|Abdel-Hady El-Gilany *
College of Medicine, Mansoura University, Egypt
|Corresponding Author: Abdel-Hady El-Gilany, College of Medicine, Mansoura University, Egypt, E-mail: [email protected]|
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Objectives: To estimate the prevalence of the common self-reported chronic diseases among adolescent students in public secondary schools in Mansoura, Egypt.
Methods: This is a cross-sectional study conducted on a sample of 1493 adolescent students. Thirty clusters were selected to cover both general and vocational public schools of both sexes in urban and rural areas. A self-administered questionnaire was used to collect sociodemographic data from the students and their families, as well as a checklist of 15 chronic diseases.
Results: About 6% of students reported one or more chronic somatic disease. The most frequent are acne vulgaris (4.2%), rheumatic heart disease (3.4%), refractive errors (1.4) and bronchial asthma (1.1%). This pattern does not show significant differences between males and females.
Conclusions: Despite the self-reported nature, our findings indicate that Egyptian adolescents are not healthy as it is often considered.
|Chronic diseases, public schools, rheumatic heart disease, Egypt|
|Running title: Chronic diseases among adolescent students|
|WHO considers adolescence as the period between 10 and 19 years. Today, approximately one-fifth of the world’s populations are adolescent, with more than four-fifths in developing countries. Health of adolescents has been somehow neglected in the past, perhaps because, as a group, they are perceived to be relatively disease free1. There is a growing interest in assessing adolescent health because mortality and morbidity rates for adolescents in Western countries have increased in the past few decades2. Improvements in therapeutic possibilities in developed countries in the last few decades have led to increasing numbers of children and young adults who have survived congenital, perinatal or other severe medical conditions3. Therefore, the prevalence of chronic diseases in children and in young adults has increased since the 1980s and still likely to increase further4.5.|
|Prevalence of chronic diseases in children ranges from 0.22 to 44%, depending on the operational definitions used5,6. Self-reported health indicators seem to be more appropriate and more efficient in surveys of health status in adolescence than health indicators based on medical records or medical statistics7.|
|There is no information about the prevalence of chronic diseases among adolescents in Egypt. Moreover, we know very little about the Egyptian adolescents, especially about self-reported health problems. The objectives of this study are to determine the prevalence and types of chronic somatic diseases among secondary school adolescent students in Mansoura, Egypt.|
|This is a cross-sectional study carried out during the period October 1, 2010 –November 1, 2010 in Mansoura, the capital of Dakahlia governorate, Egypt, located on the river Nile in the northeast of the Delta. Approval of the local directorate of education and school administration was obtained. The survey was carried out among secondary school students enrolled in general and vocational public schools.|
|Sample size was calculated using Epi-Info, version 6.02. The total number of students registered in the public secondary schools of Mansoura district was about 650 000 (according to the directorate of education). The pilot study on 200 students (not included in the full-scale study) indicated that about 5% of students reported one or more chronic disease. With the worst acceptable level 4%, the sample needed for the study was estimated to be at least 1472 at 95% confidence level.|
|Secondary schools in both educational zones (eastern and western zones) in Mansoura city as well as the rural sector were included. One general secondary school for girls and 1 for boys were randomly selected from each zone (i.e. 4 general schools in the urban sector) as well as 1 mixed school from the rural sector. Five vocational schools (1 commercial school for boys and 1 for girls; 1 industrial school for boys and 1 for girls and 1 mixed agricultural school) were selected from Mansoura city. This distribution covered all social strata, both sexes, and included both urban and rural sectors of the community.|
|From each selected school, 1 class (cluster) from each grade was randomly selected, i.e. 30 classes in all, 10 from each grade. A total of 1533 students were registered in these classes and 1493 (response rate of 97.4%) participated in the study. The others were either absent (2.2%) or refused to complete the questionnaire (0.4%).|
|With the help of the school authorities, the investigators spent 30–40 minutes in each class. Students were briefed about the study, encouraged to participate and to express their experiences. It was emphasized that all data collected was strictly confidential and the students gave fully informed verbal consent to participate.|
|Students were then asked to complete a selfadministered questionnaire on family and personal background. Socioeconomic status was calculated according to Fahmy and El- Sherbeny8. This score encompasses paternal education and work, family size, housing condition and per capita monthly income. All students were requested to check a list of 15 somatic chronic diseases, other than dental problems, which are prevalent in adolescence. The responders were asked whether or not they had suffered from any of these documented physician-diagnosed somatic health problems for more than 3 months duration, for which the student is on continuous or intermittent management.|
|Data were analysed using SPSS, version 16. Categorical variables were presented as number and percent and quantitative variables were presented as mean ± SD. Chi squared test was used for comparison between groups. P ≤ 0.05 was considered significant.|
|Data of 1493 (706 males and 787 females) students were analyzed. Their age ranged from 14 to 21with a mean of 15.8 ±1.1 years. Table (1) shows that majority of students (43/0%) were enrolled in general secondary school and belong to families of low or very low socioeconomic status (63.5%). About 6% of students reported one or more chronic disease. The most frequent are acne vulgaris (4.2%), rheumatic heart disease (3.4%), refractive errors (1.4) and bronchial asthma (1.1%) (table2). This pattern does not show significant differences between males and females (data not shown).|
|Chronic diseases are the leading cause of mortality and morbidity and they will represent an even larger burden in the future. Nowadays, young and middle-aged people are affected by chronic conditions. The economic implications of such diseases are also serious9. Our findings show that self-reported chronic diseases are not uncommon among adolescents. More than 6% of studied adolescents reported one or more chronic diseases. This low rate, compared to studies in developing countries, could be attributed to different operational definitions of chronic diseases in different studies. Obviously the measurement of the prevalence rates of chronic conditions depends on the access to health services. If access is limited, a number of patients will remain undiagnosed. However, this is a problem of ascertainment; it does not mean that these people do not fit the definition of having a chronic condition3. Behavioural and mental disorders were not included in our list of chronic diseases. Much higher rates were reported from developed countries. Epidemiological data from several countries seem to agree that 10-15% of the adolescent population have chronic diseases6. Much higher rates were reported from USA (31%)9, Netherlands (37.9%)10, and Slovakia (50%)7. No data are available from the developing countries.|
|Skin problems are common among adolescents whether self-reported or clinically diagnosed11. Acne vulgaris is the frequently reported chronic disease (4.2%). The prevalence is intermediate compared to the prevalence of self-reported skin disease in different countries. A lower rate were reported in Sudan (3.2%)13. A much higher rate was reported in Slovak (7.2% for boys and 11.0% for girls)7 and Dutch adolescents (11.0%)11 .|
|An important finding is that 3.4% of students reported that they have rheumatic heart disease. This reflects the widespread of streptococcal infection and rheumatic fever during childhood with inadequate treatment among students belonging to families of low and very low socioeconomic status. Rheumatic fever /rheumatic heart disease comprise a unique disease entity that spans the infectious and post-infectious chronic disease paradigm14. Rheumatic fever remains a disease with great morbidity and mortality in most low-and middle-income countries, despite having been nearly eradicated in high income countries. It is therefore a neglected disease and a disease of poverty. Despite the presence of effective primary and secondary prevention, treatment and rehabilitation methods, rheumatic fever and rheumatic heart disease continue to wreak a heavy toll on developing countries14-17. The prevalence of heart defects was 1.6% in adolescent males, in Israel18, and 1.5% in American adolescents4.|
|Refractive error is the third common selfreported chronic diseases in our study, accounting for 1.4% of adolescent students. A previous survey in Cairo, reported refractive errors in 22.1% examined students 19. The reported rate among Indian adolescents was 13.8%20.|
|Asthma is the most common chronic disease of childhood worldwide; the prevalence of asthma among children has increased steadily during the past two decades21-22. The selfreported bronchial asthma was 1.1%. Several factors that are highly prevalent in the study locality may predispose children to acquire asthma, including crowded houses and classrooms, low income level and frequent exposure to environmental allergens. A lower rate was reported from India (0.86%)20, Slovak (1.0% for boys and 2.2 for girls)7. Higher rates were reported from other studies; in Sudan (3.2%) 13, in USA (4.25%)4, in Alaska Native students (7.4%)23, in Dutch (12.6%)11, and in Israeli males (11.2%)18.|
|Headache/migraine and epilepsy are neurologic problems reported by 0.6% and 0.1% of students, respectively. The corresponding rates were 2.5% and 0.24% (in USA)4; 5.6% and 0.6% in Dutch11; 0.1% and 0.6% for boys and 3.0% and 6.7% for girls in Slovak (Geckova et al, 2001)7; respectively. Headache and epilepsy are the commonest neurologic disorders among Israeli male adolescents18,24.|
|In conclusion, chronic somatic illnesses are not uncommon among adolescent students. School health team should provide long-term integrated care for those students with chronic diseases, consider their requirements and provide adequate information. Rheumatic heart disease is still a common problem in Egypt. Early diagnosis and appropriate treatment of streptococcal infection is most effective primary prevention method of this disabling chronic condition.|
|It is important to direct efforts of primary health care workers for early detection of chronic somatic disease in adolescents. It is important to develop more systematic procedures to monitor students and adolescents with chronic conditions.|
|Study limitations: The study included only adolescents enrolled in public schools. Students in private school, in schools for students with special needs and out of school adolescents were not included. The selfreported nature of the chronic disease is another limitation. Only physician-diagnosed diseases were reported. However, reporting of chronic disease will be influenced by health care use; for example, adolescents of lower socioeconomic status may under-reportchronic illness because of lower rates of health care use. Despite these limitations this is the first study of chronic diseases in adolescent in our locality. It may pave the way for large scale national community-based survey to give the picture of chronic morbidity, both physical and mental, among adolescents. There is a need to develop an Arabic validated questionnaire that can be used for epidemiologic studies. Development of a comprehensive standard list of chronic health conditions based on the International Classification of Diseases would facilitate the understanding of the adolescent health in the context of the current international health framework provided by the World Health Organization.|
|The author acknowledges the help and support of schools’ administrators, physicians and nurses for their support and assistance in data collection.|
Conflict of interest
|1. World Health Organization. Programming for Adolescent Health and Development. Report of a WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health. WHO Technical Report Series 886. WHO. Geneva 1999.
2. Raphael D, Rukholm E, Brown I, et al. The quality of life profile-Adolescent version: background, description, and initial validation. J Adolesc Health 1996;19:366- 375
3. Mokkink LB, van der Lee JH, Grootenhuis MA, et al. Defining chronic diseases and health conditions in childhood (0-18 years of age): national consensus in the Netherlands. Eur J Pediatr 2008;167:1441-1447
4. Newacheck PW, Rising JP, Kim SE. Children at risk for special health care needs. Pediatrics 2006;118:334-342.
5. van der Lee J, Mokkink LB, Grootenhuis MA, et al. Definitions and measurement of chronic health conditions in childhood. A systematic review. JAMA 2007;297(24):2741-2751.
6. Sawyer SM, Drew S, Yeo MS, et al. Adolescents with a chronic condition: challenges living, challenges treating. Lancet 2007;369:1481-89.
7. Geckova A, Tuinstra J, Pudelsky M, et al. Self-reported health problems of Slovak adolescents. J Adolescence 2001;24:635-645.
8. Fahmy SI, El-Sherbini AF. Determining simple parameters for social classifications for health research. Bulletin of the High Institute of Public Health 1983; 13(5): 95-108
9. Busse R, Blumel M, Scheller-Kreinsen D, et al. Tackling chronic disease in Europe. Strategies, interventions and challenges. European Observatory on Health Systems and Policies. 2010. P.1,9
10. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Public Health 1992;82(3):364- 371
11. Tuinstra J. Health in adolescents. An empirical study of social inequality in health. The prevalence of self-reported health problems in male and female Dutch adolescents. Thesis, Groningen University. The Netherland. 1998. (Available at: http://dissertations.ub.rug.nl/files/faculties/m edicine/1998/j.tuinstra/c3/pdf Accessed at: October 25, 2010)
12. Halvorsen JA, Braaeolesen A, Thoresen M, et al. Comparison of self-reported skin complaints with objective skin signs among adolescents. Acta Derm Venereol 2008;88:573-577
13. Moykhyer ME, de Vries NK, Bosma H, et al. The prevalence of self-reported health problems and haemoglobin status of Sudanese adolescents. J Adolescence 2006;29:613-626
14. Robertson KA, Mayosi BM. Rheumatic heart disease: social and economic dimensions. S Afr Med J 2008;98(10):780-1
15. Carapetis JR, Steer AC, Mulholland EK, et al. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005;5:685-694
16. Karthikeyan G, Mayosi BM. Is primary prevention of rheumatic fever the missing link in the control of rheumatic heart disease in Africa? Circulation 2009;120:709-713
17. MBewu AD. Welcome address: Rheumatic heart disease is a neglected disease of poverty requiring a multisectoral approach for prevention and eradication. A Afr Med J 2006;96(3):231-232
18. Farfel A, Levy Y, Afek A. Trends in specific morbidity prevalence in adolescents in Israeli over 50 years period and the impact of recent migration. IMAJ 2007;9:149-152
19. El-Bayoumy BM, Saad A, Choudhury AH. Prevalence of refractive errors and low vision among schoolchildren in Cairo. East Mediterr Health J 2007;13(3):575-9
20. Dambhare DG, Bharambe MS, Mehendale AM, et al. Nutrition status and morbidity among school going adolescents in Wardha, a peri-urban area. Online J Health Allied Sciences 2010;9(2): Apr-Jun 2010
21. Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance of asthma: United States, 1980-1999. MMWR Surveillance Summery 2002;51:113
22. American Lung Association Epidemiology and Statistics Unit. Trends in asthma morbidity and mortality: lung disease graphs and charts, 2003. (Available at: http://lungusa.org/data/asthma1.pdf Accessed October 30, 2010)
23. Lews TC, Stout JW, Martinez P, et al. Prevalence of asthma and chronic respiratory symptoms among Alaska Native children. Chest 2004;125(5):51-113.
24. Bar-Dayan Y, Arnson Y, Elishkevits K. Screening for common neurologic diseases among Israeli adolescents. J Child Neurol 2010;25(3):348-51.