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DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF MEDICINE DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE CM2 SY 2011-2012 OUTPUT 3: RESEARCH

H DESIGN (REVISED) I. Group 1A, Dr. Jovilia M. Abong II. Research Question: Among students aged 13-14 with allergic rhinitis of selected schools in Dasmarias, Cavite, will exposure to air-conditioned school rooms affect the severity of their allergic rhinitis? General Objective: To determine if the exposure to the air-conditioning system affects the severity of allergic rhinitis in high school students aged 13-14, of selected schools in Dasmarias, Cavite. Specific Objectives: 1. To identify the prevalence of allergic rhinitis among high school students, aged 13-14, of selected schools in of Dasmarias, Cavite based on their exposure to air-conditioned rooms. 2. To identify the prevalence of allergic rhinitis among high school students, aged 13-14, of selected schools in Dasmarias, Cavite based on their exposure to non-air-conditioned classrooms. 3. To determine the severity of allergic rhinitis according to ARIA classifications. 4. To identify the risk factors of allergic rhinitis present in the classroom or school, such as pollen, molds, and cockroaches. 5. To determine the number of hours exposed to the classroom with or without air-conditioning system according to ARIA classifications. 6. Compare the severity of allergic rhinitis in students who are exposed to air-conditioned classrooms and those who are not exposed to air-conditioned classrooms. III. Background a. Research Hypothesis: Exposure to air-conditioned rooms alleviates the symptoms and occurrence of allergic rhinitis and poor ventilation leads to its severity. b. Conceptual Framework: Exposure Variable Exposure to Airconditioning System Disease Variable Decreased Severity of Allergic Rhinitis and alleviation of symptoms Allergens/Irritants such as pollen, molds, cockroaches, dust collecting furniture, and chalk dust Number of hours spent in classroom

Confounders

IV. Design a. Operational definition of variables i. Dependent Variable Allergic Rhinitis Allergic rhinitis (often called allergies or hay fever) occurs when the immune system overreacts to particles in the air that you breathe. When the immune system attacks the particles in the body, it causes symptoms such as sneezing and a runny nose. Over the time, allergens may begin to affect you less, and the severity of the symptoms also decreases. [1] It is characterized as the inflammation of nasal passages, usually associated with watery nasal discharge and itching of the nose and eyes after exposure to the allergen. Around two-thirds of people with allergic rhinitis manifest the symptoms before the age of 30 but the age at which the symptoms occur may vary. Genetics greatly affects the chance of having allergic rhinitis of an individual. Usually if one or both parents have the disease, their offspring will have a high chance of inheriting the disease. People with allergic rhinitis can also be restricted by the disease in their day to day activities and this may result to increase in time away from school or work. Also, in the US, millions of dollars are spent every year for doctor services and medicine for treating the chronic illness. Symptoms of this illness are triggered by many different allergens and these usually include plant pollens, molds, dust, and allergens produced by cats or dogs. The amount of these allergens is affected by the season as the spread of pollens and spores are determined by the amount of wind in a particular season. [2] ii. Independent Variable Air-conditioning System According to the Department of Health of Hong Kong, sudden change in temperature both indoor and outdoor may activate the release of inflammatory agents. They stated that the room should be maintained at around 25 degrees Celsius. [3] The air conditioner is a common appliance usually found in many buildings both private and public. It is used to cool the air found indoors to make the people inside the building more comfortable. Air conditioners nowadays are not only used for cooling the air, some types of air conditioners can warm the indoor air especially those that are found in places where people experience the winter season. In addition to their air temperature changing capability, the air conditioners nowadays are also capable of filtering, disinfecting and dehumidifying the air to make the people using the appliance more comfortable that is why the air conditioner is also regarded as comfort-making-machine by some people. [4] iii. Confounding Variables: Allergens are substances or particles that are foreign to the body and can cause allergic reaction in certain people. Pollens, molds, cockroaches, and dusts are examples of allergens which can be found in the environment. In managing allergies, it is suggested to reduce the level of exposure to these allergens. [8]

Dust Mites are arachnids not visible by the naked eye that feed on flakes on dead human skin. Mites do not bite humans or spread disease but rather allergy is triggered by the material in the stool of dust mites. They are usually found indoors with high humidity (warm and damp). They are also found in carpets, bed sheets, pillows, mattresses and box springs, furniture and stuffed animals. They decrease in number when temperature decreases and at high altitude. [1] Animal dander is loose skin cells from animals which contain secretion from glands in the animals skin. These skin cells floats in the air where they may be breathed in by people. The animal fur or hair is not an allergen, there might be dried saliva onto the hair that causes the allergy. [1] Pollens cause allergic reaction. These pollens are tiny that comes from plants (trees, grasses, ragweed, etc.). The amount of pollen in the air plays a role in developing allergic reaction. There is likely increased amounts of pollen in hot, dry and windy days, while a decreased amount during cool, damp and rainy days. [5] According to an article by deShazo and Kemp, the spores coming from molds can be a trigger in releasing the symptoms of allergic rhinitis. Also, according to them, molds thrives in damp environments such as air-conditioning vents, water traps, refrigerator drip trays, shower stalls, leaky sink and damp basements if not cleaned regularly and under certain conditions, the growth of these organisms can be considerable and exacerbate allergy symptoms. [6]Since allergic rhinitis is difficult to cure, the focus is on preventing the attack of the symptoms. Molds are seen as cotton-like element that is usually in the color of gray, green, black or white. These molds produce strong earthy and musty odors, although some are odor-free. The smell could be an indication of infection. [9] Many different triggers that may cause a student to experience symptoms of asthma and allergy are found inside a typical classroom. These triggers include the pollens from the plants found near or inside a classroom, dust mites and mold spores. The cleanliness of the room may also play a factor in triggering the allergic reactions. The students themselves may also carry allergens produced by their pet cats or dogs that may be attached to their clothes and these allergens can be in contact with the students with asthma or allergy. Chalk dusts are also usually the causes of allergic reactions inside the classroom since the teachers usually use chalks for writing on the green boards.[7] Chalk dusts are particles produced when a chalk crayon is used to write on chalkboards. These usually remain suspended in the air because these particles are not so heavy so as a result, teachers and students usually inhale small amount of these and become trapped in the mucous layers of the throat and upper lungs. This does not usually pose a threat to normal persons because the accumulated chalk dust is naturally expelled out through coughing and the remaining chalk dust is safely absorbed by the body. However, in persons with chronic breathing issues or allergic rhinitis these chalk dust can irritate their upper respiratory tract and trigger their symptoms and can be dangerous for the person who inhaled the chalk dust.[10] Cockroaches are recognized as powerful indoor allergena. They are among the oldest living species residing the earth. These creatures are hardy and adaptable that thrives in areas 3

where food and water supplies are plentiful. They can be found around dripping faucets and kitchen areas. The allergen produced by cockroaches is from the saliva, body parts and even their digestive enzymes. These particles become airborne when disturbed by motion in the room. [8] b. Research Design i. Type of study to be employed The type of study that the researchers are going to be implementing is a cross-sectional research design. The researchers deem this the most necessary research design just to see whether or not there is a relationship between the number of hours exposed to air-conditioning systems and the exacerbation of Allergic Rhinitis. Moreover, this research design is appropriate because the Disease Variable of the research, which is Allergic Rhinitis, is not a rare disease (thus eliminating the use of a case-control study). However, in doing a cross-sectional study, the researchers must take note of and control the confounding variablesways of which will be discussed in the latter part of the description of the research design. ii. Definition of study groups population and sources of subjects. The study population will be 13-14 year old children who, in the Philippine setting, are approximately first year high school students. From this population, a sample of students who have AR will be considered for the study. The sample populations will be gathered from select schools in Dasmarias, Cavite, ideally one private and public school in order to acquire subjects that have exposure to an air conditioned school environment and one that is not. iii. Steps to be undertaken: These are the steps to be done in our procedure to collect data for this project: 1. Randomly select 2 High Schools in Dasmarias, Cavite one with an air conditioning system, one without. 2. Evaluate the classroom conditions of each school.

The group will visit each high school and evaluate the environmental conditions of each classroom that will be part of the research. An integrated checklist from Health Canada and IAQ Tools for Schools [11], [12] will be given to teacher or adviser of each classroom document and evaluate the conditions. 3. Screen students for allergic rhinitis.

Each student will be screened through a questionnaire, based sections of the ISAAC questionnaire, to eliminate those who do not have allergic rhinitis from the study group. [13] This will help in making the research study more specific to those who have allergic rhinitis and how the classroom conditions can alleviate or exacerbate their symptoms.

4. Sections of the ARIA questionnaire will be given to each student who has AR in which it will ask them if their symptoms are better or worse when they are in the classroom and what specific conditions help or harm them. [14] 5. Evaluate each students questionnaire.

Each students questionnaire will be evaluated to see what particular conditions affect the severity of their AR. There will also be a particular focus on whether having an air-conditioning system present or not alleviates or worsens each students AR symptoms. iv. Schematic Diagram

Measure of Association: Prevalence Ratio Exacerbation of Allergic Rhinitis (+) (-) Total Air(+) A B A+B Conditioning System (-) C D C+D Total A+C B+D A+B+C+D c. Biases/Limitations i. Enumeration of all biases/limitations 5

The study will only focus on the role of ventilation inside the classrooms in the relief and exacerbation of allergic rhinitis among students aged 13-14 years old studying in Dasmarias, Cavite. It will not include other respiratory diseases and illness that may be affected by the difference in ventilation. The possible biases in the study are: Selection bias Expectation bias

ii. Plan to minimize these biases in the study Selection bias may happen when subjects being compared are not similar, and may result to data that is not representative of the population of interest. [15] With the use of proper screening methods for the study population, we will select subjects that are similar in almost all aspects in order to gather a more representative and comparable data. Expectation bias happens when there is no masking or blinding implemented in the study and this may influence and tarnish the data to be gathered towards the expected or desired outcome. [15] To minimize this bias, a high level of objectivity must be maintained with each of the members of the group of researchers in the gathering of data and its analysis. Bibliography [1] Healthwise Staff, Allergic Rhinitis, In: Thompson, E.G. MD, Nelson, H.S. MD, editor, Allergic Rhinitis [cited 2011 July 31] Available from: http://www.webmd.com/allergies/tc/allergicrhinitis-overview [2] Allergic rhinitis. (2010). Health encyclopedia diseases and conditions. Retrieved July 10, 2011, from http://www.healthscout.com/ency/68/208/main.html. [3] Retrieved on July 30, 2011 http://www.studenthealth.gov.hk/english/health/health_ophp/health_ophp_nos.html from

[4] Air conditioner. (2009). Air conditioning and refrigeration information. Retrieved July 30, 2011, from http://www.air-conditioning-and-refrigeration.com/air-conditioner.html. [5] Busse, P.J. MD., (2010) Allergic Rhinitis In: Zieve, D. MD., editor., [cited 2011 July 31] Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000813.htm [6] deShazo R., Patient Information: Trigger avoidance in allergic rhinitis. Retrieved on July 30, 2011 from http://www.uptodate.com/contents/patient-information-trigger-avoidance-in-allergic-rhinitis [7] Health risks in the classroom: children with asthma and allergies need to take special precautions at school. Retrieved July 30, 2011, from http://www.kidneeds.com/diagnostic_categories/articles/classrisks01.htm.

[8] Stppler, M.C., MD. Indoor Allergens In: Shiel, W.C. Jr., MD. FACP. FACR., editor, [cited 8 August 2011] Available from http://www.medicinenet.com/indoor_allergens/article.htm [9] Oliver, S., Mold Detection How to Detect Toxic Mold in your Home? [cited 8 August 2011] Available from http://ezinearticles.com/?Mold-Detection---How-to-Detect-Toxic-Mold-in-YourHome?&id=2589917 [10] Pollick, M. (2011). Is chalk dust harmful? Wise geek: clear answers for common questions. Retrieved August 8, 2011, from http://www.wisegeek.com/is-chalk-dust-harmful.htm. [11] Classroom Checklist (2007). Health Canada [Website]. Available from: http://www.hc-sc.gc.ca/ewhsemt/pubs/air/tools_school-outils_ecoles/classroom-salle_classe-eng.php [12] IAQ tools for Schools. North Hunderton-Voorhees Regional District High School [Website]. Available from: http://www.nhvweb.net/VHS/Math/ABlaustein/toolsforschools/teacher.pdf [13] ISAAC Questionnaire. International Study of Asthma and Allergies in Childhood, [Website]. 2011 [cited 2011 August 8]. Available from http://isaac.auckland.ac.nz/phases/phasethree/corequestionnaire.pdf. [14] ARIA Questionnaire. Allergic Rhinitis and its Impact on Asthma [Website]. 2011 [cited 2011 July 30]. Available from http://www.whiar.org/docs/ARIA_OnlineQuestionnaireGuidewm38sp.pdf [15] Hartman, J.M., Forsen, J.W., Wallace, M.S., Neely, J.G. (2002). Tutorials in clinical research: Part IV: Recognizing and controlling bias. Laryngoscope, 112, 23-31.

APPENDIX A ISAAC QUESTIONNAIRE FOR SCREENING STUDENTS Study Instruments for 13/14 year olds Instructions for Completing Questionnaire and Demographic Questions (Section 7.1) On this sheet are questions about your name, school, and birth dates. Please write your answers to these questions in the space provided. All other questions require you to tick your answer in a box. If you make a mistake, put a cross in the box and tick the correct answer. Tick only one option unless otherwise instructed.

___________________________________________________________________________________ SCHOOL: TODAYS DATE: Day YOUR NAME: YOUR AGE: years Day Month Year Month Year

YOUR DATE OF BIRTH:


(Tick all your answers for the rest of the questionnaire)

Are you:

MALE

FEMALE

Core Questionnaire for Allergic Rhinitis (Section 7.3) All questions are about problems which occur when you DO NOT have a cold or the flu. 1 Have you ever had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or the flu? Yes No

IF YOU HAVE ANSWERED NO PLEASE SKIP TO QUESTION 6. In the past 12 months, have you had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or the flu? IF YOU HAVE ANSWERED NO PLEASE SKIP TO QUESTION 6. 3 4 In the past 12 months, has this nose problem been accompanied by itchy-watery eyes? In which of the past 12 months did this nsoe problem occur?
(Please tick any which may apply)

Yes No

Yes No

January February March April 5

May June July August

September October November December Not at all A little A moderate amount A lot Yes No

In the past 12 months, how much did this nose problem interfere with your daily activities?

Have you ever had hay fever?

APPENDIX B CHECKLIST FOR CLASSROOM CONDITIONS General Cleanliness Yes No 1. Yes No 2. Yes No 3. Yes No 4. Yes No 5. Yes No 6. Yes No 7. Yes No 8. Yes No 9. Yes No 10. Yes No 11. Animals Yes No Yes No Yes No Yes No 1. 2. 3. 4.

Classroom is clean. Classroom is dusted and vacuumed thoroughly and regularly. Trash is removed daily. Food is not kept in classroom overnight. Food is stored in a tightly sealed container. Room is free of pests. Room is free of the use of scented cleaners. Spills cleaned. Blackboards/whiteboards are cleaned properly. Desks and lockers are cleaned regularly. There are signs of pet presence. Exposure to animal allergens minimized. Animals kept in cages as much as possible; not allowed to roam. Cages cleaned regularly. Animals are kept away from ventilation system vents to minimize the circulation of animal allergens.

Blackboards/Whiteboards Yes No 1. Use of low-dusting chalk and maintain general cleanliness. Yes No 2. On whiteboards, use of markers that release low levels of volatile organic compounds (VOCs). Yes No 3. Non-usage of portable brush cleaners, vacuums, or other processes that generate or release dust. Ventilation Yes No Yes No Yes No 1. Unit ventilator located. 2. Air supply and return vents located. 3. Windows are operable. Presence of worn and dirty carpets. Cleaning with chemicals, improper drying, or vacuuming without adequate filtration. Window coverings are used to maximize natural light. Presence of any unusual odors, including damp or musty smells Presence of any discoloured, damp or smelly building components or obvious signs of mold. 10

Building Envelope Yes No 1. Yes No 2. Yes No 3. Yes No 4. Yes No 5.

APPENDIX C ARIA QUESTIONNAIRE Which of the following options describe you?


(You may choose more than one)

A. My doctor has told me that I have asthma. B. My doctor has told me that I have allergic rhinitis. C. I sometimes have breathing problems like wheezing and shortness of breath, but Ive never been diagnosed with asthma by my doctor. D. I sometimes have symptoms like a runny nose, sneezing, and/or itchy, watery eyes, but Ive never been diagnosed with allergic rhinitis by my doctor. 1. What symptoms do you have?
(Answer Yes for any of the symptoms listed below that apply. Answer No for all that do not.)

Watery runny nose Sneezing (especially violent and in bouts) Nasal obstruction (feeling of being unable to breathe through your nose) Itchy nose Watery, red, itchy eyes 2. How long do your symptoms last?
(Answer Yes or No for each time frame below.)

Yes No Yes No Yes No Yes No Yes No

More than four days a week More than four weeks in a row 3. How do your symptoms affect you?

Yes No Yes No

(Answer Yes for any of the symptoms listed below that apply. Answer No for all that do not.)

My symptoms disturb my sleep. My symptoms restrict my daily activities (sports, leisure, etc.) My symptoms restrict my participation in school or work. My symptoms are troublesome to me. 4. How much do your symptoms bother you?

Yes No Yes No Yes No Yes No

(On a scale of 0 to 10, with 0 being Not at all and 10 as Very much, indicate how much your symptoms bother you.)

0 1 2 3

4 5 6 7

8 9 10

11