Assessing mothers’ knowledge and attitudes towards rheumatic fever and the chronic nature of rheumatic heart disease: an analysis of influential factors

Abstract

Background

The burden of rheumatic fever (RF) and rheumatic heart disease (RHD) is a significant health concern. Despite being largely preventable, their persistence is strongly linked to gaps in community awareness and preventive practices. This study aimed to assess mothers’ knowledge and attitudes towards RF and RHD and to identify modifiable factors influencing prevention.

Methods

A cross-sectional study conducted in Najran, Saudi Arabia, among 771 mothers from June to September 2025. Data were collected using a structured self-administered online questionnaire covering basic characteristics, knowledge of RF/RHD and attitudes towards preventive practices. Knowledge levels were categorised to identify major and moderate gaps.

Results

Overall, 58.8% of mothers demonstrated satisfactory knowledge while 73.3% showed positive attitudes towards preventive practices. However, detailed analysis revealed critical modifiable knowledge gaps, particularly regarding the link between untreated streptococcal infection and RHD (38.0%), susceptibility of children aged 5–15 years (31.9%) and the need for long-term penicillin prophylaxis (28.5%). In contrast, general awareness of preventive practices and common symptoms was relatively adequate. A high proportion of children (86.9%) experienced recurrent sore throat, while only 25.0% of mothers had attended RF/RHD educational programmes, highlighting a mismatch between disease exposure and preventive awareness. Logistic regression analysis identified several significant predictors of knowledge and attitudes (p<0.05). These predictors include maternal age, number of children, educational level, employment status, household income, child’s history of recurrent sore throat and prior participation in RF and RHD educational programmes.

Conclusion

Despite generally acceptable awareness of preventive practices, substantial gaps persist in critical disease-specific knowledge needed to prevent RF and RHD effectively. These modifiable deficiencies, combined with limited participation in educational programmes, highlight missed opportunities for intervention. Targeted, community-based health education focusing on early treatment of sore throat, high-risk groups and adherence to prophylaxis is essential to reduce the burden of RF and RHD.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Rheumatic fever/rheumatic heart disease (RF/RHD) are preventable conditions that remain prevalent in low-resource and middle-resource settings, largely due to inadequate awareness, delayed treatment of streptococcal infections and poor adherence to preventive strategies.

WHAT THIS STUDY ADDS

• There are significant modifiable gaps in maternal knowledge about RHD, its risk groups and prevention, with low participation in education programmes despite frequent sore throat episodes.

• Maternal knowledge and attitudes are shaped by socioeconomic and environmental factors, including education level, income, prior exposure to RF/RHD information and living conditions.

HOW THIS STUDY MIGHT AFFECT RESEARCH PRACTICE OR POLICY

• Strengthening education, integrating digital health platforms and implementing standardised clinical protocols are essential policy actions to improve awareness, early recognition and management of RF/RHD.

• Addressing socioeconomic determinants through community outreach, alongside future research on targeted educational interventions, is crucial to reduce knowledge gaps and disease burden.

Introduction

Rheumatic fever (RF) and rheumatic heart disease (RHD) remain critical health challenges, particularly in developing countries, causing significant morbidity and mortality among children. RHD is a preventable disorder that typically develops after inadequate treatment of Group A Streptococcus (GAS) pharyngitis.¹ This initial infection can trigger an autoimmune response, leading to acute RF, which progresses to RHD in approximately 60% of cases. RHD can cause serious long-term cardiac complications, including cardiac failure, stroke and early mortality.^{2 3} The age-standardised prevalence rate of the disease in the Middle East and North Africa region was 388.9 per 100 000 population in 2019, 5.4% higher than in 1990.⁴

According to the WHO, around 55 million people worldwide suffer from RHD, resulting in more than 300 000 deaths yearly.⁵ While national and regional prevalence data for Saudi Arabia (SA) are limited, studies suggest that SA, like other Middle East countries, faces a significant burden of the disease. Alqanatish et al have confirmed that the proportion of children with RHD in Saudi Arabia remains higher than the global rates.⁶ Several factors contribute to the occurrences of the disease, including overcrowding, low socioeconomic conditions, limited healthcare access and the prevalence of GAS infection.⁷ In addition to genetic predisposition, some people may be genetically predisposed to a stronger autoimmune response.⁸

RHD is the most frequently acquired heart condition in children and young adults, making effective prevention crucial. Key strategies include prompt and accurate diagnosis and treatment of GAS pharyngitis, coupled with consistent adherence to secondary prophylaxis (regular penicillin injections) for individuals with a history of RF or RHD.¹ Effective implementation of these preventive strategies depends largely on community awareness, especially among those most influential in children’s health, which is their mothers. Mothers play a key role in identifying symptoms, seeking healthcare and adhering to treatment regimens.⁹ Their awareness and attitude towards RF and RHD prevention methods and their health-seeking behaviours significantly influence the likelihood of taking preventive measures, early diagnosis and treatment of GAS infection and adherence to secondary prevention.^{10 11} Prior studies have examined knowledge, attitudes and practices related to RF and RHD in various settings and populations, laying the foundation for the development of targeted health interventions.12,15 The current study builds on these findings by adapting and modifying previously validated questionnaires to better reflect the sociocultural and health context of current study population. We aim to fill important gaps in understanding the influential factors related to RF and RHD prevention. Identifying factors influencing maternal knowledge and attitudes towards RF and RHD prevention could help develop effective, appropriate interventions and public health campaigns to improve mothers’ knowledge and attitudes and promote RF and RHD prevention, ultimately leading to improved child health outcomes and minimising the risk of childhood illnesses and their subsequent mortality. Therefore, this study aims to assess mothers’ knowledge and attitudes towards RF and RHD and analyse the influential factors.

Methods

Study design

This correlational cross-sectional study explored mothers’ knowledge and attitudes towards RF and RHD prevention in the Najran region, Saudi Arabia, and identified the factors influencing knowledge and attitudes.

Study setting

The study was conducted in the Najran region of southwest Saudi Arabia.

Participants

Participants in this study were 771 mothers recruited through convenience sampling from the general population, who completed a self-administered online questionnaire via Google Forms. The online questionnaire was distributed to recruit participants through social media groups and pages on platforms such as Facebook, Twitter, WhatsApp, Instagram and Telegram. Before accessing the questionnaire, participants were provided with detailed information about the study objectives and inclusion criteria. Informed consent was obtained electronically, and both informed consent and fulfilment of inclusion criteria were prerequisites for participation. Inclusion criteria consisted of mothers of children aged 5–15 years, ability to read and write, willingness to participate and provision of informed consent.

The following formula was used to determine the required sample size:

.$${\displaystyle {\displaystyle N=\frac{Z_{\alpha /2}^{2}XPX\left(1-p\right)XD}{E^2}}}$$

With an alpha of 0.05, Zα/2 was 1.96. Given the lack of consistent data on knowledge and attitude regarding the prevention of RF and RHD in Saudi Arabia, a prevalence of 50% was assumed. A 2-effect design and a margin of error of 0.05 were used. A 5% oversample was added to mitigate potential data loss. After data quality assessment, 35 cases were removed due to incomplete and inconsistent data, resulting in a final sample of 771 participants.

Data collection instrument

Data were collected between June and September 2025 using a self-administered questionnaire developed by the researchers based on a review of the existing literature. The questionnaire underwent face validity testing by a panel of four paediatric nursing specialists and a biostatistician. The original questionnaire was developed in Arabic to ensure its cultural and linguistic appropriateness for the study participants. The questionnaire was then translated into English using a standardised forward-and-backward translation process to facilitate analysis and reporting of the results. The questionnaire consisted of three sections.

Section 1: Participants’ basic data

This section collected basic data, including age, number of children, age of the youngest child, education, marital status, income, residence, working status, nationality, housing condition and child sore throat attacks and RF/RHD education attendance.

Section 2: Mother’s knowledge about RF and RHD

This section assessed participants’ knowledge of RF and RHD using a 23-item test adapted from previous studies.^{12 13 16} Some items were adapted nationally to reflect local community beliefs (such as iced beverages and cold air drafts as causes of recurrent sore throat), which are relevant for understanding misconceptions. These were not treated as ‘correct’ medical responses but rather as indicators of community perception. Although herbs, such as honey, are traditionally used to manage sore throat, their antibacterial and anti-inflammatory effects have been proven in previous literature.^{17 18} In addition, gargling with salt water is used to reduce pain and irritation associated with a sore throat.¹⁹ The test included 23 dichotomous (true/false) questions covering causes, high-risk groups, signs and symptoms, treatment and preventive measures. To enhance the interpretability of the findings, maternal knowledge items were categorised into levels of knowledge gaps based on the proportion of correct responses. This classification was used to identify modifiable deficiencies and prioritise preventive interventions. Acceptable knowledge: ≥75% correct responses, indicating adequate awareness with minimal need for intervention. Moderate knowledge gap: 50% to <75% correct responses, indicating partial awareness requiring targeted health education. Major knowledge gap: <50% correct responses, indicating substantial deficiency in knowledge and a high priority for intervention. This classification approach has been widely used in public health research to distinguish among levels of knowledge adequacy and to guide intervention planning. Each correct answer was awarded one point, with a maximum of 23 points. Overall knowledge scores were categorised as unsatisfactory (<70% or <16.1 points) or satisfactory (≥70% or ≥16.1 points). The 70% cut-off was chosen to represent an acceptable level of knowledge, as commonly used in educational and health-related knowledge assessments. For analytical clarity, several studies employ a consolidated 70% threshold to categorise knowledge levels into binary ’satisfactory’ and 'unsatisfactory’ groups, particularly when a dual-category classification is required.^{20 21} The test showed good internal consistency (Cronbach’s alpha=0.872).

Section 3: n attitude scale towards RF and RHD prevention

This section, adapted from previous literature,^{13 15 16} assessed attitudes towards prevention and treatment measures for RF and RHD. Eight items were rated on a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1); only one item among the eight was reversed, yielding a possible total score of 8–40. Participants were categorised as having a negative attitude (<24) or a positive attitude (≥24). The cut-off point of 24 was determined based on the scale’s theoretical midpoint. Since the instrument consisted of eight 5-point Likert items (range: 8–40), the midpoint is 24 (8×3), where three represents the neutral response. Therefore, scores ≥24 indicate a tendency towards a positive attitude, whereas scores <24 reflect a negative attitude. This approach is commonly used in Likert-scale-based attitude assessments when no established normative cut-off is available. The attitude scale also showed good internal consistency (Cronbach’s alpha=0.853).

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research.

Data analysis

Data analysis was performed using SPSS V.25. Before analysis, data were screened for inconsistencies and normality. Thirty-five inconsistent responses were excluded. Descriptive statistics were used to summarise participants’ basic data, knowledge about RF and RHD and attitudes towards RF and RHD prevention. Categorical variables are presented as frequencies and percentages, while continuous variables are presented as means and SD. Overall knowledge and attitude scores were calculated by summing the scores of individual items. Univariate and multivariate analyses were performed to identify factors influencing maternal knowledge of RF and RHD prevention. The multivariate logistic regression model included variables with p values ≤0.25 in the univariate analysis to control for potential confounding. The goodness-of-fit of the logistic regression model was evaluated using the Hosmer-Lemeshow and Omnibus tests. The model was deemed to have a good fit, as the Hosmer-Lemeshow test yielded a non-significant result (p=0.410), while the Omnibus test indicated statistical significance (p=0.001). Multicollinearity among demographic variables and maternal knowledge and attitudes was assessed using variance inflation factors (VIFs) and standard errors. No variable exceeded the threshold of VIF >10 or SE >2, suggesting no serious multicollinearity issues. The strength and direction of associations were determined using adjusted OR (AOR) with 95% CIs. Statistical significance was set at p<0.05.

Results

Mothers’ basic data

Table 1 shows that the study included 771 participants. The mean age of the study participants was 33.35 years; they had a mean number of children of 3.15, and the mean age of the youngest child was 3.61 years. Nearly equal proportions of the mothers were married (87.2%) and urban residents (88.8%). Furthermore, 82.6% were Saudi citizens, and 64.6% had university or postgraduate education. Although 59.1% of the mothers were unemployed, a large proportion reported sufficient monthly income (56.0%) and lived in a separate, well-ventilated apartment (72.9%).

Table 1. Mothers’ basic data (n=771).

Mothers’ basic data	No	%
Age (mean±SD) years	33.35±9.07
Number of children (mean±SD)	3.15±2.54
Age of the youngest child (mean±SD)	3.61±2.74
Education
Can read and write	17	2.2
Preuniversity education	256	33.2
University or postgraduate education	498	64.6
Marital status
Married	672	87.2
Divorced	53	6.9
Widowed	46	6.0
Nationality
Saudi citizen	637	82.6
Non-Saudi	134	17.4
Residence
Urban	685	88.8
Rural	86	11.2
Working status
Unemployed	456	59.1
Employed	315	40.9
Reported housing condition
Separate ventilated apartment	562	72.9
Shared apartment, but well ventilated	178	23.1
Poorly ventilated apartment	31	4.0
Personal evaluation of monthly income
Not enough for daily requirements	216	28.0
Enough only for daily requirements	432	56.0
Enough and can save money	123	16.0

Child sore throat attacks and RF/RHD education attendance

The findings in table 2 indicate that a high proportion of children (86.9%) experienced at least one sore throat attack per year, suggesting a substantial burden of recurrent throat infections within the study population. In contrast, only 25.0% of mothers reported prior attendance at educational activities related to RF and RHD, highlighting limited exposure to structured health education programmes.

Table 2. Child sore throat attacks and RF/RHD education attendance (n=771).

Items	No	%
Has a child complained of at least one sore throat attack/year
Yes	670	86.9
No	101	13.1
Prior attendance at educational activities about RF and RHD
Yes	193	25.0
No	578	75.0

RF, rheumatic fever; RHD, rheumatic heart disease.

Maternal knowledge with modifiable gaps and preventive implications

The revised analysis of maternal knowledge in table 3 revealed variable levels of awareness across different domains, with several important modifiable gaps identified. While acceptable knowledge levels were observed in areas such as antibiotic prescribing, treatment completion and recognition of common symptoms (≥75%), notable deficiencies persisted in critical aspects of disease understanding and prevention. Major knowledge gaps (<50%) were particularly evident in mothers’ awareness of the relationship between untreated streptococcal infection and RHD (38.0%), susceptibility of children aged 5–15 years (31.9%) and the importance of long-term benzathine penicillin prophylaxis (28.5%). These findings highlight significant deficiencies in core concepts essential for effective prevention of RF and its complications. Additionally, moderate knowledge gaps (50%–<75%) were observed in areas such as home-based management practices and recognition of less obvious symptoms, indicating the need for targeted health education. Misconceptions about non-medical causes of sore throat (eg, cold air exposure) were also prevalent, despite generally good awareness of preventive practices. Overall, the findings suggest that although general awareness of preventive practices is relatively adequate, critical gaps persist in disease-specific knowledge. These modifiable deficiencies underscore the need for focused educational interventions, particularly emphasising early treatment of streptococcal infections, recognition of high-risk groups and adherence to secondary prophylaxis. Finally, more than one-half (58.8%) of mothers demonstrated satisfactory total knowledge regarding RF and RHD.

Table 3. Maternal knowledge with modifiable gaps and preventive implications (n=771).

Domain	Item	No	Correct (%)	Knowledge gap	Modifiable?	Preventive implication
A common cause of a sore throat	Exposure to an infected person	576	74.7	Acceptable but improvable	Yes	Infection control education
Misconceptions about the causes of a sore throat	Iced beverages	612	79.4	Moderate misconception	Yes	Community education to correct myths
	Cold air drafts	662	85.9	Misconception persists	Yes	Awareness campaigns
Antibiotic use awareness	Only a physician prescribes antibiotics	670	86.9	Good knowledge	Yes	Reinforce rational use
	Completing the antibiotic course	670	86.9	Good knowledge	Yes	Maintain adherence programmes
Home management practices	Antibiotic necessity	574	74.4	Moderate gap	Yes	Clinical counselling
	Herbs and honey	657	85.2	Acceptable	Yes	Complementary care awareness
	Saltwater gargling	463	60.1	Significant gap	Yes	Simple home-care education
Critical RF/RHD knowledge	RHD complication of untreated infection	293	38.0	Major gap	Yes (high priority)	Core health education needed
	Age group susceptibility (5–15 years)	246	31.9	Major gap	Yes (high priority)	School-based awareness
	Long-term penicillin prophylaxis	220	28.5	Critical gap	Yes (high priority)	Follow-up adherence programmes
	Surgical treatment awareness	446	57.8	Moderate gap	Yes	Improve disease literacy
Recognition of RF symptoms	Fever	589	76.4	Acceptable	Yes	Reinforce symptom awareness
	Joint pain	645	83.7	Good	Yes	—
	Skin rash	444	57.6	Moderate gap	Yes	Clinical education
	Involuntary movements	414	53.7	Moderate gap	Yes	Awareness campaigns
	Chest pain/palpitation	619	80.3	Good	Yes	—
Preventive practices	Ventilation and sunlight	622	80.6	Good	Yes	Reinforce
	Reduce contact	604	78.3	Acceptable	Yes	Promote hygiene
	Isolation of the infected child	634	82.2	Good	Yes	Strengthen practices
	Complete antibiotics	592	76.8	Acceptable	Yes	Reinforce adherence
	Treat a sore throat early	636	82.4	Good	Yes	Promote early care seeking
Total knowledge score	Satisfactory	453	58.8	Moderate total knowledge gap	Yes	Tailored comprehensive educational programme with special emphasis on the identified gap in each item
	Unsatisfactory	318	41.2

RF, rheumatic fever; RHD, rheumatic heart disease.

Source of knowledge about RF and RHD reported by the mothers

Figure 1 shows that the internet and social media platforms were the first sources of maternal knowledge about RF and RHD (68.9%), with popular platforms including WhatsApp, Twitter, Instagram and Snapchat followed by family and friends (65.0%). The healthcare team ranked third (63.8%), followed by television and printed materials (56.7%) and, lastly, previous patients (27.0%) with RHD.

Figure 1. Source of knowledge about RF and RHD reported by mothers. RF, rheumatic fever; RHD, rheumatic heart disease.

Mothers’ attitudes toward prevention and appropriate treatment of RF and RHD

Table 4 shows that around three-quarters (73.3%) of mothers have a positive attitude towards RF and RHD prevention. Three-quarters (75.1%) of the mothers believe a sore throat should be treated with antibiotics. In addition, 79.9% of the mothers agree that expected complications of sore throat necessitate doctor visits, and 69.9% agree that RF and RHD are serious conditions that require effective preventive practices. In addition, 54.8% agree that the incidence of RHD can be reduced by improving the socioeconomic status and housing conditions, and 73.2% agree that avoiding crowded places can decrease the risk of sore throat and its complications. However, 60.0% of the participants agree that only warm fluids, herbs, and honey are effective treatments for sore throats. Lastly, 73.7% of the mothers are ready to follow RF and RHD prevention guidelines to increase their children’s safety, and 56.4% are interested in attending educational programmes on RF and RHD prevention.

Table 4. Mothers’ attitudes towards prevention and appropriate treatment of RF and RHD (n=771).

Attitude items	Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	N	%	N	%	N	%	N	%	N	%
Attitudes towards sore throat management
Sore throat treatment involves the use of antibiotics	0	0	89	11.5	103	13.4	174	22.6	405	52.5
Complications of a sore throat necessitate a doctor’s visit	0	0	71	9.2	84	10.9	316	41.0	300	38.9
It is enough to take warm fluids, herbs and honey for sore throat treatment*	14	1.8	83	10.8	211	27.4	314	40.7	149	19.3
Perception of risk and disease severity
The incidence of RHD can be reduced by improving socioeconomic status and housing conditions	34	4.4	97	12.6	217	28.1	250	32.4	173	22.4
Avoiding crowded places can decrease the risk of sore throat and its complications	17	2.2	34	4.4	151	19.6	279	36.2	290	37.6
RF and RHD are serious conditions that require effective preventive practices	34	4.4	66	8.6	132	17.1	289	37.5	250	32.4
Willingness to engage in prevention
Ready to follow the guidelines of RF and RHD prevention to increase the safety of my children	0	0	82	10.6	121	15.7	296	38.4	272	35.3
Interested in attending educational programmes about RF and RHD prevention	31	4.0	117	15.2	188	24.4	203	26.3	232	30.1
Total attitude score
Negative attitude	206	26.7
Positive attitude	565	73.3

^*The reversed item.

RF, rheumatic fever; RHD, rheumatic heart disease.

Binary logistic regression to predict mothers’ knowledge regarding RF and RHD

Binary logistic regression shows an association between maternal knowledge about RF and RHD and several demographic factors. A 1 year increase in a mother’s or a child’s age increases the OR of having satisfactory knowledge by 1.40 and 1.18 times, respectively. In addition, increasing the number of children by one child increases the OR of having good knowledge by 1.28 times. Furthermore, university-educated and preuniversity-educated mothers were more likely to have satisfactory knowledge than mothers who could read and write only. Also, employed mothers have 3.37 times higher odds of having satisfactory knowledge than unemployed mothers. In addition, mothers who have more than enough monthly income had a higher OR of having satisfactory knowledge when taking insufficient monthly income as a reference. Mothers of children with recurrent sore throats had a 3.87 times higher chance of having satisfactory knowledge than the reference group. Lastly, mothers who previously attended health education programmes on RF and RHD have a doubled OR of having satisfactory knowledge compared with women who did not attend such programmes (table 5).

Table 5. Binary logistic regression to predict mothers’ knowledge regarding RF and RHD.

Mothers’ basic data	COR (95% CI)	P value	AOR (95% CI)	P value
Age (mean±SD) years	1.310 (1.151 to 1.482)	0.000*	1.401 (0.877 to 1.961)	0.000*
Number of children (mean±SD)	1.174 (1.105 to 1.246)	0.000*	1.285 (1.157 to 1.427)	0.000*
Age of the youngest child (mean±SD)	1.177 (1.129 to 1.227)	0.000*	1.180 (1.114 to 1.249)	0.000*
Education		0.001*		0.000*
Can read and write	REF
Preuniversity education	1.541 (1.09 to 1.610)	0.027*	1.501 (1.112 to 1.621)	0.026*
University or postgraduate education	2.447 (1.707 to 3.508)	0.000*	3.113 (1.856 to 5.0)	0.000**
Nationality
Saudi citizen	REF
Non-Saudi	0.872 (0.532 to 1.623)	0.341
Residence
Urban	REF
Rural	0.923 (0.584 to 0. 1.460)	0.733
Working status
Unemployed	REF
Employed	2.164 (1.600 to 2.928)	0.000*	3.375 (2.459 to 4.719)	0.000*
Reported housing condition		0.420
Separate ventilated apartment
Shared apartment, but well ventilated	1.381 (0.701 to 3.031)	0.337
Poorly ventilated apartment	0.931 (0.524 to 1.801)	0.809
Personal evaluation of monthly income		0.000*		0.000*
Not enough for daily requirements	REF
Enough only for daily requirements	2.476 (1.704 to 3.598)	0.000*	2.524 (1.646 to 3.870)	0.000*
Enough and can save money	9.953 (5.947 to 16.657)	0.000*	7.625 (4.199 to 13.847)	0.000*
Has a child complained of at least one sore throat attack/year
No	REF
Yes	2.716 (1.952 to 6.495)	0.005*	3.871 (2.116 to 7.498)	0.000*
Prior attendance at educational activities about RF and RHD
No	REF
Yes	2.497 (1.790 to 3.483)	0.000*	2.181 (1.399 to 3.317)	0.000*

^*Statistical significance p<0.05.

AOR, adjusted OR; COR, Crude OR.

Binary logistic regression to predict mothers’ attitudes regarding RF and RHD

In table 6, a binary logistic regression found a significant association between mothers’ attitudes towards RF and RHD and most of their demographic variables. In detail, increased maternal age, number of children and the age of the youngest child were associated with a 1.35-fold, 1.31-fold and 1.79-fold increase in the mother’s odds of having a positive attitude (p<0.05). In addition, university and preuniversity education enhanced mothers’ OR for positive attitudes towards RF and RDH prevention by 3.2 and 2.5 times, respectively, compared with mothers who can only read and write. Urban area residents and employed mothers had higher odds of positive attitudes than rural area residents and unemployed mothers (p<0.05). Besides, mothers who lived in a shared apartment with good ventilation are more likely to have a positive attitude towards preventive practices than those who lived in a separately ventilated apartment. Mothers with more than enough monthly income had higher odds of having a positive attitude when compared with mothers who did not have enough monthly income (p<0.05). The mother who suffered from recurrent sore throats in her child has a 1.69-time increment in her OR for a positive attitude. Finally, mothers who previously attended health education activities on RF and RHD had a 3.2 times higher OR of a positive attitude than the reference group (p<0.05).

Table 6. Binary logistic regression to predict mothers’ attitudes regarding RF and RHD.

Mothers’ basic data	COR (95% CI)	P value	AOR (95% CI)	P value
Age (mean±SD) years	1.209 (1.131 to 1.428)	0.002	1.351 (1.231 to 1.528)	0.006*
Number of children (mean±SD)	1.229 (1.113 to 1.412)	0.000*	1.312 (1.213 to 1.502)	0.001*
Age of the youngest child (mean±SD)	1.424 (1.338 to 1.490)	0.000*	1.797 (0.690 to 2.921)	0.002*
Education		0.000*		0.000*
Can read and write	REF
Preuniversity education	2.412 (1.614 to 3.821)	0.000*	2.513 (1.720 to 3.761)	0.000*
University or postgraduate education	3.070 (1.821 to 5.176)	0.000*	3.220 (2.262 to 6.876)	0.000*
Nationality
Saudi citizen	REF
Non-Saudi	1.009 (0.663 to 1.536)	0.966
Residence
Rural	REF
Urban	16.235 (9.248 to 28.501)	0.000*	16.499 (9.260 to 29.238)	0.000*
Working status
Unemployed	REF
Employed	1.487 (1.066 to 2.075)	0.019*	1.502 (1.162 to 2.231)	0.022*
Reported housing condition		0.000*
Separate ventilated apartment	REF
shared apartment, but well-ventilated	6.630 (3.152 to 13.942)	0.000*	7.621 (4.081 to 14.872)	0.001*
Poorly ventilated apartment	0.905 (0.420 to 1.949)	0.798	0.970 (0.520 to 1.962)	0.738
Personal evaluation of monthly income		0.001*		0.000*
Not enough for daily requirements	REF
Enough only for daily requirements	1.690 (1.476 to 2.001)	0.033*	1.702 (1.635 to 2.181)	0.035*
Enough and can save money	1.850 (1.026 to 3.334)	0.021	1.920 (1.126 to 3.452)	0.027*
Has a child complained of at least one sore throat attack/year?
No	REF
Yes	1.799 (1.051 to 3.076)	0.032*	1.698 (1.0495 to 3.105)	0.037*
Prior attendance at educational activities about RF and RHD
No	REF
Yes	3.297 (1.812 to 4.523)	0.000*	3.271 (1.542 to 4.312)	0.000*

^*Values indicate high significance.

AOR, adjusted OR; COR, crude OR; RF, rheumatic fever; RHD, rheumatic heart disease.

Discussion

Improving mothers’ knowledge and attitudes is essential to effectively prevent the serious complications of RF and RHD, like heart failure and stroke.^{12 15} The current study addressed this need by assessing the knowledge and attitudes of 771 mothers towards RF and RHD prevention. The findings revealed that more than half (58.8%) of the mothers demonstrated satisfactory knowledge, and more than one-third (41.2%) had unsatisfactory knowledge, highlighting the need for continued efforts to improve maternal awareness about RF and RHD. The current findings are nearly consistent with previous studies. Specifically, a study by Fakieha et al revealed that around one-third (31.9%) of their study participants in the Makka region, Saudi Arabia, had poor knowledge regarding RF and RHD.²² In addition, Kamal et al conducted a study in all regions of Saudi Arabia and found that approximately 30% of the Saudi Arabian population had poor knowledge about acute RF.²³ Although these percentages are lower than the 41.2% in the current study, they still highlight a significant knowledge gap in the Saudi context. While more than half of the participants (58.8%) demonstrated satisfactory general knowledge of RF and RHD, a closer examination reveals an uneven distribution of knowledge across specific items. General awareness of the causes of a sore throat was relatively high. At the same time, the understanding of more important clinical aspects, such as the role of benzathine penicillin in treatment and the identification of Sydenham’s chorea as a potential complication, was significantly low. These findings reinforce the need for targeted educational interventions that address these specific gaps. These interventions should be tailored to the needs of the target population and delivered in culturally appropriate formats to ensure greater effectiveness and engagement. In contrast, several studies reported significantly higher proportions of participants with poor or unsatisfactory knowledge of RF and RHD than the current study. Specifically, Mohammed et al²⁴ found a rate of unsatisfactory knowledge of 70%, while Almedhesh¹⁶ documented 59.1%, and Eltyeb et al²⁵ demonstrated 53%. The discrepancy between the current study’s findings and the higher rates reported in comparative studies may be attributed to several key factors. First, variations in the target population’s demographics, including age, gender, educational and socioeconomic status, likely contribute to these differences. For instance, the Mohammed et al study, which included parents (mothers and fathers), found that mothers demonstrated significantly higher knowledge and practice levels than fathers. Second, disparities in assessment methodologies, such as the criteria used to categorise knowledge levels, can yield different results. Eltyeb et al employed a three-level classification system (poor, fair and good), whereas our study used a two-level classification (satisfactory and unsatisfactory). Third, access to healthcare services and educational interventions is pivotal in shaping participants’ knowledge regarding RF and RHD. Notably, 25% of participants in our study reported attending health education activities on RF and RHD, compared with only 10% in Almedhesh.

The results of the current study revealed that approximately three-quarters of participating mothers (73.3%) expressed a positive attitude towards preventing RF and RHD. This positive attitude is a prerequisite for effective prevention, as it indicates their willingness to follow recommended behaviours, such as seeking medical help for a sore throat (69.9%), adhering to antibiotic treatment (75.1%) and avoiding crowded places (73.2%). Consistent with the current study, findings indicate that nearly three-fifths of participants agreed that antibiotic adherence is essential for treating sore throats and that seeking medical help is essential for all individuals with sore throats.¹⁶ Furthermore, another study reported that 82.3% of participants emphasised the need to complete an entire course of antibiotics to treat sore throats properly, and 70.5% agreed that healthcare providers are responsible for prescribing antibiotics. A positive attitude is a significant predictor of behavioural change. Mothers who believe in prevention are more likely to take proactive measures to protect their children from RF and RHD.²⁶ Positive attitudes have been observed in several studies across different population groups, reflecting their receptivity to educational interventions on RF and RHD preventive practices.^{13 27 28}

Binary logistic regression in the current study shows associations between maternal knowledge of RF and RHD, maternal attitude towards preventive practices and several demographic factors, including age, number of children, education, employment and monthly income. In addition, mothers of children with recurrent sore throat who previously attended health education activities on RF and RHD are more likely to have good knowledge of RF and RHD and a positive attitude towards preventive practices—specifically, for attitude towards RF and RHD. Urban area residents had a higher odds for a positive attitude when compared with rural area residents. A 16-fold difference in odds reflects a massive gap in how urban and rural populations access information and care. Because rural areas often lack basic services, the relative difference between them and urban centres becomes mathematically magnified. Besides, mothers who lived in a shared apartment with good ventilation are more likely to have a positive attitude towards preventive practices than those who lived in a separately ventilated apartment.

Older mothers are expected to have cumulative life experiences, cumulative health knowledge and positive attitudes towards preventive practices for various health conditions, as well as frequent exposure to health facilities. Older mothers frequently accompany most of their family members to the hospital and are exposed to different health conditions, including RF and RHD. Along the same lines, Almedhesh found that older women may have a higher likelihood of good knowledge of RF and RHD and a positive attitude towards preventive practices.¹⁶ Furthermore, Quinlan et al found that older women have better knowledge and adherence to medication regimens when compared with younger ones.²⁹ In addition, a Saudi study conducted in the Taief region found a significant relationship between maternal age and all health awareness items related to RF and RHD prevention.¹⁴

However, it is important to note that the woman’s knowledge and attitude can be greatly influenced by other demographic predictors such as education and monthly income. The strong association among educational level, health literacy regarding different health conditions and a positive attitude towards preventive practices is well established by numerous researchers.^{18 29 30} A highly educated woman is expected to have a better understanding of medical conditions and medication regimens, and to have a positive attitude towards taking preventive measures against diseases, or at least limiting their complications. The WHO identifies higher education as the primary predictor of health literacy. Furthermore, maternal education is a critical driver of community awareness and proactive health attitudes.³¹ Education enables mothers to navigate health information effectively and engage actively with medical teams. Consequently, these mothers demonstrate better health-seeking behaviours, such as prompt treatment for sore throats and diligent adherence to preventive protocols.³¹

Monthly income is acknowledged in the current study as an important predictor for maternal knowledge about RF and RHD and their attitude towards preventive practices. However, economic conditions do not directly influence a woman’s ability to understand or retain knowledge; they have an indirect impact by decreasing women’s attention to acquiring health-related knowledge, seeking healthcare and having confidence in their ability to apply preventive practices. High income is mostly linked to higher education, higher access to healthcare services and the availability of resources to apply preventive practices. Frequent contact with healthcare providers increases the likelihood of asking questions, participating in educational programmes and accessing printed materials and the internet.¹⁶ In addition, the burden of low monthly income shifts women’s attention from preventive medicine, which includes increasing health awareness, to curative medicine. Besides, financial constraints may negatively influence adherence to medication regimens and attitudes towards preventive practices. Therefore, improving the financial and housing conditions is a very important step in improving the population’s attitude towards preventing streptococcal infection.³²

Mothers in this study whose children had recurrent sore throats demonstrated superior knowledge and preventive attitudes. This highlights the role of lived experience in health literacy; repeated contact with healthcare facilities creates 'teachable moments’ in which providers can advise on the link between untreated sore throats and RF/RHD.³³ Studies on health-seeking behaviours suggest that feeling susceptibility to specific health conditions enhances attitude toward taking preventive practices.^{34 35}

The current study showed a significant positive impact of prior educational interventions on shaping mothers’ knowledge and attitudes towards RF and RHD preventive practices. Mothers are the primary healthcare providers for their children, so their knowledge and attitudes directly affect their children’s health and well-being. The effectiveness of educational interventions to improve health knowledge and attitudes toward RF and RHD prevention has been extensively studied and proven. Therefore, the conclusion of these studies strongly supports the importance of frequent health education campaigns to involve mothers in RHD prevention efforts actively.^{12 24}

Specifically, for attitudes towards RF and RHD, urban area residents had higher odds of a positive attitude than rural area residents. The large AOR of 16 likely reflects substantial structural differences between urban and rural settings in our study area, including differences in access to health information, educational opportunities, healthcare services and exposure to awareness campaigns. In contexts where baseline knowledge or service access is very limited in rural areas, even moderate absolute differences can translate into large relative ORs. The results of the current study are consistent with previous research on health disparities.³⁶ Mostly, urban area residents have better access to healthcare facilities and health awareness campaigns, which consequently impacts mothers’ attitudes towards RF and RHD preventive practices. In addition, some rural area residents may suffer from poverty and limited educational opportunities that negatively influence both health awareness and attitudes.³⁷ Also, cultural diversity in urban areas may encourage positive attitudes towards health promotion measures and preventive practices.³⁸

As observed in the current study, the connection between living in well-ventilated shared apartments and having positive attitudes towards RF and RHD prevention is complex and seemingly contradictory. To understand this, we must carefully consider the interplay of social and environmental elements and potential confounding variables. However, it seems logical that mothers who pay more attention to ventilated apartments may also emphasise other important health practices and adhere to RHD preventive practices.³⁹ This aligns with prior research suggesting that health-promoting living environments are often associated with greater awareness and engagement in disease prevention practices.⁴⁰

Study limitations

This study has some limitations; first, it relied on a self-reported questionnaire, which may introduce recall and social desirability bias. Second, the cross-sectional design used in this research limits the ability to infer causality. Third, although the current study provides essential information on preventing RF and RHD among mothers in Najran, it is a first step towards an educational intervention. Therefore, a subsequent intervention study is recommended to overcome these limitations and build on the current findings. Furthermore, because data collection used a convenience sampling approach, the sample may not be fully representative of the general population. This method is likely to under-represent individuals from rural areas and those with limited digital literacy. Therefore, the generalisability of findings to border or more diverse populations should be approached with caution.

Conclusion and clinical implications

This study revealed that more than half of mothers had adequate knowledge, and about three-quarters expressed positive attitudes towards RF and RHD prevention. Several factors significantly influenced both knowledge and attitudes, including maternal age, number of children, educational level, working status, household income, child’s history of sore throat and previous participation in RF and RHD prevention education activities. Residence and reported housing conditions also influenced maternal attitudes. Therefore, to improve awareness of RF and RHD prevention and address identified gaps, targeted educational campaigns are recommended. These campaigns should be implemented across multiple formats and channels to achieve maximum effect. Leverage the Ministry of Health’s Sehaty platform to send automated, seasonal awareness alerts to parents about the link between untreated sore throats and RHD. Schools and universities can integrate relevant health education into their curriculum, while primary healthcare centres can serve as focal points for community interventions. Moreover, launch targeted infographics focused on the ‘Sore Throat=Heart Risk’ message across mass media (television and radio) and digital platforms, including social media (Twitter and Snapchat), to reach a broader, more diverse audience. Collaboration with key stakeholders, such as local health authorities and community leaders, is essential to ensure that messages are culturally appropriate, accessible and widely disseminated.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.