The authors have declared that no competing interests exist.
Conceived and designed the experiments: XL LS. Performed the experiments: XJ LS YZ XY BW. Analyzed the data: LS XY. Contributed reagents/materials/analysis tools: LS
. Wrote the paper: XJ LS LS YZ.
The aim of this study was to investigate the health-related quality of life (HRQOL) in 2−7-year-old children diagnosed with recurrent respiratory tract infections (RRTIs) and the impact of RRTIs on affected families.
This was a cross-sectional case-control study evaluating 2−7-year-old children with RRTIs (n = 352), 2−7-year-old healthy children (n = 376), and associated caregivers (parents and/or grandparents). A Chinese version of the PedsQL™ 4.0 Generic Core Scale was used to assess childhood HRQOL, and a Chinese version of the Family Impact Module (FIM) was used to assess the impact of RRTIs on family members. HRQOL scores were compared between children with RRTIs and healthy children. In addition, a multiple step-wise regression with demographic variables of children and their caregivers, family economic status, and caregiver’s HRQOL as independent variables determined factors that influenced HRQOL in children with RRTIs.
Children with RRTIs showed significantly lower physical, emotional, social, and school functioning scores than healthy children (
The current data demonstrated that RRTIs were associated with lower HRQOL in both children and their caregivers and negatively influenced family functioning. In addition, caregivers’ social characteristics also significantly affected HRQOL in children with RRTIs.
Recurrent respiratory tract infections (RRTIs) are one of the most commonly occurring diseases
Health-related quality of life (HRQOL) is an essential health outcome measure used in clinical trials and health service research and evaluation
Increased risk for RRTIs has considerable impact on a child’s physical functioning and family economy, including lost working days of caregivers and other family-related functions
The main diagnostic criteria for childhood RRTIs included the following guidelines
Between January 2011 and July 2011, 352 children (2−7 years) with RRTIs and their caregivers (parents or grandparents) were selected from the Pediatric Outpatient Departments at Xijing hospital and Tangdu hospital in Xi’an, China and comprised the patient group. The healthy control group included 376 healthy children (2
The selected hospitals are two of the largest AAA Hospitals in Xi’an. The AAA distinction means that they are among the best hospitals in China with the capacity to provide high-level medical services and implement high-level medical education and research projects. One of the hospitals is located in the urban center of Xi’an and the other is located in the suburbs of Xi’an. Both hospitals are available for the use by the whole population of Xi’an and both treat a comprehensive spectrum of diseases. The pediatrics departments of the two hospitals together service more than 600 patients per day, and each has more than 200 beds for admitting children. Both departments are further divided into several sub-specialties, including respiratory diseases, digestive diseases, kidney diseases, and cardiovascular diseases.
For this study, patient group criteria included the following: 1) age 2−7 years old, 2) medical records at one of the designated study hospitals, 3) pediatric-diagnosed RRTIs, 4) nursery school or kindergarten attendance, and 5) during the preceding year, only study designated hospitals were used for health care/consultation. Child subjects were excluded from the patient group if they had any other medical condition, including chronic diseases (e.g. asthma, heart diseases, renal disease, cancer, or epileptic), neurological developmental disorders(e.g. autism spectrum disorder, dyspraxia, conduct disorder), or growth abnormalities (e.g. dwarfism, failure to thrive, etc.) ,as such conditions may influence HRQOL. Subjects were also excluded if their caregivers were illiterate or reluctant to participate.
Participation of healthy control group subjects depended on the following criteria: 1) age 2−7 years old, 2) health care records located at one of the designated study hospitals, 3) diagnosed by a pediatrician as developing normally and being healthy and free from respiratory infections for the past 6 months, 4) nursery school or kindergarten attendance, and 5) during the preceding year, only study designated hospitals were used for health care/consultation. The same exclusion criteria applied to the patient group were also applied to the control group (chronic diseases, developmental disorders, growth abnormalities, and illiterate or noncompliant caregivers were excluded). In addition, children who received functional therapy for a disability or nutritional counseling for specific medical conditions were also excluded.
The Research Ethics Committee of the Fourth Military Medical University approved this study. All caregivers provided written informed consent prior to the collection of any information.
A Chinese version of the Pediatric Quality of Life Inventory™, version 4.0 (PedsQLTM4.0) was used in this study. The PedsQLTM4.0 consisted of the following three parts:
The PedsQL™ 4.0 Generic Core Scale was developed by Varni et al
The PedsQL™ 4.0 FIM was developed by Varni et al
The FIM obtains three types of summary scores: 1) The total score is calculated as the sum of all 36 items divided by the number of items answered; 2) the parent HRQOL summary score is calculated as the sum of the 20 items from Physical, Emotional, Social, and Cognitive Functioning dimensions divided by the number of items answered; 3) the Family Functioning Summary Score is calculated as the sum of the 8 items from Daily Activities and Family Relationship dimensions divided by the number of items answered.
The PedsQL™ Family Information Form was also developed by Varni et al
Five pediatric nurses, with at least 5 years of pediatric clinical nursing experience, performed this study. All of the investigators were trained prior to survey administration in order to ensure they had mastered the survey purpose and its requirements. Caregivers completed the PedsQL™ 4.0 Generic Core Scales for 2−4 year old children,whereas caregivers and 5−7 year old children completed this survey. The children’s caregivers answered The PedsQL™ 4.0 FIM and PedsQL™ Family Information Form.
An investigator explained the purpose and details of all scales so that both the caregivers and children could successfully complete the assessments. In addition, one of the main investigators carefully rechecked all the scales, and telephone interviews were conducted for any lost or incomplete information. EpiData 3.1 software was used for data entry. To ensure data accuracy, double entry mode was selected and logistical errors were corrected.
Quantitative data was expressed as
Child and caregiver demographics are reported in
Children with RRTIs (n = 352) | Healthy children(n = 376) | |
Children’s gender(boys,n(%)) | 196(55.7) | 204(54.3) |
Children’s age( |
5.2±2.3 | 5.3±1.9 |
Relation between child and Caregiver | ||
Parents, n(%) | 217(61.7) | 235(62.6) |
Grandparents, n(%) | 135(38.3) | 141(37.4) |
Caregiver’s education level(n(%)) | ||
≤9 years | 80(22.7) | 96(25.5) |
9–12 years | 124(35.2) | 108(28.7) |
≥13 years | 148(42.1) | 172(45.3) |
Family economic status (n(%)) | ||
≤1500 yuan/individual·month | 84(23.9) | 100(26.6) |
1500 ∼3000 yuan/individual·month | 140(39.8) | 144(38.1) |
≥3000 yuan/individual·month | 128(36.3) | 132(35.1) |
Dimension | Cronbach’s α coefficient | Item-summary correlation |
|
||
Physical | 0.83 | 0.51–0.69 |
Emotional | 0.81 | 0.56–0.67 |
Social | 0.76 | 0.48–0.67 |
School | 0.74 | 0.45–0.62 |
Summary scale | 0.89 | 0.54–0.68 |
|
||
HRQOL | ||
Physical | 0.89 | 0.60–0.82 |
Emotional | 0.87 | 0.57–0.76 |
Social | 0.85 | 0.56–0.84 |
Cognitive | 0.88 | 0.56–0.71 |
Communication | 0.83 | 0.46–0.67 |
Worry | 0.85 | 0.61–0.68 |
Family Functioning | ||
Family daily activities | 0.82 | 0.57–0.78 |
Family relationships | 0.89 | 0.56–0.73 |
Summary scale | 0.91 | 0.52–0.78 |
2∼4 years olds | 5∼7years olds | |||
healthy(n = 200) | RRTIs(n = 220) | Healthy(n = 152) | RRTIs(n = 156) | |
|
||||
Physical | 92.6±6.8 | 84.2±12.2ab | 93.8±8.7 | 69.8±19.6 |
Emotional | 88.7±13.3 | 63.4±13.7 |
88.1±10.7 | 62.8±14.7 |
Social | 95.4±8.0 | 79.7±13.0ab | 95.5±9.9 | 74.6±15.0 |
School | 89.5±8.0 | 67.9±7.1ab | 88.5±16.0 | 61.7±13.3 |
Summary scale | 92.1±6.7 | 75.5±7.6ab | 93.2±9.2 | 67.6±12.9 |
|
||||
HRQOL | 88.8±8.0 | 63.3±8.3 |
88.5±9.4 | 64.8±9.2 |
Physical | 89.4±12.8 | 64.5±11.4 |
91.5±9.8 | 65.3±12.2 |
Emotional | 92.6±9.2 | 63.2±12.6 |
93.5±9.5 | 65.4±13.4 |
Social | 88.9±14.0 | 61.5±12.9 |
91.2±12.3 | 65.5±17.7 |
Cognitive | 87.7±16.3 | 63.6±13.7 |
85.6±16.3 | 64.5±13.7 |
Communication | 94.4±8.9 | 73.5±15.9ab | 90.4±11.4 | 68.0±17.9 |
Worry | 57.1±18.2 | 81.9±17.5 |
61.5±18.3 | 79.6±17.7 |
Family Functioning | 85.7±12.8 | 62.0±12.9ab | 85.1±13.9 | 66.8±13.7 |
Family daily activities | 83.0±19.2 | 55.8±16.9ab | 80.8±18.8 | 62.4±17.8 |
Family relationships | 87.4±14.1 | 65.7±16.3 |
87.6±14.7 | 69.3±14.6 |
Summary scale | 87.9±7.7 | 62.9±8.4 |
87.4±9.8 | 65.0±9.7 |
Children with RRTSs in both age bands had significantly lower FIM scores than those of healthy children on every dimension except the worry dimension (
Score | Children with RRTIs (n = 156) | Healthy children (n = 152) | ||
Caregiver proxy-report | Child self-report | Caregiver proxy-report | Child self-report | |
Physical | 69.8±19.6 |
76.4±18.2 | 93.8±8.7 | 93.8±8.2 |
Emotional | 62.8±14.7 |
69.0±17.6 | 88.1±10.7 |
92.3±8.7 |
Social | 74.6±15.0 | 78.4±15.2 | 93.5±9.9 | 93.3±12.6 |
School | 61.7±13.3 |
68.2±16.8 | 78.5±15.7 | 77.7±19.4 |
Summary | 67.6±12.9 |
73.5±12.3 | 89.7±8.7 |
78.4±13.2 |
FIM Scale | Caregivers’ proxy-report Generic Core Scale | Children’s self-report Generic Core Scale | ||||||||
Physical | Emotional | Social | School | Summary | Physical | Emotional | Social | School | Summary | |
HRQOL | 0.46 |
0.59 |
0.48 |
0.53 |
0.58 |
0.51 |
0.61 |
0.58 |
0.07 | 0.08 |
Physical | 0.43 |
0.58 |
0.45 |
0.50 |
0.59 |
0.57 |
0.55 |
0.51 |
0.17 | 0.12 |
Emotional | 0.40 |
0.65 |
0.48 |
0.41 |
0.59 |
0.39 |
0.54 |
0.56 |
0.07 | 0.12 |
Social | 0.31 |
0.53 |
0.45 |
0.44 |
0.51 |
0.49 |
0.52 |
0.56 |
0.07 | 0.08 |
Cognitive | 0.36 |
0.45 |
0.38 |
0.54 |
0.51 |
0.45 |
0.51 |
0.44 |
0.12 | 0.09 |
Communication | 0.38 |
0.44 |
0.50 |
0.33 |
0.51 |
0.24 |
0.37 |
0.42 |
0.22 | 0.25 |
Worry | 0.20 |
0.39 |
0.35 |
0.36 |
0.37 |
0.28 |
0.47 |
0.36 |
0.01 | 0.14 |
Family Functioning | 0.32 |
0.45 |
0.39 |
0.37 |
0.44 |
0.32 |
0.49 |
0.47 |
0.23 | 0.38 |
Daily Activities | 0.24 |
0.45 |
0.39 |
0.34 |
0.42 |
0.27 |
0.47 |
0.51 |
0.00 | 0.10 |
Relationships | 0.31 |
0.47 |
0.41 |
0.37 |
0.47 |
0.29 |
0.42 |
0.36 |
0.20 | 0.21 |
Summary score | 0.41 |
0.63 |
0.53 |
0.53 |
0.63 |
0.48 |
0.61 |
0.57 |
0.14 | 0.17 |
Regression analysis s showed that a child’s age, relation to his/her caregiver, frequency of respiratory tract infections in the preceding year, caregiver’s education level, and caregiver’s HRQOL all significantly influenced a child’s summary score (
Influence factors | Physical | Emotional | Social | School | Summary |
Age (year) | 0.13 | – | – | – | 1.08 |
Gender (male = 1,female = 2) | 0.14 | – | – | – | – |
Relation between child and his/her caregiver (grandparents = 1,parents = 2) | – | – | – | – | 2.04 |
Caregiver education level | |||||
9–12 years | 0.69 | 0.36 | 0.33 | 0.47 | 1.51 |
≥13 years | 1.12 | 0.71 | 0.85 | 0.58 | 1.23 |
Caregiver’s HRQOL | – | 0.31 | 0.32 | – | 0.36 |
Family economic status | – | −0.27 | – | – | – |
Frequency of upper RTIs in the preceding year | 0.47 | 0.39 | 0.29 | 0.41 | 0.51 |
Frequency of lower RTIs in the preceding year | 0.54 | 0.52 | 0.58 | 0.60 | 0.63 |
Determination coefficient |
0.69 | 0.43 | 0.51 | 0.34 | 0.76 |
Note: Family economic status was stratified according to the average monthly income per individual. For multiple regression analyses, 1 = ≤1500 yuan, 2 = 1500
Our results showed that children with RRTIs displayed significantly lower HRQOL scores compared to healthy children. This result was based on physical, emotional, social, school functioning, and summary scales, and the two groups showed the greatest differences in Emotional functioning. In addition, RRTIs had a greater effect on the HRQOL of 5−7-year-olds compared to 2−4-year-old children. Moreover, families with RRTI-affected children scored lower on physical, emotional, social, cognitive functioning, communication, daily activities, relationships, economic status, and FIM summary scales scores compared to families with healthy children, however, RRTIs-affected families displayed greater Worry than families with healthy children. Taken together, these results demonstrate that RRTIs significantly influenced HRQOL in children, their caregivers, and their families.
The HRQOL assessment is becoming an important method to evaluate children’s physical and mental health, which highlights its importance and extensive application to pediatric clinical practice
Previous work by Upton et al
It is difficult to assess the accuracy of the results of child self-reports and caregiver proxy-reports. Children and caregivers may draw on different values and perspectives when they evaluate quality of life
Our current findings show that numerous variables influence HRQOL. For example, we found that a child’s age, the relation between child and his/her caregiver, a caregiver’s education level, and a caregiver’s own HRQOL were key factors contributing to the HRQOL in children with RRTIs. Similarly, Gerson’s
The effects of medical interventions are reflected not only in the changes in somatic parameters but also in emotional and social aspects of the patients’ lives. Quality of life, which reflects well-being and functioning, is a relevant end-point for evaluating the efficacy of prevention measures, treatments, and rehabilitation in children
We believe our findings have important value regarding the quality of life of children affected by RRTIs. However, we acknowledge that our study has several major limitations. First, we were unable to obtain the exact duration of each RRTI episode and the lifetime RRTI duration because acceptable clinical tools needed to measure RRTIs severity in children are not currently available in China. Therefore, we could not evaluate the influence of these factors on HRQOL. However, the frequency of lower and upper RRTIs in the preceding year (the parameter we examined here) may reflect disease severity to some extent. Generally, infections of the lower respiratory system are more severe than infections of the upper respiratory system. Thus, we performed a multiple step-wise regression analysis that distinguished between upper and lower infections as an indirect assessment of intensity. Second, we did not objectively measure caregiver’s mental and physical state because we thought caregivers would have less influence on the children’s HRQOL than the children themselves. In this study, more than 60% of caregivers were parents, and less than 40% of caregivers were grandparents. Parents were fairly young, with a mean age of 30.6±2.1 years, which suggests that they were less likely to have chronic disease at this stage in their life. We assumed that grandparents who served as primary caregivers were likely in good health in order to take care of their grandchildren. An additional limitation to this study is that HRQOL results obtained from children at large AAA hospitals in Xi’an may not be representative of the HRQOL of patients treated at different hospitals across different regions. Although our subjects may not represent all children with RRTIs in China, or even in Xi’an, our data do provide significant insight into the effects of RRTIs on HRQOL, which is useful to clinicians and researchers.
The existence of RRTIs was negatively associated with a child’s physical, emotional, social, and school functioning, and negatively affected caregivers’ quality of life, family daily activities, and relationships. Therefore, it is essential that we monitor quality of life measures in children with RRTIs and the health of their caregivers. We encourage health staff to increase education for caregivers, RRTI prevention, and psychological mediation in order to improve HRQOL in children with RRTIs and their affected family members.
The research team is grateful to all the children and their families who participated in this study.