Knowledge on Health Aspect of Children Less Than Two Years among Mothers in Al – Ramadi City, Iraq
Badeaa Thamer Yahyaa1 Shukr Mahmood Yaseen2, Mustafa Ali Mustafa Al-Samarrai1, Saad Ahmed Ali Jadoo4*
1Department of Family and Community Medicine, Faculty of Medicine, Anbar University, Anbar, Iraq.
2Medical Biology and Anatomy Department, Faculty of Medicine, Diyala University, Iraq
3Department of Public Health, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
The responsibility of mothers is mostly childcare, so their education is vital for children's illness and the influence on children's care. This study aims to assess the mothers' knowledge of children's health aspect less than two years. A descriptive cross-sectional study was conducted at the Maternity and Childhood Teaching Hospital in Al-Anbar governorate during January 2020. Two hundred and fifty married mothers who had children less than two years of age, at age (15 – 49) of mothers enrolled in the study. They were selected by non-probability convenience sampling technique. Data were analyzed using SPSS version 16.
The mean age of the study sample was 29 (±6.07). The illiterate and high educated were 16 (6.4%) and (38.8%), respectively. Their knowledge regarding breastfeeding (few hours after delivery starting breastfeeding) was (88.8%). About (56.8%) knew the benefit of breastfeeding for child and mother’s health, while only (3.2%) knew the benefit of its benefits for mothers only. Most mothers (92.0%) were known for vaccination programs for children under two years. About (86.0%) knew the benefit of vaccination of children under two years for prophylactic from disease, while only (1.6%) do not know the benefit of vaccination. The result also shows a significant association between (education of mothers, starting breastfeeding in few hours after delivery, benefit of breast feeding, social and psychological importance of breastfeeding) of mothers and age, education stage, and knowledge level. Knowledge regarding breastfeeding and vaccination and its importance among mothers was good. However, more strategies are needed to increase the health aspect of children less than two years among mothers in our community.
Keywords : Health; Breastfeeding; Vaccination; Children; Knowledge; Mothers; Iraq
Childcare is primarily the responsibility of mothers. Therefore, the mother's knowledge about childcare influences the nature and quality of care given to the child. Several studies have revealed that the mother's level of education has a positive impact on her knowledge and how she deals with child health care issues1. The promotion and support of breastfeeding are a global priority. Vast scientific literature demonstrated substantial health, social and economic benefits associated with appropriate breastfeeding, including lower infant morbidity and mortality from diarrhea and infectious diseases2. Unlike breastfeeding, formula-fed babies are more susceptible to higher infections, such as the aerobic bacteria in the intestine. The first months of life are some of the most important for child health because vital processes related to growth and development occur during this period. Therefore, a child's health will depend on careful monitoring to prevent or mitigate possible impairments to his or her health3. The early initiation of breastfeeding – putting newborns to the breast within the first hour of life–is critical to newborn survival and to establishing breastfeeding over the long term. When breastfeeding is delayed after birth, the consequences can be life-threatening – and the longer newborns are left waiting, the greater the risk. Therefore, WHO and UNICEF recommend initiation of breastfeeding within the first hour
of life and exclusive breastfeeding up to six months4.
Various studies have been carried out to assess the mothers' knowledge and their practices regarding breastfeeding. Commonly reported malpractices to include delayed initiation of breastfeeding, colostrum deprivation, breastfeeding, colostrum deprivation, feeding pre-lacteal foods, formula milk supplementation, and early introduction of complementary feeding5. Vaccination is the administration of a vaccine to help the body produce immunity against a disease6. Studies have shown that 2.5 million lives worldwide are saved by vaccination against tuberculosis, poliomyelitis, diphtheria, tetanus, and measles every year7. Despite the statistics mentioned above, vaccination for tetanus, diphtheria, meningitis is low and amounts to 75.0%8. Measles is yet to be eliminated, which remains one of the main reasons for early childhood mortality. The role of media, the internet, and social media is essential for immunization9. Mothers consider the internet as the second most reliable source after medical workers10. The research shows the necessity of enhancing technical capabilities and interpersonal communication skills of healthcare workers involved in the immunization system and health of children under five years of age because they are the most reliable source of information for most mothers11,12. This study aimed to assess the Knowledge on health aspect of children aged less than two years among a sample of mothers in Al – Ramadi city, Iraq.
Methods Study Design
A cross-sectional study was carried out in the Maternity and Childhood Teaching Hospital and Al – Ramadi Teaching hospital from 1st December 2019 to the end of February 2020. All married mothers bearing children under the age of 24 months who had attended the hospital for maternal and child healthcare and were willing to participate in the research are included in the study.
However, unmarried women and those who have no children yet or not willing to participate were excluded from the study. The study protocol was approved by the Ethics committee of the Faculty of Medicine, University of Anbar. Moreover, permission was obtained from the related hospital authority.
The sample size was calculated by assuming the prevalence rate of knowledge among Iraqi mothers in Al-Ramadi city is 50.0% with a confidence level of 95%, and an acceptable margin of 5% using the following formula: N= [Za2x P x Q/(M.E.)2]. So, n = (1.96)2× (0.50) × (0.50)/
(0.06)2=267. Due to exclusion criteria, 250 mothers have been included in this study (Table 1).
A semi-structured questionnaire with closed-ended questions was recruited to collect the data via a face-face interview. The questionnaire was divided into two parts:
Part one: was made to elicit the sociodemographic data of the surveyed women such as the age of mothers, age at marriage, education, and occupation of mothers and their husbands, number of life childbirths, history of abortions, and child deaths.
Part two: included data related to the mother's knowledge about breastfeeding and vaccination.
The statistical analysis was conducted in the form of percentages, mean, standard deviation. Chi-
square analysis was used for rate comparison. A P-value of ≤ 0.05 was considered statistically significant. The statistical analysis was carried out by using SPSS 16.
Two hundred and fifty women (response rate = 86.8%) were included in the final analysis. Table 1 shows the characteristic distribution of the study sample. The mean age of respondents was 29 (± 6.07) years (range of 16-49 years). The highest proportion (37.6%) was 25-29 years old, while the lowest frequency (2.4%) was at the age group less than 20 years. The mean age of marriage was 20.9 (±3.75) (range of 14-40 years) years. The highest proportion (48.0%) was among the age group of 20-24 years old, while the lowest percentage (0.4%) was at the age group 35 years old and above. More than one-third (38.8%) of women were highly educated (University level), compared to 59.2% of the husband's group. Most women were housewives (71.1%), compared to 53.6% and 41.2 of husbands employed in public and private sectors, respectively. Regarding parity, the highest frequency (29.2%) was two births, while the lowest frequency (1.2%) was primigravida that representatives. About 20.4% of women had an abortion at least once, 5.6%
had two abortions, and 0.8% had more than two abortions, while 73.2% stillbirth and other deaths, as shown in Table 1.
Table 1: Distribution of socio-demographic characteristics of the study sample (n=250)
Variables Categories No. %
Age ( years ) Mean ± SD 29 ± 6.07
<20 6 2.4
20 – 24 48 19.2
25 – 29 94 37.6
30 – 34 57 22.8
35 – 39 23 9.2
40+ 22 8.8
Age of marriage Mean ± SD 20.9±3.75
<20 79 31.6
20 – 24 120 48
25 – 29 45 18
30 – 34 5 2
>35 1 0.4
Education of mother Illiterate 16 6.4
Read & write 20 8
Primary 37 14.8
Intermediate 37 14.8
Secondary 43 17.2
University 97 38.8
Education of husband Illiterate 5 2
Read and write 8 3.2
Primary 18 7.2
Intermediate 26 10.4
Secondary 45 18
University 148 59.2
Occupation of mother Housewife 178 71.2
Employed 72 28.8
Occupation of husband Employed 134 53.6
Free business 103 41.2
unemployed 11 4.4
retired 0 0
dead 2 0.8
Number of life birth 0 3 1.2
1 62 24.8
2 73 29.2
3 56 22.4
4 31 12.4
5+ 25 10
Abortion 0 183 73.2
1 51 20.4
2 14 5.6
+3 2 0.8
Child deaths 39 15.6
knowledge of mothers about breastfeeding, vaccination, the proper behavior in the child's illness, and source of knowledge
Out of 250 mothers interviewed, 222(88.8%) knew that breastfeeding should be launched few hours after delivery; however, 16(6.4%) of them delayed the launch of breastfeeding for few days after delivery, and 12(4.8%) had no information (Table 2). More than half (56.8%) knew the benefit of breastfeeding for mothers and children health; and (36.0%) knew breastfeeding for growth child only, while (4.0%) of mothers did not know. The social and psychological benefit of breastfeeding about four-quarter (72.4%) of mothers knew to improve the relationship between mother and her child, only (16.4%) of mother knew psychological support for a child, while (11.2%) did not know. About (36.4%) of mothers do not know anything about the disease that prevent by breastfeeding; however (29.2%) knew breastfeeding prevents diarrhea, while (8.8%) knew breastfeeding prevents other diseases. Table two also shows that more than half (52.4%) knew the duration of breastfeeding is two years, and 24.0% knew the duration of breastfeeding is one year, while 2.0% did not know (Table 2).
Table 2: Distribution of knowledge about and vaccination of the study sample (n=250)
Variables Categories N (%)
Initiation of breastfeeding after delivery Few hours after delivery 222 (88.8) Days after delivery 16(6.4)
Do not know 12(4.8)
Benefits of breastfeeding Health and development of the child
Mother's health 8(3.2)
Mother and child health 142(56.8)
Do not know 10(4.0)
Social and psychological benefits of breastfeeding
Improving the relationship between mother and child
181(72.4) Psychological support for a
Do not know 28(11.2)
Breastfeeding prevents diseases Diarrhea 73(29.2)
Respiratory disease 40(16.0)
Do not know 91(36.4)
An appropriate period for the duration of breastfeeding
One year 60(24.0)
Two years 131(52.4)
More than two years 39(15.6)
Do not know 20(8.0)
Table 3 shows that most mothers (92.8%) knew vaccination programs for children less than two years of age, while (7.2%) did not know. About (86.0%) of the women know that immunization prevents disease, while (1.6%) did not know. Most women (93.6%) knew the necessary follow- up vaccination schedule, while (6.4%) did not know. Less than half (43.6%) did not know that no scar appears on the shoulder after two months from the first vaccine in the vaccination program;
the vaccine is repeated, while more than half (56.4%) knew. Among those who have not to give the first vaccine in the vaccination schedule after completing the first year if the child did not receive a previous dose, (56.0%) knew that not given the first vaccine after completing the first year if the child did not receive a previous dose, while (44.0%) did not know. Almost 45.6% of mothers did not know how often the child should be vaccinated for the first year, while (17.6%) knew five-time. About (31.6%) of mothers knew that the child whom feverish was required to delay the vaccine; (16.8%) knew jaundice required to delay the vaccine, while (34.8%) did not know. Only (48.8%) did not know vaccination compassion replace the vaccination program, while (51.2%) knew.
Table 3: Distribution of knowledge about vaccination of the study sample (n=250)
Variables Categories N (%)
Vaccination program for children less than two years of age
Benefits of vaccination to children Prevent disease 215(86.0) Growth of children 24(9.6)
Do not know 4(1.6)
Necessary to follow up on the schedule of vaccination
A vaccine that is given in the first week of age Yes 208(83.2)
After two months from the 1st vaccine in the vaccination program and no scar appeared on the shoulder, the vaccine is repeated?
No 109(43.6) The first vaccine in the vaccination program is
not given to the child after completing the first year of life if he did not receive a previous dose.
Times of vaccines received during the first year of age
Three times 45(18.0)
Four times 47(19.8)
Five times 44(17.6)
Do not know 114(45.6)
Cases that require delaying taken the vaccine Jaundice 42(16.8)
Do not know 87(34.8)
Vaccination campaigns replace vaccination programs.
Table 4 also shows the knowledge on the proper mother’s behavior in a child’s illness. More than three-quarters of mothers (76.4%) knew weight and height programs in health centers, while (23.6%) did not know. When the child has diarrhea and vomiting, about 50.8% of mothers give oral fluid and visit the doctor; and 33.6% immediately go to the doctor, while 15.6% give the child oral fluid only. More than half (59.6%) of mothers knew the proper behavior to decrease the temperature when the child feverish, while 40.4% immediately went to the doctor.
Table 4: Distribution of knowledge about Proper mother’s behavior in a child’s illness (n=250)
Variables Categories N (%)
Program for measuring the weight and height of the child during his visit to the health center
A child has diarrhea or vomiting Give oral fluid only 39(15.6) Give fluid and visit the doctor 127(50.8) Go to the doctor immediately 84(33.6)
Child has fever Decrease of temperature 149(59.6)
Go to the doctor immediately 101(40.4)
Sources of knowledge
Table 5 shows family and friends were the significant sources of knowledge among 31.6% of respondents; the second-highest frequency (29.2%) were the doctors, while the lowest source of knowledge included school curriculum (8.0%) and books and (3.2%), respectively.
Table 5: Distribution of source of knowledge for the study sample (n=250)
Source of knowledge N %
Family and friends 79 31.6
TV 26 10.4
School curriculum 20 8.0
Doctors 73 29.2
Social media 44 17.6
Books 8 3.2
Distribution of the study group and association between level of knowledge and some women's characteristics
Table 6 shows a significant relationship between mothers’ knowledge in terms of the date of starting breastfeeding (P=0.009), the social and psychological importance of breastfeeding (p=0.009), the appropriate period for breastfeeding (P=0.05), and the age groups age of respondents.
Table 6: The association between mother's knowledge about breastfeeding and the age groups of respondents (n=250)
Mothers' knowledge about breastfeeding < 20
20 – 29 N(%)
N(%) P- value*
Total observation 6(2.4) 142(56.8) 102(40.8)
Starting breastfeeding after delivery
Few hours after delivery 6(100) 125(88) 91(89.2) 0.009 Few days after delivery 0(-) 9(63) 7 (6.9) Do not know 0(-) 8(5.6) 4 (3.9) Health benefit of breastfeeding
For the health and development of the child 3(50) 56(39.4) 31(30.4) 0.423 For mother‘s health only 0 (-) 5(3.5) 3(2.9) For the health of mother and child 2(33.3) 79(55.6) 61(59.8) Do not know 1(16.7) 2(1.4) 7(6.9) Social and psychologically crucial for
Strength the relation between mother and child 2(33.3) 114(80.2) 65(63.7) 0.009 Support psychological state for child 1(16.7) 15(10.6) 25(24.5) Do not know 3(50.0) 13(9.2) 12(11.8) Breastfeeding prevents certain diseases.
diarrhea 1(16.7) 37(26.0) 35(34.3) 0.124 Respiratory disease 0(-) 15(10.6) 25(24.5) Allergy 0(-) 22(15.5) 2(1.9) Others 1(16.7) 14(9.9) 7(6.9) Do not know 4(66.6) 54(38.0) 33(32.4) An appropriate period for breastfeeding
One year 0() 40(28.2) 20(19.6) 0.05 Two years 3() 73(51.4) 54(52.9) Others 3() 15(10.5) 21(20.6)
Do not know 0() 14(9.9) 7(6.9)
*Significant using Chi-square test at 0.05 level
Table 7 shows a significant relationship between mothers’ knowledge in terms of the date of starting breastfeeding (P=0.012), the health benefit of breastfeeding (p=0.001), the social and psychological importance of breastfeeding (p=0.025), and the level of women's education.
Table 7: The association between mother's knowledge about breastfeeding and the educational level of respondents (n=250)
Mothers' knowledge about breastfeeding Low N(%)
Total observation 73(29.2) 80(32.0) 97(38.8)
Starting breastfeeding after delivery
Few hours after delivery 59(80.8) 73(91.3) 90(92.8) 0.012 Few days after delivery 7(9.6) 4(5.0) 5(5.1) Do not know 7(9.6) 3(3.7) 2(2.1) Health benefit of breastfeeding
For the health and development of the child 28(38.4) 36(45.0) 31(32.0) 0.001 For mother‘s health only 2(2.7) 5(6.3) 1(1.0) For the health of mother and child 35(47.9) 38(47.5) 64(66.0) Do not know 8(11.0) 1(1.2) 1(1.0) Social and psychologically crucial for
Strength the relation between mother and child 45(61.6) 58(72.5) 78(80.4) 0.025 Support psychological state for child 14(19.2) 12(15) 15(15.5) Do not know 14(19.2) 10(12.5) 4(4.1) Breastfeeding prevents certain diseases.
diarrhea 19(26) 22(27.5) 32(33) 0.409 Respiratory disease 10(13.7) 13(16.3) 17(17.5) Allergy 4(5.5) 7(8.8) 13(13.4) Others 6(8.2) 8(10) 8(8.2) Do not know 34(46.6) 30(37.5) 27(27.8) An appropriate period for breastfeeding
One year 7(9.6) 21(26.3) 32(33.0) 0.000 Two years 37(50.7) 44(55) 49(50.5) Others 19(26.0) 6(7.5) 14(14.4) Do not know 10(13.7) 9(11.2) 2(2.1)
*Significant using Chi-square test at 0.05 level
Table 8 shows a significant relationship between mothers’ knowledge about the vaccination program for children aged < 2 years (P=0.009), the first vaccine should not be given after one year of age if it has not to be given previously(P=0.004), the vaccination campaigns compensate for routine vaccination program (P=0.000), and Program for measuring the child's weight and height during visiting the vaccination health center (P=0.025) and the educational level of mothers.
Table 8: Association between mother’s knowledge about vaccination program and the educational level (n=250)
Mothers’ knowledge about vaccination Mild N(%)
Total observation 73(29.2) 80(32.0) 97(38.8)
Vaccination program for children < 2 years
Yes 66(90.4) 70(87.5) 96(99.0) 0.009
No 7(9.6) 10(12.5) 1(1.0) The benefit of vaccination for children
Prevent disease 64(87.7) 65(81.2) 80(82.5) 0.270 For children development 6(8.2) 11(13.8) 7(7.2)
Others 1(1.4) 0(-) 3(3.1)
Do not know 2(2.7) 4(5.0) 7(7.2) Necessary to follow the vaccination schedule
Yes 68(93.2) 75(93.8) 91(93.8) 0.983 No 5(6.8) 5(6.2) 6(6.2) The vaccine is given in the first week of age.
Yes 61(83.6) 62(77.6) 85(87.6) 0.199 No 12(16.4) 18(22.5) 12(12.4) Two months after the first vaccine in the
vaccination program and no scar appeared on the shoulder, the vaccine is repeated.
Yes 44(60.3) 37(46.2) 60(61.9) 0.083
No 29(39.7) 43(53.8) 37(38.1)
The first vaccine should not be given after one year of age if it has not to be given previously.
Yes 40(54.8) 33(41.2) 64(66.0) 0.004 No 33(45.2) 47(58.8) 33(34.0) The child was vaccinated during the first year of
Three times 8(10.9) 18(22.5) 19(19.6) 0.087 Four times 12(16.4) 18(22.5) 18(18.6) Five times 17(23.3) 7(8.8) 21(21.6) Do not know 36(49.3) 37(46.2) 39(40.2) The cases that require delaying the vaccine
Jaundice 9(12.3) 13(16.2) 20(20.6) 0.294 Fever 19(26.0) 27(33.8) 33(34.0) Diarrhea 7(9.6) 4(5.0) 6(6.2) Others 11(15.1) 4(5.0) 10(10.3) Do not know 27(37.0) 32(40.0) 28(28.9) The vaccination campaigns compensate for the
routine vaccination program.
Yes 25(34.2) 53(66.3) 50(51.5) 0.000 No 48(65.8) 27(33.7) 47(48.5)
Program for measuring the child's weight and height during the visit to the vaccination health center
Yes 54() 54() 85() 0.005
No 19() 26() 12()
Socio-demographic characteristic of the study sample
The study's finding revealed the highest proportion (37.6%) of women in the age group 25-29 years, a finding that is lower than other studies conducted in Baghdad (Iraq)13, and Nigera14, but similar to study conducted in United Arab Emirates15. The mean age of respondents was 29(±6.07), which is lower than the study conducted in Nigeria16. In our study, the majority (48.0%) of women were in the married age group of 20-24 years, and the mother education of the majority was university level which is higher than reported in a study conducted in Saudi Arabia17. In this study, the rate of housewife women (71.2%) exceeds that reported in Saudi Arabia18, which may be related to the low employment rate in Iraq. Although most Iraqi families have seven members and above19, the rate of Iraqi mothers in this study who have two children was 29.2%, which is different from that mentioned in other studies conducted in Italy20.
Knowledge of women about breastfeeding and vaccination
The awareness of initiation breastfeeding in this study among mothers was 88.8% in few hours after delivery and 6.4% in few days after delivery. Our findings are higher than other studies conducted in Riyadh (77.5%), Saudi Arabia21, and Egypt (83.7%)22. Knowledge of mothers about the benefit of breastfeeding for mother and child health was 56.8% which is higher than that reported in Saudi Arabia21, but lower than earlier studies conducted in Iraq23. The study finding showed that among mothers who knew the social and psychological benefit of breastfeeding, 72.4% reported improving the relationship between mother and child. However, the result is lower than 76.3%, reported by Coscone et al. (2019) in Italy20, and 77.0% reported by Mohammed et al. (2014) in Egypt22. Mothers who know breastfeeding prevents diarrhea in this study were 29.2%, reflecting poor education about breastfeeding in our community, which is much lower than 43.8% reported by other studies conducted in Nigeria16.
An appropriate period for the duration of breastfeeding
Knowledge of mothers about the appropriate period for the duration of breastfeeding was 52.4%
for two years, and 24.0% was for one year, which is lower than reported in a study conducted in Pakistan (77.0%)24, and in an Indian study (68.0%)25. Knowledge of mothers about vaccination programs for children less than two years of age was excellent (92.8%). Similarly, in a local study conducted in Baquba City, Iraq, 98.0% of mothers correctly knew vaccination programs for children less aged less than two years of age26, and an Indian study conducted in Bangalore where 90.0% of mothers knew vaccination program27. However, it is higher than results from Pakistan28 and South Kerala, India29. The study findings showed that 86.0% of respondents knew that vaccination prevents disease, which is agreed to previous Iraqi study (84.7%) conducted in Mosul30, but lower than results (96.0%) reported among mothers in Kinshasa, Democratic Republic of the Congo31 and higher than the result reported among Syrian mothers32. In this study, most mothers (93.6%) consider it necessary to follow up a vaccination schedule. However,
the result was lower than reported by other studies as in North Kashmir, India, 100% of studied women, knew that necessary to follow up vaccination schedule33.
About 83.2% of women knew that the first vaccine given to children should be in the first week of the vaccination schedule; however, such finding was lower than that reported among mothers in Uganda, where 95.0% thought to complete the vaccination schedule children34. As per WHO recommendation, the first vaccine should be administered as soon as possible after birth and before one month of age for maximum protection35. The development of a scar after the first vaccine has been used as a successful vaccination indicator. More than half (56.4%) of mothers know the vaccine should be repeated two months from the first vaccine in the vaccination program when they had no scar on the shoulder. Our finding is higher than the report in Durban, South Africa, in which (1.5%)36. This study showed that the first vaccine in the vaccination program is not given to the child after completing the first year of life if he did not receive a previous dose. The WHO universal BCG vaccination at birth is recommended in countries or settings with a high TB incidence and/or high leprosy burden. A single dose of the BCG vaccine should be given to all healthy neonates at birth, ideally together with Hepatitis B birth dose37. About 45.6% of mothers did not know the schedule of vaccines received during the first year of age. However, 18.0% of them knew about the three times vaccines should be received during the first year of age. Our finding is lower than the result (26.0%) reported in North Kashmir, India33. The child presented with fever is a condition that leads to delaying the taking of vaccine, however, some mothers consider infection a social stigma which may exacerbate the infected cases38. In our study, 31.6% of women knew the necessity of delaying the scheduled vaccine when the child is feverish. However, our finding was lower than the result (61.6%) reported in India39. More than fifty percent of mothers have a positive attitude to vaccination, and they know that vaccines save thousands of lives every year, but many people remain unvaccinated because serious are wrongly attributed to vaccination. More than three-quarters of mothers studied knew that program for measuring weight and height of the child during his visit to the health center (76.4%), and the result was higher than the result reported in Iran (71.5%)40. The proper action is to give oral fluid when the child developed diarrhea or vomiting; however, in our study, few mothers (15.6%) knew the correct behavior in such condition, which is much lower than the results (62.4%, 38.8%, 69.1%) reported by three studies conducted in Nigeria41,42,43, respectively.
Moreover, 33.6% of mothers visit the doctor immediately when the child complains about diarrhea or vomiting. Our results are much lower than that reported in Karachi, India (62%), in which mothers immediately visited the doctor44, but the result is higher than that reported in Khyber teaching hospital Peshawar, Pakistan (29.4%), where mothers consult a doctor as an action taken when a child has diarrhea45. Furthermore, the behavior of 50.8% of mothers was to give fluid and visit the doctor when the child has diarrhea or vomiting. However, the result was higher than reported (46.3%) in Iran46. The majority (59.0%) of mothers considered the proper behavior when a child has a fever is to decrease the temperature because fever is a serious health issue. Our finding was better than the result (40%) reported in Ethiopia in which47 but lower than reported in Jordon in which 90.5% of mothers tend to decrease the temperature of their children before visit the physician48.
Source of information about breast cancer
Family and friends are significant sources of knowledge about children aged less than two years among 31.6% of mothers participating in this study. Similar findings have been reported in earlier studies conducted in Iraq49,50. However, the result is higher than reported in Taif city,
Saudi Arabia (22.0%)51, but it is lower than reported in Sindh, Pakistan (57.2%)52. Moreover, 29.2% of mothers reported doctors as the second source of information; however, they had little impact in imparting knowledge. Our result is much lower than reported by other studies conducted in Saudi Arabia and Pakistan51, 52 in which 42.5% and 43.3% of mothers reported the doctor as the primary source of knowledge of breastfeeding and immunization, respectively.
The association between knowledge and socio-demographic characteristics
As reported earlier in table 6, there was a significant relationship between (knowledge in term of the date to start breastfeeding, health benefit of breastfeeding, social and psychological importance of breastfeeding, and the appropriate period of duration of breastfeeding of mothers) and some of the socio-demographic characteristics such as mothers’ age and level of education.
Unlike to earlier studies conducted in Iraq53 and Vietnam54, our study found a significant relationship between mothers’ age and their knowledge about the date of starting breastfeeding (P=0.009), the social and psychological importance of breastfeeding (p=0.009), the appropriate period for breastfeeding (P=0.05) and the age groups age of respondents. In this study, mothers with higher education were more likely to be aware of breastfeeding and its starting, health benefits, and the social and psychological importance of breastfeeding. Our findings align with many previous studies conducted in Iraq55, USA56, and Nepal 57, Turkey58. Mothers' knowledge of breastfeeding was good, which can be attributed to the cultural and religious factors favoring breastfeeding. Our result was per previous studies from Iraq55 Egypt59 and Kuwait60. Several previous studies confirmed the association between the low education of women and the less knowledge about breastfeeding53,61,62,63
. Two studies from Nigeria13,Nepal64 support our findings of the significant association between a mother’s knowledge and the appropriate period of breastfeeding. Moreover, the low level of education among mothers combined with switching to spoon feeders is more likely to increase adenovirus-related diarrhea among children65.
Additionally, the education level of mothers has significantly related to their knowledge of vaccination program for children aged less than two years; the first vaccine did not be given after one year of age, the vaccination campaigns compensate for routine vaccination program and program for measuring the child’s weight and height. Similarly, other studies confirmed the same association 66,67,68. Regarding the association of mother’s knowledge about the first vaccine in the vaccination program, which should not be given after one year of age, the result of this study was like earlier results from Iraq reported at 95.0 % in 201869. Unlike the Nigerian70 study indicated that more mothers significantly rejected vaccination campaigns, our mothers had good knowledge about the vaccination campaigns, which compensate for the routine vaccination program. Moreover, the association between the mother's knowledge and measuring the child's weight and height during the visit to the vaccination health center is fitted with the result reported in the Indian vaccination Program71.We believe that building a health system based on universal Health insurance, with the adoption of national programs, will enhance health education in the community, and especially among mothers for better home care of sick children, vaccination programs, feeding children, and avoiding accidents72.
In conclusion, this study revealed that the knowledge of mothers regarding the health aspect of children aged less than two years in term of the awareness to initiate breastfeeding and the knowledge of mothers about vaccination programs for children less than two years of age was very good (88.8%) and excellent (92.8%), respectively. More than half (50.8%) of mothers
behave properly to give fluid and visit the doctor when the child has diarrhea or vomiting. At the same time, most (59.0%) of mothers considered the proper behavior in a child has a fever is to decrease the body temperature because fever is a serious health issue. Further studies are needed, including follow-up studies for the health aspect of children less than two years of age.
Government involvement to application breastfeeding program and coverage vaccination program. There is a need for a public health education initiative and more strategies to increase mothers' awareness in our community.
 Al-Ayed IH. Mothers' knowledge of child health matters: Are we doing enough? J Family Community Med. 2010 Jan;17(1):22-8. doi: 10.4103/1319-1683.68785
 Kebede Z. Determinants of Optimum Breastfeeding Among Mothers of Child Less than Two Years in Bishoftu Town, East Shewa Zone of Oromia Region, Ethiopia, Science Journal of Public Health.2015;3 (4): 544-551. doi: 10.11648/j.sjph.20150304.23
 McClay R, Mileski M, Naiman J. Neonatal bacterial colonization of the intestine- implications for the practitioner. Journal of Ideas in Health2019;2(2):102-7.
 UNICEF, WHO. Capture the Moment – Early initiation of breastfeeding: The best start for every newborn. New York: UNICEF; 2018.
 Waiswa P, Peterson S, Tomson G, Pariyo GW. Poor newborn care practices - a population-based survey in eastern Uganda. BMC Pregnancy Childbirth. 2010 Feb 23;10:9. doi: 10.1186/1471-2393-10-9.
 Drexler M; Institute of Medicine (US). What You Need to Know About Infectious Disease. Washington (DC): National Academies Press (US); 2010. doi: 10.17226/13006.
 Duclos P, Okwo-Bele JM, Gacic-Dobo M, Cherian T. Global immunization: status, progress, challenges and future. BMC Int Health Hum Rights. 2009 Oct 14;9 Suppl 1(Suppl 1):S2. doi: 10.1186/1472-698X-9-S1-S2.
 Mooney E. Improving immunization coverage through policy in Georgia 2018. Avialble from: https://www.sabin.org/updates/blog/improving-immunization-coverage-through- policy-georgia.
 Brunson EK. The impact of social networks on parents' vaccination decisions. Pediatrics.
2013 May;131(5):e1397-404. doi: 10.1542/peds.2012-2452.
 Betsch C, Sachse K. Dr. Jekyll or Mr. Hyde? (How) the Internet influences vaccination decisions: recent evidence and tentative guidelines for online vaccine communication.
Vaccine. 2012 May 28;30(25):3723-6. doi: 10.1016/j.vaccine.2012.03.078.
 Jones AM, Omer SB, Bednarczyk RA, Halsey NA, Moulton LH, Salmon DA. Parents' source of vaccine information and impact on vaccine attitudes, beliefs, and nonmedical exemptions. Adv Prev Med. 2012;2012:932741. doi: 10.1155/2012/932741.
 Al-Samarrai MA, Ali Jadoo SA. Impact of training on practical skills of Iraqi health providers towards integrated management of neonate and child health-a multicentre cross- sectional study. Journal of Ideas in Health2018;1(1):1-6.
 Akinyinka MR, Olatona FA, Oluwole EO. Breastfeeding Knowledge and Practices among Mothers of Children under 2 Years of Age Living in a Military Barrack in Southwest Nigeria. Int J MCH AIDS. 2016;5(1):1-13.
 Jamil NF, Ali YMH. Determinants of mothers' knowledge on health aspects of children less than two years among a sample of mothers in Baghdad , Iraqi J. Comm.
 Al Ketbi MI, Al Noman S, Al Ali A, Darwish E, Al Fahim M, Rajah J. Knowledge, attitudes, and practices of breastfeeding among women visiting primary healthcare clinics on the island of Abu Dhabi, United Arab Emirates. Int Breastfeed J. 2018 Jul 3;13:26. doi:
 Ihudiebube-Splendor CN, Okafor CB, Anarado AN, Jisieike-Onuigbo NN, Chinweuba AU, Nwaneri AC, Arinze JC, Chikeme PC. Exclusive breastfeeding knowledge, ıntention to practice and predictors among primiparous women in Enugu South-East, Nigeria, Journal of pregnancy 2019; (6):1-8. https://doi.org/10.1155/2019/9832075.
 Al-Mutairi NF, Al-Omran YA, Parameaswari PJ. Breastfeeding practice and knowledge among women attending primary health-care centers in Riyadh 2016. J Family Med Prim Care. 2017 Apr-Jun;6(2):392-398. doi: 10.4103/jfmpc.jfmpc_243_17.
 Al-Ruzaihan SA, Al-Ghanim AA, Bu-Haimed BM, Al-Rajeh HK, Al-Subaiee WR, Al- Rowished FH, Badger-Emeka LI. Effect of maternal occupation on breast feeding among females in Al-Hassa, southeastern region of KSA. J Taibah Univ Med Sci. 2016 Oct 21;12(3):235-240. doi: 10.1016/j.jtumed.2016.08.013.
 Ali Jadoo SA, Sarhan Y, Al-Samarrai M, Al-Taha M, AL- Any B, Soofi A, Yahyaa B, Al- Rawi R. The impact of displacement on the social, economic and health situation on a sample of internally displaced families in Anbar Province, Iraq. Journal of Ideas in Health2019;2(1):56-9. https://doi.org/10.47108/jidhealth.Vol2.Iss1.16.
 Cascone D, Tomassoni D, Napolitano F, Di Giuseppe G. Evaluation of Knowledge, Attitudes, and Practices about Exclusive Breastfeeding among Women in Italy. Int J Environ Res Public Health. 2019 Jun 14;16(12):2118. doi: 10.3390/ijerph16122118.
PMID: 31207988; PMCID: PMC6617343.
 Shommo SA, Al-Shubrumi HSA. Breastfeeding knowledge, attitude and practice among mothers in Hail district, northwestern Saudi Arabia. IOSR 2014;3(1) :49-56.
 Mohammed ES, Ghazawy ER, Hassan EE. Knowledge, Attitude, and Practices of Breastfeeding and Weaning Among Mothers of Children up to 2 Years Old in a Rural Area in El-Minia Governorate, Egypt. J Family Med Prim Care. 2014 Apr;3(2):136-40.
 Al-Samarrai M, Al-Rawi R, Yaseen S, Ali Jadoo S. Knowledge, attitude, and practice of
mothers about complementary feeding for infants aged 6-12 months in Anbar Province,
Iraq. Journal of Ideas in Health2020;3(1):125-9.
 Safdar M, Jabeen C, Kousar R, Shahzadi C, Gilani SA. The assessment of knowledge, attitude and practices of exclusive breast feeding among lactating mothers: a case of children hospital of Lahore Pakistan , Saudi J. Med.2017; 2(3):76-84.
 Vijayalakshmi P, Susheela T, Mythili D. Knowledge, attitudes, and breast feeding practices of postnatal mothers: A cross sectional survey. Int J Health Sci (Qassim). 2015 Oct;9(4):364-74.
 Kadhum SA .Assessment of mother‘s knowledge concerning child ımmunization in primary health care centers in Baquba City. Diyala Journal of Medicine2015; 9(2):25-33.
 Srinivasa S, Agrawal A, Madhurya RM, Hiremath S. Awareness and attitude regarding postnatal care and immunization practice among antenatal mothers. Int J Contemp Pediatr. 2020;7(4):848-852. http://dx.doi.org/10.18203/2349-3291.ijcp2020114.
 Tabassum MN, Gureja AW, Tabassum S, Qamar S, Asrar A. Knowledge, attitude and practice of mothers regarding vaccination among the children under the age of five years.
Pakistan Journal of Medical and Health Sciences2017;11(2): 645-647.
 Navaneetha N, Abraham SB, Thomas T, Mary R, Bhuvanendu, Abbas H. Knowledge and perceptions regarding immunization among mothers of under five children: a community study from South Kerala. International Journal of Contemporary Pediatrics.2020;7(1):66- 71.
 Al-lela OQ, Bahari MB, Salih MR, Al-Abbassi MG, Elkalmi RM, Jamshed SQ. Factors underlying inadequate parents' awareness regarding pediatrics immunization: findings of cross-sectional study in Mosul- Iraq. BMC Pediatr. 2014 Jan 31;14:29. doi:
 Mapatano MA, Kayembe K, Piripiri L, Nyandwe K. Immunisation-related knowledge, attitudes and practices of mothers in Kinshasa, Democratic Republic of the Congo. South African Family Practice.2008;50(2): 61-61e. doi: 10.1080/20786204.2008.10873699  Al Saad M, Ali Jadoo SA. Syrian mothers, why to accept or to refuse HPV vaccine for
their teen girls. Journal of Ideas in Health2018;1(1):7-3.
 Hamid S, Andrabi SAH, Fazli A, Jabeen R. Immunization of Children in a Rural Area of North Kashmir, India: a KAP study. Online Journal of Health and Allied Sciences.2012;
 Malande OO, Munube D, Afaayo RN, Annet K, Bodo B, Bakainaga A, Ayebare E, Njunwamukama S, Mworozi EA, Musyoki AM. Barriers to effective uptake and provision of immunization in a rural district in Uganda. PLoS One. 2019 Feb 14;14(2):e0212270. doi: 10.1371/journal.pone.0212270.
 WHO Weekly Epid. Record (2018, 93:73-96) Table 2: Summary of WHO Position Papers - Recommended Routine Immunizations for Children (updated April 2019).
 Jeena PM, Chhagan MK, Topley J, Coovadia HM. Safety of the intradermal Copenhagen 1331 BCG vaccine in neonates in Durban, South Africa. Bull World Health Organ.
 WHO (Weekly Epidemiological Record 23 February 2018; 93(08):73-96.
 Alhusseiny A, Latif I, Ali Jadoo SA. Covid-19 in Iraq: an estimated cost to treat patients at a private clinic. Journal of Ideas in Health2021;4(1):304-6.
 Wani RT, Dar H, Raina ZA. Knowledge, Attitude and Practices of Mothers with Children Under Five Years of Age About Vaccination, JMSCR;2017 05(07): 24449-24454.
 Yaganeh S, Motamed N, Bousheher SN, Ravanipour M. Assessment of the knowledge and attitude of infants’ mothers from Bushehr (Iran) on food security using anthropometric indicators in 2016: a cross-sectional study. BMC Public Health 18, 621 (2018). https://doi.org/10.1186/s12889-018-5531-5.
 Raji OM, Abdullahi U, Raji IA, Oladigbolu RA, Kaoje AU, Awosan KJ. Caregivers’
knowledge, home treatment of diarrhoea disease and predictors of child diarrhoea disease in a semi urban community of Sokoto, North-west, Nigeria. Journal of Public Health and Epidemiology.2017; 9(2):16-23. https://doi.org/10.5897/JPHE2016.0889.
 Olaniyi AAO, Oyerinde O. Knowledge of causes, management and prevention of childhood diarrhoea among nursing mothers in two selected primary health centers in Oyo State, Nigeria. World Journal of Research and Review 2016;2(3): 01-05.
 Omole VN, Wamyil-Mshelia TM, Nmadu GA, Usman NO, Andeyantso EA, Adiri F.
Knowledge, attitude and practice of home management of diarrhoea among mothers of under-fives in Samaru, Kaduna State, Nigeria. Port Harcourt Med J 2019;13:19-25.
 Mumtaz Y, Zafar M, Mumtaz Z. Knowledge attitude and practices of mothers about diarrhea in children under 5 years. J Dow Uni Health Sci 2014; 8(1): 3-6.
 Hanif Z, Afridi A , Kibria Z, Maroof A, Sumayyah E. knowledge, attitude and practice of mothers regarding the use of oral rehydration solution in children's suffering from diarrhea. JKCD.2018; 8(1):37-40.
 Khalili M, Mirshahi M, Zarghami A, Rajabnia M, Farahmand F. Maternal Knowledge and Practice Regarding Childhood Diarrhea and Diet in Zahedan, Iran, Health Scope.
2013;2(1):19-24. doi: 10.17795/jhealthscope-9885.
 Sisay S, Endalew G, Hadgu G. Assessment of Mothers/Care Givers Health Care Seeking Behavior f or Childhood Illness in Rural Ensaro District, North Shoa Zone, Amhara Region, Ethiopia 2014. G.J.L.S.B.R.2017;1(1):20-34.
 Abu-Baker NN, Gharaibeh HF, Al-Zoubi HM, Savage C, Gharaibeh MK. Mothers’
knowledge and practices of managing minor illnesses of children under five years. Journal of Research in Nursing. 2013;18(7):651-666. doi:10.1177/1744987112451576
 Yahyaa BT, Al-Samarrai MAM, Ali Jadoo SA. Prevalence and perception of women about consanguineous marriage in Al-Ramadi City. Indian Journal of Public Health
Research and Development 2019;10(4): 567-573.
 Yahyaa BY. Woman’s Knowledge about Breast Cancer in Al-Ramadi City, Iraq. Annals of R.S.C.B. 2021;25 (5): 4901 – 4910.
 Alharthi AF, Al-Holaifi RN, Alnemari BA, Alosaimi AA, Alamri AD, Adil Ali Ayed ANA. Breastfeeding knowledge, attitude and practice among mothers attending Maternity Hospital at King Faisal Medical complex, Taif city, Saudi Arabia 2018. World Family Medicine. 2019; 17(12): 58-72.doi: 10.5742MEWFM.2019.93715.
 Noh JW, Kim YM, Akram N, Yoo KB, Park J, Cheon J, Kwon YD, Stekelenburg J.
Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data. PLoS One. 2018 Oct 31;13(10):e0206766. doi: 10.1371/journal.pone.0206766.
 Shaker N, Hussein K, AL-Azzawi S. Knowledge,attitude and practices (KAP) of mothers toward infant and young child feeding in primary health care (PHC) centers, Erbil city.
Kufa Journal for Nursing sciences.2012; 2(2): 118-26.
 Bui QT, Lee HY, Le AT, Van Dung D, Vu LT. Trends and determinants for early initiation of and exclusive breastfeeding under six months in Vietnam: results from the Multiple Indicator Cluster Surveys, 2000-2011. Glob Health Action. 2016 Feb 29;9:29433. doi: 10.3402/gha.v9.29433.
 Abdul Ameer A, Al-Hadi AH, Abdulla M. Knowledge, attitudes and practices of Iraqi mothers and family child-caring women regarding breastfeeding. Eastern Mediterranean Health Journal.2008;14(5):1003-14.
 Heck KE, Braveman P, Cubbin C, Chávez GF, Kiely JL. Socioeconomic status and breastfeeding initiation among California mothers. Public Health Rep. 2006 Jan- Feb;121(1):51-9. doi: 10.1177/003335490612100111.
 Acharya P, Khanal V. The effect of mother’s educational status on early initiation of breastfeeding: further analysis of three consecutive Nepal Demographic and Health Surveys. BMC Public Health 2015;15:1069.
 Uzun A, Öztürk G, Bozkurt Z, Çavuşoğlu M. Investigating of fear of COVID-19 after pregnancy and association with breastfeeding. Journal of Ideas in Health2021;4(1):327- 33. https://doi.org/10.47108/jidhealth.Vol4.Iss1.98.
 Kotb A, Mohamed A, Mohamed E, Abdel Khalek E. Knowledge and practices of working mother about breastfeeding and weaning in Assiut city, Egypt. Life Science Journal. 2012;9(1): 803-08.
 Ebrahim B, AL-Enezi H, AL-Turki M, et al, Knowledge, misconceptions, and future intentions towards breastfeeding among female university students in Kuwait. Journal of Human Lactation. 2011; 27(4): 358-66.
 Badruddin SH, Inam SN, Ramzanali S, Hendricks K. Constraints to adoption of appropriate breastfeeding practices in a squatter settlement in Karachi, Pakistan. J Pak Med Assoc. 1997 Feb;47(2):63-8.
 Ali S, Ali SF, Imam AM, Ayub S, Billoo AG. Perception and practices of breastfeeding
of infants 0-6 months in an urban and a semi-urban community in Pakistan: a cross- sectional study. J Pak Med Assoc. 2011 Jan;61(1):99-104.
 Al-Hially Y. Assessment of mothers' knowledge about breastfeeding and determining predictors. Tikrit Medical Journal. 2010;16(2):77-83.
 Sharma I, Khadka A. Assessing the level of knowledge and practice of breastfeeding among factory working mothers in Kathmandu, Nepal. Journal of Health Research2091;
33(1): 24-34. https://doi.org/10.1108/JHR-12-2018-0166.
 Ali A, Hussein A, Mahmood N. Detection of human adenovirus 40/41 among children with some hematological disorders. Journal of Ideas in Health 2019;2(2):81-6.
 Siddiqi N, Siddiqi AE, Nisar N, Khan A. Mothers' knowledge about EPI and its relation with age-appropriate vaccination of infants in peri-urban Karachi. J Pak Med Assoc. 2010 Nov;60(11):940-4.
 Mahalingam S, Soori A, Ram P, Achappa B, Chowta M, Madi D. Knowledge, attitude and perceptions of mothers with children under five years of age about vaccination in Mangalore, India Asian Journal of Medical Sciences2014;5(4):52-57.
 Ali AHM, Abdullah MA, Saad FM, Mohamed HAA. Immunisation of children under 5 years: mothers' knowledge, attitude and practice in Alseir locality, Northern State, Sudan.
Sudan J Paediatr. 2020;20(2):152-162. doi: 10.24911/SJP.106-1586870453.
 WHO, Iraq - Immunization, actual values, historical data, forecasts and projections were sourced from the World Bank in August of 2020.
 Tagbo BN, Uleanya ND, Nwokoye IC, Eze JC, Omotowo IB. Mothers’ knowledge, perception and practice of childhood immunization in Enugu. Niger J Paed 2012;39 (3):90 – 96. doi: 10.4314/njp.v39i3.1.
 Anekwe TD, Kumar S. The effect of a vaccination program on child anthropometry:
evidence from India's Universal Immunization Program. J Public Health (Oxf). 2012 Dec;34(4):489-97. doi: 10.1093/pubmed/fds032.
 Ali Jadoo SA, Alhusseiny A, Yaseen S, Al-Samarrai M, Mahmood A. Evaluation of health system in Iraq from people’s point of view: a comparative study of two different
eras. Journal of Ideas in Health2021;4(2):380-388.