About Action Against Stunting Hub Indonesia

SEAMEO RECFON, in collaboration with UK Research and Innovation The Global Challenges Research Fund (UKRI-GCRF), conducted the Action Against Stunting Hub (AASH) study from 2019 to 2024 across three countries with variation in stunting prevalence: India, Indonesia, and Senegal. In Indonesia, data collection took place in East Lombok District, West Nusa Tenggara Province.
The ‘UKRI GCRF Action against Stunting Hub’ is an interdisciplinary team comprising researchers from 17 partner institutions aimed to explore the causes and typologies of stunting through a whole child approach, considering various aspects such as epigenetics, genetics, gastrointestinal health, child care, nutrition, and education.

Cohort Study

The Action Against Stunting Hub in Indonesia conducts a cohort study comprising two main components:

Observational Cohort – This component follows pregnant mothers from their second trimester through their children’s first 24 months of life.The study employs a whole-child approach, assessing multiple dimensions of development. These include genetic and gut microbiota profiling, home environment factors such as WASH and psychosocial care, early learning environments, and food systems, including food safety and value chains of nutrient-dense foods. Assessments occur throughout pregnancy, lactation, and complementary feeding periods to capture critical determinants of child growth and development.

Intervention Study – Conducted alongside the observational cohort, this component evaluates the impact of dietary quality improvement during pregnancy on epigenetic and stunting-related outcomes. Pregnant women in the intervention group receive an egg-based dietary supplementation during pregnancy, while the control group continues with standard antenatal care, including iron and calcium supplementation and nutrition counseling. This study aims to determine the effectiveness of enhanced maternal nutrition on infant health and growth outcomes.

Early Year Study

The Early Year Study is a case-control study designed to compare children with stunting and those with normal growth between 18 and 24 months of age. Conducted in four sub-districts of East Lombok—Aikmel, Lenek, Sakra, and Sikur—this study takes place within the same setting as the ongoing observational cohort study. By recruiting equal numbers of stunted and non-stunted children, the study aims to explore the underlying biological mechanisms of stunting and its key determinants, particularly in the context of the COVID-19 pandemic.

This study seeks to:
Identify epigenetic signatures and microbiome profiles significantly associated with stunting. Discover additional candidate biomarkers and hypotheses for further investigation within the broader observational cohort.
Serve as a replication cohort to validate findings from the hub’s population-based study.
Extend monitoring beyond the two-year follow-up period of the observational cohort to assess the long-term consequences of stunting and Support further hypothesis testing.

Study Participants

Inclusion Criteria

Women aged 18-40
Pregnant between 16-20 weeks gestation
Of Sasaknese ethnicity

Exclusion Criteria

Consanguineal marriage.
Birth defects.
Multiple births.
Any known allergies to poultry eggs.
Plans to move outside the study area during the next 30 months.

Cohort Recruitment

The research team recruited 702 pregnant women during the second trimester of pregnancy between February and September 2021. Eligible participants were randomly allocated into three groups: egg intervention, control, and observational cohort. The recruitment target was 100 participants per month, and subject allocation was conducted using blocks of sixteen, consisting of 4 participants for the egg intervention group, 4 for the control group, and 8 for the observational cohort group.

Baseline, Mother at T2

Mother T2 (n=702)
Intervention (n=175)
Control (n=179)
Observational cohort (n=348)

Lost to follow up

Mother T2 – T3 (n=16)
Intervention (n=1)
Control (n=4)
Observational cohort (n=11)

Delivery

Mother and neonate (n=686)
Intervention (n=174)
Control (n=175)
Observational cohort (n=337)

Lost to follow up

Mother and Child (n=53)
Intervention (n=13)
Control (n=14)
Observational cohort (n=26)

18 Month

Mother and Child (n=634)
Intervention (n=161)
Control (n=161)
Observational cohort (n=312)

Lost to follow up

Mother and Child(n=1)
Intervention (n=1)
Control (n=0)
Observational cohort (n=0)

24 Month

Mother and Child (n=633)
Intervention (n=161)
Control (n=161)
Observational cohort (n=311)

Component

Physical Component

Cognition and Education

Food and Environment

The Action Against Stunting Hub (AASH) employs a comprehensive ‘Whole Child Approach’ to address childhood stunting, focusing on three interconnected components: physical health, cognition and education, and food and environment.

The physical health component examines factors such as anthropometry, epigenetics, microbiome analysis, biomarkers, nutritional status, and gut health. These elements are crucial in understanding the biological underpinnings of stunting.
The cognition and education component investigates child cognitive development and the influence of home and educational environments. This includes assessing early learning settings and parental support to determine their roles in mitigating the impacts of stunting.
The food and environment component explores dietary intake, water, sanitation, and hygiene (WASH) practices, and food systems. By analyzing these factors, AASH aims to identify how environmental conditions and nutrition contribute to stunting and develop effective interventions.

Below is a summary of the parameters/variables collected from each workstream:

Variables

Physical component

Theme	Analysis	Sample	Method	Status
Gut Health
	Gut microbiome	Stool	16S rRNA	Finished: September 2024
	Pathogenic bacteria	Stool	Bacteria culture	Finished: September 2023
	Parasite infection	Stool	Kato-katz and qPCR	Finished: December 2024
	Gut inflammation (MPO)	Stool	ELISA	Finished: November 2023
	Gut permeability (AAT)	Stool	ELISA	Finished: November 2023
Nutrition
	Complete Blood Count (CBC)	Blood	Hematology analyzer	Finished: November 2022
	HbA1c Levels	Blood	Compact Glycohemoglobin analyzer	Finished: February 2022
	Inflammatory and Nutritional Biomarkers (AGP, CD-14, CRP, Ferritin, FGF-21, HRP2, IFABP, IGF-1, RBP4, sTfR, Thyroglobulin)	Blood	Quansys 11-plex	Finished: October 2024
	Inflammatory and Nutritional Biomarkers (AGP, CRP, Ferritin, HRP2, RBP4, sTfR, Thyroglobulin )	Blood	Quansys 7-plex	Finished: May 2024
	Red Blood Cell Fatty Acids (RBC Fatty Acid)	Blood	GC-FID	Finished: May 2024
	Minerals	Blood	ICP-MS	Finished: October 2024
	Amino Acid	Blood	LCMSMS	Finished: October 2024
	Vitamin B and D	Blood	LCMSMS	Ongoing
	Fatty acid	Breastmilk	GC-FID	Finished
	Human Milk Oligosaccharides (HMO)	Breastmilk	LCMSMS	Finished: October 2024
	Minerals	Breastmilk	ICP-MS	Finished: October 2024
Epigenetics
	DNA methylation	Saliva	EPIC Array
Food and Environment
	Household Expenditure	NA	Interview	Finished: October 2024

Food workstream

Tools	Variable
Questionnaire-based interview	Mothers are asked about infant and young child feeding practices, household food expenditure and the main household decision-makers and influencers of these activities. Physical activity questionnaires ask mothers about the times spent on work and housekeeping including collecting water, fodder and fuel. Furthermore, there are questions on water sources, water security, sanitation and handwashing. Other questions focus on the practices of acquisition, transport, storage, preparation of ASF and the points of potential contamination in the household. Finally, other questions refer to the presence and behaviour of animals and potential transmission pathways associated with close proximity to animals, such as direct contact between animals and children or food. The hazards and risks prior to arrival of ASFs in the household are elucidated in a separate component, at the value chain level (see Cooper et al in this supplement).
Spot-check	Enumerators observe behavioural issues alongside the interview questionnaire. The data are recorded using a check list on the availability and type of sanitation facilities available at the households (eg, the place for defecation and proximity), handwashing infrastructure (eg, location, availability of water and soap), presence of animals (eg, livestock, pests), food storage facilities and practices (eg, functioning refrigerator) and food preparation (eg, easy to clean equipment).
Direct observation	Enumerators stay at the household for 3 hours around a feeding event, observing the mothers perform their daily activities and taking a passive approach to blend into the background in order to better observe hygiene related behaviours. Structured observation include activities related to water collection and storage, as well as personal, environmental and food hygiene (food preparation, storage, child feeding, handwashing and animal contact). This data collection method is a gold standard for actual observation of behavioural practices.
Biological sampling and testing	Enumerators collect samples of stored water, foods to be consumed by the children (as close to the feeding of the child as possible) and a swab of the main food preparation area at the households. Samples of hands rinse are optional. The samples are stored in a coolbox and transported to a specialised laboratory for analysis. The samples are processed in-country and tested for overall contamination and for selected pathogens (such as Salmonella, Shigella, Escherichia coli and Campylobacter for food and E. coli/faecal indicators for surfaces and water), using standard laboratory protocols (of conventional culture and PCR). Part of the samples collected are used for lab analysis and the remaining part stored under −20°C for future analysis and crosschecking.

Cognition and Education Workstream

Tool	Age Range	Variable
Ox-NDA	10-14 Months	Neurodevelopment
Inter-NDA	22-30 Months	Neurodevelopment
Bayley IV	16 Days to 24 Months	Cognitive, motor, language, social-emotional development
HOME	0-3 Years	Home environment, caregiving quality
IDELA	3:6–6:6 Years	Early learning and development
MELE	Classroom-based observation	Early learning environment
HOME (early childhood scale)	3:6–5:6 Years	Early childhood home environment

Teams

Country Lead	Dr. Ir. Umi Fahmida, M.Sc. – Country Lead AASH Indonesia
Workstream Leads	Dr. Min Kyaw Htet, M.B.B.S, M.Med.Sc. – Physical Dr. Dra. Risiatanti Kolopaking, M.Si, Psikolog. – Cognition Dr. Rita Anggorowati, M.Pd. – Education & Shared Values
Research Assistants	Nur Lailatuz Zahra, S.Gz, M.Gizi. – Food Tiffany C. Angelin, S.Si, M.Gizi. – Physical Mifa Nurfadilah, S.Si, M.Biomed. – Physical Amanda Safiera A., S.Gz, M.Gizi. – Food Winda Hapsari, S.Pi, M.Si. – Cognition, Education & Shared Values
Research Team Members	Dr. Pathurahman, S.KM, MAP. – Decision Support Tools Dwi Yanti, S.Pd, M.Biomed. – Epigenetics Sari Kusuma, S.Gz, M.Gizi. – Gut Health Dewi Shinta, S.Gz, M.Gizi. – Nutrition Arienta Rahmania Putri Sudibya, S.Si, M.Sc. – Food Safety & Gut Health Indriya Laras Pramesthi, S.KM. M.Gizi. – Food Environment Ahmad M, S.P, M.M. – Food Value Chain Dr. Dwi Priyono, M.Ed. – Learning Guideline Ith Vuthy, M.Sc, MA. – Decision Support Tools Dr. Elis Rosdiawati, M.Pd. – Learning Environment Irfan Ansori, M.Pd. – Learning Environment Fatima Rahmah, S.Psi, M.Ed. – Learning Guideline
Monitoring Evaluation Learning	Dr. Min Kyaw Htet, M.B.B.S, M.Med.Sc. – Data manager Nur Lailatuz Zahra, S.Gz, M.Gizi. – MEL Support Muhammad Qalbu Dary, S. Kom – MEL Support
Management Team	Arienta Rahmania Putri Sudibya, S.Si, M.Sc. – Hub Manager & HR Ratna Wulanti, S.P. – Finance Artati Widyarningsih, SE. – Hub Coordinator/Accounting
Ambassador	Dr. Raania Amaani, M.P.H. – Ambassador AASH Indonesia
Enumerators, Psychologist, Assessors	Sriani, S.Gz. – Field supervisor P. Crisanti Putri Artawan, S.Tr.Gz. – Enumerator Nunung Ulfayani, S.Tr.Gz. – Enumerator Yuliani Fitri, A.Md.Gz. – Enumerator Baiq Aprilya Nitami, S.Tr.Gz. – Enumerator Nirwala Hardiyanti Putri, S.Tr.Gz. – Enumerator Husna Mauladat Mariam, S.Tr.Gz. – Enumerator Nurjariah, S.Tr.Gz. – Enumerator Ananda Rizkiyana, S.Tr.Gz. – Enumerator Juliana Febrianti, S.Tr.Gz. – Enumerator Nur Izzatun Adawiyah, S.Tr.Gz. – Enumerator Bunga Ramdhiani, S.Gz. – Enumerator Baiq Diar Deliani, S.Tr.Gz. – Enumerator Aulya Riska Febriani, A.Md.Gz. – Enumerator Indah Nurkhoffifah, S.Gz. – Enumerator Riza Awliya, A.Md.Gz. – Enumerator Aizatul Qurroni, A.Md.Gz. – Enumerator Octaviana Dwiyanti, S.Tr.Gz. – Enumerator Yoserina Muharmi, S.Psi., Psi. – Psychologist M. Novita Widyawati, S.Psi., Psi. – Psychologist Raden Sukarni, M.Si. – Assessor Lalu Satria Wijaya, S.Sos. – Assessor
Officers	Adam Ozelan, S.Tr.Gz. – Field Officer Hindun Komalasari, S.Gz. – MEL Officer
Field Support	Suriadi – Logistics Siswadi – Egg courier

Experts and Advisors

International Advisory Board, Indonesian representative	Dr. Ir. Doddy Izwardi, MA
Experts	Prof. Dr.rer.nat. Asmarinah, M.Si. – Epigenetics-Genetics Prof. Dr. dr. Hamsu Kadriyan, Sp.THT-KL(K), M.Kes. – Hearing Dr. dr. Arfi Syamsun, Sp.KF, M.Si. Med. – Verbal Autopsy dr. Deasy Irawati, M.Sc, PhD. – Nutrition dr. Putu Aditya Wiguna, M.Sc, Sp.A. – Paediatrics Dr. dr. Eustachius Hagni Wardoyo, SpMK., SpKL., Subsp. PH (K). – Microbiology Pujjarrohman, M.Psi, Psikolog. – Child Development dr. Ratih Barirah, SpOG. – OB-GYN Prof. Ir. Dahlanuddin, M.Rur.Sc., PhD. – Food Value Chain
Data and Safety Monitoring Board (DSMB)	Prof. dr. Budi Utomo, M.PH, PhD. dr. Elvina Karyadi, M.Sc, PhD, SpGK. dr. Moh. Rizki, M.Pd.Ked, SpPK.
SEAMEO RECFON BOD	Prof. dr. Muchtaruddin Mansyur., M.S., PKK., PGDRM., Sp.Ok., PhD. – Director (2017 – 2022) Dr. dr. Herqutanto, M.PH, MARS., Sp.KLLP. – Director (2023 – present) Alm. Drs. Agus Haryanto, M.Ed., PhD. – Deputy Director for Administration (2016 – 2022) Dr. Zainun Misbah, M.Sc. – Deputy Director for Administration (2023 – present) Dr. Jesus C. Fernandez – Deputy Director Program (2019 – 2024)