ADMAS UNIVERSITY

KNOWLEDGE ATTITUDE AND PRACTISE OF DIARRHEAL DISEASE

AMONG MOTHERS HAVING CHILDREN UNDER FIVE YEARS IN
AREA OF SHEKH OSMAN BORAMA IN SOMALILAND

THESIS PRESENTED IN PARTIAL FULFILMENT OF DEGREE OF

PUBLIC HEALTH OFFICER IN ADMAS UNIVERSITY.

BY:

Maxamed suge dirir

Cabdi nasir xasan jaamac September, 2021

Maxamed axmed dahir Borama, Somaliland

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 DECLARATION

We, maxamed suge, cabdi nasir xassan jamac, maxamed axmed dahir, hereby
declare that this thesis our original work and has not been presented for an
award of a degree or diploma in any other university or institution.

Maxamed suge dirir ______________________ date _________

Cabdi nasir xasan jamac___________________ __________

Maxamed axmed dahir_____________________ ____________

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 Approval

This thesis has been done under our supervision and has been submitted to the
department of health science and degree of public health.

PROF. ABDILLAHI ABDIKARIM ________________ date_____________

Master of public health

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 DEDICATION

This research thesis is dedicated to everyone who taught me the values

of life, knowledge, respect, integrity, hard work, and self-improvement and to
those who taught me to simply stand up when I fall, to be all good to people,
and always encouraged me to dream and work hard towards my dreams like
my family, friend, teachers.

Finally I would like to appreciate my classmates those who gave me generous

encouragement during the preparation of this thesis.

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 Abstract

Background: Diarrheal is a public health problem in children under

five years and it is a burden in developing countries. The mothers
having children under five years are an accurate approach to prevent
diarrhoea in the mothers having children under five However, the
mortality rate among children under-five years continues to be high and
diarrheal is placed on the first factor contributing to this high mortality
rate.
Objectives: of this study was to assess knowledge, attitude and
practices of mothers having children under five years regarding for
diarrheal disease among under-five children, sheikh Osman in Borama
districts in Awdal region.
Resulting: the study used comparative cross sectional [Link] target
populations were under five children of diahrraial disease sheikh osman in
one sector with the sample size comprised of 86 calculated using
sloven’s formula.
Statistical analysis was done using spss version 20. The result of this study and
described that knowledge attitude and practice for diarrheal among mothers
having under five children in Borama.

The majority of the respondents of 46.5% had poor knowledge, 26.7% had
good knowledge and 62% had positive attitude, 12.8% had negative while the
remained 16% had neutral attitude and 78% had poor practice, 22% had good
practice.

Conclusions
This study on the findings of the research as The study was focused on four
Districts Awdal region and Major findings of the study was guttered district
Awdal region especially shekh Osman in Borama Capital city state of
Awdal region in Somaliland to assess knowledge, attitude and practice of
diarrheal among mother’s having children under five years.

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The result of this study and described that knowledge attitude and practice for
diarrheal among mothers having under five children in Borama.

Recommendations
As the study indicated the practice of the respondents were low of knowledge,
attitude and practice of diarrhea among mother’s having children under five
[Link] in order to increase the practice of the mothers about knowledge,
attitude and practice of diarrhea among mother’s having children under five
years. Much attention should be given by all responsible bodies. After analysis
and evaluating the study finding, I suggest and recommended by The
following recommends

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 Acknowledgement

Firs I would express my grateful thanks to Allah, who allowed me the

opportunity to write and complete this study within difficult condition.

Second I would like to appear my deepest gratitude to my parents who gave

me helpful role, and the kindly participating for the completion of the
research.

Third I have to be appreciating to my supervisor Lecturer. Pro. ABDILLAHI

ABDIKARIM
Who actually dedicated his valuable time and experience to give me time
cooperative guidelines and continues tightly supervision during the preparing
the thesis book, without his guidance, supervision and cooperation it would be
difficult me to mark this thesis.

Fourth, I would like to appreciation and make thankful to all my friends and
family who supported me during the study and thesis preparation especially
my brother pro. ABDILLAHI ABDIKARIM who are helped me directly and
indirectly.

Finally I like to say thankful and grateful to my ADMAS UNIVERSITY,

which is the pillar of my knowledge and built my future also the best thankful
all my lectures who participated my future building and are busy to build the
future of the young generations.

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 Definition of Terms

Knowledge: an awareness of something or state of being aware of something

Causes: make something, especially something bad o

Signs: an object, quality, or event whose presence or occurrence indicates the

probable presence

Hygiene: condition or practices conductive to maintaining health and

preventing disease, especially though cleanliness

Sanitation: is the process of keeping places clean and healthy, especially by

providing a sewage system and a clean water supply

Malnutrition: lack of proper nutrition, caused by not having enough to eat, not
eating enough of the right things.

Immunodeficiency: condition in which a body is unable to produce enough

antibodies to fight bacteria

Medications: a drug or other form of medicine that is used to treat or prevent

disease

Management: the process of dealing with or controlling things or people

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ABBREVIATIONS

HIV: human
immunodeficiency virus

PHCU: primary health

care united

DALYs: Disability
adjusted life year

WHO: world health

organization

ORS: Oral rehydration

solution

CDC: communicable
disease control

IDPs: internally
displaced persons

KAP: knowledge attitude

and practices

UNICEF: United Nations

Children’s Fun

SSA Sub-Saharan
Africa

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 List figures

figure1: respondents age of mothers.

Figure 2: respondents of marital status.

Table 1 :Occupation of mothers

Figure 3: Education level of mother’s

Figure 4: respondent the causes of diarrheal

Table 2: respondent Known
Figure 5: respondent transmit of diarrheal.
Figure 6: Prevent Diarrheal
Table 3: respondent of transmitted from one person to other person.
Figure 7: respondent Income of mothers (US $ per month)
Figure 4: respondent problem transportation
Figure 8: respondent problem the price of food
Figure 9: respondent of school fees for children
Figure 10: respondents home sanitation
Figure 11: respondent of hand after use latrines
Figure 12: respondent of the boil the water before you drink it
Figure 13: respondent of Manage Waste
Figure 14: respondent of chlorine

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Table of Contents
Acknowledgement..........................................................................................vii

Definition of Terms.......................................................................................viii

ABBREVIATIONS.........................................................................................ix

1.0 introduction................................................................................................1

1.1 Background.............................................................................................1

1.2 Problem Statement.................................................................................3

1.3 Objectives of the research......................................................................4

1.4 General objective:...............................................................................4

1.4.1 Specific objectives of the research..................................................4

1.5 Significant of the study...........................................................................5

1.6 Scope of the study...................................................................................5

1.6.1 Content scope.......................................................................................5

1.6.2 Geographical scope............................................................................5

Chapter two

2.0 Introduction...............................................................................................6

2.1 Definitions...............................................................................................6

2.2 CAUSES.................................................................................................7

2.4 Theoretical Clinical Features (Signs and symptoms).........................8

2.4.1 Symptoms associated with diarrhea may include:........................8

2.4.2 Signs associated with diarrhea may include:................................9

2.5 Theoretical risk factors for diarrhea....................................................9

2.5.1 Demographic factors.......................................................................9

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 2.5.2 Drinking water related factors.......................................................9

2.5.3 Sanitation factors:............................................................................9

2.6 Hygiene practices....................................................................................9

2.6.1 Breastfeeding:.................................................................................10

2.6.2 Malnutrition:...............................................................................10

2.6.3 Immunodeficiency:.....................................................................11

2.6.4 Eating habits:................................................................................11

2.7 Diagnosis................................................................................................11

2.7.1 Clinical Diagnosis...........................................................................11

2.8 Other factors associated with good practices for diarrhea among. .11

2.9 Critical gap analysis............................................................................12

2.10 Theoretical framework...................................................................13

2.11 The global burden of diarrheal disease in children.....................14

2.12 Management....................................................................................14

2.13 Summary of literature review.......................................................16

Chapter three

3.0 Introduction..............................................................................................18

3.1 Research area........................................................................................18

3.2 Study design..........................................................................................18

3.3 Target Population.................................................................................18

3 Sample Size...............................................................................................18

3.4 Sampling Techniques/strategies..........................................................19

3.5 Data collection techniques and instruments.......................................19

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 3.6 Data analysis.........................................................................................19

3.7 Ethical Consideration...........................................................................20

3.8 Validity and reliability.........................................................................20

3.9 Inclusion................................................................................................20

3.10
exclusion……………………………………………………………..34

Chapter four

Introduction....................................................................................................21

4.2. Socio-demographic characteristic......................................................21

4.2.1: Knowledge of mother and Diarrheal diseas...................................23

4.4 Respondents home sanitation..............................................................29

chapter five

5.1 inrtoductioN..........................................................................................32

5.2 Discussion..............................................................................................32

5.3 Conclusions........................................................................................33

5.4 Recommendations.................................................................................33

Students of public health............................................................................34

REFFERENCE.........................................................................................34

Informed Consent Dear Respondent:......................................................36

APPENDIX: B QUESTIONAIRE...........................................................38

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 CHAPTER ONE

1.0 introduction

This chapter covers the introduction of the research, include background of the
study, problems statement, purpose of the study, objectives of the study and
research of question, and this study was cover in this chapter scope of the
study, significance of the study as well as operation.

1.1 Background
Diarrheal diseases are the most major health problems in the world
which causes highest mortality and morbidity in children especially in
children younger than 5 years, and they can also affect children’s
growth and development.[1] diarrhea is the passage of loose or watery
stools occurring three or more times in a 24-hour period (2). Diarrhea
means an increased frequency or decreased consistency of bowel
movements (3).diarrhea an increase in the fluidity, volume and
frequency of stool relative the usual habits of each individual (4).
{ ADR Journals 2014}

Diarrhea is the second killer of under five children worldwide

(68).worldwide, diarrhea is the second most common cause of
morbidity and mortality among children under the age of five, follows
respiratory infection, and is also an important cause of malnutrition. on
an average, children below three years of age in developing countries
like india, experience about three episodes of diarrhea each year(5).
diarrheal disease is the second leading cause of death in children under
five years old and is responsible for killing around 760, 000 children
every year globally. It is a leading cause of child mortality and
morbidity in the world and mostly above 90% results from
contaminated food and water sources (6).

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Diarrheal diseases, which are frequently transmitted by contaminated water,
continue to be a leading cause of morbidity and mortality among children{ Dr.
Aakash Shrivastava}

under 5 years old in developing countries. An estimated 1.8 million people

die from diarrheal diseases each year, from which greater than 80% of
cases are among children under five years old.

Children in this age group suffer from an average of 2.6 episodes of

diarrhea each year, with the peak incidence occurring between 6 and
11 months of age [6] inadequate quantities and quality of drinking
water, lack of sanitation facilities, and poor hygiene cause millions of
the world’s poorest people to die from preventable primarily diarrheal
diseases each year (7) {(imr) rate in 2015,}

Globally, childhood diarrhoea contributes to a major proportion of under 5

(u5mr) and infant mortality (imr) rate in 2015, diarrhoea accounted for 9%
of childhood mortality worldwide and about 1,400 children were dying
every day thus 526,000 a year

Low and middle income countries carry a disproportionate share of the

burden of diarrheal deaths. Diarrheal diseases are poverty related.
highest number of deaths due to diarrheal (70%) occurs among
children less than two years of age living in sub Saharan Africa and
south Asia related to poor environmental conditions (8).a global effort
to protect, prevent and manage diarrheal among children has been
made over the past few decades and was successful. the annual
diarrheal deaths decreased by 50 percent from 2000 to 2015 (9).

In Somalia the under-five mortality is estimated at 200 deaths per 1,000

live births, which is one of the highest in the world. Diarrheal is the main
killer, contributing 20-25percent of all under-five mortality (15).diarrhoeal

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diseases are connected with unhygienic environments, lack of safe
drinking water and poverty.

Lack of access to safe water is a striking feature in all parts of Somalia.

only 30% of Somalis have access to safe water, with 20% in the worst
affected areas of southern Somalia particularly in areas overcrowded
by internally displaced populations (dips) increases the risk of
outbreaks of diarrheal diseases (14). According the Somaliland this
diarrheal disease it was worst affected especially areas were Awdal
region, in Borama shekh Osman that most vulnerability to occur in
diarrheal disease which related poor hygiene, sanitation and
contaminated water

1.2 Problem Statement

Diarrheal diseases are the most major health problems in the world
which causes highest mortality and morbidity in children especially in
children younger than 5 years, and they can also affect children’s
growth and development{ ADR Journals 2014}

Diarrhea is the second killer of under five children worldwide

(68).worldwide, diarrhea is the second most common cause of
morbidity and mortality among children under the age of five, follows
respiratory infection, and is also an important cause of malnutrition.
On an average, children below three years of age in developing
countries like India{ Dr. Aakash Shrivastava}

Diarrheal diseases are still the major cause of morbidity and mortality
among children worldwide and mainly in sub-SaharanAfrica. InAfrica and
especially sub-SaharanAfrica, diarrheal diseases account for over90% of
deaths in children below five years old [10] {UNICEF, 2006}

In Somalia the under-five mortality is estimated at 200 deaths per 1,000

live births, which is one of the highest in the world. Diarrhea is the main

3
 killer, contributing 20-25percent of all under-five mortality (15).diarrheal
diseases are connected with unhygienic environments, lack of safe
drinking water and poverty.{WHO in January 2011}

In Somalia, more than two decades of war and ongoing civil unrest led to
further deterioration of Somalia’s health situation (15).Somalia became
number one in the world health ranking of diarrheal disease in 2011 with a
death rate of 179 per 100,000 (15).

So that the reasons that we are searching the knowledge, attitude and
practice of diarrhea to the mothers having children under five years in
Somaliland especial Borama of area in shekh Osman that always
vulnerability to occur in diarrheal disease

1.3 Objectives of the research

1.4 General objective:
To assess the knowledge, attitude and practice of diarrhea among mothers
having under five children Area of SHEKH OSMAN BORAMA
SOMALILAND

1.4.1 Specific objectives of the research

1. To determine the knowledge of diarrhoea among mothers having under
five children aged in Area of SHEKH OSMAN
2. To describe the attitude of diarrhoea among mothers having under five
children aged in Area of SHEKH OSMAN
3. To identify the practice of diarrhoea among mothers having under five
children aged in AREA SHEKH OSMAN BORAMA IN SOMALILAND

1.4.2 Research questions

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1. What is the knowledge of mothers having under five children age in Area
of SHEKH Osman towards diarrhoea?
2. What is the attitude of mothers having under five children aged in Area of
SHEKH Osman towards diarrhoea?
What is the practice of mothers having under five children aged in Area of
SHEKH Osman towards diarrhoea?

1.5 Significant of the study

The findings of this research was generate information that knowledge attitude
and practice of 1.6 diarrheal diseases among mothers having under five
children.

It was also be useful for researchers and students who wants to read and write
about this topic to be a reference.

1.6 Scope of the study

1.6.1 Content scope
This study about knowledge attitude and practice of diarrheal disease
among mothers having under five children in Area of SHEKH OSMAN
BORAMA IN SOMALILAND

1.6.2 Geographical scope

The Republic of Somaliland is located in the Horn of Africa. It is surrounded
by Djibouti to the west, Ethiopia to the south, and the Puntland state of
Somalia to the east. Somaliland has a 740 kilometers (460 mi) coastline with
the majority lying along the Gulf of Aden. Borama, the capital city of Awdal
region is located northwest of Somaliland it is situated near the border south
with Ethiopia and northwest D. Djibouti it is far for 120km from capital city of
Somaliland, Hargiesa and its longitude is 43.33.

1.6.3 Time Scope

In this study was started on March 2021 and ended September 2021

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 CHAPTER TWO

LITERATURE REVIE

2.0 Introduction

The literature review deals with empirical and theoretical framework

according to the research questions of the study. that are indicated in
the following elements: the theoretical literature, definitions, causes,
Theoretical Clinical Features, theoretical risk factors for diarrhea, and
Other factors associated with good practices for diarrhea among
mother having under-five children of Knowledge , attitude and practice
of diarrheal diseases mong mothers having under five children Barriers
and challenges of Diarrhea diseases in children under five years,

Signs and symptoms of diarrhea diseases, General Management and

prevention of diarrhea ,essential skills in management of diarrhea and the
approach of Diarrhea diseases in children under five years care, principles
in children under five years and also the conceptual framework in this
study ,and the recap of this literature review.

2.1 Definitions
Diarrhea is defined as a passage of three or more loose or watery stools in
a 24 hours period. Various terms may use to describe diarrhea depending
upon whether the stool is loose, watery, bloody or mucoid or there is
vomiting [10].According to K.

Ramon, diarrhea is defined as change in bowel habit for the individual

child resulting in substantially more frequent and/or looser stools
(31).Although changes in frequency of bowel movements and looseness of
stools can vary independently of each other, changes usually occur in both.
Clinical features vary greatly depending on the cause, duration, and

6
severity of the diarrhea, on the area of Bowel affected, and on the patient’s
general health (31).

2.2 CAUSES
Though some diarrhoea’s are due to errors of metabolism, chemical
irritation or organic disturbance, the vast majority are caused by infectious
pathogens (16)., Bacterial infections: Diarrhea caused by enteric bacterial
infections is very important. Worldwide, especially in tropical and
developing countries, and is a serious problem among older children and
adults as well as in infants and young children. The range of causative
microorganisms is very large;

they include Escolar, Salmonella, Shigella, Campylobacter, Yesinia,

vibrio’s, and Clostridium difficile (17)., Viral infections: Rotaviruses one
of the most common causes of severe diarrhea., Other viruses may be
important causes of diarrheal disease in human, including Norwalk virus,
Norwalk-like viruses, enteric adenoviruses, caliciviruses, andastroviruses
(18).Parasites: Parasites can enter the body through food or water and
settle in the digestive system. Parasites that cause diarrhea include
Guardialamblia, Endameba histolytic, Cyclosporinecayetanensis and
Cryptosporidium (16).Food intolerances: Some people are unable to digest
some component of food, such as lactose - the sugar found in milk, or
gluten found in wheat and barley(16)Reaction to medicines, some kinds of
antibiotics (such as clindamycin, cephalosporin’s, sulfonamide), laxatives
and antacids(16).Intestinal diseases like inflammatory bowel disease or
celiac disease(16).Functional bowel disorders, such as irritable bowel
syndrome, in which the intestines do not work normally(16).

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 2.3 Epidemiology of Diarrheal Disease
Diarrhea remains the major burden of all water and sanitation related diseases
and yet it is preventable. Approximately 4 billion cases of diarrhea are
recorded globally each year leading to 2.2 million deaths, mostly among
children underage five years. [27).
In many diarrhea -endemic countries, children under five years old and
adults account for more than half of the global incidence and deaths. These
figures represent less than one per cent of all estimated cases of diarrhea
and less than 10 percent of estimated diarrhea deaths annually.

[14] However, diarrhea historical impact, frequent occurrence in

explosive outbreaks, dramatic clinical picture, regular attacks on adults as
well as children, highly contagious nature and potentially high lethality,
make it one of the most conspicuous, and most feared, diseases. Diarrhea
has remained endemic in some Asian countries for centuries (14).

It has become endemic in an increasing number of African countries with

epidemic peaks throughout the years. Recently it returned to the Americas
with ongoing transmission in Haiti and the Dominican Republic. New,
more virulent and drug-resistant strains of diarrhea continue to emerge,
and the frequency of large protracted outbreaks with high case fatality
ratios has increased, reflecting the lack of early detection, prevention and
access to timely health care [28].

2.4 Theoretical Clinical Features (Signs and symptoms)

2.4.1 Symptoms associated with diarrhea may include:
Passage of loose stool, increased frequency of passage of stool, loose,
watery consistency of stool, Low urine output, increased volume of
stool, Vomiting [31]

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2.4.2 Signs associated with diarrhea may include:
Sunken eye ball, Dry tongue and ducal mucosa, Poor skin torpor, Low
blood pressure, Lethargy, Weight loss (31).

2.5 Theoretical risk factors for diarrhea

2.5.1 Demographic factors
Demographic factors: Many studies have established that the diarrhea
prevalence is higher in younger children (33). The prevalence is highest
for children 6-11 months of age, remain at a high level among the one year
old children, and decrease in the third and fourth years of life (33).Higher
rate of diarrhea has-been observed in boys than girls (34).

2.5.2 Drinking water related factors

Water-related factors: As diarrhea is acquired via contaminated water and
foods, Water-related factors are very important determinants of diarrhea
occurrence (36).Increasing distance from water sources poor storage of
drinking water(e.g. obtaining water from storage containers by dipping, no
drinking water storage Facility), use of unsafe water sources (such as
rivers, pools, dams, lakes, streams, wells and other surface water
sources)water storage in wide mouthedcontainers9, 30, low per capita
water used have been found to be risk Factors for more diarrhea
occurrence among children less than five(36).

2.5.3 Sanitation factors:

Obviously plays a key role in reducing diarrhea Morbidity. Some
sanitation factors, like indiscriminate or improper disposal of
children’s stool and household Garbage no existence of latrine or
unhygienic toilet sharing latrine house without sewage system
increased the risk for diarrhea in children (37)
2.6 Hygiene practices
Hygiene practices Some studies have revealed that children not washing
hand before meals or after defecation mothers not washing hands before

9
feeding children or preparing foods children eating with their hands rather
than with spoons eating of cold leftovers dirty feeding bottles and utensils
Unhygienic domestic places (kitchen, living room, yard)unsafe food
Storage presence of animals inside the house presence of flies inside the
house were associated with risk of diarrhea morbidity in children (38).

2.6.1 Breastfeeding:
The literature on feeding practices and risk of diarrhea is extensive. In
general, the morbidity of diarrhea is lowest in exclusively breast-fed
children; it is higher in partially breast-fed children, and highest in fully-
weaned-children(39).In addition, a particular risk of diarrhea is associated
with bottle-feeding(40) .Many studies have shown the strong protective
effect of breast feeding.

A high Concentration of specific antibodies, cells, and other mediators in

breast milk reduces the risk of diarrhea following colonization with enter
pathogens (41).

2.6.2 Malnutrition:
The association between diarrhea and malnutrition is so common in low
income societies that the concept of a vicious circle is appealing, with
diarrhea leading to malnutrition and malnutrition predisposing to diarrhea
(42). Children whose immune systems have been weakened by
malnutrition are the most vulnerable to diarrhea.

Diarrhea, especially persistent and chronic diarrhea, undermines

nutritional status, resulting in malabsorption of nutrients (42).

2.6.3 Immunodeficiency:

Maintain health Immunodeficiency is not only a cause of persistent or

chronic diarrhea (chronic diarrhea is the major cause of morbidity and

10
death among adults with Human immunodeficiency virus - HIV) but also a
risk factor for diarrhea (43).

2.6.4 Eating habits:

Eating with the hands; eating raw foods; or drinking Uncoiled water, May
increase the risk of diarrhea (43).

2.7 Diagnosis
2.7.1 Clinical Diagnosis

Mainly from medical history and physical examination [31].

2.7.2 Laboratory Diagnosis

Macroscopic and microscopic examination of stool is sufficient for starting

treatment of diarrheal disease (31). A well-equipped laboratory is required
for culture sensitivity tests and electrolyte determination, but at a primary
health care unit(PHCU) level basic laboratory service like stool
examination is adequate [31].

2.8 Other factors associated with good practices for diarrhea among
mother having under-five children.

The findings revealed that there is a significance association between

knowledge and sex, education, occupation, monthly income and attitudes
with practice concerning to diarrhea prevention through under five
children-based care. Males (59%) were more likely to have poor
knowledge than females (52%) (p = 0.001) the respondents with secondary
and higher levels of education (48%) were significantly less likely to have
poor knowledge compared to those with primary (55%) or having no
education (58%) (p < 0.001).

Respondents who had a monthly overall household expenditure of US$ 88

or below (58%) were more likely to have poor knowledge compared to
respondents with higher monthly overall expenditure (Wahed, et al, 2013).

11
Considering the research conducted by in Nigeria at Neyagawa revealed
that about 21% are the only one who are able to describe the causes of
diarrhea and about (156)46% 16 cited correctly one or two complications
associated with diarrhea in under-five children and 9% do not know any
complication and the dehydration was most known as complication
with a percentage of 12% ,With this research, it indicated that only 44% 0f

are the only who can perform a full assessment during management of
diarrhea case among children under-five years and there was a significance
between practices and level of education that a community health mothers
had (Abdu ,2013).Although the s has contribute more in promotion of
health as well as in prevention of some diseases there is a need to
enhance and a upgrade their capacity of the s so that they are able to
deliver services efficiently and effectively.

2.9 Critical gap analysis

Considering the empirical literature review by analyzing different studies

that have been conducted the diarrhea is a public burden and this problem
is very crucial among children under-five years, different countries apply
the prevention by implementing community health approach through
community sensitization but supporting mechanisms of CHWs used are
not considered.

The supporting mechanisms should be aimed to alleviate different barriers

and challenges faced by the community health mothers.

2.10 Theoretical framework

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2.10.1 The Health Belief Model (HBM) Theoretical

It’s one of the most widely used conceptual frameworks for

understanding health behavior. developed in the early 1950s, the model
has been used with great success for almost half a century to
promote greater condom use, seat belt use, medical compliance,
and health screening use, to name a few behaviors and this can be
applied in this study concerning to assessment of s on home based care
for diarrhea prevention among under-five children. The results of the
meta-analysis provided substantial empirical support for the efficacy of
the him.

He HBM is based on the understanding that a person Was take a

health-related action Feels that a negative health condition (i.e.,
diarrhea in under-five years can be avoided Has a positive expectation
that by taking a recommended action, he/she Was avoid a negative
health condition (i.e., effective attitude and practice care Was be
effective for diarrhea prevention among under-five children) Believes
that he/she can successfully take a recommended health action (i.e., a
apply the home-based care principles comfortably and with
confidence).

13
The Health Belief Model is a framework for motivating people to take positive health actions
that uses the desire to avoid a negative health consequence as the prime motivation.

For example, diarrhea in under-five years is a negative health consequence, and the desire to
prevent diarrhea can be used to motivate s into practicing home- based care then families can
be tough about prevention of risks factors related to occurrence of diarrhea. It's important to
note that avoiding a negative health consequence is a key element of the HBM
(Zimmerman ,2005).
2.11 The global burden of diarrheal disease in children
Diarrhea is a global problem, but is especially prevalent in developing countries in
conditions of poor environmental sanitation, inadequate water supplies, poverty and
limited education (44). According to WHO, approximately one billion cases of diarrhea
occur each year worldwide causing a burden that was about 99.2 million
DALYs(disability adjusted life years) lost(44)

2.12 Management
2.12.1 Case Management
Replace fluid & electrolytes - irrespective of the etiology (give ORS or food based ORT)
feeding give increased fluid during diarrheaAnti-microbial and anti-parasites are not
required except for Diarrhea due to cholera, severe bacillary dysentery and parasites (51)
Giving ORS is Life Save to a Child with Diarrhea [51]. Fluids, meals are necessary for
dehydrated person so as to get rehydration, in young children who are under 2 years of
age must get continuously breast feeding. Medication is important I diarrhea is due to
bacteria or parasites (51).

[Link] Fluids
Oral rehydration solution (ORS) slightly sweetened and salty water) can based to prevent
dehydration. Standard home solutions such as salted rice water, soups with salt can be
given. Home solutions such as water in which cereal has been cooked, unsalted soup,
green coconut water, weak tea (unsweetened), and unsweetened fresh fruit juices can
have from half a teaspoon to full teaspoon of salt (from one-and-a-half to three grams)
added per liter(52).

Clean plain water can also be one of several fluids given. Here are commercial solutions
such as ORS which is widely distribute packets of salts and [Link] publication for

14
physicians recommends a homemade ORS consisting of one liter water with one teaspoon
salt (3 grams) and two tablespoons sugar (18grams) added [52]. Appropriate amounts of
supplemental zinc and potassium should be added if available. But the availability of
these should not delay rehydration. As WHO points out, the most important thing is to
begin preventing dehydration as early as possible. in another example of prompt ORS
hopefully preventing dehydration, CDC recommends for the treatment of cholera
continuing to give 24 Oral Rehydration Solution during travel to medical treatment(53).

[Link]. Eating

WHO recommends a child with diarrhea continue to be fed? Regular feeding takes part
the recovery of normal intestinal function. In contrast, children whose food is restricted
have diarrhea for long time and recovery of intestinal function was be slow (56).

A child must be breastfed. The WHO states "Food should never bewitch and the child's
usual foods should not be diluted. Breastfeeding should always be continued. [56]And in
the specific example of cholera, CDC also makes the same recommendation. [57

[Link] Medications.
While antibiotics are beneficial in certain types of acute diarrhea, they are usually not
used except in specific situations.[58]However, some bacteria are Developing antibiotic
resistance, particularly Shigella.[59] Antibiotics can also cause diarrhea, and antibiotic
associated diarrhea is the most common adverse Effect of treatment with general
antibiotics.

While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in

those with travellers’ diarrhea, they do not decrease the length of illness. [59].Anti
motility agents like lope amide are also effective at reducing the number of stools but not
the duration of disease [60].These agents should only be used if bloody diarrhea is not
present [61].

Alternative therapies
Zinc supplementation benefits children with diarrhea in developing countries, but only in
infants over six months old. This supports the World Health Organization guidelines for
zinc, but not in the very young.[62].Robotics reduces the duration of symptoms by one
day and reduced the chances of symptoms lasting longer than four days by 60%[63].

15
The probioticlctobacillus can help prevent antibiotic associated diarrhea in adults but
possibly not children (61).

[Link] Prevention and control of diarrhea among mother having under-five

children

The study about knowledge, attitude and practices regarding diarrhea prevention as
conducted in Dhaka, Bangladesh scale showed that 97% of the study participants had a
highly positive attitude toward diarrhea as well as its vaccine having good attitudes.

It was significant related to having knowledge about practices related to prevention of

diarrhea as indicated by respondents maintaining poor prevention practices (78%)
were more likely to have poor knowledge compared to those with good practices
(39%) (P< 0.001) ((Wahed,et al, 2013).

The skills of community health mothers is associated by the level of knowledge that the s
has about the causes of diarrhea ,with different studies indicated that failure to know that
the diarrhea can be viral cause that most of s provide the antibiotics for 14 anyone who
has diarrhea as indicated by the result by which nearly half (46,6% do not recognize the
episodes of diarrhea and only 18.8% are the only who recognize that virus can be among
the causes of diarrhea and about 40% provide antibiotic for all cases of diarrhea in
children.

There is an association between knowledge about diarrhea and the practices used to
manage the diarrhea in under-five children (Ayuk,2015).There is a significance
between knowledge about diarrhea and practices in its management as indicated by
the study where about 79 cases of diarrhea managed in ward, about 60 (75.9%) cases,
classified diarrhea correctly and 74 (93.6%) of diarrhea cases were correctly treated
according to IMCI guidelines (Venkatachalam,2012).

2.13 Summary of literature review.

The diarrhea is a burden problem worldwide. There is great number of children who
continue to die from this condition. The diarrhea diseases can be prevented through
enhanced mother hygiene related practices; to come on this target, it require mother
awareness which may be enhanced by community health mother ,however the community

16
health mothers face different barriers and challenges that continue to impede the
effectiveness of this approach.

Some training need to be implemented but not enough comparing to the load of activities that
necessity the use of mothers having children under five years.

2.14 Figure 1: Conceptual frame work

In Dependent variables Dependent variables

KAP

Knowledge
Attitude
Practice
Diarrhea diseases

Socio-economic factors

Age
Gender
Income
Education

17
 CHAPTER THREE
RESEARCH METHODOLOGY

3.0 Introduction
This chapter aims at presenting the research design, the description of the study area, study
population, sampling design, sample size and techniques, methods and tools used in data
collection, the validity and reliability, data analysis and ethical consideration to be applied in
this study.

3.1 Research area

The area which we want to take the research projects of the diarrheal disease AMONG
MOTHERS HAVING CHILDREN UNDER FIVE YEARS IN AREA OF SHEKH OSMAN which
located in west of Borama

It has a population of approached to 300-600.

3.2 Study design

Descriptive Cross-sectional study was conducted with quantitative approach that

identifies knowledge attitude and practice of diarrheal among mothers having children
under the age of five.

3.3 Target Population

The target populations was under five children of diahrraial disease of SHEKH OSMAN
BORAMA IN SOMALILAND
Study population
The study population were sample taken from the under five years, children of diarrheal
disease in sheikh Osman Borama Somaliland.
3 Sample Size
The minimum sample size will compute using the Sloven’s formula, which states that, for
any given population, the required sample size is given by;

n= N

1 + N(e2)

Where;

18
n = required sample size

N = the known population size

e = Level of significance /margin of error, which is = 0.05. Given the target population of
110 in the selected of SHEKH OSMAN BORAMA IN Awdal.
SOMALILAND. A sample size of 63 will involve in the study.

n= N .

1+N (e2)

n=110
1+110(0.05)2

n= 86

3.4 Sampling Techniques/strategies

The data collection techniques of my study will a systematic simple randomly of
respondents those live SHEKH OSMAN BORAMA IN SOMALILAND.

3.5 Data collection techniques and instruments

This is the systematic gathering of date for a particular purpose from various sources
including questionnaires, interview and observation this involves three processes:

Before data collection: the researcher is developing all the date collection tools and
making communications with research stakeholders in advance, on top of that the
researcher is organizing all the needed facilities in advance.

During data collection: the researcher in meeting with the respondents, giving them an
introduction and instructions for responding to the researcher, also in this stag the
researcher is giving the responds all the needed guidance to the respondents.

After data collection: the researcher is checking and reviewing all the process of the
collection

3.6 Data analysis

Data from the questionnaire Will coding and entering to analyse the statistical package
for social science version 16.0 (SPSS0 Descriptive analysis Will compute whereby
proportion/percentages and frequency were calculated.

19
3.7 Ethical Consideration
Before going into the details of the field assignment, the data collection person deployed
to the field introduced themselves, explained the purpose of the survey and obtained the
Will singness of respondents. In every engagement/meeting with participants, respect will
give to local cultures and norms, meeting places were selected as per participant’s
consent, and every participant will kindly requested to provide his/her genuine
opinions/ideas. Finally, when respondents finished their points, the data collection person
extended their gratitude to respondents for their time and effort in providing data.

3.8 Validity and reliability

Validity is the extent to which an instrument measures what it actually intended to
measure while reliability is the degree of consistency or dependency with which an
instrument measures the attribute it is designed to measure. To confirm excellence and
self-confidence
Of the data, additional measures will be taken to control the data by making sure the mothers
and their children Will comfortable. Moral relationship will also ensure so that Mothers allow
providing Accurate data. Again, correct interpretation and analysis of data will do by using
appropriate statistical analysis especially SPSS version [Link] on these, it will argue that
the questions and responses have reasonable and substantial degree of validity.

3.9 Inclusion criteria

All residents of Sheikh Othman mothers having children under five year’s respondent of
research questionnaire and everyone who are willing participate in this study.
3.10 Exclusion criteria
Non-resident Sheikh Othman mothers are excluded from the study who are not able to
respond to the research questionnaire.

20
 Chapter four

Date presentation, analysis and interpretation

4.1 Introduction
This chapter presents the findings of the study and discussions. The findings represented and
interpreted based on the objectives of the study.
These are presented in tables and figures following the sequence of specific research problem
regarding the knowledge, attitude and practice (KAP) among Mothers having children under
five year from Districts Awdal Borama in Somaliland and Major findings of the study was
guttered district Borama especially resident of sheikh Osman to assess knowledge, attitude
and practice of diarrheal among mother’s having children under five years.

4.2. Socio-demographic characteristic

This figure1, it showed the age of mothers were respondents (15-24) were 30 while (25-34)
were 22 while ( 35-44) were33 and others

21
Figure 2, it showed the marital status were respondents 76.7% were married while 16.3%
were divorced while 7.0% were windowed.

Figure 3, it showed the respondents of the occupation of 62.8% were house wife while 18.6%
were business woman while 18.6% were UN employed.

22
education level of mothers

Frequency Percent

illiterate 55 64.0

primary 19 22.1

secandary 12 14.0

Total 86 100.0

Table 1. it showed the level of education were respondents 64.0% were illiterate while
22.1% were primary while 14.0% were secondary

4.2.1: Knowledge of mother and Diarrheal diseas

23
Figure 4, it showed of the causes of diarrheal were respondents 34.9% were infection while
34.9% were malnutrion while 30.2% were worm infection.

Figure 5, it showed how do you know patient with diarrheal were

respondents 61.6% were water stool while 20.9% were fever while17.4%
were abnormal pain

24
Figure 6, it showed how to transmit of diarrheal were respondents 57.0% were by
contaminate of water while 43.0% were uncovered food,

How to prevent diarrheal

Frequency Percent

drinking clean
46 53.5
water
good breast
30 34.9
feeding
I don,t know 10 11.6

Total 86 100.0

Table 2, it showed how to prevent diarrheal were respondents 53.5% were drinking clean
water while 34.9% were good breast feeding while 11.6% was I don,t know

25
Diarrheal can transmitted from one person to other person

Frequency Percent

strongly
40 46.5
agree

Valid agree 23 26.7

neutral 23 26.7

Total 86 100.0

Table 3, it showed of the Diarrheal can transmitted from one person to other person were
respondents 46.5%were strongly agree while 26.7% were agree while 26.7% were neutral
4.3 Economic Factors

Figure 7, it showed the Income of mothers were respondents 38.4% were 1$> while 15.1%
were 1$ while 46.5% were 2$<

26
Figure 8, it showed the any problem of transportation were respondents 45.3% were yes
while 54.7% were no

27
Figure 9, it showed the any problem the price of food were respondents 38.4% were yes
while 61.65% were no

Figure 10, it showed do you able to school fees for children were respondents 79.1% were
yes while 20.9% were no.

28
4.4 Respondents home sanitation

Figure 11, it showed the wash your hand after use latrines were respondents 79.1% were yes
while 20.9% were no.

29
Figure 12, it showed the boil the water before you drink it were respondents 50.0% were yes
while 50.0% were no.

How to manage your waste

Frequency Percent

at home 6 7.0

by car 43 50.8
burn the
37 43.0
waste

Total 86 100.0
Table 4, it showed how to manage your waste were respondents 7.0% were at home while
50.8% were by car while 43.0% were burn the waste,

30
Figure 13, it showed do you chlorinate your drinking water were respondents 27.9% were yes
while 72.1% were no.

31
 Chapter five

Discussion, Conclusion and Recommendation

5.1 inrtoduction
The study was aimed at determining the Knowledge, attitude and practice of residents of
Awdal region on The recurrences of diarrheal in the SHEKH OSMAN BORAMA
SOMALILAND

Districts. The results of the study were based on a sample of 86 households' heads that
were found at their Homes during the period of data collection.

5.2 Discussion
This study investigated knowledge attitude and practise of diarrheal disease among the
mothers having children under five years in area of sheikh Osman, Borama Somaliland.

Later found out that the mother was aware of diarrheal in children under five, therefore, lack
of knowledge has a significant impact on children with diarrheal.

Unsafe water and unhealthy food that the mother gives to the baby are also most affected.

According to Ethiopian demographic health survey (EDHS) of 2000, 2005, 2011 and 2016
the 2 weeks prevalence of diarrheal disease among under-five children was 24, 18, 13, 12%
respectively.

Even though there was a double reduction of the prevalence of under 5 diarrheal diseases in
the last 16 years in Ethiopia, but, still it is one of the most important public issue and major
health problems of the country.

Rotavirus is among the commonest diarrheal pathogen in children worldwide that causes
about one-third of diarrhea-associated hospitalizations and 800,000 deaths per year.

Children in the poorest countries like Ethiopia account for 82% of rotavirus deaths of under-
five children.

Rotavirus can cause intestinal losses of fluid, electrolyte and nutritional deficiency which
relatively progresses rapidly to cause dehydration and death.

32
 Contaminated weaning food, inappropriate feeding practice, lack of clean water, poor hand
washing, limited sanitary disposal of waste, poor housing conditions, and lack of access to
adequate and affordable health care are aggravated factors of the under 5 diarrheal disease

5.3 Conclusions
In this chapter Conclusions and recommends on the findings of the research as The study
was focused on four Districts Awdal region and Major findings of the study was guttered
district Awdal region especially shekh Osman in Borama Capital city state of Awdal
region in Somaliland to assess knowledge, attitude and practice of diarrheal among
mother’s having children under five years.

The result of this study and described that knowledge attitude and practice for diarrheal
among mothers having under five children in Borama.

The majority of the respondents of 46.5% had poor knowledge, 26.7% had good knowledge
and 62% had positive attitude, 12.8% had negative while the remained 16% had neutral
attitude and 78% had poor practice, 22% had good practice.

5.4 Recommendations
As the study indicated the practice of the respondents were low of knowledge, attitude and
practice of diarrhea among mother’s having children under five [Link] in order to increase
the practice of the mothers about knowledge, attitude and practice of diarrhea among
mother’s having children under five years. Much attention should be given by all responsible
bodies. After analysis and evaluating the study finding, I suggest and recommended by The
following recommends:

Ministry Of Health
 I recommend the ministry of the health to promote the mothers knowledge about diarrhea
management by the mothers who has under five children particularly how to make good
practice to manage diarrheal.
 I recommend the ministry of health to make a decision making a good awareness about
diarrhea affected under five children in Awdal region, in Borama shekh Osman,
somaliland

Local government

 To improve the environmental sanitation

33
 To ensure that the all waste are good managed
 To Improving proper water storage
 Take important roll to prevent the communicable disease that caused bay lack of waste
management proper using latrine and cleaning latrine.
NGOs
 I recommend The ngos which are working on diarrhea to take part in diarrhea under five
children in Awdal region, in Borama shekh Osman, somaliland
practice promotional activities among rural mothers

Community
 I recommend the mothers who have good knowledge and practice to support the other
mothers they haven’t good knowledge and practice.
Mothers
 Also I recommend the mothers to visit health center when her child suffering diarrhea.
 To make homemade fluid when has diarrhea because prevent of dehydration.
 Always to practice the good awareness that she gived the health workers or other
mothers.

Students of public health

I recommend the students of public healthy to make a team which makes awareness
for the mothers having under five children and learn how diarrhoea diseases transmit
and prevention.

I recommend the students’ make of health education to mothers about diarrhoea its causes,
prevention and proper treatment.

34
 REFFERENCE
(EDHS) of 2000, 2005, 2011 and 2016 the 2 weeks prevalence of diarrheal disease among under-five
children.
Abrams, Benison,{1995},Control of communicable disease manual,
1. ADR Journals 2014, Diarrheal diseases are the most major health problems in the world.
2. ADR Journals 2014. diarrhea an increase in the fluidity, volume and frequency of stool.
3. Available from: URL: [Link]
4. Cairncross S, Yonli R. 2000 Domestic hygiene and diarrhoea –pinpointing the problem.
5. ChalliJira, 2001 Diarrheal Disease
6. Concise of American laboratory book, 14th edition, USA, Florida; 2011.
7. Concise of American laboratory book, 14th edition, USA, Florida; 2011.
8. Ensink JH, 2000 pinpointing the problem diarrhea.
9. Etiler N, Velipasaoglu S, Aktekin M. 2004 Risk factors for overall and persistent diarrhea in
infancy.
10. Gascon J, 2000 Diarrhea in Children under 5 Years of Age.
11. Ghosh S,. Riskbehavioural practices of rural mothers as determinants of childhood diarrhea.
Common Dis. 1997; 29(1):7-1
12. Imar ky 2015poor hygiene cause millions of the world’s.
13. Jensen PK, 2004 Is there anassociation between bacteriological drinking water quality and
childhood diarrhea
14. Johns Hopkins University. 2005 Exclusive BreastfeedingTraining For Mothers Helps
Reduce Diarrheal Disease Among Infants.
15. Marjatta BS. 2001 Water supply and diarrhea in East African community
16. Molbak K, 1997 Risk factors for diarrheal disease incidence in early childhood
Molbak K. 2000 The epidemiology of diarrheal diseases in early childhood.
17. Sobel J, Gomes TA, 2004 -Specific Risk Factors and Protective Factors for Acute Diarrheal
Illness in Children Aged 12–59 Months.
18. Tumwine JK, Thompson J, 2002 Diarrhoea and effects of different water sources, sanitation
and hygiene.
19. UNICEF, 2006 diarrheal diseases account for over90% of deaths in children below five
years.
20. UNICEF. 2016. child deaths from pneumonia and diarrhea,
21. W Roberts , 2001 keeping clean water clean in a Malawi refugee camp: WHO
Communicable
35
22. WHO & UNICEF. [2009] Acute Diarrhea still a leading cause of child deaths in Clinical
management
23. WHO in January 2011, Diarrhea is the main killer, contributing 20-25percent of all under-
five mortality.
24. WHO, 2005, prevalence of diarrheal diseases Sub-Saharan Africa countries report.
25. WHO, 2005: The treatment ofdiarrhoea.
26. WHO, 2007 socio economic status and it affects occurrence of diarrhoea.
27. Who. (2011). cholera
28. World Health Organization. (2001), Water-Immediate Solutions for persistent problems.

36
 Informed Consent Dear Respondent:
Our names are…………………………………………………..

We are students in ADMAS UNIVERSITY Faculty of Health Science, Department of Public

Health. We are here to study about knowledge attitude and practise of diarrheal disease
among the mothers having children under five years and you are chosen to participate in this
study. You are selected and included in the study as part of the sample population to
complete the questionnaire designed by us. The information obtained in this study will be
used only for research purposes to generate important information about knowledge attitude
and practise of diarrheal disease among the mothers having children under five years wish
improve the quality of the practice will improve the health of the baby and achieve change in
the society inside and outside about the killer disease that affect the infant. The study will
involve various personal issues. In order to attain this study objectives your good will, kindly
participation and genuine response is needed. Confidentiality is strictly protected and none of
your response will be reported separately. Therefore, there is no need to write your names or
ID numbers on these questionnaires. It is your right to participate or to refuse in this study.
And you can drop any individual question or the whole questionnaire. But your participation
and contribution in the study is very important to come up with important findings which
help improve quality of education. So please take few minutes to answer to the questions.
Do you have any opinion regarding this study? Do you agree to participate in this study? 1.
Yes, continue 2. No, thank you! Questionnaire code number_________________ Name of
the data facilitator __________________________ Sign__________ Date__________
Starting time ______________________ finishing time ______________________________

37
 APPENDIX: B QUESTIONAIRE

Dear respondent
We are group of the study of public health at Admas University Faculty health science
Department of Public health we are conducting a study to assess knowledge, attitude and
practice of diarrheal among mother having under five children in Awdal Borama,
Somaliland.

Please feel free to answer at your best knowledge. It’s not necessary to mention your name
and identify. We would highly be very thankful to you if you give us some of your time in
completing this questionnaire.

Section (A): Socio demographic factors of mother’s

1: Age of mothers {years]

A. 15-24
B. 25-34
C. 35-44
2. Marital status of the mother’s
A. Married
B. Divorce
C. Widowed

3: Occupation of mothers

A. House Wife
B. Business Woman
C. Un employed

4: Education level of mother’s

A. Illiterate
B. Primary
C. Secondary

Section B: Knowledge of mother and Diarrheal disease

1: What are causes of diarrhea?

A. Infection

38
 B. Malnutrition
C. Worm Infections
2: How do you Know patient with Diarrheal?
A. Water stool
B. Fever
C. abnormal pain
3: How to transmit of diarrheal?
A. By Contaminated of Water
B. Uncovered Food
4: How to Prevent Diarrheal?
A. Drinking clean water
B. Good breast Feeding
C. I don't Know
5: Diarrheal can be transmitted from one person to other person.
A. Strongly agree
B. Agree
C. Neutral
Section C: Economic Factors
1: Income of mothers (US $ per month)
A. > 1$
B. 1$
C. 2$
2: Do you have any problem transportation?
1 Yes
2 No
3: Do you have any problem the price of food?
1. Yes
2. No
4: Do you able to school fees for children?
1. Yes
2. No
Section D: respondents home sanitation
1: Do you Wash your hand after use latrines?
1. Yes

39
 2. No
2: Do you boil the water before you drink it?
1. Yes
2. No
3: How to Manage Your Waste
A. at home
B. By Car
C. Burn the waste
4: Do you chlorinate your Drinking Water?

1 Yes
2 No
BUDGET

No Activity Unite Rate Days Total

amount
1 Stationary and all print
photocopies
2 Transportation Bajaj
from the campus
the site
3 Research and data
collectors cost of
break food
4 Total

40