The Social Support of Extended Family as the protective factor of Stunting among Migrant Labour Families in Magetan, East Java

. Indonesian government targeted the stunting prevalence less than 14% by 2024. There are complex social determinants of stunting, including socio-economic background of the family, culture, parenting as well as health literacy. Migrant labour family as the vulnerable population was facing with those social determinants of stunting. This qualitative study was aimed to explore the social determinant of stunting among migrant labour family in Magetan District, East Java Province, Indonesia. A total of 15 informants who selected purposively were participated in this study. Data was collected through in-depth interviews and unstructured observations. Data analysis performed by applied Open Code 4.03 Software. Moreover, triangulation, member checking, and peer debriefing were the strategies of trustworthiness. The migrant labours in Magetan were young families with low and medium educational background. They were exposed to the parenting problems such as toddlers’ eating behaviours, lack of nutrition intake, family and social bonding, as well as growth monitoring system. Meanwhile, the family social support helped them a lot to dial with these problems. This study suggests the important to improve and empower family’s capacity in parenting issues.


Background
Indonesia has the highest stunting prevalence among southeast Asia countries.Stunting remains the public health issues in Indonesia.Indonesia's Nutrition Status Survey shows that the Indonesian stunting prevalence in 2022 is 21.6% [1,2].Moreover, the Indonesian Government has targeted to reduce the stunting prevalence in to 14% in 2024 [3].Stunting prevention and control become the national priority program and invite various stakeholders to participate in the program.
Studies showed that there were complex social determinants of stunting including child characteristics, inadequate water and supply, parental smoking, family characteristics (i.e.parent education level, parent economic background, parent occupation), parenting, food insecurity, and low caregiver education [2][3][4][5].Low level of parent education and income contributes to the stunting incidence [6].Moreover, Win et al. [7] explained that children of working mothers had 4.5 times increased odds of stunting.
Migrant labours families were vulnerable population.Study found that children of migrant labours families had low immunization, undernutrition and other health problems [8].Magetan District, East Java Province had high number of migrant labour in East Java and also had high prevalence of stunting (17.2%).Furthermore, the local government had launched Desmigratif (Desa Migrant Produktif -The productive migrant village) by developing community parenting among migrant labour families [9].This study was aimed to explore the social determinant of stunting among migrant labour families in Magetan District, East Java, Indonesia.

Method
This qualitative study carried out from April to June 2023 using case study approach [10,11].This study was focus on the social determinants of stunting among migrant labour family with children under five years old who experience stunting in Magetan District, East Java Province Indonesia.
A number of 15 people were recruited purposively as informants.They were significant person of the children under five years old who experiencing stunting from the migrant labour families (father, mother, caregivers or relatives), village midwives, Posyandu (health integrated post) cadres, nutritionist of the primary health care, member of the community development board, as well as local leaders.Data were collected through in-depth interviews by using pre tested interview guidelines.Besides, unstructured observation had been done for completing this study.In-BIO Web of Conferences 75, 05020 (2023) https://doi.org/10.1051/bioconf/20237505020BioMIC 2023 depth interviews had performed in person with each informant and the interviews duration was about 50 minutes for each informant.Moreover, the unstructured observations had been conducted to observe the informants' activities as the triangulation strategy.
The first in-depth interview went to the significant person of toddler with stunting to explore the health problems related stunting, the social determinants of stunting including parenting practice, and to explore the way of coping mechanism among them.We met the family who one of the family members became migrant labour in Asia countries.Those in-depth interviews carried out in their house.Afterward, we conducted the in-depth interviews with Posyandu cadres, village midwives, the nutritionist of the primary health care, local leaders, and the member of the community development board.Unstructured observation conducted in the Posyandu and the informant house to observe the parenting practice of the toddler families with stunting and the environment of migrant labour family to support the in-depth interviews results.
Data was analysed qualitatively by applied thematic analysis and used the Open Code 4.03 Software.Furthermore, member checking, triangulation and peer debriefing applied for trustworthiness.This study was reviewed and approved by the

Informant characteristics
There were two groups of informants.First group was the significant person of the toddlers with stunting.Secondly, related stakeholders of the stunting prevention and the migrant workers in Magetan.Table 1 described the first group informants' characteristics.  1 showed that informants came from the low socio-economic status, and they were spent many years as the migrant labours.There was a different type of work between men and women.Women tended to be household worker.As opposite, men tended to be factory worker or shopkeeper.Besides, this study showed that the father who lived with their toddlers with stunting played a doble task as informal workers such as being carpenters or farmers) and also taken care of their toddler.Meanwhile, women who lived with their toddlers with stunting more focus on caring for their children (as a housewife), and only one woman that actively in online store.
Taiwan was the most favourites destination country for migrant labour from Magetan.As young families, they had 1 -3 children.Unfortunately, this study showed that one or two toddlers was diagnosed as toddler with stunting.The stunting toddlers were boys and girls.
The second group of informants were stakeholders, who had medium and high socioeconomic background.There were frequently interacts with the toddlers with stunting and their families.Their ages were from 32 to 42 years old.

Health problems related to stunting
Toddlers with stunting among migrant labour were faced with complex problems related health.The problems came through all phases and all levels of influence (individual, family, and community or social system), as Figure 1. Figure 1 showed that the migrant labour family had low level of health literacy, lack of parenting skills and had poor bonding especially between parent and their children.Interestingly, there were difference pattern between family with women migrant labours and family with men migrant labours.Fortunately, families with men as migrant labour had a better family bonding compare to the families with women migrant labour.
The excessive screen time lead the other problems such as eating disorder, sleep disorder, social interaction disorder as well as emotional disorder.Furthermore, the migrant family also lack of parenting skills and had low level of health literacy.Some of their fathers also smoker.In addition, there were exposed to the stigma related to stunting.They were ashamed if their children diagnosed as toddler with stunting.
"…my child suffered from diarrhea for up to 20 days.People said it was okay.That was part of the growth phase and these would made my child more agile in walking (ngentheng-enthengi) (T, 40 years old, woman, her husband was a migrant labour in Malaysia) "…(they) had threatened not to come to the posyandu, when we told them that their child was suffering stunting…" (L, 38 years old, Posyandu Cadre) These was a big dilemma.In the one hand, if the Posyandu cadre did not convey the truth about the stunting status, so their family would not immediately conduct the prompt treatment.On the other hand, if Posyandu cadre tell it, they would no longer come in to Posyandu and the childrens' growth could not be monitored.

Parenting practices among migrant labour
This study showed that the parenting practices of migrant labour families was the results of various social factors interaction.The social factors include the desire to be a happy family in the one hand, and the limited abilities on the other hand.A happy family was described as a family that was able to meet the needs of its family members, and money was considered the most potential resource to meet the various needs of the family members.Economic issues was the main reason of people to become a migrant labour.They were facing with a lot of problems related to economic so they were decided to become migrant labour.
"…e…we had a lot of responsibilities related to the economic burden… and….It was seem like there was no other option (we could take..).It was not easy to earn money here…" (J, 40 years old, man, his wife is migrant labour in Taiwan) "…poor family… they were categorized as the poor family.They were also received the cash transfer program from the government..but… it did not their economic problems, so they become migrant labour…" (F, 42 years old, Community leader) They became the migrant labours as the best solution on the economic problems, since they observed, their neighbour has managed to earn a lot of money in the short time by becoming migrant labour.Furthermore, the migrant labour tried hard to "buy their family happiness" by sending a lot of money and fulfilled many kinds of family needs.They allow their children to have many toys and smartphone, as Figure 2. '…She asks for a toy... when she asks for a toy she calls her mother... unfortunately, if she does not ask then she does not want to be called... so... when she has a desire then she call her mother ... but she doesn't have a desire he doesn't want to be called (T, 38 years old, man, his wife is migrant worker in Taiwan) In fact, the migrant worker had a heavy burden.They spend a lot of time to get money.Long working hours and or very limited opportunities to go home and meet with their family were the example of migrant worker sacrifices, as quotes below.It was their way to buy the family happiness.
"…(my wife as migrant labour) work start from 05.00 am until 11.00 pm or even 12.00 pm.." (J, 40 years old, man, his wife was a migrant labour at Taiwan) "…(my husband) work at wood factory, and he has not back home yet since the first year.Now was year fourth, and our children have not meet her father yet in person… " (D, 34 years old, toddler mother, her husband work as migrant labour at Malaysia) The limited abilities of the family member were the other problem of the toddler with stunting family.Low levels of health literacy and the lack or parenting skills lead them make unhealthy decision such as giving smartphone to their toddler as a playmate.As a result, their toddlers spend their days and nights on smartphones.They did not aware on the risk of the excessive screen time among children.Their parents were happy with it because their toddler looked calm and happy.Unfortunately, other problems arise such as sleep disorders, eating disorders, and lack of social interaction.
"… it was very difficult to get my child to sleep.Until very late at night, he played his smart phone.Usually, he sleeps at 12.00 pm or 01.00 am.He does not sleep all the day.." (D, 34 year old, woman, his husband was a migrant labour at Malaysia) "…it was only 3 spoons in two days.. it was quite difficult.. (to make their children eat properly), ..yet.. sometimes she only eat snack.. (J, 40 years old.Man.his wife is migrant labour in Taiwan) ".. no..never…he does not like to eat egg or chicken.. for chicken, he only eat the souce.." (D, 34 year old, woman, his husband was a migrant labour at Malaysia) According to the data analysis, stunting among migrant labour families was a complex public health issue.This study showed that there were complex problems related to the social determinants on stunting in toddlers from the migrant labour family.Achieving the family happiness was the greatest desire of the family.Each family member, especially parent definitively would like to achieve it.Being migrant labour was the alternative solution of the vulnerable population (people who came from the low socio-economic background and did not have enough resources to fulfil their basic needs).Afterward, they would "buy the family happiness" with their money.Unfortunately, the low level of health literacy and the lack of parenting skills lead them take unhealthy decision such as giving their toddler smartphones that caused various health problems arose.
Parent of toddlers with stunting in this study had low and medium education background who live in rural area.Mother with low education and living in rural area were risk factors of stunting [4][5][6]12].They were also had low level of health literacy include eating behavior for children under five years old.A comprehensive intervention should be done to improve nutritional status during pregnancy, exclusive breastfeeding phase, complementary feeding and improving healthy eating behavior among children under five years old [12][13][14].The impact of the poor nutritional status during pregnancy and the first five years of life is not limited to the children growth phase, but also potentially improve adult morbidity and mortality [2,13].
The intervention should engage community and other stakeholders and develop public policies that enable social action.The role of the government as the regulator is needed [15].The migrant labour community was the vulnerable group whereas potentially experience to health inequality and inequity.This study showed that the policy intervention for the vulnerable population should be not limited to the economic sector, but also covered public health issues such as healthy behavior and parenting.Parenting and family issues lead to the wellbeing achievement of the community [16][17].The implementation of Desmigratif which has been developing community parenting among migrant labour families must strengthen family function as a whole.Family social capital helps people to have healthy behavior [18].Family is the important actor in public health [19].
This study indicates that family happiness was the highest desire of family, and all family members were encouraged to make it happen.They were decided to become migrant worker to increase their economic capacity in order to able fulfil the family member needs.Unfortunately, the increasing economic capacity which was imbalance with the implementation of the comprehensive family function became new threat of the family happiness.Family dimension such as family cohesion and communication were crucial for the family happiness [16][17][18][19].Moreover, the excessive screen time of children under five years old among migrant labour family was disrupt the family cohesion and communication.The awareness of the parenting skills among vulnerable group was challenging for further study.
This paper helps public health experts when developing public health intervention on stunting issue, especially for the vulnerable group.Unfortunately, this study did not explore yet the Desmigratif program from the program developer perspective.This is the weakness of this study, despite the interesting findings.

Conclusion
This study indicates that "buy family happiness" was the highest desire of the migrant labour family, and it was causing the complex problems related to stunting.Thus, public health intervention for stunting must be covered the comprehensive healthy behaviours, parenting skills and also empowered the family function.
We acknowledge the local government and the health officer of Magetan District for their hand in this study.
Medical and Health Research Ethic Committee of the Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada (REF No.: KE-FK-0523-EC-2023).

Fig. 2 .
Fig. 2. Buy family happiness The migrant worker had a communication barrier with their children.Eventhough they bought a smartphones for their children but still there was a communication barrier.