Study on the impact of the COVID-19 pandemic on stunting program implementation (sensitive and specific programs) in Sleman Regency Kajian

The COVID-19 pandemic is a new challenge for the implementation of stunting intervention in Indonesia. Therefore, monitoring the stunting program implementation during a pandemic is crucial to achieving the target of stunting reduction. This research aims to examine the pandemic’s impacts on the implementation of specific and sensitive programs, especially posyandu, iron supplementation, PMT, and Sustainable Food Program(SFG). Method, qualitative research uses a Case-Study with 17 informants selected by purposive sampling, including the stakeholders and program’s target in the working area of Tempel 2 Health Center. Data in the form of interview transcripts and other documents were collected using in-depth interviews and documentation studies in November-December 2021 and were analyzed in 3 stages: reduction, presentation, and conclusion. Result, the COVID-19 pandemic has affected specific nutrition interventions, especially in the planning, implementation, and scope of activities. It relates to social difficulties and concerns over the spread of COVID-19. In the implementation of SFG program, the pandemic does not have a significant impact. It can be interpreted that COVID-19 pandemic affects several aspect of the stunting program’s implementation. This study suggests the stakelhoders and communities to optimize the implementation of stunting intervention so it can run sustainably to reduce stunting prevalences.


Introduction
The COVID-19 pandemic is a serious challenge to reducing stunting prevalence in Indonesia.The presence of restrictions and policies in various sectors to prevent the spread of the virus and the centralization of budgets to deal with COVID-19 cause obstacles in the implementation of various programs (Maulana et al., 2022;Osendarp et al., 2021).The world crisis caused by the COVID-19 pandemic has affected the economies of society, which has led to a decrease in household access to food.This can lead to food pregnancy and increase the risk factor of stunting events in society (Akseer et al., 2020).
The government has established nutritionsensitive and specific interventions to accelerate the reduction in stunting to 14% by 2024.The government has launched nutrition-sensitive and specific interventions in order to accelerate the decline of stunting to 14% by 2024.The Ministry of Health (Direktorat Gizi Masyarakat, 2020) has issued guidelines for nutrition services during the pandemic to keep the program running (Saputri et al., 2020).However, several studies found that the COVID-19 pandemic has hampered the implementation of specific nutrition programs in several areas, such as disruption of nutrition services and the Mother and Child Health Program (MaCHP), decreased Integrated Service Center (ISC) visits, hampered immunization, administration of additonal blood tablets, and low coverage of The Supplementary Feeding (Amieratunnisa et al., 2022;Amri, 2020;Maulana et al., 2022;Rusman & Martha, 2021;Saputri et al., 2020).In the implementation of sensitive interventions, the Sustainable Food Garden (SFG/Pekarangan Pangan Lestari/P2L) program becomes a program with the lowest access to indicators and service coverage (Rahmawati & Harahap, 2022).SFP assistance has also not been a priority of the program for households with children (Sugianti & Devianti Putri, 2022).The Health Ministry, in collaboration with UGM (Gadjah Mada University), has analyzed stunting interventions in locus areas.But, on the one hand, it is also necessary to conduct studies on non-locus areas, for example, Sleman (Helmyati et al., 2022).
In the middle of the pandemic that potentially hinders nutrition repair efforts and risks reintroducing stunting cases, the Sleman District suffered a stunting prevalence of 7,24% by 2020.The Sleman District Government has also committed to the acceleration of stunting stunts by issuing Sleman Regent Regulation Number 22,1 of 2021 concerning the acceleration of integrated stunting reduction (Bupati Sleman, 2021).Besides being needed to see the problems that occur during the pandemic, studies in Sleman Regency can also provide new views and ideas as good practice lessons that can be applied to adaptation efforts and strategies during emergencies.
This research is in accordance with an assessment of the impact of the pandemic on health programs that have been carried out in other regions (Amieratunnisa et al., 2022;Amri, 2020;Maulana et al., 2022;Rusman & Martha, 2021;Saputri et al., 2020).What distinguishes this research from other studies is the case study approach that focuses on sensitive and specific nutrition intervention programs by involving various elements of program implementation from local devices to target program recipients.This study can be explored deeply from various perspectives so that it can gain more extensive knowledge regarding the impact of the pandemic on the implementation of stunting intervention programs.

Rosilia et al.
Based on those reasons, researchers are interested in identifying the course of sensitive intervention programs, especially SFG programs and specifically including ISC programs, additional blood tablets, and feeding for prenatals in Sleman Regency.

Methods
Qualitative research using a case-study design.Data collection through in-depth interviews is supported by documentation studies.This research was carried out from November to December 2021, with the location of the research and research data collection carried out in the working area of the Health Center, Tempel 2, Sleman Regency.The selection of subjects in this study used purposive sampling techniques.The subjects and informants in this study are health service officers/village community empowerment offices, agricultural service officers, field agricultural extension workers, the Health Center, ISC cadres/PKK who have been directly involved in stunting programs, and the targets of the program (adolescent girls, mothers with toddlers, and housewives).The total number of informants involved in the study was 17 people.
Data collection was conducted through indepth interviews and documentation studies.Data collection begins with taking care of permits, followed by data collection.The informant was briefed on the research and agreed to provide information by filling out informed consent before the interview began.The interview was conducted online via zoom or offline with the implementation of health protocols.The interview process is recorded in the form of video (online) or voice (offline).Document collection in the documentation study method is carried out by accessing documents from related agencies or informants and looking for sources such as policies, Operational Unit Procedures (OUPs/SOPs), technical instructions, and others on the internet.
The interview results are documented in the form of transcripts and then analyzed in three stages.

Result and Discussion
The The COVID-19 pandemic has become a challenge in handling stunting in Yogyakarta.Sleman Regency experienced the addition of a red zone, or high-risk zone, for COVID-19 transmission to double in the second week of November 2021.The increase in red zones affects people's space, which can then hinder access to health services.In addition, restrictions on economic and trade activities have caused a decrease in people's income and ability to meet their daily food needs.This can increase food insecurity, leading to an increased risk of undernutrition.The COVID-19 pandemic has become a challenge in handling stunting in Yogyakarta.Sleman Regency experienced the addition of a red zone, or high-risk zone, for COVID-19 transmission to double in the second week of November 2021.The increase in red zones affects people's space, which can then hinder access to health services.In addition, restrictions on economic and trade activities have caused a decrease in people's income and ability to meet their daily food needs.This can increase food insecurity, leading to an increased risk of undernutrition (Widiyanto et al., 2019).

Integrated Service Center (ISC) Program
The implementation of ISC during the COVID-19 pandemic adjusts to the presence or absence of cases at the location.If there is a positive case of COVID-19, the ISC is carried out independently (ISC for Family), where reporting is carried out by utilizing information and communication technology.The distribution of vitamin A and deworming drugs is still carried out by taking them alone or having them delivered to the target house by cadres.Some services that are not provided during the COVID-19 pandemic are counseling and feeding for prenatals.If there are no cases of COVID-19, the service of five ISC tables is carried out completely by implementing health protocols.
Access to ISC is one of the factors related to the nutritional status of toddlers (Diagama et al., 2019).During the pandemic, there was a decrease in toddlers' access to ISC.According to data obtained from a document study at the Health Office, the participation rate or percentage of D/S in Sleman Regency was 80,47% in 2019 (before the pandemic) and fell to 63,29% in 2020.In line with this research (Saputri et al., 2020), there was also a decrease in community access to specific stunting programs, especially related to monitoring the nutritional status of toddlers.This happened due to the cessation of ISC activities during the pandemic (Saputri et al., 2020).The decrease in access to ISC is a factor that can increase the incidence of malnutrition.The decrease in access to ISC is a factor that can increase the incidence of malnutrition (Candra, 2017).
ISC's stunting intervention acts as a prevention effort by detecting at-risk children and counseling adolescent girls and pregnant women (Achadi et al., 2021).Cadres are the main drivers in the smooth implementation of ISC and are responsible for reporting to the health center so that children at risk of stunting receive further treatment (Chahyanto et al., 2019).The knowledge and skills of cadres are important in supporting the success of ISC (Boni Lestari & Ayubi, 2021).Based on the results of in-depth interviews, it was conveyed that cadres found it difficult to monitor children at risk of stunting and malnutrition during the COVID-19 pandemic.The frequency of training and coaching to improve the skills of cadres has also decreased during the pandemic.
"The obstacles and difficulties were there during the pandemic, as was the decrease in the number of children weighing.Then we can't provide counseling to children.There are two children who are malnourished because they were born prematurely, BBLR, and there continue to be comorbidities, so we can monitor it difficult during the pandemic."(Cadres) There are changes in Operational Unit Procedures (OUPs/SOPs) and changes in the process of implementing ISC during the COVID-19 pandemic.These changes have caused target participation to decrease.This can hamper monitoring of children at risk of stunting and malnutrition and increase stunting rates in the future (Black et al., 2020).Regarding the process, the COVID-19 pandemic has affected the preparation, transportation, and distribution, as well as the reporting of the Supplementary Feeding-Recovery.Changes that occur in the preparation of the Supplementary Feeding-Recovery are the implementation of meeting activities and socialization with cadres in two shifts and the use of health protocols.The thing that needs to be considered in transporting the Supplementary Feeding-Recovery materials is the selection of the type of transport vehicle (Sugianti, 2018).The transportation of Additional Food (AF), biscuits, from the Health Ministry to the health center or from the health center to cadres or targets does not use special vehicles but uses private vehicles, trucks, or ambulances.Based on this, it shows that the process of transporting the Supplementary Feeding-Recovery materials does not pay attention to safety standards that can affect the quality of the materials (Sugianti, 2018).

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Meanwhile, the distribution of AF, biscuits, is carried out by health workers or cadres and has not been carried out in stages.When COVID-19 cases are high, reporting data on target toddlers to cadres and the Health Center through the WhatsApp application Reporting from the Health Center to health offices is carried out through the e-PPGBM digital system.Meanwhile, the distribution of AF, biscuits, is carried out by health workers or cadres and has not been carried out in stages.When COVID-19 cases are high, reporting data on target toddlers to cadres and the Health Center through the WhatsApp application Reporting from the Health Center to health offices is carried out through the e-PPGBM digital system.
Based on the results of documentation studies conducted at The Health Center Tempel 2 and Dinas Kesehatan, there was no change in the average coverage of the Supplementary Feeding-Recovery at The Health Center Tempel 2 before and during the COVID-19 pandemic.The average coverage of the Supplementary Feeding-Recovery for toddlers at The Health Center Tempel 2 was 100% in 2019 and 2020.Meanwhile, the average coverage of AF, biscuits, in Sleman Regency in 2019 was 98,46% and 98,85% in 2020.Thus, the average coverage of AF provision at The Health Center Tempel 2 is already above the average coverage of AF provision in Sleman Regency.The distribution of the Supplementary Feeding-Recovery both before and after the pandemic is still not on target.In line with research Wahyunigsih & Devi (2017) at the Jakenan Health Center, the distribution of Supplementary Feeding-Recovery from the Health Center to mothers of toddlers was not right on target, and many mothers of toddlers did not attend the distribution of additional food.Regarding timeliness, during the pandemic, the consumption of AF, biscuits, by target toddlers has not reached a minimum of 90 days of eating due to delayed distribution.Efforts to restore the nutritional status of the target will be ineffective and cause nutritional problems if the provision of AF, biscuits, is not on target and not in accordance with consumption rules (Suantari, Marhaeni, and Lindayani, 2022).
The Supplementary Feeding-Recovery Program is one of the specific stunting programs.The COVID-19 pandemic has resulted in a decrease in officer visits to toddlers targeted by the Supplementary Feeding-Recovery as well as visits from targets to nutrition services such as ISC.This results in less monitoring of the nutritional status of target toddlers.The decrease in child nutrition monitoring activities and visits to health care facilities has led to undetected child growth and development disorders (Chamidah, 2020).
"Child F (toddlers targeted by the Supplementary Feeding-Recovery at the study site) is not monitored, so their nutritional status is not monitored.In the past (before the COVID-19 pandemic), there was a provision of therapy for malnourished toddlers because this pandemic was stopped.When the COVID cases went up, I only knew the news and information like that; I didn't know the progress because there was no ISC."(Cadres).

Supplementary Blood Tablets (SBT/Tablet Tambah Darah/TTD) Program for Young Women
The program to provide SBT to young women during the COVID-19 pandemic has continued despite obstacles.The COVID-19 pandemic situation requires adjustments to program implementation (Nurmalia et al., 2022).In the Sleman Regency area, the guidelines that became the basis for adjusting the implementation of the program still refer to the circular letter from the Ministry of Health and the Sleman Regency Health Office.In the Sleman Regency area, the guidelines that became the basis for adjusting the implementation of the program still refer to the circular letter from the Ministry of Health and the Sleman Regency Health Office.
Human resources (HR) or officers involved in the implementation of this program consist of doctors or nurses, health workers, The Health Center, pharmacy departments, and School Health Unit (SHU/Unit Kesehatan Sekolah/UKS) officers (Surat Edaran Nomor HK.03.03/V/-595/2016Tentang Pemberian Tablet Tambah Darah Pada Remaja Putri Dan Wanita Usia Subur, 2016).Changes in the flow of distribution and human resources are adjustments to the situation and conditions of the area under the authority of the district or city (Direktorat Gizi Masyarakat, 2020).The adjustment carried out in Sleman Regency is a change in human resources contained in the distribution from UKS officers to village cadres.Village cadres are tasked with recording targets, distributing SBT, and recording (Adityanto et al., 2022).In addition, the impact of the COVID-19 pandemic is that there is a shortage of health workers because they are exposed to the COVID-19 virus.This has an impact on stopping the program.The human resources of this program during the COVID-19 pandemic have changed in number and function.In addition, the impact of the COVID-19 pandemic is that there is a shortage of health workers because they are exposed to the COVID-19 virus.This has an impact on stopping the program.The human resources of this program during the COVID-19 pandemic have changed in number and function.
The source of funds for the implementation of the adolescent girls' TTD program used by The Tempel 2 Health Center is taken from Health Operational Assistance (HOA/Bantuan Operasional Kesehatan/BOK).This is in line with the guidelines issued by the Indonesian Ministry of Health, namely its implementation using state budget (APBN/APBD) funding sources (Fitriana & Dwi Pramardika, 2019).The impact of the COVID-19 pandemic on the allocation of funds is a reduction in funds for financing.From the interviews, it is known that there is a reduction in funding, but it is not specific to a specific program.The COVID-19 pandemic has not affected the allocation of funds for SBT procurement; it has not reduced it."…..funding sources from HOA, schools never budget, no collaboration from schools."(Health Workers).
The target of providing SBT in the Tempel 2 Health Center area during the COVID-19 pandemic has increased.Based on the guidelines for administering SBT to young women, SBT recipients are young women aged 12-18 years or still in junior and senior high school (Fitriana & Dwi Pramardika, 2019).In its implementation during the COVID-19 pandemic, in the working area of the Tempel 2 Health Center, SBT recipients are determined or recorded by ISC cadres with the criteria of junior and senior high school students.The increase in goals occurs due to the increasing age included in the criteria for SBT recipients.There is an increase in the number of targets, so there is an increase in the number of SBT that needs to be provided by the health center.
The preparation process for the SBT program consists of needs planning, provision, and socialization (Yudina & Fayasari, 2020).Based on the results of interviews with resource persons, needs planning was carried out by village cadres to find out the number of adolescent girls in the village, which was then reported to health workers at the health center.The health center workers will calculate SBT needs and then place an order in the health center pharmacy field.The COVID-19 pandemic has had an impact on the non-implementation of routine socialization due to the policy of imposing restrictions on community activities.

"…..Yesterday it could be done in one village, yes, only once yesterday." (Health Workers)
Program monitoring is carried out with recording and reporting systems, coaching by technical teams, and field visits (Sary et al., 2021).Based on the interview results, the monitoring process during the COVID-19 pandemic experienced differences.Health workers could not directly supervise, so they were transferred to village cadres.Young women in the working area of the Tempel 2 health center admitted that supervision during the COVID-19 pandemic was looser than before the COVID-19 pandemic.During the COVID-19 pandemic, the supervisory function cannot be carried out optimally."For the monitoring function, it cannot yet be carried out by officers, but it is carried out by cadres….." (Health Workers) Recording and reporting are carried out to document information and use it in decisionmaking (Yudina & Fayasari, 2020).Based on the results of the interview, the overall recording process has not changed since the COVID-19 pandemic.Recording during a pandemic is carried out by village cadres by filling out the form provided by the health center.The langko contains targets who receive SBT for young women.Reporting by village cadres to health workers at the Tempel 2 health center once a month.From the information obtained when compared with the Guidelines for Providing SBT Rosilia et al.
for Young Women During the COVID-19 pandemic, it can be concluded that the recording and reporting processes are still not appropriate.In the guidebook, it is explained that recording and reporting are carried out directly by young women using the application "CERIA" (Prevent Indonesian Teenagers Anemia) (Direktorat Gizi Masyarakat, 2020).There is no difference in the way records and reports existed before and during the COVID-19 pandemic."…We distributed blangko to cadres, and the next month we asked ….." (Health Workers).

SFG Program as an effort to improve food security during the Pandemic
The Sustainable Food Garden (SFG) program is part of a nutrition-sensitive intervention to reduce stunting.The concept of the SFG program plays a role from upstream to downstream in supporting family food fulfillment by developing seed houses to ensure the availability of sustainable plant seeds, developing demplots as learning places, and expanding planting in the yards of each resident's house.The utilization of yards in Sleman Regency has been initiated since 2011 in the Acceleration of Food Consumption Diversity (P2KP) program with 46 villages as program recipients and switched to the Sustainable Food House Area (KRPL) program with a total of 6 new areas as recipients until 2019.However, the COVID-19 pandemic in 2020 also affected efforts to expand new areas for SFG program recipients due to the concentration of budgets to deal with COVID-19.
"In the first year of COVID, the budget immediately ran out, everything was diverted to overcome COVID....So indeed, in 2020, there was no new area growth.... Just starting again in 2021."(Field of Food Security and Diversity) "...but considering the importance of food independence during a pandemic, even assistance like this helps overcome COVID.If the assistance is in the form of money or basic necessities, it will continue to run out, but if empowered by planting vegetables in the yard, it will be sustainable, and the benefits will be felt."(Field of Food Security and Diversity) The government considers that the yard utilization program can reduce household independence by providing sustainable food sources amid the issue of food insecurity during the pandemic.So that the expansion of the SFG program will be intensified again in 2021, and the expansion is also directed at the stunting locus area.In that year, there were 2 groups of recipients of the non-stunting category SFG program in 2 sub-districts and 4 groups of recipients of the stunting category SFG program in 4 sub-districts with the same amount of funding and program coverage.
"…In 2021, what is refocused is only related to indirect coordination with the community."(Field of Food Security and Diversity) "Actually, if the pandemic itself does not have the same impact as the procurement of infrastructure facilities.Only in Juknis is there a difference compared to the previous program."(SFG program companion) Although there is still a budget focus for COVID-19, the amount of aid provided to groups has not changed.The COVID-19 pandemic also did not significantly affect the procurement of SFG program infrastructure.However, based on technical guidelines for the implementation of the SFG program, there are differences in the scope of budget use compared to the previous year, where the SFG program only focused on developing market-oriented vegetable crops, while the previous KRPL program was more comprehensive, covering vegetable, livestock, and fruit crops.
In the implementation aspect, there was a decrease in member participation in the maintenance of seed houses and demplots at the beginning of the pandemic due to busyness and concerns about the spread of the COVID-19 virus.However, the prolonged implementation of the PSBB actually has a positive impact by increasing public interest in carrying out yard utilization activities.This is shown by the addition of residents who have started planting in the yard, including residents who have not joined the SFG program.
"…Mothers also do a lot of work, especially during the pandemic when children are schooled at home ....At the beginning of Corona, it was even afraid of Mbak, so there were fewer activities in the demplot.But only at the beginning, and then, because of bored, the mothers even continue to be active again, both at home, in the nursery, and in Demplot.…"(Chief executive of SFG I program) "There have been some who have had COVID.I'm not a member of KWT.Well, we helped them with the results of the demplot.Every morning, we deliver vegetables like that.…" (Chairman of SFG II) Program implementers revealed that the SFG program facilitates household access to plant seeds and vegetables and can save on vegetable purchase expenses.During the pandemic, the harvest from the SFG program is also used to help vulnerable groups such as those who are undergoing self-isolation, underprivileged groups, pregnant women, and families with stunted children.However, program implementers revealed that SFG has not been able to meet animal protein needs.However, the program implementer stated that the SFG program can save an average consumption expenditure of Rp 50,000.00 to Rp 200,000.00 and improve the quality of food consumption in households.This is also in line with the study of the implementation of the KRPL program in Pacitan Regency and Pasuruan Regency, which shows that the KRPL program has an impact on improving the quality of food consumption and has a significant impact on household consumption expenditure (Aji & Sholihah, 2017;Purwantini et al., 2012).
Planting in the yard can be an anticipation when there is a disruption in distribution and inflation of food prices by ensuring the availability of healthy and safe food.In addition, it can also be a means of increasing physical activity and channeling stress during the COVID-19 pandemic (Savitha et al., 2021).With the jargon "mangan apa sik ditandur, nandur apa sing dipangan" (eat what is planted, plant what is eaten), it shows that planting in the yard can help meet the food needs in the household.

Conclusion
Sensitive stunting intervention programs such as ISC, The Supplementary Feeding-Recovery, and distribution of SBT for young girls as well as sensitive programs such as SFG are stunting intervention efforts that need to be continuously carried out to prevent stunting in the future.During the COVID-19 pandemic, there have been changes in resources, Operational Unit Procedures (OUPs/SOPs), and program implementation as a form of adaptation.Changes over the past 2 to 3 years due to the COVID-19 pandemic have the potential to affect program outcomes and hamper stunting prevention efforts.
Therefore, all sectors involved are expected to continue to optimize the implementation of stunting programs after the COVID-19 pandemic has passed.Learning from pandemic conditions, learning digital technology is a must both to strengthen coordination and other activities such as education, monitoring, and evaluation.In addition, it is necessary to increase public awareness to be actively involved in the implementation and various innovations and effective use of resources are needed so that the stunting program runs well and sustainable.