Engaging stakeholders to strengthen the local actions for stunting prevention and control in Lombok Barat

ABSTRACT


INTRODUCTION
Stunting is a global public health problem, and most cases occur in low-and middleincome countries, including Indonesia. 1 Over the last decade, the child stunting prevalence in Indonesia has remained high (37%) with large disparities (26% -52%) among provinces. 2 According to the Indonesian Nutrition Status Survey in 2021, the stunting prevalence in Indonesia was 24.4%. The prevalence surpasses the World Health Organization (WHO) threshold of 20%. The three provinces with the highest prevalence of stunting are Nusa Tenggara Timur (43.89%), Sulawesi Barat (40.38%), and Nusa Tenggara Barat (37.85%). 3 There are complex social determinants of stunting in Indonesia, such as health services access, household and family factors, inadequate complementary feeding, breastfeeding, infection status, political economy, society and culture, education, water, sanitation and environment, and living conditions as well as agriculture and food systems. 2 Poor nutrition awareness among family members is one of the critical aspects of the household and family factors. 1, 4 The family awareness concerning the importance of healthy nutrition is closely related to the social and cultural aspects. Accordingly, it is imperative to improve public awareness of the importance of family nutrition, especially perinatal and maternal nutrition, from conception to two years old. 1, 5 The Indonesian government has launched various programs for tackling stunting. 4 Additionally, community participation is required. Community participation will lead to the program's sustainability. 6,7 Using multiple platforms, it is feasible and effective to improve community participation in stunting prevention and control efforts through social and behavior communication change interventions. 1 Furthermore, the local context and political commitment are two strong determinants influencing the success of the stunting interventions. 3, 8 It is possible to decrease the stunting prevalence at the country-wide and local levels with the strong political commitment of their leaders. 8 It is mandatory to gain the countries' and regional leaders' attention and commitment as well as collaboration from various stakeholders in the stunting intervention programs. With these important goals, the engagement of inter-sectoral stakeholders should be routinely performed during the stunting intervention programs.
Stakeholders' engagement will further improve the research quality and help public health researchers to gain insight into 'policy windows' or opportunities for positive changes. 9 Various strategies for the stakeholders' engagement related to nutritional problems exist. For example, stakeholders' engagement can potentially be done during the research midwives), community leaders and cadres.
Data were collected from relevant documents and observations. Observations were performed during the process of stakeholder's engagement.
Unobtrusive observations were conducted in this study. The researchers observed the stakeholders' engagement process and discussed the findings with the research team to reflect the progress. Meanwhile, the documents were collected from the working papers, local notaries, or minutes. The working papers were the stakeholders' discussion results on the situation analysis and their action planning in response to the stunting problem in their community. Data were analyzed and presented descriptively. According to the observation process and available documents, the stakeholders' engagement process was developed to strengthen the local actions in the stunting prevention and control efforts in Lombok Barat.

RESULTS
Stakeholders' engagement is a continuous process. Many activities were conducted to improve stakeholder collaboration and engagement in the CINTA program in Lombok Barat, as shown in Figure 1. Figure 1 shows that there were 5 steps of the stakeholder's engagement for tackling the stunting problems in Lombok Barat, namely: (1) Needs assessment and internal planning development, (2) Lobbying and advocacy, (3) Leader commitment through memorandum of understanding (MOU) signing, (4) Developing planning and strategies, and (5) Capacity building.

Needs assessment and internal planning development
The team of researchers has been conducting a stunting intervention program in Lombok Barat since 2019. The needs assessment was accomplished by analyzing the existing data from the previous programs and evidence related to the stunting interventions in Lombok Barat. The stunting intervention program in 2019 provided the primary data for the needs assessment. Moreover, additional data were collected by unstructured interviews with the health officers of Lombok Barat (the nutritionists and health promotion staff). The unstructured interviews were focused on the intervention programs that the health office of Lombok Barat conducted. The needs assessment was conducted to identify the problems related to stunting and the potential resources needed to overcome the barriers experienced in the intervention programs.
The stunting problems in Lombok Barat were not solely related to poverty. The community has sufficient resources to meet the nutritional needs of their children. Unfortunately, community beliefs, stigmas, and cultures acted as barriers to fulfilling family nutritional needs. There was a strong social determinant of stunting identified in Lombok Barat. Furthermore, the research team developed program planning for the stunting prevention and control efforts in Lombok Barat by considering the needs assessment results. The data from this internal program planning development and dissemination stages. Moreover, stakeholder engagement must be tailormade to the situation and adjusted to the stakeholders' characteristics and concerns. This article described the process of engaging stakeholders for stunting prevention and control programs in Lombok Barat District, Nusa Tenggara Barat Province, Indonesia.

METHODS
This is the first paper of the Comprehensive and Integrated Action (CINTA) for tackling stunting in Nusa Tenggara Timur and Nusa Tenggara Barat. The study was conducted in August -December 2022. This paper focused on stakeholder engagement to strengthen local actions for tackling stunting in Lombok Barat District, Nusa Tenggara Barat Province. This study obtained ethics committee approval with registration number No: KE/FK/0026/EC/2020. There were 96 stakeholders as participants of this study in Lombok Barat who were selected purposively. The stakeholders were people in Lombok Barat who had participated in the lobbying and advocacy process, development planning and strategies, and the capacity building process. The inter-sectoral stakeholders were closely involved in the development planning and strategies, including the head office of the Development Planning Board of Lombok Barat, the Head of Lombok Barat Health office, the head officer of communication and information service, the Education and Culture Officer, Food Security services officer, Social services officer, Regional Community Development Officer, head officer of population control, family planning, women empowerment and children protection board, family welfare and empowerment officer, head officer of religion board, coordinator of forum da'I (faith leader forum) Lombok Barat, coordinator of forum adat desa (community leader forum) Lombok Barat, coordinators of village leaders in Lombok Barat, as well as the coordinators of family support teams for stunting prevention and control programs. In addition, the participants in the capacitybuilding process were primary healthcare officers (doctors, nurses, nutritionists, and

ORIGINAL ARTICLE
The lobbying and advocacy to the Health Officer and the Development Planning Board Officer was aimed to encourage them to designate the stunting interventions as the top priority of health development in Lombok Barat. In addition, they were encouraged to invite and involve other stakeholders in the stunting intervention programs due to the complexity of the social determinants of stunting in Lombok Barat. As a result, the Development Planning Board Officer was willing to invite other stakeholders to discuss forming a collaboration strategy for the stunting intervention programs. Previously, various institutions in Lombok Barat have established stunting programs as one of their agenda items. Unfortunately, there was a lack of strong coordination and collaboration between related agencies. Each institution works on stunting prevention and control efforts with its focus and programs, adjusted to the institution's vision and mission. They supported the community and encouraged the people to conduct many activities for stunting prevention. The stakeholders' discussion showed that most of them had stunting intervention programs, and they could potentially collaborate to gain the optimum results. Unfortunately, they did not collaborate in these stunting prevention efforts.

Leader commitment through MOU signing
The advocacy and lobbying can lead to more leadership commitment and support toward the stunting intervention programs.
A memorandum of understanding (MOU) of the collaboration concerning the stunting prevention and control intervention program was signed on November 3 rd , 2022, by the Head of Lombok Barat District (Figure 2). The signing process began with inter-sectoral discussion on the progress of stunting intervention programs and the follow-up plans. Many stakeholders were involved in the meeting, such as the Development Planning Board, Health Office, Religion Office, Social Affair institution, Education and Culture institution, Agriculture services, and Food Security Services.  helped the researchers prepare the next step, namely lobbying and advocacy. The research team's focus was community behavior change through creating a more supportive environment. In addition, stakeholders' engagement was mandatory to create this supportive environment and enable community members to practice healthy behaviors related to stunting prevention.

Lobbying and advocacy
Lobbying and advocacy were conducted to gain the stakeholders' awareness and commitment to the stunting intervention programs in Lombok Barat. The first lobbying and advocacy involved the public health division officer and the head of the health office. Secondly, the lobbying and advocacy targeted the head of the Development Planning Board. Each of the participants of this meeting shared about their previous programs related to stunting prevention and control. Afterwards, the Head of the District explained the district mission in the stunting prevention and control efforts. The MOU emphasized the commitment and support from the local government (Lombok Barat District) for tackling stunting issues that should involve intersectoral stakeholders. Indeed, the head of Lombok Barat District stated that the prevalence of stunting in Lombok Barat should be significantly reduced in the next few years. He expressed his hope that the stunting prevalence of Lombok Barat District would decrease to 14% in 2023 and become less than 10% in the next couple of years.

Developing program planning and strategies
Program planning and strategies were developed in a two-day workshop on November 7 th -8 th 2022, lasting more than eight hours each day. The workshop occurred at the Aula Kantor Bupati Lombok Barat (the head district offices' meeting room). The local government provided its meeting room for the workshop, reflecting its support and commitment to the program.
Various stakeholders from the intersectoral institutions (16 institutions) attended the workshop. A total of 30 people attended the workshop. On the first day of the workshop, participants were exposed to the national priority program of stunting interventions and the health behavior-changing communication strategies. Furthermore, the workshop identified the problems related to stunting, the resources and potential solutions, and developed programs and strategies to reduce the stunting prevalence at Lombok Barat. In addition, workshop participants agreed on some principles regarding program implementation, i.e. the program must be held by inter-sectoral institutions and emphasize the collaboration between institutions, utilizing local resources, and applying the community empowerment strategy (Figure 3).
The inter-sectoral institutions that should be involved in the stunting intervention programs were: the Lombok Barat Health Office; Development Planning Agency; Social Services Office; Education and Culture Services; Population Control, Family Planning, Women Empowerment and Children Protection Agency, Food Security Office, universities, Religion Department Office, and Regional Community Development Office as well as village leaders. Meanwhile, the local resources were foodstuffs and the village monetary fund (dana desa). Surprisingly, the workshop participants proposed strengthening rembuk stunting desa (a discussion forum for stunting prevention and control at the village level). They emphasized the village's (local) potential resources for tackling stunting problems.

Capacity building
Capacity building was the last step of the stakeholders' engagement accomplished in this study. The capacity building was aimed at increasing health literacy related to stunting and improving the stakeholders' ability to implement the stunting intervention programs. The audiences of the capacity building were ORIGINAL ARTICLE related to the stakeholders from intersectoral institutions, health officers and primary health care officers, midwives, health cadres, students, and community leaders. The capacity building was done in four schemes to introduce stunting and related treatment, including webinars, training, module development and MOOC, or massive open online course (Table 1).
Various capacity-building strategies were accomplished to strengthen related stakeholders in empowering community members to tackle stunting in Lombok Barat. Moreover, students from the local universities are expected to conduct community services to improve the community's nutritional status and healthy behavior. The webinar, training and MOOC were designed as an interactive (two-way communication) strategy to improve participants' capacity. The material provided was not limited to only explaining "what" and "why", but also explaining "how" they have to do specific activities and strategies to engage in capacity building. Fortunately, the participants actively asked questions during the capacity-building process (both in the online and offline programs). For example, they were asking about some obstacles related to the stigma and culture, which are not easy to change. In addition, the capacity-building forum allowed participants to share their experiences regarding the various behavior change strategies.

DISCUSSION
This study showed that the stakeholder's engagement was essential for the community empowerment in the stunting intervention programs in Lombok Barat. It is necessary to engage stakeholders continuously, starting with raising awareness, increasing health literacy, and improving their capacity to empower communities and change behaviors related to stunting prevention and control. Strong leadership and leader commitment were considered mandatory. The needs assessment and internal planning development steps helped the research team create and deliver key messages that match the stakeholders' needs. Furthermore, the capacity-building process increased the self-efficacy of the stakeholders to carry out the programs.
The community empowerment part of the stunting prevention and control efforts was difficult. Behavior change related to diet and parenting in Lombok Barat is hard due to the social stigma, community culture, and other complex social determinants of stunting. The findings showed that the local custom of early marriage was a social and cultural problem related to the high stunting prevalence in Lombok Barat. The local government encouraged the local leaders to raise community awareness concerning the negative impacts of early marriage. Generally, the determinants of stunting in Indonesia are challenging, complex, and not solely related to health issues. 2 The level of education, household wealth status, health literacy, maternal illiteracy, community-level illiteracy, water and sanitation, access to health care, society and culture significantly influence the nutrition and stunting status. 2,10 Therefore, collaboration and stakeholders' engagement must be conducted to enhance the empowering process of the community's social capital. 7, 11 Stakeholders' engagement was an engaging and proactive process and should be developed continuously to gain the stakeholders' commitment and support. Stakeholders mean individuals, organizations or community groups directly interested in our programs. 9 Stakeholders engagement could be defined as the collaboration and relationship with stakeholders to achieve the best results of our program. 7,9,11 Collaboration and strategic relationships with various stakeholders create a supportive environment for changing community behavior. 1,12, 13 The socio-ecological model recognizes that no single factor influences community behavior, and the behavior change could be performed by implementing the down-stream and up-stream level approach. 12,13, 14 Involving stakeholders was categorized as the upstream-level approach. Engaging stakeholders will encourage stakeholders to "buy in" to the health promotion program. 11, 14 This study showed that the Head of Lombok Barat District did "buy in" to the stunting intervention programs.
The needs assessment was conducted in the early phase of this study. It was done by using the previous program findings and conducting unstructured interviews with the health officers. The data helped the research team identify the methods, strategies, and key messages of the health promotion program and recognize the target audience's vulnerable groups. Developing the stunting intervention program focusing on vulnerable groups is critical. 15 Additionally, the capacity building involved the various stakeholders (health officers, health cadres, local students and related stakeholders) in improving their capacity to conduct community empowerment programs in a healthy diet, baby and children growth monitoring, and parenting. Parental empowerment was associated with the increasing of healthier parenting practices. 16, 17 The capacity building potentially increases the self-efficacy of participants. 18, 19 This study conducted capacity building through several methods (Table 1), which were targeted to various stakeholders to increase their selfefficacy to conduct a stunting intervention program. The stunting module for health officers and cadres could help them during the stunting intervention program.
As one of our limitations, this study only used observations and document analysis in the data collection methods, without conducting any interviews or further follow-up discussions with the participants. This is the main weakness of this study. This study strengthens the importance of the stakeholders' participation in the community empowerment program. Stakeholder engagement was identified as the major social capital that can improve community participation. Thus, public health researchers and practitioners must direct their attention to the stakeholders to improve the continued success of their community empowerment efforts.

CONCLUSIONS
This study concludes that involving stakeholders in stunting prevention and control efforts is necessary. The process of engaging stakeholders could be started by conducting a needs assessment and developing methods, strategies, and key messages by considering the needs assessment results. Furthermore, capacity building is important to improve the stakeholders' self-efficacy to conduct activities aimed at community empowerment. Further research is needed concerning the challenging stakeholder engagement process during community empowerment.