Assessing health related quality of life of school aged Saudi children in western province using the validated Arabic version of child health questionaire-parent form-50

Discussion

This survey-based study assessed the quality of life of healthy school-age children in the western province of Saudi Arabia using an internationally validated parents-reported tool. The study showed high scores of HRQOL in majority of the explored domains, which indicates an acceptable health status among the studied population. Relatively lower levels of health were observed for behavior, mental health, and general health perception. The questionnaire scores correlated in a moderate-to-fair fashion. Further, the questionnaire showed globally good internal consistency in the studied population, which indicates the reliability of the findings.

Parents-reported information regarding the QoL of their children is a worldwide acceptable and commonly used method, clinically, which showed fair agreement with children’s self-reported results.23 In general, HRQOL and other models of QoL underscore the subjective nature of the assessment. The degree of satisfaction with the personal health status is the cornerstone of HRQOL as compared to the ideal health status. It differs from the QoL evaluation by a physician, which is objective, by reporting the patient’s own subjective experience.24 However, it is possible to describe the personal health in an apparently-healthy sample the population by exploring different HRQOL domains, which may reflect the effect of specific unknown disease groups.25 This approach can be supported by the HRQOL criteria defined by the World Health Organization, which include the individual’s perception of his/her position in life by reference to the standards, concerns, goals, and expectations of the culture and value systems where the person lives.26 Moreover, the assessment of HRQOL should include not only the negative aspects of QoL but also the positive components of personal experience, such as ease of adaptability, hope, and satisfaction.24 However, very few studies in literature investigated HRQOL among healthy children; as most studies focused on the impact of chronic diseases or disabilities on HRQOL and included healthy, or apparently healthy, individuals as controls for afflicted ones. Thus, the discussion part of this article will mainly focus on interpreting the findings of this study and conclude by suggesting some clinical and research applications at the individual and public health levels.

An Iranian study compared the HRQOL of obese children and those afflicted with a set of chronic diseases with healthy ones. Authors used another scale, namely the Pediatric Quality of Life Inventory™ Version 4.0 (PedsQLTM 4.0), which comprises 4 subscales including physical, emotional, social and school functioning, each expressed as 0-to-100 score. By focusing on healthy group, comparison with our study reveal fairly comparable findings regarding physical functioning and social functioning, where scores ranged between 80-95 out of 100.27 Another study by Pinhas-Hamiel investigated the association of obesity with QoL by comparing apparently healthy normal weight versus obese children by means of the PedsQLTM 4.0, using both child- and parent-reported versions. Normal weight children showed >80 mean scores in physical, social and school functioning, whereas emotional functioning showed mean score of 74.1 and 73.2 in child- and parent-reported assessments;28 which is fairly comparable to findings from our study. Further, both studies demonstrated a significant association of HRQOL with weight, as obese children had significantly lower scores in all 4 dimensions. Although weight factor has not been investigated in our study, such observations indicate that children’s psychological wellbeing and behavior is sensitive even to minor disturbances and may be significantly affected by non-pathological conditions such as overweight and obesity. Such observations highlight the importance for children to grow up in a healthy psychosocial and physical environment to enable adequate psychomotor development and prevent eventual psychosocial problems in adolescence and adulthood. Therefore, home environment and the role of parents have been emphasized in promoting healthy dietary and lifestyle habits and limiting toxic factors such as energy dense foods, sedentary behaviors, and screens.29,30 Studies in this field suggest that a balance point between parental restriction and permissiveness should be maintained to prevent excessive behaviors that may result either from frustration or unhealthy habits.31-33

In the present study, statistically significant differences were found between the 2 genders concerning 6 life domains; on the other hand, the mean differences ranged between 1.77 to 5.80 on a 0-100 scale, which may not be clinically significant. However, it is worth noting that 5 of the 6 concerned domains have relationship with psychological and behavioral wellbeing with parallel impact on parents and family wellbeing. In the previously cited Iranian study, similar observation can be deduced regarding emotional functioning where boys (mean score=77.0) had lower scores compared to girls (81.5), although they achieved higher physical (90.5 versus 88.0) and social (90.5 versus 87.1) functioning scores, respectively; however, authors did not analyze the statistical significance of this fluctuation being not the scope of their study.27 Other authors of an Iranian study reported significant gender effect on the QOL among children afflicted with epilepsy, which may denote adjacent sociocultural factors inducing discrepancy between girls and boys.34

More remarkably, older and medium ages were crucial, especially for boys where behavior and psychological health was relatively disturbed associating impact on parents and family functioning. Furthermore, adolescence period was likely to be the most affected in both genders regarding physical functioning, emotional and behavioral dimensions as well as family impact with corresponding scores dropping down to 60. Comparatively, a study from Pakistan explored HRQOL among schooled adolescents using the KINDL questionnaire, which comprises 6 dimensions including physical health, emotional health, self-esteem, family functioning, social functioning and school functioning. Authors reported relatively higher scores, with mean 0 to 100 scaled scores ranging between 77.8 for self-esteem to 98.2 in family functioning, notably emotional health which was scored as high as 96.7.35 These findings fall relatively higher than ranges reported in our study among the adolescent population.

This open the gates to several interpretations and calls for further exploring eventual gender- and age-specific factors that may interfere with psychological health and psychomotor development of children such as home environment, school factors, smart devices usage, sleep disturbance, physical activity, extra-school activities, socialization, role model, so forth. A systematic review by Wu et al36 including 21 cross-sectional, 6 longitudinal, 3 school-based interventional studies, as well as one mixed design study, demonstrated a significant positive relationship of children and adolescents’ HRQOL with the level of physical activity and a negative relationship with sedentary behavior, both in a dose-dependent fashion. Therefore, interventions to increase physical activity and reduce sedentary habits are increasingly advocated among children, especially in preschools where these reduce health inequities notably among socioeconomically disadvantaged populations.37,38 In another systematic review, Wu et al39 explored the effect of diet quality and dietary habits on HRQOL among children and adolescents and concluded to a dose-dependent effect of the quality of diet on HRQOL involving several domains such physical and emotional functioning, psychological wellbeing and school achievement. Among major environmental factors associated with children’s HRQOL is the family socioeconomic status,40 notably parents’ educational level that showed significant association with several life domains and further explained the variance in parent-assessed HRQOL.41 Another modern determinant of child’s health is the screen time and usage of smart devices, which is unanimously evidenced to disturb behavior and induce negative effect on children’s physical and mental health as well as on their psychomotor development. A range of children’s health indicators are impacted by screen usage such as physical activity and weight, self-esteem, prosocial behavior, school achievement, depression and anxiety,42,43 It is crucial to explore these factors among healthy children in a screening and preventive approach and to raise awareness among parents and schooled children about the healthy and unhealthy lifestyles.

On the other hand, the observed gender and age fluctuations should be interpreted with caution especially in case of parent-reported evaluation as it may entail a significant amount of subjectivity or be biased by the parent-child relationship that may be impaired in adolescence. This hypothesis is supported by the notable lack of internal consistency observed in behavior, mental health and general health perception scales; while all these domains were the most significantly impaired in the total population, especially in adolescent boys. This should question the reliability of the CHQ-PF50 in its original form when used for this age category of Saudi children. Previously, a revised version of the WHO Quality of life questionnaire (WHOQOL-BREF) demonstrated superior performance in term of reliability among Indian adolescents compared to PedsQL.8 This highlights the need for such tools to be adapted to the local cultures and be as specific as possible to the subpopulations, in a way to improve their reliability.