|Year : 2020 | Volume
| Issue : 1 | Page : 13-18
The determinants of emergency room visits and missed school days in children with asthma in a tertiary hospital in north central Nigeria
Helen O Akhiwu1, Esther S Yiltok2, Augustine O Ebonyi2, Ibrahim Aliyu3, Stephen Oguche2
1 Department of Paediatrics, Jos University Teaching Hospital, Nigeria
2 Department of Paediatrics, Jos University Teaching Hospital/University of Jos, Jos, Plateau State, Nigeria
3 Department of Paediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||12-Jun-2019|
|Date of Decision||18-Oct-2019|
|Date of Acceptance||12-Mar-2020|
|Date of Web Publication||20-May-2020|
Dr. Helen O Akhiwu
Department of Paediatrics, Jos University Teaching Hospital, Lamingo, Permanent site
Source of Support: None, Conflict of Interest: None
Background: Asthma is a major cause of emergency room visits and missed school days. However, the magnitude of this problem in Nigeria is yet to be evaluated. This study assessed the number of emergency room visits, missed school days as well as identified their determinants. Methods: This was a cross-sectional study carried out in the Paediatric Respiratory Clinic and the Emergency Paediatrics Unit of a tertiary hospital. The number of missed school days and emergency room visits were calculated and extrapolated for the estimated population of children with asthma in the state. Results: A total of 60 children with a male to female ratio of 1: 0.6 were studied. There were an estimated 5.3 million missed school days and over 460,000 emergency room visits per year for children with asthma in Plateau state. The commonest reasons for emergency room visits were severe acute exacerbation, poor knowledge of self-management and non-response to inhaled bronchodilators while the duration of asthma diagnosis, family member with atopy, family history of asthma and exercise intolerance were the determinants of emergency room visits and missed school days. Conclusion: With 5.3 million missed school days and over 460,000 emergency room visits in a year, asthma is a disease of significant public health importance. Self-management at home must be well taught at the beginning to all the patients. Care givers and patients need to know when they need to seek for help and not wait till the acute exacerbations are severe before presenting to the hospital.
Keywords: Emergency room visits, missed school days, pediatric asthma
|How to cite this article:|
Akhiwu HO, Yiltok ES, Ebonyi AO, Aliyu I, Oguche S. The determinants of emergency room visits and missed school days in children with asthma in a tertiary hospital in north central Nigeria. J Med Trop 2020;22:13-8
|How to cite this URL:|
Akhiwu HO, Yiltok ES, Ebonyi AO, Aliyu I, Oguche S. The determinants of emergency room visits and missed school days in children with asthma in a tertiary hospital in north central Nigeria. J Med Trop [serial online] 2020 [cited 2020 Aug 14];22:13-8. Available from: http://www.jmedtropics.org/text.asp?2020/22/1/13/284633
| Introduction|| |
Bronchial asthma is a chronic inflammatory disease of the airway and it has been rated as the most common chronic respiratory disease affecting children.,, With chronic respiratory diseases being reported among the leading cause of death worldwide, asthma is a disease of significant public health importance.
Recent reports from Africa have documented a rising prevalence of asthma especially over the last two decades with reports of asthma prevalence in Nigeria said to have risen from 10.9% to about 13.9% between 1990 and 2010.,,,, Reports from various countries have also documented the increase in the morbidity and mortality from the disease.,,, with the resultant increase in emergency room visits and missed school days. Many factors are thought to contribute to this trend, among which are poor self-management practices, dependence on crisis-oriented care, amongst others.
This study evaluated the determinants of emergency room visits and missed school days in children with asthma in North central Nigeria. The information obtained is expected to guide health priority settings for Nigerian children with asthma to help improve disease control and reduce the emergency room visits and missed school days. This would eventually lead to a reduction in both the financial and social burden of the disease on the family.
| Methodology|| |
The study was a descriptive cross-sectional study of children with asthma visiting the paediatric respiratory clinic and emergency paediatric unit of the teaching hospital.
The study was carried out in the Paediatric Respiratory Clinic and the Emergency Paediatrics Unit of a tertiary Hospital in Jos Plateau state from November 2017 to October 2018.
All consecutive patients aged 6-17 years presenting with pediatric asthma that met the diagnostic criteria for asthma according to the 2017 GINA guidelines for the diagnosis of asthma in children. Patients with other underlying cardiac (congenital or acquired heart diseases etc.) or respiratory morbidities (pulmonary tuberculosis, lung abscess etc.) were excluded from the study.
Sample size determination
Using an asthma prevalence of 10%, a precision of 10% and a confidence interval of 99%, a minimum sample size of 60 patients were studied.
Ethical approval was obtained from the the ethical research committee of the teaching hospital. Informed consent was also obtained from the parents or guardians of the children recruited and assent was obtained from the children aged 7 years and above.
Patients seen at the pediatric respiratory clinic and the emergency pediatric unit who met the diagnostic criteria for asthma according to the GINA 2017 guidelines and consented to participate in the study were recruited. The study was explained to each patient/caregiver and they received a patient information sheet. After which they signed/thumb printed the consent form. The questionnaire was administered by the researcher with questions about patient age, gender, parents occupational and educational class, the child’s social class (children were classified into the social class according to the computation of Oyedeji et al.), when asthma was diagnosed, frequency of symptoms in the last 12 months, number and determinants of emergency room visits and missed school days in the last 12 months.
Statistical Package for Social Sciences (SPSS) for windows version 22 (IBM Corp, Released 2015. IBM SPSS statistics for windows, version 22. Armonk, NY) was used for data analysis. Quantitative variables were described using means and standard deviation while discrete variables were described as proportions. The number of missed school days and emergency room visits were calculated and extrapolated for the population of children in Plateau State. Chi-squared test was used to determine the association between patient characteristics and emergency room (ER) visits as well as patient characteristics and missed school days (MSD). The characteristics that were significantly associated with ER visits and missed school days are the determinants of ER visits and missed school days. P-value was significant at ≤ 0.05
| Results|| |
A total of 60 children were recruited into the study. This was made up of 38 males and 22 females giving a male to female ratio of 1: 0.6 there were a total of 1400 missed school days and 11 emergency room visits. Majority of the children (45%) presented to the emergency room only when having a very severe acute exacerbation. With 15% of the children presenting to the emergency room because they did not know what to do during an acute exacerbation. While only 10% of the children presented to the hospital immediately they developed an acute exacerbation. Other characteristics of the patients as well as the reasons for emergency room visits are recorded in [Table 1].
|Table 1: Socio demographic characteristics and reasons for emergency room visits in the study population (N = 60)|
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[Table 2] shows the test of association between patient’s characteristics and missed school days. The results of which showed that exercise intolerance, family history of asthma and family member with atopy were significantly associated with missed school days. Hence these were the determinants of missed school days.
|Table 2: Association between different patient characteristics and missed school days|
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When the reasons for visiting the emergency was tested against patient characteristics; age group, when asthma was diagnosed, family history of asthma and family member with atopy were significantly associated with reasons for visiting the emergency room, hence these were the determinants of emergency room visits (see [Table 3]).
|Table 3: Association between patient characteristics and reasons for visiting the emergency room|
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| Discussion|| |
To put all these findings in perspective; according to the 2006 census there were 1,411,031 children below the age of 14 in Plateau State and they made up 44% of the total population of the state (Nigeria also has an estimated 44% children aged below 14 years). The projected population of Plateau state for 2016 was 4,200,400, with 44% being children under 14 years therefore there are about 1,848,176 children under the age of 14years in plateau state.
A study from northern Nigeria demonstrated an asthma prevalence of 12.5% among children. This would mean that approximately 231,022 children in Plateau state have asthma. If there are 1400 missed school days for 60 children that would translate to about 5.3 million missed school days per year. With 121 emergency room visits for 60 children translating to 462,044 emergency room visits per year.
This means that this study was able to estimate that there are about 5.3 million missed school days and 462,000 emergency room visits per year among children with asthma in Plateau state with severe acute exacerbation, poor response to the use of a metered dose inhaler at home and poor knowledge of self −management being the commonest reasons for these emergency room visits.
In the United States of America, asthma accounted for some 2 million emergency room visits, 15 million physician office and hospital outpatient department visits, and 10.5 million school days missed each year. With regard to race-related disease burden, African-Americans were reportedly identified as been three times more likely to be hospitalized and three times more likely to die from asthma. With this study demonstrating 5.3 million missed school days and 462,000 emergency room visits in the state alone we fear what the national figures would be like. There is need for swift intervention because the state is already educationally disadvantaged and children further missing school does not portend well for the future.
According to the WHO data published in April 2014, asthma deaths in Nigeria reached 8, 564 or 0.45% of total health deaths and the death rate per 100,000 was put at 8.91., majority of asthma-related deaths in our environment are largely preventable. Apart from the mortality from asthma, asthma is a disease that causes chronic morbidity and functional disability on its sufferers. It affects the physical, social and psychological well-being of the patients in addition to being associated with poor concentration, impaired daily activities and significant co-morbidities especially depression and anxiety., Asthma treatment especially when complicated has been found to equate with that of other chronic conditions such as cardiovascular diseases. It has also been documented that asthmatics requiring emergency room visit or hospitalization are at significantly increased risk of future exacerbation.Suffice it to say that inadequate attention given to the management of asthma and ways of improving treatment could be a significant factor for the increase in morbidity and mortality from asthma despite major advances in understanding of the pathophysiology of the disease. This is supported by the findings that severe acute exacerbation, poor response to the use of a metered dose inhaler at home and poor knowledge of self −management were among the commonest reasons for emergency room visits.
There is a need to counsel patients and care givers adequately about the disease and educate them on the identification of trigger factors, self-management at home and when to present to the emergency room. There is also a need to reinforce this information often at every clinic visit, so that they are clear on what to do at home and how to use their medication properly and importantly not to wait to be very ill before presenting to the hospital.
Family history of asthma, family member with atopy as well as exercise intolerance were found to be the determinants of missed school days, while duration of time the patient has been diagnosed with asthma, having a family member with atopy as well as age were the determinants of emergency room visits.
Family history of asthma or family member with atopy means someone else in the family has asthma hence making the family more educated about the disease, more aware of danger signs, more aware of implications of improper treatment of acute exacerbations. This will most likely make them more proactive in seeking medical intervention. It is also not surprising that exercise intolerance is a determinant of missed school days because children like to play and when they are exercise intolerant it can affect their school attendance.
How long a patient has had the disease was also a determinant of emergency room visits with all those having had the disease for 5 years or more all having had to visit the emergency room at some point in time. This could be due to the fact that they have had the disease for a longer period of time hence would have suffered some form of complications of the disease that would make them need to present to the Emergency room.
| Conclusion|| |
There are 5.3 million missed school days and over 400,000 emergency room visits in a year, therefore asthma is a disease of significant public health importance whose magnitude really needs to be adequately appreciated and adequately addressed. Self-management at home must be well taught at the beginning to all the patients and their care givers and patients also need to know when they need to seek for help and not to wait till the acute exacerbations are severe before presenting to the hospital.
Research reported in this publication was supported by the Fogarty International Centre (FIC) of the National Institutes of Health and also the Office of the Director, National Institutes of
Health (OD), National Institute of Nursing Research (NINR) and the National Institutes of Neurological Disorders and Stroke (NINDS) under award number D43TW010130. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
The authors report no conflicts of interest related to this study.
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[Table 1], [Table 2], [Table 3]