Multilevel Analysis: Biopsychosocial Determinants and Environmental Factor on the Incidence of Diarrhea Among Children Under Five in Surakarta

Erick Zicof, Setyo Sri Rahardjo, Bhisma Murti


Background: Diarrhea is an endemic disease with a potential to become an epidemic in Indonesia. Diarrhea most often occurs in children under five years of age. This study aimed to determine the relationship between biopsychosocial factors, environmental factor, and diarrhea occurrence in Surakarta, Central Java, using multilevel analysis.

Subjects and Method: This was an observational analytic study with a cross-sectional approach. This study was conducted on October 2017 - April 2018. A sample of 200 children under five years of age was selected by fixed disease sampling, consisting of 100 children with diarrhea and 100 without diarrhea. The dependent variable was the incidence of diarrhea. The independent variables were the number of family members, maternal knowledge, maternal personal hygiene, and environmental sanitation. The data were collected by questionnaire and analyzed by multilevel logistic regression in Stata 13.

Results: The number of family member (b= 1.09; 95% CI= 0.02 to 2.15; p< 0.046) increased the risk of diarrhea. Good maternal knowledge (b= -2.30; 95% CI= -3.46 to -1.14; p<0.001), good maternal personal hygiene (b= -2.09; 95% CI= -3.48to-0.70; p<0.003), and good environmental sanitation (b= -1.64; 95% CI= -2.84to -0.43; p= 0.008) decreased the risk of diarrhea in children under five. The village had a substantial contextual effect on the incidence of diarrhea with ICC= 66.14%.

Conclusion: The number of family member increases the risk of diarrhea. Good maternal knowledge, good maternal personal hygiene, and good environmental sanitation decrease the risk of diarrhea in children under five. Village has a substantial contextual effect on the incidence of diarrhea

Keywords: diarrhea, number of family member, maternal knowledge, maternal personal hygiene, village, contextual effect

Correspondence: Erick Zicof. Masters Program in Public Health, Universitas Sebelas Maret, Jl. Ir. Sutami No. 36 A, Surakarta, Indonesia. Email: Mobile: +6281363425870.

Journal of Epidemiology and Public Health (2018), 3(3): 323-330

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Adane M, Mengistie B, Kloos H, Medhin G, Mulat W (2017). Sanitation facilities, hygienic conditions, and prevalence of acute diarrhea among underfive children in slums of Addis Ababa, Ethiopia: Baseline survey of a longitudinal study. PLoS ONE 12(8): e0182783.

Bitew BD, Woldu W, Gizaw Z (2017). Childhood diarrheal morbidity and sanitation predictors in a nomadic community. Italian Journal of Pediatrics: 1–8. doi: 10.1186/s1305201704126.

Centers for Disease Control and Prevention (2015). Diarrhea: Common Illness, Global Killer.

Dinkes Kota Surakarta (2017) Profil Kesehatan 2016 Kota Surakarta.

Dinkes Provinsi Jateng (2017). Profil Kesehatan Provinsi Jawa Tengah Tahun 2016. Semarang.

Desta BK, Assimamaw NT, Ashenafi TD (2017). Knowledge, Practice, and Associated Factors of Home Based Management of Diarrhea among Caregivers of Children Attending UnderFive Clinic in Fagita Lekoma District, Awi Zone, Amhara Regional State, Northwest Ethiopia, 2016. Nurs Res Pract. doi: 10.1155/2017/8084548.

Fauziah A, Ahmad LAI, Tina L (2016). Studi Komparatif Determinan Kejadian Diare Di Wilayah Pesisir (Puskesmas Abeli ): 1–13.

George CM, Perin J, de Calani KJN, Norman WR, Perry H, Davis TP, Lindquist ED (2014). Risk Factors for Diarrhea in Children under Five Years of Age Residing in Periurban Communities in Cochabamba, Bolivia. Am J Trop Med Hyg. 91(6): 1190–1196.

Habit RBH (2017). Hubungan kebiasaan cuci tangan dan penggunaan jamban sehat dengan kejadian diare balita. 95–106. doi: 10.20473/jbe.v5i1.

Hasan M, Richardson A (2017). How sustainable household environment and knowledge of healthy practices relate to childhood morbidity in South Asia: analysis of survey data from Bangladesh, Nepal and Pakistan. BMJ Open. 7:e015019. doi: 10.1136/bmjopen2016015019.

Imada KS, Muniz PT (2016). Socioeconomic, hygienic, and sanitation factors in reducing diarrhea in the Amazon. Rev Saude Publica. 50(77): 1–10.

Kemenkes RI (2016) Profil Kesehatan Indonesia 2015. Jakarta.

_____ (2017) Data dan Informasi Kesehatan Profil Kesehatan Indonesia 2016. Jakarta.

Lowe B, Lohse A, Andresen V, Vettorazzi E, Rose M, Broicher W (2016). The Development of Irritable Bowel Syndrome: A Prospective CommunityBased Cohort Study. 1–10. doi: 10.1038/ajg.2016.255.

Mengistie B, Berhane Y, Worku A (2013). Prevalence of diarrhea and associated risk factors among children underfive years of age in Eastern Ethiopia: A Prevalence of diarrhea and associated risk factors among children underfive years of age in Eastern Ethiopia: A crosssectional study. Open Journal of Preventive Medicine, 3, 446-453.

Maharani D, Yusiana MA (2013). Lack Of Mother’s Personal Hygiene Related To Diarrhea. 6(1): 119–128.

Merga N, Alemayehu T (2015). Knowledge, Perception, and Management Skills of Mothers with Underfive Children about Diarrhoeal Disease in Indigenous and Resettlement Communities in Assosa District, Western Ethiopia. J Health Popul Nutr. 33(1): 20–30.

Mohammed S, Tamiru D (2014). The Burden of Diarrheal Diseases among Children under Five Years of Age in Arba Minch District, Southern Ethiopia, and Associated Risk Factors: A Cross-Sectional Study. International Scholarly Research Notices.

Mukhtar A, Ibrahim M, Izham M, Pathiyil RS (2011). A survey of mothers' knowledge about childhood diarrhoea and its management among a marginalised community of Morang, Nepal. Australas Med J. 4(9): 474–479.

Mukti DA, Raharjo M, Dewanti NAY (2016). Hubungan Antara Penerapan Program Sanitasi Total Berbasis Masyarakat (Stbm) Dengan Kejadian Diare Di Wilayah Kerja Puskesmas. Jurnal Kesehatan Masyarakat (e-Journal). 4(3). ISSN: 2356-3346.

Mumtaz Y, Zafar M, Mumtaz Z (2014). Knowledge Attitude and Practices of Mothers about Diarrhea in Children under 5 years. Journal of the Dow University of Health Sciences Karachi. 8(1): 3–6.

Okour A, Alghazawi Z, Gharaibeh M (2012). Diarrhea Among Children and the Household Conditions in a LowIncome Rural Community in the Jordan Valley. J Med J. 46 (2):108- 117.

Patil SR, Arnold BF, Salvatore AL, Briceno B, Ganguly S, Colford JM Jr, Gertler PJ (2014). The Effect of India’s Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial. PLoS Med 11(8): e1001709. doi:10.1371/journal.pmed.1001709.

Pengembangan A, Keprofesian P (2011). Konsep Biopsikososial pada Keluhan Psikosomatik. 375–379.

Roman C, Solh T, Broadhurst M (2017) Infectious Diarrhea. Physician Assist Clin. 2(2017): 229–245. doi: 10.1016/.cpha.2016.12.006.

Samwel M. et al. (2014). Determinants of diarrhea among young children under the age of five in Kenya, evidence from KDHS 200809’, 28(2).

Susanti WE, Sunarsih E (2016).Determinant Of Diarrhea On Children Under Five Years In Indonesia (Advanced Analysis IDHS 2012) Jurnal Ilmu Kesehatan Masyarakat. 7: 64–72.

Thiam S. et al. (2017). Prevalence of diarrhoea and risk factors among children under five years old in Mbour, Senegal: a crossectional study. Infectious Diseases of Poverty: 1–12. doi: 10.1186/s4024901703231.

WHO (2017). Cholera. World Health Organization: Geneva.

Zeleke AT, Alemu ZA (2014) Determinants of Under Five Childhood Diarrhea in Kotebe Health’, 14(4).


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