WikiJournal Preprints/All measures led to the same conclusion: an alarming high burden of asthma among school children

First Heading
Introduction

Asthma is a global health issue with substantial burden [1]. Burden of illness is the sum of mortality and morbidity attached to that illness. Studying disease burden is important measure of disease control efforts [2]. However, quantifying disease burden is complex because health is considered a multidimensional construct [3] Researchers need to consider death rates and age at death, life expectancy and healthy life expectancy, the degree of disability [4]. To study the global burden of illness researchers use a common metric called "Disability Adjusted Life Years" [DALYs]. For specific populations researchers use different measures to study disease burden including prevalence of illness [5], risk factors and attributable fraction [6], severity classification [7], school performance and absenteeism [8], parental reported outcomes [9], use of health services, medications and hospitalizations [10] and direct cost [11].

The worldwide asthma prevalence has been reported by the ISAAC steering committee in the Global Asthma Report, 2018 [12]. The report showed current wheezing was self-reported in more than 20% of children 13-14 years. In Jordan, the prevalence of current wheezing reached up to 17% using self-report [13] and 14.8% using parent-report [14]. The illness places huge burdens on patients, families and health systems which are represented in morbidity and health care expenditures [15]. Children with asthma vary in their symptoms severity and sensitivity to allergens, hence their treatment plan differs [15]. The medications used for asthma treatment are mainly inexpensive relievers [short-acting β2 agonist] and controllers [glucocorticosteroids] [12, 16]. A study from Jordan showed that one-third of children who reported wheezing in the last 12 months used an asthma medication [17]. While all children are prescribed different types of medications, the majority of children with asthma in Jordan are prescribed inhaled relievers delivered generally by a metered-dose inhaler [MDI] [14]. Different studies showed some lack of adherence by patients to their therapeutic regimens [18] while others showed lack of knowledge and the necessary skills to use their inhaled medications [19]. Studies from Jordan with children [17] and adults [20, 21] showed few patients demonstrated correct inhaler technique which improved after training. Among the factors hindering children’s accurate use of inhaled medications was parents' overestimation of their children's self management skills [22]. Experts recommend that education of patients and their caregivers should be part of routine assessment during clinic visits [23, 12]. Because the correct inhaler technique is very important factor for controlling asthma attacks, improper MDI technique can result in poor asthma outcomes. Therefore, it's very important that children understand the appropriate way to use their inhaled medications. While school nurses are usually the source of health care the student receive at school, the absence of school nursing in Jordan left teachers and parents responsible. Some problems that occur when a nurse is not present are medication errors, and lack of early detection and lack of appropriate interventions of severe symptoms [24]. Therefore, regular assessment of burden of illness among children with asthma was necessary.

Purpose of the study

Despite advances in asthma management, variations in asthma burden still exist. The purpose of this study was to assess the burden of asthma among school children in Jordan using different measures and compare the outcomes with previously reported studies. The objectives include:

1)     assess children's asthma control including symptoms, medications and health services use

2)     describe children’s perceptions of asthma management at school

3)     assess children's ability to accurately use MDI inhalers

Methods

Sample and setting

A list of children with asthma from 10 primary schools in Zarqa city Jordan was generated based on a parent-report from a previous survey. To meet the objectives of the current study, parents of children with asthma from grades 3 to 7 were asked to complete a questionnaire about their child and to give permission for them to participate by completing a short survey about asthma management and participate in the MDI inhaler demonstration in their school. All children who provided parental permission were included in the study.

Design, measures and Procedure

A descriptive exploratory design was used to achieve the objectives of the study. Parents of children with asthma were asked to complete a questionnaire that was prepared to assess the burden of their child’s asthma. The questionnaire included two sections: demographics, and asthma burden. The burden of asthma was assessed by asking parents to rate their child’s use of inhaled medications, asthma symptoms during the previous month, and health services use during the previous 12 months. Parents were also asked to rate their child’s general health status on a visual analogue scale. Specifically, they were asked to draw a mark at the point on a 10 centimeter scale to represent the general health status of their child. Parents were asked to provide a description of any other medications prescribed for their child [medication name and dose]. On the other hand, children with asthma were asked to answer a short questionnaire about their asthma management at school including the use of their inhalers. Children's ability to demonstrate the correct use of an MDI inhaler was assessed by an expert nurse.

Inhaler use

Based on parents’ responses, children who used MDI inhalers were evaluated individually for performance and scores were documented on a short 6-step scale constructed based on recommendations from the literature. Nurse educators appointed by the research team and teachers of the schools have partnered to accomplish the evaluation of children inhaler technique. Children were individually asked to demonstrate the procedure in front of a nurse educator and teachers of the school who documented the scores on the inhaler technique sheet which outlined proper MDI technique parameters.

Data analysis

Descriptive analysis [frequency, mean and standard deviation] was calculated for demographics and asthma burden responses [general health status, inhaler use, symptoms and health services use], and children’s asthma management at school. Given the nature of the variables and the sample size, Chi-square, Kendall’s tau-sub-b, Pearson's correlations were employed as appropriate to calculate the correlation of the parents’ responses to the questionnaire [25]. To address missing data, the valid percentage was calculated based on the number of parents/teachers who completed each item. The general health status of the child was calculated as the distance on the visual analogue scale in centimeters as marked by parents. On the other hand, children’s ability to accurately use their inhalers was evaluated by calculating the frequency [percentage] of children who correctly demonstrated the skill. The total number of children with asthma in the selected schools and classes was limited hence restricted the use of further statistical tests. Violation of statistical assumptions of statistical tests increases the likelihood of reporting imprecise results [26]. Many statistical tests were not conducted due to small sample size to avoid proportions of Type I and Type II error.

Results

Demographics of children with asthma

A total of 70 children with asthma from 10 primary schools participated in the study. The sample included 19 boys [27.1%] and 51 girls [72.9%] aged between 7 and 14 years [Mean [SD] = 11.5 [1.73] years]. More than 50% [n=38] of parents indicated that at least another family member has asthma. The majority indicated having a health insurance [74.3%]. More than 65% [n=46] of the families included a smoker member with 84% and 63% smoked inside the house and the car respectively. Only 9 families [13%] indicated having an animal pet at home, and 13 [18.5%] indicated that their child has an asthma action plan written by their doctor.

A-    Burden of Asthma as reported by parents

The general health status of children was expressed by parents on a visual analogue scale. The mean score was 51.2 on scale from 0–100 [standard deviation of 29.8] ranging between 0 and 100.

1)     Asthma medications and puffer [MDI] use

Parents were asked to provide information about their child’s use of inhaled medications. Just over half of parents [61.4%, n=43] indicated that their child is currently using an asthma inhaler. Parents indicated that their children have used their inhalers for a period ranging between 1 and 12 years [M [SD] = 3.7 [3.22] years]. Only 34.1% of those children carried their inhalers all of the time while 17.1% never carried their inhaler. While 16.3%, 41.9%, 25.6% used their inhaled medications every day, most days, some days in the previous month respectively, 16.3% never used it. When asked “How many inhaler canisters did your child use in the previous month?” 18.6%, 46.5%, and 34.9% indicated they have used less than one, one, and more than one canister respectively.

Parents provided written responses to a question about their child’s asthma medications and doses. While a few provided the generic or trade name of the medications [e.g. Asmadil, Butalin, cortisone], the vast majority [86%] indicated “an inhaler” as their main medication. Most of them wrote blue inhalers [e.g. Ventolin] [34.8%], while others provided other colors [e.g. red, white, green, orange and black] without further description. Some indicated pills [e.g. Panadol, antibiotics] and syrup [e.g. Allerfin, cough syrup] beside their inhalers, while others reported a nebulized medication at the local clinic [e.g. Butalin] or an annual allergy injection. Parents provided the frequency [e.g. twice, when necessary etc.] rather than exact doses of medications [e.g. number of puffs, amount of syrup, number of pills etc.].

2)     Asthma symptoms

Table 1 presents the symptoms frequency as indicated by parents of children with asthma. The majority experienced at least some symptoms during the previous month with cough being the highest rated symptom followed by shortness of breath.

Table 1: Symptoms of asthma during the previous month (n (valid %)), N=70

3)     Health services use for asthma

Parents of children with asthma revealed a moderate to high level of health services utilization during the previous year. More than two thirds experienced at least one asthma attack [68.1%] with only 22 children [31.9%] experience none. Two thirds of children experienced school absenteeism [66.7%] because of their asthma at least once. While more than half [53.6%] visited the ER at least once, 34.8% got admitted at least once because of their asthma.

A correlation was calculated between parents’ ratings of their child’s general health on a visual analogue scale [continuous variable] and their reported symptoms and health services use [ordinal variables]. Results showed a negative medium but highly significant association between parents’ ratings of their child’s general health and reported symptoms [tau=-0.376, p=0.001, n=43]. Although not significant, the association with health services use was negative and small [tau=-0.212; p=0.064, n=43]. Both symptoms and services use was positively correlated [tau=0.397; p=0.000, n=70]. A strong correlation existed between the child’s use of their inhaler during the previous month and the frequency of carrying the inhaler with them [Spearman’s rho= 0.44, p=0.005, n=43]. Other factors were not significantly associated or have violated the assumptions of statistical tests hence not presented.

B-    Children’s perception of asthma management at school including the use of inhaled medications

Table 2 presents the perception of 39 children with asthma about their asthma management at their schools. The table shows the percentage of children who agreed with each statement. While 14 children [35.9%] brought and used their medications [inhalers] at school, only five [12.8%] of them have faced problems using their medications [annoyed by others]. All children in the sample [n=39] agreed that their school didn’t prohibit them from bringing their medications and over 87% agreed that their school teachers helped them when they got difficulty of breathing. While over half of the children reported getting breathing problems when they play sports or go in trips with the school, 33.3% reported getting an asthma attack at school.

Table2: Children’s perception of asthma management at school including the use of inhaled medications (n=39)

C-    Child inhaler technique

The 43 students from 10 primary schools who have been reported by their parents to use an inhaler have been included. The nurse educators asked children to individually demonstrate the inhaler technique as they usually do at home or school with every step noted in a separate sheet [Table 3]. Results showed most children performed incorrect inhaler technique. Nearly all steps were considered incorrect by the majority of the children [e.g. not shaking the inhaler; not exhaling before pressing; pressing inhaler after end of inhalation; stopping inhalation after pressing; insufficient breath-holding after inhalation].

Table 3: Percentage of children who correctly demonstrated the use of an MDI (N=43)

Discussion

This study assessed burden of illness among a sample of children with asthma and evaluated their ability to use inhalers correctly. According to GINA criteria [27], the majority of children in the current sample had uncontrolled or partially controlled asthma given the high rate of symptoms, use of inhalers and health services visits. According to the World Health Organization [WHO], asthma control still remain unmet worldwide even with the availability of effective accessible cheap treatments [28]. Although preventable by better adherence to management strategies, the burden of uncontrolled asthma is extensive [29]. The lack of action plans and the over use of inhaled reliever medications in light of the high frequency of symptoms and health services visits indicates a serious under control of the illness [30]. Based on these parameters, children in the current study exhibited high burden of illness.

While symptoms and health services utilization in the current sample indicate a diagnosis of persistent asthma [more than 50% indicated persistent symptoms in the previous month, and two thirds indicating at least one asthma attack], only a fraction were prescribed maintenance preventive medications. The international societies [e.g. the American Thoracic Society] regularly update guidelines on asthma treatment, with beta-2 adrenergic agonists and corticosteroids are the most used drugs [31]. According to the guidelines, therapy is proposed according to clinical severity and the level of disease control [31]. The lack of proper action plans and suitable medications in the current sample calls for an action from the health care professionals [administrators, educators, clinicians] and stakeholders to improve outcomes. Actions include more effective collaboration with patients and their caregivers in planning and implementing care [18].

Previous studies indicated inaccurate rating and perceptions of parents regarding their child’s symptoms [32]. In the current study parents were somehow reliable in indicating the general health of their children as these compared well with their burden of asthma. As symptoms [tau=-0.376] and health services [tau=0.212] increased, parents’ perceptions of their child’s general health decreased. A very important recommendation illustrates a strong relationship between parental perceptions of illness and adherence to health care providers’ advices [33]. Parental perceptions about illness and medication can be modified by health care providers during follow-up visits to foster better adherence [33], an outcome that provides a positive indicator of parents' readiness to help improve their child's asthma management. The study, however, found that parents despite their low to medium rating of the general health of their children indicated high smoking rates inside the house and the car. Studies have shown that asthma symptoms can be worsened by smoking and lead to asthma exacerbations which lead to higher rates of health services utilization [34]. An important action is higher awareness of the potential harmful effects of exposure to smoking and other triggers [35]. Adherence to management guidelines within a medical asthma action plan is also important. This includes accurate use of inhaled medications. The study found high rate of inaccurate use of inhaled medications. While the majority of children were prescribed reliever MDI, their handling [carrying, use, technique] of the inhaler was inadequate. Despite using it for years [average 3.7 years], only 34% carried inhalers all of the time and 18% used less than one canister. These outcomes indicate improper use and overuse of these reliever medications. A study found that children using lower canisters of reliever medications in a year were less likely to report current use of anti-inflammatory medications [36]. This was not the case in the current study where the majority used reliever medications with a very low use of anti-inflammatory drugs. Studies emphasized on parents' need to partner with care providers in their child's asthma management and get asthma education in structured visits [37]. A study from Egypt concluded that MDI's verbal counseling should be repeated and checked at every opportunity, especially with children, to improve and maintain the recommended MDI inhalation technique [38]. An important outcome from the current study is the inability of parents to provide appropriate description of medications prescribed for their child. While a few provided sound description of the medications, the majority provided incomplete or inaccurate medications. This calls for an urgent action by professionals and stakeholders to take action in order to ensure proper utilization of medications and related devices.

Children spend most of their time at schools; hence the ability of the school community to help the child with asthma better manage their illness is of great importance. Improving school environment is considered vital in any asthma management program. Although children in the current sample indicated getting help from their teachers and school administration, they are still faced by some stigma around their use of their medications. Therefore, interventions to improve asthma care must consider ways to address these issues including improvement in the communication among parents and school teachers. Studies from the international literature indicated that interventions in schools can successfully improve asthma control and raise the awareness of asthma [38, 39].

The outcomes of the study showed that most children poorly performed inhalation technique similar to children in previous studies who showed improper inhaler technique [40]. As children participation in their asthma control is greatly recommended, experts recommend comprehensive and repeated inhalation instructions for a long lasting effect rather than one-time instruction session [41]. Several factors affect compliance to medications regimen and technique. Children with good inhaler techniques and compliance have better control of their asthma [42, 43].

Although limited by the descriptive exploratory nature and the small sample size which limits the generalizability of the results, the general outcomes of the current study indicated several weaknesses in the management of childhood asthma among school children. The outcomes of this study besides previously reported studies lead to the same conclusion: an alarming high burden of asthma. The high frequency of asthma symptoms, the extraordinary use of medications, the high level of health services utilization, the poor handling of asthma triggers such as smoking, the inappropriate management at schools, besides the incorrect use of MDI inhalers adds to the total burden of illness among these children. Without careful review of the current situations and ignorance of such outcomes, children with asthma and their families will continue to suffer.

The significance is portrayed in the congruence of all measures within the literature and those used in the current study. The study provides nurses with overview of asthma indicators and management plans besides overview of different measures that can be tailored to assess asthma disease burden.

Conclusion

The high reported burden of asthma among the current sample [symptoms, use of inhalers and services] was aggravated by the improper use of inhalers. Parental perception is important indicator of adherence to health care providers’ advices. This calls for collaboration between professionals and stakeholders with children and caregivers in planning and implementing care. Children with asthma require thorough follow up. Their asthma outcomes indicate a poor management which calls for an action.

Acknowledgements
The author wish to acknowledge the support received from the Ministry of higher education Jordan [Scientific research Fund], also all families and children and teachers who participated in this study.

Competing interests
The author declares no conflicts of interest.

Ethics statement
An ethics approval was solicited from the Hashemite University IRB committee and the Ministry of education and each individual school. Parental informed consent was obtained for each of the children prior to their participation in the study.