ORIGINAL

Niger J Paed 2013; 40 (4): 364 –369

Ayuk AC

Oguonu T

Ikefuna AN

Ibe BC

Health-related quality of life in

school-aged children with and

without asthma in Enugu, South

East Nigeria

DOI:http://dx.doi.org/10.4314/njp.v40i4,3

Accepted: 13th February 2013

Abstract Background: Identify-

ing impaired quality of life is a

recognized component of asthma

management with no published

data in Nigerian children with

asthma. The aim of this study was

to describe the health-related

quality of life of school-aged

children with and without asthma

seen at the Asthma Clinic of the

University of Nigeria Teaching

Hospital, Enugu.

affected in asthmatics than non-

asthmatics; 73.4, SD 23.2 vs. 84.4,

SD17.3 respectively (MD 11.1, CI

= 5.0 to 17.1, p=0.002). The psy-

chosocial health summary scores

in children with and without

asthma were 77.6 SD 18.1 vs.81.1

SD15.1 (MD 3.5, CI= -1.4 to 8.4,

p= 0.24), with the highest scores

obtained in the social functioning

domain for both asthma and non-

asthma patients; 82.7, SD 20.3 and

87.6, SD 15.7(MD 4.9, p = 0.08)

respectively.

(

)

Ayuk AC

Department of Paediatrics,

University of Nigeria Teaching

Hospital, Enugu, Nigeria.

Email: adaraymond@yahoo.com,

Tel: 234-8036754123

Oguonu T

,

Ikefuna AN

,

Ibe BC

Department of Paediatrics,

College of Medicine

University of Nigeria, Enugu,

Nigeria.

Methods: Cross-sectional hospital

-based study of children aged 7-

1

7

years (with and without

In both the overall and specific

QOL domains, boys had higher

scores than girls, irrespective of

age or socioeconomic status with

an inverse relationship between

increasing age and QOL scores (r=

-0.2, p=0.07).

asthma) attending the Paediatric

Asthma and General Children

Outpatient Clinic of the Univer-

sity of Nigeria Teaching Hospital

(

UNTH) from parts of the south –

east region of Nigeria were con-

secutively enrolled. Quality of life

Conclusions: Children with

asthma showed worse QOL and

significant impairment in their

physical functioning, more notice-

able among the female study popu-

lation. Information obtained from

our QOL study forms a basis for a

more informed management plan

with regards to which age groups

are more affected and the specific

domains of health in children with

asthma that need to be given closer

attention to reduce asthma morbid-

ity. The study emphasizes the need

for QOL integration in asthma

management for a more holistic

approach to outcome evaluation of

treatment rather than the physical

outcomes.

(

QOL) scores were obtained using

the Paediatric Qu_Ta_Mlity of Life in-

ventory (PedsQL ) questionnaire

which measures the core dimen-

sions of health: physical function-

ing, emotional functioning, social

functioning and school function-

ing.

Results: There were a total of 180

study participants: (90 with

asthma and 90 without asthma).

Overall quality of life scores for

children with asthma was worse

than in those without asthma;

7

5.5, SD19.3 and 82.7, SD14.5

respectively (MD 7.1, CI = 2.3 to

2.3, p=0.01). Physical function

domain was significantly more

1

Introduction

in which he or she lives, in relation to their goals, expec-

tations, standards and concerns. Health-Related Quality

1

Quality of life is described as the satisfaction felt by an

individual with the various aspects of his or her life. It

is the individual’s perception of his/her position in life

in the context of the culture, religion and value systems

of Life (HRQoL) is the degree to which a patient’s

health status affects his/her self-determined evalu₂ ation

of satisfaction as perceived by that individual. The

measurement of health-related quality of life is based on

1

3

65

the growing recognition that health care should not only

focus on the patient’s sur₃vival or quantity of life but also

on the quality of the life.

understanding the questionnaire or did not give

consent.

Ethical Clearance and Consent

Asthma is the₄m_,₅ost common chronic illness among chil-

6

dren globally, and also in Nigeria. There is evidence

Ethical approval was obtained from the Health Research

and Ethics Committee of the hospital. Before com-

mencement of the study, permission to use₁q₆_,u₁₇estionnaire

of global increase in both prevalence and₄_,s₅e_,₇v_,₈erity of

childhood asthma in the last three decades.

Despite

effective asthma medications that are available for

symptomatic control, it is reported globally that current

treatments have not significantly reduced morbidity or

was obtained from the copyright owners.

Informed

written consent and assent were obtained from caregiv-

ers and the study participants respectively.

9

mortality. With this limitation, there is an increasing

tendency to evaluate, using quality of life measures, the

impact of asthma and its management on the daily lives

and function of affected people and to identify the s₃pe-

cific aspects of life with greater associated morbidity.

Measurements and Data Collection

Eligible participants who gave consent were enrolled.

Relevant bio-data and medical history were obtained

including age and gender. The socio-economic status

1

0-12

that assessed the effects

Some studies in Europe

18

was calculated using the method suggested by Oyedeji.

asthma had on schooling, noted differences in school

function as well as academic performance between chil-

dren with and without asthma. Their studies showed that

children₀_-₁₂with asthma had worse school function

Other socio-demographic characteristics such as place of

domicile, family structure, number of children, and or-

der of birth of the children were not studied. Quality of

Life assessment for all the participants was done using

the pre-tested interviewer-administered generic quality

of life questio_Tn_Mnai₁r₇e_,₁,₉the Pediatric Q_T_Muality of Life inven-

The PedsQL questionnaire is a

1

scores.

In Nigeria few QOL studies have been conducted in

1

3

children with chronic illness and the study on asthma

tory (PedsQL ).

1

4

was done on adult subjects. This current study was

done to document the impact of asthma on quality of life

of children with asthma in comparison to their non-

asthma counterpart, as well as to document the specific

limitations in their health- related quality of life and

ascertain any socio-demographic influence on quality of

life. Such knowledge will assist the clinician to know

the aspects of management that require more focus and

thus improve patient outcome.

robust validated 23-item generic core scale designed to

measure the core dimensions of health: physical func-

tioning (8 items), emotional functioning (5 items), social

functioning (5 items) as well as school functioning

(5 items). Physical functioning was characterized using

the parameters: Running, walking more than one block,

participating in sports activity or physical exercise, lift-

ing something heavy, taking a bath, doing chores, hav-

ing hurts or aches, low energy level. Emotional func-

tioning was characterized using the parameters: feeling

afraid or scared, feeling sad, feeling angry, trouble

sleeping, worrying. Social functioning was characterized

using the parameters: getting along with other children,

other children not wanting to be his or her friend, getting

teased by other children, not able to do things other chil-

dren can do, keeping up when playing with other chil-

dren. School function was characterized using the pa-

rameters: paying attention in class, forgetting things,

keeping up with schoolwork, missing school because of

not feeling well and missing school to go to the doctor

or hospital.

Materials and methods

Study Design and Population

This was

a cross-sectional hospital-based study,

whereby ambulatory children with and without bron-

chial asthma were enrolled consecutively. It was carried

out at the University of Nigeria Teaching Hospital

(

2

UNTH), Enugu South-east, Nigeria between November

009 and April 2010. The study site was the Pediatric

Asthma and General Children Outpatient (CHOP) clin-

ics of the hospital and the study participants were drawn

from this population. The asthma clinic is a major sub-

specialist clinic that caters for children in most of the

south east region. Children seen in the clinics are diag-

nosed with asthma based on clinical findings in keeping

with a₅sthma diagnostic criteria recommended by

The items of the four scales (Physical functioning,

Emotional functioning, Social functioning, and School

functioning) are grouped together on the actual question-

naire, so it is easy to create score both for_T_Meach of the

scales and summary scores. The PedsQL question-

naire is then further summarized into a Physical health

summary score and a psychosocial health summary

score (a combination of the social, emotional and school

functioning).

1

GINA. Sex and age matched children without asthma

and no other chronic illnesses, attending the children

outpatient clinic for laboratory result review for non-

chronic ailments such malaria and upper respiratory tract

infection were used as controls. Those with chronic

clinical conditions e.g. sickle cell anemia, congenital

heart disease, seizure disorders that may influence qual-

ity of life score, were excluded from the study. Also

excluded were children who either had difficulties in

TM

The PedsQL has been used₃across several cultures and

1

countries including Nigeria and has been shown to

have appropriateness of the conceptual and measure-

ment model, reliability, content validity, interpretability,

precision and respondent and administrator acceptability

3

66

1

7-19

It h₉as a reliability scale

even when child completed.

socio-demographic characteristics. For all parameters in

both groups (asthmatic and non-asthmatic children),

those without asthma had higher QOL scores than those

with asthma and the differences were clinically and

statistically significant for male gender (MD = 7.3 CI

1.5 to 13.2; p = 0.02); age group 14-17years (MD = 7.5

CI-1 to 16; p = 0.05), and socio-economic class III (MD

= 11.4 CI 0.5 to 22.3; p = 0.04).

1

and Crobach’s alpha of 0.70-0.93. The questionnaire

was pretested for this age group and found to have an

internal consistency coefficient ICC (Cronbach alpha) of

0

.90, which is within the stipulated range for this ques-

tionnaire. The questionnaire had been validated and

need not require further except on translation. The ques-

tionnaire was administered in the original English lan-

guage it was developed in and was not further translated.

The participants chose the corresponding scores that best

expressed any impairment in the various aspects of their

lives in the preceding week. Each participant completed

the questionnaire in about 9 minutes. The mean of all

the scores for each scale was computed as the sum of the

items over the number of items answered.

Table 1: Distribution of subjects and controls according to age

and Socioeconomic Class (SEC)

Distribution and mean age of study

population

Asthma

n (%)

Non-

Asthma

n (%)

Asthma

Mean age

Non-

Asthma

Mean age

p value

AGE

(years)

7

-9

24 (48.0)

26 (32.0)

8.5 ± 0.7

7.8 ± 0.8

0.001

Data Management and Analyses

1

7

0-13

4-17

-17

33 (46.5)

33 (55.9)

90(50.0)

38 (53.5)

26 (44.1)

90(50.0)

11.1 ± 1.1

14.9 ± 1.2

11.8 ± 2.8

11.6 ± 1.2

15.1 ± 1.1

11.5 ± 3.0

0.05

0.70

0.38

Information obtained were transferred to electronic data

base, prepared using Microsoft Office Excel 2007 and

statistical analyses done using the Statistical Package for

Social Sciences (SPSS) software version 17. The mean

differences in scores between the subjects and controls

were calculated and respective confidence intervals de-

rived. Mann-Whitney test (U) was used to determine

significance for the health-related quality of life scores

among asthma and non-asthma children. Significance

level was taken as minimal important difference (MD)

of ≥ 0.5 or p<0.05 with a mini₂m₀ um power of 80% for

the confidence interval of 95%.

SEC

I

8 (44.4)

27 (60.5)

32 (58.2)

17 (31.5)

6 (54.6)

10 (55.6)

17 (39.5)

22 (41.8)

36 (68.5)

5 (45.4)

II

III

IV

V

2

(SEC χ = 11.3, p = 0 .02)

Table 2: Health-Related Quality of life scores of children with

and without asthma on the Pediatric Quality Of Life scale.

Generic quality of life mean scores

Asthma

mean score Asthma

Non-

Mean

Diff

SCALES

(SD)

mean score

(SD)

95% CI*

p

(n = 90)

Results

(n = 90)

Total

75.5 (19.3)

73.4 (23.2)

82.7 (14.5)

7.2

2.3 to 12.3 0.01

Of the recruited participants, 17 were excluded based on

various exclusion criteria. A total of 180 participants

were enrolled into the study (90 children with asthma

and 90 without asthma), with comparable socio-

demographic characteristics, table 1. The mean age was

Physical

Psychosocial 77.6 (18.1)

Social

84.4 (17.3)

81.1 (15.1)

87.6 (15.7)

11.1 5.0 to 17.1 0.002

-1.4 to 8.4 0.24

-0.5 to 10.2 0.08

3.5

4.9

82.7 (20.3)

Emotion

77.9 (23.2)

79.9 (19.9)

1.9

-4.4 to 8.3 0.64

School func-

tion

72.0 ± 19.1 75.7 ± 17.6 3.7

-1.7 to 9.1 0.29

1

1.8 (SD 2.8) years and 11.5 (SD 3.0) years for asth-

matic and non-asthmatic children respectively.

The mean QOL scores for asthmatic and non-asthmatic

children were 75.5 and 82.7 respectively (MD = 7.2, CI

Table 3: Health-related quality of life in relation to the gender, age

and socio-economic status of the study participants.

Mean cumulative Generic Quality of Life scores

2

.3 to 12.3; p = 0.01). When specific domains were as-

sessed, the QOL scores for children with and without

asthma, in physical functioning were, 73.4 and 84.4 re-

spectively (MD = 11.1 CI 5 to 17.1; p = 0.002 (table II).

Children without asthma also had higher scores in all the

other QOL domains but without statistical significance,

table 2.

Sub-

ject

charac-

teristic

No (n)

of

subjects

asthma:

non-

Asthma

mean score

(SD)

Non-

Mean

Diff

95% CI*

P

Asthma

mean score

(SD)

(n = 90)

asthma

Gender

Male

Female

Age(years)

50:44

40:46

78.5 (15.6)

71.8 (22.7)

85.8 (12.5)

79.8 (15.7)

7.3

8.0

1.5 -13.2

-0.2 -16.3

0.02

0.12

The effects of gender, age and socio-economic status on

QOL were further studied. The social, emotion and

school function which are components of the psycho-

social domain were studied together.

7

-9

10-13

4-17

24:26

78.0 (20.8)

78.3 (20.8)

70.8 (15.9)

88.3 (8.6)

81.9 (15.2)

78.3 (16.6)

10.4

3.6

7.5

1.5 -19.3

-4.9 -12.2

-1.0 - 16.0

0.16

0.70

0.05

3

3:38

1

33:26

SEC

I

II

III

IV

V

8:10

75.3 (16.8)

81.6 (15.9)

69.9 (22.0)

73.3 (20.4)

84.6 (5.4)

83.1 (14.6)

85.0 (10.2)

81.2 (15.5)

81.8 (16.4)

87.8 (8.6)

7.8

3.4

11.4

8.5

3.2

-7.7 - 23.4

-5.4 - 12.1

0.5 - 22.3

-2.0 - 19.0

-6.3- 12.9

0.25

0.85

0.04

0.10

0.31

Effect of gender, age and social status on quality of life

scores

27:17

32:22

17:36

6:5

Table 3 shows the performance of children with and

without asthma on the PedsQL scale in relation to their

*CI for mean difference

3

67

Table 5: Psychosocial functioning quality of life scores in relation to

the gender, age and socio-economic characteristics of the study

participants.

Effect of gender, age and social status on physical func-

tioning

Mean Psychosocial functioning Quality of Life scores

In the physical function domain, significant differences

in scores were noted between the children with asthma

and the controls, in all socio-demographic characteristics

studied (table 4). Among males, QOL scores for chil-

dren with and without asthma were 76.0 vs. 88.1 (MD =

No (n) of

subjects

asthma:

non-

Asthma

mean

score

Non-

Subject

xeristic

Asthma

mean score

(SD)

Mean

Diff

95%

CI*

p

(SD)

asthma

(n = 90)

Gender

5

4

0:44

0:46

80.7

(13.9)

73.4

-3.2 to

8.5

-2.7 to

13.3

1

2.1 CI 4.9 to 19.3; p = 0.01). Using the same scale, the

Male

83.5 (14.5)

78.7 (15.3)

2.7

5.3

0.22

0.46

values among the asthmatic and non-asthmatic children

aged 14-17 years were 66.4 vs. 82.5 respectively (MD =

Female

Age

(years)

(21.7)

1

6.1 CI 6.4 to 25.8; p = 0.001). Though weakly corre-

lated, the QOL decreased with increasing age (r = -0.2, p

0.07).

2

4:26

80.1

(17.9)

77.9

(20.5)

75.3

(15.6)

-1.6 to

15.1

-4.3 to

12.0

-10.1 to

7.8

7

1

-9

86.9 (11.1)

81.8 (13.6)

74.2 (18.0)

6.8

3.9

-1.1

0.36

0.68

0.78

=

33:38

0-13

3

8

3:26

:10

In relation to the socio-economic groups, for the asth-

matic and non-asthmatic participants, the significant

finding was in SEC III, where the QOL scores were 67.1

compared to 83.0 respectively (MD = 15.9 CI 2.8 to

14-17

SEC

79.8

(16.0)

84.0

(11.3)

72.6

(21.5)

76.0

(20.1)

76.4

(15.1)

-17.2 to

20.2

-7.9 to

6.6

-3.4 to

17.2

-7.1 to

16.0

I

81.3 (20.4)

83.4 (12.0)

79.5 (2.8)

1.5

-0.6

6.9

4.5

7.4

0.76

0.72

0.41

0.42

0.31

27:17

II

2

9.0; p = 0.01).

3

1

6

2:22

7:36

:5

III

IV

V

Table 4: Physical functioning quality of life scores in relation to the

gender, age and socioeconomic status of the study participants.

80.5 (16.9)

83.0 (11.1)

-10.5

to25.3

Mean Physical functioning Quality of Life scores

No (n) of

subjects

asthma:

non-

Non-

Asthma

mean

score (SD)

(n = 90)

Subject

Xteris-

tic

Asthma

mean

score (SD)

*CI for mean difference

Mea

n

Diff

95% CI*

P

(

n = 90)

asthma

Gender

5

4

0:44

0:46

76.0

(20.7)

70.1

88.1

(12.8)

80.9

4.9 to

19.3

1.0 to

20.7

Discussion

Male

12.1

10.8

0.01

0.07

Female

(25.8)

(20.2)

This study has demonstrated differences in quality of

life between children with asthma and those without

asthma, with a statistically significant higher value of

the overall quality of life score in the latter. The lower

scores obtained in children with asthma is an indication

that chronic illnesses such as asthma do affect the qual-

ity of life o₁f children, a finding similar with Stein and co

Age

(years)

2

3

4:26

3:38

3:26

75.7

(26.4)

78.7

(23.9)

66.4

(18.4)

3.1 to

25.2

-7.0 to

13.8

6.4 to

25.8

7

1

-9

89.8 (9.2)

82.1

(20.1)

82.5

14.1

3.4

0.16

0-13

4-17

0.87

0.00

1

(18.5)

16.1

SEC

2

8

2

3

1

6

:10

70.7

(19.3)

79.1

(22.4)

67.1

(24.5)

70.6

(23.0)

76.4

(15.1)

84.2

(10.7)

86.6

(12.9)

83.0

(22.2)

83.2

(18.4)

83.8

(11.1)

-1.1 to

29.3

-4.5 to

19.6

2.8 to

29.0

0.8 to

24.4

-workers, though differed from the findings of Man-

I

13.5

7.5

0.08

0.46

0.01

0.93

0.64

22

sour and colleagues, where the defining factor may

7:17

2:22

7:36

:5

II

have been the other extraneous characteristics such as

single parenting found among 66% of the group studied,

and that may have affected their scores.

III

IV

V

15.9

12.6

7.4

-13.3

to11.7

This study also demonstrated that children with asthma

had greatest limitations in phy₂s₃ical activity compared to

their counterparts. Lang et al in Baltimore, Maryland

*

CI for mean difference

(

USA) also noted lower scores in the physical domain in

Effect of gender, age and social status on psychosocial

functioning

children with asthma. It may be inferred that physical

function such as full participation in school sports activ-

ity, running and strenuous exercise, is limited by

asthma.

In the psychosocial health summary score (combination

of emotional, social and school functioning), females

participants with asthma, had significant lower scores

than their male counterparts 73.4± 21.7 vs 80.7± 13.9,

respectively (p = 0.05). Table 5 shows that, even though

psychosocial function diminishes with increasing age,

socio-economic status age and gender were not signifi-

cant determinants of the QOL scores. (r = -0.1, p =

Psychosocial role and function, including emotions such

as fear of death and alienation from peers due to asthma

assessed in this study showed important clinical differ-

ence but not statistically significan₄t, between the tw₂o₅

2

groups studied. Rechenberg et al, and Ricci et al

found similar attribute of normal emotional function in

children with asthma in Sweden and Italy respectively,

thus showing no correlation between asthma and poor

emotional function. This is further supported by the fact

that such economically advanced countries like Sweden

0

.18).

3

68

and Italy, who may benefit from social services that pro-

vide psychological support to patients as part of their

medical package had similar emotional function in rela-

tion to asthma, as that found in less privileged countries

that may not routinely have access to such psychological

support.

Conclusions

Children with asthma showed worse QOL and signifi-

cant impairment in their physical functioning, more no-

ticeable among the female study population. Indications

from this study showing great affectation of physical

functioning suggests that children with asthma may also

require routine screening for exercise induced broncho-

spasm and may thus be better advised on need for pro-

phylactic use of inhaled bronchodilators before engaging

in strenuous physical exercise. The need to introduce

QOL questionnaire as routine in asthma clinics may

further help identify unique needs in individual patients

and form a focus for direct intervention.

The influence of age on QOL score was also noted in

this present study, demonstrating a decline in scores

with increasin₂g₄_,₂a₅ge. This finding is in consonance with

other studies.

The role of the care-giver as the pri-

mary custodian of the health needs of the child in this

early stage of life may be a logical explanation for their

higher QOL scores. An inclusion of parental opinion to

the same questions in our study may have helped to con-

firm answers given by the children within the lower age

group as the understanding of the disease may have af-

fected their response.

The finding of decline in QOL in adolescents may ne-

cessitate paying greater attention to children as they

approach this age group, possibly attending to them in

specialized adolescent clinics to be able to holistically

tackle the challenges of this age group which may inad-

vertently affect their asthma management. Setting up of

adolescent clinics is thus encouraged.

Information obtained from this QOL study would in-

form a more directed approach in managing children

with asthma and form a baseline data for future research

in QOL studies.

How a child perceives his/her qual₆ity of life has been

2

found to be influenced by gender. Our study showed

that males without asthma had significantly higher qual-

ity of life scores compared with those with asthma. Also

females had statistically significant lower quality of life

in all domains when compared to males. Boys are

known to report higher scores in self-esteem and self-

2

6

worth than girls. This may explain the lower emotion

scores in females in this study, seen in both the children

with asthma and the controls without asthma.

Authors Contributors

AA, OT: Conception/funding

A combination of parental level of education and care-

giver occupation/income is one of the determinants of

the social status. The impact of social status on quality

of life assessed in this study showed that socio-

economic class did not significantly affect the cumula-

tive quality of life scores when asthmatic and non-

asthmatic children were compared. One would assume

that availability of resources could mean better manage-

ment of asthma, and thus better control and better qual-

ity of life. However, poor appreciation of the disease by

those in the lowest SEC V, or too much insight on the

consequence of the disease by those from SEC I, may

account for the results obtained. On the other hand, fur-

ther investigation may be required to explain the results

as there are other instruments which use different pa-

rameters such as household and livestock possession

among others, to measure wealth and socio-economic

status.

AA, OT, IN, IB: Proposal writing, design of the study,

manuscript preparation

AA, OT, IN: Acquisition of the data/analysis,

interpretation and writing article

AA,OT, IN, IB: Substantial involvement in review

Conflict of interest: None

Funding: None

Acknowledgements

The authors wish to thank the families and patients who

took part in this study, faculty at PATS MECOR and the

research team at Mapi Research Institute, Lyon, France

who made the questionnaire for this study available at

no cost.

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1

.

The World Health Organization

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