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\begin{document}

\title{Childhood Diarrhea and its management- a community based study
estimating knowledge, attitude and practice of Saudi Mothers, Saudi
Arabia}



\author[1]{SULTHAN GHADEER}%
\author[1]{syeed A}%
\author[2]{Abdulaziz Alhossan}%
\author[1]{salmeen babelghaith}%
\author[1]{ziyadh Al Rabiah }%
\author[1]{Mohammed N. Al-Arifi}%
\affil[1]{King Saud University}%
\affil[2]{King Saud University College of Pharmacy}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Aim To demonstrate the best home care of children with diarrhea in our
community by investigating certain knowledge deficiencies, specific
inappropriate attitudes, and particular improper practice toward
children diarrhea and its management, this study was conducted to
evaluate knowledge, attitude and practice of Saudi mothers towards
diarrhea in their children and its management at home. Methods Online
cross-sectional validated online survey targeting Saudi mothers who are
living in Saudi Arabia was used to collect data from the beginning of
March to the end of April 2019. Results A total of 1140 mothers (52.1\%
of them are housewives) participated in the study. About of 40.3 \% of
participating mothers believed that childhood diarrhea is major problem
in Saudi community; however, Almost 23\% of the participants were unable
to identify any critical sign of sever diarrhea, and around 66\% falsely
stated that diarrhea is caused by teething. Although of 62 \% of our
participating mothers knew about the oral rehydration therapy (ORS),
only 23.5 \% of them used it for their children. Conclusion Adequate
knowledge of mothers about the critical sings, causes, transmission,
prevention, and management of childhood diarrhea should be applied in
simple language to communicate the health-related information in clear
manner.%
\end{abstract}%



\sloppy


\textbf{Childhood Diarrhea and its management- a community based study
estimating knowledge, attitude and practice of Saudi Mothers, Saudi
Arabia}

\textbf{Aim}

To demonstrate the best home care of children with diarrhea in our
community by investigating certain knowledge deficiencies, specific
inappropriate attitudes, and particular improper practice toward
children diarrhea and its management, this study was conducted to
evaluate knowledge, attitude and practice of Saudi mothers towards
diarrhea in their children and its management at home.

\textbf{Methods}

Online cross-sectional validated online survey targeting Saudi mothers
who are living in Saudi Arabia was used to collect data from the
beginning of March to the end of April 2019.

\textbf{Results}

A total of 1140 mothers (52.1\% of them are housewives) participated in
the study. About of 40.3 \% of participating mothers believed that
childhood diarrhea is major problem in Saudi community; however, Almost
23\% of the participants were unable to identify any critical sign of
sever diarrhea, and around 66\% falsely stated that diarrhea is caused
by teething. Although of 62 \% of our participating mothers knew about
the oral rehydration therapy (ORS), only 23.5 \% of them used it for
their children.

\textbf{Conclusion}

Adequate knowledge of mothers about the critical sings, causes,
transmission, prevention, and management of childhood diarrhea should be
applied in simple language to communicate the health-related information
in clear manner.

\textbf{Key words:} Diarrhea; Saudi Arabia; Knowledge; Attitude;
Children; Mother

\textbf{What's known}

\begin{itemize}
\tightlist
\item
  Every parents working hard to keep their children's healthy at all
  stages of child, and parent's knowledge and attitudes about health is
  very important
\item
  Diarrhea is a common illness that is considered a major threat to
  children, and it may lead to death in developing countries
  particularly amongst children aged up to 5 years
\item
  Enhancing mothers' proper knowledge and demonstrating appropriate
  practice is a key to prevent or halt the progression of diarrhea.
  However, mothers' harmful practices such as nourishment limitation,
  breast feeding avoidance, and utilization of inappropriate
  conventional therapy or wrong prescription have been reported.
\end{itemize}

\subsection*{What's new}

{\label{whats-new}}

In most cases, diarrhea can be treated at home by oral rehydration
therapy (ORT) that has significantly decreased the mortality related to
diarrhea disease.13 Although this method of treatment is cheap,
adequate, reasonable, and safe, few mothers listed that the aim of using
(ORS) during diarrhea is to treat dehydration of diarrhea.

In order to demonstrate the best home care of children with diarrhea in
our community(Saudi) by investigating certain knowledge deficiencies,
specific inappropriate attitude, and particular improper practice toward
children diarrhea and its management

\textbf{INTRODUCTION}

Diarrhea is a common illness that is considered a major threat to
children, and it may lead to death in developing countries particularly
amongst children aged up to 5 years \textsuperscript{1-3} Twelve million
children are estimated to die in developing countries before the age of
five years. Around 70\% of those children die because of five medical
issues; one of them is diarrhea. \textsuperscript{1,4} Despite of that
age, climate changes, and the use of rotavirus vaccine can contribute to
variations in pathogen-causative diarrhea, rotavirus was the most common
causative pathogen especially in unvaccinated children against
rotavirus.\textsuperscript{5} In Saudi Arabia, rotavirus was noticed in
41.3\% to 65.5 \% of cases causing children
diarrhea.\textsuperscript{6,7} In addition to microbial-induced
diarrhea, Diarrhea can result from intolerance of certain kinds of food
particularly lactose containing milk.\textsuperscript{8}

Regardless of diarrhea-induced causes, dirty weaning food, improper
nourishing practice, absence of clean water, poor hand washing,
constrained sterile transfer of waste, poor lodging conditions, and
absence of access to satisfactory and moderate social insurance are
aggravating factors of diarrhea in children under 5 years
old.\textsuperscript{9} A study in Saudi Arabia reported that
environmental risk factors associated children diarrhea included sewage
leakage near the home, eating out after school hours and utilizing
reusable cloths or sponges to dry dishes.\textsuperscript{10}

Enhancing mothers' proper knowledge and demonstrating appropriate
practice is a key to prevent or halt the progression of diarrhea.
However, mothers' harmful practices such as nourishment limitation,
breast feeding avoidance, and utilization of inappropriate conventional
therapy or wrong prescription have been reported.\textsuperscript{11} In
addition, the knowledge of mothers toward the signs of dehydration
secondary to diarrhea is poor.\textsuperscript{2,12} In most cases,
diarrhea can be treated at home by oral rehydration therapy (ORT) that
has significantly decreased the mortality related to diarrhea
disease.\textsuperscript{13} Although this method of treatment is cheap,
adequate, reasonable, and safe, few mothers listed that the aim of using
(ORS) during diarrhea is to treat dehydration of
diarrhea.\textsuperscript{2,13} In order to demonstrate the best home
care of children with diarrhea in our community by investigating certain
knowledge deficiencies, specific inappropriate attitude, and particular
improper practice toward children diarrhea and its management, the aim
of this study is to evaluate knowledge, attitude and practice of mothers
towards diarrhea in children and its management at home.

\textbf{METHODS AND MATERIALS}

Online cross-sectional survey based study targeting mothers who are
living in Saudi Arabia were carried out to measure knowledge, attitude
and practice of mothers towards diarrhea and its management in their
children at home. The data collection was carried out from the beginning
of March to the end of April 2019. The questionnaires for this study was
prepared after an extensive literature review from similar studies
published in this regard \textsuperscript{2,13}. The questionnaires for
this study grouped in four parts. The first part was to collect
demographic data (such as age of mother, mother's education level,
mother's job, child's age, etc.). The second part is the knowledge
domain questions with the multiple-choice options discussing subjects
like signs and symptoms of diarrhea, diarrhea causes, preventive
measures and critical signs of diarrhea as well as critical signs of
dehydration. The third part focused on manner of management practice of
diarrhea at home. The fourth part was the attitude domain questions that
were composed of 11 questions assessed by 5 point Likert Scale (strongly
agree, agree, neutral, disagree, and strongly disagree). A panel of 3
members (two professors and a researcher) from college of pharmacy, king
Saud university who were experts in preparing the study tool were
reviewed the questionnaire. The survey was translated into Arabic
language by an independent translator, and reviewed again for the
appropriateness of language before testing its validity. The
questionnaire was then validated through randomly selected 10
respondents in a pilot study carried out at college of pharmacy king
Saud university. The respondents recruited in the pilot study were
mothers and did not include in the final results or had no contact with
the subjects of the study. Reliability test was determined using
Cronbach's alpha of the questionnaire and it was found 0.73.

The sample size for this study was calculated using an online sample
size calculator (http://www.raosoft.com/samplesize.html) by assuming a
larger population size with a margin of error \selectlanguage{ngerman}± 5\% and a confidence
level of 95\%, which resulted in a sample of 384
individuals.\textsuperscript{14} Statistical Package for Social Sciences
version 25 (SPSS) software was applied to analyze the data. Descriptive
statistics and Chi-squared test were also used.

\textbf{RESULTS}

A total of 1140 respondents filled the questionnaire. About 24\% of
respondents were aged from 36 to 40 years, and only 5.4 \% of
respondents received no formal education. More than half of mothers were
housewife (52.1\%). Slight more than one third of children were aged
above 2 years. The demographic of mothers and their children are
summarized in Table 1. Table 1. Demographic data of mothers and their
children\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Variables & Number & Percentage\tabularnewline
\midrule
\endhead
\textbf{Age of the Mothers (years)} 18-20 21-25 26-30 31-35 36-40 more
than 41 years & 130 130 166 192 271 248 & 11.4 11.4 14.6 16.8 23.8
21.8\tabularnewline
\textbf{Education level} Illiterate Primary school/ secondary school
High school University Postgraduate & 62 160 244 479 195 & 5.4 14.0 21.4
42.0 17.1\tabularnewline
\textbf{Job} Employer Health staff Housewife Students Other's & 427 68
594 39 12 & 37.5 6.0 52.1 3.4 1.0\tabularnewline
\textbf{Insurance} None Governmental Private & 329 482 329 & 28.9 42.3
28.9\tabularnewline
\textbf{Age of the child (years)} Less than on year 1-2 years Above 2
years & 217 226 697 & 19 19.8 61.1\tabularnewline
\textbf{Gender of a child~[?]} \selectlanguage{english}Male Female & 456 675 & 40.0
59.2\tabularnewline
\bottomrule
\end{longtable}

*Missing Data

In this study, mother rated the critical signs of childhood diarrhea as
follows: blood in the stool (49\%), followed by thirst and dry mouth
(32.1\%), and loss of stretchiness of the skin (24.3\%). Nearly half
(49.9\%) of mothers believed that diarrhea is caused by eating dirty
food. Table 2 shows mothers' knowledge about childhood diarrhea.

Table 2. Mothers' knowledge and practice about diarrhea and its
managements\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Variables & N & \%\tabularnewline
\midrule
\endhead
\textbf{Critical signs and symptoms of diarrhea*} Passage of
\textgreater{}3 loose stools with blood in 24 hours Thirst and dry mouth
Tearless eyes Loss of stretchiness of the skin I do not know & 553 366
132 277 261 & 48.5 32.1 11.6 24.3 22.9\tabularnewline
\textbf{Cause/mode of transmission of diarrhea*} Drinking bad/dirty
water Eating dirty food Eating with dirty hands Eating expired food
Insects feeding on dirty tools Bottle of breastfeeding Unpasteurized
milk & 361 569 470 516 231 235 226 & 31.7 49.9 41.2 45.3 20.3 20.6
19.8\tabularnewline
\textbf{Management of child's diarrhea} Visit the physician Visit the
pharmacist Use ORS Give homemade fluids Feed the child with
breastfeeding Stop feeding Nothing & 786 233 262 600 100 53 41 & 68.9
20.4 23.0 52.6 8.8 4.6 3.6\tabularnewline
\bottomrule
\end{longtable}

*Multiple-answers question

In this study, the most reported practice among mothers towards
management of their child's diarrhea included seeing the physicians
(68.9\%), giving homemade fluids (52.6\%), using ORS (23.0) and visiting
pharmacists (20.4) (Table 2).

In this study, about 62\% of mothers know the ORS, but only 53.5 \% of
them recognized that ORS could prevent child from getting dehydrated.
The resources of information for utilizing ORS in childhood diarrhea
were gained mainly from medical prescription (50.3\%), followed by
family (15.7\%) and then by consultation of pharmacists (15.1\%) as
presented in Table 3.

Table 3. Mothers' knowledge about the use of ORS\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Characteristic} & \textbf{Number} &
\textbf{Percentage}\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut Do you know the ORS? Yes}\hbox{\strut No}} & 706 434
& 61.9 38.1\tabularnewline
\vtop{\hbox{\strut Role of ORS solution in diarrhea Prevents child from
getting dehydrated}\hbox{\strut Either increases or decreases
diarrhea}\hbox{\strut No role in diarrhea treatment}} & 610 183 77 &
53.5 16.1 6.8\tabularnewline
\vtop{\hbox{\strut Sources information of use ORS Medical
prescription}\hbox{\strut Consultation of
pharmacists}\hbox{\strut Family}\hbox{\strut Internet}\hbox{\strut TV}}
& 573 172 179 112 31 & 50.3 15.1 15.7 9.8 2.7\tabularnewline
\bottomrule
\end{longtable}

In this study, around 33.5\% of mothers thought diarrhea can attack
bottle-feed children. Majority of mothers (65.9\%) reported that
teething is the main cause of diarrhea. The disagreement of that
``liquid food aggravates diarrhea'' were reported by 22.5 \% of the
mothers. About 41\% mothers thought that diarrhea is a problem in the
Saudi community, and 60.9\% of mothers stated that handwashing prevents
diarrhea. More details on mothers' attitude on childhood diarrhea is
showed in Table 4.

Table 4. Mothers' attitude about childhood diarrhea\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Questionnaires\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Strongly agree n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Agree n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Neutral n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Disagree n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Strongly disagree n (\%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diarrhea attacks mostly bottle-feed children\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
146(12.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
236(20.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
522(45.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
180(15.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
56(4.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diarrhea is a disease of the poor\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
36(3.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49(4.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
223(19.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
431(37.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
401(35.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diarrhea is a problem in the community\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
124(10.9)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
347(30.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
411(36.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
190(16.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
68(6.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Teething causes diarrhea\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
282(24.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
470(41.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
239(21.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
105(9.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
44(3.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Diarrhea is a curable disease\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
559(49.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
449(39.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
81(7.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
30(2.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
21(1.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Liquid food aggravates diarrhea\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
111(9.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
243(21.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
529(46.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
209(18.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
48(4.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Oral rehydration salts solution cures diarrhea\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
141(12.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
368(32.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
485(42.5)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
122(10.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24(2.1)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Human feces are a source of diarrhea\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
120(10.5)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
196(17.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
648(56.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
133(11.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
43(3.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Handwashing prevents diarrhea\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
248(21.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
446(39.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
264(23.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
122(10.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60(5.3)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Discussion}

This study assessed the knowledge of mothers about the critical signs of
diarrhea. About 49\% of the mothers stated that the passage of three or
more loose stools with blood during the day is an obvious critical sign
of diarrhea that require hospital or physician visit, and almost 23\%
reported no knowledge of any critical sign of diarrhea. These results
showed low knowledge among Saudi mothers about the critical sings of
diarrhea, but their knowledge of the critical signs of diarrhea were
higher compared to other mothers in different communities. A study
carried out in Ethiopia found that 39.5\% of mothers stated that passage
of three or more loose stools with blood during the day is mark of
severe diarrhea.\textsuperscript{15} A similar study was done in rural
setting of Kenya determined that majority of mothers (76.4\%) did not
identify the critical signs of childhood diarrhea.\textsuperscript{16} A
study from Nepal reported that 20.8 \% of mothers identified the
red-colored diarrhea as ``the most dangerous
diarrhea''.\textsuperscript{2} The critical signs of dehydration have
the similar importance of bloody diarrhea, and the participating mothers
in our study were unable to identify the most common signs of
dehydration. Only 32.1\%, 11.6\%, and 24.3\% were able to recognize
thirst/dry mouth, tearless eyes, and loss of strictness of skin
respectively as the critical signs of dehydration secondary to diarrhea.
The poor knowledge and unrecognized sings of dehydration among mothers
are noticed globally. \textsuperscript{2,17-19} Adequate knowledge of
mothers about the critical sings of childhood diarrhea is essential as
the early referral of child with severe diarrhea is fundamental for
appropriate treatment. \textsuperscript{15}

Poor sanitation of food and water may lead to diarrhea with
approximately 3000 deaths and 135,000 hospitalizations annually
secondary to food-borne transmission of diarrhea causative pathogens in
the United States.\textsuperscript{20} With the regards for the causes
and transmission of diarrhea, nearly 50 \% of participating mothers
believed that eating polluted food is the most common cause of childhood
diarrhea, and only 31 \% of mothers identified drinking unclean water as
the reason for childhood diarrhea. In consistent with our findings, many
studies reported low level of mothers towards causes and transmission of
diarrhea.\textsuperscript{2,16,22} A study from Nigeria reported that
the most common causes for childhood diarrhea were contaminated food
(24.1\%) and unclean water (11.3\%).\textsuperscript{8} Another study
from Iran showed that only 24.66\% of mothers knew that the unclean
water can cause diarrhea.\textsuperscript{22} A study was carried out in
Malawi reported that 55 \% of mothers stated that unhealthy water is the
main causes of diarrhea.\textsuperscript{23} The change in knowledge of
childhood diarrhea could be due to variance in mothers' education
levels.

The misconception between teething and diarrhea seems disseminated
widely. The results of present study showed that 66 \% of mothers stated
teething is a reason of their children diarrhea. These results come
agreed with other studies from different
countries.\textsuperscript{8,22} In addition to the wrong belief of
association between diarrhea and teething, mothers tend to consider
diarrhea secondary to teething as ``non-serious diarrhea'', and they may
deal with it loosely even if it's accompanied by critical signs like
dehydration.\textsuperscript{24} The efforts should be applied to
educate the mothers about the critical signs of children diarrhea and to
disassociate the belief link between diarrhea and teething.

The mothers' sufficient knowledge on reasons, prevention and management
of diarrhea utilizing proper therapies is the key for home management of
childhood diarrhea.\textsuperscript{14,25} According to the Integrated
Management of Childhood Illness (IMCI) guidelines, the use of ORS is the
principle therapy of diarrhea \textsuperscript{26}. However, the use of
ORS seemed not highly encouraging among mothers. Although of 62 \% of
our participating mothers knew about the ORS, only 23.5 \% of them used
it for their children. Similar findings were reported. A study from
Nigeria reported that most of mothers (63\%) were aware of ORS, but 27\%
of them used it for their children.8 In another study did in Pakistan
mentioned that 58\% mothers used ORS to treat their childhood diarrhea
disease. \textsuperscript{12} Also in our study, it was found the main
resources of mothers regarding ORS usage were medical prescriptions
(50.3\%), family/relatives/friends (15.7\%), and pharmacists (15.1\%).
In a similar study the two main resources of ORS information were
families/friends (76\%) and pediatricians (58\%).
\textsuperscript{27}Despite of 53.3 \% of our participants reports that
``ORS prevents a child from getting dehydrated'', few mothers are using
ORS (23.5\%). The reason for a few mothers used ORS could be due to
their level of education and awareness of the mothers on diarrhea
management due to inadequate public information on this issue.

Due to the high rate of literacy and social media usage among
Saudis,\textsuperscript{28,29} and the aim of study to assess the
knowledge, attitude, and practice of mothers towards childhood diarrhea
from community perspective, the study was conducted online to diminish
geographical dependence. The study was performed with significance that
mothers' knowledge of childhood diarrhea prevention and management would
decrease the unnecessary hospital or clinic visits; however, most of the
participating mothers (68.9\%) seek treatment from medical doctor for
their children with diarrhea. This practice of mother was observed in
previous study. \textsuperscript{15} In contrast, our subjects showed
good preventive measure. The majority of mothers (70.9 \%) believed that
handwashing, which is one essential measure to decrease the prevalence
of diarrhea, \textsuperscript{30} prevents childhood diarrhea.

\textbf{CONCLUSION}

About of 40.3 \% of participating mothers believed that childhood
diarrhea is major problem in Saudi community. These beliefs are
supported by reports mentioned the prevalence of diarrhea is high in
some area of Saudi Arabia.\textsuperscript{1} However, insufficient
knowledge of childhood diarrhea and its management were observed.
Adequate knowledge of mothers about the critical sings, causes,
transmission, prevention, and management of childhood diarrhea should be
applied in simple language to communicate the health-related information
in clear manner. Also, There is a lack between the understanding the
role of ORS and its use. Understanding of ORS is not adequate and it
needs reliable efforts to highlight on importance of ORS in resolving
dehydration of childhood diarrhea.

\textbf{COMPETING INTERESTS}

The authors declare that they have no competing interests.

\textbf{FINANCIAL SUPPORT AND SPONSORSHIP}

Nil.

\textbf{DATA AVAILABILITY}

Data will be available upon request from the corresponding author of the
study

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