Effectiveness of Rumoh Gizi Gampong and Positive Deviance in Improving the Nutritional Status of Toddlers in Aceh Efektivitas Rumoh Gizi Gampong dan Positive Deviance terhadap Peningkatan

Stunting is a chronic nutritional problem that is a priority to address because it can affect the quality of children. Fulfilling the nutritional needs of children under five through positive family habits, including through family improvement and Rumoh Gizi Gampong (RGG), can significantly reduce stunting rates. The purpose of the study was to identify the effectiveness of Rumoh Gampong Nutrition and positive deviance in efforts to improve the nutritional status of toddlers in Aceh, with a quasi experimental design conducted in Merduati village, Kutaradja sub-district, Banda Aceh with 50 samples (25 intervention groups and 25 controls) using purposive sampling technique carried out on October 15, 2020-15 January 2021. Data collection using questionnaires with interview techniques, food record documentation studies and weight measurements using Dacin and height using microtoise. Data processing with paired T test, the results showed a significant difference in the intervention group on how to fulfill toddler food (p = 0.000), food intake (p = 0.000), and nutritional status (p = 0.000), there were differences in how to fulfill food in the intervention and control groups (p = 0.00), there were differences in food intake in the intervention and control groups (p = 0.001) and there were differences in body weight in the intervention and control groups (p = 0.001). It is recommended to the head of the puskesmas to support the positive deviance program and Rumoh Gampong Nutrition for all posyandu in their working area.


Intoduction
Indonesia is currently faced with a double nutritional problem, over-nutrition and undernutrition.Malnutrition results in stunting, which is a condition of failure to grow in toddlers due to chronic malnutrition, so that the child's height is shorter than children his age.The incidence of stunting only becomes apparent when a child is 2 years old and can result in various developmental disorders, physical growth disorders, as well as decreased cognitive and psychomotor abilities (Tobarasi I, 2019) .
( WHO, 2023) reports that in 2022 there will be 148.1 million children under the age of 5 who are too short compared to their age (stunting), 45.0 million children are too thin compared to their height (wasting), and 37.0 million children are too heavy compared to their height (overweight).Results of the Indonesian Nutritional Status Survey in 2021, the prevalence of stunting in Aceh was 33.2%, in 2022 it was 31.2% and 29.4% in 2023.Although the stunting rate in Aceh decreases every year, the rate is still high, nationally at this time Aceh is at number seven, the highest province for stunting.When compared with countries in ASEAN, stunting in Indonesia is better than Myanmar at 35%, but still higher than Vietnam 23%, Malaysia 17%, Thailand 16% and Singapore 4% (Rokom, 2021).Apart from that, another nutritional problem in Indonesia is that the prevalence of wasting has increased from 7.1% to 7.7%, underweight from 17% to 17.1%, and overweight from 3.8% decreased to 3.5% (Kemenkes RI, 2022).
The high rate of stunting is still high, causing this to become a priority health problem in Aceh and could pose a threat to future generations.Poor nutritional conditions in society can hamper economic growth by around 8%.This condition is the result of decreased productivity, low quality of education and lack of knowledge which are the long-term impacts of stunting.This of course requires intervention that can handle it effectively and appropriately.
Meeting the nutritional needs of toddlers can be done using various methods, one of which is forming positive family habits in meeting the good food needs of family members, especially children under five.This method is known as Family Nutrition Improvement Business (FNIB).Aceh government throughPeraturan Gubernur Aceh No. 14 Tahun 2019 Tentang Pencegahan Dan Penanganan Stunting Di Aceh, has introduced one of the stunting interventions in the community, namely Rumoh Gizi Gampong (RGG).Rumoh Gizi Gampong is a place to shape behavior and provide nutritious food for pregnant women and children by involving community participation, namely posyandu cadres and also mothers of toddlers.Research result (Ahmad et al., 2023) It was found that the Rumoh Gizi Gampong program could increase the percentage of coverage for health insurance services and the percentage of coverage for accelerated stunting reduction indicators.Likewise with the research carried out Zuhkrina, 2022) that the RGG Program has a very positive effect on stunting prevention, because after monitoring stunted toddlers for three months, they can see an increase in body weight and an increase in height.
Rumoh Gizi Gampong center carries out three scopes of activities.First, nutritional services for risk groups through the provision of provision of local supplementary food, supplementation and other nutritional services.Second, education and increasing the capacity of families, caregivers and the community regarding nutrition during pregnancy to toddler age, and third, strengthening family food security, empowering families in clean and healthy living behavior and other activities (Dinkes Aceh, 2019).To make RGG effective as an effort to prevent and deal with stunting problems, approaches need to be taken, one of which is positive deviance.In research on the effectiveness of Positive Deviance Hearth (Hearth) for Improving Malnourished Children, the results showed that there was no significant relationship between changes in children's feeding methods and the implementation of Hearth (p>0.05)(Sari et al., 2023) (Handayani & Prameswari, 2012) (Hayati et al., 2012) The positive deviance approach encourages behavioral change and empowers mothers of toddlers to take responsibility for rehabilitating their children's nutrition using local knowledge and resources.Having the experience of learning while working will increase the self-confidence and skills of mothers of toddlers in the behavior of feeding toddlers.

METHOD
Quantitative research uses a quasi experimental study design with a pre-test and post-test with control design approach.The selection of research subjects was carried out using purposive sampling.The treatment was only carried out in the intervention group, while the control group did not receive the experimental treatment.Pretest and posttest results were measured in both groups.The results of the intervention group were compared with the control group and the differences that existed were the influence of the treatment.This research was conducted on 15 October 2020-15 January 2021, in Gampong Merduati due to the launch of Rumoh Gizi Gampong so that the availability of research supporting facilities and infrastructure was considered adequate, there was support from the Banda Aceh City health office, the head of the Community Health Center and also Integrated Service Post (ISP) cadres in carrying out the research This.Activities were carried out for 11 months starting with preparation, carrying out actions and evaluating the results.The samples in this study were mothers of toddlers to measure how to fulfill nutrition and toddlers to measure food intake and body weight.The sample criteria are as follows: Toddlers with nutritional problems, low weight or the weight graph is on the yellow line in the KMS, weight has not increased for 3 consecutive months, weight has increased but not significantly for 3 consecutive months (<0.5 kg per month).Willing to be a participant, domiciled in Merduati gampong.Anticipating sample adequacy if someone drops out, the researcher ensures that the number of samples with fixed power is sufficient for this research, then the researcher calculates the number of samples using the sample size formula to estimate the mean of two unpaired groups (Paul S. Levi, 2013)  = ( 1− +  − ).2.  2 / 2 Information : n = Number of sample Z1-α = Level of significance in α 5% and CI 95% = 1,96 Z1-β = Test strength (power) 80% = 0,84 ϑ 2 = Population parameters as a measure of variance distribution Based on the formula above, the sample size in this study was increased by 15% lost to follow to 50 people for two groups (25 for the intervention group and 25 for the control group).The sampling technique used is purposive sampling.Sample selection in the control group was carried out by looking at the same or almost the same characteristics as the control group.

Data collection tools use instruments consisting of:
The instrument for identifying toddlers' weight consists of questions about the demographic data of the toddler's parents, the toddler's age and a list of weight measurement results.This instrument is a development created by researchers only to test content validity by consulting two lecturers in the nutrition department of the Health Polytechnic of the Ministry of Health in Aceh.
The instrument is in the form of a questionnaire about how families fulfill nutritional needs for toddlers to identify how families meet the weight of family members.This instrument was developed by researchers based on concepts developed by CORE (2003).To ensure the validity of the existing instrument, a validity test will be carried out on 10 mothers of toddlers in Ateuk Pahlawan village.The test results show that all existing statement items have a value of more than 0.632 so that the existing statements are considered valid.Meanwhile, for the reliability test using the Cronbach's alpha test, a value of 0.87-0.91 was obtained so that the existing statement items were also considered reliable for this research.
An instrument for food records to determine nutritional requirements for toddlers, this instrument was tested for content validity by consulting two lecturers in the nutrition department at the Aceh Ministry of Health Polytechnic The results of the data normality test using the Kolmogorov Smirnof test, obtained Asiymp.sig(2tailed) values for body weight according to age (.200), method of feeding (.141) were greater than 0.05 indicating the data was normally distributed so the bivariate test was carried out using Dependent t test for differences in body weight before and after intervention, as well as differences in the way children are given food by families before and after intervention.Toddler weight data is processed using manual calculations based on Indonesian Minister of Health Regulation No. 2 of 2020 concerning Child Anthropometric Standards.This research has passed the ethical test conducted at the Research Ethics Committee of the Faculty of Nursing, Syiah Kuala University, Banda Aceh (research code: 113260042)

Analisa Univariate
The characteristics of the respondents can be seen in the following table: Based on table 1.It is known that the characteristics of girls are greater (>50%) in both the intervention and control groups.Most children were 19 months old in the intervention group, while in the control group it was 15 months.For maternal characteristics, it was found that most of the children were 21-30 years old in the intervention group and 31-40 years old in the control group.The majority of mothers' education was secondary education in the intervention group and higher education in the control group.For work, more mothers did not work, whereas in the control group the majority of mothers worked.The majority of respondents' income is >UMP in both groups.Likewise, the number of children in both groups was 1-2 people.The majority of feeding methods for children in both groups are in the poor category with 68% and 60%.

The Effect of RGG through Positive Deviance Intervention on Body Weight.
The results of statistical tests using the dependent t test for each variable, namely toddler weight and method of feeding toddlers before and after intervention, are as follows The research results in Table 2 show that after being given positive deviance intervention, there was an increase in the mean value in the intervention group regarding how to fulfill toddler feeding (45.3 to 72.9), food intake, namely the amount of nutritional intake consumed by children (58.9 to 65.5), and Body Weight (11.01 kg to 11.93 kg).The results of statistical tests showed that there were significant differences in the intervention group regarding how to fulfill toddler meals (p = 0.000), food intake (p = 0.000), and body weight (p = 0.000).In contrast to the control group, the results of statistical tests showed that there was no difference before and after the positive deviance intervention regarding how to fulfill toddler meals (p = 0.082), food intake (p = 0.454), but for nutritional status (p = 0.023), it means there is a difference in body weight./U toddlers before and after positive deviance intervention  3 shows that there is a difference in how food is fulfilled in the control group and the intervention group with a value of p=0.001.There is a difference in food nutrient intake in the control group and the intervention group with a value of p=0.001 and a difference in BW/U (Body Weight) in the control group and the intervention group with a value of p=0.001

Conclusion Respondent characteristik
The results of research conducted by (Rahmandiani, 2019) in her research explained that the education level of mothers with stunting was most dominant at the junior high school education level at 66.4%, while Rahmawati's research in 2019 explained that mothers who had children with stunting were at the high school education level, namely (65%).
Next (Saragih, 2014) explained that children with a high educational background and maternal knowledge about nutrition had good body weight, education had a positive influence on children's protein, energy and iron intake.In contrast to the results of research on the relationship between education and employment and toddler weight, it shows that educational factors do not influence toddler weight.Meanwhile, maternal employment factors can influence toddlers' weight, mothers who do not work can increase toddlers' weight (Amirah & Rifqi, 2019).Furthermore, other researchers explained that the risk factors for stunting in toddlers are inadequate energy and protein intake, the mother's level of knowledge about malnutrition, low maternal education level, and insufficient family income, while the factors LBW, history of breastfeeding, mother's job are not.including risk factors for stunting (Tanzil & Hafriani, 2021).

How to Fulfill Food for Toddlers
The results of the study showed that the method of fulfilling food for toddlers for both groups was not good.This could possibly be due to the mother's background at secondary education level and there are also families that have more than two toddlers in one house.This condition can cause malnutrition in toddlers.Research conducted Alflah & Alrashidi, 2023 It was found that inappropriate feeding practices for infants and young children increase vulnerability to malnutrition such as inappropriate breastfeeding.Late complementary feeding, infrequent feeding and poor feeding methods, poor hygiene and care.Another thing is that the weaning time for breastfeeding is too fast (not enough) so that the nutritional content is inadequate.Inadequate feeding and breastfeeding as well as poor hygiene have been identified as the main causes of acute malnutrition.This condition results in growth disorders, diarrhea, increased infection rates, vitamin and mineral deficiencies, poor cognitive development and increased death rates among children.
The results of the research show that there is a significant difference between the way families provide food for toddlers before and after the positive deviance approach and Rumoh Gizi Gampong are implemented.The positive deviance approach and Rumoh Gizi Gampong is an activity where cadres and mothers of toddlers who experience malnutrition practice various new behaviors in terms of cooking, feeding, cleaning and caring for children in order to rehabilitate children's nutrition CORE (2003) in (Triatmaja, T.N., 2023).This certainly provides a new experience for mothers in meeting the nutritional needs of their toddlers.Another thing that is related to the mother's education, mostly middle school and high school, is a level of education that really allows the mother to more easily understand the knowledge and skills provided.Likewise, the age of some of the respondents' mothers, which ranges from 20 -30 years, is a young age which makes it easy for them to remember things they have just learned.
Researchers Tat, et.al in 2019 also showed that after being given the intervention, positive deviance behavior in feeding, child care and environmental health by mothers increased.

Food Intake for Toddlers
Preparing nutritional intake so that the nutritional needs needed and consumed by toddlers are fulfilled is a component that must be paid attention to in building quality human resources, because in nutrition there are many nutrients needed for the growth and development of a toddler, such as carbohydrates, protein, fat., vitamins, minerals and water.If a person's nutritional needs are not or are lacking, it will cause disruption to the child's growth and development.Body weight in children is a reflection of food intake consumed over a long period of time.Therefore, the availability of nutrients in a child's body determines whether the child's nutritional condition is sufficient, insufficient or excessive (Fuada, 2022).This theory is in accordance with the research results (Hidayat & Rohani, 2022) that there is a relationship between energy intake and protein intake and the incidence of stunting in toddlers.Protein is a source of building blocks for the growth and development of cells in the body.If toddlers get sufficient protein intake, especially animal protein, the child's growth will be good, and according to their age.
In line with the research results (Ilmaladuni, 2015) There was a difference in energy intake in the PD group in the normal intake category (99.4% RDA) and the energy intake in the PMTP group in the poor intake category (71.35% RDA).Statistically there is no difference in body weight between the PD and PMT programs, but the PD program can increase energy intake compared to the Providing Additional Foof (PAF) program.

Weight Toddlers
In this case, the toddler's weight is related to the weight according to age based on standards Kementerian Kesehatan RI, 2020) namely over nutrition (if the Z score is > +1 SD), normal nutrition (if the Z score is from >= -2 SD to +1 SD), under nutrition (if the Z score is < -2 SD to > = -3 SD) and malnutrition (if the Z score is < -3 SD), all toddlers who are respondents have a low BW in the category of malnutrition.Kanan & Elkhalifa, 2020) explains that the factors that cause malnutrition in children under five are more due to lack of family food security, maternal and child care, inadequate availability of health services, poor environmental conditions, as well as poor socio-economic factors, in research BB/U is largely determined by the amount of intake and types of nutrients consumed by toddlers.
The results of the research showed that after the positive deviance intervention -Rumoh Gizi Gampong showed an increase in the weight/U of toddlers on average of 0.6 -1 kg and there was a significant difference between the weight/U before and after the intervention.Positive deviance (PD) is an approach that is based on strengths and capital on the basis that society or individuals have special behavior that allows them to find better ways to overcome nutritional problems.Meanwhile, Rumoh Gizi Gampong is an activity where cadres and mothers of toddlers who experience malnutrition practice various new behaviors in terms of cooking, feeding, cleaning and caring for children in order to rehabilitate children's nutrition (The Core Group, 2003).
Study (Chek et al., 2022), also got the same results that the Positive Deviance approach can introduce the practice of providing common foods or local wisdom to low-income urban communities.Through this approach, mothers can learn together to introduce new foods to their children with the aim of increasing their children's weight.Another study conducted a Positive Deviance trial on 150 toddlers in Cianjur district, West Java who were suffering from malnutrition.The results obtained within six months of implementing the activity showed that from 30% of children with under-five status, malnutrition was successfully reduced to 10.9%, and it was obtained namely 20.9% of children experienced an increase in body weight.This illustrates that there is positive behavior from the mother.Based on the results of these trials, it can be explained that the Positive Deviance approach is very good for improving toddler nutrition (Wulan Sari, dkk, 2023) Other research conducted by Suharyati also showed that the positive deviance method took 54 days and the PMT method 102 days.In a period of three months, it is known that using the positive deviance approach, there was an increase in body weight (BB) of 920 grams, this figure is higher than using the PMT method, which was only 650 grams.Likewise, the results of monthly weight gain using the positive deviance method, namely in months I. II and III (470, 220 and 230 grams) were higher than the PAF method (300, 170 and 180 grams).It was concluded that the PD method was more effective than the PAF method (Suharyati, 2007) Positive Deviance (PD) is an approach based on strengths and capital on the basis that society or individuals have special behaviors that enable them to find better ways to overcome nutritional problems.Positive Deviance (PD) is very appropriate to increase the weight of toddlers because it maximizes the resources, skills and strategies available to the community through broad participation as well as learning and working together.Some of the behaviors of families with toddlers that can be improved through the PD approach are: Active feeding habits, providing food during illness and recovery as well as handling children who have low appetites.Besides that, the PD approach provides a quick solution in overcoming nutritional problems in toddlers (Mercy E, S. Adeosun & Okafor, Dorothy T. Ifitezue, 2017) (Chek et al., 2022) This research has limitations because it was carried out in only 30 days so the possibility of sustainability is low, however, the sustainability of this program at the posyandu can increase the sustainability of the program.

Conclusion
There are differences in the way mothers provide food for toddlers before and after using positive deviance & Rumoh Gizi Gampong, there are differences in nutritional intake for toddlers before and after using the positive deviance approach -Rumoh Gizi Gampong and there are differences in body weight among toddlers after using the positive deviance & Rumoh approach Gampong Nutrition.
It is hoped that the Health Service, Community Empowerment Department, Community Health Centers and leaders at the village level as well as posyandu cadres, can use positive deviance as a method for handling nutritional problems among toddlers in villages by making this activity an annual program or activity by utilizing resources.who is in the village.

Aknowledgment
We would like to thank the Director of Poktekkes, Ministry of Health, Aceh, Head of the Aceh Provincial Health Service, all research respondents, the research team, and all parties who helped carry out this research.

Table 1 .
Distribution of Child characteristics