Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13035 Analysis of diarrhea incidence based on demographic characteristics and hygiene behavior of adults in Indonesia and Taiwan Firdaus, Rahmadaniar Aditya Putri, Siti Damawiyah, Faridah Umamah, Difran Nobel Bistara Department of Midwifery, Faculty of Nursing and Midwifery, Nahdlatul Ulama University Surabaya, East Java, Indonesia Abstract Diarrhea is a common manifestation of gastroenteritis, affect- ing both children and adults globally. Subsequently, gastroenteritis is particularly prevalent in developing countries such as Indonesia and Taiwan. This research aimed to analyze the incidence of diar- rhea based on socio-demographics and personal hygiene in Indonesia and Taiwan. The method used in this research was a quantitative design with a cross-sectional approach, and the data collection involved interviews with adults, using a structured ques- tionnaire. The primary goal of the analysis was to examine the bivariate relationships between each variable and the incidence of diarrhea, and the logistic regression test was applied for the multi- variate test. A result from Taiwan respondents, the statistical tests showed significant relationships with age with a p-value of 0.009, education with a p-value =0.010, and personal hygiene with a p- value =0.010. Factors that influenced diarrhea in Indonesia were education with a p-value =0.038 and income with a p-value =0.08. In summary, several socio-demographics and personal hygiene practices played a significant role in the incidence of diarrhea. The differences in results obtained from Taiwan and Indonesia were attributed to differing respondent characteristics, emphasizing the importance of promoting clean and healthy behaviors, including handwashing with soap before eating and maintaining a clean envi- ronment, as effective measures to prevent diarrhea. Introduction Adult period includes diverse biological and psychosocial changes. However, diarrhea is a manifestation of gastroenteritis, which is prevalent in both children and adults globally and can be triggered by poor hygiene behavior in teenagers.1 Gastroenteritis is a condition where the feces resulting from defecation have a liq- uid or semi-liquid consistency, and contain more air than feces. Apart from its consistency, it can be accompanied by nausea, vom- iting, and increased defecation frequency exceeding three times a day.2,3 Gastroenteritis is more prevalent in developing countries compared to developed countries where the level of hygiene and sanitation is better.4-6 According to data from the World Health Organization (WHO) and UNICEF, 1.87 million people die glob- ally due to cases of gastroenteritis every year. 6 Globally, it is esti- mated that there are about 179,000,000 incidents of acute gas- troenteritis in adults every year with some patients being hospital- ized as many as 500,000 and more than 5000 patients dying.7,8 In America, at least 8,000,000 acute gastroenteritis patients are treat- ed by doctors and more than 250,000 patients are hospitalized according to data from The American Journal of Gastroenterology.9 Meanwhile, developing countries such as Indonesia and Taiwan are at risk of experiencing diarrhea. Numerous factors influence incidence of diarrhea in adults, con- tributing to its increase and prevalence. Diarrhea in adults can be caused by various factors, such as infection, food intolerance, or diseases of the digestive tract, and therefore, proactive efforts should be made to prevent its incidence.10-12 This research provides additional literature regarding the pooled prevalence of diarrhea prevention in adults. Additionally, it can add to the literature regarding the pooled prevalence of diar- rhea prevention in adolescents. Observing the phenomenon of the increased incidence of diarrhea, proactive prevention efforts are needed to mitigate its impact. Following this, maintaining good hygiene, such as washing hands properly, cooking food properly, and avoiding consumption of potentially contaminated water or food, are effective measures to prevent diarrhea.13 Materials and Methods This research was carried out using an observational analytical method with a cross-sectional method, from May - June 2021 in Surabaya, and continued in August within the PCINU Taiwan Working Area. The eligibility criteria established for the study are as follows: 1) Inclusion Criteria: Adults who are in good physical condition and possess the ability to read and write; 2) Exclusion Criteria: Individuals who are not willing to participate as respon- dents. This research aims to focus on a population of 100 migrant adults who are affiliated with PCINU Taiwan, comprising 100 adults from Taiwan and an additional 100 from Indonesia. The tar- geted population encompasses adults from diverse regions in Surabaya, including the East, West, North, and South, and they were selected at random from the overall population of interest. A questionnaire was employed as the data collection tool to ascertain demographic characteristics and the incidence of diarrhoea. The statistical analysis utilized logistic regression with hypothesis test- ing at p<0.05. Significance for public health Diarrhea is a significant public health problem that has serious impacts on individuals, families, and communities. In regions with limited access to healthcare facilities, diarrhea can lead to death if not treated quickly and effectively, specifically in developing countries. Consequently, prioritizing the prevention and control of diarrhea is very important for public health, emphasizing the significance of educating people about the importance of maintaining good health practices. [Healthcare in Low-resource Settings 2024;12(s1):13035] [page 47] Non -co mmerc ial us e o nly Results and Discussion The survey collected 200 respondents, from which the ques- tionnaire was distributed to 100 respondents (adults) in Taiwan and 100 respondents from Indonesia. Table 1 shows the results of inci- dence of diarrhea in Taiwan among 100 adults, with a focus on socio-demographic factors, obtained from 62 young adults. Subsequently, 61.3% reported no occurrence of diarrhea in the last month, while 8.1 had diarrhea. Regarding gender, 84 respondents were female, 76.2% did not experience diarrhea, and out of the 68 married respondents, 75% did not experience diarrhea, and 25% experienced it. Out of the 55 respondents who live in Taipei, 74.5% did not experience diarrhea and 25.5% did. Out of the 41 respondents whose length of stay was >6 years, the majority of 78.0% did not experience diarrhea, and 22.0 did. Regarding edu- cation, there were 57 respondents with low education, and 78.9% did not have diarrhea. 57 respondents had an income of 20-24.99, out of the 78 respondents with good behavior, 83.6% did not expe- rience diarrhea. Table 2 shows the results of the logistic regression test. The factors that influence incidence of diarrhea in Taiwan are age with a p-value = 0.009, education with a p-value = 0.010, and personal hygiene with a p-value = of 0.010 which does not affect gender, marital status, place of residence, length of stay, income. Table 3 shows the results of incidence of diarrhea in the last month in Indonesia, specifically in the city of Surabaya, based on the socio- demographics of 100 adults, with a focus on 70 young adults. The majority, consisting of 62.9% did not experience diarrhea, while 37.1% did. Regarding the gender of the 83 respondents, the major- ity of women did not experience diarrhea, namely 73.5%, while 26.5% did. Out of the 58 respondents who were married, 77.6% did not experience diarrhea, while 22.4% did. Of the 47 respon- dents who live in North Surabaya, 66.0% did not experience diar- rhea, while 34.0% experienced it. Regarding education, there were 42 respondents with low education, 57.1% had no diarrhea and 42.9% did. There were 40 respondents with an income of 5-7 million, 82.5% had no diarrhea and 17.5% did, of the 72 respon- dents with good behavior there were 73.6% and 26.4% did not suffer from diarrhea. Table 4 from the results of logistic regression shows that the factors that influence diarrhea are socio-demo- graphics, namely education with a p-value = 0.038 and income = 0.008 which does not affect age, gender, marital status, or place of residence. In this research, socio-demographic results show that age sig- nificantly influences incidence of diarrhea in Taiwan, shown by a p-value of 0.009. Conversely, in Indonesia, the p-value = 0.058 as shown in Table 1, emphasizing the largest age group affected— individuals aged 20-40, totaling 62 respondents, and this age group is vulnerable due to poor diet. This is in line with previous researches which reported that at this age, most respondents often eat out or eat unclean food, having a higher risk of developing diarrhea.14,15 Poor nutrition or changes in the gut microbiome that occur and their potential,16,17 to an unhealthy relationship with food development, and the diet of young adults can influence the likelihood of diarrhea. Contamination and spread of disease 4th International Nursing and Health Sciences Symposium Table 1. Frequency distribution of socio-demographics, hygiene behavior, on incidence of diarrhea in Taiwan. Categories No Diarrhea Diarrhea F % F % Age Early adulthood 38 61.3 24 38.7 Middle adults 34 91.9 3 8.1 Late adulthood 1 100 0 0 Gender Woman 64 76.2 20 23.8 Man 9 56.3 7 43.8 Married status Not married yet 9 56.3 7 43.8 Marry 51 75 17 25 Divorced 13 81.3 3 18.8 Residence area New Taipei 19 67.9 9 32.1 Taipei 41 74.5 14 25.5 Etc 12 75 4 25 Length of stay 1-3 years 13 52 12 48 4-6 years 28 82.4 6 17.6 >6 years 32 78.0 9 22.0 Education level Low 45 78.9 12 21.1 Intermediate 26 74.3 9 25.7 High 72 72.27 27 27 Income 10-14.999 million 1 33.3 2 66.6 15- 19.99 million 4 57.1 3 42.8 20-24.99 million 43 75.4 14 24.56 25.99-14.99 million 23 74.19 8 25.8 ≥ 30 million 2 100 0 0 Hygiene behavior Not good 12 54.54 10 45.45 Good 61 78.20 17 21.79 Table 2. Logistic regression results that influence incidence of diarrhea in Taiwan. Variables in the Equation B S.E. Wald df Sig. Exp(B) Step 1a Age -2.052 .790 6.752 1 .009 .128 gender .786 .760 1.070 1 .301 2.194 Status -.340 .488 .486 1 .486 .711 Stay -.112 .422 .070 1 .791 .894 Long .225 .396 .323 1 .570 1.253 Educate 1.189 .459 6.702 1 .010 3.284 wages -.549 .380 2.087 1 .149 .577 Hygiene -1.731 .673 6.625 1 .010 .177 Constant 3.976 2.329 2.914 1 .088 53.312 a. Variable(s) entered on step 1: Age, Gender, Status, Residence, Length, Education, Salary, Cleanliness. [page 48] [Healthcare in Low-resource Settings 2024;12(s1):13035] Non -co mmerc ial us e o nly through food must comply with hygienic procedures in handling food.18 Another socio-demographic factor that influences diarrhea is education in Taiwan with a significant result of p-value = 0.01 and in Indonesia with a significant result of p-value = 0.008. In Table 2, in Taiwan, there are 57 respondents with low levels of education, while in Table 4, in Indonesia, 42 respondents fall into the low education category, including individuals who did not attend school, or did not complete elementary school. The signif- icance of education is underscored as it profoundly shapes an indi- vidual’s mindset. Inadequate education affects the dissemination of necessary information about the importance of personal hygiene and environmental sanitation in preventing infectious dis- eases, including diarrhea.19 The level of education can increase health knowledge, acting as a key component influencing an indi- vidual’s awareness.20,21 Moreover, a higher level of education makes it easier to gain access to health-related information. In Indonesia, incidence of diarrhea is significantly influenced by income, as shown by a p-value = 0.008. In Table 3, despite a monthly income range of 5-6 million, the individuals experienc- ing the highest frequency of diarrhea fall within the income range of 1-2 million. Income can influence the risk and impact of diar- rhea, including poor food consumption patterns. This is in line with Derek Headey’s statement that low income influences many diseases because it affects nutritional status, food quality, and less clean food consumers, resulting in diarrhea.22 Subsequently, Socio-demographic factors in both Taiwan and Indonesia regard- ing gender, marital status, and place of residence did not affect incidence of diarrhea. In Taiwan, the cleaning staff is a significant factor influencing diarrhea, as showed by a p-value of 0.010. From Table 2, it was found that 78 respondents had personal hygiene. In Indonesia, of the 72 respondents, the majority, 73.6%, had good behavior. Respondents exhibiting poor personal hygiene simultaneously contributed to a higher incidence of diarrhea, leading to an increased occurrence of the condition. With respect to personal hygiene, researchers asked about washing hands, cleaning nails, and protecting food. Subsequently, washing hands regularly and correctly is an important step to prevent the spread of infection and maintain cleanliness, which includes using soap and clean water as well as correct hand-washing methods. Washing hands is behavior that reduces the risk of cross-infection transmission. With “Clean Care is Safer Care” at the top of the agenda of WHO’s global initiative on patient safety programs, it is time for developing countries to formulate much-needed policies for the implementation of basic infection prevention practices in health- care settings.23,24 Cutting nails is often considered a trivial matter in society, and even though nail cleanliness can contribute to improving people’s health status, cutting nails also prevents intestinal parasites.25 Safeguarding food is to prevent contamina- tion and the spread of disease through food.12 Maintaining clean- liness, eating healthy food, and preventing diarrhea can help reduce the risk of its development. Behavior that can reduce the risk of diarrhea is washing vegetables and fruit before consump- tion, one way of transmitting diarrhea is through serving under- 4th International Nursing and Health Sciences Symposium Table 3. Frequency distribution of socio-demographics, and hygiene behavior, on incidence of diarrhea in Indonesia. Categories No Diarrhea Diarrhea F % F % Age Early adulthood 44 62.9 26 37.1 Middle adults 25 86.2 4 13.8 Late adulthood 1 100 0 0 Gender Woman 61 73.5 22 26.5 Man 9 56.3 8 43.8 Married Status Not married yet 14 46.7 16 53.3 Marry 45 77.6 13 22.4 Divorced 11 91.7 1 8.3 Residence area East Surabaya 6 60.0 4 40.0 North Surabaya 31 66.0 16 34.0 South Surabaya 26 74.3 9 25.7 West Surabaya 7 87.5 1 12.5 Length of stay 1-3 years 13 52 12 48 4-6 years 28 82.4 6 17.6 >6 years 32 78.0 9 22.0 Education level Low 24 57.1 18 42.9 Intermediate 34 82.9 7 17.1 High 12 70.6 5 29.4 Income 1-2 million 9 42.9 12 57.1 3- 4 million 20 66.7 10 33.3 4-5 million 33 82.5 7 17.5 6-7 million 7 87.5 1 14.3 ≥ 30 million 7 100 0 0 Hygiene behavior Not good 17 60.7 11 39.3 Good 53 73.6 19 26.4 Table 4. Logistic regression results that influence incidence of diarrhea in Indonesia. Variables in the Equation B S.E. Wald df Sig. Exp(B) Step 1a Step 1a Age -.898 .475 3.580 1 .058 .407 gender -.616 .692 .791 1 .374 .540 Status .991 .666 2.214 1 .137 2.693 Stay .267 .397 .452 1 .501 1.306 Educate -.799 .386 4.293 1 .038 .450 wages -.855 .324 6.982 1 .008 .425 hygiene -.639 .581 1.210 1 .271 .528 Constant 4.033 1.841 4.799 1 .028 56.434 a. Variables entered in step 1: age, gender, status, residence, upbringing, salary, cleanliness. [Healthcare in Low-resource Settings 2024;12(s1):13035] [page 49] Non -co mmerc ial us e o nly cooked or raw food. The pathogenic causes of foodborne diseases vary due to different eating places and eating habits. The propor- tion of outdoor food consumption is increasing rapidly and, in turn, increases the possibility of pathogenic microorganisms if stored improperly. The Taiwanese government’s policy is to carry out cross-domain management, including food quality inspection, monitoring, proper treatment, packaging, and food preservation with international regulations and standards, industrial discipline, and private participation to achieve food security.26 Policy from Indonesia is facilitated through public services through BPOM (Food and Drug Supervisory Agency). Conclusions In conclusion, this research shows that diarrhea is a global problem with high levels of morbidity and mortality in various countries, specifically in developing countries, namely Indonesia and Taiwan. Several factors that cause diarrhea are socio-demo- graphics and personal hygiene. Subsequently, socio-demographic factors that influence incidence of diarrhea in Taiwan are age, edu- cation, and personal hygiene, while in Indonesia, education and income are the most influential factors in incidence of diarrhea. References 1. Li R, Lai Y, Feng C, et al. Diarrhea in under five year-old chil- dren in nepal: A spatiotemporal analysis based on demographic and health survey data. Int J Environ Res Public Health 2020;17. 2. Suhanda, Ahmad N. Medical surgical nursing care assistance for clients with digestive system disorders: acute gastroenteri- tis. Kolaborasi J Pengabdi Masy 2022;2:262–9. 3. Desak WKP. Acute Gastroenteritis. Denpasar: RSUP Sanglah; 2017. 4. Chow CM, Leung AKC, Hon KL. Acute gastroenteritis: From guidelines to real life. Clin Exp Gastroenterol 2010;3:97–112. 5. Oloruntoba EO, Folarin TB, Ayede AI. Hygiene and sanitation risk factors of Diarrhoeal disease among under-five children in Ibadan, Nigeria. Afr Health Sci 2014;14:1001–11. 6. Tuang A. Analysis of factors related to the incidence of diar- rhea in children. J Ilm Kesehat Sandi Husada 2021;10:534–42. 7. Ministry of Health Republic of Indonesia. General guidelines for the development of active alert villages and sub-districts. Jakarta: Ministry of Health Republic of Indonesia; 2016. 8. Wulandari AP. Relationship Between Environmental Factors And Sociodemographic Factors With The Incidence Of Diarrhea In Toddlers In Blimbing Village, Sambirejo District, Sragen Regency In 2009. Surakarta: Universitas Muhammadiyah Surakarta; 2019. 9. Pelletier DL, Frongillo EA, Habicht JP. Epidemiologic evi- dence for a potentiating effect of malnutrition on child mortal- ity. Am J Public Health 1993;83:1130–3. 10. Masood MSA, Alsonini NAA. Knowledge and Attitude about Reproductive Health and Family Planning among Young Adults in Yemen. Guttmacher S, editor. Int J Popul Res 2017;2017:1895472. 11. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reduc- ing vomiting related to acute gastroenteritis in children and adolescents. Sao Paulo Med J 2012;130:270. 12. Li Y, Yaling H, Jijun Y, et al. Bacteria and poisonous plants were the primary causative hazards of foodborne disease out- break: a seven-year survey from Guangxi, South China. BMC Public Health 2018;18:1–8. 13. Pokharel P, Adhikari A, Lamsal P, Adhikari R. Effect of com- plementary feeding practices and nutritional status of children (6-23 months) in Tamang Community, Ambhanjyang VDC of Makwanpur. Janaki Med Coll J Med Sci 2017;5:22–32. 14. O’brien L, Wall CL, Wilkinson TJ, Gearry RB. What are the pearls and pitfalls of the dietary management for chronic diar- rhoea? Nutrients 2021;13. 4th International Nursing and Health Sciences Symposium Figure 1. The roles faced by Indonesian migrant workers in Taiwan. [page 50] [Healthcare in Low-resource Settings 2024;12(s1):13035] Non -co mmerc ial us e o nly 15. Hunt RH, Dhaliwal S, Tougas G, et al. Prevalence, impact and attitudes toward lower gastrointestinal dysmotility and sensory symptoms, and their treatment in Canada: A descriptive study. Can J Gastroenterol 2007;21:31–7. 16. McIntosh K, Reed DE, Schneider T, et al. FODMAPs alter symptoms and the metabolome of patients with IBS: A ran- domised controlled trial. Gut 2017;66:1241–51. 17. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 2014;146:67-75.e5. 18. Pakdel M, Olsen A, Bar EMS. A Review of food contaminants and their pathways within food processing facilities using open food processing equipment. J Food Prot 2023;86:100184. 19. Miranti MG, Handajani S, Pangesthi LT, et al. Education on Sanitation and Hygiene Knowledge on Food Vendors in Semolowaru Culinary Tourism Center (CTC) Surabaya. J Pemberdaya Masy Madani 2022;6:351–67. 20. Yanti B, Mulyadi E, Wahiduddin, et al. Community knowl- edge, attitudes, and behavior towards social distancing policy as a means of preventing transmission of Covid-19 in Indonesia. Indones J Heal Adm 2020;8:4–14. 21. Abdi F, Simbar M. The peer education approach in adoles- cents. Iran J Publ Heal 2013;42:1200–6. 22. Headey D, Ruel M. Food inflation and child undernutrition in low and middle income countries. Nat Commun 2023;14. 23. Mathur P. Hand Hygin. 2011:611–20. 24. Gammon J, Hunt J. The neglected element of hand hygiene - significance of hand drying, efficiency of different methods and clinical implication: A review. J Infect Prev 2019;20:66– 74. 25. Mahmud MA, Spigt M, Bezabih AM, et al. Efficacy of hand- washing with soap and nail clipping on intestinal parasitic infections in school-aged children: a factorial cluster random- ized controlled trial. PLoS Med 2015;12:1–16. 26. Yu CP, Chou YC, Wu DC, et al. Surveillance of foodborne dis- eases in Taiwan: A retrospective study. Med (United States) 2021;100:E24424. 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13035] [page 51] Correspondence: Firdaus, Department of Midwifery, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Jl. SMEA 57 Surabaya, East Java, Indonesia. Tel.: +623018284505, E-mail: firdaus@unusa.ac.id Key words: demographic; diarrhea; hygiene Contribution: the authors contributed equally to the implementation from proposal to reporting. Conflict of interest: the authors declare no potential conflict of interest. Funding: this research was supported by the Chancellor financially sup- ported by Nahdlatul Ulama University Surabaya. Ethics approval: the Chakra Brahmanda Lentera Ethical Board granted ethical clearance under reference number 062/019/VI/EC/KEP/LCBL/ 2023.n of 1964, as revised in 2013, concerning human and animal rights. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgment: the authors express profound gratitude to the Institute for Research and Community Service (LPPM), Nahdlatul Ulama University Surabaya for supporting this research with research grant No. 0137/UNUSA-LPPM/Adm-2/ST-Pen IV/2023 Received: 4 November 2023. Accepted: 8 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13035 doi:10.4081/hls.2024.13035 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. 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