INTRODUCTION
Diarrhea is one of the major causes of child morbidity and mortality in low-income and developing countries. Children younger than 5 years are particularly vulnerable with diarrhea, accounting for more than one-quarter of all deaths in this age-group. Children younger than 5 years are estimated to account for 8% of total diarrheal deaths worldwide in 2016. 1 The problem has been widely attributed to the lack of access to quality health care and effective treatments. 2–5
In Iraq, the impacts of wars, sanctions, and sectarian violence have left a shattered health system and an ongoing public health emergency impacting vulnerable sections of the population, particularly children. 6–8 The UNICEF has indicated that diarrhea is the second most common cause of death among Iraqi children younger than 5 years. 9 A study in Baghdad hospitals between 1990 and 1997 reported a mortality rate of 28.6% among children aged less than 5 years experiencing diarrheal diseases. 10 In addition, a national study analyzing data from the Iraqi Multiple Indicator Cluster Survey showed that 21.3% of the children younger than 5 years had diarrhea. 11
Most of the deaths attributed to diarrhea result from dehydration following excessive losses of fluid and electrolytes. Thus, if home-based therapies are not effective at curbing symptoms, then providing children with prompt access to health care is critical for avoiding fatality. 12,13 Once health care is accessed, affordable and effective interventions exist in the form of oral rehydration therapy (ORT) combined with oral zinc supplements. When these treatments are given in a timely manner, they represent the optimal approach for curtailing mortality. 14–16 A critical factor in the survival of these cases is therefore the level of maternal understanding of the effective options for home-based management and the symptoms that signal the need to access health care. 13–19 Practices that conflict with the WHO treatment guidelines for the management of childhood diarrhea are sometimes relied upon in the home and include restriction of fluids, breast milk, and/or food intake during diarrhea episodes, and incorrect use of medicines. 20–22 At the very least, these delay access to potentially life-saving therapy or may even act to hasten mortality.
The literature clearly establishes a sociodemographic gradient influencing the occurrence of diarrhea in many countries. 13–25 Much less is known about the extent to which sociodemographic factors influence the maternal management of diarrhea once it develops. 23 In Iraq, despite the dire impact of diarrhea on the survival of children, there are no studies examining the influence of sociodemographic factors on how mothers seek access to health care when their children develop diarrhea. The present study was therefore undertaken to examine home-based management of diarrheal disease in children in Thi-Qar Governorate of Iraq and specifically to identify the sociodemographic factors associated with healthcare-seeking practices of mothers of children younger than 5 years. The results of this study provide important baseline information to inform national public health policies that address community needs on the management of childhood diarrhea.
METHODS
Study setting.
A cross-sectional study was conducted in Thi-Qar Governorate, southeastern Iraq, between March 2016 and February 2017. Thi-Qar has an area of 12,900 km2 and is divided into five districts (Nassriya, Al-Shatrah, Al-Rifa’i, Suq Al-Shoyokh, and Al-Chibaysih), with a total population of 1,742,852 as projected for the year 2013. 26 Thi-Qar Governorate was targeted in this study because it is considered as the least developed governorate in Iraq, with 37.8% of the population living below the poverty line of US$ 2.5/day. 26 The economy of Thi-Qar is largely rural and dependent on livestock and crop production. Unpublished data from the Surveillance Unit in Thi-Qar Public Health Division have documented frequent occurrences of acute diarrhea outbreaks among children younger than 5 years for the past several years.
Study population and sampling procedures.
In the present study, we targeted mothers who had a child or children younger than 5 years. Information on the number of households and the population demographic map in Thi-Qar districts was supplied by the primary healthcare center (PHCC) in each district. A household was considered eligible for the survey if the following criteria were met: 1) at least one child younger than 60 months living in the home and 2) the caregivers (mothers) were older than 18 years and were willing to participate in the interview. In the case where the family had more than one eligible child, then only one child was randomly selected for inclusion in the study. Mothers were approached for interview in their household by field-workers who were all female public health nurses affiliated with Thi-Qar Public Health Division. The principal investigator/author of this study provided 5 days of training for 10 field-workers and two quality control supervisors on the administration of the interview questions.
The sample size of the interviewed mothers was estimated using the single population proportion formula Z 2 P (1−P)/d 2, where P is the prevalence of diarrhea (assumed 0.5), d is the required margin of error (assumed 0.05), and Z is the normal distribution critical value corresponding to 95% confidence, resulting in a sample size of 384. Additional 116 samples (30% of the calculated sample size) were added to compensate for the anticipated nonresponse rate, resulting in a targeted sample size of 500 mother–child pairs. Two stages of sampling were conducted to select study participants from Thi-Qar community. In the first stage, five villages in each of the five districts of Thi-Qar were selected using a simple random sampling method; thus, a final sampling frame of 25 villages was eligible for the study. In the second stage of sampling, a listing of households with at least one child younger than 5 years in each of the selected villages was obtained (based on data from PHCC for each district), and a cluster of 20 households was selected from this using a systematic random sampling technique. Hence, a total of 500 households with eligible mothers of children younger than 5 years were recruited into the survey.
Questionnaire administration and ethics approvals.
Household survey data were collected using a structured questionnaire. The questionnaire was prepared in English and translated to Arabic, and then back translated into English to assure the consistency and accuracy of the questions. The survey questionnaire was pilot tested with a group of mothers (n = 10) in one of the study districts to evaluate face validity and overall understanding of the questions. The questionnaire was divided into 1) general and demographic information of the mother and child, 2) self-reported information on incidence of child diarrhea, 3) mother’s knowledge about diarrheal disease, and 4) mother’s intended actions in response to diarrhea in their children younger than 5 years.
Ethics approval and consent to participate.
Informed verbal consent was obtained from the mothers before commencing the questionnaire interviews. The study protocol and verbal consent arrangements were approved by the Murdoch University Human Research Ethics Committee (Permit no. 2015/224) to mind the educational and cultural contexts in the study setting. Aim and objectives of the study were explained to all of the interviewed mothers, and confidentiality of their information was confirmed. The study was submitted to and approved by the Ministry of Health, Iraq (Permit no. 11/5/393), and ethical approval was also granted by the Scientific and Ethical Research Committee of the Training and Developing Center for Thi-Qar Health Director (Permit no. 1/4/29364).
Measures and statistical analysis.
The collected questionnaire data were stored in Epi-Info version 3.5.1 software (Centers for Disease Control and Prevention, Atlanta, GA) and then exported for descriptive analysis in Stata version 11.0 (Stata Corp., College Station, TX). The interviewers gathered data on the occurrence of diarrhea by asking mothers “Did any of your children aged five and below pass a loose watery stool with or without blood continuously for more than three times in any particular day in the last 2 weeks?” For this response, univariable logistic regression was used to explore the relationship between predictor variables and the binary answers (yes/no) reported by the mothers (Table 1). Following from the initial univariable model, the analysis consisted of building a multivariable logistic regression model based on potential predictor factors indicated from the univariable analysis with P-value 0.25. The most appropriate final model was selected using the backward stepwise selection approach. 24 The associations were assessed by odds ratio (OR) and 95% CIs, and were considered significant at P-value 0.05. All pairwise interactions between the variables in the final model were examined for significance. Goodness of fit of the final model was assessed using the Hosmer–Lemeshow test.
Univariate analysis of factors associated with mothers (n = 500) reporting of the occurrences of diarrhea among their children aged < 5 years in Thi-Qar Governorate, Iraq
| Variable | Category | Total | Reported diarrhea, n (%)* | OR† (95% CI)‡ | P-value |
|---|---|---|---|---|---|
| District of residence§ | Al-Chibaysih | 115 | 32 (27.8) | 1.0 (−) | – |
| Nassriya | 87 | 42 (48.2) | 1.7 (0.8–3.8) | 0.084 | |
| Al-Rifa’i | 117 | 69 (58.9) | 3.7 (2.1–6.4) | < 0.001 | |
| Al-Shatra | 95 | 25 (26.3) | 0.9 (0.5–1.7) | 0.807 | |
| Suq Al-Shoyokh | 86 | 8 (9.3) | 0.2 (0.1–0.6) | 0.002 | |
| Gender of child | Female | 216 | 81 (37.5) | 1.0 (−) | – |
| Male | 284 | 95 (33.4) | 0.8 (0.5–1.2) | 0.348 | |
| Age of child§ (years) | < 2 | 74 | 21 (28.3) | 1.0 (−) | – |
| ≥ 2 | 426 | 155 (36.3) | 1.4 (0.8–2.4) | 0.185 | |
| Number of inhabitants in the household§ | < 8 | 222 | 66 (29.7) | 1.0 (−) | – |
| > 8 | 278 | 110 (39.5) | 1.5 (1.1–2.2) | 0.022 | |
| Number of children aged < 5 years in the household | < 2 | 310 | 105 (33.8) | 1.0 (−) | – |
| > 2 | 190 | 71 (37.3) | 1.1 (0.7–1.6) | 0.427 | |
| Mother breastfeeding pattern in the first 6 months of age§ | Exclusive bottle-fed | 157 | 65 (41.4) | 1.0 (−) | – |
| Exclusive breastfed | 242 | 74 (30.58) | 0.6 (0.4–0.9) | 0.027 | |
| Mix—breastfed and bottle-fed | 101 | 37 (36.6) | 0.8 (0.4–1.3) | 0.445 | |
| Mother age§ (years) | ≤ 25 | 254 | 116 (45.6) | 1.0 (−) | – |
| > 25 | 246 | 60 (24.3) | 0.3 (0.2–0.5) | < 0.001 | |
| Mother employment status§ | Not working | 399 | 153 (38.3) | 1.0 (−) | – |
| Working | 101 | 23 (22.7) | 0.4 (0.2–0.7) | 0.004 | |
| Mother education level§ | University | 44 | 9 (20.4) | 1.0 (−) | – |
| High school | 55 | 16 (29.1) | 1.5 (0.6–4.0) | 0.328 | |
| Primary | 204 | 77 (37.7) | 2.3 (1.1–5.1) | 0.032 | |
| Secondary | 101 | 36 (35.6) | 2.1 (0.9–4.9) | 0.073 | |
| Illiterate | 96 | 38 (39.6) | 2.5 (1.1–5.8) | 0.029 | |
| Mother knew about the signs of child diarrhea | No | 304 | 107 (35.2) | 1.0 (−) | – |
| Yes | 196 | 69 (35.2) | 1.0 (0.6–1.4) | 0.999 | |
| Mother received a health education message from local health department on management of child diarrhea this summer§ | No | 326 | 122 (37.4) | 1.0 (−) | – |
| Yes | 174 | 54 (31.0) | 0.7 (0.5–1.1) | 0.155 |
By mother, regarding diarrhea incidence in the last 2 weeks.
OR = odds ratio.
CI = confidence interval.
Variables with P < 0.25: predictor factor offered to the final multivariable logistic model.
Mothers were further asked about home-based management options and types of healthcare facilities that they seek in response to diarrhea in their children younger than 5 years. The key outcome measure (dependent) variables were 1) mother’s choice of treatment-seeking options and 2) alternative and/or home-based diarrhea management options considered by the mother for the management of childhood diarrhea. The individual exploratory sociodemographic (independent) variables that were assessed as predictors for mother’s choices are education level, employment status, age, and district poverty index (categorized based on the proportion of population that lived below the poverty line of US$ 2.5/day). 26 Because the outcomes consisted of categorical responses, the discrete choice model based on multinomial logistic regression was used for analysis by deploying the procedure “mlogit” in STATA software. 24 In this analysis, the reference category and a set of logistic regressions were computed as follows: for healthcare seeking, the options were medical center and pharmacy vendor, and the reference category was the option of mothers not seeking treatment (no action), whereas for alternative and/or home-based, the options were purchase of medicine from pharmacy, provide homemade fluids, and provide herbal remedies, and the reference category was to consult a traditional healer for assistance. These options are then contrasted one after the other against reference categories. The relative risk ratios (rrrs) were applied to examine the multivariate influence of the selected sociodemographic variables on mothers’ choices of healthcare seeking and alternative management options of childhood diarrhea. The goodness of fit of the model was determined by the likelihood ratio chi-square. The importance of this statistic was to show whether the model fits significantly than an empty model, which is a model not including any of the explanatory variables of the study. Statistical significance was set at 5% (P-value ≤ 0.05).
RESULTS
Baseline characteristics.
Interviews were completed between March 2016 and February 2017 with 500 mothers in Thi-Qar, southeastern Iraq. Of these, 35.2% (176/500) reported that a child, younger than 5 years, in their household suffered from diarrhea in the 2 weeks before the interview. Data characteristics among the interviewed 500 mother–child pairs are presented in (Table 1). The number of total inhabitants in the participating households ranged between four and 15 (median = 9 inhabitants), whereas the number of children younger than 5 years ranged between one and four (median = 2 children). Of the 500 children, 284 (56.8%) were males and 216 (43.2%) were females. The age of children ranged between three and 55 months (median = 20 months), whereas the age of mothers ranged between 18 and 45 years (median = 25 years). Around one-third (34.8% [174/500]) of the mothers reported receiving a health education message on management of child diarrhea from the local health department, and 39.2% (196/500) of them indicated they knew the signs of child diarrhea.
Predictors associated with the occurrence of diarrhea.
Univariable logistic regression analysis was used to screen predictor factors associated with the self-reported occurrence of diarrhea as indicated by mothers (Table 1). District of residence, age of the child, number of inhabitants in the household, breastfeeding pattern in the first 6 months, age of mothers, employment status, education level, and the delivery of health education message to mothers (from the local health department on management of child diarrhea) showed a P-value < 0.25, and hence considered as potential predictor factors based on the univariable logistic regression model (Table 1). Of these eight potential predictor factors, three were identified by the final multivariable logistic regression model as independently associated with the occurrence of diarrhea reported by the mothers (Table 2). The estimated ORs and their 95% CIs of the multivariable logistic regression model are presented in Table 2. These results (Table 2) suggest that the reported occurrence of diarrhea in their children was more likely to occur among mother–child pairs residing in Al-Rifa’i (58.9% [69/117]) and Nassriya (48.2% [42/87]) districts, and less likely to occur among mother–child pairs from Suq Al-Shoyokh district (9.3% [8/86]). Among the study subjects, the least likelihood of reported occurrence of diarrhea was among mother–child pairs of whom the mother received university education, as compared with mothers who were illiterate or received either primary or secondary education. Mothers aged > 25 years were found to have lower odds (OR = 0.4, P-value < 0.001) of reporting diarrhea in their children than those aged ≤ 25 years. None of the two-way interactions between the variables were statistically significant (P > 0.05). The Hosmer–Lemeshow goodness-of-fit test suggested no evidence of lack of fit of the final model (Hosmer–Lemeshow χ2 = 1.26, P = 0.8710).
Multivariable logistic regression model of factors significantly associated with mothers (n = 500) reporting of the occurrence of diarrhea among their children aged < 5 years in Thi-Qar Governorate, Iraq
| Predictor factor | OR* | 95% CI† | SE‡ | P-value |
|---|---|---|---|---|
| District vs. Al-Chibaysih | ||||
| Nassriya | 2.4 | (1.1, 5.3) | 0.967 | 0.026 |
| Al-Rifa’i | 3.6 | (2.1, 5.9) | 0.924 | < 0.001 |
| Suq Al-Shoyokh | 0.2 | (0.1, 3.9) | 0.107 | 0.001 |
| Level of education vs. university | ||||
| Primary | 2.1 | (1.2, 3.9) | 0.664 | 0.011 |
| Secondary | 2.1 | (1.1, 4.2) | 0.742 | 0.031 |
| Illiterate | 2.3 | (1.2, 4.8) | 0.869 | 0.016 |
| Mother age- vs. ≤ 25 years | ||||
| > 25 years | 0.4 | (0.2, 0.6) | 0.0872 | < 0.001 |
OR = odds ratio.
CI = confidence interval.
SE = standard error.
Mothers’ practices and determinants of health-seeking options.
Interviews also gathered information about mothers’ practices and health-seeking options in response to diarrhea occurring among their children (Table 3). Almost half of the mothers (55.2% [276/500]) indicated that they breastfeed their children less than the usual during diarrheal illness, and around quarter of them (27.2% [136/500]) reported providing more foods to their children while suffering from diarrhea (Table 3). Of the 500 interviewed mothers, 36.4% preferred taking their diarrheic children to a medical center treatment. Self-ordered medicines from a pharmacy were the most preferred alternative management options in almost half (52.4% [262/500]) of the interviewed mothers in Thi-Qar (Table 3). Results in Table 3 revealed that 69.6% (348/500) of the mothers reported self-purchasing of antibiotics and administration to children suffering from diarrhea. On the other hand, only 24% (120/500) indicated providing ORT to their diarrheic children. Results in Table 4 elaborate on some potential predictor factors associated with the practice of providing antibiotics and ORT among the interviewed mothers. Univariable logistic regression analysis indicated that the practice of providing antibiotics to diarrheic children was significantly higher among mothers aged > 25 years (OR = 1.5, P-value = 0.038) and mothers who received high school education (OR = 2.5, P-value = 0.051). On the other hand, the practice of providing ORT therapy was particularly associated with employed mothers (OR = 2.6, P-value = 0.008), as well as with mothers interviewed in districts with more favorable poverty status (OR = 2.5, P-value = 0.007; Table 4).
Overview of some practices reported by Iraqi mothers interviewed in Thi-Qar Governorate (n = 500) in relation to the management of diarrheal illness among their children aged < 5 years
| Variable | Category | Frequency (n) | Percentage |
|---|---|---|---|
| Breastfeeding the child during diarrhea | No change in pattern (usual) | 154 | 30.8 |
| Breastfed less than usual | 276 | 55.2 | |
| Breastfed more than usual | – | – | |
| Stop breastfeeding | 70 | 14.0 | |
| Provide the child with more frequent foods | No | 364 | 72.8 |
| Yes | 136 | 27.2 | |
| Preferred treatment-seeking options | Medical centers | 182 | 36.4 |
| Pharmacy | 108 | 21.6 | |
| No treatment | 210 | 42.0 | |
| Preferred alternative management options | Traditional healer | 170 | 34.0 |
| Herbal remedies | 26 | 5.2 | |
| Homemade fluids | 42 | 8.4 | |
| Self-ordered medicine from a pharmacy | 262 | 52.4 | |
| Antibiotic is provided to the child | No | 152 | 30.4 |
| Yes | 348 | 69.6 | |
| Oral rehydration therapy is provided to the child | No | 380 | 76.0 |
| Yes | 120 | 24.0 |
Univariate analysis of factors associated with providing antibiotics and ORT among Iraqi mothers’ (n = 500) in the course of management of diarrhea among their children < 5 years old
| Variable | Category | Antibiotic is provided to children | ORT is provided to children | ||
|---|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | ||
| Mother education level | University | 1.0 (−) | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| High school | 2.5 (0.9, 6.2) | 0.051 | 0.6 (0.2, 1.6) | 0.358 | |
| Primary | 1.1 (0.4, 2.7) | 0.820 | 1.4 (0.5, 3.6) | 0.472 | |
| Secondary | 1.2 (0.5, 3.0) | 0.604 | 0.7 (0.3, 1.9) | 0.604 | |
| Illiterate | 0.8 (0.3, 2.1) | 0.654 | 0.4 (0.1, 1.4) | 0.191 | |
| Mother employment status | Not working | 1.0 (−) | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| Working | 0.7 (0.3, 2.1) | 0.492 | 2.6 (1.3, 5.5) | 0.008 | |
| Mother age (years) | ≤ 25 | 1.0 (−) | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| > 25 | 1.5 (1.0, 2.2) | 0.038 | 1.0 (0.6, 1.5) | 0.863 | |
| District poverty index | 10–24.9% below the poverty line | 1.0 (−) | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| 5–9.9% below the poverty line | 1.5 (0.8, 2.7) | 0.121 | 2.5 (1.2, 4.8) | 0.007 | |
| ≥ 40% below the poverty line | 1.3 (0.7, 2.3) | 0.308 | 1.8 (0.9, 3.5) | 0.087 | |
| Age of children (years) | < 2 | 1.0 (−) | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| ≥ 2 | 1.1 (0.7, 1.6) | 0.591 | 0.8 (0.5, 1.3) | 0.560 | |
OR = odds ratio; ORT = oral rehydration therapy. Bold values denotes variable categories with a statistically significant difference.
Table 5 depicts the rrr for the multinomial models. The result shows that, relative to mothers with university education, those with high school education had more likelihood of seeking help through visiting medical centers (rrr = 2.4) and pharmacies (rrr = 3.7) as against mothers seeking no treatment. Among mothers from districts with 5–9.9% below the poverty line and relative to those from districts with 10–24.9% below the poverty line, the rrr for a mother opting for pharmacy versus no treatment is 0.2 (95% CI: 0.1, 0.5). As shown in Table 5, relative to mothers who received university education level, illiterate mothers were more likely to use herbal remedies and homemade fluids as alterative options for the management of diarrhea among their children, as compared with seeking help from a traditional healer. The results also show that the likelihood of using herbal remedies was higher (rrr = 2.3) among mothers aged > 25 years than among their younger counterparts (≤ 25 years; Table5).
Multinomial model estimates of preferred treatment-seeking options and alternative options as determined by mothers (n = 500, Thi-Qar-Iraq) sociodemographic characteristics
| Model—preferred treatment-seeking options (with no treatment as reference) | Medical centers rrr (95% CI) | Pharmacy rrr (95% CI) | ||
|---|---|---|---|---|
| Mother education level | University | 1.0 (−) | 1.0 (−) | |
| High school | 2.4 (0.9, 6.1) * | 3.7 (1.1, 12.2) * | ||
| Primary | 1.4 (0.5, 3.7) | 1.8 (0.5, 6.3) | ||
| Secondary | 1.6 (0.6, 4.2) | 5.7 (1.7, 18.9) * | ||
| Illiterate | 0.9 (0.3, 2.7) | 3.3 (0.9, 12.1) | ||
| Mother employment status | Not working | 1.0 (−) | 1.0 (−) | |
| Working | 1.2 (06. 2.6) | 1.5 (0.6, 3.5) | ||
| Mother age (years) | ≤ 25 | 1.0 (−) | 1.0 (−) | |
| > 25 | 1.1 (0.7, 1.6) | 0.8 (0.5, 1.4) | ||
| District poverty index | 10–24.9% below the poverty line | 1.0 (−) | 1.0 (−) | |
| 5–9.9% below the poverty line | 0.9 (0.5, 1.7) | 0.2 (0.1, 0.5) † | ||
| ≥ 40% below the poverty line | 0.8 (0.4, 1.6) | 0.6 (0.3, 1.3) | ||
| Model—preferred alternative management options (with traditional healer as reference) | Herbal remedies rrr (95% CI) | Homemade fluids rrr (95% CI) | Self-ordered medicine from a pharmacy rrr (95% CI) | |
| Mother education level | University | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| High school | 1.9 (0.1, 2.3) | 1.2 (0.2, 8.5) | 0.8 (0.3, 2.0) | |
| Primary | 4.6 (0.3, 6.4) | 6.6 (0.8, 26.5) | 1.2 (0.5, 3.1) | |
| Secondary | 2.4 (0.18, 3.2) | 1.4 (0.2, 4.4) | 1.0 (0.4, 2.5) | |
| Illiterate | 19.8 (1.3, 28.3) * | 9.4 (1.1, 26.6) * | 1.6 (0.6, 4.4) | |
| Mother employment status | Not working | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| Working | 1.9 (0.3, 10.1) | 2.4 (0.6, 9.9) | ||
| Mother age (years) | ≤ 25 | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| > 25 | 2.3 (0.9, 5.6) * | 1.1 (0.5, 2.1) | 0.8 (0.4, 1.6) | |
| District poverty index | 10–24.9% below the poverty line | 1.0 (−) | 1.0 (−) | 1.0 (−) |
| 5–9.9% below the poverty line | 0.6 (0.1, 3.0) | 1.2 (0.4, 3.5) | 0.8 (0.4, 1.5) | |
| ≥ 40% below the poverty line | 1.1 (0.2, 4.2) | 0.7 (0.2, 2.2) | 0.6 (0.3, 1.1) | |
rrr = relative risk ratio. Bold values denotes variable categories with a statistically significant difference.
P-value < 0.05.
P-value < 0.001.
DISCUSSION
To the best of our knowledge, this is the first study to investigate the sociodemographic factors associated with childhood diarrheal illness and caregiver treatment in Iraq. This study highlights the significant role of mothers in healthcare-seeking practices and alternative management options in relation to diarrheal illness among their children. In the present study, 35.2% of children younger than 5 years in Thi-Qar were reported to have experienced diarrhea in the 2 weeks before survey. This occurrence of diarrhea is higher than the rate reported for a similar age-group (21.3%) in a national household survey among Iraqi mothers in the year 2000 11 and is also higher than levels in similar household studies conducted in the Eastern Mediterranean region, including Jordan (19.1%) 27 and Egypt (23.6%; Dakahlia). 28 Nevertheless, a number of other community studies reported higher rates of diarrhea in children younger than 5 years, for example, North and South Ethiopia (30.5–31.3%), 22–29 Afghanistan (32.5%), 30 Burundi rural areas (32.6), 3 and southern Nepal (36.6%). 21
Promotion of hygiene and health education messages in the community and family is regarded as a key pillar in the fight against childhood diarrhea. 3 However, in the present study, only 34.8% of the mothers reported receiving health education messages relating to the management of child diarrhea from the local health department. The level of public health communication is lower than what was noted in studies in Ghana, where 73.7% and 79.6% of caregivers of children younger than 5 years received health education messages on diarrhea in the Volta and the northern region. In the Ghanaian studies, most of the messages were acquired through nurses in health facilities, suggesting this as potentially a low-cost community health strategy which could receive greater emphasis in Iraq. 31 Our results also showed that 39.2% of the mothers knew about signs of child diarrhea. This result is comparable to surveys conducted previously in the north of Iraq (Sulaimania), 32 Iran (Zahedan), 33 Odisha, 34 and Tanzania (Mkuranga), 35 which reported the low level of mothers’ knowledge about signs of diarrhea. The WHO indicated that the mothers’/caregivers’ perception of the signs of child diarrheal disease is a major determinant of the choice of care sought to reduce the risk of illness. 36 Mothers/caregivers in Iraq need to be empowered with accurate information to improve their knowledge and practices concerning diarrhea prevention and treatment. The training and dissemination of community nursing and public health staff would be a relatively low cost, rapidly implementable intervention which could significantly improve the treatment-seeking practices of mothers in Thi-Qar.
Among sociodemographic variables, place of residence, education, and age were important predictors associated with occurrence of diarrheal illness in the household in the 2 weeks before the study. In the multivariate analyses (Table 2), higher diarrhea occurrence rates were reported in children younger than 5 years whose mothers live in Al-Rifa’i and Nassriya districts. Such considerable spatial heterogeneity of the reported diarrhea occurrence in Thi-Qar might be a reflection of variations in the exposure to risk factors from one district to another, such as living conditions, socioeconomic status, and drinking water quality. 26 This is specifically relevant to the situation in Al-Rifa’i district where 54.1% of the population lived below the poverty line of US$ 2.5/day compared with only 12.3% of the population living in Al-Chibayish district. 26 Added to that, 48.5% of the population in Al-Rifa’i relied on public water (municipality supplied) as the main source of drinking water. 26 This is supported by our previous findings demonstrating a higher likelihood of detection of enteric pathogens in children diarrheal cases from households supplied by pubic (pipe) water, versus households using reverse osmosis water, in Thi-Qar. 37 A community cross-sectional study in Mbour, Senegal, observed children living in better-off families were less likely to have diarrhea than their lower income counterparts. 38 Our results are in line with several household studies on diarrheic children that have demonstrated that the wealth status of the family is correlated with better access to household amenities, including those related to better hygiene and environmental health, which likely reduce the risk of diarrhea. 39,40
In the current study, the reported occurrence of diarrhea was significantly lower in children whose mothers had received a university education than in children whose mothers were illiterate or received either primary or secondary education. These results are in agreement with what was reported from studies conducted in neighboring countries such as Turkey, 40 Iran, 33 and Jordan, 27 where children belonging to mothers with a higher education level (university or diploma) were less likely to have diarrhea than those whose mothers had a lower level education (primary or secondary) or were illiterate. This finding might indicate that those mothers who have a higher education level are attaining more awareness on good child-feeding practices, hygiene behaviors, and safe handling of water which in turn are important factors for reducing the risks associated with childhood diarrhea. 21–39 In addition to mothers’ education level, the present study observed that the reported occurrence of diarrhea is likely to be less in children belonging to mothers aged > 25 years compared with mothers aged ≤ 25 years. The former finding was also revealed in studies from Iraq 32 and Jordan, 27 also indicating a lower likelihood of diarrhea rates among children from mothers aged > 25 years than children belonging to mothers aged ≤ 25 years. These observations are typically argued to be linked with the experience attained on matters related to childcare with the advancement in age. 3
As shown in Table 3, the findings of this study revealed that 55.2% of the mothers reportedly breastfed their diarrheic children less than usual, and 27.2% of the mothers offering more foods to their infected children during the diarrheal illness. Similar to our finding, a recent study on management of diarrheal disease among children younger than 5 years at home in Eastern Ethiopia observed that 60.3% of the mothers reported breastfeeding their child suffering from diarrhea less than usual and 33.6% of mothers offered food more than usual to eat during the diarrheal infection of the child. 41 According to the 2004 UNICEF and WHO joint statement, encouraging mothers to continue breastfeeding and provide increased amounts of fluids and foods to children is recommended, particularly for infants with diarrhea to avoid severe dehydration and death. 36 Although the responses from this study were qualitative only, and thus levels or frequency of breastfeeding during diarrheic episodes cannot be ascribed, this is another initiative which could be promoted through an increase in public health awareness.
Our study noted that 36.4% of the mothers preferred taking their children to health centers for treatment at the time of diarrheal disease. It was reported in previous work that among the reasons for such low rates of approaching health facilities by mothers are the expectations of mothers that diarrhea will recover without treatment, or that the illness was not serious enough or due to the common perception that diarrhea was a secondary sign to new teething. 14–42 This is also thought to be related to the common practice of self-medication through pharmacies which may also be due to the mistrust of the communities in public health facilities due to various reasons such as absenteeism of medical staff, lack of medicines, and the prevailing perception that private sector medicines are more effective for the treatment of diarrhea than those from the government sector. In the current investigation, 69.6% of the mothers reported giving their children antibiotics for the management of diarrhea. This finding is not surprising as antibiotics, especially in developing countries like Iraq, are both widely prescribing and obtained directly without a prescription. 43 This high utilization of medicines without prescriptions from a pharmacy is alarming from a public health perspective for multiple reasons including failure to administer the correct antibiotic, 43,44 the probability that diarrheal disease is not due to an bacterial agent, 37 likelihood that most of the cases require ORT rather than antibiotics, and, of course, the promotion of antimicrobial resistance.
Oral rehydration therapy is a primary intervention for the management of childhood diarrhea and the most effective way to treat dehydration and decrease mortality. 14 Despite the strong advocacy by the WHO to promote awareness and the use of ORT, the use remains gravely low in developing countries. 45 We found a low proportion (24%) of mothers reported to have administered ORT to their children with diarrhea. This result is in accordance with data from former studies performed in North Africa (Egypt) 46 and West Africa (Burkina Faso), 47 where mothers reported the lower ORT use rate in both studies as 24% for the management of diarrhea in children younger than 5 years. Therefore, implementation of public health outreach programs is required to promote the usage of ORT at the Iraqi community level.
As shown in the results of our data (Table 5), level of education, mother’s age, and household income index are important determinants of where treatments are sought. Our study found that seeking care at a medical center and pharmacy was positively associated with education level of mothers, which is corroborated by other studies. 13–47 These results, as well as those from other studies, suggest that educated mothers may have better knowledge about the potentially serious nature of diarrhea, and thus were more likely to seek health care for their ill child at health facilities and pharmacy as against no seeking care, 12,18–47 whereas another study indicated that the choice of utilization of health facilities depends on treatment cost, service quality, and severity of illness. 16 Modeling results indicate that alternative options for the management of diarrhea such as using herbal remedies were found to be associated with the mothers who were illiterate and aged > 25 years, and is most likely a result of cultural beliefs in this demographic.
There are some limitations to this study. First, the assessment of diarrhea prevalence was based on what the mother reported, and there was no way to verify whether what they referred to as diarrhea was certainly diarrhea. Second, the survey did not ask about the type of diarrhea when looking at the healthcare-seeking practice, that is, whether it was acute or chronic diarrhea. However, given the nature of the study, it would not have been possible to clearly ascertain the type of diarrhea because we rely on self-reported information, and it is possible that differential health-seeking behavior was the result of differences in sickness rather than the determinants identified in our study, thus increasing bias. Third, our study relies on reported action taken by the mothers on the diarrhea management practice, and eventually, the study did not take into account other factors that could affect healthcare seeking such as treatment cost, services quality, and access to health facilities. More questions about the evaluation of healthcare services for the diarrhea management at health facilities and verification of costs should be added to future studies.
In conclusion, our study revealed that the reported occurrence of diarrhea among children younger than 5 years is high in Thi-Qar (35.2%). Lower maternal educational level, mothers’ age < 25 years, and place of residence were important factors associated with diarrhea occurrence among children younger than 5 years. The results of this study indicate that relatively cheap, cost-effective measures centered around health education, dissemination of information, and higher numbers of public health outreach staff will likely improve the maternal management of diarrheal disease and avoidance of unnecessary and potentially harmful use of antimicrobials. In future research, it will be important to review the existing health promotion activities at regional and national levels in Iraq to see if such activities have been segmented for the target audiences, including the groups of mothers identified in the present study.
ACKNOWLEDGMENTS
We would like to express profound gratitude to Thi-Qar Public Health Division, all the data collectors, field supervisors, and study participants, for their contributions to the success of this study. We would also like to extend our gratitude to Thi-Qar district administrators for their facilitation of the movement of the team and data collection.
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