The childhood period is the most important stage for the overall development during the lifespan. Brain and biological development takes place at this stage Muller and Jahn, 2009. These developments are influenced by sufficient of stimulation and nutrition, and these development effects of physique, the immune system, cognition, as well as social and emotional growth (Handal et al. 2007). Such development supports to ensure that each child achieves his or her prospective and is a constructive member of society (Uthman, 2009). When children waste their early years with a reduced amount of motivating, or a less emotionally and physically encouraging condition of brain progress is affected and indications to cognitive, social and behavioral defers. Many factors can interrupt early child development such as malnutrition (WHO, 2009). The nutritional status of children is a significant presentation of health and development; it is not only a representation of past health but an important indicator of future health (Subramanyam et al. 2010).

Malnutrition is one of the important health problems throughout the world, particularly in developing countries (Sarifzadeh et al. 2010; Hioui et al. 2010). Malnutrition is an important public health problem because it indication to improved risk of death from infectious diseases, more acute infections and a high cause of mortality, and creating additional psychosocial burdens (Jesmin et al. 2011).

Malnutrition is a condition causing stunted growth, underweight, and wasting (Faber et al. 2010; Subramanyam et al. 2010; Uthman, 2009; Kandala et al. 2011; Janevic et al.2010), insufficiency of protein, energy and other nutrients and imbalance between the nutrients the body needs and the nutrients it receives (Muller and Jahn, 2009). Malnutrition can be detected by anthropometric measurements were height/length with age (HAZ), weight with age (WAZ) and weight with height/length (WHZ) is measured against a set of WHO child and growth standards and NCHS/WHO reference (Hioui et al. 2010; Lesiapeto et al. 2010).

Malnutrition levels are still high in developing countries around the world (Sunil, 2009), an estimated wasting 9.8%, underweight 17.9% and stunting 29.2% (WHO, 2009), included Indonesia. According to the MoH Indonesia informed frequency of malnutrition in children under five years of age during the year 2010 in Indonesia 17.90% are underweight, 35.60% stunted, 13.30% showed wasting, and in West Nusa Tenggara Province 48.30% are stunting, 30.50% are underweight and 14.90% are wasting.

Many factors can be associated with the occurrence of malnutrition in children. For example, inadequate health services and an unhealthy environment (Schoeman et al. 2010; Hioui et al. 2010), socio-cultural environments (Mashal et al.2008; Noughani & Bagheri, 2010), socioeconomic, maternal, and child factors (Lesiapeto et al.2010; Hasselman et al.2006), and socio-demographic factors (Phengxay et al. 2007; Handal et al. 2007).

An understanding of the most important causes of malnutrition is imperative to be identified and an analysis would then indicate more speci¬cally the type of policies, health programs and where resources should be focused to redress the derivation causes of inequity in childhood malnutrition (Lesiapeto et al. 2010; Uthman, 2009).

OBJECTIVE

General Objective

The main objective in this research is to find out the major factors influencing the occurrence of malnutrition (stunting, underweight, and wasting) in children under five years of age.

Specific Objective

To describe prevalence of child’s factors that can influence of malnutrition in children under five year of age

To describe prevalence of mother’s factors that can influence of malnutrition in children under five year of age

To describe prevalence of household factor that can influence of malnutrition in children under five year of age

To know the dominant factor can influence of malnutrition in children under five year of age

LITERATURE REVIEW

Definition

Malnutrition is a condition manifested by stunting, being underweight, and wasting if his/her height/length with age (HAZ), weight with age (WAZ) and weight with height/length (WHZ) z-score was more than two standard deviations (SDs) below the reference median (Lesiapeto et al. 2010; Subramanyam et al. 2010; Uthman, 2009; Kandala et al. 2011; Janevic et al. 2010), insufficiency of protein, energy and other nutrients and imbalance between the nutrients the body needs and the nutrients it receives (Muller, 2009).

Stunting is characterized by shortness-for-age or measure of linear growth retardation, an indicator of chronic malnutrition and calculated by comparing the height/length with age of a child with a reference population of good nutrition and healthy children (Muller and Jahn, 2009; Sunil, 2009).

Wasting is a reflection of a recent and acute process that has conducted to substantial weight loss, usually associated with starvation and/or disease; calculated by comparing weight with height/length of a child with a reference population of good nutrition and healthy children; reveals the acute level of malnutrition or the current nutritional status of children and often used to consider the severity of the emergencies because it is intensely related to mortality (Muller and Jahn, 2009; Sunil, 2009).

Underweight is measured by comparing the weight with age of a child with a reference population of good nutrition, composite measure that indicates both acute and chronic malnutrition in children (Muller and Jahn, 2009; Sunil, 2009).

Tabel 1: Characteristic of malnutrition

Nutrition

Status classification

Z-score

Weight with age for wasting

Normal

≤ – 1SD

Slight

-1SD < Z ≤ -2SD

Medium

-2SD < Z ≤ -3SD

Acute

-3SD <

Height with age for underweight

Normal

≤ – 1SD

Slight

-1SD < Z ≤ -2SD

Medium

-2SD < Z ≤ -3SD

Acute

-3SD <

Weight with height for stunting

Normal

≤ – 1SD

Slight

-1SD < Z ≤ -2SD

Medium

-2SD < Z ≤ -3SD

Acute

-3SD <

Source: WHO (2009)

Factors influencing the occurrence of malnutrition

Child factors

The child factors are influencing the occurrence of malnutrition are, age of the child, sex of child, and breastfeeding times (Uthman, 2009). Adequate nutrition during childhood is crucial for child existence, optimal growth and development during life span. The World Health Organization (WHO) recommended of exclusive breastfeeding times (EBF) for the first six months after born (WHO, 2007). The benefit of EBF for growth, buildup the immunity and prevention of illness in young infants is unquestionable (Ulek et al. 2012). If nutrients are in short supply or unbalanced, or if the child is exposed to environmental stressors that interfere with nutrient intake or utilization, growth is impaired. The deficits incurred result in irreversible damage, with related consequences including shorter adult height, lower educational achievement, reduced adult proceeds and decreased of descendants birth weight (Sguassero, 2012).

Figure 1: Child growth standard weight with age in boy’s birth to 5 years

Source: WHO (2009)

Figure 2: Child growth standard length/height with age in boy’s birth to 5 years

Source: WHO (2009)

Figure 3: Child growth standard weight with age in girl’s birth to 5 years

Source: WHO (2009)

Figure 4: Child growth standard length/height with age in girl’s birth to 5 years

Source: WHO (2009)

Tabel 2: Age of children

No

Age groups (months)

1

0‑5

2

6‑11

3

12‑23

4

24‑35

5

36‑47

6

48‑60

Source: WHO (2009)

Tabel 3: Children’s Sex

No

Children sex

1

Male

2

Female

Source: WHO (2009)

Tabel 4: Breastfeeding times

No

Breastfeeding times (months)

1

0 – 2

2

3 – 4

3

5 – 6

Source: WHO (2009)

Mother factors

The mother factors influencing the occurrence of malnutrition are mother’s age, mother’s occupation, and mother’s education (Uthman, 2009). Mother’s education can generate different type of household effect and thereby reducing the risk of nutritional deficiency like malnutrition. The effect which will bring through mother’s education to improved health and nutrition knowledge, psychological changes and improved nutritional behavior, modification of power relations within the household in encourage of better nutrition which includes breastfeeding, weaning practice, and child feeding may lead to more effective dietary behavior on the part of mother’s who manage food resources.

Tabel 5: Mother’s age

No

Mother’s age (year)

1

15 – 19

2

20 – 24

3

25 – 29

4

30 – 34

5

40 – 44

6

45 – 49

Source: MoH Indonesia (2010)

Tabel 6: Mother’s occupation

No

Mother’s occupation

1

Housewife

2

Farmer

3

Seller

4

Civil government

Source: MoH Indonesia (2010)

Tabel 7: Mother’s education

No

Mother’s education

1

None

2

Primary school

3

Junior high school

4

Senior high school

5

Higher

Source: MoH Indonesia (2010)

Household factors

The household factors influencing the occurrence of malnutrition are single parent, two parent households, and extended family. The household performances as a context for the child as well as facilitator that offer the support associated with encouraging child health outcomes (Noughani, 2010). Single parent is family with the head of family has never been married, widowed, divorced, abandoned, or separated who take care of the children or family. Two parents household or nuclear family are the family consist of father, mother, and children living in one house. Extended family is one of family type which the family shares household agreements and expenditures with parents, siblings, or other close relatives (Friedman, 2003).

Tabel 8: Household: Parenting

No

Type of parenting

1

Single parent

2

Two parents

3

Extended family

Source: MoH Indonesia (2010)

MATERIALS AND METHODS

Conceptual Framework

Child’s factors:

Age

Sex

Breastfeeding

Mother’s Factors:

Age

Education

Occupation

Household Factor:

Parenting

Child malnutrition:

Stunting

Wasting

Underweight

Figure 5. Thesis plan conceptual framework adopted from UNICEF (1997)

Research hypothesis

Is there any relationship between child factors, mother factors, and household factor with occurrence of malnutrition in children under five years of age.

Research question

What is the most dominant factor influencing the occurrence of malnutrition in children under five years of age?

Operational definition

Malnutrition in children is the child under five years of age who has diagnosed malnutrition by Department of Health in West Nusa Tenggara Province.

Child factors are the factor in a children related to age, sex and breast feeding times of the children.

Mother factors are the factors related to age, education, and occupation of the mothers in the family.

Household factor are the factors related to parenting (single parent, two parents, and extended family) model in the family.

Methodology

Research design

Research design in this study is descriptive statistic cross-sectional study. A cross-sectional study is one of the most common and famous of study designs. In this type of research study, moreover the entire population or a subset is selected, and from these individuals, data are collected to support answer the research questions. The information that is collected describes what is going on at only one point in time (Ollsen and George, 2004).

Population and sample

Population in this research is families who have children under five years of age in West Nusa Tenggara Province of Indonesia. The focus samples are families who have children under five years of age in West Nusa Tenggara Province of Indonesia. Sampling technique in this research is using a purposive sample. The sample selection is based on the characteristics.

Inclusion Criteria

Children under five years old who live with their family

Children under five years old who not in hospital

Family who willing to take part in the study

Family in West Nusa Tenggara Province of Indonesia

One child in one family

Sample Size

The sample size was calculated using G*Power version 3.1.5 with α (error prob) = 0.05 and power (1-β error prob) = 0.80, and estimated the total minimum sample size are 113 children.

Setting

This research will be take place in families at West Nusa Tenggara Province of Indonesia.

Measurement

The anthropometric data of the children were assessed using the WHO Anthro software version 3.2.2., to measure the data about child’s factors, mother’s factors, and household factor will be using questioners. Because of this instrument used English language, the researcher will translate and then validate by translators who were expert in both the English and Indonesia languages to ensure equivalence the instrument in Indonesia language.

Ethical Consideration

Ethical approval should be granted by Kasetsart University first. Then, a permission to do the research at the provincial and district health offices, community health centers and volunteer are required. Participant information sheet (PIS), anonymity, confidentiality, and informed consent will be used to protect sample and the researcher.

Plan for data collection

The data about families who have children under five years of age collected from department of health in West Nusa Tenggara Province of Indonesia. The anthropometric data of the children were assessed using the WHO Anthro software version 3.2.2, and expressed as Z-scores for each of the anthropometric indices of malnutrition against both the new WHO child growth standards and the older NCHS/WHO reference.

A child was defined as stunted, underweight or wasted if his/her height/length with age (HAZ), weight with age (WAZ) or weight with height/length (WHZ) Z-score was more than two standard deviations (SDs) below the reference median. Direct interview with a set of questionnaires will be used to collect data from the families related with child’s factors, mother’s factors, and household factor.

Plan for data analysis

The data obtained through household interviews and anthropometric measurements were field-checked, entered into a microcomputer and then analyses using Eview 4.0. Eview provide sophisticated data analysis, regression, and forecasting tools on a Windows base computer.

The WHO and National Center for Health Statistics (NCHS) standard was employed as a reference population to determine Z-scores for height/length with age, weight with age and weight with height/length. The prevalence of stunting, underweight and wasting among children under five years of age the X² test. Both bivariate and multivariate analyses were undertaken to identify the significantly associated background variables (independent variables) with malnutrition (dependent variable). While the dependent variable is dichotomous, the independent variables are composed of categorical, ordinal, and interval/ratio variables. The associations between independent variables, which are categorical or ordinal variables, and malnutrition were examined using the X² test.

As the dependent variable is dichotomous, logistic regression was undertaken as the multivariate analysis. The background variables without a significant association with the dependent variable in bivariate analyses were dropped from independent variables for logistic regression.

A study budget

Table 9: Study budget

No

Items

Amount/ number

Estimation Price (in Rupiah)

1

Paper A4 70 GSM

5 ream

@ 50.000 = 250.000

2

Copy of questioner

5 @ 100

@ 100 = 50.000

3

Printer ink

4 colors

@ 40,000 = 160.000

4

Transportation fee

2.500.000

5

Small gift for participant

100

@10.000 = 1.000.000

Total

3.960.000 rupiah

Timetable

Table 10: Time table

Activity

2012

2013

aug

sep

oct

nov

dec

jan

feb

mar

apr

jun

july

aug

sep

Start writing proposal

Defense proposal

Ask for ethical issues

Collecting data

Analyzing data

Write chapter 4 and 5

Thesis defense

Prepare for publication