We investigated HRQoL among young people with asthma during the transition from adolescence to young adulthood, based on a large sample, with data of asthma symptoms up to approximately 24 years of age in the population-based BAMSE birth cohort. Our results revealed that HRQoL was lower in young adulthood, after the transition, than in adolescence. Furthermore, young adults with asthma having uncontrolled disease or who were physically inactive appeared to be particularly vulnerable.
The general decrease in HRQoL with age in the present study may be a part of emerging adulthood, which is characterised by changing life circumstances. For instance, as adolescents move through the educational system, they are subjected to greater academic demands and expectations (19). School satisfaction has been considered a fundamental domain for the understanding of students’ quality of life. An international comparative survey showed that perceived school pressure tends to increase in the transition through adolescence, and to differ with gender, with older girls reporting the highest levels of school pressure (20). Further, another international survey examined trends in school pressure and school satisfaction by gender among 15-year-old students between 2002 and 2018 (19). They found that school satisfaction tended to increase over the period among boys, whereas school pressure increased among girls. These sex differences were supported by our results.
Our results are in accordance with recent results from the PIAMA birth cohort, where decreased mental well-being and general health were seen from age 17 to 20 years among participants both with and without asthma (21). In the present study, HRQoL decreased among young adults with asthma, and more problems were reported in three out of five health attributes in young adulthood compared with in adolescence. A reason for this could be that the young adults are supposed to self-manage their asthma (22). This can be challenging; we saw in our previous study that young adults with asthma felt left out of the system during the transition from paediatric to adult healthcare and did not know where to turn in adult healthcare (23). Providently, the European Academy of Allergy and Clinical Immunology recently developed clinical practice guidelines to provide evidence-based recommendations for healthcare professionals to support the transitional care of adolescents and young adults with asthma (6). The recommendations include identifying and managing issues impacting HRQoL. In contrast to our study, one of the few published studies, designed to evaluate HRQoL of adolescents with asthma when they were transferred from paediatric to adult healthcare, found that HRQoL among adolescents improved between the ages of 16 and 21 years (24). This study was conducted at a children’s hospital, and the authors reasoned that one possible explanation for the improvement could be improved asthma control during this period (25).
In the present study, uncontrolled asthma had a particularly impact on HRQoL among young adults. This confirms results in prior literature and implies that patients with uncontrolled asthma should be observed more closely (18, 26). Moreover, a recent cross-sectional study found that medication adherence also correlates with better HRQoL in adolescence (27). Recent results from our BAMSE cohort show that controller medication adherence (i.e., refilling a prescription within 18 months) tends to be low in young adults with asthma (60%) (11). A recent meta-analysis indicates that non-adherence to inhaled corticosteroids is a significant problem during emerging adulthood, a potentially challenging transition (28). Therefore, a significant proportion of patients is not benefiting from effective asthma treatment in early adulthood, leading to a high prevalence of uncontrolled asthma. This highlights the need to address non-adherence in this population.
In our study, HRQoL was lower among young adults with asthma who did not fulfil the WHO’s recommendations on amount of physical activity per week compared with the ones who did. A recent systematic review evaluating the effects of physical activity on asthma outcomes showed that most studies suggest that physical activity improves HRQoL, as well as asthma control, lung function parameters and inflammatory markers among adults with an asthma diagnosis (29). However, exercise-induced bronchoconstriction (EIB) is common in patients with asthma and can be one factor negatively affect motivation and participation in physical activity (18, 30). Given the negative impact of EIB, detection of EIB in early life is an important consideration for healthcare providers, resulting in increased physical activity levels throughout life, improved cardiovascular conditioning, reduced rates of obesity and better HRQoL (31). In the present study, the young adults with asthma who did not fulfil the WHO recommendations of physical activity had increased odds of considering themselves not very healthy or fairly healthy compared with their peers who did fulfil the recommendations. However, since information on physical activity and asthma were collected at the same time, no conclusions on the temporal relationships between these variables could be drawn from our data. These results may be relevant in clinical practice as support for the benefits of non-pharmacological interventions (32).
In the present study, both young adults with adolescent-onset and those with persistent asthma had increased odds of not considering themselves healthy compared with participants without asthma. These results are supported by a recent systematic literature review which aimed to understand the challenges faced by adolescents and young adults with asthma and allergic conditions. The review found that onset of disease in adolescence was linked to impairment of HRQoL (1).
Strengths and limitations
One important strength of the present study was the prospective data collection from birth up to young adulthood, which enabled us to assess age at onset of asthma. Other strengths included the population-based design and the large and well-characterised study sample of the BAMSE cohort. Further, the EQ-5D is the most popular generic instrument for measuring HRQoL in patients with asthma (33). A recent systemic review assessed the evidence on the validity and responsiveness of five commonly used preference-based instruments, including EQ-5D (34). Based on sixteen reviews, covering more than 180 studies, results were heavily skewed towards EQ-5D, with significantly fewer studies investigating other instruments. There was evidence that EQ-5D was generally valid and responsive. Still, a variety of HRQoL instruments was used in relation to asthma, e.g., the Short Form 36 Health, the DISABKIDS asthma module questionnaire, the SF-6D and the KIDSCREEN-10 (35–38). Since asthma is an episodic disease, the ability of the generic EQ-5D instrument to reflect the full impact ‘today’ could be discussed, e.g., whether the measure can capture the impact of exacerbations between episodes; it may miss clinically important changes in asthma control (39). Although greater sensitivity may be demonstrated with a disease-specific instrument, those may lack the ability to compare utility values across diseases and may also miss side effects and comorbidities (8).
The study population consisted of participants who responded to the questionnaire and participated in the 24-year clinical examination. Since no more participants have been added between the 16- and 24-year follow-ups, and the majority had data of EQ VAS at both the 16- and the 24-year follow-ups, the decrease in EQ VAS does not seem to be explained by loss to follow-up. The lower proportion of males in the study population also did not seem to explain the generally decreased EQ VAS in young adulthood.