Asthma is one of the common chronic inflammatory diseases that primarily affects the airways. It has been estimated that around 300 million individuals in the world currently have asthma [
The extent of asthma effect on quality life has been the focus of many published researches. A study done in Nigeria revealed that around a quarter of the children attending asthma clinic were psychologically impaired and asthma interfered greatly with their daily activities [
Researchers also discovered a correlation between behavioral disorders and the degree of asthma control and quality of life. For example, poor asthma control was associated with clinically significant levels of behavioral problems, as reported in a study done in the United States [
This study was conducted in Jeddah, which is considered to be the second largest city in Saudi Arabia. It is a metropolitan area on the coast of the Red Sea with a tropical climate. It has been observed that sudden climate changes and dust storms in Jeddah tend to have their effects on asthmatic children, as geographical variations were noticed to play a role in the control of asthma [
Therefore, this study is aiming to assess the level of asthma control and its association to the quality of life of children with asthma.
This cross-sectional study was conducted over a period of eight months. The study included 106 children with bronchial asthma who were accompanied by their caregiver to the outpatient department of King Abdulaziz University Hospital and Maternity and Children Hospital, Jeddah, Saudi Arabia. An ethical approval was received for this study from the ethical committee of both hospitals.
A convenient sampling method was adopted. Children with asthma within the age group of 7-17 years were recruited from pulmonology outpatient clinics of two hospitals in Jeddah within the period from January 2017 to June 2017. On average, there are between 10 and 15 patients in each clinic with various pulmonary diseases including asthma. Patients are usually first seen by general pediatrics before being referred to pulmonology. Consent of the caregiver and an assent of the child were provided for their participation in the study. Inclusion criteria for the study included children aged 7-17 years, with physician-diagnosed asthma, who have no positive history of any other chronic medical conditions. Patients who did not fulfill these criteria were excluded.
General demographic characteristics were collected such as age, gender, nationality, and the presence of family history of asthma. This was reported by the caregiver of the child.
Validated Arabic version of the asthma control test (ACT) was used. This tool assesses general asthma symptoms and the frequency of shortness of breath, use of inhalers, and asthma influence on the child’s functional status. It categorizes the children as having controlled asthma (score more than 19) or poorly controlled asthma (score that equals 19 or less) [
A validated Arabic version of PAQLQ was used. This tool measures the functional problems (physical, emotional, and social) that are most troublesome to children as a result of their asthma. It is a self-reported questionnaire that has 23 items rated on a 7-point Likert scale from 1 (not at all) to 7 (always). Higher scores indicate better quality of life [
A validated Arabic version of SDQ was used. It is a frequently used instrument for screening psychopathology in children and adolescents. It is a valid instrument that assesses the presence of psychosocial problems through the following domains (emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial behavior). It is comprised of 25 questions and the answers are not true, somewhat true, and certainly true. Answers were scored, respectively, in a range from 0 to 2 [
Data were summarized using frequencies and percentages for categorical variables or means with standard deviation (SD) for measured variables. For the univariate analysis, variables were dichotomized based on the adequacy of asthma control into (well-controlled asthma and poorly controlled asthma). Differences between continuous data were analyzed using the independent t-test, and the Chi-square or Fisher’s exact tests were used to assess categorical variables as applicable. A P value ≤ 0.05 was considered significant. Statistical analysis was performed with IBM SPSS Statistical software package version 23.
There were 112 eligible patients. Six of them refused to participate and there were no withdrawals during data collection. The study comprised 106 children with asthma, including 74 young children (7-12 years of age) and 32 adolescents (13-17 years of age). 75% of the sample had positive family history of asthma, and most of the sample were of Saudi nationality. Demographic characteristics and social variables of the patients and their parents are given in Table
Sociodemographic characteristics of the sample.
Controlled | Uncontrolled | P value | |
---|---|---|---|
n = 17 | n = 89 | ||
Age | Mean: 11 | Mean: 10.337 | .335 |
St Dev: 2.423 | St Dev: 2.615 | ||
| |||
Gender | |||
Male | 11 (64.7%) | 55 (61.8%) | 0.821 |
| |||
Nationality | |||
Saudi | 11 (64.7%) | 64 (71.9%) | 0.550 |
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Positive family history | 11 (64.7%) | 68 (76.4%) | 0.310 |
| |||
Parents’ relationship | |||
Married | 17 (100%) | 81 (91%) | 0.199 |
| |||
Father’s education | 0.00 | ||
Elementary | 0 (0%) | 0 (0%) | |
Intermediate | 0 (0%) | 7 (8.6%) | |
High school | 4 (23.5%) | 40 (49.4%) | |
College | 10 (58.8%) | 34 (42%) | |
Higher studies | 3 (17.6%) | 0 (0%) | |
| |||
Mother’s education | 0.044 | ||
Elementary | 0 (0%) | 7 (8.6%) | |
Intermediate | 3 (17.6%) | 26 (32.1%) | |
High school | 5 (29.4%) | 28 (34.6%) | |
College | 8 (47.1%) | 20 24.7%) | |
Higher studies | 1 (5.9%) | 0 (0%) | |
| |||
Employed mother | 12 (70.6%) | 33 (40.7%) | .025 |
| |||
Family income | 0.00 | ||
Less than 5000 | 0 (0%) | 7 (8.6%) | |
5000 – 10000 | 1 (5.9%) | 31 (38.3%) | |
10000 – 15000 | 6 (35.3%) | 33 (40.7%) | |
15000-20000 | 7 (41.2%) | 10 (12.3%) | |
20000-25000 | 3 (17.6%) | 0 (0%) | |
>25000 | 0 (0%) | 0 (0%) | |
| |||
Smoking exposure at home | 5 (29.4%) | 50 (61.7%) | .015 |
| |||
Asthma duration | Mean: 76.59 | Mean: 45.88 | 0.00 |
St Dev: 37.321 | St Dev: 30.388 |
Only 16% of the sample had controlled asthma while 84% of them had poorly controlled asthma. The status of asthma control was better among children of educated parents, employed mothers, and those having high family income (P value < 0.05). In addition, asthma duration was directly related to the adequacy of asthma control, i.e., the longer the child had asthma, the less severe it was (Table
Significantly poorer quality of life was observed in children with uncontrolled asthma (p = <0.001) and all domains (activity, symptoms, and emotional function) were equally affected. Tables
The scores of pediatric asthma quality of life questionnaire and the strengths and difficulties questionnaire in relation to asthma control status.
Controlled | Uncontrolled | P value | |
---|---|---|---|
n = 17 | n = 89 | ||
PAQLQ | Mean 6.095 | Mean 4.325 | <0.001 |
St dev 0.966 | St dev 1.000 | ||
| |||
SDQ | Mean 13.177 | Mean 13.82 | 0.58 |
St dev 4.187 | St dev 4.451 |
Subanalysis of pediatric asthma quality of life questionnaire domains and the strengths and difficulties questionnaire scales in relation to asthma control status.
Controlled | Uncontrolled | P value | |
---|---|---|---|
n = 17 | n = 89 | ||
(i) PAQLQ | |||
| |||
Activity | Mean 7.529 | Mean 5.348 | 0.00 |
St dev 1.302 | St dev 1.358 | ||
| |||
Symptoms | Mean 6.018 | Mean 4.234 | 0.00 |
St dev 1.035 | St dev 1.096 | ||
| |||
Emotional function | Mean 6.235 | Mean 4.468 | 0.00 |
St dev 1.035 | St dev 1.154 | ||
| |||
(ii) SDQ | |||
| |||
Emotional problems | Mean 3.529 | Mean 4.011 | .364 |
St dev 1.772 | St dev 2.037 | ||
| |||
Conduct problems | Mean 2.588 | Mean 2.629 | .926 |
St dev 1.938 | St dev 1.612 | ||
| |||
Hyperactivity | Mean 3.706 | Mean 3.933 | .691 |
St dev 2.114 | St dev 2.152 | ||
| |||
Peer problems | Mean 3.353 | Mean 3.247 | .760 |
St dev 1.169 | St dev 1.325 | ||
| |||
Prosocial | Mean 8.412 | Mean 7.573 | .119 |
St dev 1.805 | St dev 2.0499 |
Children with controlled and uncontrolled asthma were equally affected psychosocially with no relation between asthma control and their psychosocial well-being (p = 0.58). Also, none of the SDQ domains (the emotional, conduct, hyperactivity, peer, and prosocial problems) showed any relation with asthma control status. This is further described in Tables
Three relevant findings emerged from this study. First, asthma control status among children was surprisingly low considering that those patients were approached during a follow-up appointment. Second, the quality of life of asthmatic children was significantly lower among those with poorly controlled asthma. Lastly, there was no association between asthma control and the presence of psychosocial problems among the sample.
The percentage of controlled asthma varies across the world. The reported figures in the literature are influenced by the setting of the study, sample size, and the assessment tool used.
In this study, the percentage of children with controlled asthma was 16%, which is similar to many studies worldwide, including a study done in Canada that used Canadian Pediatric Asthma Consensus Guidelines to assess asthma control among children visiting respiratory and allergy clinics, in addition to the emergency department, in which only 11% were controlled [
On the other hand, many other studies showed contrary results, including two studies done in Riyadh: one reported that 41% of the children had controlled asthma, while the other one revealed that the majority of Saudi adolescents were considered mild asthmatics [
Poor quality of life is significantly related to impaired asthma control, as implied by the PAQLQ scores in our study. Many other studies conducted in Iran, Unites States, and Saudi Arabia have shown similar results [
In addition, all the three domains of the PAQLQ (activity, symptoms, and emotional function) were found to be equally affected. The study that was held in Ta’if showed similar findings except that the activity limitations domain was found to be the most affected domain [
This study showed that there was no significant difference in the psychosocial well-being on both controlled and uncontrolled groups. This goes against what Hysing et al. [
Our findings could be explained by the small number of controlled asthmatic children. Moreover, it is suggested that asthma as a chronic illness could be influencing the behavioral health of the children regardless of their control status. A study done by Tibosch et al. [
Parents’ educational level and family income were positively related to asthma control status. Finkelstein J. a. et al. [
Moreover, it was noticed that children of employed mothers have better control of asthma; this could be because of the direct relationship between mothers’ employment status and their educational level, in addition to their ability to afford the needed medications. This finding contradicts the result of a study done in the United States which reported that maternal employment increases the likelihood for children to develop an asthma episode by 12% compared to those who are unemployed [
Authors believe that this study needs to be implemented on a larger sample size, obtained from hospitals situated in different locations in Jeddah, so it can represent the asthma control status and its relation to quality of life adequately. Moreover, an interview-based qualitative research could yield more accurate results regarding the details of asthma effect on quality of life compared to self-administrated questionnaires. Finally, conducting a study to understand the difference between the characteristics of general clinic patients and pulmonary clinic patients would help in delineating the asthma control status accurately.
This study highlights the association of poorly controlled asthma with a poor quality of life. It is recommended that the quality of life of children should be assessed and observed during clinic visits for a better holistic approach and effective improvement of outcome. Further researches are needed to study the risk factors leading to poor asthma control, the psychological effect of asthma, and the importance of screening for behavioral problems among asthmatic children.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare no conflicts of interest regarding the publication of this paper.
The authors would like to thank Bader Mohammed Basakran for his help in data collection.