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  • A cross-sectional survey was conducted in 12 health centers of United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA) located in Jordan, West Bank and Gaza. These UNRWA health centers provide primary child health care to Palestinian refugees until the age of five years, and they reach an immunization coverage of 95%-99% [10]. Health centers included in the study were: Amman New Camp, Zarqa, Baqa’a, Irbid, Jabaliah, Gaza Town, Khan Younis, Rafah, Balata, Tulkarem, Hebron and Aamary. Healthy children between 7 and 48 months of age who were visiting the well-baby clinic with their mother were eligible for enrolment. Older children were not included in the study due to the low visiting rate in health centers. Based on previous research, we used the expected prevalence rate of 10% for functional constipation [11–12]. With a confidence level of 95%, a power of 80% and a precision to the nearest 2%, the estimated sample size was 862 children. Half of the sample was from Jordan and the other half from the occupied Palestinian territory. The sample was stratified for age according to the following four age-categories: 7–12 months; 13–24 months; 25–36 months and 37–48 months. For each age category, we divided the sample size among the health centers in proportion to the total number of registered children at each health center. Data were collected by face-to-face interviews in Arabic. One nurse in Jordan and four nurses in West Bank, and a medical doctor in Gaza administered the interviews. Due to travel restrictions it was impossible to use one interviewer for all locations. All interviewers received a three-hour training including background information, consent procedure, methods of interviewing and data collection. Due to the high prevalence of illiteracy in this population, verbal consent was obtained of the mothers. Refusal of consent was documented on the data collection sheet. The questionnaire consisted of 2 parts; part 1 was administered by direct interview of the mother. This part included questions about demographic data, medical history of the child, the child’s defecation pattern and domestic violence. Part 2 was self-administrated and consisted of questions about mother’s and father’s demographics, social-economic situation and the exposure to traumatic events of the child during his/her life. The first part of the questionnaire was based on the validated questionnaire for child and adolescent functional constipation (Questionnaire on Pediatric Gastrointestinal Symptoms—Rome III Version QPGS- RIII) [13]. FC was defined by ROME III criteria for toddlers [4]. Stool retention was defined as stool withholding, large diameter stools were defined as stools that clogged the toilet, and fecal incontinence was only documented for toilet trained children. In general, toilet systems in the three different regions were comparable. Rectal mass was documented when there was a history of rectal mass discovered during rectal exam by a clinical doctor in the past. No physical examination was conducted at time of interview. Bristol stool scale was used to define hard bowel movements [14]. The child’s exposure to traumatic life events was documented and scored by using the Gaza Traumatic Checklist [15–16]. This checklist consisted of a questionnaire filled in by the mother, mothers who were illiterate received help from the interviewer. The split half reliability of the scale was r = .73. The internal consistency of the scale, calculated using Cronbach’s alpha, was α = .72 [16]. The score was analyzed as a total score and as a categorical variable, ranging from low exposure (<5), moderate exposure (5–9) to high exposure (>9) [15]. The standardized questionnaire was first written in English and afterwards translated in Arabic by a medical doctor and a communication expert, both were native Arabic speakers and had good English skills. The questionnaire was pilot tested on two representative samples and was adjusted based on the results from the pilot testing. For English and Arabic copy of the questionnaire see S1 and S2 Appendices. Data was entered and analyzed using SPSS 21.0. Descriptive statistics were used to assess prevalence rates and 95% confidence intervals of FC in the whole sample and per location. Chi-Square equations and Mann Whitney U test were used to determine the differences in demographic, social-economic data and traumatic events between locations. Multiple logistic regression was used to determine potential risk factors for the outcome FC. Dependent variable was FC, the main independent variable was location category (Jordan, West Bank and Gaza). Univariate logistic regression was first performed to assess relevant independent variables. Potential confounding variables (demographics, social-economic variables, variables related to psychosocial stress and trauma) were all included in the final model. P-values less than 0,05 were considered statistically significant. This study was conducted under jurisdiction of UNRWA, following the ethics regulations of the United Nations. The study and consent procedure has been approved by the local ethical committee of UNRWA Headquarter Ethics Office in Jordan. In addition, ethical approval was obtained from the Nebraska Medical Center Institutional Review Board.
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