Introduction
In 2008, the World Health Organization (WHO) body estimated that more than 300 million people majority of whom were children were diagnosed with asthma while many other people continued suffering unaware of their condition (Who.com, 2010). Asthma is categorized as one of the disease conditions that are both under-treated and under-diagnosed in the larger population which was responsible for 255,000 deaths in year 2005 alone; a mortality rate that is ever increasing each year (Who.com, 2010). Worldwide asthma is the most common cause of chronic diseases among children of all ages with a prevalence rate that is in the region of 30%-60% which tends to persist even during adult life (Who.com, 2010).
The prevalence of asthmatic conditions is complicated by the nature of the disease which is incurable and therefore a major public health challenge that equally affects all countries notwithstanding their developmental status. As such, the WHO strategy on control of asthmatic incidence rate is pegged on prevention and case management; in the same way the healthcare policy on asthma in Saudi Arabia is structured along the same concept. In Saudi Arabia the prevalence rate of asthma among the general population is estimated by one study to be as high as 20% and approximately 17% among school children (Al-Frayh, 1990). The purpose of this paper is to review the current literature on asthmatic disease in Saudi Arabia to accurately determine the epidemiology nature of the condition through community assessment for purposes of compiling a health report on the disease.
Background Information on Asthma in Saudi Arabia
Bronchial asthma is one of the leading forms of chronic illnesses that significantly impacts on children health in Saudi Arabia. Among the most recent research studies conducted on the prevalence of various diseases in Saudi Arabia indicates the prevalence of asthma to be at 38.6% for bronchial asthma which was by far the leading cause of morbidity for all the cases that were reviewed (Omer, 2006). This particular research study was done retrospectively by reviewing patient’s records for 5 years from 2000 in one of the leading health facilities, King Abdulaziz University Hospital in Jeddah (Omer, 2006).
An earlier research study done by Al Frayh and Al Jawaldi that sought to quantify the change in prevalence rate for asthmatic conditions in Saudi Arabia school going children found the incidence rate for asthma to be at 15% (1992). The result of this conclusion was based on two surveys that were done 9 years apart; one in 1986 which found the prevalence to be at 8% by then and the other one completed in 1995 which determined the prevalence to be at 23% among the school going children (Al Frayh & Al Jawaldi, 1992). The results of this survey become the first reliable research findings that quantified the prevalence of asthma and its rate of increase among school going children in Saudi Arabia. In actual sense the rate of asthma in school children tends to vary across regions in Saudi Arabia with Riyadh prevalence rate being pegged at 10% while Jeddah has 12% (Al Frayh & Al Jawaldi, 1992). Nationwide the official rate according to the ministry of health is capped between 4% and 23%, with highest prevalence rates being experienced in urban areas.
The present challenges in accurate determination of asthma prevalence necessary to determine the rate at which the disease has been progressing in the population are complicated by use of various epidemiological methods that are used to measure prevalence. Most notable of which include survey techniques, changing criteria for case definitions and varying population characteristics that make it impossible to replicate the study. But despite the current challenges in determination of accurate asthma prevalence, there is no doubt that the epidemic is on the increasing in Saudi Arabia, similar to many other developed as well as developing countries worldwide. It is on this background that the Saudi National Protocol for Asthma Management was developed primarily to improve the quality of care given to asthma cases (Al-Rabegi, 2004). To understand the determinants of asthma disease in school going children in Saudi Arabia, a brief overview of the condition is necessary.
Asthma Causes, Symptoms and Management
Asthma is a chronic disease that affects the airway system through inflammation that leads to hypersensitivity. Persons suffering from asthmatic conditions have airway that is obstructed by the presence of mucus plugs, bronchoconstriction and other allergens that inflames the airway when the person is exposed (Smyth, 2002). The obstruction of this airway system is responsible for the characteristic symptoms that asthmatic cases experience which includes; wheezing, breathlessness, fatigue and lack of sleep (Smyth, 2002). In general asthma is categorized into two groups, extrinsic (atopic) and intrinsic (nonatopic); extrinsic asthma is the type that is triggered by exposure to allergic external elements that tends to vary across individuals while intrinsic is the type that does not appear to be caused by any obvious allergic factor (Smyth, 2002).
Both of these forms of asthma are therefore triggered by quite different types of allergens which are used to determine the prognosis of the condition which includes pollens, tobacco smoke, specific animal fur, chemicals, dust, viral infections, drugs, emotions or even general air pollution (Smyth, 2002). The clinical process of the asthmatic condition occurs in two phases; the first stage is production of mast-cell within the lung interstitium which releases histamine caused by the lgE antibodies triggered by the allergen (Smyth, 2002). The histamine produced in lungs is transferred to the bronchi where it is responsible for the inflammation, irritation and edema in lungs that causes the bronchoconstriction which results to the typical symptoms experienced by asthmatics (Smyth, 2002).
Asthma management in cases is based on the nature and seriousness of the condition which can be categorized in any of the four clinical classifications based on diagnosis; mild intermittent asthma, mild persistent asthma, moderate persistent asthma and severe persistent asthma (Nolte, Backer, and Porsbjerg, 2001). Based on the seriousness of the condition asthma intervention is designed on five levels which include identification and elimination of trigger factors, medication, asthma attack management and clinical follow up (Al-Rabegi, 2004).
Review of Research Studies on Asthma in School Children
This section will focus on the several research studies that have sought to quantify the prevalence and incidence rate for asthma disease in school going children in Saudi Arabia. The intention is to identify common risk factors for the condition among our target groups which are school children as well as determination of the existing interventions. One of the research studies conducted in 1998 that sought to measure the disparity of prevalence rate among urban school children with school children in rural areas found a positive correlation between high prevalence rates of asthma in school children and urbanism (Hijazi, Abalkhail & Seaton).
This was one of the earliest studies that provided the first evidence that attempted to link asthma disease with high rates of air pollution that are mostly found in urban areas. The study utilized a sample size of 1444 cases pooled from two areas Jeddah and it rural environs, and thereafter analyzed the variables of interest on subjects based on their residence (Hijazi, et al, 1998). The regression analysis of the data indicated there were two major risk factors of the condition which were urban residence and lifestyle (Hijazi, et al, 1998).
The findings of the research showed high prevalence rate of asthma in urban school children to be as high as 23%; very similar to those found in developed countries (Hijazi, et al, 1998). This similarity suggests that the same culprits are responsible for the high incidence rate of asthma in Saudi Arabia cities with those found in American cities which are known to be pollutants, chemicals and lifestyles factors such as exposure to antioxidants and high fatty acids. Other lifestyle factors that were linked to the high prevalence rate of asthma in urban dwelling school children are high susceptibility of infections during early childhood and changes in diet.
The implications of these findings indicate that effective strategy for limiting new infections could be devised through modification of the major risk factors of asthma for purposes of reducing the incidence rate among children in urban areas.
Another recent research study conducted in 2005 that investigated the environmental effects on the prevalence of asthma in the general population found evidence of a strong causal relationship between high asthma incidence and low altitudes regions like the ones found in sea.
The effect of low altitude was found to be very significant in development of asthma which was at a ratio of 3:1 when compared to person living in high altitudes levels (Al-Ghamdi, Mahfouz, Abdelmoneim, Khan and Daffallah, 2008). This research study went beyond investigation of the environmental causal factors of asthma by also researching on other various known risk factors of asthma such as genetic, allergens, type of household heating method used, housing type, income level (for measuring lifestyle variable) and area of dwelling (urban or rural) (Al-Ghamdi et al, 2008).
In summary, the socio-demographic risk factors identified in the research study for asthma were use of coal and wood, low income levels, low literacy levels, mud or tent housing, use of air-conditioning, lack of electricity and presence of sheep (Al-Ghamdi et al, 2008). Some of these risk factors contrast with earlier research studies on asthma related conditions in the region but most of them conform to other studies on the subject. For instance, low income level have normally been attributed to low prevalence of asthmatic conditions but not on this study; this causal association however is explained by inability to afford clean energy and good housing which are seen to be critical factors in development of asthma.
These are not the only research studies that have been conducted to investigate the epidemiology and distribution of asthma in school children in Saudi Arabia, however they are among the most well designed that are relevant for our case analysis. Other research studies on the same subjects largely agree on the findings of these studies that we have so far summarized in previous section. Nevertheless, just to mention in brief, some of the existing research on the subject include investigation on the spectrum of skin test reactivity and it association to national prevalence of asthma in Saudi Arabia which was found to be positive. The conclusion was that “increased sensitization was associated with higher levels of asthma severity, which is compatible with present literature” (Koshak, 2006). Another research study done by Al Rawas et al found the traditional Arabian incense referred as bakhour to be a significant trigger factor for asthma but not a risk factor for the condition (Al-Rawas, Al-Maniri and Al-Riyami, 2009).
Asthma Prevention, Management and Control Challenges in Saudi Arabia
Prevention and management of asthma among cases is a public health challenge that many countries struggle with worldwide; this is largely due to the fact that the condition is incurable which leaves case management and prevention as the only viable options. The WHO strategy for prevention and management of asthma has now been integrated by many countries to complement their health policies that are designed to address the condition. It is from this framework that the Saudi National Protocol for Asthma Management (SNPAM) and the National Program on Asthma was developed to devise strategies for reduction of the incidence rate for the disease. The SNPAM attempts to address the high prevalence rate of asthma from three levels; surveillance, prevention and case management (Noha, Dashash, Saud and Mukhtar, 2003). Surveillance is intended to identify the hotspots in the region where the prevalence of asthma is at their highest to focus prevention and intervention strategies on these areas. Primary prevention is designed along the recommendation of the various research findings by limiting susceptible members of the society, such as children from the exposure to the known risk factors of the condition or by limiting the emission of these pollutants to the environment. Finally, quality medical care is essential to achieve case management that is necessary to stabilize the progression of the disease among infected persons (Noha, 2003). In this section we shall discuss the weaknesses and challenges of the Saudi healthcare system in general as pertains to management of asthma cases and more specifically the shortcoming of the SNPAM policy that is charged with the task of reducing the prevalence of asthmatic condition nationally.
A research study that investigated the quality of primary healthcare among children conducted in 2003 and published in Saudi Medical Journal by Noha et al found that prescription protocol given to “children did not conform to national guidelines for treatment of asthma” (Noha et al, 2003). The general findings of the study found that in 37% of the cases the treatment program did not document the medication given at all while preventive therapy among the most susceptible cases only occurred in 35% of the time (Noha et al, 2003). The most common type of medication prescribed to children was found to be oral salbutamol and antitussives (Noha et al, 2003). The final research findings of the study faulted the asthma management approach among children on three fronts; lack of reliable framework for case management, weak system in distribution of medication, follow up and monitoring of cases and low health education knowledge on asthma disease among caregivers and parents (Noha et al, 2003).
What is more is that asthma continues to be “underdiagnosed and undertreated” among cases despite the implementation of the SNPAM leading to sub-optimal care being given to cases (Gold, 2000). Other research studies done on the same subject in Saudi Arabia concurred with this findings as far as sub-optimal care is concerned which was attributed to limited capacity in the healthcare system in terms of lack of equipments and medications necessary to cope with the condition (Al-Shammari, Khoja, Al-Ansary, and Al-Yamani, 1996). Most government primary health care facilities (PHCC’s) suffered from shortage of the most essential asthma management equipments such as inhalers and nebulizers not to mention the medications themselves which are central to management of cases according to the SNPAM (Al-Shammani et al, 1996).
Another research study on the efficacy of the National Asthma Program in the Ministry of Health PHCCs found the quality of care to be less than optimal compared to private specialists (Khoja and al-Ansary, 1998). 11% of cases referred to PHCCs never utilized the service while 30% were referred to the private healthcare sector where quality of care was thought to be better (Berhie, 1991). The nature of the treatment itself seemed to be the root of the problem given that 46% of all treatment protocol was entirely comprised of oral salbutamol which should ideally makeup the first line of treatment for asthmatic cases (MOH.gov, 2010).
Conclusion
Despite the numerous interventions that are available in prevention and management of asthma in cases, the condition is on the increase in most urban centers fueled by risk factors of air pollution among other factors. In school going children the rate of asthma is even on the rise complicated by the high rates of underdiagnosis and lack of awareness among the target group. Its is clear from the numerous research studies that the risk factors for asthma condition are dispersed across a variety of levels which must be adequately tackled for effective results. The National Asthma Program framework for intervention is well designed and would be most effective in reducing the high asthma prevalence among school going children if it is well implemented. Based on analysis of the literature review it is evident that the best placed actors that can significantly reduce the incidence of asthma among school going children lie with the PHCC’s which is focal point for intervention.
This health report booklet is therefore very essential in bridging the gap that is missing from lack of health education as well as acting as a framework in which review of current interventions on asthma can be assessed. More importantly it will act as a reliable tool that outlines the weaknesses of the current health intervention strategies on asthma prevention and management by identifying the areas where effective intervention strategies should be focused.
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