|Year : 2022 | Volume
| Issue : 1 | Page : 40-46
Parental knowledge, attitude toward asthma, and its correlation with compliance of asthma management in children
L Caroline Silvia, J Podhini, Soundararajan Palanisamy
Department of Paediatrics, Mahatma Gandhi Medical College Hospital and Research Institute, Puducherry, India
|Date of Submission||18-Sep-2022|
|Date of Acceptance||13-Oct-2022|
|Date of Web Publication||16-Feb-2023|
Dr. L Caroline Silvia
F2, Gurukripa, 15, United India Colony 4th Cross Street, Kodambakkam, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
BACKGROUND: Asthma is one of the common chronic illnesses in children affecting about 10-15% worldwide. Proper management of asthma depends on the knowledge, attitude, and practices of the parents towards asthma which in turn will enable early intervention and prompt management.
OBJECTIVE: To determine the parental knowledge, attitude towards asthma and its correlation with the compliance of asthma management in children.
METHODOLOGY: It is a cross-sectional observational study carried out in a tertiary care hospital between January 2020 to December 2020.
RESULTS: The study included 112 participants. Mothers were the predominant caregivers (72.3%). Family history of asthma was noticed in 42.8%. 88.4% knew that their child was suffering from asthma, 18% felt that asthma is contagious. Change in the climate (91.1%), dust (60.7%), respiratory infection (49.1%), and smoke (44.6%) were the common triggers. 15% tried an alternate system of medication. Majority (87%) had moderate knowledge, 92 (82%) showed good practices. 56 (50%) exhibited negative attitude. Nearly 60% of the participants preferred inhaler therapy. The causes for non-adherence to inhaler therapy were fear of addiction (46.7%), child refusing inhaler (40%), cost of therapy (40%) and child being symptom free in between episodes (37.8%).
CONCLUSIONS: This study revealed a moderate level of knowledge and good practices towards childhood asthma among the parents of asthmatic children. Better knowledge and good practices among the parents strongly correlated with mother being the participant of the study, educational status, positive family history of asthma and persistent asthma symptoms. Better knowledge and positive attitude towards asthma was associated with adherence to inhaler therapy.
Keywords: Asthma knowledge, attitude, and practices score, nonadherence to inhaler therapy
|How to cite this article:|
Silvia L C, Podhini J, Palanisamy S. Parental knowledge, attitude toward asthma, and its correlation with compliance of asthma management in children. Indian J Allergy Asthma Immunol 2022;36:40-6
|How to cite this URL:|
Silvia L C, Podhini J, Palanisamy S. Parental knowledge, attitude toward asthma, and its correlation with compliance of asthma management in children. Indian J Allergy Asthma Immunol [serial online] 2022 [cited 2023 Mar 26];36:40-6. Available from: https://www.ijaai.in/text.asp?2022/36/1/40/369806
| Introduction|| |
Bronchial asthma is one of the most common chronic diseases among children and adolescents, affecting 10%–15% of children worldwide. It is a common cause of repeated emergency room visits, hospitalization, school absenteeism, increased family and governmental spending, and poor quality of life in the long run. The prevalence of childhood asthma ranges from 1.9% to 16.6% in different age groups in India.,,,
Asthma is often under-reported and under-treated, creating a false sense of hope among the parents that children would outgrow their disease. Parents with inadequate knowledge may not recognize the symptoms, leading to delay or inadequate treatment and follow-up, thus progressing to increased morbidity. Given that parents are the main caregivers of children, increasing their awareness and changing their attitudes and practices toward asthma would lead to better outcomes. Currently, there is little awareness about asthma among parents in most of the developing countries, including India, and there is a paucity of literature from our part of the country.,,, Our study aims to obtain information regarding asthma awareness among the parents of asthmatic children, and their attitudes and practices toward asthma.
The objective is to determine the level of knowledge, attitude, and practices of the parents/guardian of asthmatic children toward asthma and its correlation with compliance with asthma management.
| Materials and Methods|| |
This was a cross-sectional observational study conducted at a tertiary hospital in Pondicherry, India, from January to December 2020. The aim of the study was to determine the level of knowledge, attitude, and practice of the parents/guardians of asthmatic children toward asthma and their adherence to preventive therapy. Parents/grandparents of children aged 5–12 years with physician-diagnosed asthma were included in the study. Children with other chronic respiratory diseases, such as bronchiectasis, immunodeficiency disorders, and cardiac disease, were excluded from the study. The study was conducted after approval from institutional ethics committee.
Parents/grandparents who had accompanied the child with asthma to our hospital were interviewed after explaining the purpose of the study and getting consent. A standardized pretested pro forma was used. The questionnaire comprised: (1) Sociodemography, (2) Asthma control in the past 12 months and severity (based on GINA 2021 guidelines, (3) parent knowledge, (4) parent attitudes, (5) parent practices, and (6) adherence to inhaler therapy; if not, reasons for nonadherence. All questionnaires were completed by the investigator through face-to-face interviews to ensure validity.
The questions were in a Yes/No/Don't know format. Each correct answer was given a score of one and incorrect answer zero. The total possible asthma knowledge score of 24 was further subcategorized to good (17–24), moderate (9–16), and poor (0–8), respectively. The total possible asthma attitude score of 8 was divided into positive attitude (5–8) and negative attitude (0–4). The total possible asthma practice score of 8 was further subdivided into good (5-8) and poor (0-4) practices.
The sample size was calculated to be 120 participants, of which eight were not willing to participate, and hence were excluded. Data were analyzed using the Statistical Package for the Social Sciences version 13.0 (SPSS Inc., Chicago, IL, USA). Student's "t" test and Chi-square tests were used to determine the associations between the variables. A P ≤ 0.05 was considered statistically significant.
| Results|| |
The study population included parents/guardians of 112 asthmatic children between the ages of 5–12 years. There were 81 (72.3%) mothers and 30 (26.8%) fathers and one grandparent (0.9%). Fifty-three parents (47.32%) were within 20–30 years of age, 48 (42.86%) in 31–40 years, 9 (8.04%) in 41–50 years, and one (0.89%) in 51–60 years group, respectively. Ninety percent of participants were educated either up to school or college level. Regarding the place of living, 60 (53.57%) were from rural areas and 52 (46.43%) from urban areas. According to the Kuppuswamy scale for socioeconomic status, 50 (44.64%) participants belonged to the lower middle, 32 (28.57%) to the upper middle, 23 (20.54%) to the upper lower, and 7 (6.25%) to lower class category. Sixty-six (58.9%) were from joint families and 46 (41.1%) were from nuclear families. Family history of asthma was noticed in 48 (42.8%) children. The severity of asthma was intermittent in 82 (73.2%) and persistent type in 30 (26.8%), respectively. Only one child had to skip school due to maternal anxiety, and others attended school normally.
On analyzing the data regarding knowledge about childhood asthma, 99 participants (88.4%) were aware that their children were suffering from asthma. Sixty-eight (60.7%) responded that asthma was not hereditary. There were 20 (18%) respondents who felt that asthma was contagious. Ninety-seven (86.6%) considered that asthma can be controlled by medication, whereas 38 (33.9%) believed that asthma can be cured [Table 1].
Sixty (53.6%), 56 (50%), and 52 (46.4%) respondents identified breathlessness, recurrent wheezing, and recurrent cough as symptoms of asthma, respectively. Only 3 (2.7%) considered tightness of the chest as a symptom of asthma. Nearly half of them recognized any two of the symptoms. The commonly identified combination was recurrent wheezing and breathlessness.
Narrowing of the bronchi was identified as the mechanism of asthma by 72 (64.3%), followed by airway infection by 47 (42%), and obstruction of the bronchi by 20 (17.9%) respondents.
Change in climate or cold weather was the most common trigger recognized by 91.1% of participants, followed by dust (60.7%), respiratory infection (49.1%), and smoke (44.6%). Other triggers, such as pollen, animal dander, house mites, cockroach, perfumes, mosquito repellent, and exercise, were recognized by approximately 10%–15% of the participants.
Regarding their attitude toward asthma, 66 (58.9%) participants were embarrassed that their child was suffering from asthma. On questioning whether they feared about the child getting addicted to medications, 52% responded in affirmation. Nearly 15 (13.4%), 21 (19%), and 38 (33.9%) parents had an opinion that their child's intelligence, career, and growth would be affected by asthma, respectively [Table 1].
In our study, 106 (94.6%) could identify the symptoms of asthma, and 95% of the caregivers had medications at home for use in case of an exacerbation. An alternate system of medication was preferred by 15% of the participants. The practice of administering the controller medications at home and if not responding, to seek immediate medical help was followed by 90% of the participants [Table 1].
Of the 112 participants, 2% had good knowledge, 97 (86.6%) had moderate knowledge, and 13 (11.6%) had poor knowledge about asthma. Similarly, 93 (83%) showed good practices, 19 (17%) showed poor practices. Half of the study population, 56 (50%), exhibited a negative attitude.
The effect of sociodemographic characteristics on the level of knowledge, attitude, and practices was analyzed. The two participants who had good knowledge and 97 with moderate knowledge were clubbed as satisfactory knowledge (88.4%) group as the knowledge score was above 8. A significant difference in better knowledge was observed in mothers (66.7%) than in fathers (20.7%). Similarly, educated parents had satisfactory knowledge (78.6%) compared to uneducated. We also observed significantly better knowledge in participants with children having a lesser duration of symptoms, family history of asthma, and more severe presentation of asthma.
Respondents living in rural areas (32.1%) and those who did not have a family history of asthma (33%) had negative attitudes, which were statistically significant. There was no significant association between the duration of illness, relationship to the child, educational level or severity of asthma, and attitude scores. Mothers (63.4%) had satisfactory practices toward asthma compared to fathers (18.8%). Educated parents (75%) and participants with a family history of asthma (39.3%) showed significantly better practices. Participants with children having a lesser duration of symptoms and more severe presentation of asthma also had significantly better practice [Table 2].
|Table 2: Effect of sociodemographic characteristics on level of knowledge, attitude, and practices|
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We observed that participants with satisfactory knowledge exhibited good practices. A significant association between parental knowledge and practice toward asthma (P = 0.037) was eminent. [Table 3] shows that there was no significant association noted between attitude toward asthmatic children and practices in our study. Similarly, we did not observe any significant association between parental knowledge about asthma and their attitude.
Nearly 60% of the participants preferred inhaler therapy, whereas 39% preferred medication in syrup form and one respondent chose tablets as the preferred mode of treatment.
On analyzing the reasons for nonadherence to inhaler therapy, we noticed that fear of addiction to inhaled medication (46.7%) was the most common cause. Cost of therapy (40%), child refusing inhaler therapy (40%), and child being symptom-free in between episodes (37.8%) were also noted to be the other reasons [Table 4].
We observed a significant association between parental knowledge and the use of inhaler therapy indicated by 62 participants (55.4%), with satisfactory knowledge being more adherent to inhaler therapy (P = 0.030). Similarly, there was a significant association between positive parental attitude toward asthma and adherence to inhaler therapy (P = 0.044), as 38 participants (33.9%) with a positive attitude were observed being more adherent to inhaler therapy [Table 5].
|Table 5: Relationship between knowledge, attitude, and adherence to inhaler therapy|
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| Discussion|| |
The majority of participants (87%) in our study had a moderate knowledge score about asthma. Similar findings were noted by Al Otaibi and Alateeq (79.6%), whereas Amer (46%) and Venugopal and Namboodiripad (51.8%) have reported insufficient levels of knowledge about asthma.,, Nearly 88% of our cohort knew that their children were suffering from asthma. Vaishnav and Ameta and Vinodh reported 68% each, whereas, Gajanan et al. and Gulvadi and Sreenivasan VK have observed lower levels of knowledge at 46% and 36%, respectively.,,, Awareness about the disease and acceptance of the diagnosis is the key to the proper management of any disease. Although majority of the participants had moderate knowledge about asthma, 18% of the respondents had a misconception that asthma was contagious. A similar observation was made by Gulvadi and Sreenivasan VK and Shivbalan, et al., reflecting that misconceptions are still prevalent in the community., Only 8% of our participants were aware that asthma cannot be cured but controlled, which reinforced the need of proper education for the caregivers of children with asthma addressing the misconceptions and beliefs in particular. Change in climate and exposure to dust and smoke were the common triggers recognized by our participants, which were similar to earlier authors as well., Identification of various risk factors, such as family history and environmental pollution, is necessary as they are attributed to the development of recurrent wheezing and asthma.
Attitude toward asthma
Regarding the attitude toward asthma, 13.4% of participants believed that their child's intelligence would be affected due to asthma and 21.4% were unsure about it. Similarly, 18.8% felt that their child's career would be affected by asthma. Thirty-four percent of parents were worried that the growth of their children would be affected. Zhao et al. in a multi-centric study conducted in 29 cities of China have reported that 67.3% of parents were concerned about the negative influence of asthma on child's growth and 24% about the negative impact on child's intelligence. Venugopal and Namboodiripad have recorded that 40% of the parents reported a negative influence on intelligence and 62.4% on growth. One more point of concern is that 58.9% of parents get embarrassed that their child suffers from asthma, implying a negative attitude. All these data reflect about the prevailing anxiety among the parents and the need for better awareness programs to dispel the myths and misbeliefs about asthma.
Yet another major misconception among the parents was the fear of dependence on the medications used for asthma. This fear could potentially lead to rejection of these medications leaving the children prone to exacerbations and worsening of asthma. Nearly 52% of parents had such a negative opinion and around 10% were not sure about it. Only 40% of the respondents categorically rejected such an addiction. This seemed to be the major setback for the proper management of asthma. The percentage of fear of addiction to drugs observed ranged from 40% to 92% in the literature from both locally and internationally.,,,
Practice toward asthma
In the present study, majority of the participants (83%) showed good practices, which is in accordance with Sepalika et al. Exposure to smoke is a preventable risk factor and children exposed to smoke are about 2.6 times more prone to recurrent wheezing. Nearly 90% of the parents in our study took measures to reduce passive smoking at home, which is considered an important trigger. Similarly, nearly 90% of the respondents were aware of emergency medications to be given before shifting the child to the hospital. Gulvadi and VK have quoted a similar observation (90%) in their study.
Use of the alternate system of medication
Fifteen percent of the participants used an alternate system of medication. A much higher proportion of participants using alternate systems of medication ranging from 50% to 91%, had been reported by others reflecting regional and cultural differences in our country and acceptance of alternate medication.,, Seeking alternative therapy is prevalent in other countries as well. A study from Saudi Arabia has quoted a higher percentage (50%) of parents resort to home remedies, herbal remedies, and massage.
Use of inhaler therapy
In the present study, nearly 60% of the participants preferred inhaler therapy, whereas others have reported a lower usage of inhalers ranging from 13% to 44%.,,, Forty percent wished to give only in syrup form and a lone respondent chose tablets. A higher percentage of syrup usage has been observed by Venugopal and Namboodiripad (76.5%), Gajanan et al. (79%), and Gulvadi and VK (90%).,, Increased use of inhalers by our parents could be due to better knowledge and practices seen in our study.
Reasons for nonadherence to inhalers
When we analyzed the reasons for nonadherence to inhaler therapy, we observed that fear of addiction to inhaled medication (46.7%) was the most common cause, followed by the cost of therapy (40%), child refusing inhaler therapy (40%) and child being symptom-free in between episodes (37.8%). The fear of addiction to drugs being the most common factor needs to be addressed by physicians through better communication. Similar concerns have been raised by other authors as well., Nearly 40% of parents were concerned about the cost of therapy as most of our study participants belonged to the lower middle class socioeconomically. Gulvadi and Sreenivasan VK have quoted that 40% of their parents cited cost as a factor for not using inhalers. Efforts should be taken to subsidize the cost of inhaler medications used for asthma or provide them at free of cost to the needy children in Government hospitals so that compliance with inhaler therapy could be maintained.
Factors influencing the knowledge, attitude, and practices
Our study revealed a moderate level of knowledge and good practices about childhood asthma among the parents, whereas 50% of parents had a negative attitude toward asthma. This may be because of the misbeliefs and myths that are still prevalent despite better knowledge. This indicates in addition to imparting the knowledge about the disease, we also need to address the issues regarding their belief and mistrusts.
Regarding the effect of the level of knowledge, attitude, and practices, there was increased knowledge about asthma among mothers (66.7%, P = 0.028) compared to fathers (20.7%). There was a significant association between educational status and satisfactory knowledge (78.6%, P = 0.044) and good practices (75%, P = 0.017). This is in agreement with the studies by AlOtaibi and Alateeq and Dhirja et al., Positive family history of asthma and persistent asthma symptoms were significantly associated with better knowledge and practices.
We also observed that the participants with satisfactory knowledge had good practices (P = 0.037). There was a significant correlation between knowledge and attitude of the parents toward asthma and adherence to inhaler therapy (P = 0.030 and P = 0.044, respectively) in our study. Similar observations have been made by Amer and Al-Ali et al., Chiang et al. have reported that the proportion of appropriate responses on the knowledge, attitudes, and practices questionnaire in relation to good adherence was statistically significant (P = 0.043), suggesting that knowledge and attitude toward asthma do have an impact on adherence to inhaler therapy and asthma control.
As this study was conducted in a hospital setting, the findings cannot be generalized to the community level. Parent recall bias cannot be excluded. Fathers of asthmatic children constituted one fourth of the participants. They may not be the primary caregivers of the children, and hence information provided by them may not be accurate.
| Conclusion|| |
This study revealed that a moderate level of knowledge and good practices about childhood asthma among the parents/caregivers of asthmatic children. Better knowledge and good practices among the parents strongly correlated with their educational status, positive family history of asthma, and persistent asthma symptoms. Despite better knowledge, half of the study population exhibited negative attitude toward asthma. Fear of addiction, high cost, child being symptom-free in between exacerbations and child refusing to use inhalers were the common reasons for nonadherence to inhaler therapy.
As asthma is a chronic disease, correct information regarding its symptoms, triggers, treatment plan, and necessity for long-term follow-up should be discussed with the caregivers and reinforced during every health-care visit. Asthma awareness programs should be an integral part of management protocol to dispel the myths and wrong beliefs about asthma.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]