|Year : 2016 | Volume
| Issue : 1 | Page : 23-30
|Asthma-related knowledge, attitudes, practices (KAP) of parents of children with bronchial asthma: A hospital-based study
Kaushik Sudha Bhagavatheeswaran1, Jyoti Bala Kasav2, Awnish Kumar Singh3, Surapaneni Krishna Mohan4, Ashish Joshi5
1 Final Year MBBS Student, Saveetha Young Medical Researchers Group (SYMRG), Saveetha Medical College & Hospital, Faculty of Medicine, Saveetha University, Saveetha Nagar, Chennai, Tamil Nadu; Student, Operations Research in Population Health, Foundation of Healthcare Technologies Society, New Delhi, India
2 Environment Health Researcher, Department of Environment Health, Foundation of Healthcare Technologies Society, New Delhi, India
3 Public health Researcher, Department of Public Health, Foundation of Healthcare Technologies Society, New Delhi, India
4 Associate Professor & Vice Principal, Department of Biochemistry, Saveetha Medical College & Hospital, Faculty of Medicine, Saveetha University, Saveetha Nagar, Chennai, Tamil Nadu; Research Affiliate, Department of Public Health, Foundation of Healthcare Technologies Society, New Delhi, India
5 Assistant Dean and Associate Professor, CUNY School of Public Health, New York, USA; Director, Department of Public Health, Foundation of Healthcare Technologies Society, New Delhi, India
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|Date of Web Publication||22-Jan-2016|
| Abstract|| |
Background: Prevention of asthma exacerbations is one of the major challenges of public health. Parents are crucial for exacerbation prevention and management at home. This study was conducted with the objective of assessing asthma knowledge in the parents of asthmatic children and to understand parents' attitude and practices in dealing with the exacerbation of their children's asthma. Materials and Methods: A convenient sample of 100 parents of asthmatic children was enrolled. Any parents (mother or/and father) with a child aged 8 years and above, diagnosed with bronchial asthma, and attending the Outpatient Department of Paediatrics, Saveetha Medical College and Hospital with his/her child in the study period could be included. Results: In this study, 62% children were male and 38% female, the average age was 12.53 years [standard deviation (SD) 2.95], and the average time duration for living with an asthmatic condition was 6 years (SD 3). Of the parents, 80% responded that they did not know what inhaled corticosteroids were and most (86%) of them did not know how they worked, while 41% were aware of aerosol therapy. Of the respondents, 87% had never used a Children's Asthma Control Test questionnaire and 78% said that they did not have any written action plan in case of their child suffering an asthma attack. Conclusion: There is an urgent need for the preparation of parental guidelines for preventing asthma exacerbations among asthmatic children living in India.
Keywords: Asthmatic children, attitudes, bronchial asthma, challenges, parents, public health
|How to cite this article:|
Bhagavatheeswaran KS, Kasav JB, Singh AK, Mohan SK, Joshi A. Asthma-related knowledge, attitudes, practices (KAP) of parents of children with bronchial asthma: A hospital-based study. Ann Trop Med Public Health 2016;9:23-30
|How to cite this URL:|
Bhagavatheeswaran KS, Kasav JB, Singh AK, Mohan SK, Joshi A. Asthma-related knowledge, attitudes, practices (KAP) of parents of children with bronchial asthma: A hospital-based study. Ann Trop Med Public Health [serial online] 2016 [cited 2016 Dec 3];9:23-30. Available from: http://www.atmph.org/text.asp?2016/9/1/23/168704
| Introduction|| |
Medical professionals are trained to manage asthma exacerbations in hospital-based settings. However, the prevailing environmental triggers along with nonadherence to medical advice are major challenges in preventing exacerbations. 
According to the World Health Organization's global health estimates, the total number of deaths in 2011 was recorded to be 54,591,414, and noncommunicable diseases contributed to 66% of the total deaths. The severity of asthma is visible through its contribution toward 3,74,678 deaths in 2011.  Asthma, being a most common chronic disease, accounts for about 300 million individuals out of the total world population. Asthma prevalence in children is increasing worldwide. 
The definition of asthma severity, as reviewed by the Global Alliance against Chronic Respiratory Diseases, defines severe asthma as "Uncontrolled asthma which can result in risk of frequent sever exacerbations (or deaths) and/or adverse reaction to medication and/or chronic morbidity (including impaired lung function or reduced lung growth in children)." 
Among children aged 13-14 years, the global average for current wheeze was 14.1% and the Indian subcontinent recorded a prevalence of <5%. The mean global prevalence for current wheeze was found to be 11.5% for the age group of 6-7 years; the Indian subcontinent had a prevalence of 6.8%. Within the age categories of 13-14 years, 6.9% had severe asthma symptoms globally, and the Indian subcontinent showed the lowest prevalence: 2.5% among all the study centers. In the age group of 6-7 years, 4.9% of children had symptoms of severe asthma worldwide, while the Indian subcontinent had a prevalence of 2.5%. 
Asthma having been identified as a major contributor to chronic disease, knowledge in the general population for its management is very crucial. A study involving the parents of asthmatic children in Chennai showed that only 3% of the sample population knew exactly what asthma was, showing poor knowledge among parents.  These results were similar to those from a study conducted in Chandigarh  in 1995, in which lack of knowledge prevailed among the parents. In the study of Ashutoshlai, 34% of the parents believe that asthma is contagious and 48% were hesitant for referring their child as asthmatic.
This lack of knowledge in parents of children suffering with asthma prevails not only in India but also globally. A study in China including its 29 provinces showed that only 18% of parents had knowledge of asthma.  The objective of this study was to assess the knowledge of asthma among the parents of asthmatic children and to understand parents' attitude and practices in dealing with their child's asthma exacerbation.
| Materials and Methods|| |
A pilot cross-sectional study was performed during September 2013 in Saveetha Medical College, Chennai, India. A convenient sample of 100 parents of the asthmatic children was enrolled. Any parent (mother or father) with a child aged 8 years and above who was diagnosed with bronchial asthma, and attending the Outpatient Department of Paediatrics, Saveetha Medical College and Hospital with his/her child in the study period, was included in the story. Participants were informed about the study's purpose, and those eligible and agreeing to participate were enrolled in the study. Parents who were mentally or physically challenged or were involved in other clinical trials were excluded from participation in the study. The study protocol was approved by the institutional Review Board (IRB) of the Foundation of Healthcare Technologies Society, New Delhi, India (IRB#FHTS/017/2013).
Data collection tools
A modified questionnaire was prepared based on the existing validated tool. It consisted of the following content:
- Sociodemographic characteristics: Information was gathered about age (years), marital status (single/married/divorce or separated/widow), family income categories,  type of family (joint, nuclear, broken, or extended), number of family members, educational status [Primary School (1-5 std.), Secondary School (standard 6-8), High School (standard 9-10), Intermediate (standard 11-12) or post-high school Diploma, Graduate or Postgraduate, Professional or Honors, or Illiterate)], and occupational status of self. Relationship of the participant with the child was another variable. 
- Child control and conditions in the past 12 months: Information was gathered regarding gender, age, and duration of asthma condition of the child. In addition, parents were requested to mention if their child had an allergy to any substance, such as food products, pollen, or plastics. Information was also gathered about family history of the asthma; history of eczema, if present, and duration; recent asthma exacerbation; preventive measures the parents have adopted; and who is treating their child for asthma.
- Parent's knowledge: This section assesses the parent's knowledge of asthma, symptoms of asthma, stimulus and symptoms of asthma attack, and inhaled corticosteroid. A previously used questionnaire was used to know whether some specific factor could stimulate asthma, and if it does so in the case of each respondent's child. Parents were further requested to mention if they knew about aerosol therapy, if their child was on aerosol therapy, what device was used for this therapy, if it had any side effects, and from where they came to know about aerosol therapy. ,,
- Parent's attitude and beliefs: Parents were asked if they allowed their child to do everyday activities like any other apparently healthy child, such as playing outdoors, and participation in exercise and games/sports. Information was gathered on each parent's belief about the effectiveness of asthma medication in controlling the attack and whether inhaled corticosteroids could hinder the child's growth. ,
- Parent's practices: This section covers the practices each parent follows as preventive measures for his/her child. Parents were asked about the medical examinations their child went through, monitoring of the child's condition, visits to physician with the child, use of inhaled corticosteroids, any other medication they were following, and whether they had made their home and the child's room allergy-proof by covering the pillow and mattress in zipped plastic covers; also, if they used a humidifier/ vaporizer in the child's room. More information was gathered on whether they had carpeting in the child's bedroom and in other rooms, whether they had and used a gas stove to heat their house, if any mildew was present in the house, and if the child had any problem with rodents or cockroaches. Parents were requested to disclose if they had any pet in their home and if they (parents) or any other family member in the home smoked. ,
Peak flow meter reading
The research team took the peak flow meter reading of every participant's child who had asthma.
Quantitative descriptive analysis was performed using univariate statistics to report means and standard deviations for the continuous variables and frequency distribution for the categorical variables. All analyses were performed using Microsoft Excel 2007 and SPSS version 16 (SPSS Inc., Chicago, USA).
| Results|| |
The sociodemographic characteristics of the participants were shown in [Table 1]. The average age of all 100 participants was 41 years (SD = 6), and 57% of them were males. Sixty-nine percent (69%) of the participants were living in nuclear families and 85% of the participants lived in urban locations. The average number of household members was 5 (SD = 2) and the average annual household income was 565600 (SD = 430499). Its altogether different variable for assessing employment status of parents which showed that in 26% of the cases both the parents were working.
The details of the children's asthma conditions and the control were shown in [Table 2]. In this study, 62% children were males and 38% females, with an average age of 12.53 years (SD 2.95) and an average duration for living with asthmatic conditions of 6 years (SD 3). Eighty percent (80%) of the parents reported that their children had a history of allergy to suspended particulate matter (dust, smoke, and pollen), 16 % reported allergy to food items, and nearly 27% did not know if their child was allergic to some specific substance. More than half (53%) of the respondents (parents) agreed that their child had had eczema in the past, whereas 30% did not know about the disease. Those having a history of eczema had this condition for an average duration of 13.6 months (SD 17). In case of more than half (58%) of the respondents, some of the family members had a history of asthma. Regarding asthma exacerbation, 57% of the children did not have any in the last 3 months, 21% had some within 3 months, 13% in the last 1 month, whereas 5% had some in the last 2 weeks and 2% in the last 1 week. Eighty-nine percent (89%) of the respondents said "no" to the question about the use of medication as a preventive measure, whereas only 11% responded "yes," out of which only 4% knew the medicine to use as prevention and others (1%) were dependent on doctors or believed in avoiding triggers (1%). Forty-four percent (44%) of the respondents were getting their child treated by a pediatrician and 36% by a general physician, while only 19% were consulting a pulmonologist.
The majority of the participants (75%) reported that their child had had one asthma exacerbation in the last 12 months, whereas 25 % reported that it had occured twice in the last 12 months. One of the participants reported that his child had experienced three episodes of asthma exacerbations in the last 3 months.
The results with respect to the parent's knowledge about asthma are shown in [Table 3]. More than half (61%) of the participants felt that asthma was reversible bronchial obstruction, and some of them (16%) also believed that it was a communicable disease or genetic problem (4%). Only 12% of the respondents knew that "Wheezing >3 times (49%), Coughing >4 Weeks (20%), >6 Respiratory infections in last 12 months (10%) and relief after using bronchodilator (10%)" are symptoms of the asthma condition.  Twenty-eight percent (28%) of the respondents knew that chronic cough could be an indication of the asthma condition, while 53% were not able to decide whether it is a symptom of the asthma condition. Less than half (41%) of the respondents identified cold stimulation, exposure to allergens, and strong emotional changes as stimuli of asthma attacks. Twenty-eight percent (28%) of the respondents mentioned chest tightness with restricted breathing, 19% repeated strenuous coughing, and 6% dry cough after exercise or sleep as the symptoms of asthma attack. Eighty percent (80%) of the parents responded that they did not know what an inhaled corticosteroid was and most (86%) of them did not know how it worked. Forty-one percent (41%) respondents were aware of aerosol therapy, while 59% were unaware. Some respondents knew that metered-dose inhaler (MDI) + spacer (22%) and nebulizer (13%) are the devices used for aerosol therapy, whereas 61% did not respond.
Tobacco smoke was commonly perceived as a trigger (by 85%) for asthma and as a precipitating factor in their child (77%). Cold air was the secondmost commonly perceived trigger (80%). Forty-eight percent (48%) of the participants reported that pollen/outdoor mold (43%) could precipitate asthma in general and was also one of the precipitating factors in their child (48%). Thirty percent (30%) of the participants reported exercise as one of the triggers for asthma [Figure 1].
|Figure 1: Factors generally considered as causing precipitation of asthma vs factors precipitating asthma in your child|
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The results with respect to the parent's attitudes and beliefs about asthma are shown in [Table 4]. They show a very positive attitude among the parents who responded about the asthma condition of their child, as 90% of the parents responded that "yes," they would allow their children to play outdoors and more than half (64%) said that their children could exercise like a normal child. Seventy-one percent (71%) of the parents thought that their child could participate in any games/sports if their asthma was brought under control. Ninety-five percent (95%) of the parents believed that regular medication can control asthma attacks, while 28% also feared that medication might affect the child's growth. Fifty percent (50%) of the parents felt that medication might cause drug dependency, while 34% thought that it could cause weakening of immune intelligence or harm to the child's intelligence (13%). Doctors/physicians (82%) were the major source of the respondents coming to know about asthma; other source included TV/radio (9%), books (5%), and advertisements (3%).
The results with respect to the parent's practices in medicine compliance of asthmatic children were shown in [Table 5]. The results show that 28% of the children had undergone pulmonary function tests, 20% underwent allergen tests, only 4% had skin prick tests done, and 14% went through all the tests. Thirty percent (30%) of the parents were monitoring their child's condition, while 27% were visiting their physicians regularly and 17% were avoiding smoking. Sixty-six percent (66%) of the respondents said they were regularly monitoring their child's condition, but only 21% were using peak flow metering. More than half (53%) of the respondents agreed that if a peak flow meter was provided to them they would use it to monitor their child's condition. Thirty-three percent (33%) of the parents were visiting physicians only in case of asthma attacks, while just 13% were visiting once every month. Seventy-one percent (71%) of the respondents said they did not insist that their child use inhaled corticosteroids, whereas 27% were determined to use inhaled corticosteroids. Antibiotic inhaled corticosteroids (27%) and oral modulators (24%) were the medicines obtained by the majority of the respondents for use by their children. Most (91%) of the respondents agreed that making the child follow the medication regime was their utmost priority.
|Table 5: Parent's practices in medicine compliance of asthmatic children|
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The results with respect to the asthma exacerbation preventive measures are shown in [Table 6]. Eighty-seven percent (87%) of the respondents had never used a Children's Asthma Control Test questionnaire and 78% said that they did not have any written action plan in case of their child suffering an asthma attack. Most (91%) of the respondents were preventing children from coming in contact with tobacco smoke and plush toys. Seventy-nine percent (79%) of respondents were not using any plastic zip covers to cover their child's pillow and mattress. No humidifier was being used in the bedrooms of the asthmatic children in 95% of the cases. The majority of the respondents said that there was no carpeting in the child's bedroom (87%) or in the TV/family room (81%) of their house. Sixty-eight percent (68%) of the respondents were using gas stoves in their kitchen and most (96%) of them did not use it to heat their home. Only a few respondents said that there was moisture or mildew on the ceiling (15%), walls (15%), and windows (7%) of their house. The majority of the respondents said that their child did not have problems with cockroaches (87), mice (86%), or rats (88%). The majority of the respondents were avoiding keeping any type of pets (dogs 84%, cats 91%, birds 90%) and refraining from smoking (85%) in the house.
The research team used a peak flow meter to check the movement of air in the lungs of children with asthma. The average peak flow meter reading was 238 L/min (SD 34).
| Discussion|| |
Asthma can occur at any age but its onset is predominantly observed in children and adolescents.  The parents of such children are one of the important factors in the prevention and management of asthma exacerbations. Adequate knowledge of asthma management in a parent is essential for the prevention of asthma exacerbations in his/her child.
The majority of the participants had an education level of graduation or above, and one in four of the reported that both spouses were working. The majority reported that their children were allergic to one or more type of suspended particulate matter (dust, pollen grains, smoke). Almost one-third of the participants could not confirm whether their child had eczema or not. However, more than half reported a family history of asthma. Twenty percent (20%) of the participants reported that their child had experienced an episode of asthma within the last 1 month.
In the present study, 16% of the participants felt that asthma is a communicable disease. A previous study in Chennai, TN, India, showed that more than half of the total participants (54%) were not familiar with the exact nature of asthma.  In contrast, a previous study in China had shown that two-third of the participants were aware about the nature of asthma. 
Only 12% of the participants were aware that "wheezing >3 times, coughing more than 4 weeks, >6 respiratory infection in previous year and amelioration of symptoms by using bronchodilators" were features of asthma. A study conducted by Zhao et al. showed that 6.08% of the parents knew that "wheezing >3 times, coughing more than 4 weeks, >6 respiratory infection in previous year and amelioration of symptoms by using bronchodilators" could indicate asthma. 
A majority of the participants perceived that tobacco smoke was one of the triggers for asthma and that it was the cause of asthma in their child. Two-third of the participants felt that their child could exercise just like other nonasthmatic children. Regular monitoring of the asthmatic status of the child is essential in preventing flare-ups. In this study, two-third of the participants reported that they monitored their child's asthmatic status and that among these, 32% were using peak flow meters. The majority of the participants reported that they made sure that their child was adhering to medication compliance.
This study was conducted in a hospital-based setting with a relatively small sample size. Further, it was designed as a cross-sectional study, making it difficult to ascertain the temporal association. Its finding cannot be generalized with other geographical locations.
The majority of the participants had at least some knowledge about asthma and its triggers. However, very few of them used the Children's Asthma Test questionnaire for preventing asthma exacerbations and a majority of them did not have any action plan for preventing the same. There is an urgent need for the preparation of parental guidelines for preventing asthma exacerbations and its sequelae.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Surapaneni Krishna Mohan
Department of Biochemistry, Saveetha Medical College and Hospital, Faculty of Medicine, Saveetha University, Saveetha Nagar, Thandalam, Chennai - 602 105, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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