Editorial



Original Contribution and Clinical Investigation

Approaches for Improving the Nutrition and survival of orphans and vulnerable Children in Rural areas of Abia State, Nigeria
Enwereji, E. E.

Effect of ß- Thalassemia on Some Biochemical Parameters
Nazdar Ezzaddin Rasheed, Salar Adnan Ahmed



Review Articles

Prevalence and factors affecting childhood asthma in the Middle East: A literature review
Mohammad Al-Motlaq

Iranian Experts' Perspectives on Performance Evaluation of Nurse Faculties: A Qualitative Study
Mehrnoosh Pazargadi, Mahnaz Khatiban, Tahereh Ashktorab

Attitude of University Students Toward Family of Temporary Marriage in the City of Tehran
Professor Ali Reza Kaldi, Masoumeh Hardar



Community Nursing

Comparing Reasons for Nurse Migration against Intent to Leave Lebanon: A Two-Hospital Case Study
Fadi El-Jardali, Hani Dimassi, Diana Jamal

Nursing in Saudi Arabia: A Personal Perspective of A Female Nursing Student
Ms. Alaa Ali M. Al Shehri

  
 

January 2009 - Volume 3, Issue 1

Prevalence and factors affecting childhood asthma in the Middle East: A literature review


Mohammad Al-Motlaq
PhD candidate
Faculty of Medicine, Nursing, and Health Sciences
Monash University
VIC, Australia
Tel: +61 351226437
email: Mohammad.al-motlaq@med.monash.edu.au

ABSTRACT

Introduction: Asthma is a common illness during childhood. It affects more than 300 million worldwide, and its prevalence differs from one region to another.

Aims: Assess the prevalence of childhood asthma in the Middle East based on studies from countries in the region with focus on the causes, and factors affecting the illness among children and adolescents.

Methods: The research involved a review of the literature on prevalence and factors affecting occurrence of childhood asthma in the region. PubMed, Cinahl, Medline, and other relevant web pages were searched.

Results: The analysis of relevant papers on the Middle East region has revealed almost similar percentages of asthma as in the western world, apart from some countries. The overall prevalence ranged from 1.9% in rural areas, to more than 22% in urban industrialized and condensed cities. Factors that affected prevalence and occurrence of the illness varied, with environmental factors being the common indicator.

Conclusion: Further studies are recommended in the area of management of childhood asthma, and more focus should be given to prevention strategies.

Key words: Asthma, Prevalence, Children, Childhood asthma, Middle East.

 

INTRODUCTION

Asthma is a common chronic respiratory illness in children. The prevalence of the disorder has been increasing in most countries of the world. Consequently, the rates of morbidity and mortality from asthma are rising. Several independent studies were conducted in the Middle East region, which include Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates (UAE), and Yemen, to investigate different features of asthma, of importance and asthma prevalence. The region was chosen as one geographical area that incorporates almost similar cultural and environmental factors.

Asthma is environmental and inherited[1], but genetic factors are unlikely to explain the increase in a short period of time. Environmental factors are more anticipated reasons for the increase. Nevertheless, proving this requires more rigorous designs that follow cohorts over a period of time in various regions[2]. However, international research suggests that environmental factors such as air pollution are important triggers for asthma exacerbation and hospitalization[3]. There are scattered data regarding the prevalence of the illness in the Middle East. The latest results from studies by the International Study of Asthma and Allergies in Childhood (ISAAC) showed prevalence of asthma to vary between 6.6% and 29.7%[4]. Understanding asthma and its treatment would help decrease the burden and save resources. The objective of this paper was to review the literature for data on asthma prevalence and factors affecting its occurrence in the Middle East region.

 

METHODS

This study included data on asthma prevalence in children under the age of 18 years and the risk factors associated with its occurrence in the Middle East region. The research design involved a thorough literature review using databases available by Monash University Library and concluded in July, 2008. The databases included PubMed, Cinahl, Medline, and general internet searching engines. Other relevant journals and web pages were included as well. The keywords used were asthma, wheeze, child, prevalence, incidence, and Middle East (including each individual country name in the region). Although title in some articles did not reflex the whole content, relevant studies in the reference lists of each study were reviewed. This review has examined the English literature, other than Arabic, Persian, Hebrew, or Turkish.

 

RESULTS

Prevalence
A reasonable number of articles were involved in the documentation process. Number of studies on asthma factors in children varied from one country to another, with Turkey, Israel, Iran, and Saudi Arabia, being respectively the highest among the other countries in the region. Simply, there are a few studies on asthma, its aggravating factors, and indicators in the Middle East.

Different methods of measurement were used to estimate the prevalence of asthma. For example, the American Thoracic Society- National Heart and Lung Institute (ATS-NHLI) questionnaire[5], the American Thoracic Society[6], and the ISAAC questionnaire[7-18] were used. Consequently, surveyed groups on current asthma or wheezing, previously diagnosed with asthma, or asthma ever, showed different percentages. Differences between current and cumulative prevalence of asthma were noted as well.

It was noticed that some authors published their results far away from the date of study conduction, which reached 7 years in some cases (see Table 1). In most articles, the average period between data collection and publication was around two to three years. When date of conduction was not provided, publication years were considered (see Table 1).

The prevalence of asthma in the Middle East region in children under the age of 18 years ranged between 1.9% in Sanliurfa, Turkey[7] and 23% in Jeddah and Riyadh, Saudi Arabia[19].

However, the most recent publications showed the highest prevalence to be in Baghdad, Oman, Qatar, and Kuwait 22.3%, 20.7% 19.8%, and 15.6% respectively (see Table 1). Nonetheless, the prevalence of asthma of all age groups provided by GINA[20] were different than those provided by each individual study (see Table 1).

Please click here to view Table 1

Asthma prevalence is increasing among children, particularly in urban areas[4]. It has been reported in the majority of the reviewed articles that prevalence of asthma was higher in the urban central, industrial areas, rather than desert and rural areas[7,12,21-28], and living in refugee camps rather than other urban or rural areas[12,24]. It was believed that geographical factors played an important role in this variation[25,29]. However, some studies found urbanization not a significant factor[6].

Factors affecting asthma prevalence
Many factors played an important role in causing and aggravating asthma in children in the region. Of importance, family history of asthma[7,14,17,18,26,30-37], characteristics of residence [6,7,31], higher economic status and increased standards of living[7,12,19,27] [7,12,19,27], low parental education[31,37], ethnic background[9,22] male gender[6,12,14,16,23,32,35,38-40], older age[38,40], premature and low birth weight[31], environmental factors (e.g. air pollution as of industrialization, natural humidity, active and passive smoking, moulds at home, and cold exposure)[6,19,35-37,41-47], pets at home[18,19,33,34,37,45,48,49], immigration to countries with higher allergies count[50,51], childhood employment[52] diet (low intake of milk and vegetables) and obesity[6,26,27,40], other allergic disorders[14,36], recurrent or past respiratory infection[6,32,44], and early childhood wheezing[53]. On the contrary, several studies found the prevalence of asthma or asthma symptoms decreased with older children[6,12,13,42,54], foreigners or born in other countries[24,27,48] male sex[15,54] breast fed children[6] and low socioeconomic status[49]. However, a number of studies found no significant relationship with some of these factors[26,39].

Hospital admission among children with asthma in the region

A few studies from the region described the pattern, prevalence, and the risk factors for increased asthma hospitalization among children. Emergency visits and hospitalizations of asthma have risen sharply[55]; one study found 65% of asthmatics had an admission during the 12 months period[56]. Factors that contributed to increased emergency admission were younger age[56,57], low socioeconomic status[56,57], pets at home[56,58], a smoking family member[55,56], more school absenteeism[56], previous hospital visits[56,57], recent respiratory infection[57], personal or familial allergy[57], severity of the illness[55,57,59], non-compliance to therapeutic regimen[55,60,61], and unavailability of medications and devices in health care centres or inappropriate treatment[62,63].

 

DISCUSSION

The prevalence of asthma is expected to increase more in the coming decades, and regions such as the Middle East will play a major role in this increase. Some authors suggested that asthma prevalence has decreased recently[8], while others concluded that asthma prevalence has increased[19]. Generally speaking, air pollution in the region increased recently, attributed to many factors including oil fields and increased number of vehicles on streets. It was believed that the oil industry has brought rapid social and environmental changes and become a key factor in increasing asthma prevalence[26]. Both indoor and outdoor air pollution have been linked to a series of health problems including asthma. This study provided a summary of the literature related to asthma epidemiology in children in the Middle East.

Asthma prevalence in the region ranged from less than 5% to more than 20 %, a range similar to that of European countries. The difference between the countries could be attributed to the surveying methodology or the mixing of asthma diagnosis with other respiratory conditions.

Given the way of measuring the prevalence of asthma, many people still confuse the definition of the illness and provide mistaken data, which may have led to underestimation of asthma prevalence, and consequently under-diagnosis and under-treatment of the disorder[13,25,64].

Difference in methods and lack of consistent diagnostic criteria of asthma made the judgment about the studies difficult. In addition, the ISAAC researchers recommended a sample of at least 3000 children to get good estimates of prevalence in each area[65], a number that was more than the studied subjects in some of the included studies (see Table 1). Results of the review showed changing environmental factors are most likely to explain the increased prevalence of asthma in the region[39,66,67] that includes increase in factories, cars, allergens, and changes in life style; a similar belief in the west as well[4].

The "prevalence of asthma" as a term has not been characterized yet[68]. Therefore, asthma prevalence and incidence have not been exactly shaped. Epidemiological studies all over the world found that a large percentage of children under the age of five years have wheezing which predisposes quite few of them later to develop asthma. In these reviewed studies in the Middle East, wheezing was found to be a risk factor for developing asthma[53,54]. Although, children who reported current or past wheeze were different from those who reported having asthma (i.e. prevalence of self reported asthma or wheeze was far more than physician diagnosed asthma).

A few studies looked at asthma in preschool age children[69,70] in the region; one explanation of this is the inability to confirm the diagnosis of the illness before 5 years of age, or no given criteria are internationally accepted as a standard for confirming asthma diagnosis.

Consequently, the focus was on wheezing in general[69,70]. Similarly, few studies have attempted to investigate the psychological being of children with asthma in the Middle East. In 1996, a study found that self-image, family interactions, and mode of coping were lower in children with asthma than their healthy peers[71]. Although more research is required, researchers recommended more efforts in education and psychological support for asthmatics.

According to reports from GINA, asthma will affect another 100 million in the next two decades, and account for 250 thousand deaths per year[72]. Given the dearth of data on asthma mortality rates in children, saving a few studies[73], mortality rates were not included in this review. The mortality rate is disproportionately higher than asthma prevalence, thus the increased prevalence of asthma cannot be linked to an increase in the prevalence of asthma mortality[59].

Factors influencing asthma were diverse and contributed significantly to increased asthma prevalence. However, contradicting results were found, which raised questions of clarification.

Similarly, factors contributed to emergency visits were considered simple and need better awareness among patients to help them manage their symptoms more efficiently. For children who spend most of their day at school, teachers' preparedness for any emergency is important and assists in giving peace of mind to the families. Studies on childhood asthma in the region are insufficient and more effort is required to fill the gaps in the data. None of the studies explored the state of asthma management within the school boundaries. Lack of employment of current medical knowledge in managing the illness was noted[23] and the majority of the studies recommended more investigation on this subject.

The management of asthma has been widely promoted through different public health approaches supporting different programs and campaigns, which provide awareness to the public on different asthma issues. Asthma education is valuable and is a significant part of asthma management that helps in reducing morbidity from the illness and improving symptoms control [74].


CONCLUSION

High prevalence of asthma in the Middle East region is a true phenomenon that is not much less than that reported in the western countries with high prevalence. Consequently, more attention and more effort should be provided in this regard, and more data should be collected from this region. The prevention and treatment must be improved and more focus should be involved in asthma education through national programs and research. Reasons for variations in sensitivity between rural and urban areas have yet to be studied and it seems necessary to pay more attention to poorly controlled air pollution. This review provided better understanding of trends and prevalence of childhood asthma in the Middle East. The question now is: have the countries met the needs of those children?


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