Research on psychosocial aspects of asthma in the Arab world: a literature review

The importance of psychosocial factors in the management of bronchial asthma has long been recognized. This paper offers a review of research published in the English language related to psychosocial aspects of bronchial asthma in Arab countries. Several databases (PubMed, Science Direct, Springer Link, ERIC, and PsychInfo) were searched using the following keywords: bronchial asthma, Arab countries, Algiers, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine (West Bank, Gaza), Qatar, Saudi Arabia, Syria, Tunisia, Sudan, Somalia; United Arab Emirates, and Yemen. Thirty-two studies were conducted in 9 Arab countries. Almost all studies found were published in the last fourteen years with an apparent increasing rate in the last five years. In descending order, these studies addressed: knowledge of and attitudes toward asthma, quality of life, behavioral and emotional problems and factors related to academic achievement. The main results of the studies reviewed were: (a) physicians’, school staff’s, and parents’ knowledge of and attitudes toward asthma were generally unsatisfactory, (b) in-service asthma education programs significantly impacted parent and staff knowledge and attitudes, and asthma management practices, (c) quality of life in children and adolescents was significantly adversely affected by asthma, (d) asthma was a common cause of school absenteeism, and had a significant negative impact on academic achievement of students, and (e) students with asthma had significantly higher rates of behavioral and emotional difficulties compared to students without asthma. The paper concludes with a discussion about the implications of these results and a call for further research in this area.


Introduction
Bronchial asthma, a chronic condition affecting the lungs characterized by widespread, reversible, inflammation and narrowing of the airways [1], is one of the most common non-communicable chronic illnesses among children [2][3][4]. The incidence of asthma has been on the rise in the past four decades, especially in developed countries [5][6][7], with more than 300 million people affected worldwide [8].

Review
It has long been thought that psychological factors may play an important role in bronchial asthma [9][10][11][12][13]. Research published during the last few decades illustrates that psychological disorders are more common in individuals having bronchial asthma, especially if it is poorly controlled [14,15]. For instance, children with asthma are more likely than children without asthma to have anxiety and depression [16][17][18][19].
Research over the past few decades also indicates that psychological factors may influence the symptoms and management of bronchial asthma in children and adults in many ways [12]. Further, research shows that psychological stress may worsen asthma symptoms [20]. Accordingly, the research literature emphasizes the importance of psychological interventions with children and adults having asthma [21]. Bronchial asthma is one of the leading causes of hospitalization and school absenteeism among school age children [2]. One study [22] reviewed and analyzed empirical studies which examined the relationship between psychosocial factors and asthma management and morbidity in the 1980s and 1990s. This study reported that evidence indicated that psychosocial factors can play an important role in symptom expression and management.
According to the researcher, caregiver and child mental health attitudes and skills, and problem-solving skills pertaining to asthma management may be among the most important determinants of adherence and subsequent asthma morbidity. However, another study [23] compared psychosocial characteristics of children with asthma and children without asthma. Children's behaviors were assessed by parents with 15 questions. The only significant difference between the two groups was in sleep patterns (children with asthma slept less well than children without asthma). The two groups did not differ significantly in all other items related to school/learning habits, level of activity, and communication/affection. The researchers concluded that psychosocial differences between children with asthma and children without asthma were less remarkable than expected.
A recent bibliometric study of bronchial asthma in Arab countries [24] revealed that before 2000, research on bronchial asthma in Arab countries was low. The Kingdom of Saudi Arabia ranked first among the Arab countries in asthma research, and the majority of this research has been published in English. This study, however, did not provide information on psychosocial aspects of asthma in the Arab region. Rather, it only estimated the contribution of each Arab country in asthma research per year, and grouped studies into ten very general categories (i.e., medicine, immunology and microbiology, pharmacology, biochemistry, and others). To the best knowledge of the authors, no other study reviewed and analyzed asthma research in Arab countries. Accordingly, a study investigating research on psychosocial aspects of asthma in Arab countries is justified.
Thus, the purpose of the present study was to review research on psychosocial aspects of bronchial asthma carried out in Arab countries.
Studies strictly addressing epidemiology, causes and risk-factors, and treatment of asthma were excluded from the current review. First, the methodology used in identifying and reviewing relevant studies is described. Second, the findings are presented and discussed, and implications for future research on the psychosocial aspects of bronchial asthma are offered.

Methods
Our aim was to review and analyze research related to the psychosocial aspects of bronchial asthma in Arab countries published from 1990-2014 via. The search engines used were: PubMed, PsychINFO, ERIC, Spring-erLink, and ScienceDirect. The keywords entered into the search engines were: bronchial asthma, Arab countries, Algiers, Bahrain, Comoros, Djibouti, Egypt, Emirates, Jordan, Iraq, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine (Gaza and West Bank), Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, and Yemen. Reference lists at the end of articles located were also viewed in order to find additional articles. The search was restricted to studies published in English language. Table 1 shows author(s), country, sample, parameters, and main findings of each study. A total of 32 studies (26 full text articles and 6 abstracts) were found to be relevant for the purpose of this review. These studies were conducted in Egypt (8; 25%), Jordan (8; 25%), Saudi Arabia (7; 21.8%), Qatar (2; 6.3%), Tunisia (2; 6.3%), UAE (2; 6.3%), Bahrain (1; 3.1%), Kuwait (1; 3.1%), and Lebanon (1; 3.1%). The studies included a total of 71,765 participants (parents, physicians, teachers, and persons with asthma and without asthma of different ages).

Results
Only one study addressed the psychosocial aspects of bronchial asthma in Arab countries before 2000. Twenty (62.5%) of these studies involved non-probability samples. In descending order, the studies addressed the following topics: knowledge of and attitudes toward asthma, QoL, behavioral and emotional problems and factors related to academic achievement.
All studies used quantitative research methods, collecting data mainly through self-report questionnaires. The main results of the studies reviewed were as follows: Physicians' , school staff 's, and parents' knowledge of and attitudes toward asthma were generally unsatisfactory. In-service asthma education programs significantly impacted parent and staff knowledge and attitudes, and asthma management practices. QoL in children and adolescents significantly adversely affected by asthma. Asthma was a common cause of school absenteeism, and had a significant negative impact on academic achievement of students. Students with asthma had significantly higher rates of behavioral and emotional difficulties compared to students without asthma. These difficulties included, but were not limited to: sleep problems, distress, depression, and anxiety.

Discussion
The present study shows that research on psychosocial aspects of bronchial asthma in the Arab region is quite limited. Despite the increasing number of Arab studies examining psychosocial aspects of bronchial asthma in the Arab world, this type of research remains relatively limited. The average rate of research productivity in this area was about one study per year over the last quartercentury. Only 32 studies were conducted in the 22 countries comprising the Arab world over a period of   24 years. Likewise, only few psychological factors were addressed in these studies. Nonetheless, these studies shed light on some psychological factors that influence the quality of life, academic achievement, and behavioral and emotional development of children and adolescents with asthma in Arab countries. One main result reported by the studies reviewed here was that physicians' , school staff 's, and parents' knowledge of and attitudes toward asthma were generally unsatisfactory. Similar findings were reported by researchers in other countries. For instance, primary school teachers in Turkey lacked knowledge on triggers of asthma attacks and on the management of this disease [57]. In the USA, studies have revealed that lack of education for nurses, parents, and physicians were among major barriers to asthma management in schools [58]. In China, it was reported that the parents' knowledge of asthma was generally poor [59].
It was also reported by studies reviewed that in-service asthma education programs significantly impacted knowledge and attitudes, and asthma management practices. This result is in agreement with those of many studies conducted in other countries showing that training courses could have a positive impact on asthma control [60] and that education programs pertaining to application of standard treatment guidelines improved asthma control [61].
Another main result reported by the studies reviewed was that quality of life in children and adolescents was significantly adversely affected by asthma. This finding is consistent with those of previous non-Arab studies which have shown that children having asthma generally tend to have lower levels of quality of life than children without asthma [62][63][64] and that quality of life decreased with increasing asthma severity [65]. Further, studies included in this review showed that asthma was a common cause of school absenteeism, and had a significant negative impact on academic achievement of students. Similar findings were reported in other countries [66,67]. Finally, a main finding in this review was that children and adolescents with asthma had significantly higher rates of behavioral and emotional difficulties compared to children and adolescents without asthma. Similar findings were reported by many researchers in other countries [68][69][70].
While published studies provided beneficial insights into psychological factors associated with bronchial asthma in Arab countries, much research remains to be conducted. Research in Arab countries has not yet addressed many important psychological issues related to bronchial asthma. For instance, very few studies analyzed in this review attempted to utilize psychological interventions (e.g., cognitive behavioral therapy, behavioral therapies, relaxation techniques) to increase the effectiveness of asthma management and treatment through procedures such as promoting adherence and asthma control, managing emotional triggers, adopting appropriate adjustment and coping styles, and improving knowledge and attitudes, among others. No study explored the relationship between asthma and the individual's personality. Further, research on psychosocial aspects of asthma was conducted in only 9 out of 22 countries comprising the Arab world.
The research literature advocates a multidisciplinary or team approach to management of bronchial asthma [71,72]. This approach which may involve such services as patient education, self-management, counseling and nutritional advice has been shown to improve quality of life and to reduce exacerbations and hospitalizations in patients with asthma [73,74]. The studies reviewed in the current review, however, revealed that this type of research is lacking in the Arab world. Accordingly, the need for further multidisciplinary research on the role of psychological factors in asthma management in Arab countries is clear. In addition, the program curricula in medical schools in the Arab world probably need to increase students' awareness of psychological and behavioral aspects of illness, particularly chronic diseases having emotional components such as bronchial asthma. As Cuff and Vanselow [75] stated, measurable improvements in the health of individuals is unlikely to be achieved unless physicians are "equipped with the knowledge and skills from the behavioral and social sciences needed to recognize, understand, and effectively respond to patients as individuals, not just to their symptoms" (p. 3).
There is also a clear need for research addressing the potential effects of political and social turbulences on health status and care of individuals, including those with chronic illnesses such as bronchial asthma, in present-day Arab world. It is believed that "the psychological distress resulting from repetitive exposure to extreme forms of psychological trauma has put millions of civilians in the Middle East at high risk for traumarelated psychopathology" [76]. The "Arab Spring" which has touched many Arab countries recently may have significant consequences for population health. The violence and upheaval have resulted in significant political and economic challenges; difficult post-war conditions including influx of refugees throughout the region; under-employment and subsequent draining of financial, social, and health resources [77][78][79]. Another aspect that could affect health problems like asthma during "Arab Spring" is having high levels of psychological stress [76], a known serious trigger of asthma [80]. In a longitudinal cohort study [81] which investigated the role of psychological stress in the etiology of asthma, a strong association was found between stress and asthma incidence and hospitalization, use of asthma medication as well as with allergic rhinitis and atopic dermatitis in adults.
In addition, asthma is associated with environmental factors that can be increased during social unrest and civil wars, via means of fire, smoke, dust, and other toxic chemicals. Such events will not only have immediate impact, but can also have long-term effects. This has been illustrated in follow up studies [82,83] of the World Trade Center rescue and recovery workers which showed persistence of health problems such as asthma, sinusitis, gastroesophageal reflux disease, depression, post-traumatic stress disorder, and panic attacks.
As mentioned previously, the majority of studies reviewed used self-report questionnaires to collect data from participants. It is well known that self-reports are subject to various sources of inaccuracies. Two major theoretical perspectives explain validity problems in some self-reported data [84]. The first is the cognitive perspective which attributes validity problems to inaccuracies arising from comprehension and recall. The second is the situational perspective which focuses on validity problems that arise from factors related to social desirability and interviewing conditions. Also, all studies reviewed used quantitative research methods in investigating the psychosocial aspects of bronchial asthma. However, research using qualitative methods such as indepth interviews, case studies and participant observations [85] can yield important information by reflecting the experiences and stories of children and adolescents with bronchial asthma.
The present study has some limitations that need to be considered when interpreting the findings. First, this review was restricted to studies published in English and to studies published in referred journal articles. However, there may be studies published in Arabic or French (especially by researchers from Lebanon, Tunisia, Morocco, Algiers where French is widely spoken) or published as conference papers, master or doctoral theses, book chapters, etc. In addition, the studies originated from only 9 out of 22 Arab countries. These countries are quite diverse not only in terms of religion, history, economics, and politics but also in living standards and health care services. Finally, many studies reviewed involved non-probability or small samples. Therefore, caution should be exercised in making generalizations about psychosocial aspects of bronchial asthma in Arab countries.

Conclusions
Research literature in Arab countries is lacking in quality studies investigating the psychosocial aspects of bronchial asthma. There have recently been some attempts to explore this research area; nonetheless, most studies carried out so far have investigated few psychological factors related to asthma. Further research involving randomized multicenter studies and using more rigorous research methods are needed to better understand the psychosocial aspects of bronchial asthma in the Arab world.