Demographic and policy determinants of stunting among under-five children in Indonesia: A qualitative public health perspective

Abstract

Introduction: Stunting remains a persistent public health challenge in Indonesia, reflecting structural socioeconomic inequalities and uneven policy implementation. While demographic determinants are well documented, limited evidence explains how these factors interact with health policy processes. This study aimed to explore how demographic determinants of stunting among children under five are mediated through local health policy implementation dynamics. Research Methodology: A qualitative multiple-case study design was conducted in selected Indonesian districts with high stunting prevalence. A total of 25 informants participated, including 10 policy and health system actors and 15 caregivers, recruited through purposive sampling. Data were collected using semi-structured in-depth interviews and policy document review. Thematic analysis was performed using a combination of deductive coding based on the Social Determinants of Health framework and inductive coding to capture emerging themes. Results: The findings identified four interconnected themes: structural demographic vulnerability, health service delivery gaps, policy implementation and governance challenges, and socio-cultural dynamics. Although qualitative, the results indicate consistent directional relationships supported by prior evidence, where low maternal education, low socioeconomic status, high parity, and rural residence increase the risk of stunting (OR>1; p<0.05). These effects are mediated by targeting accuracy, workforce competence, intersectoral coordination, and service responsiveness. Misalignment between demographic risk profiles and policy implementation capacity contributes to persistent stunting disparities. Conclusion: Demographic determinants of stunting are structurally embedded and operate through policy-mediated mechanisms. Effective stunting reduction requires integrating demographic risk mapping with adaptive, equity-oriented policy implementation strategies, strengthening workforce capacity, and improving intersectoral coordination.