http://informahealthcare.com/jas ISSN: 0277-0903 (print), 1532-4303 (electronic) J Asthma, 2014; 51(10): 1089–1095 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2014.943372
QUALITY OF LIFE
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Association between quality of life in parents and components of asthma control in children Alfredo Cano-Garcinun˜o, MD, PhD1, Alberto Bercedo-Sanz, MD, PhD2, Isabel Mora-Gandarillas, MD3, Marı´a Teresa Calle´n-Blecua, MD, PhD4, Jose´ Antonio Castillo-Laita, MD, PhD5, Dolors Forns-Serrallonga, PhD6, Irene Casares-Alonso, 7 8 ´ MD, PhD , Luz Marı´a Alonso-Bernardo, MD , A gueda Garcı´a-Merino, MD, PhD9, Isabel Moneo-Herna´ndez, MD10, Olga 11 Corte´s-Rico, MD , Eula`lia Tauler-Toro, MD, PhD12, Ignacio Luı´s Carvajal-Uruen˜a, MD, PhD8, Juan Jose´ Morell-Bernabe´, 13 ˜ ez, MD, PhD14, Carmen Rosa Rodrı´guez-Ferna´ndez-Oliva, MD, PhD15, Marı´a Teresa AsensiMD , Itziar Martı´n-Iba´n 16 Monzo´, MD, PhD , Carmen Ferna´ndez-Carazo, MD17, Jose´ Murcia-Garcı´a, MD, PhD18, Catalina Dura´n-Iglesias, MD19, Jose´ Luı´s Monto´n-A´lvarez, MD, PhD20, Begon˜a Domı´nguez-Aurrecoechea, MD21, and Manuel Praena-Crespo, MD, PhD22 1
Centro de Salud Villamuriel de Cerrato, Palencia, Spain, 2Centro de Salud Buelna, Cantabria, Spain, 3Centro de Salud Infiesto, Asturias, Spain, Centro de Salud Bidebieta, San Sebastia´n, Spain, 5Centro de Salud Fuentes de Ebro, Zaragoza, Spain, 6Department of Clinical Psychology and Health, Universidad Auto´noma de Barcelona, Barcelona, Spain, 7Centro de Salud Venta de Ban˜os, Palencia, Spain, 8Centro de Salud La Erı´a, Oviedo, Spain, 9Centro de Salud Vallobı´n-La Florida, Oviedo, Spain, 10Centro de Salud Las Fuentes Norte, Zaragoza, Spain, 11Centro de Salud Canillejas, Madrid, Spain, 12Centro de Salud Martorell, Barcelona, Spain, 13Centro de Salud Zona Centro, Badajoz, Spain, 14Centro de Atencio´n Primaria La Mina, Barcelona, Spain, 15Centro de Salud La Cuesta, Tenerife, Spain, 16Centro de Salud Serrerı´a, Valencia, Spain, 17Centro de Salud El Valle, Jae´n, Spain, 18Centro de Salud San Felipe, Jae´n, Spain, 19Centro de Salud Arroyo de la Luz, Ca´ceres, Spain, 20Centro de Salud Mar Ba´ltico, Madrid, Spain, 21 Centro de Salud Otero, Oviedo, Spain, and 22Centro de Salud La Candelaria, Sevilla, Spain 4
Abstract
Keywords
Objective: Describe the association between parents’ quality of life and the two components of asthma control in children: impairment and risk. Methods: Cross-sectional study with children between 4 and 14 years of age with active asthma recruited at primary care centers in Spain. Asthma control was assessed according to the Third National Asthma Expert Panel Report, classifying ‘‘impairment’’ in three levels (well-controlled asthma, partially controlled, and poorly controlled), and ‘‘risk’’ as high or low. The parents’ quality of life was evaluated using the specific Family Impact of Childhood Bronchial Asthma Questionnaire instrument (IFABI-R). The association between asthma control and the parents’ quality of life was analyzed using multivariate regression models adjusted for other social and family variables. Results: Data from 408 children were analyzed. The parents’ quality of life was affected in the partially controlled asthma group when compared with well-controlled asthma, as showed by an increase in IFABI-R scores in all dimensions: functional 17.2% (p50.001), emotional 10.4% (p ¼ 0.021), and socio-occupational 6.8% (p ¼ 0.056). The differences were higher in poorly controlled asthma compared with well-controlled asthma: functional 24.3% (p ¼ 0.001), emotional 18.9% (p ¼ 0.008), and socio-occupational 11.5% (p ¼ 0.036). The ‘‘risk’’ component was independently associated with the parents’ quality of life. Of all the elements used to assess the control, the only one independently associated with the parents’ quality of life was recurrent asthma crisis. Conclusions: In asthma control, both ‘‘impairment’’ and ‘‘risk’’ in children are gradually associated with the parents’ quality of life. The global assessment of the control surpasses the importance of each individual element used in this assessment.
Control/management, morbidity and mortality, pediatrics, quality of life
Introduction Asthma is one of the most frequent, chronic childhood diseases, affecting 10% of all school children in Spain [1]. The objective of asthma treatment is to control the disease so that children with asthma are able to perform all the normal activities for their age. Asthma control is a compound
Correspondence: Alfredo Cano-Garcinun˜o, Centro de Salud Villamuriel de Cerrato, Palencia, Spain. Tel: +34 666808171. E-mail: [email protected]
History Received 20 May 2014 Revised 1 July 2014 Accepted 6 July 2014 Published online 11 August 2014
concept, made up of two components [2,3]. One of these components is impairment, which is assessed based on the frequency of symptoms, the need for rescue medication and lung function. The other component is the risk of losing control, which is generally linked to a prior history of episodes of lost control (crisis). In children, asthma affects their quality of life, which is directly linked to the degree to which the disease is controlled [4]. Parents’ experience of childhood asthma is also important; for instance, parental report of the child quality of life is related to the way in which the child receives treatment for
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his/her asthma [5]. However, the relationship between asthma control and the parents’/caregivers’ quality of life remains to be elucidated, as studies have found conflicting results [6–11]. Moreover, there are certain aspects of the relationship between asthma control and the parents’/caregivers’ quality of life that have not been studied in detail. First of all, most prior studies have classified asthma as controlled and uncontrolled, but the clinical guidelines recognize intermediate stages. Grading could be used to test the consistency of the association between asthma control and family impact, analyzing whether different degrees of control are linked to a greater impact. Second, the risk of loss of control has not been studied independently from impairment, and therefore, the relative importance of each one is not known. Third, it must be remembered that asthma control is a multi-dimensional concept, made up of a set of elements that could have a different impact on the parents’/caregivers’ quality of life. Until now, the individual effect of each element has not been evaluated and some of these elements could play a decisive role. The objective of this study was to identify the association between the parents’ quality of life and childhood asthma control (impairment and risk), including each of the individual components that define control.
Methods Using a cross-sectional design, children with asthma between the ages of 4 and 14 were studied. They were recruited from 22 primary care centers in Spain. Asthma had been diagnosed by a doctor when the patients met the following criteria: repeated symptoms suggesting asthma, symptom-free periods, response to anti-asthmatic treatment, and lack of data suggesting any other diagnosis. The children in the study had to have active asthma, defined as having shown symptoms of asthma or having received an asthma maintenance treatment in the previous 12 months. One main caregiver (mother or father), with sufficient oral and written capacity in Spanish, was interviewed. The study was approved by the Project Coordination Ethics Committee (Palencia Healthcare Area, Spain) and carried out according to the principles of the Declaration of Helsinki. All the participants – both parents and children – were informed about the nature of the study; they granted their written permission to participate in the study. The following variables were collected: (1) Degree of asthma control: according to the Third National Asthma Expert Panel Report (NAEPP-3) [2], it has two components: impairment and risk. Impairment was assessed based on the frequency of the symptoms, nighttime awakenings, short-acting beta2-agonist (SABA) use for symptom relieving, limiting daily activities, and pulmonary function (forced expiratory volume in 1 second, FEV1, and its ratio with the forced vital capacity, FEV1/FVC). Each of the variables was coded in three categories according to the NAEPP-3 (see Online Resource, Supplementary material) recommendations: without impairment (used as reference category), moderate impairment, and severe impairment. On one hand, any variable with moderate impairment means that asthma control goes from good to partial and any
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variable with severe impairment means that the asthma is considered poorly controlled. On the other hand, the risk of loss of control was assessed with four variables: hospitalization due to asthma in the previous 12 months, recent asthma crisis (in the previous month), a history of interrupted treatment due to adverse effects of the medication, and frequent crisis requiring treatment with systemic corticoids in the previous 12 months (2 compared with 1). In this context, crisis was defined as an increase of the intensity of symptoms that interferes with daily activities. The risk was classified as high if any one of these circumstances was present; otherwise, it was classified as low. All these variables were determined with a structured data collection procedure, through a clinical interview and review of the patient clinical register. Lung function was measured in children 46 years of age with basal spirometry according to the guidelines of the American Thoracic Society and the European Respiratory Society [12], using the reference values proposed by the Global Lung Function Initiative [13]. (2) The impact of asthma on the parents’ quality of life was measured using the specific Family Impact of Childhood Bronchial Asthma Questionnaire (IFABI-R) instrument, designed and validated in Spanish [14]. It is a 15-item questionnaire with four response options that explores three domains (functional, emotional, and sociooccupational) of the parents’/caregivers’ quality of life in the past 3 months. This instrument has an adequate factorial structure, a high internal consistency, and good convergent validity [14]. Scores for each dimension as well as a global score were calculated, ranging from 1 (minimal impact of asthma on parents’ quality of life) to 4 (maximum impact). (3) Family functioning was assessed using the ‘‘family Apgar’’ instrument [15] that has a validated version in Spanish [16]. This instrument is a five-item questionnaire with three response options. The result is given as the mean score and ranges from 1 (worse) and 3 (better family functioning). (4) Family social-economic data were collected by means of a direct interview with the main caregiver (mother or father). The social class was classified according to the recommendations of the Spanish Society of Epidemiology [17] (see Online Resource) and categorized as high (categories 1–2 of the mentioned classification) or low (all other categories). The educational level was classified as high (higher or university education) or low. The association between the parents’ quality of life and child’s asthma control, as well as the relationship between the parents’ quality of life and each of the individual elements making up the control assessment, was analyzed by means of multiple regression models that included covariates for age, sex, years since asthma diagnosis, sensitivity to inhalants, educational level, social class, family functioning, and responding caregiver (mother or father). In each regression model, the dependent variable was the IFABI-R score, which was log-transformed because of its non-normal distribution. On account of the logarithmic transformation, the coefficients
DOI: 10.3109/02770903.2014.943372
of the regression models (and their confidence intervals) represent the percentage difference in the IFABI-R score associated with each of the variables included in the regression model. The comparisons between proportions were performed using a Pearson’s chi-squared test while the comparisons between continuous variables were carried out with non-parametric tests (Mann–Whitney). The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS 15, SPSS Inc., Chicago, IL).
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Results In total, 510 questionnaires were given out, of which 493 (96.7%) were completed in full; 408 (80.0%) were responded by the main caregiver (mother or father). Tables 1 and 2 show the demographic, socio-economic and disease characteristics of the children included in the analysis. The children who were not included in the analysis due to incomplete data were slightly younger, with a median age of 8.0 years and an interquartile range (IQR) of 5.1–12.7 years compared with 9.7 (7.6–11.5) years, p ¼ 0.096. The time elapsed since being diagnosed with asthma was less for this group, with a median (IQR) of 4 (2–5) years in comparison with 5 (2–7) years, p ¼ 0.034. There were no other differences for any of the other variables. Table 3 shows the association between asthma control and the parents’ quality of life, based on the multivariate models. Table 1. Sample description: demographic, socio-economic, and disease characteristics. Age, years (median, IQR) 9.7 (7.6–11.5) Sex male (%) 63.5 Weight, kg (median, IQR) 35.0 (26.0–45.0) Height, cm (median, IQR) 137.6 (125.5–149.0) Age mother, years (median, IQR) 40.0 (37.0–44.0) Age father, years (median, IQR) 43.0 (39.0–46.0) Parents’ education – high school or University 59.1 degree (%) High social class (%)a 15.9 Number of members in the household (median, IQR) 4.0 (3.0–4.0) Family Apgar (median, IQR)b 3.0 (2.0–3.0) Hospitalized due to asthma (%) 27.2 Hospitalized in the previous 3 months (%) 1.2 Admitted to ICU (%) 1.5 Treatment level 1: No maintenance medication (%) 32.7 2: Mono-therapy: LA, chromones or low dose 31.7 IC (%) 3: Medium dose IC mono-therapy or low dose 25.6 IC poly-therapy (%) 4: Medium dose IC poly-therapy (%) 6.4 5: High dose IC poly-therapy (%) 3.7 Allergy to inhalants (%) 84.6 Years since asthma was diagnosed (median, IQR) 5.0 (2.0–7.0) Any crisis in previous 3 months (%) 49.6 Any crisis with SC in previous 3 months (%) 21.2 IFABI-R Functional (median, IQR) 1.67 (1.00–2.00) IFABI-R Emotional (median, IQR) 1.40 (1.20–2.00) IFABI-R Social (median, IQR) 1.14 (1.00–1.60) IFABI-R Total (median, IQR) 1.33 (1.13–1.86) IC, inhaled corticosteroids; LABA, long-acting beta adrenergic; LA, leukotriene antagonists; SC, systemic corticosteroids; IQR, interquartile range. a See text. The classification of the Spanish Society of Epidemiology was used (see Online Resource). b See text. Values may range from 1 (better) to 4 (worse parents’ quality of life).
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In all three domains, the quality of life was poorer (increase in IFABI-R scores) when the asthma control was partial, and the impact was even greater if asthma control was poor. Likewise, a high risk of losing control was independently associated with the parents’ worse quality of life. Of all the covariates included, only family functioning and social class were linked to the parents’ quality of life. Exploration of interaction between asthma control status and family functioning yielded no significant results. Table 4 shows the association between the parents’ quality of life and each individual element of the asthma control assessment. The frequent, but not moderated, use of SABA was associated with a worse quality of life in the parents for the emotional dimension. However, the only element with a strong association with all of the dimensions for the parents’ quality of life was repeated asthma crisis (Figure 1).
Discussion As with all childhood diseases, asthma is a burden for both patients and family. Parents make decisions relative to their child’s disease, such as the use of medication or going to a doctor’s appointment. Therefore, the impact of the disease on the parents’ quality of life could influence how the child’s asthma is handled and the child’s quality of life. It has been observed that the perception parents have of the severity of their child’s asthma is linked to the intensity of the antiasthmatic treatment that the child receives [5] and to his/her quality of life [18]. The present study goes further and tries to elucidate the association between parents’ quality of life and Table 2. Characteristics of asthma control in the sample. Symptoms Infrequent (%) Moderate (%) Frequent (%) Nighttime awakenings Infrequent (%) Moderate (%) Frequent (%) Interference with normal activity None (%) Some (%) Extremely (%) SABA use for symptom control Infrequently (%) Moderate (%) Frequent (%) Lung function (FEV1) impairment None (%) Moderate (%) Severe (%) Lung function (FEV1/FVC) impairment None (%) Moderate (%) Severe (%) Hospitalization in previous 12 months (%) Recent exacerbation (51 month) (%) Medication withdrawal because side effects (%) 2 exacerbations requiring SC in previous 12 months (%) Classification of asthma control (impairment) Well controlled (%) Partially controlled (%) Poorly controlled (%) High risk of loss of control (%) SC, systemic corticosteroids.
69.9 24.8 5.4 76.5 18.9 4.7 67.6 30.9 1.5 72.8 20.8 6.4 87.0 12.0 1.0 94.5 2.9 2.6 3.4 31.1 0.7 12.3 53.7 35.0 11.3 36.0
(3.1 to 18.1) (5.4 to 29.6) (10.1 to 26.5) (2.4 to 0.1) (6.3 to 5.3) (0.6 to 1.6) (10.7 to 5.0) (16.8 to 2.4) (8.3 to 3.5) (31.1 to 17.9) (14.3 to 2.0)
0.005 0.003 50.001 0.077 0.820 0.396 0.438 0.011 0.402 50.001 0.131
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The figures are the difference, in %, in the measure of the IFABI-R associated with each variable. Positive values represent a worsening in the quality of life. a With respect to the reference category ‘‘controlled asthma’’ (definitions in the text). b With respect to the reference category ‘‘low risk’’ (definitions in the text).
10.4 16.9 18.0 1.1 0.7 0.5 3.2 9.9 2.6 24.8 6.5 0.056 0.036 50.001 0.186 0.748 0.181 0.942 0.019 0.660 50.001 0.487 (0.2 to 14.2) (0.7 to 23.5) (10.0 to 26.0) (2.0 to 0.4) (4.7 to 7.0) (0.3 to 1.8) (7.4 to 8.7) (15.9 to 1.6) (4.5 to 7.6) (35.3 to 23.0) (10.9 to 5.7) 6.8 11.5 17.7 0.8 1.0 0.7 0.3 9.0 1.4 29.4 3.0 0.021 0.008 0.001 0.110 0.591 0.450 0.621 0.051 0.263 50.001 0.089 (1.5 to 20.1) (4.7 to 35.1) (6.7 to 26.5) (2.8 to 0.3) (8.8 to 5.4) (0.8 to 1.9) (11.8 to 7.8) (17.8 to 0.1) (11.1 to 3.3) (34.1 to 18.1) (18.1 to 1.4) 10.4 18.9 16.2 1.3 2.0 0.5 2.5 9.3 4.2 26.5 8.9 50.001 0.001 50.001 0.149 0.467 0.835 0.059 0.017 0.104 0.003 0.080 (7.8 to 27.5) (9.4 to 41.2) (10.8 to 31.5) (2.6 to 0.4) (9.5 to 4.7) (1.5 to 1.2) (17.9 to 0.4) (19.7 to 2.1) (12.8 to 1.3) (24.0 to 5.6) (18.4 to 1.1) 17.2 24.3 20.7 1.1 2.7 0.1 9.2 11.3 6.0 15.3 9.2 Partially controlled asthma Poorly controlled asthmaa High riskb Age (each year) Male sex Years since asthma diagnosis Sensitivity to inhalants High social class High level of education Family functioning (family Apgar) Father responds
% Difference (95% CI) p % Difference (95% CI) % Difference (95% CI)
p
% Difference (95% CI)
p
Socio-occupational R2 ¼ 0.260
Dimensions of parents’/caregivers’ quality of life measured by the IFABI-R instrument
Emotional R2 ¼ 0.206 Functional R ¼ 0.249
2
Table 3. Multivariate regression model. Association between asthma control and parents’ quality of life. Percent differences in the IFABI-R score.
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Total R2 ¼ 0.272
p
A. Cano-Garcinun˜o et al.
a
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the degree of asthma control in children, an association that was not evident in all prior studies. Dean et al. [6,7] discovered an association between the poor control of asthma and the parents’ worsening quality of life; Bender and Zhang [8] also encountered an association between the parents’ mood and the intensity of the child’s asthma symptoms; Bloomberg et al. [19] identified a progressive deterioration of parents’ quality of life as asthma control in children worsened. More recently, Stelmach et al. [9] found a correlation between the medium-term variation in the parents’ quality of life and variations in asthma control. However, Price et al. [10] found no relationship between the parents’ quality of life and the number of asthma crisis or visits to the doctor in the year prior to launching an intensive intervention program in children and adolescents with refractory asthma. Shalowitz et al. [11] found that in a low-income population, symptoms of depression in the mothers of children with asthma were linked to stress and a lack of social support, but not to the objective state of the child’s disease. We have also observed that educational activities on asthma supplied to children and/or parents can modify symptoms without changing the caregivers’ quality of life [20]. It is evident that health-related quality of life is affected by a number of external factors, and by personality traits, independently of the objective clinical status. Therefore, it is necessary that the analysis of the relationship between the quality of life and asthma control includes adjustment terms relative to family functioning and social-cultural aspects. Our research shows that there is an association between asthma control in children and their parents’ quality of life, regardless of their social class or level of education. Moreover, we have determined that there is a strong, independent association between risk of loss of control and the parents’ quality of life. Likewise, upon classifying asthma as controlled, partially controlled, and poorly controlled, we have also shown that there is a progressive relationship between the asthma control and the parents’ quality of life, as it was previously described by Bloomberg et al. [19]. Our study also underlines the multi-dimensional nature of asthma control, which cannot be substituted by individual elements. One of the elements always included in asthma control assessments is pulmonary function. It was already known that pulmonary function has no relationship with the asthmatic patient’s quality of life [21–23], and we have now shown that there is no relationship with the parents’ quality of life. From the multivariate models, the only element that clearly affects all the quality of life dimensions is the repetition of asthma crisis. Crisis cause a major family disruption, in which not only is there great concern for the child’s health, but other complications appear: family organizational difficulties, missed school, lost work days, repeated visits to the doctor, and in some cases, economic difficulties. That disruption of family life is likely the main effect of repeated asthma crisis on the parents’ quality of life. Gender differences have been identified with regard to the impact that childhood asthma has on the parents, with mothers being more susceptible. During another clinical trial, it was found that interventions that reduce maternal anxiousness improved both therapeutic adherence and asthma control [24]. In our study, when the quality of life assessment was
0.019 0.059 0.052 0.336 0.538 0.099 0.633 0.658 0.859 0.880 0.283 0.192 0.735 0.004
14.5 (2.3 to 28.2) 24.5 (0.8 to 56.2) 10.2 (0.1 to 21.6) 17.3 (15.3 to 62.4) 4.1 (8.4 to 18.3) 18.8 (3.2 to 45.9) 3.7 (10.7 to 20.5) 11.4 (48.4 to 52.0) 2.4 2.5 10.1 6.6 6.8 18.4
(21.5 to 33.7) (30.1 to 36.0) (26.0 to 9.2) (3.2 to 17.4) (38.0 to 40.2) (5.4 to 33.0)
0.277 0.285
p
6.9 (5.2 to 20.6) 11.6 (29.6 to 10.9)
% Difference (95% CI)
3.2 6.1 5.9 1.0 12.2 26.2
(22.1 to 36.9) (25.4 to 51.1) (12.8 to 28.6) (8.3 to 11.2) (41.6 to 31.9) (12.5 to 41.7)
0.9 (14.0 to 18.3) 9.6 (38.2 to 94.4)
11.0 (2.3 to 26.1) 24.2 (1.2 to 52.4)
11.5 (1.1 to 22.9) 22.4 (11.5 to 69.3)
1.8 (9.1 to 14.0) 1.8 (18.8 to 27.7)
1.4 (10.1 to 14.3) 11.3 (29.3 to 11.2)
% Difference (95% CI)
0.916 0.753
0.110 0.038
0.030 0.220
0.757 0.877
0.820 0.297
p
0.824 0.740 0.564 0.840 0.529 50.001
Emotional R2 ¼ 0.262
1.7 9.1 2.6 9.0 14.9 24.4
(20.4 to 21.5) (30.2 to 18.5) (16.5 to 13.7) (0.9 to 17.6) (16.8 to 58.8) (13.4 to 36.3)
6.5 (5.5 to 20.0) 18.5 (22.9 to 82.2)
1.6 (8.2 to 12.5) 10.1 (6.5 to 29.5)
3.4 (4.4 to 11.7) 17.9 (8.9 to 52.5)
8.3 (1.0 to 18.4) 4.9 (12.3 to 25.6)
2.0 (7.3 to 12.2) 6.3 (21.7 to 12.2)
% Difference (95% CI)
0.877 0.481 0.738 0.028 0.399 50.001
0.302 0.437
0.755 0.247
0.405 0.210
0.082 0.598
0.685 0.478
p
Socio-occupational R2 ¼ 0.262
2.2 0.6 1.4 5.3 1.1 24.4
(18.0 to 27.3) (24.5 to 30.8) (15.7 to 15.2) (2.6 to 13.7) (28.7 to 37.2) (13.4 to 36.5)
3.0 (9.0 to 16.7) 6.3 (32.0 to 66.1)
5.7 (4.6 to 17.1) 18.1 (0.2 to 39.3)
7.6 (0.6 to 16.4) 18.6 (8.6 to 54.0)
6.9 (2.4 to 17.0) 8.2 (9.8 to 29.8)
3.3 (6.2 to 13.8) 10.1 (25.0 to 7.9)
% Difference (95% CI)
Total R2 ¼ 0.319
0.847 0.964 0.855 0.192 0.948 50.001
0.634 0.788
0.288 0.047
0.069 0.198
0.151 0.397
0.505 0.252
p
Results adjusted by age, sex, years since diagnosis, allergic sensitization, social class, education level, family functioning, and respondent (father/mother). SC, systemic corticosteroids; SABA, short-acting beta2agonist. a The figures are the difference, in %, in the measure of the IFABI-R associated with each variable. Positive values represent a worsening in the quality of life. b The reference category is ‘‘infrequent’’ or ‘‘none’’.
Symptoms Moderate Frequent Nighttime awakeningsb Moderate Frequent Interference with normal activityb Some Extremely SABA use for symptom relievingba Moderate Frequent Lung function (FEV1) Impairmentb Moderate Severe Lung function (FEV1/FVC) impairmentb Moderate Severe Hospitalization in previous 12 months Recent crisis (51 month) Medication withdrawal because side effects 2 exacerbations requiring SC in previous 12 months
b
Functional R2 ¼ 0.300
Dimensions of parent/caregiver quality of lifea
Table 4. Multivariate regression model. Association between parents’ quality of life and each component of asthma control. Percent differences in the IFABI-R score.
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DOI: 10.3109/02770903.2014.943372
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Figure 1. IFABI-R score according to the number of crisis in the previous 3 months: functional dimension (white), emotional dimension (gray), socio-occupational dimension (stripes), and total IFABI-R score (dots).
provided by the father, there was a slight, yet not significant decline in the impact of asthma, especially for the functional and emotional dimensions. This study has the typical limits of cross-sectional studies, in which the direction of the effect cannot be established. It is possible that the parents’ poorer quality of life determines asthma management patterns that lead to poorer control; nevertheless, it is also possible that poor asthma control deteriorates the parents’ quality of life. Likewise, it is possible that the parents’ quality of life and asthma control, although associated, have no cause–effect relationship. We have not strived to establish causation, but rather, how these two aspects are related. It must also be mentioned that the framework of the study could influence in the generalization of the results. Our sample stems from primary care centers in which the patients representing children with asthma as they can be found in the community, rather than hospitalized patients or a population selected purposely, based on precise characteristics. The study has been performed in Spain; the social-cultural characteristics of other countries could mean that the results are not transferable. Finally, upon studying Table 4, it might seem that two asthma control elements (interference with activities and SABA use for symptom relief) have a gradual, although not statistically significant, effect on the parents’ quality of life. It could very well be that those two components are statistically significant in a larger sample size.
Conclusions Asthma control has a proportional relationship with all dimensions of parents’ quality of life; this is true for both impairment and risk. Repeated asthma crises affect the parents’ quality of life, but no other isolated elements of those used to assess asthma control have an independent and consistent effect. In managing poorly controlled childhood
asthma, the associated family impact must be considered, and more research should provide evidence about effective strategies of family intervention that would yield better health outcomes in asthma.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was financed with a grant (Healthcare Research Project PI11/02122) from the Instituto de Salud Carlos III, Ministry of Education and Competitiveness, Government of Spain.
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Parents’QoL and asthma control in children
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Supplementary material provided online.
QUALITY OF LIFE
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Association between quality of life in parents and components of asthma control in children Alfredo Cano-Garcinun˜o, MD, PhD1, Alberto Bercedo-Sanz, MD, PhD2, Isabel Mora-Gandarillas, MD3, Marı´a Teresa Calle´n-Blecua, MD, PhD4, Jose´ Antonio Castillo-Laita, MD, PhD5, Dolors Forns-Serrallonga, PhD6, Irene Casares-Alonso, 7 8 ´ MD, PhD , Luz Marı´a Alonso-Bernardo, MD , A gueda Garcı´a-Merino, MD, PhD9, Isabel Moneo-Herna´ndez, MD10, Olga 11 Corte´s-Rico, MD , Eula`lia Tauler-Toro, MD, PhD12, Ignacio Luı´s Carvajal-Uruen˜a, MD, PhD8, Juan Jose´ Morell-Bernabe´, 13 ˜ ez, MD, PhD14, Carmen Rosa Rodrı´guez-Ferna´ndez-Oliva, MD, PhD15, Marı´a Teresa AsensiMD , Itziar Martı´n-Iba´n 16 Monzo´, MD, PhD , Carmen Ferna´ndez-Carazo, MD17, Jose´ Murcia-Garcı´a, MD, PhD18, Catalina Dura´n-Iglesias, MD19, Jose´ Luı´s Monto´n-A´lvarez, MD, PhD20, Begon˜a Domı´nguez-Aurrecoechea, MD21, and Manuel Praena-Crespo, MD, PhD22 1
Centro de Salud Villamuriel de Cerrato, Palencia, Spain, 2Centro de Salud Buelna, Cantabria, Spain, 3Centro de Salud Infiesto, Asturias, Spain, Centro de Salud Bidebieta, San Sebastia´n, Spain, 5Centro de Salud Fuentes de Ebro, Zaragoza, Spain, 6Department of Clinical Psychology and Health, Universidad Auto´noma de Barcelona, Barcelona, Spain, 7Centro de Salud Venta de Ban˜os, Palencia, Spain, 8Centro de Salud La Erı´a, Oviedo, Spain, 9Centro de Salud Vallobı´n-La Florida, Oviedo, Spain, 10Centro de Salud Las Fuentes Norte, Zaragoza, Spain, 11Centro de Salud Canillejas, Madrid, Spain, 12Centro de Salud Martorell, Barcelona, Spain, 13Centro de Salud Zona Centro, Badajoz, Spain, 14Centro de Atencio´n Primaria La Mina, Barcelona, Spain, 15Centro de Salud La Cuesta, Tenerife, Spain, 16Centro de Salud Serrerı´a, Valencia, Spain, 17Centro de Salud El Valle, Jae´n, Spain, 18Centro de Salud San Felipe, Jae´n, Spain, 19Centro de Salud Arroyo de la Luz, Ca´ceres, Spain, 20Centro de Salud Mar Ba´ltico, Madrid, Spain, 21 Centro de Salud Otero, Oviedo, Spain, and 22Centro de Salud La Candelaria, Sevilla, Spain 4
Abstract
Keywords
Objective: Describe the association between parents’ quality of life and the two components of asthma control in children: impairment and risk. Methods: Cross-sectional study with children between 4 and 14 years of age with active asthma recruited at primary care centers in Spain. Asthma control was assessed according to the Third National Asthma Expert Panel Report, classifying ‘‘impairment’’ in three levels (well-controlled asthma, partially controlled, and poorly controlled), and ‘‘risk’’ as high or low. The parents’ quality of life was evaluated using the specific Family Impact of Childhood Bronchial Asthma Questionnaire instrument (IFABI-R). The association between asthma control and the parents’ quality of life was analyzed using multivariate regression models adjusted for other social and family variables. Results: Data from 408 children were analyzed. The parents’ quality of life was affected in the partially controlled asthma group when compared with well-controlled asthma, as showed by an increase in IFABI-R scores in all dimensions: functional 17.2% (p50.001), emotional 10.4% (p ¼ 0.021), and socio-occupational 6.8% (p ¼ 0.056). The differences were higher in poorly controlled asthma compared with well-controlled asthma: functional 24.3% (p ¼ 0.001), emotional 18.9% (p ¼ 0.008), and socio-occupational 11.5% (p ¼ 0.036). The ‘‘risk’’ component was independently associated with the parents’ quality of life. Of all the elements used to assess the control, the only one independently associated with the parents’ quality of life was recurrent asthma crisis. Conclusions: In asthma control, both ‘‘impairment’’ and ‘‘risk’’ in children are gradually associated with the parents’ quality of life. The global assessment of the control surpasses the importance of each individual element used in this assessment.
Control/management, morbidity and mortality, pediatrics, quality of life
Introduction Asthma is one of the most frequent, chronic childhood diseases, affecting 10% of all school children in Spain [1]. The objective of asthma treatment is to control the disease so that children with asthma are able to perform all the normal activities for their age. Asthma control is a compound
Correspondence: Alfredo Cano-Garcinun˜o, Centro de Salud Villamuriel de Cerrato, Palencia, Spain. Tel: +34 666808171. E-mail: [email protected]
History Received 20 May 2014 Revised 1 July 2014 Accepted 6 July 2014 Published online 11 August 2014
concept, made up of two components [2,3]. One of these components is impairment, which is assessed based on the frequency of symptoms, the need for rescue medication and lung function. The other component is the risk of losing control, which is generally linked to a prior history of episodes of lost control (crisis). In children, asthma affects their quality of life, which is directly linked to the degree to which the disease is controlled [4]. Parents’ experience of childhood asthma is also important; for instance, parental report of the child quality of life is related to the way in which the child receives treatment for
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his/her asthma [5]. However, the relationship between asthma control and the parents’/caregivers’ quality of life remains to be elucidated, as studies have found conflicting results [6–11]. Moreover, there are certain aspects of the relationship between asthma control and the parents’/caregivers’ quality of life that have not been studied in detail. First of all, most prior studies have classified asthma as controlled and uncontrolled, but the clinical guidelines recognize intermediate stages. Grading could be used to test the consistency of the association between asthma control and family impact, analyzing whether different degrees of control are linked to a greater impact. Second, the risk of loss of control has not been studied independently from impairment, and therefore, the relative importance of each one is not known. Third, it must be remembered that asthma control is a multi-dimensional concept, made up of a set of elements that could have a different impact on the parents’/caregivers’ quality of life. Until now, the individual effect of each element has not been evaluated and some of these elements could play a decisive role. The objective of this study was to identify the association between the parents’ quality of life and childhood asthma control (impairment and risk), including each of the individual components that define control.
Methods Using a cross-sectional design, children with asthma between the ages of 4 and 14 were studied. They were recruited from 22 primary care centers in Spain. Asthma had been diagnosed by a doctor when the patients met the following criteria: repeated symptoms suggesting asthma, symptom-free periods, response to anti-asthmatic treatment, and lack of data suggesting any other diagnosis. The children in the study had to have active asthma, defined as having shown symptoms of asthma or having received an asthma maintenance treatment in the previous 12 months. One main caregiver (mother or father), with sufficient oral and written capacity in Spanish, was interviewed. The study was approved by the Project Coordination Ethics Committee (Palencia Healthcare Area, Spain) and carried out according to the principles of the Declaration of Helsinki. All the participants – both parents and children – were informed about the nature of the study; they granted their written permission to participate in the study. The following variables were collected: (1) Degree of asthma control: according to the Third National Asthma Expert Panel Report (NAEPP-3) [2], it has two components: impairment and risk. Impairment was assessed based on the frequency of the symptoms, nighttime awakenings, short-acting beta2-agonist (SABA) use for symptom relieving, limiting daily activities, and pulmonary function (forced expiratory volume in 1 second, FEV1, and its ratio with the forced vital capacity, FEV1/FVC). Each of the variables was coded in three categories according to the NAEPP-3 (see Online Resource, Supplementary material) recommendations: without impairment (used as reference category), moderate impairment, and severe impairment. On one hand, any variable with moderate impairment means that asthma control goes from good to partial and any
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variable with severe impairment means that the asthma is considered poorly controlled. On the other hand, the risk of loss of control was assessed with four variables: hospitalization due to asthma in the previous 12 months, recent asthma crisis (in the previous month), a history of interrupted treatment due to adverse effects of the medication, and frequent crisis requiring treatment with systemic corticoids in the previous 12 months (2 compared with 1). In this context, crisis was defined as an increase of the intensity of symptoms that interferes with daily activities. The risk was classified as high if any one of these circumstances was present; otherwise, it was classified as low. All these variables were determined with a structured data collection procedure, through a clinical interview and review of the patient clinical register. Lung function was measured in children 46 years of age with basal spirometry according to the guidelines of the American Thoracic Society and the European Respiratory Society [12], using the reference values proposed by the Global Lung Function Initiative [13]. (2) The impact of asthma on the parents’ quality of life was measured using the specific Family Impact of Childhood Bronchial Asthma Questionnaire (IFABI-R) instrument, designed and validated in Spanish [14]. It is a 15-item questionnaire with four response options that explores three domains (functional, emotional, and sociooccupational) of the parents’/caregivers’ quality of life in the past 3 months. This instrument has an adequate factorial structure, a high internal consistency, and good convergent validity [14]. Scores for each dimension as well as a global score were calculated, ranging from 1 (minimal impact of asthma on parents’ quality of life) to 4 (maximum impact). (3) Family functioning was assessed using the ‘‘family Apgar’’ instrument [15] that has a validated version in Spanish [16]. This instrument is a five-item questionnaire with three response options. The result is given as the mean score and ranges from 1 (worse) and 3 (better family functioning). (4) Family social-economic data were collected by means of a direct interview with the main caregiver (mother or father). The social class was classified according to the recommendations of the Spanish Society of Epidemiology [17] (see Online Resource) and categorized as high (categories 1–2 of the mentioned classification) or low (all other categories). The educational level was classified as high (higher or university education) or low. The association between the parents’ quality of life and child’s asthma control, as well as the relationship between the parents’ quality of life and each of the individual elements making up the control assessment, was analyzed by means of multiple regression models that included covariates for age, sex, years since asthma diagnosis, sensitivity to inhalants, educational level, social class, family functioning, and responding caregiver (mother or father). In each regression model, the dependent variable was the IFABI-R score, which was log-transformed because of its non-normal distribution. On account of the logarithmic transformation, the coefficients
DOI: 10.3109/02770903.2014.943372
of the regression models (and their confidence intervals) represent the percentage difference in the IFABI-R score associated with each of the variables included in the regression model. The comparisons between proportions were performed using a Pearson’s chi-squared test while the comparisons between continuous variables were carried out with non-parametric tests (Mann–Whitney). The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS 15, SPSS Inc., Chicago, IL).
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Results In total, 510 questionnaires were given out, of which 493 (96.7%) were completed in full; 408 (80.0%) were responded by the main caregiver (mother or father). Tables 1 and 2 show the demographic, socio-economic and disease characteristics of the children included in the analysis. The children who were not included in the analysis due to incomplete data were slightly younger, with a median age of 8.0 years and an interquartile range (IQR) of 5.1–12.7 years compared with 9.7 (7.6–11.5) years, p ¼ 0.096. The time elapsed since being diagnosed with asthma was less for this group, with a median (IQR) of 4 (2–5) years in comparison with 5 (2–7) years, p ¼ 0.034. There were no other differences for any of the other variables. Table 3 shows the association between asthma control and the parents’ quality of life, based on the multivariate models. Table 1. Sample description: demographic, socio-economic, and disease characteristics. Age, years (median, IQR) 9.7 (7.6–11.5) Sex male (%) 63.5 Weight, kg (median, IQR) 35.0 (26.0–45.0) Height, cm (median, IQR) 137.6 (125.5–149.0) Age mother, years (median, IQR) 40.0 (37.0–44.0) Age father, years (median, IQR) 43.0 (39.0–46.0) Parents’ education – high school or University 59.1 degree (%) High social class (%)a 15.9 Number of members in the household (median, IQR) 4.0 (3.0–4.0) Family Apgar (median, IQR)b 3.0 (2.0–3.0) Hospitalized due to asthma (%) 27.2 Hospitalized in the previous 3 months (%) 1.2 Admitted to ICU (%) 1.5 Treatment level 1: No maintenance medication (%) 32.7 2: Mono-therapy: LA, chromones or low dose 31.7 IC (%) 3: Medium dose IC mono-therapy or low dose 25.6 IC poly-therapy (%) 4: Medium dose IC poly-therapy (%) 6.4 5: High dose IC poly-therapy (%) 3.7 Allergy to inhalants (%) 84.6 Years since asthma was diagnosed (median, IQR) 5.0 (2.0–7.0) Any crisis in previous 3 months (%) 49.6 Any crisis with SC in previous 3 months (%) 21.2 IFABI-R Functional (median, IQR) 1.67 (1.00–2.00) IFABI-R Emotional (median, IQR) 1.40 (1.20–2.00) IFABI-R Social (median, IQR) 1.14 (1.00–1.60) IFABI-R Total (median, IQR) 1.33 (1.13–1.86) IC, inhaled corticosteroids; LABA, long-acting beta adrenergic; LA, leukotriene antagonists; SC, systemic corticosteroids; IQR, interquartile range. a See text. The classification of the Spanish Society of Epidemiology was used (see Online Resource). b See text. Values may range from 1 (better) to 4 (worse parents’ quality of life).
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In all three domains, the quality of life was poorer (increase in IFABI-R scores) when the asthma control was partial, and the impact was even greater if asthma control was poor. Likewise, a high risk of losing control was independently associated with the parents’ worse quality of life. Of all the covariates included, only family functioning and social class were linked to the parents’ quality of life. Exploration of interaction between asthma control status and family functioning yielded no significant results. Table 4 shows the association between the parents’ quality of life and each individual element of the asthma control assessment. The frequent, but not moderated, use of SABA was associated with a worse quality of life in the parents for the emotional dimension. However, the only element with a strong association with all of the dimensions for the parents’ quality of life was repeated asthma crisis (Figure 1).
Discussion As with all childhood diseases, asthma is a burden for both patients and family. Parents make decisions relative to their child’s disease, such as the use of medication or going to a doctor’s appointment. Therefore, the impact of the disease on the parents’ quality of life could influence how the child’s asthma is handled and the child’s quality of life. It has been observed that the perception parents have of the severity of their child’s asthma is linked to the intensity of the antiasthmatic treatment that the child receives [5] and to his/her quality of life [18]. The present study goes further and tries to elucidate the association between parents’ quality of life and Table 2. Characteristics of asthma control in the sample. Symptoms Infrequent (%) Moderate (%) Frequent (%) Nighttime awakenings Infrequent (%) Moderate (%) Frequent (%) Interference with normal activity None (%) Some (%) Extremely (%) SABA use for symptom control Infrequently (%) Moderate (%) Frequent (%) Lung function (FEV1) impairment None (%) Moderate (%) Severe (%) Lung function (FEV1/FVC) impairment None (%) Moderate (%) Severe (%) Hospitalization in previous 12 months (%) Recent exacerbation (51 month) (%) Medication withdrawal because side effects (%) 2 exacerbations requiring SC in previous 12 months (%) Classification of asthma control (impairment) Well controlled (%) Partially controlled (%) Poorly controlled (%) High risk of loss of control (%) SC, systemic corticosteroids.
69.9 24.8 5.4 76.5 18.9 4.7 67.6 30.9 1.5 72.8 20.8 6.4 87.0 12.0 1.0 94.5 2.9 2.6 3.4 31.1 0.7 12.3 53.7 35.0 11.3 36.0
(3.1 to 18.1) (5.4 to 29.6) (10.1 to 26.5) (2.4 to 0.1) (6.3 to 5.3) (0.6 to 1.6) (10.7 to 5.0) (16.8 to 2.4) (8.3 to 3.5) (31.1 to 17.9) (14.3 to 2.0)
0.005 0.003 50.001 0.077 0.820 0.396 0.438 0.011 0.402 50.001 0.131
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The figures are the difference, in %, in the measure of the IFABI-R associated with each variable. Positive values represent a worsening in the quality of life. a With respect to the reference category ‘‘controlled asthma’’ (definitions in the text). b With respect to the reference category ‘‘low risk’’ (definitions in the text).
10.4 16.9 18.0 1.1 0.7 0.5 3.2 9.9 2.6 24.8 6.5 0.056 0.036 50.001 0.186 0.748 0.181 0.942 0.019 0.660 50.001 0.487 (0.2 to 14.2) (0.7 to 23.5) (10.0 to 26.0) (2.0 to 0.4) (4.7 to 7.0) (0.3 to 1.8) (7.4 to 8.7) (15.9 to 1.6) (4.5 to 7.6) (35.3 to 23.0) (10.9 to 5.7) 6.8 11.5 17.7 0.8 1.0 0.7 0.3 9.0 1.4 29.4 3.0 0.021 0.008 0.001 0.110 0.591 0.450 0.621 0.051 0.263 50.001 0.089 (1.5 to 20.1) (4.7 to 35.1) (6.7 to 26.5) (2.8 to 0.3) (8.8 to 5.4) (0.8 to 1.9) (11.8 to 7.8) (17.8 to 0.1) (11.1 to 3.3) (34.1 to 18.1) (18.1 to 1.4) 10.4 18.9 16.2 1.3 2.0 0.5 2.5 9.3 4.2 26.5 8.9 50.001 0.001 50.001 0.149 0.467 0.835 0.059 0.017 0.104 0.003 0.080 (7.8 to 27.5) (9.4 to 41.2) (10.8 to 31.5) (2.6 to 0.4) (9.5 to 4.7) (1.5 to 1.2) (17.9 to 0.4) (19.7 to 2.1) (12.8 to 1.3) (24.0 to 5.6) (18.4 to 1.1) 17.2 24.3 20.7 1.1 2.7 0.1 9.2 11.3 6.0 15.3 9.2 Partially controlled asthma Poorly controlled asthmaa High riskb Age (each year) Male sex Years since asthma diagnosis Sensitivity to inhalants High social class High level of education Family functioning (family Apgar) Father responds
% Difference (95% CI) p % Difference (95% CI) % Difference (95% CI)
p
% Difference (95% CI)
p
Socio-occupational R2 ¼ 0.260
Dimensions of parents’/caregivers’ quality of life measured by the IFABI-R instrument
Emotional R2 ¼ 0.206 Functional R ¼ 0.249
2
Table 3. Multivariate regression model. Association between asthma control and parents’ quality of life. Percent differences in the IFABI-R score.
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Total R2 ¼ 0.272
p
A. Cano-Garcinun˜o et al.
a
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the degree of asthma control in children, an association that was not evident in all prior studies. Dean et al. [6,7] discovered an association between the poor control of asthma and the parents’ worsening quality of life; Bender and Zhang [8] also encountered an association between the parents’ mood and the intensity of the child’s asthma symptoms; Bloomberg et al. [19] identified a progressive deterioration of parents’ quality of life as asthma control in children worsened. More recently, Stelmach et al. [9] found a correlation between the medium-term variation in the parents’ quality of life and variations in asthma control. However, Price et al. [10] found no relationship between the parents’ quality of life and the number of asthma crisis or visits to the doctor in the year prior to launching an intensive intervention program in children and adolescents with refractory asthma. Shalowitz et al. [11] found that in a low-income population, symptoms of depression in the mothers of children with asthma were linked to stress and a lack of social support, but not to the objective state of the child’s disease. We have also observed that educational activities on asthma supplied to children and/or parents can modify symptoms without changing the caregivers’ quality of life [20]. It is evident that health-related quality of life is affected by a number of external factors, and by personality traits, independently of the objective clinical status. Therefore, it is necessary that the analysis of the relationship between the quality of life and asthma control includes adjustment terms relative to family functioning and social-cultural aspects. Our research shows that there is an association between asthma control in children and their parents’ quality of life, regardless of their social class or level of education. Moreover, we have determined that there is a strong, independent association between risk of loss of control and the parents’ quality of life. Likewise, upon classifying asthma as controlled, partially controlled, and poorly controlled, we have also shown that there is a progressive relationship between the asthma control and the parents’ quality of life, as it was previously described by Bloomberg et al. [19]. Our study also underlines the multi-dimensional nature of asthma control, which cannot be substituted by individual elements. One of the elements always included in asthma control assessments is pulmonary function. It was already known that pulmonary function has no relationship with the asthmatic patient’s quality of life [21–23], and we have now shown that there is no relationship with the parents’ quality of life. From the multivariate models, the only element that clearly affects all the quality of life dimensions is the repetition of asthma crisis. Crisis cause a major family disruption, in which not only is there great concern for the child’s health, but other complications appear: family organizational difficulties, missed school, lost work days, repeated visits to the doctor, and in some cases, economic difficulties. That disruption of family life is likely the main effect of repeated asthma crisis on the parents’ quality of life. Gender differences have been identified with regard to the impact that childhood asthma has on the parents, with mothers being more susceptible. During another clinical trial, it was found that interventions that reduce maternal anxiousness improved both therapeutic adherence and asthma control [24]. In our study, when the quality of life assessment was
0.019 0.059 0.052 0.336 0.538 0.099 0.633 0.658 0.859 0.880 0.283 0.192 0.735 0.004
14.5 (2.3 to 28.2) 24.5 (0.8 to 56.2) 10.2 (0.1 to 21.6) 17.3 (15.3 to 62.4) 4.1 (8.4 to 18.3) 18.8 (3.2 to 45.9) 3.7 (10.7 to 20.5) 11.4 (48.4 to 52.0) 2.4 2.5 10.1 6.6 6.8 18.4
(21.5 to 33.7) (30.1 to 36.0) (26.0 to 9.2) (3.2 to 17.4) (38.0 to 40.2) (5.4 to 33.0)
0.277 0.285
p
6.9 (5.2 to 20.6) 11.6 (29.6 to 10.9)
% Difference (95% CI)
3.2 6.1 5.9 1.0 12.2 26.2
(22.1 to 36.9) (25.4 to 51.1) (12.8 to 28.6) (8.3 to 11.2) (41.6 to 31.9) (12.5 to 41.7)
0.9 (14.0 to 18.3) 9.6 (38.2 to 94.4)
11.0 (2.3 to 26.1) 24.2 (1.2 to 52.4)
11.5 (1.1 to 22.9) 22.4 (11.5 to 69.3)
1.8 (9.1 to 14.0) 1.8 (18.8 to 27.7)
1.4 (10.1 to 14.3) 11.3 (29.3 to 11.2)
% Difference (95% CI)
0.916 0.753
0.110 0.038
0.030 0.220
0.757 0.877
0.820 0.297
p
0.824 0.740 0.564 0.840 0.529 50.001
Emotional R2 ¼ 0.262
1.7 9.1 2.6 9.0 14.9 24.4
(20.4 to 21.5) (30.2 to 18.5) (16.5 to 13.7) (0.9 to 17.6) (16.8 to 58.8) (13.4 to 36.3)
6.5 (5.5 to 20.0) 18.5 (22.9 to 82.2)
1.6 (8.2 to 12.5) 10.1 (6.5 to 29.5)
3.4 (4.4 to 11.7) 17.9 (8.9 to 52.5)
8.3 (1.0 to 18.4) 4.9 (12.3 to 25.6)
2.0 (7.3 to 12.2) 6.3 (21.7 to 12.2)
% Difference (95% CI)
0.877 0.481 0.738 0.028 0.399 50.001
0.302 0.437
0.755 0.247
0.405 0.210
0.082 0.598
0.685 0.478
p
Socio-occupational R2 ¼ 0.262
2.2 0.6 1.4 5.3 1.1 24.4
(18.0 to 27.3) (24.5 to 30.8) (15.7 to 15.2) (2.6 to 13.7) (28.7 to 37.2) (13.4 to 36.5)
3.0 (9.0 to 16.7) 6.3 (32.0 to 66.1)
5.7 (4.6 to 17.1) 18.1 (0.2 to 39.3)
7.6 (0.6 to 16.4) 18.6 (8.6 to 54.0)
6.9 (2.4 to 17.0) 8.2 (9.8 to 29.8)
3.3 (6.2 to 13.8) 10.1 (25.0 to 7.9)
% Difference (95% CI)
Total R2 ¼ 0.319
0.847 0.964 0.855 0.192 0.948 50.001
0.634 0.788
0.288 0.047
0.069 0.198
0.151 0.397
0.505 0.252
p
Results adjusted by age, sex, years since diagnosis, allergic sensitization, social class, education level, family functioning, and respondent (father/mother). SC, systemic corticosteroids; SABA, short-acting beta2agonist. a The figures are the difference, in %, in the measure of the IFABI-R associated with each variable. Positive values represent a worsening in the quality of life. b The reference category is ‘‘infrequent’’ or ‘‘none’’.
Symptoms Moderate Frequent Nighttime awakeningsb Moderate Frequent Interference with normal activityb Some Extremely SABA use for symptom relievingba Moderate Frequent Lung function (FEV1) Impairmentb Moderate Severe Lung function (FEV1/FVC) impairmentb Moderate Severe Hospitalization in previous 12 months Recent crisis (51 month) Medication withdrawal because side effects 2 exacerbations requiring SC in previous 12 months
b
Functional R2 ¼ 0.300
Dimensions of parent/caregiver quality of lifea
Table 4. Multivariate regression model. Association between parents’ quality of life and each component of asthma control. Percent differences in the IFABI-R score.
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DOI: 10.3109/02770903.2014.943372
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Figure 1. IFABI-R score according to the number of crisis in the previous 3 months: functional dimension (white), emotional dimension (gray), socio-occupational dimension (stripes), and total IFABI-R score (dots).
provided by the father, there was a slight, yet not significant decline in the impact of asthma, especially for the functional and emotional dimensions. This study has the typical limits of cross-sectional studies, in which the direction of the effect cannot be established. It is possible that the parents’ poorer quality of life determines asthma management patterns that lead to poorer control; nevertheless, it is also possible that poor asthma control deteriorates the parents’ quality of life. Likewise, it is possible that the parents’ quality of life and asthma control, although associated, have no cause–effect relationship. We have not strived to establish causation, but rather, how these two aspects are related. It must also be mentioned that the framework of the study could influence in the generalization of the results. Our sample stems from primary care centers in which the patients representing children with asthma as they can be found in the community, rather than hospitalized patients or a population selected purposely, based on precise characteristics. The study has been performed in Spain; the social-cultural characteristics of other countries could mean that the results are not transferable. Finally, upon studying Table 4, it might seem that two asthma control elements (interference with activities and SABA use for symptom relief) have a gradual, although not statistically significant, effect on the parents’ quality of life. It could very well be that those two components are statistically significant in a larger sample size.
Conclusions Asthma control has a proportional relationship with all dimensions of parents’ quality of life; this is true for both impairment and risk. Repeated asthma crises affect the parents’ quality of life, but no other isolated elements of those used to assess asthma control have an independent and consistent effect. In managing poorly controlled childhood
asthma, the associated family impact must be considered, and more research should provide evidence about effective strategies of family intervention that would yield better health outcomes in asthma.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was financed with a grant (Healthcare Research Project PI11/02122) from the Instituto de Salud Carlos III, Ministry of Education and Competitiveness, Government of Spain.
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