Althea Vol 2 No 2 Final.indd


Althea Medical Journal. 2015;2(2)

191

Mothers’ Hand washing Practice and Diarrhea Cases in Children under 
Five in Baleendah, Bandung

M. Syafril Firdaus,1 Insi Farisa Desy Arya,2 Dadang Hudaya Somasetia3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Public Health Faculty of Medicine 

Universitas Padjadjaran, 3Department of Child Health Faculty of Medicine, Universitas 
Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, Indonesia

Abstract

Background: Diarrhea is a disease, especially in children, with high mortality and morbidity rate in 
developing countries, including Indonesia. Diarrhea can be prevented if people can apply clean and healthy 
behaviors, especially hand washing. Hand washing is the cheapest, simplest, and the most effective methods 
for prevention of diarrhea. The objective of this study is to identify the knowledge, attitude, and practice of 
mothers’ hand washing and diarrhea cases in children under five in Baleendah District, Bandung.
Methods: A descriptive study was conducted during September−November 2012 to 210 mothers who 
had children (ages 12−59 months) in Baleendah using rapid survey technique. The time allocated for each 
village was adjusted to the population proportion for each region. The data were analyzed using computer 
and was represented using frequency distribution.
Results: This study showed that the respondents had good level of knowledge and attitude of hand washing 
(83.8% and 61%, respectively), but only 21% of the respondents’ practices of hand washing was in good 
level. Most of the respondents did not wash their hands according to the 7 steps of correct hand washing. 
Moreover the percentage of children with diarrhea in Baleendah was 43.8% (92 cases) during the study.
Conclusions: There should be dissemination of information about the benefit of washing hands with 7 
steps of correct hands washing so that families can practice it and can prevent diarrhea in children under 
five. [AMJ.2015;2(1):191–8]

Keywords: Diarrhea, hand washing, practice, mother

Correspondence: M. yafril Firdaus, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, 
Jatinangor, Sumedang, Indonesia, Phone: +6285695792727 Email: msyafrilfirdaus@yahoo.com

Introduction

Diarrhea is a major cause of children mortality 
and morbidity in the developing countries. 
Based on data from the World Health 
Organization (WHO) in 2007, it was estimated 
that every year 100,000 Indonesian children 
died from diarrhea. In addition, the data from 
Health Department of Republic of Indonesia in 
2000 stated that 300 inhabitants from 1,000 
people were affected by diarrhea each year.1,2

According to Indonesian Basic Health 
Research 2007, the leading cause of death on 
children in Indonesia are diarrhea and Upper 
Respiratory Infection.3Diarrhea infection 
is more dominant in babies because their 
endurance is still weak so they are highly 
susceptible to viral and bacterial infections that 
cause diarrhea. According to United Nations 
International Children Fund (UNICEF) in 2012, 
it was estimated that each day 2,000 children 
under five worldwide died from diarrhea. In 
developing countries, including Indonesia, 

the baby suffering from diarrhea is more than 
12 times per year, making the diarrhea as the 
causes of death by 15−34% than other causes 
of death. Babies who grow up in rural areas 
are at risk of death 10 times greater than those 
who grow up in urban areas.4

In West Java Province, the incidence of 
diarrhea occurs up to 10%, surpassing the 
national average of 9%. From West Java 
Provincial Health Office report a few years 
back, it was stated that Citarum Watershed was 
given a special attention due to the incidence 
of diarrhea, one region is Baleendah.5

Baleendah District is located in South 
Bandung with an area of 985,149,5 ha width. 
Until now, the flood in Citarum River routinely 
occurs every rainy season. Baleendah and its 
surrounding areas are often flooded. Diarrhea 
and respiratory problems often rise due to 
floods in Baleendah.6 According to the Health 
Center in 2010; diarrheal diseases became 
the top three diseases for children under five 
in this district, with a number of case 2,179 
patients.7



Althea Medical Journal. 2015;2(2)

192     AMJ June, 2015

In general, clean and healthy lifestyle 
behaviors in Indonesia are still lacking and it 
is not to be a community culture. The report 
from Baleendah Primary Health Care on clean 
and healthy lifestyle behaviors in 2010, it 
was shown that from 1,050 households, only 
508 that met the clean and healthy lifestyle 
behaviors standard7.  The clean and healthy 
lifestyle behaviors data also support the 
information that the diarrhea disease will 
continue occur every year when the public 
clean and healthy behavior does not change 
better. 

According to WHO, hands are the main lines 
of germ entry into the body, as the hands often 
have direct contact with the mouth and nose. 
Hands can be exposed to germs when we come 
into contact with the body, others people, 
animals, or contaminated surfaces.1WHO 
shows that washing hands properly with soap 
at 5 critical times can reduce the incidence of 
diarrhea by 40%. The five critical times are 
before eating, after defecation and urination, 

before holding the child, after cleaning the 
child, and before preparing food.8

Based on the above description, it can be 
recognized the important roles of mothers 
who are closest to their children, the five 
significant times on washing hands with soap, 
and the high incidence of diarrhea experienced 
by children under five in Baleendah.Therefore, 
the author is interested in studying the 
knowledge, attitude, and practice of mothers’ 
hand washing as well as the occurrence of 
diarrhea cases in the children under five in 
Baleendah, Bandung District.

Methods

A descriptive study was conducted during 
September−November 2012 to 210 mothers 
who had children (ages 12−59 months) in 
Baleendah using rapid survey technique.9 The 
time allocated for each village was adjusted 
to the population proportion for each region. 

Table  1 Questions About Respondents’ Hand washing Knowledge (n=210)

No. Question Category Number of 
Respondents

(%)

1 Benefits of hand washing is to 
prevent a person affected by 
disease

Correct answer 201 (95.7)
Wrong answer 5 (2.4)
Do not know 4 (1.9)

2 Washing hands with soap is not 
only carried out when the hand 
looks dirty

Correct answer 62 (29.5)
Wrong answer 148 (70.5)
Do not know 0 (0.0)

3 Hands are the main part of the 
body as media of germs enter the 
body

Correct answer 205 (97.6)
Wrong answer 1 (0.5)
Do not know 4 (1.9)

4 Hand washing should use running 
water

Correct answer 58 (27.6)
Wrong answer 151 (71.9)
Do not know 1 (0.5)

5 There are 7 steps how to wash 
hands properly

Correct answer 37 (17.6)
Wrong answer 28 (13.3
Do not know 145 (69.0)

6 Washing hands with soap is one 
of clean and healthy behavior in 
households

Correct answer 13 (6.2)
Wrong answer 195 (92.9)
Do not know 2 (1.0)

7 Hand washing is a simple way to 
do, inexpensive and can prevent 
disease

Correct answer 201 (95.7)
Wrong answer 4 (1.9)
Do not know 5 (2.4)



Althea Medical Journal. 2015;2(2)

193M. Syafril Firdaus, Insi Farisa Desy Arya, Dadang Hudaya Somasetia: Mothers’ Hand washing Practice and 
Diarrhea Cases in Children under Five in Baleendah, Bandung

The results showed that Baleendah Village (49 
respondents), Andir Village (28 respondents), 
Manggahang Village (28 respondents), Jelekong 
Village (21 respondents), Wargamekar Village 
(14 respondents), BojongmalakaVillage 
(21 respondents), Rancamanyar Village (35 
respondets), and Malakasari Village (14 
respondents). 

The respondents had to meet the inclusion 
criteria: the child’s mother was at home during 
the study and agreed to participate in filling in 
validated questionnaire about hand washing. 

The questionnaire consisted of 5 questions 
about characteristic of the respondents, 7 
questions about knowledge and attitude 
respectively, and 9 questions about hand 
washing practice. The data were analyzed 
using computer and was represented using 
frequency distribution.

Results

Questions about hand washing knowledge 

Table  2  Questions About Respondents’ Hand Washing Attitude (n=210)

No. Question Category Number of 
Respondents

(%)

1 Mothers should wash their hands 
with soap before preparing food 
for their child,

Strongly Agree 76 (36.2)
Agree 131 (62.4)
Disagree 3 (1.4)
Strongly Disagree 0 (0.0)

2 Mothers should wash their hands 
with soap after cleaning their 
babies

Strongly Agree 87 (41.4)
Agree 122 (58.1)
Disagree 1 (0.5)

Strongly Disagree 0 (0.0)

3 Mothers do not have to wash their 
hands with soap before holding 
their child

Strongly Agree 2 (1.0)
Agree 74 (35.2)
Disagree 120 (57.1)
Strongly Disagree 14 (6.7)

4 Hand washing should use soap Strongly Agree 48 (22.9)
Agree 146 (69.5)
Disagree 16 (7.6)
Strongly Disagree 0 (0.0)

5 Hand washing is not always using 
the  running water

Strongly Agree 13 (6.2)
Agree 65 (31.0)
Disagree 114 (54.3)
Strongly Disagree 18 (8.6)

6 Mothers do not have to wash their 
hands with soap before feeding 
their child

Strongly Agree 1 (0.5)
Agree 62 (29.5)
Disagree 122 (58.1)
Strongly Disagree 25 (11.9)

7 Mothers should wash their hands 
with soap after cleaning the house

Strongly Agree 42 (20.0)
Agree 162 (77.1)
Disagree 6 (2.9)
Strongly Disagree 0 (0.0)



Althea Medical Journal. 2015;2(2)

194     AMJ June, 2015

consist of the benefit, ways of using soap, 
running water, washing hands properly, and 
preventing the disease. Most of the respondents 
could answer the question about the benefit of 
hand washing (95.7%). Hands are the main 
part of the body as media of germs to enter the 
body (97.6%). Hand washing is a simple way 
to do, inexpensive and can prevent disease 
(95.7%). The majority of mothers (69%) did 
not know about the 7 steps of how to wash 
hands properly. The rest of the questions were 
answered wrong (Table 1). 

For the question about respondents hand 
washing attitude, most of the respondents 

was agree about washing with soap before 
preparing food for their child (62,4%), after 
cleaning their babies (58.1%), and after 
cleaning the house (77.1%). Therefore, the 
respondents were disagree with the question 
about do not have to wash their hands with 
soap before holding their child (57.1%), hand 
washing is not always using the  running water 
(54.3%), do not have to wash their hands with 
soap before feeding their child (54.3%) (Table 
2).

For the level of hand washing practices, 
from 210 respondents, 193 mothers (91.9%) 
said they never washed their hands by 

Table  3  Questions About Respondents’ Hand washing Practices (n = 210)

No. Question Category Number of 
Respondents

(%)

1 Mother washing hands with soap Often 116 (55.2)
Sometimes 94 (44.8)
Never 0 (0.0)

2 Mother washing hands with 
running water frequently

Often 139 (66.2)
Sometimes 66 (31.4)
Never 5 (2.4)

3 Mother did not wash their hands 
with soap before handling the 
child

Often 18 (8.6)
Sometimes 153 (72.9)
Never 39 (18.5)

4 Mother washing hands before 
preparing food for baby

Often 155 (73.8)
Sometimes 53 (25.2)
Never 2 (1.0)

5 Mother drying hands with a clean 
towel after washing hands

Often 166 (79.0)
Sometimes 38 (18.1)
Never 6 (2.9)

6 Mother washing hands after 
cleaning the baby

Often 206 (98.1)
Sometimes 4 (1.9)
Never 0 (0.0)

7 Mother did not wash hands before 
feeding the child

Often 23 (11.0)
Sometimes 121 (57.6)
Never 66 (31.4)

8 Mother did not wash hands after 
cleaning the house

Often 21 (10.0)
Sometimes 35 (16.7)
Never 154 (73.3)

9 Mother washing hands with 7 
steps how to wash hands well and 
correctly

Often 8 (3.8)
Sometimes 9 (4.3)
Never 193 (91.9)



Althea Medical Journal. 2015;2(2)

195M. Syafril Firdaus, Insi Farisa Desy Arya, Dadang Hudaya Somasetia: Mothers’ Hand washing Practice and Diarrhea Cases in Children under Five in Baleendah, Bandung

following the 7 steps of how to wash hands 
properly (Table 3).

Knowledge, attitude, and practice are 
essential in any clean and healthy behaviors. 
Overall, a description about knowledge 
and attitude of the mothers regarding the 
importance of hand washing was in good 
category (83.8% and 61%), meanwhile for the 
description about respondent’s practice was 
in fair level (55.7%) (Table 4).

According to sociodemographic 
characteristics and affordability, it can be 
discovered that from 210 respondents, 92 
of them had their children under five with 
diarrhea in the last month (Table 5). Based 
on the age group of children, the incidence 
of diarrhea is mostly experienced in the age 
group of 12−23 months, amounting to 58.7%, 
and at least in the age group of 48−59 months 
by 8.7%.

Discussions

Based on the study result, a description on 
knowledge level of the mothers regarding the 
importance of hand washing is in good level. 
This evident is derived from the study showing 
that the average level of respondent knowledge 
is in both categories (83.8%). However, the 
existing questionnaire questions, the question 
number 5 showed that the majority of mothers 
(69%) did not know about the 7 steps of 
how to wash hands properly. This suggests 
that mothers understand the importance 
of washing hands with soap as one way of 
preventing the entry of germs into the body, 
but they do not know how to wash the hands 
properly. These results are similar to studies 

in other villages, e.g. Hegarmanah and Sayang 
Villages, Jatinangor District, it was stated that 
92.9% of women did not know about the 7 
steps how to wash hands well and correctly.10

For the level of attitudes, the results of 
this study also showed that still there were 
mothers who had a relatively less stance on 
the importance of hand washing (29%). A 
study conducted in Hegarmanah and Sayang 
Villages, Jatinangor District, showed as much 
as 78.1% of women were categorized in good 
level.10 According to Bloom, the attitude factors 
become the major influence on people’s health 
status. Maternal attitudes in health is crucial 
to the health status of the families, including 
their children. This is because the mothers 
usually become the direct caregiver for the 
child so that more interaction occurs.11

For the level of hand washing practices, 
most mothers were in the category of enough 
(55.7%). This indicates that most mothers 
do not have good knowledge about hand 
washing practice. According to WHO report, 
people who do not have access to soap will 
be difficult to implement washing hands with 
soap.12 However, the absence of soap is not a 
barrier to washing hands with soap practice 
in this study. They have reason that the hand 
still looks clean. Therefore they assumed that 
washing hands was a very time consuming, 
moreover the lack of nearby places to wash 
hands, such as a sink, had become the reason 
for the low level of the respondents’ hand 
washing practices in this study. According 
to the study performed in Hegarmanah and 
Sayang Village, Jatinangor District, the study 
showed that as much as 82.4% of women were 
categorized in poor level.10

It is also worth to highlight the questionnaire 

Table  4 Description about Respondents’ Hand washing Knowledge, Attitude, and  
                 Practice (n = 210)

No. Question Category Number of 
Respondents

(%)

1
Knowledge

Good 176 (83.8)
Fair 34 (16.2)
Poor 0 (0.0)

2
Attitude

Good 128 (61)
Fair 22 (10)
Poor 60 (29)

3
Practice

Good 44 (21.0)
Fair 117 (55.7)
Poor 49 (23.3)



Althea Medical Journal. 2015;2(2)

196     AMJ June, 2015

results about 7 hand washing practices steps 
that were performed well and correctly. From 
210 respondents, 193 mothers (91.9%) said 
they never washed their hands by following 
the 7 steps of how to wash hands properly.  It 
is caused by mothers’ lack of knowledge about 
good hand washing, given that the maternal 
ignorance about the 7 steps reaching 69%. 
These results are similar to studies in Karachi, 
Pakistan, which also stated that as many as 
84% women never washed their hands with 
the 7 steps.13

Overall, the study in Indonesia showed 
that people know many germs on the hands. 
However, hand washing behavior has not 
become a daily habit, especially in the five 
critical times to wash hands: before eating, 
after defecation and urination, before holding 
the child, after cleaning the child, and before 
preparing food. There were only about 0−34% 

who washed hands at the critical times.14,15
The results are not much different from other 

studies on developing countries. According 
to The Global Public Private Partnership for 
Hand Washing, hand washing habits in India 
reached 34%, Ghana 3%, Senegal 31%, Nigeria 
10%, and Burkina Faso 13%.12

Knowledge about health is the basis for 
behavior change, yet there is possibility 
of someone not to necessarily act on the 
knowledge base owned.16 According to the 
research in 11 major countries on hand 
washing behavior, there are three factors 
affecting the hand washing behavior: planned 
activity, motivation to conduct, and health 
behavior habits.17

Based on the study result, the incidence of 
children under five with diarrhea in the last 
month were 210 respondents and 92 (43.8%) 
mother had children under five with diarrhea 

Table 5  Diarrhea Cases in Children Under Five in The Last Month According to 
                 Sociodemographic Characteristics and Affordability

Characteristics

Diarrhea

Yes No

n % n %

Mother's Education
Not Finished elementary school 0 (.0) 1 (100.0)
elementary school Graduates 26 (55.3) 21 (44.7)
junior high school Graduate 41 (44.6) 51 (55.4)
Senior high school Graduate 20 (31.7) 43 (68.3)
Colleges Graduate 5 (71.4) 2 (28.6)

Total 92 (43.8) 118 (56.2)
Family Income

<regional minimum wage (UMR) 57 (44.9) 70 (55.1)
>regional minimum wage (UMR) 35 (42.2) 48 (57.8)

Total 92 (43.8) 118 (56.2)
Children Age (months)

12−23 54 (55.7) 43 (44.3)
24−35 21 (42.0) 29 (58.0)
36−47 9 (24.3) 28 (75.7)
48−59 8 (30.8) 18 (69.2)

Total 92 (43.8) 118 (56.2)
Children Sex

Male 48 (42.5) 65 (57.5)
Female 44 (45.4) 54 (54.6)

Total 92 (43.8) 118 (56.2)



Althea Medical Journal. 2015;2(2)

197

in the last month. The other studies conducted 
in the slums of North Jakarta with household 
survey technique showed that children under 
five with diarrhea in the last month reached 
13% children.18These results is in contrast 
with Baleendah District although both areas 
are flooded areas.

Based on the age group of children, the 
incidence of diarrhea is mostly experienced in 
the age group of 12−23 months, amounting to 
58.7%, and at least in the age group of 48−59 
months by 8.7%. These results are consistent 
with the research in Semarang. The research 
showed that  the incidence of diarrhea in 
children under five in the age group <24 
months  was (58.68%), followed by age group 
24−36 months with (24.65%) and the least in 
group aged of 37−60 months with (16.67%)16. 
Similar results were also shown by the study 
of Health Primary Center Tetehosi Foa, District 
Gido, Niasa Regency, North Sumatra19, stating 
that the largest proportion of children under 
five with diarrhea were in the age group of 
1−3 years, which was equal to 46.8%. All 
cases of diarrhea in children under five in 
Baleendah were acute diarrhea, the diarrhea 
that occurred with the duration of no more 
than 14 days. 

As conclusion, there should be information 
dissemination on the benefit of washing hands 
with 7 steps of correct hands washing through 
a simulation. In addition, the collaboration 
between health primary center and integrated 
health cares in the local community should 
also be made to promote the clean and healthy 
lifestyle behaviors campaign in the household. 
Therefore, the  families can practice the clean 
and healthy lifestyle behaviors  to prevent 
diarrhea in children under five, especially with 
washing hands with soap.

References

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M. Syafril Firdaus, Insi Farisa Desy Arya, Dadang Hudaya Somasetia: Mothers’ Hand washing Practice and 
Diarrhea Cases in Children under Five in Baleendah, Bandung



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