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Determinants of Diarrhea among Children under Two Years Old in Indonesia

I Komang Ayu Santika, Ferry Efendi, Praba Diyan Rachmawati, Eka

Misbhahatul Marah Has, Kusnanto Kusnanto, Erni Astutik

PII: S0190-7409(19)31443-4
DOI: https://doi.org/10.1016/j.childyouth.2020.104838
Reference: CYSR 104838

To appear in: Children and Youth Services Review

Received Date: 13 December 2019

Revised Date: 5 February 2020
Accepted Date: 5 February 2020

Please cite this article as: I. Komang Ayu Santika, F. Efendi, P. Diyan Rachmawati, E. Misbhahatul Marah Has,
K. Kusnanto, E. Astutik, Determinants of Diarrhea among Children under Two Years Old in Indonesia, Children
and Youth Services Review (2020), doi: https://doi.org/10.1016/j.childyouth.2020.104838

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 Determinants of Diarrhea among Children under Two Years Old in Indonesia

Authors

1. I Komang Ayu Santika

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
Email: santikayu97@gmail.com

2. Ferry Efendi
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
School of Nursing and Midwifery, La Trobe University, Australia
Email: ferry-e@fkp.unair.ac.id

3. Praba Diyan Rachmawati

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
Email: praba-d-r@fkp.unair.ac.id

4. Eka Misbhahatul Marah Has

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
Email: eka.m.has@fkp.unair.ac.id

5. Kusnanto Kusnanto
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
Email: kusnanto@fkp.unair.ac.id

6. Erni Astutik
Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
postal address: Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
Email: erniastutik@fkm.unair.ac.id

Corresponding author:
Ferry Efendi

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

Jl. Mulyorejo Kampus C Unair, Surabaya, Indonesia
+6281331533805 (M)
+62315913257 (O)
Email: ferry-e@fkp.unair.ac.id
Abstract

Introduction: Diarrhea among children under two years old remains a big challenge for the
Indonesian government due to its association with fatal cases. Diarrhea can be caused by factors
such as socio-demographics, the environment, and behavioral childcare practices. This study
aimed to assess the associated factors of diarrheal diseases among children under two years old
in Indonesia. Methods: Cross-sectional data was obtained from the 2017 Indonesia
Demographic and Health Survey (IDHS) used for the study. A total of 5,858 children, aged 0–
23 months and who lived with their mothers, were selected for this study. Binary logistic
regression was utilized to examine the determinants of diarrhea. Results: The prevalence of
diarrhea among Indonesian children under two years old was 17.16%. The mother’s age
[AOR=1.63; 95% CI=1.28–2.08], the education of the mother [AOR=1.80; 95% CI=1.35–
2.40], the type of toilet [AOR=1.40; 95% CI=1.14–1.72], non-exclusively breastfeeding
[AOR=3.30; 95% CI=2.32–4.69], and feeding from a bottle [AOR=1.21; 95% CI=1.02–1.45]
were all significantly associated with the occurrence of diarrhea. Conclusions: socio-
demographic, environmental, behavioral and childcare practice characteristics are associated
with diarrhea among children under two years old in Indonesia. This study highlighted the need
for environmental improvement and healthy behavior to reduce the number of diarrhea cases.
Increasing the awareness of the mother through counseling and health promotion about the
essential benefit of breastfeeding is inevitable. Hygiene practices should be promoted at the
household level for those who care for young children.
Keywords: diarrhea; child; Demographic and Health Survey.

Factors Associated with Diarrhea among Children under Two Years Old in Indonesia

Introduction

Globally, diarrhea is the second leading cause of death in children after pneumonia (WHO,
2017). Every year, there are 1.7 billion children who experience diarrhea and at least 525,000
die from diarrhea. Child under 3 years old experience about 3 episodes of diarrhea per year
(WHO, 2017). In low-middle income countries such as Indonesia, diarrhea still remains one of
the health problems due to its high morbidity and mortality (Kemenkes, 2011). In Indonesia,
diarrhea was the third leading cause of death in children after pneumonia and nervous system
disease (BAPPENAS, 2015). According to recent reports, it was estimated that around 7
million diarrhea cases occurred at health facilities in 2018 (Kementerian Kesehatan, 2018). All
ages are at risk of diarrhea, but the highest case of diarrhea was in children under 2 years of
age, with the highest percentage being at the age of 12–23 months at 20%, followed by age 6–
11 months at 19% (BPS, BKKBN, Kementerian Kesehatan, & ICF, 2018).
According to the national data from Indonesian Demographic and Health Survey (IDHS)
between 2002 and 2007, the prevalence of diarrhea among children under-five increased. In
2002, the prevalence of diarrhea among children under-five was 11% and increased to 13.7 %
in 2007 (BPS, BKKBN, & Kementerian Kesehatan RI, 2007). Further, data from 2012 to 2017
showed the prevalence of diarrhea at 14% in children (BPS, BKKBN, & Kemenkes RI, 2002,
2012, 2017, 2007). In addition, according to data from the Basic Health Survey 2018, the
incidents of diarrhea among children under five years of age has decreased from 2013;
however, it still shows a high rate of 12.3% (Kemenkes RI, 2018). Both IDHS and the Basic
Health Survey show that the percentage of diarrhea among those under 2 years old is the highest
among children under five years of age. Indonesia is not only struggling to decrease the
maternal mortality rate (Kurniati, Chen, Efendi, & Berliana, 2018) but also the infant and child
mortality rate as well (UNICEF, 2019); hence, this study is imperative to improve the quality
of the health services.
Previous studies that have examined the determinants of diarrhea have been done in multiple
countries, such as Ethiopia, Tanzania, Indonesia, Nigeria, and Brazil. A study conducted in
Ethiopia found that there are three factors that determined the rate of diarrhea among children:
social determinants, child care practice factors, and environmental factors (Anteneh, Andargie,
& Tarekegn, 2017). Previous research conducted in Indonesia in 2012 reported that the
mother’s age, the mother’s occupation, economic status, the children’s sex, and population
density had a significant association with diarrhea among children aged under five years old
(Eka Susanti, Novrikasari, & Sunarsih, 2016). However, studies focused on the determinants
of diarrhea among children under two years old are very rare in Indonesia.
Identifying the causes of diarrhea among children under two years old is very important in
order to learn the right prevention method that can be used to formulate an effective policy.
Therefore, this study was conducted to examine the determinants of diarrhea among children
under two years old in Indonesia.

Method
Data source
This study used IDHS 2017, which is data collected by Indonesian stakeholders with help from
Inner City Fund (ICF) International. The survey was completed in December 2017, and it
employed the cross-sectional method to collect the data. The children’s dataset was used for
this study. It contains information about children under five years old, and their health was
used as an indicator. The data about the mother of each child was also included in this dataset.
Sample size and sampling
IDHS used two-stage stratified cluster sampling to select the respondents. There were 49,627
women aged 15–49 years old who were successfully interviewed, among which this study used
the information from mothers whose youngest child was under 2 years old. According to the
inclusion criteria, 5,858 mothers were included in this study.
Variables
Dependent variable
The dependent variable of this study was diarrhea, defined as the passage of three or more loose
or liquid stools per day (WHO, 2017). This was based on the mother’s recall for each child
during the 2 weeks before the survey.
Independent variable
Due to the number of respondents per age group, the mother’s age was divided into three
categories: 15–24 years, 25–34 years, and 35–49 years. The mother’s education was divided
into four categories, namely no education, primary education, secondary education, and higher
education. The sex of the child was divided into two categories: male and female. The wealth
quintile was divided into five categories: poorest, poorer, middle, richer, and richest. To divide
wealth quintile into categories, households are given scores based on the number and kinds of
consumer goods they own, ranging from a television to a bicycle or car, and housing
characteristics, such as source of drinking water, toilet facilities, and flooring materials (BPS
et al., 2017). Based on data and categorization from the Indonesian Population Census in 2010,
residence was divided into two categories: rural and urban. The classification between rural
and urban determined by the bureau of statistics (BPS, 2010). The source of drinking water and
the type of toilet were both divided into two categories: improved and not improved. An
improved source of drinking water includes piped water, public taps, standpipes, tube wells,
boreholes, protected dug wells and springs, and rainwater. Improved types of toilets include
toilets that are used by only one household with a septic tank or non-septic tank.
The time of breast milk feeding initiation was divided into three categories: ≤ 1 hour, 2–23
hours and ≥ 24 hours. Exclusive breastfeeding and bottle feeding were divided into two
categories, namely yes and no. Exclusive breastfeeding is defined as the proportion of children
who received breast milk as their only source of nourishment in the first 6 months. They were
allowed an oral rehydration solution, drops or syrup in the form of vitamins and medicines.
Bottle feeding is defined as the proportion of children who received any liquid (including breast
milk) or semi-solid food from a bottle with a nipple in the night before the survey.
Data analysis
STATA version 14.0 was used to process the analysis of this study, including checking for the
completeness of the data. Both chi-square and binary logistic regression were performed to
assess the determinants of diarrhea among children under two years old. The strength of the
association between the independent and dependent variable was assessed using an odds ratio
with a 95% confidence interval. The variables were significant with a p-value of 0.05 and 95%
CI, which are considered to be the determinant factors of diarrhea in children under two years
old. Ethical clearance was granted by the Ministry of Health of Indonesia. Permission to use
the dataset was obtained from ICF International, part of the Demographic Health Survey
program.
Results
The prevalence of diarrhea occurred in 1,005 (17.16%) of the 5,858 children under 2 years of
age during the two weeks before the survey. Among the mothers who were interviewed, more
than half of the mothers were 25–34 years old (52.59%) and the majority had completed
secondary education (59.16%). According to child’s sex, diarrhea occurred more with males
(51.14%) than with females (48.86%). More than half of the respondents were from a rural area
(51.81%) and about 20.57% of respondents were from a poorer family (Table 1).

Table 1 – Socio-demographic characteristics of the respondents in Indonesia, 2017

Characteristics N %
Mother’s age
15-24 1397 23.85
25-34 3081 52.59
35-49 1380 23.57
Mother’s education
No education 56 0.95
Primary education 1356 23.14
Secondary education 3465 59.16
Higher education 981 16.75
Child’s sex
Male 2996 51.14
 Female 2862 48.86
Residence
Rural 3035 51.81
Urban 2823 48.19
Wealth index
Poorest 1117 19.07
Poorer 1205 20.57
Middle 1176 20.08
Richer 1195 20.39
Richest 1165 19.88

Among the mothers who were interviewed, 5,256 (89.73%) had an improved source of drinking
water in the house. The majority of the toilet facilities—4,781 (81.62%)—were also already
improved (Table 2).

Table 2 – Environmental characteristics of the respondents in Indonesia

Characteristic N %
Source of drinking water
Improved 5256 89.73
Not improved 602 10.27
Type of toilet facility
Improved 4781 81.62
Not improved 1077 18.38

Among the mothers who were interviewed, 3,548 (60.58%) gave breast milk to their child 1
hour after birth. The majority of children were not given milk exclusively (86.86%). About
1,994 mothers (34.04%) used a bottle and nipple to feed their child, while 3,864 (65.96%) did
not (Table 3).

Table 3 – Behavioral and childcare practice characteristics of the respondents in Indonesia in

2017
Characteristics N %
Time of breast milk feeding initiation
 ≤ 1 hour 3548 60.58
2–23 hours 1080 18.43
≥ 24 hours 1230 20.99
Exclusive breastfeeding
Yes 770 13.14
No 5088 86.86
Bottle feeding
Yes 1994 34.04
No 3864 65.96

Determinants of diarrhea among children under 2 years old in Indonesia

Bivariate analysis
In the bivariate analysis, almost all the variables show a significant association with diarrhea
incidents, except for the child’s sex and the time of breast milk feeding initiation (Table 4).

Table 4 – Bivariate analysis of the determinants of diarrhea among children under 2 years old
in Indonesia
Diarrhea
Variables Yes No X2
N % n %
Mother’s age
15–24 308 5.27 1088 18.58
32.74***
25–34 485 8.28 2596 44.31
35–49 212 3.61 1169 19.95
Mother’s education
No education 12 0.21 44 0.75
Primary education 261 4.46 1094 18.68 27.58***
Secondary education 617 10.53 2849 48.63
Higher education 115 1.96 866 14.78
Child’s sex 3.43
 Male 540 9.22 2455 41.91
Female 465 7.94 2398 40.93
Residence
Rural 556 9.5 2478 42.31 6.33*
Urban 449 7.66 2375 40.53
Wealth index
Poorest 141 2.41 976 16.66
Poorer 215 3.67 990 16.91
22.58**
Middle 210 3.58 966 16.5
Richer 212 3.62 983 16.78
Richest 228 3.89 937 16
Source of drinking water
Improved 875 14.94 4382 74.8 9.90**
Not improved 130 2.22 471 8.04
Type of toilet facility
Improved 767 13.09 4015 68.53 24.08***
Not improved 238 4.07 838 14.31
Time of breast milk feeding
initiation
≤ 1 hour 591 10.09 2957 50.48 4.15
2–23 hours 180 3.06 900 15.37
≥ 24 hours 235 4 995 16.99
Exclusive breastfeeding
Yes 49 0.84 721 12.3 9.44***
No 956 16.32 4132 70.54
Bottle feeding
Yes 383 6.54 1611 27.49 74.87*
No 622 10.62 3242 55.35
*p-value<0.05; **p-value<0.01; ***p-value<0.001

Multivariate analysis
In multivariate analysis, logistic regression with backward stepwise method was used to assess
the association between the independent and dependent variables. Finally, the mother’s age,
the mother’s education, the type of toilet facility, exclusive breastfeeding, and bottle feeding
all have significant associations with the occurrence of diarrhea among children under 2 years
old in Indonesia.
According to the results of the multivariate analysis, children of mothers aged 15–24 years old
had about 1.63 times greater odds of having diarrhea than children whose mothers were aged
35–49 years old [AOR=1.63; 95% CI=1.28–2.08]. The risk of diarrhea among the children of
mothers with primary education was 1.8 times greater [AOR=1.80; 95% CI=1.35–2.40],
similar to the children whose mothers had secondary education when compared to the children
of mothers with higher education [AOR=1.54; 95% CI=1.20–1.96]. Children from households
that do not have an improved type of toilet facility have 1.4 greater odds of having diarrhea
than children from households with improved toilet facilities [AOR=1.40; 95% CI=1.14–1.72].
The risk of diarrhea increases by about three times in children who are not given exclusive
breastfeeding compared to children who are given exclusive breastfeeding [AOR=3.30; 95%
CI=2.32–4.69]. When children are bottle-fed, the risk increased to about 1.21 times more than
children who do not use a bottle [AOR=1.21; 95% CI=1.02–1.45] (Table 5).

Table 5 – Multivariate analysis of the determinants of diarrhea among children under 2 years
old in Indonesia
95% CI
Variables AOR
Lower Upper
Mother’s age
15–24 1.63*** 1.28 2.08
25–34 1.11 0.90 1.38
35–49 1.00
Mother’s education
No education 1.93 0.92 4.07
Primary education 1.80*** 1.35 2.40
Secondary education 1.54*** 1.20 1.96
Higher education 1.00
Type of toilet
Improved 1.00
Not improved 1.40*** 1.14 1.72
 Exclusive breastfeeding
Yes 1.00
No 3.30*** 2.32 4.69
Bottle feeding
Yes 1.21* 1.02 1.45
No 1.00
*p-value<0.05; **p-value<0.01; ***p-value<0.001

Discussion
In Indonesia, the highest prevalence of diarrhea was found in those aged under two
years old. This is consistent with previous studies conducted in Ethiopia (Asfaha et al., 2018;
Mihrete, Alemie, & Teferra, 2014). In Ethiopia, diarrhea was mostly found in children aged 6–
23 months, with the highest peak at age 12–23 months before it started to decrease at 24
months. Children aged 4–12 months old will start to sit, crawl, and walk. Not only that but at
the age of 6 months, the children will start to feed on another food besides breast milk
(Chojnacki et al., 2019; Sembiring, 2017). These will increase how much the child is exposed
to microorganisms from the environment or their food. Therefore, intervention to improve
hygiene practice is needed to prevent the spread of the microorganism.
The mother’s age and education showed a significant association with diarrhea among
children under 2 years old, after adjusting for the other variables. The children with the
youngest mothers had greater odds of experiencing diarrhea. This finding is consistent with
previous research conducted in Kenya (Mbugua et al., 2014). The age of the mother relates to
their experience of childcare practices (Pinzón-Rondón, Zárate-Ardila, Hoyos-Martínez, Ruiz-
Sternberg, & Vélez-van-Meerbeke, 2015). Younger mothers may lack experience in good and
effective childcare practice, so the risk of diarrhea in the children would increase. Therefore, it
is necessary to consider providing education about childcare practices to young mothers to
enable the mothers to be more prepared and educated about good childcare.
The children of mothers who had a primary school level of education have 1.80 greater
odds of having diarrhea. This is consistent with the studies done in Ethiopia, which was
reported having prevalence of the diarrhea under two years old. In Ethiopia, the children of
mothers who had low education had a three times higher risk of having diarrhea (Angesom,
2015). Education will relate to the knowledge of the mothers as related to their children's health
status. Educated mothers may have more knowledge about diarrhea prevention, such as
hygiene practices, optimal feeding for their children, and good environmental sanitation
(Mihrete et al., 2014). In addition, mothers with low education may have a lower desire to seek
information regarding diarrhea prevention, so they may not have enough knowledge about how
to prevent diarrhea (Mbugua et al., 2014). The mother’s knowledge on diarrhea prevention will
influence the attitudes and actions of the mothers in turn. Therefore, education regarding the
prevention of diarrhea should be prioritized for mothers who have a low level of education.
The type of toilet facility was found to have a significant association with diarrhea
among children under two years old after controlling the other variables. Children from the
households that do not have an improved type of toilet facility have 1.4 greater odds of
experiencing diarrhea compared to children from the households with an improved type of
toilet facility. This finding is consistent with the previous studies in Ethiopia (Asfaha et al.,
2018; Dessalegn et al., 2011; Mihrete et al., 2014). An improved type of toilet facility, where
the fecal shelter is protected from the outside environment, reduces the possibility of contact
between insects and the feces. The absence of contact between insects and the feces inhibits
the transmission of diarrheal pathogens to food and drink (Asfaha et al., 2018). The more
households that have an improved type of toilet facility, the more that the risk of diarrhea will
decrease. This is because the transmission of diarrheal pathogens is inhibited. Therefore,
education about the Open Defecation Free (ODF) program should be able to encourage people
who do not have improved toilet facilities.
Exclusive breastfeeding and bottle feeding are significantly associated with diarrhea
among children under 2 years after controlling the other variables. This is consistent with the
previous studies conducted in Tanzania, Nigeria, and Brazil (Ogbo, Page, Idoko, Claudio, &
Agho, 2016; Ogbo, Nguyen, Naz, Agho, & Page, 2018; Santos et al., 2016). Exclusive
breastfeeding has also become the most influential factor in diarrhea incidents among children
in Indonesia. Breast milk is the best nutrition for a baby because it provides all that the baby
needs (Espósito & Córdoba, 2018). Breast milk will stimulate the innate immune system and
epigenetic program, which is important to prevent infection, including that of diarrhea (Verduci
et al., 2014). In addition, exclusive breastfeeding also protects the baby from food that may be
contaminated with diarrheal pathogens (Ogbo et al., 2018). Therefore, education about the
importance of exclusive breastfeeding needs to be given to the mothers. The more mothers who
exclusively breastfeed their children, the more that the incidents of diarrhea will decrease.
Children who were bottle-fed had 1.21 greater odds of experiencing diarrhea than
children who did not use a bottle. This finding is consistent with the study done in the sub-
Saharan African countries and Tanzania (Ogbo et al., 2017; Ogbo et al., 2018). Bottle feeding
increases the risk of children being exposed to diarrheal pathogens, either from the bottle or
from the fluids given (Ogbo et al., 2016). The risk of contamination can occur because of
improper hygiene when cleaning the bottle and preparing the fluid. Currently, bottle feeding is
commonly found in the community. Therefore, education about proper hygiene when cleaning
the bottle and preparing the fluid is needed. If the bottles or drinks are free from microorganism
contamination, then incidents of diarrhea can be prevented.
The limitations of this study were as follows: the data for this study was collected using
the cross-sectional method. Second, the diarrhea incidents were assessed based on the mother’s
self-recall during the two weeks before the survey. Despite the limitations, this study also has
strength. The data used was nationally representative and collected with an international
standardized questionnaire that was largely based on standard DHS phase 7 questionnaires.

Conclusion
The mother’s age, the mother’s education, the type of toilet facility, exclusive breastfeeding,
and bottle feeding remain significant factors in the occurrence of diarrhea in children under
two years old. Health promotion about diarrhea should be prioritized for young and low
educated mothers. The health programs that have already been made, such as zero open
defecation and an exclusive breastfeeding program, should be improved throughout the
communities. A health campaign about the hygiene practices of parents when preparing for
bottle feeding should be initiated while improving the participation of the mothers in exclusive
breastfeeding.

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Highlights

Exclusive breastfeeding remains a promising strategy to diminish diarrhea.

Improving education for all mothers is essential in the occurrence of diarrhea among children.

The absence of a toilet relates to the higher occurrence of diarrhea.

Health promotion regarding proper hygiene and sanitation is compulsory.

Authors statement

IKAS, FE, PDR, EMMH, KK, EA: Conceptualization, Methodology.

IKAS, FE, PDR, EMMH, KK, EA: Data curation, Writing- Original draft preparation.

FE, PDR, EMMH, EA: Supervision.

IKAS, FE, PDR, EMMH, KK, EA: Writing- Reviewing and Editing,