The Correlation between Clean and Healthy Living Behavior and Diarrhea Incidence in Children Under Five Years Old: A Literature Review Study

Diarrhea is a disease often accompanied by mortality and morbidity. Its incidence increased 1% per year from 300 thousand household samples. Lack of Clean and Healthy Living Behavior (in Indonesia, namely of a program is Perilaku Hidup Bersih Sehat or PHBS ) can affect the incidence of diarrhea. This paper analyzes the correlation between PHBS and diarrhea incidence in children under five years old. The four PHBS indicators are exclusive breastfeeding, healthy latrines, clean water, and handwashing with soap (HWS). This research was a literature review study. We used a database of google scholar and the garuda portal. In addition, journal screening included three stages. The first stage was the selection of free access journals. Then, the second stage was the selection of titles and abstracts according to the keywords ( PHBS , Diarrhea, and Children under five years old) and publication year. The third stage was selecting the background, method, results, and discussion. Eleven papers explained the correlation between the PHBS and diarrhea incidence in children under five. There were five articles revealing the association between the incidence of diarrhea and four PBHS indicators. In addition, PHBS indicators most associated with diarrhea sequentially were handwashing with soap (11 publications), exclusive breastfeeding (10 journals), healthy latrines (8 papers), and clean water (6 documents). In conclusion, exclusive breastfeeding, clean water, healthy latrines, and handwashing with soap correlate to diarrhea incidence in children under five years old. Health workers should provide health education regarding PHBS .


INTRODUCTION
Diarrhea is an abnormality in defecation with a frequency of three or more times. It is one of the environmental-based diseases. Unfortunately, it is the leading cause of morbidity and mortality. Based on data from the World Health Organization (WHO), diarrhea is a global problem with the potential for Extraordinary Events often accompanied by morbidity and mortality. Nearly 1.7 billion cases of diarrhea occur in children under five years, with a mortality rate of 525,000 each year (World Health Organization, 2017).
The incidence of diarrhea in Indonesia from 2016 to 2017 experienced a very drastic increase to 1,527 cases and 28 deaths with a Case Fatality Rate (CFR) of 1.97%. According to Basic Health Research (2018), diarrhea is a disease often accompanied by mortality and morbidity. Its incidence increased 1% per year from 300 thousand household samples. In addition, there were two provinces with the highest incidence of diarrhea, namely East Nusa Tenggara (214 cases and four deaths with a CFR of 1.87%) and Papua ( Diarrhea is still a health problem, especially in developing countries. Indonesia is one developing country with high diarrhea morbidity and mortality (Buletin, 2016). Based on the diagnosis by health workers, the highest prevalence of diarrhea was in the age group of 1-4 years (11.5%), infants (9%), and over 75 years (7.2%). In addition, a high prevalence of diarrhea was in women, rural areas, low education, and fishermen (Kementerian Kesehatan RI, 2020).
Lack of Clean and Healthy Living Behavior (in Indonesia, namely of a program is Perilaku Hidup Bersih Sehat or PHBS) can affect the incidence of diarrhea, especially in toddlers (Grafika, Sabilu en Munandar, 2017). In addition, four PHBS indicators are exclusive breastfeeding, healthy latrines, clean water, and handwashing with soap (HWS). This paper analyzes the correlation between PHBS and diarrhea incidence in children under five years old.

METHOD
This research was a literature review study on people with diarrhea, especially children under five years old. We used a database of google scholar and the garuda portal. In addition, journal screening included three stages. The first stage was the selection of free access journals. Then, the second stage was the selection of titles and abstracts according to the keywords and publication year (from 2015 to 2020).
Keywords were PHBS, Diarrhea, and Children under five years old. The third stage was selecting the background, method, results, and discussion.

RESULTS
Eleven papers explained the correlation between the PHBS and diarrhea incidence in children under five in this study.   Table 2 shows five articles revealing diarrhea is associated with all PBHS indicators. In addition, PHBS indicators most associated with diarrhea sequentially were handwashing with soap (11 publications), exclusive breastfeeding (10 journals), healthy latrines (8 papers), and clean water (6 documents).

Exclusive breastfeeding and incidence of diarrhea in children under five years old
Clean and Healthy Living Behavior (PHBS) is essential to prevent diarrhea in children under five years old. It includes four indicatorsexclusive breastfeeding, clean water use, healthy latrines, properly disposing of baby feces, and handwashing with soap. Exclusive breastfeeding is crucial because it is the best natural food source for children. (Wongkar & Futunanembun, 2017). Meanwhile, formula milk needs to pay attention to the hygiene of the baby's feeding bottles. However, some parents neglect to wash the feeding bottles properly because of busy work (Pranata et al., 2020).
Exclusive breastfeeding provides excellent protection for children because it plays a vital role in increasing the immune system. A previous study conducted by Grafika et al. (2017) in the working area of the Benu-Benua Public Health Center, Kendari, involved 104 children under five years old.
Respondents were divided into 52 in the case group and 52 in the control group. The study found that respondents (35 children under five years old) without exclusive breastfeeding had a greater risk of diarrhea than those with exclusive breastfeeding. In addition, the incidence of diarrhea in children under five years old without exclusive breastfeeding had a percentage of 67.3%. This percentage was much higher than the incidence of diarrhea in children under five years old with exclusive breastfeeding (32.7%). In addition, a similar study by Isnaniar & Lestari (2017)  2. Clean water uses and incidence of diarrhea in children under five years old People who live at the riverside had poor PHBS. They did not wash fruits and vegetables in running water. In contrast, fruits and vegetables that will be cooked should be washed with running water so that the dirt that sticks can dissolve with the water. One predisposing factor for diarrhea was a water source not 10 meters from a garbage dump or a sewage disposal site. This condition could contaminate the water with bacteria, especially E. coli. In addition, the water source should flow, and the water storage must have a cover (Safitri et al., 2017).
In addition, research by Asih & Saragih (2019) in Palembang involved 51 children under five years old.
Respondents were divided into 28 in the case group and 23 in the control group. The study found that respondents (17 children under five years old) who did not use clean water had a greater risk of diarrhea than those who used clean water. In addition, the incidence of diarrhea in children under five years old who did not use clean had a percentage of 68%. This percentage was much higher than the incidence of diarrhea in children under five years old who use clean water (42%).
Meanwhile, Ruhardi & Yuliansari (2021) research had a different result. The study concluded that there was no significant correlation between the use of clean water and the incidence of diarrhea in children under five. The odds ratio (OR) was 1.19 with a value of p=0.76 (p> 0.05).

Use of healthy latrines and incidence of diarrhea in children under five years old
Indiscriminate disposal of feces is a source of disease spread. In addition to the lack of clean water use, people living on the riverside also experienced problems with the disposal of feces. River water contaminated with bacteria causes disease transmission. Some people already had toilets available, but they did not clean and dispose of the baby's wastes properly so that bacteria could grow and spread. This condition is caused by parents' lack of knowledge and busy work (Irianty et al., 2018).
A previous study by Grafika et al. (2017)  diapers/trousers containing their child's feces on the bathroom floor. The mother did not know the impact and dangers of Indiscriminate disposal of feces (Pranata et al., 2020).

Handwashing with soap (HWS) and incidence of diarrhea in children under five years old
Handwashing with soap provides excellent protection for children to prevent bacteria spread. Research conducted by Grafika et al. (2017) in the working area of the Benu-Benua Public Health Center, Kendari, involved 104 children under five years old. Respondents were divided into 52 in the case group and 52 in the control group. The study found that respondents who did not do HWS (30 respondents) had a greater risk of diarrhea than those who did HWS. The incidence of diarrhea in children under five who did not do HWS was more significant (57.7%) than those who did HWS (45.8%). Many people already knew the importance of handwashing, but sometimes they did not understand when to wash their hands (Irianty et al., 2018). Thus, health workers must socialize with parents regarding how to wash their hands correctly and adequately (Toyibah & Apriani, 2019).

CONCLUSION
In conclusion, exclusive breastfeeding, clean water, healthy latrines, and handwashing with soap correlate to diarrhea incidence in children under five years old. Health workers should provide health education regarding PHBS.