The Global Initiative for Asthma (GINA)  and the asthma guidelines for prevention and treatment written by an expert panel from the National Heart, Lung, and Blood Institute emphasize the importance of promoting a standardized classification of asthma treatment . In this analysis of the KAP of Chinese parents of children with asthma, a wide gap was observed between recommended and actual practices, and their overall asthma-related knowledge was insufficient. Furthermore, asthma-related knowledge was associated with deficiencies in the care process. Therefore, we suggest that further investigation is required to develop asthma-related education programs for parents.
Rea et al.  found that a lack of asthma-related knowledge and improper management of non-compliance are risk factors for asthma fatality. We found a direct association between parent knowledge and asthma prevention and management practices. Therefore, we suggest that the most important component of childhood asthma treatment is parent education to improve their asthma management practices.
KAP education programs for parents of children with asthma are well-established in some Western European countries . The community system in China is in a developing stage, and is far from perfect. Examining the KAP of parents of children with asthma and developing asthma-related education and management programs have not been given sufficient attention. This is the first study of parent asthma-related KAP and their determinants in China.
Parent asthma-related knowledge
In this study, more than half (51.34%) of the parents scored ≤ 18 in the KAP questionnaire, indicating low KAP among most parents. Similar to the results of a 2009 asthma-related KAP survey in Beijing, two-thirds (63.98%) of the parents in our study knew the nature of asthma . Conversely, in a similar survey in India, the majority of respondents (54%) were not aware of the nature of asthma . Nevertheless, only 18.31% of parents in our study correctly answered ≥ 60% of the questions.
Studies have shown that asthma, especially cough variant asthma (CVA), is the leading cause of chronic cough in children [20, 21]. CVA is defined by GINA as a special type of asthma with cough as the sole or main symptom that is more common in children [1, 22]. In Chinese guidelines, CVA is diagnosed as an isolated persistent cough, with increased airway responsiveness or abnormal expiratory flow rate variability that is effectively treated with bronchodilators . In this study, only one fourth (23.74%) recognized that a chronic cough may indicate asthma. Children with persistent cough over more than four weeks should be considered for a diagnosis of chronic cough. Parent asthma-related knowledge is at a low level in China, with a lack of awareness of asthma clinical manifestations or the triggers to acute attacks. As measured by the Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire in the United States, patients with asthma had limited asthma-related knowledge, with only half of the patients correctly answering ≥ 50% of the questions .
Childhood asthma management requires multiple complex tasks. Parents need to understand the diverse triggers and basic mechanisms of an asthma attack, and to understand the necessity of maintenance medication. Parents also need to learn to monitor lung function, use C-CAT, dose rescue medications, recognize exacerbations early and adopt emergency care . In one study, 115 parents of children in Head Start Centers received asthma-related education. The results showed that the provision of education improved asthma and healthy home-knowledge, and that 98.4% of the parents made changes in their households .
In our survey, about 33.60% (835/2485) of parents would allow their children to participate in minor sports, even if their asthma was under control. This indicates that there is doubt among parents about whether children with asthma can participate in sport. In GINA, it is proposed that an indicator of asthma control is being able to participate in as much sport as healthy children . One study showed that children adhering to their asthma medication can participate in sport, improve their physical fitness, reduce the frequency of asthma attacks and prevent further exacerbation .
Among the children who were not adhering to their medication regimen, 67.32% (1673/2485) of parents worried about negative effects on children’s growth, and 23.98% (596/2485) were worried about potential harm to their child’s intelligence. This indicates that the parents’ strongest fears regarding medication are related to side effects. Despite this, most research shows that low-dose inhaled corticosteroids do not cause growth retardation, abnormal bone calcium/phosphorus metabolism or other systemic side effects [28, 29].
Regardless of the actual or desired pathways that parents obtain asthma-related knowledge, communication with medical staff is given top priority. From the perspective of many parents, good communicative relationships with health professionals are vital for encouraging progress through childhood asthma management stages . A United States study showed that parents who receive a written action plan in the pediatric emergency department are more confident in their ability to provide care for their child during an asthma exacerbation . We should support the efforts of professionals to disseminate information to improve asthma knowledge.
Guidelines recommend that the assessment of asthma severity and control should be carried out early and on a regular basis. Compared with a 1999 survey of the asthma situation and trends in Europe , this study found that the situation in China is better in terms of children taking pulmonary function tests and poorer in terms of regular monitoring. Given the low rates of peak flow meter and C-CAT test use, parents should be encouraged to use both self-monitoring tools to better monitor their child’s asthma status and provide timely and effective treatment.
Previous respiratory research has identified that children with allergic rhinitis in infancy have twice the risk of being physician-diagnosed with asthma at age 11 years . Future education programs should emphasize that upper and lower respiratory tract allergic diseases should be treated together, and combined therapy should be used for allergic rhinitis and asthma . In recent years, antibiotic abuse in the treatment of children with asthma has become increasingly prevalent. Parents of children with asthma need to be informed that antibiotics should only be taken for symptoms associated with infection and with the support of laboratory indications.
This study provides suggestions for improving the quality of parent/guardian care of children with asthma. In primary care, detailed and accurate allergen identification is essential for the proper diagnosis of allergic asthma and its successful treatment. Parent education and practical advice about allergen avoidance should be provided. Finally, referral for more extensive investigation and management should be considered .
This study was carried out in 29 cities (capital cities of provinces and municipalities and autonomous regions, with different economic levels and geographical environments). The sample size is relatively large and the results are representative of urban China. However, they may only be generalizable to cities, not rural areas. A further limitation is that many factors analyzed in this study were based on responses to questionnaires; therefore, recall bias may have been present.
It is possible that asthma control status affects parent asthma-related KAP. Further research is required to determine if interventions would be beneficial.