Maternal beliefs and behaviors in self-efficacy to prevent childhood diarrhea: a cross-sectional study

Brena Shellem Bessa de Oliveira1, Rhaiany Kelly Lopes Oliveira1, Jallyne Colares Bezerra1, Maria Jocelane Nascimento Silva1, Francisca Mayra de Sousa Melo2, Emanuella Silva Joventino1
1 University of International Integration of Afro-Brazilian Lusophony
2 Princesa do Oeste College

ABSTRACT

Aim: To investigate the association between maternal beliefs, knowledge and behaviors and their self-efficacy to prevent childhood diarrhea. Method: This is a cross-sectional, quantitative study conducted in the interior of Ceará, with 385 mothers of children under five years of age. Data collection was performed through the application of a sociodemographic form and the Maternal Self-Efficacy Scale to Prevent Childhood Diarrhea (EAPDI). Data were analyzed using the chi-square test. Results: There was a significant relationship between levels of self-efficacy and maternal behavior regarding diet during diarrhea (p=0.001); poorly cooked food (p=0.004); contaminated water (p=0.036); greasy food (p=0.007); heat (p=0.048); dirty hands/objects in the mouth (p=<0.001); drugs (p=<0.001); verminosis (p=0.012); contaminated food (p=0.001). Conclusion: Factors such as beliefs, knowledge, source of information and maternal behaviors adopted in the prevention and management of childhood diarrhea were statistically influenced by women's self-confidence in preventing this pathology.

Descriptors: Diarrhea, Infantile; Child Health; Self Efficacy; Nursing.

INTRODUCTION

Infant mortality is a worldwide problem that occurs in the majority of cases due to preventable causes, which can be prevented and treated through actions that have a low cost(1).

Although infant mortality rates are constantly being reduced, it is estimated that by 2015 there were 5.9 million deaths in children under five years of age on the planet, half of them caused by infectious diseases such as diarrhea(2).

Diarrhea consists of a worldwide public health problem and is defined as the increase in the amount of usual bowel movements of an individual and the presence of three or more stools containing feces of watery or softened characteristics over a period of twenty-four hours(2).

In Brazil, it is still possible to observe regional disparities in morbidity and mortality from this pathology. The North and Northeast regions stand out because they present the most worrying indexes, since the mortality rate in children under 1 year of age due to diarrhea is, respectively, 5 and 4 times higher than the rate presented by the South region(3).

Above all, the development of diarrhea is related to socioeconomic, demographic conditions, basic sanitation, water supply, type of home, breastfeeding and precarious general hygiene(4). Given this, it can be noted that some actions are possible to be performed by the caregivers of the children with the intention of preventing and treating this affection.

However, just taking the information to the caregivers is not enough, since this action does not guarantee that they will implement the guidelines passed(5). In this case, it is imperative to carry out activities that promote the increase of the security that the individual possesses when performing certain action**.**

This confidence of being able to perform a task based on their knowledge and skills is defined as self-efficacy(6). It is an important determinant in the prevention and management of diarrhea, since, when a person feels capable of performing something, there is an increase in the chance that such an act will be successful.

Thus, the objective of the present study was to investigate the association between maternal beliefs, knowledge and behaviors and their self-efficacy to prevent childhood diarrhea.

METHOD

This is a cross-sectional, quantitative study carried out in eight Primary Health Care Units (UAPS, acronym in Portuguese) located in urban and rural areas of a city in the countryside of Ceará.

The sample was selected for convenience and consisted of 385 mothers of children under five years of age, who were assisted in at least one of the eight UAPS selected for the research. Women who had restrictions that prevented them from understanding the instruments used were excluded.

Data collection was done through an interview at the UAPS during the months of August to October 2015. On that occasion, the signing of the Informed Consent Term (TCLE) was requested and an instrument was applied which aimed at collecting data on the socio-sanitary conditions of the families, prevention, occurrence and management of childhood diarrhea and the Self-efficacy Scale for the Prevention of Childhood Diarrhea (EAPDI, acronym in Portuguese).

The EAPDI is a Likert scale consisting of 24 items divided into two domains: family hygiene and general/dietary practices. Its response pattern ranges from 1 (totally disagree) to 5 (totally agree). Each mother who responds to it can choose only one of five response options. Thus, EAPDI scores can range from 24 to 120 points, and the level of maternal self-efficacy to prevent infant diarrhea is considered low when the sum of points obtained is equal to or lower than 109, is moderate when a score of 110 to 114 is obtained, and is high when there is a score greater than or equal to 115 points(7).

The data was organized and analyzed by the IBM SPSS Statistics program (version 20). Comparative statistics were performed using the chi-square test and a significance level of less than 0.05 was established. The research was approved by the Research Ethics Committee of the University of International Integration of Afro-Brazilian Lusophony (UNILAB), according to Opinion No. 1,164,864.

RESULTS

Regarding the characterization of the sample, it was noticed that a large part of the women participating in the study lived in the urban area (n=215, 55.8%); had an age range varying from 13 to 49 years of age, with an average of 27.55 years (SD=±7.2); lived in a consensual union (n=164, 42.7%); had 1 to 4 years of study (n=146, 38.1%); were housewives (n=187, 48.6%); and survived with a per capita income of up to R $ 197.00 (n=258, 68.4%), with an average of R $ 210.00 (SD=R$ 216.00).

Table 1 shows the existence of a correlation between maternal self-efficacy and the occurrence and management of infant diarrhea. Only maternal feeding behavior during the diarrheal event (p=0.001) was statistically significant.

Table 2 shows that maternal beliefs and knowledge about the causes of diarrhea are capable of directly influencing maternal self-efficacy for the prevention of childhood diarrhea, since most variables present a statistically significant correlation, namely: food poorly prepared (p=0.004), contaminated water (p=0.036), fatty food (p=0.007), heat (p=0.048), dirty hands/objects in the mouth (p=verminosis (p=0.012) and contaminated food (p=0.001).

From Table 3, there is a correlation between the level of maternal self-efficacy and the access to information on infant diarrhea. It was also noticed that the information passed on by community health agents (p=0.001), television (p=0.009), neighborhood/friends (p=0.009), lectures/posters (p=0.046) and personal experience (p=0.008) show statistically significant interference in maternal self-efficacy to prevent infant diarrhea.

DISCUSSION

Although there is no significant relationship between the previous existence of diarrhea and self-efficacy in this study, the literature indicates that the occurrence of an earlier diarrheal episode may influence the mothers' confidence and behaviors during subsequent diarrheal episodes that the child may experience(8).

Although most cases of mild and moderate diarrhea are treated at home(9), it is believed that the act of seeking a health service, when this occurrence takes place, is a conduct that can avoid the complications caused by gastroenteritis, namely: electrolyte imbalance, dehydration, anemia, and death(10). It should be emphasized that no statistical relationship was found between these variables in this study.

There was also no statistically significant correlation between the achievement of home recipes and the self-efficacy of the mothers. The study points out that, when diarrhea is treated by home-based methods, the underreporting of the disease and the risk of worsening symptoms are increased, since many household recipes lack scientifically proven efficacy(11).

Another finding worth mentioning is the lack of association between the use of oral rehydration serum (ORS) and maternal self-confidence to prevent diarrhea, although ORS has proven efficacy, being able to prevent about 95% of cases of diarrhea that present dehydration(12). Thus, the lack of association between these variables, verified in the present study, may be associated with the fact that mothers do not know how to handle it because of their low level of education or insufficient guidance on how to do it, which directly influences in the correct way of preparation.

Rotavirus vaccination is also a major factor in promoting the health of children, since this pathogen is one of the main agents causing childhood diarrhea(12). Although authors confirm the positive effect of the vaccine in a Brazilian setting(13), this study did not find statistical difference between rotavirus immunization and self-efficacy for the prevention of childhood diarrhea.

It was found that the type of feeding provided to children during diarrhea episodes influences the level of maternal self-confidence and that the women who sought to improve their diets and hydrate their children had higher self-efficacy scores when compared to others. However, the Ministry of Health recommends that there should be no changes in the child's usual diet and that the supply of fluids be increased(14).

It was found that the fact that mothers believed that undercooked food (p=0.004), contaminated water (p=0.036), fatty food (p=0.007), heat (p=0.048), dirty hands/objects in the mouth (p=0.001), medication (p=0.001), verminosis (p=0.012), and contaminated food (P=0.001) could cause childhood diarrhea directly influenced maternal self-efficacy to prevent this aggravation. It was also observed that maternal beliefs are influenced by cultural aspects passed through the generations, as reported by a study carried out in Rio Grande do Norte(15).

It is known that some diseases may be caused by contamination of food and that the proper washing, handling and cooking process are important means for the elimination and breakdown of the transmission chain of these pathogenic microorganisms(16). In addition, according to the literature, young children especially have a habit of placing dirty objects or hands in their mouths, contributing to increase the chances of contamination and development of diarrheic episodes(11). Therefore, it is important to emphasize the relevance of health professionals in this context, promoting health education about good habits of body, food and home hygiene, seeking to encourage mothers to perform these practices in their daily lives.

Due to the hot climate in the region where the study was conducted, the mothers associated some episodes of diarrhea with heat. Research conducted in São Paulo also points out that, because of the heat, children spend more time barefoot, drink water anywhere and food is more easily deteriorated, thus contributing to the development of childhood diarrhea(17). However, it is believed that this association carried out by the mothers of this study is due to experiences acquired previously, by the reports of their relatives, friends, and community and not necessarily by scientific evidence.

A study about maternal knowledge on childhood diarrhea performed at a university hospital in the state of Rio Grande do Norte(15) revealed, as well as this research, that mothers believe that fatty foods or foods previously not consumed by the child and immature immune systems can lead to disorders in the digestive tract, leading to childhood diarrhea. It was also found that mothers who believed that fatty foods caused diarrhea in their children felt more confident in preventing this condition than the others.

It is known that the verminoses are also responsible for triggering diarrheal events. The infection caused by these parasites occurs due to lack of hygiene, inadequately treated water and unfavorable sanitary conditions(18). Other factors that cause childhood diarrhea, according to mothers, are medications. The belief that verminoses and medications cause diarrhea promotes greater maternal care regarding general hygiene and the conscious use of remedies, acts that are effective in preventing this pathology and in increasing the confidence of these women during the care of their children.

It was also noted that there is a significant correlation between the degree of maternal self-efficacy and access to information on ways to prevent, treat and avoid complications triggered by diarrheal diseases**. The professionals who passed on more information to the mothers and who interfered positively in their self-efficacy were the community health agents (CHA) (p=0.001). They have also influenced and proved to be important sources for mothers to know about television, the neighborhood/friends, lectures/posters and personal experience.**

It is believed that the fact that CHAs are some of the main practitioners who disseminated information about the prevention of childhood diarrhea may be related to the bond and intimate contact they have with families, since they are residents of the community for which they are responsible, and they promote monthly visits, thus becoming the main mediators of information about diarrheal events.

A study about the population's perceptions about the work of the CHAs demonstrated that this population considered them as the main responsible for making the link between the community and the health services. In addition, it was noticed that the population was unfamiliar in terms of the functions of these professionals, but referred to them as important agents for scheduling exams and obtaining consultations and medications, demonstrating the confidence and the bond of these professionals with the community(19).

According to Andrade et al.(20), the more positive mothers' knowledge about diarrhea prevention, the more their self-efficacy is highlighted and they are influenced by their sources of information. Therefore, the present study shows the importance of maternal self-efficacy in the prevention of childhood diarrhea and in combating the morbidity and mortality of children**.**

CONCLUSION

Factors such as beliefs, knowledge, source of information and maternal behaviors adopted in the prevention and management of childhood diarrhea were statistically influenced by women's self-confidence in preventing this pathology.

Therefore, it is imperative that nurses and other health professionals use EAPDI during their care as a way to evaluate the self-efficacy of mothers of children under five and to seek to promote health education activities that stimulate and encourage women to take appropriate measures to prevent and treat childhood diarrhea in their children.

As a limiting factor of the study, it was verified the difficulty in obtaining the desired sample, since some institutions participating in the study did not perform weekly consultations on growth and development of the child. As a result, it relied on the spontaneous demand of the units as a way to achieve the sample. The fact that the research is unicentric is also limited as a limitation.

It is important to carry out studies aimed at elaborating and testing the effectiveness of interactive health education tools that stimulate maternal self-efficacy to prevent childhood diarrhea and make them safer during the promotion of adequate child care.

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CONTRIBUTIONS

Brena Shellem Bessa de Oliveira and Emanuella Silva Joventino contributed substantially to the design and planning or to the analysis and interpretation of the data, participated in the drafting or critical revision of the content and approval of the final version of the manuscript. Jallyne Colares Bezerra, Maria Jocelane Nascimento Silva and Francisca Mayra Sousa Melo contributed substantially to the preparation of the draft or critical revision of the content and participated in the approval of the final version of the manuscript.

FINANCING

This work was funded by the Cearense Foundation for Support to Scientific and Technological Development (FUNCAP, acronym in Portuguese).

All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 12/26/2016

Revised: 02/06/2019

Approved: 02/06/2019