Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13297 The impact of environmental health facilities and maternal behaviors on the incidence of diarrhea among children under five Yusmidiarti Yusmidiarti,1 Adi Heru Husodo,2 Susi Iravati,3 Risda Yulianti4 1Department of Environmental Health, Poltekkes Kemenkes Bengkulu; 2Department of Public Health, Faculty of Medicine, University of Gajah Mada, Yogyakarta; 3Department of Microbiology, Faculty of Medicine, Gadjah Mada University, Yogyakarta; 4Department of Nutrition, Poltekkes Kemenkes Bengkulu, Indonesia Abstract The objectives of this study were to determine the prevalence of diarrhea among children under five and assess the relationship between its risk factors related to environmental health facilities and maternal behavior. A prospective case-control community-based study was conducted in the service area of Pasar Ikan Community Health Center, Teluk Segara Subdistrict, Bengkulu City, Indonesia. A total of 140 participants were included, comprising 70 cases and 70 controls. The study found that poor qualification of clean water resources (OR=4.026, p-value=0.000), inadequate utilization of clean water (OR=5.813, p-value=0.000), poor qualification of fam- ily latrines (OR=3.574, p-value=0.000), and inadequate utilization of family latrines (OR=3.377, p-value=0.001) were significantly associated with an increased risk of diarrhea prevalence among chil- dren under five. Furthermore, unhealthy mothers’ behaviors, includ- ing frequent feeding of children outside the home (OR=2.728, p- value=0.000) and poor personal hygiene (OR=3.377, p- value=0.001), were also significantly related to a higher prevalence of diarrhea in this age group. Therefore, both substandard environ- mental health facilities and unhealthy maternal behaviors were identified as significant risk factors for diarrhea prevalence in chil- dren under five. These findings emphasize the critical importance of improving environmental health facilities and promoting positive changes in mothers’ behavior to reduce the incidence of diarrhea in this vulnerable population. Introduction The World Health Organization (WHO) classifies diarrhea in children under five as the passage of three or more loose or watery stools within a 24-hour period.1 It occurs when the digestive sys- tem is unable to properly absorb water or when it produces exces- sive fluid.2 In this age group, diarrhea is particularly concerning due to its potential to cause severe dehydration and malnutrition.3 Diarrhea can be caused by a variety of factors, including viral infections, bacterial infections, parasites, and food poisoning.4 Infectious causes are responsible for a significant number of cases of diarrhea in children under five.5 Bacterial infections, such as Escherichia coli and Salmonella, can be contracted through con- taminated food or water.6 Viral infections, like rotavirus and norovirus, are highly contagious and can spread easily in childcare settings. Parasitic infections, such as Giardia and Cryptosporidium, often occur due to poor hygiene practices.7 Various risk factors increase the susceptibility of children to develop diarrhea. Poor hygiene practices, inadequate sanitation facilities, and contaminated water sources can significantly con- tribute to the transmission of infectious agents that cause diarrhea.8 Furthermore, overcrowded living conditions and lack of proper handwashing facilities further enhance the risk of diarrhea.9 Mother’s behavior in hygiene practices plays a crucial role in preventing diarrhea. Mothers must understand and imple- ment practices such as regular handwashing with soap and clean water before feeding the children and after using the toilet.10 Additionally, ensuring a clean and safe environment for children, including proper disposal of waste, clean utensils, and proper food storage, can greatly minimize the risk of diarrhea.11 This study was conducted in Teluk Segara sub-district, Bengkulu City, Indonesia, selected for its high incidence of diar- rhea among children under five. This area has a diverse population with varying access to sanitation and clean water, making it ideal for examining the impact of environmental health factors on child- hood diarrhea. Coastal residents, mainly fishermen, often lack proper sanitation, while those inland face groundwater contamina- tion and rely on the public water system. This study explores how these contrasting conditions influence diarrhea prevalence. The aim of this study is to identify the risk factors related to environ- mental health facilities and mother behavior that might contribute to the prevalence of diarrhea in children under the age of five. Correspondence: Yusmidiarti, Department of Environmental Health, Poltekkes Kemenkes Bengkulu, Bengkulu, Indonesia. Email: yusmidiarti@poltekkesbengkulu.ac.id Key words: environmental health facilities; maternal behavior; diarrhea; children under five. Conflict of interest: the authors declare that they have no competing interests. Ethics approval and consent to participate: Ethics approval for this study was obtained from the Medical and Health Research Ethics Committee of Universitas Gadjah Mada (approval number: KE/FK/32/EC). Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 25 October 2024. Accepted: 30 November 2024. Early access: 16 December 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 2025; 13:13297 doi:10.4081/hls.2024.13297 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. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:13297] [page 75] Materials and Methods This analytical observational study used a prospective case-con- trol design conducted at the Pasar Ikan Community Health Center in the Teluk Segara Subdistrict, Bengkulu Municipality. The study included two groups: a case group of mothers with children under five who experienced diarrhea in the past year and a control group of mothers with children aged 6 months to 5 years without recent diarrhea incidents. Both groups were selected from within the health center’s service area, maintaining a 1:1 case-to-control ratio, with a total of 140 participants (70 cases and 70 controls). The sample size calculation followed Lemeshow’s guidelines for odds ratio hypoth- esis testing.12 Consecutive sampling targeted all eligible mothers vis- iting the health center. To assess the impact of environmental health facilities and maternal behaviors on the incidence of diarrhea, sever- al questionnaire items were used. These items were grouped into two main constructs: environmental health facilities and maternal behav- iors. The construct of environmental health facilities was measured using 10 items encompassing several aspects: qualification of clean water resource (2 items); availability of clean water (1 item); utiliza- tion of clean water (3 items); qualification of family latrine (3 items); and utilization of family latrine (1 item). The construct of mother behaviors was measured using 6 items related to: the habit of feeding children outside the house (2 items) and personal hygiene (4 items). Data collection was conducted using a structured questionnaire, which was pre-tested at other community health centers. The valid- ity of all items was assessed by calculating the correlation between each item and the total score using the product-moment correlation test. All items were found to be valid. Reliability was assessed using the split-half technique, resulting in a reliability coefficient of 0.8066 for environmental health facilities and 0.8245 for mother behaviors. These coefficients indicated that both instruments met the required standards for reliability. A consecutive sampling technique was employed to recruit participants until the desired sample size was achieved. The case group consisted of mothers with children aged 6 months to 5 years who presented with diarrhea at the Pasar Ikan Community Health Center for treatment and resided within the health center’s catchment area. The control group comprised moth- ers with children aged 6 months to 5 years who did not have diarrhea but visited the Pasar Ikan Community Health Center for other health concerns. Multivariate analysis used logistic regression with the Backward Method, systematically excluding non-significant vari- ables to identify significant predictors of childhood diarrhea. Ethical approval for this study was obtained from the Medical and Health Research Ethics Committee of Universitas Gadjah Mada (approval number: KE/FK/32/EC). Results The characteristics of research subjects Respondents were 140 mothers divided into two groups: 70 respondents from the case group and 70 respondents from the con- trol group. Table 1 shows that the majority of the 70 respondents in each group (case and control) were between the ages of 30 and 39 (54.2% in the case group and 51.4% in the control group); the majority of respondents in both the case group (51.4%) and the control group (54.2%) had a senior high school education back- ground; and a significant proportion of mothers in both groups were identified as primary caregivers within the household (case group: 78.6%; control group: 81.4%). Table 2 indicates that the majority of children in both the case and control groups were aged 13-24 months (38.6% and 44.3%, respectively). Furthermore, both groups had a larger proportion of male children (case: 55.7%; con- trol: 60.0%). The environmental health facilities This study found that when examining environmental health risks among 140 participants, 35.4% of those in the case group and Article Table 1. Characteristics of mothers. Variable Category Case Control N % N % Age (years) 20-29 24 34.3 27 36.4 30-39 38 54.2 36 51.4 ≥40 8 11.4 7 10.7 Education Elementary 6 8.6 7 9.3 Junior high school 28 40.0 25 37.9 Senior high school 36 51.4 38 54.2 Occupation Housewife 55 78.6 57 81.4 Self-employed 13 18.6 10 16.4 Government-employed 2 2.9 3 3.6 Total 70 100 70 100 Table 2. Characteristics of children under five. Variable Category Case Control N % N % Age (months) ≤12 9 12.9 4 5.7 13-24 27 38.6 31 44.3 25-36 15 21.4 17 24.3 >36 19 27.1 18 25.7 Sex Male 39 55.7 42 60 Female 31 44,3 28 40.0 Total 70 100.0 70 100.0 [page 76] [Healthcare in Low-resource Settings 2025;13:13297] 64.6% in the control group had access to qualified water sources. About 48.8% of the case group and 51.2% of the control group were provided with clean water. Furthermore, 38.6% of the case group and 61.4% of the control group had family latrines that adhered to hygiene standards, and 37.8% of the case group vs 62.2% of the control group had family latrines available for use. The study revealed a significant association between clean water sources and diarrhea incidence in under-five children, with those exposed to unhygienic water sources being 4.026 times more likely to suffer from diarrhea. In contrast, the availability of clean water showed no significant impact on diarrhea incidence among under-fives due to a p-value of 0.412. However, the utilization of clean water significantly affected diarrhea incidence, where chil- dren under five in households not utilizing their facilities had a 5,813 times higher chance of contracting diarrhea. The availability and utilization of family latrines were significantly related to the occurrence of diarrhea. The children were 3.574 times more likely to get diarrhea if their family latrine did not meet hygiene stan- dards and 3.377 times more likely if the latrine was not used prop- erly (Table 3). Mothers’ health behavior It was found that fewer mothers in the control group practiced feeding their children outside the house (34.6%) compared to the case group (65.4%). Similarly, a smaller percentage of mothers in the case group (37.8%) maintained good personal hygiene than those in the control group (62.2%). Mothers who fed their children outside were found to have a 2.728-fold increased risk of their chil- dren experiencing diarrhea compared to those who did not (p=0.000). Additionally, mothers with poor personal hygiene exhibited a 3.377-fold higher likelihood of their children develop- ing diarrhea (p=0.001). These results underscore the critical role of safe feeding practices and proper personal hygiene in mitigating diarrhea risks among children under five (Table 4). Multivariate analysis Based on the Wald coefficients presented in Table 5, inade- quate personal hygiene habits emerged as the most significant pre- dictor of diarrhea prevalence among children under five. This was closely followed by the use of not-qualified clean water sources, Article [Healthcare in Low-resource Settings 2025;13:13297] [page 77] Table 3. The influence of environmental health facilities on diarrhea incidence in children under five. Variable Case Control OR n % n % (CL 95%) p Qualification of clean water sources Not qualified 42 68.9 19 31.1 4,026 0 Qualified 28 35.4 51 64.6 1.977