Vol 4 No 4 Final.indd


Althea Medical Journal. 2017;4(4)

534     AMJ December 2017

Environmental Factors, Knowledge, and Hygiene Behaviour among 
Mothers: A Slum Area in Bandung City, West Java, Indonesia

Gusti Adintya Putri,1 Sri Yusnita Irda Sari,2 Yoni Fuadah Syukriani3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Public Health Faculty of Medicine, 

Universitas Padjadjaran, 3Department of Forensic and Legal Medicine Faculty of Medicine 
Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung

Abstract

Background: The increased number of population living in urban areas causes the increase of requirement 
of basic life needs as well as the increase of household and human excreta waste. If these wastes were 
not well managed, this situation would contaminate the environment. This study aimed to analyze the 
relatioship between environmental factors, knowledge and hygiene behavior among mothers who lives in 
Bandung slum area.
Methods: An analytic cross sectional study was carried out on 132 mothers who lived in Tamansari 
subdistrict in Bandung city (RW 06, 07, 15, and 16) from  May to October 2014. The primary data were 
collected using 2 sets of  questionnaire and an observation checklist. The environmental factors and 
knowledge variables were catagorized into good and poor, while hygiene behavior was catagorized into 
good, moderate, and poor. The collected data were statistically analyzed using Chi-Square test.
Results: More than half of the participants had good environmental factors (60.6%), 59 participants 
(44.6%) had good knowledge about hygiene and 83 participants (62.9%) had good hygiene behavior, 43 
participants (32.6%) had a moderate hygiene behavior, and 6 participants (4.5%) bad hygiene behavior. 
Environmental factors was related to hygiene behavior (p=0.002). However, knowledge was not related to 
hygiene behavior (p=0.539). 
Conclusions: Environment is a significant factor to hygiene behavior.

Keywords: Environmental factors, hygiene behavior, knowledge, slum area

Correspondence: Gusti Adintya Putri, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang 
Km.21, Jatinangor, Sumedang, Indonesia, Email: gustiadintya@yahoo.co.id 

Introduction

The trend of human’s habitat has shifted in the 
last few decades. According to the Population 
Division of the United Nations, since 2009, the 
number of people who lived in city areas have 
exceeded the number of people who lived in 
rural areas.1 This urbanization phenomenon 
occurred in every country in the world, 
including in the developing countries such as 
Indonesia.1 

The population growth rate would be 
parallel with the increasing demand for basic 
life needs such as living space. More people 
were likely to live in a poor environmental 
setting, such as a slum area. Moreover, this 
condition would also affect the increase 
of house waste and human excreta waste 
production, which if not well-managed would 
contaminate the environment. 

Furthermore, the contaminated 
environment will increase the risk of people 

getting diseases. Hygiene behavior would 
become one of the key aspects on preventing 
diseases. According to Fishbein, et al.2, there 
are several aspects such as knowledge and 
skills, salience of the behavior, intention to 
perform, environmental factors, and a habit 
which is known as the determinant of a person 
to perform a behaviour, as described in the 
Integrated Behavioral Model (IBM) theory.2

Bandung is one of Indonesia’s urban areas. 
The “Health profile of Bandung” year 2012 
reported that the population growth rate was 
1.25%.3 Bandung also experiences a positive 
net migration, meaning, a higher number of 
people migrated to the city.4 Tamansari is one 
of the slum areas with the highest population 
density in Bandung Wetan district (9,889/
km2), and located in the centre of the city 
along Cikapundung river.4 The aim of this 
study was to analyze the relationship between  
environmental factor,  knowledge and hygiene 
behavior among mothers in Tamansari 

AMJ. 2017;4(4):534–40

ISSN 2337-4330  ||  doi: http://dx.doi.org/10.15850/amj.v4n4.1264



Althea Medical Journal. 2017;4(4)

535

subdistrict, Bandung.

Methods

This was an observational analytic cross 
sectional study. The study was conducted 
in Tamansari subdistrict, Bandung Wetan, 
Bandung, from May to October 2014. The 
sample of the study was mothers who lived 
in Rukun Warga (RW) 06, 07, 15, and 16, 
Tamansari subdistrict. The areas were selected 
because those areas were the most densely 
populated and closest area to Cikapundung 
river. The minimum sample required in the 
study was 97 participants. Samples were 
obtained using systematic random sampling. 
There were 142 home visits but only 132 
participants gave complete information, and 
were included in the data analysis.

Primary data was collected by using two 
sets of questionnaire and one observation 
checklist. The questionnaire about 
environmental factors which was used in 
this study were obtained from World Health 
Organization-United Nation Children’s Fund 
(WHO-Unicef ) core question on drinking-
water and sanitation for household survey.5 
Accounted aspects included: type of toilet 
used, disposal of diapers, availability of trash, 
garbage disposal, clean water and drinking 
water source, waste disposal of human 
excreta, the availability of a septic tank in 
the neighborhood, and pets. Every aspect 
was given a score of 1 for improved and 0 for 
unimproved answers. Then the scores were 
accumulated and categorized either good 
(>mean) or poor (<mean).

The level of knowledge of the participants 
was assessed by an interview with questions 
adopted from a publication by Stevenson et al.6 
The questionnaire consisted of 5 subcategories: 
general cleanliness (5 questions), household 
hygiene (2 questions), food hygiene (3 
questions), hand hygiene (2 questions), and 
personal hygiene (3 questions). For each 
correct answer was given a score of 1 and for 
every wrong answer or ‘do not know’ was given 
a score of 0. The scores then were accumulated 
and categorized either good (>mean) or poor 
(<mean). It was validated to 26 respondents 
prior to the study.

Furthermore, the hygiene behavior of 
the participants was assessed with the 
observation of Hygiene Index, as written by 
Webb et al.7 The subcategories were: drinking 
water hygiene (3 indicators), food hygiene (3 
indicators), personal hygiene (3 indicators), 
and household hygiene (6 indicators). For 

every good behavior was given a score of 1 
and for any bad behavior was given a score 
of 0. The scores then were accumulated and 
categorized as good (10–15), moderate (6–
9), and poor (0–5). The ethical protocol has 
been approved by the Health Research Ethics 
Committee, Faculty of Medicine Universitas 
Padjadjaran, Ethical Exemption No. 449/UN6.
C2.1.2/KEK/PN/2014.

The data was analyzed using statistical 
application. Then, the chi square method 
was performed to determine the relationship 
between each categorical variable. The 
relationship would be considered significant 
if p<0.05. 

Results

The characteristics distribution of 
respondents in this study showed that the age 
of the respondents ranged from 20 years to 77 
years with a median age of 42 years. A total 
of 51 respondents (38.6%) were high school 
graduates or equivalent, and most respondents 
had moderate-low income each month, 
ranging from Rp500,001 to Rp 1,500,000. The 
number of people living in one house varied 
between one and twenty people. The majority 
of respondents had one to five people who 
lived in their houses (69.2%) (Table 1).

Based on environmental factors and level 
of knowledge, this study discovered that 
more than half of the respondents had good 
environmental factors, but the majority of the 
respondents had a poor level of knowledge 
about hygiene (Table 2).

Moreover, all respondents used an 
unimproved toilet (100%). A total of 107 
(81%) of them had a flush toilet while the 
other 25 (19%) did not have a flushing toilet. 
Out of 40 respondents who had children under 
the age of 3 years, 22 of them (55%) disposed 
of diapers in a way that was considered good. 
Most respondents had a trash bin in the house 
and most of them (93.1%) collected the trash to 
a temporary domestic waste disposal nearby. 
A total of 130 respondents (98.4%) used a 
clean water source that was considered good, 
and the same number of respondents used 
drinking water sources which was categorized 
as good. 

No respondents used septic tanks as 
disposal of human waste, in other words, no 
septic tank was available in the surrounding 
area of the survey. A total of 42 respondents 
(31.8%) had pets in the house and 36 of them 
(85.7%) used a cage either inside or outside 
the house. In the observation of water storage, 

Gusti Adintya Putri, Sri Yusnita Irda Sari, Yoni Fuadah Syukriani: Environmental Factors, Knowledge, and 
Hygiene Behaviour among Mothers: A Slum Area in Bandung City, West Java, Indonesia



Althea Medical Journal. 2017;4(4)

536     AMJ December 2017

as many as 83 respondents (62.9%) left 
water in a container or bucket with the risk of 
contamination, and as many as 76 respondents 
(57.6%) kept their water storage near the 
source of pollutants. 

All respondents learned about the 
necessity of washing hands after going out 
and after touching animals (100%). Most of 
the respondents (90.2%) saw the need of 
washing hands before eating, and a number 
of 125 respondents (94.7%) knew the need 
for washing hand after defecation. A total of 
127 respondents (96.2%) realised the need to 
brush their teeth at least twice a day.

Additionally, in the aspect of household 

hygiene, most respondents knew that the 
bathroom and toilet should be cleaned at least 
once a week (75.8%) and the house needs 
to be swept at least once a day (76.5%). In 
the food hygiene aspects, 130 respondents 
(98.5%) were able answer questions correctly 
regarding the need to wash hands before 
making meals, 121 respondents (91.7%) 
were aware that vegetables should be washed 
before eating, and 124 respondents (93.9 
%) agreed the need of water to be boiled or 
filtered before drinking.

Furthermore, most of the respondents 
were able to answer correctly the question 
of knowledge on aspects of hand hygiene and 

Table 1 Characteristics Distribution of  the Respondents
Variable Frequency (f ) Percentage (%)
Age
      20–29 years 12 9.1
      30–39 years 38 28.8
      40–49 years 37 28
      50–59 years 31 23.5
      > 60 years 14 10.6
Occupation
      Housewife 103 78.2
      Sales 21 15.9
      Teacher 3 2.2
      Employee 2 1.5
      Pension 3 2.2
Education
      Elementary 37 28
      Junior high 29 21.9
      Senior high 51 38.6
      Diploma 6 4.5
      Bachelor 9 6.8
Monthly Income (Rupiahs)
      < 500.000 3 2.3
      500.001–1.500.000 75 56.8
      1.500.001–3.000.000 46 34.8
      > 3.000.000 8 6.1
Number of people live in the house
      1–5 people 92 69.2
      6–10 people 35 26.5
      11–15 people 3 2.3
      16–20 people 2 1.5



Althea Medical Journal. 2017;4(4)

537Gusti Adintya Putri, Sri Yusnita Irda Sari, Yoni Fuadah Syukriani: Environmental Factors, Knowledge, and 
Hygiene Behaviour among Mothers: A Slum Area in Bandung City, West Java, Indonesia

personal hygiene. All respondents knew the 
correct hand washing must use clean water 
and soap (n=132, 100%) and as many as 104 
respondents (78.8%) realized the need for 
drying hands after washing. Most respondents 
confirmed the need to shower three times a 
day. Most of the respondents knew that the 
worn clothes needed to be changed at least 
once in more than two days and almost all 
respondents knew that underwear should be 
changed every day.

Based on observation of hygiene behavior, 

more than half of the respondents had a good 
hygiene behavior (Table 3).

Most respondents stored drinking water 
in sealed containers (95.5%), clean on the 
outside (89.4%), and filled with water at 
the time of observation (94.7%). A total of 
56 respondents (42.4%) kept clean dishes 
covered, 90 respondents (68.2%) kept clean 
dishes at high altitudes, and as many as 66 
respondents (50%) left all the food covered. A 
total of 47 respondents (36.5%) used footwear, 
the hands of 110 respondents (83.3%) were 

Table 2 Distribution of Environmental Factors and Level of Knowledge

Characteristics

Environmental 
factors

p value
Hygiene knowledge

p value
Good 

(n=80)
Poor 

(n=52)
Good 

(n=59)
Poor 

(n=73)
Age 0.340 0.522
      20–29 years 6 6 5 5
      30–39 years 22 16 10 10
      40–49 years 25 12 16 16
      50–59 years 16 15 9 9
      > 60 years 11 3 4 4
Occupation 0.121 0.976
      Housewife 57 46 35 68
      Sales 17 4 6 15
      Teacher 2 1 1 2
      Employee 2 0 1 1
      Pension 2 1 1 2
Education 0.145 0.246
      Elementary 18 19 10 27
      Junior high 16 13 9 20
      Senior high 36 14 16 34
      Diploma 3 3 4 2
      Bachelor 7 2 5 4
Monthly Income 0.910 0.046
      < 500.000 2 1 1 2
      500.001–1.500.000 45 30 18 57
      1.500.001–3.000.000 29 17 20 26

      > 3.000.000 4 4 5 3
Number of people live in the house 0.390 0.421
      1–5 people 55 37 32 60
      6–10 people 22 13 11 24
      11–15 people 1 2 0 3
      16–20 people 2 0 1 1



Althea Medical Journal. 2017;4(4)

538     AMJ December 2017

clean, and the index finger of 72 children 
(54.5%) were also clean.

In the household hygiene, there were 
89 homes of respondents (67.4%) with no 
garbage scattered outside the home, and 74 
homes of the respondents (56.1%) had no 
garbage strewn in the house. In addition, 106 
(80.3%) of respondents did not let animals 
roam in the house or patio, 72 respondents 
(54.5%) did not keep a pile of dirty clothes. 
There were no flies in a significant number of  
houses (81.1%, and among 88 houses (66.7%) 
there was not any puddle with no patio or 

around the house. 
Based on environmental factors and 

knowledge of the respondents regarding 
hygiene behavior, there was a significant 
difference between respondents who had 
good and bad environmental factors. This 
study discovered that there was a statistical 
difference between environmental factors 
and hygiene behavior (p=0.002). However, 
there were no statistical differences between 
respondents with knowledge of good and bad  
and hygiene behaviour (p=0.539) (Table 4).

Table 3 Distribution of Hygiene Behavior

Characteristics
Hygiene behavior

p valueGood 
(n=83)

Moderate 
(n=43)

Poor 
(n=6)

Age 0.735
      20–29 years 8 3 1
      30–39 years 25 12 1
      40–49 years 20 14 3
      50–59 years 19 11 1
      > 60 years 11 3 0
Occupation 0.764
      Housewife 64 35 4
      Sales 15 4 2
      Teacher 1 2 0
      Employee 1 1 0
      Pension 2 1 0
Education 0.432
      Elementary 22 12 3
      Junior high 16 11 2
      Senior high 36 13 1
      Diploma 3 4 0
      Bachelor 6 3 0
Monthly Income 0.562
      < 500.000 3 0 0
      500.001–1.500.000 47 25 3
      1.500.001–3.000.000 29 14 3
      > 3.000.000 4 4 0
Number of people live in the house 0.787
      1–5 people 55 32 5
      6–10 people 24 10 1
      11–15 people 2 1 0
      16–20 people 2 0 0



Althea Medical Journal. 2017;4(4)

539

Discussions

The rising population living in urban slums 
was clearly demonstrated in this study, one 
third of the respondents lived with more 
than five people in one house. Moreover, 
there were five household with more than ten 
people in the house. The population density 
caused by urbanization was also found in 
several other countries in the world such as in 
Kenya, India, Bangladesh, the Philippines, and 
other developing countries.8-11 Overly dense 
residential neighborhoods and inadequate 
housing conditions can increase the risk factor 
of some diseases, such as respiratory infectious 
diseases, diarrhea, cancer, to developmental 
disorders in children.12-15 Thus, the population 
density in the area is in need of concern of 
local stakeholders, in order to protect the 
community health.

More than half of the respondents, 83 
people (62.8%), had a good level of hygiene 
behaviors. This could be caused by the 
educational background of the respondents 
who were mostly high school graduates. 
However, on a higher level of knowledge, the 
majority of the respondents were still on the 
poor level (55.3%). This was not in line with the 
study by Ahuja et al.16, in Mumbai, India, where 
respondents with higher education were able 
to answer questions about knowledge better.

Among all respondents who participated 
in the study, none of them had a septic tank in 
the human waste disposal system. Absence of 
septic tanks could also contaminate the water 
sources in the neighborhood, where 66.7% 
of respondents used well-water as source 
of clean water as well as source of drinking 
water for 46 respondents (34.8%). A study 
in Langa17, a slum area in Kenya, discovered 
that most of the faecal contamination of water 
sources did not meet the criteria of the WHO 

drinking water quality due to sanitation in the 
environment are inadequate.

Afurther study must be conducted on the 
water content in the local area to confirm 
water quality concerns, as water pollution can 
cause the transmission of infectious diseases 
such as fecal-oral cholera, typhoid, hepatitis, 
polio, and ascariasis.18-19 The management of 
human sewage in the local area needs to be 
improved to reduce the risk of disease.

Furthermore, economic limitations might 
be another consideration for urban slum 
communities to choose boiling water for 
drinking instead of buying bottled water. Most 
respondents had moderate-low incomes per 
month, Rp500,001.00 up to Rp1,500,000.00. 
Consistently, more respondents used cooking 
water from water wells and water taps for 
drinking water. This was parallel with the 
study conducted by Alam, et al.20 in urban 
slums in Rajshashi, Bangladesh.

Results of this study revealed that some 
of the respondents were raising pets without 
cages and some of the respondents let their 
pets roam in and around the house. On the 
other hand, pets can be an intermediary source 
for infection either by bacteria in the body and 
through the dirt when contaminating water 
and food consumed.18 The community needs 
to be educated about the importance of pet 
hygiene to prevent transmission of disease 
through vaccination of pets and animals.

This study discovered, there was no 
significant difference of hygiene behavior 
between respondents who had a good level 
of knowledge and poor level of knowledge. 
The results were less in accordance with the 
theory of IBM, which states that the level of 
knowledge is a factor that determines the 
behavior of individual hygiene.2 There were 
other factors such as intentions, habits, and 
skills which also determined the behavior 
of individuals that were not involved in this 

Table 4 Environmental Factor and Hygiene Knowledge Regarding Hygiene Behavior

Variable
Hygiene behavior

Total 
n (%) pGood 

(n=83)
Moderate 

(n=43)
Poor 
(n=6)

Environmental factor
     Good 60(70%) 18(22.5%) 2(2.5%) 114(100%) 0.002
     Poor 23(44.2%) 25(48.1%) 4(7.7%) 18(100%)
Knowledge
     Good 36(61%) 19(32.2%) 4(6.8%) 59(100%) 0.539
     Poor 47(64.4%) 24(32.9%) 2(2.7%) 73(100%)

Gusti Adintya Putri, Sri Yusnita Irda Sari, Yoni Fuadah Syukriani: Environmental Factors, Knowledge, and 
Hygiene Behaviour among Mothers: A Slum Area in Bandung City, West Java, Indonesia



Althea Medical Journal. 2017;4(4)

540     AMJ December 2017

research.
In conclusion, environmental factors of the 

respondents based on hygiene behavior show 
a significant difference between respondents 
who have good and poor environmental 
factors. The findings are consistent with the 
theory of IBM, which states the environment 
as a determining factor of individual hygiene 
behavior.2 The limitation of the study was the 
absence of age definition of the respondent, 
which caused a large wide range (20–77 years 
old).

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