Measuring the Quality of Life in Children with Asthma in Da Nang City, Viet Nam

MEASURING THE QUALITY OF LIFE IN CHILDREN WITH ASTHMA IN DA NANG CITY, VIET NAM ABSTRACT Background: Nowadays, the cost of treatment for asthma is a huge burden in all countries of the

輔英科技大學護理系碩士在職專班

碩 士 論 文

Department of Nursing Fooyin University Master Thesis

衡量越南岘港市哮喘患童的生活品質 Measuring the Quality of Life in Children with Asthma

in Da Nang City, Viet Nam

研究生：范氏草 Graduate Student：Pham Thi Thao

指導教授：李佩育副教授 Advisor：Associate Professor Pei-Yu Lee

中 華 民 國 108 年 07 月

July, 2019

Fooyin University Recommendation Letter from the Thesis Advisor

Fooyin University Thesis/Dissertation Oral Defense Committee Certification

ACKNOWLEDGEMENTS

I would first like to thank my thesis advisor Associate Professor Pei-Yu Lee of the School of Nursing at Fooyin University in Taiwan She was always ready whenever I ran into a trouble spot or had a question about my research or writing She consistently allowed this paper to be my own work, but steered me in the right the direction whenever she thought I needed it

My sincere thanks also goes to Duy Tan University for giving me the opportunity to participate in this course Without their precious support it would not be possible to conduct this research

I would also like to thank the experts who were involved in the validation survey for this research project: M.S Nguyen Dieu Hang, M.S Tran Thi Kim Quy, M.S Pham Ngoc An and Mr Gary Michael Sanchez Without their passionate participation and input, the validation survey could not have been successfully conducted

Finally, I must express my very profound gratitude to my parents, friends and colleagues for providing me with unfailing support and continuous encouragement throughout my years of study and through the process of researching and writing this thesis This accomplishment would not have been possible without them

I want to say “Thank you” to all of you again

Master student:

Pham Thi Thao

衡量越南岘港市哮喘患童的生活品質

摘要

背景：現今治療哮喘的成本是世界各國的巨大醫療負擔。哮喘復發的症狀經常導致失眠，白天疲勞，活動能力降低和影響上學。影響兒童的發展特徵是包括身體，心理，情感，社交和智力。因此，哮喘會使兒童的生活品質大大降低。

目的：本研究的目的包括（1）探索哮喘患兒的生活品質;（2）評估哮喘症狀控制標準;（3）醫療檢查與哮喘兒童生活品質的相關性。

方法：本研究是量性橫斷面，描述性研究設計。於 2019 年 1 月至 5 月間在峴港市的峴港醫院和海洲綜合醫院共招募了 122 名 5-15 歲被診斷患有哮喘病童，經本人及監護人同意後填寫問卷。其問卷內容包括：（1）人口統計學特徵（包括兒童及其父母或監護人）;（2）生活品質問卷和（3）哮喘控制問卷。使用 SPSS 16.0 統計軟件分析其數據。

結果：大多數兒童的平均生活品質（QoL）結果（M = 67.8±9.48）為

27.9％的兒童控制不佳，48.4％的兒童部分控制佳，23.8％的兒童控制良好。哮喘病童的生活品質與哮喘症狀控制水平（p <0.001），哮喘持續時間（p <0.05），父母教育程度（p <0.01）和婚姻狀況（p <0.01）是存在差異的。而在哮喘病童的生活品質與年齡，性別，家庭收入和吸煙者家庭方面是沒有顯著差異（p> 0.05）。

結論：哮喘症狀控制水平較高的兒童 QoL 評分較高。因此，控制哮喘和決

定 QoL 標準這兩項因素是可以改善哮喘病童的生活品質。

關鍵詞：哮喘，兒童，生活品質

MEASURING THE QUALITY OF LIFE IN CHILDREN WITH ASTHMA IN DA NANG CITY, VIET NAM

ABSTRACT

Background: Nowadays, the cost of treatment for asthma is a huge burden in all

countries of the world Symptoms of asthma relapse frequently and can cause insomnia, daytime fatigue, reduced activity levels and schooling Children are characterized by physical, mental, emotional, social and mental development Therefore, asthma reduces the quality of life of children

Aim: The aims of this study were (1) To explore the quality of life in the

children with asthma; (2) To assess the level of asthma symptoms control; (3) To examine the correlations to the quality of life of children with asthma

Methods: The study was a quantitative, cross-sectional, descriptive design 122

children from the ages of 5-15 diagnosed with asthma were recruited between January 2019 and May 2019 in Da Nang Hospital for Women and Children and Hai Chau General Hospital in Da Nang City This study used questionnaires including: (1) demographic characteristics (including child and their parents or guardians), (2) quality of life instrument and (3) Asthma control questionnaire The data was analyzed using the SPSS 16.0 statistical software

Results: Most children are assessed for their quality of life (QoL) at an average

level (M=67.8±9.48) 27.9% of children were uncontrolled, 48.4% partially controlled and 23.8% controlled well There is a difference between the QoL of a

child with asthma and the level of asthma symptoms control (p <0.001), duration

of asthma years (p <0.05), educational level (p <0.01) and marital status (p <0.01)

of the child's parents There is no difference between the QoL of children with

asthma and age, gender, family income and smokers' families (p >0.05)

Conclusion: Asthma in children with a better level of symptom control had a

higher QoL score Controlling asthma and the main factors that determine QoL scores can improve a child's QoL

Keywords: Asthma, Children, Quality of life

TABLE OF CONTENTS

Recommendation Letter from the Thesis Advisor i

Thesis/Dissertation Oral Defense Committee Certification ii

Acknowledgements iii

Abstract (Chinese version) iv

Abstract (English version) v

Table of contents vi

List of tables viii

List of figures x

List of abbreviations xi

Chapter 1: Introduction 1

1.1 Statement of the Problem 1

1.2 Prevalence of Asthma in Viet Nam 4

1.3 Research purposes 6

1.4 Research Questions 6

1.5 Significance of the study 6

1.6 Conceptual definitions 7

1.7 Summary 8

Chapter 2: Literature Review 9

2.1 Outline of asthma 9

2.2 Quality of life 17

2.3 Asthma and quality of life 25

2.4 Summary 28

Chapter 3: Methodology 29

3.1 Research design 29

3.2 Conceptual Framework 30

3.3 Sampling & Setting 30

3.4 Instruments 32

3.5 Process of Questionnaire Translation 35

3.6 Research process 36

3.7 Data collection 37

3.8 Data Analysis 41

3.9 Ethical consideration 41

3.10 Summary 42

Chapter 4 Result 43

4.1 Demographic data 43

4.2 The level of asthma symptoms control 45

4.3 Reliability Test of the Questionnaire 46

4.4 Scores of total PedsQL and its domains 46

4.5 Summary 53

Chapter 5 Discussion And Conclusion 55

5.1 Discussion 55

5.2 Limitations of the Study 62

5.3 Suggestions 63

5.4 Conclusion 64

5.5 Summary 64

References 66

Appendix 76

Appendix A: Questionnaire (English version) 76

Appendix B: Questionnaire (Vietnamese version) 81

Appendix C: Agreement Form (English version) 86

Appendix D: Agreement Form (Vietnamese version) 87

Appendix E: Permission from Questionnaire 88

Appendix F: Permission from Hospitals 89

Appendix G: Grammar Editing Permit 91

LIST OF TABLES

Table 1 Diagnostic criteria for asthma in adults, adolescents, and children from

age 6–11 year-old (GINA, 2018)……….11

Table 2 Factors suggesting the possibility of patients with asthma (Ministry of Health of Vietnam, 2016) ……… 13

Table 3 Laboratory tests (Ministry of Health of Vietnam, 2016)……… 14

Table 4 GINA assessment of asthma control in adults, adolescents and children from age 6–11 year-old (GINA, 2018)……… 17

Table 5 Characteristics of the questionnaire about quality of life for children and adolescents with asthma……… 21

Table 6 How to convert points of items……… 33

Table 7 Characteristics of the questionnaire assesses the level of asthma symptom control based on GINA criteria……… 35

Table 8 Scale reliability (n = 30)……….37

Table 9 Item and Scale CVIs……… 39

Table 10 Demographic details of children……… 43

Table 11 Demographic details of parents or guardians of children………… 44

Table 12 Asthma control situation in the past 1 month……… 45

Table 13 The level of asthma symptoms control………46

Table 14 Scale reliability (formal survey with n = 122 participants)………… 46

Table 15 Mean and Standard deviation of Physical Functioning……… 47

Table 16 Mean and Standard deviation of Emotional Functioning………49

Table 17 Mean and Standard deviation of Social Functioning……… 49

Table 18 Mean and Standard deviation of School Functioning……… 50 Table 19 Mean and Standard deviation of Scores of total PedsQL and its domains………50 Table 20 Children's demographic characteristics in relation to their quality of life (T-test).……… 51 Table 21 Parents or guardians' demographic characteristics in relation to their quality of life (T-test)……… 52 Table 22 Parents or guardians’ demographic characteristics in relation to their quality of life (ANOVA)……… 53 Table 23 Relationship between the level of symptom control and the quality of life of children (ANOVA)………54

LIST OF FIGURES

Figure 1: Diagram of pathological process of bronchial asthma (Expert Panel Report 3, 2007)……… 9 Figure 2 Conceptual Framework……….30 Figure 3 The required sample size was calculated by using the G*Power version 3.0.10………32

LIST OF ABBREVIATIONS

LABA)

Questionnaire

CHAPTER 1: INTRODUCTION

This chapter focuses on the statement of the problem, prevalence of asthma in Viet Nam, research purpose, research questions, significance of the study and conceptual definitions

1.1 Statement of the Problem

According to the World Health Organization (WHO) estimates, by 2015 there were 383,000 deaths due to asthma Asthma is a non-communicable disease, characterized by continuous attacks of shortness of breath and wheezing, the severity and frequency of asthma are not the same for each person Symptoms may occur several times a day or a week in those affected and for some people

attack, the lining of the bronchial tubes swells, narrowing the airways and reducing air and reducing the amount of air entering and exiting the lungs Symptoms of recurrent asthma induce insomnia, daytime fatigue, decreased activity and absenteeism in school and the workplace Drugs that control asthma and the prevention of asthma triggers can also reduce the severity of the disease Proper management of asthma can help people achieve better quality of life (World Health Organization, 2017)

Nowadays, the cost of treatment for asthma is a huge burden on all the countries of the world Most studies on the burden of asthma come from developed countries, where large national disease surveys and large administrative databases can be integrated to provide a broad picture of the burden Indirect costs of asthma are at least equal to its direct cost Deficiencies from asthma affect people most at their peak productive working age, and parents of children with asthma are also of working age Even, the loss of individual productivity at work is greater than the inability to work in patients

with asthma A study in Canada has shown that uncontrolled asthma leads to a loss of $ 184 Canadian dollars in 2012 for per person per week Thus, 90% of them are due to lost function at work (The Global Asthma Report, 2018)

According to the survey by Lai in eight countries in the Pacific region including Vietnam, the rate of school dropout for asthma is 36.5% (Lai C., et al, 2003) A study by Dang Huong Giang conducted in Thanh Xuan and Long Bien District, Hanoi in 2012 shows asthma has made 11.3% of children in Thanh Xuan district and 8.3% of children in Long Bien district have to miss school (Giang, 2012)

While most epidemiological data on asthma are available in developed countries, information on these diseases in developing countries in Southeast Asia is very rare Costs based on the incidence of each new asthma case in Vietnam is 70,019,897 VND, of which costs for medicines and health services account for 60.55% and 39.45% The cost of asthma diagnosis and management throughout life is 51,459,674 VND per person, which is about 2.77 times higher than the cost of treating asthma (18,560,224 VND) With nearly 231,260 new cases of asthma annually, Vietnam has an economic burden based on the prevalence of asthma in its life cycle of about VND 16,193 billion (Nguyen et al., 2014)

According to the Vietnamese children's law, “Children are classified under 16 years old.” (Children's law number: 102/2016 / QH13, 2016) Adolescence is the age of transition between childhood and adulthood along with many changes and developments in physical, mental, emotional, sexual and social aspects This is the age that begins the individual's efforts to achieve the goals related to cultural expectations of society While asthma is one of the major diseases common in childhood and adolescence and its consequences not only affect the patient but

lasting effects Adolescents have many problems to deal with, then combined with a chronic illness such as asthma so these adolescents may experience feelings of failure, anger, lack of hope, lack of self-esteem, self-censorship and fear These things become more burdensome for them (Nogueira et al., 2009) According to Sawyer and colleagues, in a cohort study, quality of life (QoL) decreased in adolescents with chronic diseases such as diabetes and asthma (Sawyer et al., 2004) QoL in patients with chronic diseases, especially asthma is one of the focuses of this research Nowadays, Asthma is a chronic disease with considerable burden on health, economy and the most frequent chronic disorder

in childhood Despite growing knowledge about causes and treatment, many patients with uncontrolled asthma are still limited in social activities and have a reduced quality of life (QOL) The WHO also defines “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 2006) So, quality of life has become an important concept in evaluating health care, in both child and adult populations WHO defines “Quality of Life as individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs

well-being of a patient Asthma causes a serious burden on the quality of life related and its relation to the health of children, although effective and safe treatments are available (GINA Executive Committee, 2010) A common goal in asthma management is to achieve optimal disease control and improve the quality of life related to health (Pedersen et al., 2011) According to Prof Dr

Ngo Quy Chau, asthma and chronic obstructive pulmonary disease in particular and respiratory diseases in general have not been properly observed in Vietnam The rate of asthma in Vietnam is 4.1% of the population However, only 29.1%

of asthma patients used maintenance therapy and 39.7% of patients had good asthma control Currently, children ages 12 to 13 have the highest rate of asthma

in Asia and this number is on the rise (Ministry of health portal, 22/9/2017) However, in Vietnam in general and Da Nang city in particular, studies on the quality of life in children with chronic diseases, especially asthma is limited The lack of understanding of factors that reduce quality of life may prevent nurses from planning with children and parental care efforts to address the need for improved quality of life for children with asthma in the future Thus, the study focused on the quality of life of children with asthma This study will provide background information on the quality of life in asthmatic children

1.2 Prevalence of Asthma in Viet Nam

In Vietnam, epidemiological studies of bronchial asthma in the community is still very limited Until the year 2010, Vietnam had conducted the first investigation on asthma in adults across the country, which showed that the prevalence of asthma in Vietnamese adults is 4.1% People with asthma, Vietnam has about 4 million patients (Hanh & Doan, 2012) 64.9% of patients had to go to the emergency room because of severe asthma (Hanh & Doan, 2013) and the rate of asthma prevention only reached 26.2% The situation of controlling asthma in children in Vietnam is more alarming as more than 80% of children with asthma under 15 years have not been treated for asthma prevention (Hanh & Doan, 2013)

According to a survey of high school students in 3 schools in Hanoi, on average, 5% of the population had asthma, of which 11% of children were under

deaths per year are approximately 3,000 Many people still hide their disease, so

it is easy to miss the epidemiological investigation as well as diagnosing the disease (Doan & Long, 2006)

In Vietnam so far data on the incidence and death because of asthma related complications are still quite limited In 2003, Pham Le Tuan published the results of studying asthma in pupils in Hanoi by clinical examination and skin test results bronchial asthma of children in the inner city is 12.56%, the suburban

is 7.52% (Tuan, 2004)

In Hanoi, the ISAAC interview form was used in 2005 to investigate the incidence of wheezing in children in two elementary schools in Hanoi (aged 5-11 years), found that the rate of wheezing was 29.1% (Giang, Dung & Anh, 2010)

In 2010, the rate of wheezing in children aged 13-14 in Thanh Tri district in Hanoi is 15.1%, while the rate of children diagnosed with asthma was 2.6% (Giang, Dung & Anh, 2010)

In Da Lat in 2004, Sy DQ conducted a survey in children aged 5-15 years, the results showed that the incidence of asthma and asthma symptoms was 3.4% (Sy, Thanh Binh, Quoc et al., 2007)

In the Mekong Delta, Huynh Cong Thanh interviewed 940 parents of grade

1-2 students in Tien Giang province in 1-2007 showing that in the rate of children with a wheezed was 9%, diagnosed asthma was 2.2% (Thanh & Tram, 2009) That same year in Can Tho the number of children from 13-14 years old are with a wheeze accounted for 5%, had been diagnosed with asthma was 1.4% (Hai & Hong, 2009)

Nationally, in 2010, research on the identified asthma of adults aged 16 to over 80 in 7 Eco regions of Vietnam using the screening interview method ECRHS and medical examinations The incidence of asthma in Vietnamese adults is 4.1% Men have higher morbidity rates than women The highest rate of

asthma in Nghe An was 7.65% and the lowest was Binh Duong at 1.51% Thus, there is a difference in the incidence of asthma rates among different regions of Vietnam (Hanh & Doan, 2012) According to the 2010 survey, the mortality from asthma in the period 2005 - 2009 in Vietnam was 3.78 cases / 100,000 people in all cities and provinces in Vietnam, the mortality from asthma is on the rise (Hanh & Truong, 2012)

With the epidemiological characteristics of asthma as we know that asthma is

a real economic burden for every country

1.3 Research purposes

1 To explore the quality of life in the children with asthma

2 To assess the level of asthma symptom control

3 To examine the relationship between the quality of life of children with asthma and two other factors: (i) demographic characteristics, (ii) level of asthma symptoms control

1.4 Research Questions

1 How severities of asthmatic children affect the quality of life?

2 How is the level of asthma symptoms control in children?

3 Is there a relationship between the quality of life of asthmatic children with

demographic characteristics and the level of asthma symptom control?

1.5 Significance of the study

Asthma often limits the ability to learn, play, and live with healthy children due to the symptoms of the disease Children with asthma are more likely to develop acute asthma when taking part in strenuous activities such as playing sports, changing weather, exposure to allergens forces children to miss school days Some children are pessimistic and discouraged, because they can’t keep up with their friends or because they feel they are burden for their families These

things decrease the quality of life of children Specifically, children of this age group (5 to 15 years old) start to be more aware of society, start going to school, participate in school and group activities and have many changes in thinking Currently, research on the quality of life of asthmatic children in Vietnam is very seldom Based on that fact, I conducted research on this topic

1.6 Conceptual definitions

Demographic characteristics: In the parents or guardians of the child, the

personal information that was included was: age, academic level, income, marital status; in the children the personal information section included was: age, gender, duration of disease, disease history, smoking history

“The level of asthma control: is the extent to which the manifestations of

asthma can be observed in the patient, or have been reduced or removed by treatment” (GINA, 2018)

Quality of Life:

WHO defines “Quality of Life as an individuals’ perception of their position

in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs and their

of life include physical health, psychological, social relationships and environment” (Programme on mental health, 1997)

Asthma:

“Is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role The chronic inflammation is associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or early in the

morning These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often reversible either spontaneously

or with treatment” (GINA, 2018)

Children:

“Is under 16 years old.” (Children's law number: 102/2016 / QH13, 2016) In this study, the participants were 5 to 15 years old

1.7 Summary

Asthma is one of the main diseases that occurs in childhood and adolescence

It not only affects the patient but also the whole family The cost of treatment for asthma is a huge burden on all countries of the world Asthma often limits the ability to learn, play, and live with healthy children due to the symptoms of the disease These things decrease the quality of life of children Besides, the information on the quality of life of asthmatics in developing countries in Southeast Asia (such as Vietnam etc…) are limited

CHAPTER 2: LITERATURE REVIEW

This chapter describes an overview of the literature to assess research issues within a broader context and to demonstrate the need to conduct research in this particular asthma population Document assessment is an important step in the research process and allows researchers to perform research in the amount of

knowledge available This review of the literature includes an outline of asthma,

quality of life and relationship between asthma and quality of life

2.1 Outline of asthma

2.1.1 Definition of asthma

There are many definitions of asthma:

An international consensus report defined asthma as a “common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyper-responsiveness, and an underlying inflammation The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment” (Expert Panel Report 3, 2007)

Figure 1: Diagram of pathological process of bronchial asthma (Expert Panel Report 3, 2007)

The Global Initiative for Asthma (GINA) 2018 definition is: “Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation It

is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.” This definition was reached by consensus, based on consideration of the characteristics that are typical of

2.1.2 Etiology of and risk factors for asthma

Asthma consists of a variety of heterogeneous phenotypes, different in the way of expression, cause and pathophysiology Risk factors for each type of asthma recognized include genetic, environmental and host factors Although patients with asthma have a family history of asthma that is common, but this factor is not enough or is not necessary for the development of asthma (Burke, Fesinmeyer, Reed, Hampson & Carlsten, 2003)

The incidence of asthma varies widely around the world, possibly due to the interaction between genes and the environment

A mother that smokes, diet, nutrition, stress, the use of antibiotics and caesarean section may be prenatal risk factors for asthma

The risk factors for asthma in childhood may include allergy sensitivity, environmental tobacco smoke, animal exposure, decreased lung function in infancy, breastfeeding, structure and size family, socio-economic status, antibiotics and infections and gender

For asthma in adults, occupational exposure is a common risk factor (Subbarao, Mandhane & Sears, 2009)

2.1.3 Clinical diagnosis of asthma

The diagnosis of asthma is based on the identification of a specific type of

cough and limited airflow The pattern of symptoms is important, because respiratory symptoms may be due to acute or chronic diseases in addition to asthma

Typical respiratory symptom pattern of asthma

The following characteristics are typical of asthma and, if available, it increases the likelihood of patients having asthma:

• The symptoms vary according to time and intensity

• Symptoms are usually worse at night or early in the morning

• The symptoms vary according to time and intensity

• Symptoms that are triggered by exercise, exposure to allergens, viral infections (colds), weather changes, laughter, or stimulants such as exhaust fumes of cars, smoke or strong odors (GINA, 2018)

Table 1 Diagnostic criteria for asthma in adults, adolescents, and children from age 6–11 year-old (GINA, 2018)

DIAGNOSIS OF ASTHMA

1 History of variable respiratory symptoms

- Shortness of breath, wheeze, chest

tightness and cough

- Descriptors may vary between

cultures and by age, e.g children

may be described as having heavy

breathing

• In general, there is more than one type

of respiratory symptoms (in adults, isolated cough is rarely due to asthma)

• Symptoms occur change over time and different intensities

• Symptoms are usually worse at night or

on waking

• Symptoms usually triggered by allergens, exercise, laughter, cold air

• Symptoms usually appear or become

worse with a viral infection

2 Confirmed variable expiratory airflow limitation

Documented excessive variability in

lung function* (one or more of the

seen, the more confident the diagnosis

At least once during diagnostic process (e.g when FEV is low), confirm that FEV1/FVC is reduced (normally > 0.90 in children)

Positive bronchodilator (BD)

reversibility test* (more likely to be

positive if BD medication is

withheld before test: SABA ≥4

hours, LABA ≥15 hours)

Children: increase in FEV of >12%

predicted

Excessive variability in twice-daily

PEF over 2 weeks*

Children: average daily diurnal PEF variability >13%**

or PEF >15%

Excessive variation in lung function

between visits* (less reliable)

Children: variation in FEV of >12% in FEV1 or >15% in PEF between

visits (may include respiratory infections) BD: bronchodilator (short-acting SABA or rapid-acting LABA); FEV: forced expiratory volume in 1 second; LABA: long-acting beta-agonist; PEF: peak expiratory flow (highest of three readings); SABA: short-acting beta-agonist

*These tests can be repeated during symptoms or in the early morning

**Daily diurnal PEF variability is calculated from twice daily PEF as ([day’s highest minus day’s lowest] / mean of day’s highest and lowest), and averaged over one week For PEF, use the same meter each time, as PEF may vary by up to 20% between different meters (GINA, 2018)

No reliable test only (or gold standard) and no standard diagnostic criteria for asthma

Clinical diagnosis of asthma in children includes consideration:

- The history of wheezing recurrence or prolonged

- The presence of allergies or family history of asthma and allergies

- The absence of physical findings suggesting diagnostic alternatives

- Diagnostic tests that support diagnosis (e.g spirometry in children can perform tests)

- Clinical response consistent with inhaled bronchodilators or preventer drugs (Australia, National Asthma Council, 2016)

According to the Decision No 4888 / QD-BYT issued on September 12, 2016

of the Ministry of Health of Vietnam on "Guidelines for the diagnosis and treatment of asthma in children under 5 years of age" to diagnose asthma in children under 5 years of age should be based on medical history, clinical symptoms associated with laboratory testing Note to consider other differential diagnoses

Clinical symptoms

Table 2 Factors suggesting the possibility of patients with asthma (Ministry of Health of Vietnam, 2016)

There is a wheezing accompanied by

one of the symptoms:

- Cough

Any sign below:

- Symptoms are only available when the patient has a cold

- Shortness of breath - Cough is not accompanied by

wheezing, difficulty breathing

- Many times of normal pulmonary

symptoms

- There are signs / symptoms suggesting another diagnosis

prevention drugs)

AND Any sign below:

- Symptoms recur often

- More severe symptoms at night and

early morning

- Occurs when exertion, laughing,

crying or being exposed to cigarette

smoke, cold air, pets

- Occurs when there is no evidence of

- There is a whistling or snoring sound

when listening to the lungs

- Respond to Asthma Treatment

Note: wheezing symptoms must be correctly identified by the doctor, because the child's parents may mistakenly wheeze with another unusual breathing

implementation

- Indications for severe asthma or

Forced expiratory volume in 1 second

or peak flow measurement

(if the child is able to cooperate)

Airway obstruction syndrome with response to bronchodilator test (FEV1, PEF increased by at least 12% and 200ml) (children under 5 years of age are usually not possible)

which contributes to the assessment of airflow limitation

not recommended to do so routinely

Note: normal lung function does not exclude asthma, especially in cases of

asthma or mild asthma Bronchodilator test is negative and do not exclude asthma

Diagnostic criteria

Satisfy the following 5 criteria:

- Wheezing ± coughing again and again

- Airway obstruction syndrome: clinically there are whistling or snoring sound (±Impulse Oscillometry)

- There is a response to bronchodilator and or response to trial treatment (4-8 weeks) and worsens when the drug is discontinued

- Having a personal history or allergy family ± triggers

- Eliminate other causes of wheezing

(Ministry of Health of Vietnam, 2016)

2.1.4 Asthma symptom control

Treatment of patients with uncontrolled asthma is the cause of most of the burden of asthma (Barnes, Jonsson & Klim, 1996) Therefore, the concept of asthma control is increasingly recognized as an important aspect in evaluating

current impairment, including symptoms daily/nightly, reliever use, activity levels and quality of life and future risks, including the risk of severe, permanent lung dysfunction and side effects of treatment After treatment is established, asthma control is achieved by reducing both impairments and risk identified as the goal of asthma treatment according to the National Asthma Prevention Council Report (NAEPP) According to the National Asthma Education and Prevention Program (NAEPP), the 2015 Global Initiative for Asthma (GINA) guidelines and Expert Panel Report 3 (EPR-3), after treatment is established, the goal of asthma treatment is to achieve asthma control by reducing both risk and impairment (GINA, 2018) To determine whether there is need to adjust treatments or not, these objectives require periodic review and continuous monitoring (National Asthma Education and Prevention Program, 2007)

Treatment can often be reduced successfully, without losing control of asthma when good asthma control has been achieved and sustained that

condition for 3 consecutive months and lung function has reached a plateau The

aims of stepping down are:

• To find the most effective treatment with the minimum dose for the patient,

that is to maintain good control of exacerbations and symptoms, and to reduce

treatment costs and the ability to cause side effects

• To encourage patients to continue their asthma control treatment regularly

Patients often with intermittent treatment experience often due to concerns about

risk or cost of daily treatment Knowing this can be useful to inform them that

can achieve a lower dose if treatment with the controller is made every day

(GINA, 2018)

Table 4 GINA assessment of asthma control in adults, adolescents and

children from age 6–11 year-old (GINA, 2018)

In the past 4 weeks, has the patient

None of these

Partly controlled

1 – 2 of these

Uncontrolled

3 – 4 of these

*Excludes reliever taken before exercise

2.2 Quality of life

2.3.1 Definition of quality of life

"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Callahan, 1973)

importance of the patient's emotions and their level of satisfaction with their treatment (Higginson & Carr, 2001) When performing a quality of life measurement in a clinical setting, this helps to ensure that the focus is on the patient and not just focus on the disease or its treatment alone Advances in medicine today have raised the importance of health care not only to prolong life but also to improve quality of life

While health is an important area of overall quality of life, there are other areas - for example, jobs, housing, schools and neighborhoods The aspects of spirituality, culture and values are also important aspects of the overall quality of life that increase the complexity of the measurement (Centers for Disease Control and Prevention, 2000)

WHO defines “Quality of Life as individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs and their

view that quality of life refers to a subjective assessment placed in a cultural, social and environmental context (Programme on mental health, 1997)

2.3.2 Measuring quality of life in children

The key issue in QoL's concept is the uniqueness of each individual In an effort to accurately grasp the quality of life of each individual, some newer questionnaires have been developed, such as the Schedule for Evaluation of

Individual QoL (SEIQoL) and the WHOQOL Assessment Instrument 100 (WHOQOL-100) (Hamming & De Vries, 2007)

There have been a series of new life quality measurement tools, including general (can be used with groups of patients with different diagnosis and/or

“normal” children and therefore it creates conditions for comparison between groups) and specific diseases (supposedly more sensitive to the effects of a single condition by including specific questions for conditions in the question) Combining the value of both methods, some authors have developed common measures with specific modules on the disease (Eiser & Jenney, 2007) For example, Varni and colleagues used this method for the PedsQL Currently there are modules specifically to evaluate the quality of life of children with asthma, arthritis and diabetes and the further development for other conditions is underway (Varni, Seid & Rode, 1999) The DISABKIDS group also adopted a similar model, but this includes generic (Ravens-Sieberer, Gosch, Abel et al., 2001), general chronic diseases (Peterson, Schmidt, Power et al., 2005) and specific modules of the disease (Baars, Atherton, Koopman et al., 2005) The advantage of this module method is concise and comprehensive Independent measures on each specific disease may provide a more detailed assessment of QoL but lack provision to compare with other groups Questions about the sensitivity of the age has hindered the development of QoL measures in children

On one hand, depending on the age and level of development, the meaning of QoL also changes, indicating that central concerns for children of different ages must be addressed in sensitive measures On the other hand, narrow age-targeting measures are not enough in situations, such as clinical trials, in which the goal is to assess the change of QoL over time Although most measures target school‐aged children (Eiser & Morse, 2001) and adolescents and young people (Bhatia, Jenney, Bogue et al., 2002)

Chronic illness and treatment also have a greater impact on the family of the patient To recognize this, the official measures for the caregiver's QoL assessment have been described and again there is potential value in clinical trials In the case of treatments related to the level of morbidity equivalent, impact on the family and especially the burden on the primary caregiver may be considered in a realistic way However, the quality of life of caregivers themselves can bias their reports on the child's QoL (Eiser & Jenney, 2007) General and specific tools have been developed to assess the perceptions of patients and their carers about their health status or attenuation due to disease progression This is true of the PedsQL ™ 4.0 scale, a tool that has a reasonable and reliable signature (Varni et al, 2001)

The Pediatric Quality of Life Inventory™ (PedsQL™ 4.0) (1998) was originally developed in the English language by Varni The scale has four versions according to the child's age as follows: 2–4 years (toddlers), 5–7 years (young children), 8–12 years (children) and 13–18 years (teenagers) Furthermore, there is an additional format to be administered to parents or caregivers of children aged 5–18 years known as the parent-proxy report Its psychometric properties have been verified in different languages and contexts, with acceptable standards of reliability and validity (Roizen et al., 2008)

Table 5 Characteristics of the questionnaire about quality of life for children and adolescents with asthma

active quality of life, teenage quality of life, distress, severity, reactivity

CAQ-A: 14 items CAQ-B: 23 items CAQ-C: 41 items

function

Netherlands

'emotions' (negative emotions)

Self Parent ProxySelf Report

Proxy 5Proxy 18

- 2-18

4 domains:

(physical functioning, social functioning, emotional functioning, school functioning)

Self Parent ProxySelf Report

Proxy 5Proxy 18

- 2-18

4 domains:

(asthma symptoms, treatment problems, worry and communication)

North America

2.3 Asthma and quality of life

Quality of life can be affected by the four components of the theory of the entire human condition - psychological, physical, cultural and spiritual.These four-dimensional components are interconnected in one's life and as part of a human condition (Noro & Aro, 1996) The concept of quality of life related to health (HRQOL) and the determinants of its development from the 1980s to cover the aspects of quality of life can be clearly expressed on health, physical or mental aspects (Centers for Disease Control and Prevention, 2000) Health-related quality of life includes physical function, disease symptoms, employment and other role activities, the vitality, the psychological and self-awareness factors, the ability to perceive, the health awareness and the overall satisfaction

of life (Noro & Aro, 1996)

Respiratory symptoms are an important factor in decreasing HRQoL in patients with known asthma The chronic disease burden and socioeconomic status are factors that affect the quality of life related to health and chronic illness which is the main cause of mortality, morbidity and the use of medical resources (Centers for Disease Control and Prevention, 2001) One of the important variables that have been considered for management in airway diseases is health-related quality of life Asthma can reduce HRQoL due to the severe consequences of physical and psychological complications

Physical functioning

Children with asthma tend to have a more sedentary lifestyle than their peers When they exercise they suffer more because of difficulty breathing, called bronchospasm caused by exercise and limiting secondary activities after medical advice or family influence (Neder, Nery, Silva, Cabral & Fernandes, 1999) The most common misconception about asthma and children with asthma is the amount and type of exercise they can safely participate in Most children with

asthma do not exercise as much as children who do not have asthma because of misinformation from their parents (Evans et al., 1987)

Patients with chronic diseases have been shown to be more difficult than normal people in terms of movement, energy, pain, and emotional reactions Reduced physical energy and mobility, pain and emotional reactions become more severe when health status and quality of life are low (Noro & Aro, 1996) Teenagers with asthma experience limitations in daily activities such as going

to school and participating in recreational or sports activities (Newacheck & Halfon, 2000)

Social functioning

Apart from the common occurrence of depression and loneliness in asthma children, a child with asthma has lower self-esteem abilities because of avoiding sports activities This low self-esteem causes negative effects in peer relationships Once again due to missed sports-related activities, children with asthma miss the opportunity to build relationships with friends in sports activities (Clack, 2010) Compared with controlled asthma, a large percentage of children with uncontrolled asthma suggested avoiding all nine social activities were evaluated A large percentage of children with uncontrolled asthma showed that avoiding all nine social activities was evaluated when compared to controlled asthma Children with uncontrolled asthma avoided many social activities, including outdoor activities, sports and exercise, playing with friends, stroking and owning a pet, sleepovers, visiting friends and family In children with controlled asthma, it is rare to avoid participating in social activities Avoiding social isolation normal activities and depression can contribute to reducing the quality of life for children (Dean, Calimlim, Sacco, Aguilar, Maykut & Tinkelman, 2010)

Emotional functioning

Many studies show that people with asthma may be susceptible to depression, perhaps due to isolation may be the result comes from the uncontrolled symptoms (Ellis, 2009)

Asthma occurs in adolescence and young adulthood involves increasing severe depression, panic attacks and any anxiety disorders (Goodwin, Fergusson

& Horwood, 2004) Bender recently reported that his survey showed that high school students with asthma reported higher rates of depression such as feeling sad or hopeless (45.3 vs 29.3%) compared to students without asthma He also found that they considered suicide at a higher rate than those without asthma (31% versus 16.2%) and the rate of attempting suicide was twice as high as the national population rate (Bender, 2007)

Morrison et al studied 46 patients between the ages of 6 and 17 years to visit the Children’s Medical Center Asthma Clinic, where treatment is mainly for children from families with low incomes Thirty percent of patients with Children’s Depression Rating Scale - Revised (CDS-R) scores matching capabilities depressive disorder likely, very likely or almost certain (Morrison, Goli, Van Wagoner, Brown & Khan, 2002)

Research confirms that adolescents with asthma are more likely to have suicidal thoughts or even made an attempt to commit suicide (Ellis, 2009)

Asthma patients may present with fatigue, slow psychological, discomfort and mood and cognitive disorders (Juniper et al., 1992) Children with uncontrolled asthma are more likely to be awakened at night because of their symptoms and have to use rescue inhalers at night, have trouble getting up in the morning and get out of bed and are excessive fatigue all day (Dean et al., 2010)

School functioning

Among chronic diseases, asthma is the leading cause of absence with more than 14 million missed school days and educational opportunities each year (Houston, 2003)

Children with asthma often miss many school days due to doctor's appointments, emergency room visits, asthma symptoms and environmental factors A study showed that about 40% of students absent from school, at any given time, had been diagnosed with asthma Moreover, when these children went to school, 40% were awakened after falling asleep in class (Taras & Potts-Datema, 2005)

The absence prolonged or repeated absence from school can contribute to poor academic results Asthma can affect the ability to concentrate, memory and interrupt sleep Additionally, repeated trips from the classroom to the school's health room to have access to asthma medications may disrupt learning (Houston, 2003)

2.4 Summary

This chapter provides an overview of asthma (definition, etiology of and risk factors for asthma, clinical diagnosis), quality of life (definition, development of tools for measuring measure quality of life and ultimately the relationship of asthma and quality of life) PUBMED, NCBI, print indexes such as books, journals, publications of professional organizations, government documents were used in this study