A Spatial Analysis of Stunting and Its Determinants in Indonesia

Amelia Dyah Kartika Sari* and Rohana Uly Pradita Siregar

Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

Keywords: Lisa, Moran’s I, Spatial Analysis, Stunting.

Abstract: Introduction: Reducing childhood stunting is the first of six goals in the Global Nutrition Targets for 2025

and a key indicator in the second Sustainable Development Goals (SDGs) to Achieve Zero Hunger. Stunting

continues to be a serious public health problem in Indonesia. Significant disparities in stunting prevalence are

not only documented across various socio-economic groups but across provinces and districts as well.

Therefore, the identification of spatial patterns of stunting and its determinants is important for understanding

epidemiology of this public health challenge. Methods: Using data from Indonesian Health Profile 2021,

regression and spatial analysis performed through GeoDa software. Results: The result indicates there are 5

variables that are significantly correlated to stunting prevalence among provinces, with the human

development index being the most significant amongst all. The Moran's I for stunting is 0.182. It indicates

spatial autocorrelation in stunting over the provinces of Indonesia. It is seen from the univariate LISA maps,

that high-high clusters of stunting are found in East Kalimantan and South Kalimantan. Meanwhile the low-

low clusters are found in Southern Sumatra provinces. Conclusion: Our findings reveal greater attention

towards East Kalimantan and South Kalimantan is needed. Several social factors lead to the occurrence of

stunting. Emphasis should be placed on improving health, education, and standard of living.

1 INTRODUCTION

Reducing childhood stunting is the first of six goals

in the Global Nutrition Targets for 2025 and a key

indicator in the second Sustainable Development

Goals (SDGs) to Achieve Zero Hunger (WHO, 2023).

Stunting itself means impaired growth and

development that children experience from poor

nutrition, repeated infection, and inadequate

psychosocial stimulation. Stunting easily becomes

one of major global health problems because stunting

holds impacts to both physical and mental growth of

stunted children and it can not be cured. Children with

stunting will suffer for a lifetime and have a higher

chance to have stunted children in the future.

World Health Organization (WHO, 2023)

estimated that 22% or about 149,2 millions children

around the world were suffering from stunting in

2022. Many developing countries are trying to

overcome this public health problem, including

Indonesia. Indonesia’s Nutritional Status Survey

revealed that in 2022, stunting prevalence in

Indonesia was 21,6% which means there were around

4,5 millions stunted children amongst all live births

(Kemenkes RI, 2023). Hence the situation, the

Indonesian government has stated that stunting

prevention should be included in the national priority

program. Multi-discipline institutions and various

sectors are working together in finding the significant

causes of stunting and how to reduce stunting

incidents effectively.

Significant disparities in stunting prevalence are

not only documented across various socio-economic

groups but across provinces and districts as well.

Therefore, the identification of spatial patterns of

stunting and its determinants is important for

understanding epidemiology of this public health

challenge.

2 METHODS

An in-depth secondary data analysis was conducted

using the Indonesian Health Profile 2021. The

Indonesian Health Profile is based on routine data as

well as survey data from technical units in Ministry

of Health and other related institutions such as

Statistics Indonesia (BPS), Social Security Agency

on Health (BPJS), Ministry of Home Affairs, and The

National Population and Family Planning Board

(BKKBN). The Indonesian Health Profile presents a

national picture, comparisons between provinces, and

198

Sari, A. D. K. and Siregar, R. U. P.

A Spatial Analysis of Stunting and Its Determinants in Indonesia.

DOI: 10.5220/0012903400004564

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 198-202

ISBN: 978-989-758-727-6; ISSN: 2975-8297

trends from year to year. The data were downloaded

from the Ministry of Health website. The dependent

variable is stunting prevalence and there are 8

independent variables, which are human development

index, iron supplementation on pregnant women,

contraceptive prevalence rate, children under five-

year-old growth monitoring, basic immunisation

coverage, exclusive breastfeeding coverage,

supplementary food for maternal malnutrition and

diarrhea treatment for children under five-year-old.

Data analysis was carried out by using GeoDa. The

cluster levels of stunting prevalence were used to

develop prevalence maps at provincial levels. Spatial

heterogeneity of high prevalence/low prevalence

areas of stunting was examined using the Getis-Ord

G-statistic. An OLS (Ordinary Least Square)

regression model was fitted to evaluate the

independent variables linked to stunting prevalence.

3 RESULTS

Figure 1: Distribution of Stunting Across Province.

Figure above is a province-based distribution map of

stunting prevalence in Indonesia. Provinces with

darker colour bear higher prevalence of stunting

while the opposite, provinces shown with lighter

colour have lower prevalence of stunting. The results

of the 2021 Indonesian stunting prevalence mapping

showed a pattern of the spread of the prevalence of

stunting. The maps showed that the highest

prevalence tends to be in the eastern region, while the

lowest is in the western region. So, there's supposedly

a spatial factor that affects the spread of stunting

prevalence in Indonesia in 2021.

Figure 2: Clustering of Stunting.

There are two important informations to extract

from univariate LISA maps above. Provinces with

blue colour in southern Sumatra are called cold spots,

where prevalence of stunting is low and surrounded

by another province with similar characteristics.

Meanwhile, provinces with red colour, which are East

and South Kalimantan, are marked as hotspots, where

prevalence of stunting is remarkably high and they

are surrounded by another province with similar

situation and characteristics. This findings is

important to help the government set priorities in

stunting prevention programs. Government may need

to put special attention to the hot spot and use the cold

spot as pilot model.

Tabel 1: Spatial Regression Model.

Variable Coefficient Std.

Erro

Z-

value

P-value

CONSTAN

69.7456 11.444

6.0940

0.00000

Human

Developm

ent Index

0.745111

0.1685

4.42025

0.00001

Iron

Suppleme

ntation on

Pregnant

Women

0.156379 0.0944

754

1.6552

0.09788

Contracepti

Prevalence

Rate

-0.16277 0.0746

856

2.1794

0.02930

Children-

under-five-

year-old

Growth

Monitoring

0.154217

0.0562

428

2.7419

0.00611

Basic

Immunizat

ion

Coverage

-0.0482479 0.06273

0.76909

0.44184

Exclusive

Breastfeedin

g Coverage

0.197083

0.0508

3.8722

0.00011

A Spatial Analysis of Stunting and Its Determinants in Indonesia

199

Supplement

ary Food for

Maternal

Malnutrition

0.10804

0.06

3770

1.69

431

0.09021

Children-

under-five-

year-old

Diarrhea

Treatment

0.14105

0.05

6251

2.50

759

0.01216

LAMBDA 0.67907 0.12

7585

5.32

251

0.00000

The spatial regression model revealed that

amongst 8 independent variables in this study, only

five variables are significantly correlated to stunting

prevalence. Those variables are human development

index, contraceptive prevalence rate, children under-

five-year-old growth monitoring, exclusive

breastfeeding and diarrhea treatment for children

under-five-year-old. Human development index

variables turn out to be the most statistically

significant to stunting prevalence amongst all

variables.

4 DISCUSSION

According to the World Health Organization (WHO),

stunting is the result of inadequate physical and

cognitive development experienced by millions of

children worldwide. Rooted in a complex interplay of

socio-economic, nutritional, and environmental

factors, stunting's consequences extend far beyond

mere height disparity. Its impact can be observed in

compromised cognitive abilities, weakened immune

systems, and reduced economic productivity later in

life. Tackling stunting requires a comprehensive

approach that addresses not only nutritional

interventions but also emphasizes the importance of

clean water, sanitation, maternal and child healthcare,

and early childhood stimulation (WHO, 2015). By

recognizing the multifaceted nature of stunting and

implementing a holistic strategy, societies can work

towards breaking the cycle of intergenerational

undernutrition and fostering healthier and more

prosperous futures for children (Kemenkes RI, 2022).

This study has projected the clustering of stunting

in Indonesia based on provinces with Southern

Sumatra as cold spot, meanwhile East and South

Kalimantan as hotspot. The discovery holds

significance in aiding governmental prioritization for

stunting prevention initiatives. Special emphasis

might be necessary for addressing the areas of hot

spot, while utilizing the areas of cold spot as a

potential model for pilot programs. The identification

of potential determinants are necessary to design the

most effective and efficient stunting prevention

programmes. There are 5 (five) variables in this study

statistically proven significant in reducing stunting

prevalence. Those variables are human development

index, contraceptive prevalence rate, children under-

five-year-old growth monitoring, exclusive

breastfeeding and diarrhea treatment for children

under-five-year-old.

Human Development Index (HDI) variable has

been identified as a most significant factor

influencing stunting prevalence in children. The HDI,

a composite measure encompassing health,

education, and income indicators, reflects the overall

development status of a country. countries with

higher HDI scores tend to have lower stunting rates

due to improved access to healthcare, education, and

economic opportunities. As the HDI captures various

dimensions of human well-being, including health

services and education quality, its positive

relationship with stunting reduction underscores the

importance of holistic development approaches in

combating malnutrition and promoting child growth.

Ssentongo, et al demonstrated that a combination of

HDI and a proxy for geographical variation explained

54% of the variation in stunting (Ssentongo et al.,

2021).

Results have suggested that higher contraceptive

prevalence rate (CPR) can also have a positive impact

on reducing stunting prevalence among children. For

instance, increased contraceptive use allows women

and couples to better plan and space their

pregnancies, leading to improved maternal health and

nutrition. This, in turn, can contribute to healthier

fetal development and reduced risk of stunting in

children. Family planning programs not only

empower women with reproductive choices but also

enable them to provide better care and nutrition to

their children, thus influencing the reduction of

stunting prevalence.

A study by Kundu, et al found that increased

contraceptive use was correlated with better child

health outcomes, including reduced stunting

prevalence, highlighting the essential role of family

planning in addressing malnutrition and stunting

(Kundu et al., 2022). Another study by Migang et al

stated that by limiting the number of births, parents

can pay more attention to the growth of their children.

It is important to put extra care to children until they

are two years old as that time is known as the golden

ICSDH 2023 - The International Conference on Social Determinants of Health

200

period where the child's growth and development

process occurs optimally (Migang et al., 2022).

Children's growth monitoring plays a crucial role

as well in addressing and mitigating stunting

prevalence. Regular and systematic monitoring of

children's growth, including height and weight

measurements, provides valuable data for early

detection and intervention in cases of stunted growth.

By identifying children who are at risk or already

experiencing stunting, healthcare systems and

policymakers can implement targeted interventions,

such as nutritional supplementation, counselling on

proper feeding practices, and access to healthcare

services.

Fink, et al revealed that growth monitoring had

modest positive effects on children with stunted

growth. Growth monitoring is significant in reducing

stunting prevalence, highlighting its potential to

facilitate timely interventions that positively impact

child development and health outcomes. This

intervention may be a cost-effective tool for reducing

children’s physical growth deficits (Fink et al., 2017).

This study has also demonstrated a significant

correlation between exclusive breastfeeding coverage

and stunting prevalence. Research by Pimpin, et al

indicated that infants who were exclusively breastfed

had a lower risk of stunting compared to those who

received mixed feeding. Exclusive breastfeeding

supports optimal infant nutrition and ensures that

infants receive the appropriate nutrients needed to

prevent stunting and promote healthy physical and

cognitive development (Pimpin et al., 2019).

A more recent study by Anindya, et al stated that

infants aged 6 months who got exclusive

breastfeeding had lower risk of stunting by 0.6 times

than non-exclusive breastfeeding infants. Exclusive

breastfeeding, where infants are fed only breast milk

for the first six months of life, provides essential

nutrients and antibodies that are crucial for healthy

growth and development (Anindya et al., 2020).

The last variable correlated to stunting prevalence

is diarrhea treatment for children under-five-year-old.

Diarrhea, often caused by poor sanitation and hygiene

practices, can lead to nutrient loss, dehydration, and

overall compromised nutritional intake. Timely and

appropriate treatment of diarrhea not only prevents

the immediate adverse effects but also plays a vital

role in preventing long-term consequences like

stunting. When children's health is managed well

during episodes of diarrhea, their ability to absorb

nutrients improves, which in turn supports their

growth and development, ultimately reducing the risk

of stunting (Lee, et al., 2016).

Modern, et al emphasizes the importance of

comprehensive diarrhea treatment programs in

safeguarding child health and promoting growth,

contributing to the overall reduction of stunting

prevalence. The interaction between undernutrition

and infection creates a lethal cycle of worsening

illness and deteriorating nutritional status (Modern et

al., 2020).

5 CONCLUSIONS

The findings reveal greater attention towards East

Kalimantan and South Kalimantan is needed. Several

social factors may lead to the occurrence of stunting.

Spatial analysis showed that Human Development

Index, contraception use, exclusive breastfeeding

coverage, diarrhea treatment, and children’s growth

monitoring had a significant effect on decreasing the

prevalence of stunting in Indonesia.

It is important for the government to put special

attention on East and South Kalimantan while

designing stunting prevention programmes.

Furthermore, the optimization of Posyandu,

enhancing multi-sectoral partnership, and conducting

Communication, Information, and Education (KIE)

activities with innovative methods are strongly

encouraged to increase programme coverage.

ACKNOWLEDGEMENTS

This research is funded by Lembaga Pengelola Dana

Pendidikan (LPDP).

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