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Abstract

The awareness, attitudes, and practices of mothers regarding rheumatic fever (RF) remain obscure, therefore, this study aimed to assess the level of awareness, attitude, and practice of mothers regarding RF. A Quasi-experimental study was conducted on 100 mothers who visited medical centers in Yazd province in 2023 to evaluate the level of awareness, attitude, and practice, with the results reported after the intervention using self-made questionnaires. Statistical tests such as the Kruskal-Wallis test, T-test, One-Way analysis of variance, and Mann-Whitney were used. A significance level of P < .05 was assumed. The mean score of awareness was 6.63 (2.6) and 9.52 (2.59), attitude was 12.56 (4.75) and 17.51 (6.72) and practice was 13.97(5.52) and 19.25 (7.04) of mothers regarding rheumatic fever were before and after study, respectively. The results of mixed effects models showed that education has a significant effect on awareness (P < .001), attitude (P < .001), and practice (P < .001). The mean score of attitude, practice, and awareness were increased by 2.98, 5.28, and 4.95, respectively, after the intervention. Based on the findings, it was observed that mothers have a moderate awareness of rheumatic fever (RF) despite the high burden, poor attitude, and practice. The results of the current study also demonstrate the influence of education in promoting positive practices. Effective training can have a positive impact on the awareness, attitudes, and practices of mothers.

Keywords

attitude awareness education practice mothers rheumatic fever

What do we already know about this topic?

Studies on mothers’ awareness of rheumatic fever have been conducted, particularly in Iran, in recent years. The results indicate that despite the high burden of this disease, knowledge and awareness levels are not high. Of course, there is a lack of knowledge and attitude toward the consequences of rheumatic fever in most developing countries.

How does your research contribute to the field?

This study aims to investigate the state of awareness, attitude, and practice of mothers regarding rheumatic fever, which we have not had a new study in the past few years, especially in Yazd City.

What are your research’s implications toward theory, practice, or policy?

The results of the present study show the weak awareness of mothers about rheumatic fever and especially weak attitudes and practices regarding this disease. Considering the importance of the role of mothers in the health of children and the future health of people in society, it is possible to suggest educational content to the officials so that the education of mothers can be done successfully with the help of various educational methods and tools.

Introduction

Rheumatic heart disease (RHD) is a chronic cardiovascular condition marked by damage to the cardiac valves, with the potential to advance from asymptomatic stages to serious complications.¹

This condition is marked by its chronic and potentially life-threatening nature, spanning from initially asymptomatic phases to severe cardiac valve damage. The possibility developing of chronic RHD remains a substantial concern within the realm of public health, particularly in developing nations.

Statistical estimations point to an annual influx of 282 000 new RHD cases, accompanied by 233 000 associated fatalities, thereby aggregating to a global caseload of 15 million instances.²

Acute RF manifests as an ailment characterized by various symptoms, including, joint pain and inflammation, and valvular regurgitation leading to potential secondary heart failure, chorea, dermatological manifestations, and fever.³ In this context, using antibiotics in the treatment of streptococcal pharyngitis takes on a pivotal role as the principal measure for preventing acute RF, while continuous antimicrobial therapy assumes a secondary preventative role to avert recurrences in documented patients.^4
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It is crucial to approach the prevention of acute RF through primary and secondary measures, which include enhancing societal conditions, sanitation, and housing. To effectively control acute RF, it is important to have comprehensive awareness and understanding of sore throat occurrences, transmission mechanisms, preventive techniques, and management protocols within the public sphere.⁷

The lack of awareness about RF and RHD hinders disease control and prevention. Factors such as prejudices, social and cultural beliefs, limited educational attainment, and suboptimal environmental contexts collectively influence the level of awareness.⁸ Therefore, widespread dissemination of awareness among the general populace, along with the management of modifiable risk factors, has the potential to reduce RHD incidence rates and enhance overall quality of life.⁹ A study conducted in India in 2020 revealed that 81% of the participants had poor awareness of RHD.¹⁰ Awareness and awareness among the public are crucial for controlling RF and RHD and play a pivotal role in their management.^11
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Rheumatic fever (RF) is a cardiovascular disease found worldwide, particularly in many low-income countries.^14
-16 Acknowledging that mothers typically have the most contact with their children during the childhood years, and considering that many mothers lack knowledge about RF, their understanding and attitudes toward rheumatic fever become crucial.

A systematic review conducted in Iran in 2021 found that the prevalence of rheumatic fever in the country is estimated to be around 2% (20/100 000). This estimate is based on studies conducted in various regions of Iran, including the northern, southern, eastern, western, and central areas. Therefore, it could be considered a representative estimation of the prevalence of rheumatic fever in Iran.¹⁷

Limited studies have been published in the past few years on maternal awareness of rheumatic fever in Iran.^12,18 So this study aimed to determine the level the awareness, attitudes, and practices of mothers concerning this disease to address and mitigate potential cardiovascular consequences.

Methods

Sample Selection and Procedure

A Quasi-experimental study was conducted on mothers in Yazd province in 2023 to assess their level of awareness, attitude, and practice of RF. Out of the mothers referred to healthcare centers, 100 mothers of reproductive age were selected for the study. The study provided education to the participants as the intervention and reported the results afterward as the level of awareness, attitude, and practice.

The city of Yazd, the capital of Zed Province, is located in the center of Iran in the desert region. The population of this province in 1400 was calculated as 1 252 000 people based on the official estimate of the National Statistics Center. The province of Yazd is home to over 2979 industrial units, providing direct employment for 99 000 people. This makes it one of the country’s 5 most industrially developed provinces. However, the city faces several environmental challenges, including pollution of underground water resources, spreading pollution due to the crossing of the main south-north highway, numerous dispersed mining activities, and non-compliance with legal rules and standards for environmental damage compensation. Furthermore, Yazd ranks as one of the top 3 provinces in the country in terms of immigration rate.

Using G*Power 3.1.9.4 software, the calculated sample size was equal to 110 by considering 30% attrition rate, α = 0.05,β = 0.2, and 0.30 as the effect size which was obtained from a pilot study. The individuals were selected through convenience sampling method and we missed 10 individuals during the follow-up period.

Inclusion criteria were mothers of reproductive age with a lack of previous training. Mothers with medical education were excluded from the study. In addition, patients’ dissatisfaction led to their exclusion from the study.

The design of the researcher created questionnaire began by searching scientific sources, including books and information databases. Subsequently, in consultation with cardiologists specializing in children and adults, as well as experts in infection and health education, a bank of questions was prepared. The validity and reliability of the questionnaire were then measured.

The questionnaire was divided into 2 parts. The first part gathered demographic information included education (under diploma, diploma, and college education), number of children (2, 3, and 4), income (≤10 million IRR, 10-20 million IRR, and ≥ 20 million IRR), and age (≤35 and >35), while the second part which measured the response variables included questions about awareness, attitude, and practices. The awareness section used yes or no questions, while the attitude and practice section used a 5-choice Likert scale.

To ensure the questionnaire’s validity, both qualitative and quantitative methods were used. Qualitatively, the questionnaire was reviewed by 10 experts, including specialists in Cardiovascular Surgery, Heart Echocardiography, Heart Failure, Pediatric Cardiology, Infectious Disease, and Health Education. The experts provided feedback on grammar, phrasing, and question placement. Quantitatively, the questionnaire’s content validity was checked using the content validity ratio (CVR) and the content validity index (CVI).

Face validity was also assessed using both qualitative and quantitative methods. Qualitatively, one-on-one interviews were conducted with ten mothers of reproductive age. Quantitatively, the questionnaire was given to 10 mothers, who then rated the importance of each item using a 5-point Likert scale.

Information was obtained from mothers through face-to-face interviews and questionnaires.

During the first stage, information was gathered by completing a questionnaire. In the second stage, the educational intervention took place, which included group training and question-and-answer sessions with a cardiovascular disease specialist. After the training, educational content such as pamphlets was provided to the mothers. The third stage involved a post-test conducted 3 months later, where the questionnaires were filled out again.

Rheumatic fever questionnaire was consisted of 4 sections, including, awareness questions (n = 14), attitude questions (n = 7), and practice questions (n = 7). The questions are listed in Table 1.

Table 1.

The Questions of the RF Researcher-Made Questionnaire.

Part 1: Awareness Questions ( Yes□ No□ I don’t know□)
1. Do you know the cause of your sore throat?
**If the answer is yes, what is the main cause of sore throat? Virus/bacteria□ Cold weather□ Cold beverages□ Air pollution□
2. Do you think recurrent sore throats are important in children?
3. Do you believe that every sore throat in children requires a visit to the doctor?
**If the answer is no, which of the following cases necessitates a doctor’s visit? High fever (>38C) □ Sore throat without runny nose and cough□ Recurrent and severe sore throat□ All cases □
4. Do you think all sore throats in children require the use of antibiotics?
5. Are you aware of the necessary drug treatments to prevent rheumatic fever for treating streptococcal sore throat?
**If the answer is yes, which of the following is necessary for streptococcal sore throat treatment? Antibiotics (dryness agent)□ Home remedies □ Treatment with traditional medicines and herbs □ Other:
6. Do you think inadequate treatment of streptococcal sore throat in c
hildren can lead to heart disease and joint involvement?
7. Do you think joint pain occurring in a child with a recent history of sore throat is important and requires a doctor’s visit?
8. Do you think proper treatment of acute sore throat is an important tool in preventing heart disease?
9. Are you familiar with the cause of acute rheumatic fever and rheumatic heart disease?
**If the answer is yes, what is the main cause of acute rheumatic fever? Streptococcal sore throat□ Genetic and hereditary factors□ Autoimmune disease□ Stress and anxiety□
10. Are you familiar with the symptoms of acute rheumatic fever and rheumatic heart disease?
**If the answer is yes, what are the symptoms of acute rheumatic fever? Joint pain□ Cardiac symptoms□ Skin lesions□ All of the above□
11. Do you know the duration between the onset of sore throat and the onset of acute rheumatic fever?
**If the answer is yes, how many days do you think this duration is? Two to three weeks□ Two to three months□ Two to three years□ Immediately□
12. Are you familiar with the complications of acute rheumatic fever?
**If the answer is yes, what is the most important complication of acute rheumatic fever? Involvement of heart valves and tissues□ Joint involvement□ Skin lesions□ Nerve involvement□
13. Are you aware of the necessary drug treatments for acute rheumatic fever?
**If the answer is yes, what are the necessary drug treatments for acute phase of rheumatic fever? Anti-inflammatory drugs like aspirin or cortisone□ Vitamin D□ Acetaminophen□ Antivirals□
14. Is regular use of antibiotics necessary for prevention in case of rheumatic heart disease?
Part 3: Attitude Questions (Strongly agree□ Agree□ Neutral□ Disagree□ Strongly disagree□)
15. In my opinion, streptococcal sore throat does not lead to serious complications in children.
16. In my opinion, streptococcal sore throat are not correlated with acute rheumatic fever.
17. In my opinion, streptococcal sore throat is a simple disease that resolves on its own and does not require medical attention
18. In my opinion, herbal and home remedies can be used for treating streptococcal sore throat. .
19. In my opinion, the use of antibiotics for treating streptococcal sore throat is not necessary.
20. In my opinion, rheumatic fever is preventable.
21. In my opinion, timely medical attention for streptococcal sore throat can prevent rheumatic fever complications.
Part 4: Practice Questions (Always □ Often □ Sometimes □ Rarely □ Never □ )
22. If your child has a sore throat, how likely are you to consult a doctor?
23. How likely are you to use prescribed antibiotics by a doctor if your child has a sore throat?
24. How likely are you to take the prescribed antibiotics at the designated time and for the specified duration?
25. How likely are you to encourage your child with a sore throat to use home remedies and traditional treatments?
26. How likely are you to take your child suspected of having acute rheumatic fever to the hospital
27. How likely are you to have regular follow-up for prevention of heart valve disease after the occurrence of acute rheumatic fever resulting from sore throat?
28. How likely are you to take your child suspected of having acute rheumatic fever to a heart specialist for definitive diagnosis and echocardiography (heart imaging)?

In the current study, 10 experts in the field of cardiovascular diseases, including cardiovascular surgeons, cardiologists, infectious disease specialists, and health education experts, were invited to assist the research team in determining the content validity ratio (CVR). The CVR was calculated and found to be 0.62. Furthermore, a content validity index (CVI) greater than 0.79 was considered acceptable. Additionally, Cronbach’s alpha coefficient was .7.

Statistical Analysis

Data were analyzed using SPSS (version 21)¹⁹ software. Mean, standard deviation (SD), median and interquartile range (IQR) were reported to describe continuous variables and frequency and percentage were reported to describe qualitative variables. The One-way analysis of variance, independent samples t-test, and the Kruskal-Wallis test²⁰ were used to compare the baseline scores of awareness, attitude and practice in terms of demographic variables. To assess the effect of intervention on awareness, attitude and practice, mixed effects model was fitted adjusting the effect of demographic variables. A significance level of P < .05 was adopted.

Results

Among 100 mothers who participated in this study, 36% had under diploma, 32% had, and 35% had college education. Twenty-nine percent of them had 2 children, 51% had 3 children, and 20% had 4 children. The income of 35% of them was ≤10 million IRR. Forty-one percent had ≤10 million IRR, and 24% had over 20 million IRR (Table 2).

Table 2.

The Frequency of Mothers in Terms of Variables, Including Age, Education, Child, and Income.

Variables	Frequency (percent)
Education
Under diploma	36 (36)
Diploma	29 (32)
College education	35 (35)
Number of children
2	29 (29)
3	51 (51)
4	20 (20)
Income
≤10 million IRR^a	35 (35)
10-20 million IRR	41 (41)
≥20 million IRR	24 (24)
Age (years)
≤35	49 (49)
>35	51 (51)
Total	100 (100)

IRR: Iranian Rial (Iranian currency), According to the Central Bank of Iran, the average purchasing power parity (PPP) of 1 US dollar was equivalent to 433 072 R during the data collection period.²¹

The relation between practice, attitude, and awareness scores with variables, including education, the number of children, income, and age is shown in Table 3. Based on the results, the mean practice score was significantly different in terms of education (P < .001). Also, the attitude (P = .01) and the awareness (P = .005) score means were significantly different over the categories of age.

Table 3.

The Relation Between the Baseline Scores of Practice, Attitude, and Awareness With Demographic Variables.

Variables	Practice score	Attitude score	Awareness score
Education	Mean ± SD	Mean ± SD	Mean ± SD
Under diploma	8.94 ± 1.95	7.55 ± 1.36	4 ± 1.39
Diploma	16.72 ± 3.35	14.17 ± 1.39	6.44 ± 1.12
College education	16.85 ± 6.36	16.37 ± 4.33	9.48 ± 0.98
P-value^†	<.001	<.001	<.001
Child	Median (IQR)	Median (IQR)	Median (IQR)
≤1	10 (9)	5 (2)	10 (7)
2	15 (8)	7 (5)	14 (6)
≥3	10 (9)	7 (4)	13 (7.25)
P-value^*	.38	.13	.19
Income	Mean ± SD	Mean ± SD	Mean ± SD
≥10 m IRR	13.17 ± 5.32	12.02 ± 5.53	6.17 ± 3.12
10-20 m IRR	14.07 ± 5.89	12.75 ± 4.92	6.97 ± 2.49
≥20 m IRR	14.95 ± 5.21	13 ± 3.05	6.70 ± 1.85
P-value^†	.474	.40	.70
Age	Mean ± SD	Mean ± SD	Mean ± SD
≤35	13.06 ± 5.86	11.20 ± 4.7	5.95 ± 2.29
>35	14.84 ± 5.09	13.86 ± 4.48	7.27 ± 2.74
P-value^††	.10	.01	.005

Kruskal-Wallis test.

†

One-way analysis of variance.

††

Independent Samples t test.

The mean score of awareness, attitude and practice of mothers regarding rheumatic fever is shown in Table 4.

Table 4.

The Mean Score of Awareness, Attitude and Practice.

After	Before	Variables (range of scores)
9.52 ± 2.59	6.63 ± 2.6	Awareness (0-14)
17.51 ± 6.72	12.56 ± 4.75	Attitude (7-35)
19.25 ± 7.04	13.97 ± 5.52	Practice (7-35)

The results of mixed effects models were reported in Table 5. Based on this model, education has significant effect on awareness (P < .001), attitude (P < .001), and practice (P < .001). It was observed that after intervention the mean score of attitude, practice and awareness were increased 2.98, 5.28, and 4.95, respectively.

Table 5.

Results of Mixed Effects Model for Attitude, Practice and Awareness.

Response variable	Time	Coefficient	Std. error	t	P-value
Attitude^a	After	2.89	0.211	13.64	<.001
	before	_	_	_	_
Practice^b	After	5.28	0.86	6.07	<.001
	before	_	_	_	_
Awareness^a	After	4.95	0.48	10.14	<.001
	before	_	_	_	_

Adjusted for age and education.

Adjusted for education.

Discussion

In our study, we assessed mothers’ awareness about rheumatic fever using a researcher made questionnaire. We found that the average awareness score was 9.5 out of 14, indicating a moderate level of awareness. Interestingly, mothers over the age of 35 showed significantly higher awareness levels compared to those aged 35 and below. Moreover, we observed that mothers with higher education levels displayed greater awareness about RF.

In a study by Almadhi et al conducted in Saudi Arabia, it was revealed that 80.2% of participants had poor awareness about RF, 16.2% had fair awareness, and only 3.6% had good awareness. The study demonstrated that the overall awareness about RF and rheumatic heart disease (RHD) among the participants was suboptimal. Notably, insufficient awareness was more prevalent among individuals younger than 40, which is consistent with our findings. Another study was conducted in Tanzania and showed a relatively higher overall awareness level of RF/RHD, indicating more favorable outcomes compared to the present study’s results.²² It seems that the difference between our study and this study was due to differences in geographical and cultural areas. Most of the participants were primary healthcare providers, logically, they have a higher level of awareness about rheumatic fever than the general public.

Kamal et al, similarly reported congruent findings, wherein awareness of RF exhibited significant associations with age, occupation.²³

A recent investigation in Cameroon involved most of the senior medical students (sixth and seventh years) who have moderate to good awareness of RHD, but only a third of them have above-average awareness. There is a modest understanding of RHD among the students, which could serve as a crucial starting point for developing educational programs to raise awareness and enhance comprehension of the disease.²⁴

In an investigation by Tellawy et al, parents’ awareness and attitudes toward RHD were assessed, revealing a moderate overall level of parental awareness about RHD.¹⁸ Hassan et al, delved into the evaluation of awareness regarding the diagnosis and management of bacterial pharyngitis and their findings indicated that house officers displayed a range of awareness from poor to moderate regarding the diagnosis and treatment of bacterial pharyngitis, with particular gaps in knowing which antibiotics to prescribe. Notably, a positive practice among them was the strong concern about antibiotic resistance.²⁵

The results of our study together with the results of another study showed that several factors exert a pivotal influence on the level of awareness, encompassing prejudices, social and cultural beliefs, limited educational attainment, and poor environmental conditions.²⁶ Given the pivotal role of awareness about RF and RHD in facilitating effective control strategies,²² the implementation of training sessions is recommended. Nadeem and Saeed, also underscored the pressing need to enhance awareness surrounding RF/RHD, sore throat, and their potential complications.²⁷ Kasmaei et al unveiled insights indicating the paucity of maternal awareness in the realm of RF prevention and its associated complications. This highlighted the necessity for incorporating face-to-face educational initiatives during pregnancy and postpartum periods within family health units. Furthermore, the study underscored the significance of education in shaping awareness levels, thereby emphasizing the need to enhance education levels among women at least up to the completion of middle school.²⁸

Moreover, the attitude of mothers regarding RF was poor. The improvement in attitude was seen in mothers with a high level of education. Almadhi et al, evaluated attitude of RF and RHD among 1211 participants through an online platform and revealed that 41.7%, 32.6%, and 25.8% of participants exhibited poor, fair, and good attitude, respectively. Notably, a higher prevalence of poor attitude toward RF and RHD was observed among individuals residing in the central region.²² Isezuo et al, investigated attitude toward the prevention of RF and RHD in Nigeria on 182 participants and revealed that 168 out of 182 participants (92.3%) held a positive attitude.²⁹ In a separate investigation, Kamal et al, explored the attitude of individuals within the population toward rheumatic disease. The result of our study highlighted a significant correlation between attitude and factors such as occupation, and residential location.²³ Results of the current study showed that there isn’t a significant connection between mothers’ awareness, attitude, and practice regarding rheumatic fever and their family income. The lack of significance might be because individuals were hesitant to accurately report their income, which influenced the results.

Furthermore, they reported that the combined awareness and attitude level concerning RF among participants is 70%.²³ In another study by Hsiao et al, the impact of an educational program on enhancing fever management was assessed and the findings indicated that the implementation of an educational program effectively enhanced the awareness and attitude of clinical nurses toward fever management.³⁰

We found that the maternal practice score was low, but it was significantly higher for mothers with higher levels of education. In a study by Chelo et al, they looked at the practice of RHD among senior medical students and found that the mean practice score was 6.13 ± 1.9 out of 10. Our results differed from participants in that we evaluated mothers, while Chelo et al assessed senior medical students.²⁴

Isezuo et al, explored practice patterns associated with the prevention of RHD among primary healthcare workers and their findings indicated that less than half of the respondents displayed adequate preventive practice which was consistent with our study. According to the findings of Isezuo study, health workers exhibit suboptimal practice in preventing RHD. To address this gap, it is recommended to enhance their access to information provided by medical specialists and to update their training curriculum.²⁹ In another study, Kamal et al, investigated the practice patterns of individuals within the population regarding rheumatic diseases. The statistical analysis identified a significant correlation between practice and age.²³ The finding of this study was consistent with our study. The results of the current study also demonstrate the influence of education on promoting practices. Through brief and effective training via media and social networks, it is feasible to positively impact the attitudes and practices of individuals, particularly mothers.

The stage of change in people’s performance is the last stage after creating a change in awareness and attitude, when the person shows a change in behavior in practice. But many factors such as social, economic, cultural factors and sometimes even personal problems such as illness prevent people from changing their performance.

Based on this, it can be said that despite the effort to select the study participants from different social and economic areas of the city, again for various reasons, including the selection of the study participants from mothers of reproductive age and mothers referring to the city’s medical centers. Yazd causes more accuracy in generalizing the results. In addition, the study includes a researcher-made questionnaire developed based on the specific economic, social, and cultural characteristics of mothers in Yazd city. Its applicability to other populations may require revision and adaptation.

Conclusion

Based on these findings, the level of awareness of mothers regarding RF was moderate, while the level of attitude and practice in them was poor. Moreover, the improvement of awareness, attitude, and practice was observed in mothers with a high level of education and age range more than 35 years. One important implication of this study is the need to focus on mothers’ literacy level in raising awareness about the importance and consequences of children’s rheumatic fever.

It is recommended to hold training classes for mothers to enhance their awareness, attitude, and practice regarding RF.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:

Ethical Consideration

After the approval of this study by the research council, the Ethics code was obtained from the ethics committee of Shahid Sadoughi University (number: IR.SSU.SPH.REC.1401.114).

ORCID iD

Nahid Ardian

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