Faktor Risiko Stunting, Anemia, dan Koeksistensinya pada Anak Usia Sekolah (6-9 Tahun) di Perdesaan, Perkotaan, dan Indonesia

Abstract

Stunting dan anemia merupakan masalah kesehatan masyarakat di Indonesia. Stunting, anemia, dan Koeksistensi Stunting dan Anemia (KSA) dapat berpengaruh terhadap terhambatnya perkembangan psikomotor, sosio-emosional, serta performa akademik yang kurang baik pada anak. Usia 6-9 tahun merupakan periode anak usia sekolah yang tepat untuk mengidentifikasi faktor risiko stunting, anemia, dan KSA karena anak belum mengalami second growth spurt atau puncak pertumbuhan sebelum tinggi badan akhir tercapai, serta perempuan belum menarche. Tujuan penelitian adalah menganalisis faktor risiko stunting, anemia, dan koeksistensinya pada anak usia sekolah (6-9 tahun) di wilayah perdesaan, perkotaan, dan Indonesia. Penelitian cross-sectional ini menggunakan data sekunder Indonesian Family Life Survey (IFLS) gelombang 5 tahun 2014-2015 dari RAND Corporation, United States dengan unit analisis nasional. Penelitian ini dilaksanakan sejak Oktober 2021-Februari 2022. Subjek penelitian berjumlah 1986 anak berusia 6-9 tahun yang berasal dari 13 provinsi di Indonesia, terdiri dari 858 subjek di perdesaan dan 1128 subjek di perkotaan. Variabel penelitian adalah karakteristik subjek (usia, jenis kelamin), status gizi subjek (nilai z TB/U dan status anemia), karakteristik orang tua (usia, status merokok, lama sekolah, pekerjaan, status perkawinan, tinggi badan), karakteristik keluarga (besar keluarga, kepala keluarga, wilayah tinggal, skor sanitasi lingkungan, akses listrik, dan Wealth Index/WI), kebiasaan (frekuensi konsumsi pangan) dan kualitas konsumsi pangan subjek (Individual Dietary Diversity Score/IDDS), dan status gizi orang tua (IMT dan status anemia). Analisis data yang digunakan meliputi analisis univariat (uji deskriptif), analisis bivariat (uji beda menggunakan Independent t-test, Mann-Whitney test dan Chi-squared test (ꭓ2 ) dan uji korelasi menggunakan Pearson test, Spearman test, dan Chi-squared test (ꭓ2 )), serta analisis multivariat menggunakan uji regresi logistik). Pengolahan data status gizi subjek menggunakan WHO AnthroPlus version 1.04, dan untuk variabel lainnya menggunakan Microsoft Excel 2010 dan STATA version 16.0. Analisis data menggunakan IBM SPSS version 23.0. Rata-rata nilai z TB/U, IDDS subjek, frekuensi konsumsi telur, daging, susu, pisang, pepaya, wortel, fast food, dan makanan manis subjek signifikan lebih rendah di perdesaan dibandingkan perkotaan. Sebaliknya, rata-rata frekuensi konsumsi ikan, sayuran hijau, dan sambal signifikan lebih tinggi di perdesaan dibandingkan perkotaan. Meskipun demikian, rata-rata usia, kadar Hb, proporsi jenis kelamin subjek, frekuensi konsumsi nasi, ubi, mangga, mie instan, minuman soda, dan gorengan subjek tidak berbeda signifikan antar wilayah tinggal. Rata-rata usia, lama sekolah, tinggi badan, dan IMT orang tua; WI; skor sanitasi lingkungan; dan proporsi ibu bekerja; signifikan lebih rendah di perdesaan dibandingkan perkotaan. Sebaliknya, proporsi ayah perokok aktif dan rumah tangga yang tidak memiliki akses listrik signifikan lebih tinggi di perdesaan dibandingkan perkotaan. Meskipun demikian, rata-rata kadar Hb orang tua, besar keluarga, proporsi ayah bekerja, ibu bukan sebagai perokok aktif, kepala keluarga, dan status perkawinan orang tua tidak berbeda signifikan antar wilayah tinggal. Prevalensi stunting di perdesaan, perkotaan, dan nasional berturut-turut adalah 31,8%, 19,5%, dan 24,8%. Prevalensi anemia di perdesaan, perkotaan, dan nasional berturut-turut adalah 32,1%, 29,3%, dan 30,5%. Prevalensi KSA di perdesaan, perkotaan, dan nasional berturut-turut adalah 10,4%, 7,5%, dan 8,8%. Prevalensi stunting dan KSA signifikan lebih tinggi di perdesaan dibandingkan perkotaan. Namun, prevalensi anemia tidak berbeda signifikan antar wilayah tinggal, hanya cenderung lebih tinggi di perdesaan dibandingkan perkotaan. Faktor risiko stunting di perdesaan adalah ayah dan ibu pendek (OR=2,05, OR=2,23), skor sanitasi lingkungan rendah (OR=2,27), dan besar keluarga sedang (OR=1,42). Faktor risiko stunting di perkotaan adalah ayah dan ibu pendek (OR=2,00, OR=2,81), IDDS tergolong tidak beragam (OR=1,64), subjek anemia (OR=1,81), lama sekolah ibu <12 tahun dan 12 tahun (OR=1,90, OR=1,83), skor sanitasi lingkungan sedang (OR=2,15), dan ayah underweight (OR=1,81). Faktor risiko stunting di Indonesia adalah ayah dan ibu pendek (OR=2,00, OR=2,49), IDDS tergolong tidak beragam (OR=1,30), subjek anemia (OR=1,35), lama sekolah ibu <12 tahun (OR=1,73), skor sanitasi lingkungan rendah dan sedang (OR=2,36, OR=1,36), ayah underweight (OR=1,59). Faktor risiko anemia di perdesaan adalah usia subjek lebih muda (6-7 tahun) (OR=2,01), ayah dan ibu anemia (OR=1,92, OR=2,61). Faktor risiko anemia di perkotaan adalah usia subjek 6-7 tahun (OR=1,85), ayah dan ibu anemia (OR=1,51, OR=1,61), dan subjek stunting (OR=1,69). Faktor risiko anemia di Indonesia adalah usia subjek 6-7 tahun (OR=2,01), ayah dan ibu anemia (OR=1,69, OR=1,97), dan subjek stunting (OR=1,32). Faktor risiko KSA di perdesaan adalah usia subjek 6-7 tahun (OR=2,02), ayah dan ibu pendek (OR=1,89, OR=1,84), dan ibu anemia (OR=1,66). Faktor risiko KSA di perkotaan adalah usia subjek 6-7 tahun (OR=1,80), dan ibu pendek (OR=2,04). Faktor risiko KSA di Indonesia adalah usia subjek 6-7 tahun (OR=1,96), serta ayah dan ibu pendek (OR=1,64, OR=1,89). Karakteristik subjek dan keluarga secara umum tidak berbeda signifikan antar wilayah tinggal. Di perdesaan, konsumsi pangan lebih tidak beragam, sanitasi lingkungan dan status ekonomi lebih buruk dibandingkan perkotaan. Prevalensi stunting, anemia, dan KSA lebih tinggi di perdesaan dibandingkan perkotaan. Berbagai faktor meningkatkan risiko satu atau kedua malnutrisi. Faktor risiko utama stunting di perdesaan adalah skor sanitasi lingkungan rendah. Faktor risiko utama stunting di perkotaan dan nasional, dan KSA di perkotaan adalah ibu pendek. Faktor risiko utama anemia di perdesaan dan nasional adalah ibu anemia. Faktor risiko utama anemia di perkotaan dan KSA di perdesaan dan nasional adalah usia subjek 6-7 tahun. Oleh karena itu, keragaman konsumsi subjek yang sudah baik perlu dipertahankan. Pemerintah perlu melanjutkan program wajib belajar 12 tahun, melakukan perbaikan fasilitas air bersih dan sanitasi, dan melaksanakan pendidikan gizi terkait sanitasi lingkungan. Berdasarkan faktor risiko teridentifikasi, kebijakan untuk mengatasi stunting, anemia, maupun KSA tidak dapat digeneralisasi antar wilayah tinggal karena memiliki faktor risiko yang bervariasi. Penelitian selanjutnya disarankan menganalisis perbedaan faktor risiko stunting, anemia, dan KSA antara usia sebelum dan setelah menarche pada Anak Usia Sekolah (AUS).

Stunting and anemia are become a public health problem in Indonesia. Stunting, anemia, and coexistence of stunting and anemia (CSA) could affect the retardation of psychomotor, socio-emotional, and poor academic performance among children. Age 6-9 years is an appropriate period for school-aged children to identify risk factors of stunting, anemia, and CSA because the children have not experienced a growth spurt or peak growth before the final height is reached, and girls have not menarched. It provides a chance to catch-up and improve nutrition just before the adolescence period (the second window opportunity). The objective of this study is to analyze risk factors of stunting, anemia, and CSA among schoolaged children (6-9 years) in rural, urban, and Indonesia. This cross-sectional study using the secondary dataset of the Indonesian Family Life Survey (IFLS) wave 5 in 2014-2015 from RAND Corporation, United States, with national unit analysis. This study was obtained from October 2021- February 2022. The number of subjects were 1986 children aged 6-9 years from 13 provinces in Indonesia, consisting of 858 subjects in rural areas and 1128 subjects in urban areas. Variables being studied were subject characteristics (age, gender); subject’s nutritional status (HAZ, anemic status); parent characteristics (age, smoking status, length of study, occupation, marital status, height); household characteristics (family size, household head, living area, environmental sanitation score, electricity access and Wealth Index/WI); subject’s food habits (consumption frequency) and diet quality (Individual Dietary Diversity Score/IDDS); and parental nutritional status (BMI, anemic status). Data analysis used included univariate analysis (descriptive test), bivariate analysis (different test using Independent t-test; Mann-Whitney test; and Chi-squared test (ꭓ 2 ), and correlation test using Pearson test; Spearman test; and Chi-squared test (ꭓ 2 )), and multivariate analysis using logistic regression test. Data processing of subject’s nutritional status using WHO AnthroPlus version 1.04, and other variables using Ms. Excel 2010 and STATA version 16.0. Data analysis using IBM SPSS version 23.0. The average subject’s HAZ, IDDS, consumption frequencies of egg, meat, dairy, bananas, papaya, carrots, fast food, and sweet foods were significantly lower in rural than urban areas. In contrast, the average consumption frequencies of fish green leafy vegetables, and chili sauce were significantly higher in rural than urban areas. Nevertheless, the average subject’s age, Hb level, gender proportion, and the average consumption frequencies of rice, tuber, mango, instant noodles, coke, and fried foods were not significantly different between living areas. The average parental age, length of study, height, and BMI; WI; environmental sanitation score; and the proportion of working parents were significantly lower in rural than urban areas. In contrast, the proportions of active smoker father and household who doesn’t have electricity access were significantly higher in rural than urban areas. Nevertheless, the average parental hemoglobin level, family size, proportions of non-active smoker mother, household head, and parent’s marital status were not significantly different between living areas. The prevalence of stunting in rural, urban, and national areas were 31,8%, 19,5%, and 24,8%, respectively. The prevalence of anemia in rural, urban, and national were 32,1%, 29,3%, and 30,5%, respectively. The prevalence of CSA in rural, urban, and national were 10,4%, 7,5%, and 8,8%, respectively. The prevalence of stunting and CSA were significantly higher in rural than urban areas. Nevertheless, the prevalence of anemia was not significantly different between living areas. It tended to be higher in rural than urban areas. Risk factors of stunting in rural areas were paternal and maternal short stature (OR=2,05, OR=2,23), low environmental sanitation score (OR=2,27), and medium family size (OR=1,42). Risk factors of stunting in urban area were paternal and maternal short stature (OR=2,00, OR=2,81), IDDS classified as not diverse (OR=1,64), anemic subject (OR=1,81), maternal length of study <12 years and 12 years (OR=1,90, OR=1,83), medium environmental sanitation score (OR=2,15), and paternal underweight (OR=1,81). Risk factors of stunting in Indonesia were paternal and maternal short stature (OR=2,00, OR=2,49), IDDS classified as not diverse (OR=1,30), anemic subjects (OR=1,35), maternal length of study <12 years (OR=1,73), low and moderate environmental sanitation score (OR=2,36, OR=1,36), underweight father (OR=1,59). Risk factors of anemia in rural areas were younger subjects (aged 6-7 years) (OR=2,01), paternal and maternal anemia (OR=1,92, OR=2,61). Risk factors of anemia in urban areas were subjects aged 6-7 years (OR=1,85), paternal and maternal anemia (OR=1,51, OR=1,61), and stunted subjects (OR=1,69). Risk factors of anemia in Indonesia were subjects aged 6-7 years (OR=2,01), paternal and maternal anemia (OR=1,69, OR=1,97), stunted subjects (OR=1,32). Risk factors of CSA in rural areas were subjects aged 6-7 years (OR=2,02), paternal and maternal short stature (OR=1,89, OR=1,84), and maternal anemia (OR=1,66). Risk factors of CSA in urban areas were subjects aged 6-7 years (OR=1,80) and maternal anemia (OR=2,04). Risk factors of CSA in Indonesia were subjects aged 6-7 years (OR=1,96), and paternal and maternal short stature (OR=1,64, OR=1,89). Subject’s, parental, and household characteristics generally were not significantly different between living areas. In the rural areas, food consumption was less diverse. Environmental sanitation and economic status were also worse in rural than urban areas. The prevalence of stunting, anemia, and CSA were higher in rural than urban areas. Various factors increase the risk of one or both malnutrition. The main risk factor of stunting in rural areas was a low environmental sanitation score. The main risk factor of stunting in urban and national, and CSA in urban areas was maternal short stature. The main risk factor of anemia in urban, and CSA in rural and national areas was subjects aged 6-7 years. Therefore, a good variety of food consumption needs to be maintained. It is also necessary to continue with the 12 years compulsory education program, improvement of clean water and sanitation facilities, as well as nutrition education related to environmental sanitation. Based on the identified risk factors, policies to overcome stunting, anemia, or KSA cannot be generalized between living area because they have varied risk factors. Further research is recommended to analyze the differences in the risk factors of stunting, anemia, and CSA between age before and after menarche among School-Aged Children (SAC).