Asian Journal of Medicine and Biomedicine ... - UniSZA Journal

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AJMB, Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. Siti Norsakinah et al.

Knowledge, Attitude and Practices on Maternal Hypertensive Disorder Among Mothers in Kuantan, Pahang, Malaysia

Siti Norsakinah Binti Sidek, Radiah Binti Abdul Ghani*

Department of Biomedical Science, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia 25200 Kuantan Pahang

*radiah@iium.edu.my

Abstract

Maternal hypertensive disorder (MHD) complicates 10% of pregnancy worldwide. In Malaysia, the percentage of maternal deaths due to MHD increased from 2012 to 2017 and did not show any decline yet. Hence, this study was aimed to develop and validate the questionnaires, to measure the level of knowledge, attitude and practices (KAP) on MHD, to evaluate the associated factors and any correlation between KAP on MHD. A cross-sectional study was conducted in Kuantan, Pahang between January 2020 and March 2020. A convenience sampling was used, and self-administered questionnaires were distributed to 100 respondents that fulfil the criteria. The questionnaire was developed through literature review and validated by five medical experts. Then, the pilot study validation was resulted in 0.894 of Cronbach’s Alpha test, which achieved the reliability between the questions.

Most of the respondents had a moderate knowledge (n=63; 63.0%), moderate attitude (n=66; 66.0%) and high practices (n=61; 61.0%) on MHD. There was no significant association between socio-demographic factors and KAP of the respondents. A significant correlation is identified between knowledge and attitude (r=0.613, p<0.001) and knowledge and practice (r =0.326, p=0.001) but no significant association between attitude and practice (r=0.183, p=0.068). In conclusion, this study has revealed that majority of the respondents possess moderate knowledge and attitude, and excellent practice on MHD. Hence, future studies that related to KAP on maternal mortality and morbidity across setting should be done so that the early prevention steps can be taken to accommodate the possible problems that may arise in the future.

Keywords: Maternal Hypertensive Disorder (MHD), knowledge, attitude and practices (KAP), mothers, level, association, correlation

*Author for Correspondence

Cite as: Siti Norsakinah, B. S., Radiah, A. G. (2021). Knowledge, Attitude and Practices on Maternal Hypertensive Disorder Among Mothers in Kuantan, Pahang, Malaysia, Asian Journal of Medicine and Biomedicine, 5(S2), 24–35, https://doi.org/10.37231/ajmb.2021.5.S2.457

DOI: https://doi.org/10.37231/ajmb.2021.5.S2.457

Asian Journal of Medicine and Biomedicine, Vol 5:S2.

Original Article Open Access

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Introduction

Maternal hypertensive disorder complicates about 10% of pregnancies worldwide especially in developing countries

[1]. World Health Organization (WHO) reported that maternal hypertensive disorder was one of the three major causes of maternal death worldwide (along with postpartum haemorrhage and maternal sepsis) (2019)^[2]. Maternal hypertensive disorder is the condition where the value of blood pressure of pregnant mothers is on or above 140 mmHg for systolic blood pressure (SBP) and/or 90 mmHg or above for diastolic blood pressure (DBP) ^[3]. The prevalence of maternal deaths due to maternal hypertensive disorder was high in Latin American and the Caribbean which contributed to 25.7%, while 16% in sub-Saharan African countries and 9.1% in Asian and African countries

[4]. In Malaysia, the cases of maternal death due to MHD experience a fluctuation from 2012 to 2017, and the highest results were spot in 2012 and 2016 which were 21 cases and 20 cases from the overall complications ^[5].

The real cause for MHD is still unclear but the theory for the pathogenesis of MHD is known as a two-step theory which cause from ischemic condition of the placenta and endothelial damage of the pregnant mothers ^[6]. The consequence complication will give harm to the foetus inside the womb because the foetus depends on the placenta to get the nutrients and also for the respiratory purposes.

Consequently, the stillbirth and preterm numbers are increasing globally ^[7]. The ischemic condition of the placenta can make the endothelial layer of the mothers become damage and later leads to cardiovascular disease (CVD), pulmonary oedema, acute renal failure, headache, and seizures. This problem should be taken seriously because the effect will involve two lives, the future of the babies and as well as the mothers ^[8].

Maternal hypertensive disorder (MHD) can be categorized into four subtypes which are pre-eclampsia, chronic hypertension, chronic hypertension with superimposed pre- eclampsia, and gestational hypertension. Among these types of hypertensions, the major causes of maternal and prenatal morbidity and mortality are pre-eclampsia and eclampsia ^[9]. Factors of maternal education, age, body mass index (BMI), residential, experience in pregnancies, history of MHD, and consistency for antenatal care visits may also influence the risk to get MHD. The symptoms of MHD include headache, visual disturbance, vomiting, epigastric pain, an increase in weight, oedema in the face and abdomen, and proteinuria

[10].

To date, there was no KAP study had been done specifically for hypertensive disorder in pregnancy in Malaysia. The percentage of maternal deaths in Malaysia due to hypertensive disorder in pregnancy fluctuated from 2012 to 2017 and did not show in decline yet ^[5]. This indicates that the problem is still ongoing and can be harmful if it is not taken into consideration by the mothers. This study aimed to evaluate the level of knowledge, attitude, and practices on MHD among mothers in Kuantan, Pahang. From the result, it can help the mothers to improve themselves and take the early precautions from getting the disease in the future.

Besides, the factors that may be associated with the level of knowledge, attitude, and practices on MHD will also be identified and analysed either it gives benefits or not towards

the targeted mothers in the selected area. Lastly, any correlation between knowledge, attitude, and practices on MHD also be investigated throughout this study. In certain condition, there are associations between knowledge and attitude but not the practices. The condition may also occur oppositely whereas the population have the knowledge but lack of awareness about the disease.

Methods

Ethical Approval

This cross-sectional study was conducted between January 2020 and March 2020 in Kuantan, Pahang. An ethical approval for this study was obtained from IIUM Research Ethical Committee (IREC) on 9th March 2020 (IIUM/504/14/11/2 IREC 2020-BS (KAHS)).

Sample Size

Single proportion formula was used to calculate the number of respondents needed in this study. Based on alpha power of 0.05 and 10% non-response rate, the total estimated number of sample size required was 96 respondents ^[11]. The final respondents used in this study were total up to 100 respondents respectively to deliver reliable result.

Study Population

The study population was the group of people required for the research study. A convenience sampling was applied to select the targeted respondents by implementing inclusion and exclusion criteria.

Inclusion Criteria

Mothers who experienced pregnancy and delivery at least once, aged from 18 to 40 years old and stayed in Kuantan, Pahang became the study population for this research.

Mothers who became the respondents should had experiences in the pregnancies and deliveries at least once to answer the questionnaires because this study was conducted to measure the level of KAP on MHD. Next, the minimum requirement of age among the mothers was 18 years old because it is the legalized age to be married in Malaysia ^[12]. Besides, mothers who aged over 40 years old may be exposed to other complications in pregnancy such as gestational diabetes mellitus, preterm delivery, caesarean birth, and abnormal foetal presentation which can interfere with the result of the study ^[13].Lastly, the selected mothers were also among the residents of Kuantan, Pahang because the study was held in this area.

Exclusion Criteria

Mothers who do not understand the Malay language were excluded from becoming the respondents because the result of the study may become inaccurate and not represent the KAP of the mothers on the maternal hypertensive disorder.

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Development of Questionnaires

The progress of this questionnaire starts with the literature review and validation from the experts before continuing with the validation of the pilot study. The questionnaires were divided into four sections: Section I (socio- demographic data), Section II (knowledge on MHD), Section III (attitude on MHD) and Section IV (the practice of MHD management).

In Section I, the socio-demographic data were collected among the respondents which consists of the details of participants’ age, religion, races, occupation, average monthly household income, level of education, and residency. The questions regarding the history of pregnancy among the respondents were also included in this section which divided into eight items: total pregnancies, history and the frequencies of miscarriage, history of hypertension in oneself and family members during pregnancy, history of hypertension, daily medication and frequency on the occurrence of hypertension throughout the lifetime. In Section II, the respondents were asked on the knowledge regarding MHD. This section consists of the questions on the definition and epidemiology, risk factors, signs and symptoms, pathophysiology, and effects of MHD. For Section III, the questions asked were on the attitude of the respondents regarding MHD and for Section IV, the respondents were asked about the practices on MHD management.

The questions in the section II, III and IV were consisted of 10 questions and a typical 5-category Likert scale was used to access the KAP of the respondents on MHD. The answers were consisted of ‘Strongly Agree’, ‘Agree’, ‘Not Sure’,

‘Disagree’, and ‘Strongly Disagree’ option and the marks were ranked from five to zero marks starting from ‘Strongly Agree’ to ‘Strongly Disagree’ option.

In developing the questionnaire, the domain of interest was decided to determine what question will be measured and the approach used for this research in searching for the domain was through review of research such as journals and articles that related to the topic and not using any validated or publish questionnaire directly. The questionnaire then was validated by five medical experts, which all of them have experience in working as a Medical Doctor. All of the sentences were screened which look into the definitions used, the arrangement of the sentences, along with standard guidelines used in the medical field. The addition and elimination of the questions were occurred throughout this process based on their feedback. For example, the medical expert suggested to add how many times the doctors will take the reading of blood pressure to diagnosed patient with MHD and duration of the seizure occurred which indicated one of the symptoms for MHD. One of question was eliminated because it was not a fact to be asked in this survey.

After that, a pilot study was conducted among 15 women from IIUM Kuantan communities and some from Perlis communities before conducting the actual study. This validation was aimed to measure the understanding of people based on the sentences used in the questionnaire either it was hard to understand or not.

Data Collection

The data and information about the respondents were collected through the answers in the questionnaires and the written informed consents were obtained from the respondents who agreed to participate in this study. The questionnaires were distributed among women in Kuantan, Pahang and it also available in an online form which were distributed through WhatsApp and email. A Bloom’s cut off point was used from a previous study as a scoring system for knowledge, attitude, and practices on maternal hypertensive disorders and the final scores were categorized into good (80-100%), moderate (60-79%) and poor (≤ 59%) ^[14]. Data Analysis

Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics 20) was used to interpret all the data in this study.

Normality of the data was checked before pursuing any statistical analysis. The first objective used the reliability analysis test to validate the questionnaires through the result of Cronbach’s Alpha test. As for the second objective, a descriptive frequency was used to evaluate the level of knowledge, attitude, and practices on MHD among mothers in Kuantan Pahang. The third objective used one-way ANOVA test and Independent t-test to find related factors associated with the level of knowledge, attitude, and practices on MHD. For the last objective, Pearson’s correlation coefficient test was used to identify the correlation between the knowledge, attitude, and practices on MHD among mothers in Kuantan, Pahang.

Results

The first objective of this study is to develop and validate the questionnaire as a tool for this research. The questionnaire in this study consisted of four sections and was developed based on journals, articles, and websites. The reference papers were mostly published between 2015 until 2020 which proved that the information was up to date and current. Then, the questionnaire was reviewed by five medical experts, and the amendment was done based on their feedback. The second phase of validation proceeded with a pilot study and resulted in 0.894 of Cronbach’s Alpha test.

30 items were tested which consisted of questions on knowledge, attitude, and practices on the maternal hypertensive disorder. The test result was considered good since it was between 0.9 > α ≥ 0.8 and the reliability between the questions is achieved ^[15].

Socio-Demographic Characteristics of Participants Socio-demographic characteristics of the respondents are shown in Table 1. The mean age of the respondents is 2.09.

The highest frequency of the respondents’ age was from group 30-34 years old (45%) followed by mothers aged 35- 40 years old (32%) and 18-29 years old (23%). Nearly half of the respondents worked as government workers (45%) and 47% of the total respondents owned Bachelor degrees.

For this study, the major household income of the total respondents was between RM1,000 to RM3,900 (37%) and most of the respondents were from the urban (87%) compared to rural (13%) area. Regarding the experience in the pregnancy, 57 of the respondents have experienced

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pregnancies 1-2 times in their life, including the pregnancies that ended with miscarriages. As for the others who experienced pregnancies 3-4 times, 5-6 times and 7-8 times are among 33 respondents, 8 respondents, and 2 respondents respectively.

Scores of Knowledge, Attitude, and Practices on MHD Table 2 shows the knowledge, attitude, and practices scores from the respondents. The level of knowledge and attitude on MHD among respondents were showed moderate which resulted in (63%) and (66%). In contrast, there was a high level of practices on MHD recorded among the respondents (61%).

Association of Socio-Demographic Factors with Knowledge, Attitude and Practices on MHD

Regarding the association of socio-demographic factors with KAP of the respondents on MHD, the factors that being tested were age, occupation, residency, average monthly household income, level of education, the total number of

pregnancies, and frequency of miscarriage. Preliminary analyses were performed, and the result showed that the assumption was met, thus a parametric test was used for all categories. According to the result, there was no significant association between socio-demographic factors with the level of knowledge, attitude and practices on maternal hypertensive disorder which ranged from p-value 0.074 to 0.795 for knowledge, p-value from 0.171 to 0.963 for attitude and p-value from 0.072 to 0.968 for practice respectively (Table 3, Table 4 and Table 5).

Correlation between Knowledge, Attitude, and Practices on MHD

Table 6 showed that there was a highly significant and statistically significant correlation between knowledge and attitude and knowledge and practices of the respondents, but no association was detected between attitude with practices in this study. The correlation value for knowledge and attitude were r= 0.613, p<0.001, knowledge and practices r

= 0.326, p= 0.001, and attitude and practices r = 0.183, p = 0.068.

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Table 1 Socio-demographic data of respondents (n=100)

Demographic Characteristics Frequency (n) Percentage (%)

Age

18-29 30-34 35-40 (mean: 2.09)

23 45 32

23.0 45.0 32.0

Occupation

Government Worker Private Worker Self-employed Housewife Unemployed

45 25 4 21

5

45.0 25.0 4.0 21.0

5.0 Average Monthly Household Income

less than RM1,000 RM1,000-RM3,900 RM 4,000- RM7,900 RM8,000-RM20,000 more than RM 20,000

8 37 34 20 1

8.0 37.0 34.0 20.0 1.0 Level of Education

Secondary school

STPM/STAM/Diploma/Foundation Bachelor's degree

Master's degree Doctorate degree

11 26 47 10 6

11.0 26.0 47.0 10.0 6.0 Residence

Rural Urban

13 87

13.0 87.0 Frequency of Pregnancy

1-2 3-4 5-6 7-8

57 33 8 2

57.0 33.0 8.0 2.0 Note. The total of the highest frequency from each category is highlighted in bold.

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Table 2 Category of knowledge, attitude and practices scores on the maternal hypertensive disorder in pregnancy

Categories Frequency (n) Percentage (%)

Knowledge scores Low Moderate High

1 63 36

1.0 63.0 36.0 Attitude scores

Low Moderate High

10 66 24

10.0 66.0 24.0

Practices scores Low Moderate High

2 37 61

2.0 37.0 61.0 Note: The total of highest frequency from each category are highlighted in bold

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Table 3 Association between socio-demographic characteristic with knowledge scores (n=100)

Variable Mean Median p-value

Age

18-29 30-34 35-40

37.87 38.33 37.31

36.00 37.00 37.00

0.31

Occupation

37.91 36.76 34.75 38.67 42.80

38.00 36.00 35.00 37.00 46.00

0.074

Average Monthly Household Income less than RM1,000

RM1,000-RM3,900 RM 4,000- RM7,900 RM8,000-RM20,000 more than RM 20,000

37.13 37.60 38.89 36.95 41.00

37.50 36.00 38.00 37.00

-

0.596

Level of Education Secondary school

STPM/STAM/Diploma/Foundation Bachelor's degree

Master's degree Doctorate degree

35.18 39.46 37.85 36.20 39.33

34.00 40.00 37.00 36.50 39.50

0.103

Residence Rural Urban

39.77 37.62

38.00 37.00

0.144**

Total number of pregnancy (including miscarriages)

1-2 3-4 5-6 7-8

37.72 37.76 39.50 39.00

36.00 38.00 41.00 39.00

0.795

Frequency of miscarriage 1

2 3 N. A

37.90 39.20 43.00 37.75

37.00 42.00

- 37.00

0.691

Note. (**) Tested with Independent t-test

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Table 4 Association between socio-demographic characteristic with attitude scores (n=100)

Age

18-29 30-34 35-40

38.13 36.04 35.00

39.00 36.00 35.50

0.171

Occupation

36.29 35.88 34.00 35.43 41.80

37.00 36.00 34.50 34.00 46.00

0.278

35.88 36.08 36.80 35.50 36.00

38.50 36.00 37.00 35.00

-

0.963

STPM/STAM/Diploma/Foundation Bachelor’s degree

Master’s degree Doctorate degree

34.73 35.81 37.19 33.10 37.83

34.00 35.00 38.00 34.00 38.00

0.294

35.92 36.23

34.00 37.00

0.867**

1-2 3-4 5-6 7-8

36.61 35.15 38.75 31.00

37.00 36.00 39.00 31.00

0.257

2 3 N. A

33.58 36.80 37.00 36.80

32.00 34.00

- 37.00

0.23

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Table 5 Association between socio-demographic characteristic with practices scores (n=100)

Age

18-29 30-34 35-40

40.04 40.44 40.97

40.00 41.00 41.00

0.801

Occupation

41.31 39.88 35.50 40.10 42.40

41.00 41.00 35.50 40.00 42.00

0.193

36.50 41.11 39.80 42.20 43.00

37.50 42.00 40.00 41.00

-

0.072

STPM/STAM/Diploma/Foundation Bachelor’s degree

Master’s degree Doctorate degree

36.55 41.00 40.72 41.30 42.83

36.00 41.50 41.00 41.00 42.50

0.077

40.38 40.54

42.00 41.00

0.920**

1-2 3-4 5-6 7-8

40.39 40.55 41.38 40.50

41.00 41.00 40.50 40.50

0.968

2 3 N. A

39.63 38.60 50.00 40.75

40.00 39.00

- 41.00

0.186

Table 6 Correlation between knowledge and attitude, knowledge and practices, and attitude and practices scores on the maternal hypertensive disorder (n=100)

Variables Correlation coefficient, r p =value

Knowledge scores- Attitude scores +0.613 0.000**

Knowledge scores- Practices scores +0.326 0.001**

Attitude scores- Practices scores +0.183 0.068

Note; r-value which is positive show positive correlation; (**) p-value is statistically significant (<0.01)

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Discussion

Level of Knowledge, Attitude, and Practices of the respondents on MHD

From the result of the level of knowledge, 82% of them agreed that high blood pressure is one of the major complications in pregnancies and 64% of them have knowledge on the cut off value for the high blood pressure.

Most of the respondents did not know the real symptoms for MHD whereas 53% and 58% of them did not sure that blurred vision and abdominal pain (upper part) were among the symptoms for MHD. In addition, 56% of the respondents were also not sure on negative question in this questionnaire which about speech difficulty as one of the symptoms for MHD.

For attitude part, most of the respondents were not sure about the risk factors and the effects from MHD to pregnant mothers. This can be seen through the result of 46%, 41%

and 58% of them did not sure on the statements that the first pregnancy is more risk to get MHD, the effects of low birth weight to the new-born and the risk to get kidney damage for hypertensive mothers. 75% of the respondents agreed that they can get the information on MHD through the graphic information in a brochure produced by the Ministry of Health Malaysia (MOH).

In terms of the level of practices, most of the respondents showed a good practice on preventing MHD. This can be seen when 92% of the respondents had visited the antenatal care along the pregnancy phase and 86% of the respondents will go straight to the clinic if seizures occur more than 5 minutes in their pregnancy phase. 74% of them practiced eating foods that contain vitamin D which believed can minimize the risk to get pre-eclampsia and 80% of them had visited a valid website in searching the answers regarding MHD.

This finding was in contrast with one study in in Morocco and Netherlands in which the level of knowledge about symptoms of MHD was limited and nearly absent among the mothers. They always observe the symptoms based on self- experience or from family members ^[16]. Similarly, the knowledge among the patients that visited Gynecology and Obstetrics Teaching Hospital in Karbala, Iraq on Pregnancy Induced Hypertension (PIH) was poor ^[17]. It was suggested that, by promoting a higher level of education, it can increase back the level of knowledge of the respondents and lead people to go for treatment and prevention of the disease ^[18]. Inversely, most of the women in Southwest Nigeria had a good educational background and had a fast response towards the complications of PIH that arose in the pregnancy phase ^[19].

With regard to practices on MHD, the existing information came from the Audit Directorate at Sultan Abdul Halim Hospital, Malaysia, on eclampsia. The report from the audit was showed a positive attitude and practices from medical practitioners on a red alert system and continuous post- delivery care after the delivery phase. As a result, the rates of perinatal mortality were decreases for the second audit

[20]. Therefore, this present finding revealed that women in Kuantan, Pahang possess a moderate knowledge of maternal

hypertensive disorder which leads to a moderate attitude and good practice in seeking medical care and treatment.

Association of Socio-Demographic Factors with Knowledge, Attitude and Practices on MHD

There was no association detected between all the socio- demographic factors with the knowledge, attitude, and practices scores on maternal hypertensive disorder among the respondents. This discovery was supported by a study in Ethiopia which showed that there was no difference among the cases and controls concerning maternal educational level with MHD ^[4]. Moreover, one study in Karbala, Iraq was also showed no significant association between knowledge and educational level of the respondents about PIH ^[17]. Inversely, Mekonen et al. (2015) proposed that mothers without formal education were 2.5 times able to get PIH compared to ones who get formal education ^[21]. In addition, there was also study that shows no significant association between the residential area with knowledge score ^[17]. Other than that, this study also presented that there was no significant association detected between occupation, income, economic status and history of abortion with the score of KAP on MHD in pregnancy and supported with two reported studies in Ethiopia and Iraq ^{[4, 17]}. However, one study conducted by Tebeu et al. (2011) revealed that there was a significant association between the occupation of the mother with the risk of getting MHD ^[22]. The complexity of the works and the timing in the pregnancy phase were some of the reasons in proving the non-significant difference between occupation and MHD.

Regarding the age of the respondents, this study revealed that there was no significant association between age and score of KAP on MHD and this result was supported by a study in Ethopia about risk factors of MHD ^[4]. In a different circumstance, Omenya et al. (2018) proposed that PIH were 1.5 times prone to occur for women aged below than 20 years old ^[23] while Ayele et al. (2016) reported that MHD was seven times prone to occur in pregnant women aged 30 years and above ^[24]. The difference in the previous results compared to this study might be explained by the difference in the age distribution among mothers in Kuantan, Pahang (18-29: 23%, 30-34: 45%, 35-40: 32%). The high-risk population recruited through this study was lower in number for younger mothers and older compared to predominant group of mothers aged 30-34. From this, less information was presented among the high-risk groups in order to detect the significant difference between each group of aged.

Kahsay et al. (2018) and Omenya et al. (2018) reported that nulliparous (never having given birth) as a common risk factor for developing MHD and this align with the result of this study ^{[4, 23]}. However, most of the findings supported that those primigravid mothers were more prone to get MHD compared to multigravid mothers ^[25]. In Malaysia, it also recorded that primigravid mothers (7%) were prone to get eclampsia compared to the parous mothers (2.3%) ^[10].

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Correlation between Knowledge, Attitude, and Practices on MHD

As illustrated in Table 6, there was a significant and strong linear correlation between knowledge and attitude on MHD (r=0.613, p<0.001). The positive correlation between knowledge and attitude in this study reaffirmed the relationship between these elements. This shows that adequate knowledge in the population can lead to a positive attitude.

Meanwhile, in same table showed that there was a significant and weak linear correlation between knowledge and practice on MHD (r=0.326, p= 0.001). The association was indicated that a good practice was due to adequate knowledge of the respondents. Besides, this study exhibited the relationship between attitude and practices and there was no significant association between these two and the linear relationship was weak (r=0.183, p=0.068). It showed that the good practice of the respondents did not have a linear correlation with the attitude of the respondents. The respondents only practiced the good efforts in managing themselves from getting MHD but did not apply the information as their stand or believe regarding MHD.

Attitude usually has an intermediate role to cause the relationship between knowledge and attitude and this can be seen in the usual KAP model. But for this study, it seemed that knowledge caused an effect on the attitude and practice directly. When considered the factors were independently and controlling the third factor, the result showed that the correlation between attitude and practice was stronger compared to the correlation between knowledge and attitude. To add, there was also a correlation between knowledge and practice. This showed that respondent’s knowledge influenced their practice directly and indirectly.

The data was consistent with a study that portrayed most of the respondents had a positive attitude when they had an adequate knowledge ^[26].

Conclusion

The level of KAP among mothers was showed that they had a moderate knowledge, attitude, and good practices on MHD. The other major findings showed there was no significant association between socio-demographic factors with the knowledge, attitude, and practice scores of the respondents. Besides, the significant correlations between the elements of knowledge and attitude, as well as knowledge and practises, were discovered among the respondents. However, there was no significant association between attitude with practices of the respondents.

Acknowledgement

The authors would like to thank to Department of Biomedical Science, Kulliyyah of Allied Health Sciences and the respondents in Kuantan, Pahang that participated in this study.

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