How Is The Effect of Health Services On Toddler Diarrhea?: Ecological Analysis in Indonesia
How Is The Effect of Health Services On Toddler Diarrhea?: Ecological Analysis in Indonesia
Yuli Puspita Devi1, Milla Herdayati2, Muthmainnah, Muthmainnah3, Mahdiyyah Husna Nihar4,
Imas Elva Khoiriyah4, Az-Zahra Helmi Putri Rahayu4
1
Master Student, 2Researcher, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia, 3Doctoral
Student, 4Undergraduate Student, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
Abstract
Background: About 4 billion cases of toddler diarrhea occur worldwide each year. As many as 70% of
toddler deaths in the world were caused by diarrheal infections. This study was intended to analyze the
relationship of health services factors on the prevalence of diarrhea of infants in Indonesia.
Methods: Ecological analysis was conducted using secondary data from the Ministry of Health of
the Republic of Indonesia report in 2018. All provinces were taken as samples. Apart from prevalence
of children under five with diarrhea, 4 other variables analyzed as independent variables were, the
availability of health workers, the coverage of diarrhea services and the coverage of oralit services to
the patients, the coverage of zinc services to the patients, and the poverty factors in each provinces.
Data were analyzed using cross-tabulation and spearman test.
Results: The results show from 34 provinces, the highest prevalence of toddlers is in the Papua
Province. The results showed that the higher the percentage of poor people in the province, the
higher the prevalence of diarrhea in toddlers (r=0.363). While the low availability of health resources,
coverage of oralit use, and coverage of zinc use in patients were mostly occurring in provinces that had
a high prevalence of toddler diarrhea. This means that there was an inverse relationship between the
availability of health resources (r=-0.430), the coverage of oralit use (r=-0.149) and the coverage of
zinc use in patients (r=-0.013) with the prevalence of diarrhea in toddlers.
Conclusion: It was concluded that according to bivariate analysis on the prevalence of diarrhea of
toddlers showed that increasing availability of health resources in the provinces can help to reduce the
prevalence of toddlers by assuming other variables remain.
Keywords: ecological analysis, secondary data, diarrhea, toddlers, good health, well-being
Table 1. Descriptive statistics variables of prevalence of toddler diarrhea and other related variables in
Indonesia
Coverage
Prevalence Coverage of Coverage of
of Toddler Poor Availability of
of Toddler Patients Receiving Patients Receiving
Diarrhea Population Health Workers
Diarrhea Zinc ORS
Services
N 34 34 34 34 34 34
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 1297
Table 2. Prevalence of toddler diarrhea according to the coverage of toddler diarrhea services
Coverage of Toddler
Low High
Diarrhea Services
n % n % n %
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Figure 1. Scatter Plot of Coverage of Toddler Diarrhea Services and Prevalence of Toddler Diarrhea in
Province of Indonesia 2018.
Based on Table 2, it can be seen that the prevalence results show that the higher the health care coverage
of diarrhea is high, many occur in provinces with high and prevalence, the higher the prevalence of diarrhea
diarrhea service coverage, which is 56.3% compared of toddlers with r = 0.208 (Figure 1).
to provinces with low service coverage. Scatter plot
1298 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1
Table 3. Prevalence of toddler diarrhea according to the coverage of patients receiving zinc
Coverage of Patients
Low High
Receiving Zinc
n % n % n %
Low 7 58 5 42 12 100
High 12 55 10 46 22 100
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Figure 2. Scatter Plot of Coverage of patients receiving zinc and Prevalence of Toddler Diarrhea in Province
of Indonesia 2018.
Based on Table 3, it can be seen that the prevalence with low zinc coverage. Figure 2 also shows that the
of diarrhea is high, many occur in provinces with high lower the coverage of sufferers getting zinc the higher
zinc coverage, which is 46% compared to provinces the prevalence of diarrhea in toddlers (r = -0.013).
Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 1299
Table 4. Prevalence of toddler diarrhea according to the coverage of patients receiving ORS
n % n % n %
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Figure 3. Scatter Plot Coverage of Patients Receiving ORS and Prevalence of Toddler Diarrhea in Province
of Indonesia 2018.
Based on Table 4, it can be seen that the prevalence higher the prevalence of diarrhea of toddlers (r =
of diarrhea is high, many occur in provinces with -0.149) (Figure 3).
low coverage of oralit, which is 58.3% compared to
Based on Table 5, it can be seen that the prevalence
provinces with low coverage of oralit (36.4%). Based
of diarrhea is high, many occur in provinces with a high
on the results of the scatter plot it can be known that
percentage of poor people, which is 50% compared
the lower the coverage of patients getting oralit the
to provinces with low service coverage. Based on the
1300 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1
results of the scatter plot it can be known that the higher the percentage of poor people in the province the higher
the prevalence of diarrhea of toddlers with r = 0.363 (Figure 4).
n % n % n %
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Figure 4. Scatter Plot Poor population and Prevalence of Toddler Diarrhea in Province of Indonesia 2018.
Table 6. Prevalence of toddler diarrhea according to the availability of health workers
n % n % n %
Source: The 2018 Indonesia Basic Health Survey and The 2018 Indonesia Health Profile
Based on Table 6, it can be seen that the prevalence of diarrhea is high, many occur in provinces with a low
number of workers per 100,000 inhabitants, which is 57.1%. Based on the results of the scatter plot it can be
known that the lower the availability of health workers in the province the higher the prevalence of diarrhea of
toddlers with r = -0.430 (Figure 5).
Figure 5. Scatter Plot Availability of Health Workers and Prevalence of Toddler Diarrhea in Province of
Indonesia 2018.
services in Indonesia still meets the target of coverage compared to provinces that have coverage of patients
of diarrhea services in Indonesia, which is more than getting high oralit. Prawati research, et al (2019)
20%. Results showed the higher the coverage of also showed that there is a link between taking oralit
diarrhea services of toddlers the higher the prevalence respondents and the incidence of diarrhea in the last
of diarrhea of toddlers. This happens because the 3 months20. In addition, research by Puji and Yuniar
more coverage of diarrhea services toddlers can detect (2017) showed that there is an effect of oralit 200
the more diarrhea that toddlers experience. Not that on the consistency of feces and decreased frequency
the province needs to lower coverage to lower the of defecation in infants with acute diarrhea of mild-
prevalence of diarrhea in toddlers. moderate dehydration21.
Receiving zinc during diarrhea is proven to The results of the analysis showed that the higher
reduce the length and severity of diarrhea, reduce the the percentage of poor people, the higher the prevalence
frequency of defecation, reduce the volume of stool, of diarrhea in the province. Previous research at
and decrease the recurrence of diarrhea incidence in the Puskesmas Babakansari Bandung mentioned that
next 3 months16. Similarly, research by Restuti (2019) there is a significant relationship between parental
which showed a significant relationship between zinc income and the incidence of diarrhea in toddlers22.
intake level and the incidence of diarrhea, namely zinc The low family income makes individuals choose to
intake level with less category can be at risk of 3,095 use public latrines because of the lack of land to make
times diarrhea compared to subjects with sufficient latrines and the lack of funds to build family latrines
zinc intake level17. that can affect individuals and family members23.
Poverty is a factor in parents reducing capacity to
The results of frequency distribution showed a
support good health care for children, less likely to
high prevalence of diarrhea in infants in provinces with
have good hygiene and poor education24.
high zinc coverage. But the correlation value showed
an inverse relationship between zinc administration This study shows that the lower the availability
coverage and the prevalence of infant diarrhea. This of health workers, the higher the prevalence of
contradiction means that there was no meaningful diarrhea in a province. Previous studies have also
relationship between zinc administration in toddlers stated that the more the number of medical personnel
suffering from diarrhea and the prevalence of diarrhea and paramedics, the more qualified the available
of toddlers, the correlation value also shows a very personnel25. In line with research in West Sumatra,
small number (r = -0.013). Another study conducted Indonesia shows where the better the support provided
by Arnisam, et al (2013) showed similar results by posyandu will be lower morbidity of children to
that there was no link between Zinc intake and the diarrheal infections26. However, in contrast to the
incidence of diarrhea in toddlers18. research conducted in the West Alas Subdistrict,
Indonesia which stated that there was no meaningful
Oralit is a drug in the form of salt powder to
relationship between the role of health workers and
be liquefied as a substitute for minerals and fluids
the incidence of diarrhea of toddlers27. Health workers
that come out due to vomiting or crackling. Oralit
have an important role in the health service to improve
is administered as an intervention against impaired
the level of public health.
balance of sodium and potassium concentrations due
to dehydration19. Based on the results of the analysis, The study has limited recommendations for macro
showed that in the prevalence of diarrhea of toddlers policy because the analysis used aggregate data at the
are high, many occur in provinces that have coverage provincial level. Therefore, further research is still
of sufferers get low oralit but not much different needed to find out the factors that affect the incidence
Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 1303
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