Exploring the Role of Food Security in Stunting Prevention Efforts in the Bondowoso Community, Indonesia

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1----What is stunting in scientific terms and how it occurs could have been explained at the very beginning.

What is stunting in humans and how does it occur?

For ex.,

Stunting in humans refers to a condition characterized by low height for age, indicating that a child is significantly shorter than their peers due to inadequate growth and development. It is often used as an indicator of chronic malnutrition and poor health during critical growth periods, particularly in early childhood.

 

### Causes of Stunting:

 

1. **Malnutrition**:

   - **Inadequate Nutritional Intake**: Insufficient macronutrients (proteins, fats, and carbohydrates) and micronutrients (vitamins and minerals) can lead to stunting. This often occurs in populations with limited access to diverse and nutritious foods.

   - **Poor Feeding Practices**: Inadequate breastfeeding, inappropriate complementary feeding, and lack of dietary diversity can contribute to malnutrition.

 

2. **Infection and Disease**:

   - Frequent infections (such as diarrhea, respiratory infections, and others) can impede nutrient absorption and increase nutrient requirements. Repeated illnesses can lead to cycles of malnutrition and stunting.

 

3. **Socioeconomic Factors**:

   - Families living in poverty may lack resources to access nutritious food, healthcare, and sanitation, all of which are critical for healthy growth in children.

 

4. **Environmental Factors**:

   - Poor living conditions, such as overcrowding, lack of clean water, and inadequate sanitation can lead to higher rates of infections and malnutrition.

 

5. **Maternal Health and Nutrition**:

   - The health and nutritional status of the mother during pregnancy and breastfeeding play a crucial role. Undernourished mothers may give birth to underweight infants, increasing the risk of stunting.

 

6. **Genetic Factors**:

   - While nutrition and environment play significant roles, genetic predispositions can also influence growth patterns, although they are less commonly the sole cause of stunting.

 

### Consequences of Stunting:

 

Stunting has long-term implications, affecting not only physical health but also cognitive development, educational attainment, and economic productivity. Stunted children are more likely to experience health issues, have lower educational outcomes, and face challenges in adulthood, perpetuating cycles of poverty and poor health.

 

### Prevention and Intervention:

 

Addressing stunting requires multi-faceted approaches, including improving maternal and child nutrition, promoting breastfeeding, ensuring access to clean water and sanitation, providing healthcare services, and implementing programs that support food security and dietary diversity. Early intervention is critical, as the first 1,000 days of life (from conception to age two) are particularly important for growth and development.

 

2---What are the abbreviations given in Table 3? (STG, AV, etc.)

 

3---Has no work been done in this area? The work done could have been given and a comparison could have been made. Or if no one else has done it, it could have been said that we are the first ones to do it.

 

 

 

Author Response

Comment 1:

What is stunting scientifically and how it happens can actually be explained from the start.

What is stunting in humans and how does it happen?

What is stunting in humans and how does it occur?

For ex.,

Stunting in humans refers to a condition characterized by low height for age, indicating that a child is significantly shorter than their peers due to inadequate growth and development. It is often used as an indicator of chronic malnutrition and poor health during critical growth periods, particularly in early childhood.

Causes of Stunting:

1. Malnutrition:

- Inadequate Nutritional Intake: Insufficient macronutrients (proteins, fats, and carbohydrates) and micronutrients (vitamins and minerals) can lead to stunting. This often occurs in populations with limited access to diverse and nutritious foods.

- Poor Feeding Practices: Inadequate breastfeeding, inappropriate complementary feeding, and lack of dietary diversity can contribute to malnutrition.

2. Infection and Disease:

- Frequent infections (such as diarrhea, respiratory infections, and others) can impede nutrient absorption and increase nutrient requirements. Repeated illnesses can lead to cycles of malnutrition and stunting.

3. Socioeconomic Factors:

- Families living in poverty may lack resources to access nutritious food, healthcare, and sanitation, all of which are critical for healthy growth in children.

4. Environmental Factors:

- Poor living conditions, such as overcrowding, lack of clean water, and inadequate sanitation can lead to higher rates of infections and malnutrition

5. Maternal Health and Nutrition:

- The health and nutritional status of the mother during pregnancy and breastfeeding play a crucial role. Undernourished mothers may give birth to underweight infants, increasing the risk of stunting.

6. Genetic Factors:

- While nutrition and environment play significant roles, genetic predispositions can also influence growth patterns, although they are less commonly the sole cause of stunting.

Consequences of Stunting:

Stunting has long-term implications, affecting not only physical health but also cognitive development, educational attainment, and economic productivity. Stunted children are more likely to experience health issues, have lower educational outcomes, and face challenges in adulthood, perpetuating cycles of poverty and poor health.

Prevention and Intervention:

Addressing stunting requires multi-faceted approaches, including improving maternal and child nutrition, promoting breastfeeding, ensuring access to clean water and sanitation, providing healthcare services, and implementing programs that support food security and dietary diversity. Early intervention is critical, as the first 1,000 days of life (from conception to age two) are particularly important for growth and development. 

 

Response 1:

Thank you for your very valuable questions and input. We realize the importance of explaining scientifically what stunting is and how it occurs from the beginning in the text. Therefore, here we add an explanation in the article in the background:

" The stunting process begins when a child’s body consistently lacks sufficient macronutrients (e.g., protein and energy) and micronutrients (e.g., iron, zinc, and vitamin A), or when nutrient absorption is hindered by repeated infections, such as diarrhea or respiratory illnesses. These challenges, combined with unsupportive environmental and socioeconomic conditions, gradually hinder a child’s physical growth. Maternal nutritional status and health during pregnancy also play a vital role in determining the initial risk of stunting [6], [7], [8]. 

Stunting has long-term consequences, including impaired physical and cognitive development, lower educational achievement, reduced economic productivity, and heightened risk of chronic disease—factors that perpetuate intergenerational poverty. Preventing stunting therefore requires a holistic approach, including improved maternal and child nutrition, exclusive breastfeeding, access to clean water and sanitation, basic health services, and robust food security and diversification programs. Interventions are most effective during the first 1,000 days of life [7], [8].”

 

Thus, stunting is not just a matter of height, but is an important indicator of a child's overall health quality, nutritional status and environmental welfare. We add this explanation in the introduction to strengthen the theoretical basis of the research. Some additional explanations regarding stunting, such as the causes of stunting, include:

• Malnutrition: Lack of macro and micro nutrient intake, as well as inappropriate feeding practices such as non-exclusive breastfeeding and inappropriate MP-ASI, can cause stunting.
• Recurrent Infections: Diseases such as diarrhea and respiratory tract infections hinder nutrient absorption and increase a child's nutritional needs.
• Socioeconomic Factors: Poverty limits families' access to nutritious food, health services, and a healthy environment.
• Unhealthy Environment: Poor sanitation, overcrowding, and limited clean water increase the risk of disease and malnutrition.
• Maternal Nutrition and Health: Mothers who are malnourished during pregnancy are at risk of giving birth to babies with low birth weight, who are susceptible to stunting.
• Genetic Factors: Hereditary factors can influence growth, but are not the main cause if nutritional and environmental needs are met.

 

Comment 2:

2. What are the abbreviations given in Table 3? (STG, AV, etc.)

 Response 2:

Thank you for the review provided. In response to this question, we have added an explicit explanation regarding the abbreviations used in Table 1 in section 3. Materials and Methods, specifically in the subsection that explains the research variables.

"For structural‑model analysis, each latent variable is represented by a set of indicators denoted by abbreviations for ease of reference. Table 1 lists these codes: STG (stunting‑prevention indicators), AV (availability), AC (access), and UT (utilisation). The table systematically pairs each latent variable with its indicator codes, forming the basis for measurement in the analysis model"

 

Comment 3:

3. Has no work been done in this area? The work done can be given and comparisons can be made. Or if no one else has done it, you could say we are the first to do it.

Response 3:

Thank you for the very constructive question. In this regard, we say that much research has been carried out on stunting before, highlighting various causal factors such as poverty, sanitation, maternal education, nutritional status and access to health services.

However, our research entitled "Exploring the Role of Food Security in Efforts to Prevent Stunting in the Bondowoso Community, Indonesia" is a form of update and further contribution from previous studies, with a more specific focus on the dimensions of food security (availability, access and utilization) as a determinant in efforts to prevent stunting. In addition, the research location in Bondowoso Regency provides a different empirical context from locations that have been widely studied previously, given the unique socio-economic characteristics and local food security. Thus, although the general theme is not completely new, this research provides a new approach and perspective, and expands understanding of the relationship between food security and stunting in a regional context that has not been explored previously. We also add the state of the art of this research in the introduction in articles such as:

Tjenemundan et al. [1] highlighted the benefits of enhancing food security through community participation. Interventions such as nutrition education, homestead gardens, and food parcel distribution significantly increase awareness and strengthen community-driven nutrition efforts. Pardede and Saraan [12] further emphasized the importance of integrated food security strategies, noting that increased food production, dietary diversification, and nutrition outreach have reduced stunting in targeted groups. Additional feeding programs for toddlers and pregnant or breastfeeding mothers also play a key role in improving nutritional intake and preventing stunting.

Community-based initiatives—particularly nutrition education, homestead gardening, and targeted feeding—have shown promising results in several Indonesian districts [1], [12]. However, no prior study has systematically examined how the three core pillars of food security jointly influence multidomain stunting-prevention behaviors at the village level in East Java. This evidence gap provides the rationale for the present study.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The paper "Exploring the Role of Food Security in Stunting Prevention Efforts in the Bondowoso Community, Indonesia" offers valuable insights into the role of food security in Bondowoso by employing quantitative methods to examine the relationship between food security and stunting prevention strategies. While the paper utilizes appropriate and adequate tools, certain sections would benefit from greater focus and clarity. Below are some suggestions for improvement:

 

• It is important for the authors to provide background information about the Wonosari District, explaining why this particular district in Indonesia is of interest and what makes it unique in the context of food security and stunting. Relevant details currently located in the methodology section could also be briefly included in the introduction to offer clearer context for the reader. Additionally, the paper would benefit from an overview of the broader status of stunting in Indonesia, with a specific focus on the Wonosari District, to justify the significance of conducting research in this area.

 

• The authors state: "These findings hopefully emphasize the importance of ensuring food security..." This sentence seems premature, as the paper has not yet presented any findings at that point.

 

• The literature review section currently offers general background on the concepts of food security and stunting prevention. However, it would be more effective if the authors focused on reviewing previous research that has examined the relationship between food security and stunting prevention efforts in the region and in Indonesia. This would allow the authors to identify the research gap that this paper intends to fill, rather than simply outlining conceptual definitions.

 

• In the methodology section, the authors mention that questionnaires were distributed to every household with a stunted toddler in the selected villages. It is recommended to clarify how these households were identified as having stunted children. For example, it would be helpful to specify whether health records or reports from local clinics were used.

 

• The authors also mention conducting a preliminary survey in preparation for the research. However, the paper should explain the purpose of the survey, the types of questions included, the number of surveys distributed, how they were collected, and how the findings informed the development of the final research instrument.

 

• The study's sample includes mothers with children aged 0 to 5 years. While this is a relevant group for studies on early childhood health, the authors should explain the rationale behind selecting this specific age range, particularly in relation to stunting vulnerability and intervention timing.

 

• The discussion section presents a good summary of the findings. However, it would benefit from a deeper engagement with previous literature that closely relates to the study. This would help position the current research within the broader academic conversation and better highlight its contributions.

 

Author Response

Comment 1:

• The paper “Exploring the Role of Food Security in Stunting Prevention Efforts in the Bondowoso Community, Indonesia” offers valuable insights into the role of food security in Bondowoso by using quantitative methods to examine the relationship between food security and stunting prevention strategies. Although this paper uses appropriate and adequate tools, certain sections would benefit from greater focus and clarity. Here are some suggestions for improvement:
• It is important for the author to provide background information about Wonosari Regency, explaining why this particular district in Indonesia is attracting attention and what makes it unique in the context of food security and stunting. Relevant details currently contained in the methodology section can also be included briefly in the introduction to provide a clearer context for the reader. In addition, this paper will also benefit from a broader picture of stunting status in Indonesia, with a particular focus on Wonosari Regency, to justify the importance of conducting research in this area.

 

Response 1:

Thank you for the very constructive input. We would appreciate suggestions regarding the importance of strengthening the background context of the study area. In response to this, we have made several improvements as follows:

1. Added Background Information for Wonosari District and Bondowoso District
   We have added a brief description in the introductory section regarding the characteristics of Bondowoso Regency, including its geographical, socio-economic conditions and level of vulnerability to food security and stunting problems. Likewise with Wonosari sub-district. This information is intended to explain the reasons for selecting the study location and its relevance in the national context.
2. Overview of Stunting Status Nationally and Locally

To provide a broader context, we have also added an overview of the prevalence of stunting in Indonesia based on the latest data, then narrowed the focus to the condition of stunting in Bondowoso Regency. With this approach, we hope that readers can see the urgency and contribution of research more clearly.

3. Relocate Details from Methodology to Introduction

We have summarized some relevant information that was previously only presented in the methodology section and moved it to the introduction section, so that readers gain contextual understanding from the start.

The following sections were added:

" Based on the 2022 Indonesian Nutrition Status Survey (SSGI) report, the prevalence of stunting in Indonesia is still at 24.4%, indicating that this problem is still a serious national challenge and requires comprehensive and sustainable intervention [13]. At the provincial level, East Java recorded a stunting prevalence of 19.2%, which, although lower than the national average, still places it as one of the provinces with a high burden of stunting”.

“Bondowoso Regency—specifically Wonosari District—reported one of the highest stunting rates in East Java at 32.1% in 2023 (internal data from the Bondowoso District Health Service, 2023). Although the region maintains year-round agricultural production, high rural poverty (17%) and low dietary diversity have contributed to the stunting burden. Wonosari District, composed of 12 villages, was selected for this study due to its high stunting prevalence, patterns of food insecurity, and representative rural characteristics. Seven villages with the highest stunting rates were sampled, with 161 identified stunted children, of whom 113 were selected as respondents."

We are grateful for these suggestions as they have helped strengthen the overall research narrative. We hope that the improvements made will improve clarity.

Point 2:

• The authors stated: "It is hoped that these findings will emphasize the importance of ensuring food safety..." This sentence seemed premature, as the paper had not presented any findings at that time.

Response 2:

Thank you for your input. We realize that the use of the word "findings" in this section is inappropriate because the paper has not yet reached the results section. Therefore, we have revised this sentence so as not to give the impression that the results have been presented at the beginning. The new sentence we use is:

" This research aims to clarify the relationship between food security dimensions and stunting prevention and to underscore the importance of food security as a cornerstone of child health in rural Indonesia."

We made this change so that the writing flow is more logical and does not confuse readers.

Point 3:

• The current literature review section offers a general background to the concepts of food security and stunting prevention. However, it would be more effective if the author focused on reviewing previous research that examined the relationship between food security and efforts to prevent stunting in the region and in Indonesia. This will allow the authors to identify the research gaps that this paper seeks to fill, rather than simply outlining a conceptual definition.

Response 3:

Thank you for the very valuable advice. We understand the importance of including a review of relevant previous research to strengthen the basis of this research. However, in the structure of this paper, we do not place it in section 2 (Literature Review) separately.

On the other hand, we include an explanation of previous research explicitly in section Research Model Development. In this section, we outline the theoretical basis and results of previous research that show the relationship between the pillars of food security (availability, access and utilization) and stunting prevention practices, especially in the Indonesian context.

We chose this approach so that the discussion of the literature can be directly linked to the development of the research model we propose, while also emphasizing the research gap that we want to fill—namely the limited empirical studies that examine the relationship between food security and stunting prevention in areas with a high prevalence of stunting such as Bondowoso Regency.

Point 4:

• In the methodology section, the author states that questionnaires were distributed to every household with stunting toddlers in selected villages. It is recommended to clarify how these households were identified as having stunted children. For example, it would be useful to determine whether health records or reports from local clinics were used.

Response 4:

Thank you for the very useful advice. In response to this input, we have clarified that the determination of stunting status is carried out previously by village midwives and local health cadres, based on routine Posyandu records regarding monitoring the growth of toddlers. The data includes measurements of the child's height and age, which are then analyzed using WHO Anthro software version 3.2 to calculate the height-for-age z-score (TB/U). Children with a z-score < –2 are categorized as stunted, according to WHO standards.

Households that have toddlers with this status are then selected as respondents for distributing the questionnaire. We have emphasized this explanation in the methodology section of the article to clarify the respondent selection process based on valid health data.

" The study was conducted in January 2025 in Wonosari District, Bondowoso Regency, where the 2023 district health census recorded a stunting prevalence of 32.1 %—substantially higher than the provincial average of 21.3 %. The seven villages with the highest case counts were purposively selected (Section 3.5). Stunting status had been determined by village midwives and health cadres using routine Posyandu growth‑monitoring records. Households qualified as respondents if at least one child had been identified as stunted in these monthly records; height‑for‑age z‑scores were calculated with WHO Anthro 3.2 software. A structured questionnaire was administered face‑to‑face by trained enumerators to collect information on (i) preventive practices, (ii) household food security, and (iii) socio‑demographic characteristics.”

Point 5:

• The author also mentioned conducting a preliminary survey as preparation for the research. However, the paper should explain the purpose of the survey, the types of questions included, the number of surveys distributed, how they were collected, and how the findings informed the development of the final research instrument.

Response 5:

Thank you for the question. Before the main research was carried out, we conducted a preliminary survey in December 2024. The main aim was to ensure that the contents of the questionnaire were in accordance with the conditions and understanding of the community at the research location, as well as to facilitate the implementation process in the field.

This survey involved 30 mothers of toddlers, but they were not included in the main research sample. In this survey, we tested all parts of the questionnaire—from questions about stunting prevention practices, food security, to socio-demographic data. Data collection was carried out face-to-face by trained enumerators, with support from community health center officers and village government. The results of this survey are very helpful to us. Based on respondents' feedback, we revised the editing of several questions to make them easier to understand. We also adjusted the order of questions and interview flow to make it more comfortable when used in the field. Overall, this preliminary survey played an important role in refining the research instrument and ensuring the main data collection process ran smoothly and was relevant to the local context.

“Prior to data collection, a preliminary survey was carried out in collaboration with local health workers and village authorities to verify that the research tools were context‑appropriate and would foster respondent engagement. Community feedback guided the design of a 27‑item, five‑point Likert questionnaire (1 = strongly disagree; 5 = strongly agree) aimed at capturing stunting‑related issues in depth. Content validity was reviewed by three public‑health experts, and a pilot test with 30 mothers (excluded from the final sample) produced Cronbach’s α values ≥ 0.80 for all scales, after which minor wording adjustments were made.

Data were collected face‑to‑face by trained enumerators, supported by community health‑centre staff and village officials. Feedback from respondents highlighted the need to clarify the wording of several items and simplify the language; the question order was also adjusted to enhance interview flow. This iterative process refined the final instrument and ensured that the questionnaire was culturally appropriate and easily understood by participants.”

Point 6:

• The research sample included mothers who had children aged 0 to 5 years. Although this group is relevant for early childhood health studies, authors should explain the rationale behind selecting a particular age range, particularly in relation to stunting susceptibility and timing of intervention.

Response 6:

Thank you for the question. The selection of the age range for children from 0 to 5 years (0–59 months) in this study was based on the consideration that the toddler years are the most vulnerable and crucial period in children's growth and development. In particular, our main focus is on the first 1,000 days of life—from pregnancy to the age of two—which is known as the golden period for preventing stunting. It is during this time that children's body organs and brains develop very rapidly, so appropriate intervention will have a big impact on their future.

We also chose the age group up to 5 years because at this age symptoms of stunting usually begin to appear and can be measured clearly through growth monitoring at Posyandu. By involving mothers as the main respondents, we hope to be able to gather information directly from the people who play the most role in the daily care and feeding of children.

This age range also allows us to capture a broader picture—both in children who are still in the critical intervention period, and those who may already be showing the long-term effects of a lack of nutrition and stimulation. In this way, it is hoped that the results of this research will provide a more comprehensive understanding of stunting conditions at the household level.

" From the register of 161 stunted children (0–59 months), primary caregivers—specifically mothers—were selected as respondents, given that stunting prevention occurs mainly within the first 1 000 days and mothers are the principal decision‑makers for child feeding and hygiene.

 The 0–59‑month age range was selected because toddlerhood represents the period most vulnerable to growth and developmental disorders; the first 1 000 days are widely recognised as the “golden window” for effective stunting interventions.

In addition, signs of stunting can be observed and measured accurately in this age group through routine growth monitoring. Including children up to 59 months also captures those who have moved beyond the initial intervention period yet still exhibit the long‑term effects of chronic malnutrition.”

Point 7:

• The discussion section provides a good summary of the findings. However, it would be useful if we studied more deeply the previous literature that is closely related to this research. This will help position the current research within the broader academic conversation and better highlight its contributions.

Response 7:

Thank you for your very valuable input. We agree that linking the findings of this study to previous literature will enrich the discussion and help position this study in a broader academic context. Therefore, in the revised version, we have added several important references to strengthen the explanation of the results.

Through the addition of this literature, we hope readers can see more fully how this study is not only locally relevant, but also contributes to broader conversations in the fields of public health and community-based development.

"4. Discussion

The prevalence of stunting in Bondowoso (32.1%) is significantly higher than the national average (24.4%), underscoring the need for interventions tailored to local contexts. Consistent with multi-district studies in Java [13] and Sulawesi [1], our model confirms that improved household food security is associated with increased multidomain prevention practices and a reduced risk of stunting.

 

This study highlights the critical role of food security in preventing stunting in the Bondowoso community, Indonesia. Stunting is a severe public health concern that affects children's growth and development. Our findings support the research hypothesis by demonstrating a significant relationship between food security and the effectiveness of stunting prevention efforts. Improved food security is associated with lower stunting rates, emphasizing the importance of stable access to nutritious food. In this context, food security includes the availability of, and access to, diverse and safe food, along with public education and awareness about the importance of nutrition. These findings reinforce earlier empirical evidence, such as that presented by Ruel et al [34], which highlights the potential of food security interventions to reduce stunting in low- and middle-income countries.

Our findings align with Dewi et al. [27] who found that a one-unit increase in the food access score reduced the odds of stunting by 19%. The significant AC → EBT and AV → IPS paths (β = 0.26 and 0.86, respectively) suggest that economic access and physical availability influence different behavioral pathways—dietary diversity and program participation. Complementary breastfeeding training, delivered by Posyandu cadres as recommended by Surmita et al. [20], remains an effective strategy in rural agricultural areas. The emphasis on empowering mothers as primary caregivers in feeding and hygiene practices is consistent with the findings of Bhutta et al. [35], who showed that family-based nutrition interventions are most effective when mothers are provided with adequate knowledge and access to resources.

Strengthening food security at both the household and community levels has proven essential in reducing stunting rates. Economic factors, such as household income, significantly influence food security and the prevalence of stunting [13], [31]. Training programs for parents on complementary food preparation have shown promising outcomes in improving nutritional intake and reducing stunting [20], [32]. Education and public awareness are also crucial in enhancing food security. Informing communities about the importance of nutrition ensures that children have access to nutrient-rich foods, thereby lowering the risk of stunting [9]. Numerous studies have confirmed the strong relationship between household food security and stunting [15]. This study also aligns with the findings of Pakaya, Kadir, and Kasim [36], who emphasized that a multisectoral approach integrating nutrition, sanitation, and food security interventions is more effective than sectoral strategies alone in reducing stunting prevalence.

While AC and AV demonstrated medium-to-large effect sizes (f² ≥ 0.15), UT’s influence was more nuanced: it predicted health prevention practices but did not significantly affect toddler diet or sanitation behaviors. Similar attenuation patterns have been documented in Ethiopian cohorts, where utilization effects were mediated by maternal nutrition knowledge [16]. This pattern suggests that cognitive and behavioral factors—absent from our current model—shape how households convert resources into child-focused actions. As noted by [37], effective stunting interventions must incorporate social and behavioral dimensions at both the family and community levels as a critical component of stunting reduction strategies.

AV exerted the strongest total effect (Σβ = 2.67), reinforcing calls for village-level diversification of staple and protein sources. A recent quasi-experiment in West Java showed that maize-soybean intercropping combined with small-livestock support reduced moderate stunting by 5 percentage points in one year [28]. AV shows a strong influence on several variables such as EBT, COGS, IPS, and SHP. This emphasizes the importance of ensuring a stable supply of nutritious food to support healthy eating patterns and good health practices.

Meanwhile, resource utilization (UT) only has a significant influence on HPP, which shows the importance of using appropriate resources in supporting the health of children under five. The non-significant UT → IPS/SHP paths may reflect measurement limits (self-report bias) or the absence of cultural variables (e.g., food taboos). Future longitudinal designs should incorporate objective diet-diversity scores and qualitative probes into feeding norms.

Overall, this research confirms that comprehensive and integrated factors, including food availability, access and utilization, are critical to improving the health and well-being of children in communities vulnerable to stunting. Academically, this study contributes to strengthening the conceptual framework regarding food security and stunting at the micro (household) level, which has so far been mostly studied at the macro or national scale.”

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This study demonstrates that the three pillars of food security—availability, access, and utilization—directly influence the effectiveness of stunting prevention efforts for children under five in Bondowoso. Among these, availability emerges as the strongest lever. This finding offers a scientific foundation for local authorities to prioritize actions like diversifying food supply sources, implementing food subsidies, and promoting safe food preparation education.

However, since the model relies on self-reported data, a moderate sample size, and does not account for cultural or educational factors, further large-scale longitudinal research is needed to confirm causal relationships and improve policy recommendations.

To enhance the study's impact, Let’s clarify or expanding on the following points:

1. The study identifies the "three-legged stool" of availability, access, and utilization as key to combating stunting. Given this, what would a realistic and high-priority action package look like for the local government over the next three years? Please consider outlining potential resources, timelines, and measurable indicators.
2. The sample size of 113 out of 161 stunted children was based on the Krejcie-Morgan table, but considering that villages may differ significantly in economic and cultural aspects, does this sampling method ensure adequate representativeness? Was cluster bias tested?
3. In the PLS-SEM model, why were variables related to nutrition education and cultural habits not controlled? Could their exclusion have contributed to the non-significant relationship between utilization and IPS/SHP outcomes, making the results less convincing?
4. PLS-SEM does not test overall model fit indices (such as χ² or SRMR), making it difficult to evaluate how well the model fits the data. This is a limitation that should be acknowledged more explicitly.
5. The minimum sample size of 113 might lead to instability in path coefficients, particularly for second-order constructs. Has this been considered?
6. There is no report of multicollinearity checks among availability, access, and utilization. This could potentially inflate the beta coefficients and affect the interpretation of relationships.
7. The dependent variable—“stunting prevention efforts”—is based on self-reported measures, which could be affected by social desirability bias. Some triangulation with objective or third-party data could improve reliability.
8. Finally, instead of presenting complex SEM diagrams, the study could benefit from using clear infographics that visualize the "three pillars" along with related percentages to make the findings more accessible to a wider audience, including policymakers and community stakeholders.

Comments on the Quality of English Language

(none)

Author Response

Comment 1:

This study shows that the three pillars of food security—availability, access and utilization—have a direct influence on the effectiveness of efforts to prevent stunting in children under five in Bondowoso. Among these factors, availability is the strongest factor. These findings provide a scientific basis for local governments to prioritize actions such as diversifying food supply sources, implementing food subsidies, and promoting safe food preparation education.

However, because this model relies on self-reported data, a moderate sample size, and does not account for cultural or educational factors, further large-scale longitudinal research is needed to confirm causality and refine policy recommendations.

Response 1:

Thank you for the input provided. The findings of this study show that food availability has the greatest influence on stunting prevention efforts in Bondowoso, with food access and utilization also playing an important role. These findings support policies that focus on food diversification. However, considering limitations in sample size and measurement, further research with a longitudinal approach is recommended to ensure a stronger causal relationship.

 

Comment 2:

To increase the impact of this study, let's clarify or expand on the following points:

This study identifies the availability, access and use of a “three-legged stool” as key to combating stunting. Bearing this in mind, what would a realistic, high-priority action package for local governments look like over the next three years? Please consider outlining potential resources, timelines, and measurable indicators.

Response 2:

In the next three years, the Bondowoso regional government needs to focus on three pillars of food security to deal with stunting: food availability, access and utilization. Increasing food availability can be done by diversifying local food sources and ensuring adequate food supplies. Food access can be strengthened through conditional cash transfers for poor households who participate in child growth monitoring. Apart from that, food utilization can be increased through training of Posyandu cadres and educational programs for mothers regarding providing nutritious and safe food for their children.

It is also important to involve the agricultural, health and Posyandu sectors in supporting this policy. Indicators that can be measured include increasing the diversity of household diets, reducing stunting rates, and increasing maternal knowledge about nutrition. This package of measures needs to be complemented by further research to evaluate its impact and ensure suitability to the local social and cultural context.

“Policy implications that can be implemented based on the results of this research include: A three-year action package for Wonosari could combine (i) Food-Availability—subsidised orange-fleshed sweet-potato seed and small-ruminant starter kits; (ii) Food-Access—conditional cash transfers for households below the poverty line tied to growth-monitoring visits; (iii) Food-Utilisation—monthly cooking demos and WASH clinics led by Posyandu cadres. Indicative costs (US $75,000 per village) and key performance indicators (≥25 % increase in diet-diversity score; stunting reduction ≥3 pp y⁻¹) align with the East Java nutrition-convergence roadmap.”

 

Comment 3:

The sample size of 113 out of 161 stunted children is based on the Krejcie-Morgan table, but considering that villages may differ significantly in economic and cultural aspects, does this sampling method guarantee adequate representation? Has cluster bias been tested for?

Response 3:

Thank you for the question. To determine the sample, we used the proportional quota method by considering social and economic differences between villages.

“Using the Krejcie–Morgan formula (Table 1) for a population of 161 stunted children, a minimum sample of 113 respondents was required. Proportional‑quota sampling—adjusted with a cluster‑robust design effect of 1.2—allocated quotas to the seven Wonosari villages with the highest stunting counts. All eligible mothers of stunted toddlers were approached until quotas were met (non‑response = 8 %), and design‑based χ² tests confirmed the absence of significant cluster bias (p > 0.10)."

 

Comment 4:

In the PLS-SEM model, why are variables related to nutrition education and cultural habits not controlled? Could their exclusion contribute to the nonsignificant relationship between utilization and IPS/SHP outcomes, thereby making the results less conclusive?

Response 4:

Thank you for the question. We realize that nutritional education variables and cultural habits play an important role in stunting prevention efforts. Although these two variables are not explicitly included in our PLS-SEM model, we have tried to include indicators related to them in several other more measurable variables.

For example, in the Eating Behavior in Toddlers (EBT) variable, we have included indicators that are directly related to children's eating patterns, such as reducing instant food consumption, adequate daily energy intake, as well as exclusive breastfeeding and timely introduction of complementary foods. These indicators reflect aspects of nutrition education, because they are directly related to the knowledge and practice of providing nutritious food to toddlers.

In addition, in the Sanitation and Hygiene Practices (SHP) variable, we note the importance of correct hand washing habits and access to clean water, which reflects cultural habits of maintaining cleanliness and sanitation, which also play a role in improving children's nutritional status.

So, even though nutritional education and cultural habits are not included explicitly, these indicators still provide a picture of the influence of these factors on eating patterns and health habits that can influence children's nutritional status and the risk of stunting. However, we also suggest that further research can take into account nutritional education variables and cultural habits more specifically to enrich understanding of the factors that contribute to stunting prevention.

However, we recognize the nonsignificant UT → IPS/SHP pathway is likely due to measurement limitations, including self-report bias, as well as the exclusion of cultural variables such as dietary restrictions or feeding norms. As explained in the discussion section, future studies will include objective dietary diversity scores and qualitative approaches to capture cultural dimensions not yet accommodated in current models.

“Table 1. Research Variables

Variable	Sub Variable	Note	Indicator	Note
Stunting Prevention Efforts (STG)	Health Prevention Practices	HPP	Health insurance coverage	STG1
			Impact of social guidance	STG2
			Effect of the household environment	STG3
	Interventions to Prevent Stunting	IPS	Proactive responses to stunting information	STG4
			Consistency in stunting prevention efforts	STG5
	Eating Behavior in Toddlers	EBT	Decrease in instant food consumption	STG6
			Sufficiency of daily energy intake	STG7
			Provision of exclusive breastfeeding	STG8
			Adherence to the immunization schedule	STG9
			Timely introduction of complementary foods	STG10
			Incidence of infectious diseases	STG11
	Sanitation and Hygiene Practices	SHP	Waste management discipline	STG12
			Accessibility of clean water	STG13
			Instilling handwashing habits in children	STG14
Food Security (FC)	Food Availability	AV	Fulfillment of nutritional food requirements	AV1
			Days lacking nutritious food	AV2
			Challenges in providing complementary foods	AV3
			Storage of food supplies	AV4
	Food Accessibility	AC	Time invested in acquiring nutritious food	AC1
			Transportation expenses to reach the market	AC2
			Interruptions in transport or supply chains	AC3
	Food Utilization	UT	Frequency of health facility visits	UT1
			Frequency of serving nutritious meals	UT2
			Receiving food assistance	UT3

 

"The nonsignificant UT → IPS/SHP pathway may reflect measurement limitations (self-report bias) or the absence of cultural variables (e.g., dietary restrictions). Future longitudinal designs should incorporate objective dietary diversity scores and qualitative research into feeding norms."

 

Comment 5 :

PLS-SEM does not test overall model fit indices (such as χ² or SRMR), making it difficult to evaluate how well the model fits the data. This is a limitation that should be acknowledged more explicitly.

Response 5:

Thank you for your very valuable input. We note that PLS-SEM does not test model fit indices such as χ² in traditional SEM. However, we used SRMR (Standardized Root Mean Square Residual) to measure the overall model fit, and the results showed a value of 0.064, which is below the accepted threshold (< 0.08), indicating that our model fits the data well.

In addition, we also evaluated the model using composite reliability, AVE, and R², which shows that our model is quite reliable. Despite these limitations, we believe these results are valid enough for the purposes of our study.

"4. Results

Based on the existing research objectives and questions, as well as to evaluate the proposed hypothesis, analysis was carried out using structural equation modeling with the following research model.

 4.1       PLS-SEM analysis

Partial-Least-Squares structural equation modelling (SmartPLS 3.0) was chosen for its robustness with moderate samples and non-normal data. A post-hoc power calcu-lation (effect size = 0.15, α = 0.05, three predictors) returned 0.87, exceeding the 0.80 benchmark. Overall model fit was adequate (SRMR = 0.064 < 0.08).

The model developed based on Research Model Development in Smart-PLS 3.0 was evaluated in two stages, namely the measurement model was analyzed to assess the reliability and validity of the construct, and the structural model was analyzed to check the significance of the path coefficients in the research model.”

 

Comment 6:

The minimum sample size of 113 may cause instability of path coefficients, especially for second-order constructs. Has this been considered?

Response 6:

Thank you for the question. We understand that a minimum sample size of 113 may risk causing instability of path coefficients, especially for second-order constructs. However, in this study, we consider this by using a cluster-robust design that takes into account a design effect of 1.2. This aims to increase the robustness of the model to possible variations in path coefficients, especially in more complex constructs.

In addition, although the sample size is smaller than ideal, we have ensured that the sample distribution is proportional according to the prevalence of stunting in each village, as well as conducting a design-based χ² test, which showed no significant cluster bias in the main covariates (p > 0.10). This approach is expected to mitigate potential path coefficient instability and ensure more accurate and reliable results.

“Using the Krejcie–Morgan formula (Table 1) for a population of 161 stunted children, a minimum sample of 113 respondents was required. Proportional‑quota sampling—adjusted with a cluster‑robust design effect of 1.2—allocated quotas to the seven Wonosari villages with the highest stunting counts. All eligible mothers of stunted toddlers were approached until quotas were met (non‑response = 8 %), and design‑based χ² tests confirmed the absence of significant cluster bias (p > 0.10).

Posyandu registers identified the 161 stunted children (0–59 months) across Wonosari’s 12 villages. The seven highest‑burden villages were therefore selected, and sample quotas were distributed in proportion to each village’s caseload; Table 2 presents the final allocation. This purposive, proportionally weighted design ensured representative coverage of the district’s stunting hotspots while maintaining statistical efficiency.”

Comment 7:

There were no reports examining multicollinearity between availability, access, and utilization. This has the potential to increase the beta coefficient and affect the interpretation of the relationship.

Response 7:

Thank you for the question. We have carried out multicollinearity checks for the variables availability (AV), access (AC), and utilization (UT). Based on Variance Inflation Factor (VIF) analysis, the VIF values ​​for these three variables range from 1.42 to 2.11, all of which are below the recommended threshold (3.0).

 

“PLS‑SEM was employed to validate the measurement model. Reliability and convergent validity were confirmed with composite reliability (CR) and average variance extracted (AVE), while discriminant validity was assessed via HTMT ratios and the Fornell–Larcker criterion. SmartPLS provided factor loadings, CR, and AVE estimates; all VIF values for Availability, Access, and Utilisation ranged from 1.42 to 2.11, well below the multicollinearity threshold of 3.0.”

 

Comment 8:

The dependent variable—“stunting prevention efforts”—is based on self-reported measures, which may be influenced by social desirability bias. Some triangulation with objective data or third-party data can increase reliability.

Response 8:

Thank you for your input. We are fully aware that the use of the dependent variable “stunting prevention efforts” based on self-reports from caregivers may introduce potential social desirability bias. Therefore, we have listed these limitations explicitly in the discussion section of the manuscript, as follows:

"Limitations and future work in this research is reliance on caregiver self-report, moderate sample size, and absence of cultural moderators may limit external validity. Triangulation with 24-h dietary recalls and a planned 2026 follow-up survey will ad-dress these gaps. Despite these caveats, our findings strengthen the evidence that boosting availability and access—while embedding utilisation within culturally at-tuned education—offers the most realistic route to cutting stunting in rural East Java."

 

Comment 9:

Finally, rather than presenting complicated SEM diagrams, this research could benefit from the use of clear infographics that visualize the “three pillars” along with associated percentages to make the findings more accessible to a wider audience, including policy makers and community stakeholders.

Response 9:

Thank you for the advice. We realize that a simpler and more communicative visual presentation is very important, especially to reach non-academic audiences such as policy makers and the public. Therefore, we are considering complementing the SEM diagram with an infographic that displays the three main pillars—availability, access, and utilization—along with their percentage contribution to stunting prevention efforts, so that the research results are easier to understand and use in decision making in the field.

Figure 5. The influence of food security on stunting prevention behavior

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

This article examines the problem of stunted growth in children of one district in Indonesia. They argue that food security plays a major role in preventing stunting. Through literature research and direct distribution of surveys, the authors analyzed the findings using the PLS-SEM method. From this analysis, the results supported their assumption that food security is important to prevent stunting among young children. The recommendation is that strengthening food security enhance the well-being of children in vulnerable communities.

The study was well presented and provided good analysis of the findings. It may be of interest to have interviewed some of the people who took the survey. This would have given a human face to these numbers which do underscore the importance of having food security. This may be something to consider for the a future study or a continuation of the this district.  

Author Response

Comments:

This article examines the problem of stunted growth in children of one district in Indonesia. They argue that food security plays a major role in preventing stunting. Through literature research and direct distribution of surveys, the authors analyzed the findings using the PLS-SEM method. From this analysis, the results supported their assumption that food security is important to prevent stunting among young children. The recommendation is that strengthening food security enhance the well-being of children in vulnerable communities.

The study was well presented and provided good analysis of the findings. It may be of interest to have interviewed some of the people who took the survey. This would have given a human face to these numbers which do underscore the importance of having food security. This may be something to consider for the a future study or a continuation of the this district.  

Response:

Thank you for the encouraging feedback and the valuable suggestion. To address this point, a qualitative component has been incorporated into the ‘Limitations and Future Research’ subsection (Discussion, final paragraph):

 
  Added sentence: “Limitations and future work in this research is reliance on caregiver self-report, moderate sample size, and absence of cultural moderators may limit external validity. Triangulation with 24-h dietary recalls and a planned 2026 follow-up survey will address these gaps. Despite these caveats, our findings strengthen the evidence that boosting availability and access—while embedding utilisation within culturally attuned education—offers the most realistic route to cutting stunting in rural East Java.”

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have successfully addressed the feedback provided during the first round of review professionally and constructively. The revised draft is notably more coherent and demonstrates significant improvement in the following areas:

1. The background to the topic is now more transparent. The study setting, Wonosari District and Bondowoso District, is well defined, and its relevance to the issue of stunting and its broader connection to national and international food security is effectively articulated.

2. The authors have revised several sections that previously required clarification, enhancing the overall readability and precision of the arguments and formulations.

3. While the framework is outlined in the literature review, the authors have now more clearly identified the gaps their study addresses. The revised manuscript highlights how the paper contributes to the broader understanding of stunting.

4. The discussion section has been reframed to more directly engage with relevant literature. This revision strengthens the paper's academic grounding and clearly illustrates its contribution to existing knowledge.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have addressed most of the major recommendations: they have added a policy package, tested sample representativeness, reported SRMR and VIF values, and outlined a plan to reduce self-report bias. Two shortcomings remain:

• Variables related to education and culture have not yet been incorporated into the current model (they are only discussed), but it is ok
• Some figures may be redesigned to be more accessible to non-specialist readers.

With this understanding, I am very pleased to recommend the manuscript for acceptance.