Prevalence, Risk Factors, and Symptoms of Childhood Asthma in Jazan Region, Saudi Arabia: A Cross-Sectional Study

Accident – death – Obituary News : Introduction

It’s alarming to note that the prevalence, morbidity, and mortality of childhood asthma have increased significantly over the past four decades. Despite being the most common chronic disease among children, underdiagnosis and undertreatment remain major concerns. The prevalence of asthma symptoms among children varies significantly across the globe, with up to a 13-fold difference between countries.1 Both children and adults worldwide have a variable prevalence of asthma, ranging from 1–20%. This variation in prevalence can be attributed to different epidemiological definitions of asthma, the use of various measurement methods, and environmental differences between countries.2

Although rural areas tend to have a lower incidence of asthma, this is because factors associated with traditional rural lifestyles protect against allergic diseases. In contrast, numerous exposures related to urbanization have been identified as potential risk factors for asthma.3 Unfortunately, most asthma-related deaths occur in low- and middle-income countries.

The prevalence of asthma is high in both children and adults in Saudi Arabia (SA). According to the Saudi Initiative for Asthma (SINA 2016), the prevalence of asthma in children ranges from 8–25%. This increase in prevalence is due to several factors such as improved living standards, rapid modernization, and increased rates of urbanization.4 Studies have shown that the highest prevalence of asthma in Saudi children is in Hofuf (33.7%), Najran (27.5%), and Madinah (23.6%), while the lowest prevalence is in Abha (9%), Qassim (3.2%), and Dammam (3.6%), a center for the Saudi oil industry located on the Arabic Gulf.5 The studies show that multiple factors contribute to the high rate of asthma prevalence. These include changes in lifestyle and urbanization, as well as socioeconomic status and dietary habits. Additionally, exposure to indoor animals, allergens, dust, tobacco smoke, sandstorms, and industrial and vehicular pollutants can also play a role. While the location of residences has been identified as a factor, more research is needed to determine the impact of climate on asthma prevalence.6

Determining whether recurrent wheezing during the first years of life represents a clinical manifestation of future asthma is a challenge that can facilitate decision-making in clinical practice and the issue of guidance relating to specific preventive measures.7 The measurement of asthma-related symptoms in children and adolescents is mainly based on the International Study on Asthma and Allergy in Children (ISAAC), which aims to standardize the methodology and promote global collaboration for epidemiological research on asthma and allergic disease. The ISAAC protocol involves three phases, with the first phase utilizing core questionnaires to evaluate the prevalence and severity of asthma and allergic disease in specific populations.8

The prevalence of asthma and asthma-related symptoms in Saudi Arabia has been increasing in recent years and has been attributed to various environmental factors. These include the rapid industrialization of the country, which has led to the establishment of numerous factories in the industrial city of Baysh, located about 60 km north of Jazan city. Other factors include the proximity of farms to housing, traffic-related air pollution, frequently encountered sandstorms, and family awareness of asthma symptoms. It is recommended that periodic assessments of the prevalence of asthma and its associated risk factors be conducted to develop effective prevention and control strategies.6

The current study aims to investigate the prevalence of asthma and asthma-related symptoms and related risk factors among school-age children in the Jazan Region, Saudi Arabia.

Materials and Methods

Study Area
This study was conducted in the Jazan Region, one of the thirteen regions of SA. Located on the tropical Red Sea coast in southwestern Saudi Arabia, Jazan covers an area of 11,671 km2 and includes approximately 5000 villages and cities, with a total population of 1.5 million. Geographically, the region is divided into three areas – coastal, plain, and mountain – which are intersected by perennial rivers. These geographical factors may have an impact on the prevalence of bronchial asthma (BA) in the region.

Study Design
To fulfill the proposed objectives, the study utilized a cross-sectional design and administered the ISAAC questionnaire to school-age children in Jazan Region, SA. The questionnaires were completed during a three-month period starting from March 2023.

Sample Size
The primary objective of the research was to estimate the prevalence of BA among school children in the Jazan Region of SA. To this end, the researchers employed multistage cluster random sampling. The sample size for estimating the prevalence of BA among school children in Jazan was determined using Cochran’s formula, targeting a 95% confidence level and 5% precision based on a 15.1% anticipated prevalence rate. The final count of 1690 children accounts for anticipated non-responses and is stratified by the geographical regions, ensuring representativeness across different geographic areas and gender. Detailed calculations and considerations for the design effect and sample adjustment are available in the Appendix 1. The sample was evenly distributed between areas, education level (elementary, intermediate, and secondary schools), and both sexes, according to the sex ratio of the participating schools. Schools and students in the different clusters were chosen using a simple randomization technique, and the sample was distributed among the three geographical areas as 355, 1050, and 285 participants for coastal, plain, and mountain regions, respectively.

Data Collection
The researchers used the ISAAC – Phase I Questionnaire, which is a validated Arabic version, to evaluate the prevalence of asthma and asthma symptoms in children and adolescents. The questionnaire was used in a worldwide multicenter study that assessed the prevalence and severity of asthma in children from different populations.9 The study randomly selected children between the ages of 5 and 18 years. The questionnaire is divided into four sections, each with questions that analyze different aspects of the study’s goals. The first section collected data on the child’s age, gender, place of residence, level of education, and body mass index (BMI). The second section recorded asthma-related symptoms as defined by the ISAAC manual. Life-long wheeze was defined as wheezing or whistling in the chest at any time in the past including wheezing due to cold, chest infection, or bronchitis. Wheezing in the chest in the last 12 months refers to the presence of whistling or wheezing sounds in the chest during the past 12 months. Moreover, exercise-induced wheezing was defined as the occurrence of wheezing or shortness of breath during or after exercise. Past medical history of BA is considered whether the individual has ever been diagnosed with asthma by a doctor or other health professional. The third section contained six questions to determine the relationship between the prevalence of asthma and various risk factors. Finally, the fourth section contained seven questions to assess the risk of asthma among children and adolescents. The questionnaires were sent electronically by the academic advisors in the selected schools to the parents of the selected students who were accepted to participate in the study. The parents filled out the questionnaire based on their selected child for the study. The medical history and risk factors were reported in the questionnaire by the parents. The academic advisors played a great role in distributing the survey and following them regularly till reached the target response from the study population, which was 85% of the sample size.

Data Analysis
The Statistical Package for Social Sciences software version 23.0 (SPSS, Chicago, IL, USA) was used to enter and analyze the data. Descriptive statistics were calculated for the study variables, including frequency and percentage for qualitative variables and mean and standard deviation for quantitative variables. Appropriate tests of significance such as chi-square and t-tests were performed, and a p-value less than 0.05 was considered statistically significant.

Pilot Study
A pilot study was conducted before the main study to evaluate participants’ understanding of the survey used for data collection. The pilot study accounted for 10% of the required sample size. Specific improvements were made and some questions were reordered based on the pilot study results. It’s worth noting that the results of the pilot study were not included in the final data analysis.

Statement of Ethics
The Jazan University’s Scientific Research Ethics Committee (R.E.C) approved the study with the reference number REC-44/03/334. The study was conducted in adherence to SA’s ethical principles and the Declaration of Helsinki. Before completing the anonymous questionnaire, informed consent was obtained from each participant. The informed consent is taken in two steps, the first one is by academic advisors in the schools by sending an official email and message through WhatsApp to the parents of selected students….