Unpacking the Impact: How Polemical Childhood Images Contribute to Stunting in Indonesia

(Source: Human Initiative, 2023)

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Stunting is a highly significant nutritional problem that is caused by malnutrition. In many countries, especially developed ones such as Indonesia, stunting indicates inequality in society and reflects children’s wellbeing (De Onis & Branca, 2016). There are many negative impacts of stunting, which include damage to cognitive abilities and memory (Laksono et al., 2020), impaired motor function and decreased learning performance (Rahmawati & Sartika, 2020), thus leading to lower generational productivity and intergenerational poverty (Rahmawati et al., 2020). This leads to the discourse of childhood images that circle stunting or malnutrition, as to whether children are active participants within stunting prevention programs and how to position children better in healthcare institutions. Knowing how critical theorists such as Piaget and Vygotsky emphasised the importance of children’s active learning and participation in any setting (Cook, 2020; Newport, 2019), which in this case, the healthcare environment, these concepts are then being contented as to whether they are implementable within the context of stunting in Indonesia. Therefore, this essay will explore how malnutrition and stunting are positioned and conceptualised within discussions of childhood, how these discourses influence children and how different conceptualisations could result in alternative outcomes for youth. It will start by examining key concepts about childhood and relevant vital theorists, the conceptualisation of childhood in Indonesia, the implication of Indonesia’s cultural practice on childhood and malnutrition, possible alternatives for children’s positioning within this area and the inference of it. 

Although early childhood mortality in Indonesia has been reduced within a few years, the problem of stunting in this country is among the highest rate in the world (Ministry of Health Republic of Indonesia, 2018). The country’s target was to reduce the probability of stunting to 28% between 2015-2019. Still, this target was unreachable in 2018 as the rate went higher, reaching 30.8%, while the World Health Organisation (WHO) standard was 20% (Alfatin, 2022). According to Vaivada et al. (2020), poverty is strongly connected with the leading cause of malnutrition across the globe. In Indonesia, almost 10% of the population is impoverished, and 22 out of 1000 babies die before their 5th birthday (Asian Development Bank, 2023). These alarming statistics lead the government, as the central agency for children’s rights, to develop strategies to combat stunting in children, as stunting can lead to defective effects in children’s cognitive development (Crookston et al., 2011), limited communication capabilities (Siswati et al., 2022), and visual and motor skills (Rahmawati et al., 2020), which then leads to a more agitating problem of generational cognitive incompetence in the country (Mahmood et al., 2022). Interventions such as Pos Layanan Terpadu (Posyandu; Integrated Health Service Post), which is a community-level health service in Indonesia that is focused on maternal and early childhood development (Nazri et al., 2015), are then being implemented by the Indonesian government to reduce the prevalence of stunting, to which research has shown to indicate mixed results of efficacy (Laksono et al., 2022; Rahmawati et al., 2020; Siswati et al., 2022; Rahmawati & Sartika, 2020; Wardani et al., 2021). Furthermore, within the lens of childhood images, stunting in Indonesia reflected many images influenced by numerous aspects, most prominently local cultural practices (Diana et al., 2022; Suhardin et al., 2020). This makes stunting or malnutrition a systematically complex issue in the country that needs more than just government intervention. Indeed, the position of children in this complication is uniquely disadvantageous, as they are not the leading actor being placed in higher priority. This may explain the government’s interference efficacy in reducing childhood mortality but not stunting rates within the past few years. 

Indonesian cultural practices significantly influenced the conceptualisation of childhood within the context of stunting or malnutrition. As previously mentioned, numerous factors cause stunting, including children’s limited nutritional intake and lack of maternal education (Setyawan & Lestari, 2021). Indonesia is one of the biggest developed countries with solid cultural values influencing children’s position in the household. Diana et al. (2022) asserted that children are regarded as passive recipients of care, and influential voices within the household are held mainly by older authoritative figures such as parents or grandparents (Nazri et al., 2015). In retrospect of stunting, this problem is often regarded as an individual health concern, with a prominence on the requirement for access to proper nutrition and food. This personalised approach often overlook the wider social factors that bestow malnutrition or stunting. Within the context of children, as passive recipients of care, they do not have the full ability to contribute to their overall health and wellbeing outcomes. A case study by Suhardin et al. (2020) showed that significant cultural practices in Indonesia impacted child feeding practices and nutritional intake. As substantial cultural value determines what someone can and can not eat, how food is prepared, and when a particular food can be eaten, mothers are often convinced by what their in-laws or husband have to say about their child’s wellbeing. For instance, there is a generational belief that giving mixed water and a hefty amount of sugar can help babies to combat the summer heat. It is also a custom tradition for the grandmothers on the father’s side to have greater sovereignty over their children’s nutritional intake. Another case study in Madura Island, East Java, by Diana et al. (2022) indicates a lack of awareness from mothers concerning stunting problems, regarding it as a normal process that children go through in their early childhood as long as their children grow to a certain height or reach a certain weight. Adding this to the layer of problematic foundation that children are the passive actors in this area, they do not have the autonomy to shape their nutritional outcomes. Even growing up stunted, these children cannot contribute any input to their health (Suhardin et al., 2020). This showed how cultural practices and lack of parental education impacted children’s position in their childhood, thus making it challenging to overcome stunting. 

As the stunting problem grows significantly for children under 5 in Indonesia, the government has implemented the intervention program Posyandu, but it has partly defective implications for childhood images. Posyandu is designed as a community-based healthcare program to reduce the probability of stunting and improve children’s overall wellbeing from birth to adolescence. Posyandu has a significant role in measuring the immensity of stunting problems in the community, including early detection of sanitation and hygiene, babies' and mothers’ nutritional intake, and parenting (Rokx et al., 2018). A study has shown the implementation of external party intervention for volunteers in Posyandu by doing more health and nutrition training, resulting in a reduced stunting rate (Rahmawati & Sartika, 2020). Another study by Nazri et al. (2015) also showed a positive relationship between monthly household income and mothers’ participation rate in the effectiveness of Posyandu. However, most of the studies regarding the efficacy of Posyandu have indicated no correlation between stunting reduction and the Posyandu program (Rahmawati et al., 2020; Laksono et al., 2022; Siswati et al., 2022; Wardani et al., 2021). Furthermore, implementing the Posyandu program impacted children’s positioning in childhood in numerous ways. On one side, Posyandu can help to increase parents’ role in shaping their children’s early childhood and health outcome. By providing adequate information about breastfeeding, growth monitoring, immunisation, and nutrition training for mothers, parents’ skills and knowledge can increase, leading to better children’s wellbeing. However, there is no even distribution of early childhood health quality in Indonesia due to the ongoing problem of inadequate volunteer health and nutrition training (Rahmawati et al., 2020). In addition, Posyandu's practice also positioned children under the lens of dependency, limiting their participation within the decision-making process concerning their health, adding to the existing layers of the power imbalance between children, institutions, and parents, as children’s agency and voice are often taken for granted, disregarded, or ignored. As previously discussed, childhood understanding within the cultural lens in Indonesia sees children as obedient and respectful (Diana et al., 2022), limiting children from advocating their concerns entirely in the healthcare context. Consequently, intervention programs such as Posyandu may have only benefitted the parents in the short term, not the children, as they were not being given attention. 

The problem circulating this discourse is evident as images of childhood within the context of stunted Indonesian children become more harmful. Images of children being represented as passive recipients in healthcare and its correlation with stunted children can establish a particular perception of children. Numerous images of childhood are presented through the application of programs like Posyandu in the community. First, children are depicted as helpless and vulnerable. Numerous empirical studies have shown the emphasis on government intervention like Posyandu and the process of its establishment (Diana et al., 2022; Rahmawati et al., 2020), yet there is little evidence that children are being included in the decision-making process. The notion that these stunted children are helpless reinforces the idea that children are constantly required of safety and protection. This image may obliterate their capabilities and agency, leading to an undervaluing of their capability to contribute to expressing their proclivity in healthcare. Furthermore, images such as dependency and lack of autonomy could emerge. Due to the dependency on others (Mårtenson & Fägerskiöld, 2008) and an established communication system that is concentrated on parents and healthcare professionals (Butz et al., 2007; Young et al., 2006), children’s ability to convey their concerns in the healthcare environment is limited. One of the reasons may be that healthcare professionals may undervaluing children’s views and the lack of awareness to implement children’s input (Gilljam et al., 2016). This image could prolong the power imbalance between healthcare practitioners and children by neglecting choices and their rights to be involved in healthcare actions that influenced them significantly. In addition, stunting could lead to stigmatisation and harmful labelling, as it is a significant health problem (De Onis & Branca, 2016). Since it is an apparent physiological condition, stunting may cause unfavourable stereotypes regarding children’s potential, value, and capabilities. This could create more problems for children in later life since it will hinder their willingness to integrate into society and fully contribute to numerous aspects of their life. Most importantly, images of children that will be prominent in this situation are constraint agency and disempowerment. Images of childhood that relates to lack of agency resulted in children having less participation in their childhood. Consequently, as children will continue to believe that they have no agency power, they may not acquire critical skills such as self-advocacy and critical thinking, thus restricting them from articulating their needs, especially within the healthcare environment. 

Adopting alternative conceptualisations of childhood around the problem of stunting could lead to different results for children and childhood. By seeing children as active participants in healthcare settings, more suitable approaches can be made to increase their contribution. For instance, Setyawan & Lestari (2021) suggested a more holistic approach to better positioning children in this situation and to see children not only from the central perspective of parents’ advocacy in the healthcare settings. High barriers may be undoubtedly challenging for lower socioeconomic status families in Indonesia living in poverty. A holistic approach concerns numerous perspectives, including social characteristics, physical conditions, and biological problem factors. This approach could be suitable when assessing children’s stunting rate in Indonesia since Indonesia has embedded solid cultural values that impact childhood for Indonesian children and broader aspects of their life. However, although this method also was found effective for stunting early detection (Setyawan & Lestari, 2021), centralising the approach based on children’s voices should also be taken into consideration when assessing early risk for stunting as their input will be necessary for feedback to improve illness prevention programs. Furthermore, building strong trust between healthcare practitioners and children is essential to reduce the pressure on children to express their needs. Studies have shown that children who lack the sense that they are active participants in healthcare circumstances, like stunting, are more likely to be insufficiently prepared for procedures and examinations (Coyne, 2008; Runeson et al., 2002). Therefore, gaining more comprehension of children’s perspectives on how their contribution should be facilitated in healthcare is essential. Evidently, to perceive children as having agency and acknowledge children as people regardless of their young age will bring more attention to the significance of their treatment as unique individuals by medical providers. As Gilljam et al. (2016) stated, perceiving that children are active contributors to their wellbeing is vital as it will strengthen the sense of comfort and security between them and healthcare professionals. Consequently, these alternative conceptualisations could shift the treatments children receive as they are now active recipients in healthcare settings. 

A better conceptualisation of children as active healthcare contributors can transfigure the approach to inscribe stunting. Acknowledging children as active beneficiaries encourages them to engage in their wellbeing. It concedes their points of view, decision-making capability, and rights. This clearance increases their self-efficacy, agency, and personal authority for their health, leading to increased adherence and contribution to medical practices. Furthermore, a judicious conception emphasises the vitality of individual-centred care, which involves customising treatments to children's particular environment, requirements, and preferences. It recognises that each child is distinctive, with various social, cultural, and personalised calibre. Individual-centred care promotes more fruitful approaches attentive to children's circumstances, history, and experiences, leading to better wellbeing results. In addition, perceiving children as active receivers enables collaboration among children, their families, and medical professionals. It promotes unbolted communication, reciprocal respect, and synergetic decision-making. Collaboration confirms that the child and their family are involved in implementing and developing healthcare initiatives, strengthening trust and participation. Lastly, systemic shifts constrain a more intense comprehension of childhood within the scaffolding of stunting, which requires a shift from a condescending manner to a rights-based, child-centred methodology. The preceding transfiguration demands systemic tampering, including legislative regulations, medical professional training, and the inauguration of commendatory environments for children's active engagement and healthcare participation.

Ultimately, how children are perceived within the context of stunting significantly affects their lives and treatments in healthcare settings. The ascendant images that reflect children as passive healthcare recipients may hinder their ability to exercise self-governance, agency, and engagement in the decision-making process regarding their mental and physical welfare. This may obstruct their ability to involve in healthcare and assert their needs actively. Using alternative conceptual approaches that recognise the active engagement and agency of children in matters concerning their health can significantly improve their level of engagement. Children are able to better participate within the healthcare environment when they are being recognised as competent individual with rights. Alternating the conceptualisation of childhood and children/youth in stunting can create an atmosphere that put their point of view as prirority, foster their independence, and facilitates their holistic development. The approach promotes collaboration between healthcare professionals, youth, and their families, stimulating clear communication, collective decision-making, and confidence. The more diverse frameworks of childhood conceptualisation can also influence better life quality for Indonesian children impacted by stunting. Children have the ability to hone an agency perception, empowerment, and self-assurance, which can support their active engagement in healthcare, expression of their needs. Consequently, adopting a participatory and inclusive conceptualisation can result in improved health outcomes, increased wellbeing, and a more supportive and equitable milieu for children.

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