Higher perceived HRQoL in Moroccan children with asthma and their parents

Higher perceived HRQoL in Moroccan children with asthma and their parents

Monique Theodora Maria Veenstra-van Schie^1,&, Kelly Coenen², Hendrik Maria Koopman², Florens Gerard Adriaan Versteegh^1,3

¹Groene Hart Ziekenhuis, Department of Pediatrics, Gouda, the Netherlands, ²Leiden University, Department of Clinical Psychology, Leiden, the Netherlands, ³Ghent University Hospital, Department of Pediatrics, Ghent, Belgium

^&Corresponding author
Monique Theodora Maria Veenstra-van Schie, Groene Hart Ziekenhuis, Department of Pediatrics, Gouda, the Netherlands

The Netherlands is a multi-cultural society with 17 million residents of which approximately 20% is from nonnative descendence. The three largest ethnic groups are immigrants from Suriname (2,3%), Turkey (2,3%) and Morocco (2,1%) [1]. In the Gouda region in the central part of the Netherlands the total percentage of children from Moroccan descent aged 6-18 years is 8% [2]. In the Groene Hart Ziekenhuis (GHZ), a general teaching hospital, a group of about 70 children with asthma, aged 6-18 years from Moroccan descent are treated. Several determinants were found to be of influence on the health-related quality of life (HRQoL), with ethnicity being one of them [1,3]. None of these studies explored the Moroccan population. Therefore we investigated the differences in the perceived HRQoL between children with asthma and their parents from Moroccan (Berber and Arab) and Dutch descent.

Children diagnosed with asthma and currently under treatment in the GHZ were tested, using generic and asthma specific HRQoL instruments (DUX-25 [4], DISABKIDS [5] and the PAQLQ [6]. Parents filled in proxy versions of the questionnaires. Data were analyzed using SPSS (version 18).

In this study 33 children were included (64 % male), 16 from Moroccan and 17 matched children and parents from Dutch descent. The age of all children ranged from 6-16 years and of the parents from 31-56 years. Generally, mothers completed the questionnaires (85%). No significant differences (age, education level, and asthma severity) were found between the Moroccan and Dutch groups. Independent t-tests showed that the two parent groups only differed significantly on the DUX-25 overall score (p = 0.024) and the DUX-25 subscale physical (p = 0.004) (Table 1). Moroccan parents showed higher overall and physical subscale scores indicating a better HRQoL. Moroccan children differed significantly on the DUX-25 overall score (p = 0.002) and the subscales physical (p = 0.006), emotional (p =0.003) and home functioning (p = 0.006) (Table 1), also indicating a better HRQoL compared to children from Dutch descent. No significant differences were seen on the DISABKIDS and the PAQLQ questionnaires.

In this study no differences were found on the asthma specific HRQoL instruments PAQLQ and DISABKIDS, maybe because these questionnaires are primarily disease based [5-7]. However, compared to other studies where the general HRQoL has shown to be lower in immigrant groups [1,3], our findings showed the opposite. The significant differences on the DUX-25 (subscales overall, physical, emotional and home functioning) indicated that Dutch children and their parents experience lower HRQoL. A possible explanation could be the cultural influences on the question comprehension and response. People from Moroccan descent have a more collectivistic culture, meaning that they see their self as part of a group instead of independent from a group (more individualistic culture) [8]. More over, it is shown that people in a collectivistic culture are less assertive and direct in their communication [8] and are likely to give more socially desirable responses (no complaints) and don't talk about the negative aspects of having asthma [9]. Small sample size cannot explain the different results on the general HRQoL scores in this study. Despite repeated effort it proved very difficult to include participants from the Moroccan population. However, parents of Moroccan descent became very communicative about their child's asthma while completing the general HRQoL DUX-25 questionnaire. The questions of the DUX-25 are short and clear and invite to talk about everyday activities and to give examples. The DUX-25 answer possibilities (smileys) proved to be more accessible for most people, especially for those of whom the Dutch language is not their native language. Language can be an important determinant in explaining cultural differences in the reported HRQoL [8]. Not only the difficulties of understanding the Dutch language may explain the differences in the perceived HRQoL. Nonnative speakers may not be familiar with the many different terms that can be used to specify disease and complaints in a language, leading to less differentiation in the response. Another explanation for the fact that parents and children of Moroccan descent experienced a higher HRQoL could be that the parents were born in Morocco where there were different expectations regarding health and healthcare [10]. They are raising their children with the same ideas and beliefs about disease as their parents had. Moroccan people are more comfortable in talking about physical complaints, contrary to psycho-social complaints they rather not discuss [8]. A reason may be that they would feel ashamed for their psycho-social complaints or that they would feel miscomprehended by the Western health care system. This feeling of miscomprehension might be the reason of the attenuated answering of the questions.

The findings of this study are contrary with previous research. Results can be explained by the individualistic-collectivistic dimension, socially desirability, language and the feeling of miscomprehension. If this explanation makes sense health care workers have to invest in a good relationship with especially immigrant children and their parents, so they will have enough confidence to talk more openly about their physical as well as their psycho-social complaints.

The authors declare no competing interests.

Monique T.M. Veenstra-van Schie and Kelly Coenen acquired the data of the study. Hendrik M. Koopman and Florens G.A. Versteegh contributed to the conception and design of the study. All authors have read and agreed to the final version of this manuscript and have equally contributed to its content and to the management of the case.

This study was supported by an unrestricted grant from GlaxoSmithKline.

Table 1: unadjusted mean scores#, the range and standard deviations (SD) of the DUX-25, DISABKIDS and PAQLQ in parents of children with asthma from Dutch and Moroccan descent (upper part) and in children with asthma from Dutch and Moroccan descent (lower part)

1. Dellen Van QM, Stronks K, Bindels PJE, Öry FG, Bruil J, Aalderen Van WMC, the Peace Study Group. Health-related quality of life in children with asthma from different origins. J Asthma. 2007 Mar;44(2):125-31. PubMed | Google Scholar


2. Hanning C, Paijmans IJM, Rossum Van MF, Rijkelijkhuizen JM, Wijngaarden R, Dooremaal Van M, Lottman IGA, Terpstra NJ, Tielen JT, Poos MJJC. Groeien in Gezondheid II (Growing in Health II). Utrecht: Zuidam Uithof. 2010; p31-32. Google Scholar


3. Montalto D, Bruzzese JM, Moskaleva G, Higgins-D?Alessandro A, Webber MP. Quality of life in young urban children: Does asthma make a difference? J Asthma. 2004 Jun;41(4):497-505. PubMed | Google Scholar


4. Vrijmoet-Wiersma CM, Kooloos VM, Koopman HM, Kolk AM, Van Der Laan I, Grootenhuis MA, Egeler RM. Health related quality of life cognitive functioning and behavioural problems in children with Langerhans cell histiocytosis. Pediatr Blood Cancer. 2009; 52 (1): 116-122. PubMed | Google Scholar


5. Baars RM, Atherton CI, Koopman HM, Bullinger M, Power M, the DISABKIDS group. The European DISABKIDS project: development of seven condition-specific modules to measure health related quality of life in children and adolescents. Health Qual Life Outcomes. 2005 Nov 13;3:70. PubMed | Google Scholar


6. Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M. Measuring quality of life in children with asthma. Qual Life Res. 1996 Feb;5(1):35-46. PubMed | Google Scholar


7. Solans M, Pane S, Estrada MD, Serra-Sutton V, Berra S, Herdman M, Alonso J, Rajmil L. Health-related quality of life measurement in children and adolescents: a systematic review of generic and disease-specific instruments. Value Health. 2008 Jul-Aug;11(4):742-64. PubMed | Google Scholar


8. Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns. 2006 Dec;64(1-3):21-34. PubMed | Google Scholar


9. Uskul AK, Oyserman D. Question comprehension and response: implications of individualism and collectivism. Research on Managing Groups and Teams: National Culture & Group. 2006; 9: 177-206. Google Scholar


10. Koinis-Mitchell D, McQuaid EL, Friedman D, Colon A, Soto J, Vila Rivera D, Fritz GK, Canino G. Latino Caregivers' Beliefs about asthma: causes, symptoms, and practices. J Asthma. 2008 Apr;45(3):205-10. PubMed | Google Scholar