Family Management of Asthma in Head Start Preschool Children

Abstract

Background:

Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children in order to improve asthma control. Objective: This study examines family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children. Methods: The Family Asthma Management System Scale (FAMSS) assesses how families manage a child’s asthma. 388 caregivers completed the FAMSS at baseline. Asthma outcomes were assessed at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids required, and caregiver health-related quality of life (Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ)). Multiple regression models assessed the relationship between the FAMSS Total Score, FAMSS subscales, and asthma outcomes.

Results:

Higher FAMSS Total scores were associated with fewer courses of oral corticosteroids required (b=−0.23, p<0.01) and higher PACQLQ scores (b=0.07, p<0.05). At baseline, higher Integration subscale scores (b=−0.19, p<0.05) were associated with fewer courses of oral corticosteroids required, and higher Family Response scores were associate with higher PACQLQ scores (b=0.06, p<0.05). However, higher Collaboration scores were associated with lower PACQLQ at baseline (b=−0.06, p<0.05) and 6 months (b=−0.07, p<0.05).

Conclusion:

Among this population of low-income minority preschool children, understanding how a family manages their child’s asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of oral corticosteroids.

INTRODUCTION

Asthma is the most common childhood chronic disease in the United States and disproportionately affects low-income, minority children, who have high rates of morbidity and mortality from asthma¹. The prevalence of asthma in Black children is also twice that in white children, and Black children have more frequent emergency department visits and hospitalizations^2,3. Preschool-age children have the most asthma-related health care visits, with more emergency department visits and hospitalizations than older children, and utilize use more higher health-care resources compared to older children¹.

Effective management of a child’s asthma requires the collaboration in the family system, comprised of the child, their caregivers, and the healthcare system⁴. Families and caregivers are particularly important in the preschool age group, as they provide the majority of asthma management. Families need to be able to identify, monitor, and respond to asthma symptoms, reduce exposure to triggers, and work with their healthcare providers to achieve appropriate asthma control. Poor family functioning and family dysfunction have been associated with worse asthma management behaviors, including difficulties taking medication consistently, while family support has been positively associated with asthma control^5–8. Because of the importance of families in the preschool age group, it is vital to understand the range of behaviors families use to manage asthma in order to identify potential gaps in family asthma management and to inform the development of family-based interventions to improve asthma control.

Prior studies have shown that better family asthma management is inversely correlated with higher asthma functional impairment and measures of asthma morbidity^9,10. Other studies in school-age children demonstrated that those with better family asthma management had better inhaler technique and a recent outpatient healthcare visit¹¹. However, the role of family asthma management has not been evaluated in the preschool population, particularly for a low-income minority preschool population who are at greatest risk for poor asthma outcomes.

The objective of this study is to evaluate the association between family management of asthma, as measured by the Family Asthma Management System Scale (FAMSS), and prospective asthma outcomes of asthma morbidity among a low-income urban minority population enrolled in Baltimore City Head Start preschool programs. Outcomes include: 1) asthma control, 2) oral corticosteroid courses prescribed, and 3) caregiver health-related quality of life. We hypothesized that a higher score for family asthma management would be associated with higher probability of asthma control, fewer oral corticosteroid courses, and higher caregiver health-related quality of life at baseline and 6-month follow-up in this preschool age group.

METHODS

Participants

Participants were recruited from Baltimore City Head Start programs across 78 sites from April 2011 to November 2016 as part of a randomized trial of a multi-level home and school-based asthma education program¹². Eligible caregivers were the parent or legal guardian of a child aged 2 to 6 years, who reported that their child had a physician diagnosis of asthma or reactive airway disease, and who spoke English. An eligibility screening questionnaire was provided to all enrolled students by Head Start Staff. Eligible families who gave permission were contacted by research study staff to confirm eligibility and schedule baseline visit to obtain informed consent.

Procedures

The Johns Hopkins School of Medicine Institutional Review Board approved the study. Written informed consent was obtained prior to any data collection. Research assistants conducted home visits to complete baseline and 6-month assessments that included a structured survey with the caregiver. After baseline assessment, families were randomized to either receive a literacy-tailored family asthma education intervention (Asthma Basic Care; ABC) with Head Start education (ABC+HS) or Head Start education alone. Outcome measures were measured at baseline and 6-month follow-up. A complete description of the Head Start and Asthma Basic Care intervention has been published previously¹².

Measures

Family Asthma Management System Scale (FAMSS)

The Family Asthma Management System Scale (FAMSS) is a semi-structured interview that utilizes open-ended questions to assess family management of pediatric asthma and can be administered to caregivers of young children^9,10. The interview is recorded and rated using a standard manual with 7 subscales designed to assess key areas of asthma management: (1) Asthma Knowledge, (2) Symptom Assessment, (3) Family Response to Exacerbations, (4) Environmental Control, (5) Medication Adherence, (6) Collaborative Relationship with Health Care Provider, and (7) Balanced Integration of Asthma and Family Life (Table 1). Each asthma-management subscale is given a rating, ranging from 1 to 9, with higher scores indicating better asthma management. The FAMSS Total Score is calculated as the mean of the ratings on the constituent subscales.

TABLE 1:

Family Asthma Management System Scale (FAMSS) Subscales

FAMSS Subscale	Domains measured	Baseline Mean (SD) Range	6 Months Mean (SD) Range
FAMSS Total Score	Mean of the ratings on the subscales	4.73 (1.23) 1.7–7.7	4.90 (1.27) 1.1–8.4
Asthma knowledge	Basic anatomy of asthma, concept of chronic disease, roles of triggers, function of prescribed asthma medications	4.69 (1.71) 1–9	4.95 (1.65) 1–9
Symptom assessment	Signs of asthma exacerbation, identification of early warning signs, daily/seasonal patterns, gradation of symptoms	4.68 (1.56) 1–9	4.83 (1.55) 1–9
Family response to symptoms	Family actions taken to manage exacerbations, monitor symptoms, and implement appropriate action plan	5.05 (1.88) 1–9	5.04 (1.77) 1–9
Environmental control	Reported exposure to smoke, pets, dust, and other triggers	3.47 (2.29) 1–8	3.59 (2.32) 1–9
Medication adherence	Availability and appropriate use of rescue medications, adherence to long-term controller medications	5.53 (1.90) 1–9	5.69 (1.75) 1–9
Collaboration with health care provider	Relationship with identified care provider, including effective communication, provider’s adherence to established guidelines for asthma management	5.03 (1.74) 1–9	5.25 (1.62) 1–9
Balanced integration of asthma and family life	Effective integration of child’s asthma into family life, including family distress and coping due to child’s asthma symptoms, attention to asthma triggers and exposures, and appropriate focus on child attending school and participating in activities. Successful balance of the management of the child’s asthma and having a family life.	4.69 (1.72) 1–9	4.94 (1.82) 1–9

FAMSS Reliability

The FAMSS interview was administered, audio-recorded, and rated by a research assistant at the baseline home visit and assessment. All research assistants received training in administration and scoring with one of the original developers of the interview with review of sample interviews to establish initial reliability prior to conducting interviews with participants. Monthly consensus meetings between the research faculty member and research assistants were conducted to review select interviews and scoring. Reliability reports were completed for each of the six research assistants. Reliability scores were calculated as an intraclass correlation coefficient (ICC) ranging from 0 to 1 between two raters, with higher coefficients indicating greater reliability. Interviews were done in the context of data collection without additional education to caregivers provided. For instance, research assistants did not confirm whether medications were being used correctly, but would notify caregivers if medications were expired or empty.

Intraclass Correlation Coefficients overall ranged from 0.60 to 0.95. ICCs for each of the FAMSS subscales: Asthma Knowledge (0.72–0.93); Symptom Assessment (0.66–0.91); Family Response to Symptoms (0.61–0.90); Environmental Control (0.60–0.94); Medication Adherence (0.79–0.95); Collaborative Relationship with Health Care Provider (0.75–0.94); and Balanced Integration of Asthma and Family Life (0.64–0.88).

Asthma Control (Test for Respiratory and Asthma Control in Kids (TRACK))

The Test for Respiratory and Asthma Control in Kids (TRACK) was completed by the caregiver to assess degree of asthma control. TRACK has been validated in preschool children with asthma¹³. The TRACK contains five standardized questions, each of which was scored using a 0–20 Likert scale for a total score range of 0 to 100. A binary cutpoint of TRACK <80 was used to indicate that asthma was uncontrolled for regression models¹³. Asthma control was measured at baseline and 6 months.

Oral Corticosteroid Courses (OCS) Required

Caregiver reports of the number of oral corticosteroid courses (OCS) required over the prior three-month period were collected at baseline and 6 months.

Caregiver Health-related Quality of Life

The Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ) is a questionnaire measuring caregiver health-related quality of life and the burden of asthma on caregivers of children with asthma¹⁴. Caregivers completed the 13-item questionnaire at baseline and 6 months, which assessed problems with activity limitations and emotional functioning experienced by parents of asthmatic children. Each question was scored on a 7-point Likert scale, with 1 indicating severe impairment and 7 indicating no impairment. An overall quality of life score was calculated as the mean of the ratings on the two domains (activity limitations and emotional functioning). Higher scores indicated less impairment and better health-related quality of life. The PACQLQ was measured at baseline and 6 months.

Statistical Analyses

Descriptive statistics for the FAMSS were calculated with means, standard deviations, and ranges for FAMSS Total and subscale scores at baseline and 6 months, and also for asthma outcomes at baseline and 6 months. Two multiple regression models were used for either 1) the FAMSS Total Score or 2) all 7 subscales for each of the three asthma outcomes (asthma control, number of OCS, and PACQLQ score) at both baseline and 6 months. Logistic regression models were conducted for the outcome of uncontrolled asthma (as measured by TRACK score cutpoint <80). Negative binomial regression models were conducted for the outcome of the number of oral corticosteroid courses required in the last 3 months. Multiple linear regression models were utilized for the outcome of PACQLQ score. All models controlled for a priori selected covariates of child gender, family history of asthma, presence of atopy in the child, smoking presence in the home, and season of data collection. Models for asthma outcomes of oral corticosteroid courses and PACQLQ additionally included asthma control as a covariate. No multicollinearity was noted with selected covariates. Models at 6 months also controlled for the intervention group (Head Start education alone or ABC+HS)¹². We performed a posthoc power calculation with a total sample size of 388, 5 covariates, and 7 predictors (7 subscales), with power = 0.83 to detect a small effect size of 0.2. All analyses were conducted in Stata/MP 16.0 (StataCorp, College Station, TX).

RESULTS

A total of 14,851 caregivers (90% of all children enrolled at Head Start) completed screening from 2012 to 2016 (Figure 1). 24% of children had a reported asthma diagnosis. 1,130 (8%) were both eligible and provided permission to be contacted for the study. Overall, 404 caregivers were consented; 388 had complete data at baseline and 318 had complete data at 6 months for this analysis. The mean age of enrolled children at the time of baseline assessment was 4.2 years (SD=0.7). 373 (96%) were Black/African-American at baseline, while at 6 months, 264 (83%) who completed the assessment were Black/African American. 308 (82%) had a family income less than $30,000, and 368 (96%) received public insurance at baseline (Table 2).

FIGURE 1.

Consort diagram.

TABLE 2:

Baseline characteristics of children and caregivers

Characteristic	Baseline n (%) (n = 388)
Child characteristics
Age in years, mean (sd)	4.2 (0.7)
Sex
Male	242 (62.4)
Female	146 (37.6)
Race
Black/African-American	373 (96.1)
White (non-Hispanic)	9 (2.3)
Hispanic	6 (1.6)
Health Insurance
Medical assistance	368 (96.1)
Private insurance	8 (2.1)
Unknown or uninsured	7 (1.8)
Caregiver characteristics
Age in years, mean (sd)	31.9 (8.4)
Relationship to child
Mother/ stepmother	338 (87.1)
Father/ stepfather	26 (6.7)
Grandmother	10 (2.6)
Other	14 (3.6)
Education
Less than 9th grade	2 (0.5)
Some high school completed	73 (18.8)
High school graduate or GED	133 (34.3)
Some college or trade school	146 (37.6)
College graduate	32 (8.2)
Low household income (<$30,000)	308 (81.5)

There are 5 missing values for health insurance, 2 missing values for caregiver education, 2 missing values for caregiver employment status, and 10 missing values for household income.

FAMSS: Descriptive Statistics and Reliability Analysis

FAMSS Total Scores and Subscale Scores are described with means, standard deviations, and ranges at baseline and 6 months (Table 1). The internal consistency reliability of the FAMSS Total Score (consisting of seven subscales) was acceptable (Cronbach’s α = 0.79).

Association of FAMSS and Uncontrolled Asthma (Test for Respiratory and Asthma Control in Kids (TRACK))

60% of the children had uncontrolled asthma (TRACK score <80) at baseline (Table 3). FAMSS Total Scores and individual subscale scores were not associated with uncontrolled asthma at baseline or 6 months.

TABLE 3:

Asthma outcomes at baseline and 6 months

	Baseline (n = 388)	6 months (n = 318)
Uncontrolled asthma (TRACK score <80), n (%)	231 (60)	95 (30)
Number of oral corticosteroid courses required in prior 3 months, mean (sd)	0.37 (0.79)	0.28 (0.83)
PACQLQ Score, mean (sd)	4.20 (0.74)	4.37 (0.70)

^*Full results on asthma outcomes have been previously reported.¹²

Association of FAMSS and number of oral corticosteroids (OCS) courses required

Over a quarter of the children had required a course of oral corticosteroids in the prior 3 months at baseline, with 0.37 steroid courses as the mean number of steroid courses required at baseline (Table 3). Higher FAMSS Total Scores were associated with fewer oral corticosteroid courses in the prior three months at baseline (b=−0.23, 95% CI=−0.40 to −0.06, p=0.008) (Table 4). An association was not noted at 6 months. For FAMSS subscales, higher scores for Integration were associated with fewer courses of oral corticosteroids in the prior 3 months at baseline (b=−0.19, 95% CI=−0.35 to −0.04, p=0.014). No other FAMSS subscales were associated with courses of oral corticosteroids at baseline or 6 months.

TABLE 4:

Negative binomial regression models with FAMSS and outcome of number of oral corticosteroids required in the previous 3 months

	Baseline - Number of OCS		6 Months - Number of OCS
Variable	Coefficient	95% CI	Coefficient	95% CI
FAMSS Total Score	−0.23**	−0.40, −0.06	0.11	−0.12, 0.34
Subscales
Asthma Knowledge	−0.08	−0.23, 0.07	0.02	−0.19, 0.23
Symptom Assessment	0.15	−0.01, 0.31	0.06	−0.17, 0.29
Family Response	−0.06	−0.21, 0.10	−0.03	−0.28, 0.22
Environmental Control	−0.03	−0.15, 0.08	0.07	−0.12, 0.25
Medication Adherence	−0.10	−0.23, 0.03	0.09	−0.11, 0.30
Collaboration	0.12	−0.04, 0.28	0.11	−0.13, 0.35
Balanced Integration	−0.19*	−0.35, −0.04	−0.17	−0.39, 0.05

^*p<0.05,

^**p<0.01.

Regression models are adjusted for gender, family history of asthma, presence of atopy in the child, smoking presence in the home, season of data collection, and asthma control. Outcomes at 6 months are also controlled for the ABC intervention group.

Association of FAMSS and Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ)

PACQLQ scores at baseline ranged from 1.4–5.0, with a mean of 4.2 (standard deviation 0.7) (Table 3). The internal consistency reliability of the PACQLQ was good (Cronbach’s α at baseline = 0.86 and Cronbach’s α at 6 months = 0.87). Higher FAMSS Total Scores were significantly associated with higher PACQLQ scores at baseline (b=0.07, 95% CI=0.01 to 0.13, p=0.021) (Table 5). No associations were noted at 6 months. For FAMSS subscales, higher Family Response scores were significantly associated with higher PACQLQ scores at baseline (b=0.06, 95% CI=0.01 to 0.11, p=0.032) (Table 5). In contrast, higher scores on Collaboration were significantly associated with lower PACQLQ scores at baseline (b=−0.06, 95% CI=−0.11 to −0.003, p=0.040) and also at 6 months (b=−0.07, 95% CI=−0.12 to −0.01, p=0.015).

TABLE 5:

Multiple linear regression models for FAMSS and the outcome of the Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ)

	Baseline – Quality of Life		6 Months – Quality of Life
Variable	Coefficient	95% CI	Coefficient	95% CI
FAMSS Total Score	0.07*	0.01, 0.13	0.01	−0.04, 0.07
Subscales
Asthma Knowledge	0.04	−0.01, 0.10	0.05	−0.01, 0.10
Symptom Assessment	0.009	−0.05, 0.07	0.0001	−0.05, 0.06
Family Response	0.06*	0.01, 0.11	−0.01	−0.07, 0.04
Environmental Control	0.004	−0.03, 0.04	0.01	−0.03, 0.05
Medication Adherence	−0.04	−0.08, 0.004	0.005	−0.04, 0.05
Collaboration	−0.06*	−0.11, −0.003	−0.07*	−0.12, −0.01
Balanced Integration	0.04	−0.012, 0.10	0.03	−0.03, 0.08

^*p<0.05.

Regression models are adjusted for gender, family history of asthma, presence of atopy in the child, smoking presence in the home, season of data collection, and asthma control. Outcomes at 6 months are also controlled for the ABC intervention group.

DISCUSSION

Our study results revealed that better overall family management of asthma was associated with fewer oral corticosteroid courses for preschool children and with higher caregiver asthma-related quality of life at baseline, in a population of low-income, predominantly Black families. There was no association between family asthma management and asthma control for children at either baseline or 6 months. When examining individual FAMSS subscales, higher integration of asthma management into family life was found to be associated with fewer oral corticosteroid courses at baseline, and more effective family response to asthma symptoms was associated with higher caregiver asthma-related quality of life at baseline. In contrast to the hypothesis, greater collaboration with a healthcare provider was associated with lower caregiver asthma-related quality of life at both baseline and 6 months. While previous research has shown positive associations between family asthma management and some clinical outcomes, this is the first study to examine family asthma management in urban minority preschoolers. Since families play a central role in asthma management for this preschool age population, these results highlight specific areas for clinicians to focus on to improve family asthma management and outcomes.

Caregivers of children with asthma must establish effective asthma management strategies in order to maintain and treat their child’s asthma. The family has to develop appropriate knowledge about asthma, identify and respond to symptoms of asthma exacerbations, adhere to medication prescriptions, work in collaboration with their health care provider, and integrate their child’s asthma management into the family’s lifestyle^9,10. A family who has successfully incorporated their child’s asthma management into daily routines may be more able to take action appropriately when asthma exacerbations occur. They may also be able to treat symptoms before symptoms become severe enough to require courses of oral corticosteroids, resulting in fewer courses of steroids, consistent with our data that both better overall family asthma management and higher integration of asthma into family life are associated with fewer oral steroids at baseline. In this study population, 26% of children had required a course of oral corticosteroids in the prior three months at baseline, so any decrease in the usage of oral corticosteroids may prevent any potential adverse effects^15–17. The decrease in oral corticosteroids associated with better overall family asthma management was noted to be 0.23 courses of steroids over a three-month period for every one-point increase in the FAMSS Total Score at baseline, which may translate to one course of steroids over a three-month period for a five-point increase in the FAMSS Total Score.

In contrast to our hypothesis, higher collaboration with a healthcare provider was associated with lower caregiver asthma-related quality of life at both baseline and 6 months. This unexpected finding may be related to the young age of children in this study, for whom, the diagnosis of asthma is likely new. Thus, there may be a focus on treatment of acute symptoms rather than longer term management. Caregivers may have to interact closely with their healthcare provider about this new diagnosis to formulate a treatment plan and to learn about asthma with more frequent visits to adjust medication regimens and learn device techniques (e.g. inhalers and nebulizers). The more frequent visits or interactions with healthcare providers, whether preventatively or for asthma exacerbations, could lead to higher scores on Collaboration, but at the same time, could limit a caregiver’s normal planned activities and quality of life. Parents of children with chronic illnesses, like asthma, are already at risk for poor health-related quality of life¹⁸. Alternatively, those caregivers who interact more frequently with their healthcare providers may have a better understanding of their child’s asthma and therefore worry about symptoms more, while those caregivers who are not engaging with their providers as often may not be as worried about their child’s asthma. Furthermore, effects on caregiver quality of life in this population of low-income minority families may be complex and affected by other factors despite families collaborating effectively with their healthcare providers. In a study examining this same preschool population, 86% of caregivers had reported at least 1 barrier to healthcare access or use for their child¹⁹. These barriers to care may include a history of prior negative healthcare experiences or interactions with office staff, which may occur at clinic visits. Therefore, while families may collaborate with their healthcare provider effectively and score higher on Collaboration, they may simultaneously be facing barriers of care or marginalization during their clinic visits that could contribute to worse caregiver quality of life.

While the Balanced integration of asthma into family life and Collaboration with healthcare provider subscales were significantly associated with the asthma outcomes examined in this study, other subscales were not. Family asthma management in our study was also not associated with asthma control, whereas a previous study has showed that families with competing family priorities were more likely to have children with suboptimal asthma control²⁰. However, this study is the first study to examine the FAMSS in a preschool population, which is a younger age than has been studied previously^9–11. This group of preschool children with asthma had a mean age of 4.7 years old with ages ranging from 2 to 6 years old. Many young children may have wheezing that only occurs with viral upper respiratory infections, and asthma can change rapidly. At the same time, this group has the potential to worsen quickly with the highest rates of emergency room visits and hospitalizations compared to older children¹. As a result, subscales that are relevant for older children may not be as applicable to this age group. For instance, among this Head Start population, 44% were not on a daily controller medication for asthma, while more older children may be. Subscales such as the Adherence with asthma medications subscale do account for the use of daily controller medications, so assessment of adherence in children who are not on daily medications may affect subscale results. Families could have an understanding of asthma symptoms and the appropriate knowledge to score highly on subscales like Asthma Knowledge or Symptom Assessment, but that caregiver knowledge may not be enough to prevent the need for oral corticosteroids²¹.

There were limitations in this study, such as our reliance on caregiver reports of oral corticosteroid usage instead of medical records. Prior research has demonstrated that medical record and patient survey data have concordance²². However, families in this study may have been affected by a social desirability bias, such that they responded in a way that would be viewed favorably by study researchers. Research staff conducted interviews in the homes of families and noted that there were often inconsistencies reported by the family versus what was seen in the home; for instance, families would report no smoking in the home or no pets, while the research staff could see evidence of both in the home. Second, participants in this study were randomized to receive either a family asthma education intervention or a control group. The intervention group was controlled for as a covariate in our analyses at 6 months, but may have affected asthma outcomes over time. Third, this study utilizes the FAMSS in a preschool population, a younger population than had previously been studied with the FAMSS. Further studies may be needed to validate FAMSS subscales in this younger population. Fourth, our study excluded non-English speaking participants. Of the 14,851 caregivers who were screened, only 80 caregivers were ineligible for the study due to not speaking English, which is equivalent to <0.5% of the population screened. Finally, our study sample consisted of largely urban minority preschool children, who all attended Head Start preschools, which may limit the generalizability of our study to other populations. This population is particularly at-risk for high asthma morbidity and thus are critical to study to reduce health disparities.

The analyses from this study highlight family asthma management in low-income urban minority preschool children, a particularly vulnerable asthma patient population. Interventions to optimize asthma management should focus on a thorough assessment of a family’s ability to manage asthma, which is of increased importance in this caregiver-dependent population. Asthma is likely a recent diagnosis for preschool children and may be difficult to control given the wide range of clinical presentations²³. Clinical utilization of the topics assessed on the FAMSS will help ensure that a family has adequate asthma knowledge, the ability to balance asthma management with their daily activities, and a strong relationship with their healthcare provider, all of which may impact caregiver quality of life and any potential caregiver stressors related to their child’s asthma. Future research should focus on identifying gaps in family management to inform gaps in asthma education for this at-risk group.

Abbreviations/Acronyms:

-Family Asthma Management System Scale (FAMSS)

The Family Asthma Management System Scale is a semi-structured interview that assesses family management of pediatric asthma and can be administered directly to caregivers of young children.

-Test for Respiratory and Asthma Control in Kids (TRACK)

The Test for Respiratory and Asthma Control in Kids is a questionnaire completed by a caregiver to assess degree of asthma control.

-Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ)

The Pediatric Asthma Caregiver’s Quality of Life Questionnaire is a questionnaire measuring caregiver health-related quality of life and the burden of asthma on caregivers of children with asthma.

-Asthma Basic Care (ABC)

Asthma Basic Care is a literacy-tailored family asthma education intervention.

-Oral Corticosteroid Courses (OCS)

Caregivers reported the number of courses of oral corticosteroids required.