EMPOWERING MOTHER OF TODDLER TO OVERCOME STUNTING IN AN INTEGRATIVE WAY IN DAIRI COUNTY

: Stunting is one of the targets Sustainable Development Goals (SDGs) which are included in the 2nd sustainable development goal, namely eliminating hunger and all forms of malnutrition by 2030 and achieving food security. The target set is to reduce the number stunting up to 14% in 2024. Stunting caused by multi-dimensional factors and not only caused by PEM factors experienced by pregnant women or poor nutrition experienced by children under five. There is still a lack of household/family access to nutritious food, lack of access to clean water and sanitation. The aim of this research in the second year is to overcome the problem of stunting by empowering interventions for mothers of toddlers to improve water quality, knowledge and attitudes about PHBS and nutritional intake as well as the correct way of processing MPASI, so that they are able to provide food that meets the nutritional needs of toddlers stunting by using local local food. In this research, data analysis was carried out using the dependent t statistical test. The results of the interventions carried out provide an illustration of improving water quality, increasing mothers knowledge and attitudes about PHBS and balanced nutrition for toddlers, even joint cooking activities also improve mothers skills to be able to prepare nutritious, cheap and delicious food.


INTRODUCTION
nutritional quality of the past due to deficiencies in nutritional intake needed during the linear growth period, especially such as protein, zinc and calcium.Apart from that, it is also caused by environmental factors, one of which is poor sanitation, which causes diseases related to digestion, causing the process of absorption of nutrients, especially micronutrients, to be inadequate (Unicef, 2018).
Clean water and sanitation are essential factors in preventing stunting.The relationship between consumption of dirty water and stunting lies in the large number of microorganisms (such as pathogens and E-Coli bacteria in dirty water which, if consumed, can disrupt systems in the human body (Agustina, 2006).Some of the diseases that lurk in dirty water are diarrhea and worms.Children Those who have difficulty getting access to clean water can experience diarrhea repeatedly.In fact, during diarrhea, there is a lot of fluid and micronutrients (important nutrients) that are wasted from the child's body.Zinc is one of them.When the body is deficient in Zinc, the function of the intestines is disrupted during diarrhea.cannot be regenerated again, zinc deficiency in childhood can causestunting.
The results of the first year's research in Dairi Regency identified the causal factorsstunting isdue to poor sanitation where clean water contains E-Coli (43%), the highest is found in the villages of Sumbul, Tanjung Beringin and Batang Beruh and Silalahi; poor clean and healthy living behavior as much as 67.4%;Apart from that, it is also due to the lack of nutritional intake in toddlers including protein (46.5%), calcium (95.3%) and zinc (59.3%).
Efforts to overcome stunting must be carried out in accordance with the factors that cause this situation, namely based on the results of problem mapping.Water control can be done by utilizing technology using ceramic membranes, because ceramic technology is a technology that is currently being developed.Meanwhile, improving Clean and Healthy Living Behavior (PHBS) and balanced nutritional intake of toddlers can be done by empowering toddler mothers.The issue of increasing mothers' knowledge, attitudes and abilities to be able to provide food that meets the needs of toddlers as a step to reduce stunting rates requires integrative handling.In general, integration is a process of uniting two or more elements which results in the creation of a desire that works well and correctly.Efforts to reduce stunting will be more effective if specific and sensitive nutritional interventions are carried out in an integrated manner.In the second year the research carried out was to overcome the problems in the first year research, so that the problem formulation was whether there was an effect of maternal empowerment on improving water quality, mothers' knowledge and attitudes about nutrition and PHBS.

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RESEARCH METHODS
The type of research carried out is field research (field experiment), which is carried out by experimenting within a certain time limit on several indicators.This research was conducted in 4 villages that have high stunting rates and e coli content in drinking water, namely Sumbul, Tanjung Beringin, Batang Beruh and Silalahi villages in Dairi Regency.

A. Overview of Research Locations
Dairi Regency is one of 33 districts/cities in North Sumatra Province with an area of 192,780 hectares, which is around 2.69% of the area of North Sumatra province (7,160,000 hectares) which is located in the northwest of North Sumatra Province.In general, Dairi Regency is at an average altitude of 700 s.d.1,250 m above sea level, with 15 sub-districts.Total population of Dairi district at the end of the year 2021 is as many as 318,616 souls.
Dairi Regency has regional boundaries, where to the north it borders Karo Regency; to the east it borders Samosir Regency and Lake Toba; to the south it borders Pakpak Bharat Regency; and to the west it borders Southeast Aceh Regency.Dairi Regency has very potential natural wealth which can be utilized as a means to support the community's economy.Both from the tourism sector and the agricultural sector.In the agricultural sector, Dairi has long been famous among the public because it has quite potential natural resources.Besides that, it has great potential in the agricultural sector.Various kinds of plants will thrive, such as coffee which is well known to the wider community, corn, oranges, rice, vegetables, tubers and various types of onions.The potential and natural wealth that is owned means that the Dairi people generally earn an income from agriculture.

B. Overview of Intervention Activities Empowering Mothers of Toddlers
The implementation of this second year's research activities includes activities to address the stunting problem in an integrative manner, namely tackling the environmental and nutritional aspects simultaneously.

C. Mitigation from an Environmental Health perspective
This activity is focused on improving water quality by creating a tool that has the ability to filter, therefore technology is used that can overcome this, namely a water filtration method accompanied by a system.backwash.This tool has been tested in the community, the tool is as shown in Figure 1.several more will be handed over when evaluation activities are carried out.This tool has been registered for creation rights with DJKI.

D. Implementation of FGD
Before going to the community, nutrition officers, sanitarians and a team from the Dairi District Health Service were invited to jointly provide input and suggestions regarding the research results in 2022 and the mitigation efforts that will be carried out.The input and suggestions submitted by participants are an addition to improving community empowerment activities.This activity was guided by the researcher and chairman of the North Sumatra Persagi DPD who has been heavily involved in BKKBN for stunting prevention activities.Documentation of this activity can be seen in Figure 4. from providing counseling and education, is the MPASI recipes that already existbooklet practiced directly by toddler mothers, the researcher became a guide to the processing stages or steps carried out while still providing emphasis, for example why vegetables and salt are added to the dish later after the dish is cooked, as well as the use of animal and vegetable protein sources.to meet children's nutritional needs.This activity was very well received by the community with many questions being asked and after the food had been cooked, it was given directly to the toddlers present to see the response from the children, and all the toddlers present liked the MPASI that was served.Documentation of these activities can be seen in Figure 6:

G. Respondent Characteristics
The characteristics of the respondents in this case are mothers of toddlers including age, education and occupation, can be seen in table 1.

Table 1 Distribution of Mothers of Toddlers Based on Characteristics
Characteristics n % Age : - Based on table 1, it can be seen that the highest distribution of mothers' ages is 31-35 years old at 32.0%, followed by 26-30 years old at 30.3% and 36-40 years old at 19.7%.
If we look at the level of maternal education, it is known that the majority of mothers have a SMA/SMK education, 80.3%, followed by a junior high school education, 10.5%.This shows that the mother's education level is still in the secondary education category, this will affect the type of work and the mother's ability to receive the education provided.
The majority of mothers' jobs are as farmers, namely 46.1%, followed by housewives at 36.8%.Many mothers' jobs in these two categories are probably due to their educational attainment being only secondary so that job vacancies are limited.

H. Child Characteristics
The characteristics of children in this case are toddlers including age and TB/U nutritional status as seen in table 2. 19.7%.Meanwhile, according to the nutritional status according to the TB/U Zscore, it was found that 5.3% were very short, 60.5% were short and 34.2% were normal.

I. Decreased E-Coli and Total Suspended Solid (TSS) content
Based on initial laboratory analysis of water, especially E.coli and TSS, it is known that the concentrations of these two parameters are very fluctuating.Initial test results can be seen in Table 3:

Table 3 Measurement of e.coli and TSS parameters in three areas of Dairi Regency before filtration
From the results of the laboratory analysis above, it can be seen that the concentration of e. coli and TSS (total suspended solid) are high and exceed water quality standards according to Government Regulation of the Republic of Indonesia No. 82 of 2001 concerning Water Quality Management and control of Water pollution and PERMENKES no. 2 of 2023 concerning environmental health, namely in Chapter II article 5, the quality of drinking water does not contain microbiological, physical, chemical and radioactive elements that can endanger health.
Some water sources that can be used as raw material for drinking water and sanitation hygiene are well water, springs and river water.However, it is often found that well water or other water sources are cloudy, dirty, and smelly.As long as the quantity is still large, we can still try to purify the cloudy/dirty water into clean water that is suitable for use.One method of water purification that is often used by the community is the filtration method.
Filtration is the separation of solid particles from a fluid by passing them through a filtering medium, therefore water filtration is a condition where water penetrates a porous medium to remove suspended substances, so that it can be used by the public for sanitation hygiene purposes or as a source of drinking water.In general, the media used for water filtration are silica sand, palm fiber, activated charcoal, stones, and others.

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Asian Journal of Engineering, Social and Health Volume 2, No. 9 September 2023 The filtering method is an option that is often used, apart from not requiring high costs, making filter equipment can use materials that are easily found as a filtering medium.However, the filtration method has shortcomings, namely the media material used has a saturation point which can cause the filtration to not be optimal, so people have to regularly wash or replace the media used, therefore technology is needed that can overcome this, namely a water filtration method accompanied by systembackwash.
The examination was carried out to determine the content of e.coli and TSS contained in water originating from groundwater.The results of laboratory analysis for e.coli and TSS concentrations are expected to meet the established clean water quality standards.As stated in government regulation no.82 of 2001, the maximum limit for e.coli parameters is 1898 MPN/lOOml and TSS is 50 mg/1.Based on laboratory analysis after filtration of the water in these three areas, the quantity values of e.coli and TSS can be seen in Table 4.

Table 4 Measurement of e.coli and TSS parameters in three areas of Dairi Regency after being given filtration
The decrease in bacteria that occurs during filtration is caused by E. Coli bacteria having a pore size that is larger than the pore size of the filtration.So the process of filtering (filtration) and absorption (adsorption), where the e.coli bacteria are filtered and absorbed by activated charcoal with strong pressure causes the e.coli to stick to the filtration walls, so that the water that comes out is cleaner.This happens because e.coli which is 0.5 -1 micron in size can be filtered out by filtration.The filtration process functions to filter and capture solid materials, dissolved materials.The decrease in the number of bacteria is also caused by the source of nutrients in the water.At some point, bacterial growth will stop because the nutritional support in the environment is no longer adequate, resulting in a decline in cell numbers due to many cells no longer receiving nutrition.Until finally at the extreme point it causes total bacterial death.
Total solids (residue) are the materials remaining after the sample water has evaporated and dried at a certain temperature.Residue is considered to be the total content of dissolved and suspended materials in water.During the determination of this residue, most of the bicarbonate which is the main anion in waters has undergone transformation into carbon dioxide, so that the carbon dioxide and other gases that disappear are not included in the total solids value.TSS consists of mud and fine sand as well as microorganisms, which are mainly caused by soil erosion or soil erosion carried into water bodies.Total Suspended Solid (TSS) can float in water and will block sunlight from entering the water layer.Even though sunlight is really needed by microorganisms to carry out photosynthesis.Due to the absence of sunlight, the photosynthesis process cannot take place and as a result the life of microorganisms is disrupted.
A decrease in TSS concentration at the outlet can occur because it has the ability to filter (filtration) and absorb (adsorption) suspended solids (TSS) contained in raw water.And the function of activated charcoal is to purify water.

J. Mother's Knowledge and Attitudes about PHBS
In this research, knowledge is an important component in behavior change.Knowledge is measured using a questionnaire related to Clean and Healthy Living Behavior (PHBS).WhereasAttitude is a view or feeling accompanied by a tendency to act towards a particular object which may or may not be expected.Attitudes are often intentionally directed towards something meaning there is no attitude without an object.The average value of knowledge and attitudes of toddler mothers regarding PHBS can be seen in table 5. From table 5 it can be seen that after the empowerment intervention was carried out on mothers, knowledge increased from an average value of 7.14 to 10.0, but the increase has not yet reached the maximum number, namely 15.This indicates that mothers do not yet fully understand about PHBS is mainly about smoking and physical activity.The results of statistical tests concluded that there was a significant difference between knowledge about PHBS before and after the intervention (p<0.0001),mothers of toddlers experienced an increase in the average knowledge score of 2.86.
Meanwhile, it can be seen that the average value of maternal attitudes before the intervention was 32.06, after the intervention it increased to 39.29, with an increase of 7.23.If we look at the average value after the intervention, it has not yet reached the highest value, namely 45.The results of the analysis of respondents' answers, most respondents answered incorrectly on question number 3 regarding consumption of fruit and vegetables which must be done every day, respondents said they do not consume fruit every day, especially fruit.because it is related to availability because the market (weekend) is held once a week.Likewise with question number 8 regarding the differences in the benefits of formula milk and canned milk, which respondents considered to be the same as breast milk.The results of statistical tests concluded that there was a significant difference between attitudes about PHBS before and after the intervention (p<0.0001),mothers of toddlers experienced an increase in the average knowledge score of 7.23.The distribution of changes in mothers' knowledge and attitudes about PHBS after being categorized can be seen in table 6.In table 6 it can be seen that before the intervention was carried out, 100% of mothers had knowledge about PHBS in the poor category.After the intervention was carried out in the form of education, discussing the contents of the booklets that were distributed, the mother's knowledge changed to the good category of 25%, sufficient as much as 2, 6% and less by 72.4%.Likewise, these results show that there is still a lot of knowledge among mothers in the poor category.After interviews, several mothers answered that smoking was something their husbands couldn't avoid, so they felt they were used to it and were safe.Regarding physical activity, almost all mothers answered that they do physical activity every day, but they don't know how much time it takes to do physical activity every day.
Clean and Healthy Living Behavior (PHBS) is behavior that is practiced based on the awareness of each individual to prevent health problems such as stunting.Increasing maternal knowledge will encourage mothers to have a positive attitude in dealing with health problems in their family.With good knowledge and a good attitude, it is hoped that individual awareness will increase.There are 10 indicators related to PHBS, all of which, if implemented, will prevent stunting in toddlers.According to research conducted by Apriani (Apriani, 2018) regarding PHBS Household Orders with 10 indicators, there is a significant relationship between clean and healthy living behavior (PHBS) and the incidence of stunting.Toddlers who grow up in a household environment with a poor PHBS category are 0.575 times more likely to experience stunting compared to toddlers who grow up Page 974 Asian Journal of Engineering, Social and Health Volume 2, No. 9 September 2023 in a household environment with a good PHBS category.Likewise, according to Zubaidi (Zubaidi, 2021), there is a relationship between parental smoking behavior and the incidence of stunting in children.This is related to hampered nutritional absorption in children and the priority of the cost of shopping for cigarettes compared to the cost of shopping for nutritious food needed for children's growth and development.the risk of intrauterine failure to thrive (IUGR), which is one of the factors causing stunting.
According to (Nurbaiti et al., 2023), her research shows that there is a relationship between mother's knowledge and her attitude towards preventing stunting.Other research also shows that maternal attitudes are related to efforts to prevent stunting, but there is no relationship between maternal knowledge and efforts to prevent stunting.This research discusses that in preventing stunting, the mother's attitude, including giving food to children, is important because with a good attitude and supported by high knowledge, positive behavior will be reflected.The efforts that have been carried out by the government to improve the behavior of its people in preventing stunting are compiled in a national strategy which consists of 5 pillars to accelerate stunting prevention, specifically pillar 2 which states national campaigns and behavior change communication (Kemenkes, 2018).The strategy to achieve this pillar is to improve interpersonal communication through developing messages tailored to the needs of the target group, namely 1,000 HPK Households, WUS, and young women.Various communication channels such as posyandu, parenting classes, classes for pregnant women, and adolescent reproductive counseling have been used to convey this message (Kemenkes, 2019).
All the indicators in PHBS really support the prevention of stunting in children, so mothers' knowledge and attitudes really need to be improved and become permanent behavior, therefore empowerment of mothers really needs to be supported because mothers are always individuals who are weak in making decisions.Some mothers with environmental situations and conditions that are less supportive, or things that have become a habit in society always put them in a low bargaining position.As in this research, smoking is a normal thing for husbands to do outside or inside the house, for this reason husbands also need to improve their knowledge and attitudes so that mothers receive support and are able to implement PHBS well.

K. Mothers' Knowledge and Attitudes regarding Balanced Nutrition in Toddlers
Mothers' knowledge about balanced nutrition was measured using a questionnaire related to giving food to toddlers and several examples of MPASI foods for toddlers with the composition and Page 975 Asian Journal of Engineering, Social and Health Volume 2, No. 9 September 2023 nutritional value included and practiced directly by cooking together at their respective locations.The average value of mothers' knowledge about balanced nutrition can be seen in table 7.In table 7 it can be seen that mothers' knowledge about balanced nutrition, especially nutritional needs and food processing processes for stunted children before the intervention was carried out, was an average value of 7.10 and after the intervention it increased to 11.26 with a difference in increase of 4.16.The most common wrong answers (almost 50% of mothers of toddlers answered incorrectly) before intervention were in question number 3 about energy sources for the body, number 8 about solvent nutrients vitamins A, D, E, K, number 14 about the vitamin content in vegetables will disappear if boiled too long and number 15 is about the high nutritional content of vegetables and fruit.After carrying out cooking activities with MPASI, and demonstrating when vegetables are included in cooking, the mothers understood it better.The results of statistical tests concluded that there was a significant difference between mothers' knowledge about balanced nutrition before and after the intervention (p<0.0001),mothers of toddlers experienced an increase in the average knowledge value of 4.16.vegetables as well as adding salt which is recommended last.This processing practice was carried out directly by the mothers, guided by the researchers through the stages.
In table 8 it can be seen that before the intervention, the majority of mothers' attitudes were in the poor category (97.4%) and only a small portion were in the sufficient category (5.3%).After the intervention was carried out, there was an increase in the good (17.1%),sufficient (21.1%) and poor categories by 61.8%.This still doesn't provide a good picture, therefore health workers still need to work hard, in this case nutrition implementers (TPG) in the field, to continue to provide motivation and food processing practices, because when we do the practice of cooking together, we make MPASI.simple, participants said that they had never been taught how to cook food for toddlers, and from the simple MPASI menu using local food ingredients it turned out that the toddlers who participated were quite eager to consume the food.
Stunting really needs to be prevented as early as possible, because if this stunting condition continues and becomes more widespread among Indonesian children, it is feared that it will have a wider long-term impact on cognitive, educational and cultural abilities, abilities and endurance as well as physical skills and endurance.various chronic diseases, thus it can be predicted that stunted children will increasingly burden the country in terms of education, human resources and health.Therefore, education on balanced nutrition is an important part of preventing stunting.
Education is part of health education activities.Health education is defined as a learning process carried out for individuals, families, groups and communities with the aim of changing unhealthy behavior to healthier patterns.The health education process involves several components, including using teaching and learning strategies, maintaining decisions to make changes in action/behavior, and health education also focuses on changing behavior to improve their health status.
Knowledge about nutrition is an initial process that determines behavioral change regarding the improvement of nutritional status, so that knowledge is an internal factor that influences behavioral change.The mother's knowledge about nutrition will determine the mother's behavior in preparing food for the family.Mothers with good nutritional knowledge can provide the right type and amount of food to support their child's growth and development.Mother's knowledge about nutrition is one of the factors causing stunting in children (Nurfatimah et al., 2021).
This research is in line with Ginanjar's research (Ginanjar, 2022) where the researcher has the assumption that after health education using the lecture method greatly influences the mother's knowledge about stunting, while in this study the methods used are lectures, discussions and Page 978 Asian Journal of Engineering, Social and Health Volume 2, No. 9 September 2023 direct practice and the tools used are booklets that have been made in such a way with an easy and simple recipe.Knowledge is a mediator of behavior change.Although it is not absolute that good knowledge will give birth to good behavior.However, knowledge is the starting point for a change in behavior for the better.This shows that nutrition education activities over a longer period of time, repeated discussion and practice activities will provide better knowledge value compared to short meetings.This can happen because there is closeness that is built between the facilitator and participants so that the discussion atmosphere is fluid and the material can be absorbed more optimally.
The role of parents, especially mothers, is very important in fulfilling children's nutrition because children need parental attention and support in facing very rapid growth and development.To get good nutrition, parents need good nutritional knowledge in order to provide a balanced menu of choices so that stunting does not occur.A person's level of nutritional knowledge influences attitudes towards preventing stunting.
Likewise, this intervention activity will greatly influence mothers' attitudes about stunting, as it is known that increasing knowledge will give positive results to mothers' attitudes, so it will be effective in changing mothers' behavior and it will be easier for mothers to understand and practice what is received in educational activities in prevention stunting.

CONCLUSION
In this research it can be concluded that there is an influence of the use of ceramic membranes on the content of E Coli and Total Suspended Solid (TSS).There is an influence of Health Education (PHBS) on increasing the knowledge and attitudes of mothers of toddlers.There is an influence of nutrition education on the knowledge, attitudes and skills of mothers of toddlers regarding balanced nutrition in children stunting BIBLIOGRAPHY Agustina, R. A. (2006) (SDGs) which is included in the second sustainable development goal, namely eliminating hunger and all forms of malnutrition by 2030 and achieving food security.Condition stunting describes the Page 962 Asian Journal of Engineering, Social and Health Volume 2, No. 9 September 2023

Figure 2 .Figure 3 .
Figure 2. FGD activities in the District Health Service Hall.Dairy

Table 2 Distribution of Children Based on Characteristics
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