Recurrent abdominal pain and consulting behaviour among children in a rural community in Malaysia

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1 University of Malaya From the SelectedWorks of Christopher Boey Chiong Meng March, 2001 Recurrent abdominal pain and consulting behaviour among children in a rural community in Malaysia Christopher Boey Chiong Meng Available at:

2 C.C.M. Boey K-L. Goh From Department of Paediatrics, I Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. Address for correspondence Dr. C.C.M. Boey, Department of Paadiatrics, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. Fax: boeycm@medicine.mad.um. edu.my Acknowledgements Authors thank Associate Professor 5. Yap and Dr. H.M. Latt, Dept. of Social and Preventive Medicine, University of Malaya, for help and advice in developing study protocol and analysing results. Submitted September 4, Accepted December 15, J_IIIE- I/----- Aim. To look at predictors of consulting behaviour among children with recurrent abdominal pain in a rural community in Malaysia. Subjects and methods. A sample of 1462 school-children aged between 9 and 15 years were randomly selected from all schools in Kuala Langat, a rural district in Malaysia, Those with recurrent abdominal pain, defined according to Apley s criteria, were recruited and divided into consulters and non-consulters. A consulter was defined as a child who had sought the help of a medical practitioner at least once in the past year for recurrent abdominal pain. A detailed clinical, social and family history was obtained in all recruited children. Results. A total of 161 children were recruited: 78 [48.4%) consulters, 83 (57.6%) non-consulters. Of the consulters, 40 were boys, 38 were girls (male:female ratio = 1.1: I). The two sexes did not show a significant difference in prevalence of consulters [p=o. 189). Of the ethnic groups, only Indians had a significantly higher likelihood to consult a doctor (Indians, p=o.o06; Malays, p=o. 742; Chinese, p=o. 050). Younger children (under 12 years) had a significantly higher chance of having been brought to see a medical practitioner [p=o. 014). Children in whom age of onset of abdominal pain was below ten years were also more likely to have been seen by a doctor [p=o.o12). Children who had consulted a doctor were more likely to be missing school because of abdominal pain [pp<o.ool). Pain severity was not a significant factor (p=o.429). Multiple logistic regression analysis revealed that the only variable that remained significantly associated with health-care consultation was school absence [pco. 00 I). Conclusions. Children who saw their doctors for recurrent abdominal pain were also more likely to be those who missed school on account of abdominal pain. Following multiple regression analysis, other factors were no longer significant. Digest Liver Dis 2001;33:140-4 Key words: consulting behaviour; recurrent abdominal pain Apley and Naish reported in 1958 that 10.8% of a thousand unselected British school-aged children between of 5 and 14 years old suffer from recurrent abdominal pain which he defined as at least three episodes of abdominal pain, severe enough to affect their activities, over a period longer than three months r. Although it is an important problem that takes up a large proportion of the time of many physicians 2, there is a lack of data on the pattern of health care consultation among children with this symptom. The aim of this study is to look at consulting behaviour among children with recurrent abdominal pain in a rural community in Malaysia.

3 This is a cross-sectional study carried out between June and September The study was conducted in Kuala Langat, a rural district located in the south-west of the Malaysian state of Selangor. It covers an area of 871 square kilometres. The total population is 130,090 people with a population density of 149 per square kilometre and an average annual population growth rate of 2.2% 3. Thirty nine per cent of its population are under fourteen years of age 3. The three major racial groups are Malays, Chinese and Indians. Health facilities in Kuala Langat consist of one district hospital with 151 beds and 27 government health clinics. There are also a number of private clinics. The majority of children are seen by doctors in the government health clinics and private clinics, who are equivalent to the local general practitioners in the United Kingdom. Children needing hospital care are admitted to the district hospital and those with more severe illness are generally referred for specialist care in the nearest general hospital, about forty minutes drive away. A sample of 1462 school-children aged between 9 and 15 years old, randomly selected from all the schools in the Kuala Langat district, were interviewed and recruited into the study depending on whether they fulfilled the criteria for recurrent abdominal pain of at least three episodes of abdominal pain, severe enough to affect their activities over a period longer than three months r. As this was a community survey, a thorough diagnostic work-up was not performed in each child. Therefore, in this study, we did not divide the children into those with and those without organic causes of recurrent abdominal pain. Children recruited into the study, in this way, were divided into whether they were consulters or non-consulters. A consulter was defined as a child who had sought the help of a medical practitioner at least once in the past year for recurrent abdominal pain. All recruited children were further interviewed to obtain a detailed clinical, social and family history. Parents and teachers help was also sought when details of lthe social and family history could not be provided by the child. Data were collected from the children by only one investigator who is a paediatrician (CCMB). The history of recurrent abdominal pain was obtained exclusively from the children. Ethics This study had been approved by the Ethics Committee of the University of Malaya Medical Centre. The data obtained were analysed using SPSS 9.0 software. Bivariate analysis was initially performed to obtain estimates of significance using Chi-square tests (significant if ~~0.05). Using the significant variables identified, multiple logistic regression analysis was performed to predict the magnitude of association (adjusted Odds ratios (OR)) between health care consultation of children with recurrent abdominal pain and variables. All of the 1462 children were interviewed and of these, 161 children had recurrent abdominal pain and were recruited into the study. There were 78 (48.4%) consulters and 83 (51.6%) non-consulters. Of the consulters, 40 were boys while 38 were girls (male:female ratio = l.l:l). Table la. Prevalence of consulters according to demographic variables among children with recurrent abdominal pain in Kuala Langat. _I - Uariable 8eH Male Female Age [years1 Under 12 Over 12 Age at onset of pain (years1 Under IO Over IO Malay race No Yes Chinese race NO Yes 95% CI: 95% confidence interval; OR: Odds ratio. Non-consulter I%1 34ff4 [45.9%1 49/87 L56.3%1 20/53 [37.7%1 63/108 [58.3%1 39/91 [42.9%1 44f70 [62.9%1 33/66 [50.0%1 50/95 [52.6%1 57/121 [47.1% %) PI Consalter p value Crude DR IO/o) (85% Elf 40/74 [54.1% [ /87 [43.7%1 33/53 L62.3% [ / %) 52/91 [57.1% [ [37.1%1 33/66 ~50.0% [0.48-1X91 45/95 (47.4%) 64/l 21 [52.9% [0.23-I /40 [35.0%1 -_l_l

4 ---mm._l---.el rpt ----w ----m--e--,. -me- -D I_L-- l_l~-~~~~=-~ Table lb. Prevalence of consulters according to demographic variables among children with recurrent abdominal pain in Kuala Langat. -- ~-~~~~~~~~~~~~-~~-~ I_---- I*3_Nlg_-~,----~~----~~--~-~,"--.~,- ~_", Variable Non-con&w Consulter p value Crude OR I%1 IO/l 195% Cl1 ~~-~-~~ ~~---~~~~-~~~~~~~~~ ~~--..I I_-F._-~-~ - -~~-~.~-~---~-~-.--.,, ~ Indian race No E6.3% [43.7% Yes 7/26 (26.9%1 19/26 [73.1%1 Is subject an only child? Yes 3/5 [60.0%1 215 [40.0% ( No L51.3%1 75/154 [48.7%1 Father s occupation Non-professional [52.3%1 61/128 [47.7% ( Professional 12/28 [42.9%1 ICY28 [57.1%1 Father s education College &above 12/25 [48%1 13/25 [52% ( Not been to college (54.6%) [45.4%1 Family monthly income [in RM"l 2000 &above 9/21 (42.9%1 12/21 [57.1% [ Below /106 C54.7%1 48/106 [45.3%1 ---~-~~--~~~~~-~~--~ II - Y I I -P--~-~---~-~~-,-.~-~~"~~~~-"-~,~~~~~~ -"~-,--, * 1 United States dollar = 3.7 RM; 95% Cl: 95% confidence interval; OR: Odds ratio. Demographic features of consulters and non-consulters Table Ia, b shows the prevalence of consulters according to demographic features among children with recurrent abdominal pain in Kuala Langat. The two sexes did not show a significant difference in the prevalence of consulters (p=o. 189). Indians had a significantly higher likelihood to consult a doctor (p=o.o06), while the other two races did not show any increase in consultation (Malays, p=o.742; Chinese, p=o.oso). Younger children (under 12 years) had a significantly higher chance of having been brought to see a medical practitioner (p=o.o14). Furthermore, children in whom age of onset of abdominal pain were below ten years were also more likely to have been seen by a doctor (p=o.o12). Being an only child (p=o.702), father s educational background (p=o.363), father s occupation (p=o.553) and total monthly family income (p=o.320) were not significantly associated with the prevalence of consulters. The prevalence of consulters according to the presence of complaints of other systemic symptoms Among the consulters, 63 out of 78 (80.8%), while among the non-consulters, 67 out of 83 (80.7%), had at least one other systemic complaint such as headache. Table II shows how consulters compared with nonconsulters with regard to different systemic symptoms. There was no significant difference between consulters and non-consulters. Pain duration and severity, schooling, and symptoms in the family Pain duration was considered long if it had been pre- sent for over 6 months and short if present for only 3-6 months. Pain was considered mild to moderate if the child continued to be able to walk or only needed to sit down during an episode of pain. Pain was severe if the child had to lie down when he/she had pain. There were no significant differences between consulters and non-consulters in the duration (p=o.592) and severity of pain (p=o.429). In addition, consulters did not differ from non-consulters as to whether their sleep was interrupted by the pain (p=o.o66). Children who had consulted a doctor were more likely to be missing school because of abdominal pain (p<o.ool). However, when class teachers were asked to classify their students into either good/excellent or bad/average, no significant difference was found between consulters and non-consulters (p=o.758) (Table III). Consulters and non-consulters did not differ as to whether or not they had parents (p=o.749) or siblings (p=o.818) with complaints of abdominal pain (Table III). Multiple logistic regression analysis of health-care consultation on variables Multiple logistic regression analysis of health-care consultation on the variables identified by the bivariate analysis above was performed to obtain adjusted OR. The analysis revealed that those who sought medical consultation were also more likely to be those who were absent from school due to abdominal pain (p<o.ool; OR 0.20, 95% Confidence Interval (CI) ). The other variables were no longer significant.

5 Table Il. Prevalence of consulters according to presence of complaints of other symptoms among children with recurrent abdominal pain in Kuala Langat. -- Specifc complaints Non-consulter -- - (%I Headaches No 37/ %) Yes 4389 f50.6%1 Nausea No 67/12% f52.3%1 Ye5 16/33 [4%.5%1 limb pains No 62l115 (53.9%) Yes 21/46 [45.7%1 Lethargy No 39/ %1 Yes 44/%6 (51.2%) Constipation No 79/14% [53.4%1 Yes 4/13 [30.8%1 History of passing worms rectally No 77/154 [50.0%1 YEi 6/7 (85.7%) ~~~~~ 95% C/: 95% cofffidence interval; OR: Odds ratio. Consulter I%) 33ffo [47.1% [49.4%1 61/12% [47.7%1 17/33 L51.5%1 53/115 [46,1% [54.3% [48.0%1 42/%6 f4%.8%1 69/14% [46.6%1 9/13 (69.2%) 77/154 [50.0%1 l/7 (14.3%) p value % ll_s-- Crude OR IB5% Cl1 1.I ( ( ( % ( [ There are very few data comparing consulters and nonconsulters among children with recurrent abdominal pain in the paediatric literature. Hyams et al. in a community-based study of adolescents found that 8% of middle and high school students with recurrent abdominal pain had seen a physician for this complaint in the previous year 4. These consultations were correlated with abdominal pain severity, frequency, duration and disruption of normal activities but not with anxi- ety, depression, gender, family structure or ethnicity 4. Most of the literature on health care seeking among patients with recurrent abdominal pain are based on adult studies. Sandler et al. found that a significant proportion of the adult population (14%-22%) had symptoms compatible with the irritable bowel syndrome, but only a small number sought medical aid 5. On surveying 566 healthy subj(ects, Sandler et al. noted that 86 (15%) had bowel dysfunction compatible with irritable bowel syndrome, but most of those affected (53 or 62%) had never consulted a doctor for these symptoms 5. Sandler Table Ill. Prevalence of consulters accordina to school variables and svmotoms in the familv amona children with recurrent abdominal nain in Kuala Variable Non-consulter Consulterf%l p value Grude OR [%I w!! 611 ~~-- SE;l absence due to recurrent abdominal pain 59/82 [72.0%1 23/82 [2%.0%1 <O.OOl 5.88 [ Yet? 24/79 [30.4%1 W79 [69.6%1 Perceived academic ability by teacher Good/excellent 32/60 [53.3%1 2%/60 [46.7% (0.56~2.201 Bad/average 3%/75 [50.7%1 37/75 [49.3%1 Ab$minal pain in parents 60/111 [54.1%1 51/111 [45.9% fo Yes 9/l% [50.0%1 Recurrent abdominal pain in siblings 911% [50.0%1 No 64/119 [53.%%1 55/119 (46.2%) 0.81% 1.16 [ Yes 5MO [50.0%1 YIO f50.0%1 ---L_I-PPP 95% Cl: 95% confidence interval; OR: Odds ratio.

6 et al. found that subjects with bowel dysfunction reported more non-gastrointestinal symptoms, and those with bowel dysfunction who visited their doctors were also more likely to see them for their non-gastrointestinal symptoms 5. There are other adult studies looking at factors associated with the decision to consult with dyspepsia and other forms of recurrent abdominal pain. Lydeard and Jones interviewed, in their homes, a random sample of 69 patients with dyspepsia who had consulted their general practitioners and 66 subjects with dyspepsia who had not consulted 6. The authors could not explain differences in consultation behaviour by differences in self-reported severity or frequency of symptoms or by the presence of associated symptoms. The most marked difference between the two groups was concern among the consulters about the possible seriousness of symptoms. Consulters were more likely to be worried about cancer and heart disease and to have experienced more disruptive or life-threatening events than non-consulters. The results highlight the need to look beyond the presentation of common symptoms in general practice to patients fears about the significance of the symptoms and to non-physical determinants of consultation behaviour. The present study provides data on health-care consultation in children with recurrent abdominal pain in a rural community in Malaysia. Compared with the results of Hyams et al. s study 4, a larger proportion (48.4%) of children with recurrent abdominal pain had consulted doctors. The difference may be related to the different cultural settings in which the two studies were carried out. The other possible reason is that Hyams et al. studied adolescents whereas this study included younger children from the age of nine years. Parental anxiety might be higher when younger children are involved, resulting in a higher rate of healthcare consultation. Indeed, bivariate analysis suggests that factors associated with an increased prevalence of consulters include age under 12 years, age at onset of abdominal pain under 10 years and absence from school. Like in the study by Hyams et al, gender was not an important factor in determining consulting pattern. It is interesting to note that severity of pain was not a significant variable. The increased prevalence of consulters among Indians on bivariate analysis is also interesting. The underlying reason is unclear although it may be related to ethnic differences in perception of the significance of abdominal symptoms. IJnfortunately, no data are currently available concerning this aspect among the different ethnic groups. As all the subjects were from the same district, it is unlikely that differences were due to better access to medical care. On performing multiple logistic regression analysis, the only factor significantly associated with a higher prevalence of health-care consultation was a tendency to miss school. In other words, this preliminary study suggests that children who saw their doctors for recurrent abdominal pain were also more likely to be those who missed school on account of abdominal pain. This may be related to the possibility that those patients and parents who perceived the abdominal pain to be significant enough to warrant health care consultation were also those who felt that rest at home was necessary. Whether this is a reflection of a specific psychological predisposition is unclear from the present study. Other factors such as demographic features, pain characteristics, the presence of other complaints and the presence of abdominal pain in parents and siblings were no longer significantly associated with increased health-care consultation after multiple regression analysis. It would be useful to conduct further studies to look at the psychological characteristics of children with recurrent abdominal pain who consult doctors as well as those who miss school, using validated psychological tests. Further studies will also be performed among urban children and it would be interesting to compare the consulting behaviour of urban children with the results of the present study. Apley J, Naish N. Recurrent abdominal pains: A field survey of 1000 school children. Arch Dis Child 1958;33: ? Levine MD, Rappaport LA. Recurrent abdominal pain in school children: the loneliness of the long-distance physician. Pediatr Clin North Am 1984;31: Population and housing census of Malaysia (Selangor state population report). Department of Statistics, Malaysia; Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 1996;129: j Sandler RS, Drossman DA, Nathan HP, McKee DC. Symptom complaints and health care seeking behaviour in subjects with bowel dysfunction. Gastroenterology 1984;87: Lydeard S. Jones R. Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters. J R Co11 Gen Pratt 1989;39:494-8.