We conducted a cross-sectional study with a school-based sample whereby a questionnaire was distributed to primary and middle schoolchildren aged 7–16 years in governmental schools in Kuwait. Equal boys and girls schools were randomly selected from two major governorates in Kuwait; Al-Farwaniyah, the most densely populated and farther away from the center of the State of Kuwait, and Hawally, which is more urbanized and central in location. These two governorates were chosen to cover the geographic diversity of Kuwait.
The number of Kuwait students in academic year 2018/2019 according to the information from Kuwait Ministry of education in primary and middle schools is 127653. Of those, 71448 (55.97%) are girls and 56205 (44.03%) are boys. We calculated the sample size to be 950 using a special formula based on reported prevalence of headache from previous national and international epidemiological studies, which is around 54.4% and of migraine, 9.1% [10–11]. Then, the sample was increased by 20% to overcome the problem of non-response and missing data.
Representative random sample of school classes was selected, stratified by grade (3rd, 5th, 7th, 9th ), and school type (school for boys and schools for girls). So, the final selection of schools and school classes covered the age spectrum from childhood through adolescence and reflected Kuwaiti students of schools appropriately. Subjects were excluded if refused to participate, were non-Kuwaiti nationals, had history of medical or neurological disease or were absent on the day of the survey.
The survey used Lifting the Burden, Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire that was translated into Arabic [12]. The Child HARDSHIP for children aged 6–11 years and Adolescent HARDSHIP questionnaire for adolescents aged 12– 17 years were used in this study. The HARDSHIP questionnaire has already demonstrated validity and acceptability in multiple languages and cultures including the Arabic Language. This questionnaire questions included sociodemographic, screening and diagnostic questions and enquiries of various domains and quality of life. The last part of the questionnaire included questions on the use of healthcare system in the past, medication use, and Headache-Attributed Lost Time Index questionnaire. Burden questions referred to the numbers of days missed from school, leaving school early or with impaired everyday activities due to headache, within the previous four weeks. Data were obtained from the children and adolescents themselves after explanation of the questions by physician of the study team. Questionnaire distribution and data collection were organized and conducted by physician supervisors during a school class as a paper-pencil version. To collect study data, well trained physicians conducted face to face interviews using Child and Adolescent HARDSHIP questionnaires. Written informed consent was obtained from all participants and their parents before the questionnaire was distributed. The participants were granted the right to decline participation at any time during data collection. Diagnoses were performed by HARDSHIP algorithm [13]. Confirmation of diagnosis was done by headache specialist applying ICHD-3 criteria[14].
The team leader reliably stored all completed questionnaires at the end of each day. Errors were corrected by discussing them with the interviewer and a revisit was arranged if discrepancies could not be corrected. The team leader monitored and assisted researchers on a regular basis to resolve any problems and to review the completed questionnaires. The fieldwork was carried out over a period from 1/10/2018 till 1/1/2019.
Ministry of health and ministry of Education in Kuwait approved the study. Participants was given a simple explanation about the aim of the study being considered an ethical issue. All data were protected in accordance with the ethical guidelines of the Council for International Organizations of Medical Sciences and the principles in the Declaration of Helsinki [15–16].
Statistical Analysis
The data from completed questionnaire were entered on IBM SPSS Statistics 20.0. Data entry was double-checked with inconsistencies reconciled by reference to the source documents. An error rate of 1.9% was identified. Proportions, 95% CIs, means, and standard deviations (SDs) were used to summarize the distribution of variables.