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Parents’ knowledge and awareness towards hand foot mouth disease in Malaysia: A survey in Selangor

Open AccessPublished:March 19, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101027

      Abstract

      Background

      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.

      Keywords

      1. Introduction

      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).
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      • Tran T.T.
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      Clinical and aetiological study of hand, foot and mouth disease in southern Vietnam, 2013-2015: inpatients and outpatients.
      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.
      • WHO
      A Guide to Clinical Management and Public Health Response for Hand, Foot and Mouth Disease (HFMD).
      In Malaysia, the first documented outbreak of HFMD was reported in April 1, 997.
      WHO. Outbreak of hand, foot and mouth disease in Sarawak: cluster of deaths among infants and young children.
      It is a major national health concern and outbreaks occurring every two to three years since the first outbreak.
      • NikNadia N.M.
      • Sam I.C.
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      • et al.
      Cyclical patterns of hand, foot and mouth disease caused by enterovirus A71 in Malaysia.
      In 2018, there were 76,776 HFMD cases in the country with a significant increase in the number of cases compared to 2017. 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.
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      Deaths of children during an outbreak of hand, foot, and mouth disease in Sarawak, Malaysia: clinical and pathological characteristics of the disease.
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      • Chua K.B.
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      Identification of enterovirus 71 isolates from an outbreak of hand, foot and mouth disease (HFMD) with fatal cases of encephalomyelitis in Malaysia.
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      Enterovirus 71 from fatal and nonfatal cases of hand, foot and mouth disease epidemics in Malaysia, Japan and Taiwan in 1997-1998.
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      • et al.
      Deaths in children during an outbreak of hand, foot and mouth disease in Peninsular Malaysia--clinical and pathological characteristics.
      • Suliman Q.
      • Said S.M.
      • Zulkefli N.A.
      Predictors of preventive practices towards HFMD among mothers of preschool children in Klang district.
      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.
      • Othman N.
      • Ismail W.N.
      • Noriah C.
      • Mazlan N.
      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.
      ,
      • Zarin A.
      • Teh T.P.
      • Tee J.X.
      • et al.
      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.
      • Othman N.
      • Ismail W.N.
      • Noriah C.
      • Mazlan N.
      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.
      • Zarin A.
      • Teh T.P.
      • Tee J.X.
      • et al.
      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.
      • Suliman Q.
      • Said S.M.
      • Zulkefli N.A.
      Predictors of preventive practices towards HFMD among mothers of preschool children in Klang district.
      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.
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      • Azman M.N.
      Preschool education in Malaysia: emerging trends and implications for the future.
      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.
      • Mahadzar S.A.S.
      • Rahman H.A.
      Knowledge, attitude and practice towards hand, foot and mouth disease (HFMD) among nursery governesses in Klang Valley, Selangor.
      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.
      • Wainstein B.K.
      • Sterling‐Levis K.
      • Baker S.A.
      • Taitz J.
      • Brydon M.
      Use of the Internet by parents of paediatric patients.
      • Omair A.
      Sample size estimation and sampling techniques for selecting a representative sample.
      • Harapan H.
      • Aletta A.
      • Anwar S.
      • et al.
      Healthcare workers' knowledge towards Zika virus infection in Indonesia: a survey in Aceh.
      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. 1
      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.

      2.2 Study instrument and data collection

      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.
      • Ruttiya C.
      • Tepanata P.
      Knowledge attitude and preventive behaviors towards hand foot and mouth disease among caregivers of children under five years old in Bangkok.
      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.
      • Harapan H.
      • Rajamoorthy Y.
      • Anwar S.
      • et al.
      Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study.
      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.
      • Harapan H.
      • Aletta A.
      • Anwar S.
      • et al.
      Healthcare workers' knowledge towards Zika virus infection in Indonesia: a survey in Aceh.
      ,
      • Harapan H.
      • Rajamoorthy Y.
      • Anwar S.
      • et al.
      Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study.
      ,
      • Rajamoorthy Y.
      • Taib N.M.
      • Munusamy S.
      • et al.
      Knowledge and awareness of hepatitis B among households in Malaysia: a community-based cross-sectional survey.
      The estimated odds ratio (OR) was interpreted in relation to one of the categories, which was designated as the reference category.
      • Rajamoorthy Y.
      • Taib N.M.
      • Munusamy S.
      • et al.
      Knowledge and awareness of hepatitis B among households in Malaysia: a community-based cross-sectional survey.
      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.
      • Cohen J.
      Statistical power analysis for the behavioral sciences: Jacob Cohen.
      The 95% confidence intervals (95% CI) for rs were calculated as described previously.
      • Bonett D.
      • Wright T.
      Sample size requirements for Pearson, Kendall, and spearman correlations.
      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.
      Table 1Respondent's demographic characteristics (n = 485).
      Variablen(%)
      Gender
      Male15632.2
      Female32967.8
      Age group (year)
      20–29387.8
      30–3935673.4
      40–498216.9
      50 or above91.9
      Education
      High school or below11223.1
      Certificate or diploma16634.2
      Bachelor's degree17836.7
      Postgraduate education296.0
      Occupation
      Public sector10722.1
      Private sector25452.4
      Self-employed7014.4
      Others5411.1
      Race
      Malay31063.9
      Chinese11323.3
      Indian5812.0
      Others40.8
      Marital status
      Married47497.7
      Divorced/widow/widower112.2
      Household income
      Less than RM1000173.5
      RM1001-RM300016133.2
      RM3001-RM500015523.7
      RM5001-RM70005912.2
      RM7001-RM9000479.7
      RM9001 or above8617.7
      Number of children
      112024.7
      219139.4
      310020.6
      4 and above7415.3

      3.2 Knowledge and awareness towards HFMD

      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).
      Variablesn%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 bacteria12726.2
      HFMD occurs all year round35674.0
      Another name of HFMD is foot and mouth disease11523.7
      Most HFMD patients recover within 1 week35773.6
      HFMD only affect children25051.5
      B. Transmission of HFMD (max score: 9)7.52 (1.50)
      It is transmitted via oral route.35873.8
      It is transmitted from infected sheep, cattle and swine.34571.1
      It can be spread from the care giver of the infected child39781.9
      It is transmitted by direct contact with the infected people from them
      a) nose discharge43188.9
      b) faeces34270.5
      c) fluid from the blisters44291.1
      d) saliva45694.0
      e) toys44190.9
      f) utensil43790.1
      C. The clinical features of HFMD (max score: 8)6.90 (1.42)
      Red spot and blister on hand46896.5
      Itchy skin rash42487.4
      Mouth ulcer46195.1
      Poor appetite44792.2
      Diarrhea31665.2
      Tiredness34070.1
      Vesicle at mouth, hand-palm, foot, bottom, knee44892.4
      Fever44692.0
      D. Prevention and treatment of HFMD (max score: 5)2.88 (1.01)
      Good personal hygiene is the main methods to control HFMD46395.5
      There is no vaccine to protect against HFMD infection at the moment32967.8
      Alcohol gel cannot kill the causative agent of HFMD20241.6
      Hand cleaning with water (without soap) is sufficient to prevent HFMD29460.6
      HFMD is treated with antibiotics11022.7
      E. Severe signs of HFMD (max score: 9)5.08 (2.60)
      Fever >39 °C degree for more than 2 days44090.7
      Crying most of time34771.5
      Has difficulty to sleep35974.0
      Sleepy or sleep all the time23147.6
      Seizures/fits20642.5
      Difficult to breathing24851.1
      Unable to walk or stand straight and shaking.20943.1
      Vomits many times26354.2
      Skin changes to blue colour16433.8
      F. Management of a child having HFMD (max score: 11)10.16 (1.44)
      Let the child rest485100.0
      Reduce the fever by putting wet towel on child head44291.1
      Give fever medication (e.g. Ibuprofen, Tylenol)45193.0
      Clean the child's mouth carefully45694.0
      Avoid breaking any vesicles or blisters46094.8
      Feed the child with nutritious food47698.1
      Provide adequate healthy drink to the child46796.3
      Clean the child's faeces or wash hand after cleaning the child's faeces46495.7
      Boil the child's clothes before washing34567.0
      Ensure the child use separate bowl and spoon44291.1
      Reduce contact between the sick child and healthy ones46395.5
      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
      45593.8
      Wash and clean the care giver's hands of the sick child45994.6
      Wash and clean the toys belong to the sick child46696.1
      Wash and clean the areas where the sick child is playing45894.4
      Children should drink boiled water and eat well cooked food.46094.8
      Separate the HFMD infected child with other children45694.0
      The HFMD infected child should stay at home46195.1
      Person/individuals with HFMD should cover their mouth when coughing45794.2
      Avoid contact with saliva from an infected person46395.5
      B. Awareness of signs and symptoms of severe HFMD (max score: 5)3.54 (0.94)
      Persistent high fever46395.5
      Ulcer at mouth and throat459.3
      Limb weakness43188.9
      Lethargy41585.6
      Frequent vomiting37376.9
      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).
      VariableGood knowledge (%)Univariate logisticMultivariate logistic
      OR (95% CI)p-valueOR (95% CI)p-value
      Gender
      Male54 (34.6)1.01 (0.68–1.51)0.954
      Female (R)113 (34.3)1
      Age group
      20–2914 (36.8)1.17 (0.25–5.41)0.844
      30–39130 (36.5)1.15 (0.28–4.68)0.845
      40–4920 (24.4)0.65 (0.15–2.82)0.560
      50 and above (R)3 (33.3)1
      Education
      High School or below37 (33.0)1.10 (0.46–2.64)0.838
      Certificate or Diploma57 (34.3)1.16 (0.50–2.72)0.729
      Bachelor's degree64 (36.0)1.25 (0.54–2.90)0.608
      Postgraduate (R)9 (31.0)1
      Occupation
      Public sector (R)45 (42.1)11
      Private sector76 (29.9)0.59 (0.37–0.94)0.0260.59 (0.36–0.97)0.038
      Self-employed26 (37.1)0.81 (0.44–1.51)0.5150.77 (0.40–1.50)0.440
      Others20 (37.0)0.81 (0.41–1.59)0.5400.91 (0.44–1.85)0.784
      Race
      Malay (R)109 (35.2)11
      Chinese42 (37.2)1.09 (0.70–1.71)0.7031.13 (0.70–1.84)0.620
      Indian15 (25.9)0.64 (0.34–1.21)0.1710.70 (0.36–1.37)0.303
      Others1 (25.0)0.62 (0.06–5.98)0.6750.48 (0.05–4.98)0.540
      Marital status
      Married163 (34.4)1. (0.91–5.20)0.832
      Divorced/widow/widower5 (45.4)1
      Household income
      <RM10008 (47.1)1.24 (0.43–3.51)0.6921.43 (0.49–4.20)0.519
      RM1001-RM300049 (30.4)0.61 (0.35–1.05)0.0730.67 (0.38–1.19)0.172
      RM3001-RM500041 (35.7)0.77 (0.43–1.37)0.3710.79 (0.44–1.44)0.445
      RM5001 -RM700015 (25.4)0.47 (0.23–0.98)0.0440.49 (0.23–1.03)0.059
      RM7001-RM900018 (38.3)0.86 (0.42–1.79)0.6890.90 (0.43–1.90)0.786
      RM9001 and above (R)36 (41.9)11
      Number of children
      144 (36.7)0.85 (0.47–1.54)0.5900.94 (0.51–1.75)0.846
      264 (33.5)0.74 (0.43–1.29)0.2840.75 (0.42–1.32)0.312
      329 (29.0)0.60 (0.32–1.13)0.1130.63 (0.33–1.21)0.163
      4 or more (R)30 (40.5)11

      3.4 Awareness of HFMD and associated factors

      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).
      VariableGood awareness (%)Univariate logisticMultivariate logistic
      OR (95% CI)p-valueOR (95% CI)p-value
      Gender
      Male118 (75.6)0.81 (0.52–1.27)0.359
      Female (R)261 (79.3)1
      Age group (year)
      20–2934 (89.5)2.43 (0.37–15.95)0.356
      30–39273 (76.7)0.94 (0.19–4.61)0.939
      40–4965 (79.3)1.09 (0.21–5.74)0.917
      50 and above (R)7 (77.8)1
      Education
      High School or below85 (75.9)1.00 (0.39–2.60)0.997
      Certificate or Diploma133 (80.1)1.28 (0.51–3.26)0.601
      Bachelor's degree139 (78.1)1.13 (0.45–2.85)0.789
      Postgraduate (R)22 (75.9)1
      Occupation
      Public sector (R)85 (79.4)1
      Private sector198 (78.0)0.92 (0.53–1.59)0.754
      Self-employed52 (74.3)0.75 (0.37–1.52)0.424
      Others44 (81.5)1.14 (0.50–2.62)0.759
      Race
      Malay (R)257 (82.9)11
      Chinese80 (70.8)0.50 (0.30–0.83)0.0070.48 (0.29–0.81)0.005
      Indian39 (67.2)0.42 (0.23–0.79)0.0070.44 (0.23–0.83)0.011
      Others3 (75.0)0.62 (0.06–6.06)0.6800.62 (0.06–6.29)0.688
      Marital status
      Married371 (78.3)1.25 (0.64–5.06)0.623
      Divorced/widow/widower (R)8 (72.7)1
      Household income
      <RM100011 (64.7)0.42 (0.14–1.30)0.1330.43 (0.13–1.37)0.153
      RM1001-RM3000125 (77.6)0.79 (0.41–1.53)0.4910.76 (0.38–1.51)0.431
      RM3001-RM500090 (78.3)0.82 (0.41–1.66)0.5860.75 (0.36–1.54)0.430
      RM5001 -RM700047 (79.7)0.90 (0.39–2.06)0.7950.83 (0.35–1.94)0.661
      RM7001-RM900036 (76.6)0.75 (0.31–1.78)0.5110.68 (0.28–1.65)0.393
      RM9001 or above (R)70 (81.4)11
      Number of children
      191 (75.8)0.80 (0.40–1.61)0.529
      2150 (78.5)0.93 (0.48–1.81)0.831
      379 (79.0)0.96 (0.46–2.01)0.906
      4 and above (R)59 (79.7)1

      3.4.1 Source of information

      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).
      Sources
      A participant could choose more than one source on information.
      n (%)Good knowledgeGood awareness
      Newspapers174 (35.9)59147
      Internet338 (69.7)120270
      Hospital151 (31.1)54124
      Radio109 (22.5)4090
      Child's school114 (23.5)3890
      Health centre135 (27.8)49119
      Television172 (35.5)61144
      Social media256 (52.8)89213
      Never received information6 (1.2)25
      Others7 (1.4)26
      a A participant could choose more than one source on information.

      4. Discussion

      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.
      • Adhikari S.
      • Paudyal B.
      • Sigdel K.R.
      • Basnyat B.
      Meningitis due to scrub typhus: the importance of a differential diagnosis in an endemic area.
      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.
      • Ding Z.
      • Li Y.
      • Cai Y.
      • Dong Y.
      • Wang W.
      Optimal control strategies of HFMD in Wenzhou, China.
      ,
      • Cordeiro J.
      • Silva A.L.
      • Nogueira R.M.
      • et al.
      Exuberant hand-foot-mouth disease: an immunocompetent adult with atypical findings.
      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,
      • Malaysian Communications
      Multimedia Commission
      Internet Users Survey 2018: Statistical Brief Number Twenty-Three.
      which make up the majority (73.3%) of the respondents in this study. However, online health-related information is often inaccurate.
      • Scullard P.
      • Peacock C.
      • Davies P.
      Googling children's health: reliability of medical advice on the internet.
      • Storino A.
      • Castillo-Angeles M.
      • Watkins A.A.
      • et al.
      Assessing the accuracy and readability of online health information for patients with pancreatic cancer.
      • Fisher J.H.
      • O'Connor D.
      • Flexman A.M.
      • Shapera S.
      • Ryerson C.J.
      Accuracy and reliability of internet resources for information on idiopathic pulmonary fibrosis.
      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.
      • Ministry of Education Malaysia
      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.
      • Suliman Q.
      • Said S.M.
      • Zulkefli N.A.
      Predictors of preventive practices towards HFMD among mothers of preschool children in Klang district.
      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.
      • Suliman Q.
      • Said S.M.
      • Zulkefli N.A.
      Predictors of preventive practices towards HFMD among mothers of preschool children in Klang district.
      Previous studies found that parents' occupation was associated with knowledge of children's heart disease
      • El Mahdi L.M.
      • Hashim M.S.
      • Ali S.K.
      Parental knowledge of their children's congenital heart disease and its impact on their growth.
      as well as health-related issues in children such as dental caries.
      • Kato H.
      • Tanaka K.
      • Shimizu K.
      • et al.
      Parental occupations, educational levels, and income and prevalence of dental caries in 3-year-old Japanese children.
      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.
      • Hooi P.S.
      • Chua B.H.
      • Lee C.S.
      • Lam S.K.
      • Chua K.B.
      Hand, foot and mouth disease: University Malaya medical centre experience.
      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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