THE ROLE OF INDIVIDUAL, HOUSEHOLD, AND,

PRIMARY HEALTH CARE’S SERVICES TO SEVERE

MALNUTRITION IN UNDER FIVE YEARS CHILDREN

IN INDONESIA

By :

Budi Setyawati

Julianti Pradono

Rika Rachmalina

NATIONAL INSTITUTE OF HEALTH AND RESEARCH DEVELOPMENT

MINISTRY OF HEALTH-2014

BACKGROUND

The first five years of live times is very important,

there is ‘Period window of opportunity’ in first

two years very critical period for brain,

physical and mental development in children.

Failure of growth in this period is adverse and

irreversible (Unicef, 1998).

Impaired growth in children will decrease their

intelligency (Licari et al, 2005)

Severe malnourished children is more likely to

die than those who are not (Pelletier, 2003).

METHOD

Desain: a cross-sectional study

Data : National Basic Health Research (Riskesdas

2010) & Health Facilities Research (Rifaskes

2011).

Sampel :

Under five years old children (0-59 mo).

The family of those under five years old children.

Primary health care.

Dependent variable :

nutritional status of children under five years.

METHOD

Independent variables:

Individual level (4) : infection, energy-protein consumption, weighing, immunization;

Family level(7) : mother’s education; mother’s parity; drinking water quality; facilities of defecation; liquid waste disposal; household waste handling ; Family’s economic status

Primary health care of sub-district level (7) : services; training; reporting; Ratio of physicians and population; midwives and population; TPG and population; Region with DTPK status (Daerah tertinggal, perbatasan kepulauan; remote area, borderline or islands).

Variables Operational Definitions Indicators

Individual level (children under five years old)

Severe

malnutrition Based on Z-Score of weight for age value

Severe malnutrition is Z-Score < -3

(WHO, 2005)

0 : Z-score ≥ -3

1 : Z-score < -3

History of

children’s

illnesses

History of being suffered from malaria or other

illnesses within first 6-48 hours of birth or in the

first 28 days of birth

0 : never been ilness

1 : had the illness

Immunization

Status Having complete immunization according to

children’s age. (Tuberculosis, Dipthery-Pertussis,

Measles, Polio, Tetanus, Hepatitis B).

0 : Complete

Immunization

1: Incomplete

Immunization

Energy-protein

Intake

The adequacy of energy-protein intake according

to RDA (AKG WKNPG, 2004). 0 : adequate energy

protein intake

1: inadequate energy

protein

consumption

Routine

weighing the

children

Weighing the children in consecutive months for

the last 6 month (according to age).

0 : weighing in

consecutive months

1: not weighing in

consecutive

moths

Variables Operational Definitions Indicators

Household level

Mother’s

education

mother's formal education 0 : ≥ SMP (junior high

school)

1 : < SMP

Parity The number of children had been born 0 : children < 3

1 : children ≥ 3

Family economic

status

Total living cost expenditure, using quintil 2. (Rp.

1,085,523)

0 :enough( ≥ quintil 2)

1 : less (< quintil 2)

The quality of

drinking water

composite variables of drinking water quality

(colorless, tasteless, and odorless). the distance

between the source of drinking water to septic

tank/stool (> 10 m) is also considered, when the

water source is from wells/ pumps /springs /

reservoirs /

0 : good quality

1 : not good quality

Variabel Definisi Operasional Indikator

Fesses

disposal

facilities

Composites of toilet type and fesses disposal.

Good : type of toilet is swan neck and landfills septic

tank/SPAL.

Not good : the toilet plengsengan/pit/cubluk/no or a

final disposal of excreta: pool/field/river/sea lake/ holes

in the ground /beach/field/garden.

0 : good

1 : not good

Household

liquid waste

disposal

Good:

bathrooms/washrooms and kitchen waste is discarded

into the SPAL or covered disposal in the yard.

Not good:

Waste is discarded into opened disposal in the

yard/outside yard/ shelters (ground)/ into the

gutter/river.

0 : good

1 : not good

Household

waste

handling

Good:

garbage is discard into trailer trash/landfilled in the

house yard/ composting

Not good:

garbage is burned/dumped into the river stream

/ditches/sea or carelessly discarded.

0 : good

1 : not good

Variabel Definisi Operasional Indikator

Primary health care at sub-distric level

Training Training of growth monitoring and management of

malnutrition.

Good: The primary health centre provide training.

0 : good

1 : not good

Health

services

Composite from variables : service of weighing children’s

body, giving PMT recovery (recovery supplementary

feeding), prevention of diarrhea, and immunization

outside /inside the building.

0 : good

1 : not good

Writing report Monthly reporting (nutrition, MCH and immunization) and

nutritional surveillance reporting.

0 : good

1 : not good

The ratio of

doctors and

population

The number of doctors in Primary health care (PHC) per

population. Ideal: ≥ 40 physicians / 100,000 population.

0 : ideal

1 : not ideal

The ration of

midwifes and

population

The number of midwifes in Primary health care (PHC) per

population. Ideal: ≥ 100 bidan /100.000 penduduk 0 : ideal

1 :not ideal

The ratio of

TPG and pop

The number of in Primary health care (PHC) per

population. Ideal: ≥ 22 TPG /100.000 penduduk.

(TPG=nutritionists)

0 : ideal

1 : not ideal

DTPK status DTPK is remote area, in the borderline or islands. 0 : non DTPK

1 : DTPK

METHOD

Data management: Cleaning the data

Composite the data (grouping some certain data)

Data analysis:

Data is analysed using logistic regression to obtain candidate variables that influence severe malnutrition. Further analysis is using modeling multilevel logistic regression using Stata program

RESULTS

Overall samples that were analyzed: 7613

children under five years old living in 7032

families and in 1887 sub-districts in Indonesia.

5.60%

84.40%

Nutritional status of under five children

Severe malnutrition

not severe

malnutrition

RESULT

94.4

5.6

14.1

85.9

35.7

64.3

53.3

46.7

83.7

16.3

0

10

20

30

40

50

60

70

80

90

100

Tidak buruk Buruk Cukup Kurang Rutin ditimbang Tidak rutinditimbang

Imunisasilengkap

Imunisasi tidaklengkap

Sehat Pernah sakit

Status Gizi Kons. Energi – Protein Penimbangan Imunisasi Status sakit

Individual sample characteristic

RESULT

Household sample characteristic

RESULT

Variables OR 95% CI p

Individual level

Weighing children 1,28 1,026 – 1,607 0,029*

Energy-protein intake 1,41 1,001 – 1,991 0,049*

Immunization status 1,33 1,078 – 1,645 0,008*

Household level

Mother’s education 1,61 1,302 – 1,996 0,005*

Mother’s parity 1,33 1,088 – 1,629 0,01*

Household waste handling 1,59 1,210 – 2,078 0,05*

Primary health care at sub-distric level

Reporting 1,33 1,087 – 1,624 0,05*

THE RESULTS OF MULTIVARIATE ANALYSIS ON SEVERE MALNOURISHED

UNDER FIVE YEARS OLD CHILDREN IN INDONESIA

FINAL MODEL OF MULTILEVEL LOGISTIC REGRESSION ANALYSIS OF SEVERE MALNOURISHED

CHILDREN UNDER FIVE YEARS 0LD IN INDONESIA

Model1

(null)

Model 2

(Individual)

Model 3

(household)

Model 4

(PHC)

Individual level

Weighing the children: not routinely 0,368 0,320 0,317

Energi-protein intake : inadequate 0,600 0,473 0,460

Immunization status : incomplete 0,609 0,383 0,387

Household level

Mother’s education : < SMP 0,520 0,503

Mother’s parity: ≥ 3 0,360 0,364

Household waste handling: not

good

0,699 0,696

Primary health care at sub-distric level

Reporting : not good 0,427

Random Efect (SE)

Varians level 2 (household) 3,340 2,971 3,096 2,975

Varians level 3 (primary health

care)

1,234 0,914 0,673 0,641

ICC( INTERCLASS CORRELATION COEFFICIENT)

ICC Model

ICC level 1 (Individual) 41,8%

ICC level 2 (Household) 42,5%

ICC level 3 (Primary health care at sub-distric level) 15,7%

From the calculation of the ICC is shown that the role of

household level to severe malnutrition status of under five

years old children in Indonesia, is the greatest (42.5%,) in

household level, followed individual level (41.8%) and health

services in sub-district Primary health care level (15.7%).

VALUE OF OR, MOR AND IOR FOR RISK SEVERE MALNUTRITION IN CHILDREN Level 0 Level 1 Level 1,2 Level 1,2,3

Odds Ratio (OR)

Determinant of Individual level

Weighing the children: not

consecutive month/not routinely

1,44 1,38 1,37

Energi-protein intake: inadequate 1,82 1,60 1,58

Immunization status : incomplete 1,84 1,47 1,47

Median Odds Ratio (MOR)

Household level 5,72 5,18 5,36 5,18

PHC at sub-distric level 2,89 2,49 2,19 2,15

Interval Odds Ratio (IOR)

Determinant of household level

Mother’s education : ≥ SMP 1 1

: <SMP 0,069-40,82 0,073-37,68

Mother’s parity : < 3 1 1

: ≥ 3 0,059-34,78 0,063-32,79

Household waste handling: good 1 1

: not good 0,083-48,82 0,088-45,70

Determinant of PHC at sub-distric level

Report writing: good 1

: not good 0,36-6,54

RESULT

Peran var tk Individu terhadap gizi buruk

Tk RT : PCV (3,340-2,971)/3,340 x 100% = 11,04%

var tk indiv (penimbangan, konsumsi energi-protein dan imunisasi) menerangkan 11,04% variasi gizi buruk pada tk RT.

Tk Kec : PVC : (1,234-0,914)/1,234 x 100% = 25,93% var tk indiv (penimbangan, konsumsi energi-protein dan imunisasi) menerangkan 25,93%. variasi yang terjadi di tingkat kecamatan.

OR Penimbangan ; 1,37 ; OR kons energi-prot : 1,58; OR imunisasi : 1,47

RESULT

Peran var RT thd gizi buruk

Tk RT :2,971 3,096 var RT ≠ berperan pd variasi gizi buruk di tk RT

Tk yankes : PVC : (0,914-0,673)/0,971 x 100% = 26,37% . peran var

RT (pendidikan ibu, jumlah anak dan penanganan sampah) dapat

menerangkan 26,37% variasi di tk yankes

MOR : 5,36 balita di RT (≠ rutin ditimbang, konsumsi energi-

protein < kecukupan, imunisasi ≠ lengkap, ibu ≠ tamat SMP, jumlah

anak ≥ 3 orang, dan penanganan sampah kurang baik) berpeluang

gizi buruk 5,36 kali. Nilai MOR > 1 menunjukkan bahwa terdapat

variasi kejadian gizi buruk antar rumahtangga

IOR lebar variasi gizi buruk antar rumahtangga besar. Nilai IOR

pd var RT mencakup angka satu variasi gizi buruk antar RT >

pengaruh variabel kontekstual TK RT (pendidikan ibu, jumlah anak

dan penanganan sampah) terhadap kejadian gizi buruk.

RESULT

Peran var Tk Yankes kecamatan

Peranan var tk yankes dapat menerangkan terjadinya variasi yang terjadi pada tk RT(3,9%) dan kecamatan (4,75%).

MOR : 2,5 balita yang tinggal di kecamatan berisiko (balita yang penimbangannya ≠ rutin, konsumsi energi-protein < kecukupan, imunisasi ≠ lengkap, jumlah anak ≥ 3 orang, penanganan sampah <baik dan pembuatan laporan <baik) berpeluang 2,5 kali mengalami gizi buruk dibandingkan responden yang tinggal di kecamatan yang kurang berisiko terhadap kejadian gizi buruk. MOR > 1 : terdapat variasi kejadian gizi buruk antar kecamatan.

CONCLUSION

Severe malnutrition in under five children is a combination of compositional factors (individual) and contextual factors (household and PHC at sub-district).

The largest role is in household level (42.5%), followed by individual level 41.8%, and PHC at sub-district level (15.7%).

Children have a risk of having severe malnutrition when having inadequate protein-energy intake (OR: 1.58), incomplete immunizations (OR: 1.47) and being weighed not routinely (OR: 1.37).

Household have a risk of having children suffering from malnutrition 5.36 times, when having inadequate protein-energy intake, incomplete immunizations, and being weighed not routine, mother’s formal education is junior high school, having ≥ 3 children, and have unwell household waste handling.

CONCLUSION

Children who live in sub-district PHC which having

inadequate protein-energy intake, incomplete

immunizations, and being weighed not routine,

mother’s formal education is junior high school,

having ≥ 3 children, have unwell household

waste handling and writing report is not good

category have 2.5 times suffering from severe

malnutrition.

SUGGESTION

to prevent malnutrition in children under five years old, an effort of well-preventive and promotive should be done, mainly in health promotion programs for mother, such as knowledge of parenting (consumption, immunizations and monitoring children’s weight) as well as household and environmental sanitation.

For health care personel in primary health care, it is important to do a valid report as for early detection of severe malnutrition and follow-up of the result of that report

Thank You