FKUMS/VII/2023.Vol 5 the statistical tests that have been carried out show that there is a relationship between maternal education and the incidence of stunting in toddlers aged 0-59 months in Bonomerto, Suruh District, Semarang Regency with an Odds Ratio (OR) = 33.526(95% CI = 4.257 -264.040),meaning that mothers with a high level of education has a 33.526 times chance of preventing stunting under five at the age of 0-59 months compared to mothers Vol 5

Table 1 Characteristics of Respondents (n=144)
Based on table 1 it is known that the respondents in this study totaled 144 adults with an age range of 20 years to 44 years.A total of 136 people (94.4%) were married or married and 8 people (5.6%) were divorced.Bonomerto area, Suruh District, Semarang Regency, as many as 57 married couples (39.6%) had one child, 54 couples (37.55) had two children, 30 couples (20.8%) had three children, and 3 couples (2.1%) have four children.The average population in the Bonomerto area, Suruh District, Semarang Regency for wives/mothers does not work (59.7%) while husbands/fathers work as laborers/farmers (36.1%).

Table 2 Frequency Distribution of Factors Associated with Stunting in Toddlers Aged 0- 59 Months in Bonomerto, Suruh District, Semarang Regency (n=144)
Table2explains that of the 144 respondents who were sampled in this study, most of them had high school education or equivalent, as many as 78 people (54.2%) with high income in 100 families (69.4%).In the variable of antenatal care visits, 114 people (79.2%) are classified as having frequent antenatal care visits.The weight of newborns in the Bonomerto area, Suruh District, Semarang Regency, as many as 121 babies (84%) were classified as normal and as many as 92 babies (63.9%) in that area were exclusively breastfed.Then there were 129 babies (89.6%) in Bonomerto, Suruh District, Semarang Regency who were not stunted.