Jurnal Keluarga Berencana

P-ISSN: 2527-3132 E-ISSN: 2503-3379

Vol. 10 No. 1 Tahun 2025
https://ejurnal.kemendukbangga.go.id/

ENVIRONMENTAL FACTORS INFLUENCING DIARRHEA INCIDENCE

AMONG CHILDREN AGED 0–23 MONTHS
1Muhamad Zakki Saefurrohim, 2Rea Ariyanti
1,2Public Health Department, Public Health Faculty, University of Mulawarman
Corresponding Email: [email protected]

ABSTRACT
Diarrhea remains a primary public health concern contributing to significant morbidity and
mortality among children under five years of age, particularly in developing countries, including
Indonesia. This study aimed to create a predictive model of environmental factors associated with
the incidence of diarrhea among children aged 0–23 months. A cross-sectional design was
employed, utilizing secondary data from the 2018 Indonesian Basic Health Research Survey
(RISKESDAS—Riset Kesehatan Dasar). Data were collected through structured interviews
utilizing household and individual questionnaires, encompassing responses from 27,280 mothers
with children aged 0–23 months. Data were analyzed using ordinal logistic regression. The
findings indicated that households with 5–7 members, use of unprotected drinking water sources,
and feces disposal practices not involving toilets were significantly associated with increased risk
of diarrhea among children aged 0–23 months. The predictive model accounted for only 0.02% of
the variance in diarrhea incidence, suggesting that 99.98% of the variation is attributable to other
unmeasured factors. It is recommended that public health stakeholders prioritize interventions
aimed at improving water quality, promoting safe sanitation practices, and addressing household
overcrowding to reduce the burden of diarrhea in this vulnerable age group.
Keywords: Diarrhea; Children aged 0-23 months; Environmental Factors.

INTRODUCTION
Diarrhea remains a primary public health concern contributing to significant morbidity and
mortality among children under five years of age, particularly in developing countries, including
Indonesia. (Al-Mubarokah & Sartika, 2022; Soelaeman et al., 2023a). Based on the results of a
household health survey, there was an increasing prevalence of diarrhea in Indonesia from 7% in
2013 to 8% in 2018 (Ministry of Health of the Republic of Indonesia, 2018). According to the 2018
Indonesian Basic Health Research Survey, the highest prevalence of diarrhea was observed among
children aged 12 to 23 months, reaching 7.9 percent. The prevalence was higher in urban areas,
at 5.2%, and among children from low socioeconomic households, at 6.0%. In addition, the
prevalence among male children was 5.2%, slightly higher than that among female children, which
was 4.7%. Furthermore, data from the 2019 Indonesian Health Profile indicated that the highest
age-specific prevalence of diarrhea occurred in the one to four age group, at 11.5%, followed by
infants, at 9% (Ministry of Health of the Republic of Indonesia, 2023).
According to the World Health Organization's Disability-Adjusted Life Years (DALYs) measure, the
overall burden of diarrhea is higher than that of any other gastrointestinal neoplasm. The DALY
value for diarrhea is 2.69, significantly higher than for colorectal neoplasms (0.43), liver
neoplasms (0.38), or even esophageal neoplasms, which are only 0.06 (WHO, 2021). Diarrhea in
toddlers, if not treated further, can cause dehydration, which can result in death. One of the risk
factors for diarrhea is environmental factors, including basic ecological sanitation, such as access
Email Corresponding: Article History
[email protected] Received: 30-04-2024 Accepted: 30-06-2025
© 2024 The Author(s). This is an open-access article under Attribution-NonCommercial-ShareAlike
4.0 International License (https://creativecommons.org/licenses/by-nc-sa/4.0/)
to clean water facilities, healthy toilets, and proper waste disposal facilities (Paul, 2020).
Sanitation plays a crucial role in creating healthy homes and as a means to prevent
environmentally based diseases (Kurniawati & Abiyyah, 2021). Globally, about 90% of diarrhea-
related deaths in children under five are caused by inadequate access to clean water, sanitation,
and hygiene. Each year, more than 297,000 children under the age of five die from diarrheal
diseases linked to poor water, sanitation, and hygiene (CDC, 2021; UNICEF, 2009; WHO, 2020).
Several environmental factors also contribute to the incidence of diarrhea in young children
(Soelaeman et al., 2023b). Previous studies have shown that factors such as large household size,
a high number of children under five, limited access to healthcare services, improper fecal waste
disposal, and unsafe drinking water sources increase both the risk and impact of diarrhea in
children (CDC, 2021; UNICEF, 2009; WHO, 2020).
The number of family members reflects household population density, which can create
unhygienic conditions and increase the risk of food and water contamination. Crowded living
spaces can significantly affect the health of occupants and contribute to the spread of disease. In
households with a larger number of family members, the likelihood of direct contact between
individuals increases, facilitating the transmission of infectious diseases. A household density of
more than four people is particularly associated with a higher risk of diarrhea in toddlers. This is
because diarrhea is a contagious disease that can affect both children and adults. When adults in
the household experience diarrhea, toddlers living in the same environment are also at greater
risk of infection (Sari & Sartika, 2021).
In addition to household size and the number of toddlers, sanitation factors such as the source of
drinking water are also key risk factors for diarrhea. Unprotected water sources located near
toilets or septic tanks are easily contaminated. Escherichia coli (E. coli), a bacterium that causes
diarrhea and is transmitted via the fecal-oral route, can enter water supplies during rainfall,
carrying human or animal waste into the ground or nearby springs. When water sources do not
meet safety standards, the risk of diarrhea in toddlers increases. Contamination may occur at the
source, during distribution, or in household storage. (Irjayanti et al., 2024).
Additionally, the availability of feces disposal facilities is also suspected of influencing the
incidence of diarrhea in children. There are still people who lack access to feces disposal facilities
that meet the necessary criteria. (Irjayanti et al., 2024; Yulda & Fitriani, 2023). Having a healthy
and good family toilet can be believed to prevent the transmission of chronic diarrheal diseases
caused by infection pathways. Sanitary feces disposal aims to accommodate and isolate feces,
preventing direct or indirect contact with humans, disease transmission, and environmental
pollution. (Kurniawati & Abiyyah, 2021).
Thus, the study aims to analyze the environmental factors that influence the incidence of diarrhea
in children aged 0-23 months in Indonesia using the proportional odds model in ordinal
regression. This study is essential because the ordinal logistic regression method used provides a
more in-depth analysis of the relationship between environmental characteristics and the severity
of diarrhea. This approach has not been widely explored in previous studies. The results of this
study provide new and more specific information that could help in developing more effective
diarrhea prevention strategies for the under-five age group, which is vulnerable to this disease.

METHOD
This study is a secondary data analysis based on the 2018 Basic Health Research Survey
(RISKESDAS) conducted by the Indonesian Ministry of Health. The RISKESDAS employed a cross-
sectional design and was implemented at the national level, covering households across all 34
provinces, 416 districts, and 98 cities in Indonesia. The analysis focused on data from 27,280
women with children aged 0 to 23 months who completed the questionnaire in full. The research
instruments and data collection procedures followed the standardized protocol of the 2018

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 RISKESDAS, using structured questionnaires administered through interviews and physical
measurements conducted by the RISKESDAS research team.
The dependent variable in this study is the diarrhea status of toddlers aged 0 to 23 months,
classified into three categories: experiencing diarrhea within the past two weeks, experiencing
diarrhea between one and two months ago, and never experiencing diarrhea. The independent
variables include environmental factors such as the number of household members, categorized
as more than three adults or three or fewer adults; the number of children under five in the
household, categorized as two or more toddlers or fewer than two toddlers; access to health
services, considered limited if there is no transportation available to health facilities; disposal of
toddler feces, categorized as inappropriate if feces are not disposed of via a septic tank; and the
source of drinking water, classified as poor if the water source is uncovered.
The analysis employed ordinal logistic regression with a proportional odds model to investigate
the relationship between diarrhea incidence and predictor variables, including the number of
toddlers in the household, the number of household members, access to health services, drinking
water sources, and feces disposal methods.

RESULTS
Based on univariate, bivariate, and multivariate analysis, the following results were obtained:
Table 1. Characteristic of Research Respondents and Bivariate Analysis
History of Diarrhea p-
Category Yes, in < 2 Weeks Yes, in > Weeks – 1 month Never value
n % n % n %
Number of Toddlers in the House
More than three 53 6.4 33 4.0 743 89.6 0.063
toddlers
2 toddlers 500 7.4 225 3.3 6,072 89.3
1 toddler 1,486 7.6 799 4.1 17,369 88.4
Number of Household Members
More than 8 183 7.2 104 4.1 2,272 88.8 0.001
5-7 980 7.1 485 3.5 12,430 89.5
1-4 876 8.1 468 4.3 9,482 87.6
Access to Health Services
Unreachable 114 8.7 59 4.5 1,135 86.8 0.036
Reachable 1,925 7.4 998 3.8 23,049 88.7
Drinking Water Source
Unprotected water 371 8.3 171 3.8 3,927 87.9 0.033
Protected water 1,668 7.3 886 3.9 20,257 88.8
Disposal of Feces
Besides the toilet 1,300 7.8 676 4.1 14,698 88.1 0.002
The toilet 739 7.0 381 3.6 9,486 89.4
Source: Secondary data from RISKESDAS (2018)
Table 1 shows a significant relationship between the number of household members, access to
health services, drinking water sources, feces disposal, and a history of diarrhea in toddlers, with
p-values of 0.001, 0.036, 0.033, and 0.002, respectively. The number of toddlers in the house did
not show a significant relationship with a history of diarrhea in toddlers (p-value 0.063).

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 Table 2. Simultaneous Parameter Estimation Test
Model -2 Log Likelihood Chi-Square df Sig.
Intercept Only 287.674
Final 249.9 37.775 5 0.000
Source: Author’s Calculation (2024)

Table 2 shows the comparison results between the model with only an intercept and the final
model. The -2 Log Likelihood value decreased from 287.674 in the intercept-only model to 249.9
in the final model, indicating an improvement in model fit. This suggests that when intercept
modeling was carried out, the model fit value increased, making the intercept model the most
suitable model for this research. The chi-square test yielded a value of 37.775 with 5 degrees of
freedom and a p-value of 0.000, indicating that the addition of predictor variables in the final
model significantly improved the model fit compared to the intercept-only model.
Table 3. Partial Parameter Estimation Test
p- CI 95%
Variable Estimate Wald df OR
value Lower Upper
Constants 1 -2.511 3741.3 1
Constants 2 -2.05 2765.5 1
The number of family members is more than 8
(X1) 0.132 3.6 1 0.057 1.141 1.004 1.306
Number of family members 5-7 (X2) 0.183 20.9 1 0.000 1.201 1.111 1.300
Access to Health Services unreachable (X3) -0.161 3.6 1 0.058 1.175 1.387 1.005
Drinking water sources are not protected (X4) -0.076 2.2 1 0.136 1.079 1.191 1.024
Disposal of feces other than to the toilet (X5) -0.122 9.4 1 0.002 1.130 1.221 1.045
Source: Author’s Calculation (2024)

Table 3 shows that having more than eight family members increases the odds of diarrhea in
children aged 0-23 months; however, this result is not statistically significant (OR = 1.141, 95% CI
[1.004, 1.306], p = 0.057). The number of family members, 5-7, also significantly increases the
odds of diarrhea (OR = 1.201, 95% CI [1.111, 1.300], p = 0.000). Inaccessible access to health
services tends to reduce the odds of diarrhea, but the results are not significant (OR = 1.175, 95%
CI [1.005, 1.387], p = 0.058). Unprotected drinking water sources are associated with a higher
odds of diarrhea, but the results are not statistically significant (OR = 1.079, 95% CI [1.024, 1.191],
p = 0.136). Disposal of feces other than to the toilet significantly increased the chance of diarrhea
in children aged 0-23 months (OR = 1.130, 95% CI [1.045, 1.221], p = 0.002). The ordinal
regression equation with its threshold is as follows:
Logit (Y1) = -2,511 = 0,132x1 +0,183X2-0,161X3-0,076x4-0,122x5
Logit (Y2) = -2,05 = 0,132x1 +0,183X2-0,161X3-0,076x4-0,122x5

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 Table 4. Model Fit Test and Parameter Estimation
Goodness-of-Fit
Nagelkerke
Chi-Square df Sig.
25.624 41 0.971 0.002
Source: Author Calculation (2024)
Table 4 shows the results of the model fit test, indicating that the model has a good fit with the
data, based on the very high chi-square p-value (0.971). However, the very low Nagelkerke R²
value (0.2%) indicates that the model explains only a small portion of the variation in the data.
This means that environmental characteristic factors, such as the number of toddlers in the house,
the number of household members, access to health services, drinking water sources, and feces
disposal, affect the incidence of diarrhea in children aged 0-23 months in general by only 0.2%. In
contrast, 99.8% is influenced by other factors not included in this model test.

DISCUSSION
Diarrhea remains a significant public health problem, especially in developing countries, where it
is a major cause of morbidity and mortality in children under two years of age. Diarrhea is the
leading cause of death in toddlers besides pneumonia. Diarrhea in toddlers occurs when the
excretion of abnormal liquid stools, where children can defecate frequently or more than 3 times
a day in children and 4 times a day in infants, with a water content of more than 100- 200ml
(Rokhmiati et al., 2024). Several studies have investigated the risk factors contributing to
diarrhea, with a focus on environmental, demographic, and behavioral aspects. (Rahmat et al.,
2023; Syukrilla et al., 2023; WHO, 2020). This study highlights the findings of environmental
factor characteristics that have a significant relationship with the incidence of diarrhea in children
aged 0-23 months in Indonesia, namely the number of family members, quality of water sources,
and sanitation practices on the incidence of diarrhea (p value <0.005), while insignificant factors
such as the number of toddlers and access to health services.
Research results consistently show that larger family sizes, especially those with 5-7 members,
are associated with a higher prevalence of diarrhea in children aged 0– 23 months. A study in
Ethiopia found that the odds of diarrhea in children under five years of age were 5.2 times higher
in families with more than five family members compared to those with ≤5 family members (AOR
[95% CI] = 3.4 [1.7–17.6]) (Bekele et al., 2021a). Households with more than four members are at
significantly higher risk of diarrhea due to increased person-to-person contact and potential poor
household hygiene. (Ayalew et al., 2018; Hashi et al., 2016). Household density increases the risk
of transmission of diseases that cause diarrhea in children through contaminated water, food, and
poor hygiene, but family size is not associated with diarrhea in children under five years of age if
other risk factors remain constant and family life is (Bekele et al., 2021b). A research report in
Wonago District, Southern Ethiopia, showed results that children in households with more than
five family members were about three times more likely to experience moderate to severe
diarrhea than those living in smaller families. (Tesfaye et al., 2020). Another study found that the
likelihood of diarrhea among children under five was 5.2 times higher in families with more than
five members compared to those with five or fewer members. (Bekele et al., 2021c).
Another factor associated with diarrhea in children aged 0-23 months is the quality of drinking
water sources. Research in Northern Nigeria showed that children were 1.2 times more likely to
experience diarrhea in families with unsafe water sources than in families with safe water sources.
(Berhe & Berhane, 2014a). Research in Medebay Zana District, Northwest Tigray, reported that
diarrhea was 1.8 times more likely to occur in families with unsafe water sources compared to
families with safe water sources. This suggests that children who consume water from wells,
rivers, or other unprotected sources are at a significantly higher risk of contracting pathogens that
cause gastrointestinal infections. (Asfaha et al., 2018; Berhe & Berhane, 2014b). The lack of proper
water treatment and safe storage practices further exacerbates these risks. The availability of

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clean water sources is one key effort to improve community health. Environmental health is
organized to create a healthy environment, namely a condition that is free from risks that
endanger human health and safety (Harsa, 2019).
The quality of drinking water sources plays a crucial role in the incidence of diarrhea, particularly
among children under the age of five. Unprotected water sources are vulnerable to contamination
by bacteria, viruses, and parasites that cause diarrhea. Notably, E. coli, a standard indicator of fecal
contamination, is frequently detected in unprotected water and is strongly linked to an increased
risk of diarrhea in young children. Research indicates that children consuming water
contaminated with E. coli have approximately a 22% higher likelihood of developing diarrhea
compared to those who drink uncontaminated water. (Luby et al., 2015; Parvin et al., 2021).
In addition to the quality of drinking water sources, other sanitation practices, especially feces
disposal, have also been identified as critical determinants of diarrhea prevalence in children.
Research by Bekele et al. (2021) Emphasized that improper feces disposal, such as open
defecation or using unauthorized places other than toilets, significantly increases the likelihood
of contracting diarrheal diseases. Open defecation is defined as human feces that are released
carelessly, not disposed of in a septic tank, resulting in contamination (e.g., disposal of human
feces in fields, forests, bushes, ditches, water channels, terraces, pastures, backyards, or other
spaces), leading to potential exposure to enteric pathogens. Each gram of fresh human feces
contains 101 helminth eggs, 106 bacteria, 106 viruses, and 104 protozoan cysts. (Irawaty, 2022;
Hajj-Mohamad et al., 2019). WHO reports that toilet use is an independent predictor of diarrheal
disease, with families without toilets six times more likely to experience diarrhea than families
with toilets. These practices contribute to environmental contamination and facilitate the
transmission of infectious agents to children through various routes, including contaminated
hands, food, and water. Open defecation can serve as a breeding ground for flies. If these insects
land on food, they can transfer bacteria to food consumed by humans. (Suryaningsih & Wijayanti,
2020).
Based on the Indonesian Minister of Health Regulation Number 3 of 2014 concerning Community-
Based Total Sanitation, one way to break the chain of disease transmission is by using healthy
toilets. Every family is required to have and use a healthy toilet that is accessible to every family
member. The upper structure of the bathroom, consisting of walls and a roof, must be able to
protect its users from weather and other disturbances. The middle part of the toilet must have a
waste disposal hole with a gooseneck type. For buildings that do not use gooseneck construction,
a cover must be equipped. The toilet floor must be made of a waterproof material, non-slip, and
must be connected to the Sewage Drainage Channel (SPAL). The lower structure of the toilet must
be equipped with a septic tank or septic system that can prevent pollution. (Fauziyah &
Siwiendrayanti, 2023).
The results of this study also highlight several factors that were found to have no significant
association with diarrhea in the analyzed models. The number of toddlers in the household did
not show a substantial impact on the incidence of diarrhea. These results observe that the
presence of several young children does not independently increase the risk of diarrhea,
suggesting that other factors, such as maternal hygiene practices and education, may play a more
critical role. Furthermore, access to health services was not significantly associated with the
prevalence of diarrhea in this study. The WHO report states that although access to health services
is essential for treatment, it does not necessarily prevent diarrhea from occurring, highlighting
the importance of preventive measures and education. (WHO, 2019). The study methodology has
several shortcomings, including reliance on secondary data, which results in a narrow selection
of variables, limitations of the cross-sectional survey design, and a low explanatory power of the
statistical model. These issues underscore the need for a more comprehensive approach,
potentially involving longitudinal data collection, a broader range of variables, and more robust
statistical methods to understand better the factors influencing diarrheal disease incidence in
children.

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CONCLUSION
This article examines the environmental factors that influence the incidence of diarrhea among
children aged 0–23 months in Indonesia, using ordinal logistic regression. The findings indicate
that households with 5–7 members, the use of unprotected drinking water sources, and improper
disposal of feces significantly increase the risk of diarrhea. However, the constructed model
explains only 0.02% of the variation in diarrhea incidence, suggesting that 99.98% of contributing
factors (such as behavioral, nutritional, or specific infectious factors) remain unmeasured. Key
recommendations include environmental-based interventions, such as improving access to clean
water, promoting safe sanitation practices, and reducing household overcrowding. Additionally,
education on personal hygiene and domestic waste management should be enhanced to prevent
the transmission of diseases.
This study has several limitations, including the use of secondary data, which restricts the
variables that can be analyzed; a cross-sectional design that cannot establish causal relationships;
and a low Nagelkerke R² value, indicating the model's limited explanatory power. Future research
should adopt longitudinal or qualitative designs to understand better the dynamics of risk factors
associated with diarrhea. Additional variables, such as child nutritional status, breastfeeding
practices, and maternal education levels, should also be included. Collaboration with
policymakers is essential to implement these findings into more comprehensive public health
programs, such as the development of sanitation infrastructure and community-based behavioral
change campaigns.

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