Assessment of Physical Quality of Life Domain of Adolescents with Acute Lymphocytic Leukemia at Teaching Hospitals in Baghdad City

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INTRODUCTION
Acute lymphoblastic leukemia (ALL) is a disease characterized by an uncontrolled proliferation and maturation arrest of lymphoid progenitor cells in the bone marrow resulting in an excess of malignant cells. It is a complex malignant blood disease that affects hematopoietic cells of the bone marrow and is typified by the malignant proliferation of lymphoblast that affect the normal process of maturation and differentiation of cells in the bone marrow, resulting in the replacement of normal bone marrow tissue with cancerous cells (1), Cancer is the most common cause of disease related death in children in industrialized societies. And ALL is the most common cancer in adolescents (2)(3) .
The annual incidence of ALL is 3 to 4 cases per 100,000 children. It occurs more frequently in males than in females, and the peak onset is between 2 and 6 years of age (3) . ALL accounting for one-third of cancer diagnoses in children younger than 15 and 28% of cancer diagnoses in those younger than 20 (4) .
Aggressive therapies have led to dramatic improvements in survival, but they also have raised concerns about the impact of pediatric cancer and its treatment on quality of life (QoL) and behavioral adjustment (5) . The survival rate of ALL, the most common malignancy in children, has improved in recent years to a 5-year survival rate of about 80%. Because cure rates have increased, more emphasis has been placed on reducing toxicities of therapy, improving QoL during treatment and minimizing long-term effects of therapy (2) .
QoL is now considered an important outcome measure for children with cancers not just in the long term but also during courses of treatment. The focus on ALL is important because, ALL accounts for most childhood cancers (1) .
In health care, the concept or term of QoL, often used interchangeably with the term 'health related quality of life' (HRQOL). Generally QoL is understood as a multi-dimensional construct concerning an individual's perception of the impact of illness and its treatment upon his/her health, wellbeing or functioning in relation to physical, psychological, and social aspects of life (1) (6) .
This study aims to assess the physical quality of life's domain of adolescents with acute lymphocytic leukemia at teaching hospitals in Baghdad city and find out the relationships between the physical quality of life domain of adolescents with acute lymphocytic leukemia and their demographic characteristics.

MATERIALS AND METHODS
Study Design: A descriptive study design was conducted on adolescents having ALL and their age range between 10 years to 19 years. The study started from the period of 20 th November 2011 to 2 nd July 2012 and aims to assess the physical quality of life's domain of adolescents with acute lymphocytic leukemia at teaching hospitals in Baghdad city. Study Sample: A non-probability purposive sample of 50 adolescents with ALL and the duration period of disease equal or more than 6 months and the ages of all participants are between 10 years to 19 years and they meet the inclusion criteria were selected from hospitals in Baghdad City: oncology department at the Children Welfare Teaching Hospital, Child's Central Teaching Hospital, Baghdad Teaching Hospital, AL-kadimiya Teaching Hospital and the National Center for Research and Treatment of Hematology in Baghdad. The Study Instruments: For the purpose of the study, the instrument, questionnaire format, was designed and constructed by the investigators depending on WHO QoL domains and extensive review of available literature and studies related to the concept of QoL (7) .The questionnaire format consists of two parts: PartI: Adolescent's Patient Demographic Characteristics which includes three sections: Section I: Adolescent's Demographic Data This section includes data concerning the respondents' general characteristics: gender, age, residency, occupation and their Level of education. Section II: Disease Related InformationIt includes items concerning ALL disease itself such as, adolescents' age at the onset of illness, and the duration of chemotherapy treatment. Section III: Socio-economic Status Scale (SESS) Socioeconomic status scale obtained after the calculation of socioeconomic information about parents' occupation, parents' education, crowding index, family type and family properties (house expenses like, type of housing, housing size, household asset, possession of a car & other house excess) according to (6) .The calculated score help in classified the family level of socioeconomic as high or moderate or low level. The following equation used to the following calculate of: Crowding index = According to the total scores of SESS three social economic levels represented as following: high SES (80-100), middle SES (60-79), and low SES (59 and less) (6) .

Part II: Physical quality of Life Measurement Scale:
This questionnaire format comprised of structured questions (15 items), concerning the physical quality of life's domain of adolescents with ALL & composed of: pain and discomfort (3 items), activities of daily living (4 items), fatigue (5 items), and sleep and rest (3 items), all of these items explained how the disease affects the physical characteristics of adolescents with ALL.

Data collection:
The data collected by the investigators and semi-structured interview technique used with adolescent, individually interviewed" face to face", after taking the initial consent of each adolescent to participate in the study. The process started from 1 st of February until the 15 th of April 2012. An approximately (20-25) minutes spends with each sick adolescent to complete the interview and filling of the questionnaire format.

Rating and Scoring of the Questionnaire Format
The items have been rated and scored according to the following patterns: Three point likert scales is used for rating the items as always=3, some time=2, never=1, for all items. The lowest score explains no effects on QoL domain while the highest score reflects the effects of ALL upon QoL domain of adolescents . Data Analyses: The data of the present study were analyzed by using statistical package of social sciences (SPSS) version 12. The descriptive and inferential statistical data analysis approaches were used in order to analyze the study data.
The mean of score calculated according to the following equation: A mean of score of < 1.5 was considered low; (1.5-2.4) was considered moderate and ≥2.5 was considered high.
Multiple Linear Regression that perform to examine the correlation between two variable dependent variable x and independent variable y more than one variable.  were graduates of primary school.  Table (1B): Demonstrates disease information, (46%) of the study sample were within age (15-18) years at the onset of illness,(44%) their duration of chemotherapy treatment is within (1-6) months,( 78%) of the sample didn't have relatives with the same disease,( 88%) of the sample got the medication (chemotherapy) from Hospitals.

DISCUSSION
The findings of the present study table (1A), indicated that more than half of the sample were male and agrees with (Sung, et al., 2011) (2) reported that most of their study sample were males 119(57.8%).
The dominant age group of the present study sample are within (15-19 ) years , this findings disagreed with (Plasschaert, et al., 2004) (8) who stated that (ALL) occurs in children as well as in adults, but the incidence changes with age. The highest incidence is in children under the age of five years old (5.7 per 100,000 person years), followed by the 5-to 9-years old (2.7) and the 10-to 14-years old (1.6).
The results also revealed that highest percentage of the study sample are living in urban area and this result agrees with a study conducted by (Ma'ala, 2001) (6) mentioned that majority of her sample 138(86.2) were living in urban areas. Moreover, the present study revealed that two third of the sample were students and this result agrees with (Ma'ala, 2001) (6) study who mentioned that most of her sample (58.8%) were students. Moreover the findings also revealed that the highest percentage of ALL adolescents were graduated from primary school and intermediate respectively. This findings inconsistent with (Al-Mosooi, 2004) (9) studied results that highest percentage of her study sample (51.7%)of adolescents graduated from primary school (table 1A).
( Table 1 B) shows that almost half of the sample have the disease between the age of (15-18) years. This findings disagreed with (Ma'ala, 2001) (6) reported that most of her sample (43.8%) have the disease at the age of (10-12 years). Concerning the duration of chemotherapy treatment the highest percentage of the study sample are within (1 -6) months and most of the sample not having relative with the same disease. A high percentage of sample take free medication (chemotherapy) from hospitals which help in reducing the burden of the disease on adolescents' condition and these findings were supported by (Abdullah, 2011) (10) study (Impact of Chemotherapy upon Quality of Life for Patients with Chronic Myeloid Leukemia) who mention that all the patients of his study sample 130(100%) receiving of the medication from hospitals.
In relation to the Socioeconomic status (SES) the present study findings revealed that the most of the sample came from the low level of the SES (table 1C). This result agrees with a study conducted by (Ma'ala, 2001) (6) and her findings that (61.3%) of the sample came from family of a low SES.
All aspect of the physical domain and sub domain affected by the diseases and its treatment at moderate level except sleep and rest sub domain that revealed low level affect (table 2).
According to (AL Ahwal, 2005) (11) who indicated that the majority of cancer patients have some form of physical or practical problems that may affect their QoL.
Moreover the treatment of leukemia is long, painful and invasive which also mention by (Golchin, et al., 2004) (12) . They also mentioned that frequent hospitalizations, numerous physical side effects and limitations in daily activities following the treatment all affects significantly on the child's QoL. Consequently, treatment side effects and its impact on children's QoL has gained great importance and QoL issue will be paid more attention than survival duration. (Barbosa, et al., 2002) (13) findings of the(Musculoskeletal manifestations as the onset of acute leukemias in childhood) supported the findings of the present study and they reported that thirty-eight of their sample (62%) had limb pain and/or joint pain. The daily living activities subdomain affects adolescent's with ALL of the present study at the moderate level and this result supported by (Aznar,et al., 2006) (14) study report that ALL patients demonstrated significantly lower intensity and reduced amounts of total activity during weekdays. These study results correspond with previous investigations, that have shown that physical activity levels in survivors of childhood leukemia tend to be lower than in healthy controls.
In regard to fatigue, the present study results presented that most of ALL adolescent experience fatigue. Moreover, the subjects' are affected at moderate level. This result supported by (Savage, et al., 2009) (1) specifically measured fatigue which was reported as problematic for children on treatment for ALL compared to children off treatment.
Concerning sleep and rest, the present study findings revealed that subjects are affected at low level. This result might be due to the burden of ALL and its treatment on the bone and body organs and leads to fatigue, restless and appear obviously on patients' rest and sleep Table (3) reflects the results of multiple regression analyses which indicated statistical significant association between physical domain and adolescents' gender at Pvalue (0.012,). This result agree with (2) mentioned that there is significant relationship between the patients' gender with physical domain and psychosocial domain.
The age is highly significant with physical domain and the result showed that residency of adolescent were affected in physical domain too. Moreover, there is also non-significant correlation between the adolescents' occupation with physical domain. According to (Al-Mosooi, 2004) (9) stated that no significant relationship between adolescents occupation and physical domain of her sample. There is non-significant relationship between the adolescents' level of education and physical domain. The present findings also reflected high significant relationship between physical domains and adolescents' age at the onset of illness.
The results of the present study shows high significant relationship between physical domain and duration of chemotherapy treatment & relatives having the same disease. The family history has significant relationship with physical domain (Al-Mosooi, 2004) (9) . The results of the present study also shows no significant relationship of supply of chemotherapy with physical domain. While there is high significant relationship between physical domain and SES. This findings was supported by (Ma'ala, 2001) (6) who reported that statistical significant association between physical domain with SES.

CONCLUSIONS
 The present study indicated that the physical QoL domain was affected by ALL at moderate level.

RECOMMENDATION:
1. The establishment of hematology and oncology center 2. An education program for adolescents with ALL started to help them live a better life.