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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access  Full Text Article                                                                                                                                         Research Article 

The Relationship of Knowledge, Attitudes, and Practices of Fe Tablet Consumption of Mothers with Toddlers with Stunting Incidences in Cilembu Village, Sumedang Regency in 2019

Wiradi Suryanegara¹*, Ida Bagus Eka Utama Wija²

¹ Department of Medical Community, Medical Faculty, Universitas Kristen Indonesia, Jakarta, Indonesia

² Department of Pediatrics, Medical Faculty, Universitas Kristen Indonesia, Jakarta, Indonesia

INTRODUCTION

Stunting is a chronic malnutrition problem caused by inadequate nutritional intake for a long time due to feeding that is not following nutritional needs. Stunting occurs when the fetus is still in the womb, and only appears when the child is two years old. Malnutrition at an early age increases infant and child mortality, causes sufferers to get sick quickly and have poor posture as adults ¹. The cognitive abilities of the sufferers are also reduced, resulting in long-term economic losses for Indonesia. The stunting rate in Indonesia did not experience a significant decline in 2007, 2010, and 2013. In 2007 the stunting rate in Indonesia was 36.8%. Meanwhile, in 2010 and 2013, the percentages were 35.6% and 37.2%, respectively ².

Haemoglobin is a protein that carries oxygen throughout the body in red blood cells. Haemoglobin requires iron as an element of its formation. Additional iron is needed to form haemoglobin in pregnant women to support fetal growth and maternal needs. Pregnant women need additional iron to meet the needs of haemoglobin formation to support the mother and fetal growth needs. Iron deficiency will cause iron deficiency anaemia, decreasing haemoglobin levels in red blood cells. According to WHO, the prevalence of anaemia in pregnant women worldwide in 1993 – 2005 was 41.8%. Research conducted in Ethiopia in 2011 with the prevalence of anaemia in pregnant women is 32.6%. Riskesdas in 2013 researched and found the incidence of anaemia in pregnant women was 37.1%, and in 2018 the prevalence of anaemia in pregnant women increased to 48.9% ^{3; 4}.

Anaemia in pregnant women can be caused by various factors, including a history of parity, nutritional status of KEK (Chronic Energy Deficiency), education history, and consumption patterns of iron tablets as the fetus grows. Anaemia in pregnancy will increase along with other physiological changes during pregnancy, increasing the need for iron itself. It will then be related to the pattern of fetal growth and development ⁵.

In Vaivada's study, it was found that giving Fe tablets to pregnant women with a risk of iron deficiency anaemia could reduce the risk of preterm birth by 14%. However, only 38.1% of pregnant women consume Fe tablets of more than or equal to 90 tablets during their pregnancy in Indonesia. According to Riskesdas 2018, the data shows that the level of compliance of pregnant women is still lacking for consuming Fe tablets ⁶.

The prevalence of the relationship between knowledge of pregnant women about Fe tablets in Agam Regency in 2014 regarding the importance of Fe tablets is 30%. While at the "Sebrang Padang" Health Center in 2013, the prevalence of pregnant women's attitudes about giving iron tablets in the work area was obtained by 58% of pregnant women with less knowledge and 52% of pregnant women with negative attitudes in consuming iron tablets. Research conducted in Cilembu village, Sumedang district, found that the percentage level of knowledge of pregnant women about giving iron tablets was insufficient 2.6% and 51.3% the level of knowledge of pregnant women about stunting was poor ⁷.

Therefore, researchers want to conduct further research on the knowledge, attitudes and behaviour of mothers who have stunted children about giving Fe tablets and stunting in Cilembu Village, Sumedang Regency in 2019. The formulation of the problem answered in this study is "Is there a relationship between knowledge, attitude and, and the practice of consuming Fe tablets for mothers who have children under five with stunting in Cilembu Village, Sumedang Regency in 2019?". The research aims to determine the Relationship of Knowledge, Attitudes, and Practices of Consumption of Fe Tablets in Mothers Who Have Toddler Children with Stunting Incidence in Cilembu Village, Sumedang Regency in 2019.

Literature Review 

Stunting (dwarf) is a condition where toddlers have a length or height that is less than their age or age. Stunting conditions can only be seen after the baby is two years old. According to the Ministry of Health (Kemenkes), stunting is a child under five with a z-score of less than -2SD/standard deviation (stunted) and less than -3SD (severely stunted). This condition is measured by a length or height of more than minus two standard deviations of the WHO child growth standard median ^{8; 9}.

The incidence of short toddlers, commonly referred to as stunting is a nutritional problem in toddlers today. In 2017, 22.2% or around 150.8 million children under five in the world experienced stunting. However, this figure has decreased compared to the stunting rate in 2000, which was 32.6% ⁸. In 2017, more than half of stunted children under five came from Asia (55%), while more than a third (39%) lived in Africa. Of the 83.6 million stunted children under five in Asia, the highest proportion came from South Asia (58.7%), and the lowest was Central Asia ¹⁰.

Based on the World Health Organization (WHO) data, Indonesia is included in the third country with the highest prevalence in the South-East Asia Region (SEAR). The average prevalence of stunting under five in Indonesia in 2005-2017 was 36.4% ⁸. In 2015 the Ministry of Health carried out Monitoring of Nutritional Status (PSG). According to Riskesdas 2018, 19.3% of Indonesian children under five are in a short category, which increased from 19.2% in 2013. With the highest percentage in East Nusa Tenggara Province ^{8; 10; 11}.

According to WHO, the prevalence of stunted toddlers becomes a public health problem if the prevalence is more than 20% or more. Therefore, because the prevalence of stunting in Indonesia is still high, it is a health problem that must be addressed ⁸. Toddler stunting is a chronic nutritional problem that occurs since the baby is in the womb and the early days after the baby is born. It can be caused by many factors such as socioeconomic conditions, maternal nutrition during pregnancy, infant pain, and lack of nutritional intake in infants. Stunting toddlers in the future will have difficulty in achieving optimal physical and cognitive development ^{8; 9.} Research conducted by Goodarz et al., who researched the risk factors that play a role in stunting 137 developing countries, explained that the most important risk factors were temporary maternal structure, maternal anaemia, low birth weight, diarrhoea, and diarrhoea in children, and poor sanitation ¹². Another factor that plays a role in stunting is the intake of exclusive breastfeeding as a toddler. Research in Southern Ethiopia shows that infants who do not receive exclusive breastfeeding for six months are at high risk of stunting ¹⁰.

Family socioeconomic status such as family income, parental education level, mother's knowledge of nutrition, and the number of family members can indirectly relate to stunting. Research conducted by Khoirunimah et al. in Surabaya regarding factors related to stunting explained that birth length, history of exclusive breastfeeding, family income, mother's education, and knowledge of maternal nutrition are significant factors ¹².

Fe tablets are supplements that contain iron. Iron is a mineral needed to form red blood cells (Hemoglobin) ¹³. The function of iron is to transport electrons in energy metabolism and as an immune-forming enzyme, and as a solvent for drugs.

Diversity in food consumption plays an essential role in helping increase the absorption of Fe in the body. The presence of animal protein, vitamin C, vitamin A, folic acid, other micronutrients can increase the absorption of iron in the body. Another benefit of consuming food sources of iron is the fulfilment of the adequacy of vitamin A because food sources of iron are usually also a source of vitamin A ¹⁴. The need for substances during pregnancy increases, this increase is increased to meet the fetus's needs for fetal growth, placental growth and increased maternal blood volume ¹⁵.

The need for iron will increase in the second and third trimesters, which is about 6.3 mg per day. To meet the needs of this, iron can be taken from iron reserves and an adaptive increase in iron absorption through the gastrointestinal tract. If iron reserves are minimal or none at all while iron content and absorption from food is small, then supplementation is needed to meet the iron needs of pregnant women ¹⁵.

Iron absorption is affected by many factors. Animal protein and vitamin C increase absorption. Coffee, tea, calcium salts, magnesium can bind Fe, thereby reducing the amount of absorption. Therefore, Fe tablets should be swallowed together with foods that can increase absorption, while foods that bind Fe should be avoided or not eaten simultaneously. In addition, it is also important to remember that additional iron should be obtained from food ¹⁶. Oral iron supplements can cause nausea, vomiting, stomach cramps, heartburn, and constipation (sometimes diarrhoea). However, the degree of nausea caused by each preparation depends on the amount of elemental iron absorbed. Doses of iron above 60 mg can have a pleasing effect on pregnant women, so that non-adherence in the use of iron tablets with low doses is more likely to be tolerated (taken) than high doses. For many women, a low dose is sufficient ¹⁷.

Giving blood-added tablets during pregnancy is one of the most suitable ways for pregnant women to increase Hb levels to the desired level because it is very effective where one tablet contains 60 mg Fe. Each tablet is equivalent to 200mg of ferrosulfate. At least 90 tablets are given until 42 weeks after delivery during pregnancy, since the first examination of pregnant women ¹⁷. Iron deficiency affects the quality of human resources, namely the ability and work productivity. Iron deficiency can occur due to consumption of an unbalanced diet or impaired absorption of iron. Iron deficiency generally causes paleness, weakness, fatigue, dizziness, lack of appetite, decreased body fitness, decreased workability, decreased immunity and impaired wound healing. In addition, the ability to regulate body temperature decreases. In children, iron deficiency causes apathy, irritability, decreased ability to concentrate and learn ^{18; 19.} Behaviour is an action that can be observed and has a specific frequency, duration and purpose, both consciously and unconsciously ²⁰. Health behaviour is one of the factors that affect a person's health status. Health behaviour is influenced by internal factors, including knowledge, perception, emotion, motivation, and external factors, including physical and non-physical environment ²¹. Before a person faces a new behaviour, several processes occur, namely awareness, interest, trial and cognitive ²².

Knowledge is the result of knowing or knowing that occurs through sensory processes, especially the eyes and ears of particular objects. According to Juju S Suriasumantri, knowledge is everything humans know about a particular object: a mental wealth obtained through rationality and experience. Knowledge is the result of a process of human action involving all beliefs in the form of awareness in the face of known objects, including information captured by the five senses and then developed through language and thinking skills. The process of knowledge formation begins when information is captured through perception and then stored and displayed again through memory. A person's knowledge is influenced by several factors, including education, media and information exposure. Knowledge is closely related to education, and it is expected that someone with a high level of education has broader knowledge ²³. It does not mean that someone with a low level of education has insufficient knowledge. Education affects a person's behaviour in life patterns, especially in motivating attitudes in roles. The higher a person's education, the easier it is to receive information ²⁴.

Sources of information are everything that becomes an intermediary in conveying information. The more information a person gets, the more knowledge he has ²⁵. The existence of new information obtained by someone will provide a new cognitive foundation for forming knowledge. A person with low education but much exposure to good information can increase his knowledge. Information obtained by a person is processed in two ways, namely assimilation and accommodation. Assimilation is the process of incorporating new information obtained into existing knowledge, while accommodation is the adjustment to new information ²⁶. Mass media is a means to communicate or share information, including print media, namely newspapers, books, magazines, and electronic media, namely TV, radio, and films. The role of the mass media in conveying information will increase a person's knowledge so that it will affect the person's attitude to make decisions, and it is related to the person's behaviour.

Based on various opinions, attitude is defined as a tendency to act like or dislike an object or to reject or accept a particular object based on an assessment of the object. Attitude is the emergence of an action or behaviour or a person's response to a situation ²². Attitude is an evaluative response that only arises when a person is faced with a stimulus that requires a reaction. An evaluative response is a form of reaction based on the evaluation process in a person who gives conclusions to the stimulus in good and bad values, positive and negative, pleasant or unpleasant ²⁴. Attitude is a person's readiness or willingness to act, but there is no action or activity on the stimulus that arises but is a predisposition for an action or behaviour. Attitude is divided into passive and active, and the passive attitude only knows, thinks or has certain perceptions. An active attitude is called practice. Attitude structure consists of three components: cognitive components, affective components, and conative components ²⁷. Attitudes are influenced by personal experience, culture, other people considered necessary, mass media, educational institutions and religious institutions, and emotional factors within the individual ²². Practice is an enthusiastic attitude or an action taken related to a response to a stimulus that arises, which can be observed directly. Action is a response to the stimulus received by the individual in the form of natural or open action ²⁸.

RESEARCH METHOD

The research method used is the cross-sectional analytical research method, which aims to analyze the relationship between knowledge, attitudes, and practice of consuming Fe tablets in mothers who have children under five with stunting in Cilembu Village. The time of this research took place from June 24, 2019, to July 5, 2019. The research location was in Cilembu Village, Sumedang Regency. The population in this study were mothers who had children under five in RW 8, 9, 11 in Cilembu Village, as many as 90 people. The number of samples carried out in this study was taken by the Slovin formula with an error limit of 0.1. the number of samples obtained is 47 people. The sampling method used in this study is non-random sampling with purposive sampling method, which will take all data that meet the inclusion criteria of 45 respondents. The data processing technique in this study uses the computational calculation of the SPSS (Statistical Product and Service Solution) program, consisting of data editing, data coding, data entry and tabulating. The analysis technique used in this research is by using the univariate test to see the frequency distribution of the research variables and measuring the behaviour of mothers who have children under five in consuming Fe tablets. The analytical technique was used to present data from two variables in a cross-tabulation, namely the behaviour of pregnant women and adherence to antenatal care. In this analysis, the Fisher's Exact Test will also be carried out to prove a significant relationship between the knowledge, attitudes and behaviour of mothers who have children under five in consuming Fe tablets with the incidence of stunting.

RESULT AND DISCUSSION

This research was conducted on a sample of mothers who had children under five in June 2019 in Cilembu village, Sumedang Regency, West Java, with 45 respondents. The age distribution of mothers with children under five can be seen in Table 1 as follows:

Table 1: Maternal Age Distribution

Based on the table above, it was found that most of the respondents aged 20-30 years were 24 respondents (59.1%) and aged 31-40 years were 15 respondents (22.7%) While respondents aged >40 years were four respondents (18.2 %), and respondents aged <20 years were two people (8.9%). The distribution of the mother's work can be seen in Table 4.1.2 as follows:

Table 2: Distribution of Mother's Occupation

The table above shows that most respondents work as housewives as many as 26 people (57.8%). While the respondents who work as farmers are six people (13.3%), workers are nine people (20.0%), as traders are two people (4.4%), as civil servants are one person (2.2%). And others in the amount of 1 person (2.2%). The distribution of the mother's work can be seen in Table 4.3 as follows.

Table 3: Education Distribution

Based on the table above, it was found that most of the respondents had a junior high school education of 8 people (36.4%), and eight people graduated from high school (36.4%). Meanwhile, four people (18.2%) have completed primary school education, and two respondents have D3/SI/S2 education (9.1%). 

Univariate analysis - The description of the knowledge of mothers and children under five about the consumption of Fe tablets in Cilembu Village, Sumedang Regency, is as follows.

Table 4: Description of Knowledge of Mothers and Children under five about the consumption of Fe tablets in Cilembu Village, Sumedang Regency

Berdasarkan tabel di atas, diperoleh gambaran pengetahuan Ibu dengan anak balita tentang konsumsi tablet Fe di Desa Cilembu Kabupaten Sumedang, yaitu ibu yang memiliki pengetahuan baik sebanyak 38 orang (84,4%), ibu yang memiliki pengetahuan cukup sebanyak 4 orang (8,9%), dan ibu yang memiliki pengetahuan kurang sebanyak 3 orang (6,7%). 

Gambaran sikap Ibu dengan anak balita tentang konsumsi tablet Fe di Desa Cilembu Kabupaten Sumedang sebagai berikut.

Tabele 5: Gambaran Sikap Ibu dengan anak balita tentang konsumsi tablet Fe di Desa Cilembu Kabupaten Sumedang

Based on the table above, a description of the attitudes of mothers with children under five about the consumption of Fe tablets in Cilembu Village, Sumedang Regency is obtained, namely mothers who have a good attitude as many as 30 people (66.7%) and mothers who have a poor attitude as many as 15 people (33.3% ). 

The description of the practice of mothers with toddlers regarding the consumption of Fe tablets in Cilembu Village, Sumedang Regency is as follows.

Table 6: Overview of Mother's Practices with toddlers regarding consumption of Fe tablets in Cilembu Village, Sumedang Regency

Based on the table above, the description of the practice of mothers with children under five regarding the consumption of Fe tablets in Cilembu Village, Sumedang Regency, namely pregnant women who have good practices as many as 12 people (26.7%) and pregnant women who have bad practices as many as 33 people (73.3% ). 

Bivariate analysis - the relationship between knowledge of mothers and children under five about the consumption of Fe tablets with the incidence of stunting in Cilembu Village, Sumedang Regency as follows.

Table 7: Relationship between knowledge of mothers and children under five about the consumption of Fe tablets with the incidence of stunting in Cilembu Village, Sumedang Regency

The above tables show that mothers who have good knowledge with stunting toddlers on Fe tablet consumption are 18 people (40.0%), sufficient knowledge is three people (6.7%). Less knowledge is one person (2.2%) of Mothers who have good knowledge with children under five who are not stunted on Fe tablet consumption are 20 people (44.4%), sufficient knowledge is one person (2.2%), and lack of knowledge is two people (4.4%). Based on the Fisher's Exact Test results, a P Value> of 0.05 was 0.596, which means that there is no relationship between the mother's knowledge about consuming Fe tablets and the incidence of stunting.

Table 8: Relationship between mother's attitude and under-five children regarding consumption of Fe tablets with stunting in Cilembu Village, Sumedang Regency

The above table shows 17 mothers with stunting toddlers who have a good attitude towards consuming Fe tablets (37.8%) and five people with a bad attitude (11.1%). Mothers with non-stunted toddlers who have a good attitude towards consumption of Fe tablets as many as 13 people (28.9%), and mothers who have a poor attitude as many as ten people (22.2%). Based on the Fisher's Exact Test results, a P Value> of 0.05 is 0.065, which means that there is no relationship between the mother's attitude about consuming Fe tablets and stunting incidence.

Table 9. Relationship between mother's practice and under-five children regarding consumption of Fe tablets with stunting in Cilembu Village, Sumedang Regency

The above table shows 16 mothers with stunting toddlers who have good practices in consuming Fe tablets (35.6%) and six people (13.3%) who have bad attitudes. Mothers with children under five who are not stunted who have a good attitude towards the consumption of Fe tablets are 17 people (37.8%), and mothers who have a bad attitude are six people (13.3%). Based on the Fisher's Exact Test results, a PV value of > 0.05 was 0.615, which means that there is no relationship between the maternal practice of consuming Fe tablets and the incidence of stunting.

Based on the research that has been done, it was found that knowledge of Fe tablets, which was owned by mothers who had children under five in Cilembu village in June 2019, was in a suitable category, with a good attitude level, but the practice of consuming Fe tablets was in a wrong category. Based on the Fisher's Exact Test results, it was found that there was no relationship between the knowledge, attitudes, and practices of mothers who had children under five regarding the consumption of Fe tablets with the incidence of stunting in Cilembu Village, Sumedang Regency.

Following the research results which indicated a relationship between iron intake and the incidence of stunting in toddlers, and iron intake is not a risk factor for stunting in toddlers ²⁹. In a study conducted stated that there was no significant relationship between mother's knowledge of iron with the incidence of anaemia ³⁰. Based on research conducted said that consuming supplements or Fe tablets before six months of gestation and no more than 90 tablets during pregnancy are at risk of preventing low birth weight babies ³¹. The results of this study are also in line with the research conducted found that there was no significant relationship between Hb Third trimester pregnant women with stunting ³².

Jayanti in her research found that there was no significant relationship between the level of substance consumption iron with the incidence of stunting in children aged 6-24 months in the working area of the Randuagung Health Center, Lumajang Regency ³³.

CONCLUSION

Based on the results of the research "The Relationship of Knowledge, Attitudes, and Practices of Fe Tablet Consumption in Mothers with Toddler Children with Stunting Incidence in Cilembu Village, Sumedang Regency in 2019", which was carried out on 45 samples, the following conclusions were obtained: a) Based on univariate analysis, the description of mothers' knowledge with children under five about the consumption of Fe tablets in Cilembu Village, Sumedang Regency, it can be concluded that mothers who have good knowledge are 38 people (84.4%), pregnant women who have sufficient knowledge are four people (8.9%), and pregnant women who have adequate knowledge as many as three people (6.7%); b) Based on the univariate analysis of the description of the attitude of mothers with children under five about the consumption of Fe tablets in Cilembu Village, Sumedang Regency, it can be concluded that pregnant women who have a good attitude are 30 people (66.7%) and pregnant women who have a bad attitude are 15 people (33,3%); c) Based on the univariate analysis of the description of the practice of mothers with children under five regarding the consumption of Fe tablets in Cilembu Village, Sumedang Regency, it can be concluded that there are 33 pregnant women (73.3%) who have good practices and 12 pregnant women who have bad practices ²⁶. ,7%); d) Based on bivariate analysis of knowledge of mothers with children under five about Fe tablet consumption in Cilembu Village, Sumedang Regency, it can be concluded that mothers who have good knowledge with stunting toddlers on Fe tablet consumption are 18 people (40.0%), sufficient knowledge is three people (6, 7%), and lack of knowledge as much as one person (2.2%). Mothers who have good knowledge with children under five who are not stunted on the consumption of Fe tablets are 20 people (44.4%), sufficient knowledge is one person (2.2%), and less knowledge is two people (4.4%). Based on the Fisher's Exact Test results, P Value> of 0.05 was 0.596, it shows no relationship between mother's knowledge of Fe tablet consumption and stunting; e) Based on the bivariate analysis of the attitudes of mothers with their children under five about Fe tablet consumption in Cilembu Village, Sumedang Regency, it can be concluded that mothers with stunting toddlers who have a good attitude towards consuming Fe tablets are 17 people (37.8%). Five people who have a bad attitude are (11.1%). Mothers with children under five who are not stunted who have a good attitude towards the consumption of Fe tablets are 13 people (28.9%), and mothers who have a bad attitude are ten people (22.2%). Based on the results of the Fisher's Exact Test, P Value> of 0.05 was 0.065, which means that there is no relationship between the mother's attitude about consuming Fe tablets to the incidence of stunting; and f) Based on the bivariate analysis of the practice of mothers with children under five regarding Fe tablet consumption in Cilembu Village, Sumedang Regency, it can be concluded that mothers with stunting toddlers who have good practices on consuming Fe tablets are 16 people (35.6%), and six people who have bad attitudes people (13,3%). Mothers with children under five who are not stunted who have a good attitude towards the consumption of Fe tablets are 17 people (37.8%), and mothers who have a bad attitude are six people (13.3%). Based on the Fisher's Exact Test results, a P Value> of 0.05 is 0.749, which means that there is no relationship between the mother's practice of consuming Fe tablets and the incidence of stunting.

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