Association of Mother’s Behavior with Diarrhea in Toddler

(6-23 Months) in Public Health Center, Tasikmalaya District

Siti Novianti, Puji Nurul Hidayah

Study Program of Public Health, Universitas Siliwangi, Siliwangi Street, Tasikmalaya, Indonesia

Keywords: Diarrhea, Mother's Behavior, Toddler.

Abstract: Diarrhea is still a public health problem in Indonesia, with a high prevalence of cases. Mother‘s behavior is a

determinant factors related to diarrhea. The purpose of this study was conducted to determine the relationship

between Mother’s behavior and the incidence of diarrhea in toddlers aged 6-23 months at Ciawi Public Health

Center, Tasikmalaya District. The research design used case control study. Sample was 39 cases and 39

controls calculated using EpiInfo. The sampling technique used purposive sampling. Respondents consisted

of mothers of toddlers aged 6-23 months from the case and control groups. The research instruments used

questionnaires. Statistical analysis using chi square test. Most respondents have primary school education

level (39.7%) and work as housewives (97.4%). The result showed that there was a statistically significant

between mother’s behavior and the incidence of diarrhea in toddler with p value 0.031; and OR value 3.321).

They’re necessary to collaborate between health workers at the Ciawi Health Center and mothers of toddlers

to improve the behavior of mothers in diare prevention.

1 INTRODUCTION

Diarrhea is defined as loose stools more than three

times a day (WHO, 2017). The cause of diarrhea is a

bacterial infection due to stimulation of the intestinal

mucosa by toxins, such as E. coli or V. cholera 01

toxins (Kementerian Kesehatan Republik Indonesia,

2010). Diarrhoeal disease is a leading cause of

mortality and morbidity, and mostly results from

contaminated food and water sources (WHO, 2017).

According to UNICEF (2017), the prevalence of

diarrhea in children under five in the world is 8%.

Riskesdas data 2018 (Riskesdas, 2018) in Indonesia

showed that the prevalence of diarrhea in children

under five is still high at 11%, has increased from the

results of Riskesdas in 2013 (2.4% of prevalence).

Several provinces in Indonesia have higer prevalence

of diarrhea. The provinces that have a high prevalence

of diarrhea in children under five include North

Sumatra, Papua, Aceh, Bengkulu, West Nusa

Tenggara, West Kalimantan, West Sumatra, West

Java, Banten and Central Sulawesi. Of the 10

provinces, West Java province is the eighth province

that has the prevalence of diarrhea in children under

five above the national prevalence of 12.84%.

Based on the 2018 Riskedas Results in West Java

Province, there are several cities/districts with the

prevalence of diarrhea in children under five above

the average prevalence of West Java. One of them is

Tasikmalaya Regency with a prevalence of diarrhea

in toddlers of 12.96%. The incidence of diarrhea in

toddler most often occurs in toddlers with an age

range of 12-23 months.

Diarrhea in toddlers can lead to fatal

consequences such as death and malnutrition. Death

in children under five can occur due to weight loss

and infection. In addition, death in infants can also be

caused by dehydration. When diarrhea, toddlers will

experience changes in the form of stools that are more

liquid which can increase fluid expenditure. Increased

fluid loss also occurs in the intestine, along with

electrolyte expenditure. As a result, severe

dehydration occurs in toddlers which can end in death

(Murno et al, 2011).

Another consequence that can be caused by

diarrhea is malnutrition. Diarrhea and malnutrition

have a two-way relationship. Diarrhea can lead to

malabsorption and maldigestion which can reduce the

intake of nutrients. This is what can cause

malnutrition in children with diarrhea. On the other

hand, children with malnutrition are also often cause

by diarrhea (Black et al, 2008). According to WHO

Novianti, S. and Hidayah, P.

Association of Mother’s Behavior with Diarrhea in Toddler (6-23 Months) in Public Health Center, Tasikmalaya District.

DOI: 10.5220/0010758700003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 177-181

ISBN: 978-989-758-542-5

177

(2017), the age most susceptible to diarrhea is the age

of children 0-59 months.

According to H. L. Blum (Shi et al, 2019), there

are 4 factors that affect the degree of public health,

such as consisting of environmental factors,

behavioral factors, genetic factors and health

services. The mother's behavior is very important.

Because mothers are the closest people to toddlers,

both when eating, bathing, and playing, mothers are

more involved (Hendrastuti, 2019). Behavioral

factors consist of maternal parenting (Syam et al,

2020), exclusive breastfeeding, hand washing habits,

use of milk bottles (Tina et al, 2016), and drinking

water storage (Hendrastuti, 2019).

Another mother's behavior is related to drinking

water treatment. Drinking water consumed must be

safe and does not contain E.coli bacteria. According

to Purwaningsih (2014), the mother's behavior in

boiling water has an OR of 2.62. In addition to the

above variables, a variable that can cause diarrhea is

the behavior of using the latrine. The behavior of

using latrines according to Lidiawati's research

(2016), is also a risk factor for diarrhea in children

under five (OR = 4.52). This shows that toddlers with

poor stool management are 4.52 times more at risk of

developing diarrhea compared to toddlers with good

stool management and are thrown into the latrine.

The subdistrict of Ciawi, is an area with a high

prevalence of diarrhea in the district of Tasikmalaya,

with the cases in 2019 are 765 toddlers or 71.83% and

694 cases in 2020 (Ciawi Health Center, 2020). The

numbers of cases in the Ciawi Health Center are still

relatively high compared to other diseases with an

average of 82 visits per month. The highest diarrhea

visits throughout 2020 came from toddlers aged 6-23

months, which was 33.1% of the total visits.

The high incidence of diarrhea in children under

five in the subdistrict of Ciawi needs attention to be

studied more deeply. With the hope that there will be

no fatalities caused by diarrhea in toddlers. Therefore,

by looking at the data and the results of the initial

survey on the behavior of mothers.

2 METHODS

This study uses a case-control design. The population

is toddlers aged 6-23 months at the Ciawi Health

Center. A case was defined as ≥3 loose stools per day

in a child who presented to the Ciawi Health Center

(Puskesmas) for medical care in the last two months

(January-February 2021). The control sample is a

neighbor of the cases and has the same sex as the

cases and had no diarrheal illnesses. Samples were

taken purposively based on the inclusion criteria.

Respondents are mothers or families who take

care of toddlers and live in one house. The

independen varibles are mother’s behavior (boiling

water before drinking, wash hands with soap after

defecation, unsafe disposal of stool’s children/use the

latrine). Respondents are mothers or people who take

care of toddlers and live in the same house. The

sample inclusion criteria are to have a complete

address and contact number so that they can be found,

and are willing to be respondents.

Sample is calculated using EpiInfo for case-

control studies, with reference OR from Lidiawati's

(2016) study. The number of samples for each group

is added by 10% so that the total number of cases are

39 and the control are 39. The research instrument is

a questionnaire. Data collection trough interviews

with respondent and data analysis using chi square

tes using SPSS.

3 RESULTS

3.1 Characteristic of Samples

The majority of samples, both cases and controls,

were male (66.7%) and female were 23.3%.

3.2 Characteristic of Respondents

Table 1: Univariate Analysis.

Variables Category Case

(n=39)

Control

(n=39)

Mother’s

education

level

Finished

Elementary

Finished Junior

High School

Finish Senior

High School

Finished

College

17(43,6)

15(38,5)

6 (15,4)

1 (2,6)

14(35,9)

7 (17,9)

4 (10,3)

Proffesion Housewife

Employee

Enterpreneu

39 (100)

0 (0,0)

37(94,8)

1 (2,6)

Mother’s

age

Mean : 31 yo (6,9 SD)

Min : 18

Max : 50

Boiling

water

before

drinking

Yes

6 (15,4)

33(84,6)

1 (2,6)

38(97,4)

Washing

hands

with soa

Yes

13(33,3)

26(66,7)

14(35,9)

25(64,1)

ICSDH 2021 - International Conference on Social Determinants of Health

178

after

defecation

Children

stool

disposal

Unsafe

Safe

24(61,5)

15(38,5)

19(48,7)

20(51,3)

Mother’s

behavior

cate

Poor

Good

18(46,2)

21(53,8)

8 (20,5)

31(79,5)

The education level of the majority in the case

group was elementary school graduates (43.6%).

While in the control group, the education level that

became the majority consisted of two types, namely

elementary school graduates and junior high school

graduates. Both have the same percentage of (35.9%).

The type of work that became the majority in the two

groups was housewives with a percentage (100% and

94.9% respectively.

The mean ages of mother are 31 years old. The

total of 84.6% of the case group used boiling boiled

drinking water, as many as 66.7 mothers washed their

hands with soap after defecating, as many as 61.5%

of mothers in the case group carried out unsafe

children's stool disposal. The behavior of mothers in

the poor category in

the case group are 46.2% while

in the control group are 20.5%. The behavior of

mothers in the good category in the case group

amounted to 53.8% and in the control group

amounted to 79.5%.

3.3 Bivariate Analysis

Table 2: Bivariate Analysis between Mother’s Behavior

and Incidence of Diarrhea.

Mother’

Behavio

Incidence of Diarrhea

(CI:95

Case Control

n % n %

Poor

Good

46,2

53,8

20,5

79,5

0,03

3,321

(1,22-

9,03

)

Total 39 100 39 100

Bivariate analysis showed that from 26

respondents with poor maternal behavior, 18 toddlers

(46.2%) suffered from diarrhea and as many as 8

toddlers (20.5%) did not suffer from diarrhea.

Meanwhile, out of 52 respondents with good maternal

behavior, 21 toddlers (53.8%) suffered from diarrhea

and 31 toddlers (79.5%) did not suffer from diarrhea.

Chi square test found that there was a significant

relationship with p value 0.031 (<0.005) and has OR

3.321. This means that mothers with poor behavior

have a 3.321 times higher risk of having a toddler

with diarrhea compared to mothers who have good

behavior.

4 DISCUSSION

The behavior of mothers in this study consisted of

several indicators, consist of the behavior of boiling

water before drinking, washing hands after

defecating, and childrens stool disposal. Boiling is the

most commonly used reported Household Water

Treatment (HWT) method globally. The reported use

of boiling is particularly widespread in many Asian

nations, including China, which is 85% of rural

residents report boiling drinking water,16 as well as

an estimated 95% in Mongolia and 91% in Indonesia

and Vietnam (Rosa & Clasen, 2010; Cohen &

Colford, 2017).

Hand washing promotion in communities

prevents one quarter of diarrhea episodes with a

higher effect size when soap was provided free of cost

(Ri et al., 2015; Edward et al., 2019). The standard

practices for hand washing include before feeding a

child, after defecating, or handling a child who has

defecated and before cooking (Curtis, Scott &

Cardosi, 2005). Specific times of hand washing have

shown different outcomes of diar_rhea episodes, as in

a trial in rural Bangladesh where hand washing after

defecation with and without soap had significantly

higher odds of less diarrhea, but not before feeding a

child, or after cleaning a child who had defecated

(Luby et al., 2018). Human feces are the main source

of diarrheal pathogens. They are also the source of

shigellosis, typhoid, cholera, all other common

endemic gastro-enteric infections, and some

respiratory infections: just one gram of human feces

can contain 10 million viruses and one million

bacteria. While the routes are numerous, they all

emanate from one source: feces. While secondary

measures, which is food handling, water purification,

and fly control, may have an impact, far more

important are the primary barriers – sanitation and

handwashing – after fecal contact. These barriers

prevent fecal pathogens from reaching the domestic

environment in the first place (Curtis, Scott &

Cardosi, 2005).

The habit of washing hands reflects the quality of

health. Mother's actions hand washing is often

neglected and sometimes due to situations and

conditions where there are no washing facilities hand.

For example, mothers and toddlers eat snacks then

don't wash your hands first the reason is because there

are no washing facilities available (Pandean, 2016) .

Association of Mother’s Behavior with Diarrhea in Toddler (6-23 Months) in Public Health Center, Tasikmalaya District

179

According to the World Health Organization

(WHO), a child’s stool is considered to be disposed

of safely when the child uses the toilet/latrine; the

faeces is put/rinsed in the toilet/latrine or buried. On

the contrary, the disposal of faeces is considered

unsafe if the faeces are put/rinsed in a drain/ditch,

thrown in the garbage, left or buried in the open

(WHO/UNICEF, 2006; Bawankule et al., 2017).

The research of Taosu and Azizah (2013) in Bena

Village, East Nusa Tenggara, showed that there is a

significant relationship between the behavior of

housewives and the incidence of diarrhea in toddlers.

The behavior of housewives consisted of washing

hands before eating, washing hands after defecating,

washing milk bottles, boiling drinking water and

exclusive breastfeeding. The results are also in line

with research by Marissa, Oktavia (2013) in

Semarang and Riza (Riza et al, 2018. The study

showed that there is a significant relationship

between maternal behavior and the incidence of

moderate dehydration in toddlers (p value 0.010) and

the Odd Ratio has 4,7.

The incidence of diarrhea in toddlers aged 6-23

months in the Ciawi Health Center area mostly

(46.2%) occurred in mothers who had poor behavior.

In this study, two aspects of behavior that are still not

good in the research population are hand washing

with soap after defecation and safe disposal of toddler

stool. There is a need for health interventions through

information communication and education to

mothers. One of these activities can be done through

weighing children under five (Posyandu) which are

carried out regularly every month.

5 CONCLUSIONS

This study concluded that there was a significant

relationship between maternal behavior and the

incidence of diarrhea in children aged 6-23 months in

the Ciawi Health Center (p value 0.031) and

(OR=3.321). In an effort to control the incidence of

diarrhea in toddlers 6-23 months, it is necessary to

collaborate between health workers at the Ciawi

Health Center and mothers of toddlers to improve the

behavior of mothers of toddlers. The thing that can be

done is to intensify counseling to mothers of toddlers

in each posyandu about diarrhea prevention behavior

in toddlers.

ACKNOWLEDGEMENTS

This research was carried out with an internal

research grant from the Institute for Research and

Quality Assurance of Education (LP2M-PMP)

Siliwangi University

REFERENCES

Bawankule, R., et al. (2017). Disposal of children’s stools

and its association with childhood diarrhea in India.

BMC Public Health. BMC Public Health, 17(1), pp. 1–

9. doi: 10.1186/s12889-016-3948-2

Black, et al. (2008). Multi-country analysis of the effects

of diarrhoea on childhood stunting. Multi-country

analysis of the effects of diarrhoea on childhood

stunting, 37(4), pp. 816–830. doi: 10.1093/ije/dyn099.

Cohen, A. & Colford, J. M. (2017). Effects of boiling

drinking water on diarrhea and pathogen-specific

infections in low- and middle-income countries: A

systematic review and meta-analysis. American Journal

of Tropical Medicine and Hygiene, 97(5), pp. 1362–

1377. doi: 10.4269/ajtmh.17-0190.

Curtis, V., Scott, B. & Cardosi, J. (2005). The handwashing

handbook. World Bank. Available at:

http://scholar.google.com/scholar?hl=en&btnG=Search

&q=intitle:The+Handwashing+Handbook#1.

Dinas Kesehatan Kabupaten Tasikmalaya. (2019). Data

Balita Penderita Diare. Tasikmalaya : Bidang P2P.

Edward, A., et al. (2019). Association of mother’s

handwashing practices and pediatric diarrhea: Evidence

from a multi-country study on community oriented

interventions. Journal of Preventive Medicine and

Hygiene, 60(2), pp. E93–E102. doi: 10.15167/2421-

4248/jpmh2019.60.2.1088.

Hendrastuti, C. B. (2019). Hubungan Tindakan Pencegahan

Ibu dengan Kejadian Diare pada Balita. Jurnal

PROMKES, 7(2), p. 215. doi:

10.20473/jpk.v7.i2.2019.215-222.

Kementerian Kesehatan Republik Indonesia. (2010). Buku

Pedoman Pengendalian Diare. Jakarta : Direktorat

Jenderal Pengendalian Penyakit dan Penyehatan

Lingkungan.

Kementerian Kesehatan Republik Indonesia. (2013). Hasil

Riset Kesehatan Dasar (Riskesdas) Tahun 2013. Jakarta

: Kemenkes RI.

Kementerian Kesehatan Republik Indonesia. (2018). Hasil

Riset Kesehatan Dasar (Riskesdas) Tahun 2018. Jakarta

: Kemenkes RI.

Lidiawati, M. (2016). Hubungan Sanitasi Lingkungan

Dengan Angka Kejadian Diare Pada Balita Di Wilayah

Kerja Puskesmas Meuraxa Tahun 2016. Jurnal Serambi

Saintia, 4(2), pp. 1–9.

Luby, S. P., et al. (2018). Effects of water quality,

sanitation, handwashing, and nutritional interventions

on diarrhoea and child growth in rural Bangladesh: a

cluster randomised controlled trial. The Lancet Global

ICSDH 2021 - International Conference on Social Determinants of Health

180

Health. Elsevier Ltd, 6(3), pp. e302–e315. doi:

10.1016/S2214-109X(17)30490-4

Marissa, O. J. (2015). Hubungan Sanitasi Lingkungan,

Sosial Ekonomi dan Perilaku Ibu terhadap Kejadian

Diare dengan Dehidrasi Sedang pada Balita di Wilayah

Kerja Puskesmas Mangkang Kota Semarang Tahun

2015. Universitas Negeri Semarang. Available at:

http://lib.unnes.ac.id/22939/.

Murno, et al. (2011). Diarrhea and dehydration. Diarrhea

an Dehydratioon, 90(2), p. 266. doi:

10.1080/00325481.1991.11701026.

Purwaningsih, R. (2014). Hubungan Antara Penyediaan Air

Minum Dan Perilaku Higiene Sanitasi Dengan Kejadian

Diare Di Daerah Paska Bencana Desa

Banyudonokecamatan Dukun Kabupaten Magelang.

Unnes Journal of Public Health, 2(2).

Pandean, M. M. (2016). Perilaku Ibu Sebagai Faktor Risiko

Diare pada Balita di Kecamatan Dimembe Kabupaten

Minahasa Utara. Kesehatan Lingkungan, (2).

Ciawi Health Center. (2020). Data Diare Balita.

Tasikmalaya : Pemegang Program Diare.

Ri, E., et al. (2015). Cochrane Library Trusted evidence.

Informed decisions. Better health. Cochrane Database of

Systematic Reviews [Intervention Review] Hand

washing promotion for preventing diarrhoea. (9), pp. 1–

94. doi:

10.1002/14651858.CD004265.pub3.www.cochranelibr

ary.com.

Riza, et al. (2018). Hubungan Perilaku Hidup Bersih Dan

Sehat (Phbs) Dengan Kejadian Diare Pada Balita.

PROMOTIF: Jurnal Kesehatan Masyarakat, 8(1), p. 1.

doi: 10.31934/promotif.v8i1.224.

Rosa, G. & Clasen, T. (2010). Estimating the scope of

household water treatment in low- and medium-income

countries. American Journal of Tropical Medicine and

Hygiene, 82(2), pp. 289–300. doi:

10.4269/ajtmh.2010.09-0382.

Shi, L. & Singh, D. A. (2019). Essentials of The U . S .

Health Care System. 5th edn. Burlington: Jones &

Bartlett Learning.

Syam, et al. (2020). Kejadian Diare Pada Balita

Berdasarkan Teori Hendrik L. Blum Di Kota Makassar.

Media Kesehatan Politeknik Kesehatan Makassar,

15(1), p. 50. doi: 10.32382/medkes.v15i1.1060.

Taosu & Azizah. (2013). Hubungan Sanitasi Dasar Rumah

dan Perilaku Ibu Rumah Tangga dengan Kejadian Diare

pada Balita di Desa Benu Nusa Tenggara Timur. Jurnal

Kesehatan Lingkungan, 7(1), pp. 1–6.

Tina, et al. (2016). Faktor-faktor yang Berhubungan dengan

Kejadian Diare pada Balita Umur 6-59 Bulan di Wilayah

Kerja Puskesmas Poasia Tahun 2016. 3(2), pp. 13–22.

World Health Organization. (2017). Diarrhoeal Diseases.

Available at : https://www.who.int/news-room/fact-

sheets/detail/diarrhoeal-disease

WHO/UNICEF. (2006). Core questions on drinking-water.

World Health Organization, p. 25.

Association of Mother’s Behavior with Diarrhea in Toddler (6-23 Months) in Public Health Center, Tasikmalaya District

181