The relationship between healthy behavior and environmental sanitation with water quality in stunting occurrence work area of Sikabu Community Health Center Padang Pariaman

Stunting is a long-term nutritional deficiency from insufficient intake and recurrent infectious diseases. One of the factors that can influence stunting is the limited access to clean water. This research analyzes the relationship between healthy behavior and environmental sanitation with water quality in stunting occurrences. This is a quantitative descriptive study with a cross-sectional design. The population includes all mothers with stunted toddlers in the working area of Sikabu Community Health Center, Padang Pariaman Regency, totaling 49 individuals. The sampling technique employed was total sampling. Behavior and sanitation assessments were conducted using a questionnaire. Data collection took place from September 14 to 18, 2023. Microbiological parameters were evaluated using the Most Probable Number (MPN) method, while inorganic chemical parameters were assessed using spectrophotometry. Data processing involved Spearman rank statistical tests, where a p-value <0.05 was considered statistically significant. The research results indicate a significant relationship (p<0.05) between behavior and microbiological and inorganic chemical water quality parameters, with correlation coefficients of 0.745 and 0.604, respectively. There is a significant relationship (p<0.05) between sanitation and microbiological and inorganic chemical water quality parameters, with correlation coefficients of 0.658 and 0.520, respectively. This study concludes that there is a significant relationship between good behavior that has a positive impact on sanitation and drinking water quality on the level of stunting in the Sikabu Puskesmas working area of Padang Pariaman Regency with a correlation coefficient of (p<0.05).


Introduction
The global agreement on sustainable development, emphasizing equality and human rights, is known as the Sustainable Development Goals (SDGs).One of the SDGs for 2030 is to ensure the long-term availability and management of sanitation facilities and clean water [1].According to the World Health Organization (WHO) data in 2017, 2.2 billion people lacked access to safe drinking water, and 4.2 billion people worldwide lacked sanitation facilities.After India and China, Indonesia had the third-worst sanitation situation globally in 2017.Indonesia ranked the lowest among ASEAN countries in terms of water and sanitation availability, according to data from Indonesia Urban Water Sanitation and Hygiene (IUWASH) and the United States Agency for International Development (USAID) [2].
Limited access to clean water and sanitation increases the risk of recurring infections.Recurrent infections can disrupt nutrient absorption in toddlers, leading to stunting and even death [3,4].According to WHO in 2021, there were 2.6 million deaths each year worldwide due to consuming contaminated or unfit water [5].The influence of access to clean water and sanitation on stunting aligns with research in Ethiopia in 2000 by Mulugeta Gebreayohanes and Awrajaw Dessield.The study found that households consuming unprotected river water were 68% more likely to have stunted children [6].
Microbiological and inorganic chemical parameters in drinking water directly relate to health.Microbiological indicators, such as E. coli and characteristics of total coliform bacteria, indicate human fecal contamination.One inorganic chemical parameter is the nitrite and nitrate level, depicting contamination by nitrogen fertilizers, organic waste from animals or humans, and household waste [7].
Stunting is a condition in toddlers whose height is below the age-standardized norm.Physically, stunted toddlers are smaller than their non-stunted counterparts.Stunting is a long-term nutritional deficiency due to inadequate intake and recurrent infections.Children experiencing stunting face challenges in mental development, experience a decline in IQ, perform poorly academically, and may even face mortality [8].Stunting can hinder economic growth and disrupt productivity [4].
In 2017, the number of stunted toddlers worldwide reached 150.8 million (22.2%).Stunting incidents in Asia identified 86.6 million, with 58.7% distributed in South and Southeast Asia.Indonesia had the third-highest stunting prevalence in the Southeast Asia Region (SEAR) according to the World Health Organization (WHO) [9].
Based on the Indonesia Child Nutrition Status Study (SSGBI), stunting prevalence in Indonesia tends to fluctuate.There was an increase from 2007 to 2013, a decline from 2014 to 2016, and an increase again from 2017 to 2018, followed by a decrease in 2019 to 27.7%.The prevalence of stunting for West Sumatra in 2021 and 2022 was 23.3% and 25.2%, respectively.For Padang Pariaman Regency in 2021 and 2022, it was 28.3% and 25%.Stunting data in August 2022 in Padang Pariaman Regency amounted to 2.5 people, with the Sikabu Community Health Center's working area having the highest percentage, with 208 individuals (27.6%).The Indonesian government aims to reduce stunting to 14% by 2024.
Given this background, an analysis is needed to understand the relationship between behavior, environmental sanitation, and water quality in stunting occurrences in the working area of Sikabu Community Health Center, Padang Pariaman Regency.

Method
This study is quantitative descriptive research with a cross-sectional approach.The population consists of mothers with toddlers exhibiting short or very short height-for-age indices (PB/U or TB/U) categorized as stunted and severely stunted in the working area of Sikabu Community Health Center, Padang Pariaman Regency.The study utilizes both primary and secondary data sources.Primary data is obtained through researcher-conducted interviews with respondents using questionnaires and water sampling from households with stunted toddlers.Primary data collection involves interviewing families with stunted toddlers registered in the e-PPGBM application.The interview guide is derived from two experts' modified and validated Stunting Case Audit Form.Secondary data comes from weight measurements conducted by the Padang Pariaman District Health Office in February 2023, where 49 toddlers were categorized as stunted and severely stunted.The sampling technique employed is total sampling.Respondents in this study are mothers of stunted toddlers who willingly provide consent and complete questionnaires.Data collection occurred from September 14 to 18, 2023.Microbiological parameters are assessed using the Most Probable Number (MPN) method, conducted at the Biology Laboratory of Universitas Negeri Padang.Inorganic chemical parameter assessment uses spectrophotometry, and the examination is carried out at the Laboratory Health Unit of the West Sumatra Provincial Health Office.

Results and discussion
This research was conducted on 49 stunted toddlers in the working area of Sikabu Community Health Center, Padang Pariaman Regency.The family profile of the respondents can be seen in Table 1.It is known that the distribution of the age of parents of stunted toddlers is mostly in the age range of (30-39) years, consisting of 29 fathers (59.18%) and 26 mothers (53.07%).The distribution of the parents' education is mostly at the high school level or equivalent, with 26 fathers (53.00%) and 34 mothers (69.40%).The distribution of parents' occupations shows that 38 fathers (77.55%) work as daily casual laborers, and 45 mothers (91.84%) work as housewives.The distribution of parents' income reveals that 33 fathers (67.35%) have income in the range of IDR 1.500.000-< IDR 2.500.000, and 47 mothers (95.92%) have income in the range of IDR < 500.000-< IDR 1.500.000.The distribution of the number of family members shows that 39 families (79.60%) have 3-5 family members, and 10 families (20.40%) have 6-8 family members.Regarding the distribution of the number of toddlers, it is known that 41 families (83.67%) have 1 toddler, and 8 families (16.33%) have 2 toddlers.From the data on the source of drinking water, it is known that 30 families (61.20%) obtain their drinking water from a well, 4 families (8.20%) use water from a gallon, and 15 families (30.60%) get their drinking water from a public water supply (PDAM).The profile of stunted toddlers is evident in Table 2.It is known that the majority of stunted toddlers fall within the age range of (13 -24) months, totaling 24 individuals (48.98%), and (25 -36) months, totaling 16 individuals (32.65%).The gender distribution reveals that the majority are female, totaling 26 individuals (53.10%).Most toddlers were born with a weight range of (2.1 -3.0) kg, totaling 35 individuals (71.43%).The distribution of birth length shows that the majority of toddlers were born with a length range of (49 -51) cm, totaling 31 individuals (63.27%).The current weight distribution indicates that most fall within the weight range of (6.7 -11.7) kg, totaling 40 individuals (81.63%).The distribution of current length reveals that the majority fall within the length range of (64 -81) cm, totaling 26 individuals (53.06%).Regarding the distribution of breastfeeding duration, it is known that the majority fall within the age range of (13-24) months, totaling 28 individuals (57.10%).Based on the behavior profile related to stunting in Table 3, it is known that the majority of respondents defecate in a toilet with a septic tank, totaling 32 individuals (65.30%).Most respondents do not dispose of their toddler's feces in the toilet, totaling 30 individuals (61.20%).All respondents have processed the drinking water they use by boiling it and/or consuming water directly from a gallon facilitated by a Drinking Water Depot, totaling 49 individuals (100.00%).The distribution of respondents who empty the water tank shows that the majority do it every month, involving 32 individuals (65.30%).The distribution of respondents who dispose of waste in the landfill amounts to 47 individuals (95.90%).The distribution of respondents who wash their hands after defecation totals 48 individuals (99.00%).The distribution of handwashing before holding a child involves 42 individuals (85.70%).The distribution of handwashing before feeding includes 44 individuals (89.80%).From the table, it is known that the majority of respondents have a type of toilet called "Jamban Leher Angsa," totaling 31 families (63.30%).The distribution of alternative defecation places shows that the majority respond with "none" (still using Jamban Leher Angsa), totaling 25 families (51.00%).The ownership distribution of a Wastewater Disposal Channel (SPAL) indicates that the majority have it "available" at home, totaling 33 families (67.30%).The distribution of the availability of drinking water sources shows that the majority have it "available," totaling 47 families (95.90%).The distribution of the availability of drinking water sources "available" in agricultural areas amounts to 26 families (53.10%).The distribution of the availability of clean water sources for daily needs "available" totals 48 families (98.00%).The distribution of the availability of Septic Tanks "available" within a distance of < 10 meters from the water source totals 41 families (83.70%).Based on the data above, a correlation test was conducted on the behavior and sanitation profiles with water quality (microbiological and inorganic).Table 5 displays the correlation between behavior and microbiological parameters.The strength of the relationship (correlation) is found to be 0.745 with a significance value of 0.000 (< 0.005), indicating that the relationship between these two variables is statistically significant and positive, and the relationship is strong.This means that the better the behavior, the less likely the microbiological water quality will be contaminated.From Table 6, which presents the correlation test between behavior and inorganic chemical parameters, a correlation strength of 0.604 and a significance value of 0.000 (< 0.005) are obtained.This indicates that the relationship between these two variables is statistically significant and positive, and the relationship is strong.In other words, the better the behavior, the less likely the inorganic chemical water quality will be contaminated.The correlation between sanitation and the quality of drinking water is presented in Tables 7 and 8. From Table 7, the strength of the relationship (correlation) is found to be 0.658 with a significance value of 0.000 (< 0.005) between sanitation and microbiological parameters.Therefore, it can be said that the relationship between these two variables is statistically significant and positive, and the relationship is strong.This means that the better the sanitation, the less likely the microbiological water quality will be contaminated.Based on Table 8, the strength of the relationship (correlation) is found to be 0.520 with a significance value of 0.000 (< 0.005) between sanitation and inorganic chemical parameters.Therefore, it can be said that the relationship between these two variables is statistically significant and positive, and the relationship is strong.This means that the better the sanitation, the less likely the inorganic chemical water quality will be contaminated.The family plays a crucial role in the growth and development of toddlers with stunting.The interaction between stunted toddlers and their families, as well as the surrounding environment, constitutes a holistic unity in carrying out social-cultural functions, ecological functions, and economic functions.The social-cultural function implies that the family introduces traditions, habits, and customs to its members.The age range of parents of stunted toddlers in the working area of Sikabu Community Health Center, Padang Pariaman Regency, is (30-39) years, with high school education, reflecting readiness to fulfill the role as parents.Therefore, the ecological function allows the family to interact with the physical environment, both within the household and with the surroundings such as water, soil, plants, and animals, ensuring proper functioning.However, challenges are found in fulfilling economic needs.The distribution of the number of family members with stunted toddlers reveals that 39 families (79.60%) have 3-5 members, and 10 families (20.40%) have 6-8 members, with fathers mainly working as daily laborers and mothers as homemakers.The income distribution of parents with stunted toddlers is in the range of < Rp 500.000-< Rp 1.500.000.This situation is in line with the data from the Central Statistics Agency (BPS) of Padang Pariaman Regency in 2023, which indicates a 7.22% increase in the poverty rate, affecting 30.41 thousand people, triggered by the COVID-19 pandemic.This percentage has reduced to 6.25% (24.44 thousand people), with 49.518 people engaged in daily labor.Poverty is measured by the ability to fulfill basic needs, considering the economic aspect [10].Consistent with the research by K. Anwar and Setyani, most parents aged 26-35, 52.1% of mothers and 43.8% of fathers, have stunted toddlers.Parental age affects childcare practices, especially in terms of feeding.The majority of parents have completed high school education, with 70.8% of mothers and 70.8% of fathers having graduated from high school.Child nutrition status is influenced by the parent's education level, which affects the information reception about family health improvement.Education also impacts income, especially for fathers as breadwinners.Most fathers work as laborers, 46.9%.The father's occupation contributes to the purchasing power for meeting nutritional needs.Most family incomes are ≤ Rp 4.8 million, 89.6%, with the majority having ≤ 4 family members, 80.2% [11].
Unhealthy parenting practices can expose toddlers to the risk of disease, characterized by decreased appetite, nausea, vomiting, and, over time, growth disorders.Unhealthy behaviors include defecation in toilets without septic tanks or toilets with septic tanks located less than 10 meters from water sources.Defecating in toilets with non-goose neck constructions, improper disposal of feces, and not washing hands contribute to environmental contamination, especially of drinking water sources.Even though some families have septic tank toilets, a small proportion of families with stunted toddlers still practice open defecation near rivers or in their yards.This condition aligns with the study by Desyanti and Nindya on stunted toddlers in Surabaya, who more often experience diarrhea.Diarrhea can lead to many deaths among toddlers in developing countries, caused by enteropathogenic Escherichia coli bacteria.Not washing hands can support the contamination of consumed food and beverages, and buying and consuming unhygienic food can trigger diarrhea in toddlers.Handwashing with soap before handling toddlers, before feeding them, and after defecation can reduce the risk of stunting by 14% [12].
According to the World Health Organization (WHO), indirect factors causing stunting include sanitation, the environment, and water availability.Limitations in consuming qualified drinking water and inadequate facilities increase the risk of infection.Thus, the nutritional intake intended for growth and development is replaced by the need for resistance and healing from ongoing infections, posing a threat of death to toddlers.Poor sanitation contributes to limited access to drinking water, improper toilet facilities, and poor handwashing habits.
High-quality drinking water meets the standards set by the government in Regulation of the Minister of Health of the Republic of Indonesia No.492/MENKES/PER/IV/2010, which states that water should be physically, chemically, radioactively, and microbiologically suitable.The regulation stipulates several quality requirements for drinking water, including E. coli ranging from 0 to >2400 CFU/100 ml, with a median of 210.000CFU/100 ml, and total Coliform bacteria ranging from 0 to >2400 CFU/100 ml, with a median of 210,000 CFU/100 ml.The range of nitrite concentration is (0.000 -0.180) mg/l, with a median of 0.00600 mg/l, and the range of nitrate concentration is (0.089 -21.00) mg/l, with a median of 2.600 mg/l [13].
Escherichia coli (E.coli) bacteria are one of the bacteria found in human feces.The E. coli quality standard is 0 CFU/100 ml.E. coli contamination in wells can be caused by wells located less than 10 meters from a septic tank, poorly constructed wells, the absence of Wastewater Treatment Facilities (SPAL), proximity to other sources of pollution such as livestock pens, well depth, soil topography, and the habits of the surrounding community who do not maintain cleanliness around wells.
Nitrogen compounds (nitrite, nitrate, and ammonia) in water naturally come from the metabolism of aquatic organisms and the decomposition of organic materials by bacteria.Additionally, natural sources of nitrate and nitrate in nature can be produced naturally or from human activities.The natural sources of nitrite and nitrate are the nitrogen cycle, while human activity sources come from the use of nitrogen fertilizers, industrial waste, and human organic waste.
Nitrogen that has undergone several oxidations produces nitrite.Since nitrite is a temporary byproduct of the oxidation of ammonia into nitrate, its existence is short-lived.Nitrite is not permanent and can be oxidized to form nitrate or converted into ammonia [7].
Stable nitrogen compounds include nitrate compounds.This substance is used when fertilizers are applied to vegetables.If urea fertilizer is widely used, it will expose nitrate through vegetables, especially leafy green ones, as well as through root vegetables and in drinking water.Although nitrate levels are generally low in nature, they can increase in areas where fertilizers containing nitrate are used [14].
Water pollution caused by agricultural practices, such as using nitrogen fertilizers that increase the concentration of nitrate compounds in water, is a concern related to the use of groundwater as a source of drinking water.The produced nitrate will reach the groundwater, potentially lowering water quality.Many nitrate molecules in the body can impact neurological and hematological functions.The hematological effect of nitrate can cause methemoglobinemia, known as blue baby syndrome.In infants under six months, hemoglobin (Fe2+) undergoes oxidation and is transformed into methemoglobin (Fe3+).Methemoglobin (MetHb) cannot carry oxygen, leading to cyanosis, tissue hypoxia, seizures, and death when its concentration in the body exceeds its capacity to convert into hemoglobin.Adults consuming nitrate compounds may be at risk of cancer [15].
Water quality influenced by domestic waste is identified by the presence of nitrate.This situation aligns with the research conducted by Nitis Aruming in the Citrosono Grabang Village, Magelang Regency, indicating water pollution marked by the presence of nitrite and nitrate due to waste from household farming activities, fisheries, livestock waste, and excessive fertilizer, polluting water bodies 10 due to excessive nutrient increase.The presence of nitrite in the human body can disrupt the binding of oxygen by the blood and, for a prolonged period, can result in growth and developmental failure [16].
This research is consistent with a study by Arie et al., which measured nitrite levels in dug wells used as drinking water sources.They collaborated with the Regional Health Laboratory (Labkesda) of Cilacap Regency.The average nitrite concentration was found to be 0.03 (mg/L), with a maximum nitrite value of 0.22 (mg/L) and a minimum nitrite value of 0.005 (mg/L).Some samples exceeded the threshold value of 0.006 mg/l, as the sampling points were close to agricultural areas located 53.4 meters away, containing significant nitrogen compounds from adequate fertilization residues [17].

Conclusion
This study found a significant relationship between healthy behavior and a positive impact on sanitation and drinking water quality on the level of stunting in the Sikabu Health Centre working area of Padang Pariaman Regency with a correlation coefficient of (p<0.05).

Table 1 .
Respondent identity profile

Table 2 .
Profile of Stunted toddler's characteristics

Table 3 .
Profile of behavior related to the occurrence of stunting

Table 4
displays the sanitation facility profile in families with stunted toddlers.

Table 4 .
Sanitation profile in families with stunted toddlers

Table 5 .
Relationship between behavior and microbiological parameters of drinking water in the occurrence of stunting in the working area of Sikabu Community Health Center, Padang Pariaman Regency

Table 6 .
Relationship between behavior and inorganic chemical parameters of drinking water in the occurrence of stunting in the working area of Sikabu Community Health Center, Padang Pariaman

Table 7 .
Relationship between sanitation and microbiological parameters of drinking water in the occurrence of stunting in the working area of Sikabu Community Health Center, Padang Pariaman Regency

Table 8 .
Relationship between sanitation and inorganic chemical parameters of drinking water in the occurrence of stunting in the working area of Sikabu Community Health Center, Padang Pariaman Regency