Cite this article as Lwin KZ, Putra IGNE. Mothers' knowledge of the causes and prevention associated with diarrhea among under-five children in Hlaing Thar Yar Township, Yangon, Myanmar. Global Health Management Journal. 2018; 2(3): 76-83. Global Health Management Journal www.publications.inschool.id PUBLISHED BY Original Research Article ISSN 2580-9296 (ONLINE) Mothers' knowledge of the causes and prevention associated with diarrhea among under-five children in Hlaing Thar Yar Township, Yangon, Myanmar Khaing Zar Lwin 1,2,*, I Gusti Ngurah Edi Putra 1,3 1 Institute for Population and Social Research, Mahidol University, Thailand. 2 Karuna Mission Social Solidarity (KMSS), Yangon, Myanmar. 3 Center for Public Health Innovation (CPHI), Faculty of Medicine, Udayana University, Indonesia *Corresponding author. Email: lwin.khinezar11@gmail.com ARTICLE INFO ABSTRACT Article history: Received 29 August 2018 Reviewed 31 August 2018 Received in revised form 08 September 2018 Accepted 21 October 2018 Background: Diarrhea among under-five children remains a major public health problem in developing countries, such as Myanmar. Its complications contribute to the worse health outcomes as well as increase the child mortality in Myanmar. Hlaing Thar Yar was recognized as a township with the highest incidence of diarrhea in Yangon region. Aims: This study aimed to identify the association of mother’s knowledge on diarrhea with the diarrheal disease among under-five children in Hlaing Thar Yar Township, Yangon, Myanmar. Methods: This was a cross-sectional study by collecting primary data in the Hlaing Thar Yar Township of Yangon, Myanmar from November to December 2016. About 277 records of mothers and their under-five children have been collected through multistage random sampling. A dependent variable in this study was the occurrence of diarrhea among under-five children whilst independent variables consisted of socio-demographic characteristics of parents and five domains of mother’s knowledge on diarrhea. Data were analyzed by using univariate, bivariate and multivariate analysis. Results: This study found that a half (53.43%) of under-five children suffered diarrhea within two weeks prior to the survey. Based on multivariate analysis by controlling all socio-demographic factors, two out of five domains of mother’s knowledge showed significant association. An increased one score of mother’s knowledge on causes and prevention of diarrhea contributed to decrease the likelihood of diarrheal disease by 37% (OR=0.63; 95%CI=0.44-0.90) and 27% (OR=0.73; 95%CI=0.54-0.99), respectively. Conclusions: This study confirmed that the knowledge of mothers on causes and prevention of diarrhea appears to have important effects on the occurrence of diarrhea among the under-five children. Therefore, health promotion program with an emphasis on providing information related to diarrhea causes and prevention is worth to enhance mother’s knowledge and their ability to prevent diarrhea among under-five children in Hlaing Thar Yar Township, Yangon. Keywords: Diarrhea Under-five children Mothers’ knowledge Causes and prevention Myanmar © 2018 Publications of Yayasan Aliansi Cendekiawan Indonesia Thailand This is an open-access following Creative Commons License Deed – Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) INTRODUCTION Diarrhea is the second leading cause of death among under-five children. It is estimated that 525,000 under-five children die because of diarrhea every year [1]. Not surprisingly then, the incidence of diarrhea among under-five children remains a major public health issue in low- and middle- income countries which plays important role as a key driver to child mortality [2]. In developing countries, nearly http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://publications.inschool.id/index.php/ghmj/index http://inschool.id/ mailto:lwin.khinezar11@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 77 Global Health Management Journal, 2018, Vol. 2, No. 3 half of the babies delivered within a year, they did not pass their first birthday mainly due to pneumonia, diarrhea and malnourishments [3]. Similar to the situation in Myanmar as developing country, the main direct causes of death among under-five children continue to be diarrhea, acute respiratory infection, and malaria, exacerbated by underlying malnutrition contributing to 50% of total deaths [4]. Ministry of Health reported that 7.7 % of the total deaths among under-five children in Myanmar were caused by diarrhea [5]. According to the report from Multiple Indicator Cluster Survey in Myanmar, the prevalence of diarrhea in last two weeks accounted for 6.7% among children under five years old in 2010 [6]. Diarrhea is one of the seasonal diseases in Myanmar which commonly occurs in rainy and summer seasons. The reported number of diarrhea cases in Yangon as the populous region in Myanmar increased from 11,016 in 2011 to 13,919 in 2013 [7]. Hlaing Thar Yar is one of the townships in Yangon, Myanmar which comprises 20 wards, 18 villages under 9 village tracts [8]. The total population of Hlaing Thar Yar was 687,867, consisting of 322,862 males and 365,005 females and 70.1% of population settled in urban area [9]. Concerning the housing condition, 68% of the total houses in Hlaing Thar Yar Township were made from bamboo, 12% were timber house, 6% were with brick foundation, and the remaining were bungalow [9]. Under-five mortality rate in Hlaing Thar Yar Township was quite high compared to other townships in Yangon. A study conducted by United Nations Human Settlements Programme (UN-Habitat) in 2013, found that Hlaing Thar Yar Township was the highest incidence in Yangon for the diseases related to poor environmental conditions and lack of water and sanitation facilities (diarrhea, dysentery, malaria, and tuberculosis). This township was also designated as the highest prevalence of diarrhea of among all townships in Yangon [10]. With several complications of diarrhea among under- five children, it obviously impacts to their physical development. Moreover, dehydration caused by severe diarrhea is one of the major causes of child mortality in Myanmar [11]. A study in Pakistan found that children who suffered diarrhea during the last one year were more likely to become malnutrition than children who did not suffer diarrhea [12]. Indeed, diarrhea is a preventable disease, but the inadequate knowledge of mother as the one who mainly takes care children and their improper approach towards the prevention, care, and management of diarrhea lead to the high likelihood of diarrhea among children as well as its mismanagement [13]. A previous literature from India showed that only 44% of mothers knew that the diarrhea can be prevented [14]. Given to those issues, it is necessary for mothers to have relevant information on diarrhea in order to prevent diarrhea as well as have adequate management for children with diarrhea. The prevalence of diarrhea in Hlaing Thar Yar Township is the highest one compared to other townships in Yangon. To our knowledge, no study has been conducted to reveal factors associated with the occurrence of diarrhea among under-five children in Hlaing Thar Yar Township. In the context of Myanmar, mothers play a major role in taking care children which implies that their knowledge on diarrhea might contribute to the occurrence of diarrhea among under-five children and hence, it needs to be assessed. Mothers' knowledge is one of the possible predictors of diarrheal disease among under-five children. The comprehensive knowledge on diarrhea might play an important role in the decision-making and action among mothers related to diarrhea prevention for their children. Therefore, this study was intended to examine the association between mothers’ knowledge on diarrhea with diarrheal disease among under-five children in Hlaing Thar Yar Township, Yangon, Myanmar. METHODS Population and samples This was a cross-sectional study by collecting primary data in Hlaing Thar Yar Township, Yangon, Myanmar from November to December 2016. The population of this study was children aged under-five years old with an inclusion criterion that mother can be interviewed at the time of survey. Sample for this study was calculated based on the formula for two population proportions with an assumption 95% confidence interval (CI), 80% power, 45% as the proportion of diarrhea among under-five children from previous study (p2) [3], and 30% (15% lower than p2) as the estimation of diarrhea among under five children where their mothers have good knowledge on diarrhea (p1), resulting in a minimum samples of 256 married women with under-five children. This study successfully collected 277 samples through multistage random sampling procedure, consisting of 1) selecting four wards and three villages from the 20 wards and 18 villages in Hlaing Thar Yar Township by cluster Global Health Management Journal, 2018, Vol. 2, No. 3 78 random technique and 2) selecting a number of households from selected wards and villages through simple random sampling by using a sampling frame of household data from Township Administrative Department. Mothers who had under-five children were interviewed to document their socio- demographic characteristics, knowledge on diarrhea, and the diarrhea occurrence of their last under-five child. A self-designed and pretested structured questionnaire was employed. In addition, written informed consent was obtained before face-to-face interview. The variables For this study, diarrhea was defined as one of the followings: passage of three or more loose watery motion, more than usual loose watery motion, a single large watery motion in a day, or mother’s assessment that her child passed more frequent liquid stools. The dependent variable in this study was the occurrence of diarrhea in two weeks prior to the survey in order to minimize recall bias and that recall period has been used in several surveys [6, 11]. Independent variables consisted of socio-demographic characteristics of parents and five domains of mother’s knowledge on diarrhea as presented by following conceptual framework (Figure 1). Those indicators of knowledge developed in this study followed the indicators presented in WHO report [1, 15]. There are five domains of knowledge, consisting of knowledge on causes, symptoms, complications, management, and prevention of diarrhea. The number of questions used to measure knowledge varied by domain, such as 3 items for a domain on causes, 5 items for symptoms, and 4 items for each domain on complications, management, and prevention. Each item was scored one for a given correct answer. Furthermore, the score of each domain was summed up with the maximum score is equal to the total number of questions. A high score of a particular domain approaching the maximum value reflects high level of knowledge on that domain. Statistical analysis Data were analysed descriptively to present data distribution of variables. Moreover, Chi-square test and Independent sample t-test were used for bivariate analysis purpose. Meanwhile, binary logistic regression analysis was performed for multivariate analysis in order to examine the effects of socio- demographic characteristics and knowledge of mother toward the occurrence of diarrhea among under-five children. Odds ratio (OR), 95% confidence interval (CI) OR and p-value were reported in this study. Figure 1. Conceptual framework showing association between independent variables and the occurance of diarrhea RESULTS Table 1 shows the percentage distribution of socio- demographic characteristics of respondents. Nearly 80% of the mothers completed secondary and higher education and 42.96% of them reported as full-time housewife at the time of survey. Regarding husband’s characteristics, 78.70% completed secondary and higher education and they worked in odd job (37.55%), company (35.74%), and run small owned business (26.71%). More than half of couples lived in the house with brick foundation (58.12%) and did not own the house (59.21%). Regarding the monthly income, about a half of the couples had income more than 150,000 kyats (51.62%). Importantly, this study found that more than a half (53.43%) of under-five children experienced diarrhea in past two weeks. In d e p e n d e n t V a ri a b le s Socio-demographic Characteristics - Education level of mother - Occupational status of mother - Education level of father - Occupational status of father - Home condition - Home ownership - Monthly income Dependent Variable Occurrence of diarrhea Knowledge on Diarrhea - Knowledge on causes of diarrhea - Knowledge on symptoms of diarrhea - Knowledge on complications of diarrhea - Knowledge on management of diarrhea - Knowledge on prevention of diarrhea 79 Global Health Management Journal, 2018, Vol. 2, No. 3 Table 1. Respondents’ distribution (N=277) Variables N % Education level of mother No education and primary 56 20.22 Secondary and higher 221 79.78 Occupational status of mother Employed 158 57.04 Unemployed 119 42.96 Education level of father No education and primary 59 21.30 Secondary and higher 218 78.70 Occupational status of father Odd job 109 39.35 Small owned business 70 25.27 Staff at private company 98 35.74 House condition Condo/bungalow 62 22.38 Brick foundation 161 58.12 Timber house 54 19.49 House ownership Yes 113 40.79 No 164 59.21 Monthly income ≤ 150,000 kyats 134 48.38 > 150,000 kyats 143 51.62 Occurrence of diarrhea No 129 46.57 Yes 148 53.43 Table 2 exhibits the mothers’ knowledge on causes of diarrhea. There were three main causes of diarrhea used in this study which included eating unclean food, eating food with fly infestation, and drinking unclean water. About 91.34% of the mothers were aware that unclean food can cause diarrhea and 67.51% knew the diarrhea can be caused by taking fly infested food, and less than a half (45.85%) of them were aware on drinking unclean water can cause diarrhea. Results present the mother’s knowledge on symptoms of diarrhea. The symptoms during suffering diarrhea consisted of child drinks liquid eagerly, dry tear when child is crying, child’s skin becomes normal slowly when punching the skin of forehead and abdomen and child shows sunken eye. Among these symptoms, 94.58% of the mothers knew the symptom of dry tear when baby is crying and 77.62 % were aware on the sunken eye during when child is suffering diarrhea. If related to mother’s knowledge on complications of diarrhea, most of the mothers understood that malnutrition and dehydration are the complications of diarrhea, accounting for 83.39% and 76.53%, respectively. Unfortunately, the majority did not know that shock and convulsion are also the severe complications of diarrhea. Table 2. Mothers’ knowledge on diarrhea (N=277) Mothers’ knowledge to % Causes of diarrhea Unclean water 45.85 Fly infestation to food 67.51 Unclean food 91.34 Total Score (Mean ± SD) 2.05 ± 0.87 Symptoms of diarrhea Drinking liquid eagerly 52.35 Sunken eye 77.62 When pinching abdominal skin, it reaches normal slowly 31.77 When pinching forehead skin, it reaches normal slowly 3.61 Dry tear when baby is crying 94.58 Total Score (Mean ± SD) 2.60 ± 0.80 Complications of diarrhea Malnutrition 83.39 Dehydration and loss of mineral salt 76.53 Shock 5.05 Convulsion 5.42 Total Score (Mean ± SD) 1.71 ± 0.77 Managements of diarrhea Drinking ORS 97.83 Drinking Coconut 13 Drinking gruel 27.44 Taking fresh food 23.83 Total Score (Mean ± SD) 1.62 ± 0.78 Prevention of diarrhea Washing hand before handle of food 91.34 Covering food to prevent flies blown 78.34 drinking water sterilized by boiling 61.01 Washing hand after going toilet 70.40 Total Score (Mean ± SD) 2.60 ± 1.07 Regarding the first management of diarrhea at home prior to hospital visit as presented by Table 2, about 97.83 % of the mothers were aware that their child needs to drink oral rehydration solutions (ORS) as an important treatment of diarrhea. Meanwhile, less than a half of them knew that taking fresh food, drinking gruel, and coconut water are also the treatment of diarrhea at home. Considering to the mothers’ knowledge in preventing the diarrhea, the majority of the mothers believed that the occurrence of diarrhea can be prevented through some approaches such as Global Health Management Journal, 2018, Vol. 2, No. 3 80 washing hand before handling food (91.34%), covering food to prevent flies blown (78.34%), and drinking sterilized boiling water (61.01%), whereas only 29.60% of mothers knew that washing hand after using toilet can prevent diarrhea. The total score (Mean ± SD) of each domain of mothers’ knowledge in Table 2 indicates the mothers acknowledge the symptomps of diarrhea and how to prevent. However, mothers may need more knowledge in managing the diarrhea and how to deal with the complications. The statistical analysis (Table 3) acknowledges there were seven variables included such as educational level and occupational status of the couples, house condition, house ownership status, and monthly average income. However, no statistically significant association between socio-demographic characteristics with diarrheal disease among under-five children was found. As shown in Table 4, this present study found that all domains of knowledge were found significantly associated with occurrence of diarrhea. Mothers with no child suffering diarrhea in last two weeks had significantly higher level of knowledge on causes, symptoms, complications, management, and prevention of diarrhea. Table 3. Association between socio-demographic characteristics and the occurrence of diarrhea (N=277) Variables Occurrence of diarrhea Chi-square test p-value No (%) Yes (%) Education level of mother 0.0006 0.981 No education and primary 26 (46.43) 30 (53.57) Secondary and higher 103 (46.61) 118 (53.39) Occupational status of mother 1.1561 0.282 Employed 78 (49.37) 80 (50.63) Unemployed 51 (42.86) 68 (57.14) Education level of father 0.0197 0.889 No education and primary 27 (45.76) 32 (54.24) Secondary and higher 102 (46.79) 116 (53.21) Occupational status of father 0.0281 0.986 Odd job 51 (46.79) 58 (53.21) Small own business 32 (45.71) 38 (54.29) Staff at private company 46 (46.94) 52 (53.06) House condition 1.0567 0.590 Condo/bungalow 31 (50.00) 31 (50.00) Brick foundation 76 (47.20) 85 (52.80) Timber house 22 (40.74) 32 (59.26) House ownership 0.0085 0.927 Yes 53 (46.90) 60 (53.10) No 76 (46.34) 88 (53.66) Monthly income 0.3358 0.562 ≤ 150,000 kyats 55 (41.04) 79 (58.96) > 150,000 kyats 74 (51.75) 69 (48.25) Table 4. Association between mother’s knowledge on diarrhea and the occurrence of diarrhea Knowledge on diarrhea Occurrence of diarrhea t-test p-value No (mean ± SD) Yes (mean ± SD) Causes of diarrhea 2.29 ± 0.80 1.84 ± 0.87 4.43 <0.0001 Symptoms of diarrhea 2.74 ± 0.83 2.48 ± 0.74 2.71 0.0071 Complications of diarrhea 1.81 ± 0.64 1.61 ± 0.85 2.09 0.0377 Management of diarrhea 1.72 ± 0.96 1.53 ± 0.56 2.01 0.0457 Prevention of diarrhea 2.89 ± 1.05 2.35 ± 0.85 4.31 <0.0001 81 Global Health Management Journal, 2018, Vol. 2, No. 3 Table 5. Binary logistic regression of factors associated with the occurance of diarrhea Variables Model I Model II Model III OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value Socio-demographic characteristics Education level of mother No education and primary Reference Reference Secondary and higher 1.46 0.12 - 18.22 0.771 1.40 0.10 - 20.64 0.804 Occupational status of mother Employed Reference Reference Unemployed 1.40 0.84 – 2.33 0.196 1.51 0.87 - 2.59 0.140 Education level of father No education and primary Reference Reference Secondary and higher 0.64 0.05 – 7.87 0.727 0.70 0.05 - 10.01 0.793 Occupational status of father Odd job Reference Reference Small own business 1.08 0.56 – 2.09 0.821 1.70 0.82 - 3.52 0.150 Staff at private company 1.36 0.61 – 2.11 0.686 1.21 0.63 - 2.34 0.570 House condition Condo/Bungalow Reference Reference Brick foundation 0.99 0.53 – 1.83 0.968 0.90 0.47 - 1.74 0.761 Timber house 1.17 0.51 – 2.64 0.713 0.99 0.41 - 2.38 0.979 House ownership Yes Reference Reference No 0.89 0.53 – 1.48 0.645 0.88 0.51 - 1.52 0.644 Monthly income ≤ 150000 Reference Reference > 150000 0.61 0.36 – 1.04 0.068 0.59 0.33 - 1.06 0.078 Knowledge on Diarrhea Causes of diarrhea 0.65 0.46 - 0.91 0.013 0.63 0.44 - 0.90 0.012 Symptoms of diarrhea 0.82 0.56 - 1.20 0.308 0.80 0.54 - 1.19 0.276 Complications of diarrhea 1.12 0.76 - 1.66 0.567 1.09 0.73 - 1.61 0.680 Management of diarrhea 1.03 0.72 - 1.49 0.855 0.93 0.63 - 1.38 0.732 Prevention of diarrhea 0.73 0.54 – 0.98 0.034 0.73 0.54 - 0.99 0.046 LR chi square (df) 5.75 (9) 25.73 (5) 33.48 (14) Pseudo R-square 0.0150 0.0672 0.0875 DISCUSSION This study found a half (53.43%) of the under-five children in Hlaing Thar Yar Township suffered diarrhea within two weeks preceding the survey. This finding is almost similar to the result of a baseline survey conducted by World Vision Myanmar in Hlaing Thar Yar Township in 2012 which found that nearly half (45%) of under-five children suffered diarrhea in one month prior the survey [3]. Obviously, different sampling and data collection procedure, assessment, and inclusion criteria of samples might play important roles for the differences. It is important to note that the prevalence of diarrhea among under- five children in Hlaing Thar Yar Township was very high compared to other country’s settings, such as in Banten, Indonesia of 18.9% [16] and in Gujarat, India of 35.3% [17]. The high prevalence of diarrhea in Hlaing Thar Yar Township might be due to poor hygienic conditions and inadequate of water and sanitation facilities [10]. Beyond those existing environmental factors that are well-known to contribute to diarrhea occurrence, this study attempts to identify the association between mother’s knowledge of diarrhea with diarrheal disease among under-five children in Hlaing Thar Yar Township. Based on multivariate analysis after controlling all socio-demographic of parents and household, two domains of knowledge, namely knowledge on causes and prevention of diarrhea were associated with diarrheal disease among under-five children. Both domains of knowledge play an important role as Global Health Management Journal, 2018, Vol. 2, No. 3 82 preventive factors since those declined the likelihood of diarrhea. Similarly, other previous studies also confirmed the same findings. A study conducted in West Ethiopia found that not knowledgeable mothers of causes, transmission, and prevention of diarrhea were more likely to have children experiencing diarrhea in last 15 days by 3.62 times [18]. In addition, another study also supports this finding where poor level knowledge of mothers on causes and prevention of diarrhea was associated with high odds of diarrhea among infants, reported by a study in Nigeria [19]. It is understandable then, mothers who had a higher knowledge about causes and prevention of diarrhea, they were more likely to prevent diarrheal disease among children. Being knowledgeable of causes and prevention of diarrhea leads mothers to have good practices in terms of feeding their children as well as eliminating transmission of diarrhea. Meanwhile, other domains of knowledge showed insignificant association, such as knowledge on symptoms, complications, and management. Those types of knowledge might be not strong factors associated with mother’s prevention acts of diarrhea, but they are more related to diarrheal management practices for children who are suffering from diarrhea. Findings from this study suggested that enhancing knowledge of mothers related to causes and prevention of diarrhea is worth considering to prevent diarrheal diseases among under-five children in Hlaing Thar Yar Township. An advocacy can be addressed to the authorized persons of public health department at district level in order to develop health promotion program aiming to increase mother’s awareness and skills of diarrhea prevention in Hlaing Thar Yar Township. Moreover, health care providers from rural health center and sub-rural health center play important roles in health promotion program to educate and provide information to mothers and other family members about diarrhea and its prevention acts. This efforts to decrease diarrhea prevalence is in line with a vision of the Global Action Plan for Pneumonia and Diarrhea (GAPPD) which aims to eliminate pneumonia and diarrhea-related deaths by 2025, by accessing universal prevention and treatment. Therefore, an investment in a program which provides comprehensive knowledge on diarrhea helps mothers to avert diarrhea. In addition, mothers also need to be equipped with adequate management skills for children with diarrhea in order to avoid unexpected complications and mortality. It should be noted however, level of knowledge and awareness might be not sufficient to prevent diarrheal disease [20]. A massive improvement of environmental quality such as adequate supply of clean water and sanitation facilities should be taken into account as a way to create enabling condition for diarrhea prevention. CONCLUSION The prevalence of diarrhea among under-five children in Hlaing Thar Yar Township was quite high. The occurrence of diarrhea among under-five children was significantly associated with mothers’ knowledge on causes and prevention of diarrhea. Therefore, a health promotion program should be designed to enhance mother’s knowledge on causes and prevention of diarrhea in order to prevent the diarrheal disease. Furthermore, it impacts positively on the health status of children that can reduce morbidity and mortality among children. CONFLICT OF INTERESTS Authors declared that there is no conflict of interest. REFERENCES 1. World Health Organization. Diarrhea Disease Fact Sheet. Geneva: World Health Organization. 2017. Retrieved from: http://www.who.int/news-room/fact- sheets/detail/diarrhoeal-disease [Accessed: 28/07/2018] 2. Fischer WC, Perin J, Aryee M, Boschi PC, Black R. Diarrhea Incidence in Low- and Middle-income Countries in 1990 and 2010: A Systematic Review. BMC Public Health. 2010; 12(220). 3. World Vision Myanmar. Knowledge, Attitude and Practice (KAP) Survey: Maternal and Child Health (From Miracle to Reality) Project: Baseline Report. World Vision Myanmar: Yangon; 2012. 4. Myint SYS. 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