Table 9. Condition of 30 Respondent under-fives at Birth in Banyumulek Village, Lombok Condition of the under-fives at birth Total (n) Percentage (%)
Full-term 24 80
Preterm/Premature 4 13
Other condition* 2 7
Total 30 100
*low birth weight babies
Tabel 10. Distribution of under-fives Weight at Birth and Length at Birth in Banyumulek Village, Lombok
Weight at Birth (grams) Length at Birth (centimeter)
Average 2800 48.5
Maximum 3900 52
Minimum 1400 45
Table 11. Weight-for-age Z-score comparison of 30 under-fives in Banyumulek Village between before and after intervention
Table 13. Weight-for-length Z-score comparison of 30 under-fives in Banyumulek Village between before and after intervention
Z-score Nutrition Status Before Intervention (n) After Intervention (n)
-2 SD up to + 1 SD Normal 25 25
- 3 SD up to < - 2 SD Wasted 4 4
< - 3 SD Severely wasted 1 0
> + 3 SD Overweight 0 1
BANTEN
Demographic Distribution
The age range for participating under-fives is quite diverse. From 0 to 3 Years. In the results of BLS, the percentage of 2 year olds dominates the age distribution of under five, namely 12 out of 20 people or around 55%. Next, in the ELS data collection, there were 9 new under-fives who were children of pregnant women who were included in the intervention target. So based on the results of the ELS, ages 1 and 2 years are the majority of beneficiaries, namely as many as 9 people or around 32% in each age group.
The educational level of the families of the mothers of the under-aged group is quite diverse.
Starting from not finishing elementary school to D3. The highest percentage of education level for husbands is elementary school graduates, which is 50%. While the highest level of education for wives is elementary and junior high school graduates, which is 40% each. Next, based on the results of the ELS, the majority of the last education of the husband and wife were elementary school graduates, with percentages of 61% and 50%, respectively.
Table 14. Demographic Distribution of 28 under-fives in Tanjung Pasir Village, Banten
Variable Total (n) Percentage (%)
Gender
Girl 17 61
Boy 11 39
Age
0 Year Old 8 29
1 Year Old 9 32
2 Years Old 9 32
3 Years Old 2 7
Table 14. Demographic Distribution of 28 under-fives in Tanjung Pasir Village, Banten (continued) Background Education (Mother)
Elementary School 14 50
Junior High School 9 32
Senior High School 4 14
Diploma 1 4
Background Education (Father)
Elementary School 17 61
Junior High School 5 18
Senior High School 6 21
Income of the Parents per Month (Rp)
< 1.5 Million 5 18
1.5 - 2 Million 12 43
> 2 Million 8 29
Did not answer 3 11
Balanced Nutrition Practices and PHBS
Based on the results of BLS, 70% or 14 mothers under two have given exclusive breastfeeding to their children when they were 0-6 months old. However, 30% or 6 mothers under two do not give exclusive breastfeeding to their children at the age of 0-6 months for unspecified reasons. Next, based on the results of the ELS, there was an increase in exclusive breastfeeding for under-fives to 75% or 21 people. Another 25% still do not give exclusive breastfeeding because the mother is under two working, the color of the mother's breast milk is clear so it is considered not good for consumption, and/or given other foods, such as formula milk and wafers because the child is considered not full.
Figure 25. Percentage Distribution of respondents who breastfed their babies for 6 months In the Clean and Healthy Living Behavior (PHBS) practice, 60% or 12 under-fives admitted that they had diligently washed their hands with soap and clean water. However, 30% or 6 people still only occasionally wash their hands with soap and clean water, while 10% or 2 under-fives rarely do so. Next, based on the results of the ELS, 89% 25 mothers under two and under two have often washed their hands using soap and clean water, and 11% or 3 other people only occasionally.
Figure 26. Percentage Distribution of respondents who wash their hands with soap and clean water In the practice of balanced nutrition, only 15% or 3 mothers under two are diligent in giving fruit and vegetables to their children, while the majority (70%) 14 people admit that they only occasionally consume it, and 15% or 3 mothers under two rarely give fruit and vegetables to his son.
Next, based on the ELS results, there was an increase in fruit and vegetable consumption from 15%
to 21% or 6 people. Meanwhile, 79% or 22 people sometimes eat fruit and vegetables.
Figure 27. Percentage Distribution of respondents who consume fruits and vegetables in a day Based on the BLS results, 95% or 19 under-fives often consume carbohydrate-sourced foods in a day and only 5% or 1 person occasionally consumes carbohydrate-sourced foods in a day. Next, based on the results of the ELS 96% or 27 under-fives often consume carbohydrates every day and the other 4% only occasionally.
Figure 28. Percentage Distribution of respondents who consume carbohydrate sources food in a day Based on the results of the BLS, 85% or 17 under-fives are diligent in consuming food sources of animal protein in a day. Meanwhile, 15% or 3 people admitted that they only occasionally consumed food sources of animal protein in a day, such as eggs, chicken, beef, or fish. Next, based on the results of the ELS, there was an increase to 96% or 27 under-fives who often consumed food sourced from animal protein in a day, and 4% or 1 other person only occasionally.
Figure 29. Percentage Distribution of respondents who consume food sources of animal protein in a day
Based on the results of the BLS, 45% or 9 under-fives admitted that they always consumed food sources of vegetable protein in a day. Meanwhile, 6 people (30%) admitted that they only occasionally and 5 people (4%) rarely consumed food sources of vegetable protein in a day, such as tofu and tempeh. Next, based on the results of the ELS, there was an increase from 45% to 86% or 24 children under the age of five who often consumed food sources of vegetable protein in a day. While 11% or 3 people only sometimes and 4% or 1 other person it is still rare.
Figure 30. Percentage Distribution of respondents who consume food sources of plant protein in a day
Based on the results of the BLS, 35% or 7 under-fives still frequently consume packaged snacks in a day. Meanwhile, 55% or 11 of the infants admitted that they ate only occasionally and the other 10% rarely consumed packaged snacks. Some examples of packaged snacks that are often consumed by under-fives include; chips, wafers, biscuits, rio tea and tea juice. Next, based on the results of the ELS, there was an increase in absorption of packaged snack consumption from 10% to 36% or 10 under-fives who rarely consumed packaged snacks in a day. Meanwhile, 25% or 7 other people still often and 39% or 11 others only sometimes.
Figure 31. Percentage Distribution of respondents who consume packaged snacks in a day Anthropometric Measurement
Based on the data below, there were 1 babies who were born with low birth weight (LBW), which weighed 2400 grams. Babies that can be said to be born with low weight are babies who have a birth weight of less than 2500 grams or 2.5 kg.
Apart from LBW, the baby's birth length must also be considered. The birth length standard for babies is said to be normal if the babies have a minimum birth length of 48 cm. Based on the data obtained all babies have birth length of 48 cm or above, thus all babies are considered normal.
Table 15. Condition of 28 under-fives at Birth in Tanjung Pasir Village, Banten Condition of the under-fives at birth Total (n) Percentage (%)
Normal 27 96
Premature 1 4
Total 28 100
Table 16. Distribution of under-fives Weight at Birth and Length at Birth in Tanjung Pasir Village, Banten
Weight at Birth (grams) Length at Birth (centimeter)
Average 3300 49.4
Maximum 5300 53
Minimum 2400 48
Table 17. Weight-for-age Z-score comparison of 21 under-fives in Tanjung Pasir Village between before and after intervention
Z-score Nutrition Status Before Intervention (n) After Intervention (n)
-2 SD up to + 1 SD Normal 6 3
- 3 SD up to < - 2 SD Underweight 9 12
< - 3 SD Severely underweight 6 6
Table 18. Length-for-age Z-score comparison of 21 under-fives in Tanjung Pasir Village between before and after intervention
Z-score Nutrition Status Before Intervention (n) After Intervention (n)
- 2 SD up to + 3 SD Normal 5 4
- 3 SD up to < - 2 SD Stunted 11 9
> +3 SD Severely stunted 5 8
Table 19. Weight-for-length Z-score comparison of 21 under-fives in Tanjung Pasir Village between before and after intervention
Z-score Nutrition Status Before Intervention (n) After Intervention (n)
-2 SD up to + 1 SD Normal 17 18
- 3 SD up to < - 2 SD Wasted 4 3
iii. Discussion
Hemoglobin in Pregnant Women
Hemoglobin level is one of the important measurements which is required and needs to be monitored regularly in pregnant women. Not only it is important to ensure the mother’s health but also its fetus. Moghaddam & Barjasteh (2015) explains the effect of hemoglobin status with maternal and perinatal mortality and low birth weight. The incidence of anemia can increase up to fourfold in pregnant women compared to other women in general during their first to third trimester.Laflamme (2011) observed the fluctuation of hemoglobin concentration over the three trimester and found a trend that hemoglobin levels tend to decrease and increase during the first and third trimester, respectively. Unfortunately, the data taken and provided in this report does not take into account the gestational age. Thus, based on the data obtained alone it can only be assumed that all beneficiaries are in their third trimester. If the assumption is taken into consideration then most pregnant women are classified as normal or have hemoglobin level more than 11.0 g/dL, although some can be considered anemic for those whose last measurement is below than 11.0 g/dL. These are some of the examples of the importance in regular monitoring of hemoglobin level, due to the detrimental effects towards fetal growth and development and pregnancy outcomes (Haider, et al., 2013). Low
Low birth weight is a crucial period that can affect one’s future health, as it is included in 1000 first days of life where most growth and development in a child is the highest. In association with stunting that is highlighted in this program, Putri, et al. (2021) mentioned preterm birth and low birth weight babies are 2.12 times more likely to grow as stunting compared to babies born normal with normal birth weight. Several other studies also mentioned higher risks to subnormal growth, illnesses and neurodevelopmental problems that are associated with social riks as well (Hack, et al., 1995).
In order to reduce the risk, the nutrition of the mother needs to start as early as before conception to be regularly monitored and prepared, including hemoglobin (Putri, et al., 2021). As such, practice of balanced nutrition intake and clean and healthy lifestyle are included in the assessment. Based on the results there is a significant improvement observed after 6 months of intervention. Most importantly regular blood tablet intake is also observed which is very important to be increased especially before giving birth. Hemminki & Starfield (1978) mentioned that taking blood tablets regularly can increase infant birth weight, however Khambalia, et al. (2009) also mentioned that the effect will be more consistent and significant to reduce anemia if the supplements were taken before conception.
Anthropometric Measurement
After 6 months of intervention in all three villages, the highlighted output was observed in anthropometric measurement results of which was further analyzed and standardized using a Z-score from the Ministry of Health, Indonesia (2020).
As the goal of the program is to reduce the number of malnourished and undernourished of under fives, thus based on the body weight and length/height measured every two weeks, these data are converted into 3 categories; weight-for-age, length/height-for-age, and weight-for-length.
Weight-for-age z-score is used to determine if the under fives have the appropriate body weight for their age, if less than the standard then they are categorized as underweight or severely underweight. Length/height-for-age is used to determine if the under fives have the appropriate length/height for their age, if less than the standard then they are considered as stunted or severely stunted. Lastly, weight-for-length is used to determine the overall health status of the under-fives, from severely wasted, wasted, normal, possible risk of being overweight, overweight, and obese.
Tette et al., (2015) & Ahmad et al., (2020) explains the crucial role of community level socioeconomic status to incidence of malnutrition in both developed and developing countries.
Education, poverty, access to clean water, sanitation are some of which factors mentioned to affect health outcomes to the population. Among those mentioned, poverty and maternal education were found to have the most significant effect on malnutrition in children (Ahmad et al., 2020, Abuya et al., 2012). While children in developing countries or with low socioeconomic status are 2.5 times more vulnerable to malnutrition compared to the one in higher socioeconomic status (Ahmad et al., 2020).
In all of the targeted areas, Losari, Banyumulek, and Tanjung Pasir Village all can be classified as areas with low socioeconomic status. Although the data for monthly income in Losari Village was not recorded, both maternal education backgrounds were dominated with elementary school graduates. As for Banyumulek, the mother’s background education was mostly senior high school graduates and elementary school graduates for the father’s. While in Tanjung Pasir both parents are dominated with elementary school graduates, the same as in Losari. The income varies in Banyumulek and Tanjung Pasir starting from below 1.5 Million Rupiah per month to 1.5 - 2 Million
Rupiah per month, respectively. The effect of low socioeconomic status shown on the number of malnutrition children among the beneficiaries. Furthermore, after the intervention a similar trend was observed in Losari and Tanjung Pasir with a decrease in the number of children with normal z-score of weight-for-age and length-for-age. Contrary to that, results from Banyumulek show a positive increase in the number of children with normal z-score of weight-for-age and length-for-age.
As the data recorded regarding income from each beneficiary were not complete, based on the maternal education alone the highlighted differences were on the background education of the mothers’ in Banyumulek Village. Most mothers there were senior high school graduates which meant a higher education level compared to mothers in Losari and Tanjung Pasir. Abuya et al. (2012) mentioned that there is a strong correlation between maternal education and child’s health, of which children born in higher educated women will be less vulnerable to malnutrition that can manifests into stunting, wasting, and underweight and/or obese compared to those born from women with lower education. Higher knowledge, open-mindedness, and ability to recognize sickness as well as searching for help from the experts are some of the highlighted superiority of higher education women have (Abuya et al., 2012).
Corresponding to the effect of education in the daily practice of balanced nutrition and clean and healthy living (PHBS), there are positive changes observed between before and after intervention in all target areas. The increase in exclusive breastfeeding practices, consumption of carbohydrates, animal protein and plant protein as well as washing hand practices were observed after all education sessions were delivered. This suggests that education plays a crucial role in increasing the healthy diet and clean and healthy living practices. However, the above results are not completely exempted from any other factors that happened both during and after the intervention.
Inconsistency of beneficiaries might be the one the factors that can affect these results.
Throughout 6 months of intervention there are several beneficiaries who got replaced due to moving away, graduated from malnourished status, and other personal reasons of which they did not mention. Thus, some only receive the benefits for several months rather than 6 months. Another factor that might affect the results are the health condition of the under-fives. As body weight can fluctuate from time-to-time, sickness can highly affect the body weight of the under-fives as well.
Children with low birth weight, feeding problems, diarrhea, fever, and other non-communicable diseases may increase the risk of malnutrition (Tette et al., 2015). Over 6 months of intervention, most of the children, especially in Tanjung Pasir got diarrhea and fever alternately, thus a lot have lost a sum of their body weight. Human error can not also be exempted, the condition of measurement in the field especially during the recording of the data may greatly affect the end-results obtained. Other than the facilitator from HI, there are kader, representatives from the village who helped arrange the meetings and thus they were also involved in measuring the body weight and length/height of the children. Additionally, the children sometimes cry or throw tantrums when measured. Thus, an inaccurate measurement of body weight and length/height may affect the results when plotted in the z-score diagram.
b. Nyalakan Harapan
Nyalakan Harapan was a similar project as Pahlawan Gizi where the Human Initiative wants to address the nutrition related problem in the target area. However, different from Pahlawan Gizi, this project was a monthly project thus was only for 1 month due to different sources of funding. It was held from November until December for four weeks in Tanjung Pasir village as the only target area. The intervention program includes nutrition education, supplementary feeding, cooking class,
anthropometry measurement. Similar to Pahlawan Gizi, the beneficiaries were chosen based on the data from local public health centers or puskesmas. However this time the total beneficiaries was only 25 and only consists of the under-fives. As for the measurement tool and benchmark, baseline survey (BLS) was done before any intervention was given to 25 beneficiaries. The survey included the demography distribution of participants, diet practices, and Perilaku Hidup Bersih dan Sehat (PHBS) or clean and healthy lifestyle. Following that the intervention was done through meetings that were held every once a week, thus 4 meetings in total. Usually a meeting lasts for about 3 hours. Upon the participants arrival, they are asked to do anthropometry measurements such as weight and height.
Followed with nutrition education for around 20 minutes by the local nutritionist and the author. The education covers feeding practices and the importance of breastfeeding practices. The nutrition education session was done alternately with cooking class to further visualize the application of the theories that were taught. While after those sessions, supplementary feeding is given to the participants to be taken home. Lastly, by the 4th meeting, an end-line survey (ELS) was conducted as a tool to observe the results of the intervention.
In this project, the author got the opportunities to participate in all of the activities for 4 weeks. It includes doing anthropometric measurement, taking baseline and endline surveys, doing cooking demonstrations and giving the education class.
i. Method
Anthropometry measurement
The anthropometry measurements were done to the children. The measurement includes body weight, length/height, head circumference and upper-hand circumference.
For body weight measurement, digital weight scales were used. The children who can stand on their own weigh themselves. However, those who cannot stand on their own will be weighed with their mother and their weight will be calculated based on the difference of the children’s weight with their mother and the mother’s weight alone. The length of the children were measured using an infantometer. The children will be laid down on the infantometer with their head on the top part and in a straight posture. For the head and upper-hand circumference, measuring tape was used to measure.
Baseline and endline survey
Baseline and endline surveys were done by doing a one-on-one interview with each of the under-fives parents. The baseline survey contains information about their children’s age, birth weight, birth length. It also includes their children’s daily diet practices and how they apply a clean and healthy lifestyle. The same type of questions were used in the endline survey in order to observe the difference between before and after the intervention.
Cooking demonstration
The cooking demonstration was led by the author with the help from the local midwives and local volunteers in Tanjung Pasir village. For that session, the facilitator gave the theme regarding MPASI or complementary foods for infants aged 9-12 months and above 12 months. For infants aged 9-12 months the menu was potato porridge with papaya sauce and nasi tim with fish and eggs for children aged 12 months and above. After the menu was decided, the local volunteers will prepare the ingredients and prepare all of the ingredients so that during the session the procedure left was
just to cook and mix all ingredients. After the dishes are cooked, they are distributed to the children’s parents to try and share it with their children.
Education class
The education class was first delivered by the author with the theme PHBS (Praktik Hidup Bersih dan Sehat) practice, efforts to prevent acute kidney failure in children. The author made a poster related to the theme in advance as a tool to deliver the education. After the information was delivered, the local nutritionist and HI’s facilitator were also to add and open a q&a session for the beneficiaries.
c. Rumah Bunda Sehat (RBS)
Rumah Bunda Sehat was a 9 month project that started around April and ended in January.
The whole project was done in RBS Bekasi. In this particular project, the author was only involved in two kinds of activities in October and November. The first one was to conduct an On-site Distribution Monitoring (ODM) and the second one was to help during the Mama Chef event.
i. Method
On-site Distribution Monitoring (ODM)
ODM was done using Microsoft Form platform. The questions were previously made by the project manager, then converted it into microsoft form. On the day of the event, the author and the project manager take turns interviewing the participants and committee members to fill the ODM survey. The survey consists of 21 questions with 4 sections; execution time and activities, experts, providing assistance, and events and committee. Around 19 answers were collected and were tasked to analyze the answers using Microsoft Excel.
Mama Chef
Mama chef program was done mainly by the local committee members and HI only overview and assists the event through funds, banner printing, sounds system renting, materials for coloring competition, contact experts for nutrition seminar sessions, etc. The task assigned before the day of the event, to take the banner from the vendor and print the materials for the coloring competition.
While on the day of the event the task given was to take documentation and overview the whole event.
ii. Results
On-site Distribution Monitoring (ODM)
As mentioned above, there are 4 sections throughout the survey and below are some of the representative questions taken from each section. Overall there are two types of questions, one with linear scale while the other one fills in the blank. For the linear scale, the scale is represents as below;
1 = not good 2 = less good 3 = enough 4 = good 5 = very well