Volume 89, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



We present an innovative approach for analyzing diarrheal prevalence data that uses latent variables to model the relationships between multiple, interdependent environmental risk factors, and socioeconomic mediators. This strategy was applied to elucidate diarrheal longitudinal prevalence risk factors in children 1–4 years of age in low-income areas of Jakarta, Indonesia. Through a prospective cohort study, we identified 257 children who had at least one episode of diarrhea. At the onset of the study, we collected responses to 44 indicators, covering a wide range of previously identified diarrhea risk factors, including demographic and socioeconomic factors. We used exploratory factor analysis to uncover four latent categories of risk factors and their respective indicators from the initial pool of 44 indicators. Thereafter, we used structural equation modeling to model the relationships between the four risk categories and diarrheal longitudinal prevalence, controlling for socioeconomic and demographic covariates. Our final model elucidated several pathways to longitudinal diarrheal prevalence. Most notably, poverty exerts its effect on increased diarrheal prevalence via dual pathways: poor household hygiene and food quality, controlling for covariates. Implications of this and other findings for disease control in Jakarta are discussed.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Liu L, Johnshon HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, , 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 21512161.[Crossref] [Google Scholar]
  2. Lerman SJ, Shepard DS, Cash RA, , 1985. Treatment of diarrhea in Indonesian children: what it costs and who pays for it. Lancet 2: 651654.[Crossref] [Google Scholar]
  3. Agtin MD, Soeharno R, Lesmana M, Punjab NH, Simanjuntak C, Wangsasaputra F, Nurdin D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H, Sjahrurachman A, Sudarmono P, von Seidlein L, Deen JL, Ali M, Lee H, Kim DR, Han O, Park JK, Suwandono A, Ingerani Oyofo BA, Campbell JR, Beecham HJ, Corwin AL, Clemens JD, , 2005. The burden of diarrhoea, shigellosis, and cholera in north Jakarta, Indonesia: findings from 24 months surveillance. BMC Infect Dis 5: 89.[Crossref] [Google Scholar]
  4. Lima AA, Guerrant RL, , 1992. Persistent diarrhea in children: epidemiology, risk factors, pathophysiology, nutritional impact, and management. Epidemiol Rev 14: 222243.[Crossref] [Google Scholar]
  5. WHO/UNICEF, 1985. The Management of Diarrhoea and Use of Oral Rehydration Therapy. Geneva: World Health Organization. [Google Scholar]
  6. Grantham-McGregor S, , 1995. A review of studies of the effect of severe malnutrition on mental development. J Nutr 125: 2238S. [Google Scholar]
  7. Brown KH, , 2003. Diarrhea and malnutrition. J Nutr 133: 32853325. [Google Scholar]
  8. Moore SR, Lima NL, Soares AM, Oria RB, Pinkerton RC, Barrett LJ, Guerrant RL, Lima AA, , 2010. Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children. Gastroenterology 139: 11561164.[Crossref] [Google Scholar]
  9. Niehaus MD, Moore SR, Patrick PD, Derr LI, Lorntz B, Lima AA, Guerrant RL, , 2002. Early childhood diarrhea is associated with diminished cognitive function 4 to 7 years later in children in a northeast Brazilian shantytown. Am J Trop Med Hyg 66: 590593. [Google Scholar]
  10. Morriss S, Cousens SN, Kirkwood BR, Arthur P, Ross DA, , 1996. Is prevalence of diarrhea a better predictor of subsequent mortality and weight gain than diarrhea incidence? Am J Epidemiol 144: 582588.[Crossref] [Google Scholar]
  11. Bernd G, Strina A, Teles CA, Prado MS, Barreto ML, , 2006. Risk factors for childhood diarrhea incidence. Dynamic Analysis of a Longitudinal Study Epidemiology 17: 658667. [Google Scholar]
  12. Fewtrell L, , 2005. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 4252.[Crossref] [Google Scholar]
  13. Aulia H, Surapaty SC, Bahar E, Susanto TA, Roisuddin Hamzah TM, , 1994. Personal and domestic hygiene and its relationship to the incidence of diarrhoea in South Sumatra. J Diarrhoeal Dis Res 12: 4248. [Google Scholar]
  14. Blum D, Feachem RG, , 1983. Measuring the impact of water supply and sanitation investments on diarrhoeal diseases: problems of methodology. Int J Epidemiol 12: 357366.[Crossref] [Google Scholar]
  15. Esrey SA, Habicht J-P, , 1986. Epidemiologic evidence for health benefits from improved water and sanitation in developing countries. Epidemiol Rev 8: 117129.[Crossref] [Google Scholar]
  16. Esrey SA, Potash JB, Shiff RC, , 1991. Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bull World Health Organ 69: 609621. [Google Scholar]
  17. Semenza JC, Roberts L, Henderson A, Bogan J, Rubin CH, , 1998. Water distribution and diarrheal disease transmission: a case study in Uzbekistan. Am J Trop Med Hyg 59: 941946. [Google Scholar]
  18. Arnold BF, Colford JM, , 2007. Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: a systematic review and meta-analysis. Am J Trop Med Hyg 76: 354364. [Google Scholar]
  19. Sima L, Desai MM, McCarty KM, Elimelech M, , 2012. Relationship between use of water from community-scale water treatment refill kiosks and childhood diarrhea in Jakarta. Am J Trop Med Hyg 87: 979984.[Crossref] [Google Scholar]
  20. Semba RD, , 2009. Purchase of drinking water is associated with increased child morbidity and mortality among urban slum-dwelling families in Indonesia. Int J Hyg Environ Health 212: 387397.[Crossref] [Google Scholar]
  21. Pickering H, Hayes RJ, Tomkins AM, Carson D, Dunn DT, , 1986. Alternative measures of diarrhoeal morbidity and their association with social and environmental factors in urban children in The Gambia. Trans R Soc Trop Med Hyg 81: 853859.[Crossref] [Google Scholar]
  22. Manun’ebo MN, Haggerty PA, Kalengaie M, Ashworth A, Kirkwood BR, , 1994. Influences of demographic, socioeconomic and environmental variables on childhood diarrhoea in a rural area of Zaire. J Trop Med Hyg 97: 3138. [Google Scholar]
  23. Genser B, Strina A, Teles CA, Pardo MS, Barreto ML, , 2006. Risk factors for childhood diarrhea incidence: dynamic analysis of a longitudinal study. Epidemiology 17: 658667.[Crossref] [Google Scholar]
  24. Pruss A, Kay D, Fewtrell L, Bartram J, , 2002. Estimating the burden of disease from water, sanitation, and hygiene at a global level. Environ Health Perspect 110: 537542.[Crossref] [Google Scholar]
  25. Eisenberg JN, Scott JC, Porco T, , 2007. Integrating disease control strategies: balancing water sanitation and hygiene interventions to reduce diarrheal disease burden. Am J Public Health 97: 846853.[Crossref] [Google Scholar]
  26. Esrey SA, Feachem RG, , 1989. Interventions for the Control of Diarrhoeal Disease among Young Children: Promotion of Food Hygiene. Geneva: World Health Organization. [Google Scholar]
  27. Esrey SA, Habicht J-P, Casella G, , 1992. The complementary effect of latrines and increased water usage on the growth of infants in rural Lesotho. Am J Epidemiol 135: 659667.[Crossref] [Google Scholar]
  28. Barreto ML, Genser B, Strina A, Teixeira MG, Asssis AM, Rego RF, Teles CA, Prado MS, Matos SM, Santos DN, dos Santos LA, Cairncross S, , 2007. Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: assessment by two cohort studies. Lancet 370: 16221628.[Crossref] [Google Scholar]
  29. Santos CA, Strina A, Amorim LD, Genser B, Assis AM, Prado MS, Barreto ML, , 2012. Individual and contextual determinants of the duration of diarrhoel episodes in preschool children: a longitudinal study in an urban setting. Epidemiol Infect 140: 689696.[Crossref] [Google Scholar]
  30. Fahrmeir L, Raach A, , 2007. A Bayesian semiparametric latent variable model for mixed responses. Psychometrika 72: 327346.[Crossref] [Google Scholar]
  31. MacDonald RP, Ho RM, , 2002. Principles and practice in reporting structural equation analyses. Psychol Methods 7: 6482.[Crossref] [Google Scholar]
  32. Badan Pusat Statistik, 2004. National Socio-Economic Survey (NSES). Jakarta, Indonesia: SUSENAS. [Google Scholar]
  33. Wright JA, Gaundry SW, Conroy R, Wood D, Du Perez M, Ferro-Luzzi A, Genthe B, Kirimi M, Moyo S, Mutisi C, Ndamba J, Potgieter N, , 2006. Defining episodes of diarrohoea: results from a three-country study in sub-Saharan Africa. J Health Popul Nutr 24: 816. [Google Scholar]
  34. Du Perez M, Conroy RM, Wright JA, Moyo S, Potgieter N, Gundry SW, , 2008. Use of ceramic water filtration in the prevention of diarrheal diseases: a randomized controlled trial in rural South Africa and Zimbabwe. Am J Trop Med Hyg 70: 696701. [Google Scholar]
  35. Levine MM, Caplan ES, Waterman D, Cash RA, Hornick RB, Snyder MJ, , 1977. Diarrhea caused by Escherichia coli that produce only heat-stable enterotoxin. Infect Immun 17: 7882. [Google Scholar]
  36. Kaplan JE, Schonberger LB, Varano G, Jackman N, Bied J, Gary GW, , 1982. An outbreak of acute nonbacterial gastroenteritis in a nursing home. Am J Epidemiol 116: 940949.[Crossref] [Google Scholar]
  37. Laffan AM, McKenzie R, Forti J, Conklin D, Marcinko R, Shrestha R, Bellantoni M, Greenough WBI, , 2011. Lactoferrin for the prevention of post-antibiotic diarrhoea. J Health Popul Nutr 29: 547551. [Google Scholar]
  38. Banks MR, Farthing MJ, Hawkey CJ, Bosch J, Richter J, Garcia-Tsao G, Chan F, , 2012. Diarrhea. , eds. Textbook of Clinical Gastroenterology and Hematology. New York: John Wiley and Sons, 3242.[Crossref] [Google Scholar]
  39. Simanjuntak CH, Punjabi NH, Wangsasaputra F, Nurdin D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H, Sjahrurachman A, Sudarmono P, Seidlein LV, Acosta C, Robertson SE, Ali M, Lee H, Park J, Deen JL, Agtini MD, Clemens JD, , 2004. Diarrhoeal episodes and treatment-seeking behavior in a slum area of north Jakarta, Indonesia. J Health Popul Nutr 22: 119129. [Google Scholar]
  40. Gupta SK, Suanto A, Gray A, Astuti BW, Jain N, Rolos R, Hoekstra RM, Quick R, , 2007. Factors associated with E. coli contamination of household drinking water among tsunami and earthquake survivors, Indonesia. Am J Trop Med Hyg 76: 11581162. [Google Scholar]
  41. Dibley MJ, Sadjmin T, Kjolhede CL, Moulton LH, , 1996. Vitamin A supplementation fails to reduce incidence of acute respiratory illness and diarrhea in preschool-age Indonesian children. J Nutr 126: 434442. [Google Scholar]
  42. Loehlin JC, , 1998. Latent Variables Models: An Introduction to Factor, Path, and Structural Analysis. Third edition. Mahwah, NJ: Lawrence Erbaum Associates. [Google Scholar]
  43. Arbuckle JL, , 2010. AMOS: A Structural Equation Modeling Software. Chicago, IL: Small Waters Corporation. [Google Scholar]
  44. Byrne BM, , 1989. Multigroup comparisons and the assumption of equivalent construct validity across groups: methodological and substantive issues. Multivariate Behav Res 24: 503523.[Crossref] [Google Scholar]
  45. Steiger JH, Lind JC, , 1980. Statistically Based Tests for the Number of Factors. Iowa City, IA: Psychometric Society. [Google Scholar]
  46. Browne MW, Cudeck R, , 1989. Single sample cross-validation indices for covariance structures. Multivariate Behav Res 24: 445455.[Crossref] [Google Scholar]
  47. Pickering AJ, Julian TR, Marks SJ, Mattoili MC, Boehm AB, Schwab K, Davis J, , 2012. Fecal contamination and diarrheal pathogens on surfaces and soils among Tanzanian households with and without improved sanitation. Environ Sci Technol 46: 57365743.[Crossref] [Google Scholar]
  48. Julian TR, MacDonald L, Guo Y, Marks SJ, Kosek M, Yori PP, Pinedo SR, Schwab K, , 2013. Fecal indicator bacteria contamination of fomites and household demand for surface disinfection products. Am J Trop Med Hyg 89: 869872.[Crossref] [Google Scholar]
  49. Lin A, Arnold BF, Afreen S, Goto R, Huda T, Haque R, Raqib R, Unicomb L, Ahmed T, Colford JM, Jr Luby SP, , 2013. Household environmental conditions are associated with enteropathy and impaired growth in rural Bangladesh. Am J Trop Med Hyg 89: 130137. [Google Scholar]
  50. Stevens J, , 1996. Applied Multivariate Statistics for the Social Sciences. Third edition. Mahwah, NJ: Erlbaum. [Google Scholar]
  51. Clasen T, Schmidt W, Rabie T, Roberts I, Cairncross S, , 2007. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BMJ 334: 782.[Crossref] [Google Scholar]
  52. Sobsey M, , 2002. Managing Water in the Home: Accelerated Health Gains from Improved Water Supply. World Health Organization Sustainable Development and Healthy Environments. Geneva: World Health Organization. [Google Scholar]
  53. Esrey SA, Feachem RG, Hughes JM, , 1985. Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities. Bull World Health Organ 63: 757772. [Google Scholar]
  54. Barreto ML, Milroy CA, Strina A, Prado MS, Leite JP, Ramos EA, Ribeiro H, Alcantara-Neves NM, Teixeira M d G, Rodrigues LC, Guerreiro H, Trabulsi LR, , 2006. Community-based monitoring of diarrhea in urban Brazilian children: incidence and associated pathogens. Trans Rl Soc Trop Med Hyg 100: 234242.[Crossref] [Google Scholar]
  55. Black RE, Brown KH, Becker S, , 1984. Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics 73: 799. [Google Scholar]

Data & Media loading...

  • Received : 01 Sep 2012
  • Accepted : 30 Jul 2013
  • Published online : 06 Nov 2013

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error