MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH THE NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY *** ĐANG HUONG GIANG EPIDEMIOLOGICAL CHARACTERISTICS OF ASTHMA IN 13-14-YEAR-OLD CHILDREN AND THE EFFECTS OF HEALTH EDUCATION INTERVENTION IN TWO DISTRICTS OF HANOI Science: Epidemiology Code: 62 72 01 17 SUMMARY OF THE DOCTORAL DISSERTATION HA NOI - 2014 The project was completed at the National Institute of Hygiene and Epidemiology The scientific advisors: 1. Prof. Nguyen Tien Dung 2. Prof. Đang Đuc Anh Reviewer 1: Reviewer 2: Reviewer 3: The dissertation had defended at the meeting hall of the National Institute of Hygiene and Epidemiology. In ………………… The dissertation is available at: 1. The National Library 2. The National Institute of Hygiene and Epidemiology LIST OF THE PUBLICATIONS BY THE AUTHORS RELATED TO THE DISSERTATION 1. Đang Huong Giang, Nguyen Tien Dung, Đang Đuc Anh (2011), "Quality of life of children with asthma in Bach Mai and Saint Paul hospitals, Hanoi in 2010-2011", Journal of preventive Medicine, No 7(125), Set XXI, pp. 22-27. 2. Đang Huong Giang, Nguyen Tien Dung, Đang Đuc Anh (2014), "The status of asthma knowledge among 13-14-year-old children with asthma at Thanh Xuan and Long Bien districts in Hanoi, 2012", Journal of preventive Medicine, No 1(149), Set XXIV, pp. 58-63. 3. Đang Huong Giang, Nguyen Tien Dung, Đang Đuc Anh (2014), "Effectiveness of school-based education program for 13-14-year-old schoolchildren with asthma at Thanh Xuan and Long Bien districts in Hanoi, 2012-2013", Journal of preventive Medicine, No 1(149), Set XXIV, pp. 64-70. 1. Introduction Asthma is a common chronic respiratory disease, affecting people of all ages particularly of childhood. The predominant symptoms such as wheezing, cough, breathlessness and chest tightness are intermittent, more severe at night and early morning, affecting on daily life and sometimes fatal. The prevalence and morbidity rates due to asthma are rising in many areas in the world. Although there are no cure for asthma but we can control disease and maintain control it for a long period of time by conducting health education programs. In Viet Nam, the statistics of the national survey demonstrated that the prevalence associated with asthma in adults was 4.1%, 64.9% among patients visited emergency departments, more than 80% of asthmatic children under fifteen has never been treated with preventor while some studies revealed that knowledge of parents on asthma was impaired. Studying epidemiological characteristics of asthma and carrying out the interventions in communities to manage asthma and to improve quality of life of patients is practical and essential research. Thus, we conducted the study "Epidemiological characteristics of asthma in 13-14-year-old children and the effects of educational intervention at two districts in Ha Noi". The study objectives were 1. To describe some epidemiological characteristics of asthma in 13- 14-year-old children at Thanh Xuan and Long Bien districts in Ha Noi in 2012. 2. To assess the effeciveness of educational intervention in two researched districts 2. New scientific contributions - The study defined the prevalences of diagnosed asthma in 13-14-year-old children at two districts in Ha Noi and discribed some common trigger factors. - This study is the first for establishing the modern asthma management for schoolchildren and assessing the effects of health education intervention with outcomes: asthma status, school absenteeism, knowledge about asthma and quality of life of the children. 3. Practical value of the study -The results of study about the prevalences of asthma in children helped physicians realize the popularity of asthma in communities. Furthermore, the information about the asthmatic trigger factors permitted doctors choose the suitable intervention to control those factors. - The study affirmed the effects of health education intervention on controlling asthma symptoms, school absenteeinsm due to asthma and improving the asthmatic knowledge and demonstrated that this method could be applied in many schools. 4. The structure of the dissertation: The dissertation consists of 126 pages including, introduction 2 pages, literature review 32 pages, objectives and methods 19 pages, results 27 pages; discussion 29 pages, conclusions 2 pages and recommendation 1 page. There are 23 tables, 13 charts and 3 pictures, 118 references including 25 in Vietnamese and 93 in English. Chapter 1. Literature review 1.1 Epidemiology of asthma: There are three methods of identifying cases of asthma that being used commonly in epidemiological researchs in the world: asking directly patients for self-reporting of the asthma dianognosis and/or the most common sypmtoms of asthma such as wheezing and assessment of bronchial reactivity of the airway to exercise. 1.1.1 Epidemiology of asthma in the world 1.1.1.1 Prevalence - The prevalence of asthma in childhood: the prevalences of 13-14-year- old children being diagnosed asthma varied between 1.6% to 28.2% and they were lower than having wheezing. In 6-7-year-old children the prevalences of being diagnosed asthma ranged from 1.4% to 27.2%. The difference of the prevalences of wheezing and asthma between countries is larger than within country. - The prevalence of asthma in adulthood: in 64 coutries in adults aged 18-99- years the prevalence of doctor-diagnosed asthma was lowest in Viet Nam (1.8%) and highest in Australia (32.2%). According to the World Health Organization, the variation in the prevalence of asthma between different countries is 21-fold. 1.1.1.2 Factors influencing the prevalence of asthma. - Environmental factors: The indoor factors (fungi, domestic dust, insects, cockroaches, tobacco smoke) and outdoor factors (air pollution, dust and smoke) influence the prevalences of asthma. Some jobs associated with higher risk for occupational asthma are farming work, painting, cleaning solution and plastic manufacturing. - Host factors: the factors such as sex, weight, atopy have been considered as asthma risk factors. Male sex is a risk factor for asthma in childhood, and people who have BMI≥25 seem to have asthma with 1.51 fold higher than those with a average-weighted. The risk of asthma among children whose parents had atopic diseases are 3.29 times higher than other children. 1.1.1.3 Times trends of asthma: In United State, Australia, some European developed countries (Finland, Sweeden, Newziland, the UK) and Asian countries such as Hongkong, Singapore, Thailand the prevalences of asthma and wheezing are rising. 1.1.1.4 Incidence: Currently, there are no methods to measure the incidence of asthma accurately. In the UK, the incident of asthma was high (136.6/10.000/year), The American statistics showed that incidence of asthma was 3.8/1000/year, during one year new onset rates were highest in Auturm and Winter. 1.1.1.5 Asthma mortality: in 2000 mortality among American patients hospitalized for asthma were 0.5%. In some countries such as Switzerland, Portugal and Japan the reduction in asthma mortality have appeared by increasing use of inhaled corticoides 1.1.2 Epidemiology of asthma in Viet Nam In our country statistics data on prevalence and mortality of asthma is lack. In 2003, the prevalence of asthma among children in Ha Noi was 12.56% in urban areas and 7.52% in rural areas. In 2007, the prevalence of diagnosed asthma among 13-14-year-old children in Can Tho was 1.4%. The prevalence of asthma in Vietnamese adults was 4.1%; the rates of asthma in male was higher in female. However, Viet Nam has ackowledged that the rates of asthma mortality were increasing. 1.2 Asthma and wheezing symptom 1.2.1 Asthma 1.2.1.1 Definition: Asthma is a chronic inflammatory disorder of the airway in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment. 1.2.1.2 Mechanisms of asthma: there are three main disease progressions of asthma: airway chronic inflammation, airway narrowing and airway hyperresponsiveness 1.2.1.3 Causal and risk factors: including host factors and environmental factors - Host factors consist of genetic, obesity, sex and age. - Environmental factors consist of allergens (domestic allergens, furred animals, pollen, fungi), respiratory inflammation, air pollution, tobacco smoke, food, drugs. - Another factors: endocrin, climate, exercise, stress. 1.2.1.6 Asthma treatments: In GINA asthma treatment steps the education is the first. 1.3 The role of education in asthma preventional strategy: The experts evaluated that asthma education is a cheap and effective intervention in asthma management and prevention. 1.3.1 The activities of education: multiple educational methods have been used such as exchange information, discussion, asthma consultant, asthma clubs. 1.3.2 Effectiveness of education interventions: There have been many studies about effectiveness of education on asthma. - The effectiveness on asthma symptoms: education intervention for parents reduced visits to emergency room, admissions to hospital and attacks of asthma compared with the control group. - The effectiveness on school absenteeism: education for primary schoolchildren eliminated days of school missed due to asthma. - The effectiveness on keeping well treatment: education helped patients to realize the significance and essential of follow-up treatment, therefore this could reduce the number of children who were unschedules doctors visits. - The effectiveness on children’s knowledge of asthma: education in the schools improved schoolchildren’s knowledge, using inhaler skill, helped children to choose activity and increased asthmatic knowledge of caregivers. - The effectiveness on quality of life: asthma impairs the quality of life of the patients. According to researchers, the effects of education on patients' quality of life were not clear and this should be investigated in more studies. Chapter 2. RESEARCH METHODOLOGY Sample and setting - The sample for objective 1: The 13-14-year-old schoolchildren have been studying 7-8th grade from the secondary schools at two districts Thanh Xuan and Long Bien. - The sample for objective 2: the asthmatic children of two districts Thanh Xuan and Long Bien who participated in the characteristic epidemiological study. - Inclusion criteria: The children who enrolled in the intervention study were asthmatic children based on the criteria of the International study of asthma and allergy in childhood (ISAAC), the physician-diagnosed asthma. - Exclusion criteria + The children without agreed to participate in the study. + The children transfered to another school which is out side of study's setting - The setting: the study was conducted at two districts Thanh Xuân and Long Bien in Ha Noi. Two districts were chosen purposively because of differences in geography and level of urbanization 2.2 Methodology 2.2.1 Study designs - Cross-sectional survey. - Longitudinal intervention community study with control group. 2.2.2 Sample sizes and sampling methods 2.2.2.1 Sample size and sampling method for objective 1 - Sample size: using the formula for estimating population proportion   2 2 2/1 )1(   p pp zn    Where: p - prevalence of diagnosed-asthma among 13-14-year-old children estimated from the previous study=2.6%; α - significance level was chosen = 0.05%, z- corresponding to 95% confidence level = 1.96, ε- disired precision was chosen = 0.22. A required minimum sample size was 2973.4 children. In each district at least 3000 children would have enrolled. - Sampling method: purposive and simple random sampling. The sampling based on instruction of ISAAC, in each geographical area the sampling unit will be a school. Step 1: districts Thanh Xuan and Long Bien were chosen purposively Step 2: choosing the schools randomly by making a table sample of each districts, the schools were selected in study by randomly drawing school by school untill there were at least 3000 13-14-year-old children. Step 3: whole 13-14-year-old children in selected schools were enrolled in study. Actually, in each district 8 schools were selected. 2.2.2.1 Sample sizes and sampling methods for objective 2 - Sample sizes: there were 4 outcomes in the study: asthma status including day and night symptoms, asthma control test score; school absences; knowledge of asthma and quality of life. Untill now there has been no study knowledge of asthma among schoolchildren so this study used three outcomes including school absences, asthma control test score and quality of life score to calculate sample size for intervention objective. + Outcome is school absences, using the formula estimating the difference between two proportions. 2 21 2211 2 , )( )1()1(( pp ppppz n     Where: n is the minimum sample size in each of intervention and control groups; p 1 - proportion of children being abcent from school from the previous study =38.5%; p 2 - proportion of children being absent from school was expected the result to be 18.5%; α- type I error was chosen at 0.05% corresponding to significant level 95%; β - type II error was chosen at 0.2% corresponding to power 80%, we have z α,β = 7.9. Hence, a required minimum sample size was 77 children. Providing for 10% of drop-out study participants sample size was 85 children in each group. [...]... change, cold and exercise 3.3 The effectiveness of educational intervention Selected Thanh Xuan district in the intervention group and Long Bien in the control group In September 2013 there were 7 children in two districts transfering their schools to another ones 3.3.1 Characteristics of children with asthma at baseline - Characteristics of asthma status Table 3.13 Percentage of characteristics of asthma. .. objective 2 - Intervention contents + Selected intervention district was Thanh Xuan The intervention was performed in schools by healthcares and teachers of the schools who have exprienced in the training course about asthma The control group was Long Bien, the asthmatic children were received the traditional health care and would received the intervention of the study one year later The materials of intervention. .. characteristics of asthma in 13-14-year-old children and the effects of health education intervention in two districts of Hanoi , we came to the conclusions as follow: 5.1 Epidemiological characteristics of asthma - Prevalence of being diagnosed asthma in 13-14-year-old children at Thanh Xuan district was 4.3%, similar to prevalence at Long Bien 3.5% (p>0.05) Prevalence of being diagnosed asthma in males... asthma children between two districts The baseline asthma knowledge of the children was low and no difference between two districts Quality of life of the children was impaired and two districts had similar impairment of quality of life 4.3.2 Effectiveness on asthma status - We observed that the percentage of children having day-time symptoms in the intervention district decreased from 25.6% at baseline... the requisite of maitaining education 4.3.3 Effectiveness on quality of life: we found that the improvement in quality of life' score in term of symptoms in the intervention district was significant compared with the control district (p . Thailand the prevalences of asthma and wheezing are rising. 1.1.1.4 Incidence: Currently, there are no methods to measure the incidence of asthma accurately. In the UK, the incident of asthma. practical and essential research. Thus, we conducted the study " ;Epidemiological characteristics of asthma in 13-14-year-old children and the effects of educational intervention at two districts. CHARACTERISTICS OF ASTHMA IN 13-14-YEAR-OLD CHILDREN AND THE EFFECTS OF HEALTH EDUCATION INTERVENTION IN TWO DISTRICTS OF HANOI Science: Epidemiology Code: 62 72 01 17 SUMMARY OF THE DOCTORAL DISSERTATION