Measuring HRQOL and its determinants in the pediatric population can provide insight into developing more targeted public health policies planned by multiple stakeholders [14]. To our knowledge, this study was the first study assessing HRQOL and its determinants in the general pediatric population in Indonesia. Surprisingly, the total score of HRQOL in our general pediatric population is higher than those in the references study by Varni et al., 89 + 9 vs 84 + 12 (self-reports) and 92 + 6 vs 82 + 15 (proxy-reports) [15]. However, the mean total score of our study was similar to the scores from healthy children in India (87 ± 11) for self-reports and 90 ± 9 for proxy reports) [16]. This may be explained by the fact that our population positively perceived and were satisfied with their life. According to WHO, quality of life is a personal perception of their position in life in the context of their culture and value system and related to their goals, expectations, values, and concerns [17].
In both self-reports and proxy reports, the school functioning was the lowest score among the other domains. It may be explained by almost half of our respondents, especially in the age of 2–12 years, had an acute illness. It may result in school absences and lower the school score. This finding is similar to the study assessing HRQOL of children with acute febrile illness [14] and in bronchitis children [18] which used the PedsQL™ and found the school functioning was the lowest score.
Sociodemographic determinant of Child HRQOL
We found some sociodemographic characteristics related to children's HRQOL. Children who were living in the rural area reported better HRQOL than their urban counterparts. This is remarkable, considering the rural area is associated with a low-resource setting. The finding may probably be due to different perceptions or expectations about HRQOL and life amenities between rural and urban children [16]. As reported by a previous study [19], we found that children with higher father's education level had higher HRQOL, both from the self-reports and proxy reports. Higher levels of parent's education might increase parent's awareness and knowledge about their children's health and supported to get better occupations and income, which led to better HRQOL and life expectancy [19]. On the contrary, we did not find any influence of maternal educational level on children's HRQOL. It may be explained by the fact that in most of Indonesia's families, fathers still hold the leading role. Indonesia is using a patriarchal system which is still common in society and generally accepted by the community. This system raises the principle and value that all the family's decisions, including children's education and health-seeking behavior, are managed by the fathers [20].
A previous study found the health insurance ownership influenced a child's HRQOL [21]. We found that children from self-funding insurance families had higher HRQOL scores than children from families with government-paid insurance or no insurance, both from proxy-reports as well as self-reports. In our population, health insurance ownership may indirectly reflect family socioeconomic status. Since 2014, the Indonesian government introduced National Health Insurance. This obligatory national health insurance system combines government-paid health insurance for poor families and contributory-based (self-funding) health insurance for the more prosperous families [22]. In addition, people with health insurance receive more appropriate and recommended use of health services and have better health outcomes. In contrast, people with no insurance are less likely to receive preventive and screening services, regular and continuing source of care [23].
Interestingly, our adolescence group had higher HRQOL than younger children. This finding contradicts previous studies that found declining HRQOL with increasing age [24]. It may be related to the higher prevalence of acute disease in younger Indonesia's children. We found a higher proportion of 2–12 years old children (56%) suffered from an acute illness than the adolescent group (38%).
Child health determinants on Child HRQOL
Most studies assessing the influences of chronic health problems on a child's HRQOL [5, 14, 19], but few studies assessed the influence of acute illness. A study on determinants of HRQOL in Dutch school-age children's in the general population found that children who had acute health complaints showed lower scores of HRQOL [5]. Our study found that the best predictor of children's HRQOL was the presence of acute illness during the past month. In multivariate regression analysis, we consistently found that having an acute disease, such as upper respiratory symptoms and diarrhea, during the past month lowers the child's HRQOL from the self-reports and proxy reports across all domains. More than one-third of our children have cough or/and coryza, with or without fever, during the past month. We excluded children who were hospitalized during the past last month. Our sample represented that upper respiratory tract symptoms are a prevalent child health problem in our setting. Most acute cough is due to upper respiratory tract infection (URTI) [25]. Even though URTI is associated with low mortality, it significantly disturbs children's daily activities such as sleeping and eating and may cause school absence and parent work absence [26]. A previous study assessing the effect of acute cough on child HRQOL using the Parent-proxy Children's Acute Cough-specific QoL (PAC-QoL) Questionnaire found that children who suffered acute cough have lower HRQOL across all domains [27].
We found that perinatal factors, namely LBW and abnormal delivery, lower the child's HRQOL based on proxy-reports. This result was similar to a review study assessing the impact of preterm and LBW on HRQOL of preschool- and school-aged children, adolescents, and young adults. The review found that the history of prematurity and LBW lower the HRQOL at various age groups. The effect of LBW and gestational age is greatest during the younger period, but the effect extended into adulthood [28]. Our finding is quite essential since LBW is still a significant public health problem. In 2015, an estimated 20.5 million live births were LBW, 91% from low-middle income countries, mainly southern Asia (48%) and sub-Saharan Africa (24%) [29]. The prevalence of LBW in our study population was 5.6 % (self-reported) and 6.0% (proxy-reported), similar to the prevalence of LBW reported by Indonesian Basic Health Research 2018, which was 6.2% [10]. LBW has been identified as a risk of adverse outcomes other than infant mortality-morbidity, including impaired neurodevelopment outcome at school-age and non-communicable diseases later in life [30]. A systematic review and meta-analysis studies on the impact of LBW on South Asian children found that children who were born LBW have significant impairment on cognitive and motor function [31]. Our study provides an additional value to use HRQOL assessment, a simple but valid and reliable tool, to detect the impact of perinatal problems on the whole aspect of health in the preschool to adolescence period. Our finding also emphasized the importance of preventing LBW.
Strengths and limitations
This study has some limitations. This study was a cross-sectional study; therefore, the results only support an association between determinant variables and HRQOL, not causality. In addition, other determinants were not assessed, and thus further research is needed. We also did not consider the school environment. A study in urban schoolchildren found that children's perception of closeness to school personnel and the school environment and "school connectedness' were significantly related to the HRQOL [21]. We excluded children who have been diagnosed with chronic health problems, mental and behavioral health problems. However, a cluster sampling approach using the Health and Demographic Surveillance System (HDSS) sample frame makes this study represent HRQOL of "healthy" children in the semi-urban city of Indonesia. Including acute health complaints and LBW, common health problems in developing countries, as determinants of children's HRQOL, support the importance of health promotion and prevention. Using both proxy-reports and self-reports is also the strength of the study. We found there was a fair to moderate agreement between self-reports and proxy reports. Self-report is considered the standard for measuring HRQOL, because it is more likely to accurately represent internal measures of health than the proxy reporting. However, parent proxy-report should be considered as a secondary measure contributed to health-seeking behavior or health care usage.