A multilevel analysis of the triple burden of malnutrition in Indonesia: trends and determinants from repeated cross-sectional surveys

BACKGROUND: Although child malnutrition has been reducing, the coexistence in mothers and children of various forms of malnutrition has continued to rise around the world. In the Indonesian context, a knowledge gap exists on the coexistence of multiple malnutrition burdens. This study examines trends in the coexistence of the triple burden of malnutrition (TBM) among mother–child pairs living in the same house and explores multilevel (individual, household, and community) factors associated with TBM in Indonesia. METHODS: We used data from the 2013 and 2018 Indonesia Basic Health Research, the nationally representative survey of the Indonesian population, as repeated cross-sectional surveys. Study samples were mothers and children (0–59 months old), who resided in the same household and indicated by the same identifier number. The anthropometric measurements of the mothers and children, and the hemoglobin levels of the children were collected. We employed a multilevel mixed-effects model to consider the hierarchical data structure. The model captured the role of cluster, district, provincial differences, and the individual, household, community-level, and TBM status characteristics. RESULTS: Of 3,891 mother–child pairs analyzed, 24.9% experienced TBM. Girls had 63% higher odds than boys of TBM (aOR: 1.63; 95% CI: 1.30 to 2.03). Significantly lower odds were found in children of mothers who had a gestational age lower than 37 weeks (aOR: 0.72; 95% CI: 0.55 to 0.94). At the household level, children with a father who had a high-school, primary-school, or no school education had significantly higher odds of TBM than children of fathers who had graduated from academy. Children of mothers who visited Antenatal Care (ANC) no more than 6 times had significantly lower odds (aOR: 0.65; 95% CI: 0.47 to 0.88). Children of mothers who consumed Iron and Folic Acid (IFA) supplements had significantly lower odds. CONCLUSION: TBM is related to characteristics at not just the individual level but also the family and community levels. To achieve significant outcomes, integrated nutrition interventions in Indonesia should also consider family and community factors.