Factors associated with parental knowledge, attitude, and practice regarding childhood constipation: a cross-sectional study

Introduction

Constipation is a common condition among children worldwide, affecting approximately one in ten children (1,2). Its prevalence peaks between 1 and 4 years, with rates ranging from 18% to 26% (3). In Thailand, the prevalence of constipation among preschool children varies between 2.4% and 25.1% (4,5). Children with constipation often experience various nonspecific symptoms, such as abdominal pain, loss of appetite, and difficulty passing stool (6). Beyond its physical effects, childhood constipation can also have psychological impacts, contributing to increased stress and healthcare costs for families (7,8).

Parental understanding of childhood constipation is crucial in its prevention and management. Parents with limited knowledge about the condition may struggle to recognize and address it appropriately, potentially leading to delayed diagnosis and treatment (9). A systematic review by Thompson et al. found that most parents have inadequate knowledge of childhood constipation, with only a small percentage possessing accurate and sufficient information about the condition (10).

However, research on the factors influencing parental knowledge, attitude, and practice (KAP) regarding childhood constipation remains limited. Therefore, this study aims to assess the factors associated with parental KAP concerning constipation in children aged 1–5 years. We present this article in accordance with the STROBE reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-31/rc).

Methods

Study design and population

A cross-sectional study was conducted at a kindergarten and primary school in Sai Mai District, Bangkok, Thailand, from January 2023 to October 2024. Convenience sampling was used to select participants. Inclusion criteria included parents who were the primary caregivers of children aged 1–5 years, able to communicate verbally, and literate in Thai. Exclusion criteria comprised parents with visual impairments or diagnosed mental disorders. Data were collected using a self-administered structured questionnaire.

Multiple linear regression was used to determine the optimal sample size for identifying factors associated with KAP scores. A medium effect size (f² =0.15) was assumed, with a test power of 0.80, a reliability alpha level of 0.05, and six predictors. Using the G*Power program, the calculated sample size was 98 participants. To account for a 20% dropout rate, a total of 118 participants were targeted to ensure at least 98 subjects were available for analysis.

Research instruments

The questionnaire used in this study consisted of two parts:

• Part I: this section collected explanatory variables related to parents, including demographic information such as their relationship with the child, age, educational level, and family’s monthly income (in Thai Baht). Additionally, data on parental access to health information regarding childhood constipation were collected.
• Part II: the KAP questionnaire was used to assess parental perceptions of constipation in children aged 1–5 years.

KAP questionnaire

The KAP questionnaire consisted of 18 questions distributed across three domains, as summarized in Tables 1-3:

• Knowledge domain: 5 questions with three response options; correct answers were scored as 1, and incorrect answers as 0.
• Attitude domain: 5 statements rated on a five-point Likert scale, with scores ranging from 0 to 4.
• Practice domain: 8 dichotomous questions, where “yes” responses were scored as 1 and “no” responses as 0.

The reliability of the questionnaire was assessed using the test-retest method, yielding an intraclass correlation coefficient of 0.91 [95% confidence intervals (CI): 0.77–0.96], indicating high reliability. Validity was confirmed through the Item-Objective Congruence method (11).

Data collection

The self-administered questionnaire was distributed through two methods based on participants’ preferred method:

• Face-to-face surveys: the questionnaire was provided in paper format.
• Online surveys: the questionnaire was administered via Google Forms.

Statistical analyses

Descriptive statistics were performed for demographic data and KAP scores. Categorical variables were presented as frequencies and percentages, while continuous variables were reported as means with standard deviations (SD). Associations between independent variables and KAP scores were analyzed using dummy variable regression. Both simple and multiple linear regression analyses were performed using the backward elimination method. Results were expressed as β coefficients with 95% CI. A P value of <0.05 (two-sided) was considered statistically significant. All statistical analyses were performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics committee of Bhumibol Adulyadej Hospital (approval number IRB No. 36/64) and informed consent was taken from all individual participants. They were informed about the voluntary nature of their participation, received adequate disclosure regarding the research, and were assured that their data would be anonymized and securely stored to maintain confidentiality.

Results

A total of 140 participants completed the study and were randomly assigned to two groups based on their preferred method: the face-to-face group (n=50) and the electronic media group (n=90). The majority of parents in the study were mothers (76.4%). The mean (SD) age of parents and children was 37.46 (5.65) years and 4.07 (1.01) years, respectively. Most participants held a bachelor’s degree or higher (81.4%) and reported a family monthly income of ≥30,000 Thai baht (70.7%). The baseline characteristics of the participants are summarized in Table 4. Regarding sources of health information, an equal number of participants (n=67, 47.9%) reported receiving information from either one to two sources or more than two sources. The distribution of health information sources is illustrated in Figure 1.

Figure 1 Different sources used for health information.

Parental KAP on childhood constipation

The items assessing parental perception of childhood constipation are presented in Tables 5-7. In the knowledge domain, most participants provided correct answers. In the attitude domain, the majority of participants had a positive attitude, except regarding stool soiling as an indication of constipation (item A4). Less than half (47.8%) had a negative attitude, while approximately 30% held a neutral stance. In the practice domain, a minority of parents engaged in key practices, including performing toilet training after a meal (item P1), monitoring their children’s bowel movements (item P6), and refraining from forcing their children if they were not ready for toilet training (item P8) (32.1%, 23.6%, and 46.4%, respectively). The mean (SD) scores for knowledge (possible range: 0–5), attitude (possible range: 0–20), and practice (possible range: 0–8) were 3.94 (1.07), 14.93 (3.10), and 5.48 (1.29), respectively.

Factors associated with KAP scores

Both simple and multiple linear regression analyses, using the backward elimination method, were conducted to examine variables associated with KAP scores, employing dummy variable regression analysis. The results indicated that the relationship with the child, education level, and family monthly income was significantly associated with knowledge in the simple linear regression analysis [(β =0.471, 95% CI: 0.054–0.888, P=0.03), (β =0.866, 95% CI: 0.426–1.306, P<0.001), and (β =0.633, 95% CI: 0.252–1.015, P=0.001), respectively]. However, in the multiple linear regression analysis, only education level and family income remained significant [(β =0.710, 95% CI: 0.221–1.199, P=0.005) and (β =0.424, 95% CI: 0.016–0.832, P=0.04), respectively] (Table 8). In contrast, no significant associations were found between any variables and attitude scores (P>0.05) (Table 9). However, both simple and multiple linear regression analyses revealed that the relationship with the child and the ability to assess the reliability of information were significantly associated with practice scores {[simple linear regression; (β =0.507, 95% CI: 0.005–1.009, P=0.048) and (β =0.740, 95% CI: 0.107–1.374, P=0.02), respectively], [multiple linear regression; (β =0.574, 95% CI: 0.064–1.085, P=0.03) and (β =0.786, 95% CI: 0.153–1.418, P=0.02), respectively]} (Table 10).

Discussion

Parents’ understanding of childhood constipation is crucial for its prevention. A KAP questionnaire is a valuable tool for identifying baseline perceptions, behaviors, and misconceptions related to a specific health-related topic (12). However, limited research in Thailand has examined the factors associated with parental perceptions of childhood constipation. Therefore, this study aimed to explore the factors influencing parental KAP regarding childhood constipation.

The demographic profile of our study revealed a predominance of mothers among the surveyed parents (76.4%). This finding aligns with a study by Alwashali et al., which highlights the central role of mothers in childcare decisions (13). Additionally, a high percentage of participants had a bachelor’s degree or higher and a family income of ≥30,000 baht per month, reflecting a relatively well-educated sample with a high socioeconomic status.

Most parents obtained health information from the internet (26.5%) and Facebook (17.6%). Today, social media is an integral part of modern parenting, offering convenience and the opportunity to connect with like-minded parents. However, discerning the quality of health information can be challenging, leaving parents vulnerable to misinformation (14).

The findings within the knowledge dimension of this study indicate that education level and family income were associated with knowledge scores. These results are consistent with previous studies showing that health literacy is influenced by socioeconomic indicators such as social status, education, and financial resources (15). Educated parents are more likely to actively seek information and engage in health-related discussions (16). Conversely, lower education levels are associated with a poor understanding of health information, leading to suboptimal decision-making regarding health matters (17). Furthermore, higher family income levels may contribute to greater attention to personal and family health, as financial stability enables access to better healthcare resources and information (18).

The attitude dimension of this study revealed no association between parental demographic characteristics, access to health information on childhood constipation, and parental attitude scores. However, previous studies have shown that factors such as age, sex, education level, and income can influence parental attitudes (19). The limited sample size in our study may have led to insufficient data for regression analysis.

The practice dimension of this study provides important insights into the relationship between parental practices and their ability to judge the reliability of health information. Alwashali et al. demonstrated that mothers actively seek healthcare information, underscoring the need for targeted educational interventions to enhance their knowledge and practices in childcare (13). Furthermore, the reliability and trustworthiness of health information sources were highly valued, consistent with findings from previous research. Specifically, the majority of parents preferred following influencers with pediatric health-professional backgrounds over those without, as professional credentials provided a sense of trustworthiness (20).

The results of this study indicate that while most parents demonstrated adequate knowledge, gaps in attitudes and practices were evident. Many participants held negative attitudes toward stool soiling awareness and exhibited poor practices, such as inadequate toilet training after meals and a lack of monitoring of bowel movements. Similarly, our previous survey of 306 parents revealed the same misconceptions in the attitude and practice domains (11).

There are several limitations to this study. First, its generalizability is constrained by the relatively homogeneous sample. The research was conducted in a kindergarten and primary school in the Sai Mai District of Bangkok, an area where parents tend to have higher education levels and socioeconomic status than the broader Thai population. Second, the use of non-random convenience sampling may have introduced selection bias and further limited the representativeness of the sample. Third, the cross-sectional design restricts the ability to infer causal relationships between variables. Future research should address these limitations by employing randomized sampling methods, including more diverse populations, and utilizing longitudinal designs to validate and expand upon these findings.

To the best of our knowledge, this is the first study exploring factors associated with parental perceptions of childhood constipation. These findings can serve as baseline data for health educators, policymakers, and researchers to develop tailored and reliable educational materials aimed at improving parental perceptions of childhood constipation.

Conclusions

This study emphasizes the need for targeted educational interventions to improve parental KAP related to childhood constipation. Our findings indicate that higher education levels, greater family income, the mother’s involvement in childcare, and the ability to assess the reliability of health information are positively associated with better parental understanding and management of childhood constipation. These results highlight the importance of accessible, reliable health information sources and tailored programs, particularly for socioeconomically disadvantaged families. Policymakers, healthcare providers, and educators can use these insights to develop effective strategies that reduce the burden of childhood constipation and promote better child health outcomes.

Acknowledgments

The authors acknowledge Warongporn Pongpinyopap for editorial assistance in improving the written English in this manuscript. In addition, the authors thank the use of ChatGPT to improve language and readability.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-31/rc

Data Sharing Statement: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-31/dss

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-31/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-31/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics committee of Bhumibol Adulyadej Hospital (approval number: IRB No. 36/64) and informed consent was taken from all individual participants. They were informed about the voluntary nature of their participation, received adequate disclosure regarding the research, and were assured that their data would be anonymized and securely stored to maintain confidentiality.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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