Health cadres are volunteers or healthcare workers in the village who possess knowledge and skills in delivering basic healthcare services to the community. These people have direct access to the community at the grassroots level, playing an essential role in detecting, preventing, and addressing stunting. This study aimed to explore the experience of health cadres to increase understanding of their role in the community to address stunting. This study was carried out using a qualitative method and Focus Group Discussions (FGD), which included 40 participants for data collection. The instrument used was an FGD interview, consisting of questions about stunting, the experience as cadres, and the identification of stunting problems in the village. Subsequently, the data obtained were analyzed using the narrative analysis method. The identified themes included role played as cadres and the associated challenges. The roles that were identified included assisting primary health care programs, providing health education to mothers, weighing children, making referrals when there were problems, and helping to collect data needed by primary health care. The challenges observed were community perceptions underestimating the problem of stunting, attitudes of mothers, stigma in society about stunting, and other activities of health cadres. In conclusion, this study shows that the roles of cadres are expected to be an important factor in handling stunting. Consequently, providing adequate training and supervision for health cadres is essential to improve their role in the community.

Stunting is a chronic nutritional problem widely recognized as a major global child health problem. A child is said to be stunted when the height measurement according to age is < -2 standard deviations below the median standard set by WHO for children under 5 years of age. The World Health Organization (WHO) states that stunting becomes a public health problem when the prevalence reaches ≥ 20% of the population.1 Based on the United Nations report in 2018, the global prevalence of stunting was observed to be 22.2%. In Indonesia, the prevalence decreased from 37.2%to 30.8% between 2013 and 2018, along with a significant reduction to 27.67% in 2019 according to the study on the Nutritional Status of children.2-4 Although there is a significant reduction, stunting persists as a major problem due to the higher prevalence of more than 20% set by WHO. Generally, stunting is a condition where children experience stunted physical growth due to chronic malnutrition during the first 1,000 days of life, from pregnancy to the age of 2 years. This condition has serious implications for the physical, cognitive, and social development of children, capable of reducing the productivity and quality of life in adulthood. Previous studies have shown that stunting is a risk factor for developing chronic diseases.5-7 This long-term impact shows that the focus of handling stunting is directed towards promotive and preventive strategies including multisector collaboration. Factors related to the incidence of stunting in Indonesia include individual, family, and community.8,9 Regarding individual characteristics, stunting is related to gender, birth weight, morbidity, infection rates, and diet. In the context of family and society, sociodemographic factors, health services, and family knowledge in caring for children influence the incidence of stunting.9-12 Lack of maternal knowledge and negative parenting are also associated with a higher risk of overcoming stunting.13 Other factors include limited health personnel to deliver health education, leading to low healthcare delivery, particularly in remote areas. To address this challenge, stunting management program with a community empowerment method is required.15,16

The role of health cadres is crucial, particularly in the sociocultural method to empower the community in addressing stunting. Health cadres are volunteers or healthcare workers at the village or neighborhood level, possessing knowledge and skills in delivering basic healthcare services to the community. These people have direct access to the community at the grassroots level, playing significant roles in detecting, preventing, and addressing stunting.15 The roles of health cadres in stunting management are attributed to several factors, including proximity to the community, as majority typically reside in the same region, possessing knowledge of the local needs and customs. This proximity facilitates effective engagement with the community and the provision of appropriate methods. Another factor is the effectiveness of early stunting detection through regular child weight measurement at Pos Pelayanan Terpadu (Posyandu). Health cadres can also educate the community about the importance of balanced nutrition and child care. Furthermore, there is provision of nutrition education to pregnant and breastfeeding mothers, as well as information on supplementary feeding for children. Health cadres have the potential to be pioneers in the development of healthy community by increasing the awareness of child nutrition and health, thereby contributing to stunting prevention efforts.15-19 In Indonesia, the roles of health cadres in maintaining health of children under five have a positive impact on efforts to preserve the quality of life and development. These roles include monitoring growth and development, provision of health education for pregnant and breastfeeding mothers, early detection and health referrals, as well as family health education and community health campaigns.20 However, health cadres often face challenges such as limited resources in terms of personnel, knowledge, and skills, including lack of understanding, hindering the ability to change the wrong perceptions of the community.17,21 This shows the need for adequate support to optimize the roles of health cadres in preventing stunting. Therefore, this study aimed to explore the experiences of health cadres in carrying out their roles in stunting management in the community.

This study used a qualitative method and focus group discussions (FGD) for data collection. Qualitative data were collected to explore the experience of health cadres regarding the roles and challenges of handling stunting in the community. FGD was selected to interview several participants systematically and simultaneously due to the strength of convenience, economic advantage, high face validity, and speedy results.

The selection of participants was carried out using a purposive sampling method, a non-random technique that determined specific characteristics. This study included 40 community health cadres of Pos Pelayanan Terpadu (Posyandu) from seven districts who had stunting cases. The inclusion criteria of the participants were a minimum experience of 6 months, ability to read and write, previous experience in stunting program, and willingness to participate in study activities to completion. To ensure that key participants represented the village, selections were made from all sub-districts.

The instrument used was FGD interview, consisting of questions about stunting, the experience as cadres, and the identification of stunting problems in the village. Participants were divided into four discussion groups, each consisting of 10 people. Subsequently, four facilitators who conducted the FGD were public health experts experienced in qualitative study and nurses in Primary Health care. Before the discussion, the study objectives were explained and participants provided their consent. FGD was conducted once, with each discussion lasting for an average of 60-90 minutes. All interviews and FGD were digitally recorded and transcribed verbatim while the data obtained were processed as descriptive qualitative for analysis and conclusion. The transcripts were translated from the original Indonesian language into English for publication purposes.

Ethical approval for this study was granted by the Health Research Ethics Committee Faculty of Health Sciences Universitas Brawijaya, Number 4735/UN10.F17.10/TU/2022. During the study process, the objectives were explained and participants provided written consent. Moreover, only the research team engaged in the investigation had access to the data.

All participants in this study were female (100%), with an average age of 48.1 years (middle adulthood) (97%). The majority (55%) had a high school degree in education background, while 92% were married. Furthermore, 35% of participants had experience as cadres for more than 10 years and 10% had the longest of > 20 years. The data about characteristic participants are presented in Table 1.

The data analysis found three main themes that described the experience of health cadres when dealing with stunting. The identified themes included (1) the reason to become cadres, (2) roles as cadres, and (3) challenges. These themes as described in Figure 1 represent roles and challenges when dealing with stunting in the community from the perspective of cadres.

Becoming a cadre is a personal initiative motivated by passion, filling free time, volunteering, and a desire to learn. This was mentioned by the following participants:

In addition to personal initiative, the willingness to become a cadre is influenced by the feeling of responsibility toward the environment. This phenomenon occurs because cadres feel responsible for resolving problems found in the community.

This was mentioned by the following participants:

Another reason was the obligation to serve as a cadre, often appointed by the chairman due to the lack of volunteers. This was mentioned by one participant :

“I was appointed by the chairman of the community association because there was no one else (P1.7)”

The roles of cadres include assisting primary health care programs, providing health education to mothers, weighing children making referrals when there are problems, and helping in the collection of data required by the primary health care.

This was mentioned by the following participants:

“I help with the supplementary feeding program, we invited mothers and gave additional food to their children” (P3.8)

These cadres are also tasked with providing education to pregnant and breastfeeding mothers about nutrition and the importance of breastfeeding.

The challenges faced as cadres are experiences acquired during the stunting management process. These include community perceptions underestimating the problem of stunting, attitudes of mothers, stigma in society, and other activities of cadres. The challenges faced by cadres also include the community’s perception that the problem of stunting is trivial and unserious.

This was mentioned by the following participants:

Stigma about stunting in the community results in difficulty in initiating change and increasing participation. This was mentioned by the following participants:

The attitude of mothers in caring for their children is also a challenge for cadres in solving the problem of stunting in the community. This was mentioned by the following participants:

Health cadres stated that challenges faced included their engagement with other jobs, leading to suboptimal performance sometimes. This was mentioned by the following participants:

“I have another job, which limits frequent participation in the posyandu (P4.2)”

Based on the results, there are three main themes obtained from the experience of cadres. The identified themes included the reason to become a cadre, role-play, and challenges. The reason for becoming cadres is a significant factor that facilitates the performance of required roles, as personal initiative increases self-confidence and empowerment.22 Cadres who carry out their roles voluntarily have a sense of enjoyment, which motivates and improves performance.23,24 Internal motivation, including self-actualization, achievement, and responsibility, play a significant role in enhancing self-motivation and facilitating good performance.24 Additionally, knowledge and active participation in each stage of community increase self-empowerment.15

Efforts to increase the knowledge, skills, and motivation of cadres are the main strategy for capacity optimization. The inclusion of cadres in every stage of implementing community empowerment, increasing knowledge, and external support in the form of financial incentives are efforts to increase cadre motivation.25,26 Furthermore, increasing the number of cadres and program funding is essential to strengthen stunting program effectiveness.27,28

The roles of health cadres included evaluation of children’s weight, providing health education to mothers, preventive programs such as offering additional feet, making referrals when there are problems, and administrative tasks by collecting data required for primary health care. Other roles that were identified included the provision of information and education along with monitoring, early detection, and appropriate interventions.20 Health cadres also play a significant role in helping the community understand the importance of good nutrition, monitoring children’s growth, and providing support in efforts to prevent and treat stunting. Through these efforts, health cadres contribute to reducing stunting rates and improving the health of children in Indonesia. Support from the government and community is essential to increase the knowledge and skills of health cadres to optimize their roles.29-32

The challenges faced by health cadres include the perception of the community that the problem of stunting is trivial and unserious. Despite being a significant concern in Indonesia, there is still a public perception that underestimates stunting due to negative stigma and low knowledge.33,34 To overcome this challenge, health cadres can facilitate the understanding and provision of information regarding the perceptions of the surrounding community. This information will be useful in identifying the right strategy, providing required efforts to increase awareness, and understanding of stunting. Based on community empowerment, stunting management requires active and responsive participation, as wrong perceptions and low knowledge can become obstacles to achieving optimal outcomes.

Stunting is still observed negatively by the community, leading to a stigma associated with underprivileged families or as “bad luck.” This stigma can make people reluctant to seek help or talk openly about stunting, thereby hindering preventive and management efforts. In this study, some people were found to still reject the term stunting for their children, leading to suboptimal management and prevalence of new cases. Furthermore, the lack of family understanding regarding the effect of stunting, including long-term impacts on health, education, and productivity in adulthood, can lead to errors in feeding children and prevent early detection of growth problems.

Efforts that can be made to increase public understanding about stunting include educational campaigns such as outreach at the community level, providing information through mass media, and using educational materials to aid understanding. Health education can be carried out by health cadres to provide information and assist in the early detection of growth problems directly in community forums. Meanwhile, the negative stigma towards stunting can be overcome through a culturally sensitive method. The inclusion of the community in discussions and problem-solving also serves as a potential solution to reduce stigma and build collective support for stunting prevention. By increasing awareness about the serious impact of stunting and reducing the negative stigma, the community can mobilize stronger collective efforts to prevent and treat stunting.

In conclusion, this study showed the significant roles of health cadres in overcoming stunting among children in Indonesia. According to the sociocultural method, the roles that were identified included the implementation of preventive measures, provision of education, and enhancing community awareness about the importance of proper nutrition. Although several challenges were found, specifically regarding negative perception and stigma about stunting, the roles of health cadres in overcoming stunting were found very valuable. With adequate support, continuous training, as well as collaboration with community and religious leaders to increase understanding of stunting through cultural methods, health cadres could possess the potential to reduce stunting rates in Indonesia and improve the future quality of life for children.