|Year : 2021 | Volume
| Issue : 3 | Page : 192-196
Assessment of Quality of Life in Childhood Asthma: A Prospective Comparative Study
Divyesh Savdahiya, Jagdish Singh, Neha Agarwal, Vivek Athwani, Sunil Gothwal
Department of Paediatrics, SMS Medical College and J K Lon Hospital, Jaipur, Rajasthan, India
|Date of Submission||02-Jan-2021|
|Date of Decision||29-May-2021|
|Date of Acceptance||18-Aug-2021|
|Date of Web Publication||04-Mar-2022|
Department of Paediatrics, SMS Medical College and J K Lon Hospital, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Context: Childhood asthma is common and affects quality of life (QOL). Aim: The aim is to compare the QOL using pediatric asthma QOL questionnaire with standardized activities (PAQLQ [S]) before and after 4 weeks of standard asthma treatment in children with asthma. Settings and Design: This prospective observational study was conducted in the department of pediatrics at a tertiary care center in North India from January 2019 to December 2019. Subjects and Methods: Children aged 7–17 years with asthma were subjected to PAQLQ (S) before and after 4 weeks of standard asthma treatment. Subgroup analysis was done as per severity of asthma at presentation and control of asthma after 4 weeks' treatment. Statistical Analysis Used: The results were analyzed using Wilcoxon signed-rank test. Results: One hundred asthmatic children (mean age10.94 ± 1.9, M:F = 64:36) were evaluated. All 3 domains (activity limitation, symptoms, and emotion) of QOL affected equally and all domains had shown significant improvement after 4 weeks of standard asthma treatment. Children with severe asthma had activity limitation (P = 0.073) and no improvement in emotional score (P = 0.057). Children with uncontrolled asthma showed deterioration in QOL (P = 0.50). There was no difference in QOL among urban and rural residing children, family history of asthma/allergy, and socioeconomic status of parents (P > 0.05). Conclusions: Strategic asthma management in children improved symptoms, activity limitations, and emotional domains of QOL while, children with uncontrolled asthma showed deterioration in QOL.
Keywords: Childhood asthma, pediatric asthma quality of life questionnaires, quality of life
|How to cite this article:|
Savdahiya D, Singh J, Agarwal N, Athwani V, Gothwal S. Assessment of Quality of Life in Childhood Asthma: A Prospective Comparative Study. CHRISMED J Health Res 2021;8:192-6
|How to cite this URL:|
Savdahiya D, Singh J, Agarwal N, Athwani V, Gothwal S. Assessment of Quality of Life in Childhood Asthma: A Prospective Comparative Study. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:192-6. Available from: https://www.cjhr.org/text.asp?2021/8/3/192/339037
| Introduction|| |
Asthma is common chronic disease in children, has a prevalence of 10%–30% in children. It affects quality of life (QOL) in children in terms of physical, psychological, emotional, self-esteem, stress, and school performance. It has a strong emotional impact which may be expressed in social constraints, depression, insomnia, stress, or even affective disorders for members of the family. According to the global initiative for asthma (GINA) guidelines, rating of asthma control is defined on the basis symptoms control mainly. However, the treatment of childhood asthma must be targeted in multi-domains includes symptomatic control, induction of long-term disease-free state and feeling of emotional wellbeing.
As defined by the WHO QOL is individual perception of position of life in context of culture and value systems in which they live and in relation to individual's goals, expectations, standards, and concerns. QOL for a child with asthma has been defined as the measure of emotions, asthma severity/symptoms, missed school days, activity limitations, and visits to the emergency department. QOL in asthmatic children was assessed by limited number of studies and only one study was conducted in South Asian children., Pediatric asthma QOL questionnaire with standardized activities (PAQLQ [S]) is a validated tool to assess QOL in asthmatic children aged 7–17 years of age. Hence, we have planned this study to evaluate QOL in asthmatic children using PAQLQ (S); as our concern is to allow these children to lead better life and improve QOL.
| Subjects and Methods|| |
This comparative study was carried out in the department of pediatrics, at a tertiary care teaching institute at North India from January 2019 to December 2019. The study was approved by institutional research review board. Children aged 7–17 years of age with diagnosis of bronchial asthma, who have not received asthma treatment or received irregular noncomplaint treatment in the past 4 weeks, were enrolled as study participants (OPD/IPD/Both). Children who have received systemic steroids in past 2 weeks and have other chronic illnesses with asthma or received systemic antibiotics for chest infections were excluded. Primary objective was to compare QOL using PAQLQ (S) before and after 4 weeks of standard asthma treatment. Secondary outcome was to assess QOL as per severity of asthma and asthma control after 4 weeks of treatment.
Sample size calculation
Sample size calculated at alpha error of 0.05 with power of 80% assuming pretreatment and posttreatment (after 4 week) mean PAQLQ score of 4.660 and 5.911 respectively as per reference article. To detect a minimum difference of 0.05 in pretreatment and posttreatment PAQLQ score (standard deviation [SD] = 1.2) required sample size was 100 case. Considering a dropout rate of 15% at follow up, sample size came to be 118, and further rounded off to 120 cases. Informed written consent was taken from guardians of all enrolled participants. Children were managed as per standard protocol of institute as per severity of asthma assessment of GINA guidelines (2015) after detailed history and physical examination. In respiratory physiology laboratory of our institute pulmonary function testing was done, which included forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ration, and peak expiratory flow rate (PEFR). Following this children were subjected to self-administered PAQLQ (S). Children were followed up as per severity of asthma. All children were asked to follow-up at 4 weeks. Control of asthma assessment was done as per GINA Guidelines. Along with routine management, children were subject to repeat pulmonary function testing and PAQLQ (S).
Self-administered pediatric asthma quality of life questionnaire with standardized activities
These QOL questionnaires developed by Juniper et al. Permission to use this validated tool for children aged 7–17 years was provided by Professor Juniper et al. PAQLQ (S) consists of 23 items including three domains, i.e., symptoms (10 items), activity limitation (5 items), and emotional function (8 items). Children were subjected to these items without interference of guardians as they were asked to sit at a distance from child. The questionnaire is available in both language Hindi/English and each item was rated on 7 point Likert-scale, where 7 mean no impairment and 1 means maximum impairment. The score of each domain was calculated as the mean score for items pertaining to that subdomain.
Data were filled in predesigned pro forma and compiled in excel spreadsheet. Quantitative data were summarized as mean (SD) and qualitative data were summarized as proportion. Qualitative data were analyzed using Wilcoxon signed-rank test when analysis was done on same subject before and after treatment. P < 0.05 was considered statistically significant. All statistical analysis were done using SPSS software version 16 (Chicago, Illinois).
| Results|| |
During the study period, 250 asthmatic children aged 7–17 years of age reported to us. Out of them only 180 children fulfilled inclusion criteria and 60 excluded for various reason, i.e., taken systemic steroid in last 2 weeks (n = 32), taken systemic antibiotics for chest infection (n = 19), and refusal to consent (n = 9). So at initial stage, 120 children with asthma were enrolled. After 4 weeks, 20 children were lost to follow-up, so 100 children were included in posttreatment analysis. Baseline characteristics of study participants are summarized in [Table 1]. Mean PAQLQ (S) was improved significantly after 4 weeks of treatment. It was improved significantly in all 3 domains of PAQLQ (S) symptoms, activity limitations, and emotional functions [Table 2]. Mean FEV1/FVC ratio (83.23 ± 11.3 and 90.1 ± 16.4; P = 0.01) and PEFR (73.7 ± 20.7 and 87.2 ± 18.6; P = 0.01) showed significant improvement posttreatment.
|Table 2: Primary outcome of study-change in pediatric asthma quality of life questionnaire with standardized activities score 4 weeks' posttreatment|
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We have done subgroup analysis as per severity of asthma at presentation and control of asthma at 4 weeks of treatment [Table 3] and [Table 4]. Children presented with severe asthma had activity limitation and no change in emotion function even after 4 weeks of treatment [Table 3]. Children who had no control on asthma after 4 weeks of treatment had no improvement of QOL in all domains [Table 4]. Mean PAQLQ (S) score was remained unchanged in underweight children after 4 weeks' posttreatment (P = 0.15), however, overweight and normal weight children had significant improvement in QOL (P < 0.05). Pretreatment total PAQLQ score was higher in males than females though nonsignificant (P > 0.05) but posttreatment total PAQLQ scores were significantly higher in males than females (P = 0.01). There was no difference in QOL among urban and rural residing children in both pretreatment and posttreatment (P > 0.05). QOL was also not affected by family history of asthma/allergy and socioeconomic status of parents.
|Table 3: Secondary outcome of study-change in pediatric asthma quality of life questionnaire with standardized activities score 4 weeks' posttreatment as per severity of asthma|
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|Table 4: Secondary outcome of study-change in pediatric asthma quality of life questionnaire with standardized activities score 4 weeks' posttreatment as per control of asthma|
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| Discussion|| |
The treatment of asthma is multidimensional and it is not only related with control of symptoms but also related with overall well-being of child.
In this study, we found that in asthmatic children symptoms, activity limitations, and emotional domains of QOL were affected and these were improved with asthma treatment at 4-week follow-up. This was possibly due to our regular counseling sessions of each patient at every visit for better compliance and drug delivery.
A study by Nair et al. in children of the same age group using mini-PAQLQ resulted that QOL in activity limitation domain affected most and emotional domain least. They noticed QOL improved significantly activity and symptoms domain similar to our study, but no improvement in emotional aspect in contrast to our study. Similar to Nair et al. PAQLQ (S) score was lowest in emotional function domain among cases of pediatric asthma in a study by Wander et al. and Vazquez-tello et al., According to severity of asthma at admission, subgroup analysis was done and concluded that medical management alone did not show improvement in emotional and activity domain of QOL in severe asthma category, while uncontrolled asthma showed overall deterioration in QOL in our study. Similar to our study Al-Gewely et al. found that uncontrolled asthma was associated with the lowest QOL scores (n = 140). In contrast of our study, they also found that parental smoking, systemic steroids, poor compliance to drugs, asthma-related hospital admission, and level of asthma control were the determinants of overall PAQLQ score.
Similar to our study Vazquez-tello et al. and Matsunaga et al. found that QOL was related to asthma control and asthma severity in children and adolescents, being better when asthma was well controlled and asthma severity was lower., Activity limitation domain was more affected in children and adolescents. Vazquez-tello et al. also reported that common asthma aggravating factors were physical activity, parental tobacco smoke, perfumes, and household detergents. We did not look for other common asthma aggravating factors in our study.
Walker et al. concluded that QOL in children had not shown correlation with asthma severity. A systematic review reported that severity of asthma, economic level, and number of children in the family affected QOL of children with asthma. While, lack of asthma control was, the only factor associated with negative HRQoL in a study conducted Petsios et al.
Nair et al. reported that all domains of QOL showed significant improvement as per parent's perspective but emotional domain showed deterioration as per children's perspective. In contrast to Nair et al., Walker et al. did not observe any association between parent and child total QOL scores, while we have not evaluated parent's perspective in our study.
Although the pretreatment total PAQLQ score was higher (statistically nonsignificant) in males than females, posttreatment total PAQLQ scores was significantly higher in males than females (P = 0.01) in our study. Similarly, our study and Reichenberg and Broberg observed effect of gender on QOL in asthmatic children. Wafy et al. observed gender difference in QOL in both children and their parent's assessment. However, in contrast to above studies, Kouzegaran et al. observed that Pediatric QL scores were significantly better in the girls.
Some studies compared QOL in asthmatic children than healthy controls. Wafy et al. compared asthmatic outpatients children (n = 230) with nonasthmatic (n = 272) children and found significant differences between two groups as regard symptom, activity, impact and total score of St George's Respiratory Questionnaire. QOL score was negatively correlated with asthma severity. Lower QOL was associated with school absences, younger females and among patients with poorer adherence to treatment. We studied only asthmatic children in our study and did not compare with controls.
Hallstrand et al. evaluated QOL in adolescents (n = 160) with mild asthma using Peds QL questionnaire. These patients had lower levels of physical, emotional, and school performance than the healthy children of the same age did. Similarly Elshazly et al. concluded that childhood asthma significantly adversely affects the QOL of the affected children and their primary caregivers. Walker et al. reported that caregivers emotional and activity domain of QOL was associated with severity of asthma in children, but the child's QOL score in any domain not correlated with severity of asthma in children. This effect may be seen due to recall bias in children as they had a long time gap of 10 month between two assessments. Kouzegaran et al. done similar study in children aged 8–12 years, had similar results.
Wander et al. studied QOL in newly (n = 20) or previously diagnosed (n = 70) children and found more impairment in PAQLQ (S) scores if the onset of symptoms was before 1 year of age.
Blackman and Gurka reported that children with asthma had higher rates of attention-deficit/hyperactivity disorder; depression, behavioral disorders, and learning disabilities. These disabilities were directly proportional to severity of asthma.
Miadich et al. found moderate association between asthma severity and child QOL. Banjari et al. evaluated QOL in asthmatic children in Saudi Arabia using PAQLQ and significantly poorer QOL was observed in children with uncontrolled asthma (P ≤ 0.001). Children with controlled and uncontrolled asthma were equally affected psychosocially (P = 0.58). El-Gilany et al. assessed QOL and their associated factors and found low socioeconomic status, uncontrolled and severe asthma were associated with low QOL of both asthmatic child and his caregivers.
Strength of our study was that it was one of the few studies which have evaluated effect of treatment on QOL in asthmatic children in South Asia region. Our study has few limitations like we did not evaluated parents and caregiver's perspective for QOL and have relatively shorter follow-up.
| Conclusions|| |
The symptoms, activity limitations, and emotional domains of QOL in asthmatic children were affected and improved with asthma treatment at 4 weeks' follow-up in our study. The improvement in all domains may be due to our regular counseling sessions of patients and parents on every visit. Children with uncontrolled asthma showed deterioration in QOL. QOL of asthmatic patients was not affected residence (urban/rural), family history of asthma/allergy, and socioeconomic status of parents. Children and caregivers both must be counseled regarding better QOL with proper treatment on each visit for optimum outcome of drug treatment. Further studies with longer duration of follow-up are required to justify present guidelines of asthma which is mainly focused on symptoms domain of QOL.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]