|Year : 2022 | Volume
| Issue : 1 | Page : 19-24
Correlation between parental knowledge regarding components of written asthma action plans and asthma control levels in asthmatic children in Southern Taiwan
Yi-Pei Tai1, Hsiu-Chuan Wang2, Yu-Cheng Tsai3, Ching-Chung Tsai4, Yuan-Yi Huang3, Yu-Tsun Su4
1 Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan; U-Sheng Hospital, Pingtung, Taiwan
2 Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan
3 Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan; College of Medicine, I-Shou University, Kaohsiung, Taiwan
4 Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
|Date of Submission||29-Apr-2022|
|Date of Decision||15-Jun-2022|
|Date of Acceptance||24-Jun-2022|
|Date of Web Publication||02-Jan-2023|
Department of Pediatrics, E-Da Hospital, I-Shou University, #1, Yi-da Road, Jiaosu Village, Yanchao District, Kaohsiung 82445
Department of Pediatrics, E-Da Hospital, I-Shou University, #1, Yi-da Road, Jiaosu Village, Yanchao District, Kaohsiung 82445
Source of Support: None, Conflict of Interest: None
Background: Under the hypothesis that poor asthma control in Taiwan is associated with the underuse of written asthma action plans (WAAPs), we investigate the relationship between parental knowledge of key components of WAAP and asthma control levels. Materials and Methods: We conducted a prospective study from July 2019 to July 2021. “Written Asthma Action Plan” questionnaires were completed by the parents of asthmatic children, and the responses were correlated to the asthma symptom control level according to the Global Initiative for Asthma guidelines. Results: A total of 67 asthmatic children were enrolled (males 71.6%, mean age 6.3 ± 3.3 years). The asthma control level was significantly related to WAAP questionnaire score. The key components of “know the daily medication and how to use them” and “know the triggers and how to deal with them” both showed significantly higher understanding rates in the partly controlled children compared to the uncontrolled children (P < 0.005). The rates of having WAAPs were both below 10% in these two groups. Conclusion: The asthma control level was significantly and positively related to the understanding of key WAAP components. The development of an easy-to-use WAAP and its use as a standard tool for asthmatic children is expected to greatly improve asthma control in Taiwan.
Keywords: Asthma, asthma action plan, asthma control level, children, knowledge
|How to cite this article:|
Tai YP, Wang HC, Tsai YC, Tsai CC, Huang YY, Su YT. Correlation between parental knowledge regarding components of written asthma action plans and asthma control levels in asthmatic children in Southern Taiwan. Pediatr Respirol Crit Care Med 2022;6:19-24
|How to cite this URL:|
Tai YP, Wang HC, Tsai YC, Tsai CC, Huang YY, Su YT. Correlation between parental knowledge regarding components of written asthma action plans and asthma control levels in asthmatic children in Southern Taiwan. Pediatr Respirol Crit Care Med [serial online] 2022 [cited 2023 Feb 8];6:19-24. Available from: https://www.prccm.org/text.asp?2022/6/1/19/366616
| Introduction|| |
Pediatric asthma is a common chronic disease which imposes a heavy burden on healthcare systems worldwide.,, Asthma attacks and worsening lung functions greatly affect the quality of life. The strategies to treat asthma include developing a patient–doctor partnership, identifying and reducing exposure to risk factors, monitoring asthma control, and managing asthma exacerbations., The aim of the partnership is to equip patients and caregivers with the knowledge to play a major role in the treatment plan by discussing asthma severity, setting treatment goals, and developing a self-management plan, all of which have been shown to be beneficial in reducing asthma morbidity both in adults and children.,,, The Global Initiative for Asthma (GINA) guidelines recommend that all children should be provided with a written asthma action plan (WAAP) according to an individual’s clinic condition, and that this WAAP should include details of how to recognize and respond to signs of worsening asthma.,,,
Asthma involves complex mechanisms and has many endotypes and phenotypes. There are obvious differences in the clinical manifestations and corresponding medications between individuals, and therefore personalized self-management plans are recommended for all asthma patients., A WAAP should include the following key components: usual asthma medications, when and how to increase inhaled medications and start oral corticosteroids based on symptoms and/or peak expiratory flow, how to deal with the triggers and how to access medical care if symptoms fail to respond.,, The patients are educated to recognize the signs of an attack, how to relieve airflow obstruction, and how to control acute inflammation episodes with the early application of rescue therapy and adjusting the anti-inflammatory medications., The use of a WAAP and self-management of asthma in children and adolescents have been shown to significantly improve lung function, and reduce school absences, activity limitations, emergency department visits, and night disturbances.,
Asthma is still the most common chronic disease in Taiwan, and there is potential to improve control. Under the hypothesis that poor asthma control is associated with the underuse of WAAPs, we investigated the relationship between knowledge of key WAAP components and asthma control in Taiwan.
| Materials and Methods|| |
In this prospective study, asthmatic children below 18 years of age visiting a pediatric pulmonology outpatient clinic at a reference center in a university-affiliated hospital between July 2019 and July 2021 were enrolled, who were diagnosed as asthma according to the Global Initiative for Asthma guidelines. The informed consents were obtained from parents. Asthmatic children coexistent with cardiovascular, neurologic, or chronic lung diseases were excluded. The parents of the children completed a “Written Asthma Action Plan” questionnaire. The clinical data of the children were collected and characterized according to asthma symptom control. The percentage of those using a WAAP and whether the parents understood the key components of WAAP were analyzed. The study protocol was approved by the hospital’s Ethical Review Committee.
Levels of asthma symptom control
The children were divided into well-controlled asthma group, partly controlled asthma group (PCG), and uncontrolled asthma group (UCG) according to the GINA guidelines. The level of asthma symptom control was evaluated according to the following four clinical findings, with each being scored as 0 for “No” and 1 for “Yes”: In the past four weeks, has the patient had “Daytime asthma symptoms more than twice/week?”, “Any night waking due to asthma?”, “SABA reliever for symptoms more than twice/week?”, and “Any activity limitation due to asthma?” A total score of 0 was defined as well-controlled asthma; a score of 1 or 2 was defined as PCG; and a score of 3 or 4 was defined as UCG.
The WAAP questionnaire was designed to assess a caregiver’s knowledge regarding the key components of a WAAP. Sex, age, asthma severity, GINA asthma symptom control level, and the WAAP questionnaire responses were recorded [Table 1]. The 15 questions were categorized into six components: 1) know the daily medication and how to use them, 2) know the emergency medication and how to use them, 3) identify and respond when the asthma gets worse, 4) identify and respond to an asthma attack, 5) know the triggers and how to deal with the them, and 6) contact information of the health care providers. Each question was scored 1 if the caregiver knew the knowledge and 0 if not. The WAAP questionnaire scores were compared between the different asthma control groups.
|Table 1: Characteristics of the asthmatic children according to level of asthma symptom control according to the GINA guidelines|
Click here to view
Descriptive analysis was used to assess the distribution of variables, including the level of asthma symptom control and questionnaire scores. The chi-square test and Fisher’s exact test were used to investigate correlations between categorical variables from the questionnaires with different asthma control status. The Mann-Whitney U test was used to compare differences in WAAP questionnaire mean scores. SPSS was used for all statistical analyses (version 15 for Windows®, SPSS Corporation, Chicago).
| Results|| |
Patients and WAAP knowledge questionnaires
A total of 70 asthmatic children initially met the criteria, however, three eligible cases did not participate in this study due to the time-consuming of filling out the WAAP questionnaire and other personal reasons. Finally, 67 asthmatic children were enrolled [Table 1], of whom 71.6% were male, and the mean age was 6.3 ± 3.3 years. There were no significant differences between the asthma status groups in age, sex, time since the diagnosis, and grade of severity (P = 0.147; P = 0.401; P = 0.053; and P = 0.056, respectively). There were 5 (7.45%) children in the well-controlled group, 33 (49.3%) in the PCG, and 29 (43.3%) in the UCG. Sixty-seven WAAP questionnaires which had been completed by the caregivers of the children were collected. We only analyzed differences between the PCG and UCG, as the number of children in the well-controlled group was too small (n = 5) to analyze.
Relationships between asthma control status and WAAP questionnaire score
The relationships between asthma control status and WAAP questionnaire score are shown in [Figure 1]. The asthma control level was significantly related to WAAP questionnaire score. The WAAP score in the PCG was significantly higher than that in the UCP, with 9.6 ± 3.3 in the PCG and 6.4 ± 4.5 in the UCP (P = 0.005)
|Figure 1: Mean WAAP questionnaire scores of the parents of all patients, partly controlled group, and uncontrolled group|
**p value, partly controlled group versus uncontrolled group
Click here to view
Relationships between asthma control status and the understanding rate of items in the WAAP questionnaire
When we further analyzed the responses in the WAAP questionnaire, we found there were significant differences between the PCG and UCG in five items (P < 0.05, [Table 2]). These five items were: “know the anti-inflammatory medicine”, “know the dose and frequency of anti-inflammatory medicine”, “know the correct instructions of how to use the anti-inflammatory medicine”, “know the predisposing factors”, and “know the allergens”. The first three items were in the “know daily asthma medication” component, and the last two items were in the “deal with the triggers” component.
|Table 2: The understanding rate (%) of each item in the WAAP questionnaire for all patients, partly controlled and uncontrolled asthma groups|
Click here to view
Utilization rate of WAAPs between the partly controlled and uncontrolled asthma groups
Low understanding rates for “know about WAAP” and “have your own WAAP” were noted in both the PCG and UCG (P > 0.05), at only 33.3% and 9.1% in the PCG, and 20.7% and 0% in the UCG, respectively [Table 3].
|Table 3: Utilization rate of WAAPs between the partly controlled and uncontrolled asthma groups|
Click here to view
| Discussion|| |
To evaluate the relationship between asthma control and strategy of WAAPs, we conducted a prospective questionnaire-based study and investigated the asthma control status and knowledge of WAAPs in Taiwan. We found a positive close relationship between knowledge regarding the key WAAP components and asthma control status, showing the importance of including WAAPs in the treatment strategy for pediatric asthma. Goronfolah et al. reported that WAAPs were effective in increasing the patients’ knowledge about their condition, improving their quality of life and functional limitations, and increasing their confidence level about controlling their asthma. In addition, Lakupoch et al. reported a significant reduction in emergent room visits, unscheduled outpatient department visits, admission days and school absence days in patients who used WAAPs. Properly educating the patients and parents regarding knowledge of WAAPs has the potential to improve asthma control in Taiwan. In our study, there were significant differences in the understanding of knowledge in the “know the daily medications and how to use them” and “know the triggers and how to deal with them” components in the WAAP questionnaire between the PCG and UCG.
In the “know daily asthma medications” component, the PCG had significantly higher understanding rates of all three items than the UCG. This means that the caregivers of the children in the PCG had better understanding of “know the anti-inflammatory medicine”, “know the dose and frequency of anti-inflammatory medicine”, and “know the correct instructions of how to use the anti-inflammatory medicine”, and this was related to better control of asthma. Anti-inflammatory agents are the main medications used to control the inflammatory status, and stabilize the condition after recovering from an asthma exacerbation. However, knowledge of medications, good drug compliance, and accurate use including the kind, dose, and inhalation technique is complex, time-consuming, and needs to be taught repeatedly. Bhupathi et al. reported that in spite of inhaled corticosteroids being effective in the management of asthma, oral medications and nebulizers are the mainstay treatment in the majority of the cases in India. Social stigma, fear of addiction, and lack of knowledge are the major reasons for the reluctance of parents towards the use of inhalers. Using WAAPs to reinforce the comprehension and acceptance of inhaled corticosteroids, including the side effects and instructions, is important, and will lead to better control of asthma.
In this key component, the understanding rate of “know the correct instructions of how to use the anti-inflammatory medicine” was both unsatisfactory in both the PCG (54.5%) and UCG (25%). In Thailand, Pothirat et al. reported that inhalation techniques in asthma patients were mostly unsatisfactory, especially in those who had been treated by a pulmonologist for less than 2 years. They concluded that face-to-face training could significantly improve the technique for all devices. Almomani et al. conducted a study of 150 pediatric asthma patients on the proper handling of asthma inhalers in 2019–2020, and found that correct technique rates of 13.4%, 38.5%, and 28.9% for Metered dose inhalers (MDI), Turbohaler, and Diskus, respectively. They also found that a higher number of correct MDI steps and fewer errors in critical steps were associated with a higher level of parental knowledge. Continuous education on appropriate inhaler techniques for asthmatic children is mandatory.
In the “know the triggers and how to deal with them” component, the PCG had significantly higher understanding rates of “know the predisposing factors” and “know the allergens” than the UCG. This means that the caregivers of the children in the PCG had better understanding of these items, and this was related to better control of asthma. The first strategy to treat asthma is to know and avoid the predisposing factors. The most common predisposing factors are allergens, infections, exercise, emotional changes, medications, and temperature changes. Sensitization and allergens can be checked using blood tests and clinical correlations, and the most common allergens are mites, dog hair, cat hair, cockroaches, house mites, fungi, chemical stimulants, seafood, eggs and milk. Pathogens can be identified through virus and blood tests for mycoplasma pneumonia. The other predisposing factors can be assessed by the history of asthma exacerbations. In some situations, an allergen test or microorganism survey may not be performed. The predisposing factors are complex and easy to forget, and therefore it is preferable to write down the information rather than just telling them. WAAPs may act as a friendly reminder.
We also found that only 27.6% of parents knew about WAAP and 4.8% of children and parents had their own WAAP before this study. Both the PCG and UCG had low understanding rates for “know about WAAP” and “have your own WAAP” at only 33.3% and 9.1% in the PCG, and 20.7% and 0% in the UCG, respectively. The reasons for the infrequent use of WAAPs included too time consuming for doctors and difficult for parents to understand. In 2017, Lakupoch et al. conducted a prospective study using newly developed WAAPs in 49 children aged 5–18 years old with asthma, and found a significant decrease in emergency room visits after 6 months. These newly developed WAAPs used pictures of asthma symptoms along with a simple format, and colorful pictures of all available medications and devices, which the authors concluded were easier to understand. Moreover, the WAAP was user-friendly, and the physicians could complete it within 5 minutes. A WAAP is an important tool to remind the patients to prevent the triggers, monitor themselves confidently, use controllers and relievers correctly, contact the healthcare providers as needed, and finally promote asthma control. It is important to improve the format of WAAPs by making them more user friendly and emphasize the benefits of using them so that they become the standard strategy to promote the quality of asthma care in children.
There are some limitations to this study. First, this is a cross-sectional study, and we studied the correlation between parental knowledge regarding components of WAAP and asthma control levels in asthmatic children at one clinic visit. We did not evaluate the effectiveness of the WAAP, since we did not follow-up the patients with regards to asthma symptom control level after a WAAP intervention. Second, because well-controlled asthma patients were transferred or chose to visit a local clinic, the number of well-controlled asthma patients was small, and therefore we only compared the PCG and UCG. Besides, during the COVID-19 pandemic, a relatively smaller number of patients searched the healthcare services in medical centers.
In conclusion, our results demonstrated that the asthma control level was significantly and positively related to the understanding status of key components in the WAAP questionnaire. Although a persistent high prevalence of pediatric asthma is noted in Taiwan, the utilization rate of WAAPs is very low. The development of an easy-to-use WAAP and its use as a standard tool for asthmatic children is expected to greatly improve asthma control in Taiwan.
We would like to thank Miss Liang-Yu Lin, Miss Chaio-Fen Huang, Miss Ting-Yu Sung, and Mr. Jhen-Hong Wong for data collection, editing assistance, and general support.
Financial support and sponsorship
This study was supported by grants from E-Da Hospital (grant nos. EDAHP108051, EDAHP 111049, EDAHT110005 and EDAHT111006).
Conflicts of interest
The authors declare that they have no conflicts of interest.
Availability of data and material (data transparency)
The patients’ data were collected during the presence at E-Da hospital. According to the regulation of E-Da Hospital Ethical Review Committee and the “Personal Information Protection Act” in Taiwan, patients’ raw data cannot be made public. The interpretation of the analyzed results acquired from medical records been unlinked to patients’ identification and is available from the corresponding author upon request of the editorial staff.
Code availability (software application or custom code)
Yu-Cheng Tsai, Yu-Tsun Su and Ching-Chung Tsai conceptualized the study, collected grants, and wrote the initial paper; Yi-Pei Tai , Hsiu-Chuan Wang and Yuan-Yi Huang contributed to data collection and data analysis; Yuan-Yi Huang and Yu-Tsun Su contributed to the study design and edited the paper. All authors approved the final paper as submitted.
The study protocol was approved by the E-Da Hospital Ethical Review Committee.
Consent to participate
All the participants signed the requirement of consent.
Consent for publication
The authors have agreed that the article be published by Pediatric Respirology and Critical Care Medicine.
| References|| |
Reddel HK, Boulet L-P. 2022 GINA Report, Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma. 2022. https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf
Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Götz M, et al
; European Pediatric Asthma Group. Diagnosis and treatment of asthma in childhood: A PRACTALL consensus report. Allergy 2008;63:5-34.
Bush A. Asthma: what’s new, and what should be old but is not! Pediatr Respirol Crit Care Med 2017;1:2-10.
MacGillivray ME, Flavin MP. Canadian paediatric asthma action plans and their correlation with current consensus guidelines. Paediatr Child Health 2014;19:362-6.
Gibson PG, Powell H. Written action plans for asthma: An evidence-based review of the key components. Thorax 2004;59:94-9.
Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: Systematic review and meta-analysis. BMJ 2003;326:1308-9.
Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al
. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003;1:CD001117.
Coté J, Cartier A, Robichaud P, Boutin H, Malo JL, Rouleau M, et al
. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med 1997;155:1509-14.
Al-Muhsen S, Horanieh N, Dulgom S, Aseri ZA, Vazquez-Tello A, Halwani R, et al
. Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children. Ann Thorac Med 2015;10:123-31.
] [Full text]
Goronfolah L, Abulaban A, Barnawi AI, Jawi M, Alhadhrami W, Baatiah NY. The effectiveness of written asthma action plan at the national guard health affairs’ asthma clinic. Cureus 2019;11:e6247.
Lakupoch K, Manuyakorn W, Preutthipan A, Kamalaporn H. The effectiveness of newly developed written asthma action plan in improvement of asthma outcome in children. Asian Pac J Allergy Immunol 2018;36:88-92.
Bhupathi, S.D. and Vidhyasagar, , Beliefs and Factors Affecting the Usage and Compliance of Inhalers in Treatment of Asthma in Children
. Journal of Pharmaceutical Research International 2021 33:18-24.
Pothirat C, Chaiwong W, Limsukon A, Phetsuk N, Chetsadaphan N, Choomuang W, et al
. Real-world observational study of the evaluation of inhaler techniques in asthma patients. Asian Pac J Allergy Immunol 2021;39:96-102.
Almomani BA, Al-Qawasmeh BS, Al-Shatnawi SF, Awad S, Alzoubi SA. Predictors of proper inhaler technique and asthma control in pediatric patients with asthma. Pediatr Pulmonol 2021;56:866-74.
Su YT, Yang YN, Li YC, Tsai CC, Chen LM, Lin YC, et al
. Age-dependent distribution of the atopic phenotype and allergen sensitization among asthmatic children in southern taiwan. Asian Pac J Allergy Immunol 2016;34:206-11.
Su YT, Lin YT, Yang CC, Tsai SS, Wang JY, Huang YL, et al
. High correlation between human rhinovirus type C and children with asthma exacerbations in taiwan. J Microbiol Immunol Infect 2020;53:561-8.
[Table 1], [Table 2], [Table 3]