Health-Related Quality of Life and Its Determinants Among Children with Congenital Heart Defects in Lagos, Nigeria: A Comparative Cross-sectional Study

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N. Okoromah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7054428/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Thehealth-related quality of Life (HRQoL) of children with congenital heart defects (CHDs) and their caregivers is important in holistic management. This study evaluated the HRQoL and its predictors among children with congenital heart defects attending Lagos University Teaching Hospital Methods: A comparative cross-sectional study among 180 children with congenital heart defects (CHDs) and healthy controls. HRQoL was assessed using the Paediatric Quality of Life Inventory [PedsQL™]. Socio-demographic data and clinical characteristics were also obtained and tested based on HRQoL scores to determine if there were possible associations. Results: The mean age was 10.34 ± 3.3 years. The mean physical functioning (60.37±24.4 vs. 83.07±20.8), emotional functioning (75.96±16.3 vs. 83.14±15.3), social functioning (72.03±21.5 vs. 89.00±17.4), school functioning (59.06±21.7 vs. 77.67±20.0), and the overall total HRQoL scores were (66.85±15.3 vs. 83.22±14.7) in CHDs compared to controls, respectively. The parent proxy HRQoL scores correlate positively with the child’s scores. Only social class and types of CHDs were associated with HRQoL scores. Conclusion: The study reveals the low HRQoL in the populations with CHDs compared with the healthy controls, buttressing the need for holistic care that addresses medical, surgical and social support in children with CHDs. Trial Registration : Not Applicable Congenital Health Defects Health Quality of Life Children Figures Figure 1 Background Congenital heart defects (CHDs) are structural defects of the heart and/or great vessels present at birth but may manifest at any time after birth. 1 CHDs are broadly classified into acyanotic and cyanotic based on the presence or absence of cyanosis 1 . They are the leading cause of birth defect-related morbidity and mortality worldwide 2 . In most developed countries, the provision of prenatal screening, early diagnosis and interventional modalities, including open heart surgeries, has resulted in increased survival of children with CHD and consequent maturity into adulthood. 3 This is considerably different to developing countries like Nigeria, challenged with the diagnosis and management of children with CHD, bottlenecks accounting for the documented poorer outcomes. 4 , 5 The diagnosis of CHD in a child has far-reaching impact on the holistic health and wellbeing of the child as well as the parents/caregivers, the family and the community. 6 The negative impact cuts across the biophysical health, psychological, cognitive and social functioning of the child and the caregivers/parents. 7,8 The significance of a holistic approach to health is buttressed by the World Health Organization (WHO) definition of health as a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. 9 However, healthcare services over the years have focused mainly on the biophysical rather than the social and mental aspects of health in children with CHD; this, in turn, could impact the overall quality of life of these children. 10 – 12 Health-related quality of life (HRQoL), a subset of Quality of life, is defined as an individual’s perception of their position in life in the context of their culture and value systems in which they live and with their goals, expectations, standards and concerns. It is a crucial measure in clinical practice and research, as a determinant of patient satisfaction and overall general outcome. 13 HRQoL is a measure of the effectiveness of healthcare delivery in any nation. 14 According to the American Heart Association Scientific statement on Cardiovascular health, patient-reported health status is an important predictor of cardiovascular events, hospitalisation, cost of care and mortality. 15 The HRQoL tool is important in the care and evaluation of long-standing chronic diseases such as CHD, as clinical measures alone may not entirely reflect the disease burden. 16 , 19 Therefore, evaluation of the composite and discrete HRQoL will enhance holistic patient-centred care as well as help to better characterise the impact of healthcare delivery on patients’ health. This study evaluates the health-related quality of life and identifies its predictors among children with congenital heart defects attending Lagos University Teaching Hospital. This evaluation will help identify significantly at-risk groups and contribute to early and appropriate interventional therapies, particularly psychological support, among others. Methods This comparative cross-sectional study involved children living with CHDs aged 5–17 years who presented for routine clinic or echocardiogram at the Paediatric Cardiology unit of the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. The study was conducted over six (6) months (January to June 2022). The study aimed to evaluate the health-related quality of life and identify its predictors among children with congenital heart defects compared with healthy age, sex and socioeconomic status-matched controls. The inclusion criteria were children with echocardiographically confirmed congenital heart defects aged 5 years to 17 years, written informed consent obtained from parents/caregivers of patients, and assent from the children seven years and above, after approval from their parents. Excluded from the study were children with clinical features suggestive of genetic syndromes such as Down syndrome (hypotonia, flattened nasal bridge, upward slanting eyes and short neck with generous nuchal skin) and those with an acute illness at the time of the study or hospitalisation within the previous four weeks. The control group were healthy children aged 5 years to 17 years with no known CHDs or acquired heart disease, and whose clinical examinations did not suggest underlying cardiac disease. They were recruited from children on a one-time follow-up at the consultant Outpatient Clinics for non-chronic conditions, general Outpatient Clinics, Dental Clinics and healthy siblings of patients with confirmed CHDs who came along during a follow-up visit. The sample size was determined using the formula for comparison of two means between two independent populations 17 Number per group (n)= ( \(\:\frac{2\:(\text{Z}{\sigma\:}}{\text{E}})\) 2 n = sample size Z = critical value at 95% confidence interval σ = the common standard deviation of children with CHD from a similar study E = margin of error. On average, the differences in mean between healthy controls and children with CHD = 5 Where Z = 1.96 σ = 15.9 using findings from a similar study 18 E = 5 n = 78. To account for incomplete data, an additional 10% (8) of the minimum sample size calculated was recruited, totalling 86. The number was rounded up to 90. Therefore, 90 children with CHD and their caregivers were studied, as well as 90 children without CHD. Ethical approval was obtained from the Lagos University Teaching Hospital Health Research and Ethics Committee (LUTH HREC) with the ethical approval number: 3138. Consent and assent forms were completed and signed by the parents/guardians and patients aged 7 years and above, respectively. For children presenting in the clinic, the attending physician communicated the details of the study to the parents/guardians and patients, followed by a detailed clinical examination. A short interviewer-administered proforma was also used to obtain information about the patient, including biodata, socioeconomic class. Information about factors which could impact HRQoL, including clinical information such as the presence of comorbidities, frequency of hospital admissions, and cardiac surgeries, was also elicited. The HRQoL was assessed using the PedsQL™ Generic Core Scale questionnaire by the interviewer according to the recommended guideline, which required that, when feasible, the PedsQL should be completed before the respondents complete any other health data forms and before they see their physician or healthcare provider. 19 , 20 The instructions and items were read out to each participant clearly and privately in a designated room at the clinic and cardiovascular laboratory. At the beginning of each domain of PedsQL, the recall interval instructions of the last one month were emphasized to remind the participant to respond only to the specific period. The PedsQL generic core scale questionnaire was administered independently to the caregiver and the child according to the age groups. Child (7–12 years) and teen (13-17years) have both child and proxy report. Each participant was questioned in English language version of the PedsQL tool. The same procedure was followed for the control group. To ensure validity, the child and caregiver administered their versions of the scale separately. DATA ANALYSIS Data collected was recorded, validated and analysed using the Statistical Package for Social Sciences (SPSS) software (version 23) Armonk, NY: IBM Corp. The information obtained from the PedsQL questionnaire was analysed according to the scoring protocol of the PedsQL. The Likert scale was reverse-scored and linearly transformed to a 0-100 scale as follows: 0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0. The composite HRQoL and the HRQoL domains were represented as mean with standard deviation scores. The degree of association between the child and proxy report was determined using Pearson’s correlation. Association between independent factors and HRQoL scores was tested using students’ t test or analysis of variance as appropriate. Statistical significance was accepted at p values < 0.05. Following the analysis, the results of children with low HRQoL were communicated with the parents and managing consultants, in a bid to ensure review of modifiable factors and improvement in management of the children. Results One hundred and eighty children were enrolled in this study: 90 children with CHDs and 90 healthy controls. The mean age ± standard deviation (SD) was 10.34 ± 3.3 years for both groups. The distribution of participants by sex was 55.6% male and 44.4% female in both groups. The two groups did not differ significantly in age, gender, and socioeconomic class, as shown in Table 1 . The clinical characteristics of participants with CHDs as shown in Table 2 . The distribution of CHD types includes Atrial Septal Defect (ASD) at 3.3%, Bicuspid Aortic Valve at 1.1%, Complete Atrioventricular Septal Defect (AVSD) at 5.6%, Double Outlet Right Ventricle (DORV) at 4.4%, Ebstein anomaly at 2.2%, Partial AVSD at 3.3%, Patent Ductus Arteriosus (PDA) at 7.8%, Pulmonic Stenosis (PS) at 3.3%, Shone complex at 2.2%, Transposition of the Great Arteries (TGA) at 3.3%, Tetralogy of Fallot (TOF) at 34.4%, Truncus Arteriosus at 4.4%, Ventricular Septal Defect (VSD) at 23.3%, and VSD with ASD at 1.1%. Regarding hospital admissions in the last year, only ten percent (10%) were admitted. 46.7% of participants had undergone surgery, while 53.3% had not. Among the 41 participants who underwent surgery, 40.0% had definitive surgery and 6.7% had palliative surgery. 52.2% were on routine medication. Health-Related Quality of Life (HRQoL) scores of the study participants. Table 3 : The mean physical functioning (60.37 ± 24.4 vs. 83.07 ± 20.8), emotional functioning (75.96 ± 16.3 vs. 83.14 ± 15.3), social functioning (72.03 ± 21.5 vs. 89.00 ± 17.4), school functioning (59.06 ± 21.7 vs. 77.67 ± 20.0), and the overall total HRQoL score (66.85 ± 15.3 vs. 83.22 ± 14.7) were significantly lower in the CHD group compared to the healthy controls. Significantly lower HRQoL were reported in the overall (75.07 ± 13.7 vs. 84.94 ± 12.2), physical (71.30 ± 21.6 vs. 87.02 ± 14.5), social functioning (80.81 ± 18.5 vs. 90.73 ± 14.3), and school functioning (72.00 ± 18.7 vs. 80.94 ± 16.1) domains by parents/caregivers’ proxy report of children with CHDs compared to the healthy controls. Although emotional functioning domain scores were lower in the CHD group (76.17 ± 18.0 vs. 81.06 ± 18.8), this difference was not statistically significant. Furthermore, there was a statistically significant positive correlation (Pearson correlation = 0.511, p < 0.001) between child-reported and proxy-reported Health-Related Quality of Life (HRQoL). See Fig. 1 The child-reported HRQoL did not significantly differ across any of the examined variables, including age group, sex, socioeconomic class, CHD type (p = 0.239), admission history (p = 0.368), school absences, surgery history, and routine medication use. However, parent-reported HRQoL was significantly associated with social class and CHD type only, with higher social class and acyanotic CHD being associated with significantly better parent-reported HRQoL. There were no significant association between the parent-reported HRQoL with respect to age, sex, admission in the last year, number of missed school terms, surgery and routine medication. Table 4 Table 1 Socio-demographic characteristics of participants Heart defects (n = 90) n (%) Controls (n = 90) n (%) Total χ 2 p-value Age group (Years) 5–7 8–12 13–17 Mean ± SD 20(22.2) 47(52.2) 23(25.6) 10.34 ± 3.3 20(22.2) 47(52.7) 23(25.6) 10.34 ± 3.3 40(22.2) 94(52.7) 46(25.6) 0.000 1.000 Sex Male Female 50(55.6) 40(44.4) 50(55.6) 40(44.4) 50(55.6) 40(44.4) 0.000 1.000 Social class High Middle Low 52(57.8) 26(28.9) 12(13.3) 52(57.8) 26(28.9) 12(13.3) 104(57.8) 52(28.9) 24(13.3) 0.000 1.000 Table 2 Clinical characteristics among participants with congenital heart defects Variable Frequency (n = 90) Percentage Type of CHD ASD 3 3.3 Bicuspid aortic valve 1 1.1 Complete AVSD 5 5.6 DORV 4 4.4 Ebstein anomaly 2 2.2 Partial AVSD 3 3.3 PDA 7 7.8 PS 3 3.3 Shone complex 2 2.2 TGA 3 3.3 TOF 31 34.4 Truncus arteriosus 4 4.4 VSD 21 23.3 VSD + ASD 1 1.1 Admission in last one year Yes No 9 81 10.0 90.0 Number of missed schools’ term 2–3 ≥ 4 51 39 56.7 43.3 Surgery Yes No 42 48 46.7 53.3 Type of surgery (n = 41) Definite Palliative 36 6 40.0 6.7 Routine medication Yes No 47 43 52.2 47.8 ASD- Atrial septal defect, VSD- Ventricular septal defect, PDA- Patent ductus arteriosus, AVSD- Atrioventricular septal defect, DORV- Double outlet right ventricle, PS- Pulmonary stenosis, TGA- Transposition of great arteries, TOF- Tetralogy of Fallot Table 3 HRQoL among congenital heart defect subjects and age/sex and socioeconomic class matched participants Heart defect (n = 90) Mean ± SD Controls (n = 90) Mean ± SD t-value p-value Child report Physical domain 60.37 ± 24.4 83.07 ± 20.8 6.619 < 0.001* Emotional domain 75.96 ± 16.3 83.14 ± 15.3 3.402 0.003* Social domain 72.03 ± 21.5 89.00 ± 17.4 5.822 < 0.001* School domain 59.06 ± 21.7 77.67 ± 20.0 5.977 < 0.001* Composite score 66.85 ± 15.3 83.22 ± 14.7 7.977 < 0.001* Proxy report Physical domain 71.30 ± 21.6 87.02 ± 14.5 5.728 < 0.001* Emotional domain 76.17 ± 18.0 81.06 ± 18.8 1.782 0.076 Social domain 80.81 ± 18.5 90.73 ± 14.3 4.031 < 0.001* School domain 72.00 ± 18.7 80.94 ± 16.1 3.430 0.001* Composite score 75.07 ± 13.7 84.94 ± 12.2 5.102 < 0.001* *Significant Table 4 Relationship between HRQOL and demographic/clinical characteristics among CHD Child reported HRQoL Parent reported HRQoL Mean ± SD p-value Mean ± SD p-value Age group (Years) 5–7 8–12 13–17 68.86 ± 16.9 65.40 ± 14.8 68.14 ± 14.9 0.626 77.80 ± 14.3 73.35 ± 12.9 76.22 ± 14.3 0.431 Sex Male Female 65.32 ± 14.7 68.77 ± 15.9 0.289 75.55 ± 14.7 74.47 ± 12.5 0.713 Social class High Middle Low 68.84 ± 15.7 64.36 ± 15.1 63.62 ± 13.6 0.351 78.79 ± 12.7 72.10 ± 13.7 65.34 ± 12.1 0.003* CHD type Acyanotic Cyanotic 68.84 ± 14.7 65.03 ± 15.7 0.239 78.46 ± 12.7 71.97 ± 4.0 0.023* Admission in last one year Yes No 62.38 ± 13.6 67.34 ± 15.4 0.368 75.38 ± 16.3 75.04 ± 13.5 0.943 Number of missed schools’ term 2–3 ≥ 4 68.21 ± 15.3 65.08 ± 15.2 0.339 77.14 ± 14.0 72.36 ± 12.9 0.101 Surgery Yes No 68.35 ± 15.3 65.54 ± 15.3 0.386 76.84 ± 14.1 73.52 ± 13.2 0.252 Routine medication Yes No 66.14 ± 15.4 67.96 ± 15.3 0.579 73.65 ± 13.4 77.20 ± 13.6 0.219 *Significant Discussion Our study evaluated the health-related quality of life and identified its predictors among children 5–17 years with CHDs compared to healthy age, sex and socio-economic matched controls in Lagos. The child and parent reported mean composite HRQoL was lower in the CHD group compared to controls. The school functioning and physical functioning were the most affected domains as reported by the child and parent/proxy, respectively. Higher socioeconomic class and type of cardiac defect significantly affected the parent-reported HRQoL scores. The overall HRQoL score was significantly lower in children with CHD compared to their healthy counterparts. This aligns with findings by previous works that revealed reduced HRQoL in children with CHD relative to peers without chronic health conditions. 21 – 23 The lower HRQoL could be explained by the chronic nature of CHD and its associated complications, in addition to parental anxiety, repeated hospital admissions, surgical interventions, and routine clinic visits, which often disrupt normal developmental experiences, interactions and play. This cumulatively contributes to a diminished quality of life in physical, emotional, social, and school functioning domains. 24 – 26 In contrast, reports by Teixeira et al., 24 in Portugal and Moons et al., 25 in Belgium, found that participants with CHD exhibited higher HRQoL scores compared to their peers. The difference in study design may explain the variations, in addition to their study population, which included young adults who have lived with the CHD and adapted to the condition over many years with better coping mechanisms, psychological adjustment, and, consequently, higher self-reported HRQoL. School functioning was the most impacted domain of HRQoL among children with CHD. This finding is similar to previous studies, which identified school functioning as the most affected domain. 21 , 22 The plausible explanation for this is because of the frequent disruption of academic activities, characterized by prolonged school absenteeism, academic underperformance, difficulty integrating with peers, as a result of repeated hospital visits for routine follow-ups and/or admissions for acute exacerbations of their condition. 27 Similar impairments in HRQoL, especially the school functioning, have been documented in children living with other chronic conditions such as epilepsy, nephrotic syndrome, and type 1 diabetes mellitus. 28 – 32 These highlight the critical need for targeted interventions aimed at supporting academic participation and performance in children with chronic illnesses, such as individualized education plans, hospital-based schooling programs, and caregiver–school collaboration to enhance cognitive development and educational attainment in this vulnerable population. In contrast, the emotional domain was the least affected among our study population. This may be attributed to the gradual development of adaptive coping mechanisms and psychosocial resilience as children age. 33 Over time, many children with CHD gain a better understanding of their condition, benefit from peer support, and receive consistent family and community encouragement, which collectively enhance their emotional stability. The positive correlation between child-reported and proxy-reported composite HRQoL scores affirms the findings of Uzark et al. 21 in the USA, who reported a significant correlation between parent and child assessments of HRQoL in paediatric CHD populations. However, Krol et al. 22 in the Netherlands and Abassi et al. 34 in France reported disparity between child and proxy reports, with children rating their HRQoL more favourably than their parents. Krol et al. 22 postulated that parents’ reports of lower HRQoL scores are due to concern about their child's condition, which may not fully reflect the child's own lived experience. Thus, a heightened estimation of the disease’s impact on daily functioning, especially in domains such as emotional and social well-being. There was no significant association between age and the composite HRQoL in our study population, suggesting potential age-related trends in the perception of well-being among children with CHD. Although children aged 5–7 years reported the highest mean composite HRQoL scores, compared to those in the 8–12-year age group. These findings are consistent with previous studies, which observed age-related variations in HRQoL, with younger children typically reporting higher scores than their older counterparts. 23 , 24 , 34 , 35 A possible explanation for this trend is that younger children, particularly those aged 5–7 years, may have a limited cognitive capacity to fully comprehend the implications of their chronic condition, in addition to adequate parental care and protection, which minimizes their awareness of the social and functional limitations associated with CHD. 36 Contrary, children in the 8–12-year age group may be at a developmental stage where they become aware of their health status, physical limitations, and social differences. Furthermore, studies have suggested that older children and adolescents (13–17 years) gradually develop better coping strategies and psychosocial adjustment mechanisms, with greater resilience. 24 , 33 Furthermore, gender had no effect on the HRQoL among children with CHD. This finding is consistent with earlier studies that also reported no significant gender differences in HRQoL outcomes among pediatric CHD populations. 35 , 37 This could be explained by the standardized approach in the management of CHDs, irrespective of gender. Thus, quality of life outcome reinforces the importance of maintaining gender equity in pediatric healthcare services. A positive association between higher SES and parent-reported HRQoL scores was observed. This highlights the potential influence of parental perceptions shaped by their social and economic context. Most participants in this study were from high socioeconomic backgrounds, which may have contributed to the more favourable HRQoL assessments by parents. Families in higher SES have greater access to healthcare resources, higher health literacy, with resultant ability to effectively seek care for their child’s condition, as well as have optimistic perception of the child’s quality of life. This effect of SES on the HRQoL is supported by Cassedy et al. 38 who reported that lower family income and low socioeconomic status were significantly associated with poorer HRQoL outcomes in children with CHD. There was a significant association between parent-reported HRQoL scores and the type of CHD, with children having cyanotic CHD reporting lower HRQoL scores compared to their acyanotic counterparts. This finding agrees with the study by Sertcelik et al. 37 , who reported significantly lower scores in the psychological domain among children with cyanotic CHD, highlighting the greater psychosocial burden experienced by this subgroup. The presence of cyanosis in CHD often indicates more complex structural anomalies and a greater need for medical and surgical interventions, which can contribute to physical limitations, increased anxiety, and social exclusion. 39 Contrary to Teixeira et al. 23 and Knowles et al. 24 , both studies showed no significant association between cyanosis and HRQoL scores. These may be attributable to differences in study populations, severity and type of CHD, sample size, and the tools used to assess HRQoL. There were no association of the impact of cardiac surgery on HRQoL scores among children with CHD. This is because most of our participants have not undergone surgical interventions, which could have limited the ability to detect differences in HRQoL. However, Teixeira et al. 24 reported better HRQoL scores, particularly in the physical and social domains, among children with CHD who had not undergone surgery compared to those who had surgery. The plausible explanation is that individuals after surgery experience the resultant pain and discomfort frequently and thus have restrictions in their daily lives and limitations in physical activity. Similarly, studies by Drakouli and Landolt observed impaired HRQoL scores in children post-cardiac surgery, suggesting that surgical intervention may not uniformly translate to improved perceived well-being. 7 , 40 – 42 This finding underscores the importance of comprehensive preoperative counselling, long-term follow-up, and multidisciplinary care, including neurodevelopmental and psychosocial support, to optimize quality of life in children undergoing cardiac surgery. Our study did not demonstrate a statistically significant association between HRQoL scores and the number of missed school days, frequency of hospital admissions, or the use of routine medications. However, it is noteworthy that children who had been hospitalized or were on long-term medication reported lower mean composite HRQoL scores, as did their caregivers. These findings are in line with those of Knowles et al., 23 who observed that prolonged school absence was associated with low HRQoL in children with CHDs. Hospitalizations and the need for continuous medication may serve as indicators of disease severity or complexity, potentially contributing to functional limitations, emotional distress, and social withdrawal. These challenges, while not statistically significant in this study, may still have clinically relevant implications for the child's perceived quality of life. STRENGTHS AND LIMITATIONS This is one of the first studies in Nigeria to characterise the impact of CHDs on the HRQoL in children. However, the cross-sectional nature of the study, as well as the hospital-based design, may limit the generalizability of our findings. We believe our findings will provide the basis for the comprehensive evaluation and a multidisciplinary approach to the care of children with CHDs, which integrates not only medical and surgical management but also psychosocial support for both the child and their caregivers Conclusion This study found that the HRQOL scores of children with CHD were lower than those of age, sex, and socioeconomic class matched healthy controls. School functioning was the most affected domain in children living with CHD. There is thus a need for holistic care strategies in managing children with CHD to minimize hospital admissions, promote school continuity, and support psychosocial well-being. Interventions should also include mental health services, school reintegration programs, physical rehabilitation, and social skill development, all tailored to promote a better quality of life. Abbreviations CHDs Congenital heart defects HRQoL Health Related quality of life LUTH Lagos University Teaching Hospital PedsQL Paediatric Quality of Life Inventory SES Socioeconomic status SPSS Statistical Package for the Social Sciences WHO World Health Organization Declarations Ethics approval and Consent to Participate Ethics declarations: All procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed Consent: Ethical approval was obtained from the Lagos University Teaching Hospital Health Research and Ethics Committee, Lagos, with IRB number; ADM/DCST/HREC/APP/3138. The purpose, processes, and expected outcome of the study were explained to participants and their caregivers (for those younger than 18 years), and their assent and informed consent were obtained before the commencement of the study. Confidentiality was maintained, and the freedom to withdraw at any time from the study without negative consequences was emphasized. Consent for Publication Not Applicable Availability of data and materials The data used in this study will be made available from the corresponding author following consensus agreement with other co-authors on a reasonable request. Competing Interest The authors declare no conflict of interest Funding There was no grant or sponsorship for this work Author Contributions Conceptualization: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy Data curation: Omotola O. Majiyagbe. Formal analysis: Omotola O. Majiyagbe, Abideen O. Salako Investigation: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy Data curation: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy Methodology: Omotola O. Majiyagbe, Abideen O. Salako Project administration: Omotola O. Majiyagbe, Abideen O. Salako Resources: Omotola O. Majiyagbe, Abideen O. Salako Supervision: Abideen O. Salako, Christy A. N. Okoromah. Validation: Abideen O. Salako, Christy A. N. Okoromah. Writing – original draft: Omotola O. Majiyagbe, Abideen O. Salako Writing – review & editing: Omotola O. Majiyagbe, Abideen O. Salako, Christy A. N. Okoromah. Acknowledgement Our depth of appreciation to all the children and parents/caregivers who participated in the study and continue to entrust their care in the hands of the paediatric team at the Lagos University Teaching Hospital. Our immense gratitude to all those who continue to provide care for children living with CHDs. References Tantchou Tchoumi JC, Butera G, Giamberti A, Ambassa JC, Sadeu JC. Occurrence and pattern of congenital heart diseases in a rural area of sub-Saharan Africa. Cardiovasc J Afr. 2011;22(2):63–6. Van Der Linde D, Konings EEM, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJM, et al. Birth prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol. 2011;58(21):2241–7. Report of the British Cardiac Society Working Party. Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK. Heart. 2002;88(Suppl 1):11–4. Mocumbi AO, Lameira E, Yaksh A, Paul L, Ferreira MB, Sidi D. Challenges on the management of congenital heart disease in developing countries. Int J Cardiol. 2011;5(3):285–8. Bode-Thomas F. Challenges in the management of congenital heart disease in developing countries. Congenital heart disease-selected aspects. Croatia: Tech Europe. 2012;18:263–73. Tak YR, McCubbin M. Family stress, perceived social support and coping following the diagnosis of a child's congenital heart disease. J Adv Nurs. 2002;39(2):190–8. Drakouli M, Petsios K, Giannakopoulou M, Patiraki E, Voutoufianaki I, Matziou V. Determinants of quality of life in children and adolescents with CHD: a systematic review. Cardiol Young. 2015;25(06):1027–36. Spijkerboer AW, Helbing WA, Bogers AJ, Van Domburg RT, Verhulst FC, Utens EM. Long-term psychological distress, and styles of coping, in parents of children and adolescents who underwent invasive treatment for congenital cardiac disease. Cardiol Young. 2007;17(6):638–45. WHO | Life expectancy. WHO. 2018; (Accessed at https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/ on 26th June, 2019). Greenfield S, Nelson EC. Recent developments and future issues in the use of health status assessment measures in clinical settings. Med Care. 1992;30(5 Suppl):MS23–41. Grol R, Wensing M, Eccles M, Davis D, editors. Improving patient care: the implementation of change in health care. Volume 18. Wiley; 2013 Mar. Razzaghi H, Oster M, Reefhuis J. Long-term outcomes in children with congenital heart disease: National Health Interview Survey. J Pediatr. 2015;166(1):119–24. Health-Related Quality of Life (HRQL). (Accessed at http://qol.thoracic.org/sections/key-concepts/health-related-quality-of-life.html on 28th June, 2019). WHO | WHOQOL: Measuring Quality of Life. WHO. 2014; (Accessed at https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/ on 22nd March, 2019). Rumsfeld JS, Alexander KP, Goff DC Jr, Graham MM, Ho PM, Masoudi FA, Moser DK, Roger VL, Slaughter MS, Smolderen KG, Spertus JA. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association. Circulation. 2013;4(22):2233–49. Solans M, Pane S, Estrada M-D, Serra-Sutton V, Berra S, Herdman M, et al. Health-Related Quality of Life Measurement in Children and Adolescents: A Systematic Review of Generic and Disease-Specific Instruments. Value Heal. 2008;11:742–64. Hajian-Tilaki K. Sample size estimation in epidemiologic studies. Casp J Intern Med. 2011;2(4):289–98. Mellion K, Uzark K, Cassedy A, Drotar D, Wernovsky G, Newburger JW, et al. Health-Related Quality of Life Outcomes in Children and Adolescents with Congenital Heart Disease. J Pediatr. 2014;164(4):781–e7881. PedsQL TM. March, (Pediatric Quality of Life Inventory TM)(Pediatric Quality of Life Inventory TM) (Accessed at http://www.pedsql.org/about_pedsql.html on 29th 2019). Pediatric Quality of Life Inventory™ (PedsQL™). Scaling And Scoring. (Accessed at https://www.prismsports.org/UserFiles/file/PedsQL-Scoring.pdf on 29th March, 2019). Uzark K, Jones K, Slusher J, Limbers CA, Burwinkle TM, Varni JW. Quality of Life in Children With Heart Disease as Perceived by Children and Parents. Pediatr. 2008;121(5):e1060–7. Krol Y, Grootenhuis MA, DestrÉe-Vonk A, Lubbers LJ, Koopman HM, Last BF. Health related quality of life in children with congenital heart disease. Psychol Health 2003:1;18(2):251–60. Knowles RL, Day T, Wade A, Bull C, Wren C, Dezateux C, et al. Patient-reported quality of life outcomes for children with serious congenital heart defects. Arch Dis Child. 2014;99(5):413–9. Teixeira FM, Coelho RM, Proença C, Silva AM, Vieira D, Vaz C, et al. Quality of Life Experienced by Adolescents and Young Adults With Congenital Heart Disease. Pediatr Cardiol. 2011;32(8):1132–8. Moons P. Is the severity of congenital heart disease associated with the quality of life and perceived health of adult patients? Heart. 2005;91(9):1193–8. Assessing Health-Related Quality of Life in Congenital Heart Disease - American College of Cardiology. (Accessed at https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/06/30/13/43/the-impact-of-neurodevelopmental-and-psychosocial-outcomes on 29th March, 2019). Ansari A, Pianta RC. School absenteeism in the first decade of education and outcomes in adolescence. J Sch Psych. 2019;76:48–61. Lagunju IA, Akinyinka O, Orimadegun A, Akinbami FO, Brown BJ, Olorundare E. Health related quality of life of Nigerian children with epilepsy. Afr J Neurol Sci 2009;28(1). Flora OC, Nnenna CU, Mary I, Ugochi A, Chidozie IB. Evaluation of the Health Related Quality of Life of Children Aged 5–18 Years with Type 1 Diabetes Mellitus Seen in South Eastern Nigeria. Int J Clin Med Res. 2018;5(2):27–34. Mbanefo NR, Odetunde OI, Okafor HU, Oguonu T, Ikefuna AN, Ubesie AC, et al. The Clinical Parameters Affecting the Health-Related Quality of Life of Children with Nephrotic Syndrome. Archives Nephrol. 2018;1(1):11–8. Aronu AE, Uwaezuoke N, Chinawa JM, Bisi-Onyemaechi A, Ojinnaka NC. Health-related quality of life in children and adolescents with epilepsy in Enugu. Need for targeted intervention. Nig J Clin Prat. 2021;24(4):517–24. Kourkoutas E, Georgiadi M, Plexousakis S. Quality of life of children with chronic illnesses: A Review of the Literature. Procedia-Social and Behavioral Sciences. 2010; 1;2(2):4763-7. Bottolfs M, Støa EM, Reinboth MS, Svendsen MV, Schmidt SK, Oellingrath IM, Bratland-Sanda S. Resilience and lifestyle-related factors as predictors for health-related quality of life among early adolescents: a cross-sectional study. J Int Med Res. 2020;48(2):03. Abassi H, Huguet H, Picot MC, Vincenti M, Guillaumont S, Auer A, et al. Health related quality of life in children with congenital heart disease aged 5 to 7 years: a multicentre controlled cross-sectional study. Health Qual Life Outcomes. 2020;12(1):366. Eagleson KJ, Justo RN, Ware RS, Johnson SG, Boyle FM. Health-related quality of life and congenital heart disease in Australia. J Paediatr Child Health. 2013;49(10):856–64. Jardine J, Glinianaia SV, McConachie H, Embleton ND, Rankin J. Self-reported quality of life of young children with conditions from early infancy: a systematic review. Paed. 2014;134(4):1129–48. Sertcelik T, Alkan F, Yalin Sapmaz S, Coskun S, Eser E. Life quality of children with congenital heart diseases. Türk Pediatr Arşivi. 2018;53(2):78–86. Cassedy A, Drotar D, Ittenbach R, Hottinger S, Wray J, Wernovsky G, et al. The impact of socio-economic status on health-related quality of life for children and adolescents with heart disease. Health Qual Life Outcomes. 2013;11:99. Tahirović E, Begić H, Nurkić M, Tahirović H, Varni JW. Does the severity of congenital heart defects affect disease-specific health-related quality of life in children in Bosnia and Herzegovina? Eur J Pediatr. 2010;169:349–53. Landolt MA, Valsangiacomo Buechel ER, Latal B. Health-Related Quality of Life in Children and Adolescents after Open-Heart Surgery. J Pediatr. 2008;152(3):349–55. Daliento L. Measurement of cognitive outcome and quality of life in congenital heart disease. Heart. 2005;92(4):569–74. Hickey PR. Neurologic sequelae associated with deep hypothermic circulatory arrest. Ann Thorac Surg. 1998;65:65–70. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers invited by journal 04 Aug, 2025 Editor invited by journal 09 Jul, 2025 Editor assigned by journal 09 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 05 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7054428","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495731564,"identity":"564f6b43-e0a8-4ecf-8c85-927fe3a75a8d","order_by":0,"name":"Majiyagbe Omotola","email":"data:image/png;base64,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","orcid":"","institution":"Massey Street Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Majiyagbe","middleName":"","lastName":"Omotola","suffix":""},{"id":495731570,"identity":"f6304e48-4f22-4987-a3a2-56d672aeeafc","order_by":1,"name":"Salako Abideen","email":"","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Salako","middleName":"","lastName":"Abideen","suffix":""},{"id":495731580,"identity":"ce4870d4-35a6-46c3-b0e9-17c0ef86d335","order_by":2,"name":"Christy A. N. Okoromah","email":"","orcid":"","institution":"Lagos University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christy","middleName":"A. N.","lastName":"Okoromah","suffix":""}],"badges":[],"createdAt":"2025-07-05 17:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7054428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7054428/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88501456,"identity":"8861819c-e3f1-4d6a-80f1-82eef334dbed","added_by":"auto","created_at":"2025-08-07 06:54:11","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150193,"visible":true,"origin":"","legend":"\u003cp\u003ePearson correlation= 0.511; p\u0026lt;0.001*\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation between child-reported and parent-reported HRQoL\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7054428/v1/dd040fae6560fc707a8862bb.jpeg"},{"id":88501562,"identity":"ddf9947d-d132-4af5-a167-61fea6cfb38d","added_by":"auto","created_at":"2025-08-07 06:54:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1302139,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7054428/v1/a2f093c2-4da1-45c8-8fb7-f5b97cd57c6c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health-Related Quality of Life and Its Determinants Among Children with Congenital Heart Defects in Lagos, Nigeria: A Comparative Cross-sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eCongenital heart defects (CHDs) are structural defects of the heart and/or great vessels present at birth but may manifest at any time after birth.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e CHDs are broadly classified into acyanotic and cyanotic based on the presence or absence of cyanosis \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. They are the leading cause of birth defect-related morbidity and mortality worldwide \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In most developed countries, the provision of prenatal screening, early diagnosis and interventional modalities, including open heart surgeries, has resulted in increased survival of children with CHD and consequent maturity into adulthood.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This is considerably different to developing countries like Nigeria, challenged with the diagnosis and management of children with CHD, bottlenecks accounting for the documented poorer outcomes.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe diagnosis of CHD in a child has far-reaching impact on the holistic health and wellbeing of the child as well as the parents/caregivers, the family and the community.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The negative impact cuts across the biophysical health, psychological, cognitive and social functioning of the child and the caregivers/parents.\u003csup\u003e7,8\u003c/sup\u003e The significance of a holistic approach to health is buttressed by the World Health Organization (WHO) definition of health as a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, healthcare services over the years have focused mainly on the biophysical rather than the social and mental aspects of health in children with CHD; this, in turn, could impact the overall quality of life of these children.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHealth-related quality of life (HRQoL), a subset of Quality of life, is defined as an individual’s perception of their position in life in the context of their culture and value systems in which they live and with their goals, expectations, standards and concerns. It is a crucial measure in clinical practice and research, as a determinant of patient satisfaction and overall general outcome.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e HRQoL is a measure of the effectiveness of healthcare delivery in any nation.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e According to the American Heart Association Scientific statement on Cardiovascular health, patient-reported health status is an important predictor of cardiovascular events, hospitalisation, cost of care and mortality.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The HRQoL tool is important in the care and evaluation of long-standing chronic diseases such as CHD, as clinical measures alone may not entirely reflect the disease burden.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Therefore, evaluation of the composite and discrete HRQoL will enhance holistic patient-centred care as well as help to better characterise the impact of healthcare delivery on patients’ health.\u003c/p\u003e\u003cp\u003eThis study evaluates the health-related quality of life and identifies its predictors among children with congenital heart defects attending Lagos University Teaching Hospital. This evaluation will help identify significantly at-risk groups and contribute to early and appropriate interventional therapies, particularly psychological support, among others.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis comparative cross-sectional study involved children living with CHDs aged 5–17 years who presented for routine clinic or echocardiogram at the Paediatric Cardiology unit of the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. The study was conducted over six (6) months (January to June 2022). The study aimed to evaluate the health-related quality of life and identify its predictors among children with congenital heart defects compared with healthy age, sex and socioeconomic status-matched controls.\u003c/p\u003e\u003cp\u003e The inclusion criteria were children with echocardiographically confirmed congenital heart defects aged 5 years to 17 years, written informed consent obtained from parents/caregivers of patients, and assent from the children seven years and above, after approval from their parents. Excluded from the study were children with clinical features suggestive of genetic syndromes such as Down syndrome (hypotonia, flattened nasal bridge, upward slanting eyes and short neck with generous nuchal skin) and those with an acute illness at the time of the study or hospitalisation within the previous four weeks.\u003c/p\u003e\u003cp\u003eThe control group were healthy children aged 5 years to 17 years with no known CHDs or acquired heart disease, and whose clinical examinations did not suggest underlying cardiac disease. They were recruited from children on a one-time follow-up at the consultant Outpatient Clinics for non-chronic conditions, general Outpatient Clinics, Dental Clinics and healthy siblings of patients with confirmed CHDs who came along during a follow-up visit.\u003c/p\u003e\u003cp\u003eThe sample size was determined using the formula for comparison of two means between two independent populations\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNumber per group (n)= (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{2\\:(\\text{Z}{\\sigma\\:}}{\\text{E}})\\)\u003c/span\u003e\u003c/span\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003en = sample size\u003c/p\u003e\u003cp\u003eZ = critical value at 95% confidence interval\u003c/p\u003e\u003cp\u003eσ = the common standard deviation of children with CHD from a similar study\u003c/p\u003e\u003cp\u003eE = margin of error. On average, the differences in mean between healthy controls and children with CHD = 5\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eWhere Z = 1.96\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eσ = 15.9 using findings from a similar study\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eE = 5\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003en = 78. To account for incomplete data, an additional 10% (8) of the minimum sample size calculated was recruited, totalling 86. The number was rounded up to 90. Therefore, 90 children with CHD and their caregivers were studied, as well as 90 children without CHD.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eEthical approval was obtained from the Lagos University Teaching Hospital Health Research and Ethics Committee (LUTH HREC) with the ethical approval number: 3138. Consent and assent forms were completed and signed by the parents/guardians and patients aged 7 years and above, respectively.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor children presenting in the clinic, the attending physician communicated the details of the study to the parents/guardians and patients, followed by a detailed clinical examination. A short interviewer-administered proforma was also used to obtain information about the patient, including biodata, socioeconomic class. Information about factors which could impact HRQoL, including clinical information such as the presence of comorbidities, frequency of hospital admissions, and cardiac surgeries, was also elicited. The HRQoL was assessed using the PedsQL™ Generic Core Scale questionnaire by the interviewer according to the recommended guideline, which required that, when feasible, the PedsQL should be completed before the respondents complete any other health data forms and before they see their physician or healthcare provider.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e The instructions and items were read out to each participant clearly and privately in a designated room at the clinic and cardiovascular laboratory. At the beginning of each domain of PedsQL, the recall interval instructions of the last one month were emphasized to remind the participant to respond only to the specific period.\u003c/p\u003e\u003cp\u003e The PedsQL generic core scale questionnaire was administered independently to the caregiver and the child according to the age groups. Child (7–12 years) and teen (13-17years) have both child and proxy report. Each participant was questioned in English language version of the PedsQL tool. The same procedure was followed for the control group. To ensure validity, the child and caregiver administered their versions of the scale separately.\u003c/p\u003e\u003ch2\u003eDATA ANALYSIS\u003c/h2\u003e\u003cp\u003eData collected was recorded, validated and analysed using the Statistical Package for Social Sciences (SPSS) software (version 23) Armonk, NY: IBM Corp. The information obtained from the PedsQL questionnaire was analysed according to the scoring protocol of the PedsQL. The Likert scale was reverse-scored and linearly transformed to a 0-100 scale as follows: 0 = 100, 1 = 75, 2 = 50, 3 = 25, and 4 = 0. The composite HRQoL and the HRQoL domains were represented as mean with standard deviation scores. The degree of association between the child and proxy report was determined using Pearson’s correlation. Association between independent factors and HRQoL scores was tested using students’ t test or analysis of variance as appropriate. Statistical significance was accepted at p values \u0026lt; 0.05. Following the analysis, the results of children with low HRQoL were communicated with the parents and managing consultants, in a bid to ensure review of modifiable factors and improvement in management of the children.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOne hundred and eighty children were enrolled in this study: 90 children with CHDs and 90 healthy controls. The mean age\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) was 10.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 years for both groups. The distribution of participants by sex was 55.6% male and 44.4% female in both groups. The two groups did not differ significantly in age, gender, and socioeconomic class, as shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe clinical characteristics of participants with CHDs as shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The distribution of CHD types includes Atrial Septal Defect (ASD) at 3.3%, Bicuspid Aortic Valve at 1.1%, Complete Atrioventricular Septal Defect (AVSD) at 5.6%, Double Outlet Right Ventricle (DORV) at 4.4%, Ebstein anomaly at 2.2%, Partial AVSD at 3.3%, Patent Ductus Arteriosus (PDA) at 7.8%, Pulmonic Stenosis (PS) at 3.3%, Shone complex at 2.2%, Transposition of the Great Arteries (TGA) at 3.3%, Tetralogy of Fallot (TOF) at 34.4%, Truncus Arteriosus at 4.4%, Ventricular Septal Defect (VSD) at 23.3%, and VSD with ASD at 1.1%. Regarding hospital admissions in the last year, only ten percent (10%) were admitted. 46.7% of participants had undergone surgery, while 53.3% had not. Among the 41 participants who underwent surgery, 40.0% had definitive surgery and 6.7% had palliative surgery. 52.2% were on routine medication.\u003c/p\u003e\n\u003cp\u003eHealth-Related Quality of Life (HRQoL) scores of the study participants. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e: The mean physical functioning (60.37\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4 vs. 83.07\u0026thinsp;\u0026plusmn;\u0026thinsp;20.8), emotional functioning (75.96\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3 vs. 83.14\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3), social functioning (72.03\u0026thinsp;\u0026plusmn;\u0026thinsp;21.5 vs. 89.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.4), school functioning (59.06\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7 vs. 77.67\u0026thinsp;\u0026plusmn;\u0026thinsp;20.0), and the overall total HRQoL score (66.85\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3 vs. 83.22\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7) were significantly lower in the CHD group compared to the healthy controls.\u003c/p\u003e\n\u003cp\u003eSignificantly lower HRQoL were reported in the overall (75.07\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 vs. 84.94\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2), physical (71.30\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6 vs. 87.02\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5), social functioning (80.81\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5 vs. 90.73\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3), and school functioning (72.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7 vs. 80.94\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1) domains by parents/caregivers\u0026rsquo; proxy report of children with CHDs compared to the healthy controls. Although emotional functioning domain scores were lower in the CHD group (76.17\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0 vs. 81.06\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8), this difference was not statistically significant.\u003c/p\u003e\n\u003cp\u003eFurthermore, there was a statistically significant positive correlation (Pearson correlation\u0026thinsp;=\u0026thinsp;0.511, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between child-reported and proxy-reported Health-Related Quality of Life (HRQoL). See Fig.\u0026nbsp;1\u003c/p\u003e\n\u003cp\u003eThe child-reported HRQoL did not significantly differ across any of the examined variables, including age group, sex, socioeconomic class, CHD type (p\u0026thinsp;=\u0026thinsp;0.239), admission history (p\u0026thinsp;=\u0026thinsp;0.368), school absences, surgery history, and routine medication use. However, parent-reported HRQoL was significantly associated with social class and CHD type only, with higher social class and acyanotic CHD being associated with significantly better parent-reported HRQoL. There were no significant association between the parent-reported HRQoL with respect to age, sex, admission in the last year, number of missed school terms, surgery and routine medication. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic characteristics of participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHeart defects (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge group (Years)\u003c/p\u003e\n \u003cp\u003e5\u0026ndash;7\u003c/p\u003e\n \u003cp\u003e8\u0026ndash;12\u003c/p\u003e\n \u003cp\u003e13\u0026ndash;17\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20(22.2)\u003c/p\u003e\n \u003cp\u003e47(52.2)\u003c/p\u003e\n \u003cp\u003e23(25.6)\u003c/p\u003e\n \u003cp\u003e10.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20(22.2)\u003c/p\u003e\n \u003cp\u003e47(52.7)\u003c/p\u003e\n \u003cp\u003e23(25.6)\u003c/p\u003e\n \u003cp\u003e10.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40(22.2)\u003c/p\u003e\n \u003cp\u003e94(52.7)\u003c/p\u003e\n \u003cp\u003e46(25.6)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50(55.6)\u003c/p\u003e\n \u003cp\u003e40(44.4)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50(55.6)\u003c/p\u003e\n \u003cp\u003e40(44.4)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50(55.6)\u003c/p\u003e\n \u003cp\u003e40(44.4)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial class\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52(57.8)\u003c/p\u003e\n \u003cp\u003e26(28.9)\u003c/p\u003e\n \u003cp\u003e12(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52(57.8)\u003c/p\u003e\n \u003cp\u003e26(28.9)\u003c/p\u003e\n \u003cp\u003e12(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e104(57.8)\u003c/p\u003e\n \u003cp\u003e52(28.9)\u003c/p\u003e\n \u003cp\u003e24(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical characteristics among participants with congenital heart defects\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of CHD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBicuspid aortic valve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete AVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDORV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEbstein anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartial AVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePDA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShone complex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTOF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTruncus arteriosus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVSD\u0026thinsp;+\u0026thinsp;ASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission in last one year\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e90.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of missed schools\u0026rsquo; term\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2\u0026ndash;3\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of surgery (n\u0026thinsp;=\u0026thinsp;41)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDefinite\u003c/p\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoutine medication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.2\u003c/p\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eASD- Atrial septal defect, VSD- Ventricular septal defect, PDA- Patent ductus arteriosus, AVSD- Atrioventricular septal defect, DORV- Double outlet right ventricle, PS- Pulmonary stenosis, TGA- Transposition of great arteries, TOF- Tetralogy of Fallot\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eHRQoL among congenital heart defect subjects and age/sex and socioeconomic class matched participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHeart defect\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eChild report\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.37\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.07\u0026thinsp;\u0026plusmn;\u0026thinsp;20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.96\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.14\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.03\u0026thinsp;\u0026plusmn;\u0026thinsp;21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.06\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.67\u0026thinsp;\u0026plusmn;\u0026thinsp;20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComposite score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.85\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.22\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProxy report\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.30\u0026thinsp;\u0026plusmn;\u0026thinsp;21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.02\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.728\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.17\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81.06\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.81\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90.73\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.94\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.430\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComposite score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.07\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.94\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*Significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRelationship between HRQOL and demographic/clinical characteristics among CHD\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eChild reported HRQoL\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eParent reported HRQoL\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge group (Years)\u003c/p\u003e\n \u003cp\u003e5\u0026ndash;7\u003c/p\u003e\n \u003cp\u003e8\u0026ndash;12\u003c/p\u003e\n \u003cp\u003e13\u0026ndash;17\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.86\u0026thinsp;\u0026plusmn;\u0026thinsp;16.9\u003c/p\u003e\n \u003cp\u003e65.40\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e\n \u003cp\u003e68.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77.80\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\n \u003cp\u003e73.35\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\n \u003cp\u003e76.22\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65.32\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\n \u003cp\u003e68.77\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75.55\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\n \u003cp\u003e74.47\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial class\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.84\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e\n \u003cp\u003e64.36\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1\u003c/p\u003e\n \u003cp\u003e63.62\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e78.79\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e\n \u003cp\u003e72.10\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e\n \u003cp\u003e65.34\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHD type\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAcyanotic\u003c/p\u003e\n \u003cp\u003eCyanotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.84\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\n \u003cp\u003e65.03\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e78.46\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e\n \u003cp\u003e71.97\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.023*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission in last one year\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.38\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/p\u003e\n \u003cp\u003e67.34\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e\n \u003cp\u003e75.04\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of missed schools\u0026rsquo; term\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2\u0026ndash;3\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.21\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003cp\u003e65.08\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/p\u003e\n \u003cp\u003e72.36\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.35\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003cp\u003e65.54\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76.84\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e\n \u003cp\u003e73.52\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoutine medication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66.14\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\n \u003cp\u003e67.96\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e73.65\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e\n \u003cp\u003e77.20\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*Significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study evaluated the health-related quality of life and identified its predictors among children 5\u0026ndash;17 years with CHDs compared to healthy age, sex and socio-economic matched controls in Lagos. The child and parent reported mean composite HRQoL was lower in the CHD group compared to controls. The school functioning and physical functioning were the most affected domains as reported by the child and parent/proxy, respectively. Higher socioeconomic class and type of cardiac defect significantly affected the parent-reported HRQoL scores.\u003c/p\u003e\u003cp\u003eThe overall HRQoL score was significantly lower in children with CHD compared to their healthy counterparts. This aligns with findings by previous works that revealed reduced HRQoL in children with CHD relative to peers without chronic health conditions.\u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The lower HRQoL could be explained by the chronic nature of CHD and its associated complications, in addition to parental anxiety, repeated hospital admissions, surgical interventions, and routine clinic visits, which often disrupt normal developmental experiences, interactions and play. This cumulatively contributes to a diminished quality of life in physical, emotional, social, and school functioning domains.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In contrast, reports by Teixeira et al.,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e in Portugal and Moons et al.,\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e in Belgium, found that participants with CHD exhibited higher HRQoL scores compared to their peers. The difference in study design may explain the variations, in addition to their study population, which included young adults who have lived with the CHD and adapted to the condition over many years with better coping mechanisms, psychological adjustment, and, consequently, higher self-reported HRQoL.\u003c/p\u003e\u003cp\u003eSchool functioning was the most impacted domain of HRQoL among children with CHD. This finding is similar to previous studies, which identified school functioning as the most affected domain.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The plausible explanation for this is because of the frequent disruption of academic activities, characterized by prolonged school absenteeism, academic underperformance, difficulty integrating with peers, as a result of repeated hospital visits for routine follow-ups and/or admissions for acute exacerbations of their condition.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Similar impairments in HRQoL, especially the school functioning, have been documented in children living with other chronic conditions such as epilepsy, nephrotic syndrome, and type 1 diabetes mellitus.\u003csup\u003e\u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e These highlight the critical need for targeted interventions aimed at supporting academic participation and performance in children with chronic illnesses, such as individualized education plans, hospital-based schooling programs, and caregiver\u0026ndash;school collaboration to enhance cognitive development and educational attainment in this vulnerable population.\u003c/p\u003e\u003cp\u003eIn contrast, the emotional domain was the least affected among our study population. This may be attributed to the gradual development of adaptive coping mechanisms and psychosocial resilience as children age.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Over time, many children with CHD gain a better understanding of their condition, benefit from peer support, and receive consistent family and community encouragement, which collectively enhance their emotional stability.\u003c/p\u003e\u003cp\u003eThe positive correlation between child-reported and proxy-reported composite HRQoL scores affirms the findings of Uzark et al. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e in the USA, who reported a significant correlation between parent and child assessments of HRQoL in paediatric CHD populations. However, Krol et al. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e in the Netherlands and Abassi et al. \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e in France reported disparity between child and proxy reports, with children rating their HRQoL more favourably than their parents. Krol et al.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e postulated that parents\u0026rsquo; reports of lower HRQoL scores are due to concern about their child's condition, which may not fully reflect the child's own lived experience. Thus, a heightened estimation of the disease\u0026rsquo;s impact on daily functioning, especially in domains such as emotional and social well-being.\u003c/p\u003e\u003cp\u003eThere was no significant association between age and the composite HRQoL in our study population, suggesting potential age-related trends in the perception of well-being among children with CHD. Although children aged 5\u0026ndash;7 years reported the highest mean composite HRQoL scores, compared to those in the 8\u0026ndash;12-year age group. These findings are consistent with previous studies, which observed age-related variations in HRQoL, with younger children typically reporting higher scores than their older counterparts.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e A possible explanation for this trend is that younger children, particularly those aged 5\u0026ndash;7 years, may have a limited cognitive capacity to fully comprehend the implications of their chronic condition, in addition to adequate parental care and protection, which minimizes their awareness of the social and functional limitations associated with CHD.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Contrary, children in the 8\u0026ndash;12-year age group may be at a developmental stage where they become aware of their health status, physical limitations, and social differences. Furthermore, studies have suggested that older children and adolescents (13\u0026ndash;17 years) gradually develop better coping strategies and psychosocial adjustment mechanisms, with greater resilience.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurthermore, gender had no effect on the HRQoL among children with CHD. This finding is consistent with earlier studies that also reported no significant gender differences in HRQoL outcomes among pediatric CHD populations.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e This could be explained by the standardized approach in the management of CHDs, irrespective of gender. Thus, quality of life outcome reinforces the importance of maintaining gender equity in pediatric healthcare services.\u003c/p\u003e\u003cp\u003eA positive association between higher SES and parent-reported HRQoL scores was observed. This highlights the potential influence of parental perceptions shaped by their social and economic context. Most participants in this study were from high socioeconomic backgrounds, which may have contributed to the more favourable HRQoL assessments by parents. Families in higher SES have greater access to healthcare resources, higher health literacy, with resultant ability to effectively seek care for their child\u0026rsquo;s condition, as well as have optimistic perception of the child\u0026rsquo;s quality of life. This effect of SES on the HRQoL is supported by Cassedy et al.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e who reported that lower family income and low socioeconomic status were significantly associated with poorer HRQoL outcomes in children with CHD.\u003c/p\u003e\u003cp\u003eThere was a significant association between parent-reported HRQoL scores and the type of CHD, with children having cyanotic CHD reporting lower HRQoL scores compared to their acyanotic counterparts. This finding agrees with the study by Sertcelik et al. \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, who reported significantly lower scores in the psychological domain among children with cyanotic CHD, highlighting the greater psychosocial burden experienced by this subgroup. The presence of cyanosis in CHD often indicates more complex structural anomalies and a greater need for medical and surgical interventions, which can contribute to physical limitations, increased anxiety, and social exclusion.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Contrary to Teixeira et al. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and Knowles et al. \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, both studies showed no significant association between cyanosis and HRQoL scores. These may be attributable to differences in study populations, severity and type of CHD, sample size, and the tools used to assess HRQoL.\u003c/p\u003e\u003cp\u003eThere were no association of the impact of cardiac surgery on HRQoL scores among children with CHD. This is because most of our participants have not undergone surgical interventions, which could have limited the ability to detect differences in HRQoL. However, Teixeira et al. \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e reported better HRQoL scores, particularly in the physical and social domains, among children with CHD who had not undergone surgery compared to those who had surgery. The plausible explanation is that individuals after surgery experience the resultant pain and discomfort frequently and thus have restrictions in their daily lives and limitations in physical activity. Similarly, studies by Drakouli and Landolt observed impaired HRQoL scores in children post-cardiac surgery, suggesting that surgical intervention may not uniformly translate to improved perceived well-being.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis finding underscores the importance of comprehensive preoperative counselling, long-term follow-up, and multidisciplinary care, including neurodevelopmental and psychosocial support, to optimize quality of life in children undergoing cardiac surgery.\u003c/p\u003e\u003cp\u003eOur study did not demonstrate a statistically significant association between HRQoL scores and the number of missed school days, frequency of hospital admissions, or the use of routine medications. However, it is noteworthy that children who had been hospitalized or were on long-term medication reported lower mean composite HRQoL scores, as did their caregivers. These findings are in line with those of Knowles et al., \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e who observed that prolonged school absence was associated with low HRQoL in children with CHDs. Hospitalizations and the need for continuous medication may serve as indicators of disease severity or complexity, potentially contributing to functional limitations, emotional distress, and social withdrawal. These challenges, while not statistically significant in this study, may still have clinically relevant implications for the child's perceived quality of life.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSTRENGTHS AND LIMITATIONS\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis is one of the first studies in Nigeria to characterise the impact of CHDs on the HRQoL in children. However, the cross-sectional nature of the study, as well as the hospital-based design, may limit the generalizability of our findings. We believe our findings will provide the basis for the comprehensive evaluation and a multidisciplinary approach to the care of children with CHDs, which integrates not only medical and surgical management but also psychosocial support for both the child and their caregivers\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that the HRQOL scores of children with CHD were lower than those of age, sex, and socioeconomic class matched healthy controls. School functioning was the most affected domain in children living with CHD. There is thus a need for holistic care strategies in managing children with CHD to minimize hospital admissions, promote school continuity, and support psychosocial well-being. Interventions should also include mental health services, school reintegration programs, physical rehabilitation, and social skill development, all tailored to promote a better quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCHDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCongenital heart defects\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHRQoL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth Related quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLUTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLagos University Teaching Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePedsQL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePaediatric Quality of Life Inventory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocioeconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations:\u0026nbsp;\u003c/strong\u003eAll procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from the Lagos University Teaching Hospital Health Research and Ethics Committee, Lagos, with IRB number; ADM/DCST/HREC/APP/3138. The purpose, processes, and expected outcome of the study were explained to participants and their caregivers (for those younger than 18 years), and their assent and informed consent were obtained before the commencement of the study. Confidentiality was maintained, and the freedom to withdraw at any time from the study without negative consequences was emphasized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study will be made available from the corresponding author following consensus agreement with other co-authors on a reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;authors\u0026nbsp;declare\u0026nbsp;no\u0026nbsp;conflict\u0026nbsp;of\u0026nbsp;interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere\u0026nbsp;was\u0026nbsp;no grant\u0026nbsp;or\u0026nbsp;sponsorship for\u0026nbsp;this\u0026nbsp;work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy\u003c/p\u003e\n\u003cp\u003eData curation: Omotola O. Majiyagbe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFormal analysis: Omotola O. Majiyagbe, Abideen O. Salako\u003c/p\u003e\n\u003cp\u003eInvestigation: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy\u003c/p\u003e\n\u003cp\u003eData curation: Omotola O. Majiyagbe. Salako Abideen, Okoromah Christy\u003c/p\u003e\n\u003cp\u003eMethodology: Omotola O. Majiyagbe, Abideen O. Salako\u003c/p\u003e\n\u003cp\u003eProject administration: Omotola O. Majiyagbe, Abideen O. Salako\u003c/p\u003e\n\u003cp\u003eResources: Omotola O. Majiyagbe, Abideen O. Salako\u003c/p\u003e\n\u003cp\u003eSupervision: Abideen O. Salako, Christy A. N. Okoromah.\u003c/p\u003e\n\u003cp\u003eValidation: Abideen O. Salako, Christy A. N. Okoromah.\u003c/p\u003e\n\u003cp\u003eWriting – original draft: Omotola O. Majiyagbe, Abideen O. Salako\u003c/p\u003e\n\u003cp\u003eWriting – review \u0026amp; editing: Omotola O. Majiyagbe, Abideen O. Salako, Christy\u0026nbsp;A.\u0026nbsp;N.\u0026nbsp;Okoromah.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur depth of appreciation to all the children and parents/caregivers who participated in the study and continue to entrust their care in the hands of the paediatric team at the Lagos University Teaching Hospital. Our immense gratitude to all those who continue to provide care for children living with CHDs.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTantchou Tchoumi JC, Butera G, Giamberti A, Ambassa JC, Sadeu JC. Occurrence and pattern of congenital heart diseases in a rural area of sub-Saharan Africa. Cardiovasc J Afr. 2011;22(2):63\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Der Linde D, Konings EEM, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJM, et al. Birth prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol. 2011;58(21):2241\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReport of the British Cardiac Society Working Party. Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK. Heart. 2002;88(Suppl 1):11\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMocumbi AO, Lameira E, Yaksh A, Paul L, Ferreira MB, Sidi D. Challenges on the management of congenital heart disease in developing countries. Int J Cardiol. 2011;5(3):285\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBode-Thomas F. Challenges in the management of congenital heart disease in developing countries. Congenital heart disease-selected aspects. Croatia: Tech Europe. 2012;18:263\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTak YR, McCubbin M. Family stress, perceived social support and coping following the diagnosis of a child's congenital heart disease. J Adv Nurs. 2002;39(2):190\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDrakouli M, Petsios K, Giannakopoulou M, Patiraki E, Voutoufianaki I, Matziou V. Determinants of quality of life in children and adolescents with CHD: a systematic review. Cardiol Young. 2015;25(06):1027\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpijkerboer AW, Helbing WA, Bogers AJ, Van Domburg RT, Verhulst FC, Utens EM. Long-term psychological distress, and styles of coping, in parents of children and adolescents who underwent invasive treatment for congenital cardiac disease. Cardiol Young. 2007;17(6):638\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO | Life expectancy. WHO. 2018; (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/\u003c/span\u003e\u003cspan address=\"https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 26th June, 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenfield S, Nelson EC. Recent developments and future issues in the use of health status assessment measures in clinical settings. Med Care. 1992;30(5 Suppl):MS23\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrol R, Wensing M, Eccles M, Davis D, editors. Improving patient care: the implementation of change in health care. Volume 18. Wiley; 2013 Mar.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRazzaghi H, Oster M, Reefhuis J. Long-term outcomes in children with congenital heart disease: National Health Interview Survey. J Pediatr. 2015;166(1):119\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHealth-Related Quality of Life (HRQL). (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://qol.thoracic.org/sections/key-concepts/health-related-quality-of-life.html\u003c/span\u003e\u003cspan address=\"http://qol.thoracic.org/sections/key-concepts/health-related-quality-of-life.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 28th June, 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO | WHOQOL: Measuring Quality of Life. WHO. 2014; (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/\u003c/span\u003e\u003cspan address=\"https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 22nd March, 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRumsfeld JS, Alexander KP, Goff DC Jr, Graham MM, Ho PM, Masoudi FA, Moser DK, Roger VL, Slaughter MS, Smolderen KG, Spertus JA. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association. Circulation. 2013;4(22):2233\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSolans M, Pane S, Estrada M-D, Serra-Sutton V, Berra S, Herdman M, et al. Health-Related Quality of Life Measurement in Children and Adolescents: A Systematic Review of Generic and Disease-Specific Instruments. Value Heal. 2008;11:742\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHajian-Tilaki K. Sample size estimation in epidemiologic studies. Casp J Intern Med. 2011;2(4):289\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMellion K, Uzark K, Cassedy A, Drotar D, Wernovsky G, Newburger JW, et al. Health-Related Quality of Life Outcomes in Children and Adolescents with Congenital Heart Disease. J Pediatr. 2014;164(4):781\u0026ndash;e7881.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePedsQL TM. March, (Pediatric Quality of Life Inventory TM)(Pediatric Quality of Life Inventory TM) (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.pedsql.org/about_pedsql.html\u003c/span\u003e\u003cspan address=\"http://www.pedsql.org/about_pedsql.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 29th 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePediatric Quality of Life Inventory\u0026trade; (PedsQL\u0026trade;). Scaling And Scoring. (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.prismsports.org/UserFiles/file/PedsQL-Scoring.pdf\u003c/span\u003e\u003cspan address=\"https://www.prismsports.org/UserFiles/file/PedsQL-Scoring.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 29th March, 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUzark K, Jones K, Slusher J, Limbers CA, Burwinkle TM, Varni JW. Quality of Life in Children With Heart Disease as Perceived by Children and Parents. Pediatr. 2008;121(5):e1060\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrol Y, Grootenhuis MA, Destr\u0026Eacute;e-Vonk A, Lubbers LJ, Koopman HM, Last BF. Health related quality of life in children with congenital heart disease. Psychol Health 2003:1;18(2):251\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKnowles RL, Day T, Wade A, Bull C, Wren C, Dezateux C, et al. Patient-reported quality of life outcomes for children with serious congenital heart defects. Arch Dis Child. 2014;99(5):413\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTeixeira FM, Coelho RM, Proen\u0026ccedil;a C, Silva AM, Vieira D, Vaz C, et al. Quality of Life Experienced by Adolescents and Young Adults With Congenital Heart Disease. Pediatr Cardiol. 2011;32(8):1132\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoons P. Is the severity of congenital heart disease associated with the quality of life and perceived health of adult patients? Heart. 2005;91(9):1193\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAssessing Health-Related Quality of Life in Congenital Heart Disease - American College of Cardiology. (Accessed at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/06/30/13/43/the-impact-of-neurodevelopmental-and-psychosocial-outcomes\u003c/span\u003e\u003cspan address=\"https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/06/30/13/43/the-impact-of-neurodevelopmental-and-psychosocial-outcomes\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e on 29th March, 2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnsari A, Pianta RC. School absenteeism in the first decade of education and outcomes in adolescence. J Sch Psych. 2019;76:48\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLagunju IA, Akinyinka O, Orimadegun A, Akinbami FO, Brown BJ, Olorundare E. Health related quality of life of Nigerian children with epilepsy. Afr J Neurol Sci 2009;28(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlora OC, Nnenna CU, Mary I, Ugochi A, Chidozie IB. Evaluation of the Health Related Quality of Life of Children Aged 5\u0026ndash;18 Years with Type 1 Diabetes Mellitus Seen in South Eastern Nigeria. Int J Clin Med Res. 2018;5(2):27\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMbanefo NR, Odetunde OI, Okafor HU, Oguonu T, Ikefuna AN, Ubesie AC, et al. The Clinical Parameters Affecting the Health-Related Quality of Life of Children with Nephrotic Syndrome. Archives Nephrol. 2018;1(1):11\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAronu AE, Uwaezuoke N, Chinawa JM, Bisi-Onyemaechi A, Ojinnaka NC. Health-related quality of life in children and adolescents with epilepsy in Enugu. Need for targeted intervention. Nig J Clin Prat. 2021;24(4):517\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKourkoutas E, Georgiadi M, Plexousakis S. Quality of life of children with chronic illnesses: A Review of the Literature. Procedia-Social and Behavioral Sciences. 2010; 1;2(2):4763-7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBottolfs M, St\u0026oslash;a EM, Reinboth MS, Svendsen MV, Schmidt SK, Oellingrath IM, Bratland-Sanda S. Resilience and lifestyle-related factors as predictors for health-related quality of life among early adolescents: a cross-sectional study. J Int Med Res. 2020;48(2):03.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbassi H, Huguet H, Picot MC, Vincenti M, Guillaumont S, Auer A, et al. Health related quality of life in children with congenital heart disease aged 5 to 7 years: a multicentre controlled cross-sectional study. Health Qual Life Outcomes. 2020;12(1):366.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEagleson KJ, Justo RN, Ware RS, Johnson SG, Boyle FM. Health-related quality of life and congenital heart disease in Australia. J Paediatr Child Health. 2013;49(10):856\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJardine J, Glinianaia SV, McConachie H, Embleton ND, Rankin J. Self-reported quality of life of young children with conditions from early infancy: a systematic review. Paed. 2014;134(4):1129\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSertcelik T, Alkan F, Yalin Sapmaz S, Coskun S, Eser E. Life quality of children with congenital heart diseases. T\u0026uuml;rk Pediatr Arşivi. 2018;53(2):78\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCassedy A, Drotar D, Ittenbach R, Hottinger S, Wray J, Wernovsky G, et al. The impact of socio-economic status on health-related quality of life for children and adolescents with heart disease. Health Qual Life Outcomes. 2013;11:99.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTahirović E, Begić H, Nurkić M, Tahirović H, Varni JW. Does the severity of congenital heart defects affect disease-specific health-related quality of life in children in Bosnia and Herzegovina? Eur J Pediatr. 2010;169:349\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLandolt MA, Valsangiacomo Buechel ER, Latal B. Health-Related Quality of Life in Children and Adolescents after Open-Heart Surgery. J Pediatr. 2008;152(3):349\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDaliento L. Measurement of cognitive outcome and quality of life in congenital heart disease. Heart. 2005;92(4):569\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHickey PR. Neurologic sequelae associated with deep hypothermic circulatory arrest. Ann Thorac Surg. 1998;65:65\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Congenital Health Defects, Health, Quality of Life, Children","lastPublishedDoi":"10.21203/rs.3.rs-7054428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7054428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThehealth-related quality of Life (HRQoL) of children with congenital heart defects (CHDs) and their caregivers is important in holistic management. This study evaluated the HRQoL and its predictors among children with congenital heart defects attending Lagos University Teaching Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA comparative cross-sectional study among 180 children with congenital heart defects (CHDs) and healthy controls. HRQoL was assessed using the Paediatric Quality of Life Inventory [PedsQL™]. Socio-demographic data and clinical characteristics were also obtained and tested based on HRQoL scores to determine if there were possible associations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The mean age was 10.34 ± 3.3 years. The mean physical functioning (60.37±24.4 vs. 83.07±20.8), emotional functioning (75.96±16.3 vs. 83.14±15.3), social functioning (72.03±21.5 vs. 89.00±17.4), school functioning (59.06±21.7 vs. 77.67±20.0), and the overall total HRQoL scores were (66.85±15.3 vs. 83.22±14.7) in CHDs compared to controls, respectively. The parent proxy HRQoL scores correlate positively with the child’s scores. Only social class and types of CHDs were associated with HRQoL scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe study reveals the low HRQoL in the populations with CHDs compared with the healthy controls, buttressing the need for holistic care that addresses medical, surgical and social support in children with CHDs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e: Not Applicable\u003c/p\u003e","manuscriptTitle":"Health-Related Quality of Life and Its Determinants Among Children with Congenital Heart Defects in Lagos, Nigeria: A Comparative Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 06:53:36","doi":"10.21203/rs.3.rs-7054428/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-01T05:37:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244895224926601705435088040325741291481","date":"2025-08-19T14:28:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-04T13:14:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-09T13:28:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T04:49:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T04:47:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-07-05T17:31:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67aae046-a6e3-418b-80fb-9d955367d763","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T06:53:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-07 06:53:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7054428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7054428","identity":"rs-7054428","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}