Assessment of quality of life in asthmatic children and adolescents: A cross sectional study in West Bank, Palestine.

BACKGROUND: Asthma is one of the most common chronic illnesses among children and adolescents. It can severely affect their quality of life (QoL). Our study assessed the QoL and analyzed potential risk factors for poor QoL among asthmatic children and adolescents.
METHODS: This was a cross-sectional comparative study. Pediatric Asthma Quality of Life Questionnaire (PAQLQ) was used to measure the QoL and Asthma Control Test (ACT) was used to evaluate asthma control. The Chi-square test and independent t-test were used to compare variables. We used Multivariate logistic regression to identify the association between determinants and outcomes. Statistical significance was set at p<0.05.
RESULTS: We recruited 132 participants. We found that 47 patients (35.6%) had controlled Asthma and 85 patients (64.3%) had uncontrolled Asthma. When compared to uncontrolled asthma individuals, participants with controlled asthma had improved QoL and scored significantly higher in the symptom domain (P = 0.002), activity domain (P = 0.004), emotional domain (P = 0.002), and overall PAQoL scores (P = 0.002). Hospital admission affects significantly all domains of PAQOL (P<0.05). Poor QoL was significantly associated with hospitalization for asthma (OR = 3.4; CI: 2.77-3.94, P = 0.01), disease severity (OR = 3.0; CI: 2.41-3.61, P = 0.01), uncontrolled asthma (OR = 2.88; CI: 2.21-3.41, P = 0.019), and male gender (OR = 2.55; CI: 1.88-2.91, P = 0.02).
CONCLUSIONS: The results of the present study showed that in children and adolescents, uncontrolled asthma, disease severity, and previously hospitalized patients were associated with poor QoL. These factors must be considered when planning a comprehensive care plan for a better quality of life.

Introduction

Asthma is ranked as the 14th most disability condition in the world, with 14% prevalence among children, posing a significant disease burden [1]. The past three decades have seen increases in both prevalence and severity of childhood asthma in particular, as indicated by increased hospitalization rates and asthma mortality [2, 3]. Beyond the global burden of the condition, frequent and episodic asthma attacks limit the ability of children to participate in normal activities and thus significantly affect their quality of life.

Among Middle Eastern children aged 13–14 years, asthma prevalence was reported to be around 7.6%, with the lowest rate in Iran (0.7%) and the highest in Iraq (22.3%, specifically in Bagdad). Meanwhile, an intermediate prevalence was observed in West Bank, Palestine (3.8%), but recent episodes of wheezing were higher (8.9%). Similar findings were obtained from nearby countries, such as Jordan, where the prevalence was 4.1% for asthma, and 8.3% for wheezing [4].

A poorly controlled asthma in a growing child may have detrimental effects on their emotional, intellectual, and physical development [5]. From a quality of life (QoL) perspective, it’s essential to direct management decisions to asthma control rather than its severity, ensuring the QoL improvement [6, 7]. A broad description of health-related QoL encompasses numerous dimensions, from general well-being and physical functioning or symptoms through mental health aspects such as cognitive, emotional functioning, and social well-being and functioning [8].

QoL assessment helps assess the burden of disease, offers new insights into the effects of risk factors, and is also a critical public health tool for evaluating health policy requirements, such as directing a strategic plan, decision-making concerning the utilization of funds, and assessing the efficacy of medical technology and public health initiatives. In assessing the QoL in children with Asthma, one of the most commonly used is the Pediatric Asthma Quality of Life Questionnaire (PAQoLQ), which provides insight into the patient’s perspective, their experience of chronic illness, the comparison of procedures, drugs, and other interventions [9], highlighting QoL enhancement the main objective of asthma management [10-12]. Children with asthma have QoL as reduced as children with other chronic diseases such as nephrotic syndrome, chronic kidney disease, and epilepsy [13-15].

Several studies investigating asthma control in children are from abroad, and there is a lack of local studies that extensively explore the problem in Palestine. Therefore, this study aimed to assess the QoL and analyze potential risk factors for poor QoL among asthmatic children and adolescents.

Methods

Study design

This was a cross-sectional comparative study on children and adolescents diagnosed with asthma at two primary governmental outpatient clinics in Ramallah and Hebron, West Bank, Palestine, from November 2020 to March 2021.

Study population and eligibility criteria

Asthmatic children and adolescents 6–17 years old who had been diagnosed by a physician at least 6 months prior were eligible for this study. A six-month period allowed adequate time to determine whether or not the children’s asthma was controlled and not identify other comorbidities. Children without confirmed asthma diagnosis, asthmatic children with acute exacerbation at the time of recruitment, and children with asthma aged less than 6 years and more than 17 years were excluded.

Sampling

We calculated a minimum sample size of 130 using a sample size calculator (see http://www.raosoft.com) to achieve a 5% margin of error, 95% confidence interval, and 80% response rate for 280 patients in the 2 clinics. We used a simple random sampling technique to recruit 132 participants.

Data collection instrument

A structured, self-administered questionnaire was used for data collection. The questionnaire consisted of three sections: 1) demographic characteristics and clinical information, 2) the Asthma Control Test (ACT), and 3) the PAQLQ. Asthma control was evaluated using the ACT, a validated, internationally recognized asthma control assessment tool [15, 16]. Its questions use a 5-point Likert-type rating scale and assess both daytime and nocturnal asthma symptoms, use of rescue medications, and the effect of asthma on daily activities for the last four weeks. The scores range from 5 (poor control of asthma) to 25 (complete control of asthma), with higher scores reflecting greater asthma control [15]. The internal consistency reliability of the ACT survey was 0.85, measured by Cronbach’s alpha. A score of <19 points indicates uncontrolled asthma, and ≥ 19 indicates controlled asthma.

Children’s quality of life was measured using the PAQLQ, a validated self-reported questionnaire consisting of 23 questions spanning three domains (symptoms, activity limitation, and emotional function) [17]. Five questions evaluate the distress activities, ten questions are about the discomfort caused by asthma attacks, and eight questions inquire about the emotional function by assessing how asthma frustrates, scares, annoys, or upsets the patients [17, 18]. Responses are rated on a 7-point Likert scale ranging from 1 (most severe impairment) to 7 (no impairment at all). The arithmetic mean of the answers to the 23 questions is determined to give the total score [17, 18], for which a higher score indicates better quality of life. PAQoL score ranges from minimal or no impairment (≥ 6.0) to severe impairment (< 3.0) [19]. PAQoL is reproducible in patients who were stable with an intraclass correlation coefficient (ICC = 0.95), which also indicates the instrument’s strength to discriminate between subjects of different impairment levels.

Data collection measures

The study investigator and clinical pharmacists working at the study sites recruited eligible children and adolescents and matched them with one main caregiver (father, mother, others) who accompanied them and consented, on their behalf, to participate in the study after receiving all information about the study aim and objectives. The participants completed the questionnaires in 15 to 20 min, with 80% completing the questionnaire in 15 min or less.

Statistical analysis

Statistical analysis was performed using SPSS software (version 25; SPSS Inc., Chicago, IL, USA). The chi-squared test was used to measure the relationship between categorical variables, and the independent t-test to measure the association between the means of continuous variables. Descriptive statistics were performed using means and standard deviations for numerical data and as summary frequencies and percentages for categorical data. ANOVA and other Tests were used as appropriate. In statistical tests, P-values ≤ 0.05 were considered to be statistically significant.

Ethical approval

This study was approved by the Research Ethical Committee of Al-Quds University (Ref No: 164/REC/2020). Approval for data collection was obtained from the Palestinian Ministry of Health in Ramallah and Hebron, Palestine. Study details were provided to each patient and their parents (father or mother) with the information about the right to withdraw at any time. Caregivers gave written consent, and children gave verbal consent before data collection. Confidentiality was ensured by the anonymity of the questionnaires and no disclosure of information collected to anyone outside the study. The study was conducted following the Declaration of Helsinki.

Results

Participants’ characteristics

A total of 132 children (6–17 years old) participated in the study. The mean age was 8.6 ± 3.0 years, and 79 (59.8%) were boys. Only one-third of the parents, either fathers or mothers, had a university education, 40 (30.3%) and 46 (34.8%), respectively. All participants’ mean duration of asthma was 30.9 ± 19.4 months, and most of the parents were smokers, 101 (76.5%). Clinically most of the patients were taking Short-Acting Beta Agonists, 101(76.5%), and two-thirds were taking ICS, 88 (66.6%). More than half of the participants, 75 (56.8%), had a history of asthma-related hospital admissions (Table 1).

Table 1

Patient characteristics and univariate analysis results.

Variable n (%)	All patients (132)	Controlled asthma (47)	Un-controlled asthma (85)	P-value
Gender
Male	79(59.84)	29(61.70)	50(58.82)	0.74¥
Female	53(40.15)	18(38.29)	35(41.17)
Age
6–9 years	85(64.39)	32(68.08)	53(62.35)	0.77¥
10–14 years	35(26.51)	13(27.65)	23(27.05)
14–17 years	12(9.09)	3(6.38)	9(10.58)
Father’s education
Illiterate/elementary	24(18.18)	5(10.63)	19(22.35)	0.04¥
School-level	68(51.51)	34(72.34)	34(40)
College/university level	40(30.30)	28(59.57)	12(14.11)
Mother’s education
Illiterate/elementary	26(19.69)	4(8.51)	22(25.88)	0.02¥
School-level	60(45.45)	14(29.78)	46(54.11)
College/university level	46(34.84)	29(61.70)	17(20)
BMI
Underweight	71(53.78)	26(55.31)	45(52.94)
Normal	46(34.84)	14(29.78)	32(37.64)	0.45¥
Overweight	10(7.57)	6(12.76)	4(4.70)
Obese / ≥ 95th percentile	5(3.78)	1(2.12)	4(4.70)
ED visit last year
0	25(18.93)	15(31.91)	10(11.76)	<0.001¥
1–2	75(56.81)	25(53.19)	50(58.82)
≥ 3	32(24.24)	7(14.89)	25(29.41)
Smoking exposure at home
Yes	101(76.51)	29(61.70)	72(84.70)	0.01¥
No	31(23.48)	18(38.29)	13(15.29)
School absenteeism
Yes	89 (67.4)	23 (48.9)	66 (77.6)	0.01¥
No	43 (32.6)	24 (51.1)	19 (22.4)
Medications
SABA	101(76.51)	36(76.59)	65(76.47)	0.53
ICS	88(66.66)	30(63.82)	55(64.70)	0.41
Nebulizers	57(43.18)	20(42.55)	37(43.52)	0.53
Interleukin modifiers	20(15.15)	8(17.02)	12(14.11)	--
Anticholinergics	16(12.12)	8(17.02)	8(9.41)	--
Systemic steroids	45(26.51)	11(23.40)	34 (40.0)	0.01
Duration of asthma (months ±SD)	30.9 ± 19.4	30 ± 19.4	32.2 ± 20.1	0.6*

Qol: Quality of Life.

¥: Chi-square test for categorical groups.

*: T-Student Test.

Level of asthma control

We divided participants into two groups based on their ACT scores: controlled asthma (ACT score≥ 19) and uncontrolled (ACT score <19). Most (67%) participants with controlled asthma had mild asthma, 22% had moderate asthma, and 11% had severe asthma. In contrast, 53% of participants with uncontrolled asthma had mild asthma, 26 had moderate asthma, and 21% had severe asthma. Uncontrolled asthma was significantly related to lower parents’ education levels (p = 0.04 for father education and p = 0.02 for mother’s education), frequent hospital ED admissions (p = 0.001), smoking exposure at home (p = 0.001), school absenteeism (p = 0.001), and systemic steroids use (p = 0.001) (Table 1).

Quality of life (QoL)

The most common restricted activity during the week preceding the study among patients was playing with friends (19.05%), followed by playing football (13%) and walking (12.1%) (Fig 1).

Fig 1

Common activities affected by asthma.

The overall PAQoL score was significantly higher in the controlled asthma group (Mean = 4.37) (p = 0.002) than in the uncontrolled asthma group (Mean = 3.56). The controlled asthma group also scored higher on all components indicating better symptoms control (P = 0.002), lower activity limitation (P = 0.004), and better emotional state (P = 0.002) compared to the uncontrolled asthma group (Table 2).

Table 2

Effect of asthma control on PAQoL scores.

The Dependent Variables	Asthma Control	N	Mean	Std. Deviation	t	P*
Overall PAQOLQ scores	Uncontrolled Asthma	85	3.56	1.18	-3.14	.002
	Controlled Asthma	47	4.37	1.54
Score of symptoms	Uncontrolled Asthma	85	4.51	1.15	-3.15	.002
	Controlled Asthma	47	5.29	1.47
Score of activity limitation	Uncontrolled Asthma	85	2.68	1.26	-2.96	.004
	Controlled Asthma	47	3.52	1.72
Score of emotional function	Uncontrolled Asthma	85	4.24	1.27	-3.17	002
	Controlled Asthma	47	5.07	1.51

* Independent Samples T-Test

A significant difference was found in symptoms severity, activity impairment, and emotional function. Few participants in the controlled asthma group (4%) had severe symptoms compared to those in the uncontrolled asthma group (15%). Severe activity impairment was reported by the majority (66%) in the uncontrolled group, whereas, in the controlled group, it was reported by 40%. Moderate emotional impairment was higher in the uncontrolled asthma group (84%) than in the controlled asthma group (61%) (Fig 2).

Fig 2

The distribution of the degree of impairment reported by the patients in the PAQoL components (symptoms, activity, and emotional domains) by levels of asthma control.

Participants with no hospital admission history for asthma scored significantly higher (Mean 4.4) (p = = 0.001) in QoL than participants with a history of one or more hospital admissions (Mean = 3.1). Hospital admissions didn’t significantly affect school attendances. However, school absenteeism was significantly associated with lower PAQoL symptoms (p = 0.01) and emotion function (p = 0.04) scores (Table 3).

Table 3

Effect of hospital admission and school absenteeism on patients’ QoL scores.

	School absenteeism	Mean ± SD	t-test	P	Hospital admission	Mean ± SD	t-test	p
Overall PAQoL scores	No	4.1 ± 1.12	1.7	0.07	No	4.4 ± 1.92	3.1	0.01
	Yes	3.6 ± 1.13			Yes	3.1 ± 1.22
Score of activity limitation	No	3.2± 1.21	0.9	0.13	No	3.9 ± 1.18	3.3	0.01
	Yes	2.9 ± 1.14			Yes	2.6 ± 1.11
Score of symptoms	No	5.2 ± 1.17	2.4	0.01	No	4.3 ± 1.32	2.8	0.01
	Yes	4.5 ± 1.41			Yes	3.2 ± 1.24
Score of emotional function	No	4.9 ± 1.22	2.0	0.04	No	4.3 ±1.31	2.8	0.01
	Yes	3.9 ± 1.19			Yes	3.1 ± 1.17

PAQoL: Pediatric asthma quality of life; P < 0.05: Significant; SD: Standard deviation

Male gender, hospitalization for asthma, asthma severity, and control were significantly associated with poor QoL (p<0.05). The hospitalization had the strongest association with the QoL (OR = 3.4; CI: 2.77–3.94), followed by asthma severity (OR = 3.0; CI: 2.41–3.61), uncontrolled asthma (OR = 2.88; CI: 2.21–3.41) and male gender with the weakest association (OR = 2.55; CI: 1.88–2.91) (Table 4).

Table 4

Risk factors associated with poor QoL (Multiple regression analysis).

Variables in the Equation
	B	S.E.	OR	p-value	95% CI
Gender (Male)	0.93	0.381	2.55	0.022	1.88–2.91
Hospitalization	1.22	0.588	3.4	0.010	2.77–3.94
Age	-0.193	0.439	0.825	0.661	0.11–1.21
History of Asthma	0.113	0.764	1.12	0.584	0.56–1.43
Asthma severity	1.09	0.54	3.0	0.011	2.41–3.61
Duration of Asthma	0.086	0.101	1.09	0.611	0.44–1.68
Fathers’ education	0.166	0.451	1.18	0.580	0.71–2.01
Mothers’ education	0.26	0.611	1.30	0.191	0.87–1.79
Systemic Steroids	0.111	0.199	1.11	0.24	0.73–1.94
BMI	-0.127	0.439	0.88	0.677	0.43–1.46
Smoking exposure	0.190	0.494	1.21	0.211	0.69–2.10
Asthma control *	1.06	0.491	2.88	0.019	2.21–3.41

*Uncontrolled asthma, CI: Confident interval, OR: Odd Ratio. S.E: Standard error, B: the regression weight.

Discussion

According to our knowledge, this is the first study to assess the QoL and associated factors among Palestinian children and adolescents with asthma. Moreover, our study took into account the asthmatic children and adolescents and their parents’ reports. As such, its findings represent the quality of life from the participants’ and their parents’ perspectives.

All three PAQoL domains (activity, symptoms, and emotional function) were affected by uncontrolled asthma, with activity being the most affected (p = 0.004). Similar findings were reported in different studies on Saudi asthmatic children and adolescents [20] and Swedish asthmatic children aged 7–9 years old [21]. In Nigeria, a survey on asthmatic children and adolescents revealed that participants were concerned about exacerbations and associated daily life activity limitations [22]. However, some other studies found the symptoms domain to be the most affected [22, 23]. This discrepancy could be attributed to the exclusion of patients with exacerbations or any related symptoms, which could impact the perceived QoL.

Only 47 (35.6%) of our study participants had controlled asthma, similar to the reported 30% of patients with asthma having controlled asthma status in a survey of 7236 asthmatic patients from the Middle East and North Africa [24]. Participants reported low quality of life, which had a direct association with disease severity and control. Asthma control is directly linked to a patient’s physical and emotional capability and their QoL [25, 26]. Another study from Egypt revealed that asthmatic children and adolescents with controlled asthma had higher PAQoL scores than their counterparts with uncontrolled asthma [27]. Garina et al. conducted a study on Indonesian asthmatic adolescents aged 12–14 years old. They found correlations between the total PAQoL score and asthma severity (p<0.001, r = −0.5) and the level of asthma control (p<0.001, r = 0.6) [28].

The observed decrease in all domains of the PAQoL score among children having asthma-related hospitalizations implies that, in the case of poor asthma control with more frequent symptoms, physical activity is low, and patients are more emotionally affected, hence the lower PAQoL scores [19, 29]. Similarly, a study of asthmatic patients conducted in Australia found a strong association between the number of hospital admissions and poor QoL [30]. Another study carried out in the USA using the Child Health Questionnaire Parental Form-28 identified strong associations between asthma severity and pediatric asthma with poor QoL [31]. Another indicator of poor asthma control in children is school absenteeism, which is associated with lower PAQoL scores, particularly in our study participants’ PAQoL symptoms and emotional domains scores. These findings align with Dean et al. findings of a strong correlation between school absenteeism with poor QoL in the USA [32].

Multivariate analysis revealed the association between the male gender and poor QoL. Contrary to our findings, Indinnimeo et al. found that female patients were more likely to have poor QoL than male patients. He attributed that to a higher proportion of females in his study with exposure to secondary smoking [33]. Our study also indicated that exposure to secondary smoking was significantly related to more uncontrolled asthma cases (p = 0.001) (Table 1).

Our analysis did not identify increased BMI as having any significant effect on asthma control or PAQoL scores. Several previous studies reported lower QoL and asthma control scores among asthmatic children and adolescents with increased BMI [34-36]. Our study indicated no significant effect of higher BMI on asthma control or PAQoL scores. This might be due to a higher percentage (88.62% for underweight and normal weight) of patients with low BMI in our sample.

Limitations

We recruited children with asthma who had attended primary care units, thereby excluding patients in hospitals with relatively more severe asthma. Consequently, our study sample may not represent all children with asthma, and our findings may not be generalized to the asthmatic population in Palestine at large.

Our study was questionnaire-based and relied on self-reports, which makes it prone to recall bias, as such overestimation or underestimation of asthma control or quality of life by participants.

This was a cross-sectional study. Therefore, causal associations cannot be drawn between the factors examined here. Prospective follow-up studies are recommended to confirm the results.

Conclusion

This study highlighted that participants had poor QoL. The unique needs of asthmatic children and adolescents must be considered when planning a comprehensive care plan for a better quality of life, with particular emphasis given to uncontrolled asthma, disease severity, and previously hospitalized patients as there are the most prominent risk factors for poor QoL. Further research on the factors contributing to poor asthma control, the psychological effects of asthma, hospitalized patients, parents’ quality of life, and the importance of screening for behavioral problems among asthmatic children is recommended.

Univariate and multiple regression analyses evaluating the association of quality of life and clinical variables.

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Reviewer #2: General comments

The authors conducted a cross-sectional study whose aim was to investigate the quality of life (QOL) of children and adolescents with asthma. One hundred and thirty-two (132) participants were evaluated with the validated asthma control test (ACT) questionnaire and the pediatric asthma quality of life (PAQOL) questionnaire. The major finding was the low QOL scores seen among children with uncontrolled asthma. Although an interesting study (given the novelty in the authors’ clime), the authors need to address and clarify some major and minor issues on the manuscript for its improvement. For instance, the authors should state clearly the research question. Did they investigate if asthma control and severity affect QOL in children and adolescents with asthma? Or if there is a difference in the QOL between children with controlled and uncontrolled asthma?

Specific comments

Major issues

1. Abstract: For a manuscript of this nature (in line with the journal’s guidelines), I thought it should have been a structured abstract rather than an unstructured abstract. In line with the former, a background or introduction to the study should have been the first subheading. Under this subheading, the authors should have stated the research problem or gap they sought to solve or fill. I find the conclusion of the study findings rather curious. The authors stated: ‘Palestinian asthmatics children have surprisingly low quality of life, especially children with uncontrolled asthma.’ Were the authors not expecting children with uncontrolled asthma not to have low QOL? They should recall that they mentioned in the results that factors that affected QOL included disease severity, uncontrolled asthma etc.

2. Introduction: The first sentence needs referencing. The third sentence suggests (rightly so) that children with uncontrolled asthma have low QOL scores. Thus, I suggest the authors should mention previous studies on the QOL of children with uncontrolled asthma, and the QOL instruments used, the flaws (if any) on their use, and the advantage of using their chosen QOL instrument. These facts should form part of the justification of their present study. I do not agree with the statement before the study objective which read: ‘Although the treatment objectives for asthma are relative clear, the relationship between the asthma and the QOL of children is still not well-understood topic’ Rather, it is well documented that children with asthma has reduced QOL like children with other non-communicable chronic diseases such as nephrotic syndrome, chronic kidney disease and epilepsy.

3. Methods: The authors stated that the study was ‘a cross-sectional, analytical clinical.’ They should clarify the phrase. I would prefer to call the study ‘a cross-sectional comparative study’. It appears the authors compared the QOL of children with controlled asthma with that of children with uncontrolled asthma. Although the authors stated the sample size calculation and the inclusion/exclusion criteria, they failed to indicate their sampling method. The third item in their exclusion criteria were children who had difficulty in understanding the questionnaire. Why should it be so when the ACT questionnaire was administered by parental proxy? On the other hand, the PAQOL questionnaire was directly administered (self-administered) to the patients who were aged 6-17 years. Were the younger age groups able to understand the questions related to all the domains? Wouldn’t interviewer-administration have been a better option? Why was a non-generic health-related QOL questionnaire like PedsQLTM 4.0 Generic Core Scale not used as part of the study instruments? Given that asthma causes psychosocial disorders in children, this tool would have properly evaluated the psychosocial domain of the patients, which PAQOL could not achieve.

4. Results: This section was not clearly defined in the manuscript. I guess it started with the subheading titled ‘Patient characteristics’. The first sentence under the subheading is vague- ‘Of the 188 patients approached for this study, a total of 132 agreed to take part (response rate 70.2%).’ Was informed consent applicable to all the patients (stated age range of the patients was 6-17 years? The sentence also exposed the absence or the lack of clarity in the employed sampling method? The stated mean age was 8.6 ± 3.0. Was it in years or months? Table 2 appears redundant. I think the prose suffices. The title of Figure 1 should be modified for clarity. The subheading titled ‘The association between PAQOL, hospital admission and school absenteeism’ should be replaced by the title of Table 4 which aptly captures the discussion better. In Table 5, what is the meaning of the abbreviation ‘B’ and ‘Sig.’ for the variables predicting lower PAQOL scores?

5. Discussion: This section appears poorly written. In order to provide a robust discussion, I advise the authors to re-write this section using the following suggestions: (1) paragraph one should comprise a summary of the major research gap or problem they are trying to fill or address and its importance (2) paragraph two should provide a critical analysis of the major findings of the study and how they compare with previously published studies (3) paragraph three should discuss additional findings and how they fit with existing literature (4) paragraph four should be on study limitations (5) paragraph five can focus on future research directions (6) the last paragraph should be the overall conclusion and the major impact of this study (how does your study address the research question or fill the research gap?).

Minor issues

1. Several syntax and grammar errors litter throughout the manuscript. Given that the authors may not be from native English-speaking environment, I advise an English-language editing of the manuscript to make it polished.

Reviewer #3: Thank you to give me the chance to review the research paper “Assessment of quality of life in asthmatic children and adolescents: A Cross sectional study in West Bank, Palestine. The study is well organized and written, however, I have some comments which I hope the authors would consider to improve the quality of the manuscript.

Abstract

- Please rephrase the objective to become clearer

- In the abstract section No need to mention Inc., Chicago, IL, USA [optional]

- As the beginning of the paragraph please rephrase “ This indicated a better symptoms

- Control”

Introduction

- Could you add a paragraph to show the level of asthma control among pediatric in Palestine?

- As the last paragraph in the introduction of your study , rephrase the sentence to be fit with the aims in your study in Palestine

Methods

- In the ACT test would you mention the original validity and reliability of the questionnaire and NOT only at your setting

- Same to Qol questionnaire the original validity by the publisher

- Elaborate more, what was the average interview time or how long it took to complete the survey

- Were the pilot findings included in the study analysis? Not clear

Results

- You mentioned Number / % in some points you mentioned only %. Please be consistent

- In the text mention exactly the P-Values as expressed in the Table 4

- Also explain the numbers between brackets are percentages or SD

-

Discussion

- Rephrase “ Another indicator of less well-controlled disease is school absenteeism, which is likewise”

- The abbreviation of PQOL and Qol. please modify the manuscript accordingly

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Reviewer #2: Yes: Samuel Uwaezuoke

Reviewer #3: No

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Submitted filename: Reviewers comments for PLOS ONE (QOL scores for asthma).docx

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3 May 2022

Response to editor and reviewer comments was uploaded in this submersion

Submitted filename: Response to the reviewers.docx

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30 May 2022

31 May 2022

Revision 2

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Due to major revision in the first manuscript, 3 references were retracted and replaced with new references in revision 1. However, now all references are relevant and cited in the main text.

Reviewer #1: After reframing the abstract, objectives, results, and the discussion the study provides a valid conclusion that may help in planning a compressive care program for pediatric asthmatic patients.

Thank you

Reviewer #2: You have substantially addressed my concerns about your manuscript. However, painstakingly go through your abstract section again to ensure that the information there is clear and aligns with the body of your manuscript. For instance, the following statement lack clarity- 'The participants with controlled asthma significantly score higher in symptoms control (P= 0.002), activity (P=0.004), emotional state (P=0.002) and in all over PAQoL scores (P=0.002) among control group.' The control group mentioned here, I guess, refers to uncontrolled asthma group.

The sentence was amended and clear. Controlled asthma (mean better controlled) and score higher (better quality of life domains)

When compared to uncontrolled asthma individuals, participants with controlled asthma had improved QoL and scored significantly higher in the symptom domain (P=0.002), activity domain (P=0.004), emotional domain (P=0.002), and overall PAQoL scores (P=0.002)

The 'cross-sectional analytic' study under Methods should align with 'Cross-sectional comparative' study mentioned in the body of the manuscript

The sentence was amended accordingly

Submitted filename: revision 2 letter.docx

Click here for additional data file.

15 Jun 2022

Assessment of quality of life in asthmatic children and adolescents: A Cross sectional study in West Bank, Palestine

PONE-D-22-00022R2

Dear Dr. Khdour,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all the concerns and have made relevant changes to the manuscript. These amendments have increased the clarity of the abstract.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Samuel Uwaezuoke

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20 Jun 2022

PONE-D-22-00022R2

Assessment of quality of life in asthmatic children and adolescents: A Cross sectional study in West Bank, Palestine

Dear Dr. Khdour:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Tai-Heng Chen

Academic Editor

PLOS ONE