Factors for Minimum Acceptable Diet Practice among 6–23-Month-Old Children in Rural and Urban Areas of Indonesia

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J Korean Acad Fam Med. 2024;.kjfm.23.0284

Publication date (electronic) : 2024 June 7

doi : https://doi.org/10.4082/kjfm.23.0284

Rika Rachmawati^,, Rika Rachmalina, Yunita Diana Sari, Tri Wurisastuti, Kencana Sari, Ayunina Rizky Ferdina, Noviati Fuada, Tin Afifah

Research Centre for Public Health and Nutrition, The National Research and Innovation Agency, Cibinong, Indonesia

^*Corresponding Author: Rika Rachmawati Tel: +62-21-3169059, E-mail: rika016@brin.go.id

Received 2023 December 28; Revised 2024 March 8; Accepted 2024 March 8.

Abstract

INTRODUCTION

Malnutrition persists among Indonesian children under the age of 5 years, with rates varying across urban and rural regions. In Indonesia, about 17.1% of children less than 2 years old were stunted (16.2% in urban areas and 18.1% in rural areas), 7.2% were wasted (7.1% in urban areas and 7.5% in rural areas), and 11.4% were underweight (10.6% in urban areas and 12.3% in rural areas) [1]. In 2013, Basic Health Research discovered that 28.1% of children aged 1 to 5 years had iron-related nutritional anemia (30.3% in urban regions and 25.8% in rural areas) [2]. Anemia was found in 59.4% of children aged 6–23 months, and they were the most likely to suffer from anemia [3].

Adequate nutrition is critical for optimal health and growth in the first few months of life. After 6 months of age, breast milk is insufficient to meet the nutritional requirements of newborns. The shift from exclusive breastfeeding to family meals is essential between the ages of 6 and 23 months, making toddlers prone to malnutrition. In addition to breastfeeding, optimal complementary feeding practices are necessary to prevent malnutrition and child mortality [4].

Many factors affect infant and young feeding practices, such as sociodemographic characteristics, the economy, and the availability of rural and urban facilities. Significant variances exist between the geographic locations and wealth quintiles. According to the 2017 Indonesia Demographic and Health Survey (IDHS), the proportion of children aged 6–23 months who satisfied the infant and young feeding practice guidelines varied between urban (47.8%) and rural (35.3%) districts [5]. Approximately 33% of children within that age group did not reach the required minimum frequency of meals, one-quarter did not meet the minimum dietary variety requirement, and almost half did not meet the recommended diet quality requirement [6].

A composite metric called the minimum acceptable diet (MAD) considers dietary quality and quantity. To facilitate the healthy development of infants and young children, MAD must be fulfilled. Although MAD in children aged 6–23 months has been researched in Indonesia [7,8], no study has been conducted on the variables that impact MAD depending on the location of living in urban and rural settings. To enhance the prevalence of MADs and mitigate malnutrition rates in Indonesia, a comprehensive understanding of the underlying factors contributing to the low occurrence of MAD among children aged 6–23 months must be developed considering the issues encountered in both urban and rural areas. Therefore, this study aimed to identify the risk factors for MAD in 6–23-month-old infants in rural and urban Indonesia.

METHODS

1. Data Sources and Study Population

A nationally representative dataset from the IDHS 2017 (IDKR71FL) was used for the secondary data analysis. The IDHS used a two-stage stratified sampling design to select census blocks and households. The numbers of eligible households and women aged 15–24 years for the interview were 47,963 and 49,267, respectively. Details on the IDHS method have been provided elsewhere [5]. The analysis was limited to married women aged 15–49 years who had a last-born child aged 6–23 months living with her. A total of 4,688 children were included in this study. Figure 1 illustrates the participant selection process for the IDHS 2017 dataset.

Figure. 1.

Selection of participants.

4. Data Analysis

STATA ver. 15.1 (Stata Corp., College Station, TX, USA) was used to analyze the data using a multiple logistic regression model with stratification based on the area of residence (urban or rural). The size of the outcome and independent factors was examined using a descriptive analysis utilizing a frequency distribution for children living in each type of residential area (Table 1). The chi-square test was used to assess the differences in all independent variables in relation to the MAD status (Table 2). Variables with P-values less than 0.25 were then included in the multivariate logistic regression analysis to investigate the predictors of MAD in children aged 6–23 months in each area (Table 3). All independent variables included in the multivariate analysis were adjusted for the relationship between MAD status and other independent variables. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to assess the strength of the relationship (Table 3). Statistical significance was defined as a P-value <0.05. The percentage of Indonesian children aged 6–23 months at the national level was calculated using sample weights.

Table 1.

Frequency distribution of characteristics of the household, child, and parents based on urban and rural areas

Table 2.

Frequency distribution of respondents based on the characteristics of household, child, and parents and MAD status in urban and rural areas

Table 3.

Multivariate analysis on the variables related to household, child, and parents and MAD status in urban and rural areas

RESULTS

DISCUSSION

This study indicated that over half of the children under 2 years of age in urban and rural areas did not meet the MAD. Area of living (rural and urban) influences the access to MAD in Indonesian children aged 6–23 months [11]. To explore this, we investigated the characteristics associated with MAD compliance in children aged 6–23 months living in urban and rural regions and examined the factors behind MAD achievement in both.

According to this study, socioeconomic and sociodemographic factors that were strongly associated with MAD in both rural and urban areas were the household wealth index, maternal working status, and father’s age. This study found that the higher the household wealth index, the greater the odds of ensuring MAD in children. A better wealth index provides a better opportunity for meeting MAD in children [12]. This means that the higher the household wealth index, the better the chance of accessing necessities, health care, and knowledge of excellent newborn and small-child feeding habits. Wealthier households also tend to consume nutritious and varied food because of sufficient resource supply [13]. Households in urban areas are more likely to employ domestic paid caregivers for childcare or domestic support. The higher the wealth index, the better the chance of accessing this service [14].

Regarding employment and MAD status, we observed that children whose mothers work, in either urban or rural areas, are more likely to receive MAD than those whose mothers stay at home. This indicates that MAD administration was relatively stable in both settings. This also highlights the positive impact of formal maternal employment on child nutrition and suggests potential areas for focused efforts to improve child nutrition in various economic settings.

The correlation between maternal employment and MAD adherence is contingent upon various factors, including working hours, job type, income levels, and access to food resources [11]. Similar patterns have been observed in other nations, such as Ethiopia, where working mothers exhibited a 1.7-fold higher likelihood of ensuring that their children meet MAD standards than did non-working mothers [15,16].

Although economic and educational levels normally increase with age, we discovered that children were less likely to have MAD if their fathers were older than 35 years. This indicates that there may be unidentified factors linking the father’s age and child’s MAD status, warranting further studies. In Indonesia, traditional divisions of household tasks are still relatively strong, with females being more responsible for childcare than their husbands [14,17]. This may explain why older fathers probably contribute less to childcare and feeding practices, as observed in our study. Nevertheless, this is only a minor fraction of the overall determinants of children’s MAD status, and the pattern may vary in different scenarios.

The characteristic of the child, in this case, was age, which was also associated with ensuring MAD. Our findings imply that the chance of meeting MAD increased remarkably with the increase in the child’s age, which is consistent with those from a similar study using IDHS 2012 data [18] and another study in developing countries [19]. Other meals are typically introduced to exclusively breastfed children at an age of 6 months, which may explain why babies aged 6–11 months are less likely to receive MAD [20]. These babies likely exhibit a decreased tendency toward selective eating habits as they grow older, because they will have more developed teeth and immune systems [21]. Mothers may also perceive that younger babies are not adequately equipped to digest certain foods [22].

Children living in urban areas were more likely to achieve MAD than those living in rural areas. Urban mothers had better access to information; health service institutions; and media such as the internet, television, and newspapers to enhance their knowledge of healthy feeding practices. Urban areas also facilitate mothers’ access to diverse foods through establishments such as markets, greengrocers, and malls and to prepared foods from restaurants, cafés, food stalls, bakeries, or urban eateries. We also found that children living in rural areas were more likely to have low dietary diversity. Better and equitable access to food producers, using a variety of locally available foods and employing vegetable gardens, is needed.

A few maternal factors have been linked to MAD exclusively in urban or rural areas. Mothers who participate in household decisions and perform ANC visits at least 4 times during pregnancy increase the likelihood of children in rural areas having MAD. In this study, most mothers visited ANC 4 times or more during pregnancy, with a higher proportion of these mothers being from urban areas than from rural areas. However, the number of mothers visiting ANC 4 or more times in urban areas was not related to child-feeding practices, especially MAD. In contrast to the results of other studies [23], our analysis showed that ANC visits were an independent factor associated with MAD only in children from rural areas.

As part of the important maternal healthcare services, ANC provides a platform to counsel mothers to prepare the foundations for healthy motherhood. During ANC, mothers can receive counseling from health workers about appropriate feeding for infants and young children, which may increase the odds of MAD. This indicates that a sufficient frequency of ANC visits may increase the chances of MAD access for children in rural areas, perhaps because of their practice of following the health workers’ advice. Furthermore, the mothers included in this study were relatively young, between 15–34 years old, and their education can influence their knowledge, attitudes, and behavior toward the information provided. Mothers who live in rural areas tend to listen more to the health workers [24]. Additionally, we observed that mothers in rural areas had more autonomy in feeding their children.

Maternal autonomy has emerged as a crucial social determinant that affects children’s health and development, particularly concerning MAD practices. Drawing on insights from studies conducted in Ghana [25] and Bangladesh [26], this study underscores the importance of financial decision-making autonomy in shaping MAD outcomes. Children whose mothers exhibit greater independence are more likely to receive nutrition that aligns with the recommended standards, encompassing diverse food choices and consistent meal frequencies. Our findings highlight a significant impact within rural households, where maternal involvement in decision making significantly increased the likelihood of a child attaining MAD status by 1.58 times. This study establishes a clear link between maternal autonomy and child nutrition and provides compelling evidence that highly autonomous mothers have the capacity to nourish their infants in accordance with global benchmarks. These findings emphasize the need for targeted interventions and policies that empower mothers, particularly in rural settings, to ensure improved child health and development.

Moreover, urban mothers living with their husbands were strongly associated with ensuring MAD to their children. Social assistance from the husband helps reduce psychological issues such as depression, while improving the well-being and viability of both mothers and offsprings.

A study in Uganda reported that children who were cared for by a combination of mothers and fathers had a greater chance of achieving MAD 2.7 times than children who were only cared for by their mothers [27]. Children raised by both parents had better complementary feeding behaviors, demonstrating that fathers may help mothers by providing extra support and incentives.

An association between living with a husband and MAD was not observed in families living in rural areas. This is probably because the traditional cultural roles of mothers as caretakers of children and fathers as breadwinners are common in rural families in Indonesia. According to a study conducted in Northern Ghana, fathers’ engagement in childcare chores such as feeding, cooking, maintaining company with the child, or washing the child remained a strong independent predictor of MAD [28]. Another study in Indonesia also reported the father’s influence on the success of breastfeeding practices measured by the father’s support during pregnancy, at birth, and first breastfeeding; postnatal support; fathers’ involvement in childcare; and positive attitude toward married life [29].

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