Nutrition 29 (2013) 1368–1373

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Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

The use of oral rehydration salt in managing children under 5 y old

with diarrhea in the Gambia: Knowledge, attitude, and practice
Famara Sillah M.Sc. a, b, Hsin-Jung Ho M.Sc. a, Jane C-J. Chao Ph.D. a, c, d, *
a
School of Nutrition and Health Sciences, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
b
Ministry of Health and Social Welfare, Quadrangle, Banjul, The Gambia, West Africa
c
Master Program in Global Health and Development, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
d
Nutrition Research Center, Taipei Medical University Hospital, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Diarrhea is a leading cause of mortality in children under the age of 5 y in developing
Received 15 January 2013 countries. To our knowledge, no other studies have investigated the management of diarrhea in the
Accepted 20 May 2013 Gambia. The aim of this study was to assess maternal knowledge, attitude, and practice in the
causes, prevention, and management of diarrhea in children under the age of 5 y in the Gambia.
Keywords: Methods: Four hundred mothers with children who have diarrhea and are under the age of 5 y were
Childhood diarrhea
randomly recruited. Data were collected using structured questionnaires, including demographic
Oral rehydration solution
information, knowledge about diarrhea, attitude toward the management of diarrhea, and practice
Knowledge
Attitude for the prevention and management of diarrhea. c2 and Student’s t tests were used for the
Practice descriptive and quantitative analysis, respectively. Simple and multiple linear regressions were
Mothers used to determine the association between the variables. A P-value < 0.05 was considered
statistically significant.
Results: The mean of maternal knowledge (K), attitude (A), practice (P), and knowledge–attitude–
practice sum (KAP) scores were 14.4, 6.3, 13.2, and 33.9, respectively. The mean of knowledge
scores were significantly higher in mothers who responded positively for germs (13.4 versus 12.6)
and dirty hands (13.7 versus 13.0) as causes of diarrhea. Mothers with education had significantly
higher knowledge (14.7 versus 14.2) and attitude scores (6.6 versus 6.1) in management of diar-
rhea. However, the study found a low use rate (4%) of oral rehydration solution in practice. Multiple
linear regression analysis revealed that maternal age was positively associated with practice
(b ¼ 0.061) and KAP scores (b ¼ 0.102). The number of children in the family was positively
correlated with attitude scores (b ¼ 0.408). Socioeconomic status was positively associated with
attitude (b ¼ 0.549), practice (b ¼ 0.841), and KAP scores (b ¼ 1.887).
Conclusions: The mothers have high knowledge scores in the management of diarrhea; however,
use of oral rehydration solution is low among children with diarrhea under the age of 5 y in the
Gambia. Higher maternal age and socioeconomic status are correlated with higher practice and
KAP scores.
Ó 2013 Elsevier Inc. All rights reserved.

Introduction immunity. Diarrhea is one of the major causes of mortality in

Diarrhea, caused by a variety of bacterial, viral, and parasitic
organisms, is a symptom of gastrointestinal infection, which can
be spread through contaminated food or drinking water, or from
person to person due to poor hygiene [1]. Severe diarrhea leads
to fluid loss, and may be life threatening, particularly in young
children and individuals who are malnourished or have impaired
* Corresponding author. Tel.: þ886-2-2736-1661; fax: þ886 2 2737 3112.
E-mail address: chenjui@tmu.edu.tw (J. C.-J. Chao).
0899-9007/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nut.2013.05.014
children under the age of 5 y old, and 1 billion diarrhea episodes
and 3 million to 5 million deaths from diarrhea occur in the
world each year [2,3]. Diarrhea has been reported as a leading
cause of death among children in developing countries. The
prevalence and mortality of diarrhea were 3 billion to 5 billion
cases and 5 million to 10 million deaths, respectively, each year in
Africa, Asia, and Latin America between 1977 and 1978, where an
estimated 1.3 billion episodes and 4 million deaths occur each
year in children under the age of 5 y [4]. The incidence of diar-
rhea in children (ages 0–59 mo) declined from 3.4 episodes per
 F. Sillah et al. / Nutrition 29 (2013) 1368–1373
child per year in 1990 to 2.9 in 2010 in low- and middle-income
countries in six World Health Organization regions (Africa, the
Americas, Eastern Mediterranean, Europe, South East Asia, and
Western Pacific) [5]. The average prevalence of diarrhea was 12%
among 244 children ages 6 to 35 mo with a mean of 2.4 to 2.9
episodes per child in an urban community of the Gambia [6].
Age, nutritional status, and the treatment of diarrhea are
some of the critical factors affecting the prevalence and mortality
of diarrhea in young children. The incidence of diarrhea peaks in
the first 2 y and declines thereafter [7]. The treatment of diarrhea
with oral rehydration solution is beneficial in preventing dehy-
dration and death of young children [8–10]. The use of oral
rehydration solution was associated with a 25% reduction in
unscheduled follow-up visits for acute diarrhea in children under
the age of 5 y [11].
Diarrhea leads to weight loss in infants. Diarrhea reduced
weight by 15.4 g/d in infants ages 7 to 12 mo in an urban
community of the Gambia [12]. The previous study also revealed
that the reduction of weight due to diarrhea in weaning infants
was four times more frequent than in exclusively breast-fed
infants (14.4  2.9 versus 3.6  3.5 g/d; P < 0.01), and diar-
rhea had no significant effect on growth in exclusively breast-fed
infants, suggesting that breastfeeding prevents weight loss
caused by diarrhea in infants. No study has explored the
management of diarrhea, which is the major public health
problem in the Gambia among children who are the most
vulnerable to diarrhea. Therefore, this study investigated oral
rehydration therapy by mothers managing children under the
age of 5 y with diarrhea in the Gambia.
Materials and methods
Participants
The number of participants was determined by 5% to 10% of the average
number of outpatients visiting the clinic in 1 mo. All participants were the
mothers who are the primary caregivers and had at least one child under the age
of 5 y who had experienced diarrhea at least once before or at the visit to the
clinic. Those who could not communicate through reading, writing, or speaking
were excluded from the study. There were 400 mothers who met the selection
criteria; they were randomly recruited out of 5000 outpatients who visited the
Department of Polyclinic at Royal Victoria Teaching Hospital in Banjul, the
Gambia in 1 mo by the researcher. This study was approved by the Royal Victoria
Teaching Hospital ethical committee and conducted in accordance with the
guidelines. Considering limited reading and writing ability of the participants
(267 versus 133 for those with and without the ability to read and write), a verbal
consent was obtained from all participants before the study.
Data collection
The questionnaires were used to determine the knowledge, attitude, and
practice of the mothers in managing children with diarrhea. One well-trained
researcher collected data using structured questionnaires including demo-
graphic information (14 questions), knowledge in the causes, diagnosis, and
symptoms of diarrhea (9 questions), attitude for feeding children with diarrhea
(6 questions), and practice for the prevention and management of diarrhea by
oral rehydration solution (11 questions). The researcher developed the ques-
tionnaires, and the three nutritionists assessed the validity of the questionnaires
to verify the content validity. After revising the contents of the questionnaires
according to the suggestions and comments of the nutritionists, the reliability of
the questionnaires was evaluated by the consistency test. Test and retest surveys
were conducted in 20 mothers after 2 wk by the same researcher, and 90%
consistency between test and retest surveys was observed in this study. Ques-
tionnaires were administered to 400 participants by interview in the Department
of Polyclinic at Royal Victoria Teaching Hospital from July to August 2011.
Participants in the study were voluntary and free to withdraw. The researcher
checked all the questionnaires to ensure that none was missing for further
analysis.
1369
Data analysis
The researcher scored the questionnaires to evaluate the mothers’ knowl-
edge, attitude, and practices. Answers to questions were graded as correct,
partially correct (when there are more than one correct answers), and wrong, and
scored as 2, 1, and 0, respectively. The full scores of knowledge, attitude, and
practice are 18, 12, and 22, respectively. The scores of all the questions in each
part were summed to give the total score as a weighted index score for the level
of knowledge, attitude, and practice in terms of managing diarrhea among
children under the age of 5 y. The KAP score is the sum of knowledge (K), attitude
(A), and practice (P) scores. The tertiles of knowledge, attitude, and practice
scores are defined as low, medium, and high, respectively.
Literacy is defined as the ability to read and write, and illiteracy indicates
inability to read and write. Socioeconomic status (SES) was determined using the
social classification criteria developed previously [13], and comprised of five
social classes in which classes I and II are the elites, class III is the middle class,
and classes IV and V are the lowest class in accordance with the scoring system
based on mother’s education and father’s occupation.
Statistical analysis
All statistical analysis was performed using SAS (Statistical Analysis System,
version 9.3, SAS Institute Inc., Cary, NC, USA). c2 test was used for the descriptive
analysis. Student’s t test was used to determine the differences between the
groups who responded no or yes in the same cause of diarrhea and between the
groups with or without education in the management of diarrhea. Simple and
multiple linear regressions were used to explore the association between the
variables. Pearson’s correlation coefficient (r) and regression coefficient (b) were
calculated using simple and multiple linear regression models, respectively. A
P-value < 0.05 was considered statistically significant.
Results
Table 1 demonstrates the demographic characteristics of the
400 mothers (ages 15–47 y) who completed the questionnaires.
The literacy rate of the mothers was 66.7%, and 13.5%, 42%, and
8.8% of mothers had primary, secondary, and tertiary education,
respectively, whereas 35.7% mothers had no or nonformal
education. Most children (60%) were between the ages of 0 and
12 mo, whereas 15.5% and 24.5% of children were between 13
and 24 mo and older than 24 mo, respectively. The majority of
mothers (98.3%) reported low (21%) or middle (77.3%) income,
and only 1.7% reported high income. Most mothers (56.8%) were
stay-at-home moms, whereas 25.3% and 9% of mothers were
traders or government-employed, respectively. The occupations
of the rest (9%) of the mothers were maid, food vendor, and hair
braider. Of the mothers, 83.7% and 16.3% had extended and
nuclear family systems, respectively. The religion of the mothers
was 96.3% Islam and 3.7% Christianity.
The majority of participants (n ¼ 346, 86.5%) defined diarrhea
as frequent passage of watery stool (data not shown), and 37
(9.3%) mothers indicated diarrhea as an increase in stool
frequency and liquidity. Less than 5% of mothers defined diarrhea
as the presence of blood or mucus in stool (n ¼ 11, 2.7%) or the
presence of weakness and lethargy in children (n ¼ 6, 1.5%).
Table 2 indicates maternal knowledge in the causes of diar-
rhea. The majority of the mothers indicated germs (72%) as
a cause of diarrhea. Only a few mothers indicated cultural
practices (31.7%), dirty hands (27%), prolonged breastfeeding
(11.3%), pregnancy or early weaning (7%), and colostrum (1.3%) as
causes of diarrhea. Most mothers who identified cultural prac-
tices as a cause of diarrhea indicated that diarrhea occurred in
children during teething and when parents had early sexual
behavior while breastfeeding. The mean of knowledge scores
was significantly higher in the mothers who responded posi-
tively for germs (13.4 versus 12.6; P ¼ 0.0019) and dirty hands
(13.7 versus 13; P ¼ 0.0100) as the causes of diarrhea compared
with those who responded negatively. The means of knowledge
scores for colostrum, pregnancy or early weaning, cultural
1370 F. Sillah et al. / Nutrition 29 (2013) 1368–1373

Table 1 Table 2
Demographic characteristics of the participants (N ¼ 400) Knowledge scores between the mothers who responded negatively and posi-
tively in different causes of diarrhea
Variable n %
Age group (y) Causes of diarrhea Number of Mean of knowledge P-value
19 23 5.7 mothers (%) score* (95% CI)
20–34 329 82.3 Colostrum 0.1657
>34 48 12.0 No 395 (98.7) 13.2 (13.0–13.5)
Marital status Yes 5 (1.3) 11.4 (8.4–14.4)
Not married 18 4.5 Germs 0.0019y
Married 382 95.5 No 112 (28) 12.6 (12.1–13.1)
Parity Yes 288 (72) 13.4 (13.2–13.7)
1 110 27.5 Dirty hands 0.0100y
2 93 23.2 No 292 (73) 13.0 (12.7–13.3)
>2 197 49.3 Yes 108 (27) 13.7 (13.3–14.1)
Age of children. mo Pregnancy or early weaning 0.9771
0–12 240 60.0 No 372 (93) 13.2 (13.0–13.5)
13–24 62 15.5 Yes 28 (7) 13.2 (12.4–14.1)
>24 98 24.5 Cultural practices 0.1396
Literacy No 273 (68.3) 13.1 (12.8–13.3)
No 133 33.3 Yes 127 (31.7) 13.5 (12.0–13.9)
Yes 267 66.7 Prolonged breastfeeding 0.9457
Education level No 355 (88.8) 13.2 (13.0–13.5)
No/nonformal 143 35.7 Yes 45 (11.3) 13.2 (12.4–14.0)
Primary 54 13.5
CI, confidence interval
Secondary 168 42.0
* The full score of knowledge is 18, which was calculated by a total of 9
Tertiary 35 8.8
questions with 2 points for each question if answered correctly.
Occupation y
P < 0.05 indicates significant differences for the means of knowledge score
Stay-at-home mom 227 56.7
between the mothers who responded no or yes in the same cause of diarrhea by
Small-scale trading 101 25.3
using Student’s t test.
Government employed 36 9.0
Other 36 9.0
Babysitter compared with those without education in the management of
None 222 55.5
Grandparents 60 15.0
diarrhea (Table 3). However, there were no significant differ-
Mother takes child to work 70 17.5 ences in practice scores between the mothers with and without
Nursing home 12 3.0 education in the management of diarrhea.
Other older children 36 9.0 The proportion of low (0–6), medium (7–12), and high (13–18)
SES
scores of knowledge was 0.8%, 50.9%, and 48.3% in the mothers
Low 84 21.0
Middle 309 77.3 with literacy, and 3%, 62.4%, and 34.6% in those without literacy
High 7 1.7 (Table 4). The distribution of score levels in knowledge was
Family system significantly different between the mothers with and without
Nuclear 65 16.3 literacy (P ¼ 0.0041). Most mothers had medium scores of atti-
Extended 335 83.7
Religion
tude (64.8% versus 66.9%) and practice (58.8% versus 60.9%) in the
Islam 385 96.3 groups with and without literacy. However, the distribution of
Christianity 15 3.7 score levels in attitude and practice was not different between the
SES, socioeconomic status mothers who were or were not literate.
The present study found a low use rate (4%) of oral rehydra-
tion solution (ready-made sachets) for the management of
practices, and prolonged breastfeeding as the causes of diarrhea diarrhea (Table 5). The use rate of oral rehydration solution in the
were not different between the mothers who responded posi- mothers with no or nonformal, primary, secondary, and tertiary
tively and negatively. education was 2.8%, 5.6%, 4.2%, and 5.7%, respectively. The use
Most mothers (n ¼ 370, 92.5%) responded positively about rate of oral rehydration solution in the mothers who had primary
the serious illness of diarrhea in children due to the loss of fluid to tertiary education was 4.7%, and that in the mothers who had
or dehydration and eventual death (data not shown). However, no or nonformal education was 2.8% (P ¼ 0.4514). The use rate of
the present study found only 25% (n ¼ 100) of mothers knew to
use oral rehydration solution when the children had diarrhea,
and among those, 80% (n ¼ 80) of mothers knew how to prepare Table 3
oral rehydration solution correctly (data not shown). The The scores in knowledge, attitude, and practice between the mothers with and
majority of the mothers (80.8%) obtained the information sour- without education in the management of diarrhea
ces about diarrhea from health workers (data not shown). Other Education in the Mean of score* (95% CI) P-value
information sources about diarrhea included workshop (23.5%), management of
Yes (n ¼ 166) No (n ¼ 234)
schools (7.3%), friends (4%), and relatives (4%). diarrhea
The means of maternal knowledge, attitude, practice, and Knowledge 14.7 (14.3–15.1) 14.2 (13.9–14.5) 0.0316y
KAP scores were 14.4 (80% of full score), 6.3 (52.5% of full score), Attitude 6.6 (6.2–6.9) 6.1 (5.9–6.3) 0.0178y
Practice 13.4 (13.1–13.8) 13.0 (12.7–13.4) 0.1379
13.2 (60% of full score), and 33.9 (65.2% of full score), respectively
(data not shown). The percentage of mothers with and without CI, confidence interval
* The full scores of knowledge, attitude, and practice are 18, 12, and 22,
education in the management of diarrhea was 41.5% and 58.5%,
respectively, which were calculated by a total number of questions with 2 points
respectively. Mothers with education in the management of for each question if answered correctly.
diarrhea had significantly higher scores in knowledge (14.7 y
P < 0.05 indicates significant differences between the groups with and
versus 14.2; P ¼ 0.0316) and attitude (6.6 versus 6.1; P ¼ 0.0178) without education in management of diarrhea by using Student’s t test.
 F. Sillah et al. / Nutrition 29 (2013) 1368–1373 1371

Table 4 Table 6
Distribution of score levels in knowledge, attitude, and practice between illit- Pearson’s correlation coefficient (r) between demographic variables and
eracy and literacy groups knowledge, attitude, practice, and KAP scores

Score level (scores)* Illiteracy Literacy Total P-value Variables Knowledge Attitude Practice KAP*
(n ¼ 133) (n ¼ 267) (N ¼ 400) Age of mothers 0.127 0.088 0.170 0.188
n % n % n % P 0.0111y 0.0786 0.0006x 0.0002x
Marital status –0.087 –0.058 –0.032 –0.085
Knowledge 0.0041y
P 0.0816 0.2471 0.5270 0.0894
Low (0–6) 4 3.0 2 0.8 6 1.5
Number of children 0.080 0.160 0.121 0.170
Medium (7–12) 83 62.4 136 50.9 219 54.7
P 0.1107 0.0013z 0.0153y 0.0006x
High (13–18) 46 34.6 129 48.3 175 43.8
Age of children 0.027 –0.019 –0.004 0.003
Attitude 0.9014
P 0.5942 0.6989 0.9412 0.9455
Low (0–4) 32 24.1 67 25.1 99 24.7
Occupation –0.004 0.065 –0.012 0.019
Medium (5–8) 89 66.9 173 64.8 262 65.5
P 0.9404 0.1960 0.8077 0.6989
High (9–12) 12 9.0 27 10.1 39 9.8
SES 0.097 0.107 0.153 0.173
Practice 0.1307
P 0.0538 0.0320y 0.0021z 0.0005x
Low (0–7) 26 19.5 37 13.9 63 15.7
Literacy 0.003 0.130 0.070 0.094
Medium (8–15) 81 60.9 157 58.8 238 59.5
P 0.8884 0.0094z 0.1615 0.0593
High (16–22) 26 19.6 73 27.3 99 24.8
Education level –0.010 0.144 0.069 0.092
* The full scores of knowledge, attitude, and practice are 18, 12, and 22, P 0.8512 0.0038z 0.1662 0.0665
respectively, which were calculated by a total number of questions with 2 points
SES, socioeconomic status
for each question if answered correctly.
y * The total scores of knowledge (K), attitude (A), and practice (P).
P < 0.05 indicates significant differences for the distribution of score levels y
P < 0.05.
between illiteracy and literacy groups by using c2 test. z
P < 0.01.
x
P < 0.001 by using simple linear regression.
oral rehydration solution in mothers with low, middle, and high
SES was 6%, 3.6%, and 0%, respectively. However, neither Maternal age (b ¼ 0.061; P ¼ 0.0219 for practice scores;
maternal education level (P ¼ 0.7628) nor SES (P ¼ 0.2622) b ¼ 0.102; P ¼ 0.0470 for KAP scores) and SES (b ¼ 0.841;
significantly affected the use of oral rehydration solution when P ¼ 0.0025 for practice scores; b ¼ 1.887; P ¼ 0.0005 for KAP
the children had diarrhea. scores) were positively correlated with practice and KAP scores.
Table 6 shows correlation coefficient (r) between demo-
graphic variables and knowledge, attitude, practice, and KAP
Discussion
scores using simple linear regression. Maternal age (r ¼ 0.127;
P ¼ 0.0111) was positively correlated with knowledge scores. The
Maternal knowledge of causes and management of childhood
number of children (r ¼ 0.160; P ¼ 0.0013), SES (r ¼ 0.107;
diarrhea is critical in the reduction of the morbidity and
P ¼ 0.0320), literacy (r ¼ 0.130; P ¼ 0.0094), and education level
mortality rates caused by diarrhea, which are still high in the
(r ¼ 0.144; P ¼ 0.0038) were positively associated with attitude
Gambia. The present study revealed that mothers educated in
scores. Maternal age (r ¼ 0.170; P ¼ 0.0006), number of children
the management of diarrhea had significantly higher knowledge
(r ¼ 0.121; P ¼ 0.0153), and SES (r ¼ 0.153; P ¼ 0.0021)
and attitude scores compared with those without education.
were positively correlated with practice scores. Maternal age
However, neither maternal literacy nor education level affected
(r ¼ 0.188; P ¼ 0.0002), number of children (r ¼ 0.170;
maternal practice in the management of diarrhea among chil-
P ¼ 0.0006), and SES (r ¼ 0.173, P ¼ 0.0005) were positively
dren, which is consistent with no correlation between maternal
associated with KAP scores.
literacy or education level and practice scores using both simple
Knowledge scores were not affected by demographic vari-
and multiple linear regression analyses. The differences among
ables using multiple linear regression analysis (Table 7). The
number of children (b ¼ 0.408; P ¼ 0.0052) and SES (b ¼ 0.549;
Table 7
P ¼ 0.0172) were positively associated with attitude scores.
Regression coefficient (b) between demographic variables and knowledge, atti-
tude, practice, and KAP scores using multiple linear regression
Table 5
Distribution of educational level and SES between the mothers with and without Variables Knowledge Attitude Practice KAP*
use of oral rehydration solution
Age of mothers 0.047 –0.006 0.061 0.102
Variable Use of oral rehydration solution P-valuey P 0.0790 0.7893 0.0219y 0.0470y
Marital status –0.946 –0.277 –0.072 –1.295
Yes (%)* No (%)* Total P 0.1099 0.5698 0.9018 0.2535
Education level 0.7628 Number of children 0.077 0.408 0.131 0.616
No/nonformal 4 (2.8) 139 (97.2) 143 P 0.6617 0.0052z 0.4546 0.0689
Primary 3 (5.6) 51 (94.4) 54 Age of children 0.036 –0.006 –0.017 0.013
Secondary 7 (4.2) 161 (95.8) 168 P 0.6855 0.9330 0.8438 0.9416
Tertiary 2 (5.7) 33 (94.3) 35 Occupation 0.015 0.142 –0.005 0.151
Total 16 (4) 384 (96) 400 P 0.9066 0.1730 0.9651 0.5321
SES 0.2622 SES 0.496 0.549 0.841 1.887
Low 5 (6) 79 (94) 84 P 0.0755 0.0172y 0.0025z 0.0005x
Middle 11 (3.6) 298 (96.4) 309 Literacy 0.555 0.252 0.448 1.254
High 0 (0) 7 (100) 7 P 0.2730 0.5456 0.3720 0.1964
Total 16 (4) 384 (96) 400 Education level –0.203 0.109 –0.023 –0.117
P 0.2233 0.4267 0.8888 0.7143
SES, socioeconomic status
* The percentage of the mothers with or without use of oral rehydration SES, socioeconomic status
solution in the same education level. * The total scores of knowledge (K), attitude (A), and practice (P).
y y
P values indicate the tendency for the distribution of educational level and P < 0.05.
z
SES between the mothers with and without use of oral rehydration solution by P < 0.01.
x
using c2 test. P < 0.001 by using multiple linear regression.
1372 F. Sillah et al. / Nutrition 29 (2013) 1368–1373
knowledge, attitude, and practice in the management of diarrhea
might be attributed to the fact that some mothers could not
apply their knowledge of the management of diarrhea due to
busy schedules in doing housework and taking care of other
children.
Most of the mothers (72%) identified germs as a cause of
diarrhea, indicating a high level of mothers’ knowledge in the
cause of diarrhea in the present study. Water (96.6%) and poor
environmental hygiene (96.6%) were considered as the cause of
diarrhea by the Yalata aboriginal community in South Australia
[14]. Teething (50.3%), malaria (42.6%), and contaminated food
(25.9%) were the most common causes of diarrhea responded by
the participants in rural villages of Mali [15]. In contrast to our
findings, a low level of knowledge in the causes of diarrhea was
observed among caregivers in northwestern Nigeria [16] and in
the northeast district of Botswana [17]. Some perceived causes of
diarrhea given by the mothers in Botswana included worms in
the brain or in the stomach, a bewitched child, malnutrition,
teething, and watermelons [17]. Education and sociocultural
environment might affect maternal knowledge regarding the
cause of diarrhea.
More than 90% of mothers responded positively that diar-
rhea is a serious childhood illness, and 86.5% of mothers
demonstrated that diarrhea leads to the loss of fluid. The data
suggested that most of the mothers had knowledge of diarrhea
as a threatening childhood disease. Only 20% of mothers knew
how to prepare oral rehydration solution correctly, and 4% of
mothers used oral rehydration solution as a treatment when the
children had diarrhea. The data indicated that a low use rate of
oral rehydration solution was observed in mothers who had
knowledge in the management of diarrhea using oral rehydra-
tion solution, and there was no significant correlation between
maternal education level and the use of oral rehydration solu-
tion. However, a previous study found a significant correlation
between maternal knowledge of the signs of dehydration and
the use of oral rehydration solution for home treatment (odds
ratio, 3.36; 95% confidence interval, 1.24–10.63) in rural
Indonesia [18]. A study of children in Columbia showed that
only 54% of mothers recognized at least two correct signs of
diarrhea, but 49% of mothers used commercial oral rehydration
solution for under the age of 5 y with diarrhea [19]. The factor of
the mother living with the grandmother was significantly
correlated with increased maternal knowledge [19], which
suggests that grandmothers play an important role in passing
on their knowledge and experiences to the mothers. In-
consistency in these results could be due to the differences
in study population, assessment methods, and sociocultural
environment.
More than 80% of mothers (n ¼ 323, 80.8%) got the infor-
mation regarding management of diarrhea from health workers.
Similar to the previous studies [20,21], 75.8% of mothers learned
about oral rehydration solution from a health professional,
especially a particular doctor in Pakistan [20]. Most of the
mothers obtained the information about oral rehydration solu-
tion from doctors (37.2%), the media (25%), and their mothers
(20%) in Rawalpindi [21]. The majority (88.6%) of parents or
caregivers of children younger than 5 y responded that infor-
mation from health professionals was most important for the
management of diarrhea in the United States [22]. These results
suggest that information sources from health professionals is
primary and crucial for the management of childhood diarrhea.
Mothers who were illiterate were more likely to have low and
medium knowledge in managing diarrhea, and educated
mothers had higher knowledge in managing childhood diarrhea.
However, maternal education level was not associated with the
rate of oral rehydration solution use. Higher knowledge in
managing diarrhea was not consistently correlated with
increased use or correct use of oral rehydration solution. In
Pakistan, 77.4% of mothers who were caregivers for children with
diarrhea under the age of 5 y were familiar with the oral rehy-
dration solution, 84.7% of mothers had used oral rehydration
solution, and most (62.5%) of the mothers knew the correct
method to prepare an oral rehydration solution sachet pack,
which was the predominant type of oral rehydration solution
used [21]. More than 90.6% of mothers were aware of oral
rehydration solution, and 60% used oral rehydration solution in
the home management of diarrhea in children under the age of
5 y in rural Maharashtra in India [23]. However, among the
mothers who had used oral rehydration solution, only 37.8% of
mothers used it correctly [23]. A study in rural Aligarh in India
showed that 70.4% of mothers knew about oral rehydration
solution, and among those, only 30.2% of mothers knew the
correct method for preparing it [24]. In Nigeria, although all
mothers had heard of oral rehydration solution, only 20% had
a good level of knowledge of the home management of acute
watery diarrhea, and 7.5% had used oral rehydration solution
[25]. The previous study also found that 27.6% and 14.3% of
mothers knew to prepare salt sugar solution and oral rehydra-
tion solution correctly, but the level of knowledge in oral rehy-
dration therapy for childhood diarrhea has decreased since its
implementation in the early 1990s in Nigeria [26], indicating that
a knowledge gap may exist in the newest generation of mothers.
The difficulties of appropriate use of oral rehydration solution
could be due to lack of knowledge in the clinical significance of
oral rehydration solution for dehydration and correct prepara-
tion of commercial oral rehydration solution [27]. Other diffi-
culties with the use of oral rehydration solution were insufficient
quantities and too short a duration of oral rehydration solution
administration for childhood diarrhea [28,29]. The data suggest
that a gap still exists in knowledge, attitude, and correct practice
of management of diarrhea in certain countries including the
Gambia. Thus education, training, and follow-up of the mothers
by health professionals are essential for appropriate manage-
ment of childhood diarrhea.
Multiple linear regression analysis demonstrated that
maternal age and SES as the main factors in score performance
were positively correlated with practice and KAP scores.
However, the previous studies observed that neither age [22,30]
nor SES [30] of parents or caregivers was associated with their
general knowledge of diarrhea. The present study showed that
maternal education level was not correlated with the use of oral
rehydration solution, knowledge, attitude, practice, or overall
KAP score. Similar to our findings, no evidence demonstrated that
caregivers’ education was related to their knowledge score [30].
However, literacy rate showed a positive relation with adequate
knowledge of oral rehydration solution preparation [21]. The
mothers with better SES may have wider availability and better
accessibility of health services to improve their knowledge, atti-
tude, and practice in managing childhood diarrhea, which further
leads to reducing childhood mortality from diarrhea [31].
There are certain limitations in the present study. The study
target was women of reproductive age and nursing mothers who
visited the Department of Polyclinic at Royal Victoria Teaching
Hospital, which limits the source of the participants and excludes
women and health facilities in other regions of the country. The
study was unable to recruit fathers and other caregivers such as
aunts and grandmothers. Therefore, generalization of the study
to other areas and populations is limited.
 F. Sillah et al. / Nutrition 29 (2013) 1368–1373
The findings of this study revealed that the mothers had good
knowledge in the management of childhood diarrhea, but which
did not influence their practice, especially in the use of oral
rehydration solution, in managing childhood diarrhea. Because
most children with diarrhea are treated at home, caregivers need
to have basic knowledge about the management and care prac-
tice of childhood diarrhea to shorten the duration, reduce the
severity, and prevent the recurrence of childhood diarrhea.
Mothers’ greater academic skills were independently associated
with improved care during episodes of childhood diarrhea
[32]. Therefore, intervention is needed to enhance caregivers’
practice for improving home-based care management of child-
hood diarrhea by a nurse practitioner and other health profes-
sionals. The best approach is to implement a program to improve
mothers’ practice in the management of childhood diarrhea
through educating and training younger mothers by health
professionals, or by more experienced older mothers who were
shown to be more effective in the management of childhood
diarrhea, when the mothers visit clinics in the prenatal and
postnatal periods of children under the age of 5 y. The imple-
mentation of a diarrhea training unit in Jos University Teaching
Hospital in Nigeria, which provides education and skill training
on prevention and home management of diarrhea to mothers,
has reduced the incidence of childhood diarrhea and the number
of children in hospital care [33]. Additionally, the clinical
program can be further strengthened to improve the use of oral
rehydration solution during an episode of diarrhea. Public
awareness programs for the use of oral rehydration solution can
be implemented regarding correct preparation of oral rehydra-
tion solution and continuous feeding during an episode of diar-
rhea through electronic and print media.
Conclusion
In conclusion, use of oral rehydration solution is low among
children under the age of 5 y with diarrhea in the Gambia despite
mothers having high knowledge scores in the management of
diarrhea. Maternal age and SES are positively correlated with
practice and overall KAP scores.
Acknowledgments
The authors would like to thank the Royal Victoria Teaching
Hospital, Banjul, The Gambia, especially Dr. Ousman Nyang, the
Chief Medical Director who approved the conduct of this study.
We also thank Mr. Sillaba Drammeh, the Department Matron
of Polyclinic, to assist questionnaire data collection, and Mr.
Almamy Jobarteh, the Director of Sunshine Insurance Company,
to assist the printing of questionnaires.
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