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Corresponding author. Department of Economics, Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman, Sungai Long Campus, Jalan Sungai Long, Cheras, 43000, Kajang, Selangor, Malaysia.
Department of Economics, Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman, Sungai Long Campus, Cheras, 43000, Kajang, Selangor, Malaysia
Department of Pre-clinical Sciences, Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Sungai Long Campus, Cheras, 43000, Kajang, Selangor, Malaysia
Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, 43400, UPM Serdang, Selangor, Malaysia
Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, IndonesiaMedical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, IndonesiaTropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia
Department of Economics, Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman, Sungai Long Campus, Cheras, 43000, Kajang, Selangor, Malaysia
Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, IndonesiaMedical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, IndonesiaTropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia
Outbreaks of hand foot mouth disease (HFMD) is endemic in Malaysia and causes outbreaks and deaths amongst young children. The aim of this study was to assess the knowledge and awareness towards HFMD and their associated determinants among parents in Malaysia.
Methods
A community-based cross-sectional study was conducted between January and March 2020 in Selangor state of Malaysia using a self-administered survey. The validated questionnaires were distributed to parents with children attending kindergartens in the nine districts of Selangor through multistage sampling. Logistic regression was used to estimate the differences in knowledge and awareness between groups and to identify their associated variables.
Results
We received 690 participant responses of which 485 were included in the final analysis. We found that only 34.4% of parents had good knowledge and 78.1% had good awareness of HFMD. The multivariate analysis found that those who were working in the private sectors had lower odds of having good knowledge compared to those who were working in the public sectors, adjusted odds ratio (aOR): 0.59; 95%CI: 0.36–0.97. Compared to Malay, Malaysian Chinese and Malaysian Indian had lower odds of having good awareness with aOR: 0.48; 95%CI: 0.29–0.81 and aOR: 0.44; 95%CI: 0.23–0.83, respectively.
Conclusion
Although parents' awareness was relatively high, they have poor knowledge on HFMD in particular to identify the symptoms of severe cases, basic treatment and preventive measures of HFMD. HFMD information needs to be communicated in a simplified language including in online communications to improve parents’ knowledge and awareness of HFMD.
Hand foot mouth disease (HFMD) is a common viral infection in children and is caused by enteroviruses, mainly Coxsackie virus A16 (CVA16) and Enterovirus 71 (EV71).
The disease is transmitted through direct contact with the discharge of infected persons such as saliva and blister fluid, and through faecal-oral route. In most cases, the disease is self-limiting, lasts less than a week, with skin eruptions on hands, feet or buttocks and ulcers in the mouth. However, delayed diagnoses and treatment may lead to severe complications such as meningitis, encephalitis, and polio-like paralysis that may be fatal.
All Malaysian states recorded the increase of HFMD cases and Selangor state, the most populous state in the country and has a diverse population, was the hardest hit with 21,282 cases.
Even with the recent increase in cases, only a few studies of HFMD have been conducted in Malaysia, and they have focused mostly on epidemic, clinical, pathological characteristics or perception of the disease.
Data on knowledge and awareness of HFMD among the parents and caregivers, who are the key players in taking precautionary steps to prevent the spreading of the disease, are still lacking. It is important to assess the level of knowledge and awareness in the community, focusing on parents and caregivers, so appropriate preventive interventions can be tailored to curb the future occurrence of the disease.
Previous studies of the knowledge and awareness of HFMD in Malaysia have been limited in scope.
Knowledge, attitude and practices regarding hand, foot and mouth disease (HFMD) of visitors in hospital tengku ampuan afzan, Pahang, Malaysia. Echnology, science, social sciences and humanities international conference.
An Interventional Study on the Knowledge, Attitude and Practice on Hand, Foot and Mouth Disease Among the Parents or Caregivers of Children Aged 10 and below at Nanga Sekuau Resettlement Scheme from 26th March to 10th June 2012.
In a study conducted at dermatology and paediatric department of a hospital in Pahang, more than half of the respondents (17 out of 32 surveyed) were aware of the symptoms of the disease but only 13 respondents know that the disease is spread through contact with an infected person.
Knowledge, attitude and practices regarding hand, foot and mouth disease (HFMD) of visitors in hospital tengku ampuan afzan, Pahang, Malaysia. Echnology, science, social sciences and humanities international conference.
However, due to the small sample size and sampling location, the findings cannot be generalized. In another study at the Nanga Sekuau Resettlement Scheme, 61.1% of parents or caregivers had good knowledge, 52.2% had good attitudes and 55.8% maintained good preventive practices towards HFMD.
An Interventional Study on the Knowledge, Attitude and Practice on Hand, Foot and Mouth Disease Among the Parents or Caregivers of Children Aged 10 and below at Nanga Sekuau Resettlement Scheme from 26th March to 10th June 2012.
The majority of that study population belonged to the Iban ethnic group and may not be comparable to other groups in Malaysia, the three largest being Malays, Malaysian Chinese, and Malaysian Indians. Another study found insufficient knowledge of HFMD among mothers.
This study took place in KEMAS (Kemajuan Masyarakat) preschools, which are set up by the Department of Community Development to educate children from low-income families.
Lastly, in a recent study, it was found that 28.6% and 16% of nursery educators in nurseries at public universities and private residential areas in Klang Valley, Selangor, have good knowledge of HFMD, respectively.
The scarcity of available scientific literature indicates the need for more comprehensive data related to knowledge and awareness among Malaysians in order to inform state- and national-level policies. Building off of previous researches, the aims of this study were to characterize knowledge and awareness regarding HFMD among parents in Malaysia and to identify their associated determinants.
2. Methods
2.1 Study design and sampling method
A cross-sectional survey was conducted in Selangor state which encircles the capital Kuala Lumpur. The state is the most populated state in Malaysia with a surface area of 8104 km2 and a population of 5.79 million. A report by the Ministry of Health indicated that the total number of HFMD cases reported for Selangor state was the highest in 2018.
Selangor consists of nine districts: Gombak, Klang, Kuala Langat, Kuala Selangor, Petaling, Sebak Bernam, Sepang, Ulu Langat, and Ulu Selangor; and to represent the population, between 3 and 5 kindergartens from each district were randomly selected. The sample size for this project was calculated using Raosoft Sample Size Calculator (http://www.raosoft.com/samplesize.html) as used previously.
In this study, 385 participants were required as a minimal sample size based on the following assumptions: (a) since no previous study were available related to the rate of good knowledge and awareness towards HFMD in Malaysia, the rate of good knowledge and awareness were assumed to be 50%; (b) 5% margin of error, and (c) 95% confidence level. The participants were selected using a three-stage clustered sampling method (Fig. 1). Using the nine administrative districts in Selangor as sampling frames, the number of samples from each district was calculated based on its population size proportion (i.e., high numbers in some districts and low in some districts). In the second stage, kindergartens that agreed to participate in this study were selected randomly based on the list of kindergarten in each district. In the final stage, the number of parents recruited from each kindergarten was given a “quota” to meet the calculated sample size for each district and were conveniently selected through the kindergarten operator. We planned to double the sample size to 770 to avoid an insufficient sample size due to incomplete data.
Fig. 1Diagram of three-stages sampling method of the study. N: number of students for each district, K: kindergarten, n: number of student selected bases on the quota for each kindergarten.
To assess the knowledge and the awareness, a self-administered survey was planned from January 13 to April 1, 2020. However, due to coronavirus disease 2019 (COVID-19) outbreak, the survey was stopped on March 16, 2020. It required approximately 10 min to complete the survey. The hard copy of a dual-language questionnaire (Malay and English) was distributed to and collected from the parents through the kindergarten teachers. The questionnaire to assess the knowledge and awareness domain were developed based on from a previous study.
See Additional file 1 for detailed questionnaire. The questionnaire also covered a range of explanatory variables (basic demographic data, education attainment, and the number of kids). In addition, the sources of information regarding HFMD were also collected. A reliability test of questionnaires within the domain of knowledge (47 items) and awareness (15 items) was conducted among 20 participants prior to the study. The Cronbach's alpha score was 0.75 and 0.70 for the knowledge and awareness domain, respectively, suggesting a good internal consistency of the items in the scale.
2.3 Measures
2.3.1 Response variables
To measure the knowledge of HFMD, a set of a 47-questions questionnaire assessing the cause, sign and symptom, transmission, prevention, treatment and management of HFMD was used. For awareness, 15-questions questionnaire assessing the awareness of infected child, sign and symptoms of severe complication of HFMD was used. The possible responses to all of the questions within both knowledge and awareness domains were “yes” or “no” and there was no “do not know” option provided. Each correct answer was given a score of one, and incorrect one, zero. The knowledge and awareness of a participant have computed as the total sum of correct responses such that a higher score indicated better knowledge and awareness towards HFMD infection.
2.3.2 Explanatory variables
Data on age, gender, educational attainment, race, type of occupation, marital status and household monthly income were collected from each participant. The respondents were also asked about the number of kids. Furthermore, the source of information about HFMD was collected by asking the respondents to choose from the list provided (newspaper, internet, hospital, radio, child school, health care, television, and social media).
2.4 Statistical analysis
For the statistical analysis propose, the level of knowledge and awareness was dichotomized into “good” and “poor” based on an 80% cut-off point as used previously.
To assess the association between the explanatory variables and the response variables, a multivariate logistic regression analysis was employed. In univariate logistic regression, all explanatory variables were analyzed separately and explanatory variables with p < 0.25 in this step were then included in the multivariate analyses. The p < 0.25 was used to avoid excluding the possible important explanatory variables in univariate analysis as described previously.
Confounding factors were explored by comparing the difference between the adjusted odds ratio (aOR) in multivariate analyses and unadjusted OR in univariate.
The correlation between scores of knowledge and awareness was assessed using Spearman's rank correlation (rs) based on the Kolmogorov–Smirnov normality test. A rule of thumb for interpreting the correlation coefficient using the following criteria: 0–0.25 = weak correlation, 0.25–0.5 = fair correlation, 0.5–0.75 = good correlation and greater than 0.75 = excellent correlation.
All significance tests were two-tailed and a p-value of less than 0.05 was considered to be statistically significant. All analysis was performed using the Statistical Package of Social Sciences version 23.0 software.
2.5 Ethics approval and consent to participate
The Scientific and Ethical Review Committee of Universiti Tunku Abdul Rahman approved this study protocol (approval U/SERC/17/2020). A brief explanation of the study was given to all participants and written informed consent was obtained from all participants prior to enrolment. Participation was voluntary, anonymous, and no direct financial compensation was offered.
3. Results
3.1 Respondents’ characteristics
We received 690 participant responses during the study period and 205 data were excluded from the final analysis due to missing information. Most of the missing information was the answers on knowledge and awareness domains and therefore could not be included in the analysis. A total of 485 (70.3%) participants, well-distributed from regions of the district, were analyzed. The main basic demographic information of those excluded had no significant different from those who included in the analysis. The proportion of the gender was different, 32.2% vs. 67.8% for males and females, respectively (Table 1). The majority of the respondents aged between 30 and 39 years old (73.4%) and most were Malay (63.9%), followed by Malaysian Chinese (23.3%) and Malaysian Indian (12.0%). Approximately 36.7% of the respondents had bachelor degrees and more than half of the participants were working in private sectors (52.4%). More than half (56.9%) of respondent's household monthly income in the range of RM1000 to RM5000 (equal to US$ 233.7 and US$ 1168.9, respectively, using a June 2020 exchange rate) and 39.4% of them have two kids.
Most parent's knowledge of the causative agents of HFMD was poor (Table 2). Only 26.2% of respondents knew that the HFMD was not caused by bacteria and the majority (74%) believed HFMD occurs all year round. Most of the parents knew about the transmission of HFMD for example 94% knew that saliva is the main route of transmission. Out of the total, 96.5% knew that red spots and blisters on hand are the clinical features of HFMD and good personal hygiene is the main method to control HFMD (95.5%). More than 90% of parents knew that fever of more than 39 °C for more than two days is a severe sign of HFMD. All the parents (100%) wanted their child to rest if they were infected with HFMD.
Table 2Frequency of correct responses to knowledge and awareness of HFMD (n = 485).
Variables
n
%
Mean score (±SD)
Knowledge domain
A. General information and the causative agent of HFMD (max score: 5)
2.49 (1.11)
HFMD is caused by bacteria
127
26.2
HFMD occurs all year round
356
74.0
Another name of HFMD is foot and mouth disease
115
23.7
Most HFMD patients recover within 1 week
357
73.6
HFMD only affect children
250
51.5
B. Transmission of HFMD (max score: 9)
7.52 (1.50)
It is transmitted via oral route.
358
73.8
It is transmitted from infected sheep, cattle and swine.
345
71.1
It can be spread from the care giver of the infected child
397
81.9
It is transmitted by direct contact with the infected people from them
a) nose discharge
431
88.9
b) faeces
342
70.5
c) fluid from the blisters
442
91.1
d) saliva
456
94.0
e) toys
441
90.9
f) utensil
437
90.1
C. The clinical features of HFMD (max score: 8)
6.90 (1.42)
Red spot and blister on hand
468
96.5
Itchy skin rash
424
87.4
Mouth ulcer
461
95.1
Poor appetite
447
92.2
Diarrhea
316
65.2
Tiredness
340
70.1
Vesicle at mouth, hand-palm, foot, bottom, knee
448
92.4
Fever
446
92.0
D. Prevention and treatment of HFMD (max score: 5)
2.88 (1.01)
Good personal hygiene is the main methods to control HFMD
463
95.5
There is no vaccine to protect against HFMD infection at the moment
329
67.8
Alcohol gel cannot kill the causative agent of HFMD
202
41.6
Hand cleaning with water (without soap) is sufficient to prevent HFMD
294
60.6
HFMD is treated with antibiotics
110
22.7
E. Severe signs of HFMD (max score: 9)
5.08 (2.60)
Fever >39 °C degree for more than 2 days
440
90.7
Crying most of time
347
71.5
Has difficulty to sleep
359
74.0
Sleepy or sleep all the time
231
47.6
Seizures/fits
206
42.5
Difficult to breathing
248
51.1
Unable to walk or stand straight and shaking.
209
43.1
Vomits many times
263
54.2
Skin changes to blue colour
164
33.8
F. Management of a child having HFMD (max score: 11)
10.16 (1.44)
Let the child rest
485
100.0
Reduce the fever by putting wet towel on child head
442
91.1
Give fever medication (e.g. Ibuprofen, Tylenol)
451
93.0
Clean the child's mouth carefully
456
94.0
Avoid breaking any vesicles or blisters
460
94.8
Feed the child with nutritious food
476
98.1
Provide adequate healthy drink to the child
467
96.3
Clean the child's faeces or wash hand after cleaning the child's faeces
464
95.7
Boil the child's clothes before washing
345
67.0
Ensure the child use separate bowl and spoon
442
91.1
Reduce contact between the sick child and healthy ones
463
95.5
Awareness
A. Awareness of infected child (max score: 9)
8.52 (1.28)
If a child is infected with HFMD: Wash and clean the child's hands
455
93.8
Wash and clean the care giver's hands of the sick child
459
94.6
Wash and clean the toys belong to the sick child
466
96.1
Wash and clean the areas where the sick child is playing
458
94.4
Children should drink boiled water and eat well cooked food.
460
94.8
Separate the HFMD infected child with other children
456
94.0
The HFMD infected child should stay at home
461
95.1
Person/individuals with HFMD should cover their mouth when coughing
457
94.2
Avoid contact with saliva from an infected person
463
95.5
B. Awareness of signs and symptoms of severe HFMD (max score: 5)
In total, 78.1% of respondents (379 out of 485) had a good awareness of HFMD. Most parents knew how to care for the infected child: by washing and cleaning the child's hands (93.8%), toys (96.1%), and the play areas (94.4%); washing and cleaning the caregivers' hands (94.6%); isolating (94.0%) and keeping the child at home (95.1%); avoiding contact with saliva from an infected person (95.5%); and for the infected person to cover their mouth when coughing (94.2%). Most parents (95.5%) were aware that persistent high fever is a sign of severe HFMD. However, only 9.3% of the respondents knew that the ulcers in the mouth or throat are signs of severe HFMD (Table 2).
The correlation test revealed that there was significant and positive correlations between total knowledge score and total score of awareness (r = 0.28, p < 0.001).
3.3 Knowledge of HFMD and associated factors
We found that 167 (34.4%) participants had a good knowledge of HFMD. Univariate logistic regression analysis shows that type of occupation and income were associated with knowledge in some degree. The multivariate analysis indicated that only occupation was associated with knowledge of HFMD (Table 3). Respondents who were working in the private sector had lower odds of having a good knowledge of HFMD compared to those working in public sectors (OR: 0.59; 95% CI: 0.36–0.97).
Table 3Factors associated with participant's knowledge, good vs. poor (n = 485).
In this study, 379 (78.1%) respondents were categorized as having good awareness of HFMD. Univariate logistic regression analysis found that race and household income were associated with the awareness (Table 4). The multivariate analysis suggested that only race was associated with awareness. Compared to Malay parents, the odds of having a good awareness was low among Malaysian Chinese parents (OR: 0.48; 95% CI: 0.29–0.81) or being Malaysian Indian parents (OR: 0.44; 95% CI: 0.23–0.83).
Table 4Factors associated with participant's awareness, good vs. poor awareness (n = 485).
Approximately 69.7% of the participants received information on HFMD from the internet followed by social media (52.8%) and newspapers (35.9%) (Table 5). Health care centres such as hospitals (31.1%) and health centre (27.8%) had a less significant role as an information source for HFMD. In addition, 23.5% and 22.5% of participants received HFMD information through children's schools and the radio, respectively. Parents with high knowledge and awareness score were seen among those who were active on the internet and social media.
Table 5Sources of HFMD information among the parents (n = 485).
Our study surveyed parents in a community of Selangor state, Malaysia, to determine their levels of knowledge and awareness towards HFMD, which in recent years has resulted in many outbreaks within the state. We found poor knowledge, which could hamper efforts to control the disease, and which could lead to increases in economic burden. Limited knowledge may also delay parents to seek medical treatment or hospital admission, and could lead to complications such as meningitis, myocarditis, or death. One common misconception was that the disease can be caused by bacteria that could lead to overuse of antibiotics, and increase antibiotic resistance. Although there is limited information out of Malaysia, antibiotic resistance is a critical problem in South Asia, affecting, for example, treatments for bacterial infections.
Many parents also did not understand that HFMD could be transmitted through faeces and one of the clinical features is diarrhea. Poor understanding of the faecal-oral route transmission of HFMD may pose a risk of dissemination of the virus through public toilets and via food handlers. Therefore, reinstalling the information to the public, targeted education to the parents and the caretakers of children in nursery and kindergarten on the mode of faecal-oral transmission of HFMD should be emphasised. Misunderstood of the benefits of alcohol gel in the prevention of HFMD transmission and unsatisfactory knowledge of the requirement of soap as disinfectants reflect the vast majority of parents were unsure about methods of disinfectants (i.e., prevention strategy) for HFMD. Although the disease is predominantly a problem in children, the risk of spread to other age groups, including immunocompromised adults, could be possible from children.
The internet and social media are the two most common sources for HFMD information for the respondents. This finding is in line with the increasing accessibility to the internet in Malaysia and that the high percentage of internet users seek information on the internet as well as to share information on social media, particularly among those in their 20s and 30s,
This could perhaps partially explain the low knowledge of HFMD in the respondents despite high awareness and highlights the need to educate the public on assessing the reliability of online medical information.
One of the surprising findings was only 23.5% of the respondents in this study received HFMD information through the respective kindergartens. Given the high preschool enrolment rate in Malaysia at 85.35% in 2018; 79.72% and 90.82% enrolment rates for cohorts 4+ years and 5+ years, respectively.
Malaysia Education Blueprint 2013-2025, Annual Report 2018 Ref: Ministry of Education. Education Performance and Delivery Unit. Malaysia Education Blueprint 2013-2025.
Kindergartens personnel involvement is crucial to ensure adequate HFMD understanding among the parents. Awareness and information on HFMD should be given to parents periodically. Education authorities should take the initiative to collaborate with kindergarten operators in this aspect. This not only could promote timely dissemination of the information to a high proportion of the population with children at the vulnerable age to HFMD, but it could also ensure that correct information is delivered to the target groups.
Other studies have found sociodemographic predictors of HFMD knowledge and awareness in different settings.
In our study, multivariate analaysis shows that working in public sectors was associated with a good knowledge compared to those who working in private sector. However, another study showed no significant difference.
Our findings suggest that being Malay was associated with good awareness compared to being Malaysian Chinese and Malaysian Indian.
To increase the knowledge of HFMD among parents in Malaysia some strategies need to be adopted. Methods of delivery HFMD education should be improved along with the advancement in technology. Alongside with health information delivery through traditional channels (hospitals and healthcare centres) and conventional media (radio, television and newspaper), automated short message service (SMS)-based health information and web-based medical services or mobile health applications are among the technologies that could be explored by health authorities to increase the accessibility of reliable and accurate HFMD information to the public. These electronic and social media could be effective channels for caretakers to obtain knowledge on HFMD.
In this study, despite the significant positive correlation between knowledge and awareness on HFMD among the respondents, the correlation is weak (r = 0.28) where the majority of the respondents have good awareness but poor knowledge. To address misconceptions among parents, tailored educational messages should able to fill the knowledge gaps that are identified in this study such as the cause of the disease, severe signs of HFMD besides fever, signs of severe HFMD and that the disease is able to infect adults. Continuous information is very much needed to impart the needed knowledge to reduce the possible overuse of over-the-counter antibiotics in HFMD and delay in seeking medical treatment in severe cases that may lead to fatal complications.
Our study has some limitations. The participated parents only represented Selangor state and those who send their children to kindergartens. While the major ethnic groups in Selangor state were well represented in this study, the majority of the respondents were among the more highly educated group and more mothers were participated leading to a large gender deviation. A general representative from other states in Malaysia and parents for homeschooling children was not included. The cross-sectional design of this study limits the determination of the improvement of knowledge and awareness among the respondents across time.
5. Conclusion
Knowledge among kindergarten parents about HFMD was not satisfactory although they have high awareness. Efforts led by the health authorities and communities' participation are needed to enhance the public's knowledge of the disease. The HFMD information needs to be communicated in simplified language with a frequent reminder by automated short message service, posters, mass media and online communications to parents in different languages (Malay, Chinese and Tamil) and through parents occupations especially to parents who are sending their children to the kindergartens or nurseries.
Additional files
Additional file 1: Questionnaire used to assess the knowledge and awareness towards hand foot mouth disease among parents in Malaysia.
Fundings
This study was funded by Universiti Tunku Abdul Rahman Research Fund (UTARRF), grant number IPSR/RMC/UTARRF/2019-C1/Y03 .
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Authors’ contributions
Conceptualization, Y.R., O.H.T., N.M.T., M.M. and H.H.; Data curation, Y.R., O.H.T., N.M.T., and S.M.; Formal analysis, Y.R., S.A., and H.H; Investigation, Y.R., O.H.T., and N.M.T.; Methodology, Y.R, S.M., S.F.S., and H.H., Resources, Y.R., and O.H.T.; Software, S.A.; Validation, Y.R., A.L.W., M.M., A.A.K., and H.H.; Writing – original draft, Y.R, O.H.T., N.M.T., and H.H.; Writing – review & editing, Y.R, O.H.T., N.M.T., A.L.W., M.M., A.A.K., S.A., S.F.S., and H.H. All authors have read and agreed to the published version of the manuscript.
Declaration of competing interest
The authors declare that they have no competing interests.
Acknowledgments
The authors would like to thank the questionnaire moderator committee from the Faculty of Health Sciences, Universiti Putra Malaysia: Dr. Rosliza Abdul Manaf, Department of Community Health and Dr. Siti Zulaikha Binti Zakariah, Department of Medical Microbiology and Parasitology.
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Knowledge, attitude and practices regarding hand, foot and mouth disease (HFMD) of visitors in hospital tengku ampuan afzan, Pahang, Malaysia. Echnology, science, social sciences and humanities international conference.
An Interventional Study on the Knowledge, Attitude and Practice on Hand, Foot and Mouth Disease Among the Parents or Caregivers of Children Aged 10 and below at Nanga Sekuau Resettlement Scheme from 26th March to 10th June 2012.
Malaysia Education Blueprint 2013-2025, Annual Report 2018 Ref: Ministry of Education. Education Performance and Delivery Unit. Malaysia Education Blueprint 2013-2025.
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