Environmental Exposure and Pediatric Asthma Prevalence in Saudi Arabia: A Cross-Sectional Study

Introduction: Asthma is a chronic respiratory disease characterized by recurrent episodes of wheezing and shortness of breath. Currently, there is no cure for asthma. However, through accurate diagnosis, appropriate therapy, and effective management strategies, individuals with asthma can achieve a better quality of life. This study focused on determining the prevalence and environmental risk factors of pediatric asthma among children in Saudi Arabia. Methods: This cross-sectional study was undertaken from January 2023 to August 2023, encompassing five key regions in Saudi Arabia: Central, Eastern, Northern, Southern, and Western. A structured online questionnaire was disseminated to parents/guardians of children aged 2-18 with a confirmed diagnosis of asthma. The objective was to garner insights regarding pediatric asthma prevalence and associated risk factors within these regions. The questionnaire was designed with considerations for sociodemographic factors, environmental exposures, and known asthma triggers. From the survey's distribution, a total of 1666 responses were accumulated and processed for further analysis. Results: The survey saw the participation of 1666 respondents. The age bracket of 8-13 years had the highest representation, accounting for 52.5% of the total participants. From the total cohort, 26.9% had been diagnosed with pediatric asthma. It was also observed that 56.7% of the participants resided in areas marked by high traffic or were proximate to busy roads. Additionally, 30.7% of the respondents pinpointed specific times in the year when asthma symptoms intensified. When dissecting the data, it was discerned that there were statistically significant associations between the prevalence of pediatric asthma, gender, and the regions of Saudi Arabia with reference to air pollution exposure. Notably, gender had an odds ratio of 1.12, while the regional distribution held an odds ratio of 1. Conclusion: Our study vividly highlights the intricate landscape of pediatric asthma across Saudi Arabia, indicating its prevalence and drawing attention to associated risk factors. Noteworthy observations include the pronounced impact of gender and regional variances, particularly concerning air pollution exposure, on asthma incidence. The insights gleaned from this research are invaluable in steering the formulation and implementation of strategic interventions geared towards bolstering children's health and enhancing their life quality in regions bearing the brunt of pediatric asthma.


Introduction
Bronchial asthma (BA) stands as the most common chronic illness in the pediatric age group, wielding profound implications on public health, encompassing both morbidity and mortality [1].In children diagnosed with BA, the inflammation of the airways makes them hypersensitive and readily reactive to allergens and irritants.Such a heightened reactivity often manifests in distinct symptoms, notably wheezing and breathlessness [2].While asthma remains an ailment without a definitive cure, its impacts can be significantly mitigated with timely diagnosis, adherence to prescribed medication, consistent follow-ups, and a robust management plan focusing on trigger avoidance [3].
In the global panorama, there's a discernible surge in the prevalence of BA, especially among children [4].Within Saudi Arabia's context, although several epidemiological studies have been directed at delineating the prevalence of BA in children, results have shown variability, with reported prevalences fluctuating between 8-25% in the last thirty years [5].This escalating trend is believed to resonate with shifts in lifestyles and augmented environmental exposures [6].Attributes like socioeconomic dynamics, urbanization, changing dietary patterns, increasing encounters with air pollutants from sources like vehicular emissions and industrial outputs, exposure to tobacco smoke, the influx of sandstorms and dust, and heightened interaction with domestic pets, among other allergens and contaminants, have emerged as pivotal in influencing both the onset and exacerbation of BA [7][8][9][10].
Our study endeavors to explore the connection between certain environmental exposures and BA prevalence among children in Saudi Arabia.Specifically, it delves into the increasingly popular trend of owning domestic pets and its potential influence on BA prevalence, steering away from globally acknowledged correlations, thereby presenting a fresh perspective on the subject.

Study area and design
The study spanned across the entirety of Saudi Arabia, encapsulating five distinct regions: Central, Eastern, Northern, Southern, and Western.This research was anchored in a cross-sectional design and extended from August 2022 to August 2023.The data collation mechanisms integrated both online and in-person questionnaires directly from the child or their guardian.

Study setting
The research was orchestrated under the aegis of King Faisal University, drawing on their resources and extensive networks to ensure a comprehensive reach across various regions of Saudi Arabia.This ensured the inclusion of participants from diverse settings such as emergency rooms, clinics, and the general public.

Study population and sampling
The study zeroed in on children aged 2-14 years diagnosed with asthma.Given that the pediatric age in Saudi Arabia culminates at 14 years, our focus was adjusted accordingly.The total sample size was 1666.Arriving at this figure factored in a 95% confidence interval, a margin of error of ±5%, and an expected asthma rate of 385.Convenience sampling was the method of choice, cherry-picking participants based on their accessibility and willingness.The age cap was set at 14 years in alignment with the regional pediatric definition, and the decision to exclude children below 2 years was informed by the potential challenges in diagnosing asthma reliably in this age group.Those not meeting the criteria, unwilling to partake, or unable to give informed consent were excluded.

Data collection
The International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, tailored to the study's requirements, was the cornerstone for data collection.This questionnaire was tri-segmented, delving into demographics, outdoor air pollution exposure, and indoor allergen interaction.Strict measures ensured data access was exclusive to the research team, upholding the sanctity of participant confidentiality.

Study variables
The independent variables encapsulated demographics such as age, gender, educational background, professional status, and region.Conversely, the dependent variables zoomed in on asthma indicators and respiratory safeguards, underscoring exposures to external air pollutants (like traffic and industrial sites) and indoor allergens (like flora and dust mites).

Preliminary assessment
A precursor pilot study involving 20 participants was rolled out before the primary data-gathering phase.This step was instrumental in affirming the questionnaire's dependability and lucidity, leading to subtle content refinements.

Ethical considerations
The ethical endorsement was procured from King Faisal University's research ethics committee, bearing the ethical number KFU-REC-2023-MAY-ETHICS1148.Consent was sought and obtained, or in certain scenarios, waived from every participant.This ethical compliance accentuated voluntary involvement, data confidentiality, and sidestepping potential conflicts of interest.

Data analysis
SPSS software version 28.0 (IBM Corp., Armonk, NY) was the analytical tool of choice, enabling correlation and regression examinations and Chi-square testing to unearth connections between environmental interactions and pediatric asthma prevalence.

Study limitations
Inherent limitations comprised the dependence on participant self-reporting, potential recall biases, and the cross-sectional model's inability to conclusively attribute causation.

Demographic characteristics
Table 1 shows that a total of 1666 participants were included in the study, representing diverse demographic profiles.The majority of participants were within the 2-6 age range (52.5%), with females comprising 57.1%.Urban areas were the predominant residential location (84.5%).

Count
Column

General questions regarding environmental exposures and pediatric asthma prevalence
Table 2 shows most experienced asthma symptoms rarely or never (70.6%).Air quality perceptions varied, with 41.6% rating it as "Good."Indoor smoking exposure was reported by 22.3%.Furthermore, 11.8% reported observing mold or dampness at home.

Multivariate (linear regression) model to identify the factors predicting the air pollution
Table 5 shows gender significantly influenced air pollution exposure, with females 1.54 times more likely to be exposed.Education level, employment status, and geographic location also exhibited significant associations (p < 0.001).

Indoor allergen exposure
Allergen exposure factors were evaluated, with 50.8% reporting allergies to dust mites and 76.5% having carpets or rugs at home.Houseplants were present in 53.8% of homes, while pets were allowed in only 9.2% of children's bedrooms (Table 6).

Liner regression model between air pollution and allergen exposure
The predictor variable "Air pollution" demonstrated a significant positive relationship (B = 0.733, 95% CI = 0.612 to 0.970, p < 0.001) with allergen exposure (Table 8).

Discussion
Our investigation sought to identify the prevalence of pediatric asthma in children within Saudi Arabia, leveraging an online and hard copy survey format.The perceived quality of air was rated as "Good" by 41.6% of participants.This aligns with a prior study in Rabigh City that reported similar percentages in asthma prevalence among its young demographic [11].Notably, regional disparities in asthma prevalence were observed, with locations recording the highest rates, which have been attributed to various factors, including gender, diet, household pets, and environmental interactions.
Central to our inquiry was understanding the link between potential environmental risk factors and pediatric asthma.Noteworthy findings include a 56.7% exposure to traffic-congested zones and 28.2% proximity to industrial settings.Additionally, 59.2% reported ongoing construction activities in their vicinities, and a significant 30.7% observed seasonality in asthma symptoms.This observation is bolstered by a Cleveland study which found increased pediatric asthma-related doctor visits in areas with elevated air pollution [12].Furthermore, research from Riyadh solidified the connection between heightened serum polycyclic aromatic hydrocarbon (PAH) levels and childhood asthma [13].Factors like respirable particulate matter, black carbon, nitrogen dioxide, and ozone were associated strongly with pediatric asthma, particularly in those under regular corticosteroid treatment [13][14][15].Intriguingly, our data suggests a gender bias, with females 1.54 times more likely to experience heightened air pollution exposure.Socio-economic variables such as educational attainment, occupation, and residence also had significant ties to exposure levels (p < 0.001).
Delving into the well-documented correlation between allergies and asthma [11,13], our research found that 50.8% were allergic to dust mites and 76.5% had carpets at home.Interestingly, only 9.2% allowed pets in the children's rooms.Reinforcing our observations, a study from Southern Florida found a notable percentage of children diagnosed with asthma also had heightened sensitivity to common allergens [16].Another Kuwaitbased study emphasized the connection between pet ownership and allergic manifestations, including asthma [17].In our context, sensitization to dust mites was more indicative of childhood asthma than pet ownership.Key demographic variables such as gender and educational levels also had substantial associations with allergen exposure.
However, it's paramount to note this study's limitations.Potential recall bias is inherent in selfadministered questionnaires.While we utilized a reliable tool, there remains the possibility of inaccuracy in some responses.The participant demographic, limited to parents engaging in the online survey, may not offer a holistic representation.Furthermore, the cross-sectional nature of the study design hinders our ability to derive cause-and-effect relationships between environmental and allergen exposure vis-à-vis asthma occurrence.

Conclusions
The present study embarked on a detailed exploration of pediatric asthma within Saudi Arabia, emphasizing the roles of environmental influences and allergen exposures.Our findings resonate with existing literature, pinpointing regional variances in asthma prevalence.Furthermore, our data underscores strong links between environmental determinants, notably heavy traffic and industrial vicinity, with pediatric asthma manifestation.Household allergens, especially dust mites and specific carpet types, emerged as substantial contributors to the disease's prevalence.In addition, socio-economic and gender dynamics demonstrated noteworthy impacts on the susceptibility and severity of asthma symptoms in children.While our methodology predominantly leaned on self-reported questionnaires, introducing a potential bias, and its cross-sectional framework curtailed in-depth causative insights, it laid the groundwork for refined future investigations.To truly augment the literature and provide transformative insights, there's an imperative for more granular, longitudinal studies, potentially utilizing advanced techniques and larger, diversified samples.Such future endeavors can pave the way for crafting tailored public health interventions, addressing the specific needs of the pediatric population in Saudi Arabia concerning asthma.

TABLE 1 : Demographic Characteristics Demographic
Characteristics -Participant distribution by age, gender, city of residence, and geographic location

Table 3
shows participants indicated exposure to heavy traffic or busy roadways (56.7%) and identified industrial facilities nearby (28.2%).Ongoing construction activities near residential areas were reported by 59.2% of participants.Notably, 30.7% reported a correlation between asthma symptoms and specific times of the year.

TABLE 3 : Air pollution exposure
Air Pollution Exposure -Exposure to traffic, industrial facilities, construction, and seasonal asthma symptoms.Participants' mean Likert scores revealed that spending time outdoors in high air pollution areas (3.79) and using air purifiers (3.27) were common practices.Additionally, the perception of visible air pollution(3.65)andkeepingwindowsopen for fresh air (3.75) received moderate agreement (Table4).

TABLE 5 : Multivariate (linear regression) model to identify the factors predicting air pollution
Multivariate (Air Pollution) -Odds ratios predicting air pollution exposure by gender, education, employment, and location.
Is anyone in your household allergic to dust mites?

TABLE 7 : Indoor exposure of allergen (Likert analysis)
Allergen (Likert) -Mean scores for bedding, carpet cleaning, houseplants, soft furnishings, and sun exposure practices.

TABLE 9 : Multivariate (linear regression) model to identify the factors predicting the allergen exposure
Multivariate (Allergen) -Odds ratios predicting indoor allergen exposure by gender, education, employment, and location.