Stunting concept
Informants (parents) did not have clear indications to determine whether their children were short or tall. Indicators of their children’s height were obtained by comparing them to their peers. Children were considered to have a short stature if they were shorter than their peers, and vice versa.
"He's short (my son is short), he has a tall friend…it's okay, he'll be tall when he grows up, he'll be tall after circumcision, now he's still small" (Informant 36).
“I see his friends are short… my son is taller… I gave him vegetables, nutritious food, and took him to the Posyandu (Integrated Health Post) so my son would not be not short… In this neighborhood, a lot of children ate (given by their mother) sugar water ma'am…” (Informant 40).
Most Madurese thought that stunting was caused by genetic factors. For example, if the parents are short, the children will also be short. In addition, many parents thought stunting was not a health problem. Children with short stature are normal, and it is not something to be concerned about. As long as children wanted to eat, could do physical activities well, and were not fuzzy, then it meant that the children were fine and healthy. On the contrary, when the children could not do the normal activities, they would sense that something was wrong with them. People have different perceptions regarding stunting and being underweight. Underweight (severe and moderate) was considered a malnutrition problem. Meanwhile, stunting was not a nutrition problem. The parents will be ashamed (disgraced) when their children are diagnosed with malnutrition because they will be considered incompetent in caring for them.
In general, stunting was not a health concern for them. Parents were more focused on the health of the children’s eyes and physical and spiritual condition. Some informants said they did not know about stunting. Most of them thought that stunting was heredity.
“A short baby, I think it is a matter of genetic. The proof is my child. Even though he is short, he is agile and has become a smart boy in his class” (Informant 35).
‘What is stunting? Is it inheritance or what caused it? I’ve been told that stunting is not an inheritance factor, but what I see is that when the father is tall, then the children are tall. However, when the father is short (just like my neighbors), then the whole family will be short too, because their mom is short too” (Informant 33).
" Yes, it was destiny. From the God, who destined the children is short. His father is a short man, his mother is a short woman, and his grandfather is a short man. What can you do." (informant 33).
People’s knowledge of stunting was limited only to knowing the term, and most of them thought it was not a big problem because they thought stunting was hereditary and could not be changed. People also believed that stunting was their destiny. It was a dogma that had to be accepted and was unable to be changed. However, some residents were curious about stunting and asked what stunting was and how to prevent it (after hearing about the stunting issue). On the other hand, the active Posyandu cadres had more exposure to stunting information from the health workers (especially midwives) than housewives.
"The midwife used to give us information about stunting several times at the Posyandu, I also wondered whether my child was a stunted baby or not. The midwife also gave lessons on nutrition for stunted children." (Informant 31)
Several informants mentioned that their children were taller than their parents at the same age. Some informants stated that their children consumed more milk, so they were taller than their parents. People believed that short children usually had special advantages, such as high intelligence and agility.
“"Well, I hope, even though my son is short, he can be as clever as Mister Habibi (former Indonesian President) and Mister Mahfud MD (Madurese who became Indonesian minister), because usually short people have a clever and ingenious mind." (Informant 35)
Eating concept
The concept of eating, according to the Madurese, is “eating rice.” Therefore, the most important thing is to eat rice. The Madurese respondents considered if someone is not yet consuming rice, then that person is said to have not yet eaten. Eat without other dishes is fine as long as there is rice on the plate. Observations discovered that many stunting children (mainly under 1 year old) were only given rice and soup compared to normal children who eat various food. Many children consumed rice with soup only (without the vegetables, meat, fish, or noodles) such as fish stock, vegetable soup, meatball soup, instant noodles soup, and soto soup. The stunting children’s diets were less diverse than normal children.
"For people in here, the most important food is rice Miss..., just eat rice with no fish is okay, as long there is rice. For children are given soup or stock, just like that, to make the rice be swallowed quickly. Soto soup, Sarimi (instant noodles) soup, meatball soup. Sarimi soup be the most type of soup added to rice which eaten almost everyday." (Informant 13)
Child feeding practices
In general, children’s consumption consists of staple foods and animal and or plant protein foods. Rice, corn rice, and noodles were the most commonly consumed staple foods. Meanwhile, saltwater fish, freshwater fish, and eggs were the most popular animal foods. Fried tempeh or fried tofu were popular plant protein sources. These animal and plant protein sources foods are widely available in the nearest food stalls or mobile vegetables vendors with affordable prices, and children consumed it daily.
Children under five had low consumption of vegetables and fruit. Most children only ate vegetable soup to make it easier for them to swallow food. The vegetables provided consisted solely of water/soup and no actual vegetables. The noodle soup was also preferred and consumed by children younger than 1 year.
The complementary foods often given to children under 1 year were mashed foods such as baby porridge, rice porridge, rice flour porridge, rice cake, and smooth or mashed papayas or bananas. The porridge was then added with soup, fish stock, vegetable soup, or plain water (if there was no soup or stock) to make the children easily swallow the food (Fig. 2). Some children over 1 year old were still given mashed rice with stock, soup, or water. Observation of non-stunting children showed that their parents added milk to their children’s porridge.
Children (above 1 year old) who ate solid food were given family food and snacks. The snack consumption habit was relatively high in order to make children calm and not fuzzy.
Children over 2 years old were eating family food and snacks. Figure 3 shows that children ate white rice, corn rice (a mix of white rice and finely ground corn), or noodles as carbohydrate food sources. Fried fish, eggs, and fried foods (tempeh, tofu, or corn fritters) were mostly consumed as animal and plant protein food sources. Moringa leaves and vegetable soup were the most common vegetables consumed by children under five (Fig. 4).
According to children’s nutritional status, many stunted children (particularly those under 1 year old) were fed only rice and soup or fish stock. In contrast, non-stunting children ate rice with other dishes such as fried fish, fried tempeh or tofu, and vegetable soup.
Snacks that were consumed by children were meatballs (pentol), nuggets and sausages, fried food, puffed and extruded snacks, jelly, bread, biscuits, chips, and others that were widely available around the house (Fig. 5). Observation revealed that many parents were not limiting or restricting their children’s snacks.
The snack expenditure for children varied, ranging from IDR 5000–15,000 a day (equal to USD 0.34–1.11). The pocket money and snacks for children in the coastal area were higher and more varied than those in the agricultural areas. The observation showed that children 2–5 years old had been given sugar-sweetened beverages and soft or carbonated drinks.
Meatballs (pentol) were a very popular snack among toddlers and their mothers. Almost every day, toddlers consume meatballs (pentol) for IDR 5000–10,000 (equal to USD 0.34–0.67). Meatballs in the agricultural area were made from tapioca flour, wheat flour, and spices and then boiled. Finally, it was served with chili sauce or sweet soy sauce. Meanwhile, the meatball dough in the coastal area was enriched with fish or shrimp. There were abundant meatball sellers (mobile vendors and food stalls) in both regions, making it easy for children or their mothers to buy these snacks daily.
Some mothers assumed healthy food was expensive (beef, chicken, milk, apples, and pears), so they could not consume it daily. Meanwhile, the observation showed that they could easily access vegetables and fruits that grew around their house such as moringa leaves, corn, mung beans, sugar-apple, and mango. Corn and mung beans are the most widely cultivated plants besides rice in Gunung Maddah Village. The Moringa trees grew around their house, and their leaves could be harvested at any time. There were also sugar-apple “srikaya” (Annona squamosa) and mango trees in the surroundings. The locals did not know that the vegetables and fruits around their houses were healthy food.
" Where does the money come from to buy fish, vegetables, and milk? Fruits are seasonal. If it's in season, we eat fruit; otherwise, we don't eat it” (Informant 31)
People often neglect sufficient and diverse food consumption (balanced nutrition). Instead, most people think they should eat modestly, but it is crucial to have a good house. They care more about their social status and their assets, especially having a magnificent and wonderful house. Having a decent and big house is an essential thing for people. Most houses in the agricultural and coastal areas were permanent houses with bricks and walls.
" Yes, people think it does not matter what you eat, as long as they can eat something, not the results of their work that is eaten continuously, so the results of their work cannot be seen if the house is not made of stone (permanent house with brick and walls) and not luxurious. The family will be ashamed. " (informant 31)