 |
|
Brief Reports Indian Pediatrics 2003; 40:874-879 |
|||||||||||||||||||||||||||||||
|
Social and Economic Impact of Childhood Asthma |
|||||||||||||||||||||||||||||||
|
Rakesh Lodha, Madhavi Puranik, Namita Kattal and S.K. Kabra From the Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Correspondence to: S.K. Kabra, Additional Professor,
Department of Pediatrics, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi-110 029, India.
Key words: Childhood asthma, Economic impact, Social impact. Epidemiological data suggests an increase in childhood asthma(1). Like many other chronic disorders, childhood asthma is likely to have an impact on the social and emotional aspects of lives of the children and their families. In addition, there may be consider-able financial burden on families. Literature about the socio-economic impact is mainly available from the developed countries(2-5). Little information is available from India(6). We undertook this study to assess the impact of asthma on activities and schooling of children and on some aspects of family life. We have tried to determine the direct costs to the family. This information should help in better planning for providing care to children with asthma and their families. Subjects and Methods The study was carried out in the Pediatric Chest Clinic of a tertiary care hospital in north India over a 6 month period (July 2000-December 2000). Children diagnosed to have bronchial asthma were included in the study. The diagnosis of asthma was made according to available guidelines and the severity recorded(7). Children with other concurrent chronic illnesses were excluded from the study. The demographic details were recorded. We also recorded the parental education, occupation and per capita income. Parental education was recorded as the number of years of formal education. Details of the illness were recorded by taking history from the parents and the child, wherever feasible. The nature of therapy was assessed. The state of control of symptoms was graded as well controlled, partially controlled, and uncontrolled. This was assessed by enquiring about the number and severity of acute exacerbations and PEFR measurements in preceding 6 months. Symptoms were considered as well controlled if there were less than 3 mild exacerbations in preceding 6 months and the PEFR was normal for height. If the child had more than 3 mild exacerbations or any moderate/severe exacerbation in the preceding 6 months, and the frequency of symptoms showed a decrease, his/her symptoms were considered as partially controlled. A child with no improvement or worsening of symptoms was considered uncontrolled. The parents were interviewed about their approach to various activities of the child. Restriction on the activities was judged on a 3-point scale ranging from none to severe restriction. Impact on schooling was assessed by recording the school absenteeism due to asthma in preceding 6 months. Dietary restrictions, if any, and their severity were also assessed on 3 point scale. The monthly expenditure on the therapy of the child was recorded. Also, the number of physician visits and number of emergency department visits were recorded. The impact of child’s illness on parental occupation was judged by the number of leaves parents had to take because of child’s illness. Results 162 children (126 boys, 36 girls) were studied. The median age was 10 years (range 1.8-16 years). The demographic details are shown in Table I. Fathers of children studied were more educated than mothers. Only 16% of mothers were employed. The median monthly per capita income was Rs. 1000. Table I Characteristics of Study Population
The median (95% confidence interval) age at onset of symptoms was 2.75 years (2-3.9 years) and the median (95% confidence interval) duration was 5 (4-6) years. 87% of children had either mild or moderate persistent asthma. Table II shows the details about the disease and treatment. Table II Disease Characteristics
Playing: One hundred and six (65.4%) children had some restriction imposed on their play activities because of asthma. The restrictions were more commonly seen in children with moderate or severe persistent asthma [60/84 (71.4%)] than with mild disease [46/78 (58.9%)] (P = 0.002). Children with uncontrolled symptoms were more likely to suffer restrictions [17/19 (89.5%)] than children with partial [62/77 (80.5%)] or complete control of symptoms [27/66 (40.90%)] (P <0.001). Other physical activities: Eighty-seven (59.8%) children had restrictions on other physical activities. Again, these were more common in children with moderate or severe persistent asthma (P = 0.04) and those with poor control of symptoms (P <0.001). Restrictions on going out of house were reported in seventy nine (48.8%) children. Sixty-four (59.8%) of 107 parents who responded to this question, reported placement of some restrictions on children for attending social functions. Dietary restriction: As many as 133 (82%) families limited the intake of cold/refrigerated products by the children. The frequency of restriction was similar for different severity of disease and different levels of control. Thirty-seven (22.8%) children had restrictions on intake of fatty food item considered ‘heavy’ by their parents. Other food items such as curd, spices, some fruits, etc were restricted in 94 (58%) children. Impact on schooling: Children attending school (n = 145) absented from school for a median (95% confidence interval) of 4(2-5) days in preceding 6 months because of events related to asthma. The median absence increased with disease severity; 0 in mild intermittent to 5.5 days in severe persistent (P <0.001). Similar relationship was observed with the level of control. The median absence in well-controlled group was nil. On the other hand children with uncontrolled symptoms absented from school for a median of 27.5 (11.4- 41.4) days (P < 0.001). Health Care Services sought: These children required a median of 4(3-4) physician visits in the preceding 6 months for increased symptoms. The median number of physician visits made by children with mild intermittent asthma was 1.5, mild persistent asthma 4, moderate persistent asthma 3, and severe persistent asthma 5.5. The number of visits increased with increasing severity, however, the differences were not statistically signifi-cant. As expected, children with poor/some control of symptoms made more visits [median 5 (95% confidence interval: 4-6)] than those whose symptoms were controlled [median 3 (95% confidence interval: 2-3)] (P <0.001). Twenty-four (14.8%) children-required emer-gency department visit hospitalization in the preceding 6 months. No statistically signifi-cant differences were observed according to the severity of illness or level of control. Impact on parents work: Forty three (26.4%) of the fathers reported absence from work for a median (95% CI) of 4 days (3-8 days) because of children’s illness in the preceding 6 months. On the other hand, 50% of 26 working women took leave for 5 (3.3-18) days for the same reason. Other aspects of daily life and family life: This aspect was evaluated in 62 families. The distribution of the diagnostic and control categories were similar to the other 100. None the parents reported any adverse impact of illness on the relationship of the child with siblings/peers. Twelve (19.35%) of parents felt that child’s illness has limited their activities. Ten families (16.1%) had to make special adjustments in their life (referring to life style and activities). Restriction of family’s social life was reported by 15 (24.2%) families while 12 (19.35%) reported adverse effect on the family’s holidays. Expenditure on therapy: The median monthly expenditure on the child’s therapy was Rupees 333.3 (300-400). The expenditure in children with moderate (Rs. 400) or severe (Rs. 540) persistent asthma was more than that in children with mild intermittent asthma (Rs. 100). In five of the seven children with intermittent asthma, the median monthly expenditure on therapy was less than Rs. 100. Discussion As the incidence of childhood asthma is increasing, in addition to providing optimal medical management, it is important to understand its impact on various aspects of life. In this study, we have observed significant impact on childhood activities, schooling and dietary practices. Also, there is considerable financial burden on the family. The extent to which asthma affects children in their activities depends largely on the severity of disease and the level of control. Earlier studies have reported adverse effect on ability of child to participate in sports activities. In a study by Donnelly, et al. 61% of parents of asthmatic children reported that their children’s participation in sports was restricted(8). Coughlin(9) reported sporting activities were affected in 64% of 111 children with asthma, while 22% had been advised to avoid such sports. These figures are similar to 65.4% observed in our study. Some studies however have reported little impact of childhood asthma on their activities(10). Most of the studies were performed when regular maintenance therapy for asthma was not well accepted. A recent study evaluating the relationship between disease and psycho-logical adaptation in asthmatic children reported that mild to moderate asthma imposed modest effects on the daily life but not on the psychological health of these children(11). These restrictions may either be due to the symptoms or the physicians may have advised these. The parents appeared to be imposing restrictions even in the absence of acute symptoms. It is important to decide whether the restrictions imposed are due to poor symptom control or due to parental or personal reaction to the disease state and apprehension of aggravation of symptoms due to certain activities. This differentiation will help in deciding the interventions: modifying therapy or changing the attitudes. In a 1988 National Health Interview Survey in the United States of America, it was determined that almost 30 percent of children with asthma experienced some limitation of physical activity, compared to only 5% of children without asthma(4). Asthma is one of the common reasons for children’s absence from school affecting child’s academic performance. We recorded the absences in the preceding 6 months only, so as to limit problems with recall. The absences were more frequent in children with more severe disease and those with poor control of symptoms. Our findings are similar to that reported in literature. In a study by Speight, et al.(12) it was observed that, since starting school, one third of 7 year old asthmatic children had missed more than 50 days schooling as a result of asthma symptoms. This was reported to be thrice more than usual number of absences(12). While younger children are more likely to be affected, older children may also experience serious impact on their education(13). There is a significant impact on the dietary practices. Irrespective of the severity of disease or level of control, a large proportion of families restricted various food items; particularly cold/refrigerated products such as cold water, ice, ice creams, etc. While this may not affect nutrition of child significantly, they may lead to psychological problems. Management of a child with asthma also involves significant financial costs. Direct costs include the costs of medication, medical bills, and cost of health service utilization such as clinic visits and hospital admissions. Indirect costs include the adverse economic impact of the disease on the family. The cost of asthma has been documented in several different health care systems in developed countries. In the US, estimates of this cost range from 5.5% to 14.5% of total family income(14-15). A comparable figure for the cost of asthma treatment in India is 9% of per capita annual income(6). In our study, the families spent approximately one-third of the monthly per capita income on medications alone; the proportion was much higher for severe persistent asthma. The monthly expenditure in mild intermittent asthma appears more than expected. However, there were only seven children with inter-mittent asthma and in five, the monthly expenditure was less than hundred rupees. There was some loss of work also. In addition, there are indirect costs because of visits made to physician, etc. The expenditure reported here does not include hospital/physician charges. These are also important in children being managed in private health care set-ups. While the management of childhood asthma has improved significantly with time, it still has significant impact on child’s activities, schooling, family life and family’s finances. It is important to assess these aspects so as to improve quality of care. Contributors: RL and SKK were involved in designing the study, analyzing the data and drafting the manuscript. MP and NK collected the data. SKK will act as guarantor for the paper. Funding: None. Competing interests: None stated.
| |||||||||||||||||||||||||||||||
|
References | |||||||||||||||||||||||||||||||
|
|
