Mothers’ knowledge, attitude and home management of diarrhoea among children under five years old in Lagos, Nigeria

Background Diarrhoea is a leading cause of death among children under five years old globally. It remains a major cause of morbidity and mortality among this age group in Nigeria. Using simple home management, mothers play important roles in the prevention and control of diarrhoea among these children. Aim This study aimed to assess mothers’ knowledge, attitude and practice in the prevention and home management of diarrhoeal diseases among children under five years old in Lagos, Nigeria. Setting This study was conducted within the communities of Kosofe local government area of Lagos State, Nigeria. Methods A descriptive cross-sectional study design was conducted using a multistage sampling technique. Data were collected using a structured interviewer-administered questionnaire and analysed using EPI info version 7.2.1. Chi-square statistic was used to test the association between variable at the level of significance of 5%. Results A total of 360 respondents participated in this study. The mean age of the respondents was 32.5 ± 5.5 years. About 59.2% of respondents had good knowledge, 59.2% of them had positive attitude, and 53.1% of them had good practice towards prevention and home management of diarrhoea. Age (p = 0.007), occupation (p = 0.008) and level of education (p = 0.001) were significantly associated with practice of home management of diarrhoea among children under five years old. Conclusion Educated, employed, and married mothers were more likely to have good prevention and home management practices towards diarrhoea in their children under five years old.


Introduction
living in impoverished and undeveloped areas also have higher fatality rates compared to children living in developed countries due to lack of access to quality healthcare, timely intervention, and effective treatment with oral rehydration solution (ORS) and zinc. 4 In Nigeria, the 2013 demographic health survey revealed that 10% of children under five years old had diarrhoea in the 2-week period prior the survey. 7 The 2018 Nigeria Demographic Health Survey (NDHS) also showed that the two weeks prevalence of diarrhoea preceding the survey among children under five years old was 13%. 8 This makes diarrhoea a very important public health issue in Nigeria.
Diarrhoea is one of the commonest illnesses that has the greatest negative impact on the growth and development of infants and young children. 5 Apart from diarrhoea being a major cause of morbidity and mortality, it also has a significant impact on growth due to reduction in appetite, altered feeding practices and decreased absorption of nutrients. 9 There is a marked negative relationship between diarrhoea and physical growth and development of a child. 10 Each day of illness due to diarrhoea produces a weight deficit of 20 g -40 g. Infants who spend more than 20% of their time with diarrhoea have a weight deficit of approximately 370 g at follow-up after one year of age. 11 Children with diarrhoea in the first 24 months of birth are 1.5 cm shorter than children who never had diarrhoea. 12 Home management of diarrhoea has been recognised and advocated for by WHO, United Nations Children's Fund (UNICEF) and Integrated Management of Childhood Illness to reduce the impact of diarrhoea, especially in children. 1,2,4,6 Diarrhoeal diseases among children under five years old can be prevented at both primary and secondary levels by improving sanitation, water quality, early recognition of dehydration and prompt oral rehydration therapy with the use of ORS or other  appropriate fluids that are available at home. 5 Good feeding practices and better hygiene practices of children under five years old could prevent incidences of and death from diarrhoea. Other factors that can aggravate the incidence of diarrhoea in children are inappropriate feeding practices of mothers, feeding with contaminated weaning food, lack of clean water, poor handwashing or hygiene, limited sanitary disposal of waste and poor housing conditions. 5 The aim of this study was to assess the knowledge, attitude, and practice of mothers towards prevention and home management of diarrhoea among children under five years old, in Kosofe local government area (LGA) of Lagos State, Nigeria. Specific objectives included the following: •

Study design
This was a descriptive cross-sectional study.

Setting
Kosofe LGA is an urban LGA located in the Northern part of Lagos State, Nigeria. It is bounded by three other LGAs namely, Ikeja, Ikorodu and Somolu LGAs. It also shares a boundary with Ogun State. 13 It has its headquarters located at Ogudu. It is a bustling commercial city, being the terminal for most food items and fruits brought into Lagos State, from different parts of Nigeria. It serves as a place of residence for those who come in from all over the country to trade in the various markets. Kosofe also houses civil servants and government officials.

Study population
The study population included mothers of children under five years old who are permanent residents of Kosofe LGA of Lagos State, Nigeria.

Inclusion Criteria
The study included all mothers who: • Have lived within Kosofe LGA for at least one year.
• Gave consent to participate.

Exclusion Criteria
The study excluded: • Mothers who were very ill or sick • Mothers whose children were very ill or sick

Sample size determination
The sample size for this study was calculated using the Cochran formula with a precision of 5% at 95% level of confidence interval. For this study, p (proportion of women with good knowledge of diarrhoeal disease) was assumed to be 62.5% based on a previous study. 5 A minimum sample size of 360 was calculated. In order to compensate for non-response and invalid data forms, a non-response rate of 10% would be estimated. Final sample size = 400

Sampling techniques
A multistage sampling technique was used to select respondents in the study. This was done in five different stages. Initially two wards were selected using simple random sampling from the 10 wards in Kosofe LGA. Secondly, 10 streets were selected using simple random sampling from each of the selected wards, from the list of streets obtained from the local government development authority. Thirdly, systematic sampling method was used to select 20 houses in each street after the appropriate sampling interval was calculated. Then fourthly in each house, a household was selected by simple random sampling, when more than one household met the selection criteria. However, when a selected household had no eligible respondent, another household was selected within the same house using simple random sampling. In cases where no household met the selection criteria in a house, the next house was then chosen. This continued until 20 households were selected per street. The fifth stage was the selection of respondents. Only one eligible respondent was interviewed from each household. If there were more than one eligible respondent in a household, a respondent was selected by simple random sampling. The sampling was done until the required 400 respondents were recruited to the study.

Data collection tool
The instrument for data collection was an intervieweradministered questionnaire, adapted and modified from previous literature. 16,17,18,19 The questionnaire contained four sections. Section A contained questions on sociodemographic status of the respondents, Section B contained questions which assessed knowledge, Section C contained questions which assessed attitude and finally Section D contained questions which assessed the practice of mothers regarding prevention and home management of diarrhoea among children under five years old.
The questionnaire was pre-tested to assess for reliability on 40 mothers of children under five years old using simple random sampling method in Surulere LGA. Surulere was chosen due to its similar demographic characteristics with the study area. The questionnaire was revised afterwards for completeness, clarity, consistency and uniformity. Content adjustments were made accordingly.

Data scoring and grading
There were 14 questions on knowledge; some of the questions had multiple answers; 28 was the highest possible score. Each correct answer was scored 1 mark while a wrong answer was scored zero. A total score > 14 was considered as good knowledge, while a total score of ≤ 14 was considered as poor knowledge.
Nine positive and negative statements on opinion and attitude of mothers towards diarrhoea were stated. The rating scale was measured as follows: positive statement with strongly agree, agree, indifferent, disagree, and strongly disagree was scored 5, 4, 3, 2, and 1, respectively, and vice versa for negative statements. The scores ranged from 23 to 41. Each score was summed up and means of each calculated. Overall mean score was found to be 31.9 ± 3.20 standard deviation (s.d.). This was classified into two namely, positive attitude ≥ mean (32-41), and negative attitude < mean (23-31).
Eighteen questions on practice were asked. Some of the questions had multiple answers; 26 was the highest possible score. Each correct answer was scored 1 mark while a wrong answer was scored zero. A total score > 13 was considered as good practice, while a total score of ≤ 13 was considered as poor practice.

Data analysis
Immediately after the data collection was completed, each questionnaire was thoroughly reviewed for completeness and consistency. The collected data were entered and analysed using EPI info computer software version 7.2.1 (CDC, Atlanta, GA, United States). Descriptive statistical analysis was used to compute frequency, percentages, and means of the study variables. Chi-square analysis was used to test for the association between categorical variables. The level of significance was set at 5%.

Ethical considerations
Ethical clearance number ADM/DCST/HREC/APP/3046 was granted and obtained from the Health Research Ethics and Committee of the College of Medicine, University of Lagos, Lagos Nigeria. Informed verbal consent was also obtained directly from the respondents before the interview. This was received after the purpose of study, the envisaged benefits and harm was explained to them. Privacy was ensured during interviews. Voluntary withdrawal was also allowed for participants.

Results
In the 20 houses surveyed, 408 mothers met all the inclusion criteria, five mothers were very ill, while 14 mothers had sick children. Twenty-nine questionnaires were incompletely filled and removed from analysis. Only 360 completely filled questionnaires were analysed.    (Table 3).

Overall attitude towards prevention and home management of diarrhoea
Overall, 201 (55.8%) had positive attitude, while 159 (44.2%) had negative attitude towards diarrhoea.

Home management practices for the diarrhoea
The health-seeking behaviour and feeding practices of respondents about their children, 198 (55.0%) sought help from the hospital, while 114 (31.7%), 84 (24.2%) and 39 (10.9%) sought help from the pharmacy, traditional medicine sellers and a family member, respectively (Table 5). Less than half 169 (46.9%) gave more breast milk than usual during diarrhoea, 142 (39.4%) gave the same amount of breast milk, while 35 (9.7%) gave less milk than usual. Almost half 176 (48.9%) gave more water than usual during diarrhoea, 111 (30.83%) gave same water as usual, while 60 (16.7%) gave less water than usual. Less than half 153 (42.5%) gave more food than usual during diarrhoea, while 123 (34.2%) gave less food than usual during diarrhoea episodes. Less than half 163 (45.3) had ever prepared salt and sugar solution before the study. More than half 248 (68.90%) had given ORS to their children; 142 (39.4%) also gave zinc; 159 (44.2%) also gave vitamin A; and 127 (35.3%) gave traditional or herbal medicine.

Overall practice towards prevention and home management of diarrhoea
Overall, 191 (53.1%) had good practice, while 169 (46.9%) had poor practice towards diarrhoea prevention and home management.

Factors Associated with Knowledge, Attitude, and Practice towards Diarrhoea Prevention and Home Management
There was statistically significant association between knowledge and all sociodemographic characteristics excluding marital status. There was a statistically significant association between attitude and level of education (χ 2 = 14.68, p = 0.002).

Multivariate analysis
Mothers who had more than six years of education, who were employed and those who were married (odds ratio [OR] = 4.52, p = 0.000), (OR= 2.52, p = 0.000), (OR = 2.12, p = 0.013), respectively, were more likely to have good knowledge about diarrhoea, than mothers who had six years of education or less, who were unemployed or unmarried.
Mothers who were married were 1.8 times more likely to have positive attitude towards diarrhoea, than mother who were unmarried (OR = 1.84, p = 0.034).
Respondents who had more than six years of education were 1.9 times more likely to have good practice towards diarrhoea than respondents who had less than six years of education.
Also, mothers who were married and those who were employed (OR = 2.03, p = 0.015), (OR = 1.80, p = 0.016), were more likely to have good practice towards diarrhoea prevention and home management than mothers who were unmarried or unemployed (Table 7).

Discussion
All respondents in this study fell within reproductive ages of 18 to 55 years. More married mothers than unmarried mothers took part in the study. This may be because married women are usually more willing to bear children than women who are not married. A higher proportion of participants were low-income earners with secondary and tertiary education. This is similar to the study done in Uyo. 19 Participants were mostly Christians and Yoruba by tribe. This is not surprising because this is the predominant ethnic group and religion in Lagos State.
Oral rehydration solution is one of the most important medical advances of the 20th century and the cornerstone of fluid replacement. 20 Oral rehydration solution reduces stool output and vomiting in children by 20% and 30%, respectively. 20 It can replace water and electrolytes (sodium, chloride, potassium and bicarbonate) that are lost via liquid stools, vomit, sweat, urine and breathing. 20 About 80% of respondents in this study knew that, ORS can be used for rehydration and treatment during diarrhoea episodes. This is less than a study conducted in Ibadan, where half of respondents rightly stated the use of ORS. 21 But it is similar to a study conducted in Ethiopia. 22 However, only 68% of respondents actually gave ORS to their children when they had diarrhoea. This might be due to the fact that respondents sought help in places other than hospitals, such as herbalists and family members. This is similar to a study conducted in kano where women were not using the correct method of treating diarrhoea at home by using ORS first and alone. They started off with ORS but continued to use other combination of antibiotics, and herbal medicines at various stages of the episode concomitantly with ORS. 23 Handwashing with soap can reduce the occurrence of diarrhoeal disease, especially when carried out at critical moments, such as after using the toilet, after cleaning a child's bottom and before handling food. 21 Studies have revealed that handwashing with water alone is much less effective in preventing diarrhoeal disease than using soap. 24,25,26,27 Soap is effective in breaking down grease and dirt that carry germs and disease-causing pathogens. Using soap also lengthens the amount of time spent washing hands, compared to using water alone. 24,25 Seventy percent of the respondents knew that handwashing without soap before preparing meals for a child can cause diarrhoea. Attitude wise 46% of respondents agreed that it is important to wash hands with water and soap before meals. And as regards practice, 51% had a special place for handwashing in their houses, 76% washed their hands before food preparation, and more than 86% washed their hands with soap and water. This result is similar to a study conducted in Sudan 28 where about 80% washed their hands before food preparation, out of whom 50% washed their hands with soap and water. But this was contrary to a study carried out in Ethiopia where only 50% of respondents washed their hands before food preparation. 29 These discrepancies may be due to the differences in sociodemographic characteristics of participants in the different studies.
Exclusive breastfeeding is defined as no other food or drink, not even water, except breast milk (including milk from a milk bank or wet nurse) for the first six months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines). 20 UNICEF and WHO recommends the exclusive breastfeeding of children, because breast milk contains all the nutrients needed. Breast milk substitutes such as formula and other kinds of milk, or porridge are nutritionally inadequate and can be contaminated, thereby exposing infants to the risk of illness and mortality. Seventytwo percent of the respondents in this study breastfed exclusively, out of which only 28% did that for at least six months. This is less than a study conducted in India where of all children less than six months 56% were exclusively breastfed. 29 It is however more than a study conducted in Benue state where the practice of exclusive breastfeeding was as low as 2%. 30 In this study, 24% sought help from traditional healers while 55% sought help from the hospital during diarrhoea episodes. Some sought help from both hospitals and herbalists. This is more than a study carried out in Ibadan 21 where only 4% gave native medicine. The use of traditional or herbal medicine during diarrhoea should be discouraged regardless of their availability and accessibility, because of vague dosages, and preparation of medicines under unhygienic conditions, and as evidenced by microbial contamination of many herbal preparations sold in the markets. 31 Good feeding practices with appropriate fluids such as salt and sugar solutions, soups and weaning foods that are readily available at home can prevent dehydration and replace electrolytes that are lost during diarrhoea episodes. 5 In this study only 42% gave more food than usual during diarrhoea episodes. Giving the same amount of foods or less during episodes may be out of ignorance and cultural beliefs in a bid to prevent more vomiting and stooling. This is similar to a study conducted in Oyo, where mothers advocated withholding food from children who had diarrhoea. 32 Similarly, only 48% of respondents in this study gave more water than usual during diarrhoea episodes. This is not a good percentage because water makes up the greater percentage of children's body weight. Also, children utilise more quantity of water over the course of a day, than adults as a result of their high metabolic rates. Moreover, the kidney in younger children conserve less amounts of water. 33 This poor practice may be because only 8% of respondents knew that marked thirst for water is one of the danger signs of diarrhoea.
In this study there was statistically significant association between practice and age, occupation, income, level of education, and ethnicity. Further analysis revealed that respondents who had more than six years of education were 1.9 times more likely to have good practice towards diarrhoea than respondents who had less than six years of education. Also, mothers who were married and those who were employed were more likely to have good practice towards diarrhoea prevention and home management than mothers who were unmarried or unemployed. This is similar to a study conducted in Ethiopia 18 where mother's marital status and educational status were significantly associated with caregivers' practice.
The study can be used as a baseline for other studies. There are few studies on home management of diarrhoea from the same study in the study area. Firstly, it can also be a blueprint to conduct an interventional study in the particular area. Secondly, the design was community-based descriptive crosssectional study where probability sampling was used. One of the limitations of this study design is that the establishment of a temporal relationship between the exposure and outcome variables are impossible. Thirdly, the study area was chosen through convenience sampling as a result of time constraint.
Female education should be encouraged, because it can improve the understanding of mothers, on how to prevent and manage diarrhoea, thereby reducing the fatality of diarrhoea in children. Secondly, female empowerment should be prioritised because they are the primary care givers in a family. Women should be encouraged to get jobs and earn an income. Women who are empowered are better placed to make decisions that lead to better outcomes for their children. Finally, male involvement and support should be encouraged. Men who are involved and supportive of their wives are more likely to take better care of their children during diarrhoea episodes.