Discussion
Allergic rhinitis (AR) and asthma are among the most common diseases
globally and they usually persist throughout life. There has been a
visible spike in the rate at which people are contracting respiratory
allergies across the world, of which allergic rhinitis and asthma are
the most prominent; the former accounts for 20-30 % cases of
respiratory allergies while the latter affect around 15 % of the
population2,14. These allergies, with increase in
severity, have a debilitating effect on the productive, social, and
emotional aspects of patients, disrupting their and their caregiver’s
daily lives15. Despite such significant effects,
respiratory allergies are generally underestimated.
Furthermore, there is no unanimity among studies of childhood asthma and
allergic rhinitis highlighting the connection between the severity of
the disease and child’s quality of life. Some studies report that severe
or poorly managed asthma cause impairment of social, physical, and
academic lives of paediatric patients, whereas several other studies
disregard it(7,16). The paucity of studies conducted
in India especially in paediatric patients for measurement of QOL of
patients and caregivers made us conduct this study using mPAQLQ and
PACQLQ questionnaires in our population, where children were suffering
from asthma and/or rhinitis.
Approximately 70% of subjects of our study were in the 7-12 years age
group whereas only 30 % were adolescents. Similar distribution was seen
in previous study also. 66% out of 69 patients were in the age group of
7-12 years and 33 % in 13- 17 years age group12. This
could be either because respiratory allergies affect more in lower age
group or adolescent age group patients get distributed among Pediatric
and adult physicians.
Boys (60.6%) outnumbered girls (39.4%) in the study cohort. The trend
was similar to other diseases over past few years. The study done by
Scala et al in 56 Brazilian children showed female predominance in the
study population17. A study done in Indian Population
by Singh and associates in 20 children showing quality of life score in
Indian asthmatic children receiving inhaled corticosteroid therapy also
showed higher male proportion (male=55%)18. The male
preponderance may be explained by preferential sex selection either by
disease or by society for seeking medical help in developing countries.
Out of 246 children, 8% were suffering from AR and 27% from Asthma
alone whereas two-third (65%) had both symptoms. A multicenter study
done in India, by Jaggi V et al among 1161 adult asthmatic patient
showed the prevalence of co-existing AR in asthma patients to be
65.24%19. In western population, prevalence of AR
with Asthma was about 50-100% as reported by Gaugris et
al20. Our study findings of combined involvement of
nose and airways highlights the concept of ‘united airway disease’.
Out of 69 asthmatic patients, Nair et al in their study had 74%
patients of moderate severe asthma whereas mild variety were only 26
%12. Boran P et al conducted study in 305 Turkish
children suffering from asthma. Among them, 82% of children had
intermittent asthma and 18% had persistent asthma. Sixty-four percent
of asthmatics also had allergic rhinitis21.In our
study, mild (56%) and persistent (78%) grade of asthma were more than
the moderate- severe or intermittent type. This could be possibly
because moderate severe cases used to get admitted earlier and report
less in OPD. More people presented with persistent disease rather than
being affected intermittently for 3-4 days many times in a year. This
can be explained by possible poor compliance with medications or
incorrect inhaler techniques.
When compared with the education of the caregiver, the severity or
chronicity of disease (AR/Asthma), there was no significant difference
seen (p = 0.422) as per the education of caregiver. This could possibly
be because the study was done in urban population, 90% of whom had
attained a bachelor’s degree so had better understanding of disease
process and accessibility to healthcare was easy for them. Additionally,
a rare possibility could be their ignorance and hence difficulty to
perceive the difference in QOL of themselves as well as their children.
A study conducted by Walker J et al involving subjects from 201 rural
families reached to a conclusion that perception about the quality of
life in subjects depends upon how well the asthma in children was
controlled rather than their education level. For instance, it was
observed during the course of study that in cases where asthma severity
in children aggravated, not only such children missed school their
parents had had to take their days off from work to look after their
wards, resulting in a diminished sense of quality of
life22. Juniper et al reported that there are
significant changes in QOL as the severity of Asthma increases
(p=<0.001). On the other hand, Annett et al and Montalto et al
found no difference in QOL based on the severity of
asthma13,15,23,24. A systematic review with
meta-analysis on asthma control in the quality of life levels of
asthmatic patients’ caregivers highlighted that asthma control levels
can influence the total HRQOL scores of parents or relatives of children
and adolescents with asthma25.
The result in emotional domain in children showed no significant
difference in QOL in various grades of AR/Asthma (p=0.496) (p=0.918) and
agreed with past studies. A study done among 305 Turkish children by
Boran P and colleagues showed that severity of asthma and presence of
allergic rhinitis were found to be significant factors associated with
impaired QOL of these children in other domains except for emotional
function21. Diette et al observed among 438 children
and their caregivers that nighttime awakening reduced attendance of both
child and their caregivers in school and at workplace,
respectively26.
It was found that activity limitation domain of children showed
significant difference with the severity of asthma in many studies.
Study done by Leynart in 850 French population of young adults in two
centers using SF-36 questionnaire suggested that AR alone causes less
impairment of physical activity than with patients of both allergic
rhinitis and asthma5. Our study results were
inconsistent with the others as it was seen that there is no significant
difference between activity limitation with the different grades or
severity of AR/Asthma (p=0.384), (p=0.561). This could be possibly
because of limited sample size and because a great chunk of our sample
size belonged to mild variety whose activities were less limited.
A study conducted by Callery et al in 25 British children aged from 9 to
16 years of age group along with their caregivers also reported change
in QOL of parents with the severity of asthma in
children27. Similarly, Juniper et al reported
significant change in QOL of caregiver in both the domains (emotional
and activity limitation) (p<0.0001) with disease
severity13. A Saudi Arabian study by Nafeesa et al
concluded that caregiver emotional status is vital for the success of
asthma management among patients. In addition, effective control status
is also required to ensure low levels of anxiety among patients and
their caregivers28. In our study, when compared with
caregiver emotional and activity limitation score for calculating QOL
score there was no statistically significant difference (p value = 0.549
and 0.446 respectively).
The possible reason for no significant changes seen in PACQLQ score was
that parent’s perception of QOL related to disease severity was less.
Secondly, our study was single visit study. No follow up questions post
treatment of AR/Asthma were asked. So, any change noted in QOL of
parents could not be assessed. Thirdly, for cases below 12 years of age,
it is not prudent to form an opinion about the impact of asthma severity
on child’s quality of life based on parent’s reportage alone. According
to research done by Callery et al, parents report was insufficient to
get an understanding of the children’s quality of life as they failed to
provide complete information about the disease
severity29. Lastly, our small sample size could be
another added reason.