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"ABSTRACTThe social impact of the crisis in Indonesia, both monetary and natural disaster had been investigated by some studies. There is empirical evidence at national level that suggests the crisis impact is very heterogeneous both between urban and rural areas and across regions. It is also found that there is little connection between initial poverty levels and the extent to which an area had been hit by the crisis. The main objective of this study was to investigate the influence of the recent economic crisis and the benefit of the Social Safety Net Program for the nutritional status of under-five children during the economic crisis in selected poor areas of Indonesia. A cross sectional study to get information on the nutritional status of children and its determinants in urban poor area of Jakarta, and rural areas of Banggai in Central Sulawesi, and Alor-Rote in East Nusa Tenggara was followed by another cross sectional study in one selected poor urban area of Cilincing sub-district, Jakarta to see the changes of key determinant(s) of the under-five children's nutritional status after receiving the Social Safety Net intervention program for 1 year period. Two-stage cluster sampling was used to get 1078 households with under-five children in the urban poor area of Jakarta, and 262 and 631 households with under-five children each for the rural areas of Banggai and Alor-Rote, respectively as the subjects of the cross-sectional study-1; and 587 households with under-five children for the cross sectional study-2 in poor urban area of Cilincing sub-district. For both studies, general socio-demographic characteristics, socio-economic, health and nutritional status, and child feeding practices data were collected through interview and observation methods using structured questionnaires. Anthropometrical assessments (of weight, stature, and arm-circumference) were done both for children and their mothers in both studies. Hemoglobin assessment was done for sub-samples of approximately 50% of the total under-five children in both studies. Quality control procedures were performed during the course of the study. Data collection for both studies was performed from January 1999 to January 2001. It revealed that 34% of fathers in the study area of Jakarta had finished junior high school and even less for mothers (22%). More than 70% of the fathers had no regular income and 7% of the sample households had both the fathers and mothers work regularly. About 42 % of the sample households was classified as having sufficient purchasing power and less that 60% of sample households was classified as having appropriate luxury goods (mostly of electronic goods). For the study area in Banggai, 23% of fathers had finished junior high school and even only 10% for mothers. Approximately 14% of the fathers had no regular income and 24% of the sample households was classified as having appropriate employment status. About 45% of the sample households was classified as having sufficient food production/purchasing power in this study and less than 50% of the sample households was classified as having appropriate luxury goods (mostly of cultivated land). For the study area in Alor-Rote, 23% of fathers had finished junior high school and even only 10.9% for mothers. Approximately 21% of the fathers had no regular income and 47% of the sample households had both the fathers and mothers work regularly. About 48% of the sample households was classified as having sufficient food production/ purchasing power in this study and 26% of sample household was classified as having appropriate luxury goods (mostly of cultivated land). Besides having a high severity of anemia (>40%), under-five children in the urban poor area of Jakarta had a very high severity of wasting (>15%) as compared to the medium severity of stunting condition (20-29%). Similar findings were found for the rural area of Banggai. Different findings for the rural area of Alor-Rote were only for its very high severity in stunting condition (>40%). By multivariate and path analyses, it was shown that Jakarta as the study site contributed significantly to the variation of wasting indicator (WHZ value) as the recent-type of malnutrition, and Alor-Rote as the study site contributed significantly to the variation of stunting indicator (HAZ value) as the longterm-type of malnutrition. For hemoglobin value, both Jakarta and Alor-Rote as the study sites contributed to its variation. High prevalence of infectious diseases in all study areas were significantly related to the higher prevalence of wasting in the study areas of Jakarta and Banggai, and also significantly related to the higher prevalence of stunting and anemia in the study area of Alor-Rote. For Jakarta, besides infectious diseases, BMI status of mothers and the possession of motorcycle used for income earning were also significantly related to the prevalence of wasting. On the other hand, for Alor-Rote, besides infectious diseases, possession of luxury goods (access to electricity, possession of transportation facility and electronic goods), environmental sanitation (housing conditions), maternal nutritional knowledge and access to complete immunization were also significantly related to the prevalence of stunting. And, infectious diseases and households' employment status contributed to the variation of stunting (HAZ value). Furthermore, for anemia, access to health services (for complete immunization) was the only key determinant which contributed significantly to the variation of hemoglobin value in Jakarta. For Alor-Rote, besides infectious diseases, formal education of the parents, employment status (especially working mothers), environmental sanitation (especially access to safe drinking water), maternal nutritional knowledge and access to health services were also significantly associated with the prevalence of anemia. And, infectious diseases, environmental sanitation, access to health services and households' employment status contributed significantly to the variation of hemoglobin value in Alor-Rote. The Social Safety Net Intervention Program in the urban poor area of Cilincing sub-district, Jakarta resulted in significant improvement in the prevalence of wasting and anemia among under-five children but not for the prevalence of stunting. It was also found that maternal and childcare, access to health services and hemoglobin were still retained as determinants of child malnutrition besides households' employment status and variety of food intake. There is a need to improve the nutritional and health status of under-five children and their mothers through the existing health care system providing basic health services and improving the capacity of health staffs across Indonesia as part of the decentralization process. Besides, the private sector and communities may support the local government in the form of informal Social Safety Net intervention programs. The significant association found between mother's BMI and wasting status of their under-five children found in this study can be used to prioritize the appropriate type of intervention needed by the poor households. Furthermore, since anemia was highly prevalent, besides iron supplementation, chronic diseases such as tuberculosis and malaria, and the prevalence of thalasemic-trait should also be considered. Further operational and academic research in the area of health and nutrition are needed to be able to construct a model that provides indicators used to predict the nutritional condition in each community setting across Indonesia during any crisis. "

"ABSTRAKIt is well known that iron and zinc deficiencies have negative consequences on growth and development; therefore combined iron and zinc supplementation has been proposed to be applied at community level. However, studies on zinc supplementation and infant's growth have shown inconsistent results. While physiological factors may partly explain the variation in findings, contribution of care specifically psychosocial care to the outcomes has been less discussed. This study aims to investigate whether effect of micronutrient (zinc, iron, vitamin A) supplementation in improving infants' growth and developmental outcomes is modified by levels of psychosocial care. The main hypothesis of the study is that zinc and iron supplementation improves growth and developmental outcomes of the infants and that the effect is improved with more favorable psychosocial care. The study involved 800 infants aged 3-6 months living in the rural area of East Lombok, West Nusa Tenggara. The main study was a double-blind community intervention study where syrup -consisting of zinc alone, Z (10 mg/d), zinc+iron, ZF (10 mg of each/day), zinc+ iron+ vitamin-A, ZFA (10 mg/d for each zinc and iron, 1,000 IU for vitamin-A), or placebo-- were given in daily dose for six months. The measured outcomes were growth, index on mental (MDI) and psychomotor (PDI) development using Bayley Scale of Infant Development II (BSID II), and micronutrient status (hemoglobin, serum zinc, ferritin, and retinol). Psychosocial care was assessed using Home Observation for Measurement of the Environment (HOME) Inventory scale. Other data included morbidity, food intake, childcare practices, resources for care, and socio-economic condition. Significant effect on serum zinc was observed in Z, ZF and ZFA groups and on serum retinol in ZFA group (p<0.05). Prevalence of anemia and low iron storage (ferritin <10 µg/L) remained the same in ZF and ZFA groups while increased (p<0.01 for hemoglobin, p<0.05 for ferritin) in Z and placebo groups. In general there was no significant effect of the supplementation on growth (HAZ, WHZ, WAZ). However, positive response on linear growth (HAZ) was observed among initially stunted infants, especially stunted boys who receive both zinc and iron (ZF and ZFA groups, p<0.05). There was an improvement of mental development in all groups, but only significantly in ZF group (p<0.05). In addition, subjects whose anemia remained uncorrected had significantly lower mental scores than those who were not/ no longer anemic (p<0.05). Better psychosocial care was associated with better growth, and the difference in growth among upper and lower levels of psychosocial care is minimal in the infants who received iron-zinc supplementation, suggesting that both supplementation and psychosocial care had an effect on growth. However, during the six-month supplementation, combination of both supplementation and better psychosocial care was not more significant than interaction of iron-zinc supplement and male sex (for HAZ) or levels of psychosocial care alone (for WAZ). Growth is determined not only by micronutrient intake and status but also by the contributing role of psychosocial care. Psychosocial care affected growth indirectly through better nutrient intake and health practices, and possibly through direct mechanism, which was not yet identified. The effect of zinc+ iron supplementation on mental development was stronger when combined with better psychosocial care and higher hemoglobin level. Accelerated mental performance was also observed in placebo, suggesting that factor(s) other than nutritional factor(s) may influence mental performance. On the other hand, psychomotor outcome was more predicted by nutritional status (WAZ), age, nutrient intake and illness. Results from this study concluded that mental development was determined both by micronutrient status and psychosocial care. Psychosocial care affected mental development partly through better initial mental performance, but mainly direct suggesting that environmental factor(s) had a stronger role than initial status in determining mental performance. Six months after the supplement was no longer given, growth (HAZ, WAZ, WHZ) remained better in infants having better psychosocial care. The association between growth (HAZ, WAZ) and HOME score at six months after the end of supplementation became stronger than during the intervention period, whereas positive benefit of the supplementation on -HAZ among boys -as observed by the end of the 6-month supplementation- was no longer maintained at this point of time. During the six-month supplementation, the subsequent six months, and over the total 12-month period, nutrient intake together with illness and psychosocial care were significant determinants of nutritional status (HAZ and WAZ). Results of this study suggest that incorporating care elements including encouragement of psychosocial care in supplementation/nutritional programs should improve its effectiveness and sustainability. The study also recommends further study to investigate more optimal iron: zinc ratio (probably more than 1:1) when given to anemic, iron deficient subjects and to investigate the mechanism connecting psychosocial care and nutrition/ health outcomes. "