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The Evaluation of Lung Function in Rural Dwelling Children

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The Evaluation of Lung Function in Rural Dwelling Children THE EVALUATION OF LUNG FUNCTION IN RURAL DWELLING CHILDREN A Thesis Submitted to the College of Graduate Studies and Research In Partial Fulfillment of the Requirements For the Degree of Master of Science In the Department of Community Health and Epidemiology University of Saskatchewan by Lakshmi Balakrishnan Copyright Lakshmi Balakrishnan, September 2016. All Rights Reserved Abstract Background: Asthma severity indicators and their risk factors are understudied in the farming and non-farming populations. Further study is needed. Our objective was to evaluate rural exposures and pulmonary function in a rural pediatric population and their relationships. Methods: For this study, data from the Saskatchewan Rural Health Study (SRHS) child component was used. SRHS is a population-based study, conducted in 2011, evaluating the health of rural dwelling residents in the province of Saskatchewan, Canada. The SRHS is designed as a cohort study. However, the data used for this analysis is from the baseline data collection. The initial data collected included a parent-completed survey questionnaire answered on behalf of the child. From this study sample, a subset of children (6-14 years old) was selected to participate in clinical testing, which included anthropometric measures and pulmonary function testing (PFT) using spirometry (n=584). PFTs followed ATS criteria and all statis- tical analyses were controlled for child age, sex, and height. Results: Among children participating in the clinical testing, 47.5% were female and 54.5% lived on a farm. Of those living on farms, 77.5% were livestock farms. The mean percent predicted value (PPV) for Forced Expiratory Volume in 1 second (FEV1) and forced vital capacity (FVC) among those living on the farm were 104.8% and 105.4%, respectively while the mean PPV for FEV1 and FVC among the non-farm dwellers were 102.7% and 101.4%, respectively. After adjustment for potential confounders using linear regression, higher FEV1 (p=0.03) and FVC (p=0.006) were seen among farm dwelling children while there was a trend to- wards lower FEV1/FVC ratio (p=0.09) among farm dwellers compared to non- farm dwellers. Higher FVC and lower FEV1/FVC ratio were also seen with chil- dren who regularly emptied grain bins (p<0.05). Trends towards a higher FEV1 (p=0.14) and FVC (p=0.08) were also seen with children living on a farm in the first year of life. Conclusion: Differences in lung function were seen between farm and non-farm rural dwelling children and certain farming activities, specifically, emptying grain bins. Despite !I a higher FEV1 and FVC among farm dwellers, the FEV1/FVC ratio was lower compared to non-farm dwellers. A trend towards a higher FEV1 and FVC was also seen with living on a farm in the first year of life suggesting that differences in lung function seen in farm dwelling children may not be purely due to reverse causality. Co-Authorship This thesis represents the work of Lakshmi Balakrishnan in collaboration with her supervisor, Dr. Joshua Lawson from the University of Saskatchewan, as well as additional co-authors on the thesis manuscript, “The Evaluation of Lung Function in Rural Dwelling Children”. Dr. Balakrishnan and Dr. Lawson were involved in the formation of the research questions as well as the completion of the data analysis, interpretation of results and preparation and revision of the manuscript for the current analysis. Dr. Balakrishnan was responsible for partial cleaning of the dataset. Dr. Lawson provided suggestions, guidance and editorial input into the creation of the manuscript. Dr. Lawson, Dr. Rennie, Dr. Pahwa, Dr. Karunayake and Dr. Dosman were involved with the conception and design of the initial study, completion of the data collection, and critical review and editing of the manuscript. !II Acknowledgements I would like to express my gratitude toward those who guided and sup- ported me throughout this process. First and foremost, I would like to thank my supervisor, Dr. Lawson, for his guidance and support during this thesis. His expertise, thoughtful insight, and constructive and timely feedback were invaluable toward the completion of this thesis. Not enough can be said toward his leadership, pa- tience and wise counsel. Next, I would like to thank the Saskatchewan Rural Health Study team and the Estevan Cohort Study team at the University of Saskatchewan. I am grate- ful for the efforts of Dr. Rennie, Dr. Dosman, Dr. Pahwa, and Dr. Karunanayake, who reviewed the manuscripts in this thesis and I thank them for the constructive feedback. I would also like to thank the Clinical Investigator’s Program for the fi- nancial support I received and the opportunity to present this work at the 2015 American Thoracic Society Meeting. It was an amazing experience. I would espe- cially like to thank Dr. Gary Groot, Dr. John DeCoteau and Ms. Angie Zoerb for their support and encouragement through the pursuit of my Masters. This program complemented my thesis and served to deepen my interest in rural and communi- ty health. I would like to thank the Department of Surgery and the General Surgery Resident Program for being so understanding and accommodating in my pursuit !III for further education. Fifth, I would like to thank the faculty and staff members in the Depart- ment of Saskatchewan Community Health and Epidemiology at the University of Saskatchewan for creating a supportive and positive atmosphere. Special thanks to the outstanding instructors of these courses. I would also like to thank my classmates and those belonging to the Rural Health Study Research Group. Your passion for learning and epidemiology is contagious. Thank you for listening to my practice presentations and giving such helpful feedback. Finally, I would like to thank my family (Amma, Appa, Divya and Kyler) and friends for their love, encouragement, patience and unwavering support. Words cannot express how much your presence in my life and support mean to me. I would like to dedicate this Masters to my loving father, for all his love, support, and passion in academic pursuit. I miss you and love you everyday and carry you in my heart always. !IV Table of Contents Abstract ……………………………………………………………………….. I-II Co-Authorship ....................................................................................................... II Acknowledgements…………………………………………..………………III-IV List of Tables ………………………………………………………….…….…..VI Chapter 1 Introduction…………………………………………………………….1 Chapter 2 Literature Review …….………………………………………………..4 2.1 Scope of Literature Review …………….…………………….…………..4 2.2 Methods of Literature Review….…….………………………………..….4 2.3 Respiratory Health……………………….………………………………..5 2.4 Lung Function Testing ..…..…….……………………………………..….6 2.5 Lung Disease among children ………………………..……….……….…9 2.6 Asthma Diagnosis and Evaluation of Asthma Severity …..………..……10 2.7 Impact of Respiratory Disease ………………………………………..…13 2.8 Asthma Risk Factors ……………….……………………………………17 2.9 Asthma Severity/Morbidity …………………………..…………………18 2.10 Predictors of Lung Function ……………………………….……………22 2.11 Gaps in the Literature………………………. .………………………….24 2.12 Problem Statement and Rationale………………………..………………26 2.13 Objectives ……………………………….……………..………………..27 Chapter 3 Methodology .……………….………………………………………..28 3.1 The Saskatchewan Rural Health Study ………………………………….28 3.2 Methodology .………………….………..……………………………….28 3.2.1 Study Design .……………………………………..…………….……….28 3.2.2 Study Population ………………………………………..….…….….…..28 3.2.3 Study Protocol ..….…………………………..………………………….31 3.2.3.1 Questionnaire ……………………………………………..………….….32 3.2.3.2 Clinical Measures .…………….…………………………..…………….32 3.3 Statistical Analyses and sample size …………………………….………34 3.3.1 Statistical Analyses ..………………………………………….…………34 3.3.2 Statistical Power and Sample Size ..….………………………………….35 3.4 Preliminary descriptive results .………………………….…………..….36 3.4.1 Population Charactersistics ……………………………………………..36 3.4.2 Study Population ..……………………………………………………….37 3.4.3 Comparison of characteristics between farm and non-farm children ..….43 3.4.4 Pulmonary Function levels………………………………………………47 Chapter 4 Paper ………………………………………………………………….50 4.1 Abstract…..………………………………………………………………50 4.2 Background................................................................................................52 4.3 Materials and Methods……..…..……..……..…….…………………….53 4.3.1 Study design and population…………………………………………….53 4.3.2 Study protocol…………………….….………………………………….54 !V 4.3.2.1 Questionnaire…………………………………………………………….54 4.3.2.2 Anthropometric and lung function measures…………………………….55 4.4 Statistical Analysis……………………………………………………….56 4.5 Results …………………………………..…….…………………………58 4.6 Discussion …………………………..………..………………………….59 4.7 Conclusion………………..…….………………………………………..63 References………………………….…………………………………………….64 Chapter 5 Summary of Results and Discussion.....................................................77 5.1 Summary of Results….………………………………………………….77 5.2 Discussion……….……………………………………………………….79 5.3 Assessment of selection bias…………………………………………….81 5.4 Assessment of Information bias.................................................................82 5.5 Assessment of Confounding…….……………………………………….82 5.6 Interaction………………….…………………………………………….83 5.7 External Validity........................................................................................83 5.8 Additional Potential Limitations…..…………………………………….84 5.9 Strengths of the Study……………..………………………….…………85 5.10 Recommendations, applications and future research directions…………85 5.11 Conclusion ................................................................................................87
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