Is adolescent health a priority program? A qualitative study on the stunting prevention program in Gunungkidul, Yogyakarta, Indonesia

Introduction

Stunting is a national priority in Indonesia. Adolescents are an important target for stunting prevention [1]. Good nutrition in adolescents can help prevent stunting in the next generation because maternal health during pregnancy greatly affects child growth [2]. Research in India has provided evidence that adolescents who experience malnutrition are at risk of giving birth to babies that are 0.25 standard deviations (SD) shorter than their age and five times more likely to experience stunting compared to children born to adult mothers [3].

Several health improvement programs for adolescents have been carried out in various parts of the world. The Adolescent Health Program in Bangladesh – involving water, sanitation, and hygiene (WASH) practices and deworming – seeks to improve nutritional status and anemia in unmarried adolescent girls in rural areas. That program is part of the Bangladesh government’s efforts to address malnutrition among adolescents, especially adolescent girls [4]. The Adolescent Girls Empowerment Program (AGEP) in Zambia is a program that provides education on reproductive health, nutrition, and economic empowerment to adolescent girls. With a focus on preventing early pregnancy and improving adolescent health, AGEP aims to reduce the risk of stunting in children in the future [5]. A large-scale integrated nutrition program in Nepal, funded by the United States Agency for International Development and known as Suaahara II, has an adolescent-focused learning agenda aimed at supporting the health and nutritional well-being of adolescent girls [6].

In Indonesia, the Weekly Iron Folic Acid (WIFA) supplementation program for school-age girls has been implemented by the Indonesian Government since 2016. The program aims to prevent anemia, improve nutritional status, and ensure better health for adolescent girls so that the risk of giving birth to stunted children in the future can be reduced [7]. Data show that the prevalence of anemia among adolescent girls in Indonesia is quite high, reaching between 32.4 % and 61 % in certain regions [8]. This program not only focuses on preventing anemia but also contributes to reducing stunting rates by improving maternal nutrition before and during pregnancy [7], 8]. Although the program has been running, challenges in terms of compliance and distribution of the tablets persist. Only around 10–31 % of adolescent girls are reported as having received WIFA tablets in the past 6 months [7], 9].

Other studies have yielded mixed results regarding the effectiveness of the Weekly Iron Folic Acid (WIFA) supplementation program. In East Java and East Nusa Tenggara, program coverage and compliance were found to be low, with only 9–18 % of girls taking at least one tablet within 6 months [7]. A study in Cianjur, West Java, found no significant difference in hemoglobin levels between stunted and non-stunted girls participating in the program [10]. In Bogor, the program reduced anemia prevalence from 20.7 to 15.2 % after 4 months but was deemed to be not fully effective [11]. Nutrition education has shown promise in increasing iron intake among adolescent girls, with one study reporting a significant increase in mean iron intake following the intervention [12]. In addition, the “RS Centing” program carried out by the government of Gresik Regency has been effective in increasing adolescent understanding and positive attitudes regarding stunting prevention efforts with a p-value <0.01 [13].

Gunungkidul Regency is one of the areas with the highest prevalence of stunting in the Special Region of Yogyakarta (DIY). The results of the 2024 Indonesian Health Survey showed that the stunting rate in Gunungkidul was still at 22.2 %. This figure is still much higher than the target of the 2020–2024 National Medium-Term Development Plan which stipulates that it will be 14 % by the end of 2024 [14]. A study is needed to determine the extent to which the program pays attention to adolescent health as a key factor in long-term prevention efforts.

This study aims to analyze whether adolescent health has become a priority in the stunting prevention program in Gunungkidul, as well as how the program is implemented in the field. Using a qualitative approach, this study will explore the understanding, policies, and implementation of health programs related to adolescents in the region.

Research method

This research uses a qualitative method with a phenomenological approach. It was conducted in Gunungkidul Regency, Yogyakarta. Data collection was carried out through in-depth interviews and a focus group discussion (FGD). The participants were selected using purposive sampling, with the following criteria: officials from the PKPR (youth health care program) at the Community Health Center (Puskesmas), and from the Community Empowerment and Village, Population Control and Family Planning Office (DPMKP2KB) from the Family Health Section of the Gunungkidul Regency Health Office.

The FGD involved 10 PKPR officials. Meanwhile, the in-depth interviews involved the head of the Family Health Section of the Gunungkidul Regency Health Office, an official from the Satgas stunting (stunting task force), and the Gunungkidul Regency DPMKP2KB Office. In the data collection process, the researcher acted as the main instrument and was assisted by four research assistants. The FGD and in-depth interviews were conducted using guidelines compiled based on a literature review related to stunting prevention programs for adolescents. The researchers also used a recorder, camera, and field notes to document the data collection process. There were four research assistants in this study. They assisted in the in-depth interview and FGD process, as well as data recording using a voice recorder, camera, and field notes. To align perceptions, they used interview and discussion guidelines that had been prepared based on previous literature reviews.

The validity of the data in this study used source triangulation (the heads of the Family Health Section of the PKPPR program at the Puskesmas, and the stunting task force of the DPMKP2KB Office in Gunungkidul Regency) and peer debriefing. All data obtained from the results of FGD and in-depth interviews were transcribed and coded using NVivo software. After the data were transcribed and reread to understand their context, coding and categorization were carried out to identify key themes that emerged related to the evaluation of the adolescent empowerment program in preventing stunting. The data analysis process started with the data collection, and coding was carried out simultaneously and continuously until data saturation was achieved.

Results and discussion

Data collection using the interview method was conducted with two informants from the DPMKP2KB Office and the Gunungkidul Regency Health Office. A FGD was conducted with 10 PKPR officials from the Gunungkidul Regency Puskesmas Table 1. The interviews were conducted at the DPMKP2KB Office and the Gunungkidul Regency Health Office Table 2. The FGD was conducted in the Germas Hall of the Gunungkidul Regency Health Office. The interviews and FGD were conducted by researchers.

In this research activity, the characteristics of the informants involved varied in terms of ages and experience related to adolescent health and stunting prevention programs in Gunungkidul. The FGD participants consisted of midwives from the Puskesmas and their ages ranged from 25 to 54 years. Most participants had work experience in midwifery and had been working for the PKPR program for more than 3 years, with a main focus on serving pregnant women and toddlers.

The in-depth interviews involved the Gunungkidul Health Office and DPMKP2KB. The health officials interviewed had positions as policy makers in the fields of public health, nutrition, maternal and child health, especially related to reproductive health programs, and stunting prevention.

Figure 1:

Research overview.

The results of the study revealed three main themes that emerged from the in-depth interviews and the FGD, namely (1) Program implementation, (2) barriers to program implementation, and (3) suggestions Figure 1.

Program implementation

The implementation of the intervention program to prevent stunting in adolescents in Gunungkidul Regency has resulted in program achievements and monitoring and evaluation have been carried out.

Barriers to program implementation

There have been barriers to the implementation of the intervention program for adolescents in Gunungkidul Regency; namely, it has not become a priority program, there is a lack of motivation and commitment, and challenges to health programs for adolescents have emerged.

Suggestions

Efforts to increase the effectiveness of the implementation of the intervention program in preventing stunting in adolescents in Gunungkidul Regency require innovation, cross-sectoral cooperation, and program monitoring and evaluation.

Discussion

This study was conducted to explore the implementation of the stunting prevention program for adolescents in Gunungkidul Regency. Adolescents are an important part of the stunting prevention program. They can act as role models and educators for their peers in the prevention of stunting. Increasing their knowledge can empower adolescents in their role as agents of change who are able to help prevent stunting [15]. Therefore, adolescents not only need to know the phenomena that occur in their community but also need to learn and be involved in dealing with problems that exist in society [16]. Aside from increasing knowledge, empowering adolescents will improve their attitudes toward the healthy behaviors that are important to the prevention of stunting [17]. However, training, orientation, continuity, and guidance are needed to ensure the success of the program [16].

This study highlight the importance of educating and empowering youth in stunting prevention efforts, aligning with Indonesia’s national target to reduce stunting prevalence to 14 % by 2024 and the Sustainable Development Goals (SDGs) [18], 19]. Community-based participatory research and health education programs targeting adolescents have shown promising results in increasing knowledge about stunting prevention [18], 20]. These interventions focus on various aspects, including recognizing stunting, proper nutritional practices, and the importance of the first 1,000 days of life [19]. By engaging youth, particularly through school-based programs and community organizations, these initiatives aim to promote behavioral changes that can contribute to improving child health and well-being, ultimately helping to achieve sustainable development goals in health [18], 20].

The results of this study show that health prevention programs for adolescents in Indonesia face significant challenges. The PKPR (adolescents health care services) program does not yet have a special allocation of funds and human resources for its implementation which potentially can cause it to lack the funds and human resources it needs [21], 22]. The activities of the PKPR program are carried out simultaneously with other programs meaning that there is no monitoring and evaluation and continuity for the program. Its activities are often combined with other initiatives, so monitoring, evaluation, and continuity are inadequate [21]. Studies in various regions, including Pekanbaru, Banda Aceh, and Bandung, have revealed common problems such as inadequate staff training, limited facilities, and weak partnerships [22]. Adequate human resources and funding determine the success of adolescent stunting prevention programs, although certain sectors still need improvement [8], 23]. Good planning is also important to support the success of the program because, if it is planned carefully, it can indicate better implementation of adolescent health programs. Therefore, cross-sectoral collaboration is needed for adolescent stunting prevention programs. As mentioned in the research results that show how cross-sectoral cooperation is important for the continuity of the stunting prevention program for adolescents. Cross-sectoral cooperation can be carried out between regional organizations such as the health office working in collaboration with the education office. In addition to cross-sectoral cooperation, the commitment of all parties involved – targets, companions, and partners – is also no less important in the implementation of the intervention program for adolescents.

Research findings show that adolescent health has not been a priority in stunting prevention. Involving adolescents in stunting prevention provides long-term benefits and can break the cycle of stunting [24]. However, barriers such as misunderstandings about stunting and suboptimal adolescent health services hinder their participation [24], 25]. At the grassroots level, there is a lack of awareness about stunting, its impacts, and prevention methods [25].

As mentioned in the results of this study, One strategy to increase the effectiveness of the implementation of the intervention program for adolescents, and its achievements in preventing stunting, is to carry out monitoring and evaluation. In the FGD and interviews, conducting monitoring and evaluation periodically once a month and involving parents would increase the compliance of adolescent girls in consuming iron tablets by reminding them to take them while at home. The Indonesian Government has an application aimed at preventing stunting in prospective brides called ELSIMIL. The ELSIMIL is an innovative tool aimed at reducing stunting rates in Indonesia by screening and supporting prospective brides and grooms [26]. The application provides efficient screening and data entry for Family Support Team members, though some technical challenges remain [27]. ELSIMIL serves as a preventive measure for potential marital issues and is being considered as a potential administrative requirement for marriage [28].

This condition is complicated by the lack of commitment and unhealthy behavior of the targets. The informants said that adolescents were not compliant in consuming the iron tablets. Low compliance in consuming iron supplements is a significant problem which is often associated with a lack of knowledge and parental supervision [17], 29]. Educational interventions can significantly improve knowledge and attitudes towards iron supplementation [30]. Barriers to stunting prevention include geographical challenges, limited budgets, and poor household consumption patterns [29]. Effective dissemination of information through websites, social media, and direct communication with health workers is essential [31]. Despite improvements after education, some adolescents still lack adequate knowledge, highlighting the need for continued efforts to raise awareness and promote iron supplement consumption [30]. Cross-sectoral cooperation is crucial for effective stunting prevention and reduction. Multiple studies highlight the importance of multi-sector partnerships and convergence actions in addressing this complex issue [32], 33]. These collaborations involve various stakeholders, including government agencies, universities, civil society organizations, and private companies [32].

Conclusions

The conclusion of this study is that the implementation of stunting prevention programs for adolescents in Indonesia faces several significant challenges. Adolescents have an important role as agents of change in preventing stunting through empowerment, increasing knowledge, and attitudes toward healthy behavior. However, the implementation of the program is still constrained by the lack of adequate funding and human resources, as well as weak monitoring, evaluation, and continuity of the program. Other challenges include low compliance of adolescents in consuming iron supplements, which is often caused by a lack of knowledge, parental supervision, and commitment of adolescents. The lack of cross-sector commitment, as well as geographical and budget challenges, exacerbate the situation. To overcome these problems, continuous efforts are needed in education, awareness raising, and better cross-sector collaboration to ensure the success of the stunting prevention program for adolescents. Effective dissemination of information through various media and adequate training is also key to improving the implementation of this program. The stunting prevention program for adolescents in Gunungkidul plays an important role in building a healthier generation. Despite several challenges, the program has achieved several successes, such as increasing adolescent understanding of health, providing iron tablets, and education through PKPR. However, the implementation of this program still faces major obstacles, namely lack of funding, limited human resources, and weak monitoring and evaluation. To increase the effectiveness of the program, innovation, cross-sector collaboration, and increased involvement of parents and the community are needed. To ensure the program runs better, strong synergy is needed between the Health Office, Education Office, and other stakeholders. Intensive socialization to adolescents and parents needs to be done to increase awareness of the importance of adolescent health in preventing stunting. In addition, routine monitoring and evaluation of the program must be carried out so that strategies can be adjusted. Innovations such as peer counseling and healthy canteens also need to be developed to be more attractive to adolescents. Further research is needed to evaluate the long-term impact and find a more effective approach in preventing stunting.