P. Sestini

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Monaldi Arch Chest Dis2006; 65: 4, 181-183 EDITORIALQuestionnaires for asthma in children:written or video?P. SestiniChildhood asthma is widely recognised as amajor health problem both in industrialised and indeveloping countries [1]. The study of the epidemi-ological aspects of the disease is crucial for identi-fication of potential risk factors to develop appro-priate prevention strategies, and for assessing theburden of the disease to deploy adequate healthcare interventions [2]. Since symptoms of asthmaare often easy to identify, questionnaires have al-ways been the major tool used to collect informa-tion on the epidemiology of this condition [3].However, the understanding of a written descrip-tion of asthmatic symptoms varies widely acrossdifferent languages and cultural groups, limitingthe usefulness of questionnaires when comparingpopulations with different backgrounds. In particu-lar, the word “wheezing”, which is largely used toidentify asthmatic symptoms in English speakingcountries, has no equivalent in many languages.Furthermore, different groups from the same lan-guage may use different word to describe the samesymptom [4]. To overcome these difficulties, theISAAC steering committee, when planning an in-ternational survey on the prevalence of asthma,proposed a video questionnaire, containing fivescenes depicting children with different “typical”symptoms of asthma [3]. The rationale, was the as-sumption that the visual language would rendermore homogeneous the understanding of the ques-tions and possibly would help to better identifyasthmatic symptoms as compared with a conven-tional written questionnaire [5]. Verification of thisbasic assumption would require a direct compari-son of the sensitivity and specificity of the twoquestionnaires in groups with similar clinical char-acteristics but different language, a task which hasnever been attempted. Nevertheless, the videoquestionnaire has been validated in relatively smallstudies using bronchial hyper-responsiveness [6-10]and clinical diagnosis of asthma by an expert [11]as the gold standard.Despite having been widely used in the ISAACphase I study, the video questionnaire never reallygained popularity, mainly because it was soon ap-parent that the prevalence of symptoms reportedusing the video questionnaire is lower than with thewritten questionnaire and that the agreement be-tween the two questionnaires is poor in most cen-tres [12-14]. So, despite any clear evidence thatsymptoms reported with the written questionnaireare more associated with asthma or are less biasedcompared with the video, the latter was not used inthe phase II of the ISAAC and, although still rec-ommended, it was not a mandatory requirement inthe phase III if the study [2].In the present issue of the Monaldi Archives,two groups; one from Iran and one from Mozam-bique present data on the epidemiology of child-hood asthma in their countries, comparing theISAAC video and written questionnaires [15-16].Like most of previous reports using these instru-ments, they found that the video questionnaire pro-vided lower symptom prevalence estimates thanthe written one (although this does not seem to oc-cur for some questions in Mozambique), and thatthe agreement between the two questionnaires waspoor. What is the value of this data, and what doesthe data tell us?One of the most popular hypothesis to explainthe lower report of wheezing symptoms of thevideo questionnaire is that it would only identifythe more severe cases of asthma [12, 14]. The datafrom Mozambique [16] strongly suggests that thisis not the case, as no difference has been found inthe prevalence of video-reported symptoms be-tween rural and urban areas, whereas the writtenquestionnaire indicated more severe forms of asth-ma in the latter. A more likely explanation is thatthe sensitivity of the video questionnaire is justlower than anticipated in preliminary validationstudies. These were mostly conducted using hyper-responsiveness as the gold standard, but the corre-lation of this parameter with childhood asthma canbe poor [17]. Indeed, the only study using clinicaldiagnosis of asthma as the gold standard provideda quite less optimistic estimate of the sensitivity ofthe video questionnaire [11]. Several reasons couldexplain a low sensitivity of the video questionnaire.First, patients with asthma experiment an “inner”sensations, which could be difficult to identify on avideo scene, as their body self image could be quitedifferent from the real appearance [18, 19]. Fur-thermore, most parents of children with asthmahave problems identifying wheezing episodes onMonaldi Arch Chest Dis 2006; 65: 4, 181-183.Department of Clinical Medicine and Immunological Sciences; Section of Respiratory Diseases; University of Siena, Italy.Correspondence: Prof. Piersante Sestini, Department of Clinical Medicine and Immunological Sciences; Section of RespiratoryDiseases; University of Siena, Italy; Viale Bracci 3, 53100 Siena, Italy; e-mail sestini@unisi.it182P. SESTINI video [20] and only about 50% of a group of physi-cians from India correctly identified wheezingscenes in the ISAAC questionnaire [21]. It seemsunrealistic to expect children to perform better thanparents or physicians. Finally, unfamiliarity withthe terms used in the written questionnaire couldcause uncertainty in the children, leading to over-reporting of symptoms with this instrument [22].This could be the reason for the difference ob-served between video and written questionnaires inthe study from Iran [15], where the report of a di-agnosis of asthma was much closer to the preva-lence of wheezing detected by the video than by thewritten questionnaire [15]. Interestingly, the differ-ence between the two questionnaires appears to bemuch smaller in Mozambique, where the Por-tuguese version of the ISAAC questionnaire wasused, which has been clinically validated [23]. De-spite this fact, the report of severe asthma in thewritten questionnaire in that study was sometimeshigher than the report of any wheezing, suggestingsome misunderstanding of the written questions, asis also well described by the authors [16]. Further-more, the prevalence of wheezing on exercise,night wheeze and severe attacks in Mozambiqueappear to be higher with the video questionnaire.Although the authors did not always manage toprovide data from comparable questions, the morestriking result from these studies overall is that theprevalence of asthma-like symptoms is consistent-ly higher in Mozambique than in Iran according tothe video questionnaire, while the findings usingthe written questionnaire are more variable andsometimes opposite. In the absence of objectivemeasurements, we can only conclude that present-ly we cannot rely on either questionnaire for com-paring the prevalence of asthma between these twocountries. Clearly, we need further studies provid-ing a better knowledge of both instruments andpossibly the development of more effective tools toidentify asthmatic children independently from lo-cal and cultural factors.The picture changes, however, if we look to thevalue of this data for the knowledge of the burdenof asthma within each country. Here both instru-ments appear to be useful to compare the preva-lence of asthma-like symptoms in different groupsand to follow the future trends of the disease overtime, which are likely to provide useful informationon the factors associated with changes in the preva-lence of asthma in these developing countries. Pos-sibly more importantly, they may be extremely use-ful to deploy interventions to decrease underdiag-nosis of asthma and improve the health care forasthmatic children. Since, as also shown in thesereports, we know that the disagreement betweenthe two questionnaires affects the positive agree-ment much more than the negative [12, 14], chil-dren positive to either questionnaires have an high-er risk of having asthma than those negative toboth, and a deeper screening of these childrencould help to identify many cases of undiagnosedasthma. This approach has been proved extremelyvaluable to children from deprived schools in theUnited States, where the video questionnaire hasbeen shown to be able to identify a substantialnumber of children with undiagnosed asthma unde-tected by the written questionnaire [24] and hasbeen integrated in a very successful interventionprogramme [25]. In the end, we must keep in mindthat the main objective of epidemiologic research isto improve the health of people, and this can besometimes achieved even with imperfect tools andwithout a complete knowledge of the mechanismsinvolved.References1. 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Shaw RA, Crane J, Pearce N, et al. Comparison of avideo questionnaire with the IUATLD written question-naire for measuring asthma prevalence. Clin Exp Aller-gy 1992; 22: 561-8.7. Shaw R, Woodman K, Ayson M, et al. Measuring theprevalence of bronchial hyper-responsiveness in chil-dren. Int J Epidemiol 1995; 24: 597-602.8. Lai CK, Chan JK, Chan A, et al. Comparison of theISAAC video questionnaire (AVQ3.0) with the ISAACwritten questionnaire for estimating asthma associatedwith bronchial hyperreactivity. Clin Exp Allergy 1997;27: 540-5.9. Gibson PG, Henry R, Shah S, et al. Validation of theISAAC video questionnaire (AVQ3.0) in adolescentsfrom a mixed ethnic background. Clin Exp Allergy2000; 30: 1181-7.10. Hong SJ, Kim SW, Oh JW, et al. The validity of theISAAC written questionnaire and the ISAAC videoquestionnaire (AVQ 3.0) for predicting asthma associat-ed with bronchial hyperreactivity in a group of 13-14year old Korean schoolchildren. J Korean Med Sci2003; 18: 48-52.11. Fuso L, de Rosa M, Corbo GM, et al. Repeatability ofthe ISAAC video questionnaire and its accuracy againsta clinical diagnosis of asthma. Respir Med 2000; 94:397-403.12. Pekkanen J, Remes ST, Husman T, et al. Prevalence ofasthma symptoms in video and written questionnairesamong children in four regions of Finland. Eur Respir J1997; 10: 1787-94.13. Pizzichini MM, Rennie D, Senthilselvan A, Taylor B,Habbick BF, Sears MR. Limited agreement betweenwritten and video asthma symptom questionnaires. Pe-diatr Pulmonol 2000; 30: 307-12.14. Crane J, Mallol J, Beasley R, Stewart A, Asher MI.Agreement between written and video questions forcomparing asthma symptoms in ISAAC. Eur Respir J2003; 21: 455-61.183QUESTIONNAIRES FOR ASTHMA IN CHILDREN: WRITTEN OR VIDEO?15. Gharagozlou M, Khalili S, Hallajmofrad M, et al. Gen-der similarity in low agreement between written andvideo ISAAC asthma questionnaires. Monaldi ArchChest Dis 2006; 65: 184-88.16. Mavale-Manuel S, Joaquim O, Nunes E, et al. Preva-lence of asthma-like symptoms by ISAAC video ques-tionnaire and comparison with the ISAAC written ques-tionnaire in Mozambican schoolchildren. Monaldi ArchChest Dis 2006; 65: 189-95.17. Siersted HC, Mostgaard G, Hyldebrandt N, Hansen HS,Boldsen J, Oxhoj H. Interrelationships between diag-nosed asthma, asthma-like symptoms, and abnormal air-way behaviour in adolescence: the Odense SchoolchildStudy. Thorax 1996; 51: 503-509.18. Brook U, Gabai A, Peleg D. Self-image of asthmaticchildren expressed in their drawings. Harefuah 1989;116: 627-30.19. Freedman M, Rosenberg S, Divino C. My body feels outof control! In: Living Well with asthma. New York:Guilford; 1998. p. 35-53.20. Cane RS, McKenzie SA. Parents’ interpretations of chil-dren’s respiratory symptoms on video. Arch Dis Child2001; 84: 31-34.21. Van Sickle D. Perceptions of asthma among physicians:an exploratory study with the ISAAC video. Eur RespirJ 2005; 26: 829-34.22. Koffi N, Kouassi B, Ngom A, Aka-Dangui E. Interet duquestionnaire video dans l’evaluation de la prevalence del’asthme en Afrique. Med Trop (Mars) 2000; 60: 412-3.23. Sole D, Vanna AT, Yamada E, Rizzo MC, Naspitz CK.International Study of Asthma and Allergies in Child-hood (ISAAC) written questionnaire: validation of theasthma component among Brazilian children. J InvestigAllergol Clin Immunol 1998; 8: 376-82.24. Mangione S, Elia J, Bauer N, Villanueva A, Tollerud D.Asthma prevalence among inner-city school children: avideo survey in twelve Philadelphia middle schools.Sixty-fifth international scientific assembly of theAmerican College of Chest Physicians; Chicago, IL;November 1999. Chest 1999, Suppl 21: 300S.26. Voelker R. Screen for Asthma at School. JAMA 2000;284: 2585.Pavia - Università, Aula Magna

Questionnaires for asthma in children: written or video?

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Questionnaires for asthma in children: written or video?

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