RESEARCH ARTICLEOpen Access
The knowledge, attitudes and practices of parents
of children with asthma in 29 cities of China: a
Jing Zhao1*, Kunling Shen2, Li Xiang2, Guoqing Zhang1, Meng Xie1, Juan Bai1and Qiyi Chen1
Background: Asthma is becoming increasingly prevalent among children in China. Poor parent knowledge and
attitudes often contribute to inappropriate management practices, leading to deficiencies in the care process. We
aimed to document the knowledge, attitudes and practices (KAP) of parents of children with asthma and analyze
how knowledge and attitudes relate to practices. Our secondary objective was to identify the factors associated
with parent KAP scores.
Methods: A KAP questionnaire was distributed to parents caring for 2960 children (0–14 years) diagnosed with
asthma for at least 3 months from China’s 29 provinces. A 50-item questionnaire was devised for this cross-sectional
survey based on a comprehensive review of the subject. Questionnaires were scored on 30 items regarding parent
asthma-related KAP, with one point for every correct response and a possible range of 0–13 for knowledge, 0–7 for
attitudes and 0–10 for practices. Higher scores indicated better KAP. Chi-squared tests and logistic regression were
used to identify factors associated with practices and combined KAP scores.
Results: The response rate was 83.95% (2485/2960). Only 18.31% (455/2485) of parents correctly answered ≥ 60%
of the knowledge questions (mean = 5.69). Most (89.85%; 2226/2485) gave positive responses to ≥ 60% of the
attitude questions (mean = 5.23) while 67.89% (1687/2485) correctly answered ≥ 60% of the practices questions
(mean = 6.19). Knowledge and attitudes were positively associated with pulmonary function testing, regular
physician visits, monitoring with a peak flow meter and the Children’s Asthma Control Test questionnaire,
avoidance of asthma triggers, using an inhaled β2 receptor agonist and adherence to medication regimen (p ≤ 0.05).
Attitudes were also associated with allergen testing. In logistic regression analysis, high KAP scores (dichotomized by a
cut-off score of 18) were positively associated with food allergy, rhinitis, physician visits, frequency of visits and parent
education (p < 0.05, OR > 1).
Conclusions: Generally, the parents’ KAP were poor. A gap between recommended and actual practice was observed,
which may be related to inadequate knowledge about and poor attitudes toward childhood asthma. Improving
knowledge and attitudes may encourage better practices among parents of children with asthma.
Keywords: Asthma, Knowledge, Attitudes, Practices, Parents, China
* Correspondence: email@example.com
1Capital Institute of Pediatrics, Beijing, China
Full list of author information is available at the end of the article
© 2013 Zhao et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Zhao et al. BMC Pediatrics 2013, 13:20
Asthma is one of the common chronic diseases among
children. Increases in asthma prevalence, morbidity and
mortality have intensified public health concern . In
2000, asthma affected an estimated 0.12–3.34% of children
(aged 0–15) in China, with a wide range of associated pro-
blems and high health costs . School absenteeism of
more than 10 days per year occurs among 42.47% of chil-
dren with asthma. It is the leading cause of ambulatory
visits and hospitalizations among children . This poten-
tially fatal chronic disease carries a significant burden for
patients, families and communities .
Asthma management refers to the monitoring and con-
trol of symptoms and the prevention of exacerbations. It
aims to improve long-term control and reduce the need
for emergency treatment . However, many children with
either diagnosed or undiagnosed asthma go untreated,
resulting in a poor quality of life . A wide gap exists bet-
ween recommended and actual practice, owing to educa-
tional barriers and a lack of adequate asthma-related
knowledge . According to childhood asthma guidelines,
parent training to improve their asthma-related know-
ledge, altitudes and practices (KAP) should be included in
routine clinical care [1,8]. Asthma-related knowledge
includes an understanding of pathological mechanisms,
medications and prevention . A good attitude is
reflected by confidence and positive relationships with
physicians . Good practices refer to timely interven-
tion and active management with appropriate care .
To improve childhood asthma management, an assess-
ment of parent KAP is a significant requirement. The pri-
mary objective of this study was to document the KAP of
parents of children with asthma and identify how know-
ledge and attitudes relate to practices. Our secondary ob-
jective was to identify the factors associated with parent
KAP scores. A cross-sectional survey of KAP was con-
ducted on parents of children with asthma in China’s 29
provinces and cities (except for Xinjiang and Tibet). Pa-
rent KAP were measured by the three domains of an
Asthma Knowledge, Attitudes and Practices Question-
naire. Survey findings indicate that asthma-related educa-
tion for parents/guardians is required to improve asthma
care and management.
Design and ethics
Using a questionnaire, we conducted a cross-sectional sur-
vey of the KAP of parents of children with asthma. We
constructed the study questionnaire based on the metho-
dology of KAP studies conducted in other countries, and
adapted it to the Chinese situation and culture.
The Medical Ethics Committee of the Capital Institute of
Pediatrics gave approval for the study and each respondent
provided written informed consent.
The study was conducted in the asthma clinics of ter-
tiary hospitals in 29 cities (capital cities of provinces,
municipalities and autonomous regions). By simple ran-
dom sampling, we selected 2960 children with asthma
aged 0–14 years (born between 1 January 1995 and 31
October 2009) who presented at a hospital between 1
May and 31 October, 2009, and had been diagnosed with
asthma for at least 3 months. The diagnoses must have
conformed with the guidelines for the diagnosis and
management of childhood asthma of the Chinese Me-
dical Association Pediatric Respiratory Study Group.
The KAP questionnaire was designed by asthma experts
by referring to the Asthma Insights and Reality in Europe
[12,13] survey and the Asthma Control Test . After
pilot testing, the questionnaire was discussed and revised
by the asthma experts until the final version was formed.
The 50-item questionnaire comprised five parts: (1) ge-
neral information about the parents of children with
asthma; (2) child conditions and asthma control in the
past 12 months, (3) parent knowledge; (4) parent attitudes
and beliefs, and (5) parent practices. The questionnaires
were scored on 30 items regarding parent asthma-related
KAP, with one point for every correct response. Incom-
plete questionnaires were not scored. All questionnaires
were completed by investigators through face-to-face
interviews with children with asthma and their parents to
Analysis of data
All data were entered into EpiInfo version 6.0 (CDC,
Atlanta, USA) in duplicate. Data were categorized and
analyzed using Statistical Package for Social Sciences ver-
sion 13.0 (SPSS Inc., Chicago, IL). Quantitative variables
were described by means and standard deviations, and
qualitative variables by frequency distributions, propor-
tions and percentages. Logistic regression and chi-squared
tests were used to determine the associations between
factors. A p-value < 0.05 was considered statistically
Patient (child) characteristics
In total, 2485 valid questionnaires were collected, a
response rate of 83.95%. There were 1660 (66.8%) male
children and 825 (33.2%) female children. Their average
age was 7.20 ± 3.09 years, and the average disease course
was 2.81 ± 2.05 years. More than a third (37.6%) of the
children had a history of food allergy, nearly half (48.5%)
had a history of eczema, more than half (58.59%) had
rhinitis and nearly a third (29.7%) had a family history
Zhao et al. BMC Pediatrics 2013, 13:20
Page 2 of 6
Parent knowledge, attitudes and practices
In the 2485 valid questionnaires, the average combined
KAP score was 17.11± 3.92, with level expression: the
fourth level (< 18 points) 51.43% (1278/2485), the third
level (18–20 points) 29.58% (735/2485), the second level
(21–24 points) 16.86% (419/2485), and the highest level
(> 24 points) 2.13% (53/2485).
Parent asthma-related knowledge
The knowledge component of the questionnaire contained
13 items. The average score was 5.69 ± 2.10 and 18.31% of
parents scored ≥ 8. Many parents (63.98%) knew that
asthma is a chronic allergen-induced airway inflammatory
disease. Only 6.08% (151/2485) knew that “wheezing > 3
times, coughing > 4 weeks, > 6 respiratory infections in the
last year and relief after using bronchodilator” could suggest
asthma. Almost two thirds (63.58%) of parents knew that
wheezing more than three times suggests asthma. By con-
trast, only 23.74% (590/2485) recognized that a chronic
cough may indicate asthma. “Self-withdrawal, catching a
cold, exposure to allergens, strong emotional changes and
cold stimulation” were identified by 11.03% (274/2485) of
parents as precipitants of asthma. “Repeated strenuous
coughing, chest tightness with restricted breathing and dry
cough after exercise or sleep” were identified by 20.97%
(521/2485) of parents as suggestive of an asthma attack.
Parents exhibited a low level of asthma-related knowledge,
with a better understanding of the nature of asthma, but a
lack of awareness of clinical manifestations of the disease
and the indicators of acute attacks.
Parent attitudes and beliefs
The attitudes component of the questionnaire contained
seven items. The average score was 5.23 ± 1.283 and
most parents (89.58%) scored ≥ 4. A total of 83.30%
(2070/2485) of parents knew that asthma is controllable
with regular medication. Most (84.67%) believed that
their child could participate in sports if their asthma was
under control, and of these parents, 60.31% (1269/2104)
believed that children with asthma could exercise as
much as healthy children. However, 33.60% (835/2485)
of parents would allow their children to participate in
minor sports only. In items related to adherence with
inhaled corticosteroids, 67.32% (1673/2485) of parents
worried about negative effects on children’s growth,
40.56% (1008/2485) worried about drug dependence,
and 23.98% (596/2485) were worried about potential
harm to their child’s intelligence. Regarding access to
asthma knowledge, 80.63% (2003/2485) of parents pre-
ferred to communicate with physicians.
The practice component of the questionnaire contained
10 items. The average score was 6.19 ± 1.57, and more
than half of the parents (67.89%) scored ≥ 6. Regarding
examination, two-thirds (68.25%) of children had under-
gone allergen tests, of which 76.24% (1293/1696) had
undergone skin prick tests and 66.96% (1664/2485) had
undergone pulmonary function tests. However, only 25.03%
(622/2485) had used a peak flow meter to monitor their
daily condition, and only 7.00% (174/2485) had used the
children’s Asthma Control Test questionnaire. Regarding
monitoring, 73.88% (1836/2485) of parents of children with
well-controlled asthma regularly took their child to see a
physician, among which 67.05% (1231/1836) visited every
1–3 months. Most parents avoid their child being exposed
to tobacco smoke (94.78%) and plush toys (88.17%). Many
(81.53%) parents of children with controlled asthma
insisted on their child adhering to their medication regi-
men, of which 78.33% (1587/2026) adhered to the correct
use of inhaled corticosteroids/compounds and 31.44%
(637/2026) to oral leukotriene receptor modulators. In
1456 children with comorbid allergic rhinitis, 34.68%
(505/1456) adhered to the correct use of nasal steroids. In
addition, 18.87% (469/2485) of parents also used antibiotics
as supplementary therapy, regardless of whether their child
exhibited symptoms associated with infection.
Influence of parent knowledge and attitudes on practices
Table 1 shows that parent asthma-related knowledge
(dichotomized by cut-off score of 8) was associated with
eight aspects of pulmonary function testing, regular phy-
sician visits, asthma monitoring with a peak flow meter
and the C-CAT questionnaire, avoidance of asthma trig-
gers (including smoke and plush toys), using an inhaled
β2 receptor agonist and adherence to medication regimen.
There were no associations between parent knowledge
and allergen testing or using antibiotics.
Table 2 shows that parent asthma-related attitudes
(dichotomized by a cut-off score of 4) were significantly
associated with allergen testing, pulmonary function
testing, regular physician visits, monitoring with a peak
Table 1 Influence of parent asthma-related knowledge on
χ2 Sig. OR95% CI
Review of lung function 9.1030.003 1.414 1.128 1.771
Regular physician visit 19.612 0.000 1.780 1.3762.034
Monitor with a peak flow meter 2.9500.000 5.921 4.767 7.353
Monitor with the C-CAT1.8010.000 7.034 5.108 9.688
Avoid passive smoking 17.272 0.000 4.882 2.13811.148
Avoid plush toys29.676 0.000 3.404 2.136 5.424
Acute inhaled of β2 receptor
36.448 0.000 1.891.534 2.328
Adherence to medication
46.803 0.000 3.406 2.353 4.932
Zhao et al. BMC Pediatrics 2013, 13:20
Page 3 of 6
flow meter and the C-CAT questionnaire, smoke avoi-
dance, using an inhaled β2 receptor agonist and better
adherence to medication regimen. Better practices were
associated with positive parent attitudes.
Factors associated with parent KAP questionnaire scores
A logistic regression analysis was used to determine the
effects of multiple factors on parent KAP score. The
dependent variable was KAP questionnaire score (dicho-
tomized by cut-off score of 18). The independent variables
are parent education, monthly family income, course of
asthma in children, food allergy history, eczema history,
coexist with allergic rhinitis, family history of asthma,
regular return visits for asthma control, frequency of re-
view. Table 3 shows that food allergy, rhinitis, regular
physician visits, frequency of physician visits and parent
education had positive associations with KAP scores.
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 standar-
dized classification of asthma treatment . In this ana-
lysis 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 know-
ledge was insufficient. Furthermore, asthma-related know-
ledge 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 know-
ledge and improper management of non-compliance are
risk factors for asthma fatality. We found a direct asso-
ciation 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
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 determi-
nants 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 na-
ture of asthma . Nevertheless, only 18.31% of parents
in our study correctly answered ≥ 60% of the questions.
Studies have shown that asthma, especially cough va-
riant 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 per-
sistent cough, with increased airway responsiveness or
abnormal expiratory flow rate variability that is effect-
ively 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 trig-
gers to acute attacks. As measured by the Knowledge,
Attitude, and Self-Efficacy Asthma Questionnaire in the
Table 2 Influence of parent asthma-related attitudes on
χ2 Sig.OR 95% CI
Allergen testing5.175 0.023 1.3621.0431.778
Review of lung function5.920 0.015 1.3871.065 10806
Regular return visit55.834 0.000 2.5822.0003.333
Monitor with a peak flow meter23.396 0.000 2.4701.6943.601
Monitor with the C-CAT6.799 0.009 2.5281.2295.202
Avoid passive smoking7.765 0.005 1.9301.2063.088
Acute inhaled of β2 receptor
21.358 0.000 2.113 1.529 2.919
Adherence to medication
3.8620.000 11.300 8.533 14.964
Table 3 Factors associated with parent KAP scores
B S.EWald df Sig.Exp
0.386 0.058 43.89310.000 1.471 1.312 1.649
0.2270.102 4.9301 0.026 1.255 1.0271.533
0.592 0.101 34.1271 0.000 1.808 1.482 2.206
0.910 0.287 10.05010.002 2.485 1.415 4.362
0.155 0.073 4.46110.035 1.167 1.0111.347
−3.362 0.296 128.817 1 0.000 0.035
Zhao et al. BMC Pediatrics 2013, 13:20
Page 4 of 6
United States, patients with asthma had limited asthma-
related knowledge, with only half of the patients cor-
rectly answering ≥ 50% of the questions .
Childhood asthma management requires multiple com-
plex tasks. Parents need to understand the diverse triggers
and basic mechanisms of an asthma attack, and to under-
stand 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 educa-
tion improved asthma and healthy home-knowledge, and
that 98.4% of the parents made changes in their house-
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 partici-
pate 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, re-
duce the frequency of asthma attacks and prevent further
Among the children who were not adhering to their
medication regimen, 67.32% (1673/2485) of parents wor-
ried 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 sup-
port 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 chil-
dren 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 antibio-
tics 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 identifi-
cation 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 investiga-
tion 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 environ-
ments). 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, re-
call bias may have been present.
It is possible that asthma control status affects parent
asthma-related KAP. Further research is required to de-
termine if interventions would be beneficial.
In this study, consistencies between parent knowledge,
attitudes and practices were identified. This indicates
that improved asthma knowledge and attitudes can en-
courage parents to correctly monitor their child’s asthma
condition and better manage and adhere to their medi-
cation regimen. In this survey, parent education had
a positive association with KAP scores. Education le-
vel will affect the parents’ ability to acquire knowledge.
Higher-educated parents have more asthma knowledge
and can better provide the appropriate care. A history of
food allergy and rhinitis was positively associated with
Zhao et al. BMC Pediatrics 2013, 13:20
Page 5 of 6
parent KAP scores. This indicates that these parents are Download full-text
more likely to seriously consider the allergy status of their
children. Regular physician visits, when asthma is con-
trolled, can bring more opportunities for asthma educa-
tion to parents.
The authors declare that they have no competing interests.
JZ conceived of the study idea, developed the design and edited the
manuscript. MX participated in study development and edited the
manuscript. GQZ participated in the study design, performed the statistical
analysis and helped draft the manuscript. QQH, QYC and JB participated in
the study development and data entry. All authors read and approved the
The authors wish to thank all the children and their parents for their
participation, and the physicians for their contribution.
1Capital Institute of Pediatrics, Beijing, China.2Beijing Children’s Hospital,
Received: 1 June 2012 Accepted: 31 January 2013
Published: 4 February 2013
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Cite this article as: Zhao et al.: The knowledge, attitudes and practices
of parents of children with asthma in 29 cities of China: a multi-center
study. BMC Pediatrics 2013 13:20.
Zhao et al. BMC Pediatrics 2013, 13:20
Page 6 of 6