Development of the “KARUNI” (young adolescents community) model to prevent stunting: a phenomenological study on adolescents in Gunungkidul regency, Yogyakarta, Indonesia

Introduction

Stunting or a condition of failure to thrive due to chronic malnutrition is one of the main health problems faced by many developing countries. Its impact is not only seen in height that is lower than the standard for a particular age but also in cognitive development and long-term ability to be productive. A study conducted by the World Bank shows that when stunted children become adults, they are 20 % less productive than those who were healthy children [1]. In addition, long-term effects are also associated with decreased fat oxidation ability, which causes the risk of obesity and degenerative diseases. The results of a multicenter survey conducted by Poh et al. involving 16,700 children in Indonesia, Malaysia, Thailand, and Vietnam showed that stunting was significantly associated with decreased IQ, especially non-verbal, with a value of <89 (OR 1.65 95 % IK: 1.64–1.66) [2].

So far, the main focus of stunting prevention programs has been more directed at pregnant women, toddlers, and children under the age of two (the first 1,000 days of life). However, there is a segment of the population that is crucial in breaking the chain of stunting, but it is often overlooked: adolescents, especially adolescent girls. These girls will become mothers in the future who determine the quality of the next generation. Malnutrition, anemia, and poor reproductive health in adolescent girls have the potential to increase the risk of giving birth to stunted children. Research in India provides evidence that adolescents who experience malnutrition are at risk of giving birth to babies 0.25 standard deviations shorter than the average weight for their age and are five times more likely to experience stunting compared to children born to adult mothers [2].

Innovative stunting prevention programs conducted during adolescence have developed in recent years in various parts of the world including nutrition education, iron supplementation, nutrition interventions and awareness campaigns on the importance of healthy eating patterns [3], [4], [5], [6], [7]. The nutrition intervention program in Ethiopia (called the School Feeding Program) focuses on nutrition education and interventions for adolescent girls. The results of the study explained that the school feeding program has improved nutritional status and academic achievement. However, to ensure the sustainability of the program, the program must be supported by national policies and budget allocation is needed too [7]. Next is the Nutrition-Friendly Schools Initiative program implemented in Latin America and Africa. This program seeks to create a school environment that encourages healthy behaviors, including balanced nutrition. By providing nutritious food at school, this program supports adolescents in obtaining adequate nutrition, which will affect their health and reproductive abilities in the future [8]. In addition, a school-based weekly iron and folic acid supplementation program has been effective in reducing anemia in a group of prospective adolescent girls aged 10–19 years in Ghana [9]. Another program implemented in Delhi, India, namely the provision of weekly iron and folic acid (PIA) supplements accompanied by monthly health education has been effective in reducing the prevalence of anemia in school-age adolescent girls [10] Recent studies emphasize the importance of involving adolescents in stunting prevention efforts. Health education programs targeting teenagers have shown significant improvements in knowledge about stunting and its prevention (Asatuti et al., 2021; [11]). These initiatives can be integrated into school curricula and community activities, focusing on balanced nutrition, family planning, and early childhood care [11]. Forming youth groups dedicated to stunting prevention has proven effective in raising awareness and promoting community engagement [11]. Additionally, monitoring nutritional status and providing nutrition education to adolescents are crucial steps in preventing stunting (Asatuti et al., 2021). By educating teenagers as future parents, these programs aim to reduce stunting rates and improve overall community health. The studies emphasize the need for continued efforts in adolescent education and involvement as a key strategy in the long-term prevention of stunting. Effective stunting prevention measures include providing nutritional education to influential parties such as community health workers, mothers of toddlers, and women of childbearing age (Fristiwi et al., 2023). By educating teenagers as future parents, these programs aim to reduce stunting rates and improve overall community health.

Stunting is one of the pressing public health problems in Indonesia. Various efforts have been made to reduce its prevalence, but the problem remains a serious threat to future generations. The results of the 2023 Indonesian Health Survey showed that the stunting rate was still 21.5 %, down only 0.1 % from 2022 [12]. This challenge is exacerbated by the lack of attention paid to adolescent health in existing stunting prevention programs. Data show that many adolescents in Indonesia experience nutritional problems such as anemia, unbalanced food intake, and minimal knowledge about reproductive health and nutrition. The current prevalence of adolescent anemia is 15.5 % and the prevalence of malnutrition is 15.9 % [12]. Nutritional status, especially in adolescent girls, needs more attention because adolescent girls are prospective mothers who will give birth to the next generation. The lack of early intervention in adolescents’ health causes them to be less prepared to play the role of healthy mothers later in life, meaning that the cycle of stunting continues.

To answer this challenge, there needs to be innovation in the form of interventions specifically aimed at adolescents as part of a long-term stunting prevention strategy. Referring to WHO recommendations, it is necessary to strengthen interventions to improve maternal nutrition and health, starting from adolescent girls. The KARUNI (young adolescents community) model is an innovative program designed to improve adolescent health and nutrition as a first step in breaking the chain of stunting. This model is designed to equip adolescents, especially adolescent girls, with the knowledge and skills they need to maintain their health, including education about balanced nutrition, reproductive health, and the importance of early preparation for a healthy pregnancy. The KARUNI program prioritizes a community-based approach, where adolescents are actively involved in educational activities and mentoring related to health and nutrition. In addition, KARUNI groups also play a role in building adolescent awareness about the importance of their role in preventing stunting by improving nutritional status and overall health. Individual compliance in carrying out a behavior will encourage the emergence of self-efficacy towards that behavior [13]. Research indicates that Daily meal tracking tools have been shown to significantly enhance nutrition knowledge and attitudes among teenagers aged 13–16 [14]. Health education programs covering various aspects of healthy living, including nutrition and exercise, can help late adolescents make informed decisions about adopting healthier lifestyles and increase their self-confidence in implementing these changes [15]. Educational and communicative approaches tailored to adolescents’ characteristics and needs can promote healthy behaviors, with studies showing improvements in health knowledge and lifestyle practices after such interventions [16]. Effective nutrition education methods for adolescents include social media, audiovisual tools, and conventional media, with peer educator training playing a key role in successful implementation [17].

Adolescent empowerment plays a crucial role in stunting prevention. Women’s empowerment, particularly in education and knowledge, significantly impacts stunting prevention in children aged 6–59 months [18]. Media-based health education, especially social media platforms like TikTok and Instagram, has proven effective in increasing adolescents’ understanding of stunting prevention [19]. Nursing interventions targeting adolescent mothers can contribute to preventing stunting in their children, focusing on nutrition during pregnancy and breastfeeding [20]. Health education programs aimed at increasing adolescents’ knowledge about proper nutrition and stunting prevention have shown positive results, as evidenced by improved pre- and post-test scores [21]. These studies highlight the importance of empowering adolescents through education, media interventions, and targeted healthcare initiatives to address the global issue of stunting and improve nutritional outcomes for both adolescents and their future children.

This study aims to design a model for an early adolescent group called the KARUNI model as an innovative stunting prevention program that focuses on groups of adolescents. Karuni in this study was conducted to design a new model for empowering teenagers and parents to prevent stunting. By integrating community-based interventions, this program is expected to improve knowledge and healthy behavior among adolescents, as well as strengthen their readiness to support stunting prevention efforts in the future. The results of this study are expected to provide significant contributions to developing a more comprehensive stunting prevention strategy, starting from the adolescent age phase as the foundation of the health of future generations.

Research method

This study uses a phenomenological approach that aims to explore and describe how adolescents understand, experience, and interpret stunting prevention programs in their daily lives. This study uses the perspective of teenagers as the target users of Karuni. The study was conducted in Gunungkidul Regency, Yogyakarta, Indonesia. The main subjects or informants in this study were adolescent girls aged 12–15 years. The supporting informants in this study were officials running the Adolescent Health Care Program (PKPR) at the community health center (Puskesmas), the Health Office, and the Community Empowerment and Village, Population Control and Family Planning (DPMKP2KB) office. The selection criteria for the informants used purposive sampling based on their direct experience in intervention programs for stunting prevention in adolescents and their willingness to share their experiences in depth. The number of informants in this study was 12 adolescent girls, 10 officials from the PKPR program at the Pusksmas, one person from the Health Office, and one person from the DPMKP2KB office.

The data collection method to explore the experiences and perceptions of the subjects was carried out using in-depth interviews and focus group discussions (FGDs). FGD activities for adolescent girls were conducted in the hall of SMP Negeri 2 Karangmojo (junior high school). The FGD activities for the PKPR program holder group at the Puskesmas were conducted in the community hall of the Gunungkidul Health Office. In-depth interviews with the stunting task force at DPMKP2KB were conducted in that office’s meeting room, while interviews with the Health Office were conducted in the room of the head of the family health section. In each group, FGDs and interviews lasted for 1 h. In the data collection process, the researcher acted as the main instrument and was assisted by four research assistants. FGDs and in-depth interviews were conducted using guidelines compiled based on a literature review related to stunting prevention programs for adolescents. These guidelines include open-ended questions so that participants can provide in-depth responses according to their experiences. In addition to the FGD and in-depth interview guidelines, the researcher also used a recorder, camera, and field notes to document the data collection process. This study focuses on the perspective of adolescents for model development, exploring adolescent behavioral problems, exploring adolescent material needs, and identifying appropriate media education for adolescents.

The validation of the data in this study was carried out through the triangulation of sources, namely adolescent girls aged 12–15 years, the head of the DPMKP2KB at the Health Office, officials from the PKPPR program at the Puskesmas, the stunting task force of the DPMKP2KB office in Gunungkidul district, and peer debriefing. All data obtained from the results of FGDs and in-depth interviews were transcribed and coded using NVivo software. In this study, data saturation was achieved after conducting in-depth interviews with the informants. Interviews were conducted repeatedly until no new information or themes were found that were relevant to the study. At this point, the data obtained provided a complete and comprehensive understanding of the experiences of adolescents in the ongoing stunting prevention program. This data saturation is an indicator that the information collected is sufficient and adequate to answer the research questions, and that there are no more significant new variations from the data collected.

This study pays attention to the principles of research ethics, especially those involving adolescents as research subjects. Prior to the study, permission was obtained from the research ethics committee (No.1.538/VI/HREC/2024) issued by RSUD Moewardi (government hospital). In addition, participants and parents or guardians were given an informed consent form explaining the purpose, procedures, and the participant’s right to withdraw at any time during the study. The confidentiality of each participant’s identity was maintained by using anonymous codes in the presentation of the research results.

Results

In this study, the data collection method was interviews conducted with four informants, namely two young women, one stunting task force member from the DPMKP2KB Office, and one Head of Social Welfare from the Gunungkidul Regency Health Office. The focus group discussions (FGDs) were conducted with 10 young women and 10 PKPR officials from the Gunungkidul Regency Health Office. Interviews were conducted at the offices of the DPMKP2KB Office and Gunungkidul Regency Health Office, while focus group discussions with PKPR officials were conducted in the public hall of the Gunungkidul Regency Health Office and the FGDs with adolescents were conducted in the hall of SMP Negeri 2 Karangmojo (junior high school). The interviews and FGDs were conducted by researchers assisted by research assistants (Tables 1 and 2).

There were 20 participants in the FGD activity, consisting of two large groups, namely midwives working at the Puskesmas and students. The ages of the participants varied from 13 to 54 years. The Puskesmas midwives had an age range of 25–54 years, while the students were between 13 and 14 years. All of the Puskesmas midwives had a Diploma III educational background, indicating that they had completed higher education in midwifery and the students were at the junior high school level (Tables 1 and 2).

There were four participants, two of whom were professionals, and two others were junior high school students. The ages of the professional participants were 36 and 41 years, while the age of the junior high school student participants was 14 years. The first participant had a master’s degree and the second participant had a bachelor’s degree and the other two participants were currently still at junior high school. After data collection was conducted. The research data was analyzed using content analysis. The interview results were transcribed, then codes were determined and combined into categories and find the thems as follows (Figure 1).

Figure 1:

Research overview.

According to the results of the FGDs and in-depth interviews conducted on the four target groups, five main themes were obtained related to the adolescent intervention program as an effort to prevent stunting in Gunungkidul Regency. These five themes are program implementation, obstacles to program implementation, adolescent needs, suggestions and design of the KARUNI model.

Program implementation

The intervention program for adolescents in preventing stunting in Gunungkidul Regency has been implemented in terms of program achievements where in its implementation monitoring and evaluation have been carried out to measure the impact of the program. According to the findings, several intervention programs targeting adolescents, such as the Adolescent Health Care Service (PKPR), education for adolescents, provision of Fe tablets, health screening. Monitoring has also been carried out routinely monthly, quarterly, semi-annually, annually.

Barriers to implementation

The results of the FGD and in-depth interviews show that several barriers to the implementation of the adolescent health intervention program as an effort to prevent stunting, namely the adolescent health intervention program has not been a priority program, there is still a lack of motivation and commitment from related parties meaning that there are still challenges in the implementation of the next program.

Needs of adolescents

Currently, adolescents are faced with various conditions that affect their health and well-being. Limited access to information about nutrition and health, as well as unhealthy behavior patterns, can contribute to an increased risk of stunting. Adolescent knowledge about the importance of balanced nutrition and a healthy lifestyle is crucial in preventing this problem. In addition, adolescent behavior which is often influenced by their social and cultural environment can also affect eating habits and lifestyle.

Suggestions

As an effort to increase the effectiveness of the program, especially preventing stunting through interventions with adolescents, the government – as policymakers – and health workers – as program implementers – need to make various efforts, including innovating, conducting cross-sectoral collaboration in specific interventions, and conducting periodic and continuous program monitoring and evaluation.

KARUNI model design

The KARUNI model is an innovative approach to stunting prevention specifically designed for adolescents aged 12–15 years. The main focus of this model is empowering adolescents through education about nutrition, reproductive health, and clean and healthy living behavior (PHBS). This study revealed that the formulation of KARUNI model included program duration, media and sources of health information for adolescents, and methods for improving adolescent health.

Discussion

This study reveals various important aspects of the efforts to reduce the prevalence of stunting through an adolescent health approach. This study describes the active role of puskesmas (community health centers) and schools in implementing the Adolescent Health Care (PKPR) program, providing iron tablets, and various health screening activities aimed at changing adolescent behavior. The PKPR is implemented at the puskesmas level as the spearhead of adolescent health services [22], 23]. This program includes various services such as reproductive health education and health screening [23]. In addition, the formation of adolescent cadres who care about stunting is also an important strategy in efforts to prevent stunting and improve child health [11]. Various studies have shown that collaboration between puskesmas and schools is very important to implement these programs [24], 25]. However, challenges remain, including inconsistent implementation and limited resources. Routine health services for adolescents can help prevent new health problems and reduce the incidence of existing problems, such as anemia [25].

Other findings indicate that monitoring and evaluation are key elements in the success of stunting prevention programs. Evaluations are conducted regularly to monitor behavioral changes and the effectiveness of interventions, such as compliance with iron tablet consumption. However, several obstacles such as a lack of health literacy among the public and coordination between institutions are obstacles to carrying out optimal evaluations. Monitoring and evaluation are crucial elements in the success of stunting prevention programs. Routine evaluations are conducted to monitor behavioral changes and the effectiveness of interventions, such as compliance with iron tablet consumption [26]. However, several obstacles hinder optimal evaluation, including the low health literacy among the public and a lack of coordination between institutions [27], 28].

Research shows that adolescent health interventions face significant implementation challenges, including limited financial resources, lack of coordination between sectors, and inadequate human resources [29], 30]. In Ghana and India, studies have shown that many planned strategies for adolescent health are only partially implemented or not implemented at all [30], 31]. A lack of engagement with adolescent perspectives and cultural contexts also hinders effective implementation [30]. In addition, standardized measurement instruments and long-term follow-up studies are needed, especially in low- and middle-income countries [32]. To improve adolescent health programs, experts recommend a multisectoral approach, increased funding, better training for health service providers, and greater involvement of young people in policy development and implementation [29], 31].

Recent studies highlight the importance of targeted interventions for adolescents in stunting prevention programs. Media-based health education, particularly social media platforms like TikTok and Instagram, has shown effectiveness in increasing adolescents’ knowledge about stunting prevention [19]. However, addressing stunting requires a comprehensive approach that considers factors such as dietary patterns, eating disorders, and body image among adolescent girls in high-prevalence countries [33]. A multi-site Indonesian cohort study is ongoing to better understand the developmental trajectories of stunted and non-stunted adolescents, examining growth, nutrition, psychosocial wellbeing, and pubertal development [34]. These findings underscore the need for holistic, adolescent-focued strategies to combat stunting and improve overall health outcomes.

This study highlights the importance of involving adolescents in stunting prevention efforts. Adolescents can act as effective agents of change and peer educators if equipped with the appropriate knowledge and skills [35], 36]. Community service approaches involving adolescents have shown promising results in increasing awareness and commitment to reducing stunting rates [11]. Educational interventions, such as nutrition counseling training for adolescents, have shown significant improvements in their knowledge of stunting and their ability to counsel peers and mothers of young children [37].

Conclusions

This study emphasizes the importance of the approach to adolescent health in efforts to reduce the prevalence of stunting through collaboration between puskesmas and schools. The Adolescent Health Care Program (PKPR), provision of iron tablets, and health screening are key strategies in increasing awareness of nutrition and reproductive health for adolescents, especially girls. However, the implementation of this program still faces challenges, including limited resources, the need for coordination between institutions, and low health literacy among the public. Involving adolescents as agents of change – such as through training and their role as peer educators – is an important step in strengthening the effectiveness of stunting interventions and expanding their impact in the community.