ISRA MEDICAL JOURNAL

Volume 4 Issue 3 Sep 2012

ORIGINAL ARTICLE

KNOWLEDGE, ATTITUDE AND PRACTICE OF MOTHERS

TOWARDS ORAL REHYDRATION THERAPY IN DUHOK
Akrem Mohammad Al-Atrushi 1, Saad Younis Saeed 2, Shireen Muhsin Yahya3
ABSTRACT
OBJECTIVES: The main objective is to assess the knowledge, attitude and practice of mothers towards the
use of oral rehydration solution in the treatment of acute diarrhea in children less than five years old and to
assess the compliance of mothers and the outcome of this treatment.
STUDY DESIGN: a cross sectional survey with prospective follow up.
PLACE AND DURATION OF THE STUDY: The study was done in Duhok-Kurdistan region, North of Iraq.
st
st
The study took four months from 1 of April to 31 of July 2011.
SUBJECTS AND METHODS: Data for the study were collected from three primary health care centers in
Duhok, north of Iraq in the period between 1st of April and 31st of July 2011. The study included the mothers of
300 children who had diarrhea and were treated by oral rehydration solution. Specific questions were
directed to the mothers to assess their knowledge, attitude and practice towards oral rehydration therapy and
five days after starting treatment, mothers were asked by phone about their compliance and the outcome of
their children. Results were statistically analyzed by Chi square using P value.
RESULTS: In 54% of cases , mothers had low level of education most of whom were housewives and 64% of
the children involved were<2 years old, 59% of them were males. In201cases (67%) mothers did not know
exactly what oral rehydration solution is used for in cases of diarrhea and 77% didn't believe it is enough as a
treatment. The proper way for preparation of oral rehydration solution was unknown to48% of mothers and
35.7% did not know the proper way for the administration of oral rehydration solution while 59% of them didn't
know that it should be discarded after 24 hours. One hundred and two mothers (34%) didn't comply with its
use and stopped it while 129 mothers (43%) didn't know how to behave if the child develops vomiting.
Compliance of the mothers was better among mothers whose children were three years or more of age,
mothers with good knowledge and positive attitude towards the use of oral rehydration solution and those
with moderate to good practice with the use of oral rehydration solution.
CONCLUSIONS: The mothers have poor KAP towards the use of ORS and this is comparable with results of
other studies done in different parts of the world. Better maternal knowledge, attitude and practice towards
the use of oral rehydration solution are associated with more compliance to its use. Further studies are
recommended to assess the causes of non-compliance and to improve knowledge, attitude and practice of
the mothers towards the use of oral rehydration solution.
KEY WORDS: Oral rehydration therapy, gastroenteritis, knowledge.
INTRODUCTION
Diarrheal disease is one the leading causes of
worldwide childhood morbidity and mortality resulting
in 1.4 to 2.5 million deaths annually. Loss of intestinal
fluid caused by gastroenteritis may lead to severe
hypovolemia, shock and death particularly in children
1. Assistant Professor of Pediatrics
2. Assistant Professor of Community Medicine
3. Department of Family and Community Medicine
College of Medicine, University of Duhok, Iraq

Correspondence to:

Dr. Akrem Mohammad Al-Atrushi

Assistant Professor of Pediatrics

College of Medicine, University of Duhok, Iraq
E-mail: akramatrushi_duhok@yahoo.com

younger than five years of age [1].

Although the total number of deaths globally from
diarrheal diseases remains high, the overall mortality
rate has steadily declined over the last few decades
[2]
. This decline especially in developing countries is
largely due to the use of early and appropriate oral
rehydration therapy (ORT) with oral rehydration
solution (ORS) being its main component as well as
improved nutrition and water sanitation measures [3].
The early use of ORT at home in children with
diarrhea decreases the number of outpatient visits
and hospitalizations and overall medical costs.
Despite the success of ORT in developing countries
and established guidelines supporting its use in
children with gastroenteritis by the American
academy of Pediatrics and the Center for the Disease
Control, the full benefit of ORT in USA and other
developed countries has not been realized on
132

account of underutilization [4].

The use of ORS largely depends on the level of
knowledge and attitude of mothers. Misconceptions
are prevalent that prevent the use of ORS during
diarrhea. Many mothers believed that one needs a
prescription from a doctor in order to buy ORS or
ORS has a bad taste or no fluids to be given during
[5]
diarrhea .
ORS consists of a solution of salts and sugars which
is taken by mouth. It is taken around the world but is
most important in the developing world where it saves
millions of children a year from death due to
[6]
diarrhea .
In developing countries, only 39% of children under
five with diarrhea receive the recommended
treatment (ORT with continued feeding) to prevent
dehydration and worsening nutritional status. Africa
has the lowest levels of treatment coverage (35%)
followed by South Asia (37%) and the Middle East
and North Africa (39%), East Asia and Pacific
(excluding China) have the highest treatment
coverage level at 55% [7].
Boys and girls receive appropriate care at similar
rates. Children in urban areas (42%) are more likely
to receive the recommended treatment than those
living in rural areas (38%). Similarly, children from the
healthiest households (40%) are more likely to
receive the recommended treatment than those from
[8]
the poorest households (34%) .
Among patients, barriers to using ORS and continued
nutrition during diarrheal disease include cultural
practices [9], lack of parental knowledge [10], lack of
training medical professionals and cost of
[11]
commercially available ORS .
Diarrhea control program needs to be reinforced to
improve existing practices regarding management of
acute diarrhea in children under -five years of age [12].
This study aims to assess the knowledge, attitude
and practice (KAP) of mothers towards the use of oral
rehydration solution in the treatment of
acute
diarrhea in children and to assess the compliance of
these mothers to its use and the relation of such a
compliance to the socio-demographic characteristics
of mothers and their children and the outcome of this
treatment.
PATIENTS AND METHODS
This is a cross sectional survey with prospective

133

follow up done in the city of Duhok, north of Iraq in the

st
st
period from 1 of April to 31 of July 2011. The sample
was taken from three primary health care centers out
of 14 centers in the city. These were Yazdey Adare,
Qazi Mohammad and Shindokha. The sample taken
included 300 mothers of children who were under five
years of age, had acute diarrhea, with mild to
moderate dehydration and treated by oral
rehydration solution.
Specific questions were directed to the mothers of
those children to assess their socio-demographic
characteristics including the age of the mother,
degree of her education, her occupation and also the
age and sex of the child. Knowledge of the mother
about ORS was assessed by asking her about its
composition and benefit. Attitude of the mother was
assessed by asking her whether she thinks it is
enough as a treatment and if there are any side
effects behind its use. Practice of the mother towards
oral rehydration solution was assessed by asking her
about its preparation, administration, storage, when
to discard it and how to behave if the child develops
vomiting. After five days, the mothers were asked by
phone about their compliance to the use of ORS and
the causes of non-compliance and the outcome of
their children.
The socio-demographic and KAP variables were
described by their frequencies and percentages. The
relationship between the socio-demographic
variables of mothers and their children and
compliance to the use of ORS was tested by Chi
square test using P value less than 0.05 to define
statistical difference.
RESULTS
The study sample included 300 mothers and their
children. The sample distribution according to
primary health care centers as follows: A large
percentage of the sample was taken from Qazi
Mohammad primary health care center (178, 59.3%);
the remaining was from Yazdey Adare health care
center (62, 20.7%) and Shindokha health care center
(60, 20%).
Mothers' age ranged from 16 years to 45 years with a
mean of 28.9 and SD of 5.4 years. Children's age
ranged from 2 months to 53 moths with a mean of
19.6 and SD of 12.3 months.

ISRA MEDICAL JOURNAL

Volume 4 Issue 3 Sep 2012

Table-1- Sample distribution by the socio- demographic characteristics of mothers and their children
CHARACTERISTICS
Mothers' Age:
15-24 years
25-34 years
35-45 years
Education of the mothers:
Illiterate
Can read and write
Primary school
Secondary school
Higher education
Occupation of the mothers:
Housewife
Employed outside
Children's Age:
<12 months
12-23 months
24-35 months
36-47 months
48-60 months
Sex of the child:
Female
Male
Total

NUMBER

PERCENT

55
192
53

18.3
64
17.7

108
41
87
34
30

36
13.7
29
11.3
10

259
41

86.3
13.7

91
102
53
33
21

30
34
17.7
11
7

123
177
300

41
59
100

NUMBER

PERCENT

267
32
1

89
10.7
0.3

101
99
100

33.7
33
33.3

4
47
249
300

1.3
15.7
83
100

Table-2- Level of knowledge of mothers about ORS

KNOWLEDGE OF MOTHERS
Knowledge of the composition of ORS
Low
Moderate
Good
What is it used for?
Stopping diarrhea
Treating dehydration
Do not know
Do you think it is beneficial?
No
Somewhat
Yes
Total

Low knowledge means that the mother simply knows

it is a solution and doesn't know of what it is
composed. Moderate knowledge means that she
knows it is a solution of sugar and salt. Good
knowledge means she knows that it contains sugar
and the electrolytes that are lost in diarrhea.

Considering attitude of mothers towards ORT, this

study shows that 231 mothers (77%) believe it is not
enough as a treatment and 69 (23%) mothers agreed
using it alone without antibiotics while 297 mothers
(99%) agree there are no side effects behind its use.

134

Table-3- The practice of mothers towards ORS

PRACTICE OF MOTHERS

NUMBER

PERCENT

144
148
8

48
49.3
2.7

168
9
123

56
3
41

107
142
51

35.7
47.3
17

58
183
59

19.3
61
19.7

78
93
129
300

26
31
43
100

Preparation of ORS:
Low
Moderate
Good
Duration allowed for use of ORS after preparation:
Low
Moderate
Good
The way of ORS administration:
Low
Moderate
Good
How to store ORS:
Low
Moderate
Good
How to behave if vomiting develops:
Stop ORS
Give it slowly
Do not know
Total
The compliance of the mothers that was tested by
asking the mother by phone shows that 189 mothers
(66%) gave ORS all over the recommended duration
while 102 mothers (34%) did not. Two hundred and
one mothers (67%) had the patience to give slowly
while 99 mothers (33%) did not. Among the 102 noncompliant mothers, in 73(24.3%) of cases the child

refused to take it and in 19cases (6.3%) the cause

was vomiting while in 10 cases (3.3%) the child's
condition deteriorated
The outcome of children after five days was as
follows: 168(56%) of the children improved, 69 (23%)
patients remained the same, 38 (12.7%) needed
intravenous fluid and 25 (8.3%) were worse.

Table-4- Relationship between compliance of mothers and socio-demographic characteristics

CHARACTERISTICS
Mothers' age:
15-24 years
25-34 years
35-45 years
Education of the mothers:
Illiterate
Can read and write
Primary school
Secondary school
Higher education

135

COMPLIANT
NO. (%)

NONCOMPLIANT
NO. (%)

TOTAL
NO. (%)

32 (16.2)
125 (63.1)
41 (20.7)

23 (22.5)
67 (65.7)
12 (11.8)

55 (18.3)
192 (64)
53 (17.7)

67 (33.8)
31 (15.7)
54 (27.3)
22 (11.1)
24 (12.1)

41 (40.2)
10 (9.8)
33 (32.4)
12 (11.8)
6 (5.9)

108 (36)
41 (13.7)
87 (29)
34 (11.3)
30 (10)

ISRA MEDICAL JOURNAL

Occupation of mothers:
Housewife
Employed outside
Children's age:
<12 months
12-23 moths
24-35 months
36-47 months
48-59 months
Sex of the child:
Female
Male
Total

P value for the mothers' age was 0.1, for the

education of mothers was 0.22, for occupation of the
mother was 0.162 and for the children's age was

Volume 4 Issue 3 Sep 2012

167 (84.3)
31 (15.7)

92 (90.2)
10 (9.8)

259 (86.3)
41 (13.7)

61 (30.8)
65 (32.8)
23 (11.6)
29 (14.6)
20 (10.1)

30 (29.4)
37 (36.3)
30 (29.4)
4 (3.9)
1 (1)

91 (30.3)
102 (34)
53 (17.7)
33 (11)
21 (7)

78 (39.4)
120 (60.6)
198 (100)

45 (44.1)
57 (55.9)
102 (100)

123 (41)
177 (59)
300 (100)

0.431 all are not significant while for the children's

age, P value was <0.001 which is statistically
significant.

Table-5- The relationship between KAP and compliance of mothers towards ORT
KAP
Knowledge:
*Didn't know or said it stops diarrhea
*Treats dehydration
Attitude (Is it enough as treatment);
*No
*Yes
Level of practice:
*Low
*Moderate-good
Total

COMPLIANT NONCOMPLIANT
NO. (%)
NO. (%)

TOTAL
NO. (%)

P Value

113 (57.1)
85 (42.90

88 (86.3)
14 (13.7)

201 (67)
99 (33)

<0.001

143 (72.2)
55 (27.8)

88 (86.3)
14 (13.7)

231 (77)
69 (23)

0.006

77 (38.9)
121 (61.1)
198 (100)

67 (65.7)
35 (34.3)
102 (100)

144 (48)
156 (52)
300 (100)

<0.001

Table-6- Relationship between compliance of mothers and outcome of children

COMPLIANT
NO. (%)

NONCOMPLIANT
NO. (%)

TOTAL
NO. (%)

8 (4)

55 (53.9)

63 (21)

The same

24 (12.1)

45 (44.1)

69 (23)

Improved

166 (83.8)

2 (2)

168 (56)

Total

198 (100)

102 (100)

300 (100)

OUTCOME
Worse or needed intravenous fluid

P value for this table is <0.001 which is a significant relationship

136

DISCUSSION
Despite the fact that availability of ORS can
substantially reduce the mortality and morbidity
resulting from diarrhea, poor knowledge pertaining to
diarrhea and its management has posed the third
world countries with diarrhea associated deaths and
[13]
ill health among children .
The age of all mothers involved in this study ranged
from 16 to 45 years with a mean of 28.9 which is lower
than in a study done in Thailand where the average
[14]
age was 40 years but near the average age in an
Iranian study where it was 28.5 [15].
About half of the mothers in our study had low level of
education and 86.3% of them were housewives
which is almost comparable to the findings of another
study where 52% of mothers had elementary school
or lower and 62% were housewives [14].
The socio-demographic profile of the current study
also showed that 64% of the included diarrhea cases
were children under two years of age and males
represented 59% and these results are comparable
to the results of a Pakistani study where 68% of the
affected children were under two years of age and
males represented 62% [12].
Regarding the knowledge of mothers about ORS,
89% of mothers had no information about the
composition of ORS; the explanation is that this is a
medically related topic and those mothers thought it
is a medication prescribed by doctors while 10.7% of
mothers knew that it is composed of salts and sugars
and just one mother who was a nurse knew the exact
composition of ORS.
Considering attitude of
mothers towards its use, one third of mothers thought
that it stops diarrhea, another third thought it treats
dehydration and 83% of them believed in its benefit in
treating dehydration .This result is better than others
studies in other parts of the world where 61% of
mothers believed in its usefulness and 23% thought it
stops diarrhea [14]. Seventy seven percent of mothers
didn't agree to use alone without antibiotics. This may
be attributed to local doctor's practice in the use of
antibiotics, anti-amebic and anti-emetic medications
in the treatment of acute diarrhea and not explaining
to the mothers that ORT and continued feeding are
treatment of choice. Use of antibiotics in treatment of
acute diarrhea has been reported in 42.8% in one
study [12] and 55.9% in another [16]. In our study, 99% of
mothers believe there are no side effects behind the
use of ORS and this result is higher than the results of
another study where 73% believed there are no side
effects behind its use [14].
The practice of mothers towards use of ORS is poor
so that half of the mothers in this study did not know
the proper way of its preparation and one third didn't
137

know how to administer it and almost two thirds didn't

know how to behave or even stopped it if the child
developed vomiting. Such a low level of practice
towards ORS can be found in many developing
countries; in an Indian study, just 11% of mothers
knew how to prepare it and 22% of mothers knew how
to administer it [17] and in another study in the same
country, 38.7% of mothers knew how to prepare it and
[5]
41.6% knew how to administer it .
In this study, two thirds of mothers complied with the
use of ORS. The most common reason for noncompliance was the child's refusal to take it because
of the bad taste, vomiting and then deterioration of
the patient's condition. In a study in Nigeria, 45% of
mothers did not comply with its use mainly because of
vomiting and refusal of the child to drink it [18].
The outcome of children after five days in our study is
improvement in more than half of patients and there
was a significant correlation of this improvement with
the compliance of their mothers to ORS use and this
result is even better than the outcome in the Nigerian
study where improvement was in 44% of cases [18].
The association between socio-demographic
characteristics and compliance of the mothers shows
increased compliance with age of the child and the
level of education of the mothers probably because of
more use of ORS in this age group. This result is
comparable to the results of an Indian study where
69.8% of compliant mothers were literate and
[5]
realized the role of ORS .
Regarding age of children, compliance increased
after the age of 35 months because children of such
an age tolerate ORS better than the younger. Sex of
the child had no significant relation with compliance
of the mothers while a study in Thailand showed no
relation of the compliance of mothers with neither age
[14]
nor sex of children .
In this study, the compliance of mothers with the use
of ORS was better in mothers with good knowledge,
positive attitude and moderate to good practice with
use of ORS and this result is comparable to a study
[14]
done in Thailand .
CONCLUSIONS
From this study we concluded that;
1. Most mothers do not know the role of ORS in
diarrheal diseases and do not believe in using it
alone.
2. Practice of the mothers considering the use of
ORS was generally poor.
3. The KAP of the mothers relates positively with
their compliance to the use of ORS.
4. The outcome of children with diarrhea relates
positively with the compliance of mothers to the

ISRA MEDICAL JOURNAL

5.

6.

use of ORS.
The socio-demographic factors of mothers had
no significant association with their compliance
except for an increased compliance with
increased child's age.
Further studies are recommended to assess the
reasons for poor KAP of mothers and how to
improve that.
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