Population Health in Saudi Arabia: Asthma - Case Study Example

ASTHMA IN SAUDI ARABIA Allergic diseases are very common among children in the current century. The prevalence of allergic disorders among children in the Western countries is as high as 41%. Of the many allergic diseases, bronchial asthma is the most common among children with the highest rate of mortality and morbidity. Saudi Arabia is a country where allergic diseases, in particular, asthma are very common among the school going children. The disease is a growing concern for the Saudi government since it leads to increased absenteeism in schools, lack of social and sports activities. Several studies have been carried out in this regard which proves the point that despite the fact that asthma medicines are available easily still asthma is on the rise among school children (Frayh et al. 2001). Asthma has been defined in different ways. The common definition used to define asthma by the clinicians is the “variable airflow obstruction”. Some other definitions also describe asthma as an “inflammatory disease”. However researchers are not satisfied with the definitions since they do not distinguish between the asthmatic and the non asthmatic. For that matter the diagnosis of asthma remains clinical (Frayh et. al. 2001). Moamary (2008) defines asthma in the following manner: “Asthma is a chronic inflammatory disorder with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. These episodes are usually associated with reversible airflow obstruction.” In this paper I aim to discuss the prevalence of Asthma in Saudi Arabia. My basic focus would be on the school going children. I intend to discuss the prevalence, etiology and preventive measures taken by the Saudis to counter asthma. I will also discuss the traditional approach adopted by the Saudis to counter the disease. Towards the end I will discuss some of the interventions that might prove beneficial to control asthma. To support my research, I intent to explore the scientific journals and authentic websites. Saudi Arabia is a big country with a covering area of 2.25 million square kilometers. The country is rich in oil which has contributed a lot in boosting its economy through export. It has developed tremendously in the past three decades. The Saudi government has invested a lot in the health care system, education, housing and environment for the benefit of the people. It is a country with a huge network of roads, sea ports, airports, industries, and power and desalination plants. The largest share in GDP comes from the industrial sector (51%). The service sector contributes 43% in GDP and the 5% comes from the agriculture sector. The average household income increased massively between 1970 and 1990 since the government shared the benefits of the petroleum industry with the Saudi people. Non communicable diseases such as cardiovascular diseases and diabetes are common in Saudi Arabia. Among children the most common form of illness is the allergic diseases, in particular, asthma (World Health Organization, 2007). The Saudi government has taken giant leaps to provide basic health facilities to its people. For that reason the research carried out by the World Health Organization states that 95% of the people have access to asthma medications (Moamary, 2008). Still the prevalence of asthma, in particular, the bronchial asthma is on the rise among Saudi school going children. Almost 11.5% Saudi children have wheezing (Dawood et al. 2000). Asthma symptoms among Saudi school children have been studied in great detail. Bronchial asthma nationally occurs in 10% of all Saudi children (Frayh et al., 1997). Studies have shown that dry cough, wheezing, itching eyes, nose and other parts of the skin are very common among Saudi children. Some statistics related to asthma among Saudi children are mentioned below: In Saudi Arabia the prevalence of childhood asthma is between 6.5%-12.6% and 4.5% and 9.5% among boys and girls with a ratio 1.5: 1 of boys and girls (Dawood et al, 2000). Bronchial asthma is the most common form of asthma among Saudi children. 11.5% Saudi children have wheezing (Dawood et al. 2000). Nationally 10% of all Saudi children have bronchial asthma (Frayh et al., 1997). 95% of Saudi population has access to asthma medicines (Moamary, 2008). Doctor diagnosed asthma occurs in 4-17% of Saudi children (Hijazi et al., 1998). In 1995, 23% of children were declared asthmatic as compared to 8% in 1986 (Hijazi et al., 1998). 59% of children developed asthma due to smoking family members (Al Ghamdy, 2000). 48.5% of children had family history of asthma (Al Ghamdy et al., 2000). Approximately 88% asthmatic children experienced symptoms that severely affected their sleep, increased their stay in the hospital and increased school absence (Al Ghamdy et al. 2000). 18-30% Saudi population used Unconventional Treatment (UT) methods to cure asthma. Some of the risk factors have been mentioned below. RISK FACTORS ENVIRONMENT: Westernized Lifestyle: Saudi Arabia is a country that has developed rapidly over the past three decades owing to its petroleum power. A large majority of people live in large cities and have adopted a lifestyle quite different from their forefathers. However people have still maintained a traditional life style in the country districts and villages. Studies carried out in the past have proven the fact that doctor diagnosed asthma occurs in 4-17% of Saudi urban children. This is indicative of the fact that asthma is more common in those who have adopted a westernized lifestyle where dietary patterns include intake of antioxidants and fatty acids (Hijazi et al, 1998). In a study carried out in the past a comparison related to the prevalence of asthma between rural and urban children was carried out. The questionnaires investigated the relationship between the symptoms of asthma and different variables such as residential environment (rural or urban), sex and parental educational level. The results showed that as far as symptoms of asthma were concerned, dry cough was more common in Jeddah than in rural areas. In Jeddah asthma was more common in male children than in females. Wheezing severity remained the same in both sexes. In females nasal and skin symptoms such as itchy hands, nose and eyes were more common. On the other hand the most common symptom in rural areas were cough and exercise wheeze. Comparative study of the symptoms between rural and urban children indicated the fact that asthma was more common in areas where people had adopted westernized lifestyle (Hijazi et al. 1998). Indigenous population: The same questionnaire that is mentioned above was re analyzed for finding out the relationship of asthma with Saudi nationality. It was found that asthma symptoms were more among Saudi rural and urban children than the non Saudi children. Surprising was the fact that all the foreigners were Arabs and belonged to the Middle East region. Still the difference existed. Researchers have still not been able to identify the reason for the relationship between asthma and Saudi nationals (Hijazi et al. 1998). The above mentioned research clearly showed there is a difference in the occurrence of asthma symptoms among rural and urban dwellers, among male and females and among Saudi nationals and foreigners. At the same time no relationship was found between asthma and social and educational background of the child. Thus among Saudi nationals environment and lifestyles play an important role in determining the severity of asthma. Indoor Allergens: The most common indoor allergens in Saudi Arabia are House Dust Mites (HDM) (Dermatophagoides pteronyssinus and D. farina), cat fur, cockroach, sheep wool and goat and dog hair. HDM play an important role in enhancing the symptoms of bronchial asthma in patients. Mattresses and carpets are a common source of mites in a typical house environment. To understand the relationship between the mites and the severity of bronchial asthma skin prick tests of the patients from different Saudi cities were carried out. The cities included Abha, having mild climate and humidity around 80-90%, Jeddah, having hot climate with humidity around 90%, Qassim, agricultural region with humidity around 50-70% and Riyadh having hot climate and low humidity of 40%. The result showed that HDM species Dermatophagoides pteronyssinus and D. farinae were found in abundance in different regions of the country and its severity added to the severity of the symptoms of bronchial asthma. In Saudi Arabia people spend more time indoors as a part of tradition and due to hot climate. This results in greater exposure to indoor allergens. Thus the severity in the symptoms of bronchial asthma becomes more evident (Abdulrahman et al., 1997). Children having pets at home are also exposed to asthma. In a study conducted on children belonging to the dry region of Riyadh and coastal area showed 71.8% and 54% children allergic to cat fur, 39.4% and 34.5% allergic to cockroach, 26.7% allergic to sheep wool, 8.4% and 28.7% allergic to dog hair and 38% and 49.5% were allergic to cotton flock. All these allergens increased the symptoms of asthma among children. (Abdulrahman et al., 1997). Passive Smoking: Relationship between asthma and passive smoking was also studied in the past. Children having pets and family members smoking experienced symptoms of asthma. In 1986 and 1995, 17% and 35% of asthmatic children reported one or more family members smoking. The study indentified the fact that the number of children with one or more family member smoking doubled in a period of nine years (Frayh et al. 2001). Bronchial asthma was also found to be prevalent among boys in the city of Al Khobar where people were reported heavy and long time smokers (Dawood, 2000). Another study carried out in 2000 stated that 59% of children developed asthma due to smoking family members Al-Ghamdy et al. 2000). Diet: Diet is an important risk factor among asthma patients. Some studies were carried out in Saudi Arabia to find out the relationship between the different foods and prevalence of asthma. For that purpose dietary patterns of children from urban city of Jeddah and rural areas of Saudi Arabia were examined and studied. Both rural and urban children were evaluated as per the requirements laid down by the ISSAC. The result showed that atopy, family history and eating at fast food outlets played an important role in the prevalence of asthma among Saudi children. Since eating at fast food outlets was more frequent in urban cities so the greater prevalence of asthma with severity was noted there. At the same time lowest intake of milk, vegetables, fiber, vitamin E, calcium, magnesium, sodium and potassium were also declared as risk factors for wheezy illness. Lowest intake of vitamin E was stated to be linked with a threefold increase in risk as compared to other factors. This study is indicative of the fact that dietary patterns in childhood play an important role in understanding asthma. Studies all over the world have also proven the point that change in diet patterns has resulted in increased cases and severity of asthma (Hijazi et al. 2000). Family History: Children with family history of asthma are also at greater risk of asthma. Almost all the studies carried out on the topic have proven the point that family history is a risk factor. Approximately 48.5% asthmatic children reported to have a history of asthma in the family (Al Ghamdy et al., 2000). Research carried out on school boys in the city of Al Khobar stated that 35.5% asthmatic children had father with asthma, 27.7% reported mother with asthma and 7.8% reported sibling with asthma (Al Dawood et al., 2000). COMMON INTERVENTION STRATEGIES AMONG SAUDI POPULATION FOR THE PREVENTION OF ASTHMA: It has been observed that a common practice among Saudis is the use of unconventional treatment for the cure of asthma. Moamary (2008) interviewed 200 patients and found out the different strategies they used to counter asthma. Approximately 34.5% patients agreed to have used unconventional techniques. Older patients had greater tendency to adopt unconventional techniques (UT). UT was also common in patients with longer duration of asthma. 44.9% used more than one modality of UT. Less than 1% used the following modalities: caffeine, ginger (zingiber officinale), acupuncture, garden cress (Arabic: Rashaad), tea and mint. Recitation of the verses from the Holy Quran, herbs, honey and cautery were also used for the treatment of asthma (Moamary, 2008). Majority of the Arabs have strong faith in the unconventional treatment methods. Out of the interviewed patients 57% stated to have observed some benefits of the UT, 66.7% agreed to advise their friends to use the UT. 85.5% believed that conventional medicines were better than UT and 98% of the studied population continued to use conventional medicines along with UT. There has been no thorough research on the efficacy of the UT but to consider it useless would undermine its unexplored benefits (Moamary, 2008). Typical unconventional treatment used in a Muslim community includes the following: Recitation of the Holy Quran: It has been observed that Saudi people have strong faith in the verses of the Holy Quran which they frequently recite in order to cure asthma. Verses such as “If Allah touch thee with affliction, none can remove it but He; if He touch thee with happiness, He hath power over all things} (Quran; Sura no. 6: verse no. 17) and “O mankind!, there hath come to you an admonition from your Lord and a healing for the (diseases) in your hearts and for those who believe, a Guidance and a Mercy} (Quran; Sura 10: verse 57” have built strong faith among the Muslims in the healing power of God. Likewise honey, which has been stated in the Quran as a cure for all diseases is greatly used by the Saudis to counter all kinds of illness. Approximately one fourth of the study population used honey for asthma (Moamary, 2008). Blackseed is another herb that is used by Saudis for asthma and other diseases. Prophet Muhammad (SAW) stated fourteen hundred years back that blackseed had the healing powers against all diseases except death. Famous philosopher Ibn-e- Sina stated that blackseed “stimulates the bodys energy and helps recovery from fatigue or dispiritedness”. A Saudi report stated that the blackseed has “thymoquinone induced relaxation of guinea-pig isolated trachea, either alone or in combination with honey”. Some repots state that its bronchodilator effect helps the asthma patients (Moamary, 2008). Garlic is another herb used by the asthma patients in Saudi Arabia. Approximately 4.5% of the patient population stated to have used garlic to minimize the symptoms of asthma. It is considered useful as it improves the natural body defense against diseases and improves the chronic airway inflammation of the asthmatics. Caffeine is also believed to improve the airway function for at least four hours. It is considered as a weak bronchodilator. Some Saudis also consume tea and coffee to minimize the symptoms of asthma. A quarter of the population also used unknown mixtures given to them by the perfume (itar) makers. There has been no research carried out on the contents of the mixtures and it is believed that they might contain traces of asthma medications such as theophylline corticosteroids (Moamary, 2008). Other forms of UT used by Saudis include acupuncture, homeopathy and breathing techniques (Moamary, 2008). Strategies to Control Asthma: Saudi Arabia is a country that has invested a lot in providing health care facilities to its people. For that matter “Saudi Protocol” was conducted which focused on providing asthma education to the physicians. The aim of Saudi Protocol was to emphasize the use of anti inflammatory therapy as the most effective component of asthma treatment, encouraging the use of inhalation therapy over oral medicines, prescribing inhaled sodium cromoglycate for children with mild asthma and minimizing the use of ketotifen. The conference was conducted in 19 different cities of the country and 8% of the total physician population participated in it. Physicians were given lectures on different aspects of mild and chronic asthma. The results were studied by evaluation of the situation before and after the conference (Al Shimemery et al. 2006). It was observed that the basic reason for the deaths due to asthma was because of the lack of sufficient anti inflammatory therapy and over dependence on bronchodilators. The results of the conference indicated the fact that the physicians were doing the same which resulted in the increased mortality rate among asthmatics. Approximately 40-63% of the physicians also prescribed antibiotics. In Jeddah, under use of steroids in the emergency rooms was also observed. The Saudi Protocol in fact helped the physicians in improving the management of asthma in a better way. The physicians made better use of anti inflammatory therapy, inhalation therapy and ketotifen prescription was reduced almost to nil. Upon comparison of the management of asthma by the physicians it was found that they did better after attending the conference as compared to the situation before the conference. Educating the physicians actually helped the physicians in understanding asthma minimizing the severity of the symptoms among patients with chronic form of illness (Al Shimemery et al. 2006). Some other strategies have also been used by other countries that have helped them in controlling asthma among school children. One such strategy was used by Vermont Department of Health which emphasized on making an action plan for the patients by the physicians in collaboration with the school nurses. Another strategy was adopted by the San Diego City Schools where nurses were given the job to collect data on the health status of the students. The nurses were supposed to collect all the information such as rate of absenteeism, peak level and amount of medication etc. Based on this information peak flow and meter dose inhalers were given to those children who did not have them. The plan showed 0.2% decrease in severity of symptoms among school children. The third action plan was implemented in the African countries in which educating the masses about the risk factors of asthma was considered important. At the same time people trained about the use of asthma tools and how to distinguish between corticosteroid and long term beta 2 treatments. Keeping the Saudi environment in mind, in my opinion the best strategies would be those implemented in the San Diego Schools and the African countries. The strategy adopted by the Vermont Health Department, which demands of the physicians to chalk out plan for asthma management may not be that effective because in Saudi Arabia since 80% of the physicians are expatriates and therefore the language has always been a barrier to understand the problems of the patients in an appropriate manner (Al Ahmadi, 2005). Nevertheless it is important to educate the physicians because deaths due to asthma have been attributed in most cases to poor professional skills. A survey of physicians prescribing asthma medicines showed 65% children were under prescribed, 27% were given inappropriate medicines and 27% overlooked the drug interactions (Al Ahmadi, 2005). In such a situation, in my opinion it would be best to utilize the San Diego strategy in which the local school nurses would be able to help the children with asthma. Moreover Saudi Arabia is a Muslim country where male and female population is segregated. Therefore it would be difficult for the male physicians to access the female schools. In such a situation school nurses can best come to the rescue of the asthmatic patients. Training the patients for the management of asthma would be equally good for the management of asthma. To conclude Saudi Arabia is a rich country. Providing basic health facilities to the general public is one of the top most priorities of the Saudi government. The Saudi protocol is an effective method for the management and treatment of asthma since it has shown some good results. At the same time other strategies such as educating the patients and seeking help from the school nurses can be adopted to control asthma which can prove beneficial for the people of Saudi Arabia. References Abdulrahman S. Al-Frayh, Syed M. H, Mohammad O. G R, Bente S. Khalid Al-M , Sultan T, (1997). “House Dust Mite Allergens in Saudi Arabia: Regional Variations and Immune Response”, Annals of Saudi Medicine, Vol. 17. No. 2. Pg. 156-160. Al Ahmadi, H. Roland, M. (2005). “Quality of Primary Health Care in Saudi Arabia: A Comprehensive Review,” International Journal for Quality in Health Care, Vol. 17. No. 4. Pg. 331-346. Retrieved on October 25, 2008 from http://intqhc.oxfordjournals.org/cgi/reprint/17/4/331 Al- Dawood, K. (2000). “Epidemiology of Bronchial Asthma among School Boys in Al-Khobar City, Saudi Arabia: Cross Sectional Study.” Croatian Medical Journal, 41(4). Pg. 437-441. AL-Ghamdy Y S., AL-Haddad N S., Abdelgader  M H., Qureshi  N A., Saleh M A., Khalil M M. (2000). “Socioclinical Profile of Children with Asthma in Al-Majmaah Health Province.” Saudi Medical Journal, Vol. 21. Pg. 847–851. Al Shimemery A., Al-Ghadeer H., Giridhar H.,Al-Jahdali H., Al-Moamary M., Khan J., A-Mobeireek A., Wazzan A. (2006). “Impact of an Extensive Asthma Education Campaign for Physicians on their Drug Prescription Practices.” Vol.1, Issue 1. Pg.20-25. Frayh, A.R., Shakoor, Z., Rab, M.O.G., Hasnain, S.M. (March 2001). “Increased Prevalence of Asthma in Saudi Arabia”, Annals of Allergy, Asthma and Immunology. Vol. 86. Pg. 292-295. Hijazi N., Abalkhalil B., Seaton A. (1998). “Asthma and Respiratory Symptoms in Urban and Rural Saudi Arabia.” European Respiratory Journal, Issue 12. Pg. 41-44. Moamary MS. (2008). “Unconventional therapy use among Asthma Patients in a Tertiary Care Center in Riyadh, Saudi Arabia.” Annals of Thoracic Medicine, Vol.3, Issue.2. Pg. 48-51. “Saudi Arabia”, Country Cooperation Strategy at a Glance, World Health Organization. (2007). http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_sau_en.pdf Read More