Exploring environmental risk factors for diarrhea: Evidence from the Indonesian Health Survey, 2023

Article information

Environ Anal Health Toxicol. 2026;41.e2026001

Publication date (electronic) : 2026 January 8

doi : https://doi.org/10.5620/eaht.2026001

Muhammad Aidil Fitrah^1,, Muhamad Zakki Saefurrohim², Yura Witsqa Firmansyah^3,4

¹Department of Environmental Health, Faculty of Public Health, Universitas Mulawarman, Samarinda City, Indonesia

²Department of Epidemiology, Faculty of Public Health, Universitas Mulawarman, Samarinda City, Indonesia

³Department of Hospital Administration, College of Health Science (STIKES) Adi Husada, Surabaya City, Indonesia

⁴Environmental Science Doctoral Program, Graduate School, Universitas Sebelas Maret, Surakarta City, Indonesia

^*Correspondence: aidilfitrah@fkm.unmul.ac.id

Received 2025 June 12; Accepted 2025 October 6.

Abstract

Introduction

Diarrhea is still a significant public health problem globally, as reflected by data from the World Health Organization (WHO). Annually, there are about 1.7 billion cases of diarrhea worldwide. The disease is also a major cause of death, with mortality reaching 443,832 cases in children under five years old and 50,851 cases in children aged 5 to 9 years, making it the third leading cause of death in children aged 1 to 59 months [1,2]. A similar problem exists in Indonesia, where 50 out of every 1,000 children under five die from diarrhea. In 2020, health service coverage for diarrhea patients in all age groups reached only 44.4%, and for children under five, it was only 28.9%, falling short of the national target[3] . The inequality in services between provinces is quite striking, with coverage of diarrhea patients across all age groups ranging from 4.9% in North Sulawesi to 78.3% in West Nusa Tenggara. As for the coverage of diarrhea patients under five, the figure ranged from 4.0% in North Sulawesi to 61.4% in West Nusa Tenggara.

According to UNICEF, nearly 70% of household drinking water sources in Indonesia are contaminated with fecal matter, posing a high risk of diarrheal disease transmission, particularly among children under five[4]. The Sustainable Development Goals (SDGs), especially SDG 6, target universal access to safe and affordable drinking water by 2030, yet this remains unlikely without substantial improvements in sanitation and water quality [5]. In Indonesia, although 93% of households have access to improved drinking water sources, only 11.9% use safely managed water that meets physical, chemical, and microbiological standards [6,7]. Improved sources include piped water, protected wells, protected springs, rainwater, and safe refillable bottled water, while unimproved sources comprise unprotected wells/springs, surface water, and unsafe refillable water. Piped water, considered the gold standard, is used as the main drinking water source by only 13.1% of households [8,9], and even when available, it must meet quality, quantity, affordability, and accessibility criteria to be deemed safely managed [7,10]; however, in many developing countries, drinking water quality remains poor, contributing to a high burden of waterborne diseases [11].

While various efforts have been made to reduce the burden of diarrheal disease—such as the development of sanitation infrastructure, provision of safe drinking water, and promotion of clean and healthy living behavior (PHBS-Perilaku Hidup Bersih dan Sehat) [12,13] . the incidence rate of diarrhea has not shown a significant decline. This suggests that the causes of diarrhea are not only clinical but also strongly linked to the quality and safety of water, sanitation, and hygiene in the living environment [14,15]. A number of previous studies have tried to identify the relationship between environmental aspects and diarrhea incidence, but generally have limitations in terms of area coverage, sample size, and the number of variables analyzed. Most of the studies were localized and unable to describe conditions at the national level, even though Indonesia has high geographical diversity and social characteristics. In addition, some studies tend to isolate one or two risk factors, such as water quality or latrine access, without considering the complex interactions between other environmental factors such as liquid waste management, water storage, and community hygiene behavior.

Based on this need, this study utilizes large-scale national data collected through the 2023 Indonesian Health Survey (IHS). With more than 877,000 respondents, this study presents a comprehensive picture of the relationship between household environmental conditions and the incidence of diarrhea. Various aspects were analyzed, ranging from access to clean water, physical quality of water, treatment methods, types of storage containers, to sanitation and hygiene practices. This approach allows for a more detailed mapping of relevant risk factors, as well as providing a more representative picture of the patterns of diarrhea incidence in Indonesia. Through systematic statistical analysis, the results of this study are expected to make a meaningful contribution to diarrhea prevention and control efforts through evidence-based strategies that consider the context of the wider Indonesian living environment.

Materials and Methods

Results

The characteristics of respondents presented are classification by gender and age. Environmental exploration is reviewed from the sources and physical quality of drinking water; drinking water treatment and storage; raw water sources; liquid waste quality; solid waste treatment; access to sanitation and hygiene-sanitation. Table 1 below presents the complete research results.

Table 1.

Frequency distribution of environmental risk factor variables with diarrhea incidence in Indonesia in 2023 (n= 877,531)

Based on the results of the 2023 national survey of 877,531 respondents (Table 2), 16,380 individuals (1.9%) experienced diarrhea, while 861,151 respondents (98.1%) did not experience diarrhea. In terms of demographic characteristics, 580,299 respondents (66.1%) were in the productive age group (15–64 years) and 297,232 (33.9%) were in the unproductive age group (<15 or >64 years), with 463,269 females (52.8%) and 414,262 males (47.2%) Concerning drinking water sources, 187,519 respondents (21.4%) used risky drinking water sources, while 690,012 (78.6%) used non-risky sources. A total of 41,535 respondents (4.7%) used drinking water with unqualified physical quality, and 835,996 (95.3%) used qualified water. Drinking water treatment is still a concern, as 344,050 respondents (39.2%) did not treat their drinking water, while 533,481 (60.8%) did. In terms of drinking water storage, 215,025 (24.5%) used open containers, while 662,506 (75.5%) used closed containers. Risky raw water sources were still used by 118,397 respondents (13.5%), and 759,134 (86.5%) used non-risky sources.

Table 2.

Relationship between environmental factors and diarrhea incidence in Indonesia by 2023.

Other environmental factors such as liquid waste disposal, 702,168 respondents (80%) still use open containers, and only 175,363 (20%) have used closed containers. A total of 568,681 respondents (64.8%) were found not to be doing waste management properly, while only 308,850 (35.2%) were doing it properly. In terms of sanitation access, 35,677 respondents (4.1%) did not have proper access, while 841,854 (95.9%) had access to proper sanitation. Finally, in terms of sanitation hygiene, 218,492 respondents (24.9%) were in poor condition, while 659,039 (75.1%) showed good sanitation hygiene conditions. This finding confirms that although most of the population has access to proper sanitation and water, a number of environmental risk factors such as improper water treatment, open liquid waste disposal, and poor hygiene still contribute to the incidence of diarrhea in Indonesia. Table 2 below explains the risk factors of environmental conditions with cases of diarrhea.

Table 2 shows the results of bivariate analysis that most environmental factors have a significant association with the incidence of diarrhea in Indonesia in 2023. Respondents in the unproductive age group (<15 or >64 years) were more likely to experience diarrhea compared to those in the productive age group (OR = 1.703; 95% CI: 1.651–1.757), while males had a lower likelihood compared to females (OR = 0.900; 95% CI: 0.872–0.928). Use of risky drinking water sources was significantly associated with an increased incidence of diarrhea (OR: 1.113; 95% CI: 1.073-1.154; p = 0.001), as was consumption of water with unqualified physical quality (OR: 1.597; 95% CI: 1.504-1.695; p = 0.001). However, drinking water treatment did not show any significance (p = 0.753). Storage of water in open containers was also significantly associated with diarrhea (OR: 1.045; 95% CI: 1.008-1.080; p = 0.016).

Furthermore, the use of risky raw water sources (OR: 1.326; 95% CI: 1.273-1.382; p = 0.001), disposal of liquid waste through open channels (OR: 1.097; 95% CI: 1.055-1.142; p = 0.001), and improper waste management (OR: 1.152; 95% CI: 1.115-1.191; p = 0.001) also showed a significant association with diarrhea. In addition, inadequate access to sanitation (OR: 1.541; 95% CI: 1.444-1.645; p = 0.001) and poor sanitation hygiene behavior (OR: 1.236; 95% CI: 1.194-1.278; p = 0.001) reinforced the finding that behavioral factors and sanitation infrastructure play an important role in the incidence of diarrhea. Table 3 below explains the AOR values in both models.

Table 3.

Relationship between environmental factors and diarrhea incidence in indonesia by 2023..

Table 3 shows the multivariable logistic regression analysis revealed that several environmental factors were significantly associated with diarrhea. The poor physical quality of drinking water increased the risk of diarrhea (AOR = 1.478; 95% CI: 1.391–1.571; p = 0.001). Drinking water that was not appropriately treated (AOR=1.073; 95% CI: 1.037–1.110; p = 0.001), unsafe storage of drinking water (AOR = 1.056; 95% CI: 1.017–1.096; p = 0.004), and using unsafe raw water sources (AOR = 1.199; 95% CI: 1.148–1.252; p = 0.001) also increased the risk. Other factors such as poor wastewater disposal (AOR = 1.047; 95% CI: 1.005–1.089; p = 0.026), inadequate solid waste management (AOR = 1.083; 95% CI: 1.046–1.122; p = 0.001), lack of access to sanitation (AOR = 1.311; 95% CI: 1.225–1.403; p = 0.001), storage water containers (AOR = 1.056; 95% CI: 1.017-1.096; p = 0.004) and poor hygiene (AOR = 1.148; 95% CI: 1.108–1.189; p = 0.001) were also significant. The source of drinking water was not substantial (p = 0.253) and was removed from the final model.

Figure 1.

Adjusted Odds Ratio (AOR) results for water and sanitation variables.

Discussion

The results of this study provide empirical evidence that environmental factors have a significant contribution to the incidence of diarrhea at the population level in Indonesia. Based on the analysis of data from the 2023 Indonesian Health Survey (IHS), which included 877,531 respondents, it was found that diarrhea is still an important public health problem with a prevalence of 1.9%. Although this figure appears relatively small proportionally, when translated into absolute terms, the number of diarrhea cases remains significant and imposes a large economic and health burden. In a multivariate logistic regression model, several environmental indicators were found to be significantly associated with diarrhea incidence, both statistically and substantively. The physical quality of unqualified drinking water (cloudy water, color, taste, foam, or odor) showed the strongest influence on diarrhea incidence (Adjusted Odds Ratio/AOR = 1.478; 95% CI: 1.391-1.571; p = 0.000). This finding is in line with the results of previous studies showing that drinking water quality is one of the main determinants in the transmission of diarrheal diseases, particularly through microbiological contamination by pathogenic agents such as Escherichia coli, Shigella spp., and Vibrio cholerae [17–19]. Contamination can occur at the water source, during the distribution process, or storage at the household level. This study also showed that the use of risky raw water sources (such as rainwater, surface water, or unprotected wells) had a significant association with diarrhea incidence (AOR = 1.199; 95% CI: 1.148-1.252; p = 0.0010. Although most households in this study accessed technically feasible water sources, there is still a high vulnerability to contamination if these water sources are poorly managed or used without additional treatment [20–22]. This fact indicates that access to clean water is not only determined by the availability of the source but also by the quality of the source and water management practices at the household level.

Interestingly, the variable of treating drinking water before consumption did not show a statistically significant association in the bivariate model (p = 0.753), even though this practice is theoretically known to be effective in reducing the risk of waterborne diseases. This can be explained through possible differences in the treatment methods used (e.g. inadequate boiling, filtration without disinfection, or use of ineffective chemicals), as well as possible recontamination during storage. Therefore, the presence of this variable in the model highlights the importance of thorough quality control of water treatment practices, including public education on effective water treatment techniques [23].

Not only that, drinking water sources in the initial multivariate model were also found to be statistically insignificant (p = 0.253) and were subsequently removed. These findings are consistent with recent global evidence showing that factors at the point of use, rather than the type of water source, often determine the risk of contamination. A comprehensive meta-analysis from The Lancet (2022) reported that water treatment technologies at the household level, such as filtration, solar disinfection, and chlorination, can reduce the risk of diarrhea by 30–50%, while improvements to the water supply source alone showed inconsistent or insignificant effects [24,25]. Similarly, a Cochrane systematic review concluded that source-based interventions (e.g., improvements to supply systems or chlorination at the point of use) rarely achieve meaningful reductions in diarrhea incidence [25].

The type of water storage container was also shown to contribute to diarrhea risk, with open containers such as buckets without lids having an association with increased diarrhea incidence (AOR = 1.056; 95% CI: 1.017-1.096; p = 0.004). Open containers may increase the risk of water recontamination by vectors (such as flies and insects), unclean hands, and dust particles [26,27]. Although the contribution is relatively small compared to other variables, it is important to remember that this risk is cumulative, especially in environments that have multiple exposures to various sanitation determinants [28-30].

In terms of domestic wastewater management, this study confirmed that disposal of wastewater into open sumps was associated with the incidence of diarrhea (AOR = 1.047; 95% CI: 1.005-1.089; p = 0.026). Uncovered disposal systems allow waste runoff to contaminate the surrounding environment, including dug wells or surface water sources, which in turn become sources of drinking water contamination. This is reinforced by the finding that inappropriate solid waste management, such as burning, landfilling, or dumping into waterways, also showed a significant association with an increased incidence of diarrhea (AOR = 1.083; 95% CI: 1.046-1.122; p = 0.000). Improperly managed organic waste provides an ideal medium for the development of disease vectors such as flies, cockroaches, and rats, which are known to play a role in the transmission of pathogens that cause diarrhea [31-33]. Therefore, environmental management needs to not only focus on water and sanitation but also include an integrated waste management system [34,35]. In terms of access to sanitation, households that do not have access to proper latrines (e.g., latrines without goosenecks, without closed sumps, or non-functioning shared latrines) have a higher risk of experiencing diarrhea (AOR = 1.311; 95% CI: 1.225-1.403; p = 0.000). Access to adequate sanitation facilities is a fundamental component in breaking the chain of fecal-oral transmission [36,37]. This study consistently supports the findings of WHO and UNICEF that improved access to proper sanitation is directly associated with reduced diarrhea incidence, especially in vulnerable age groups such as children under five [38,39].

In addition to physical infrastructure, community hygiene behavior is also an important factor evidenced in this study. Poor sanitation hygiene practices, such as not washing hands with soap at critical times (after defecation, before eating, or before preparing food), significantly increased the risk of diarrhea incidence (AOR = 1.148; 95% CI: 1.108-1.189; p = 0.000). This suggests that good behavior in sanitation management needs to be accompanied by education and the provision of supporting facilities, such as the availability of clean water, soap, and easily accessible hand-washing facilities [40–42]. Although health promotion programs have been carried out by various institutions, implementation challenges are still encountered, especially in areas with low education and income levels [43]. In this context, health promotion approaches need to be reviewed to place more emphasis on community-based behavior change strategies that are adapted to local social and cultural conditions.

Overall, this discussion shows that the incidence of diarrhea in Indonesia is multifactorial with a dominant contribution from interrelated environmental factors, in terms of infrastructure, behavior, and risk management. Therefore, diarrhea management strategies must be designed intersectorally and holistically, including complementary preventive and promotive aspects. The government and stakeholders need to integrate findings such as these into public policy, by strengthening environmental and behavioral intervention programs in a more targeted manner, based on risk data and local needs. In addition, the results of this study provide a strong basis for the development of an environmental risk surveillance system for water-based diseases such as diarrhea, as well as input for mapping priority areas for intervention based on the identified risk profile. In the context of the Sustainable Development Goals (SDGs), particularly targets 6.1 and 6.2 on universal access to safe drinking water and proper sanitation, the findings confirm that achieving these targets depends not only on infrastructure development, but also on improving the quality of behavior, resource governance, and strengthening the capacity of communities to maintain environmental hygiene independently. Thus, this study not only makes an academic contribution in understanding the environmental determinants of diarrhea incidence, but also has high practical value in supporting sustainable and evidence-based public health development policies.

This study has several limitations. First, as a cross-sectional design, it cannot establish causal relationships between environmental factors and diarrhea incidence. Second, the analysis relied on self-reported data from the 2023 Indonesian Health Survey, which may be subject to recall bias and reporting errors. Third, some potential confounding variables, such as nutritional status, climate variation, and seasonal effects, were not included in the analysis due to data unavailability. Lastly, water quality indicators were based on household responses rather than direct laboratory testing, which may affect the accuracy of exposure classification.

Conclusions

This study confirmed that household environmental factors have a significant contribution to the incidence of diarrhea in Indonesia. Based on the analysis of data from the 2023 Indonesian Health Survey (IHS), which covered more than 877,000 respondents, it was found that environmental aspects such as the physical quality of drinking water, raw water sources, access to proper sanitation, liquid and solid waste management, types of water storage containers, and sanitary hygiene behavior are important determinants of diarrhea incidence. Among all the variables analyzed, the physical quality of drinking water was recorded as the most influential factor in diarrhea incidence after controlling for other variables. Although most households have access to water and sanitation, there are still gaps in the quality, management, and usage behavior that lead to vulnerability to environment-based diseases. These findings suggest that diarrhea control approaches cannot rely solely on clinical interventions or the provision of physical infrastructure, but must be done comprehensively through the integration of environmental development, behavior change education, and strengthening sanitation governance at the household level. In the context of achieving sustainable development goals, especially SDGs points 3 and 6, the results of this study reinforce the urgency of evidence-based interventions that consider the geographical, social, and behavioral diversity of communities. Therefore, future public health policies need to consider national data-based risk mapping that enables more focused, adaptive, and sustainable intervention planning to reduce the burden of diarrheal disease in Indonesia.

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