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Risk Factors of Infant Diarrhea and Under-five Children Diarrhea

BACKGROUND: Infant and under-five children diarrhea in Indonesia is a health problem that seriously impacts death. AIM: The main objective of this study was to determine the most significant factors that influence infant and underfive children diarrhea between the years 2012 and 2017. METHODS: This study used data from the Indonesia Demographic and Health Survey of 2012 and 2017 with a cross-sectional design. We modeled the infant and under-five of age children diarrhea as categorical dependent variable (diarrhea vs. no diarrhea of the infant and under-five of age children). At the same time, 14 covariates are used as an independent variable using χ2 statistic and multiple logistic regression (MLR). FINDINGS: For infant diarrhea, television as an information resources showed the highest positive coefficient (OR = 1.966; β = 3.35; and p = 0.001) significant covariate for 2012. Higher mother education was negative correlation (β = –2.31 and p = 0.021) for infant diarrhea in 2017. For under-five children diarrhea, reading newspaper and magazine < 1 a week showed positive coefficients (OR = 1.059; β = 2.62; and p = 0.009) for 2012. Sex of household head female showed the highest positive coefficient (OR = 1.387; β = 2.82; and p = 0.005) for under-five children diarrhea in 2017. CONCLUSIONS: The finding has important policy implications for infant and under-five of age diarrhea intervention programs. Thus, activities focus on the proper hygienic toilet, improving health information from newspapers, magazines, and TV. Edited by: Ana Vucurevic Citation: Kurniawan AW, Nursalam N, Devy SR, Ahsan A, Astutik E, Nurbadriyah W, Hastuti AP. Risk Factors of Infant Diarrhea and Under-five Children Diarrhea. OpenAccess Maced J Med Sci. 2022 Feb 15; 10(G):400-406. https://doi.org/10.3889/oamjms.2022.8291


Introduction
Indonesia is globally, with a population of 264 million spread across 34 provinces and 17,000 islands (Trading Economics. Indonesia -Economic Indicators . Diarrhea diseases remain among the most common causes of mortality and morbidity in children, particularly in low-and middle-income countries (Liu et al., 2015) [3]. Diarrheal is the second leading cause of death in children and is responsible for killing around 525,000 children every year (World Health Organization, 2017) [4]. Diarrhea accounts for an estimated 3.6% of the global disease burden, as expressed in disability-adjusted life years (Murray et al., 2012) [5].

Input IDHS data
The data sets used in this study were derived from the 2012 and 2017 surveys. The IDHS data set consisted of 16652 respondents, taken from 2012 and 15963 respondents, and taken from 2017. In 2012, 517 infant diarrhea and 1914 under 5 years of age diarrhea were among these. In 2017, 475 infant diarrhea and 1788 under 5 years of age had diarrhea. The sampling techniques, survey design, survey instruments, measuring system, and quality control have been discussed (IDHS data source: https://dhsprogram. com/data/dataset/Indonesia_Standard-DHS_2017. cfm?flag=0).

Methodological approach
Our methodology is based on the application of bivariate analysis, namely, χ2 test, to examine various predictors and response variables using a single population. We used the STATA 15 software system for our research. The methodology used MLR, where the goal was to determine which predictor variables influence (a) infant diarrhea and (b) under-five diarrhea. The main predictor variables are the type of place, gender of the child, mother's age, mother's and father's education, sex of household head, wealth index, birth order, type of toilet facility, radio, TV, newspaper or magazine, and province (Table 1).

Ethical review and consent
The IDHS in 2012 and 2017 obtained ethical permits from the Ministry of Health of Indonesia. All respondent identifiers were deleted from the data and written informed consents were provided by each participant. The ICF International, which is part of the DHS program, approved the use of such data in this study.

Results using χ 2 -test: Understanding associations
The χ 2 -test shows the association between the selected covariates of infant and under-five diarrhea. Table 2 contains the results of the Chi-square test.
The first column of Table 2 represents the attributes of selected covariates sequentially for which the association is to be tested. Based on their respective p-values, in 2012, we say that mother's age, father's education, wealth index, birth order, radio, and province are significant covariates for infant diarrhea. Whereas, type of place, gender of the child, mother's age, mother's and father's education, wealth index, type of toilet facility, source of water, radio, TV, reading newspaper or magazine, and province are also significant covariates for under-five diarrhea.
In 2017, the type of place, mother's age, mother's and father's education, wealth index, type of toilet facility, TV, and reading newspaper or magazine were significant factors for infant diarrhea. Whereas, kind of place, gender of the child, mother's age, mother's and father's education, wealth index, type of toilet facility, TV, and province are also significant factors for under-five diarrhea.

Results using MLR
We create Table 3 to show the logistic effect of the selected covariates on infant and under-five diarrhea. Table 3 have been selecting covariates and odds ratio (OR) which are statistically significant. Using the MLR, television showed the significant covariate (p=0.001) for 2012. The corresponding ORs were 1.966. While age of the mother 30-39 years (p=0.004) in 2012 and > 40 years (p=0.04) was significant covariates.
The sex of household head female (p-0.005) showed the most significant covariate for 2017. The corresponding OR was 1.387. Then, the second most significant covariate in 2017 was birth order 2-6 years (p= 0.009). The corresponding OR was 1.215. Information resources and reading magazine < 1 a week was significant (p= 0.038) for 2017. The corresponding OR was 1.167. The unprotected main water source (p=0.037) was significant. The corresponding OR was 1.148. While age of the mother > 40 years (p=0.005) was significant.

Discussion
Using the χ 2 test, we have got six significant covariates out of 14 covariates for infant diarrhea in 2012 and eight covariates in 2017. Using the χ 2 test, 12 significant covariates were in 2012 and 10 in 2017. This is shown in Table 2 in online supplementary document, using χ 2 for infants and under-five: 2012 versus 2017.     Table 2 in Online Supplementary Document indicates that type of place, gender of the child, mother's age, mother's and father's education, wealth index, type of toilet, source of water, TV, reading newspaper or magazine, and region are the first 11 top importance covariates for under-five diarrhea in 2012. On the other way, mother's age, mother's and father's education, wealth index, type of toilet, and region are the first six top importance covariates for under-five diarrhea in 2017. Table 3 in the online supplementary document shows that the first top significant covariate is watching TV and it was high importance covariates for infant diarrhea in 2012. We have only one covariate; reading newspapers or magazines was an important covariate for under-five diarrhea in 2012. In 2017, we had three significant covariates for under-five diarrhea in online supplementary document. Among them, the female sex of household head was the highest importance covariates for under-five diarrhea. The lower risk significant factors are: Birth order 2-6 years and reading newspaper and magazine < 1 a week, whereas we had only 11 important covariates out of 14 in 2017.
Television is an important covariate for infant diarrhea in 2012, reading newspaper or magazines as significant covariates for under-five diarrhea in 2012 and 2017. Our studies also found radio associated with diarrhea pada infants and under-five in 2012. Women who read newspapers/magazines were more likely to provide sufficient fluids and food, and those exposed to the TV were more likely to provide zinc supplementation. Since mothers' exposure to newspaper/magazines, TV, and radio showed associations with some recommended practices for treating childhood diarrhea, mass media has the potential to improve diarrhea management practices (Alam et al., 2019) [13]. Mass media has disseminated several public messages regarding various social and medical issues. Studies have been conducted to determine whether there is an association between mass media exposure and people's knowledge, practice, and health outcomes (Naugle and Hornik, 2014) [14].  [16] shows that a mother's age has a significant risk of diarrhea in children. This study shows that the mother's age significantly influences diarrhea in infants underfive between 2012 and 2017. In our research, χ 2 -test indicates a relationship between the gender of a child with under-five diarrhea in 2012 and 2017. From the results of multiple logistic regression, it was found that the sex of toddler girls is lower the risk of diarrhea than boys in 2012. While researching de Oliveira Borba Vasconcelos et al. (2018) [16] and Melese et al. (2019) [12], there is no relationship between sex and the incidence of diarrhea in infants. Diarrhea in boys under five may be caused by their activities outside the home, playing in the field or playing with dirt in a dirtier condition, while toddler girls play more in the house with cleaner conditions.
Our results from the result of the χ 2 -test showed a relationship of type of place with under-five diarrhea in 2012 and 2017. There was a relationship between the type of residence and diarrhea in infants in 2012. Workie et al. (2019) [9] found that living in the rural has a higher risk of under-five diarrhea than in the  [16], living in cities is more at risk of diarrhea in infants in 1997 and living in villages is more at risk of diarrhea in infants in 2006.
The result of the χ 2 -test shows that there is a relationship between a mother's education with infant diarrhea in 2017. There is a relationship between a mother's education with under-five diarrhea in 2012 and 2017. Father's education significantly affected diarrhea in infants and under-five in 2012 and 2017. Results research Mulatya and Ochieng (2020) [17] parents or caregivers with lower education were twice likely to predispose their children to a diagram, which is consistent with other findings. Lower educated parents have limited knowledge and awareness on appropriate child care as they are less likely to access healthcare services and messaging than higher educated counterparts. Mother's literacy influences hygienic practices, child feeding, weaning, and sanitation practices, essential factors for childhood diarrhea.  [15] shows no relationship between water source and diarrhea. Instead, research Otsuka et al. (2019) [19] children from households using open containers for water storage were significantly associated with an increased risk of diarrhea. Depending on the etiology, diarrhea diseases can be transmitted through many pathways. Blocking one or two transmission pathways cannot meet the purpose, as sources of infection remain ubiquitous, which may explain the missing effect in our study settings.

Conclusions
In 2012, in Online Supplementary Document, significant covariates were: Mother's age, father's education, wealth index, birth order, radio, and province are significant covariates for infant diarrhea. Whereas, type of place, gender of the child, mother's age, mother's and father's education, wealth index, type of toilet facility, source of water, radio, TV, reading newspaper or magazine, and province are also significant covariates for under-five diarrhea. In 2017, type of place, mother's age, mother's and father's education, wealth index, type of toilet facility, TV, and reading newspaper or magazine are significant factors for infant diarrhea. Whereas, type of place, gender of child, mother's age, mother's and father's education, wealth index, type of toilet facility, TV, and province are also significant factors for underfive diarrhea. This study allows policy makers to make appropriate decisions to reduce infant and under-five diarrhea in Indonesia.