Attitude Towards Home-Based Management of Diarrhea and Associated Factors Among Mothers of Under-Five Children of Fagita Lekoma District, Northwest Ethiopia, 2020

Background: Diarrhea is the second most common cause of morbidity and mortality among children under 5 years old, following acute respiratory tract infection. Despite that home interventions can prevent 57% of mortality related to diarrhea. However, still mothers’ attitudes towards home-based diarrheal management range from 39-78% as a result of different factors. Objective: This study aimed at assessing attitudes towards home-based management of diarrhea and associated factors among mothers of under-ve children attending health care institutions. Methods: An institutional-based cross-sectional study was conducted. Systematic random sampling was used to select study participants. Data were entered using Epidata version 3.1 and exported to SPSS version 25. The result was presented in frequency and percentage using tables and �gures. Binary logistic regression was used to analyze the data. Those variables with p-value <0.2 in bivariate were entered in multivariate analysis to avoid confounding variables whereby p-value <0.05 were considered as signi�cantly associated.


Introduction
Diarrhoea is a condition associated with the passage of three or more watery or loose stools in a single day (1).Annually according to the WHO reports more than 700 million episodes of diarrhoea in under-ve children in developing countries (2).In the globe, diarrhoea is the second most common cause of morbidity and mortality among children under 5 years old, following acute respiratory tract infection (3,4).Besides it is the leading cause of malnutrition in children under-5 years whereby around 60-70% of deaths are due to loss of water and essential minerals (5)(6)(7).
It is an established fact that the Sustainable Development Goals (SDG-3) is targeted to reduce under-ve mortality to 25 deaths per 1,000 live births by 2030 (8).However, Only 59 deaths per 1000 live births of under-5 mortality were achieved in the Ethiopian Mini Demographic Health Statistics (EMDHS) of 2019 (9).Consequently, Ethiopia was among the top 10 countries with an under-ve mortality rate of 178 per 1000 live birth(8).
In Sub-Saharan Africa, the cases remain high due to poor perception of primary caregivers' management of diarrhea especially mothers (10,11).Studies showed that positive mothers' attitudes towards homebased management of diarrhea (HBMD) range from 39-78% (12)(13)(14)(15)(16)(17)(18).Home-based uids include, a mixture of salt, sugar, and water, breast milk, Gruels (diluted mixtures of cooked cereals and water), soup, rice water.Proper home-based interventions of diarrhea can prevent nearly three-fth of mortality related to diarrhea.Hence, the more positive a mother's attitude causes fewer babies who will experience diarrhea.Consequently, it maintains good quality of life by reducing morbidity and mortality (5,(19)(20)(21).
There is very limited study on mothers' attitude towards home-based diarrheal management besides some uses attitude of mother's as a factor that could affect the practice home-based management of diarrhea.Studies suggested that the lack of mothers' attitudes was mainly in uenced by social and cultural beliefs (22)(23)(24)(25).Furthermore, factors like age of the mother, residence, knowledge of HBMD, being single, being less educated, being a housewife were found signi cantly associated with mothers' attitude towards home-based diarrheal management (5,12,13,20,26,27).Some of the techniques used to enhance mothers' attitude towards home-based diarrheal management were the provision of education for mothers regarding early home-based case management of childhood diarrhoea along with mobilization of community on home management of diarrhoea to increase awareness and improve practice level (20,28).Thus, boosting the knowledge of mothers will improve their attitude toward diarrhoea management (5).The purpose of this study was to assess the attitude of mothers towards Home-based diarrheal management and associated factors in under-ve children attending health centres of Fagita Lekoma District, Northwest Ethiopia, 2020

Materials And Methods
Study Design, Period and setting An institutional based cross-sectional study was conducted from February to March 2020.The study area was Fagita Lekoma district, which is found in Awi Zone of Amhara Regional State and is located 472 km far from Addis Ababa, the capital city of Ethiopia, and 100 km far from Bahir Dar, the capital city of Amhara National Regional State.According to the district health o ce report in 2020, it has a total population of 169,205 of which the estimated number of under-ve children was 22,839.In this district, there are 6 health centers, 3 private clinics, and 27 health posts with 52 health extension workers which give health care services to the population in the district.

Population
All mothers attending under-ve clinics whose child has an episode of diarrhea in the past three months were source population.Those mothers attending under-ve clinics during the data collection period were a study population.Those mothers who were not volunteers to participate in the study and whose children need urgent referral were excluded.

Sample Size Determination.
The sample size for this study was calculated using a single population proportion formula based on the following assumptions: A systematic random sampling technique was employed to select the study participants from all health centers of Fagita Lekoma district.Based on the last three-month under-ve health care services the average daily ow was calculated.The number of the under-ve visits in the second quarter of the year of 2020 in Addis Kidamie, Finzit, Fagita, Waze, Gezehera, and Chiguali health centers was 1242, 341, 296, 801, 264, and 524, respectively.Then, the number of actual study participants from each HC was calculated and taken proportionally by using the formula  = (/) ×  (Figure 1).

Operational de nition
Favorable attitude: Those who scored above mean on attitude questions(26) Unfavorable attitude: Those who scored below mean on attitude questions(26) Diarrhea: The passage of three or more watery or loose stools in a single day (1) Data Collection Method and Tool.
Structured interview questionnaires were adapted and modi ed from differently related literature to collect the data on the Sociodemographic variables, attitude-related questions, and associated factors (27)(28)(29)(30).It was prepared in English and then translated to Amharic language and then was retranslated into English to check for its consistency.The data were collected through a face-to-face interview by trained collectors.Four BSc nurses and one supervisor for data collection activities were recruited.
Data Quality Control.
To assure the data quality, the recruited data collectors were trained for half days on the objective, con dentiality of information, the relevance of the study and respondent's right, pretest, informed consent, and techniques of an interview.Before going into data collection, the structured questionnaire was pretested on one private clinic for consistency of understanding the survey tool, and modi cations were done accordingly.Close supervision was undertaken during data collection Data Processing and Analysis.
Data were entered using Epi data version 4.6 software and analyzed using SPSS version 25.Data cleaning and cross-checking were done before analysis.Descriptive statistics were summarized using the mean, and standard deviation.Frequencies and percentages were used in the presented table, gures and text.Bivariate and multivariate analysis were used to identify factors associated with mothers attitudes towards home-based management of diarrhea in binary logistic regression.

Discussion
Understanding mothers' attitude is the principal element in understanding their intention to know and practice home-based management of diarrhea (31).Early management and recognition of danger signs are key strategies in treating diarrhoeal diseases at home (32).Based on the ndings more than half of the participants had favorable attitude 51.9%, 95%CI (46.8, 57.1).The current study is in line with a study conducted in Finote selam 50.1%(26).The possible explanation might be due to similar socio-economic status.The current study is lower than studies in Pakistan (12,32), Indonesia (13), and Yemen( 14) with prevalence positive maternal attitude of 73.6% Indonesia 77.1%, and Yemen 69.2% respectively.The possible explanation might be due to differences in a study setting, sample size, sampling techniques, socio-economic and cultural differences.However, in Indonesia assessed only an infant and that of Peshawar was conducted in private and public hospitals.That of Pakistan was conducted on urban dwellers among early child age.In Ethiopia, a study in Assosa 62.9% (33), the possible explanation was a different study design which was community-based and sample size differences.The current study is higher than studies in Nepal Indian(16), Pakistan (32) and Ethiopia Dire Dawa (34) with 39%,44.6% and 45.1% respectively.The difference is due to study duration, sampling techniques, and sample size variation.However, a study in Nepal Indian study assessed only mothers' attitudes toward diarrhoea not on management.That of Pakistan was conducted rural residence in mothers among diarrhoea among early child age.
Mothers whose age group from 36-45 and >45 years were 7.79 and 9.55 times more likely to have a favorable attitude on home-based diarrheal management respectively, as compared to those mothers age groups from 15-24 years.This is supported by the studies conducted in Nigeria (29) and Ethiopia(26).The possible explanation might be due to as age of the mothers increase their experience toward diarrheal management increases.
In this study, being single and being divorced were about 82% and 75% are less likely to have a favorable attitude on home-based diarrheal management respectively, as compare to mothers who had married.This result is in line with a study conducted in Fenote Selam, Ethiopia(26).This may be due to most of husbands' were educated compared to mothers, an educated people have an increased levels of awareness and knowledge, due to gathering information from different sources this leads to good attitude and practice related to child health due to this reason when mothers are married, sharing of knowledge and support each other in different aspect of home-based activities including home-based diarrheal disease management.
This study also revealed that caregivers who have primary education and secondary and above education were 7.26 and 8.43 times more likely to have a favorable attitude respectively, as compared to illiterate.This study was supported by a previous study in Ethiopia(26).The fact is that highly educated mothers have higher access to information than mothers who are illiterate.
In this study, daily labour are about 5.44 times more likely to have favorable attitude on home-based diarrheal management as compared to housewife mothers.This could be due to the fact that they great connection with others through information sharing in their working areas.
In addition, those mothers who know about the preparation of ORS 6.72 times more likely to have favorable attitude about HBMD as compared to their counterparts.The possible justi cation might be those mothers knowing about the preparation of ORS also knowing the importance of ORS, how and when to give ORS to the child, this leads to increase maternal con dence on home-based management of diarrhea and develop favorable attitude on perception HBDM.

Limitation
Firstly, Due to cross-sectional nature of the study we could not determnine cause and effect at the same time.Secondly, There is a shortage of literature for factors associated with attitude of mothers

Figures Figure 1
Figures 2 , where  is minimum sample size required for the study,  is margin of

Table 2 :
Personal related variables of mothers in Fagita lekoma district, North West Ethiopia, 2020(n=422) (48.6%) agree cause diarrhea, 185(43.8%)agreed diarrhea can be managed at home, and nearly two-fth 164(38.9%)agreed that vaccination can prevent diarrheal disease, 182(43.1% Attitude of mothers towards home-based management of diarrheaThe mean attitude score of the study participants' was 21.03±4.00.Majority 177(41.9%) of participants agreed that diarrhea is a problem in the community.Around 155(36.7%)agreed that diarrhea is a curable disease.Ninety-seven 182 (43.1%) participant's had agreed that diarrhea attacks mostly bottle-feed children, 205

Table 3 :
Attitude of mothers towards home-based management of diarrhea in under-ve children in Fagita district, North West Ethiopia, 2020(n=422)In bivariate analysis; maternal age, number of children, monthly income, marital status, maternal educational status, occupation, information on HBMD, and knowing about the preparation of ORS were factors associated with mothers' attitude on home-based management of diarrhea.In Multivariate analysis; maternal age, marital status, maternal educational status, occupation, and knowing about the preparation of ORS were factors associated with mothers' attitude on home-based management of diarrhea.However number of children and monthly income were not statistically signi cant.Knowing about how to prepare ORS (AOR: 6.72, 95%CI: 3.62,12.48)weresignicantly associated variables with the out came variable in the multivariate regression (Table4).

Table 4 :
Binary logistic regression analysis for factors affecting mothers' attitude towards home-based management of diarrhea under-ve children of Fagita Lekoma district, Northwest Ethiopia, 2020 ConclusionAbout half of the mothers had a favorable attitude in this study.Maternal age, marital status, maternal educational status, occupation, and knowing about the preparation of ORS were factors associated with mothers' attitude.The fo focus should be made on creating awareness and educating younger mothers, illiterate, unmarried couples, not knowing how to prepare ORS to boost mothers' attitude.: Adjusted Odds Ratio, CI: Con dence Interval, EMDHS: Ethiopian Mini Demographic Survey, ETB: Ethiopian Birr, HBMD: Home Based Management of Diarrheal, IRB: Institutional Review Board, ORS: Oral Rehydrated Salt, SDG: Sustainable Development Goal, WHO: World Health Organization AORDeclarationsEthics approval and consent participate Ethical clearance approved by Institutional Review Board (IRB) of the School of Nursing University of Gondar.A permission letter was written to the district administrator's o ce.Then, the administrator allowed us to conduct the study.Informed consent is obtained from all the participants and