Accessibility of Mother and Child Health Services to Stunting Incidence in Leti Island, Southwest Maluku District

One of the nutritional problems that can worsen the quality of life of children in achieving growth and development is stunting. Stunting receives greater attention than other nutritional statuses because in addition to a higher prevalence it can also indicate something more serious than just short body size. This type of research is a quantitative study that uses analytic observational with a case control study design to see the effect of the independent variables on the dependent variable. The sampling technique in this study was simple random sampling with a total sample of 164 people, 82 people in the case group and 82 people in the control group. The results of this study indicate that there is an effect between exclusive breastfeeding and health services on the incidence of stunting, while for the basic immunization variable there is no effect on the incidence of stunting. Meanwhile, based on the multivariate test, it was found that the variable that had the most influence on the incidence of stunting was health services. As for suggestions for this research, it is hoped that the Health Service will further improve health services to monitor the growth of toddlers and for mothers of toddlers to visit health services regularly.


INTRODUCTION
According to the World Health Organization (2020), nutritional problems in toddlers are still a world problem including stunting, wasting and overweight.Malnutrition during infancy is always associated with specific vitamin mineral deficiencies and is associated with certain micronutrients.In recent years there have been many studies on the impact of inadequate intake of nutrients, starting from the increased risk of infectious diseases and death which can hinder growth and development. 1e of the nutritional problems that can worsen the quality of life of children in achieving growth and development is stunting.Stunting receives greater attention than other nutritional statuses because in addition to a higher prevalence it can also indicate something more serious than just short body size.
Stunting has an impact on children's lives until they grow up, especially the risk of physical and cognitive development if not handled properly (A.Sutriyawan and C.C. Nadhira, 2020).The achievement of the World Health Assembly (WHA) stunting prevalence target ensures a reduction in stunting rates in 2015 and the Sustainable Development Goals (TPB), namely eliminating all forms of malnutrition by 2030. 2 The problem of nutritional status in toddlers in Indonesia has disparities between regions (provinces, districts).Based on the magnitude of the stunting problem, an area is considered to have a mild stunting problem if the stunting problem is between 20-29%, moderate if it is 30-39% and severe if it is ≥40%.The problem of stunting is one of the problems faced by the world, especially in poor and developing countries.Stunting is a health problem because it is associated with the risk of morbidity and mortality, suboptimal brain development, resulting in delayed motor development and retarded mental growth.This is a serious threat to the existence of children as the successor of a nation.In addition, stunting is also a widely accepted predictor of poor-quality human resources, which then reduces the productive capacity of a nation in the future. 3e government has set stunting as one of the priority programs.Based on the Regulation of the Minister of Health Number 39 of 2016 concerning Guidelines for Implementing the Healthy Indonesia Program with a Family Approach, efforts have been made to reduce the prevalence of stunting in toddlers, including monitoring toddler growth, organizing Supplementary Feeding (PMT) activities, organizing early stimulation of toddler development and providing services optimal health. 4 order to achieve optimal health status for everyone, serious attention must be paid continuously to the implementation of health-oriented national development, guarantees for health care, increased professionalism and decentralization of the health sector.The main target of public health services is the community and certain groups.Meanwhile for public health services, the staff serving are community health experts.The main focus is to prevent disease, and the main target is of course the community as a whole. 5veral factors that can affect the incidence of stunting include history of breastfeeding, basic immunization status, under-five birth weight and under-five body length/height, parental education, utilization of health services, and stunting management.A history of breastfeeding provides a risk of becoming stunted, 3.7 times higher in toddlers who are not given exclusive breastfeeding (breastfeeding <6 months) compared to toddlers who are given exclusive breastfeeding (≥ 6 months). 6Research conducted by Teshome (2009) 7 shows that children who do not get colostrum have a higher risk of stunting.

MATERIALS AND METHODS
The type of research used in this study is a quantitative method with a case control study to see the effect of the independent variables on the dependent variable.The sampling technique in this study was simple random sampling with a total sample of 164 people, 82 people in the case group and 82 people in the control group.The research location was carried out on Leti Island, Southwest Maluku Regency, Maluku Province.The time of research and data collection was carried out in March 2023.The research instrument used was a questionnaire.Data analysis used statistical tests using univariate analysis tests, bivariate analysis tests and multivariate analysis tests.

Characteristics of respondents
Based on the table above, it shows that of the 164 male respondents the most were in the case and control categories, namely 42 (51.2%)for the case category and 43 (52.4%) for controls.As for the mother's education, the highest number of cases was the junior high school education level, namely 31 (34.5%) and for the controls, namely the high school level, namely 37 (45.1%).For most children's birth weight ≥ 2500 grams in the case and control categories, namely 78 (86.6%) for the case category and 82 (100%) in the control.While the body length of the children born was the most in the case category <50 cm, namely 43 (52.4%) and the category of cases ≥ 50 cm were 46 (56.1%).

Univariate analysis
Based on table 2, it shows that out of 164 respondents, 82 respondents were included in the stunting category in the case group, while there were 82 respondents in the control group who were not in the stunting category.
Based on table 3, it shows that of the 82 respondents each in the case and control groups, there were 46 (56.1%) respondents in the case group included in the category of exclusive breastfeeding which was not good enough, while in the control group there were 51 (62.2%) respondents who were in the category of giving Exclusive breastfeeding is good.
The basic immunization variable showed that out of 82 respondents each in the case and control groups, there were 81 (98.7%) case group respondents included in the complete basic immunization category while in the control group there were 77 (93.9%) control group respondents who were in complete basic immunization category.The health service variable shows that of the 82 respondents in the case and control groups, 64 (78.0%) of the case group respondents fall into the incomplete health service category, while in the control group there are 82 (100%) respondents in the health service category.incomplete.

Bivariate analysis
Table 4 shows that there are 36 respondents (43.9%) in the exclusive breastfeeding variable in the exclusive breastfeeding category who are stunted, while those who are not stunted are 51 respondents (62.2%) and 46 respondents (56.1%) with less exclusive breastfeeding both experienced stunting, then 31 respondents (37.8%) who were not stunted.Based on the results of data analysis using Chi Square, it was found that the p value = 0.028 <0.05 means that Ha is accepted and H0 is rejected so that it can be interpreted that there is an effect of exclusive breastfeeding on stunting events on Leti Island, Southwest Maluku Regency.and development of children.Babies who don't get enough breast milk mean they have poor nutritional intake and can cause malnutrition, one of which can cause stunting.If a baby who is not old enough, namely 6 months, is given food other than breast milk, it will cause the baby's intestines to be unable to digest food and the baby will be susceptible to disease due to lack of intake.So that toddlers who often suffer from infectious diseases will cause their growth to be stunted and unable to achieve optimal growth.

Effect of basic immunization on stunting incidents
According to the theory of immunization comes from the word immune, immune, or resistant, children are immunized, meaning they are given immunity against a certain disease.Children are immunized, meaning they are given immunity against a certain disease.Children are immune or resistant to a disease but not necessarily immune to other diseases (Ministry of Health, Republic of Indonesia, 2015).
Immunization is an attempt to actively generate/increase a person's immunity to a disease, so that if one day they are exposed to the disease they will not get sick or only experience mild illness. 12munization is very important given to children because of the process of inducing immunity artificially either by vaccination (active immunization) or by administering antibiotics (passive immunization).
In this case, active immunization stimulates the immune system to form antibodies and cellular immune responses that can fight the infecting agent.Unlike passive immunization, this immunization provides temporary protection through administration of exogenously produced antibodies or transplacental transmission from mother to fetus.Immunizations greatly affect the avoidance of various diseases.If a child often experiences various diseases, it can cause the child to get sick or hinder/disturb the child's growth, therefore it is important for children to get immunizations. 13e completeness of immunization in this study was seen from the MCH book records.Owning a MCH handbook/child health record book is very important especially for knowing the schedule or type of immunization given to toddlers.By owning the book, the respondent's parents can find out what types of immunizations have been given and which immunizations have not been given. 14rious factors that cause stunting in children come from the child himself or from outside the child.Stunting can be caused by direct or indirect factors.The direct causes of stunting are nutritional intake, the presence of infectious diseases, mother's knowledge while the indirect causes are parenting, poor sanitation, unclean environment, food availability, socioeconomic factors and mother's height, parents' income, birth weight Low. 15 From the results of the study there were 81 respondents (98.7%) in the complete basic immunization category who were stunted, while those who were not stunted were 77 respondents (93.9%) and as many as 1 respondent (1.3%) with incomplete basic immunization who experienced stunting, then 5 respondents (6.1%) were not stunted.
Based on the results of data analysis using Chi Square, it was found that the p value = 0.212 > 0.05 this means that Ha is rejected and H0 is accepted so that it can be interpreted that there is no effect of Basic Immunization with Stunting Incidents on Leti Island, Southwest Maluku Regency.
This research is in line with research conducted by Fajariyah & Hidajah (2020) which shows that immunization status has no relationship with the incidence of stunting in children aged 2-5 years in Indonesia.Immunization status is not related to the incidence of stunting in toddlers in Kedung Jati Village. 16is research is not in line with research conducted by Taswin et al (2023) 15 in Pasarwajo Village, Buton Regency, Southeast Sulawesi For the basic immunization variable, it was stated that out of 164 respondents there were 81 respondents (98.7%) in the complete basic immunization category who were stunted, while those who were not stunted were 77 respondents (93.9%) and 1 respondent (1.3%) with basic immunization incomplete who experienced stunting, then 5 respondents (6.1%) who were not stunted.Based on the results of data analysis using Chi Square, it was found that the p value = 0.212 > 0.05 this means that Ha is rejected and H0 is accepted so that it can be interpreted that there is no effect of Basic Immunization with Stunting Incidents on Leti Island, Southwest Maluku Regency.
For the Health Service variable, it was stated that out of 164 respondents there were 18 respondents (22.0%) in the complete health service category who experienced stunting, while those who were not stunted there were 82 respondents (100%) and as many as 64 respondents (78.0%) with incomplete health services who experienced stunting, then 0 respondents who were not stunted.Based on the results of data analysis using Chi Square, it was found that the p value = 0.000 <0.05, this means that Ha is accepted and H0 is rejected so that it can be interpreted that there is an influence of health services on Stunting Incidents on Leti Island, Southwest Maluku Regency.

Multivariate analysis
Based on the results of the Multiple Logistic Regression Test, it was found that the variable value that had the most influence on the Incidence of Stunting on Leti Island, Southwest Maluku Regency, was the Health Service variable.After further analysis, it was obtained a strong value of influence (β) from the variable Exclusive breastfeeding, meaning that health services twice affected the incidence of stunting on Leti Island, Southwest Maluku Regency.

DISCUSSION
The effect of exclusive breastfeeding on stunting incidents Breast milk is the only ideal food that is the best and most perfect for babies to meet the physical and psychological needs of babies who are growing and developing. 8Babies who are given breast milk grow better than babies who are given water or additional food before the age of 6 months. 9om the results of the study there were 36 respondents (43.9%) in the category of good exclusive breastfeeding who were stunted, while those who were not stunted were 51 respondents (62.2%) and as many as 46 respondents (56.1%) with poor exclusive breastfeeding who experienced stunting, then 31 respondents (37.8%) who were not stunted.
Based on the results of data analysis using Chi Square, it was found that the p value = 0.028 <0.05 means that Ha is accepted and H0 is rejected so that it can be interpreted that there is an effect of exclusive breastfeeding on stunting events on Leti Island, Southwest Maluku Regency.
This research is in line with research conducted by Lestari and Zurrahmi (2023) 10 in Tapung District where a p value = 0.000 (p ≤ 0.05) was obtained.This means that there is a significant relationship between the history of exclusive breastfeeding and the incidence of stunting in Gading Sari Village, Tapung District.
This research is not in line with research conducted by Hikmarachim et al (2019) 11 in Bogor Regency where the results obtained were a p value = 0.661 (p > 0.05).This means that exclusive breastfeeding is not related to the incidence of stunting in toddlers in Bogor Regency.
Based on the research above, the researchers assume that babies who do not get exclusive breastfeeding are prone to stunting.Breast milk is a nutritional intake that fits the needs of babies and will help the growth Province where the value ρ = 0.009 was obtained where ρ = <0.05so that it is interpreted that there is a significant relationship between basic immunization and stunting.
In another study it was stated that complete immunization does not guarantee that these toddlers can avoid a disease but by immunizing it is hoped that it will reduce the risk of these toddlers getting a disease.There are several things that affect the benefits and effectiveness of immunization, such as the quality of the vaccine that is given does not meet standards or is not good enough.So that toddlers who are fully and incompletely immunized have the same opportunity to experience stunting. 17e influence of health services on stunting incidents Health services according to (Prana, 2013)  From the results of the study there were 18 respondents (22.0%) in the complete health service category who experienced stunting, while those who were not stunted there were 82 respondents (100%) and as many as 64 respondents (78.0%) with incomplete health services who experienced stunting, then 0 respondents who are not stunted.
Based on the results of data analysis using Chi Square, it was found that the p value = 0.000 <0.05, this means that Ha is accepted and H0 is rejected so that it can be interpreted that there is an influence of health services on Stunting Incidents on Leti Island, Southwest Maluku Regency.
This research is in line with research conducted by Farrah Okky, Nina, Mury (2013) at the Kedung Banteng Health Center which stated that there was a significant relationship between health service facilities and the incidence of stunting (P value = 0.013) with a sample of 50 respondents.Based on the results of the chi-square test between health service facilities and the incidence of stunting, it can be seen that the value of p = 0.013 where p <0.05 means that there is a relationship between health service facilities and the incidence of stunting in rural and urban areas. 19is research is not in line with research conducted by Ida Aryani and Herbert (2018) at the Medan Deli Health Center where based on the results of bivariate analysis using the chi square statistical test, p = 0.323 (p value > 0.05) means that Ho is accepted and Ha is rejected, this shows that there is no relationship between health service facilities and the incidence of stunting in toddlers in the Medan Deli Health Center Work Area.
Judging from the results of the respondents' answers where as many as 89% answered the category of incomplete health services in terms of utilization of Posyandu, health counseling, provision of supplementary food, provision of vitamin A and weighing services.so that the factor that most influences the incidence of stunting in this study is health services.Where health services play an important role in improving the nutritional status of children, mothers can use it to obtain correct health information.Efforts to increase the utilization of health services can be carried out in various ways, for example participating in nutrition and health counseling and toddler nutrition counseling to prevent stunting in toddlers.

Multivariat output
Based on the results of the Multiple Logistic Regression Test, it was found that the variable value that had the most influence on the Incidence of Stunting on Leti Island, Southwest Maluku Regency, was the Health Service variable.After further analysis, it was obtained a strong value of influence (β) from the variable Exclusive breastfeeding, meaning that health services twice affected the incidence of stunting on Leti Island, Southwest Maluku Regency.
This research is in line with previous studies, in Buton Tengah Regency which stated that the utilization of health services was lacking with the incidence of stunting under five by 54.5% where toddlers who did not utilize health services had a 3.086 times higher chance of experiencing stunting compared to toddlers who sufficiently utilized health services. 10bits in efforts to obtain health services play an important role in improving the nutritional status of children.Where mothers can use it to obtain correct health information.Efforts to increase the utilization of health services can be carried out in various ways, for example participating in nutrition and health counseling and toddler nutrition counseling to prevent stunting in toddlers. 21

CONCLUSIONS AND RECOMMENDATIONS
The conclusions drawn from the results and discussion are that there is an effect of exclusive breastfeeding and health services on the incidence of stunting on Leti Island, Southwest Maluku Regency, there is no effect of complete basic immunization on the incidence of stunting on Leti Island, Southwest Maluku Regency.Based on the multivariate test, the most influential variable is health services.
As for suggestions for the Head of the Southwest Maluku Regency Health Service, the results of this study indicate that the most influential factor is health services so it is hoped that the Health Service will further improve health services to monitor the growth of toddlers and for mothers of toddlers to visit health services regularly.For the community, medical personnel and related agencies are expected to carry out routine and further monitoring of children's height so that related problems can be identified so that appropriate interventions can be carried out and for other researchers it is advisable to increase the number of samples and cover a wider research area.

Table 5 : Multivariate test results for stunting on Leti Island, Southwest Maluku Regency.
18are efforts that are carried out alone or jointly in organizations to maintain and improve health, prevent and cure disease and restore the health of a person, family, group and community.These health efforts are carried out by focusing on services for the wider community in order to achieve optimal health degrees, without neglecting the quality of services for individuals.Services at the Puskesmas cover 15 activities, namely family health, nutrition improvement, food and beverage security, environmental health, occupational health, mental health, disease eradication, disease healing and health restoration, public health education, security of pharmaceutical preparations and medical devices, security additives, school health, sports health, traditional medicine and dimension health, the management of Community Health Centers is generally under the Health Service (RI Ministry of Health, 2015).