Parental knowledge, attitude and management practices of childhood diarrhoea in the UAE

Abstract

Background:

Childhood diarrhoea remains a significant public health concern in the United Arab Emirates (UAE). Since parental awareness directly influences health-seeking behaviour and management decisions, this study aims to evaluate gaps in parental knowledge, attitudes and practices related to childhood diarrhoea.

Design and methods:

A quantitative, cross-sectional survey was conducted in the UAE using a self-administered online questionnaire, and 492 responses were collected. Data was analysed using IBM SPSS-26.

Results:

21.1% (n = 104) of participants considered themselves very knowledgeable about diarrhoea, with females being 1.86 (95% CI: 1.86–1.28; p < 0.001) times more likely to have a higher knowledge than males. The median diarrhoeal knowledge score was 9 ± 5. While participants demonstrated good understanding of methods of disease contraction, only 43.7% (n = 215) recognised that diarrhoea is contagious. Most participants were unable to identify key symptoms of diarrhoea with 86.6% (n = 426) failing to recognise that diarrhoea could present with loss of skin turgor. Both highest degree obtained and field of work were statistically significant factors in parental diarrhoea knowledge (p = 0.006 and p < 0.001, respectively). Parental attitudes were measured across several distinct factors and the median value obtained was 2 ± 6. Most parents felt capable of managing diarrhoea; however, 6.7% (n = 33) admitted feeling completely unprepared, and nearly half (49.0%, n = 241) reported feeling worried or anxious if their child had diarrhoea. Furthermore, in terms of practices, most parents recognised key interventions, with 74.8% (n = 368) increasing fluid intake and 70.3% (n = 346) offering bland foods.

Conclusion:

The overall participants’ knowledge ranged from inadequate to moderate, revealing gaps in symptom recognition and misconceptions about disease causes. Addressing these gaps through targeted education programmes for expecting parents could enhance disease recognition, reduce unnecessary medical interventions and improve diarrhoea management, easing the burden on children in the UAE.

Introduction

Diarrhoea is not an illness, but a consolidation of symptoms, hinting at many underlying diseases. It is usually caused by bacterial, viral, or protozoal infections. Due to it being a common manifestation, it poses a significant global health concern. Diarrhoea is defined as the passage of loose and watery stool more frequently than usual or more than 3 times a day, and its pathophysiology is heavily influenced by the underlying disease causing it. Acute diarrhoea lasts for 14 days, while chronic episodes last more than 4 weeks.^1,2 Severe or persistent diarrhoea may lead to various complications, such as dehydration, electrolyte imbalance, organ damage, hypotension, coma and in extreme cases, shock and eventually death. ² According to the World Health Organisation (WHO), diarrhoea management consists of five key steps: rehydration, nutritional support, zinc supplementation, optimal application of antibiotics and parental education. ²

Despite significant advancements in healthcare, diarrhoea remains a leading cause of morbidity and mortality in children below 5 years of age. ³ The WHO estimates that 1.3 million children die annually from diarrhoeal complications and inadequate treatment; primarily occurring in low income and developing regions such as South Asia and Sub-Saharan Africa, secondary to poverty, limited healthcare access and inadequate sanitation.^4–7

Effective management of diarrhoea relies heavily on parental awareness and appropriate health-seeking behaviours. Inadequate parental response can lead to unfortunate complications, often due to ignorance of the associated symptoms and risk factors. Additionally, management of acute diarrhoea in emergency departments is inefficient, and tends to involve inappropriate antibiotic prescriptions, and unnecessary investigations, which further contribute to higher healthcare costs. ⁸

No world region is exempt from the burden of diarrhoea. According to the Global Burden of Disease (GBD), in 2021, diarrhoeal diseases accounted for 1.49 million disability-adjusted life-years (DALYs) and a neonatal morality rate of 723.3 per 100,000 in the Middle East and North Africa region, suggesting an urgent need for intervention to mitigate the disease’s impact. ⁹ In the UAE, current evidence on parental knowledge and health practices regarding childhood diarrhoea is limited and has not been previously evaluated. As such this study aims to investigate parental knowledge, attitudes and practices towards childhood diarrhoeal and its management.

Methodology

Study design

A quantitative, cross-sectional, community-based study, using a convenient snowballing sampling method, was conducted to assess the knowledge, attitudes, and practices of the UAE population on childhood diarrhoea.

Study population

The study was conducted in Abu Dhabi, Dubai, Sharjah and the northern Emirates, targeting parents and expecting parents who spoke either Arabic and/or English, as those are the two languages spoken by the researchers. Visitors and non-residents were excluded from the study. An online self-administered questionnaire was utilised to recruit participants between January 16, 2025, and February 20, 2025. Online distribution of the questionnaire was chosen for its efficiency in gathering data from many respondents. To ensure broad and diverse participation, the survey link was distributed via a standardised invitation message on multiple digital platforms, including WhatsApp groups, social media platforms like Facebook and Instagram and email. Additionally, parents were approached in public venues, such as malls and parks, provided a brief explanation of the study and were invited to complete the survey on their phones. This combined approach ensured wider coverage and minimised selection bias.

Sample size

A minimum sample size of 385 was calculated based on 5% marginal error and 50% prevalence using the following formula: $n=\frac{4p\left(1-p\right)}{S{E}^2}$ , where n = sample size, p = expected prevalence and SE = sampling error. The sample size was then increased by 20% to account for potential non-responses, incomplete data and to compensate for completed questionnaires by participants who did not meet the inclusion criteria; hence resulting in a final minimal sample size of 462 participants.

Questionnaire development and pilot study

An online self-administered questionnaire was developed and adapted from a previous study conducted in Saudi Arabia. ¹⁰ The questionnaire was initially developed in English and then translated into Arabic. It consisted of 39 questions, divided into four sections: demographics, ¹⁰ knowledge of diarrhoea, ¹¹ attitude and management practices of diarrhoea. ¹⁸ The questionnaire was reviewed and pre-tested in a pilot study to ensure its clarity and comprehensibility.

Patient and public involvement

Public members were involved in the development of the questionnaire, particularly in the pilot phase. Prior to the commencement of the study, the questionnaire was piloted on 15 individuals, 6 individuals piloted the Arabic version and 9 piloted the English. Based on the feedback, the questionnaire was refined to ensure better understanding and eliminate ambiguity. Importantly, data obtained from the pilot were not included in the analysis.

Data collection and ethical consideration

Data was collected using the online questionnaire, approved by the research ethics committee at the University of Sharjah (Reference number: REC-24-11-28-03-F). The participants were asked to complete it at their convenience. Before beginning the survey, participants were provided with an information sheet detailing the purpose of the research, and written, informed, consent was obtained electronically. No personal identifiers were collected to ensure confidentiality.

Data analysis

Data analysis was performed using IBM SPSS Version 26 (IBM Corp., Armonk, NY, USA). The study’s demographic data included sex, age, education level, number of children, ethnicity and occupation. The normality of the scale data was assessed through statistical testing using the Kolmogorov-Smirnov test. Group mean score comparisons were made using Kruskal Wallis and Mann-Whitney U tests. Categorical data were presented as frequencies and percentages and analysed using the chi-square test. Valid percentages were reported to address missing data.

In this study, knowledge was defined as participants’ awareness of facts, signs and symptoms, causes, risk factors, and preventive measures of childhood diarrhoea. To evaluate knowledge, participants’ responses were scored, one point was awarded for agreeing with a true statement or disagreeing with a false one, while incorrect responses received negative points, and a total score was computed. Participants scoring ≤ 1 IQR below the median (a score ≤ 4) were considered to have inadequate knowledge; those scoring ≥ 1 IQR above the median (a score ≥ 14) were considered to have adequate knowledge, and scores between 4 and 14 were classified as moderate knowledge.

Attitudes referred to participants’ feelings, beliefs and perceptions towards childhood diarrhoea, reflecting their acceptance, or prioritisation of recommended behaviours or interventions. Attitudes were assessed using a 5-item Likert scale.

Practices encompassed the self-reported behaviours and actions that participants engaged in, including their adherence to recommended preventive or management measures, and were considered appropriate if participants consistently followed the guidelines. A p-value of ≤0.05 was considered statistically significant.

The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. ¹¹

Results

Demographics

A total of 554 questionnaires were completed, after excluding those who did not meet the inclusion criteria (living in the UAE and having children/expecting a child), 492 responses were analysed. Almost two-thirds of the participants (64.2%, n = 316) were females, 28.9% (n = 142) had two children and 5.3% (n = 26) were expecting a child. A third of the participants lived in Dubai (33.3%, n = 164), followed by Abu Dhabi (30.1%, n = 148). The median age of participants was 42 (IQR = 14), 31.9% (n = 157/466) were 30–39 years old, and 31.1% (n = 153/466) were 40–49 years old. More than half of the participants (56.3%, n = 277) had a bachelor’s degree, 70.9% (n = 349) were non-Emirati Arab and 34.6% (n = 170) were unemployed/housewife (Table 1).

Table 1.

Knowledge and attitudes of the participants towards diarrhoea per demographic characteristics.

Characteristic	All		Perceived high diarrhoea knowledge		Diarrhoea knowledge score
	(n)	(%)	(%)	p-Value	Median ± IQR	p-Value
Sex
Male	176/492	35.8	30.7	<0.001*	8 ± 6	<0.001**
Female	316/492	64.2	69.3		10 ± 6
Age
18–29	41/466	8.8	7.9	0.264*	9 ± 5	0.955***
30–39	157/466	33.7	32.5		9 ± 6
40–49	153/466	32.8	33.3		9 ± 5
50 and above	115/466	24.7	26.2		9 ± 7
Place of residence
Abu Dhabi	148/492	30.1	30.7	0.268*	9 ± 7	<0.001***
Dubai	164/492	33.3	33.9		10 ± 5
Sharjah	128/492	26.0	26.3		8 ± 5
Northern Emirates	52/492	10.6	9.1		7 ± 6
Highest degree obtained
Diploma or lower	97/492	19.7	20.6	0.638*	8 ± 6	0.006 ***
Bachelor’s degree	277/492	56.3	56.0		9 ± 5
Postgraduate degree	118/492	24.0	23.4		10 ± 7
Nationality
Emirati (UAE National)	66/492	13.4	12.8	0.174*	8 ± 5	<0.001***
Non-Emirati (Other Arab)	349/492	70.9	72.9		9 ± 6
Non-Arab	77/492	15.7	14.3		11 ± 5
Field of work
Healthcare	71/492	14.4	15.6	0.053*	11 ± 6	<0.001***
Non-healthcare	251/492	51.0	48.2		8.5 ± 6
Unemployed/Housewife	170/492	34.6	36.2		9 ± 5
Number of children
Expecting our first born	26/492	5.3	3.6	0.002 *	8 ± 7	0.095***
I have 1 child	91/492	18.5	16.4		10 ± 5
I have 2 children	142/492	28.9	28.9		9 ± 6
I have 3 children	102/492	20.7	22.9		9 ± 6
I have 4 or more children	131/492	26.6	28.1		8 ± 6
Age of youngest child
0–1 year	75/492	15.2	12.0	0.001 *	9 ± 6	0.017 ***
2–5 years	149/492	30.3	30.2		9 ± 5
6–10 years	87/492	17.7	17.7		9 ± 6
11–15 years	75/492	15.2	17.7		10 ± 6
Above 15 years	106/492	21.5	22.4		8 ± 6

^*Pearson’s Chi-Square test, **Mann-Whitney U test, *** Kruskal-Wallis test.

Bold entries indicate a statistically significant result, where a p-value ≤0.05 was considered statistically significant.

Knowledge regarding diarrhoeal disease

When asked about their perceived knowledge of diarrhoea and its management, 21.1% (n = 104) of participants considered themselves very knowledgeable, while 56.9% (n = 280) reported being moderately knowledgeable. As expected, participants who had children were 3.30 (95% CI: 1.48–7.38; p = 0.002) times more likely to report being knowledgeable compared to those expecting their first child. Female participants were also 2.62 (95% CI: 1.69–4.05; p < 0.001) times more likely than males to perceive themselves as knowledgeable. Interestingly, no statistically significant difference in perceived knowledge was observed across the different occupational groups (p = 0.053; Table 1).

The median diarrhoeal knowledge score among participants was 9, with an interquartile range of 5. Scores ranged from −10 to 20, within a possible scale spanning from −64 to 64. Interestingly, those who claimed to be knowledgeable were 1.86 (95% CI: 1.21–2.87; p = 0.005) times more likely to have a higher knowledge score. When asked about the definition of diarrhoea, only 22.4% (n = 110) answered incorrectly. Females were 1.86 (95% CI: 1.86–1.28; p < 0.001) times more likely to have a higher knowledge than males. It is also important to note that only 43.7% (n = 215) were aware that diarrhoea could be contagious.

In terms of symptoms of diarrhoea, 84.3% (n = 415) did not recognise that diarrhoea could present with blood in stool and 86.6% (n = 426) were not aware that tearless eyes could be a sign of severe dehydration secondary to diarrhoea. Similarly, loss of skin turgor was not recognised as a symptom of diarrhoea in 86.2% (n = 424) of the participants. Both lactose and food intolerance were not commonly identified as underlying causes of diarrhoea (63.8%, n = 314 and 55.7%, n = 274, respectively). Finally, 45.1% (n = 222) incorrectly thought that teething causes diarrhoea. Importantly, only 29.1% (n = 143) were aware that a complication of diarrhoea, if not treated appropriately, is death and organ damage (27.4%, n = 135; Figure 1(a) and (b)).

Figure 1.

Perceived clinical signs and symptoms (a) and red flags (b) of diarrhoea reported by participants.

The overall knowledge of methods by which diarrhoea is contracted were good, eating without washing hands (75.6%, n = 372), contaminated water (72.2%, n = 355), contaminated food (71.3%, n = 351), and expired food (60.6%, n = 298) were commonly recognised by the participants. As for the most common sources of knowledge that the participants claimed, 78.0% (n = 384) stated that they took their information from healthcare professionals, 40.6% (n = 199) from official governmental websites and only 24.4% (n = 120) from social media.

Attitudes towards diarrhoeal disease

When asked about the parent’s concerns regarding the spread of the disease; 57.1% (n = 211) were concerned about diarrhoea spreading to their other children, 32.5% (n = 160) worried about transmission to other children in school and 24.0% (n = 118) worried about contracting diarrhoea themselves. Interestingly, 40.2% (n = 198) did not believe that diarrhoea was contagious. In terms of preparedness, only 6.7% (n = 33) of participants felt that they were not prepared at all. Emotionally, nearly half of the respondents (49.0%, n = 241) stated that they would feel worried or anxious if their child had diarrhoea, while 6.5% (n = 32) indicated they would feel overwhelmed.

Regarding participants’ beliefs about the triggers of diarrhoea, 53.9% (n = 265) positively affirmed cold weather/air conditioning could cause it. Additionally, 27.2% (n = 134) believed that diarrhoea is a normal process for ‘cleansing’ the body while 54.7% (n = 269) considered diarrhoea in infants to be normal. When asked about the use of antibiotics for treating diarrhoea, 42.1% (n = 207) disagreed with their use (Figure 2).

Figure 2.

Participants’ attitudes towards diarrhoea including beliefs, treatment and prevention.

Participants were asked how they would respond if their physician informed them that their child had mild diarrhoea and did not require hospital admission. Fortunately, the majority (87.4%, n = 430) stated that they would trust the doctor’s judgement. As for when would the parents allow their child to return to school after an episode of diarrhoea, 31.7% (n = 156) believed it should be after consulting with their doctor, 28.9% (n = 142) said after being asymptomatic for 24 h, 18.7% (n = 92) preferred waiting for 48 h and only 0.8% (n = 4) felt that there is no need to wait.

Practices towards diarrhoeal disease

Parental attitudes were measured across several distinct factors and the median value obtained was 2 ± 6. Scores ranged from −9 to 15, within a possible scale spanning from −21 to 21. When managing an episode of childhood diarrhoea, 74.8% (n = 368) of participants said they would increase their child’s fluid intake and 70.3% (n = 346) would offer them bland foods; notably, females were 1.56 (95% CI: 1.03–2.36; p = 0.037) times more likely to increase their child’s fluid intake and 1.63 (95% CI: 1.10–2.43; p = 0.015) times more likely to offer bland food during an episode. Giving children soups was also common (46.3%, n = 228) among participants, while only 6.3% (n = 31) suggested not feeding the child at all. When it came to breastfeeding, 25.4% (n = 125) stated they would increase breastfeeding, whereas 6.1% (n = 30) said they would avoid it. Interestingly, 18.7% (n = 92) of respondents believed that drinking carbonated drinks such as 7up could help treat diarrhoea, and 13.8% (n = 68) thought that eating dry foods like crackers could cure it.

Generally, preventive practices were also widely acknowledged by the participants. When it came to good hand hygiene 91.3% (n = 449) recognised its importance, and 83.5% (n = 411) agreed that clean water and proper food handling is essential. Teaching children not to put objects in their mouths was supported by 63.2% (n = 311). However, only 31.5% (n = 155) reported avoiding reheating rice multiple times, and 37.6% (n = 185) knew that should not give honey to babies under 1 years of age. Interestingly, no significant difference was found between avoiding reheating rice multiple times and both age (χ² = 2.316, df = 3, p = 0.51) and highest degree earned (χ² = 4.158, df = 2, p = 0.125). Similarly, no significant association between highest degree earned and the practice of avoiding giving honey to babies under 1 year (χ² = 0.929, df = 2, p = 0.628).

Discussion

Despite diarrhoea being largely preventable and easily managed with timely and appropriate care, it remains a significant cause of morbidity and mortality among children worldwide. ⁹ In the UAE, diarrhoea poses a considerable public health concern, particularly among children under 3 years of age. One study reports that only 6%–10% of patients who sought medical care ultimately required hospitalisation, indicating a degree of urgent care centres misuse. ¹² As such, this study aimed to identify gaps in the parental knowledge and management strategies employed pertaining to childhood diarrhoea.

Overall, participants had limited knowledge regarding childhood diarrhoea, especially in recognising its red flags, contagious nature and the preventive role of vaccination, especially the rotavirus vaccine. In the Middle East, rotavirus is a common cause of gastroenteritis, with reported rates ranging from 10% to 46% in Saudi Arabia, ¹³ 61% in Syria, ¹⁴ and 25% in the UAE.^12,15 Additionally, a Saudi study further highlighted this knowledge gap, revealing that only 9.6% of participants were aware that the vaccine could help prevent the ailment. ⁷

Although participants’ perceived knowledge did not significantly differ across the place of residence, a statistically significant difference was observed in actual knowledge scores. Participants living in the Northern Emirates had lower scores compared to those living in more developed Emirates such as Dubai and Abu Dhabi. Such variance could be due to differential access to healthcare services and education resources such as health awareness campaigns.

While participants were generally aware of the definition of diarrhoea, when it comes to red flags, over three-fourth of participants failed to identify bloody stool, tearless eyes and loss of skin turgor as signs of severe dehydration. Similar findings were reported in a Saudi study where only half of the participants identified bloody stool as an alarming sign, and about one-third recognised the signs of dehydration. ¹⁰ Similar findings were also reported in Ethiopia, Kenya and Nepal; respondents failed to identify bloody stool and signs of severe dehydration as red flags that require immediate medical attention.^16–18 Prompt recognition of those signs is crucial for timely referral; significantly enhancing the effectiveness of management. ¹⁰

Although medical information is readily available, many parents continue to hold common misconceptions about the causes of childhood diarrhoea. In our study, a common false belief quoted by participants included the idea that diarrhoea can be caused by exposure to cold weather or by swimming shortly after eating. Additionally, nearly half of the participants also cited teething as a cause. This misconception of teething is widespread and lacks scientific evidence; multiple studies across the Middle East and North Africa region and internationally highlighting this issue.^19–22 In a Saudi Arabian study, mothers reported teething as the leading cause of diarrhoea, followed by viral infection. ⁷ Furthermore, about one-third of our participants viewed diarrhoea as a normal bodily cleansing process. This findings mirrors that in the Malang Raya region, where participants believed diarrhoea to be linked to development millstones. ² Importantly, despite being well-established medically, lactose and food intolerance were rarely reported by our participants.

As for the sources of transmission, most of the participants correctly identified contaminated water and food, unclean hands and expired food. These findings are in contrast with previous studies conducted in the region, for example, about one-third of mothers in Saudi Arabia and one quarter in Iran were able to recognise contaminated water as a source of transmission.^10,23

It is important to note that participants generally had positive attitudes regarding diarrhoea and its management; more than half of the participants were concerned about spreading the disease to other children. Most of them trusted the doctor’s treatment plan, including the decision on when the children could safely resume school, showing an overall readiness to follow professional guidance and be socially responsible. However, despite this reasonable level of awareness, many parents admitted to feeling anxious and unprepared when dealing with diarrhoeal episodes at home.

As for parental management practices followed, a mixture of both effective and ineffective practices were noted. On the positive side, many highlighted that they would increase their child’s fluid intake, provide soft, blended or mashed food, and maintain breastfeeding during diarrhoeal episodes. These practices align with the WHO’s recommendations for managing childhood diarrhoea and are similar to findings reported in a previous study conducted in Turkey, showing that mothers usually follow established yet beneficial practices regardless of their educational level.^6,24 However, several ineffective, harmful practices were also noted in our study, including giving carbonated drinks or stopping feeding altogether, which may exacerbate dehydration and delay recovery. Similar inappropriate practices such as food avoidance, cessation of breastfeeding, the use of wrong prescriptions and improper conventional therapy have been reported in multiple African studies.^25,26 Additionally, in our study, the majority reported preferential reliance on herbal treatment instead of medical intervention. While this may be rooted in traditional beliefs, it can delay seeking appropriate treatment, which can worsen the symptoms.

Recommendations

With the increased burden of childhood diarrhoea in the UAE, our findings highlight the need for health awareness campaigns focusing on childhood diarrhoea, its clinical symptoms, red flags and signs of dehydration and basic home management practices. It is also essential to raise awareness about transmission methods and preventive measures, particularly among parents of primary school children. Moreover, we highly recommend implementing geographically and ethnically targeted public health programmes to educate the community on this critical issue.

Limitations

Snowball and convenience sampling were utilised in this study which may lead to sampling bias and limited generalisability. Furthermore, having a higher proportion of female participants could affect the balance of perspectives and further affect the generalisability of the findings. Additionally, illiterate individuals, those who do not speak Arabic nor English and those without electronic means were unable to participate in the study. Furthermore, since the data were collected electronically, this can introduce several biases, such as selection, recall and social desirability biases. However, given that the online survey was anonymous and respondents completed it in their own privacy, the impact of any social desirability bias is reduced. While participants were recruited from all seven Emirates, they were not represented equally and the distribution was not stratified. However, we do not expect this to affect the validity of the results as the UAE is a metropolitan country with a majority of the participants being from the largest Emirates, which are the commercial and cultural hubs of the UAE.

Conclusion

While parents demonstrated good awareness of the causes of childhood diarrhoea, significant gaps in symptom recognition and misconceptions about disease transmission persist, influencing health-seeking behaviour. These misconceptions lead to conflicting management practices, potentially contributing to unnecessary medical visits. Addressing these gaps through targeted education programmes, particularly for expecting parents, could enhance disease recognition in households and promote evidence-based practices.