DESCRIPTIVE STUDY


A NON-COMPARATIVE DESCRIPTIVE STUDY OF THE RISK FACTORS FOR CHILDHOOD DISABILITY, AND THE REHABILITATION SERVICES IN JEDDAH, SAUDI ARABIA

Sherine Shawky, DrPH, Bahaa A. Abalkhail, DrPH, Nadia K Soliman, PhD, Mohammad N. Kordi, DrPH.

Department of Community Medicine and Primary Health Care, College of Medicine and Allied Health Sciences, King Abdulaziz University, Jeddah, Saudi Arabia

أهداف البحث: إبراز عوامل الخطورة الكامنة في مجتمعنا التي يمكن أن تؤدى إلى ولادة طفل معاق و الإلمام بالخدمات التأهيلية المتاحة للأطفال ذوى الاحتياجات الخاصة.

طريقة البحث: تم جمع البيانات من ستة مراكز تأهيل للإعاقات السمعية و البصرية و العقلية في مدينة جده خلال شهر إبريل (نيسان) 1999، و قد تم نقل البيانات عن المؤشرات الاجتماعية و الديموغرافية و الصحية من الملفات بمراكز التأهيل، بالإضافة إلى المقابلة الشخصية مع الأطفال المعاقين للتعرف على الخدمات المقدمة لهم من قبل المراكز.

نتائج البحث: مازالت بعض عوامل الخطورة آلتي يمكن تصحيحها و آلتي تزيد من نسبة فرص ولادة طفل معاق قائمة في مجتمعنا مثل الزواج و الإنجاب في سن مبكرة أو في سن متقدمة للجنسين، كذلك الأمية و البطالة و كثرة الإنجاب و زواج الأقارب. كما تم رصد ارتفاع في نسبة الأطفال المعاقين للأباء بوظائف عسكرية والأمهات العاملات . كما تم ارتفاع في نسبة الإعاقة لدى الأطفال بنسب عن الحالة الصحية للأم و الطفل أثناء الحمل و الولادة و ما بعد الولادة. كما وجد أن مختلف الخدمات التأهيلية متاحة للأطفال المعاقين بمراكز التأهيل .

الخلاصة: الحاجة إلى تدخل صحي على محورين، الأول هو الوقاية المستقبلية من حالات الإعاقة لدى الأطفال من خلال البحث المستمر لإثبات و تجنب مؤشرات الخطورة الضارة بالصحة وتحسين العناية بالأم و الطفل. و الثاني هو تعضيد الخدمات التأهيلية المتاحة من أجل تحسين الخدمات المقدمة لهم بشكل يعينهم على الحياة بشكل أفضل مع تخفيف معاناتهم.

الكلمات المرجعية: الإعاقة، مؤشرات الخطورة، العناية بالأم و الطفل، السعودية

Objectives: Identify the possible risk factors in our community that may influence having a disabled child, and identify the rehabilitation services available to disabled children.

Methods:Data were collected from six rehabilitation institutes for auditory, visual and mental disabilities in Jeddah Cityduring April 1999. Complete data available on sociodemographic and medical risk factors were extracted from the institutes’ files. Personal interviews with the disabled were conducted to confirm information on the services offered to them.

Results:Certain modifiable risk factors affecting child health, such as early and   late marriages   and   childbearing,   illiteracy,   unemployment,   high   parity   and 

Correspondence to:

Dr. Sherine Shawky, P.O. Box 115, Jeddah 21411, Saudi Arabia

consanguineous marriages still exist in our community. Occupational hazards were also detected among military workers and working women. Disabilities related to perinatal health with antenatal, natal and postnatal components were also observed. According to resources available, various rehabilitation services are offered to disabled children.

Conclusion: The need for intervention in two areas of health is crucial. The first is the prevention of future disabilities through continuous research, modification of unfavorable habits and the strengthening of the quality of perinatal care. The second is the improvement of rehabilitation services in order to raise the quality of life of the handicapped.

Key words: Childhood disability, handicapped, risk factors, consanguineous mar­riage, perinatal care, Saudi Arabia.


INTRODUCTION

It has been estimated that over three-quarters of the world’s disabled children under 15 years of age live in developing countries1. The burden of childhood dis­ability as a public health problem and the services offered to this category of patients in developing countries remain relatively unrecognized. There is a major information gap in the Third Worldconcerning the magnitude of the problem and the needs, in terms of prevention, rehabilitation, medical and social requirements, to combat this problem.2-4

                Saudi Arabiahas undergone rapid eco­nomic development in the last few decades. This is consequently reflected in improved health care services and the decrease in infant mortality.5 Overtly disabled children are now more likely to survive in greater numbers and pose a major drain on the health and social services. Many studies on the subject have been done in the Kingdom, each focusing on a single type of child disability. Definitions in these studies have not been uniform, neither have the data been published. A recent national survey in the Kingdom reported the prevalence of major disabilities as approximately 4.0% of the population.6 Epidemiologic studies tackling the potential risk factors specific to our community are still lacking. Overall evaluation of perinatal care and programs directed at disabled children are mostly hospital-based. Nevertheless, there are govern­ment and private rehabilitation institutes all over the Kingdom that offer various services to this category of the population.

                An analysis of the problem of disability in the Kingdom would give an indication of the situation in the Middle Eastand emphasize potential risk factors specific to the traditions in the region. Basic data from the specialized rehabilitation institutes are of enormous importance as they constitute data banks suitable for an evaluation of the problem as well as the development of relevant local prevention programs and health interventions directed at improving the quality of life. Consequently, the study was initiated with basic data from rehabilitation institutes for disabled children to give some insight into (a) the potential risk factors and (b) the services available for disabled children.

MATERIAL AND METHODS

Study Population

Data were collected from the major govern­mental rehabilitation institutes in Jeddah that specialize in single disability care. There are three specialized governmental institutes for boys and three twin institutes for girls. The Al-Amal Rehabilitation Insti­tute, established in 1970, provides special education for the auditory disabled (deaf-mutes) with an IQ of at least 70. The Al-Noor Rehabilitation Institute, established in 1983, offers special education for visually disabled children with visual acuity not exceeding 6/60 and IQ of at least 70. The Al-Tarbyia Al-Fikrayia Rehabilitation Insti­tute, established in 1975, is for the educa­tion of mentally disabled children with minimum IQ of 50.

Data collection

Data were collected during April 1999 on all children in the six governmental rehabili­tation institutes in Jeddah. Only the complete files of children present in the institutes during the data collection period were considered. Basic data on socio­demographic status and the potential risk factors were extracted by trained medical students under the direct supervision of medical staff, from the institutes’ social, psychological and medical files. Trained medical students interviewed the disabled children to confirm the data collected on services provided.

Data and statistical analysis

Data entry and analysis were done using SPSSfor Windows (Version 9.05). Three cohorts were defined: the auditory disabled (deaf-mutes), the visually disabled, and the mentally disabled children. Parity was defined as the mother’s parity at childbirth including the index child. Multiparity was defined as having at least 5 children, in­cluding the index-disabled child. Spon­taneous abortion, fetal death and/or infant mortality were defined as having had at least one experience during the mother’s reproductive life preceding the birth of the index disabled child. All conditions of maternal and disabled child’s health con­sidered were those diagnosed by physicians and recorded in the medical files. Chi-square test was used to detect significant differences in the proportions among the three cohorts.

RESULTS

A total of 421 auditory disabled, 178 visually disabled, and 666 mentally disabled children were enrolled in the study. Their ages ranged from 6to 20 years with mean + SD of 13.7 + 3.1. Of the total, 53.3% were boys and 46.7% girls. The majority were of Saudi nationality (85.8%) and residents in Jeddah (80.6%). Table 1 shows the sociodemographic characteristics of the disabled children in Jeddah City.

                Fathers’ current ages ranged from 22 to 70 years (mean + SD of 44.9 + 9.7). Fathers’ extreme age marriages (Table 2) were observed, with 16.9% of the fathers below the age of 20 years at the time of marriage, and 9.6% in this age group at the time of birth of their children.  At the other extreme, 8.0% of the fathers married at the age of at least 50 years and 9.6% of them had children. Young fathers (<20 years) were more associated with having an auditory disabled child while older fathers (50+ years) were more likely to have a mentally disabled child (P<0.001). Around 27.9% of the fathers had never attended school and the highest proportion were among the parents of auditory disabled children, but results were not of statistical significance.

                Unemployed fathers (11.5%) were more likely to have a visually and mentally disabled child. Also, 42.8% of the fathers  had a military assignment and were prone to having children belonging to the mentally disabled cohorts.


Table 1:Sociodemographic characteristics of disabled children in governmental rehabilitation institutes of Jeddah

Variables

Auditory (n=421)

Visual (n=178)

Mental (n=666)

No. (%)

No. (%)

No. (%)

Age:

< 10

50 (11.9)

36 (20.2)

125 (18.8)

10-14

131 (31.1)

80 (44.9)

352 (52.9)

15+

240 (57.0)

62 (34.8)

189 (28.4)

Sex:

Boy

113 (26.8)

78 (43.8)

483 (72.5)

Girl

308 (73.2)

100 (56.2)

183 (27.5)

Nationality:

Saudi

345 (81.9)

148 (83.1)

592 (88.9)

Non-Saudi

76 (18.1)

30 (16.9)

74 (11.1)

Residence:

Jeddah

306 (72.7)

142 (79.8)

572 (85.9)

Outside

115 (27.3)

36 (20.2)

94 (14.1)

Education:

Preschool

38 (9.0)

4 (2.2)

109 (16.4)

Primary

206 (48.9)

128 (71.9)

542 (81.4)

Intermediate

95 (22.6)

24 (13.5)

15 (2.3)

Secondary

82 (19.5)

22 (12.4)

  0 (0.0)

Table 2: Father's risk factors among mothers of children in Jeddah city by type of disability

Father's risk factors

Auditory (n=421)

Visual (n=178)

Mental (n=666)

No. (%)

No. (%)

No. (%)

Marital age:*

<20 years

107 (25.4)

36 (20.2)

71 (10.7)

20-29 years

190 (45.1)

86 (48.3)

237 (35.6)

30-39 years

79 (18.8)

29 (16.3)

188 (28.2)

40-49 years

23 (5.5)

18 (10.1)

100 (15.0)

50+ years

22 (5.2)

9 (5.1)

70 (10.5)

Childbirth age:* 

<20 years

61 (14.5)

24 (13.5)

37 (5.6)

20-29 years

229 (54.4)

92 (51.7)

234 (35.1)

30-39 years

79 (18.8)

30 (16.9)

206 (30.9)

40-49 years

30 (7.1)

22 (12.4)

104 (15.6)

50+ years

22 (5.2)

10 (5.6)

85 (12.8)

Education:

Never

131 (31.1)

47 (26.4)

175 (26.3)

Primary

87 (20.7)

45 (25.3)

155 (23.3)

Intermediate

58 (13.8)

24 (13.5)

82 (12.3)

Secondary

99 (23.5)

34 (19.1)

155 (23.3)

University and +

46 (10.9)

28 (15.7)

99 (14.9)

Occupation: †

Unemployed

28 (6.7)

24 (13.5)

94 (14.1)

Skilled laborer

43 (10.2)

19 (10.7)

54 (8.1)

Private

64 (15.2)

34 (19.1)

107 (16.1)

Government

91 (21.6)

37 (20.8)

129 (19.4)

Military

195 (46.3)

64 (36.0)

282 (42.3)

* p<0.001,  † p<0.05

Table 3: Mother's risk factors among disabled children in governmental rehabilitation institutes in Jeddah

Maternal risk factors

Auditory (n=421)

Visual (n=178)

Mental (n=666)

No. (%)

No. (%)

No. (%)

Marital age:*

<16 years

  65 (15.4)

20 (11.2)

51 (7.7)

16-19 years

126 (29.9)

62 (34.8)

167 (25.1)

20-29 years

188 (44.7)

72 (40.4)

317 (47.6)

30-39 years

33 (7.8)

18 (10.1)

116 (17.4)

40+ years

  9 (2.1)

6 (3.4)

15 (2.3)

Childbirth age*

<16 years

24 (5.7)

6 (3.4)

8 (1.2)

16-19 years

  88 (20.9)

36 (20.2)

88 (13.2)

20-29 years

217 (51.5)

90 (50.6)

352 (52.9)

30-39 years

75 (17.8)

36 (20.2)

161 (24.2)

40+ years

17 (4.0)

10 (5.6)

57 (8.6)

Education*

Never

268 (63.7)

80 (44.9)

327 (49.1)

Primary

  68 (16.2)

33 (18.5)

129 (19.4)

Intermediate

  48 (11.4)

31 (17.4)

102 (15.3)

Secondary

26 (6.2)

19 (10.7)

65 (9.8)

University and +

11 (2.6)

15 (8.4)

43 (6.5)

Working status*

Housewife

416 (98.8)

159 (89.3)

638 (95.8)

Working

5 (1.2)

19 (10.7)

28 (4.2)

Parity

Primi

  95 (22.6)

41 (23.0)

136 (20.4)

Para1

78 (18.5)

38 (21.3)

127 (19.1)

Para2

63 (15.0)

25 (14.0)

109 (16.4)

Para3

65 (15.4)

         16 (9.0)

83 (12.5)

Para4+

120 (28.5)

58 (32.6)

211 (31.7)

Consanguinity*

No

179 (40.4)

98 (55.1)

348 (52.3)

First degree

199 (47.3)

62 (34.8)

230 (34.5)

Others

  52 (12.4)

18 (10.1)

  88 (13.2)

*p<0.001


                The current mother’s age ranged from 21 to 60 years (mean + SD: 39.4 + 8.1 years). As shown in Table 3, mothers who married before their 16th birthday accounted for 10.8% and those who gave birth before that age accounted for 3.0%. At the other extreme, mothers who married at 40 years or over accounted for 2.4% while those in this age group who gave birth accounted for 6.6%. Young maternal marital and child­bearing ages were mainly observed among auditory disabled children while late marriages and childbearing were mainly associated with visual and mental disability (p < 0.001). Approximately, 53.4% of the mothers had never attended school and 95.9% did not work. Maternal illiteracy and unemployment were more marked among the auditory and mentally disabled cohorts (p<0.001). Multiparity at childbirth ac­counted for 30.8% and was marked among the visually and mentally disabled, but the results did not reach statistical significance. Consanguineous marriages were reported in approximately 51.3% of the cases, 75.7% of

these were among first degree relatives. 


Table 4: Mother's past history and perinatal risk factors among disabled children attending governmental rehabilitation institutes in Jeddah

Maternal risk factors

Auditory (n=421)

Visual (n=178)

Mental (n=666)

No. (%)

No. (%)

No. (%)

Mother's past history

Spontaneous abortion*

24 (5.7)

3 (1.7)

14 (2.1)

Fetal death &/or infant mortality

  9 (2.1)

5 (2.8)

  7 (1.1)

Previous disabled child† 

102 (24.2)

51 (28.7)

104 (15.6)

Perinatal risk factors

German measles

28 (6.7)

  4 (2.2)

2 (0.3)

Threatened abortion†

  7 (1.7)

15 (8.4)

13 (2.0)

Pre-eclampsia†

  5 (1.2)

16 (9.0)

10 (1.5)

Natal & Postnatal risk factors

Caesarian/assisted labor†

15 (3.6)

7 (3.9)

48 (7.2)

Prematurity (<28 weeks) †

13 (3.1)

18 (10.1)

25 (3.8)

Very low birthweight (<1500 gm)

  7 (1.7)

11 (6.2)

121 (18.2)

Jaundice†

17 (4.0)

4 (2.2)

62 (9.3)

Oxygen therapy‡

10 (2.4)

8 (4.5)

48 (7.2)

Admission to Neonatal Intensive Care

  Unit†

14 (3.3)

8 (4.5)

  92 (13.8)

*p<0.05 p<0.001 p<0.01

Table 5: Rehabilitation services offered to disabled children attending governmental rehabilitation institutes in Jeddah

Services*

Auditory (n=421)

Visual (n=178)

Mental (n=666)

No. (%)

No. (%)

No. (%)

Social services

Grants

276 (65.6)

119 (66.9)

166 (24.9)

Meals

180 (42.8)

  64 (36.0)

154 (23.1)

Boarding

145 (34.4)

  64 (36.0)

  94 (14.1)

Social support

227 (53.9)

  39 (31.9)

120 (18.0)

Psychological

248 (58.4)

100 (56.2)

178 (26.7)

Medical services

Physiotherapy

193 (45.8)

  37 (20.8)

102 (15.3)

Medical

  90 (21.4)

  51 (28.7)

107 (16.1)

Dental care

288 (68.4)

100 (56.2)

140 (21.0)

Vaccination

268 (67.9)

106 (59.6)

190 (28.5)

Educational services

Physical exercise

230 (54.6)

102 (57.3)

184 (27.6)

Manual work

139 (33.0)

  68 (38.2)

103 (15.5)

Drawing

313 (74.3)

119 (66.9)

195 (29.3)

Cooking

209 (49.6)

  70 (39.3)

59 (8.9)

Knitting

295 (70.1)

  60 (37.3)

67 (10.1)

*p<0.001

Con­sanguinity occurred more among the parents of the auditory disabled children (p<0.001).

                As shown in Table 4, past history of spontaneous abortion was mainly reported in the mothers of the auditory disabled (p<0.05), while fetal deaths and/or infant mortality were mainly seen among mothers of the visually disabled cohorts, but results did not reach statistical significance. Con­ditions that affected the mother during pregnancy, such as german measles, were reported for the auditory disabled, but the results were not significant. Threatened abortions and pre-eclampsia were reported mainly for the mothers of the visually dis­abled cohort (p<0.001). Severe prematurity (less than 28 weeks gestation) was observed more among the visually disabled children (p<0.001). There were more caesarian sec­tion deliveries, very low birthweight (less than 1500g), jaundice, oxygen therapy at birth and admission to neonatal intensive care units among the mentally disabled cohort (p<0.01).

                Six institutes offer education to disabled children up to the secondary level, using specially adapted syllabi. In every institute, in addition to the teaching staff there are a social worker, psychologist and a medical doctor. In varying proportions social, psycho­logical, medical, and other educa­tional services are offered to these children (Table 5). The institutes which were best were those which cared for the auditory and the visual disablilities while those rated lowest were those institutes that cared for the mentally handicapped. In spite of the public informtion efforts of the rehabilita­tion institutes, most of the families of disabled children knew of these institutes only from their friends or neighbors; 99.2% of the auditory disabled, 73.2% of the visually disabled, and 92.3% of the mentally disabled children were taken to the institutes by their families, on their own. Those referred from pri­mary health care units, school health and the private sectors were few and did not exceed 3.0%. Similarly, except for the visually disabled, who formed about 25.0% of those admitted to the institutes, those referred from the govern­ment hospitals were very few.

DISCUSSION

Childhood disability is a public health con­cern since it affects the health and economic status of nations. The disabled child is a result of multiple factors. Most of these factors are modifiable by controlling the risk factors known to influence infant health and rectifying the quality of health services provided in our society.

The results of our study open multiple areas for research and discussion. They also  aid in formulating hypotheses on deter­minants of childhood disability that could be restricted to the Middle East, illustrated by the conditions in the Kingdom.

                This study has emphasized certain risk factors that still exist in our society. They include extreme age (early and late) of mar­riage and childbearing for both genders, as well as multiparity, illiteracy, unemploy­ment and consanguineous marriages. Our results have shown that early marriage and childbearing, in both genders, have in­creased the risk of having an auditory disabled child. Arab countries as a whole are known to have a high rate of early marriages, a practice related to tradition and beliefs.7-9

                It is true that early marriage and child­bearing save the population from many health hazards but there should be a lower age limit for marriage and consequently child­bearing, taking into account the bio­logical maturity of both sexes. On the other hand, late childbearing maternal multiparity was also observed for both parents. In marriages that take place when the couples are old, child bearing in both genders tended to predispose to a mentally disabled child. Maternal multiparity predisposed to visually and mentally disability. Also, high parity, and thus pregnancies in old age, is typical for the Middle East region as documented in several studies.7,910-12 Studies on the distri­bution of paternal age and its relation to child health are still lacking.

                Illiteracy and unemployment were very high among the parents, especially the mothers. Illiterate jobless mothers were at higher risk of having an auditory and mentally disabled child. Illiterate fathers were more prone to have an auditory disabled child, while jobless fathers were more likely to have a mentally and visually disabled child. Illiteracy and unemployment are other factors previously reported in the region.8,9

                A healthy occupational environment is a second factor to be considered. Fathers engaged in military jobs were at a higher risk of having auditory and mentally dis­abled children. This occupation should be investigated as a possible risk factor that may influence the health of offspring. Previous investigations have shown that even after adjustment for the economic condition, an infant whose mother is illiterate is more likely to die during the post­neonatal period than one whose mother is literate.13,14

                Female education is a major advantage to future health. Education improves women’s awareness, which is reflected in the quality of her life. The higher the level of the woman's education, the healthier she will be because she will have healthier active life style, nutritional habits, economic condi­tions and personal hygiene. Female educa­tion motivates women to continue their careers, discourages early marriage, and provides better marriage prospects, and in the event of consanguineous marriage, it also makes them aware of the importance of premarriage counseling and availability of health care services. Moreover, education strengthens mother’s awareness of the quality of life of her offspring when she follows appropriate feeding practices, and childcare, early detection and better management of life threatening conditions. In short, female education makes mothers more efficient in raising their children.13,16

                The father’s education and work affect the family’s well-being through a similar mechanism. However, research on paternal risk factors is still insufficient.

                Consanguineous marriage is the dominant marriage pattern in many Third World countries, particularly in the Arab World.7,9,10,17-20 Consanguinity is wide-spread in the Kingdom and is related to the culture. It was found in our data to be strikingly high, especially among first- degree relatives. This was more marked among parents of the auditory disabled.

                Perinatal health is vital for child health and responsible for the pathogenesis of many health conditions.21-24 Perinatal care is the best means for improving maternal and child health. Unfortunately, few maternal and child health conditions during the perinatal period were available for analy­sis. Maternal factors included threatened abor­tion and pre-eclampsia and were observed more among mothers of the visually disabled cohorts. Severe preterm (before 28 weeks gestation) and very low birth weight (<1500g) births are other indicators for antenatal care. Prematurity was mainly observed among the visually disabled cohort, while the very low birthweights were more among the mentally disabled. Caesarian section deliveries were reported mainly in the mentally disabled children. Such postnatal conditions as jaundice, oxygen therapy and admission into a neo­natal intensive care unit at birth were more prevalent among mentally disabled children.

                A wide variety of services, including special education, social, psychological, medical and rehabilitation services are offered to the disabled children. These services are available for both genders, Saudis as well as non-Saudis, and residents of Jeddah Cityand surrounding areas. The service that ranked the lowest were the institutes that cared for mentally disabled children. This could be explained by the fact that these children are usually less capable than the other disabled, and were limited in what they would do and consequently over­burdened the services offered to them. Nevertheless, participation of all profes­sionals in the field is crucial in order to support the effort of the rehabilitation centers.

                We conclude that much effort is required to reduce the incidence of future disability. This could be achieved through reducing the potential risk factors in our community and improving the quality of perinatal care and rehabilitation services in order to raise the quality of life for those infants who survive.

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13.   Becerra J, Atrash H, Perez N, Saliceti JA. Low birthweight and infant mortality in Puerto Rico. American Journal of Public Health 1993; 83: 1572-6.

14.   Terra de Souza AC, Cufino E, Peterson KE, Gard­ner J, Vasconcelos do Amaral MI, Ascherio A. Variations in infant mortality rates among municipalities in state of Ceará, Northeast Brazil: an ecological analysis. Int J Epid 1999; 28:267-75.

15.   Shawky S, Milaat WM, Abalkhail BA, Soliman NK. Could maternal education explain excess rate of childhood handicap? A study in two maternity hospitals in Jeddah, Saudi Arabia. Saudi Medical Journal 2001; 22:841-4.

16.   Al-Salem M, Rawashdeh N. Consanguinity in North Jordan: Prevalence and pattern. J Biosoc Science 1993; 25:553-6.

17.   Gevi D, Nathan R, Freudilich M. Consanguinity and congenital heart disease in rural Arab population in Northern Israel. Human Hered 1986; 36:213-7.

18.   Hamamy HA, Al-Bayat N, Al-Qubaisy W. Con­sanguineous matings in the Iraq urban population and the effect of pregnancy outcome on infant mortality. IraqMed J 1986; 34:65-80.

19.   Saha N, Hammad RE, Mahmoud S. Inbreeding effects on reproductive outcome in a Sudanese population. Hum Hered 1990; 40:208-12.

20.   Saha N, Al-Shaykh F. Inbreeding levels in Sudan. Biosoc Science 1998; 20:333-6.

21.   Zakzouk SM, Daghistani KJ, Jamal TS, Al-Shaikh AA, Hajjaj MF. A survey of childhood hearing impairment. Saudi Medical Journal 1999; 20:783-7.

22.   Weisglas-Kuperus N, Baerts W, de Graaf MA, van Zanten GA, Sauer PJ. Hearing and language in preschool very low birth weight children. Int J Pediatr Otorhinolaryngol 1993; 26:129-40.

23.   Borradori C, Fawer CL, Buclin T, Calame A. Risk factors for sensorineural hearing loss in preterm infants. Biol Neonate 1997: 71:1-10.


-0001-11-30

BRONCHIAL ASTHMA


SCHOOL BOYS WITH BRONCHIAL ASTHMA IN AL-KHOBAR CITY, SAUDI ARABIA: ARE THEY AT INCREASED RISK OF SCHOOL ABSENTEEISM?

Kasim M. Al-Dawood,FFCM(KFU), Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة :كان الهدف من إجراء  هذه الدّراسةالمقطعيةهو تحديد معدل فترةالغياب عن المدرسةبينالتّلاميذالسّعودييناللذين يعانون من الرّبو القصبي بمدينةالخبر والعوامل المرتبطة معه

طريقة الدراسة: هذهدراسةمقطعية. تضمّنمنهج الدراسة توزيعإستبانة خاصة وقدأكملتمنقبلالوالدين لما مجموعه  1482تلميذاًمن الذينوافقواا المعاييرالخاصة للدّراسة.

نتائج الدراسة:معدل حالات الربوالمشخّصة بواسطة الإستبانة كان  9.5% (141/  1482) . كان معدل الفترةالغيابية عن المدرسةبين الأولاد المصابين بالربو هو  13.6±3.4يوماًمقارنة ب  3.7±2.2يوماًبينالأولاد الأصحاء. كان هذا المعدل بين الأولاد المصابين بالربو ذا إرتباطإيجابي مهم بأولئكالذينكانوا أصغر ،مع تناقص المستوى الإجتماعيالإقتصادي، وجود حيواناتأليفةفيالمنزل ،مع شخصمدخنفي العائلةفي الوقت الحالي (أبّأوكلاالوالدين)، مع التاريخ المرضي لزيارة  غرفة الطوارئ بالمستشفى أو الدخولإلىالمستشفى. بينما كان هذا المعدل ذا إرتباطسلبي ومهم  بالإستعمالالمصاحبللأدوية الوقائية ضد مرض الربو متضمنة تلك المستعملة بشكلملائم . تعاطى الأولاد المصابون بالربو منالطبقات الإجتماعيةالإقتصاديةالمتوسّطةوالأوطأالأدوية الوقائية بشكل  أقل و لكن كانلديهم تواريخأكثرلزيارةغرفة  الطوارئ والدخولإلىالمستشفى. تم رصد معادلةالإنحدار الخطيّةالمتعددةللفترةالكليّةللغيابعنالمدرسةخلالالسّنةالأكاديميةالحاليةتم رصدها .

الخاتمة :عانى أطفال المدارس المصابون بالربو من معدل فترةغيابية عن المدرسة أعلى من زملائهم الأصحاء .عائلات أطفال المدارس المصابين بالربو منالطبقات الإجتماعيةالإقتصاديةالأوطأ كانوا أكثر عرضة لأثار هذا المرض.

الكلماتالمرجعية: الربو القصبي الطفولي ،الغياب  عن المدرسة، المملكة العربيةالسعودية

Objective:The objective of this cross-sectional study was to determine the mean period of school absenteeism (MPSA) among Questionnaire Diagnosed Asthmatic (QDA) Saudi schoolboys of Al-Khobar city and the factors associated with it.

Methods:The methodology of this cross-sectional study included the distribution of a self-administered questionnaire, which was completed by the parents of 1482 schoolboys who satisfied the selection criteria of the study.

Results:The prevalence rate of QDA was 9.5% (141/1482).  MPSA among Questionnaire Diagnosed Asthmatic Boys (QDAs) was 13.6 ±3.4 days compared to

Correspondence to:

Dr. Kasim M. Al-Dawood,, Associate Professor, Department of Family & Community Medicine, College of Medicine, King Faisal University, P.O. Box 2290, Al-Khobar 31952, Saudi Arabia

3.7 ±2.2 days among non-QDA boys (non-QDAs). Among QDAs, it was associated significantly and positively with those who were younger, with a decreasing level of socioeconomic class, history of pets at home, presence of a current smoker in the family (father or both parents), visit to a hospital emergency room, and admission to hospital. It was significantly and negatively associated with concomitant use of prophylactic medication(s), including those used appropriately. QDAs from middle and lower socioeconomic classes used less prophylactic medication(s) but had had more visits to an emergency room and had admissions to hospital. The multiple linear regression equation for the total period of school absenteeism (TPSA) during the current academic year was generated.

Conclusions: QDAs have higher MPSA compared to their non-asthmatic classmates. The impact of this disease increases particularly among QDAs belonging to lower socioeconomic families.

Key Words: Childhood asthma, School absence, Saudi Arabia


 

INTRODUCTION

Bronchial asthma during childhood has been considered the single most prevalent cause of childhood disability in the past 25 years.1 Children who are frequently absent from school tend to perform poorly and are more likely to drop out before graduation from high school.2 Increased school absenteeism among children was shown to be related to low assessment made by teachers of their social, psychological and educational adjustment.3 Excessive school absenteeism was also found to be associated with future unemployment, maladjusted behavior, wasted opportunity and increased welfare costs.2 Persistent school absenteeism may signal such health problems as inability to cope with, or manage chronic illnesses such as bronchial asthma. In addition to emergency room visits and hospitalization, school absenteeism was considered a valid morbidity marker for asthma.3 As a tool, school absenteeism patterns can be made readily available for use as indicators of childhood or/and family dysfunction that may really be the result of unmet health needs.4

                Reports from Eastern Saudi Arabia estimated the prevalence of bronchial asthma among school children as approximately 10%5,6 and there is enough evidence to suggest that the prevalence of this disease is on the increase.7 Consequently, morbidity and mortality of bronchial asthma continues to rise.8,9 In Eastern Saudi Arabia, environmental factors were found to be associated with the etiology of bronchial asthma among school children.5,6,10 The prevalence of bronchial asthma among Saudi school children was found to be higher in industrial, agricultural and urban areas than in the desert and rural areas.5,11,12

                A fair number of studies have been conducted in Saudi Arabia to investigate certain aspects of this disease, including the prevalence of this health problem among children.5-12 However, to the best of the investigator’s knowledge, no study has been conducted to measure school absenteeism among asthmatic children as an indicator of disability among school children in Al-Khobar city.

                This study is an essential means of providing a profile of some of the factors that affect childhood asthma and its severity. Factors affecting the duration of absenteeism will also be determined. This is expected to help in improving the design and provision of appropriate services to those children and their families. The main objective of this study was to determine the MPSA among asthmatic Saudi schoolboys in Al-Khobar City, in comparison with their non-asthmatic classmates, during the current academic year of the study. Another objective was to determine the factors associated with the TPSA during the same period.

POPULATION AND METHODS

The Saudi boys in elementary and preparatory schools at Al-Khobar city were the subjects of this cross-sectional study, which was conducted towards the end of the second term of the 1995 academic year. Al-Khobar Cityis located on the Arabian Gulfcoast in the Eastern part of the Kingdomof Saudi Arabia. A total of 22077 schoolboys were identified at Elementary (15829 [71.7%]) and Preparatory (6248 [28.3%]) schools in Al-Khobar city. A sample of 1550 schoolboys (7% of the total number of schoolboys in the study area) was calculated as our sample. The determination of the sample size was based on the usual equation of sample estimation.13 In that equation, 7% was used as the estimated proportion of bronchial asthmatics among school children in the study area, based on an earlier study in the region.8 This sample size was determined as what would give a high degree of accuracy of the estimated proportion as narrow as +1% away from the true estimated population proportion. The determined total sample of 1550 schoolboys (elementary = 1110 [71.6%] and preparatory = 440 [28.4%]) was drawn from the total number of schools through simple random sampling (4 elementary + 2 preparatory schools). The total number of sample students in each school was in accordance with the ratio they represented in relation to the total number of students in all schools (at each level of education). In each school, the sample was drawn evenly and randomly from different academic classes. The non-inclusion of schoolgirls in this study was due to difficulty in gaining access, a limitation that previous investigators had faced.11

                The methods used included a self-administered pre-tested and pre-coded ques­tionnaire directed to parents. This questionnaire was previously standardized, validated and applied to the Saudi community.5,10,11 The questionnaire used in this work was subjected to a reliability test based on psychometric analysis using the split-halves method and the general Spearman-Brown formula,14 which indicated a reliability of 95%.

                The definition of asthma used in this study was modified from the Medical Research Council (MRC) definition.15 The criteria selected to identify asthmatic children were as follows: Any schoolboy whose parents responded to all of the following questions with “Yes” was considered a Questionnaire Diagnosed Asthmatic (QDA), otherwise the subject was considered a non-Questionnaire Diagnosed Asthmatic (non-QDA): (1) Has your child ever had an attack of wheezing? (a whistling noise that comes from the chest). (2) Has your child ever had attacks of shortness of breath with wheezing? (3) Does the breathing of your child become normal in between attacks? Each family was classified into upper, middle and lower socio-economic class based on the aggregate score of the father’s education, occupation and income.16

                The boys and their parents were requested to give details of personal data such as age, area of residence, father’s education, occupation and income. Data included the history of smoking by any household member and, more specifically, parental smoking habit. A positive current smoking history was defined as having a smoker in the family during any period of the current academic year. The survey inquired about the history of presence of family pet(s) at home (bird, cat, etc.). The presence of at least one pet at home, any time during the current academic year, was considered a positive history. Data collected also included information about the medications which had been used, or which were being used currently or regularly by the child during the current academic year, the duration of use and how they were/had been administered. The survey inquired about use of prophylactic medications for asthma by the QDAs. “Ever use” prophylactic medication(s) was defined as the positive history of using at least one prophylactic medication during the current academic year. Absence of such history was considered as “Never use.” If such medications were being/had been used, they were further classified as either (a) Appropriate, or (b) Inappropriate (based on the dosage, frequency and method of administration). Histories pertaining to frequencies and reasons of school absenteeism, hospital admissions, emergency room visits during the current academic year were also collected. “Ever visited hospital emergency room” was defined as at least one emergency hospital visit and “Ever admitted to hospital” was defined as at least one hospital admission due to bronchial asthma during the current academic year. “Never visited emergency” and “Never admitted to hospital during the current academic year” were defined as absence of such specific histories. School records were checked for the exact TPSA during the current academic year.   

                The statistical program SPSS/PC +(17) was used to calculate chi-square differences and to assess the statistical significance of contingency tables. Z-test was used to test the differences between the 2 mean and the F-test of the analysis of variance (A NOVA) was used to test the significance of the difference between more than 2 mean. Multiple linear regression was used to analyze the data. TPSA during the current academic year was the dependent variable. The independent variables consisted of: age of the child (in years), socioeconomic class (coded as lower=1, middle=2, upper=3), history of the presence of pets at home (coded as no=1, yes=2), presence of a family member at home who is a smoker (coded as no=1, yes=2), presence of father who smoked at home (coded as no=1, yes=2), or both (coded as no=1, yes=2). They also included histories of visits to the hospital emergency room (coded as never=1, ever=2) and admission to hospital (coded as never=1, ever=2), both due to bronchial asthma; and the history of the use of prophylactic medication(s) (coded as never=1, ever=2). The stepwise method was used to determine the final multiple regression model. A test was considered statistically significant at P-value <0.05.

RESULTS Sample Characteristics

A total of 1550 schoolboys were included in this study but the total of returned completed questionnaires was 1482 which gave a response rate of 95.6%. Twenty-one schoolboys (1.4%) were excluded from the study because they did not live in Al-Khobar City. The remaining 47 students (3.0%) declined to participate for reasons not related to the study.

                The cumulative prevalence of            QDA in the total sample was 9.5% (141/1482). The ages of the boys ranged from 6-15 years. The mean age of the schoolboys in the total sample was 10.7 ±3.1 years. There was no statistical difference in mean age among QDAs (10.3 + 2.1 years) and non- QDAs (10.3 + 2.2 years), Z-test = 0.54, p 0.58.


 

Table 1: Sample characteristics of QDAs and Non-QDAs

Variable

QDAs (n=141)

No. (%)

Non-QDAs (n=1341)

No. (%)

p-value

Age groups (years)

0.90

6-9

47 (33)

430 (32)

9-12

45 (32)

443 (33)

12-15

49 (35)

468 (35)

Socio-economic class

0.12

Upper (n=223)

22 (15.6)

201 (15.0)

Middle (n=756)

62 (44.0)

694 (51.8)

Lower (n=503)

57 (40.4)

446 (33.2)

Absence in days (Mean ±S.D)

13.6 ±3.4

3.7 ±2.2

<0.0001

Table 2:Comparison of MPSA and factors in QDAs' characteristics

Variable

QDA (n=141)

No. (%)

MPSA

(days)

S.D. (days)

p-value

Age groups (years)

0.001

6-9

47 (33)

13.2

2.4

9-12

45 (32)

11.5

2.1

12-15

49 (35)

8.6

2.2

Socio-economic class

0.001

Upper

22 (15.6)

  7.5

2.7

Middle

62 (44.0)

  9.3

2.3

Lower

57 (40.4)

11.4

2.1

Pets at home

0.0001

Yes

72 (51.1)

12.6

1.6

No

69 (48.9)

  5.3

1.4

Smoking by father

  0.0001

Yes

76 (53.9)

13.4

2.4

No

65 (46.1)

  7.3

3.1

Smoking by both mother and father

  0.0001

Yes

11 (7.8)

16.3

3.7

No

130 (92.2)

11.4

1.2

Smoking by a family member

  0.0001

Yes

86 (61.0)

14.3

2.4

No

55 (39.0)

6.1

2.7

Hospital emergency visit

  0.0001

Ever use

92 (65.2)

12.4

1.4

Never use

49 (34.8)

  8.2

3.6

Hospital admission

  0.0001

Ever use

17 (12.1)

12.4

3.6

Never use

124 (87.9)

  6.2

1.4

Use of prophylactic medications(s)

  0.0001

Ever use

52 (36.9)

  6.7

2.8

Never use

89 (63.1)

10.4

2.3

Appropriateness of prophylactic medication (n=52)

0.007

Appropriate

37 (71.2)

4.7

2.5

Inappropriate

15 (28.8)

7.3

3.4

Table 3:Multiple linear regression coefficients and equation for TPSA during the current academic year in Al-Khobar QDAs

Independent variable

Coefficient value

SE (B)

95% CI

p-value

Constant

11.54

2.86

5.93, 17.14

0.0001

Presence of a smoking family member

6.03

2.83

0.48, 11.58

    0.035

Socioeconomic class

           -1.63

0.68

-3.0, -0.32

    0.015

Use of prophylactic medication(s)

           -1.7

0.45

-2.58, -0.81

0.0002

Visit to hospital Emergency Room

1.98

0.17

1.65, 2.31

0.0001

Equation: TPSA = 11.54 + 6.03 (presence of a smoking family member) – 1.63 (socioeconomic class) – 1.7 (use of prophylactic medication(s) + 1.98 (visit to hospital Emergency Room)

R2=0.48, p-value <0.00001, SE=Standard Error, CI = Confidence Interval


 

                A total of 223 (15 %) schoolboys were found to belong to upper socio-economic class families as against 756 (51 %) and 503 (34 %) in the middle and lower socio-economic classes, respectively. No statistically significant difference was found among QDAs and non-QDAs regarding their socio-economic class, chi-square = 3.46, p 0.12 (Table 1).

                There was a statistically significant difference in MPSA during the current academic year among QDAs (13.6 +3.4 days) and non-QDAs (3.7+2.2 days), Z-test= 33.8, P<0.0001 (Table 1). 

                Table 2 shows that the sample rate of the presence of pets at home among QDAs as 51% while the rates of presence of a smoking family member, father and both parents were 61%, 54.0%, 8.0%, respectively. It was interesting to find that all mothers who smoked were married to husbands who also smoked (fathers of QDAs). The rate of QDAs who had visited the emergency room was 65.0% and it was 12.0% for those who had been admitted to hospital, due to bronchial asthma. Only 37.0% of QDAs were found to have used prophylactic medication(s), and 71.0% of these users had not used them appropriately.

Association between MPSA and factors in schoolboys’ characteristics

The highest prevalence of QDA was 35.0 % (49/141), and was among schoolboys aged between 12-15 years (Table 1); however, the MPSA was found to be associated significantly and positively with younger QDAs  (Table 2). Similarly, MPSA was found to be associated significantly and positively with the QDAs’ decreasing socioeconomic level, pets at home and with a smoking family member, father or both parents. The MPSA was also found to be associated positively with QDA boys who had visited the emergency room or who had been admitted to hospital due to bronchial asthma. However, significantly negative associations were found between MPSA and QDAs who had ever used prophylactic medication(s) and among those who used them appropriately.

                QDAs from the lower socioeconomic class (26%) were found to have used prophylactic medication(s) significantly less than QDAs from upper and middle socioeconomic classes together (44%), chi-square=4.6, P<0.025. However, QDAs from the lower socioeconomic class who were found to have attended the hospital emergency room and who had been admitted to hospital due to bronchial asthma (81% and 21%) were significantly more than QDAs from upper and middle socioeconomic classes together (55% and 6%), chi-square=10.1 and 7.3 with P<0.005 and P<0.01, respectively.

Multiple linear regression for TPSA during the current academic year

Table 3 shows the multiple linear regression coefficients and equation for the TPSA during the current academic year. The presence of a family member who smoked and the history of visits to the hospital emergency room were found to correlate positively with TPSA, while the socioeconomic class of the family and the history of the use of prophylactic medications correlated negatively with TPSA. The variability in these 4 factors could explain up to 48% of the variation of TPSA during the current academic year.

DISCUSSION

The response rate of 95.6% in this study was encouraging. This was probably due to the easy non-invasive method used, and the cooperation of school­teachers and families. This supports previously reported successes using self-administered questionnaires on bronchial asthma.5,8,10,11,18

                In support of similar findings from previous studies,19-21 MPSA among asthmatic boys found in this study was significantly more than among non-asthmatic boys. Similar to earlier findings reported, there was no significant difference in socioeconomic class between QDAs and non-QDAs, excluding the variation of this factor as a possible cause for the difference in this study.20 While MPSA among QDAs was also found to be higher than the same reported in other similar studies (22-24), this study is in accordance with earlier findings suggesting the decrease of the period of school absenteeism among asthmatic children as they got older.20

                In this study, socioeconomic class was not related to the presence or absence of QDA. Our finding is therefore, consistent with earlier similar studies here in Saudi Arabia,11,12 Arab25 and other countries.26-29

                Our results, consistent with the findings of others showed that a period of absenteeism from school (an indicator of the severity of bronchial asthma) was significantly associated with low socioeconomic class,30 history of emergency hospital visits,1 hospital admissions,1,30,31 non- or under-use of prophylactic medication(s),22,32-37 parental or a family member smoking,38 and presence of pets at home.38

                The rates of those who had attended hospital in emergency and who had been admitted to hospital in this study, were higher than those in the reports of other investigators.1,30,31 TPSA together with histories of emergency hospital visits and hospital admissions are well-recognized reflections of the degree of severity of bronchial asthma.1,3,31 In this work, asthmatic children belonging to families from lower and to a lesser extent middle socioeconomic classes were at a higher risk of such impacts. Similar findings were reported earlier.30

                These findings should be taken into consideration when designing and providing health care for this particular group of asthmatics. It is well documented that severe asthma is generally most prevalent in the lower socioeconomic class28,29 and that the lack of awareness of the varying degrees of severity of asthma may have resulted in the conflicting results in studies in relation to the association with socioeconomic class.28,29

                Compared with similar earlier work,22 the rate of those who had used prophylactic medication(s) in this study was comparatively low, indicating a high rate of undertreatment. Reports have shown that absence from school was reduced by 10-fold37 and that overall disability because of asthma had fallen by about 50%34 after the initiation of prophylactic medications. Though doctors in Saudi Arabia were known to diagnose asthma early and readily,5,10,11 this study proves that undertreatment is still a problem requiring resolution.

                The multiple linear regression model for TPSA (response variable) had a reasonable multiple correlation with the explanatory variables. The goodness of fit represented by the multiple regression coefficient was acceptable for similar studies, explaining reasonably the variability in TPSA. Similar associations between the response variable and some of the explanatory variables have been documented by earlier investigators.1,30,33,38 The association between these explanatory variables and TPSA can establish the basis in any screening program for bronchial asthma among school children.

                This study may be considered a base line for further, broader studies covering a wider range of ages and female children in the same area in the future. Based on the results of this study, those in authority in the Ministry of Health and Education may consider investigating the reasons beyond the current situation. More effort should be exerted in providing health education to asthmatic children and their parents in an effort to address this problem and factors that contribute to its severity.  Primary care physicians should be aware of such environmental factors as smoking and the presence of pets at home that are associated with poor asthmatic management outcome. They should also encourage parents to adhere to instructions on proper follow up and the use of prophylactic medications. Physicians and schoolteachers may consider school absentee records as an indicator of the severity of bronchial asthma among schoolboys in Al-Khobar city. Asthmatic schoolboys with a high rate of absence from school should be screened for possible associated factors such as the presence of a family member who smokes, a reduction or the lack of prophylaxis, visits to hospital emergency room, and belonging to the lower socioeconomic class. It is envisaged that the modification of some or all of these factors would moderate the severity and the disability associated with this disease and lessen TPSA. More attention may be directed towards asthmatic children belonging to socioeconomically dis-advantaged families.

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20.   Parcel Gs, Gilman SC, Nader PR, Bunce H. Comparison of asbsence rates of elementary schoolchildren with asthma and nonasthmatic schoolmates. Pediatrics 1979; 64:878-81.

21.   Peckham C, ButlerN. A national study of asthma in childhood. J Epidemiol Community 1978; 32:79-85.

22.   Hill RA, Standen PJ, Tattersfield AE. Asthma, wheezing, and school  absence in primary schools. Arch Dis Child 1989; 64:246-51.

23.   Braback L, Kalvesten L. Asthma in schoolchildren. Factors influencing morbidity in Swedish survey. Acta Paediatr Scand 1988; 77:826-30.

24.   Bremberg SG, Kjellman NI. Children with asthma: how do they get along at school?  Acta Paediatr Scand 1985; 74:833-40.       

25.   Moussa MA, Skaik MB, Yaghy OY, Sawanes SB, Bin-Othman SA. Factors associated with asthma in school children. Eur J Epidemiol 1996; 12:583-8.

26.   Ormerod LP, Myers P, PrescottRJ. Prevalence of asthma and ‘probable’ asthma in the Asian population in Blackburn, UK. Respir Med 1999; 93:16-20.

27.   Ones U, Sapan N, Somer A, Disci R, Salman N, Guler N, Yalcin I. Prevalence of childhood asthma in Istanbul, Turkey. Allergy 1997; 52:570-5.

28.   Mielck A, Reitmeir P, Wjst M. Severity of childhood asthma by socioeconomic status. Int J Epidemiol 1996; 25:388-93.

29.   Lin S, Fitzgerald E, Hwang SA, Munsie JP, Stark A. Asthma hospitalization rates and socioeconomic status in New York State (1987-1993). J Asthma 1999; 36:239-51.

30.   Bez C, Schulze J, Riel B, Bungert B, Klockner M, Zortea G, Zielen S. Hospital admission for bronchial asthma: comparison betweenn inpatient children and patients attending ambulatory asthma education.Pneumologie 1999; 53:26-30.

31.   Le Roux P, Bourderont D, Loisel I, Collet A, Boulloche J, Briquet MT, Le Luyer B. Epidemiology of infantile asthma in the Le Havre region. Arch Pediatr 1995; 2:643-9.

32.   Mostgaard G, Siersted HC, Hansen HS, Hyldebrandt N, Oxhoj H. Reduced forced expiratory flow in schoolchildren with respiratory symptoms: the Odense Schoolchild Study.Respir Med 1997; 91:443-8.

33.   PatersonNA, Peat JK, Mellis CM, Xuan W, Woolcock AJ. Accuracy of asthma treatment in schoolchildren in NSW, Australia. Eur Respir J 1997; 10:658-64.

34.   AndersonHR, Butland BK, Strachan DP. Trends in prevalence and severity of childhood asthma. BMJ 1994; 308: 1600-4.

35.   Brook U. The importance of inhalation of beta 2 sympathomimetic drugs in the home care treatment of asthma in children. Ann Allergy 1989; 63: 37-8.

36.   Dawson KP, Fergusson DM, Horwood LJ, Mogridge N. Ketotifen in asthma. Aust Paediatr J 1989; 25:89-92.

37.   Speight AN, Lee DA, Hey EN. Underdiagnosis and undertreatment of asthma in childhood. Br Med J 1983; 286:1253-6.

38.  Peters A, Dockery DW, Heinrich J, Wichmann HE. Short-term effects of particulate air pollution on respiratory morbidity in asthmatic children. Eur Respir J 1997; 10:872-9.


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CORRELATES


CORRELATES OF VARIOUS PRESENTATION MODES OF ACUTE OTITIS MEDIA IN SAUDI CHILDREN

Al-Joharaah M. Al-Quaiz, MRCGP, Department of Family & Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة :وصف العلاقة بين مختلف النسق للأعراض وتحديد النواب للنتائج الغير مرضية لمرض التهاب الأذن الوسطى الحاد في الأطفاال دون 5 سنوات.

طريقة الدراسة : هذه الدراسة مقطعية لعينة عشوائية في 11 مركز صحي في مدينة الرياض على مدى ثلاثة شهور. ضمت هذه الدراسة 140 طفل أعمارهم دون 5 سنوات جاء و ا بأعراض جديدة لالتهاب حاد في الأذن الوسطى. شارك في هذه الدراسة 28 طبيب رعاية أولية. ُشخص هذا المرض بعد اخذ تاريخ المرض و فحص غشاء الطبلة بواسطة منظار الأذن.

عرفت النتائج الغير مرضية للمرض بوجود نجيج الأذن.

نتائج الدراسة : غالبية الأطفال اشتكوا من ارتفاع الحرارة (62%)‘  و التهاب المجاري التنفسية العليا (58%)  و الآم الأذن (54 %).وجد أن هناك علاقة بين التهاب المجاري النفسية العليا و التوتر وعدم القدرة على النوم مع احمرار و بهتان طبلة الأذن ,  وكانت ذات دلالة إحصائية  (P< 0.05).

كما وجد أن أطفال الآباء الأميين كانوا أكثر عرضة للشكوى من نجيج الأذن .(X2=4.66,P< 0.05)

أما الرضاعة الصناعية في السرير فزادت من الإصابة بنجيج الأذن بنسبة مرتين

     .(OR =2.26,95%CI: 1.01-5.05)

لقد وجد أن مص الإصبع قلل من الإصابة ببروزالطبلة0((OR=0.29,95%CI: 0.07-0.94

الخلاصة :إن وجود التهابات المجاري التنفسية العليا والتوتر وعدم النوم عند الاطفال الذين عانوا من التهابات الأذن الوسطى كان مصاحبا لاحمرار وبهتان الطبلة0 كما أن مص الإصبع كان عامل حماية من بروز الطبلة . كذلك وجد أن أمية الآباء و الرضاعة الصناعية كانتا نائبين لنجيج الاذن.

الكلمات المرجعية : التهابات الأذن الوسطى الحادة‘ الأعراض‘  النتائج الغير مرضية‘  عوامل الخطورة ‘المملكة العربية السعودية.  

Purpose: To describe correlates of various modes of presentation and identify some surrogates of poor outcome of children less than 5 years with Acute Otitis Media (AOM).

Patients and Methods: This is a cross-sectional survey conducted at 11 primary health care centers in Riyadhcity over 3 month period. A total of 140 children, each less than 5 years of age and presenting with a new episode of AOM were enrolled. Twenty-eight family physicians participated in the study. Each physician made the diagnosis of AOM based on history and clinical examination of the tympanic membranes (TM) using an otosocope. Poor outcome was defined as children presenting with otorrhea.

Correspondence to:

Dr. Al-Joharah M. Al-Quaiz, Department of Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia

Results: The majority of children presented with fever (62%), URTI (58%) and earache (54%). Presence of URTI, irritability, or sleeplessness were positively associated with redness and dullness of TM (p<0.05). Thumb sucking reduced the risk of bulging (OR = 0.29, 95% CI: 0.07-0.94).  Children of illiterate fathers were more likely to present with otorrhea (X2= 4.66, p< 0.05). Bottle feeding increased the risk of otorrhea by two fold (OR = 2.26, 95% CI:1.01-5.05).

Conclusion: Children with AOM presenting as URTI, irritability or sleeplessness will showed redness and dullness of the TM as clinical signs of the disease. Thumb sucking was found to be protective from bulging of the TM. Having an illiterate father and being bottle fed were found to be surrogates of otorrhea .

Key words:Acute otitis media, presentation, poor outcome, risk factors, Saudi Arabia.


 

INTRODUCTION

Acute Otitis Media (AOM) is one of the commonest childhood problems seen by general practitioners. In the UK about 10% of children under five years old are seen at least once every year with this condition.1 In the USA, AOM is the most common diagnosis for children under two years of age.2

Although AOM is a very common problem worldwide, prevalence studies are not available in Saudi Arabia. In a recent epidemiological study, a representative sample of 6421 children aged 2 months to 12 years, were examined and screened for hearing loss. Hearing impairment was detected in 494 (7.7%) of the children. Chronic secretory and suppurative otitis media were responsible for 326 (5.07%), and sensori-neural hearing loss for 168 (2.6%) of these children.3

Acute otitis media episodes constitute the greatest risk factor for chronic secretory4 and suppurative5 otitis media and is considered the most common cause for anti-microbial use in children.(1) Furthermore, there seems to be an emerging consensus among practitioners that AOM is over diagnosed and sometimes over treated.6 Of late, the value of prescribing antibiotics is being questioned, especially with the increasing reports of antibiotic resistance. There is thus need for family physicians to have good knowledge of the possible risk factors, presentation, and surrogates of poor outcome of AOM. This will help to accurately diagnose the disease, identify modifiable risk factors and prescribe antibiotic treatment more appropriately.

At the moment, there is a dearth of studies on AOM in Saudi Arabia and as a preliminary step, the present study was undertaken to describe correlates of various modes of presentation and identify some surrogates of the poor outcome of AOM in children less than five years old.

PATIENTS AND METHODS

The cross-sectional survey study was conducted at 11 primary health care centers ( PHCC) in Riyadh, Saudi Arabiabetween September and December 1998 inclusive. These centers serve The National Guard employees and their families in their residential area (Iskan). Consequently, 90% of the study population were children of soldiers and army officers.

Children less than five years of age and presenting with a new episode of AOM during the study period were enrolled. A new episode was defined as a child’s visit with a diagnosis of AOM with no such diagnosis in the preceding 3 months. AOM was defined as redness of the TM, or loss of translucency of landmarks of the drum, or bulging of the drum, or perforation and otorrhea with local and systematic symptoms.7 Children with a history of chronic ear disease were excluded from the study.

A meeting was arranged with the physicians involved in the study and a standarization of  the diagnosis of AOM was established to be followed throughout the study. Presentation of AOM was considered early when a child presented with redness, dullness/opacity or bulging of the TM, and a presentation late when there was otorrhea. Poor outcome was defined as presenting with otorrhea. Children were assessed at the time of the visit for  poor outcome. The data collection sheet included items on patients’ demographic characteristics, presenting symptoms, suspected risk factors and clinical findings of the tympanic membrane. Past history was defined as one or more attacks of AOM occurring at least three months previous to the present attack. The suspected risk factors were sociodemographic factors, breast feeding, bottle feeding, the use of pacifiers,  thumb sucking, smokers in household, presence of siblings, previous episodes of otitis media, number of children in one bed room, other siblings with AOM, and  history of allergic rhinitis mentioned in previous studies.8,9

The minimum sample size for this study was estimated as 139 assuming a prevalence rate of 10% for AOM in the population and within this to tolerate an absolute deviation of 5% at a 95% confidence level. In the course of the last year, six hundred cases of AOM were diagnosed in the PHCC. And since thirty family physicians were available, it was estimated that each family physician would have seen an average of five children with new attacks of AOM over a three-month period. Accordingly, every doctor working in these centers was requested to complete the record form of five consecutive patients with AOM seen in his / her clinic.

Each physician based his clinical diagnosis of AOM on history and clinical examination of the tympanic membranes using an otoscope and following the agreed definitions of AOM. When the ear canal was blocked or the family physician had difficulty in examining the TM, it was reported as not visualized and was excluded from the analysis.

The data was processed in a microcomputer and analyzed by means of SPSS-version 9. The chi-square and Fisher's Exact Tests (when applicable) were used to assess the significance of associations between categorical variables. The risks of clinical signs of the TM were investigated by calculating the odds ratio and their 95% confidence intervals.

RESULTS

A total of 140 children who satisfied the inclusion criteria were enrolled over the three-month period of this study. However, five of the records were excluded because the data was incomplete in most of the variables. With 28 family physicians participating, the participation rate was 93.3%.

The demographic characteristics of the 135 subjects showed that their ages varied from 4 months to 60 months with a mean age of (25±16). A sizeable majority of the children (63%) were males. Sixty seven percent of the mothers were illiterate, while 51% of the fathers had elementary/ intermediate education. Most of the children (91.1%) lived in small villas.

A sizeable majority of children were found to  have redness  of  the  TM (76.2%),


 

Table 1:Presenting symptoms related to clinical signs of children with AOM, Riyadh, Saudi Arabia1999

Presenting

Total (%)

Clinical signs of AOM

Symptoms

(N=135 )

Redness (%)

N=103

Dullness (%)

N=38

Bulging (%)

N=43

Otorrhea (%)

N=43

Fever

84 (62.2)

68 (66.0)

31 (81.6)

30 (69.8)

25 (58.1)

URTI

78 (57.7)

67 (65.0)*

28 (73.7)*

27 (62.8)

21 (48.8)

Irritability

54 (40.0)

51 (49.5)*

31 (81.6)*

22 (51.2)

  10 (23.3)*

Sleeplessness

44 (32.5)

42 (40.8)*

25 (65.8)*

17 (39.5)

    7 (16.2)*

Vomiting/Diarrhea

  11 (8.8)

   10 (9.7)

3 (7.9)

2 (4.7)

        3 (7.0)

Earache

69 (51.1)

60 (58.3)*

25 (65.8)

25 (58.1)

14 (32.6)

H/O Impaired hearing

7 (5.1)

6 (5.8)

  5 (13.2)*

3 (7.0)

2 (4.7)

Ear discharge

47 (34.8)

20 (19.4)*

11 (28.9)

4 (9.3)*

  38 (88.4)*

*Significant, p<0.05

Table 2:The estimated risk of some clinical signs of children with AOM with respect to some demographic variables, Riyadh, Saudi Arabia1999

Demographic variables

Total (%)

(N=135)

Bulging (%)

(N=43)

Otorrhea (%)

(N=43)

Age in months:

0-12

37 (27.4)

11 (25.6)

15 (34.9)

12-30

53 (39.3)

19 (44.2)

14 (32.6)

30

45 (33.3)

13 (30.2)

14 (32.6)

Gender:

Male

84 (62.2)

28 (65.1)

25 (58.1)

Female

51 (37.8)

15 (34.9)

18 (41.9)

Level of education of father:

Illiterate

47 (34.3)

10 (23.3)

  18 (41.9)*

Elementary/Intermediate

69 (51.5)

23 (53.5)

21 (48.8)

Secondary/University

19 (14.2)

10 (23.3)†

4 (9.3)

Level of education of mother:

Illiterate

91 (67.4)

26 (60.5)

28 (65.1)

Elementary/Intermediate

36 (26.6)

11 (25.6)

14 (32.6)

Secondary/University

8 (5.9)

    6 (14.0) ‡

1 (2.3)

Housing:

House/villa

129 (95.6)

39 (90.7)

40 (93.0)

Flat

6 (4.4)

4 (9.3)

2 (7.0)

*As comparing frequencies of children with otorrhea to those with bulging of TM in illiterate fathers (X2=4.66, P<0.05)

†Secondary/University father’s level of education vs illiterate (OR=4.00, 95%CI:1.11-14.76)

‡Secondary/University mother’s level of education vs illiterate (OR=7.27, 95%CI:1.11-76.43)


 

23.3% of which were bilateral. The right ear was associated with more redness of the TM than the left ear (X2  = 6.25, p<0.02). No statistically significant difference was detected in either ear with respect to other TM clinical signs.

Table 1 shows the distribution of the presenting symptoms in relation to clinical signs of AOM in these children. Redness of the TM was significantly positively associated with URTI, Earache, Irritability, and Sleeplessness, (p < 0.05). While


 

Table 3:The estimated risk of some clinical signs of children with AOM with respect to maternal and childhood variables, Riyadh, Saudi Arabia1999

Maternal and chidlhood variables

Total (%)

(N=135)

Bulging (%)

(N=43)

Otorrhea (%)

(N=43)

Breast feeding

89 (66.9)

31 (73.8)

28 (66.7)

Bottle feeding

57 (42.2)

21 (48.8)

24 (55.8)*

Pacifier use

23 (17.0)

9 (20.9)

8 (18.6)

Thumb sucking

28 (20.7)

4 (9.3)†

13 (30.2)

Household smoking

28 (20.7)

7 (10.3)

9 (20.9)

Presence of siblings

15 (85.2)

38 (88.4)

36 (83.7)

Previous episodes of AOM

67 (50.0)

21 (48.8)

25 (58.1)

No. of children with one bedroom:

<2

55 (40.7)

22 (51.2)

18 (41.9)

3-4

54 (40.0)

13 (30.2)

19 (44.2)

5

26 (19.3)

8 (18.6)

6 (14.0)

Other siblings with AOM

55 (40.7)

13 (30.2)

15 34.8)

History of allergic rhinitis

5 (3.7)

0 (0.0)

1 (2.3)

*Bottle feeding vs non-bottle feeding (OR=2.26, 95%CI:1.01-5.05)

†Thumb sucking vs non-thumb sucking (OR=0.29,95%CI:0.07-0.94)

dullness of the TM was positively associated with URT, earache, sleeplessness, irritability and a history of impaired hearing ,(p< 0.05). On the other hand, otorrhea was negatively associated with irritability, sleeplessness and earache, (p<0.05).

The frequency distributions of some clinical signs of children with AOM according to demographic variables are presented in Table 2. Children whose fathers or mothers had secondary/university education showed 4 to 7 fold increased risk of having bulging eardrums in comparison with those who were illiterate (OR= 4.00, 95%CI:1.11-14.76) and (OR=7.27, 95% CI:1.11-76.43) respectively. Also the majority of children with illiterate fathers (38.1%) presented with otorrhea (X2 =4.66, p< 0.05). No statistically significant associations were found with age, gender or housing.

Table 3 shows the frequency distribution of some clinical signs of AOM according to maternal and childhood variables. Fifty five point eight percent of the children with otorrhea, with a two fold increased risk (OR=2.26, 95%CI: 1.01 - 5.05) were bottle-fed. Thumb sucking had a negative association with bulging TM (OR=0.29, 95%CI: 0.07-0.94). Breast feeding, pacifier use, household smoking, presence of siblings, number of children in one bedroom, other siblings with AOM, age at first attack of AOM and history of allergic rhinitis did not show any  statistically significant associations  with the clinical signs  (p 0.05).

DISCUSSION

The results of this study showed a male preponderance which is in accordance with most studies.10-13 Only a few have not report any sex differences.14 Furthermore, the majority of children who presented with AOM were between 12-30 months, the age of first attack being < 12 months. This finding is similar to most studies, which showed that children between (6-12 months) run the greatest risk of getting AOM.9,11,13-15 The findings on history, symptoms, and some physical signs were similar to those reported by other investigators. The rates 62%, 58% and 51% for fever, URTI and earache respectively are similar to the rates reported by other investigators.16 Some studies even showed that the proportion presenting with fever ranged from 27% to 90%, earache 23% to 90% and URTI 20% to 76%.16-19 It is suggested that the simultaneous occurrence of earache with URTI is indicative of AOM, though its absence does not preclude it.18

Redness and bulging of TM and otorrhea were the most prevalent clinical signs. The former was detected in 76% of the children, a rate lower than those reported by other researchers.16  However, it should be noted that redness of the TM is not specific to AOM as it may present with a crying child, efforts to remove cerumen or caused by a viral URTI.20 A more accurate diagnosis is likely to be made when the eardrum of child suspected of having AOM is examined for bulging and not just redness or dullness. This is supported by findings in controlled studies on myringotomy in which it was found to have a very high specificity to AOM.21

In the present study, 32% of the children were found to have bulging eardrums and similar were the rates of otorrhea. This is higher than what was previously reported.16-22 This may indicate late presentation of patients with AOM, resulting in delayed initiation of treatment. A recent meta-analysis showed that antibiotic treatment reduced the rate of perforation and otorrhea of AOM by 50%.23 The findings also showed that early presentation of children with AOM was significantly  associated with such symptoms as irritability, sleeplessness, earache and URTI. None of these symptoms were associated with bulging of the TM probably because of small sample size. In accordance with other studies24 it was found that redness of the TM was more prevalent in the right than the left ear.

Surrogates of poor outcome are important to identify as these enable doctors, with the help of parents, to modify some habits and patterns of behavior and direct antibiotic prescription more precisely to those in real need. Fathers’ level of education was significantly associated with otorrhea. Children with early presentation of AOM (bulging of the eardrums) were more likely to have parents of higher educational level, while those with late presentation (otorrhea) had illiterate fathers. This could be explained by the fact that better educated parents are more aware of the problems of delaying medical assistance and thus seek help early in an effort to reduce the severity and complications of the illness.

Bottle-feeding was reported to increase the risk for AOM.7 In our study it was found to be positively associated with otorrhea. Bottle-feeding on cow’s milk-based formulas has been reported to cause the so-called positional otitis media.7 It had been postulated that in young infants, there is reflux of milk through the Eustachian tube to middle ear cavity. The direct contact with cow’s milk might induce certain immunological events in the mucus membranes in the middle ear cavity in susceptible individuals. An early-onset otitis may predispose to recurrence through meta-plastic mucosal change.7

In the present study, thumb sucking in children with AOM was found to reduce the bulging of the TM. It is postulated that frequent thumb sucking in the absence of URTI leads to an increase in negative Eustachian tube pressure.25,26 That in turn, decreases the middle ear cavity pressure, reducing TM bulging. Further research is needed to find out whether thumb sucking in children with AOM results in less susceptibility to perforation of TM and otorrhea.

LIMITATIONS OF THE STUDY

Comparative rates of signs and symptoms are difficult to interpret since designs vary in different studies and age specific data may not be similar.

The diagnosis of AOM in children in PHCCs remains challenging. With the diversity of criteria used in practice in specific criteria for the diagnosis have been difficult to validate or standardize.27

There is an emerging consensus that acute otitis media is over-diagnosed.6 This is attributable in part to poor sensitivity and specificity of symptoms in young children, and the difficulty of accurate diagnosis with an otoscope especially in an ill and uncooperative child.

CONCLUSIONS

It is necessary to have health education programs for illiterate parents so that their health awareness of the importance of early detection of any ear problem may improve. These health education programs should also emphasize the value and reasons for advocating breast-feeding rather than bottle-feeding. The importance of establishing standardized criteria and accurate diagnosis of ear pathology in primary care points to a need to establish guidelines for diagnosis and management.

More research and follow up studies using bigger sample size is required to identify other predictors of poor outcome, so that antibiotics could be targeted more precisely.

ACKNOWLEDGMENT

The author is grateful to Prof. E.A. Bamgboye, Consultant Medical Statistician for his constructive reviews and comments and Dr. Aida al-Dougaither, Consultant family physician for her help in collecting the data.

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