Clinical Epidemiology and Global Health 14 (2022) 100998

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Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Assessment of knowledge, attitude, and practice of child caregivers towards

oral rehydration salt and zinc for the treatment of diarrhea in under 5
children in Gondar town
Dawit Kumilachew Yimenu a, Asmamaw Emagn Kasahun b, Mohammed Chane a,
Yeelshaddai Getachew a, Biruktawit Manaye a, Zemene Demelash Kifle c, *
a
Department of Social Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
b
Department of Pharmaceutics, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
c
Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Diarrhea is the second-largest cause of death in under-five children, killing an estimated seven
Attitude hundred sixty thousand children in Africa each year. This study aimed to assess the knowledge, attitude &
Diarrhea practice of child caregivers towards oral rehydration salt and zinc use for the treatment of diarrhea in under 5
Knowledge
children in Gondar town, Amhara regional state, Ethiopia.
Oral rehydration salt
Methods: Institutional based cross-sectional study was conducted at the pediatrics outpatient department of the
Practice
Zinc University of Gondar comprehensive specialized hospital. Data was collected using a structured questionnaire
and were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 20. Frequencies and
percentages were used to describe descriptive data and the results were presented using tables and figures. Both
binary and multivariable logistic regression analyses were conducted to test for association between the different
variables.
Results: A total of 306 caregivers were participated in the study. The majority of them 269(87.9%) defined
diarrhea as the occurrence of watery or loose stool three and more times a day. Almost all caregivers but a few
297(97.1%) believed that diarrhea is a series problem of childhood. Caregivers’ educational level, occupational
status, and sex were significant factors associated with their knowledge about Oral Rehydration Salt and zinc (P
≤ 0.05), while occupational status was the only significant factor associated with their attitude (P ≤ 0.05).
Female caregivers were found 2.8 times more practical about Oral Rehydration Salt and zinc utilization for
diarrheal management compared to male counterparts (AOR = 2.875(1.319,6.263)). Similarly, employed
caregivers were 2.9 times more to have good practice than unemployed caregivers (AOR = 2.927(1.533,5.587).
Conclusion: There was good knowledge, attitude, and practice about Oral Rehydration Salt and zinc consumption
among child caregivers in Gondar. Regular educational strategies aimed at improving child caregivers’ aware­
ness of diarrhea disease management and utilization of Oral Rehydration Salt and Zinc tablets are advised.

1. Background could also be non-infectious, such as food indiscretions or digestive is­

sues and problems of mal-digestion and mal-absorption.3
Diarrhea is defined as, “the passage of three or more loose or liquid Diarrheal disease (DD) is still a major public health issue around the
stools per day (or more frequent passage than is normal for the indi­ world, coming in second only to pneumonia as a cause of death in
vidual)”.1,2 It can be acute or chronic, and blood may be present, as in children under the age of five. Approximately 1.5 million people die
dysentery. Diarrhea can be caused by a variety of reasons, including each year as a result of it all over the world.4 It is also the leading cause
bacterial, protozoal, and viral illnesses, such as rotavirus, cholera, and of death among children in Ethiopia. Diarrheal illness affects 13.3% of
typhoid enteritis, all of which are transmitted by the fecal-oral route. It children under the age of five, according to the EDHS 2012. In 2007,

* Corresponding author. Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, P.O. Box: 196, Gondar,
Ethiopia.
E-mail address: zeme2010@gmail.com (Z.D. Kifle).

https://doi.org/10.1016/j.cegh.2022.100998
Received 16 January 2022; Received in revised form 3 February 2022; Accepted 10 February 2022
Available online 16 February 2022
2213-3984/© 2022 The Authors. Published by Elsevier B.V. on behalf of INDIACLEN. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Ethiopia’s child mortality rate was 199 per 1000 live births, or around By adding a non-response rate of 5% the final sample size was 306.
one out of every five deaths. It’s treatable as well as preventable.5
Rehydration using oral rehydration salts (ORS) solution is an 2.3. Data collection methods and procedure
important part of treating diarrhea.6 During episodes of diarrhea,
rehydration therapy is an essential step to save children’s lives. Every A structured, interviewer-administered questionnaire was used for
year, however, millions of children die as a result of a failure to data collection. The questionnaire was adapted from previous studies
adequately replace the fluid. Oral rehydration therapy (ORT) for diar­ and modified to fit the current study setup.11–14 First, the English version
rhea could prevent over 1.5 million fatalities per year or 15% of all of the questionnaire was prepared. Then it has been translated to the
deaths in children under the age of five.7 Diarrhea morbidity and mor­ Amharic version (local language) then back to English. The question­
tality can be reduced with proper home management. Dehydration naire consisted of four parts. The first part contains questions about the
owing to a loss of fluids and electrolytes is thought to be the cause of socio-demographic characteristics of caregivers and their dependents.
60–70% of diarrhea-related deaths. Knowledge of the causes of diarrhea The second part consisted of eleven questions to assess the knowledge of
and the accompanying warning indicators among caregivers, as well as the participants. The third and fourth parts consist of six and nineteen
the prevention of dehydration during diarrheal episodes through the use questions to assess the attitude and practice of the study participants.
of Oral Rehydration Salts, are all important factors.8,9 Dependent variables: Knowledge, Attitude, and Practice of the
In developing countries, diarrheal illnesses remained the second child caregivers on ORS and Zinc utilization.
leading cause of death in children under the age of five. Diarrhea is also a Independent variables: Caregiver’s factors (Sociodemographic and
major killer of children in Ethiopia, making it a severe public health work-related characteristic; age, sex, level of education, marital status,
issue. Every year, an estimated 73,700 children under the age of five religion, occupation etc …), Child related factors (Demographic char­
years die because of diarrhea.10 acteristics; age of the child, breastfeeding, sex, number of under-five
Oral Rehydration Salts solution and zinc uses a component of child children etc …), Other factors (Partner’s occupation, educational sta­
survival strategy. However, available studies and information provided tus, income etc …).
limited or inadequate knowledge to increase Oral Rehydration Salts
solution and zinc use. This is study will provide information on de­ 2.4. Operational definition of terms
terminants of Oral Rehydration Salts solution and zinc use aimed at
guiding health providers & policymakers in improving childhood mor­ • Caregiver: A person who is responsible for a child.
bidities and mortalities due to diarrhea. Thus, this study aimed to assess • Diarrhea: the passage of three or more loose or liquid stools per day
the knowledge, attitude & practice of child caregivers towards oral • Dehydration: the loss of water from the body, as a result of diarrhea.
rehydration salt and zinc use for the treatment of diarrhea in under 5 • Good attitude: who answer above the mean of the attitude question
children in Gondar town, Amhara regional state, Ethiopia. was considered as having a good attitude.
• Good knowledge: who answer above the mean of the Knowledge
2. Method and materials question was considered as having good knowledge.
• Good practice: who able to answer above the mean of the practice
2.1. Study design, period, and area question was considered as having good practice
• Oral Rehydration Therapy (ORT): administration of recommended
A descriptive study was conducted at the university of Gondar fluid by mouth to prevent or correct dehydration as a result of
comprehensive specialized hospital. The hospital is located in Gondar diarrhea.
city, North West Ethiopia. It is located 737 km away from the capital city • Oral Rehydration Salt (ORS): A Solution used for the replacement
of Ethiopia. It is one of the most prestigious hospitals in the country of water secondary to diarrhea.
currently serving about seven million people in the catchment area. The • Poor attitude: who answer below the mean of the attitude question
study was conducted from August 07/2021 to September 10/2021. was considered as poor attitude.
Source population: All caregivers living in Gondar town having • Poor knowledge: who answer below the mean of the knowledge
under 5 children. question was considered as poor knowledge.
Study population: All under-five child caregivers in Gondar town • Poor practice: who answer below the mean of the practice questions
that fulfill the inclusion criteria. was considered as Poor practice.
Inclusion and Exclusion criteria: The inclusion criteria includes • Rehydration: replacement of fluid.
those under-five child caregivers in Gondar town that presented to the
pediatric outpatient department of the University of Gondar specialized 2.5. Data quality management
hospital during the study period, and those volunteers to participate in
the study. However, the exclusion criteria include those under-five child To ensure the quality of the data the following activities were un­
caregivers that were unable to communicate freely with the data col­ dertaken: careful design, translation, and retranslation of the question­
lectors due to medical conditions and/or language barriers. naire, close supervision of the data collection procedures, proper
categorization and coding of the data, reviewing the collected data for
2.2. Sample size determination accuracy and completeness by data collectors and supervisors, and by
checking the recorded data. A pre-test of the questionnaire was also
The sample size was calculated by using single population proportion conducted on 5% of the total sample size before the actual data collec­
formula with the following assumption. Prevalence of caregiver’s tion, and necessary amendments were made based on the feedback. The
knowledge of ORS 74.4%, based on the finding of a study conducted in participants in the pre-test were excluded from the final study.
Wolaita Sodo town in 2016,11 the margin of error of 5%, and confidence
interval of 95%. 2.6. Data analysis

n = (Z α/2) 2 P (1-P) /d2 After data collection, each questionnaire was checked for
completeness and consistency by data collectors. The collected data
Where, n = the sample size, Z = Critical value = 1.96, P= Prevalence =
74.4%, d = Margin of error = 5% were entered and analyzed using Statistical Package for Social Sciences
(SPSS) version 20. Frequencies and percentages were used to describe
n = (1.96)2 X 0.744(1–0.744) / (0.05)2 = 292 descriptive data and the results were presented using tables and figures.

2
D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Table 1 Table 1 (continued )

Distribution of socio-demographic variables of the study participants (caregivers Variable Category Frequency Percentage
and children). (N = 306) %
Variable Category Frequency Percentage Does all of your children No 13 4.2
(N = 306) % fully vaccinated? Other 2 0.7
Sex Male 50 16.3 Where do you take your To health institution 305 99.7
Female 256 83.7 child whenever s/he/ Traditional healer 1 0.3
Age of caregiver in years 15–24 32 10.5 they get diarrhea? Didn’t take s/he/ - -
24–35 212 69.3 them to anywhere
>35 62 20.3 Other - -
Religion Orthodox 238 77.8 Do you have health Yes 91 29.7
Muslim 54 17.6 insurance? No 215 70.3
Catholic 0 0 Did your child get diarrhea Yes 76 24.8
Protestant 12 3.9 in the last two weeks? No 230 75.2
Othera 2 0.7 Did your child receive ORS Yes 62 20.3
Level of education No formal 10 3.3 solution in the last two No 244 79.7
education weeks?
Primary school 58 19.0 a
Jewish.
Secondary school 108 35.3 b
Student, Labor work.
(9–12)
Higher education/ 130 42.5
university/college Both binary and multivariable logistic regression analyses were con­
Residence Rural 30 9.8 ducted to test for association between the different variables and a P-
Urban 276 90.2
Occupational status Employed 160 52.3
value of ≤0.05 was used to declare statistical significance at 95% Con­
Searching for job/ 29 9.5 fidence Interval (CI).
unemployed
House wife 117 38.2
3. Result
Type of occupation Health worker 12 3.9
Non health worker 148 48.4
Marital status: Single 8 2.6 A total of 306 caregivers were participated in the study. The mean
Married 286 93.5 age of the caregivers was 31.5 [SD ± 7.4] and more than two-thirds of
Divorced 7 2.3 them 212 (69.3%) were found to be between 25 and 35 years. Of the
Widowed 5 1.6
total caregivers, 256 (83.7%) of them were females and 238 (77.8%) of
If married, what does your Governmental 114 37.3
husband/wife do? employee them were Orthodox in Religion. About 296 (96.7%) of the participants
Private employ 83 27.1 have had a formal education in which 130 (42.5%) have a higher
Merchant 55 18.0 educational status. The majority of the caregivers 160 (53.3%) were
House wife 15 4.9
employed and more than 90% of them were urban residents (Table 1).
Otherb 19 6.2
What is the highest level of No formal 7 2.3
Concerning partner’s sociodemographic status, 164 (53.6%) of the
education he/she has education caregivers reported that their partners have higher degree educational
attained? Primary school 30 9.8 level (diploma/degree and above level). In occupational status of
Secondary school 85 27.8 spouses, 114(37.3%) were public servants followed by 83(27.1%) of
(9–12)
them being private employees. Among the employed spouses, 21(6.9%)
Higher education/ 164 53.6
university/college were health workers. More than half of the caregivers 170 (55.6%) earn
Type of profession Health worker 21 6.9 above 5000-birr monthly income and the majority of households 184
Non health worker 265 86.6 (60.1%) of were a family of four and five (Table 1).
Monthly income 6 2.0
<1000
The age of the children ranges from 0 to 59 months with a mean of
1000–30000 60 19.6
3000–5000 70 22.9
2.7 years [SD ± 1.21] and the majority 95 (31.0%) were between 36 and
>5000 170 55.6 47 months followed by 91 (29.7%) between 48 and 59 months. The
Family size < or equal to 3 77 25.2 majority of the children were males 163(53.3%). Most of the children
4 to 5 184 60.1 293(95.8%) were fully vaccinated and 248 (81.0%) were exclusively fed
45 14.7
breast milk for six months (Table 1).
>5
Relation of caregiver to the Mother 245 80.1
child Father 47 15.4
Sister/brother 3 1.0
Grandparent 9 2.9
3.1. Knowledge of caregivers about diarrhea and its management
Age of child 0–11 month 15 4.9
12–23 month 47 15.4 The majority of the participants 269 (87.9%) defined diarrhea as
24–35 month 58 19.0 occurring when the stool was watery or lose more than three or more
36–47 month 95 31.0
times and 21 (6.9%) participants indicated diarrhea as the presence of
48–59 month 91 29.7
Sex of child Male 163 53.3 blood. Most caregivers 297(97.1%) believed that diarrhea as a series
Female 143 47.7 problem of childhood illness and 268(87.6%) knew the danger signs
For how long was your Less than 6 months 49 16.0 related to childhood diarrhea. About 257 (84.0%) of caregivers had
child on exclusive 6 months 248 81.0 awareness about different causes of acute diarrhea in which 219 (71.6%)
breastfeeding Greater than 6 9 2.9
months
reported it as caused by poor hygiene.
Is your child currently Yes 84 27.5 More than half of caregivers 157(51.3%) said ORS should be started
breastfeeding? No 222 72.5 soon after the first/second motion of watery stool noticed, followed by
How many children under 1 206 67.3 118(38.6%) reported to be started after two days of watery stool. Almost
five do you have in your 2 99 32.4
half of caregivers 151(49.3) said ORS should be administered after each
house? 3 and above 1 0.3
Yes 293 95.8 bowel motion and 113(36.9%) reported every hour (Table 2).
All study participants reported that they have heard about ORT
packet, but only 242(79.1%) were answered correctly for replacement of

3
D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Table 2 Table 2 (continued )

Knowledge of caregivers about ORS and zinc usage for diarrheal disease man­ Variable Category Frequency Percentage
agement for under-five children in Gondar town, Amhara regional state, North (N = 306) %
West Ethiopia, 2021.
Where did you get Health facility 254 83.0
Variable Category Frequency Percentage information about Family 11 3.6
(N = 306) % ORS/Zinc? Friend 4 1.3
What do you understand Frequent passing of 269 87.9 Media 24 7.8
by diarrhea? watery stool (3 or more I’m a health 7 2.3
times) professional myself
Frequent passing of 6 2.0 Otherd 6 2.0
non- watery stool Total 360 100
Blood in stools 21 6.9 ORS: Oral Rehydration Salt.
Greenish stools 7 2.3 a
Transferred from sick person.
Mucus in stool 3 1.0 b
Eye ball-sucking.
Other, specified - - c
Do you think diarrhea is Yes 297 97.1 Nasogastric tube.
d
a serious child illness? No 9 2.9 Reading Instruction.
What do you think are Poor hygiene 219 71.6
the causes of diarrhea? Food poisoning/ 242 79.1
water loss and prevention of dehydration. Most participants 226
contaminated food
Contaminated water 201 65.7
(73.9%) reported that they also heard about zinc and 158(51.8) indi­
Teething 49 16.0 cated that zinc is used to decrease diarrhea followed by 45(14.7%)
Intestinal parasite 19 6.2 reporting it to be used for preventing dehydration. Respondents’
Othera 2 0.7 knowledge about ORS was gained from health facilities 254(83%), fol­
Do you know any danger Yes 268 87.6
lowed by the media 24 (7.8%) (Table 2).
signs related to No 38 12.4
diarrhea in a child?
What are some of the Becoming weak or 218 76.8
3.2. Attitude of child caregivers towards oral rehydration salt (ORS) and
danger signs lethargic frequent
associated with passing of diarrhea zinc
diarrhea? Repeated vomiting/ 107 37.7
vomiting everywhere About 164 (53.6%) of the study participants thought that ORS is the
Fever and blood in 154 54.2 mainstay of the treatment of diarrhea and 210 (68.6%) agreed that
stool
adding zinc in the treatment will improve the outcome. One hundred
Marked thirst of water 53 18.7
Poor feeding 88 31.0 seventy 170(55.6%) participants thought Diarrhea can be effectively
Reduced urine output 13 4.6 treated at home using salt and sugar solution. Only 48(15.7%) agreed
Otherb 8 2.8 homemade oral rehydration solution is equally effective as the ORS
Do you think diarrhea is Yes 291 95.1
formulation provided at health facilities, 193(63.1%) disagreed and 65
Preventable? No 15 4.9
The Purpose of ORS is? To Stop diarrhea 53 17.3 (21.2%) were neutral. One hundred ninety-three (91.8%) of the study
Reduce the duration of 9 2.9 caretakers believed that feeding a child with diarrhea will not aggravate
Diarrhea the disease. Moreover, two hundred ninety-six (96.7%) of the re­
Replace the body salts, 242 79.1 spondents believed that whenever the child gets diarrhea additional
energy and water lost
food and fluid should be given. (Fig. 1)
in diarrhea
Prevents diarrhea 2 0.7
I do not know - -
3.3. Diarrhea management practice of child care-givers
ORS is given with: Feeding bottle 49 16.0
Cup and spoon 243 79.4
Otherc 14 4.6 Of the total participants, 295(96.4%) had ever experienced ORS use,
I do not now - - and 206(67.3%) participants had experienced zinc use. In addition, 190
How soon should the use After two days of 118 38.6 (44.0%) of caregivers had the practice of giving rice water to their child
of ORS Start? watery stool
After three days of 26 8.5
with diarrhea, and 90 (20.8%) of the caregivers had the practice of
watery stool giving salt and sugar solution. Among those who ever used ORS, 290
Soon after the first/ 157 51.3 (94.8%) have the practice to use ORS only for 24 h once after it is
second motion of reconstituted.
watery stool noticed
About 288(94.1%) of caregivers prepared ORS correctly by adding
I do not know 5 1.6
Timing of ORS Every hour 113 36.9 one ORS sachet to 1000 ml of water while. The majority of the re­
administration: It is After each bowel 151 49.3 spondents 102(33.3%) used previously boiled and cooled water to pre­
given motion pare ORS solution, while 190(62.1%) use highland water. After
After vomiting 21 6.9 reconstitution, only 99 (32.4%) of caregivers gave the solution after the
To prevent diarrhea 16 5.2
before it starts
passage of every loose stool, while most of them 147(48.0%) gave six
I don’t know 5 1.6 and above times per day. (Fig. 2)
Have you ever heard Yes 226 73.9 One hundred eighty-one (59.2%) respondents gave zinc per day and
about zinc? No 80 26.1 117(38.2%) administer it correctly for 10–14 days. More than half 163
The purpose of zinc is? Doesn’t have any 9 2.9
(53.3%) of caregivers stored ORS Sacket/zinc tablet on a shelf followed
purpose
To decrease the 158 51.6 by 82(26.8%) inside a bag or an object. Most of the participants reported
diarrhea that they dispose of unused ORS Sacket 245(80.1%) and zinc tablet 226
To prevent 45 14.7 (73.9%) in the waste disposal area. (Table 3)
dehydration Of the total 306 caregivers, 199(65%) of them had good knowledge,
No idea 92 30.1
Other 2 0.7
and 257(84.0%) them had a good attitude about the management of
diarrhea and use of ORS and zinc. In addition, 187 (61.1%) of them were
found to have good practice of diarrhea management and ORS/Zinc

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D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Table 3 Table 3 (continued )

Practice of under-five child caregivers towards diarrheal disease management Variable Category Frequency Percentage
using ORS and zinc in Gondar town, Amhara region, North West Ethiopia, 2021. (306) %
Variable Category Frequency Percentage Three times daily 10 3.3
(306) % Four times daily 3 1.0
What do you feed your Breast milk only 14 4.6 I do not know 96 31.4
child on diarrhea? Breast milk + infant 25 8.2 Zinc is given for the Three days 21 6.9
formula duration of Five days 38 12.4
Complementary 152 49.7 Seven days 28 9.2
feeding only 10–14 days 117 38.2
Complementary 99 32.4 Othere 5 1.6
feeding plus breast milk I do not know 97 31.7
Normal family diet 15 4.9 Do you think ORS price is Yes 20 6.5
Othera 1 0.3 expensive No 260 85.0
Have you ever given oral Yes 295 96.4 I do not know 26 8.5
rehydration salt to your No 11 3.6 Where did you store the Inside refrigerator 24 7.8
child? ORS sachet and Zinc Shelf 163 53.3
Have you ever given Zinc Yes 206 67.3 tablet at home? Inside the bag/object 82 26.8
to your child? No 100 32.7 on the table 31 10.1
What type of home-made Sugar and salt solution 90 20.8 Otherf 6 2.0
oral solution do you Salt with water 5 1.2 Did you check/request Yes 219 71.6
give to your child with Juice 29 6.7 the expiry date for the No 87 28.4
diarrhea? Soup 59 13.7 ORS and zinc tablet
Rice water 190 44.0 you purchased?
Otherb 5 1.2 Did you request for Yes 285 93.1
I do not give anything 54 12.5 information regarding No 21 6.9
After how long the The same day 134 43.8 the use of ORS and zinc
diarrhea started do you Second day 142 46.4 tablet from a health
give ORS and zinc to Third day 14 4.6 professional/
your child? Fourth day 2 0.7 pharmacist whenever
I do not know 14 4.6 you purchased these
How do you prepare 1 sachet of ORS -300 2 0.7 products
ORS? mls (3 coke bottle) of Where do you disposed Waste disposal area 245 80.1
water unused ORS solution/ Toilet 31 10.1
1 sachet of ORS -500 10 3.3 sachet? Under the ground 6 2.0
mls (1 small size of Outside the compound 4 1.3
mineral bottle) Burn 4 1.3
1 sachet of ORS -750 2 0.7 Otherg 16 5.2
mls (1 medium size of Where do you disposed Waste disposal area 226 73.9
mineral bottle) unused zinc tablets? Toilet 26 8.5
1 sachet of ORS 288 94.1 Under the ground 6 2.0
-1000mls (1 L of water) Outside the compound 4 1.3
1 sachet of ORS 1 0.3 Burn 6 2.0
-1500mls (1.5 L or large Otherg 38 12.4
size of mineral of
ORS: Oral Rehydration Salt.
water) c
prepare it with 2-L water.
Other preparations 3 1.0 a
Who taught you how to Friend/neighbor/ 14 4.6 will not give any food.
b
mix ORS solutions and relative Lemon, water and salt solution.
c
how to administer Health provider 266 86.9 I’m health professional.
d
zinc? Media 8 2.6 More than 72 h.
Read instruction myself 17 5.6 e
1day,2 day.
Otherc 1 0.3 f
Drawer, Drug box.
How often should ORS be Once a day 8 2.6 g
I will use it again.
given? 2–3 times a day 24 7.8
4–5 times a day 22 7.2
6 & above times a day 147 48.0 utilization (Fig. 3).
After the passing of 99 32.4
every loose stool
No idea 6 2.0
3.4. Factors associated with caregivers knowledge towards ORS and zinc
How much ORS solution As much as s/he can 279 91.2 use in under-five children
should be given to a drink
child with diarrhea? Coffee cup of 100 ml 10 3.3 In the bivariate analysis, a significant association was observed be­
Don’t know/can’t 17 5.6
tween the educational status of caregivers and their knowledge about
answer
Other (specify) - - ORS and zinc utilization for diarrheal disease case management. Highly
How long should the 24 h. 290 94.8 educated (university, college) caregivers were 13.3 times more likely to
mixed ORS last? 48 h. 1 0.3 have knowledge about ORS and zinc utilization than those who were not
72 h. 4 1.3 had formal education. (COR = 13.3(2.686, 66.193)). Caregiver’s occu­
Otherd 11 3.6
What water do you use to Previously boiled and 102 33.3
pational status was among the socio-economic factors which were
mix ORS solution? cooled water significantly associated with the knowledge of ORS and zinc usage on
Drinking water 13 4.2 diarrheal disease case management. Caregivers with occupational status
Any available water 1 0.3 of employed were 2.949 times more likely knowledgeable about ORS
Highland water 190 62.1
and zinc utilization than those who were housewives. (COR = 2.949
Zinc is given Daily 181 59.2
Twice daily 16 5.2 (1.759, 4.943)). Caregivers with a monthly income of 3000–5000 were
also found 14.444 times more likely knowledgeable about ORS and zinc
utilization than those who were housewives (COR = 14.444(1.580,

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D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Fig. 1. Attitude of caregivers towards Oral Rehydration Salt (ORS) and zinc use for diarrheal disease management in under-five children in Gondar town, Amhara
regional state, North West Ethiopia, 2021.

Fig. 2. Attitude of caregivers regarding the frequency of Oral Rehydration Salt (ORS) administration for management of diarrhea in under-five children in Gondar
town, Amhara region, North West Ethiopia, 2021.

132.0)). no formal educations level (COR = 4.872(1.212,19.591)), (COR = 4.148

In the multivariable regression analysis, caregivers’ educational (1.065,16.154)). Similarly, employed caregivers were 2.144 times more
status, occupational status, and sex were the significant factors associ­ likely to have a good attitude about ORS and zinc utilization than their
ated with the knowledge of ORS and zinc usage in diarrheal disease counterparts (COR = 2.144(1.108, 4.149)) (Table 5).
management. Female caregivers were found 2.804 times more knowl­ In the multivariable regression analysis, however, only occupational
edgeable than males (P = 0.012). In addition, caregivers who have had status of the caregivers was significantly associated with their attitude.
higher education were 6.293 times more knowledgeable (P = 0.049), Employed caregivers were found to be 2.408 times more likely to have a
and those employed caregivers were 2.313 times more knowledgeable good attitude about ORS and zinc utilization than unemployed re­
(P = 0.015) than their counterparts, respectively (Table 4). spondents (P = 0.041) (Table 5).

3.5. Factors associated with caregivers attitude towards ORS and zinc use 3.6. Factors associated with care-givers practice towards use of ORS and
in under-five children zinc in under five children

In the bivariate analysis, a significant association was observed be­ In the binary logistic regression analysis, there was a statistically
tween the educational status of caregivers and their attitude about ORS significant association between caregivers’ educational level, occupa­
and zinc utilization for diarrheal disease case management. Caregivers tional status, family size, and sex with their practice on ORS and zinc
with high school education, and with higher education (college, uni­ usage for diarrhea management at a P-value of ≤0.05. Caregivers with
versity level) were 4.872 and 4.148 times more likely to have a good high school and higher education levels (Diploma, Degree) were 6.537
attitude about ORS and zinc utilization, respectively than those who had and 9.00 times more likely to have good practice compared with those

6
D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Fig. 3. KAP of Oral Rehydration Salt (ORS) and Zinc use for diarrheal disease management among caregivers of under-five children in Gondar town, Amhara regional
state, North West Ethiopia, 2021.

Table 4
Association of the socio-demographic variables with knowledge of ORS and zinc usage in under-five children in Gondar town, Amhara regional state, North West
Ethiopia, 2021.
Variables ORS and Zn use Knowledge Total COR (95%CI) P-value AOR P-value

Poor Good

Educational level No formal education 8 2 10 1 1 1 1

Primary school 30 28 58 3.250(0.634,16.648) 0.157 2.547(0.416,15.585) 0.312
High school 41 67 108 7.676(1.55,38.004) 0.013 4.234(0.699,25.651) 0.116
Higher education 40 90 130 13.3(2.686,66.193) 0.002 6.293(1.006,39.357) 0.049
Residence Rural 16 14 30 1 1 1 1
Urban 103 173 276 1.722(0.806,3.680) 0.161 1.450(0.613,3.430) 0.397
Occupational status Employed 43 117 160 2.949(1.759,4.943) 0.001 2.313(1.180,4.533) 0.015
Searching for job 17 12 29 0.828(.367,1.868) 0.649 0.654(.240,1.783) 0.406
House wife 59 58 117 1 1 1 1
Monthly income <1000birr 2 4 6 1 1 1 1
1000-3000birr 34 26 60 3.571(0.393,32.476) 0.258 4.092(0.387,43.216 0.241
3000-5000birr 24 46 70 14.444(1.580,132.0 0.018 10.086(0.940,108.212 0.056
>5000birr 59 111 170 12.347(1.406,108.4) 0.023 6.632(.636,69.202 0.114
Family size < or equal to 3 14 18 32 1 1 1 1
4 to 5 85 127 212 1.428(0.823,2.476) 0.205 1.039(0.535,2.018) 0.910
>5 20 42 62 1.110(0.522,2.362) 0.787 0.770(0.304,1.949) 0.581
Marital status Single 2 6 8 4.500(0.408,49.654) 0.219 9.475(0.456,196.942) 0.146
Married 108 178 286 2.923(.480,17.709) 0.244 1.918(0.198,18.567) 0.574
Divorced 5 2 7 0.600(0.053,6.712) 0.680 0.336(0.018,6.292) 0.465
Widowed 4 1 5 1 1 1 1
Age 15–24 14 18 32 1 1 1 1
25–35 85 127 212 0.612(0.254,1.473) 0.274 0.377(0.125,1.135) 0.083
>35 20 42 62 0.907(.496,1.657) 0.750 0.600(.275,1.309) 0.199
Sex Male 21 29 50 1 1 1 1
Female 86 170 256 1.431(.771,2.657) 0.256 2.804(1.254,6.270) 0.012

Abbreviations: AOR: Adjusted odds ratio, COR: Crude odds ratio, CI: Confidence interval, ORS: Oral Rehydration Salt, and Zn: Zinc.

that have no formal education, respectively (COR = 6.537 4. Discussion

(1.323,32294)), (COR = 9.000(1.829,44.29)). Similarly, employed
caregivers, those with a family size of >5, and female caregivers were Diarrhea is a leading cause of morbidity and mortality in under-five
2.768, 2.444, and 1.288 times more likely to have a good practice than children, particularly in developing nations. It is critical to treat diarrhea
their counterparts, respectively (Table 6). well before dehydration sets in. Millions of children’s lives may be saved
In the multivariable analysis, however, only occupational status of if caregivers were taught how to give their children ORS, Zinc, and
the caregiver and their sex were the only factors associated with their proper home care.12 The cornerstone of fluid replacement is oral rehy­
practice at P ≤ 0.05. Employed caregivers were 2.9 times more to have dration therapy. Proper awareness and administration of oral rehydra­
good practice than their unemployed counterparts (AOR = 2.927 tion solution is one of the components of the WHO diarrhea control
(1.533,5.587). Similarly, female caregivers were found 2.8 times more program.15,16
practical about ORS and zinc utilization for management of diarrhea In the present study, 295(96.4%) of the caregivers have had ever
compared to males (AOR = 2.875(1.319,6.263)) (Table 6). experienced ORS use. This finding is higher than a survey conducted in
Wolaita sodo, in which 186(74.4%) of the caregivers experienced ORS
use.11 This could be attributed to the difference in the prevalence rate of

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D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

Table 5
Association of the socio-demographic variables with attitude of ORS and zinc usage in under-five children in Gondar town, Amhara regional state, North West Ethiopia,
2021.
Variables ORS and Zn use Attitude Total COR (95%CI) p-value AOR P-value

Poor Good

Educational level No formal education 4 6 10 1 1 1 1

Primary school 14 44 58 2.095(0.516,8.504) 0.301 1.019(0.192,5.414) 0.983
High school 13 95 108 4.872(1.212,19.591) 0.026 2.093(0.382,11.472) 0.395
Higher education 18 112 130 4.148(1.065,16.154) 0.040 1.319(0.226,7.679) 0.758
Residence Rural 4 26 30 1 1 1 1
Urban 45 231 276 0.790(0.263,2.373) 0.674 0.719(0.221,2.338) 0.583
Occupational status Employed 18 142 160 2.144(1.108,4.149) 0.024 2.408(1.035,5.607) 0.041
Searching for job 6 23 29 1.042(0.383,2.835) 0.936 0.983(0.316,3.053) 0.976
House wife 25 92 117 1 1 1 1
Monthly income <1000birr 2 4 6 1 1 1 1
1000-3000birr 13 47 60 1.808(0.297,10.992) 0.520 2.775(0.351,21.946) 0.333
3000-5000birr 13 57 70 2.192(0.262,13.277) 0.393 2.146(0.276,16.708) 0.466
>5000birr 21 149 170 3.548(0.612,20.575) 0.158 3.401(0.455,25.443) 0.233
Family size < or equal to 3 34 43 77 1 1 1 1
4 to 5 74 110 184 0.877(0.425,1.809) 0.722 0.752(0.328,1.723) 0.500
>5 11 34 45 1.477(0.484,4.505) 0.493 1.769(0.480,6.518) 0.392
Marital status Single 0 8 8 242332 0.99 28621 0.99
Married 44 242 286 8.250(1.340,50.806) 0.23 5.933(0.723,48.677) 0.097
Divorced 2 5 7 3.750(0.331,42.467 0.286 3.378(0.222,51.488) 0.381
Widowed 3 2 5 1 1 1 1
Age 15–24 7 25 32 1 1 1 1
25–35 28 184 212 1.840(0.728,4.652) 0.198 1.914(0.684,5.358) 0.216
>35 14 48 62 0.960(0.343,2.684) 0.938 1.044(0.291,3.740) 0.948
Sex Male 9 41 50 1 1 1 1
Female 40 216 256 1.185(0.535,2.629) 0.676 1.542(0.580,4.098) 0.385

Abbreviations: AOR: Adjusted odds ratio, COR: Crude odds ratio, CI: Confidence interval, ORS: Oral Rehydration Salt, and Zn: Zinc.

Table 6
Association of the socio-demographic variables with the practice of ORS and zinc usage in under-five children in Gondar town, Amhara regional state, North West
Ethiopia, 2021.
Variables ORS and Zn use Practice Total COR (95%CI) p-value AOR P-value

Poor Good

Educational level No formal education 8 2 10 1 1 1 1

Primary school 30 28 58 3.733(0.729,19109) 0.114 3.084(0.487,19.531) 0.232
High school 41 67 108 6.537(1.323,32294) 0.021 4.332(0.692,27.135) 0.117
Higher education 40 90 130 9.000(1.829,44.29) 0.007 5.183(0.796,33.747) 0.085
Residence Rural 16 14 30 1 1 1 1
Urban 103 173 276 1.920(0.900,4.095) 0.092 1.537(0.663,3.56) 0.316)
Occupational status Employed 43 117 160 2.768(1.673,4.579) 0.001 2.927(1.533,5.587 0.001
Job seekers 17 12 29 0.718(0.315,1.635) 0.430 0.611(0.231,1.615) 0.320
House wife 59 58 117 1 1 1 1
Monthly income <1000birr 2 4 6 1 1 1 1
1000-3000birr 34 26 60 0.382(0.065,2.250) 0.288 0.422(0.062,2.860) 0.377
3000-5000birr 24 46 70 0.958(0.164,5.613) 0.962 0.576(0.084,3.967) 0.575
>5000birr 59 111 170 0.941(0.164,5.288) 0.945 0.446(0.067,2.961) 0.403
Family size < or equal to 3 34 43 77 1 1 1 1
4 to 5 74 110 184 1.175(0.686,2.012) 0.556 0.900(0.479,1.694) 0.745
>5 11 34 45 2.444(1.082,5.522) 0.032 2.103,0.805,5.496) 0.129
Marital status Single 2 6 8 12.00(0.796,180.974) 0.073 22.873(0.903,579.448) 0.058
Married 108 178 286 6.593(0.727,59.755) 0.094 9.461(0.664,134.719) 0.097
Divorced 5 2 7 1.600(0.104,24.703) 0.736 1.986(0.081,48.657) 0.674
Widowed 4 1 5 1 1 1 1
Age 15–24 14 18 32 1 1 1 1
25–35 85 127 212 1.162(0.549,2.461) 0.695 1.105(0.478,2.556) 0.816
>35 20 42 62 1.633(0.679,3.931) 0.274 1.957(0.664,5.766) 0.223
Sex Male 22 28 50 1 1 1 1
Female 97 159 256 1.288(1.698,2.377) 0.041 2.875(1.319,6.263) 0.008

Abbreviations: AOR: Adjusted odds ratio, COR: Crude odds ratio, CI: Confidence interval, ORS: Oral Rehydration Salt, and Zn: Zinc.

diarrheal disease in children between the two study areas. diarrhea.9

In the present study, it was found that about 65% of the caregivers In this study, female caregivers were found 2.804 times more
had good knowledge about ORS and zinc utilization for treating diar­ knowledgeable about ORS and zinc utilization than male counterparts.
rhea. This result was greater than a study done in Botswana in which This could be due to the frequent involvement of females (usually
only 32% of the caregivers were reported to have good knowledge.17 A mothers) in the care of their children when they were sick and this could
study done in Nigeria also showed that about 69.3% of mothers knew increase the chance that they will be more exposed to health education
about ORS use and only 18.5% of caregivers had heard of Zinc use in and medical information as compared to male counterparts (fathers). In

8
D.K. Yimenu et al. Clinical Epidemiology and Global Health 14 (2022) 100998

addition, caregivers who have had higher education and those employed at any point of the interview. Moreover, the confidentiality of the in­
were 6.293 and 2.313 times more knowledgeable than their counter­ formation was assured by using an anonymous questionnaire and
parts, respectively. keeping the data in a secured place.
This study also revealed that 84% of the participants had a good
attitude towards ORS and zinc usage which is higher than a study done Availability of data and materials
in wolaita sodo town, 76.8%.11 Caregivers’ employment status was also
a significant factor associated with their attitude towards ORS and Zinc Most of the data is included in the manuscript. Additional can be
utilization in which employed caregivers were found to be 2.408 times found from the corresponding author based on reasonable request.
more likely to have good attitude about ORS and zinc utilization than
unemployed respondents. This could be due to the fact that employed
Funding
caregivers would have better knowledge and access to medical infor­
mation during their study times and/or at their workplaces which will
No funding to report.
have a direct influence to their overall health-related knowledge, atti­
tude and practice.
Employed caregivers were also found 2.9 times more likely to have Declaration of competing interest
good ORS and Zinc usage practice than their unemployed counterparts.
Similarly, female caregivers were found 2.8 times more practical about The authors declares that they have no competing interests.
ORS and zinc utilization for management of diarrhea compared to
males. This could be because of the fact that female caregivers (mostly
Acknowledgment
mothers) are naturally very caring to their children’s health and will
most likely follow medical instructions in the care for their children.
We would like to acknowledge University of Gondar for material
In this study, about 94.1% of the caregivers followed the correct
supports.
procedures in the preparation of ORS solution. This finding was greater
than other studies done in Diredawa (85.4%), and India (76.7%).13,14
This could be justified by differences in educational status/awareness References
level of participants in these studies, and or frequent education by health
1 Satcher D. Food safety: a growing global health problem. JAMA. 2000;283(14),
workers in the present area due to the high prevalence of under-five 1817-1817.
diarrheal disease which will, in turn, increase caregivers’ awareness of 2 Kotloff KL. The burden and etiology of diarrheal illness in developing countries.
the care strategies. Pediatr Clin. 2017;64(4):799–814.
3 Olopha OO, Egbewale B. Awareness and knowledge of diarrhoeal home management
In the present study, the majority 86.9% of the caregivers gain in­ among mothers of under-five in Ibadan, Nigeria. Univers J Publ Health. 2017;5(1):
formation about ORS and zinc utilization from health workers. A similar 40–45.
study conducted in Assela town, Ethiopia showed that (62.3%) of the 4 Ogunrinde OGRT, Owolabi OA, Anigo KM. Knowledge, attitude and practice of home
management of childhood diarrhoea among caregivers of under-5 children with
caregivers received their information about ORS and zinc utilization diarrhoeal disease in Northwestern Nigeria. J Trop Pediatr. 2012;58(2):143–146.
from the health workers.16 This could be due to frequent health facility Journal of tropical pediatrics. 2012 Apr 1.
visits and subsequent meetings with health professionals and/or the 5 CSA I. Ethiopia Demographic and Health Survey. Central Statistics Agency and ICF
International: USA, Addis Ababa, Ethiopia and Calverton. 2012. Maryland. 2011.
involvement of health extension workers that regularly provide 6 Lemma F, Matji J. Child nutrition in Ethiopia: a review article. Ethiop J Pediatr Child
home-based health education in these areas. Health. 2014;10(10):1–15.
7 Blum LS, Oria PA, Olson CK, Breiman RF, Ram PK. Examining the use of oral
rehydration salts and other oral rehydration therapy for childhood diarrhea in Kenya.
4.1. Limitation of the study Am J Trop Med Hyg. 2011;85(6):1126.
8 Mengistie B, Berhane Y, Worku A. Predictors of Oral Rehydration Therapy use among
As the study is cross-sectional and depends on self-reported assess­ under-five children with diarrhea in Eastern Ethiopia: a community based case
control study. BMC Publ Health. 2012;12(1):1–7.
ment, under-reporting is more likely to occur. It is possible that some
9 Ugwu J, Ezeagu I, Ibegbu M. Awareness and practice of zinc therapy in diarrheal
caregivers may not remember the details about the usage and practice of management among under-five caregivers in Enugu State, Nigeria. Int J Med Health
ORS and Zinc (recall bias) which may affect the reliability and validity of Dev. 2019;24(2):63–69.
the data. 10 Kumar S, Subita L. Diarrhoeal diseases in developing countries: a situational analysis.
Kathmandu Univ Med J. 2012;10(2):83–88.
11 Yasin Ddeky, Halala Y. Assessment of knowledge, attitude& practice of child care
5. Conclusion givers towards oral rehydration salt for diarrhea treatment in under 5 children in
wolaita sodo town, SNNPR/2016. Assessment. 2017;7(4).
12 Abera A, Assefa E. School of Nursing and Midwifery, Jimma University, Jimma,
There was good knowledge, attitude, and practice about Oral south west Ethiopia.
Rehydration Salt and zinc usage among child caregivers. Occupational 13 Workie Hm, Sharifabdilahi As, Addis Em. Mothers’ knowledge, attitude and practice
status of caregivers was significantly associated with all three variables; towards the prevention and home-based management of diarrheal disease among
under-five children in Diredawa, Eastern Ethiopia, 2016: a cross-sectional study.
knowledge, attitude, and practice. Regular educational strategies aimed BMC Pediatr. 2018;18(1):1–9.
at improving child caregivers’ awareness of diarrhea disease manage­ 14 Lamberti Lm, Fischer Walker Cl, Taneja S, Mazumder S, Black Re. The association
ment and utilization of ORS and Zinc tablets are advised. between provider practice and knowledge of ORS and zinc supplementation for the
treatment of childhood diarrhea in Bihar, Gujarat and Uttar Pradesh, India: a multi-
site cross-sectional study. PLoS One. 2015;10(6), e0130845.
Ethical consideration 15 Liben Ml, Abebe Y, Birara S, et al. KNOWLEDGE, ATTITUDE AND PRACTICE
TOWARDSORAL REHYDRATION SALTIN AYSAITA TOWN, AFAR REGIONAL
STATE, NORTHEASTERN ETHIOPIA.
Ethical clearance of the study was obtained from the ethical review
16 Adanech E. Assessment of Knowledge, Practice and Utilaization of Oral Rehayderation
board of the school of Pharmacy, the University of Gondar with an Therapy for Acute Watery Diarrhoeal Disease Case Management Among Mothers
approval number of SOP/272/2013. Verbal consent was obtained from (Caregivers’) of Under-five Children in Assela Town, Ethiopia. Addis Ababa University;
each participant. Participation in the study was on a voluntary basis, and 2015.
17 Mosweu GJ. Knowledge, Attitude and Practices of Caregivers (KAP) on Management of
participants were informed of their right not to participate in the study if Childhood Diarrhoes Amond Children Aged between 0-5 Years Attending Child Welfare
they do not want to participate and the right to withdraw from the study Clinic (CWC) in Mogoditshane Village. 2018. Botswana.