http://informahealthcare.com/jas ISSN: 0277-0903 (print), 1532-4303 (electronic) J Asthma, 2014; 51(6): 660–666 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2014.903964
QUALITY OF LIFE, ADHERENCE AND CONTROL
The quality of life of Brazilian adolescents with asthma: associated clinical and sociodemographic factors Lı´gia Menezes do Amaral, MD1, Lucas Moratelli2, Pamella Valente Palma3, and Isabel Cristina Gonc¸alves Leite, PhD4 Division of Pulmonology, Department of Internal Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil, 2School of Medicine, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil, 3School of Dentistry, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil, and 4Department of Public Health, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil
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1
Abstract
Keywords
Objective: Asthma is the most common chronic disease among adolescents. This study assessed the quality of life (QOL) related to health in adolescents with asthma and its determining factors (demographic, socioeconomic, and clinical). We also separately evaluated each of the parameters that comprised the asthma control classification. Methods: This was an observational, cross-sectional study of 114 adolescents who had doctor-diagnosed asthma. QOL was assessed using a version of the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) that was adapted and validated for Brazil, and higher scores indicated a better QOL. The level of asthma control was assessed using the rating system proposed by the Global Initiative for Asthma, and sociodemographic factors were evaluated. Results: When the averages of the PAQLQ domains and overall scores were compared to the potentially explanatory variables, significantly lower average PAQLQ scores were obtained for individuals with an inadequate level of asthma control (p50.001). Of the control components, daytime symptoms, nighttime symptoms, and limited physical activity were related to QOL. However, the use of the b2 agonist and the peak flow functional parameter were not related to QOL. Conclusions: The level of asthma control was related to QOL, but this association manifested mainly in the subjective control domains, such as nighttime and daytime symptoms and physical activity limitations. The objective domain for control classification, represented by pulmonary function, was not an independent predictor or determinant of the QOL of adolescent asthma patients.
Diagnostics, epidemiology, Pediatrics, quality of life, treatment
Introduction Asthma, the most common chronic illness among adolescents, is a serious public health problem worldwide and in Brazil, which is one of the countries with the highest prevalence rates of the disease. Brazil faces social and economic problems similar to a number of countries in Latin America and other parts of the world [1–4]. Little is know about Brazilian adolescents with asthma. However, is know that approximately 17 000 adolescents are admitted to hospitals every year in Brazil because of asthma, thus making asthma the thirdmost common cause of hospitalization among children and teens in the country [5]. Asthma impairs the physical activity of patients, and it negatively affects the patients’ social, emotional, and educational lives. When asthma is not
Correspondence: Lı´gia Menezes do Amaral, Division of Pulmonology, Department of Internal Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil. Jose´ Manoel Ribeiro St, Juiz de Fora – Juiz de Fora, Minas Gerais 36038318, Brazil. Tel: 55 32 4009 5109. E-mail: [email protected]
History Received 22 April 2013 Revised 27 February 2014 Accepted 9 March 2014 Published online 7 April 2014
controlled, it can be highly debilitating and even fatal. The heavy load that asthma imposes on social aspects is widely acknowledged, and it can contribute to school absenteeism, productivity loss, and reduced participation in family and social life [3–6]. The multicenter International Study for Asthma and Allergies in Childhood (ISAAC) that was conducted in 56 countries identified an active asthma prevalence of 1.6–36.8%. The average prevalence found in the 20 Brazilian cities that participated in the study was 20%, which was the eighth highest among the countries studied [3,4]. A separate analysis of the prevalence of asthma in the adolescent population, i.e. ISAAC-PHASE 3, revealed an average prevalence of 19% [7]. Assessments of asthma based only on outcomes such as morbidity and mortality are insufficient; thus, an increased search for other patient-oriented measures and assessments has begun. From that perspective, quality of life (QOL)related aspects have emerged as important outcomes in clinical trials, healthcare service assessments, and clinical practice, thereby leading to improved communication between doctors and patients. QOL was defined by the
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DOI: 10.3109/02770903.2014.903964
World Health Organization-Quality of Life Group (WHOQOL) as an ‘‘individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns’’ [2]. QOL is therefore an additional dimension in the assessment and measurement of the results of public policies and clinical interventions [8–10]. Asthma-related QOL has been evaluated in pediatric population, but most of the studies have focused on younger children. Information on asthma-related QOL in adolescents is scarce. The impact of asthma on this age group is regarded as a combination of crises, having the impositions of a chronic disease combined with the identity construction phase [2]. The relationship between level of asthma control and QOL is already well known [11], yet separately assessing the relationship of each component, subjective and objective, of control can provide important information for clinical management, and even for the construction of public policies focused on adolescents with asthma. The aim of the present study was to assess the asthmarelated QOL in adolescents and its relationship with demographic, socioeconomic, and clinical factors. Among the clinical factors being evaluated separately, the relationship of each of the parameters that comprise the classification of control of the disease and asthma related QOL.
Methods Design, study population and data collection The present study is a cross-sectional, observational epidemiological study that was performed in an outpatient setting. The sample consisted of adolescents aged 12–18 years of both sexes who were medically diagnosed with asthma and treated at the Adolescent Pneumology Outpatient Clinic, which is a secondary healthcare unit affiliated with the Department of Children and Adolescent Health of the Health Secretary of the Juiz de For a municipal government in the state of Minas Gerais, Brazil. Juiz de Fora is a city of about 516 246 inhabitants located in southeastern Brazil [12]. The exclusion criteria were clinical or functional diagnosis of other respiratory diseases; concomitant diagnosis of other diseases affecting QOL, such as neurological and immunosuppressive illnesses and neoplasias; and cognitive deficits that would hinder the patient’s understanding of the questionnaires. The data were collected between August 2011 and August 2012. During the study period, 118 adolescents with asthma were treated at the outpatient clinic, and 114 were interviewed, with parents’ written consent and teens assent, as described in Figure 1. Written informed consent was obtained from the study participants. Instruments All of the participants responded to the complete, validated, and adapted Brazilian Portuguese language version [13] of the Pediatric Asthma QOL Questionnaire [14]. The questionnaire, which was specifically designed to assess asthma-related QOL in children and adolescents with asthma, comprises 23 items that are distributed among 3 domains (symptoms,
Associated clinical and sociodemographic factors
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Figure 1. Study population.
activity limitation, and emotional function) [14]. The participants answered the PAQLQ in face-to-face interviews in the absence of their caregivers, as recommended by the questionnaire’s author. The answer options are set on a 7-point scale, where 01 indicates maximal impairment, and 07 indicates no impairment. The results are expressed as the average scores for each domain and the average total score. The PAQLQ was used in the present study after its author granted authorization. The outcome variable was QOL, as assessed by the averages of the three PAQLQ domains and overall scores. The sociodemographic and economic variables that were assessed were age, sex, skin color, marital status, body mass index (BMI), smoking, passive smoking, the presence of domestic animals in the household, number of siblings, number of residents in the household, residence in a rural or urban setting, educational level of the participants and their parents, household income, the head of household’s employment status, the number of family members contributing to the household income, participation in government aid programs, monthly drug expenses, and socioeconomic class, which was based on economic classification criteria. Questions regarding parents’ education level and family income were answered by the persons responsible who accompanied the adolescents. Socioeconomic status was categorized according to economic classification criteria of the Brazilian Association of Research Companies [15], which takes into consideration household, education level, and family income characteristics in the differentiation of social classes. To measure the peak of expiratory flow (PEF), a Mini-Wright (Clement ClarkeR) peak flow meter was used. BMI was calculated using the formula: weight (kg)/[height (m)]2 [16]. To assess the level of asthma control, the classification that was formulated by the Global Initiative for Asthma was used. This classification evaluates: daytime symptoms, nocturnal symptoms, need for reliever, limitation of physical activities, lung function and assessment of future risk. Based on this parameter, GINA classification divides the levels of asthma control into: controlled, partly controlled, and uncontrolled in an evaluation period of 4 weeks [6].
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Data analysis
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The Statistical Package for Social Sciences (SPSS v.15, Chicago, IL) software was used for the statistical analysis of the data. The QOL parameters were obtained from the means and corresponding standard deviations. Following the application of the Kolmogorov–Smirnov normality test, the average QOL values were compared by ANOVA with a significance level of 5% and using univariate regression. To investigate the influence of the clinical and sociodemographic variables, a multivariate regression analysis was performed. In the case of categorical variables, stratification was performed at two or more levels (according to their distribution in the univariate analysis). Clinically relevant variables and those of statistical significance in the bivariate analysis (p50.20) were included in the multivariate analysis (Table 5). Ethical considerations The project was submitted to the Research Ethics Committee of the University Hospital of the Federal University of Juiz the Fora (Universidade Federal de Juiz de Fora – UFJF), as required by Resolution 196/96 of the National Health Council (Conselho Nacional de Saude) and its complements, as well as the Ethics Code from 1988 (Articles 122 to 130), and it was approved under Protocol No. 314/10.
Results Descriptive statistical analysis A total of 114 patients answered the questionnaire. Table 1 includes the results of the descriptive statistical analysis of the demographic variables. Of the participants, 69.8% were younger than 15 years old, and 50.9% were male; 21.1% belonged to Social Class B (monthly gross household income between USD 1269.00 and USD 2187.00) and 61.4% C (monthly gross household income between USD 465.00 and USD 763.00), according to the criteria of the Brazilian Association of Research Companies (Associacao Brasileira de Empresas de Pesquisas [ABEP]) [15]. Regarding the level of asthma control, 50.9% of the participants exhibited partially controlled asthma, and 39.5% exhibited uncontrolled asthma. These data are included in Table 2, which presents the clinical characteristics of the sample. Correlations among levels of asthma control and PAQLQ domains Upon comparing the variables that were related to the level of asthma control to the average scores of the three PAQLQ domains and the overall PAQLQ score, we observed a statistically significant correlation between poor control and lower QOL scores (p50.001). These results are described in Table 3, which further suggests a relationship between each parameter in the classification of asthma control level and QOL, indicating that the subjective parameters of asthma control, such as the frequency of daytime symptoms
J Asthma, 2014; 51(6): 660–666
Table 1. Demographic and socioeconomic characteristics of adolescents with asthma treated at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora, Minas Gerais, Brazil, 2011/2012 (n ¼ 114).
Variable Age 12–14 years old 15 or older Sex Male Female Self-declared skin color White Brown Black BMI Low weight Normal weight Overweight Obesity I, II and III Adolescent’s education level 0–4 years 5–8 years 9 years 12 years Caregiver’s education level 0–4 years 5–8 years 9–12 years More than 12 years Gross income in dollars/ month–ABEP classification B1 (USD 2187.00) B2 (USD 1269.00) C1(USD 763.00) C2 (USD 465.00) D(USD 353.00) Residence area Urban Rural Receiving medication free of charge Yes No Partially Presence of domestic animals No Yes
Absolute frequency (n)
Relative frequency (%)
74 32
69.8 30.2
58 56
50.9 49.1
57 21 36
50.0 18.4 31.6
23 47 14 7
25.3 51.6 15.4 7.7
2 83 28 1
1.8 72.8 24.6 0.9
54 29 29 1
47.8 25.7 25.7 0.9
2 22 29 41 20
1.8 19.3 25.4 36.0 17.5
97 17
85.1 14.9
80 10 19
73.4 9.2 17.4
37 77
32.5 67.5
BMI, Body mass index; ABEP, Brazilian Association of Research Companies (Associac¸a˜o Brasileira de Empresas de Pesquisa).
(p ¼ 0.027), the presence of nighttime symptoms (p50.001), and activity limitation (p50.001), correlated with the QOL domain scores and the overall score. A similar relationship was not observed between QOL and the objective parameter of asthma control, which was represented by PEF in the present study. Correlations among demographic and socioeconomic variables and the three PAQLQ domains and overall PAQLQ score Table 4 describes two other variables that correlated significantly with the PAQLQ scores: the presence of domestic animals, which exerted a protective effect on all of the domains (p ¼ 0.012), and the caregiver educational level, which correlated with the emotional function domain of QOL (p ¼ 0.017). In addition, obesity exerted a negative impact
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DOI: 10.3109/02770903.2014.903964
on the PAQLQ domain scores and overall score (p50.028). The remainder of the demographic and socioeconomic variables did not exert a significant impact on QOL.
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animals (p ¼ 0.010) remained significantly associated after adjustment.
Discussion Multiple linear regression analysis The variables that attained a significance level less than or equal to 0.20 were included in a multiple linear regression analysis. In the multivariate analysis, as show in Table 5, the significance level was 5% (p ¼ 0.05). After multivariate analysis, the variables level of asthma control (p ¼ 0.000), daytime symptoms (p ¼ 0.023), nighttime symptoms (p ¼ 0.000), limitation of physical activities (p ¼ 0.000), asthma severity (p ¼ 0.000), and the presence of domestic
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Table 2. Clinical characteristics of adolescents with asthma treated at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora, 2011/2012 (n ¼ 114).
Variable Level of asthma control Controlled Partially controlled Uncontrolled Rhinitis No Yes Smoking No Yes Passive smoking No Yes Treatment at emergency services in the previous month No Yes Treatment at emergency services in the previous year No Yes
Absolute frequency (n)
Relative frequency (%)
11 58 45
9.6 50.9 39.5
6 108
11.8 88.2
111 3
97.4 2.6
64 49
56.6 43.4
93 21
81.6 18.4
53 60
46.9 53.1
Asthma substantially affects the QOL of patients, and this effect has been attributed to multiple factors, among which asthma control seems to play a central role [11,17]. According to the main consensus on this subject, the attainment and maintenance of asthma control is the main aim of treatment [6,18]. The present study uncovered an important correlation between QOL and the level of asthma control, which was in agreement with the Brazilian and international literature [11,17,19]. Regarding the correlation between asthma control and QOL, three of the subjective parameters of asthma control (namely, daytime symptoms, nighttime symptoms, and activity limitation) were statistically related to QOL. The need for relief/rescue medication or for the functional component of asthma control, which was represented in the present study by PEF, did not have a similar influence on QOL. This information may have implications for the clinical management of asthmatic adolescents to the extent that they value the importance of the subjective components of control in QOL. These findings agree with results reported in the international literature [20,21]. The lack of correlation between lung-function parameters and QOL might be partially explained by the fact that the functional assessment was conducted using a single, isolated measurement, whereas QOL was measured over a period of time (1 week, in the case of the PAQLQ) [21]. In addition, the variations in PEF throughout the course of the day exhibited a stronger correlation with daytime symptoms than isolated functional measurements did because asthma symptoms correlated better with variations in the airway caliber over time than with an isolated measurement at a single moment. It would be interesting for future research to investigate whether serial functional measurements or other functional
Table 3. Correlations among levels of asthma control and PAQLQ domains, Adolescent Pneumology Outpatient Clinic, Juiz de Fora, Minas Gerais, Brazil, 2011/2012. Average of domains (±SD) Variables Level of asthma control Controlled Partially controlled Uncontrolled Daytime symptoms in the previous week Up to twice More than twice Nighttime symptoms in the previous week None Any Use of relief medication in the previous week Up to twice More than twice Limitation of physical activities in the previous week None Any Peak of expiratory flow Normal 580% of the theoretical value
n
(%)
11 58 45
(9.6) (50.9) (39.5)
63 51
(55.3) (44.7)
58 56
(50.9) (49.1)
86 28
(75.4) (24.6)
47 67
(41.2) (58.8)
44 48
(47.8) (52.2)
Symptoms
Activity limitations
Emotional
Total
p50.001 5.05 (±1.87) 4.38 (±1.28) 3.51 (±1.01) p ¼ 0.004 4.42 (±1.47) 3.71 (±1.06) p50.001 4.61 (±1.45) 3.57 (±0.98) p ¼ 0.097 4.22 (±1.39) 3.74 (±1.12) p ¼ 0.001 4.59 (±1.37) 3.76 (±1.23) p ¼ 0.775 4.09 (±1.43) 4.18 (±1.27)
p50.001 5.25 (±1.68) 4.17 (±1.34) 3.42 (±1.10) p ¼ 0.008 4.29 (±1.42) 3.60 (±1.26) p ¼ 0.007 4.32 (±1.42) 3.63 (±1.27) p ¼ 0.084 4.11 (±1.44) 3.59 (±1.14) p50.001 4.66 (±1.41) 3.50 (±1.17) p ¼ 0.758 4.00 (±1.49) 4.09 (±1.21)
p ¼ 0.006 5.34 (±1.58) 4.69 (±1.28) 4.06 (±1.34) p ¼ 0.495 4.59 (±1.42) 4.41 (±1.34) p ¼ 0.001 4.93 (±1.44) 4.06 (±1.18) p ¼ 0.872 4.52 (±1.43) 4.47 (±1.23) p50.001 5.14 (±1.29) 4.06 (±1.27) p ¼ 0.379 4.37 (±1.42) 4.63 (±1.39)
p50.001 5.20 (±1.66) 4.44 (±1.18) 3.68 (±1.00) p ¼ 0.027 4.49 (±1.34) 3.93 (±1.08) p50.001 4.66 (±1.35) 3.76 (±0.96) p ¼ 0.212 4.30 (±1.31) 3.96 (±1.04) p50.001 4.79 (±1.23) 3.81 (±1.11) p ¼ 0.576 4.17 (±1.34) 4.32 (±1.17)
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Table 4. Correlations among demographic and socioeconomic variables and the three PAQLQ domains and overall PAQLQ score, Adolescent Pneumology Outpatient Clinic, Juiz de Fora 2011/2012. Average of domains (±DS)
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Variables Education level of the mother or caregiver 0–4 years 5–8 years 9 years or more Presence of domestic animals Yes No Animal spends the night in the room Yes No Age Up to 14 years old 15 years old or older Sex Male Female BMI Low weight Normal weight Overweight Obesity I, II and III Average household income Up to USD 308.00 2 minimum wages or more ABEP classificationa Class B Classes C and D
n
(%)
54 29 30
(47.8) (25.7) (26.5)
77 37
(67.5) (32.5)
9 67
(11.8) (88.2)
76 34
(69.1) (30.9)
58 56
(50.9) (49.1)
23 47 14 7
(25,3) (51,6) (15,4) (7,7)
51 61
(45.5) (54.5)
24 90
(21.1) (78.9)
Symptoms
Activity limitations
Emotional
Total
p ¼ 0.081 4.06 (±1.45) 3.76 (±1.17) 4.53 (±1.24) p ¼ 0.023 4.30 (±1.32) 3.69 (±1.33) p ¼ 0.385 3.92 (±1.35) 4.33 (±1.32) p ¼ 0.514 4.20 (±1.32) 4.02 (±1.40) p ¼ 0.136 4.29 (±1.31) 3.91 (±1.36) p50.013 4.54 (±1.30) 4.09 (±1.29) 4.38 (±1.46) 2.70 (±0.81) p ¼ 0.262 3.97 (±1.25) 4.26 (±1.42) p ¼ 0.362 4.33 (±1.58) 4.04 (±1.28)
p ¼ 0.348 3.96 (±1.37) 3.75 (±1.34) 4.27 (±1.46) p ¼ 0.012 4.20 (±1.25) 3.51 (±1.55) p ¼ 0.510 3.93 (±1.00) 4.23 (±1.29) p ¼ 0.320 4.11 (±1.34) 3.82 (±1.47) p ¼ 0.094 4.19 (±1.29) 3.76 (±1.46) p50.084 4.57 (±1.45) 3,99 (±1.32) 3.83 (±1.26) 3.20 (±0.85) p ¼ 0.654 3.91 (±1.42) 4.03 (±1.39) p ¼ 0.438 4.18 (±1.28) 3.93 (±1.42)
p ¼ 0.017 4.31 (±1.36) 4.25 (±1.24) 5.12 (±1.41) p ¼ 0.026 4.70 (±1.32) 4.09 (±1.44) p ¼ 0.248 4.22 (±1.39) 4.77 (±1.32) p ¼ 0.517 4.61 (±1.33) 4.42 (±1.47) p ¼ 0.190 4.67 (±1.34) 4.33 (±1.41) p50.106 4.82 (±1.16) 4.51 (±1.52) 4.51 (±1.44) 3.32 (±0.61) p ¼ 0.331 4.39 (±1.34) 4.65 (±1.41) p ¼ 0.301 4.77 (±1.52) 4.44 (±1.34)
p ¼ 0.051 4.13 (±1.29) 3.93 (±1.13) 4.68 (±1.23) p ¼ 0.012 4.42 (±1.18) 3.79 (±1.32) p ¼ 0.306 4.03 (±1.14) 4.46 (±1.19) p ¼ 0.429 4.32 (±1.21) 4.12 (±1.34) p ¼ 0.110 4.40 (±1.19) 4.02 (±1.30) p50.028 4.64 (±1.14) 4.21 (±1.28) 4.30 (±1.34) 3.02 (±0.45) p ¼ 0.317 4.10 (±1.21) 4.34 (±1.30) p ¼ 0.314 4.45 (±1.39) 4.15 (±1.21)
a
ABEP classification – monthly gross income: Class B (from USD 1269.00 to USD 2187.00) and Class C (from USD 465.00 to USD 763.00). Conversion rate on 10/23/2012, BRL 1.00 ¼ USD 2.02.
Table 5. Final result of the multiple linear regression model, asthma patients attended at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora – Minas Gerais – Brazil, 2012. Variable Level of asthma control Daytime symptoms Nighttime symptoms Limitation of physical activities Presence of domestic animals
badjusted
p
0.144 0.037 0.129 0.145 0.049
50.001 0.023 50.001 50.001 0.010
parameters could be related to the QOL in asthmatic adolescents [22]. The presence of domestic animals is a controversial topic in the assessment of asthmatic patients. Because of the complexity of this relationship and for methodological reasons [23], the protective effect found in the present study must be addressed cautiously. Some studies have attributed a protective effect against the future development of allergies to the presence of domestic animals in early childhood [24]. A meta-analysis performed by Takkouche et al. [25] in 2008 concluded that exposure to cats exerted a slight protective effect against asthma that did not occur with exposure to dogs and that further, careful investigation of the effect of such exposure was needed to assess the role of pets in diseases with a known allergic component. Asthma and obesity are prevalent diseases that have an important impact on public health, and their complex, mutual interaction has been widely reported in the literature [26,27]. As in the present study, which showed lower average domain
scores and total QOL scores among obese participants, the recent literature also indicates a poorer asthma-related QOL and poorer disease control among obese patients with asthma compared to asthma patients with normal weight [28,29]. However, it is worth noting that the number of obese participants in the present study was small, which hindered a proper analysis of the correlation between obesity and asthma. Studies of socioeconomic factors and asthma have yielded conflicting results [30]. The present study did not find a correlation between socioeconomic variables and QOL in patients with asthma, which was in agreement with results from other studies that specifically addressed the adolescent population [30–32]. Furthermore, the assessment of the influence of socioeconomic variables was hindered by the fact that the participants in the present study were mostly from economic classes B and C (80.7%). Regarding the correlation between higher average scores in the emotional function domain of the PAQLQ and the educational level of their caregivers, several studies have described parental educational level as a factor that correlates with knowledge about asthma and thus affects aspects related to adherence to treatment [33]. Even when the importance of the correlation between QOL and clinical variables, such as those related to asthma control, is recognized, it is worth emphasizing the four components of health status in children with asthma that were suggested by Juniper et al. [22] in 2004: asthma-specific QOL, airway caliber (functional component), daytime symptoms, and nighttime symptoms. These components direct
Associated clinical and sociodemographic factors
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DOI: 10.3109/02770903.2014.903964
attention to the main assumptions that underlie the appropriate treatment of asthma: the prevention of mortality, the reduction of morbidity, and the improvement of patient wellbeing. Therefore, clinical measurements of asthma control provide information on the first two foundations of appropriate treatment, whereas QOL more appropriately reflects patient wellbeing [22]. Future studies that assess instruments designed to address all the dimensions of asthma and facilitate the use of these instruments in clinical practice within different cultural contexts might contribute to improved QOL in adolescents with asthma and help improve communication between patients and doctors, thus reducing the impact of disease on clinical, emotional, and social functioning [34]. Future studies are needed to develop, implement, and assess interventions that promote better asthma control and better QOL for patients. Studies in young children have demonstrated the relationship between asthma-related QOL with determinants such as control, disease severity and socioeconomic conditions. Recent study in Scotland highlights asthma control as the factor most amenable to intervention [35]. However, there are still few studies in the adolescent population. There are no studies in adolescents that assess, separately, the components of asthma control and its relationship to QOL. The limitations of the present study are inherent to crosssectional observational studies, in which the relationship between cause and effect cannot be established effectively. Therefore, it is not possible to state whether asthma control is the cause or the consequence of improved QOL. In addition, the employed study was a convenience sample, and the results of this sample may not permit generalization. Another limitation is that, even though they were in a specialized care service for respiratory illnesses in adolescents and medications for control and relief were provided free of charge, a small percentage of our sample was composed of patients who had adequate control of the disease.
2. 3. 4.
5.
6.
7.
8. 9. 10.
11.
12.
13.
Conclusions Correlating each of the domais of asthma control with the QOL of adolescents with asthma may contribute to a better approach that promotes better QOL for this population. Public policies and programs for asthma control that have been launched in Brazil in recent years have facilitated patient access to required medication [36]; however, to meet the goal of improving the QOL of adolescents with asthma, public health policies must go beyond medication and provide information to patients and caregivers. Such information could facilitate the appropriate control of symptoms and promote self-care and adherence to treatment, thereby affording adolescents a safe and complete transition into adult life.
Declaration of interest
14. 15.
16.
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The authors have no conflict of interest. 19.
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29. Dixon AE, Holguin F, Sood A, Salome CM, Pratley RE, Beuther DA, Celedo´n JC, Shore SA, American Thoracic Society Ad Hoc Subcommittee on Obesity and Lung Disease. An official American Thoracic Society Workshop report: obesity and asthma. Proc Am Thorac Soc 2010;7:325–335. 30. Hancox RJ, Milne BJ, Taylor DR, Greene JM, Cowan JO, Flannery EM, Herbison GP, et al. Relationship between socioeconomic status and asthma: a longitudinal cohort study. Thorax 2004;59:376–380. 31. Goodman E. The role of socioeconomic status gradients in explaining differences in US adolescents’ health. Am J Public Health 1999;89:1522–1528. 32. Alvim CG, Picinin IM, Camargos PM, Colosimo E, Lasmar LB, Ibiapina CC, Fontes MJ, Andrade CR. Quality of life in asthmatic adolescents: an overall evaluation of disease control. J Asthma 2009;46:186–190. 33. Ho J, Bender BG, Gavin LA, O’Connor SL, Wamboldt MZ, Wamboldt FS. Relations among asthma knowledge, treatment adherence, and outcome. J Allergy Clin Immunol 2003;111: 498–502. 34. Wilson SR, Rand CS, Cabana MD, Foggs MB, Halterman JS, Olson L, Vollmer WM, et al. Asthma outcomes: quality of life. J Allergy Clin Immunol 2012;129:S88–123. 35. Turner SW, Mehta A, Ayres JG, Palmer CN, Mukhopadhyay S. G153 determinants of quality of life in children with asthma who live in Scotland. Arch Dis Child 2013;98:A71. 36. Amaral LM, Palma PV, Leite IC. Evolution of public policies and programs for asthma control in Brazil from the perspective of consensus guidelines. J Bras Pneumol 2012;38:518–525.
QUALITY OF LIFE, ADHERENCE AND CONTROL
The quality of life of Brazilian adolescents with asthma: associated clinical and sociodemographic factors Lı´gia Menezes do Amaral, MD1, Lucas Moratelli2, Pamella Valente Palma3, and Isabel Cristina Gonc¸alves Leite, PhD4 Division of Pulmonology, Department of Internal Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil, 2School of Medicine, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil, 3School of Dentistry, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil, and 4Department of Public Health, Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora – UFJF), Juiz de Fora, Minas Gerais, Brazil
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Abstract
Keywords
Objective: Asthma is the most common chronic disease among adolescents. This study assessed the quality of life (QOL) related to health in adolescents with asthma and its determining factors (demographic, socioeconomic, and clinical). We also separately evaluated each of the parameters that comprised the asthma control classification. Methods: This was an observational, cross-sectional study of 114 adolescents who had doctor-diagnosed asthma. QOL was assessed using a version of the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) that was adapted and validated for Brazil, and higher scores indicated a better QOL. The level of asthma control was assessed using the rating system proposed by the Global Initiative for Asthma, and sociodemographic factors were evaluated. Results: When the averages of the PAQLQ domains and overall scores were compared to the potentially explanatory variables, significantly lower average PAQLQ scores were obtained for individuals with an inadequate level of asthma control (p50.001). Of the control components, daytime symptoms, nighttime symptoms, and limited physical activity were related to QOL. However, the use of the b2 agonist and the peak flow functional parameter were not related to QOL. Conclusions: The level of asthma control was related to QOL, but this association manifested mainly in the subjective control domains, such as nighttime and daytime symptoms and physical activity limitations. The objective domain for control classification, represented by pulmonary function, was not an independent predictor or determinant of the QOL of adolescent asthma patients.
Diagnostics, epidemiology, Pediatrics, quality of life, treatment
Introduction Asthma, the most common chronic illness among adolescents, is a serious public health problem worldwide and in Brazil, which is one of the countries with the highest prevalence rates of the disease. Brazil faces social and economic problems similar to a number of countries in Latin America and other parts of the world [1–4]. Little is know about Brazilian adolescents with asthma. However, is know that approximately 17 000 adolescents are admitted to hospitals every year in Brazil because of asthma, thus making asthma the thirdmost common cause of hospitalization among children and teens in the country [5]. Asthma impairs the physical activity of patients, and it negatively affects the patients’ social, emotional, and educational lives. When asthma is not
Correspondence: Lı´gia Menezes do Amaral, Division of Pulmonology, Department of Internal Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil. Jose´ Manoel Ribeiro St, Juiz de Fora – Juiz de Fora, Minas Gerais 36038318, Brazil. Tel: 55 32 4009 5109. E-mail: [email protected]
History Received 22 April 2013 Revised 27 February 2014 Accepted 9 March 2014 Published online 7 April 2014
controlled, it can be highly debilitating and even fatal. The heavy load that asthma imposes on social aspects is widely acknowledged, and it can contribute to school absenteeism, productivity loss, and reduced participation in family and social life [3–6]. The multicenter International Study for Asthma and Allergies in Childhood (ISAAC) that was conducted in 56 countries identified an active asthma prevalence of 1.6–36.8%. The average prevalence found in the 20 Brazilian cities that participated in the study was 20%, which was the eighth highest among the countries studied [3,4]. A separate analysis of the prevalence of asthma in the adolescent population, i.e. ISAAC-PHASE 3, revealed an average prevalence of 19% [7]. Assessments of asthma based only on outcomes such as morbidity and mortality are insufficient; thus, an increased search for other patient-oriented measures and assessments has begun. From that perspective, quality of life (QOL)related aspects have emerged as important outcomes in clinical trials, healthcare service assessments, and clinical practice, thereby leading to improved communication between doctors and patients. QOL was defined by the
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DOI: 10.3109/02770903.2014.903964
World Health Organization-Quality of Life Group (WHOQOL) as an ‘‘individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns’’ [2]. QOL is therefore an additional dimension in the assessment and measurement of the results of public policies and clinical interventions [8–10]. Asthma-related QOL has been evaluated in pediatric population, but most of the studies have focused on younger children. Information on asthma-related QOL in adolescents is scarce. The impact of asthma on this age group is regarded as a combination of crises, having the impositions of a chronic disease combined with the identity construction phase [2]. The relationship between level of asthma control and QOL is already well known [11], yet separately assessing the relationship of each component, subjective and objective, of control can provide important information for clinical management, and even for the construction of public policies focused on adolescents with asthma. The aim of the present study was to assess the asthmarelated QOL in adolescents and its relationship with demographic, socioeconomic, and clinical factors. Among the clinical factors being evaluated separately, the relationship of each of the parameters that comprise the classification of control of the disease and asthma related QOL.
Methods Design, study population and data collection The present study is a cross-sectional, observational epidemiological study that was performed in an outpatient setting. The sample consisted of adolescents aged 12–18 years of both sexes who were medically diagnosed with asthma and treated at the Adolescent Pneumology Outpatient Clinic, which is a secondary healthcare unit affiliated with the Department of Children and Adolescent Health of the Health Secretary of the Juiz de For a municipal government in the state of Minas Gerais, Brazil. Juiz de Fora is a city of about 516 246 inhabitants located in southeastern Brazil [12]. The exclusion criteria were clinical or functional diagnosis of other respiratory diseases; concomitant diagnosis of other diseases affecting QOL, such as neurological and immunosuppressive illnesses and neoplasias; and cognitive deficits that would hinder the patient’s understanding of the questionnaires. The data were collected between August 2011 and August 2012. During the study period, 118 adolescents with asthma were treated at the outpatient clinic, and 114 were interviewed, with parents’ written consent and teens assent, as described in Figure 1. Written informed consent was obtained from the study participants. Instruments All of the participants responded to the complete, validated, and adapted Brazilian Portuguese language version [13] of the Pediatric Asthma QOL Questionnaire [14]. The questionnaire, which was specifically designed to assess asthma-related QOL in children and adolescents with asthma, comprises 23 items that are distributed among 3 domains (symptoms,
Associated clinical and sociodemographic factors
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Figure 1. Study population.
activity limitation, and emotional function) [14]. The participants answered the PAQLQ in face-to-face interviews in the absence of their caregivers, as recommended by the questionnaire’s author. The answer options are set on a 7-point scale, where 01 indicates maximal impairment, and 07 indicates no impairment. The results are expressed as the average scores for each domain and the average total score. The PAQLQ was used in the present study after its author granted authorization. The outcome variable was QOL, as assessed by the averages of the three PAQLQ domains and overall scores. The sociodemographic and economic variables that were assessed were age, sex, skin color, marital status, body mass index (BMI), smoking, passive smoking, the presence of domestic animals in the household, number of siblings, number of residents in the household, residence in a rural or urban setting, educational level of the participants and their parents, household income, the head of household’s employment status, the number of family members contributing to the household income, participation in government aid programs, monthly drug expenses, and socioeconomic class, which was based on economic classification criteria. Questions regarding parents’ education level and family income were answered by the persons responsible who accompanied the adolescents. Socioeconomic status was categorized according to economic classification criteria of the Brazilian Association of Research Companies [15], which takes into consideration household, education level, and family income characteristics in the differentiation of social classes. To measure the peak of expiratory flow (PEF), a Mini-Wright (Clement ClarkeR) peak flow meter was used. BMI was calculated using the formula: weight (kg)/[height (m)]2 [16]. To assess the level of asthma control, the classification that was formulated by the Global Initiative for Asthma was used. This classification evaluates: daytime symptoms, nocturnal symptoms, need for reliever, limitation of physical activities, lung function and assessment of future risk. Based on this parameter, GINA classification divides the levels of asthma control into: controlled, partly controlled, and uncontrolled in an evaluation period of 4 weeks [6].
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Data analysis
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The Statistical Package for Social Sciences (SPSS v.15, Chicago, IL) software was used for the statistical analysis of the data. The QOL parameters were obtained from the means and corresponding standard deviations. Following the application of the Kolmogorov–Smirnov normality test, the average QOL values were compared by ANOVA with a significance level of 5% and using univariate regression. To investigate the influence of the clinical and sociodemographic variables, a multivariate regression analysis was performed. In the case of categorical variables, stratification was performed at two or more levels (according to their distribution in the univariate analysis). Clinically relevant variables and those of statistical significance in the bivariate analysis (p50.20) were included in the multivariate analysis (Table 5). Ethical considerations The project was submitted to the Research Ethics Committee of the University Hospital of the Federal University of Juiz the Fora (Universidade Federal de Juiz de Fora – UFJF), as required by Resolution 196/96 of the National Health Council (Conselho Nacional de Saude) and its complements, as well as the Ethics Code from 1988 (Articles 122 to 130), and it was approved under Protocol No. 314/10.
Results Descriptive statistical analysis A total of 114 patients answered the questionnaire. Table 1 includes the results of the descriptive statistical analysis of the demographic variables. Of the participants, 69.8% were younger than 15 years old, and 50.9% were male; 21.1% belonged to Social Class B (monthly gross household income between USD 1269.00 and USD 2187.00) and 61.4% C (monthly gross household income between USD 465.00 and USD 763.00), according to the criteria of the Brazilian Association of Research Companies (Associacao Brasileira de Empresas de Pesquisas [ABEP]) [15]. Regarding the level of asthma control, 50.9% of the participants exhibited partially controlled asthma, and 39.5% exhibited uncontrolled asthma. These data are included in Table 2, which presents the clinical characteristics of the sample. Correlations among levels of asthma control and PAQLQ domains Upon comparing the variables that were related to the level of asthma control to the average scores of the three PAQLQ domains and the overall PAQLQ score, we observed a statistically significant correlation between poor control and lower QOL scores (p50.001). These results are described in Table 3, which further suggests a relationship between each parameter in the classification of asthma control level and QOL, indicating that the subjective parameters of asthma control, such as the frequency of daytime symptoms
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Table 1. Demographic and socioeconomic characteristics of adolescents with asthma treated at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora, Minas Gerais, Brazil, 2011/2012 (n ¼ 114).
Variable Age 12–14 years old 15 or older Sex Male Female Self-declared skin color White Brown Black BMI Low weight Normal weight Overweight Obesity I, II and III Adolescent’s education level 0–4 years 5–8 years 9 years 12 years Caregiver’s education level 0–4 years 5–8 years 9–12 years More than 12 years Gross income in dollars/ month–ABEP classification B1 (USD 2187.00) B2 (USD 1269.00) C1(USD 763.00) C2 (USD 465.00) D(USD 353.00) Residence area Urban Rural Receiving medication free of charge Yes No Partially Presence of domestic animals No Yes
Absolute frequency (n)
Relative frequency (%)
74 32
69.8 30.2
58 56
50.9 49.1
57 21 36
50.0 18.4 31.6
23 47 14 7
25.3 51.6 15.4 7.7
2 83 28 1
1.8 72.8 24.6 0.9
54 29 29 1
47.8 25.7 25.7 0.9
2 22 29 41 20
1.8 19.3 25.4 36.0 17.5
97 17
85.1 14.9
80 10 19
73.4 9.2 17.4
37 77
32.5 67.5
BMI, Body mass index; ABEP, Brazilian Association of Research Companies (Associac¸a˜o Brasileira de Empresas de Pesquisa).
(p ¼ 0.027), the presence of nighttime symptoms (p50.001), and activity limitation (p50.001), correlated with the QOL domain scores and the overall score. A similar relationship was not observed between QOL and the objective parameter of asthma control, which was represented by PEF in the present study. Correlations among demographic and socioeconomic variables and the three PAQLQ domains and overall PAQLQ score Table 4 describes two other variables that correlated significantly with the PAQLQ scores: the presence of domestic animals, which exerted a protective effect on all of the domains (p ¼ 0.012), and the caregiver educational level, which correlated with the emotional function domain of QOL (p ¼ 0.017). In addition, obesity exerted a negative impact
Associated clinical and sociodemographic factors
DOI: 10.3109/02770903.2014.903964
on the PAQLQ domain scores and overall score (p50.028). The remainder of the demographic and socioeconomic variables did not exert a significant impact on QOL.
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animals (p ¼ 0.010) remained significantly associated after adjustment.
Discussion Multiple linear regression analysis The variables that attained a significance level less than or equal to 0.20 were included in a multiple linear regression analysis. In the multivariate analysis, as show in Table 5, the significance level was 5% (p ¼ 0.05). After multivariate analysis, the variables level of asthma control (p ¼ 0.000), daytime symptoms (p ¼ 0.023), nighttime symptoms (p ¼ 0.000), limitation of physical activities (p ¼ 0.000), asthma severity (p ¼ 0.000), and the presence of domestic
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Table 2. Clinical characteristics of adolescents with asthma treated at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora, 2011/2012 (n ¼ 114).
Variable Level of asthma control Controlled Partially controlled Uncontrolled Rhinitis No Yes Smoking No Yes Passive smoking No Yes Treatment at emergency services in the previous month No Yes Treatment at emergency services in the previous year No Yes
Absolute frequency (n)
Relative frequency (%)
11 58 45
9.6 50.9 39.5
6 108
11.8 88.2
111 3
97.4 2.6
64 49
56.6 43.4
93 21
81.6 18.4
53 60
46.9 53.1
Asthma substantially affects the QOL of patients, and this effect has been attributed to multiple factors, among which asthma control seems to play a central role [11,17]. According to the main consensus on this subject, the attainment and maintenance of asthma control is the main aim of treatment [6,18]. The present study uncovered an important correlation between QOL and the level of asthma control, which was in agreement with the Brazilian and international literature [11,17,19]. Regarding the correlation between asthma control and QOL, three of the subjective parameters of asthma control (namely, daytime symptoms, nighttime symptoms, and activity limitation) were statistically related to QOL. The need for relief/rescue medication or for the functional component of asthma control, which was represented in the present study by PEF, did not have a similar influence on QOL. This information may have implications for the clinical management of asthmatic adolescents to the extent that they value the importance of the subjective components of control in QOL. These findings agree with results reported in the international literature [20,21]. The lack of correlation between lung-function parameters and QOL might be partially explained by the fact that the functional assessment was conducted using a single, isolated measurement, whereas QOL was measured over a period of time (1 week, in the case of the PAQLQ) [21]. In addition, the variations in PEF throughout the course of the day exhibited a stronger correlation with daytime symptoms than isolated functional measurements did because asthma symptoms correlated better with variations in the airway caliber over time than with an isolated measurement at a single moment. It would be interesting for future research to investigate whether serial functional measurements or other functional
Table 3. Correlations among levels of asthma control and PAQLQ domains, Adolescent Pneumology Outpatient Clinic, Juiz de Fora, Minas Gerais, Brazil, 2011/2012. Average of domains (±SD) Variables Level of asthma control Controlled Partially controlled Uncontrolled Daytime symptoms in the previous week Up to twice More than twice Nighttime symptoms in the previous week None Any Use of relief medication in the previous week Up to twice More than twice Limitation of physical activities in the previous week None Any Peak of expiratory flow Normal 580% of the theoretical value
n
(%)
11 58 45
(9.6) (50.9) (39.5)
63 51
(55.3) (44.7)
58 56
(50.9) (49.1)
86 28
(75.4) (24.6)
47 67
(41.2) (58.8)
44 48
(47.8) (52.2)
Symptoms
Activity limitations
Emotional
Total
p50.001 5.05 (±1.87) 4.38 (±1.28) 3.51 (±1.01) p ¼ 0.004 4.42 (±1.47) 3.71 (±1.06) p50.001 4.61 (±1.45) 3.57 (±0.98) p ¼ 0.097 4.22 (±1.39) 3.74 (±1.12) p ¼ 0.001 4.59 (±1.37) 3.76 (±1.23) p ¼ 0.775 4.09 (±1.43) 4.18 (±1.27)
p50.001 5.25 (±1.68) 4.17 (±1.34) 3.42 (±1.10) p ¼ 0.008 4.29 (±1.42) 3.60 (±1.26) p ¼ 0.007 4.32 (±1.42) 3.63 (±1.27) p ¼ 0.084 4.11 (±1.44) 3.59 (±1.14) p50.001 4.66 (±1.41) 3.50 (±1.17) p ¼ 0.758 4.00 (±1.49) 4.09 (±1.21)
p ¼ 0.006 5.34 (±1.58) 4.69 (±1.28) 4.06 (±1.34) p ¼ 0.495 4.59 (±1.42) 4.41 (±1.34) p ¼ 0.001 4.93 (±1.44) 4.06 (±1.18) p ¼ 0.872 4.52 (±1.43) 4.47 (±1.23) p50.001 5.14 (±1.29) 4.06 (±1.27) p ¼ 0.379 4.37 (±1.42) 4.63 (±1.39)
p50.001 5.20 (±1.66) 4.44 (±1.18) 3.68 (±1.00) p ¼ 0.027 4.49 (±1.34) 3.93 (±1.08) p50.001 4.66 (±1.35) 3.76 (±0.96) p ¼ 0.212 4.30 (±1.31) 3.96 (±1.04) p50.001 4.79 (±1.23) 3.81 (±1.11) p ¼ 0.576 4.17 (±1.34) 4.32 (±1.17)
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Table 4. Correlations among demographic and socioeconomic variables and the three PAQLQ domains and overall PAQLQ score, Adolescent Pneumology Outpatient Clinic, Juiz de Fora 2011/2012. Average of domains (±DS)
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Variables Education level of the mother or caregiver 0–4 years 5–8 years 9 years or more Presence of domestic animals Yes No Animal spends the night in the room Yes No Age Up to 14 years old 15 years old or older Sex Male Female BMI Low weight Normal weight Overweight Obesity I, II and III Average household income Up to USD 308.00 2 minimum wages or more ABEP classificationa Class B Classes C and D
n
(%)
54 29 30
(47.8) (25.7) (26.5)
77 37
(67.5) (32.5)
9 67
(11.8) (88.2)
76 34
(69.1) (30.9)
58 56
(50.9) (49.1)
23 47 14 7
(25,3) (51,6) (15,4) (7,7)
51 61
(45.5) (54.5)
24 90
(21.1) (78.9)
Symptoms
Activity limitations
Emotional
Total
p ¼ 0.081 4.06 (±1.45) 3.76 (±1.17) 4.53 (±1.24) p ¼ 0.023 4.30 (±1.32) 3.69 (±1.33) p ¼ 0.385 3.92 (±1.35) 4.33 (±1.32) p ¼ 0.514 4.20 (±1.32) 4.02 (±1.40) p ¼ 0.136 4.29 (±1.31) 3.91 (±1.36) p50.013 4.54 (±1.30) 4.09 (±1.29) 4.38 (±1.46) 2.70 (±0.81) p ¼ 0.262 3.97 (±1.25) 4.26 (±1.42) p ¼ 0.362 4.33 (±1.58) 4.04 (±1.28)
p ¼ 0.348 3.96 (±1.37) 3.75 (±1.34) 4.27 (±1.46) p ¼ 0.012 4.20 (±1.25) 3.51 (±1.55) p ¼ 0.510 3.93 (±1.00) 4.23 (±1.29) p ¼ 0.320 4.11 (±1.34) 3.82 (±1.47) p ¼ 0.094 4.19 (±1.29) 3.76 (±1.46) p50.084 4.57 (±1.45) 3,99 (±1.32) 3.83 (±1.26) 3.20 (±0.85) p ¼ 0.654 3.91 (±1.42) 4.03 (±1.39) p ¼ 0.438 4.18 (±1.28) 3.93 (±1.42)
p ¼ 0.017 4.31 (±1.36) 4.25 (±1.24) 5.12 (±1.41) p ¼ 0.026 4.70 (±1.32) 4.09 (±1.44) p ¼ 0.248 4.22 (±1.39) 4.77 (±1.32) p ¼ 0.517 4.61 (±1.33) 4.42 (±1.47) p ¼ 0.190 4.67 (±1.34) 4.33 (±1.41) p50.106 4.82 (±1.16) 4.51 (±1.52) 4.51 (±1.44) 3.32 (±0.61) p ¼ 0.331 4.39 (±1.34) 4.65 (±1.41) p ¼ 0.301 4.77 (±1.52) 4.44 (±1.34)
p ¼ 0.051 4.13 (±1.29) 3.93 (±1.13) 4.68 (±1.23) p ¼ 0.012 4.42 (±1.18) 3.79 (±1.32) p ¼ 0.306 4.03 (±1.14) 4.46 (±1.19) p ¼ 0.429 4.32 (±1.21) 4.12 (±1.34) p ¼ 0.110 4.40 (±1.19) 4.02 (±1.30) p50.028 4.64 (±1.14) 4.21 (±1.28) 4.30 (±1.34) 3.02 (±0.45) p ¼ 0.317 4.10 (±1.21) 4.34 (±1.30) p ¼ 0.314 4.45 (±1.39) 4.15 (±1.21)
a
ABEP classification – monthly gross income: Class B (from USD 1269.00 to USD 2187.00) and Class C (from USD 465.00 to USD 763.00). Conversion rate on 10/23/2012, BRL 1.00 ¼ USD 2.02.
Table 5. Final result of the multiple linear regression model, asthma patients attended at the Adolescent Pneumology Outpatient Clinic of Juiz de Fora – Minas Gerais – Brazil, 2012. Variable Level of asthma control Daytime symptoms Nighttime symptoms Limitation of physical activities Presence of domestic animals
badjusted
p
0.144 0.037 0.129 0.145 0.049
50.001 0.023 50.001 50.001 0.010
parameters could be related to the QOL in asthmatic adolescents [22]. The presence of domestic animals is a controversial topic in the assessment of asthmatic patients. Because of the complexity of this relationship and for methodological reasons [23], the protective effect found in the present study must be addressed cautiously. Some studies have attributed a protective effect against the future development of allergies to the presence of domestic animals in early childhood [24]. A meta-analysis performed by Takkouche et al. [25] in 2008 concluded that exposure to cats exerted a slight protective effect against asthma that did not occur with exposure to dogs and that further, careful investigation of the effect of such exposure was needed to assess the role of pets in diseases with a known allergic component. Asthma and obesity are prevalent diseases that have an important impact on public health, and their complex, mutual interaction has been widely reported in the literature [26,27]. As in the present study, which showed lower average domain
scores and total QOL scores among obese participants, the recent literature also indicates a poorer asthma-related QOL and poorer disease control among obese patients with asthma compared to asthma patients with normal weight [28,29]. However, it is worth noting that the number of obese participants in the present study was small, which hindered a proper analysis of the correlation between obesity and asthma. Studies of socioeconomic factors and asthma have yielded conflicting results [30]. The present study did not find a correlation between socioeconomic variables and QOL in patients with asthma, which was in agreement with results from other studies that specifically addressed the adolescent population [30–32]. Furthermore, the assessment of the influence of socioeconomic variables was hindered by the fact that the participants in the present study were mostly from economic classes B and C (80.7%). Regarding the correlation between higher average scores in the emotional function domain of the PAQLQ and the educational level of their caregivers, several studies have described parental educational level as a factor that correlates with knowledge about asthma and thus affects aspects related to adherence to treatment [33]. Even when the importance of the correlation between QOL and clinical variables, such as those related to asthma control, is recognized, it is worth emphasizing the four components of health status in children with asthma that were suggested by Juniper et al. [22] in 2004: asthma-specific QOL, airway caliber (functional component), daytime symptoms, and nighttime symptoms. These components direct
Associated clinical and sociodemographic factors
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DOI: 10.3109/02770903.2014.903964
attention to the main assumptions that underlie the appropriate treatment of asthma: the prevention of mortality, the reduction of morbidity, and the improvement of patient wellbeing. Therefore, clinical measurements of asthma control provide information on the first two foundations of appropriate treatment, whereas QOL more appropriately reflects patient wellbeing [22]. Future studies that assess instruments designed to address all the dimensions of asthma and facilitate the use of these instruments in clinical practice within different cultural contexts might contribute to improved QOL in adolescents with asthma and help improve communication between patients and doctors, thus reducing the impact of disease on clinical, emotional, and social functioning [34]. Future studies are needed to develop, implement, and assess interventions that promote better asthma control and better QOL for patients. Studies in young children have demonstrated the relationship between asthma-related QOL with determinants such as control, disease severity and socioeconomic conditions. Recent study in Scotland highlights asthma control as the factor most amenable to intervention [35]. However, there are still few studies in the adolescent population. There are no studies in adolescents that assess, separately, the components of asthma control and its relationship to QOL. The limitations of the present study are inherent to crosssectional observational studies, in which the relationship between cause and effect cannot be established effectively. Therefore, it is not possible to state whether asthma control is the cause or the consequence of improved QOL. In addition, the employed study was a convenience sample, and the results of this sample may not permit generalization. Another limitation is that, even though they were in a specialized care service for respiratory illnesses in adolescents and medications for control and relief were provided free of charge, a small percentage of our sample was composed of patients who had adequate control of the disease.
2. 3. 4.
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8. 9. 10.
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12.
13.
Conclusions Correlating each of the domais of asthma control with the QOL of adolescents with asthma may contribute to a better approach that promotes better QOL for this population. Public policies and programs for asthma control that have been launched in Brazil in recent years have facilitated patient access to required medication [36]; however, to meet the goal of improving the QOL of adolescents with asthma, public health policies must go beyond medication and provide information to patients and caregivers. Such information could facilitate the appropriate control of symptoms and promote self-care and adherence to treatment, thereby affording adolescents a safe and complete transition into adult life.
Declaration of interest
14. 15.
16.
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18.
The authors have no conflict of interest. 19.
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