Journal of Epidemiology and Public Health (2018), 3(3): 342-352

https://doi.org/10.26911/jepublichealth.2018.03.03.05

Analysis of the Contextual Effect of Village Characteristics and

Other Determinants of Diarrhea in Children Under Five,
Banjarnegara, Central Java

Lusia Arina Cahyaningrum1)3), Setyo Sri Rahardjo 2), Bhisma Murti1)

1)Masters Program in Public Health, Universitas Sebelas Maret

2)Faculty of Medicine, Universitas Sebelas Maret
3)District Health Office Banjarnegara, Central Java

ABSTRACT

Background: Diarrheal disease is the leading cause of child death and illness in the world.
Diarrhea is one of the most potent endemic diseases in Indonesia. Children under five were the
most affected group by this disease. This study aimed to determine the effect of nutritional status,
information exposure, prevention behavior, income, social capital, and environmental sanitation
on the incidence of diarrhea in children under five in Banjarnegara District, Central Java, using
multilevel analysis.
Subjects and Method: This was an analytic observational study with a case-control design. The
study was conducted in Banjarnegara, Central Java, from January to February 2018. A total of 25
villages was selected using stratified random sampling, based on village stratification criteria. A
sample of 250 children under five was selected for this study by fixed disease sampling, consisting
of 125 children with diarrhea and 125 healthy children. The dependent variable was diarrhea. The
independent variables at level 1 were nutritional status, information exposure, prevention
behavior, income, social capital, and environmental sanitation. Village stratification was used as
the contextual factor at level 2. The data were collected by a set of pre-tested questionnaire and
analyzed by multilevel logistic regression analysis using Stata 13.
Results: Poor nutritional status (b= 1.33; 95% CI= -0.14 to 2.82; p= 0.077), poor prevention
behavior (b= 1.52; 95% CI= 0.81 to 2.24; p<0.001), low income (b= 1.52; 95% CI= 0.80 to 2.25;
p<0.001), weak social capital (b= 1.80; 95 % CI= 1.04 to 2.56; p<0.001), and poor environmental
sanitation (b= 1.12; 95% CI= 0.39 to 1.85; p= 0.003) increased the risk of diarrhea. Exposure to
information (b= 0.90; 95% CI= 0.17 to 1.64; p= 0.015) decreased the risk of diarrhea. The village
stratification showed a strong contextual effect on the incidence of diarrhea with intra-class
correlation (ICC)= 15.78%.
Conclusion: Poor nutritional status, poor personal hygiene, low income, weak social capital, and
poor environmental sanitation increase the risk of diarrhea.

Keywords: determinant, diarrhea, children under five, multilevel analysis

Correspondence:
Lusia Arina Cahyaningrum. Masters Program in Public Health, Universitas Sebelas Maret, Jl. Ir.
Sutami 36 A, Surakarta, Indonesia. Email: [email protected].
Mobile: +6282226835687.

BACKGROUND tation. Infectious diarrhea is widespread

Diarrheal disease is the leading cause of throughout developing countries (WHO /
children death and illness in the world, and UNICEF, 2017).
is largely due to contaminated food and In total, an estimated of 58% (34-
water sources. Worldwide, 780 millions 72%) of all diarrheal cases occur in low-
people lack access to good drinking water and middle-income countries, or 57%
and 2.5 billions do not have good sani- worldwide, due to the environment, result-

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ing in 842,000 deaths annually (Prüss- diarrhea (Ma et al., 2014; Pang et al., 2015;
Ustün et al ., 2012). Children under the age Budhathoki et al., 2016)
of three experience an average of three The incidence of the disease is
episodes of diarrhea each year in low- closely linked to a risk factor that is
income countries. Each episode removes basically all of the factors that play locally
the nutrients needed for growth. As a specific in each disease event. One strategy
result, diarrhea is a major cause of mal- which is in line with the concept is the Desa
nutrition, whereas malnourished children Siaga program which is expected to be able
are more likely to experience diarrhea to independently identify the risk factors,
(WHO / UNICEF, 2017). overcome health problems and be able to
Diarrhea is still one of the most apply clean and healthy living behavior
potent endemic diseases in Indonesia and (PHBS) (Ministry of Health RI 2010).
often leads to death. Based on infectious The proportion of cases of diarrhea
diseases, diarrhea is the third leading cause in Central Java, in 2015 was about 67.7
of death after TB and Pneumonia (Ministry percent. The clinical prevalence of diarrhea
of Health, 2011b). in Central Java was 4.7%, the rate is greater
The incidence of diarrhea based on than the prevalence of clinical diarrhea in
symptoms in all age groups was 3.5% and Indonesia of 3.5% (Dinkesprop Jateng,
incidence of diarrhea in children under five 2017).
was 6.7%. The period prevalence of The estimated number of people with
diarrhea of all age groups was 7% and in diarrhea in Banjarnegara Regency is 21,702
children under five was 10.2%. The group of people from 1,041,104 population of
diarrhea sufferers is mostly in the age Banjarnegara. Meanwhile, the number of
group of children under five (Ministry of diarrhea sufferers reported was handled at
Health, 2013). the health facility was 22,306 people (101,
Based on the Health Profile of 5%). The percentage of population with
Indonesia, in 2015, there were outbreaks of decent sanitation access (healthy latrines)
diarrhea spread in 11 provinces, 18 districts is still quite low at 45.1%. The number of
/ cities, with the number of 1,213 people villages that have implemented the beha-
with 30 deaths and 2,47% case fatality rate vior of stop defecating arbitrarily ranged
(CFR). The mortality rate when outbreak of 18.35% or 18 villages of the total 278 villa-
diarrhea is expected to be <1%. ges and sub-districts (Health office of
Environmental-based health chal- Banjarnegara, 2017).
lenges caused by the use of clean water, The purpose of this study was to
inadequate sanitation, and poor hygiene analyze the incidence of diarrhea in infants in
behavior can cause the incidence of diar- Banjarnegara regency based on PRECEDE-
rheal diseases (Lawrence et al., 2016). PROCEED model using multilevel analysis.
The contribution of individual fac-
tors that affect the incidence of diarrhea SUBJECTS AND METHOD
also varies in different regions or regions, 1. Study design
among others, due to cultural differences The study is an observational analytic study
and social values, economic status, gender, with cross sectional design. It was
maternal education as caretakers, know- conducted in Banjarnegara, Central Java,
ledge of hygienic behavior as well as eating Indonesia, from January to February 2018.
habits and hygiene behavior to prevent

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2. Population and sample resides are related to the ownership of

The source population in this study was healthy latrines, the availability of clean
toddlers in Banjarnegara regency. The water, the disposal of waste water and the
sampling used was fixed disease sampling garbage disposal facilities.
technique. The subjects consisted of 250 Strata desa siaga was defined as a
people, coming from 10 subjects in each strata of the village where the residents
unit level 2 i.e. 25 villages. easily get daily health services, able to
3. Study variables develop UKBM, carry out community-
The dependent variable was diarrhea. The based surveillance and environmental
independent variables were nutritional sta- sanitation so that people apply Clean and
tus, information exposure, diarrhea pre- Healthy Behavior.
vention behavior, family income, social 5. Study instrument
capital, environmental sanitation. The assessment of nutritional status was
4. Operational definition of variable done by weight measurement using scales,
The occurrence of diarrhea is described as a then it is assessed based on the anthro-
condition in which there is defecation with pometric standard of child nutritional
consistency of fluid with mucus / not, blood status assessment which has been deter-
/ not with frequency of 3x a day in the last 2 mined by Ministry of Health. The environ-
months. mental sanitation data uses an observation
The nutritional status of children sheet. Data on standby village stratum were
under five years of age was measured by an obtained based on the annual report of
antopometric measurement based on body District Health Office. Other data were
weight by age (WAZ). obtained using questionnaires.
Exposure of information was defined 6. Data Analysis
as information received by mothers Univariate analysis was conducted to see
through various media or activity about the frequency distribution and percentage
behavior of prevention and the diarrhea characteristics of the subjects. Bivariate
disease. analysis was conducted to study the rela-
Diarrhea prevention behavior was tionship between diarrhea occurrence and
defined as a behavior shown by respon- the independent variables using chi-square
dents in preventing the occurrence of test and odds ratio calculation (OR) with
diarrheal disease. confidence level (CI) of 95%. Furthermore,
Family income was defined as a state multivariate analysis was conducted by a
that describes the income of the whole multilevel logistic regression.
family obtained through working done with 7. Research Ethics
the average income per month in the last 6 The research ethics included informed
months. consent, anonymity, confidentiality and
Social capital represents a mutual ethical clearance. The ethical clearance in
movement among people in a society and this study was conducted in Dr. Moewardi
social organization to achieve the goal of hospital, Surakarta, Central Java.
living together that cannot be achieved
personally. RESULTS
Environmental sanitation was defined 1. Subjects characteristics
as the environmental conditions surround- The subjects consisted of 250 children.
ing the houses where the respondent Case group (diarrhea) of 125 under five

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children and 125 under-five children in rienced diarrhea of 95 people (53.1%). Most
control group (not diarrhea). The frequency of the education level of mothers whose
distribution of the characteristics of the children did not experience diarrhea was
study subjects is described in Table 1. high school graduate with 37 people
Table 1 shows that the proportion of (67.3%).
maternal age in children experienced the 2. Bivariate analysis on the deter-
highest incidence of diarrhea in the age minants of diarrhea
group ≥30 years for about 63 people Bivariate analysis was conducted to observe
(49.2%), as well as the proportion of the existence of independent variables
maternal age whose children did not (nutritional status, information exposure,
experience the highest diarrhea incidence prevention behavior, income, social capital,
in the age group ≥30 years for about 65 and environmental sanitation) with the
people 50.8%). dependent variable (diarrhea occurrence).
Most of the mothers did not work, The result of bivariate analysis can be seen
both in children without diarrhea for about in table 2.
84 people (46.9%) and toddlers who expe-
Table 1. The Characteristics of Subjects
Diarrhea Occurrence
Subject Total
Characteristics No diarrhea diarrhea
n=125 % n=125 % n=250 %
Maternal Age
<30 years old 60 49.2 62 50.8 122 100
≥30 years old 65 50.8 63 49.2 128 100
Maternal Occupation
Not working 84 46.9 95 53.1 179 100
Labor 3 33.3 6 66.7 9 100
Employee 19 61.3 12 38.7 31 100
Entrepreneur 13 72.2 5 27.8 18 100
Civil Servant 6 46.2 7 53.8 13 100
Maternal Education
No formal education 4 57.1 3 42.9 7 100
Primary school 25 32.9 51 67.1 76 100
Junior high school 37 46.3 43 53.8 80 100
Senior high school 37 67.3 18 32.7 55 100
University 22 68.8 10 31.3 32 100
Strata of desa siaga
Pratama 20 33.3 40 66.7 60 100
Madya 30 42.9 40 57.1 70 100
Purnama 26 43.3 34 56.7 60 100
Mandiri 49 81.7 11 18.3 60 100

3. The results of multilevel analysis prevention behavior (b= 1.52; 95% CI= 0.81
Multivariate analysis describes the effects to 2.24; p<0.001), income <Rp 1,490,000
independent variables to a dependent (b= 1.52; 95% CI= 0.80 to 2.25; p<0.001),
variable by a multilevel logistic regression. weak social capital (b= 1.80; 95% CI= 1.04
Table 3 showed that abnormal nutritional to 2.56; p<0.001), and poor environmental
status (b= 1.33; 95% CI= -0.14 to 2.82; p= sanitation (b= 1.12; 95% CI= 0.39 to 1.85;
0.077), lack of information exposure (b= p= 0.003) were positively associated with
0.90; 95% CI= 0.17 to 1.64; p= 0.015) , poor diarrhea in children.

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Table 2. Bivariate Analysis of Determinants of Diarrhea Occurrence

Diarrhea Occurrence
Total
Variable No diarrhea diarrhea OR 95% CI p
n % n % n %
Nutritional status
Normal 119 51.5 112 48.5 231 100 2.3 0.095
0.8 – 6.3
Underweight 6 31.6 13 68.4 19 100
Information
exposure
Good 81 68.6 37 31.4 118 100 4.4 2.6 – 7.4 <0.001
Poor 44 33.3 88 66.7 132 100
Prevention
behavior
Good 98 71 40 29 138 100 7.7 4.4 – 13.6 <0.001
Poor 27 24.1 85 75.9 112 100
Family income
High 96 67.6 46 32.4 142 100 5.7
3.3 – 9.9 <0.001
Low 29 26.9 79 73.1 108 100
Sosial capital
Strong 70 72.2 27 27.8 97 100 4.6 2.7 – 8.0 <0.001
Weak 55 35.9 98 64.1 153 100
Environmental
sanitation
Good 78 60 52 40 130 100 2.3 1.4 – 3.9 0.001
Poor 47 39.2 73 60.8 120 100

Table 3 The results of a multilevel logistic regression on the determinants of

diarrhea occurrence in children
95% CI
Diarrhea OR p
Lower upper
Fixed Effect
Abnormal nutritional status 1.33 -0.14 2.82 0.077
Lack of information exposure 0.90 0.17 1.64 0.015
Poor prevention behavior 1.52 0.81 2.24 <0.001
Income <Rp 1,490,000 1.52 0.80 2.25 <0.001
Lack of social capital 1.80 1.04 2.56 <0.001
Poor environment sanitation 1.12 0.39 1.85 0.003
Random Effect
Strata of desa siaga 0.61 0.10 3.48
n observasi = 250
Log likelihood = - 105.1
LR test vs. logistic regression, p< 0.001
ICC = 15.78%

In the multilevel analysis, the ICC = DISCUSSIONS

15.78%. The indicator indicated that the 1. The effect of nutritional status on
condition of standby village in each strata the incidence of diarrhea.
has a contextual influence on the occur- The result of this study showed that there
rence of diarrhea by 15.78%. The number was a significant effect between children’s
was larger than the standard of role of nutritional status and the incidence of
thumb size of 8-10%. It showed that village diarrhea. Children with poor nutritional
stratification had a strong contextual effect status increased the risk of diarrhea. In this
on the incidence of diarrhea. study, as many as 112 children (48.5%)

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from 231 children with normal nutrition exosure and the incidence of diarrhea.
have diarrhea. This was probably because Mothers with poor exposure information
there were several other factors beside the may increase the risk of diarrhea in
nutritional status that caused the toddlers children.
to experience diarrhea. Some causes of Diouf et al. (2014) explained that the
diarrhea in addition to bacterial or viral prevalence of diarrhea was found to be
infections, among others, were allergies, lower in children where the primary care-
mal absorption, poisoning, immune defici- giver/ nanny has received access to infor-
ency, and other causes (Soebagyo, 2008; mation about health education (OR= 0.45;
Widoyono, 2011; Irianto, 2014). 95% CI= 0.21 to 0.97; p= 0.043). Health
A study by Narzah (2016) about information especially about handwashing
factors related to the incidence of diarrhea with soap in Burundi effectively prevented
in Purbalingga District stated that nutri- and protected children from diarrheal
tional status has a direct influence on the diseases.
incidence of diarrhea. Similar to a study by Ejemot-Nwa-
Tickell et al. (2017) compared the diaro et al. (2015) which showed that an
severity of diarrheal disease that occurred average decreased in episodes of diarrhea
in children with and without malnutrition. was 1.68 times less in the intervention
Children with malnutrition experienced groups, which were groups that received
more severe diarrhea than children who health information about handwashing
were not malnourished. The malnutrition practices in risk populations at home. The
status of toddlers suffering from diarrhea provision of health information also affect-
was more accompanied by the prevalence of ed the frequency of hand washing by seven
pathogens in feces. The prevalence of times per day compared to the control
pathogens reduces immune response and group by three times per day.
increased the risk of diarrhea. The information about the way for a
According to WHO/UNICEF (2017), healthy life, health care, avoiding illness
severe diarrhea caused loss of fluid, and and others would increase the knowledge of
may be life-threatening, especially in young individuals, groups or communities. The
children and people who were malnourish- enhancement of knowledge was expected to
ed or have impaired immunity. improve the understanding and could
Children with severe malnutrition change the behavior to be healthier
have an increased risk of acute infectious (Sulaeman et al., 2015)
diseases and death (Bhutta et al., 2017). 3. The effect of diarrhea prevention
Malnourished children have a higher likeli- behaviour on the incidence of
hood of having persistent diarrhea, and diarrhea.
thin children have a higher risk of having The result of this study showed that there
diarrheal episodes that progressed to was an effect between diarrhea prevention
persistent diarrhea (Budhathoki et al., behavior and the incidence of diarrhea.
2016). Mothers with poor prevention behavior
2. The effect of health information increased the risk of diarrhea in children.
exposure on the incidence of The results of this study is consistent
diarrhea. with a study by Agustina et al. (2013),
The result of this study showed that there which stated that maternal hygiene beha-
was an effect between health information vior in preparing and managing food in

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young children. Budhathoki et al., (2016) of these things required money (Tarwoto
stated that the practice of washing hands and Wartonah, 2011; Woldu et al., 2016).
with soap and flowing water had a prevent- The prevalence of diarrhea tend to be
ive effect on the incidence of diarrhea. higher in groups with lower household
Proper handwashing practices could reduce expenses per capita (Ministry of Health RI,
more than one-third of the diarrhea 2011).
episodes (Beaugerie and Sokol, 2013; The result of this study is consistant
Budhathoki et al., 2016). with a study by Azage et al., (2016) which
Ma et al., (2014) studied that there showed that the probability of diarrhea
were 6 behavioral factors which significant- occurring in children from poor households
ly related to the incidence of diarrhea: hand was 1.63 times (OR= 1.63; 95% CI= 1.12 to
washing before meals and after defecate, 2.36) higher than children from wealthy
hand washing behavior by using soap and households. People from wealthy house-
flowing water, the consumption of raw holds tend to apply better hygienic and
seafood behaviour, using the same knife environmental sanitation behaviors and
and cutting board for raw or processed become their standard of living, therefore,
food, using the same chopsticks to pick up it can prevent the incidence of diarrhea.
raw or cooked food, and performing regular 5. The effect of social capital on the
physical activity. incidence of diarrhea.
One of the things that can prevent The result of this study showed that there
diarrhea and pathogen infection was the was an effect between social capital and the
behaviour of defecation in healthy latrines incidence of diarrhea. Toddlers in an envi-
and did not dispose adults or children's ronment with weak social capital increased
feces in the wrong places (Sevilimedu et al., the risk of experiencing diarrhea. According
2017). In contrast to the study by Islam et to Hasbullah (2006) in Susilo, (2016), the
al., (2018) which stated that most house- core dimension of social capital placed in
holds in Bangladesh perform unsafe child- people's ability to work together to build a
ren's feces disposal practices. This practice network to achieve common goals. This was
was not associated with diarrhea because reinforced by the values and norms that
the child's feces may not be the main expo- became the main elements such as trust,
sure to dirt that contributed significantly to reciprocity, caring, giving, and receiving.
the risk of enteric disease occurring in the Strong social capital enabled the
country. community members to share health infor-
4. The effect of family income on the mation, access, and better use of resources
incidence of diarrhea. which were available in the community for
The result of this study showed that there local problem solving in order to improve
was an effect between family income and community health status (Murti, 2010;
the incidence of diarrhea. Children with low Bisung et al., 2014).
family income have a higher risk of Social capital was associated with the
diarrhea than toddlers with high family ability to identify health problems through
income. the exchange of information such as
The embodiment of healthy behavior neighbors advising each other and provi-
required health facilities and infrastructure ding advice or information to obtain health
such as soap, clean water facilities, the services (Sutisna et al., 2006).
availability of trash can, and others. And all

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A study by Levison et al., (2011) in the dumped with soil. In people who did not
village of Usoma, Kenya revealed that the have toilets should be considered to build
lack of trust among the community was a the toilet together. However, every house-
major obstacle to overcome water and sani- hold should have a toilet (UNICEF, 2010).
tation problems in that area. Access to This was supported by a study done by
water and sanitation would reduce water- Bitew et al. (2017) reported that the exist-
borne diseases, especially diarrhea in ence of inadequate and unprotected water
children (Kamara et al., 2017). resources was significantly one of the
Regardless of the difference in social predictors of diarrhea in children.
status, societies with higher levels of social 7. The effect of village stratification
capital, especially in terms of social and on the incidence of diarrhea
network participation, showed healthier The results showed that the condition of
behavior and feel healthier both physically standby village in each strata has a contex-
and psychologically (Nieminen et al., 2013). tual influence on the occurrence of diarrhea
6. The effect of environmental sanita- by 15.78%, so it was highly important to
tion on the incidence of diarrhea note.
This study also produced findings that Allert village was one of the strategies
there was an effect of environmental sani- that has the leverage to move and empower
tation on the incidence of diarrhea. Child- the community as a step to healthy village.
ren with poor environmental sanitation Standby village was expected to solve
were at risk for experiencing diarrhea com- health problems, disaster, and health emer-
pared to toddlers who have good environ- gency independently. The main purpose of
mental sanitation. Ministry of Health RI, standby village was to empower the com-
(2017) stated that sanitation that did not munity. Empowerment as a facilitation
fulfill health requirements lead to the emer- effort that was persuasive and non-instruc-
gence of environmental-based diseases, one tive through an organized learning process
of them was diarrhea. to foster a well-coordinated response (Hill
Environmental sanitation factors in a et al., 2014).
research conducted in Ethiopia on 600 The mutual cooperation activities as a
subjects, including the availability of toilet form of active participation of the commu-
facilities, solid waste disposal methods, and nity in relation to environmental sanitation
household drinking water were significant in active standby village which can be
risk factors causing diarrhea in children. developed, among others, environmental
Children from the households which did improvement movement in the form of
not have toilet facilities were 2 times more clean water facilities development, clean
likely to have diarrhea than those from Friday activity, sewerage, improvement of
households with better toilet conditions healthy houses, and also the movement
(Asfaha et al., 2018). prevention and control of disease risk
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Azizah (2013), showed that the most domi- Provincial Health Office, 2011).
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