Challenges and Strategies in Parenting Undernourished Toddlers: A Maternal Perspective Dry Land, Kupang City East Nusa Tenggara- Indonesia

Introduction

Undernutrition among children under five remains a persistent public health challenge in Indonesia, especially in eastern provinces such as East Nusa Tenggara, where stunting and underweight rates exceed national averages.^1,2 Poverty acts as a fundamental determinant of undernutrition, significantly restricting access to nutritious food, safe water, sanitation, and essential healthcare services, particularly evident in regions such as East Nusa Tenggara.^4,5 For example, studies in East Nusa Tenggara have observed that poverty levels were 20.4% in 2012, peaking at 22.6% in 2014, and remaining high at 21.9% in 2017.⁶ Most current interventions and policy responses are based on standardized assumptions about feeding behavior, access to food, and knowledge of nutrition, often overlooking the local cultural beliefs, emotional burdens, and contextual realities that shape maternal decision-making.⁷ In dry land Kupang City, where cultural diversity, poverty, and limited health access intersect, mothers face unique challenges in caring for undernourished toddlers. This study is novel in its qualitative, phenomenological approach to exploring the real-life, parenting experiences of mothers whose children are categorized as undernourished, recognizing that their voices are often underrepresented in both research and program design.^8,9,10 Such an approach is particularly valuable in contexts like Kupang, where cultural diversity, poverty, and limited health access add layers of complexity to maternal experiences. In the context of undernourished toddlers, this implies that even when mothers are aware of the need for nutritional support, access to appropriate healthcare and nutritional programs might be severely hampered.¹¹ Furthermore, the concept of “nutritional parenting patterns” is gaining recognition as a key determinant of a toddler’s nutritional status. The exploration of maternal experience is not only timely but essential.^12,13 Maternal experience, encompassing socio-cultural and emotional dimensions of parenting, significantly influences child nutritional status, particularly in regions like Indonesia where undernutrition and stunting remain pressing public health concerns. As Indonesia moves toward reducing stunting and improving child health through national strategies, there is an urgent need for evidence that is rooted in local context and informed by the everyday realities of caregivers.^14,15

Children under five years old are vulnerable to health and nutrition disorders because their needs increase, and they are unable to ask for and find food themselves. Data from the Indonesian Health Survey (IHS) in 2023 on the prevalence of nutritional status (BW) of children aged 0-59 months in Indonesia reveals that East Nusa Tenggara Province occupies the sixth highest level of wasting, reaching 9.4% among 38 other provinces. One of the causes of the high rate of undernutrition in children under five is maternal parenting. Parenting is all forms and processes of interaction between parents and children that can affect the development of the child’s personality.¹⁷ Fulfillment of children’s physical and psychological needs that are not optimal can trigger health problems in these children, one of which is malnutrition due to not maximizing the fulfillment of children’s eating and drinking needs. The diet applied to a family depends on the mother’s behavior in preparing and managing what the family will consume.¹⁸

The IHS provided details on the incidence of underweight toddlers in Oesapa Village, specifically 478 cases, identified through the August 2024 nutrition indicator coverage data from the Oesapa Community Health Center. This figure indicates that Oesapa Village has the highest incidence among five villages, including West Oesapa, South Oesapa, Lasiana, and Kelapa Lima. However, the referenced scientific literature does not contain specific data from the Oesapa Community Health Center, Oesapa Village, or the other mentioned villages regarding nutrition indicator coverage or the incidence of underweight toddlers in August 2024. Malnutrition among children, encompassing both under- and over-nutrition, has significant short- and long-term impacts on health and development. Dietary patterns and food intake are critical determinants of nutritional status. A study in coastal communities in Gresik, despite the plentiful availability of protein from fish, found issues of undernutrition linked to feeding practices, food quality, and food safety among toddlers.¹⁹ Studies have shown that inadequate complementary feeding practices can significantly impact a child’s growth and development.²⁰ The underlying causes of inadequate nutrition, particularly among vulnerable populations, are deeply rooted in a complex interplay of resource scarcity across human, financial, and structural domains within broader social, economic, and political contexts.²² This research seeks to examine the experiences of mothers in Oesapa Village as they care for toddlers who are undernourished. Due to the issues mentioned in the background, the researcher aims to investigate the experiences of mothers in parenting underweight toddlers in the area served by Public Health Center (PHC) Oesapa in Kupang City. It is hoped this research will inform locally grounded, dialogic, and empowering interventions that strengthen emotional, social, and cultural capacities to sustain household nutritional resilience.

Methods

Results

There were 29 informants in this study, consisting of 10 mothers with malnourished toddlers as the primary informants, 12 supporting informants, and 7 cadres as key informants. The primary informant is an individual who possesses technical knowledge and details about the research issue to be studied. The main informants in this study were mothers with malnourished toddlers aged 12-59 months in Oesapa Village. Key informants who provided information on the causes of child malnutrition based on their experience in feeding practices, hygiene practices, environmental sanitation practices, and child care. Table 1 shows that most of the key informants had a high school education, were aged 20-35 years, and were unemployed. Families had two to four biological children, and malnutrition among toddlers was most prevalent among boys who were the second to fourth child.

Supporting informants are individuals who can provide additional information to assist in the analysis and discussion of qualitative research. Supporting informants are people who have information about malnourished toddlers in Oesapa Village. Supporting informants can sometimes provide information that is not provided by the main informants or key informants. Informants supporting this study consisted of the immediate families of mothers of malnourished toddlers, Nutrition Officers, and the environmental health coordinator at the Oesapa Community Health Center. Most of the supporting informants were husbands, Mothers-in-law, and health workers, consisting of nutritionists and environmental health coordinators. The husbands had high school and junior high school education, while the health workers involved had bachelor’s degrees and diplomas. The husbands’ occupations were mostly craftsmen or entrepreneurs, as shown in Table 2. The main information from the supporting informants was about how the husbands supported their wives in overcoming their children’s nutritional deficiencies, starting from nutritional intake, personal hygiene practices, and environmental health to reduce the risk of infectious diseases.

The key informants in this study were posyandu cadres in Oesapa Village, as shown in Table 3. The main information obtained from in-depth interviews with key informants was mothers’ compliance with the health center program and child health care strategies. Most mothers had fully immunized their children, while one mother had not fully immunized her child. Compliance with posyandu activities was found to be high, with most mothers attending posyandu regularly, while some mothers did not attend posyandu regularly. Compliance with providing supplementary food to children was found to be variable, with most children not always finishing their supplementary food, while some children finished their supplementary food. Maintaining children’s health, there were various answers, including maintaining diet and hygiene, feeding regularly, maintaining playtime, using oil, giving vitamins and medicine when children suddenly fall ill, and watching over and paying attention to children when they play, eat, and snack. There was awareness of the importance of maintaining children’s health in various ways, such as maintaining diet, child hygiene, and giving vitamin supplements. Efforts to recover children when they are sick are carried out through a gradual approach, starting from home care to seeking medical help at health facilities. In terms of using medicine when children are sick, it is known that all mothers give medicine regularly. From the above quote, informant PI2 explains that in caring for a sick child, she gives medicine regularly according to the instructions or prescriptions from health workers. This shows compliance with the rules for medication use recommended by the community health center or other health facilities.

Discussion

The lived experiences of mothers raising malnourished toddlers in the difficult socioeconomic and environmental circumstances of Kupang City’s dryland areas are examined in this study in a novel way. It draws attention to parenting styles with cultural roots, restricted access to food and flexible maternal techniques that have not been extensively covered in earlier research. The results provide context-specific evidence to guide local nutrition interventions and family support programs in arid and resource-constrained settings, providing fresh perspectives on how mothers deal with food insecurity, inadequate sanitation, and restricted access to health services. This study draws attention to a cultural perspective on child nutrition that is underrepresented in the majority of public health nutrition initiatives. Emotional stress and maternal sacrifice due to gender norms and financial difficulties was a recurring theme where mothers put the nutritional needs of other family members ahead of their malnourished children. Despite being understudied in nutritional research, emotional strain and role conflict were crucial in this situation.

Feeding practices in children under five show the involvement of mothers as primary caregivers who play a central role in every aspect of feeding and childcare.^26,27 This study showed the majority of those who care for children are mothers. In the family environment, the caregiving role is generally held by the mother as the main caregiver who is responsible for meeting the basic needs of the child, including affection, stimulation and fulfillment of nutrition. This is in line with research by Rahman²⁸ which shows that the problem of malnutrition in toddlers can be influenced by the mother’s behavior or attitude in choosing inappropriate food. In the assisted family, the mother’s role is typically replaced by the grandmother.^29,30

In this study, the majority of exclusive breastfeeding history was up to six months. This is a favorable protection against malnutrition based on research by Kukeba, et.al.³¹ which showed there were 39 toddlers (72.2%) malnourished from mothers who did not breastfeed, while only 6 toddlers (27.3%) did not experience malnutrition from mothers who breastfed.^32,33 Infants not exclusively breastfed do not get the optimal nutrients contained in breast milk, so their immune system becomes weaker and more susceptible to disease. This condition affects the overall nutritional status of infants.

In facing the challenges of children who resist eating, mothers strategize by persuading.³⁴ This reflects democratic parenting where the mother persuades the child to eat.³⁵ When toddlers struggle to eat, mothers need to persuade them in various fun ways, not letting children wait until they feel like eating.³⁶ In daily life, the application of personal hygiene of toddlers is shown through the behavior of washing hands after defecation which is routinely carried out by the majority of mothers and children,³⁷ although the habit of washing hands before eating has not been fully implemented consistently for various reasons such as the urgency to satiate hunger so that this good habit is neglected.³⁸ Unclean hands and long nails can be a breeding ground for germs and bacteria, especially those that cause diarrheal diseases.³⁹ Various diseases can be easily spread through contaminated food or through hand-to-mouth contact. The habit of washing hands can reduce the risk of disease transmission, both in the digestive tract (through feces) and the respiratory tract.^40,41

Brushing teeth twice a day, in the morning and before going to bed at night, is very important to maintain oral health and prevent early tooth decay. The majority of toddlers in this study only brush their teeth once a day. Tooth decay can interfere with eating patterns, because pain when chewing food can reduce appetite and affect the nutritional adequacy of children.⁴² Early childhood caries is a significant chronic disease of childhood if children’s teeth do not get this proper preventative treatment.⁴³ If caries is not treated, tooth decay will worsen and can cause various problems, both for children and their parents. Children often complain of tooth pain and infection as a result of this condition. As a result, the child’s appetite and drinking intake may decrease, which ultimately leads to malnutrition.

Clean and healthy living behavior cannot be separated from environmental cleanliness. Environmental cleanliness is realized by mothers in various forms such as household waste management. Mothers show good behavior because the garbage is disposed of to minimize the possibility of environmental-based diseases due to poor waste management. The experience of caring for children in a state of illness shows that health complaints that are often experienced by toddlers include fever, cough, runny nose, loose stools, and red and itchy spots on the body. Toddlers are vulnerable to various diseases. Most of these diseases are basically harmless and only cause discomfort in the short term. Examples of diseases commonly experienced by children and are temporary include sore throat, smallpox, and various skin problems for which good nutrition is protective.⁴⁴

In complying with the puskesmas program, mothers complete their children’s immunizations, routinely bring toddlers to the posyandu as a form of growth monitoring and disease prevention, and deworming drugs received tend to be well consumed.⁴⁵ Even so, not all toddlers finish the supplementary food provided.^46,47 The findings in this study are in line with the findings in the study by Keats, et.al. that showed that maternal compliance in implementing the malnutrition program from the Primary healthcare (PHC) includes active participation in posyandu activities, compliance in providing supplementary feeding, immunization, and deworming.⁴⁸ The provision of PMT, deworming, and immunization is generally done through posyandu activities, so mothers who routinely bring their children to posyandu not only get access to these services, but can also periodically monitor the growth and development of their children who experience nutritional problems.

Conclusion

Mothers in dry land Kupang City, East Nusa Tenggara, face significant challenges in managing undernourished toddlers, arising from a complex interplay of environmental vulnerabilities (drought, dry land agriculture, El Niño impacts), socio-economic constraints (poverty, low agricultural productivity) and cultural practices that may inadvertently impact health outcomes without adequate medical integration. The high prevalence of stunting and malnutrition in the region is a direct consequence of these interacting factors, often compounded by issues such as low birth weight and insufficient maternal nutritional knowledge. The experiences of these mothers highlight the critical need for interventions that are culturally sensitive, context-specific, and address the fundamental drivers of malnutrition. There is a need to investigate the effectiveness of community-based nutritional education programs for mothers and other caregivers that integrate local food sources and traditional practices while addressing modern nutritional science. Further studies should examine the role of community health workers in providing targeted support and education to mothers of undernourished toddlers, considering the unique socio-cultural dynamics.

Funding

The authors received no financial support for this article.

Conflicts of interest

No potential conflict of interest