The Relation of Mother's Knowledge, Parenting Patterns and Household Food Security Status with Stunting Case in Children Aged 6-23 Months (Regional Study of Landasan Ulin Health Center, Banjarbaru City)

: Stunting is a condition of failure to thrive due to malnutrition for a long time so that children are shorter than normal children their age. Stunting is not only caused by one factor but by many factors. The prevalence of stunting at the Landasan Ulin Health Center continued to increase from 2018 (16.0%), 2019 (21.89%) and 2020 (22.26%). Objective: To determine the relationship between maternal knowledge, parenting and household food security status with the incidence of stunting in children aged 6-23 months in the working area of the Landasan Ulin Health Center, Banjarbaru City. Methods: This type of research is an observational analytic study with a Cohort Retrospective design. The population of this study was all children aged 6-23 months in the working area of the Landasan Ulin Health Center and a sample of 92 children using the purposive sampling technique. Results: The knowledge of the mothers of children under two years was in the less category (47.8%), the parenting pattern for the children was in the sufficient category (39.1%), the household food security status was mostly classified as food insecure (42.4%) and the children who experienced stunting were less (40.2%) . Conclusions: There is a relationship between mother's knowledge, parenting, and household food security status with the incidence of stunting in children aged 6-23 months in the working area of the Landasan Ulin Health Center.


INTRODUCTION
Stunting is one of the Sustainable Development Goals (SDGs) targets, which are included in the 2nd sustainable development goal, namely eradicating hunger and all forms of malnutrition by 2030 and achieving food security. The target is to reduce the stunting rate to 40% by 2025. To achieve this, the government has established stunting as one of the priority programs based on the Minister of Health Regulation no. 39 of 2016 concerning Guidelines for Healthy Indonesia Program Operators with Family Approach (Kemenkes RI, 2018).
One of the health problems experienced by children in the world is stunting. In 2017, 22.2% or around 150.8 million children under two years old experienced stunting. More than half of them come from Asia or as much as 55% (Kemenkes RI, 2018). Indonesia ranks third out of eleven countries with the highest prevalence of stunting in the South-East Asia Regional (SEAR) (WHO, 2018). Based on the Basic Health Research (2018) results, South Kalimantan Province is in the 11th rank of 34 provinces, with a prevalence of stunting under children of 13.3% (Balitbangkes, 2018).
The Banjarbaru City Health Office in 2020 reported that the prevalence of stunting in Banjarbaru was 15.21%. The highest prevalence of stunting is at the Landasan Ulin Health Center which continues to increase from 16.0% in 2018 to 21.89% in 2019 and 22.26% in 2020. Thus, it can be said that the prevalence of stunting at the Landasan Ulin Health Center is still higher than the WHO standard with a maximum stunting limit of 20% and is still above the target of the 2020-2024 National Medium-Term Development Plan (RPJMN) which targets stunting reduction in the next five years in numbers. 14% (Perpres No. 72 tahun 2021).
Stunting is a condition of failure to thrive due to malnutrition for a long time, so children are shorter than normal children their age. Stunting will have a short-term impact in the form of a high threat of morbidity and mortality, in the medium term in the form of low intellectual and cognitive abilities, and in a long time in the form of low quality of human resources and various problems related to degenerative diseases in adulthood (Siswati, 2018).
Based on the Conceptual framework of the determinants of child undernutrition put forward by UNICEF (2013) in Nurfaradila (2020), stunting is not only caused by one factor but by various factors that are categorized as direct causes (lack of nutrition and infection), indirect causes (household food security, parenting, environmental health, and health services), as well as various root causes (education, knowledge, skills and family income).
Parenting is one of the factors that cause stunting in children under two. Inadequate parenting patterns, namely in breastfeeding and complementary feeding, child feeding practices, psychosocial stimulation, hygiene and sanitation practices, and health services, will affect children's nutritional status (Susuilaningdyah, 2013).
A mother's knowledge plays a crucial role in child development. A person's nutritional knowledge will affect attitudes and behavior in food selection. The lack of mothers' knowledge and perspectives makes it challenging to choose nutritious foods for their children and families (0lsa, 2017). Household food security indirectly has an impact on the problem of malnutrition, one of which is the incidence of stunting in children under five (Verawati, 2021). According to Sirajuddin et al. (2018) the fulfillment of food needs is determined by purchasing power, knowledge, and the ability of regions and households to produce and provide sufficient and safe food. Families that can fulfill this are said to be families that have good food security (Hamzah, 2016). If a family experiences difficulties providing food, the level of consumption will automatically decrease. If it occurs continuously, it can trigger children to experience chronic malnutrition, resulting in stunting (Adelina, 2018).
Based on the above problems, the researcher is interested in researching "the relationship of mother's knowledge, parenting patterns and household food security status with the stunting case in children aged 6-23 months in the working area of the Landasan Ulin Health Center, Banjarbaru City".

METHODS
This study employed observational analytic research with a Cohort Retrospective design. The study was carried out in the Landasan Ulin Health Center, Banjarbaru City working area, in January-April 2022. The research population was all children aged 6-23 months with a total of 1,202 children with a sample of 92 respondents. The sampling technique used was purposive sampling. The data were collected by conducting direct measurements and interviews using a questionnaire sheet. The data analysis used Spearman's Rank test with 95% confidence level and α=0.05.

The Characteristics of Respondent
The results of the research on respondent characteristics that have been carried out in the working area of the Landasan Ulin Health Center found that the age of most children was >12 -23 months 65.2%, the gender of the children was mostly male (54.3%), the most parental education was high school / Equal, namely mother (56.5%) and father (59.8%), the most occupation of the mother is as a housewife (87.0%), the father's occupation is the most as employee (45.7%), most family income is high (58, 7%), and the largest number of family members is in the small category (46.7%) ( Table 1).

Stunting Incident
The results showed that the number of children who did not experience stunting was 59.8% (Table 2).

Mothers' Knowledge
The results showed that the mother's level of knowledge at most was in the weak category, which was 47.8%. (Table 3).

Parenting Pattern
The result of the research shows that the most parenting pattern is sufficient category, which is 39.1%. (Table 4).

Household Food Security Status
The results showed that the most household food security status was classified as food security, namely 42.4%. (Table 5).

Relation of Mothers' Knowledge and Stunting Case in Children under 2 Years
The results showed that the ρ-value (0.012) < (0.05), so it was concluded that there was a relationship between a mother's knowledge and the incidence of stunting in children under five. (Table 6).

The Relation of Parenting Pattern and Stunting Incident in Children under 2 Years Old
The results showed that the ρ-value (0,000) < α (0,05), so it was concluded that there was a relationship between parenting patterns and the incidence of stunting in children under 2 years old (Table 7). The

Relation of Household Food Security Status with Stunting Incident in Children under 2 Years Old
The results showed that the ρ-value 0,000 so that it was concluded that there was a relationship between household food security status and the incidence of stunting in children under two years old. (Table 8).

Stunting Incident
The research in the Landasan Ulin Health Center working area showed that more than half of the children, or as many as 59.8%, were not stunted. However, it's necessary to be aware that as many as 40.2% of children under two years old were stunted. This study was in line with the research conducted in the working area of the Jati Makmur Public Health Center, Binjai Utara by Dakhi (2018), which stated that the number of children who were stunted was lower than the number of children who were not stunted.
Several factors that may influence the incidence of stunting in this study were the mother's knowledge, access to information, income, and inappropriate parenting, especially on feeding patterns, which will affect the provision and selection of food for children under 2 years old which were closely related to the nutritional intake of children under five years old and could causes children to experience stunting.
Several actions could be taken to reduce the prevalence of stunting. It was first, optimizing breastfeeding practices starting with early initiation of breastfeeding and continuing with exclusive breastfeeding for 6 months. Second, the most effective intervention in preventing stunting, especially during complementary feeding, after the child is 6 months old, is improving the quality of the child's diet. Third, because stunting is related to the environment, socio-economics, and culture, direct nutrition interventions must be integrated with sensitive interventions such as infection prevention through clean water and increasing PHBS. The integration of specific nutrition programs and sensitive nutrition programs that were able to reach the target significantly contributed to reducing the prevalence of stunting (Rahmawati, 2021).

Mothers' Knowledge
The results of the research conducted in the working area of the Landasan Ulin Health Center showed that the mother's knowledge mainly was in the poor category, which was 47.8%.
After conducting interviews, it was found that the questions that were answered most correctly were questions about the meaning of exclusive breastfeeding (64 people), the meaning of complementary feeding (74 people) and the right age for giving complementary feeding (83 people). For questions about nutrition, some respondents were able to answer correctly. However, for questions regarding stunting only a few mothers could answer the questions correctly.
The thing that might cause the mother's low knowledge about stunting is the lack of information about stunting in the working area of the Landasan Ulin Health Center. Almost half of the mothers of children under 2 years old had weak knowledge, and thus they wouldn't know the impact and efforts to tackle stunting.
One's knowledge was not only obtained from formal education but from the experience of oneself or others who come from reading, mass media, and others (Oktaningrum, 2018). Handayani (2011) in Retni & Nikmawati (2021) explains that mothers with insufficient nutritional knowledge tend to choose foods that are most attractive to the senses, and do not make choices based on the nutritional value of food. On the other hand, those with more knowledge of nutrition use more rational considerations and knowledge about the nutrition of the food.

Parenting Pattern
The results of the research conducted in the Landasan Ulin Health Center working area showed that the highest number of parenting patterns was in the sufficient category, which was 39.1%. However, 25.0% was still in the poor parenting categories.
After conducting interviews using questionnaires, it was found that there were still many inappropriate parenting styles for children under two years old. For example, mothers who do not provide food with a complete composition, namely carbohydrates, animal protein, vegetable protein, vegetables, and fruit, do not schedule meals for their children. In addition, it is also often found that mothers give instant porridge and do not provide food according to portions based on their age. However, for child health care, parenting and environmental hygiene and sanitation have been practiced quite well. So it can be concluded that the parenting pattern that is more dominant in influencing the incidence of stunting in the working area of the Landasan Ulin Health Center is the feeding parenting pattern.
Factors that may cause poor feeding parenting is due to lack of knowledge and family economic factors. The lack of a mother's knowledge about stunting and its impact on children's growth and development causes the mother's parenting pattern to be not optimal, especially in feeding children.
According to Notoatmodjo (2005) in Sofyan (2020), maternal parenting is the behavior of mothers in raising their children. Attitudes and knowledge influenced the behavior itself. Good knowledge would create a good attitude. Then if the attitude was judged appropriate, good behavior would appear. Mothers with good parenting tend to have children with good nutritional status, and vice versa, mothers with less nutritional parenting, tend to have children with poor nutritional status as well (Juliani, 2018).

Household Food Security Status
The results of research conducted in the working area of the Landasan Ulin Health Center showed that families with food insecure categories were more likely to be found, namely 42.4%. However, among stunting children, many families with household food security status in the food insecure category with severe hunger of as much as 23.9%.
One of the factors that are likely to be the cause of the high level of food insecurity with severe hunger in stunting children was family economic problems. Family characteristics data showed that most families of stunting children have incomes less than minimum wage. During interviews, several mothers said that in the last 12 months, they were sometimes worried that the food would run out before getting the money to buy it back, and there were even families who sometimes only relied on certain types of low-cost food to feed their children due to lack of money to buy food.
The socio-economic level of the family has a close relationship with the availability of food in the family. The higher the socio-economic level of the family, the greater the opportunity for good food availability. In the other hand, low food availability will increase the risk 3.64 times greater to produce stunting children compared to food availability of a good family. The problem of access and availability of food for the poor was a combined problem of poverty, lack of permanent jobs, low and non-permanent cash income and limited purchasing power (Bappenas, 2011).

Analisis Bivariat
The

Relationship of Mothers' Knowledge and the Stunting Incident
Based on the results of the study, it was found that mothers who had good knowledge were found in 80.0% of non-stunted children, and mothers who had less knowledge were found in 52.3% of stunted children. The results of the spearman rank analysis show that there is a relationship between the mother's level of knowledge and the incidence of stunting in children under two in the working area of the Landasan Ulin Health Center, Banjarbaru City(ρvalue 0.012).
This happened because to get good nutrition, requires good nutritional knowledge from parents in order to provide a balanced menu of choices. Mothers with a better level of knowledge are likely to apply their knowledge for their children, especially providing food according to the nutrients needed by children so that they don't experience nutritional deficiencies.
The results of interviews with respondents indicated that many mothers of the children under 2 years stated that they didn't know what stunting was and most had never looked for information related to child nutrition through books, the internet, and others. However, there were some mothers who stated that they had previously heard the term stunting on television but did not know what stunting meant because they did not pay much attention to it. In this case, knowledge is very influential on the incidence of stunting. Knowledge is obtained from various sources such as leaflets, posters, counseling, internet, and so on. With advances in technology today, the internet could be put to good use to provide education about stunting, for example the wide spread of communication, information, and education on stunting through social media, creating blogs, websites, and so on (Hutabarat, 2021).
This study was in line with the research of Langi, et al (2019) where there's a significant relationship between mother's knowledge of the incidence of stunting at the Kawangkoan Health Center, Minahasa with = 0.01 (ρ < 0.05) (Langi, 2019). Inadequate nutritional knowledge, lack of understanding of good eating habits, and understanding of the nutritional contribution of various types of food will cause nutritional problems (Wulandari, 2013).
Based on the results of the study, it was found that mothers who had good parenting patterns were found in children who were not stunted, as many as 87.9%. Meanwhile, mothers who have less parenting are found in stunting children as much as 73.9%. The results of the spearman rank analysis show that there is a relationship between parenting and the incidence of stunting in children under two in the working area of the Landasan Ulin Health Center, Banjarbaru (ρ-value 0.000).
The results of interviews with respondents found that several mothers did not provide food with a complete composition (carbohydrates, animal protein, vegetable protein, vegetables and fruit) to their children, did not schedule their children's meals, and did not fit the portion based on age. However, for the pattern of children's health care as well as environmental hygiene and sanitation has been done quite well. This study shows that maternal parenting is very influential on the incidence of stunting. Mothers were expected to pay more attention to parenting and feeding their toddlers. Family support, especially fathers, to take a role in helping to improve better maternal parenting is important to implement and support and teach children to eat nutritious foods to prevent stunting. Mothers were also expected to be able to widen their knowledge so that they can learn more deeply to improve parenting patterns.
The research of Rosliana, et al (2020) was in line with this study which showed that there's a significant relationship between maternal parenting and the incidence of stunting with a p value of 0.000 [24]. Bella's research, et al (2020) is also in line with this study which shows a significant relationship between the incidence of stunting and feeding parenting with a p value of 0.000.

The Relation of Household Food Security Status with Stunting Incident
Based on the results of the study, it was found that the number of children under 2 years who were not stunted were more in the food security category, namely 79.5%. Meanwhile, stunting children were more in the food insecure category with a severe degree of hunger, which was 86.4%. The results of the spearman rank analysis showed that there's a relationship between household food security status and the incidence of stunting in children under two in the working area of the Landasan Ulin Health Center, Banjarbaru (ρ-value 0.000).
Based on the interview results, several mothers said that in the last 12 months they sometimes worried if the food ran out before getting the money to buy it back, they couldn't provide balanced nutritious food for the household, and obtained basic food which sometimes depended on government rations. It's known that house hold food security level supports the level of the children consumption, both energy and protein. The low level of children's consumption could affect the growth and development of children.
Family food security was influenced by the family's economic status. The higher the economic status of the family, the food in the family will be sufficient in quantity, variety, and quality of food. The low amount, variety and quality of food will cause nutritional problems in toddlers, namely stunting. This is in accordance with research by Arlius (2017) in Fadzila and Edy (2019) which states that food security and nutritional status of children under five years old have a close relationship, family that lack food will affect the nutritional status of the family.
In addition, the results of this study are also in accordance with the theory of causes of nutritional problems issued by UNICEF (2013) which explains that nutritional problems are caused by two causes, namely lack of food intake and infectious diseases. An indirect cause of nutritional problems and a direct factor affecting food intake is family food security. Therefore, food security that is not guaranteed at the family level makes the unavailability of sufficient food in quantity and quality of nutrition will reduce the food intake of family members, especially children, so that if it occurs in a long time it will lead to nutritional problems, one of which is stunting (UNICEF, 2013).

CONCLUSION
Based on the results of research that has been carried out related to the incidence of stunting in the working area of the Landasan Ulin Health Center, Banjarbaru City, the results of the analysis are as follows: the age of the most children is >12 -23 months 65.2%), the gender of the most children is male (54.3% ), most of the parents' education is high school/equal, namely mother (56.5%) and father (59.8%), the mothers' occupation is mostly as a housewife (87.0%), the father's most occupation is as an entrepreneur (45.7%), the highest family income is high (58.7%), the largest number of family members is in the small category (46.7%), and the number of children under two years who experience stunting (40.2%) is less than those who are not stunted (59.8%). The results of the analysis are as follows: there is a relationship between the level of knowledge of mothers, parenting patterns and household food security status with the incidence of stunting in children under two years old 6-23 months.