JPED Journal

Introduction

Diarrhoea, a common illness marked by frequent loose or watery stools occurring three or more times daily [1], remains a major public health issue-especially in low- and middle-income countries-due to its adverse effects on the survival, growth, and development of infants and young children [2,3]. Globally, diarrhoeal disease is the second leading cause of death among children under five, accounting for approximately 1.5 million deaths each year, with sub-Saharan Africa bearing the highest burden [4-6] In Sierra Leone, diarrhoea ranks among the top causes of childhood mortality, responsible for an estimated 64.38 deaths per 100,000 children under five [7]. These fatalities often result from fluid and electrolyte loss, leading rapidly to dehydration [8,9]. Additionally, each diarrhoeal episode can cause a daily weight loss of 20–40 g, contributing to significant growth deficits in early childhood [10].While diarrhoeal diseases can be mitigated through both primary and secondary prevention, effective homebased management especially through the prompt use of oral rehydration solutions (ORS) or appropriate home available fluids is essential for reducing mortality [11]. The World Health Organization (WHO) and UNICEF recognize the contribution of home-based diarrhoea management in improving child survival, and advocates for caregivers’ empowerment through education and awareness creation on proper diarrhoea prevention and management practices [12,13].  This study was therefore done to assess caregivers’ knowledge, attitude, and practice (KAP) toward diarrhoea prevention and home-based management, which invariably impacts the burden of childhood diarrhoea diseases.

Materials and Methods

Study Design and Participants

This descriptive cross-sectional study was conducted among caregivers of children admitted to the general paediatric wards at ODCH between May and June 2024. Participants were selected using a non-probability convenience sampling method. Eligible participants were primary caregivers responsible for healthcare decisions regarding the child. Individuals with physical impairments affecting communication were excluded.

Study Setting

ODCH is a government tertiary paediatric hospital in the Freetown, Sierra Leone, serving as part of the University of Sierra Leone Teaching Hospitals Complex. The hospital, located in a densely populated urban area, has 164 inpatient beds and dedicated units for neonatal care, emergency, high dependency, intensive care, oncology, therapeutic feeding and general paediatrics.

Measurement and data collection procedure

Data was collected using a structured questionnaire by three trained data collectors who are medical interns with bachelor degree in medicine and surgery through face to face interview. The data collectors were responsible for the completeness and consistency of data at the site. The questionnaire comprised of four (4) sections. The first part contains questions about the socio-demographic characteristics of caregivers. The second part consisted of eight questions to assess the knowledge of the participants. The third and fourth parts consist of eight and nine questions to assess the attitude and practice of the study participants respectively. Knowledge, attitude, and practice levels were categorized based on mean scores.

Operational definition of terms

Diarrhoea: the passage of three or more loose or liquid stools per day [1].

Dehydration: the loss of water from the body, as a result of diarrhea [12]

Rehydration: The correction of dehydration with oral rehydration salts (ORS) or home prepared solution [12].

Oral Rehydration Therapy (ORT): The administration of fluid by mouth to prevent or correct the dehydration that is a consequence of diarrhea. It is a mixture of clean water, salt and sugar [12].

Good knowledge: study participant who correctly answered the mean score and above of the knowledge questions, was considered as having good knowledge [13].

Poor knowledge: study participant who correctly answered below the mean score of the knowledge questions, was considered as having poor knowledge [13].

Positive Attitude: study participant who correctly answered the mean score and above of the attitude questions, was considered as having a positive attitude [14].

Negative Attitude: study participant who correctly answered below the mean score of the attitude questions, was considered as having negative attitude [14].

Good practice: study participant who correctly answered the mean score and above of the practice questions, was considered as having good practice [15].

Poor Practice: study participant who correctly answered below the mean score of the practice questions, was considered as having poor practice [15].

Ethical considerations

Permission for the study was obtained from the management and the research committee of Ola During Children’s hospital. Written informed consent (by signature or thumbprint) was obtained from those who volunteered.

Data Analysis

Data was entered into the Statistical Package for Social Sciences (SPSS) version 25.0 for IBM electronic spreadsheet. Frequencies and percentages were used to describe descriptive data and the results were presented using tables and figure. The association between socio-demographic factors and caregivers’ knowledge, attitude and practice towards the prevention and home-based management of diarrhea, were evaluated using chi square or Fisher’s exact test as appropriate. Multivariate analysis with logistic regression was carried out, to look for independent association. The level of significance was set at p <0.05 in all the statistical analyses.

Results

A total of 110 caregivers have participated in the study with a response rate of 100%. So, 110 respondents’ data were included in the analysis process.

Socio-demographic characteristics of the caregivers

In this study, the majority of caregivers (34; 30.9%) were in the age of 25–29 years with the mean age of 27.99 [SD ± 5.2] years. Almost all caregivers were females (105; 95.5%) and 69 (62.7%) of them were Muslims. Eighty-three (75.5%) of the participants have had a formal education with 75 (68.2%) having at least secondary level of education. The majority of the caregivers 91 (82.7%) were employed and more than half of them were urban residents (Table 1). Concerning partner’s socio-demographic status, 90 (81.8%) of the caregivers reported that their partners have at least secondary level of education; 107(97.3%) of them were employed and over twothirds earn above 1000 Leones monthly income (Table 1a,b).

Table Ia: Socio-demographic characteristics of the caregivers

Table 1b: Socio-demographic characteristics of the caregivers

Caregivers’ knowledge about diarrhea prevention and management among under-five children

More than half of the caregivers (62; 56.3%), defined diarrhea as the passing of loose stool 3 or more times per day, while, 20 (18.2) caregivers described the presence of blood in the stool as diarrhoea. Nearly all respondents (109; 99.1%) thought diarrhea to be a serious illness among children, and the use of contaminated water (94.5%), hand washing without soap before preparing food (82.7%), and use of unclean infant feeding bottles (82.7%), were the common causes of diarrhea stated. 

Most caregivers knew that breastfeeding should be continued during diarrhea episodes (94; 85.5%) and agreed to the use of oral rehydration solution (ORS) to treat diarrhea (72; 65.4%); but they did not believe diarrhea can be managed at home (96; 87.3%). Weakness or lethargy (105; 95.5%) was the most identified danger sign of under-five diarrheal disease, followed by repeated vomiting (76; 69.1%) and poor feeding (76; 69.1%). Only a few respondents acknowledge the presence of reduced urine output (7; 6.4) and marked thirst for water (7; 6.4%), as danger signs for diarrhoea (Table 2).

Table 2 : Caregivers’ knowledge about diarrhea prevention and management among under-five children *Multiple responses were allowed.

Caregivers’ attitudes toward prevention and home-based management of under-five diarrhea

A total of 107 (97.3%) respondents acknowledged that diarrhoea is a serious disease that can lead to death, 83 (75.5%) agreed that infants who are bottle fed are more likely to contract diarrhoea than infants who are directly breastfed, 105 (95.5%) agreed that it is important to handwash before preparing meals for their children, while 82 (74.6%) agreed that exclusive breastfeeding for at least the first 6 months of life is important in preventing diarrhoea. The majority (93; 84.6) agreed that oral rehydration fluids can be prepared at home, while 85 (77.3%) agreed that giving oral rehydration treatment is necessary during diarrhoea. More than half (56; 50.8%) were unsure about the importance of vaccination for diarrhoea prevention; 94 (85.5%) rightly disagreed to the statement; open disposal of faeces does not affect the occurrence of diarrhoea (Table 3).

Table 3: Caregivers’ attitudes toward prevention and home-based management of under-five diarrhea; SA, Strongly agree; A, Agree; Un, Undecided; D, Disagree; SD, Strongly disagree.

Practices of caregivers towards the prevention and home management of diarrhea among under-five children

From the total respondents, the majority (62; 56.4%) practised exclusive breastfeeding. Although there was no special place for hand washing in their houses (91; 82.7%), most caregivers (87; 79.1%) still washed their hands with water and soap, especially after attending to their child who had defecated (103; 93.6). Less than half 25 (22.7%) disposed their child’s faeces in the toilet, 72 (65.5%) disposed child’s faeces in the dustbin outside their houses, while 13 (11.8%) simply rinsed faeces into the gutter while washing (Table 4).

Most of the caregivers (69; 62.7%) sought help from healthcare providers during the time of diarrheal diseases, which informed the common use of ORS (92; 83.6%); and about a quarter (31; 28.2%) prepared salt and sugar solution (ORT) at home when ORS was unavailable. Additional treatment given to their children during diarrhea illness was mostly Zinc tablets (76; 69.1%) (Table 4).

Table 4: Practices of caregivers towards the prevention and home management of diarrhoea among under-five children; *Multiple responses were allowed.

The overall level of knowledge, attitude, and practice of caregivers in the prevention and home-based management of diarrhea among under-five children

Overall, 81 (73.6%) caregivers had good knowledge about the prevention and home-based management of under-5 diarrheal diseases, while 29 (26.4%) had poor knowledge (Figure 1). The majority had a positive attitude (89; 80.9) and a similar proportion demonstrated good care practices (93; 84.5%).

Figure 1: The overall level of knowledge, attitude, and practice of caregivers in prevention and home-based management of diarrhea among under-five children.

Factors Associated with Knowledge, Attitude, and Practice towards Diarrhoea Prevention and Home-based Management

Younger age, lower educational status and residence within rural settings, were consistently among the socio-economic factors of caregivers, which were significantly associated with poorer knowledge, attitude and practice regarding the prevention and home-based management of under-5 diarrheal diseases. Other socio-demographic characteristics that demonstrated variable levels of significant were monthly income and occupation of caregivers, as well as the age and educational status of their partners (Table 5).

Table 5: Factors Associated with Knowledge, Attitude, and Practice towards Diarrhoea Prevention and Home-based Management; Le = Leones

Multivariate Analysis

In multivariate analysis, caregivers who resided in urban areas and had more than six years of education, were more likely to have good knowledge [(OR= 4.365, p = <0.001) and (OR = 2.133, p = 0.006) respectively], positive attitude [(OR= 2.735, p = 0.007) and (OR = 2.535, p = 0.013) respectively] and good practices [(OR= 2.383, p = 0.019) and (OR = 3.153, p = 0.002) respectively] about the prevention and home-based management of under-5 diarrheal diseases, as compared to those who resided among rural communities and had acquired six years of education or less.

Older caregiver were 3.0 times more likely to have positive attitude towards diarrhea prevention and home-based management, than younger caregivers were (OR = 3.092, p = 0.003).

Respondents who were employed and had older partners, [(OR= 2.070, p = 0.041) and (OR = 2.029, p = 0.045)] respectively, were more likely to have good practice towards diarrhoea prevention and home-based management, than caregivers who were unemployed or had younger partners (Table 6).

Table 6: Multivariate Analysis.

Discussion