Barriers to Stunting Intervention at a Community Health Center: A Qualitative Study

: Stunting is one of Indonesia's most prevalent nutritional problems, with a prevalence rate of 24.4%. In Samosir Regency, the prevalence of stunting remains relatively high at 28.4%. Community health centers are crucial in the community's efforts to accelerate stunting reduction. This study aimed to explore the barriers a community health center faces in implementing the stunting reduction acceleration program. Method: Using a qualitative case study design, the study was conducted at Buhit community health center in Samosir Regency from August to December 2022. The key informants for this study included the community health center leader, head of administration, nutritionist, and midwife. Data were collected through in-depth interviews and document review. The results identified several barriers to the implementation of the Accelerated Stunting Reduction Programme. These barriers encompassed limited staff resources and concurrent positions, the availability and suitability of anthropometric tools, a lack of coordination in planning activities between management and program officers, families' fear of the negative stigma associated with stunting, and low levels of community participation. Farmers who do not comply with safe behavior will have a higher health risk because of the toxicity of pesticides that can be directly inhaled and enter through the pores of the farmers' skin.


Introduction
Stunting is a condition of chronic malnutrition indicated by a child's height being less than -2 standard deviations (SD) from the WHO global reference for children of the same age.The problem of stunting is most prevalent in developing countries, including Indonesia (Rahmawati & Agustin, 2020;Wulandari et al., 2022).The condition of stunting in children is influenced by poor nutritional intake and frequent infections before or after birth, which increase their risk of illness and mortality.The long-term effects of stunting include suboptimal physical growth and poor cognitive development, leading to subpar educational performance and diminished intellectual, motor, and socio-economic capacities (WHO, 2021).
The prevalence of stunting in Indonesia is still relatively high compared to other countries (Beal et al., 2018).The Study on Nutritional Status of Under-Five Children in Indonesia 2019 reported a relatively high prevalence of stunting in Indonesia (27.67%).The government has set a target for reducing stunting from 2020 to 2024 by 14%.The specific target for stunting reduction in 2021 is 21.1%.The prevalence of stunting in 2021 is 24.4%.However, the reduction in stunting cases is still below the target set by the President, which is around 3-3.5%, with the aim of achieving a prevalence of 14% by 2024 (Kementerian Kesehatan, 2018Kesehatan, , 2021)).
The government has taken steps to address the issue of stunting through various nutrition management programs, both specific and sensitive in nature.However, despite all the efforts made, the results have not been sufficient in combating the problem of stunting (Wardita et al., 2021).Primary care is widely regarded as the foundation of a healthcare system, as it places greater emphasis on prevention and early management of health issues (Li et al., 2015).The main provider of primary healthcare services in Indonesia is the community health center, which is a community health facility at the sub-district level.Its primary objective is to provide curative, preventive, and health promotion services to the community through various programs.
The main role of a community health center is to deliver primary outpatient care.However, a community health center is also utilized for promoting and implementing community health initiatives, such as nutritional education, immunization, and health information campaigns (Anita et al., 2016;Limato et al., 2019).
From the initial survey conducted, it was found that the stunting reduction acceleration program has been implemented.However, based on the prevalence data of stunting in Buhit community health center, several villages still serve as stunting hotspots with relatively high prevalence rates.The data from August 2022 shows that there are 138 cases of stunting (6.17%) out of 2,236 children under five years old.A study reported that the limited success of the stunting reduction acceleration program can be attributed to suboptimal planning and budgeting, as well as poor coordination and allocation of responsibilities among cross-sectoral units within local government agencies (Carolina & Ilyas, 2021).Program evaluation is a systematic application of scientific methods aimed at assessing the design, implementation, improvement, or outcomes of a program, policy, or initiative (Santo et al., 2022).Therefore, this study aims to explore the barriers that contribute to the suboptimal implementation of the stunting reduction acceleration program.The findings of this research are expected to provide valuable insights for stakeholders in formulating policies related to accelerating stunting reduction.

Study design
This research adopted a qualitative approach with a case study design, aiming to obtain in-depth information from key informants regarding the implementation of the stunting reduction acceleration program at Buhit community health center in Pangururan District, Samosir Regency.

Participants
The study was conducted from August to December 2022 and involved key informants, including the head of health center (IF01), administrative head (IF02), nutritionist (IF03), and village midwife (IF04).These informants provided valuable insights into the implementation of the program and the barriers encountered.

Data collection
The stunting reduction acceleration program focuses on several aspects, including human resources (SDM) and facilities, planning, mobilization, implementation, monitoring, control, and evaluation.A guideline for in-depth interviews was used as an instrument to collect data from the informants.A voice recorder was utilized to capture the conversations during the interviews, thereby enhancing data accuracy.Additionally, the researcher conducted document review related to the stunting reduction acceleration program and carried out observations during the data collection process.

Data analysis
The data were analyzed by examining the context of the questions and analyzing the primary data obtained from informant interviews, as well as secondary data from the review of documents related to the stunting reduction acceleration program.The qualitative analysis process involved three simultaneous activities: data reduction, data presentation, and verification/conclusion drawing.

Trustworthiness
Data triangulation was conducted by crosschecking information from multiple sources.The triangulation methods used include source triangulation, which involved comparing the results from interviews among different informants, and method triangulation, which involved comparing data from interviews with relevant research documents.

Ethical consideration
This research has undergone an ethical review procedure and was declared ethical by the Universitas Prima Indonesia's Research Ethics Commission with Number: 001/KEPK/UNPRI/XI/2022.

Characteristics of Respondents
The Buhit community health center is located in Pangururan District, Samosir Regency, and its service area covers 25 villages and 3 urban areas, with an average monthly service of 1,655 individuals.In 2022, out of a total of 2,236 children under five years old, 285 (12.74%) were classified as underweight, 91 (4.06%) were at risk of overnutrition, 35 (1.56%) were classified as overweight, 15 (0.67%) were classified as obese, 138 (6.17%) were classified as stunted, 286 (12.79%) were classified as wasted, and 65 (2.9%) were classified as underweight.Efforts to improve nutrition included the provision of vitamin A capsules and iron tablets.
The informants for this study consist of four individuals who are considered to provide sufficient and accurate information regarding the implementation of the stunting reduction acceleration program.The informants include the community health center head, administrative head, nutritionist, and village midwife.

Human Resources
Human resources (HR) is crucial in implementing a program or policy.This study's term "human resources" refers to the resources needed or involved in the stunting reduction acceleration program.From in-depth interviews regarding HR in the management of the community health center related to the stunting reduction acceleration program, it was found that human resources are adequately provided for according to Regent Regulation No. 65 of 2022.The human resources include the head of community health center, nutritionists, doctors, village midwives, cadres, and cross-sectoral (non-health) stakeholders such as district officials, village facilitators, village heads, and the Village Family Welfare Movement (PKK).The human resources have received training or socialization regarding the stunting reduction acceleration program, such as joint awareness campaigns to prevent stunting.
"…The human resources involved in the stunting prevention and eradication program include doctors, the head of the community health center, the nutrition program officer, and village midwives, all of whom have received training.Additionally, the program also involves the district officials, village heads, and their staff, as well as the posyandu cadres.It is fortunate that everything is in accordance with the Regent's Decree on the prevention and eradication of stunting."(IF01)."… Regarding stunting specifically, in the village, there is myself as the village midwife, along with the village cadres, the village head, village officials, and the community.There have been training sessions, such as socialization activities, but the cadres expressed their desire for more specialized training.'"(IF04).
However, the researchers also found issues regarding the workload of staff members who have additional positions.Human resources with dual roles or overlapping positions include the head of administration, who is also responsible for nutrition services.This condition is due to the lack of specific human resources for general administration in Buhit community health center.

Facilities and Infrastructure
The facilities and infrastructure referred to in this study are the resources needed to support the stunting reduction acceleration program.The interview results indicate that several villages still do not have anthropometric equipment used in examining children with stunting.Additionally, some villages still use anthropometric equipment that does not comply with the Standard Operating Procedure (SOP).The lack of funding allocation from the village funds is a factor influencing the inadequacy of facilities and infrastructure.
"…The facilities and infrastructure are still inadequate, as there are several villages that do not have anthropometric kits."(IF02)."…So far, the facilities and infrastructure are still insufficient, as the allocation of funds from the village budget is reported to be insufficient."(IF03)

Planning
In formulating the planning for the acceleration of stunting reduction program, the management of the community health center refers to the Minister of Health Regulation No. 2 of 2020 on Child Anthropometric Standards and Minister of Health Regulation No. 44 of 2016 on Community Health Center Management Guidelines.The individuals involved in the planning process include the nutrition program officer, which consists of the nutrition implementer, head of administration, and head of the community health center who acts as the decision-maker in the planning process.They will also coordinate with the Health Office.
"…The reference documents used for planning the stunting reduction acceleration program are the Minister of Health Regulation No. 2 of 2020 on Child Anthropometric Standards and the Minister of Health Regulation No. 44 of 2016 on Community Health Center Management Guidelines.The planning itself is prepared by the program holder, and I, myself, will be responsible for finalizing and approving the plan."(IF01)."…the planning is done by the nutrition program manager, the head of administration, and the head of the community health center."(IF03).
The informants also stated that the planning is conducted annually for each year and quarterly.The planning process begins with identifying issues based on available data, followed by analyzing the identified issues to determine priority problems.Subsequently, the planning is developed according to the prioritized problems and finally documented in the form of a Plan of Action (POA).The finalized planning is then approved by the head of the community health center and coordinated with the health department.
"…Every year, we create a planning, for example, for each Posyandu activity.The health center personnel, particularly the nutritionist, assess the nutritional status of children during these activities.Based on the findings, we develop the planning to address any identified issues, and then document it in the form of a Plan of Action (POA).As the responsible personnel, I am the one who finalizes and approves the POA".(IF01) "… First, we determine the target data by identifying the priority issues.Then, we proceed with planning the interventions accordingly.This process is usually conducted annually, and sometimes on a quarterly basis."(IF02) According to the informant, planning has been carried out in accordance with the existing DPA (Document of Budget Implementation) and documented in the form of a POA (plan of action).However, there are still challenges in its finalization.The obstacles faced during the planning process include a lack of understanding between the program managers, who are responsible for developing the plan, and the head of the health center, who approves the plan.Additionally, there is resistance and negative responses from families regarding the stunting status of their children, which further complicates the budget planning for interventions due to the lack of reliable target data.
The solution implemented to address the resistance from parents is to approach them directly by conducting home visits.This aims to establish a closer relationship and better communication with the parents.As for the issue of plan approval, the program managers continue to implement the planning according to the plan set by the head of the health center.
"…We have adhered to the Document of Budget Implementation (DPA), but sometimes the prioritization of issues by the program manager may not necessarily align with that of the higher authorities."(IF02) "…There are still residents who express anger and refuse to accept the categorization of their children as stunted."(IF04)

Action
The movement and implementation of the stunting reduction program are carried out by program implementers, including nutritionists and village midwives, as well as the involvement of the health center's doctors, KIA/KB (Maternal and Child Health/Family Planning), and Health Promotion teams.In addition to healthcare professionals, the village authorities, such as the village head, village officials, the Village Women's Empowerment and Family Welfare Movement (PKK), and community health workers (kaders), are also engaged in the movement and implementation activities.
"… The movement and implementation of the stunting reduction program involve the participation of nutritionists, village midwives, and sometimes doctors, KIA/KB (Maternal and Child Health/Family Planning) teams, and health promotion staff."(IF03) "… I myself am a village midwife, and I am assisted by the village head and its members, as well as community health volunteers (kader)."(IF04) According to the information provided by the informant, the implementation and execution of the program are carried out in a phased manner.Prior to the implementation, a series of mobilization activities take place.Mobilization is conducted through meetings and socialization, such as advocacy meetings involving various programs and sectors related to growth monitoring activities, commonly known as "rembug stunting" at the district and village levels, as well as mini workshops.The implemented activities include the provision of iron supplements to adolescents, home visits, tracking and support for nutritional interventions for pregnant women with nutritional problems and malnourished children, community education and awareness campaigns, monthly weighing sessions, vitamin A supplementation, and the provision of supplementary food, such as bread for pregnant women and children.In some villages, a program called "dapur dasyat" (formidable kitchen) is implemented twice a month, supported by the relevant P3APPKB agency.The implemented programs and activities related to stunting prevention have been carried out in accordance with standard operating procedures (SOP) and aligned with the Plan of Activity Implementation.
"…First, there is a mobilization phase before the actual implementation.During the mobilization phase, activities such as advocacy across different programs and sectors take place, including district-level and village-level stunting discussions ("rembug stunting") as well as mini workshops.Regarding the implementation, there are several activities conducted.For example, iron supplementation is provided in schools, home visits are conducted specifically targeting households with malnourished children, and nutritional support is provided for undernourished pregnant women.Additionally, awareness campaigns and education sessions are organized, and vitamin A supplementation is given."(IF01) "… There is also a program called "Dapur Dahsyat" supported by the relevant department of the Integrated Health and Family Planning (P3APPKB), which is conducted twice a month.Additionally, the health center distributes bread to pregnant women and children under five years old.However, other planned activities, such as providing milk for stunted children and those at risk of stunting using village funds, have not been implemented yet.

" (IF04)
There are several obstacles, such as the incomplete availability of anthropometric equipment in some villages and a lack of community awareness and enthusiasm to participate in the accelerated stunting reduction program.To address the lack of anthropometric equipment, the nutrition personnel have advised the cadres to request the village to provide the necessary equipment in accordance with Regent Regulation No. 65 of 2022.To increase community engagement in the accelerated stunting reduction program, direct visits to households are conducted by the healthcare workers.
"… There are challenges in the field, such as incomplete infrastructure and facilities, and the solution is to request the cadres to propose these issues to the village head."(IF03)"… It has been implemented but hasn't been fully effective because sometimes the community doesn't want to participate in the activities.The solution is proactively visiting the households and engaging directly with the community members at their homes."(IF4)

Supervision, Control, and Evaluation
Supervision, control, and evaluation need to be carried out to ensure that the planned and implemented activity targets are achieved optimally.From in-depth interviews, it was found that supervision, control, and evaluation are conducted on a monthly basis at each integrated health post (posyandu).Supervision is conducted first, followed by control to ensure that activities are carried out according to the established plans.Subsequently, an evaluation of the activities is conducted to obtain feedback for improvement of each implemented activity.Evaluation activities take place during monthly mini workshops at the health center.The monitoring of activities' progress and the reduction of stunting cases can be observed through the E-PPGBM application, which serves as a form of supervision to ensure the smooth implementation of the program.
"… The supervision is conducted monthly at each integrated health post (posyandu).The utilization of the E-PPGBM application allows for monitoring the progress and reduction of stunting cases on a monthly basis for each village."(IF01) "… The evaluation results from each activity are presented during the miniworkshop (lokmin) at the community health) to assess the smoothness of the activities using the E-PPGBM application.From there, the reduction or increase in stunting cases can be monitored."(IF03) The obstacle faced is the insufficient number of program managers, considering there are 45 integrated health posts (posyandu) in Buhit community health center, and up to 6 posyandu sessions are held simultaneously in a day.This situation results in inadequate supervision by the health center staff.The solution implemented is to seek assistance from other healthcare professionals, such as health promotion officers and other willing personnel.
"… The challenge lies in the limited number of nutrition officers, as there are only two of them, while the number of integrated health posts (posyandu) is 45, and sometimes up to 6 posyandu sessions are held simultaneously in a day.As a result, the supervision and monitoring conducted by the nutrition officers may not be optimal due to the workload."(IF01) "… We face difficulties in managing our time effectively due to the high workload.As a result, we seek assistance from other healthcare professionals who are not primarily responsible for nutrition-related tasks."(IF03)

Discussion
This study provides an overview of the challenges faced in implementing the stunting reduction program at one of the primary health centers in Samosir District.The study's findings reveal that the personnel involved in implementing the stunting reduction program have additional job responsibilities.This situation inevitably leads to a lack of focus in fulfilling their primary duties.The healthcare organization is a social system in which human resources play a crucial role (Specchia et al., 2021).Previous research has concluded that a shortage of human resources in the implementation of a policy or program will affect the level of success and achievement set (Nilsen et al., 2020).Furthermore, individuals who hold multiple positions tend to have lower work effectiveness due to limited time available to accomplish multiple tasks according to the set targets (Sholichah, 2023).Dual roles are often observed among healthcare workers in primary health centers due to limited staffing.This situation can have an impact on suboptimal service delivery (Shofiah et al., 2019).The number of human resources should be adjusted to the workload assigned, to ensure optimal implementation of a program (Edú-Valsania et al., 2022;Maslach & Leiter, 2017).Therefore, periodic calculations of the ideal requirements for the number and hierarchy of positions for each healthcare worker should be conducted (WHO, 2016a).Furthermore, the study results also indicate that the supervision of program implementation is suboptimal due to the insufficient number of program managers.This obstacle needs to be addressed promptly to ensure that the program's target group can be reached and provided with appropriate health interventions.
Another obstacle that arises is the lack of anthropometric tools such as height measurement devices, as well as the condition of the tools not meeting the standard requirements.This situation affects the continuity of the program, leading to inaccurate measurement results and low coverage rates of the program's target population.The World Health Organization (WHO) emphasizes that the availability of accurate anthropometric data is crucial as a source for determining stunting intervention policies and addressing other nutritional issues (WHO, 2016b).The availability and accessibility of healthcare equipment are essential prerequisites for achieving success in interventions and implementing healthcare programs (Ayah et al., 2020).
One of the challenges that arise during the planning phase is the lack of understanding between program managers as plan developers and the head of the health center as the plan approver.Previous studies have concluded that effective interaction between supervisors and staff leads to positive health service outcomes.(Versteeg et al., 2012) Effective interaction can be fostered through effective communication between leaders and staff.Communication skills assist leaders in setting goals and strategies to achieve success in a health program (Jankelová & Joniaková, 2021;Restivo et al., 2022).In addition, another barrier is the resistance and negative response from families regarding the stunting status of their children.A study has reported that a significant number of stunted children face negative stigma (Widiastuti et al., 2022).This stigma can lead parents to hide the nutritional problems their children are facing and delay seeking healthcare (Bliss et al., 2016).Healthcare providers need to establish therapeutic communication and avoid blaming the families.In addition, extensive socialization about stunting is necessary to dispel the negative stigma associated with stunting in the community (Setiyowati, 2017).

Conclusion
The success of health center management in addressing a health issue is greatly influenced by various components such as human resources, infrastructure, and the presence of effective and measurable management processes (planning, implementation, and monitoring, control, and evaluation).This study highlights that these components are key factors that determine the success of the accelerated stunting reduction program.The human resources component deserves more attention as the limited number and qualifications can hinder managerial functions such as monitoring.The availability of measurement tools is also limited, resulting in low program coverage.Effective communication between leaders and staff in planning should also be improved.Furthermore, healthcare providers' communication with families of stunted children and the community needs to be enhanced to minimize the negative stigma associated with stunting.Negative stigma discourages children and families from seeking stunting treatment.