In the Field in Lombok: Capacity Building and the Fight Against Stunting

Written by Dr Isobel Gabain, Global Centre for Neglected Tropical Disease Research, with contributions from Dr Martin Walker and Professor Joanne Webster (Global Centre for Neglected Tropical Disease Research) and Mifa Nurfadilah, Dr. Min Kyaw Htet and Dr. Umi Fahmida (Southeast Asian Ministers of Education Organization, Regional Centre for Food and Nutrition (SEAMEO RECFON))

A little Indonesian girl, around five years old, stands very still as the enumerator lowers the stadiometer gently into place. Her height is recorded, then her weight, followed by a structured set of questions for her mother about the household, her child’s recent health, and feeding practices. A stool sample is then collected for parasitological analysis. The whole process takes only half an hour; she recognises the enumerators, who have visited regularly throughout her mother's pregnancy and at repeated follow-up points across her first few years of life. Each party understands their role and trusts the other. This visit follows several years of relationship-building between enumerators, researchers and the community in East Lombok.

Approximately 150.2 million children under five were classified as stunted globally in 2025, defined as falling more than two standard deviations below the World Health Organization's (WHO's) height-for-age z-score. Parasitic infections are thought to contribute to stunting through multiple pathways, yet causal evidence remains incomplete (Gabain et al., 2023). The Action Against Stunting Hub (AASH) was a UK Research and Innovation (UKRI)-funded project which followed approximately 600 mother-child pairs across the first 1000 days of life - from pregnancy through to two years of age in Indonesia. Although the AASH programme has now finished, the cohort children in Indonesia have been regularly followed up by the team until now.  

This offers a rare and important opportunity to examine both their current parasitic infection status and how earlier maternal and child infection relate to their physical growth and development before they enter school. The timing matters, because school entry marks a major transition in children’s mobility, social mixing and environmental exposures, all of which may alter infection risk. Continued engagment with the cohort also helps establish the feasibility of future follow-up through later childhood and adolescence. Such longitudinal cohorts, with detailed early-life exposure data already in place, are rare and offer an unusual opportunity to understand how infection and other early-life factors shape growth and development across the life course.

In March 2025, Dr Martin Walker and Dr Isobel Gabain travelled to Lombok, Indonesia, for this purpose. The visit had two aims: to deliver hands-on capacity building training to our Indonesian research partners, and to visit the AASH field site in East Lombok, where the cohort of mothers and children live, and where this school-aged children follow up was to take place.

Capacity Building Component

A key aim of the visit was to support in-country analytical capacity for the next phase of the project. The school-age follow-up will generate a rich dataset linking parasitology, growth and developmental measures collected across multiple time points. To help ensure these analyses can be led within Indonesia, we delivered targeted training for staff and students from our partner institution, SEAMEO RECFON at the Universitas  Indonesia, with some participants joining us in person in Mataram and others online from Jakarta.

Martin opened the training with a deep dive into the analysis of longitudinal datasets: how to handle data collected from the same individuals at multiple time points, and how to draw meaningful conclusions from that complexity. Following this, he led a practical workshop in R, allowing participants to work through applied examples relevant to longitudinal cohort analysis. Isobel then provided training on directed acyclic graphs (DAGs), a method used to map assumed causal relationships between variables before beginning analysis. DAGs can help identify which factors should be accounted for in statistical models and are especially useful when working with complex longitudinal data. Participants again had the opportunity to put the theory into practice in a workshop setting. Finally, Martin then returned to provide training on the transmission dynamics of infectious diseases - giving giardiasis as an example, exploring how such parasitic infections can spread through populations, and how mathematical models can help us to understand and predict that process.

Together, these sessions were designed not only to support analysis of the upcoming school-age follow-up, but also to strengthen broader in-country capacity in handling and interpreting complex epidemiological datasets. The skills covered are directly relevant to analysing the AASH cohort data - approximately 600 mother-child pairs tracked from pregnancy through early childhood, and now into the preschool years - and to supporting country-led analysis of future follow-up work. Training materials from all three sessions will also be made available on our GCNTDR webpage for wider use.

In The Field

We left Mataram behind and drove to East Lombok to visit the AASH Hub office and join the field team for a day of data collection. The Hub office was set up specifically for the AASH project - shelves of folders and files documenting years of careful, methodical work. We met the local enumerators who carry out the fieldwork, travelling by motorbike to reach families in the area. Being local to East Lombok themselves, they bring familiarity and allow visits to run smoothly. Then we went to visit a cohort mother and her daughter. The interview with the mother was conducted with great care and sensitivity, using a structured questionnaire covering household and child health information, while the child’s measurements and stool sample were collected, labelled and logged efficiently for later analysis.

Looking Ahead

The children in this cohort are now approaching five years old. This is a critical point just before school entry, when we have a rare opportunity to assess their current growth, development and parasitic infection status, and to explore how infection in early life may have shaped these outcomes. This is the next phase of our project, and the analytical capacity we built during our time in Lombok, we hope, will be useful for the team.

We left Indonesia with a shared sense of purpose, and a great appreciation for the dedication of our Indonesian colleagues. Our deepest thanks go to Dr Umi Fahmida, Dr Min Kyaw Htet, Mifa Nurfadilah and all the staff and students at SEAMEO RECFON and in the field teams in East Lombok.

Testimonials

 “The training significantly strengthened my understanding of longitudinal data analysis and how to apply it in real cohort studies. The combination of hands-on R practice and conceptual sessions on mixed models and DAGs will be very valuable for improving the rigor of our future analyses and publications.”

–             ECR (Mifa Nurfadilah)

“This training provided valuable new perspectives on advanced longitudinal modelling, particularly in analysing infections as both exposures and outcomes within dynamic cohort settings. The focus on time-varying exposures, including lagged and cumulative infection measures, as well as age-and context-specific effect modifications, was especially relevant to our work. These insights will directly strengthen the analytical rigor of our future research on child health, infection, and nutrition within the AASH cohort.”

– Theme lead (Min Kyaw Htet):

This blog was written by Dr Isobel Gabain, Dr Martin Walker and Professor Joanne Webster, Royal Veterinary College / Global Centre for Neglected Tropical Disease Research

Mifa Nurfadilah, Dr. Min Kyaw Htet and Dr. Umi Fahmida , Southeast Asian Ministers of Education Organization, Regional Centre for Food and Nutrition (SEAMEO RECFON)

This work is funded by Research England and the Royal Veterinary College through the Global  Centre for Neglected Tropical Disease Research (GCNTDR).

Training materials will be available shortly on our GCNTDR webpage.