The ISAAC program has provided a worldwide assessment of asthma symptoms prevalence by standard methods. Despite the use of standard questionnaires and validated study protocols, including those for the use and translation of questionnaires, difficulties in the comparability of information may unavoidably influence the results to some degree. For example, the questionnaires were translated into 39 languages, some of which had no colloquial terms for symptoms such as wheezing. For that reason, the video questionnaire has been shown to be more reproducible than the written questionnaire .
The aim of the current study was to translate ISSAC written questionnaire into Arabic and to find a suitable method of application of ISAAC asthma questionnaire to improve the perception and response of the middle (preparatory) school students in Al-Sharkiya Governorate as a step to update the Egyptian prevalence of asthma among children.
We conducted the study at hand on 175 students who were randomly selected from 6 middle (preparatory) schools in El-Sharkiya Governorate during March–April 2018, and we considered it as a pilot study to select the more suitable method to be applied on larger samples representing all the governorates. The age of the studied group ranged from 13 to 15 years with a mean of 13.71 years. Forty-one percent of the studied students were males, and 58.9% were females. Forty-eight percent of them lived in urban areas while 52% lived in rural areas, and the social class of the studied students according to Al-Gelany questionnaire was mostly moderate (46.3%) (Table 1).
Written questionnaire (WQ) only and written questionnaire preceded by ISAAC videos
We analyzed the students’ answers of the ISAAC asthma questionnaire, and we found that 40% of the studied group reported wheezy chest at any time in the past (first question) by using written questionnaire only, which decreased to 11.4% of students by using videos before filling written questionnaire (Table 2). The prevalence of lifetime asthma was 11.5% and 7.7% in Thessa Loniki and Athens regions of Greece, respectively ; 8.3% in Lebanon; and 11.3% in Cyprus , and that was in agreement with our result when we used videos before WQ.
Studying of the construct validity of the ISAAC written questionnaire as regards bronchial hyper-responsiveness symptoms demonstrated that the question regarding wheezing within the last 12 months (second question) had the highest sensitivity, specificity, and positive and negative predictive values, underscoring the idea that it was the key question for diagnosis and detecting the prevalence of current asthma . Accordingly, we considered the question for wheezing in the last 12 months (the second question) as the diagnostic one for current asthma and denoting its prevalence.
In our study, and by analyzing the students’ answers, 31.4% of the studied group reported wheezes in the last 12 months (current wheezy) by using WQ only, and the percentage of positive answers decreased to 5.1% when we used videos before WQ and we consider this result as our prevalence of asthma.
In comparison with our results, other Egyptian studies estimated the prevalence of the questionnaire diagnosed current asthma and revealed that the overall prevalence of childhood asthma was 7.7% in the Nile Delta region of Egypt , while in Cairo, 2006, it was 14.7% .
On the other hand, the prevalence records of current wheeze (the answers of question no. 2 in asthma questionnaire) among 13–15-year-old children in other countries of the Mediterranean, Middle East, and North Africa who participated in the ISAAC phase 3 were 14.5% in Malta, 10.4% in Morocco, 8.7% in Algeria, 13.2% in the Islamic Republic of Iran, 11.7% in Pakistan, 7.6% in Kuwait , 8.7% in Cyprus , and ranged from 3.9 to 6.5% in different Syrian centers .
According to the results of the second pilot (videos before WQ), we found that the prevalence of wheeze in the last 12 months was approximately the same as that in countries with low prevalence and approximately as half to that in countries with high prevalence, but according to the results of the first pilot (WQ only), the prevalence of wheeze in the last 12 months was three times higher than that of countries with high prevalence and approximately ten times higher than that of countries with low prevalence.
By analyzing the results of answers about asthma frequency (question no. 3) and severity (questions no. 4 and 5), the most common frequency of wheeze was from 1 to 3 times in the last 12 months (24.6% and 4% in the two pilots respectively). Sixteen percent and 3.4% of the studied students reported wheezes causing awakening from sleep less than one night per week in the two pilots, respectively, and the wheeze was severe enough to affect talking in 26.3% and 3.4% of them in the two pilots, respectively. In agreement with our results in the second pilot study, in the Syrian Arab Republic, the prevalence of severe speech-limiting wheeze ranged from 2.0–3.5% in 13–14-year-olds .
In our study, 40.6% and 12% of the studied students answered positively for self-reported asthma diagnosis by history (question no. 6) in the two pilots, respectively. Fifty-two percent and 12% reported wheezes after exercise (question no. 7) in the two pilots, respectively. Also, the answers showed that 54.9% and 9.1% of the students reported dry cough in the last 12 months (question no. 8) in the two pilots, respectively (Table 2).
Agreement between the written and video questionnaires
According to the ISAAC study group, the video and written questionnaires were completed approximately by 317,000 children in the 13–14-year age group in 38 countries. In general, the prevalence of wheeze in the last 12 months was higher in the WQ than that in the VQ and there were large variations in the prevalence of asthma symptoms between the WQ and VQ throughout the world . There is also a wide variation in the agreement between WQ and VQ among regions. The kappa value for the wheeze in the last 12 months was between 0.4 and 0.66 (moderate agreement) in only 20 centers, and in the other 79 centers that performed the study, it was less than 0.4 (poor agreement). The overall proportion of agreement (po) was high, ranging from 0.77 to 0.98, with a good negative agreement (0.8–0.99) but poor positive agreement (0.06–0.67). Agreement tended to be higher for English-speaking centers, with less variation in agreement than for other languages . In our study, the kappa value of the agreement for answers of question 2 (current asthma) was 0.006 indicating very poor agreement between the answers of WQ alone and the answers of WQ after showing VQ. These results are closely correlated with those of phase 1 of the ISAAC study group .
It was clear that the previous knowledge and experience about the asthma symptoms affected the agreement between the two methods of applying the questionnaire. Some of the studied children at first answered positively to the written questions, but then gave negative answers to the video. These children probably did not understand the written questions but recognized the symptom when they watched the video .
Other study reported similar result, but they differently explained it as some children may interpret the video sequence as being more severe than their experience of wheezing, by giving a positive answer to the written question and a negative answer to the video, and explained those who responded negatively to the written questionnaire but positively to the video were uncertain about the meaning of the written term wheezing but recognized the symptom when it was shown to them audio-visually .
From our observation, we preferred showing video scenes before WQ as in the second pilot and that was opposite to the ISAAC methods which stated that the video questionnaire must always be shown after the written questionnaire .