The Gammarana Intervention Succeeded in Restraining the Increase

in Stunting during the COVID 19 Pandemic in Enrekang, South

Sulawesi

Sirajuddin

1,2

, Saifuddin Sirajuddin

, Abdul Razak Thaha

, Amran Razak

, Ansariadi

Ridwan M. Thaha

, Purnawan Junadi

, Pungkas Bahjuri Ali

Doctoral Study Program, Faculty Public Health, Hasanuddin University, Indonesia

Department of Nutrition and Dietetic Health Polytechnic of Makassar, Indonesia

Department of Nutrition, Faculty Public Health Hasanuddin University, Indonesia

Department of Health Policy, Faculty Public Health Hasanuddin University, Indonesia

Department of Health Environment, Faculty Public Health Hasanuddin University, Indonesia

Department of Health Promotion, Faculty Public Health Hasanuddin University, Indonesia

Department of Hospital Administration, Faculty Public Health Indonesia University, Jakarta, Indonesia

The National Development Planning Agency, Jakarta Indonesia

Keywords: Stunting, COVID-19, Nutrition Intervention.

Abstract: Enrekang is the district with the highest prevalence of stunting in South Sulawesi. The Indonesian

government designated pilots for a stunting prevention convergence intervention project, called Gammarana.

The purpose of this study is to evaluate the impact of the program on stunting prevention during the COVID19

pandemic. The method is quasi-experimental. The intervention group was given macronutrient supplements,

micronutrient supplements, child feeding education and natural interventions. The control group was given

natural intervention (IFA-S, Antenatal Care and Growth Monitoring). The intervention group was located in

30 villages and the control group was 30 villages with similar socio-demography. Intervention for 6 months.

Results, stunting in the intervention group increased from 18.7% to 20.1% or 1.4%, while stunting in the

comparison group increased from 16.4% to 19.51% or 3.1%. Overall stunting increased from 17.7% to 19.9%

or 2.1%. The results of the Wilcoxon test showed that there was no change in stunting in the intervention

group (p=0.293) while in the comparison group it increased significantly (p=0.048) as well as overall

(p=0.016). Conclusion, The Gammarana intervention was able to restrain the rate of increase in the

prevalence of stunting during the COVID-19 Pandemic.

1 INTRODUCTION

Stunting has become a serious public health problem

in Indonesia. This is addressed on a regional basis,

especially in areas with a stunting prevalence of

>20%. The Indonesian government, especially South

Sulawesi, has established a focus area for stunting

prevention, one of which is the Enrekang District.

This district had a stunting prevalence of 48% in

2019, before the COVID-19 pandemic spread

(Kemenkes, 2018).

The problem at present is that there are no results

of an extensive, population-scale impact evaluation of

the intervention. This is required, because the track

record of sustainable interventions, is very useful to

be refined. The experience of a broad community-

based intervention is one of the potential lessons

learned from the experience that is very well imitated

(Haselow, Stormer și Pries, 2016),(Hossain et al.,

2017a)

The absence of efficacy studies of stunting

prevention interventions in Indonesia is due to the

absence of specific and sensitive nutrition

intervention packages designed in the perspective of

evaluation studies but generally designed and

implemented in the perspective of program

orientation alone. Several programs are implemented

as routine activities and their impact on stunting

reduction has not been specifically measured. Routine

program packages such as folic acid supplementation

for pregnant women and adolescent girls,

Sirajuddin, ., Sirajuddin, S., Thaha, A., Razak, A., Ansariadi, ., Thaha, R., Junadi, P. and Ali, P.

The Gammarana Intervention Succeeded in Restraining the Increase in Stunting during the COVID 19 Pandemic in Enrekang, South Sulawesi.

DOI: 10.5220/0010760000003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 195-203

ISBN: 978-989-758-542-5

195

supplementary food supplementation for chronically

deficient pregnant women, high-dose vitamin A

supplementation for children aged five years, salt

iodization in endemic goitre areas, regulation of

mother's milk, surveillance for monitoring the growth

of children under five, and basic immunization

packages for children under five and pregnant

women. On the other hand, sensitive intervention

packages for both the agricultural and environmental

sectors have also been carried out throughout

Indonesia. (Beal et al., 2018),(Aryastami et al.,

2017), (Prawirohartono, Nurdiati și Hakimi, 2016).

Although the intervention package has been

carried out on a massive scale, there are very few

study reports that examine its impact on stunting

reduction. This fact needs to be explained as a result

through the evaluation of a large-scale stunting

prevention intervention program. The Government of

Enrekang Regency, South Sulawesi, has made a pilot

project of a comprehensive stunting prevention

approach involving a sensitive and specific approach

at the village level. Thirty villages were targeted for

intervention with an estimated stunting number of

2230 children and 120 pregnant women in 2020,

(Jeon et al., 2019),(Haselow, Stormer și Pries, 2016).

Based on the evidence base of other studies on the

impact of micronutrient supplementation,

macronutrients and nutritional literacy that are

aligned with improvements in environmental

sanitation, theoretically stunting will decrease by

around 4% per year. All of the above studies were

carried out under normal conditions(S. et

al.,2016),(Olney et al., 2018),(Gelli et al., 2018). The

results of the above study were then adopted as the

basis for implementing stunting prevention

interventions in Enrekang Regency, which is called

the local term Gammarana.

Gammarana, is a unique innovation in the stunting

prevention program, because it is based on evidence

from previous randomized studies, but also when the

new normal system was implemented in Indonesia.

Can this intervention package provide an alternative

to stunting prevention, when pressure from external

environmental factors due to the COVID-19

pandemic is increasing (Pérez-Escamilla,

Cunningham și Moran, 2020)? Access and services

were stopped in a direct form, but eventually,

adaptation was carried out so that stunting did not

increase further. (Akseer et al., 2020). This

evaluation study aims to analyze the impact of

Gammarana on stunting prevention in Enrekang

district when the COVID-19 pandemic has not ended.

METHODS

This study is quasi-experimental, investigating the

impact of Gammarna on stunting

2.1 Study Design

This study was conducted in 60 villages, 30 villages

as the intervention group and 30 villages as the

comparison group. The comparison villages had the

same characteristics (7 indicators) in aspects of food

security (p=0.111), agricultural land area ratio

(p=0.317), access to clean water (p=0.154), latrine

status, family planning (p=0.545), basic

immunization (p= 0.999), exclusive breastfeeding

(p=0.999), and growth monitoring (p=0.317) and

health insurance (p=0.999), these are presented in

other study reports (1). The duration of this study was

180 days, baseline and endline measured stunting

status, while the comparison of confounding variables

was controlled by selecting similar villages.

(Sirajuddin et al., 2021)

The intervention village was selected based on the

consideration of high stunting prevalence and has

been designated by the Enrekang district government

as a stunting focus village, while the comparison

village was chosen intentionally by the researchers

with the criteria, geographically being in one sub-

district, having similarities in 7 indicators to control

for confounding variables.

Another similarity between the two groups is

natural intervention, namely folic acid

supplementation for pregnant women, adolescent

girls, basic immunization for children under five,

supplementary feeding for pregnant women, chronic

lack of energy, and growth monitoring. The

difference with the intervention group is the

Gammarana intervention component.

ICSDH 2021 - International Conference on Social Determinants of Health

196

Figure 1. The Sample enrolled and finally analysed

2.2 Participants

2.2.1 Pregnant

Pregnant participants as targets who were given

protein supplementation, and Moringa capsules.

Pregnant is known based on the results of amenorrhea

history followed by a urine test. If it is declared

positive for pregnancy, then deregister as a subject.

This is done by the Midwife of the Health Center. The

total number of pregnant was 200 in the intervention

village and 100 in the comparison village. Of this

number who gave birth in the period August 2020 to

February 2021, 30 in the Intervention Village and 30

in the Comparison Village. This pregnant participant

was registered because the pregnancy outcome in the

form of birth height was the primary outcome

variable in this study.

2.2.2 Child 0-23 Months

Children aged 0-23 months were enrolled as subjects

in this study. An 855 out of 1086 in the intervention

village and 636 out of 997 in the comparison village.

Excluded children with birth defects, adopted

children from outside the region, down syndrome,

caregivers who did not participate in Gammarana, did

not record anthropometry (weight and height) at the

beginning and end of the program. Determination of

age based on birth certificate documents, calculated

in the full month method.

The Gammarana Intervention Succeeded in Restraining the Increase in Stunting during the COVID 19 Pandemic in Enrekang, South

Sulawesi

197

Table 1: Characteristic of the Subject Intervention and Control

Mean SD Mean SD Mean SD

Food security composite scores

3.83 1.34 4.20 1.27 4.02 1.31

0.111

The ratio of land for agriculture

0.16 0.32 0.08 0.06 0.12 0.23

0.317

The ratio of foo

roduction

0.07 0.03 0.08 0.04 0.07 0.04

0.393

The ratio of poverty quantile 1

0.06 0.03 0.05 0.02 0.06 0.03

0.034

Foo

Securit

Index

57.9611.04 61.129.33 59.5410.26

0.531

Access latrine (%)

91.369.20 89.2010.54 90.289.87

0.321

Access wate

treated (%)

94.785.79 92.9812.74 93.889.85

0.154

Famil

Plannin

(%)

18.3416.53 26.5223.76 22.4320.71

0.545

Delivery in health facilities (%)

80.1921.71 81.6330.16 80.9126.06

0.691

Basic immunization (%)

96.875.62 97.685.19 97.285.38

0.999

Exclusive

reastfeedin

(%)

93.2010.16 93.407.66 93.308.92

0.999

Growth monitorin

(%)

94.518.67 96.973.21 95.746.60

0.317

Health insurance Access (%)

47.6510.64 50.9811.15 49.3210.93

0.999

2.3 The Component of Gammarana

Their Component of intervention was Taburia

supplementation, Moringa extract capsule

supplementation, protein supplementation and

nutrition education. This was only given to the

Taburia is given to all children aged 6-23 months, the

response dose is 1 sachet / 2 days/child. How to give,

prepare children's food, separate 1/3 part, shake the

taburia, tear the package and sprinkle it on 1/3 of the

preparing the Taburia, continue to be breastfed for

those who are still breastfed. The total number of

sachets for each child is 90 sachets for 180 days, One

sachet = 1 g.

Provision Taburia to children is carried out by

skilled caregivers, through demonstrations and

simulations, guided by nutritionists, carried out by

skilled caregivers. Each village has 1 nutritionist

specifically for the Intervention village, while the

comparison village has no nutritionists in the village.

The nutritional contribution of each sachet (1 g) to

the Recommended Daily Allowance (RDA) (%) for

pregnant, age of 19-30 years, trimester 2, vitamins and

minerals is vitamin A (13.90), Bi1 (35,71), B2

(31.25), B3 (34.72), B6 (26.32), B12 (22.22), folic

acid (25.00), vitamin C (35.29), pantothenic acid

(50.00), Vitamin D3 (33.33), Vitamin E (400),

Vitamin K (36,36), Iodine (227,27), Iron (74,07), and

Zn (41,67) and selenium (68,97). Taburia has been

registered at the Center for Drug and Food Control No

SD 171250351, and LPPOM MUI: 01251097470214.

Intervention village, while the natural intervention

was not only given to the comparison village group

but also the intervention village.

2.3.1 Taburia Suplementation

separated food, mix well, try to consume this mixture

for <30 minutes, should not be mixed with soupy

foods and drinks, wash hands before and after.

2.3.2 Moringa Extract Capsule

Moringa extract capsules (MEC) were taken every

pregnancy, the response dose is 1 capsule per day

during pregnancy. The contribution of RDA (%)

Vitamin A (0.19), Vitamin E (2.93), Vitamin C

(2,55), Iron (2,00), Zinc (0,01) and selenium (0.24).

The MEC has been registered at the Center for Drug

and Food Control No TR203339021.

2.3.3 Proten Supplementation

Proten supplementation (PR) is given to all pregnant.

The response doses are one sachet every 2 days. The

method of preparation is to dissolve the PR powder in

warm or cold water according to the tastes of pregnant

women, 200 ml of water. Drink immediately < 30

minutes after preparation. The entire contents of one

sachet are made for one serving, cannot be divided

into two or more. Leftovers that are not used should

not be saved for the next gift but must open a new

bag. a sachet 52 g.

ICSDH 2021 - International Conference on Social Determinants of Health

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Table 2: The impact of nutrition intervention on reducing stunting

Group

utritional Status

seline n(%)

ndline n(%)

elta n(%) Wilcoxon Test

-Value

Intervention Stunting 160 (18,7) 172 (20.1) 1.4 0.293

ormal 695 (81,3) 683 (79.9)

Total 855 (100) 855 (100)

Control Stuntin

104(16.4) 124(19.5) 3.1 0.048*

ormal 532(83.6) 512(80.5)

Total 636 (100) 636(100)

Total Stuntin

264 (17.7) 296 (19.9) 2.1 0.036*

ormal 1227 (82.3) 1195(80.1)

Total 1491 (100) 1491 (100)

Mann-Whitne

P-Value 0,238 0,767

*=significant <0,05, differences before –after for control (natural intervention) and across group

The provision of PR is carried out by pregnant

after skillfully preparing, guided by nutritionists in

each village. Nutritional contributions to the RDA

(%) of pregnant are energy (17.50), fat (14.86),

protein (27.4), carbohydrates (17), sodium (23.33),

calcium (24.89), vitamin A (1.90) B1 (117.14), B2

(29.38), B3 (19,19), B5 (43.33), B6 (120.53),

B7(2.6), Vitamin C (38.82), Selenium (75.86). and

Iron (22.22.) and Zinc (16.67). It is also given to

children aged 12-23 months who have not gained

weight. The response doses is sachet/day (25 g)

dissolved in 100 ml of cold or warm water. Giving is

carried out by skilled caregivers, guided by

nutritionists. Nutritional contributions to the RDA of

pregnant are energy (32,59), fat (22.22), protein

(33.33), carbohydrates (31.63), sodium (23.33),

vitamin A (4,28), B1 (328), B2 (156) , B3 (31.67),

B5 (130), B6 (458), B7(3.31), Vitamin C (82.50),

Selenium (122). and Iron (85,71). PR has been

registered with BPOM No: 862513022005.

2.3.4 Biscuits for Children

Biscuits for children (BFC) were given to children

aged 6-23 months in both groups. The duration of

administration was divided into two, namely wasting

toddlers <-2SD median WHO Anthro 2006 was given

for 1 month. Meanwhile, if wasting <-3SD is given

indefinitely until the nutritional status of the WHZ

score is at least -2SD. The response dose for each

administration is the age of 6-11 months given 8

pieces (80 g) per day, 12-23 months of age given 12

pieces (120 g) per day. Energy 160 kcal, 3.2-4.8 g

protein, 4-7.2 g fat. Enriched with 11 vitamins (A, D,

E, K, B1, B2, B5, B3, B16, B12) and 7 kinds of

minerals (Iron, Iodine, Zn, Calcium, Sodium and

Phosphorus. The provision of BFC is accompanied by

nutrition education by nutrition workers at the Public

Health Centres in the comparison villages and by

volunteer nutritionists in the intervention villages.

2.3.5 Biscuits for Pregnant

The Biscuit for Pregnant (BFP), given to pregnant. in

both groups. The dose of administration is 2

pieces/day for the first trimester, and 3 pieces daily @

20 g or 60 g / day for the second and third trimesters.

Energy 270 kcal, 6 g protein, 12 g fat. Enriched with

10 vitamins (A, D, E, K, B1, B2, B3, B16, B12) and

7 kinds of minerals (Iron, Iodine, Zn, Calcium,

Sodium and Phosphorus.

The duration of administration of BFP without

chronic energy deficiency (upper arm circumference

> 23.5 cm) is for 1 month, while for pregnant women,

upper arm circumference < 23.5 cm, is given during

pregnancy until it reaches >= 23.5 cm. Another

provision for the provision of biscuits to pregnant

women is that the provision of complete food remains

the main reference, while this package is only a

supplement.

2.3.6 Growth Monitoring

Growth monitoring (GM) is carried out once a month.

Measurement of body weight using an accuracy of 0.1

kg. Measurement of height using length board to the

nearest 0.1 cm. Measurements were taken at the

beginning and end of the intervention in both groups.

Enumerators who carry out measurements have been

trained in anthropometric techniques and are declared

eligible to carry out according to their competencies.

The measurement results are inputted into the Big

of Nutrition Surveillance Indonesia Data at each

location, according to the month of measurement. The

z-score was calculated using the WHO Anthro 2006

application. Extreme values + 6 SD were excluded

from the analysis. The index used is BAZ, HAZ and

WHZ.

The Gammarana Intervention Succeeded in Restraining the Increase in Stunting during the COVID 19 Pandemic in Enrekang, South

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199

2.3.7 Iron Folic Acid Supplementation

Iron Folic Acid supplement (IFA-S), given to

pregnant. Dosage response for prevention 90 tablets

during pregnancy. The contribution of folic acid and

iron respectively 60 mg (10%) and 0.25 mg (1%) to

Recommended Daily Allowance (RDA) of Indonesia.

2.3.8 Basic Immunization

Basic immunization (BI) provision for infants

younger than 24 hours. It giving hepatitis B

immunization (HB-0). 1 month age giving Bacille

Calmette Guerin

(BCG) and Poliomyelitis 1. Infants

aged 2 months giving of vaccine Diphtheria-Tetanus-

Pertussis (DPT) Haemophilus influenzae type b

(Hib1), poliomyelitis

-2, and Rotavirus. Infants aged

3 months: DPT-HB-Hib 2 and poliomyelitis 3. Infants

aged 4 months: DPT-HB-Hib 3, poliomyelitis

2.3.9 Nutrition Education

Nutrition education (NE) is given to the caregivers,

by nutritionists in each village. The material given is

related to breast milk and complementary foods for

breastfeeding. Education is carried out twice a month

for 6 months, through home visits. Educational guide,

compiled and provided to every nutritionist.

2.4 Outcomes

Primary outcomes are the number and percentage of

stunting before and after the intervention, in

Gammarana and Comparative villages. Stunting is

known from the Z value of the 2006 WHO Reference

LAZ score. Values <-2 SD are called stunting. This

calculation uses the WHO Anthro 2005 software

version 3.2.2. Biologically implausible values LAZ -

6<LAZ>+5 and were excluded from the analysis.

The prevalence of stunting in this study was

calculated before and after the intervention for the

same subject (dependent). If the subject did not

complete the data at the beginning and at the end, then

he was excluded from the analysis. Analysis of

stunting changes using a paired test approach.

2.5 Sample Size

A total of 2333 children were enrolled, 170 were

excluded because their height was not measured at the

beginning of the screening so that the remaining 2063

were. These were then divided into two groups,

namely intervention 1086 and control 997. In the

intervention group, 231 were excluded because the

age was more than 23 months at the end of the

program. did the final measurement, because they did

not undergo the intervention for 5 months. In the

control group, 362 were excluded due to incomplete

anthropometry and out of the area. The final sample

size in the intervention group was 855 and in the

control group was 636.

2.6 Randomisation

Randomization, carried out at the level of selection of

the comparison village, after being selected, all

children in the village are registered as subjects and

then screened for age and willingness to participate.

In the intervention village, no randomization was

carried out because this village was selected from all

villages with the highest prevalence of stunting in the

Enrekang District of 30 so that there were 30

intervention villages and 30 comparison villages.

Allocation concealment mechanism was not done,

because controlling the mobility of subjects between

villages was not feasible.

2.7 Statistical Method

Stunting efficacy was tested from ordinal data on

stunting status before and after the intervention in

both groups. Test the normality of the data with the

Kolmogorov Test p = 0.000, so the Wilcoxon test was

used. Conversion from LAZ values to categorical

data follows, the following criteria: Stunting if the

LAZ value is <-2 SD, and Normal if >=-2 SD. There

are only 2 categories, namely stunting and normal.

Data analysis with SPSS 16.0. This study was

recognized by the Hasanuddin University Ethics

Committee

and registered with The Registry for

International Development Impact Evaluations

(5.24.2021).

RESULTS

During this 6-month study, the number of children

under five who intervened was 1086 in locus villages,

997 in non-locus villages. The coverage of children

changes every month, duo to the number of births and

leave over the age of 23 months do not compare.

Investigate of stunting efficacy interventions only

took place on children who were intervened for 6

months, excluded children who did not reach the 6-

month intervention. Does not reach because the age is

past 23 months and or the age has not reached 6

months. The number of eligible children is 855 in

Gammarana village and 636 in Non-Gammarana

ICSDH 2021 - International Conference on Social Determinants of Health

200

village (Figure:1)

The findings of this study show that in the

intervention group there was no change in stunting

proportion although increased by 1.4%. On the other

hand, in the control group, it was found that there was

a significant increase in stunting at (p=0.048) is 3.1%.

Due to this high increase, overall it is known that the

increase is 2.1% (p=0.036) (Table 2). Of course, this

finding proves that if there is an intervention, the

increase in stunting can be prevented, although the

reduction is still difficult to achieve because this study

used a two-paired sample, not an independent sample.

If the phenomenon is like this, then the

effectiveness of prevention in newborns is required.

If children were born from mothers who covered in

the Gammarana were able to reduce stunting, the

stunting population will decrease significantly. The

decline in this intervention is a decrease that is

triggered by the absence of new cases and vice versa,

newborns tend to have good nutritional status or are

not stunted.

DISCUSSION

The result of this study is that the Gammarana

intervention succeeded in restraining the rate of

stunting increase in the intervention village because it

only increased by 2.1% while in the comparison

village is increased by 3%. Unable to reduce stunting,

due to various factors that are thought to be indirectly

related to the condition of the COVID-19 pandemic,

in which access to basic health services was delayed

for several months before finally reopening at the end

of 2020 on a limited basis.

There are two approaches used in many studies,

namely independent samples and paired samples. If

the change in stunting is calculated based on the free

sample, then the design is cross-sectional twice at the

beginning and end. This has the advantage that

changes in the percentage of stunting are very

dynamic, especially in a small population. The

population will change according to the distribution

of birth age and stunting prevention efficacy. If the

efficacy is good and the birth rate is high, a real

reduction in stunting occurs even in a very short time.

The study in this study uses a paired sample model

so that the direction of change in stunting will focus

more on delaying new cases due to interventions in

subjects who have not been stunted effectively or not.

In stunted subjects, the ability to get out of this zone

is very difficult. This is related to the line of height

growth in children does not apply throughout the

year.

The experience of various studies in testing the

efficacy of stunting prevention through RCT studies

shows that if the intervention goes well, the reduction

is estimated to be >4% per year. Of course, the

intervention runs in a period of between 4-6 years.

This is a child's life cycle as a period of growth and

development. The difference with this study is that

here, it is a pilot program that continues to be

developed (Hossain et al., 2017b).

Similar studies to this study in Burkina Faso

(Lanou et al., 2019), (Fadnes et al., 2016) and

(Muhoozi et al., 2018), where there was no decrease

in stunting after the intervention, but also no increase

in stunting. On the one hand, this provides an

advantage because there is no increase in stunting

cases. This phenomenon is interesting to discuss

because various possibilities are unique to be

discussed. The first is that stunting rehabilitation is

very difficult, due to the accumulation of nutritional

deficiencies that have an impact on the ability to

absorb nutrients in the digestive tract. This is

associated with stunting as an indication of chronic,

not an acute deficiency. On the other hand,

inflammation increases demand but decreases

appetite. Recovery must be gradual and requires

patience on the part of the caregiver.

In addition, the studies reported by (Olney et al.,

2018), (Gelli et al., 2017), succeeded in reducing

stunting, because they not only managed to prevent

new cases but managed to rehabilitate stunting to

normal. This is especially found in cases of stunting,

the threshold difference between normal and mild

stunting, and the majority of the age is < 12 months.

This age still can increase in height between 10-23 cm

for one year, if nutritional intake meets the RDA. A

micronutrient enrichment base intervention with

maximal adherence control and coverage will find

results like this.

The limitation is that the coverage and adherence

to the intervention package are not optimal due to the

irregular supply of materials, which is caused by the

refocusing of the budget due to the pandemic.

However, this does not reduce the quantity and

quality of interventions at the end of the program,

because coverage can be maximized. This causes

some intervention packages to be given after the

program ends and after the follow-up program which

was not reported in this study.

The generalizability of this study is that

Gammarana can be replicated with noted

improvements in the timely mechanism of micro and

macronutrient packet administration. One way is that

Gammarana is continued in the second year in the

Enrekang districts and others in South Sulawesi. The

The Gammarana Intervention Succeeded in Restraining the Increase in Stunting during the COVID 19 Pandemic in Enrekang, South

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201

interpretation of the results of this study is that

stunting prevention must be evidence-based and

Gammarana provides a way out for the use of

macronutrient, micronutrient supplementation and

nutrition education intervention packages controlled

by nutritionists through home visits as educators.

The evidence in this study is consistent with the

results of studies in Burundi (Leroy, Olney și Ruel,

2018), Bangladesh (Mridha et al., 2016), Tanzania

(Locks et al., 2016), Burkina Faso (Lanou et al.,

2019), Mali (Adubra et al., 2019), Uganda (Carroll et

al., 2017). Although these studies are known to differ

from those of studies in Guatemala (Olney et al.,

2018), Bangladesh (Shafique et al., 2016), Malawi

(Gelli et al., 2018), Phipipina (Kandpal et al., 2016)

and Ghana (Kandpal et al., 2016), these differences

are not the main substance that renders the results of

these studies inapplicable. Each community group

has different determinants, so that modifications are

only needed on the context and mechanism side, but

do not differ on the underline side of the intervention

package. The strategy to overcome the differences in

context mechanism side, but do not differ on the

underline side of the intervention package. The

strategy to overcome the differences in context and

mechanism in each social unit of society is by

analyzing the right situation when the initial design of

the intervention control the implementation process

with an up to date approach. (Mirzoev et al., 2016),

(Jeon et al., 2019), (Lacouture et al., 2015). It takes

consistency and focuses from program

implementation. This can be done with the

cooperation of stakeholders as practitioners and

academics as independent reviewers who are free of

conflicts of interest.

5 CONCLUSIONS

Gammarana can suppress the rate of stunting increase

during the COVID-19 pandemic so that it can be

replicated in new areas.

ACKNOWLEDGEMENTS

Thank you, to the government of Enrekang District,

Faculty of Public Health Hasanuddin University and

Health Polytechnic of Makassar.

REFERENCES

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