Methods for stunting education in impoverished rural areas using illustrated modules in local languages

Abstract

This paper presents a novel approach to addressing the challenge of stunting in impoverished rural areas of North Sumatra, Indonesia, through the use of illustrated educational modules in the local Nias language. Stunting, a significant health issue affecting young children's physical and cognitive development, is prevalent in these communities. Traditional educational methods using the national language have proven ineffective due to cultural and linguistic barriers. By employing focus group discussions and in-depth interviews with local mothers, community leaders, and healthcare professionals, a tailored educational module was developed that incorporates local beliefs and practices. This module translates essential health information into the local language and pairs it with culturally relevant illustrations, enhancing understanding and engagement among the target audience. The module was validated through pilot testing, showing high effectiveness in communication and user engagement. This approach not only addresses the immediate educational needs regarding stunting prevention but also sets a framework for similar interventions in other linguistically and culturally distinct regions

• 1.Community education requires modules that are attractive and easy to understand.
• 2.This method originates from an assessment of local conditions.
• 3.This method can help conduct stunting education in areas far from access.

Graphical abstract

Specifications table

Subject area:	Medicine and Dentistry
More specific subject area:	Health Education
Name of your method:	Module for stunting education
Name and reference of original method:	Not applicable
Resource availability:	https://doi.org/10.6084/m9.figshare.25963237.v1

Background

Stunting in young children, defined by the World Health Organization (WHO) as a height-for-age more than two standard deviations below the median of the WHO Child Growth Standards [1], is a global issue. Existing data indicate that 162 million children worldwide currently suffer from stunting [2]. Africa and Asia contribute the most to the global prevalence, accounting for 49 % and 82 % of all young children affected by stunting, respectively [3]. Indonesia ranks fifth among countries with the highest burden of stunting worldwide [4]. Despite the goals set by President Jokowi's vision and mission, the government aims to reduce the stunting rate to just 14 % by 2024 [5].

The impact of stunting is profound. It reduces immune function, increases the likelihood of illness and associated healthcare costs, decreases productive days (Disability-Adjusted Life Years, DALYs), and impairs optimal physical, mental, and cognitive development in young children [6,7]. This aggregation of issues diminishes human capital capacity [8], affecting the productivity of families, communities, and even nations [9]. The cost implications of managing this are substantial [10].

The knowledge, attitudes, and behaviors of communities influence stunting. However, these factors are embedded within the socio-cultural contexts of societies. The WHO refers to these as the social determinants of health, accounting for about 30 % of health status [11,12]. Thus, efforts to change community behaviors regarding stunting must employ appropriate social channels to be effective. The diverse socio-cultural conditions in Indonesia contribute to the challenges in reducing stunting, suggesting that overly generic (one-size-fits-all) approaches are less optimal and even counterproductive. Behavioral changes can more readily occur by optimizing social channels originating from within the community.

Social channels require educational media tailored to their target audiences. Therefore, there is a need for educational materials that are easily understood and engaging so the target audience can refer to them to understand stunting issues and use them as teaching tools during educational sessions. While there have been interventions using pictorial/comic-based educational media [[13], [14], [15]], to our knowledge, no such media based on local conditions have been reported until now. This paper will discuss our experience designing educational media about stunting, used to deliver education in rural areas with a high prevalence of stunting.

Method details

Context

Among Indonesia's 34 provinces, North Sumatra is one of the 18 provinces with a stunting prevalence above the national average [16,17]. At the onset of this study, the existing data painted a dire picture. In North Sumatra, five out of the fifteen most concerning areas are located on the island of Nias [18], where exceptionally high stunting rates are recorded. Specifically, as reported to the Coordinating Minister for Human Development and Cultural Affairs during his March 2021 visit to Nias District, 60 % of young children are stunted.

The island of Nias is inhabited by the Nias tribe, who speak the local Nias language. Most residents live in rural areas, primarily earning their livelihoods through agriculture. The educational level is generally low, and women are particularly disadvantaged due to the patrilineal tradition.

In Indonesia, stunting education modules have traditionally been uniform, utilizing the Indonesian language. A significant drawback of these educational modules is their lack of engagement and effectiveness in reaching the target audience despite previous trials of available social channels [19].

Initial process

To develop the module, Focus Group Discussions (FGDs) and in-depth interviews were conducted. Six FGD sessions were held in various locations, including North Nias, Gunungsitoli City, and South Nias. Participants included mothers of young children, community leaders, and religious figures. The core objective of these discussions was to gather preliminary information circulating within the community regarding issues related to stunting. A significant amount of unclear information was found regarding the definition of stunting, its causes, and prevention measures. Many community members believe that stunting is a hereditary condition stemming from the physical traits of parents. Traditional practices, often believed to cause stunting, remain prevalent. Additionally, there is generally a lack of emphasis on the importance of health check-ups for pregnant women and children under five years of age.

A triangulation method was applied to validate the findings by discussing them with health professionals. Six health workers from the Health Department in the research locations were interviewed. These informants provided perspectives on the traditional practices prevalent in the community. It was also confirmed that educational materials in the Nias language could have been more easily understandable and specifically designed for the local context.

Design

Utilizing data from FGDs and in-depth interviews, the module's content was drafted. Collaboration with health communication experts was then undertaken to further refine and structure the material, resulting in the following summary (Table 1).

Table 1.

Module content summary.

No	Item	Explanation
1	Target audience	Mothers of young children and women of reproductive age.
2	Purpose	To provide a comprehensive explanation regarding stunting
3	Learning objective	1. Definition of stunting. 2. Signs of stunting. 3. Causes of stunting. 4. Impacts of stunting. 5. Prevention of stunting.

After the material design was finalized, narratives in Indonesian were developed for each learning objective. Each learning objective led to several narratives, totaling 29 in all (Table 2).

Table 2.

Details narratives of each page.

Picture Number	Learning Objective	Narratives
Cover	–	Let's Combat Stunting Together
1	Definition of Stunting	Stunting is a growth disorder in children characterized by a height significantly shorter than that of peers of the same age.
2	Definition of Stunting	Stunting occurs due to a chronic lack of adequate nutrition over an extended period.
3	Signs of Stunting	What are the signs of stunting in a child? Delayed ability to walk
4	Signs of Stunting	Low academic performance and difficulty understanding subjects at school.
5	Signs of Stunting	Lack of motivation to engage in physically activity.
6	Signs of Stunting	Delayed onset of speech development.
7	Impacts of Stunting	Stunting has severe effects on a child's future
8	Impacts of Stunting	Children are more prone to illness. Illnesses prevent children from attending school.
9	Impacts of Stunting	Illness consumes parents' time. Illness incurs financial costs.
10	Impacts of Stunting	Difficulty in learning leads to poor academic achievements and higher dropout rates.
11	Impacts of Stunting	Increased risk of developing chronic diseases such as diabetes, obesity, heart disease, cancer, stroke, and frailty in old age.
12	Causes of Stunting	Stunting can be prevented during pregnancy. Since a mother carries her baby for 9 months, it is essential for her to receive adequate nutrition throughout this period.
13	Causes of Stunting	The first 1000 days of life are critical. This includes the 270 days in utero and the first 730 days after birth, which are crucial for preventing stunting.
14	Causes of Stunting	Pregnant women should not neglect their diet.
15	Causes of Stunting	Pregnant women should follow iron supplement recommendations provided by local health centers.
16	Causes of Stunting	Excessive dietary restrictions can decrease the essential nutritional intake needed for fetal development.
17	Prevention of Stunting	Therefore, husbands should ensure that their pregnant wives consume nutritious food.
18	Prevention of Stunting	Husbands should ensure their wives get sufficient rest during pregnancy.
19	Prevention of Stunting	Husbands who participate in household chores like cooking and cleaning can positively impact their wives' health.
20	Prevention of Stunting	Pregnant women should attend regular prenatal check-ups at the local health post (Posyandu), ideally accompanied by their husbands.
21	Prevention of Stunting	Unhealthy drinking water sources can lead to diarrhea, which affecting the health of pregnant women and young children.
22	Prevention of Stunting	A dirty environment increases the risk of stunting.
23	Prevention of Stunting	After birth, a child's weight should be monitored at the local health post (Posyandu).
24	Prevention of Stunting	For the first six months, mothers should exclusively breastfeed their babies.
25	Prevention of Stunting	Food provided to infants should be age-appropriate.
26	Prevention of Stunting	Both parents should share childcare responsibilities.
27	Prevention of Stunting	Couples should discuss and plan their birth spacing.
28	Prevention of Stunting	There should be no discrimination between sons and daughters; both are blessings.
29	Prevention of Stunting	Let's work together to free Indonesia from stunting.

After the narratives were revised and aligned with their corresponding learning objectives to ensure clarity, a Nias language translator with substantial experience in translating from Indonesian to Nias was contacted

The translation process was conducted using a discussion method. The meaning of the narratives in Indonesian was discussed with the translator, who then crafted the equivalent in Nias. These translations were reviewed to ensure that the meanings in Nias accurately corresponded with the Indonesian text. This iterative process continued until a collective agreement on the Nias versions was reached, resulting in 29 narratives in both Indonesian and Nias

To create the module, an engaging combination of graphics and text was aimed at capturing the target audience's attention. To achieve this, communication was established with the module illustrator. The illustrator was initially briefed on the target audience and the narratives that had been developed

At least three critical considerations must be made when collaborating with an illustrator. First, the images must be easy to read. Second, they should be distinct from the narrative. Third, they should incorporate ornaments and feature figures dressed in attire commonly worn by the Nias tribe (Fig. 1). After clarifying these points, the illustrator proceeded to create the illustrations. Several revisions were necessary before the images for the module were finalized.

Fig. 1.

Several images within the module (page. 1, 9 and 24).

Finalization

To enhance the module, colourful printing was chosen to make it appealing to the target audience. Given that this module would be used in community meetings across three locations over six months of education, over 5000 copies of this standard-sized book module were distributed (Fig 2). Collaboration was undertaken with the local church and the District Health Office to gather the mothers participating in the training. Meetings with the participants were typically held at convenient locations such as community meeting halls or church buildings.

Fig. 2.

Modul's cover.

Method validation

Furthermore, prior to the mass production of the module, a pilot test was conducted with 30 randomly selected individuals in locations distinct from the target educational sites. The pilot test participants were mothers who closely resembled the target group for the educational intervention, specifically mothers with young children (under 5 years old). These participants were recruited from regions different from the intervention sites, with assistance from the local church, which had valuable insights into the demographic's profile of mothers we were seeking. The participant's mothers were then gathered in community meeting halls. At each of the three pilot test locations, 10 participants took part.

Before the activity commenced, an explanation of the work and the type of assistance sought from participants was provided by completing the pilot test questionnaire. During the pilot test, each participant was guided to clarify any items they might not fully understand, ensuring the purpose of each question was distinguishable. The pilot test questions were provided in two languages, Indonesian and the local language, to facilitate better understanding and response accuracy. During the pilot test, each participant requiring help in reading or rephrasing each question presented was assisted.

Eight questions, rated on a scale from 1 to 10 (with 1 indicating the lowest rating and 10 the highest), were administered through a written questionnaire. Each participant's responses were recorded on the provided questionnaire. The completed questionnaires were reviewed before collection to minimize errors. The results of this module pilot test are presented in Table 3.

Table 3.

Pilot test result.

No	Question	Score (n = 30)
1	Attractive Presentation	9.166667
2	Language Easy to Understand	9.1
3	Engaging Illustrations	8.633333
4	Message Easy to Remember	8.866667
5	Able to Motivate	9.066667
6	Usefull	9.566667
7	Important for Others to Read	9.1
8	Recommendations Will Be Followed	8.966667
	Mean score	9.058

Consequently, the module received excellent evaluations from the pilot test participants. Qualitatively, during education activities, participants' responses to reading and using the module were very positive.

Limitations

Although this method is unique, it is tailored to the specific needs of a particular target audience. Moreover, since the module is relevant to Nias language speakers, a team knowledgeable in Nias language is necessary from the design phase through to the delivery of educational content. Consequently, the use of this module is highly limited outside of this specific context.

Ethics statements

There is no human subjects or animal experiment were involved in this research. Written consent applied during pilot test only

CRediT authorship contribution statement

Cashtri Meher: Conceptualization, Methodology, Validation, Formal analysis, Resources, Data curation, Writing – review & editing, Writing – original draft, Visualization, Supervision. Fotarisman Zaluchu: Methodology, Validation, Formal analysis, Resources, Data curation, Writing – review & editing, Writing – original draft, Visualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.