ABSTRACT
Background
In Indonesia, stunting remains a health issue among children aged < 5 years, with a prevalence of 36.8% in 2021, the highest prevalence of malnutrition in the said age group, and the quality of drinking water consumed being one of the main causes. This study aimed to identify the quality of drinking water and determine the risk factors for stunting.
Methods
This study was conducted at four Primary Health Care work areas in an urban city between July and October 2022 using a cross-sectional study design with 172 under-fives, 106 of whom had drinking water-related stunting. The sampling methods employed were two-stage, including cluster and purposive sampling. Data collection included anthropometric measurements, interviews, and collecting drinking water samples. This study used the logistic regression test for multivariate analysis.
Results
The results showed that 93.6% of the drinking water was positive for microbiological agents, whereas analysis of heavy metals in drinking water revealed concentrations within acceptable limits as defined by standard drinking water quality regulations. Multivariate analysis showed that exposure to microbiologically contaminated drinking water was significantly associated with a higher risk of stunting. Children exposed to contaminated drinking water had a 3.3 times higher risk of stunting (OR 3.328; 95% CI 1.681–6.587). Additional confounding factors such as children over 23 months of age, history of infectious disease, low birth weight, and poor hygiene practices also contributed to increased stunting risk.
Conclusion
This study highlights the significant role of drinking water quality in the incidence of stunting among children under five. The high prevalence of microbiological contamination in household drinking water was strongly associated with increased stunting risk. Children exposed to contaminated water were over three times more likely to experience stunting. While concentrations of heavy metals remained within safe limits, additional confounding factors including child age, history of infectious disease, low birth weight, and poor hygiene practices further exacerbated the risk. These findings underscore the urgent need for integrated public health interventions focusing on water safety, hygiene education, and early childhood care to effectively reduce stunting prevalence in urban communities.
Keywords: drinking water, epidemiologic determinants, stunting, urban population
Stunting is a condition of delayed growth in children aged < 5 years due to chronic malnutrition, recurrent infections, and lack of psychosocial stimulation characterized by a height-for-age z-score of less than −2 standard deviation1 (stunting) and less than −3 SD (severe stunting).1,2,3 Stunting constitutes a major global health issue.4 In 2020, 20% or approximately 149.2 million children aged < 5 years worldwide were stunted. However, this figure had decreased compared with the stunting rate of 32.6% in 2000. In 2017, more than 50% of the world’s stunted children were from Asia (53%), whereas more than one-third (41%) lived in Africa. According to the prevalence data collected by the World Health Organization,3 Indonesia is the third country with the highest prevalence in the Southeast Asia region. From 2005 to 2017, the average prevalence of stunting in Indonesia was 36.4%.1 Stunting can negatively affect the health sector and other sectors. The impact of stunting in the health sector includes increased morbidity and mortality due to infection.5 Globally, 45% of under-five mortality is associated with malnutrition, especially stunting. Moreover, stunted children are at a risk of recurrent infections, including diarrhea, pneumonia, and measles.6 A child’s brain optimally develops until 2 years old, and malnutrition during this time increases the risk of developmental and cognitive impairments in children.7
A previous study showed that the period from pregnancy to 2 years old (known as the first 1,000 days of life) is a golden opportunity for preventing stunting. The WHO’s target for stunting is to reduce the number of stunted children under-five by 40% by 2010–2025.8 One of the World Health Assembly community-based strategies for reducing stunting prevalence is to improve the quality of drinking water, sanitation, and hygiene as well as protect against the risk of infections, including diarrhea and malaria.9 A previous study in Indonesia reported that mothers with stunted children in rural areas remain indifferent to the influence of stunting and are unaware of different parenting approaches in managing stunting. The Indonesian government has included stunting as one of its priority programs.10 Based on the Minister of Health Regulation Number 39 of 2016 concerning Guidelines for Implementing the Healthy Indonesia Program with a Family Approach, intervention in children under 5 years old is one of the efforts made for reducing stunting prevalence. These interventions include monitoring under-fives for their growth, organizing supplementary feeding activities for under-fives, establishing early stimulation of child development, and providing optimal health services. However, interventions that have proven effective are not prioritized in the policies and programs implemented by various sectors. Stunting, which was designated as a national priority in 2015–2019, has not been translated into priority programs and activities by relevant sectors/agencies.8 Non-essential heavy metals, including mercury, lead, chrome, arsenic, and cadmium, have no beneficial effects on the human body and are even hazardous and can cause poisoning. At very low concentrations, essential heavy metals can maintain various physiological and biochemical functions in life; however, at levels exceeding certain concentration thresholds, they become detrimental and even toxic.11
To produce a healthy generation, identification of risk factors and prevention and control of stunting should be conducted. This study aimed to identify the quality of drinking water, which could be a risk factor for stunting, and determine the factors of stunting in urban areas to provide references for further stunting control programs in Indonesia.
MATERIAL AND METHODS
Study location
This study was carried out in an urban area of Semarang, Central Java between April and October 2022, during which 1,489 stunting cases were recorded in Semarang. The research focused on four Primary Health Care (PHC) service areas that were selected because of their relatively high prevalence of stunting. Two of these PHCs are located in low-lying coastal zones, while the other two are situated in higher-altitude districts in the southern part of the city. PHC 1, located in a coastal sub-district with an area of 11.39 km2 and a population density of 10,572.18 individuals/km2, reported the highest number of stunting cases in the city, totalling 194 cases (13.03%). PHC 2, which has the highest population density in the city at 12,146.92 individuals/km2, ranked second with 114 cases (7.66%). Meanwhile, PHC 3 and PHC 4, both situated in the highland region and together covering an area of 39.47 km2, recorded 109 cases (7.32%) and 100 cases (6.72%), respectively.
Study design
This study used a cross-sectional study design. The sampling technique used multistage random sampling, including cluster and purposive technique sampling. Determinants of the area and primary health were taken by the cluster sampling technique and determinants of respondents used the purposive technique. The dependent variable in this study was stunted children under 5 years of age, which was confirmed by calculating the height-for-age z-score (less than −2). The independent variable was the quality of the drinking water (analyzed by the amount of coliform, Escherichia coli (E. coli), dissolved iron, ammonia, fluoride, chloride, total chromium, dissolved manganese, dissolved zinc, nitrate, sodium, and nitrite) age, gender, history of illness, birth weight, mother’s education, immunization, family income, and hygiene practice. Hygiene practices using the basic health research questionnaire (riskesdas) 2013 consists of 3 subscales namely house components, sanitation facilities and occupant behaviour with 17 question items and total score > 80 that indicate good hygiene category.
Drinking water assessment
Drinking water tests were conducted at the Health Laboratory and Medical Device Testing Center (Central Java Provincial Health Laboratory and Medical Device Testing Center). The drinking water examinations performed included microbiological examinations (APHA 2017, Section 9222.j), comprising coliform and E. coli, and physiochemical examinations, comprising dissolved iron, total chromium, dissolved manganese, dissolved zinc, ammonia (SNI 06.6989.30.2005), fluoride (SNI 06.6989.29.2005), chloride (SNI 6989.19.2009), nitrate (APHA 4500-NO3B), dissolved sodium (SNI 06.2428.1991), and nitrite (SNI 06.6989.9. 2004). Drinking water sampling was conducted by obtaining samples during home visits of families with under-fives. Drinking water samples for microbiological tests were collected in 500-mL dark sterile bottles with tight brass caps provided by the laboratory. First, the mouth of the bottle was cleaned using 70% alcohol and burned it until the smell of alcohol was no longer noted. Subsequently, drinking water samples were poured into the bottle, closed, placed in a clear plastic, and stored at a temperature of 23°C–37°C. Physiochemical samples (5 L) were collected and stored in 5-L clean and tightly sealed jerry cans. Sampling was performed by collecting drinking water at the respondent’s house one by one.
Data quality control
All data obtained were confirmed with data from the Maternal and Child Handbook, interviews with caregivers and mothers of children aged < 5 years, and confirmed data with local health workers and medical records from the local health center. Raw data entry was performed in Excel, which was subsequently double-checked before coding.
Data processing and analysis
Anthropometric data were exported in WHO Anthro software to analyze the height-for-age z-score of children under five. The collected data were input to Excel and coded before being entered in SPSS version 25. The independent variables of this study include age [< 24 month / 24–59 month], gender [male/female], income [under local minimal wage/over local minimal wage], maternal education [less than senior high school/more than senior high school], birth weight [low: under < 2,500 g/normal: > 2,500 g], hygiene practice [bad/god], disease history [yes/no], immunization [complete/incomplete] and microbiological agent [positive/negative].
Multivariate analysis variables were selected from all variables that had potential. Selected variables were then analyzed for logistic regression using the stepwise method and a final logistic regression model. The results of the water content analysis were subsequently coded, with values less than or equal to the mean value and more than the mean value.
This study has received ethical clearance approval from the Health Research Ethics Committee of Faculty of Medicine, Universitas Diponegoro with number 151/EC/KEPK/FK-UNDIP/VI/2022.
RESULTS
Based on table 1, there were 172 children aged < 5 years whose drinking water samples were analyzed showed that the microbiological content, including the coliform content, in the drinking water was higher than the standard drinking water quality regulations. The average coliform content is 135.36 ± 63.84/100 mL. The results of the heavy metal analysis showed that the heavy metal content remained within the safe limits of the drinking water quality standards.
Table 1. Characteristics of the drinking water (n = 172).
| Variables | Unit | Standard* | Mean ± SD (min–max) |
| Coliform | mg/L | 0 | 135.360 ± 63.84 (0–200) |
| Escherichia coli | mg/L | 0 | 8.310 ± 16.808 (0–45) |
| Dissolved iron | mg/L | 0,3 | 0.210 ± 0.265 (0–0.828) |
| Ammonia | mg/L | 1.5 | 0.035 ± 0.015 (0–0.103) |
| Fluoride | mg/L | 0.229 ± 0.122 (0–0.730) | |
| Chloride | mg/L | 250 | 11.945 ± 17.304 (0–86.30) |
| Total chromium | mg/L | 0.024 ± 0.016 (0–0.048) | |
| Dissolved manganese | mg/L | 0.4 | 0.019 ± 0.021 (0–0.110) |
| Dissolved zinc | mg/L | 3 | 0.032 ± 0.021 (0–0.079) |
| Nitrate | mg/L | 50 | 3.623 ± 2.696 (0–7.94) |
| Sodium | mg/L | 200 | 24.168 ± 21.811 (0–95.6) |
| Nitrite | mg/L | 3 | 0.006 ± 0.011 (0–0.066) |
Water source: refillable water (72.7%), dug well (22.6%), water gallon (3.5%), and piped water or local Water Supply Utility (1.2%). Microbiological examinations (APHA 2017, Section 9222.j), dissolved iron, total chromium, dissolved manganese, dissolved zinc, ammonia (SNI 06.6989.30.2005), fluoride (SNI 06.6989.29.2005), chloride (SNI 6989.19.2009), nitrate (APHA 4500-NO3B), dissolved sodium (SNI 06.2428.1991), and nitrite (SNI 06.6989.9. 2004). *Regulation of the Minister of Health of the Republic of Indonesia no. 492/MENKES/PER/IV/2010 on Drinking Water Quality Requirements. SD, standard deviation.
Based on the nutritional status of the included under-fives in Table 2, there were 106 exhibited stunting, and 66 were normal under-fives. Of the under-fives, 80 (46,51%) and 92 (53,49%) were males and females, respectively; 130 (75,58%) under-fives were aged 24–59 months, and 42 (24,42%) were aged < 23 months. Under-fives aged > 23 months had a higher prevalence of stunting than those aged 0–23 months.
Table 2. Participant characteristics.
| Variables | All (n = 172) |
Stunting | Normal |
| (n = 106) | (n = 66) | ||
| Age, months | |||
| 24–59 | 130 (75.58) | 95 (55.23) | 35 (20.35) |
| < 24 | 42 (24.42) | 11 (6.4) | 31 (18.02) |
| Gender | |||
| Male | 80 (46.51) | 44 (25.58) | 36 (20.93) |
| Female | 92 (53.49) | 62 (36.05) | 30 (17.44) |
| Birth weight | |||
| Low | 45 (26.16) | 40 (23.26) | 5 (2.91) |
| Normal | 127 (73.84) | 66 (38.37) | 61 (35.47) |
| Mother’s education | |||
| < Senior high school | 59 (34.3) | 43 (25) | 16 (9.3) |
| Senior high school | 113 (65.70) | 63 (36,62) | 50 (29.07) |
| Income | |||
| < regional minimum wage | 136 (79.07) | 92 (53.49) | 44 (25.58) |
| ≥ regional minimum wage | 36 (20.93) | 14 (8.14) | 22 (12.79) |
| Hygiene practices | |||
| Bad | 26 (15.12) | 23 (13.37) | 3 (1.74) |
| Good | 146 (84.88) | 83 (48.26) | 63 (36.63) |
| Disease history | |||
| Yes | 94 (54.65) | 68 (39.53) | 26 (15.12) |
| No | 78 (45.35) | 38 (22.09) | 40 (23.26) |
| Immunization | |||
| Incomplete | 41 (23.84) | 24 (13.95) | 17 (9.88) |
| Complete | 131 (76.16) | 82 (47.67) | 49 (28.49) |
| Microbiological agents | |||
| Positive | 161 (93.60) | 98 (56.97) | 63 (36.63) |
| Negative | 11 (6.40) | 8 (4.65) | 3 (1.74) |
| Coliform | |||
| Poor | 12 (6.98) | 9 (8.49) | 3 (4.55) |
| Good | 160 (93.02) | 97 (91.51) | 63 (95.45) |
| Escherichia coli | |||
| Poor | 137 (79.65) | 82 (77.36) | 55 (83.33) |
| Good | 35 (20.35) | 24 (22.64) | 11 (16.67) |
| Dissolved iron | |||
| Poor | 146 (84.88) | 91 (85.85) | 55 (83.33) |
| Good | 26 (15.12) | 15 (14.15) | 11 (16.67) |
| Total chromium | |||
| Poor | 85 (49.42) | 55 (51.89) | 30 (45.45) |
| Good | 87 (50.58) | 51 (48.11) | 36 (54.55) |
| Dissolved manganese | |||
| Poor | 138 (80.23) | 85 (80.19) | 53 (80.30) |
| Good | 34 (19.77) | 21 (19.81) | 13 (19.70) |
| Dissolved zinc | |||
| Poor | 141 (81.98) | 86 (81.13) | 55 (83.33) |
| Good | 31 (18.02) | 20 (18.87) | 11 (16.67) |
| Ammonia | |||
| Poor | 144 (83.72) | 86 (81.13) | 58 (87.88) |
| Good | 28 (16.28) | 20 (18.87) | 8 (12.12) |
| Fluoride | |||
| Poor | 90 (52.33) | 51 (48.11) | 39 (59.09) |
| Good | 82 (47.67) | 55 (51.89) | 27 (40.91) |
| Chloride | |||
| Poor | 155 (90.12) | 91 (85.85) | 64 (96.97) |
| Good | 17 (9.88) | 15 (14.15) | 2 (3.03) |
| Nitrate | |||
| Poor | 92 (53.49) | 35 (53.03) | 57 (53.77) |
| Good | 80 (46.51) | 31 (46.97) | 49 (46.23) |
| Dissolved sodium | |||
| Poor | 142 (82.56) | 85 (80.19) | 57 (86.36) |
| Good | 30 (17.44) | 21 (19.81) | 9 (13.64) |
| Nitrite | |||
| Poor | 125 (72.67) | 79 (74.53) | 46 (69.70) |
| Good | 47 (27.33) | 27 (25.47) | 20 (30.30) |
*Univariate data n (%).
Based on birth weight, 45 under-fives had LBW (< 2,500g), and 127 had normal weight. The prevalence of stunted under-fives with low birth weight was 23.26%. The prevalence of stunted under-fives with a history of illness was 64,1%, which was higher than the prevalence of stunted under-fives who did not have a history of illness, which was 35,9%. Data on the history of illness encompassed acute respiratory infections, typhoid fever, pneumonia, diarrhea, and measles experienced by children aged < 5 years during the last 3 months.
Multivariate logistic regression analysis in Table 3 revealed that microbiological contamination in household drinking water was a significant predictor of stunting. Children consuming contaminated water had a more than threefold increased risk of stunting compared to those consuming clean water (OR 3.328; 95% CI 1.681–6.587).
Table 3. Final logistic regression model.
| Variables | P-value | OR (95% CI) |
| Microbiological agents | ||
| Positive | 0.044* | 3.328 (1.681–6.587) |
| Negative | 1 | |
| Nitrate | ||
| Poor | 0.950 | 1.031 (0.385–2.764) |
| Good | 1 | |
| Age | ||
| 24–59 month | < 0.001* | 4.965 (2.245–10.979) |
| < 24 month | 1 | |
| Birth weight | ||
| Low | < 0.001* | 6.197 (2.798–13.724) |
| Normal | 1 | |
| Income | ||
| < regional wage | 0.060 | 3.074 (1.720–5.494) |
| > regional wage | 1 | |
| Disease history | ||
| Yes | 0.019* | 1.343 (1.145–4.795) |
| No | ||
| Hygiene practices | ||
| Poor | 0.001* | 4.680 (1.814–12.072) |
| Good | 1 |
*P < 0.05. CI, confidence interval; BW, low birth weight; OR, odds ratio. Stepwise method.
Several confounding factors also contributed to stunting risk. Children aged over 23 months were nearly five times more likely to experience stunting than younger children (P < 0.001; OR 4.965; 95% CI 2.245–10.979). A history of illness significantly increased the likelihood of stunting (P = 0.019; OR 1.343; 95% CI 1.145–4.795).
In addition, children with low birth weight were more vulnerable to growth impairment, and poor household hygiene practices were associated with elevated stunting risk. These findings underscore the multifactorial nature of stunting, with drinking water quality as the leading environmental determinant.
DISCUSSION
Stunting is indicative of severe irreversible physical, physiological, and cognitive impairment due to chronic malnutrition in early life. Childhood stunting can be caused by several factors from both pre and postnatal development phases, including poor nutritional intake that does not meet the nutritional needs of children aged < 5 years accompanied by rapid growth of under-fives, the incidence of infections, and the household environment.12, 13
For the drinking water sources, 72,7%, 22,6%, 3,5%, and 1,2% of the respondents used refillable water, dug well, water gallon, and piped water or Local Water Supply Utility, respectively. The drinking water used by the respondents was tested for microbiological content and heavy metal levels. The results of the drinking water quality examination in Table 1show that several drinking water sources containing coliforms did not meet the drinking water quality standards, with an average coliform content of 135.36 ± 63.84/100 mL, whereas the analysis of heavy metals in drinking water revealed concentrations within acceptable limits as defined by standard drinking water quality regulations.
Heavy metals are naturally occurring elements that have a higher density and higher atomic mass and are denser than water. Lead, iron, mercury, cadmium, zinc, arsenic, and chromium are heavy metals.14,15,16 Some heavy metals, including zinc, selenium, and iron, are essential micronutrients for the body; however, ingestion of heavy metals through contaminated drinking water and excessive consumption of water and food pose significant health risks, including mortality.15 Coliforms are the largest bacteria detected in feces and polluted water; therefore, the presence of coliforms frequently indicates fecal contamination. Drinking water with coliform bacteria detected indicates that the water has been contaminated.17 Previous studies have reported that malnourished children are equally affected by yeast, mold, and coliform-contaminated food. Previous research data showed that 73% of drinking water samples were contaminated with coliforms, indicating issues with water supply and microbial contamination in slums.18
The proportion of respondents who experienced stunting with positive water quality containing microbiology was 98 (56.97%) respondents greater than the stunting respondents with negative water quality containing microbiology, namely 8 (4.65%). Drinking water has an important role for health. Drinking water consumed daily must meet the requirements to be free from pathogenic bacteria such as E. coli and coliform. According to Permenkes No. 492 of 2010, drinking water must have an E. coli content of 0 MPN/100m. if drinking water is contaminated with bacteria it can trigger infectious diseases such as recurrent diarrhea which results in impaired metabolic processes and nutritional absorption until the growth process is inhibited.19, 20
Based on the final multivariate logistic regression model (Table 3), the quality of drinking water emerged as a significant environmental determinant of stunting. Children consuming microbiologically contaminated water had a 3.3 times higher risk of experiencing stunting compared to those consuming clean water (P = 0.044; OR 3.328; 95% CI 1.681–6.587). Thus, contaminated drinking water can be considered an environmental risk factor contributing to child growth failure. Clean water quality is a protective factor, but this factor cannot stand alone but is an indirect factor along with parenting and feeding and drinking habits of children, causing fecal-oral infection which results in stunting.21 Research in Ethiopia shows that sanitation problems and access to drinking water as well as clean living behaviour (especially the habit of providing drinking water) are contributing factors to stunting.22
Based on the research data (Table 2), there were 172 respondents with 106 stunting respondents and 66 non-stunting respondents. Of the 106 stunting respondents, 68 (39.53%) stunting respondents had a history of illness while 38 (22.09%) other stunting respondents did not have a history of illness. Frequent and prolonged illness can affect the nutritional status of under-fives through loss of appetite, metabolic disorders and behavioural changes. Table 3 shows the results of the multivariate fix model of this study and obtained a P value of 0.019, OR 1.343, 95% CI 1.145–4.795. These results indicate that respondents with a history of illness have a risk of 1.34 times experiencing stunting. Based on these results, poor personal hygiene and poor diet can cause children to experience infections. these results are in line with previous research which shows that a history of illness is associated with stunting.23 Infections reduce appetite, interfere with nutrient absorption and metabolism, worsen children’s nutritional status, and negatively impact linear growth. The reciprocal relationship between infection and malnutrition leads to decreased immunity and increased risk of malnutrition and infectious diseases.24,25,26,27,28 Lack of nutrition can prolong the duration of healing and decrease immunity, making children under five vulnerable to infection. If prolonged, this can stunt growth and increase the risk of stunting.27, 29
Chloride is an inorganic ion present in water and is easily dissolved in water samples. Research on the health implications of chloride exposure is scarce; however, chloride mineral water is beneficial for intestinal function, including stimulating intestinal peristalsis and secretion of water and intestinal electrolytes. In addition, chloride ion deficiency in the body can reduce the osmotic extracellular fluid, which causes increased body temperature. Chloride can also increase bile secretion and bile flow to the duodenum.30, 31 In previous studies, toddlers who were exclusively fed with formula milk with insufficient chloride content were treated for failure to thrive, constipation, refusal to eat, muscle weakness, and developmental delay due to alkalosis, hypokalemia, hypochloremia, and decreased urinary excretion of chloride.32 Conversely, for the chemical parameters of drinking water, no significant relationship was found with stunting. However, for microbiological quality, the findings confirmed that contamination was significantly associated with higher risk of stunting. The absence of association in chemical parameters may be explained by the limited number of samples.
In the present study, age has an association with the incidence of stunting, with children aged > 24 months showing a 4.9-fold higher risk of stunting than those aged 0–24 months. These results are consistent with those of previous studies conducted on children aged 6–59 months, indicating that children aged 6–23 months have a lower risk of stunting than those aged 24–59 months.6, 33, 34 Furthermore, a study on children aged < 2 years showed that toddlers with older ages (12–23 months) have a tendency to experience stunting compared with younger toddlers (< 12 months).33, 35, 36 The suboptimal growth associated with increasing age may occur owing to rejection due to shifting from breast milk to complementary and regular food. Childhood growth issues will occur if the consumption by toddlers cannot fulfill the nutritional needs according to the age of the toddler. With an increase in nutritional needs, linear growth disorders may develop when toddlers do not receive the required consumption.4, 6, 37
Previous studies showed similar results that infants with LBW were more at risk of stunting than toddlers who were born with normal weight.27, 28, 38, 39 Moreover, a previous study on preschool children in India indicated that children born with LBW have a 19% higher risk of stunting.39
Low income levels may reflect a family’s ability to purchase and access good quality food, adequate health services and sanitation facilities, and safe drinking water.13, 40 In addition, family income level can be associated with food security and fulfilment of a varied diet, where families with higher income levels tend to achieve better food security and a more varied diet.13, 33, 40 In our study, family income was not associated with child stunting.
Hygiene practice is another factor that influences the incidence of stunting. Hygiene practices are the efforts applied by mothers and children to maintain and protect children’s hygiene. In our study, multivariate analysis show are consistent with those of previous studies, indicating that good hygiene and sanitation behaviours can improve the health of toddlers and reduce the risk of stunting.41,42,43 Hygiene practices performed by parents to children may improve child growth through the prevention of various morbidity risks.43, 44 The interaction between poor hygiene practices and contaminated water sources may further exacerbate infection risks, underscoring the importance of household-level interventions.
Strengths of this study is that this study employed a comprehensive assessment of drinking water quality, both microbiological and physicochemical parameters, providing a thorough evaluation of environmental risk factors for stunting. A wide range of potential determinants (child age, disease history, birth weight, hygiene practices, maternal education, and family income) were analyzed, allowing for a multifactorial understanding of stunting risk. The use of validated data collection tools, standardized laboratory methods, and rigorous data verification processes enhanced the reliability and validity of the findings.
On the other hand, the limitations of this study is that as a cross-sectional study, causal relationships cannot be established. Some subgroups had small sample sizes, limiting statistical power. Self-reported data on variables such as disease history and hygiene practices may have introduced bias. The geographic limitation to a single urban area restricts generalizability, and unmeasured confounders such as dietary intake and maternal nutrition were not assessed.
This study highlights the significant role of drinking water quality in the incidence of stunting among children under five. The high prevalence of microbiological contamination in household drinking water was strongly associated with increased stunting risk. Children exposed to contaminated water were over three times more likely to experience stunting. While concentrations of heavy metals remained within safe limits, additional confounding factors including child age, history of infectious disease, low birth weight, and poor hygiene practices further exacerbated the risk. These findings underscore the urgent need for integrated public health interventions focusing on water safety, hygiene education, and early childhood care to effectively reduce stunting prevalence in urban communities.
Acknowledgments
Acknowledgments: This study was supported by a grant from the Faculty of Medicine, Universitas Diponegoro. The funder had no role in considering the design of the study, in the collection, analysis, and interpretation of the data, in writing the report, or in the decision to submit the article for publication.
Footnotes
The authors declare no conflict of interest.
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