Indian J Pediatr (July 2013) 80(7):544–548 DOI 10.1007/s12098-012-0930-6

ORIGINAL ARTICLE

Quality of Life in Children with Asthma in Rio de Janeiro, Brazil Patricia Gomes de Souza & Clemax Couto Sant’Anna & Maria de Fátima B. Pombo March

Received: 14 January 2012 / Accepted: 22 November 2012 / Published online: 21 December 2012 # Dr. K C Chaudhuri Foundation 2012

Abstract Objectives To evaluate the impact of asthma on activity limitation, symptoms and emotional function in the healthrelated quality of life (HRQL) of asthmatic children. Methods A cross-sectional study involving 59 children of 7 to 12 y of age. A standardized version of the Pediatric Asthma Quality of Life Questionnaire was used to evaluate HRQL and the current criteria for socioeconomic stratification in Brazil were used to assess socioeconomic status. Independent variables evaluated included clinical and sociodemographic characteristics. The association between mean HRQL scores and the independent variables was evaluated using the Mann-Whitney, Kruskal-Wallis and Dunn tests. Statistical significance was defined as a p-value<0.05. Results Thirty-two families (56.1 %) had a total household income of more than two minimum wages, while 37 families (62.7 %) were considered lower middle class. Mean overall HRQL score was 4.8±1.3 (out of a maximum score of 7), suggesting reasonable HRQL. There was a weak association between independent variables and mean overall HRQL scores and the mean scores in the emotional function domain. Higher socioeconomic status was related to higher scores for the symptoms domain (p00.041). Furthermore, children exposed to indoor mould reported greater impairment in the symptoms domain(p00.022). The severity of asthma was associated with the activity limitation domain (p00.025). Conclusions These results showed a reasonable mean HRQL score and an association between the severity of asthma and the activity limitation domain. P. Gomes de Souza (*) : C. Couto Sant’Anna : M. d. F. B. Pombo March Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil e-mail: [email protected]

Keywords Asthma . Quality of life . Child

Introduction Asthma is the most common chronic disease in children and adolescents and a serious global health issue that severely affects health-related quality of life (HRQL) [1]. Due to its chronic course, asthma may restrict a child’s life physically, emotionally and socially [2]. Children with asthma are distressed by their symptoms of difficulty in breathing, wheezing and coughing, and are limited in their day-to-day activities such as sports, schoolwork and participation in other activities with friends. Furthermore, both children and their families undergo an emotional strain as a result of the condition [3]. Good objective tests lung function, bronchial hyperactivity and peak expiratory flows and good quality of life (QoL) are important indicators of an improvement in the prevention and management of asthma [4]. The HRQL would be definitely compromised in asthmatic children, therefore, understanding the patient’s subjective perception of the impact of asthma on his daily life may help to change asthma management with a potentially better outcome. The present study was conducted to assess HRQL and its associated factors in Brazilian children with asthma.

Materials and Methods A cross-sectional study was conducted using a convenient sample of 59 out patients of 7 to 12 y of age with medical diagnosis of asthma attending a pediatric chest clinic in Rio de Janeiro between January 2009 through June 2010. Subjects were excluded from the study if they had an illness other than asthma that could affect HRQL or a lung infection in the previous 30 d; systemic corticosteroid use in the

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past 2 wk; or if they were illiterate and/or had any form of cognitive impairment. Asthma severity was classified as intermittent or persistent in accordance with the IV Brazilian Guidelines for Asthma Management [5]. Other data investigated were: any other associated allergic disorders over the past 12 mo (allergic rhinitis, food allergy, atopic dermatitis, allergic conjunctivitis), previous and current inhaled corticosteroid (ICS) use, duration of current ICS use and family history of atopy. The following demographic and socioeconomic characteristics were also evaluated: age, gender, occupation of the head of the family, household income, family structure, number of individuals living in the household and exposure to household allergens and pollutants. Socioeconomic status was classified according to the criteria for socioeconomic stratification in Brazil into A (upper class), B (upper middle class), C (lower middle class), D (working class) and E (lower class) [6]. The questionnaire was applied to the patient’s caregiver by the principal investigator. HRQL was assessed using the Brazilian Portuguese version of the interviewer-administered Standardised Pediatric Asthma Quality of Life Questionnaire PAQLQ(S) developed by Juniper et al. This questionnaire was culturally adapted and validated for use in Brazilian Portuguese by the MAPI Research Institute, Lyon, France [7]. This 23-item questionnaire measures HRQL in patients of 7 to 17 y of age with asthma and has been shown to be reliable, valid and responsive throughout this entire age range. The PAQLQ(S) includes three primary domains: activity limitation (five items), symptoms (ten items) and emotional function (eight items). It takes approximately 10–15 min to complete the questionnaire. Children were asked to recall impairments they have experienced during the previous wk with the use of a 7-point categorical scale ranging from extremely bothered to not bothered or all of the time to none of the time (1 indicates maximum impairment and 7 indicates no impairment). Scores were calculated as previously described in the original publication: Socioeconomic status was classified according to the Brazilian Economic Classification Criteria (Critério Brasil) into the following categories (A1, A2, B1, B2, C1, C2, D and E), with A1 being the highest and E being the lowest, based on education and ownership of consumer durable goods. A child’s scores on questions referring to overall HRQL and to each individual domain were added and divided by the number of questions. Results were expressed as a mean score per item for each domain and for all the 23 questions together, and range from 1 to 7 [7]. The present study was approved by the Ethics Committee of the Martagão Gesteira Institute of Child Care and Paediatrics. In all cases, informed consent was obtained from at least one of the child’s parents and from the patient him/ herself. Permission to use the PAQLQ(S) was obtained from its authors.

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The Statistical Analysis System, version 6.11 was used for data management and analysis. Mean HRQL scores and their association with the independent variables were analyzed using the Mann-Whitney, Kruskal-Wallis and Dunn tests and P-values < 0.05 were considered statistically significant.

Results Data from 59 eligible children and their caregivers were analysed. The mean age of the children was 10 y (± 1.6) and 37 (62.7 %) of the participants were male. According to the definition of the severity of asthma: 14 patients (23.7 %) were classified as having intermittent asthma and 45 (76.3 %) as having persistent asthma. The use of ICS was reported by 39 patients (66.1 %), 26 (66.7 %) of whom had been in treatment for at least 3 mo. Eighty-five percent of the patients also had allergic rhinitis. Forty-nine patients (83.1 %) reported a family history of atopy. Fifteen patients (25.4 %) were considered passive smokers and 16 (27.1 %) reported indoor mould exposure. According to the criteria for socioeconomic stratification in Brazil, 37 families (62.7 %) belonged to social class C (lower middle class), while 11 families (18.6 %) belonged to class B (upper middle class) and 11 families (18.6 %) belonged to class D (working class). None of the families belonged to social classes A (upper class) or E (lower class). Thirty two families (56.1 %) earned more than two minimum wages. Table 1 shows the distribution of the median and mean overall HRQL values for all the patients and the scores obtained in each of the three domains separately. The mean overall HRQL score was 4.8±1.3. The associations of the overall HRQL scores and the scores obtained in the three domains with the patients’ demographic and socioeconomic characteristics are described in Table 2. As shown, children with persistent asthma had a mean score of 4.5±1.4 in the activity limitation domain compared to a mean score of 5.4±1.2 for the children with intermittent asthma in this same domain (p00.025). Furthermore, children exposed to mould reported greater impairment in the symptoms

Table 1 Distribution of overall and domain scores of the PAQLQ(S) Score

Mean

SDa

Median

Minimum

Maximum

Overall score Symptoms Activities Emotions

4.8 4.7 4.7 5.0

±1.3 ±1.3 ±1.4 ±1.3

5.0 4.7 4.8 5.2

2.5 2.1 2.6 2.2

6.7 7.0 7.0 7.0

a

Standard deviation

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domain, with a mean score of 4.0±1.2 compared to 5.0±1.3 in unexposed children (p00.022) (Table 2). No significant association was found between overall HRQL scores and the socioeconomic or demographic variables analyzed.

Discussion Little is known about the factors associated with HRQL in children with asthma. The main findings of the present study

Table 2 Clinical and sociodemographic characteristics and PAQLQ(S) mean scores Variable

Age Gender Occupation of the head of the family Household income Family structure Residence type

Number of individuals living in the household

Current ICSa use Previous ICSa use Duration of current ICSa use Allergic rhinitis Food allergy Atopic dermatitis Allergic conjunctivitis Severity of asthma Family history of atopy Passive smoking Moulds exposure Pets Socioeconomic stratification

Overall

Activities p*

Mean

p*

Mean

p*

Mean

p*

7–9 y 10–12 y Male Female Employed Unemployed/retired 0 2 minimum wages > 2 minimum wages Nuclear Others Own Rent Others 03 4 to 5 >5 Yes No Yes No < 3 mo 0 3 mo

4.6 4.9 5 4.4 4.8 4.4 4.7 4.8 4.8 4.7 4.5 4.9 5.1 4.7 4.7 5.3 4.7 5 5 4.5 4.6 4.7

0.42

4.6 4.9 4.9 4.4 4.8 4.3 4.7 4.7 4.8 4.6 4.3 4.8 5.2 4.4 4.7 5.6 4.6 5 4.9 4.5 4.5 4.6

0.32

4.6 4.8 4.9 4.3 4.7 4.4 4.6 4.8 4.8 4.6 4.6 4.7 4.8 4.7 4.7 4.8 4.6 4.8 4.9 4.4 4.4 4.8

0.62

4.8 5.1 5.2 4.6 5 4.6 4.9 5 4.9 5 4.6 5.1 5.2 4.9 4.9 5.4 4.8 5.2 5.2 4.6 4.9 4.8

0.35

Yes No Yes No Yes No Yes No Intermittent Persistent Yes No Yes No Yes No Yes No Bb Cc Dd

4.8 4.7 4.8 4.8 4.9 4.8 4.7 4.8 5.3 4.6 4.8 4.7 4.4 4.9 4.4 4.9 5 4.6 5.4 4.6 4.6

0.096 0.51 0.9 0.95 0.32

0.58

0.44 0.2 0.85 0.86 1 0.72 0.88 0.072 0.71 0.24 0.14 0.24 0.24

Inhaled corticosteroid; b Upper middle class; c Lower middle class; d Working class

*

Mann-Whitney/Kruskal-Wallis tests Dunn test

Emotions

Mean

a

**

Symptoms

4.8 4.4 4.6 4.7 5.1 4.7 4.6 4.7 5.4 4.5 4.7 4.6 4.3 4.9 4.6 4.8 4.9 4.5 5.5 4.4 4.9

0.2 0.66 0.96 0.51 0.14

0.13

0.27 0.49 0.86 0.53 0.91 0.4 0.87 0.025 0.86 0.23 0.62 0.28 0.056

4.7 4.8 4.6 4.7 4.7 4.7 5 4.7 5.1 4.6 4.7 4.6 4.2 4.9 4 5 4.9 4.6 5.6 4.6 4.2

0.096 0.56 0.61 0.66 0.86

0.98

0.71 0.2 0.42 0.84 0.86 0.96 0.57 0.26 0.85 0.13 0.022 0.59 0.041**

5 4.9 5.1 4.9 4.9 5 4.6 5 5.5 4.8 5 4.8 4.7 5 4.5 5.1 5.2 4.8 5.2 4.9 4.8

0.11 0.59 0.77 0.54 0.3

0.71

0.37 0.058 0.92 0.82 0.82 0.95 0.37 0.092 0.53 0.52 0.17 0.28 0.68

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were the statistically significant associations between the symptoms domain and socioeconomic status and between the symptoms domain and exposure to mould. No previous studies conducted in Brazil have reported these findings. The mean overall HRQL score found in the present study was 4.8 (out of a maximum score of 7), suggesting reasonable HRQL. This finding is similar to reports published by other investigators in Brazil [8, 9]. In the present study, the children were enrolled and treated at a specialist asthma outpatient clinic, which may have affected the results in a positive direction. The PAQLQ(S) was selected for use in the present study because it deals with factors that are important for the evaluation of HRQL in children with asthma. It was developed to measure the functional, physical (symptoms and activity limitation domains) and psychological (emotional domain) effects of this disorder [7]. In the present study, there was a higher prevalence of boys. Being male constitutes a risk factor for asthma in childhood due to the narrower airways and higher airway resistance in males compared to females [10]. Girls had lower HRQL scores compared to boys (p0 0.096). Girls would be more anxious about their health and are therefore more likely to over-report their symptoms and emphasize their disabilities compared to boys [2, 11]. No correlation was found between the socioeconomic and demographic variables evaluated and overall HRQL score or the scores in the emotional function domain. There was a high prevalence of allergic rhinitis (84.7 %) that may have contributed towards reducing the HRQL scores. To the best of authors’ knowledge, no previous studies have shown an association between impairment in the symptoms domain and exposure to mould. One Brazilian study showed a high rate of asthma symptoms in the most severely deprived socioeconomic class, which may have been affected by environmental factors such as exposure to house-dust mites, mould or cat dander [12]. More severe asthma was associated with a trend towards a negative effect on overall HRQL score (p00.076) and on the score in the emotional function domain (p 00.092). Moreover, patients with severe asthma reported more limitations to their activities, a finding that is similar to results published from previous studies conducted in Serbia [1] and Iran [10]. Nordlund et al. [13] found that the overall HRQL score was lower in children with severe asthma compared to those subjects in whom asthma was controlled (5.4 vs. 6.7, p <0.001). According to Cerović et al. [1], impairment in the activity limitation domain is explained by the patient’s concerns about exacerbating their asthma. It is logical that these children would avoid any activities that could trigger an asthma attack. In the present study, there appeared to be a trend towards higher scores in the emotional function domain in patients

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who reported previous ICS use compared to those who had not previously used these drugs (p00.058). A review of the literature revealed conflicting results with respect to this relationship. Parents whose children are prescribed preventive medication may take this to mean that their children have very significant asthma. Excessive parental concerns of vulnerability can disrupt the child-parent relationship, leading to behavioral and emotional problems in the child [14]. The lack of any relationship between steroid therapy and overall HRQL score is in agreement with the findings of other previous studies [15, 16]. Nevertheless, a study conducted by Nogueira [17] showed that adolescents who were undergoing steroid treatment and/or using rescue medication had poorer overall HRQL scores compared to those not in use of these drugs. The explanation offered by these investigators was that patients with problematic severe asthma are prone to developing exacerbations and are, therefore, often under treatment with steroids or bronchodilators. In contrast, another study showed that after 12 wk of ICS treatment, improvements in lung function, asthma symptoms and HRQL scores were found in pediatric patients with asthma [18]. In addition, adherence to prescribed medication is an important factor in improving HRQL. Common concerns about ICS therapy, including a fear of side effects and misunderstandings in relation to the use of asthma medication, may reduce compliance with therapy [19]. Although the present results failed to show any statistically significant association between asthma and the emotional function domain, it should be noted that emotional and behavioral disorders might represent risk factors for exacerbating asthma. Particularly in adolescence, limitations to activities, the embarrassment caused by the symptoms or the regular use of medication, and the anxiety caused by shortness of breath, render asthma a high risk factor for mental health disorders [20]. According to studies conducted in Brazil, there is no correlation between overall HRQL scores and socioeconomic variables [8, 9, 17]. The lack of any relationship between socioeconomic variables and HRQL has also been reported in a study involving asthmatic adolescents enrolled in public schools in Belo Horizonte in the state of Minas Gerais, Brazil [8]. The present findings show a statistical trend towards higher scores in the activity limitation domain for patients belonging to social class B compared to the scores obtained in this domain by patients from social classes C and D. Belonging to a racial minority, having a lower household income and inadequate social support are some of the variables repeatedly found to be related to an increase in the prevalence and severity of asthma and the use of resources by patients with asthma [21]. In a study conducted in Italy, the prevalence of chronic cough was associated with

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increased urbanization and lower socioeconomic status [22] and showed that higher household income was related to higher scores in all the HRQL domains and also to higher overall HRQL scores in children with asthma. Families with a higher socioeconomic status are more likely to have a higher education level, a greater understanding of their children’s treatment, adequate social support and easier access to care. These variables may contribute towards improving compliance with therapy. Van Dellen et al. [23] found that asthmarelated quality of life was significantly lower among children in immigrant groups compared to ethnic Dutch children. The lower socioeconomic status of immigrant groups may explain these lower scores [23]. The small sample size and the fact that all the children were observed only once, constitute limitations to the present study. Despite concentrated efforts, it proved impossible to include any more children. The present sample consisted of patients using a public healthcare system whose socioeconomic status was homogeneous. One interesting observation from the present study was that most families belonged to social class C and in 56.1 % of the families monthly household income was over two minimum wages, which is not considered unfavourable [17]. Contributions All authors designed the study protocol, analyzed the data and revised critically the manuscript. All authors approved the submitted version. Conflict of Interest None.

Role of Funding Source

None.

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