A Comparative Analysis of Factors Affecting Uncontrolled Asthma among Paediatric Population in Urumqi vs Islamabad

The prevalence of paediatric asthma, a serious worldwide health issue, varies greatly across different geographical areas. Particularly striking contrasts have been found between Islamabad, Pakistan, and Urumqi, China, prompting a comparison of the underlying causes of uncontrolled asthma. Objective: To determine and evaluate the variables in�uencing uncontrolled asthma in children in the populations of Urumqi and Islamabad. Methods: A comparative cross-sectional study on children with uncontrolled asthma aged 3 to 18 years old was carried out in Urumqi, China, and Islamabad, Pakistan. Analysis of hospital data were used to evaluate the uncontrolled factors related to patient's demographics, medical history, factors related to asthma control and living conditions and the environment. Results: In both cities, the study found important causes of uncontrolled asthma. Poor inhaler technique, raised BMI, environmental triggers such pollen allergies, poorly ventilated homes, and treatment non-compliance were also noted in both populations. In addition, the study indicated that uncontrolled asthma was present in 32% of paediatric patients in Urumqi and 56% of those in Islamabad for a variety of reasons. Conclusions: The results underscore the importance of context-specic interventions in managing paediatric asthma. Measures such as improving inhaler techniques, ensuring treatment compliance, healthy BMI and proper ventilation can signi�cantly improve asthma control in paediatric populations of both Urumqi and Islamabad.

on the region. Asthma occurrence has been linked to genetics, ethnicity, and the calibre of both indoor and outdoor surroundings. Given how much time individuals spend indoors and the possibility for exposure to a range of allergens and irritants, including dust mites, mildew, pet dander, and cigarette smoke, the indoor environment in particular has gained attention recently [3,4]. Asthma prevalence has increased annually in China, where fast economic development has resulted in major changes to living conditions. These changes have had a considerable negative in uence on children's physical health and placed a heavy nancial strain on their families [1]. Due to its Factors Affecting Uncontrolled Asthma among Paediatric Population

I N T R O D U C T I O N
The prevalence of paediatric asthma, a serious worldwide health issue, varies greatly across different geographical areas. Particularly striking contrasts have been found between Islamabad, Pakistan, and Urumqi, China, prompting a comparison of the underlying causes of uncontrolled asthma. Objective: To determine and evaluate the variables in uencing uncontrolled asthma in children in the populations of Urumqi and Islamabad. Methods: A comparative cross-sectional study on children with uncontrolled asthma aged 3 to 18 years old was carried out in Urumqi, China, and Islamabad, Pakistan. Analysis of hospital data were used to evaluate the uncontrolled factors related to patient's demographics, medical history, factors related to asthma control and living conditions and the environment. Results: In both cities, the study found important causes of uncontrolled asthma. Poor inhaler technique, raised BMI, environmental triggers such pollen allergies, poorly ventilated homes, and treatment noncompliance were also noted in both populations. In addition, the study indicated that uncontrolled asthma was present in 32% of paediatric patients in Urumqi and 56% of those in Islamabad for a variety of reasons. Conclusions: The results underscore the importance of context-speci c interventions in managing paediatric asthma. Measures such as improving inhaler techniques, ensuring treatment compliance, healthy BMI and proper ventilation can signi cantly improve asthma control in paediatric populations of both Urumqi and Islamabad.

M E T H O D S
distinct physical and climatic features, Urumqi, the capital of the Xinjiang Uyghur Autonomous Region in northwest China, is a city of great signi cance. However, recent epidemiological surveys of asthma in children in Urumqi have been scarce, creating a knowledge gap in understanding the current situation and the risk factors contributing to the disease in this region. [5][6][7][8]. Children and adolescents are particularly prone to asthma attacks, w h i c h c a n c a u s e t h e m to m i ss s c h o o l , re q u i re hospitalization, and in severe cases, even lead to death. Despite advancements in asthma management, many pediatric patients continue to suffer from uncontrolled asthma. Good asthma control is the main management goal according to current asthma management guidelines, as this decreases the risk of asthma exacerbations and improves the quality of life.
[9]. However, uncontrolled asthma is still highly prevalent (26% in Western Europe) despite the availability of effective asthma treatment [10]. Several factors of uncontrolled asthma in children have been previously described such as age, male gender, maternal education level, exposure to indoor smoking, pet ownership and high use of short-acting ß2-agonists, incorrect inhaler technique, poor adherence to asthma medication and the presence of co-existing diseases. Many children with asthma have co-existing atopic diseasesincluding food allergy, allergic rhinitis, and atopic dermatitis -or recurrent respiratory tract infections which makes asthma uncontrollable [11][12][13]. controlled period from 1 January to 30 June of 2021 was also taken into account for comparison. The datasets from Urumqi and Islamabad each contained 874 cases, while the dataset from Urumqi had 738 cases. Both in Urumqi, China, and Islamabad, Pakistan, the data gathering procedure was conducted in accordance with the same guidelines to maintain uniformity. Information about children's health status was gathered using a thorough proforma, with an emphasis on asthma symptoms in particular. The proforma contained questions on demographic information, BMI, medical history, history and treatment of allergies, family history of asthma and allergy, the number of follow-ups in the last 6 months, the number of asthma attacks in the last 6 months, the number of hospitalizations due to asthma in the last 12 months, the number of antibiotics used up to 12 months and possible triggering factors for asthma participation, use of corticosteroids, inhaler technique, forced expiratory volume in 1 second (FEV1) at rst diagnosis, treatment for asthma, treatment compliance and information on living conditions and the environment like ventilation in house, quality of indoor air, the number of rooms in the house, and the number of people living in one room. Statistical analyses were performed using the SPSS software. Descriptive statistics were used to summarize the characteristics of the study population. The association between potential risk factors and asthma control was evaluated using logistic regression models, adjusting for potential confounders. Differences in asthma control and associated risk factors between the two cities were analyzed using Chi-square tests for categorical variables and t-tests for continuous variables. Ethical approval for the study was obtained from the respective local research ethics committees in both countries. Con dentiality of the participants' information was ensured throughout the study.

R E S U L T S
There were signi cant variations between the data of two cities. Data from Urumqi had a higher percentage of boys compared to Islamabad with a higher prevalence of overweight children. Moreover, there were more children in Urumqi with history of allergies, family history of allergies and a higher proportion of children receiving treatment for allergies compared to Islamabad (Table 1).  Dust/air pollution is more commonly reported in Urumqi, while ower/pollen is reported more frequently in Islamabad. Furthermore, there are variations in the use of corticosteroids for asthma treatment, with higher usage in Islamabad compared to Urumqi. Moreover, Islamabad has a higher percentage of non-ventilated houses and a slightly higher proportion of houses with poor indoor air quality compared to Urumqi which may contribute to poor asthma control. 70.66% of the participants in Urumqi had good ventilation in their houses in comparison to the Islamabad. Air quality was measured by the presence of withering, discolorations, unpleasant smells in and around the houses. Good air quality was labelled where there was no smell, satisfactory was labelled when there was presence of foul smell occasionally while moderate air quality means presence of smell sometimes (Table 4).

Prevalence of Uncontrolled Asthma
Regarding factors related to asthma control, Urumqi and Islamabad exhibit differences in the reported triggering factors (Table 3). The table depicts the key factors related to uncontrolled asthma. The chief factor for uncontrolled asthma in Islamabad was reported to be of poor inhaler techniques, followed by Flower/pollen allergies and non-compliance to treatment compared to Urumqi, which has the chief factors of High BMI (Table 5). Similarly, in Islamabad, high BMI is not a signi cant factor, accounting for 24.54% of asthma cases. While not signi cant, it is important to consider weight management as a part of overall asthma management, as obesity can impact respiratory health. The prevalence of obesity has reached epidemic levels in many populations in recent years and has been identi ed as a risk factor for asthma [21]. Furthermore, overweight and obese individuals tend to experience more severe asthma symptoms compared to those of normal weight [22]. High BMI among children is a modi able risk factors which can be dealt with targeted interventions that improve asthma control and overall management. Non-compliance to treatment is a signi cant factor in both Urumqi and Islamabad. In Urumqi, it accounted for 17.51% of asthma cases. While in Islamabad, the non-compliance was reported to be at 63.67%. Low adherence is a signi cant contributor of poor asthma control which may be addressed through patient education, support systems, and interventions to improve asthma management outcomes [23]. Pollen allergy is reported to be a major cause for both allergic asthma and uncontrolled asthma [24]. In our study, in Urumqi 19.23% of participants identi ed ower/pollen as a triggering factor for asthma, while in Islamabad, a signi cantly higher percentage of 85.64% reported the same. Apart from pollen, other triggering factors were also assessed in the study. Other factors such as Tobacco smoke, strong odors, child exercise, child sports, cold air/cold weather, and medicines showed relatively similar prevalence rates between the two cities while dust/air pollution was reported as a triggering factor by a higher proportion of participants in Urumqi (47.73%) compared to Islamabad (20.19%), suggesting that air pollution may be more prevalent in Urumqi and could contribute to asthma exacerbations in that area. Dust/air pollution is reported to be a potent risk factor for respiratory problems [25]. These results highlight the need for targeted interventions to manage allergies and reduce exposure to allergens in both  Majeed et al.,[26]. These ndings align with existing literature that details numerous risk factors for uncontrolled asthma and poor symptom control, including treatment adherence, environmental triggers, family history of asthma, and poor inhaler techniques. The high rates of uncontrolled asthma found in Urumqi and Islamabad are concerning. For example, in the United States, about 44% of children with current asthma had uncontrolled asthma from 2018 to 2020 [27]. The higher rates in Islamabad suggest a more signi cant burden of disease in that city, more likely to be attributed to controllable factors like compliance issues and use of inhaler techniques. Adherence to asthma medication is a critical aspect of controlling the disease. However, medication non-adherence is a signi cant concern, especially among urban minority patients. [28]. Several risk factors undermine medication adherence in children, including factors like male gender, non-Asian ethnic background, living in a larger household, older age at diagnosis, living in rural areas, and lower socio-economic status [29]. Both unintentional and intentional factors contribute to non-adherence, including lack of parental involvement, lack of access to appropriate medications, improper inhaler technique, child psychological distress, caregiver psychological distress, issues in family functioning, poor child and family understanding of asthma and asthma medications, and a lack of community support [30].

C O N C L U S I O N S
In both cities, the study found important causes of uncontrolled asthma. Poor inhaler technique, raised BMI, environmental triggers such pollen allergies, poorly ventilated homes, and treatment non-compliance were also noted in both populations. In addition, the study indicated that uncontrolled asthma was present in 32% of paediatric patients in Urumqi and 56% of those in Islamabad for a variety of reasons.