1. Introduction
The most prevalent chronic disease among children worldwide is asthma [
1]. According to the World Health Organization (WHO), 262 million people globally suffer from asthma [
2]. In 2019, according to Global Burden of Disease (GBD) data, 6.16% of the population suffered from asthma [
3]. In Croatia, the prevalence of asthma was 4.61% for all ages and 4.66% for children younger than 14 years [
3]. Asthma is usually described as a heterogeneous illness with many different clinical phenotypes such are allergic or non-allergic asthma, among others [
4,
5]. Recurrent respiratory symptoms like shortness of breath, cough, or wheezing, chest tightness, together with different degrees of expiratory airway flow limitation are defined as asthma. Patients suffer from exacerbation that sometimes can be resolved without medication, but on the other hand, can be fatal.
Regular, daily inhaled corticosteroids (ICS) are a preferred controller choice [
6], and even with low daily doses, it would impact asthma hospitalizations and deaths [
7]. The minimum effective dose of ICS is recommended to avoid possible corticosteroid side effects [
8]. Yet, with an excellent safety profile and well-documented suppression of airway inflammation [
9], ICS also have local and systemic side effects [
10].
Side effects of ICS are dose-reliant and more often occur in high-dose corticosteroid asthma users [
11]. Some local side effects like oral candidiasis, dental caries, and dysphonia can be avoided with better inhaler technique, valve chamber use, and rinsing a mouth and face with water after corticosteroid inhalation [
10]. One of the major parent’s concerns is the impact of inhalational corticosteroid use on their children’s linear growth; suppressed growth velocity or reduced final height, an effect that may be a delivery device- or drug molecule-dependent [
12,
13]. The fact that uncontrolled asthma and atopy have a negative influence on linear growth too must be presented during pediatric asthma visits [
14]. High-dose ICS use may cause adrenal suppression and lead to adrenal insufficiency under stress or therapy withdrawal [
15]. Given the possible side effects, the concern of parents when using ICS for asthma therapy and control is understandable.
Even though reasons are still not completely understood, the ICS adherence rate in children with asthma is only 50% [
16]. Poor ICS adherence is a potentially modified risk factor for exacerbation, even in patients with few asthma symptoms [
17], so it is important to enlighten parents about that fact.
Perceptions of chronic diseases are a driver of patient behavior and may have an influence on treatment outcomes [
18]. Parental decision to give a child prescribed ICS is based on their perception of asthma and can be modified through partnership with a clinician [
19]. According to recent literature, fear of using ICS is documented in up to 67.3% of families with children suffering from asthma [
13]. To deal with this important adherence obstacle, clinicians must identify, in every individual family parents’, the main beliefs and fears about prescribed ICS.
Parents of children with asthma have a primary responsibility to monitor for symptoms and properly administer controller therapy [
20]. Parents’ goals, preferences, and concerns about disease and medication must be communicated as a means to promote their active role [
21]. Good communication strategies between experts and parents will help to achieve the much-needed partnership necessary for successful treatment [
22] and improved outcomes of child asthma [
23,
24,
25]. Training parents to ask information and seek clarification in any doubt about treatment will result in better medication adherence [
26].
This study aimed to gain insight into parents’ perception of asthma, their fears, and beliefs about using ICS in 2–10-year-old children using two questionnaires, TOPICOP and B-IPQ. The hypothesis of this study was that the parents of children with well-controlled asthma will have less fear and concerns about ICS and have a positive influence on ICS treatment adherence.
To our knowledge, this is the first cross-sectional research using these two questionnaires for this particular purpose and population.
4. Discussion
As previous studies about the natural history of asthma suggested, asthma symptoms start at an early age tend to continue in true adulthood [
30]. According to available literature, 80% of asthma starts up to the fifth year of the child’s life [
31], with the predominance of male gender until the age of 10 [
32]. Our respondents were also male children slightly older than five years since it is the most frequent group of patients with asthma in our pediatric pulmonologist practice.
Sensitization to common aeroallergens of children with asthma involved in this study was 52%, which was assessed with an allergen-specific immunoglobulin E (IgE) level or skin prick test. Similar numbers were published by Arbes et al. in their research where 56.3% of asthma patients between 6 and 59 years were attributed to atopy [
33]. The literature indicates that early-age allergic sensitization is a major predictor for persistent asthma development [
34].
Almost all children of our participants had a positive family history of atopic dermatitis, allergic rhinitis, or food allergies. Only 14.9% of parents had a history of asthma, but among all members of the family, a history of asthma was observed in 69.6% of cases. The results emphasize the need to take a wider family history because the possibility of asthma development grows with the number of family members with asthma [
35]. Almost three-quarters of the children of our respondents had comorbidities (allergic rhinitis, atopic dermatitis, food or drug allergy), that can be easily explained by “atopic marsh” development [
36]. Physical activity is one of the non-pharmacological treatments of asthma because of its impact on general health [
9]. Around half of the observed children with asthma in this study were involved in some kind of organized sports activity which is encouraging proof of a healthy lifestyle. There was a small number families with household pets, mostly dogs and cats, which is desirable and recommended for these allergen-sensitized children [
37]. A recent meta-analysis by Ji et al. showed a significant occurrence of childhood asthma in dog and cat owners [
38].
As previously reported, mothers have a critical role in their children’s quality of life and development of anxiety [
34], one of the “treatable traits” [
39], and risk factors for asthma exacerbation [
8]. In our study, the questionnaires were, in 99 percent of cases, answered by mothers who were mostly high school educated and employed.
To examine the fear of parents about ICS usage and divide them into two groups; “afraid” and “not afraid of ICS treatment”, we used the TOPICOP questionnaire similar to Choi et al. [
40]. While the question of adherence obstacles and thoughts to corticosteroid therapy is usually discussed during asthma child visits, the roots of these worries are rarely explored. It can be based on personal experience, non-medical information from family, friends, social media [
41], or other parents of asthmatic children, and sometimes confusing information from medical professionals [
42].
The TOPICOP scale was constructed to make it easier for clinicians to identify beliefs and worries for that specific person and specific health problems, and direct conversation to resolve it and improve their treatment adherence [
28]. Our respondents were mostly afraid of using higher ICS doses, and totally or partially agreed to stop practicing ICS as soon as possible in around 70% of cases, higher than one-third of the parents previously observed by Yoos et al. [
43]. Based on the TOPICOP questionnaire, 28.4% of our respondents were afraid of using ICS and two-thirds were concerned about steroid’s side effects. An Israelian study reported fears and concerns about ICS in 30.4% of mothers of children with asthma [
44]. A much higher percentage of corticophobia group was reported in adult asthma patients (52.6%) [
45]. The same authors reported that 67.3% of respondents believed that ICS may damage the lungs. Only 5% parents of our respondents shared the same fear. Around half of adult asthma patients believe that ICS will make them fat [
45], while only around 10% of parents in our study had the same opinion.
Comparing the data from the children’s medical records and two groups of parents (those who are afraid of using ICS and those who are not), we see those parents of male children older than five years, with comorbidities, and previous hospitalization due to asthma have a greater fear of using ICS. This same group of parents is more inclined to use complementary and alternative therapy with donkey milk, black seed oil, vitamin D, etc., which are perceived as safe alternatives to corticosteroid treatment. The same was noticed in the work of Lee et al. on parents of children with AD [
46]. In our study, unemployed parents without medical education were more afraid of using ICS. These results are in accordance with those reported by Bos et al., who stated that medically educated parents of AD children have significantly less fear of corticosteroid use [
47]. Fear of ICS usage is even stronger considering that parents are often warned about the side effects of corticosteroid use by social media, friends, family members, and medical professionals (pharmacists and physicians) [
42]. The impact of employment status on fear of using ICS is still not established, yet evidence from the literature suggests an important role of parents, especially mothers’ employment status, on general child health [
48]. Many children in this study were treated for asthma at the emergency room, and parents of those children showed an increased fear of using ICS. Parents who had not personally used corticosteroids had a greater fear of using topical or inhaled corticosteroids than oral ones. Perhaps the fear of corticosteroids is device-dependent and related to the route of administration [
13,
49].
To examine how well parents know their child’s illness, to what extent it affects their life, and how well they think they could control it, the B-IPQ questionnaire was used. The results of this study showed that the child’s illness affects the parents’ life, also emotionally, causing concern, anger, and helplessness; this is more than in adult asthmatic patients from the original Broadbent et al. study [
27]. Parents in this study were aware of the chronic character of the disease and believed that the illness will last for some time. They felt that they understood their child’s disease well, they were controlling it well, and believed that ICS therapy was helping their children. Parents who have a fear of using ICS perceive their child’s illness more seriously, are more worried about therapy, and react more emotionally to their child’s illness. Similar results can be found in the study of Conn et al. [
50], who reported that parents who rated their children’s asthma attacks as more severe have more concerns about therapy. Parents who feel that they have less control over their child’s illness and treatment want to terminate using ICS as soon as possible. They are reluctant to use a higher dose of ICS significantly more than other interrogated parents. Based on that, we must make an impact on parents’ confidence in treating child asthma, because less confident parents tend to reduce ICS dose and are more concerned about addiction and toxicity of ICS [
44]. The obtained results present parents believing that longer asthma duration will result in more side effects of ICS. That can be explained by the burden of “chronicity” and is similar to reports that parents better perceive short-term OCS therapy [
49].
Based on the mentioned beliefs and parents’ fear of using ICS, it is highly recommended to clearly explain the therapy plan to the parents, set short- and long-term goals, and duration of the therapy during asthma-related pediatric visits [
8]. This will result in better adherence and better child asthma control.
Comparing the results of the child’s illness control and the parent’s perception of the disease, we can conclude that asthma affects the lives of parents whose children have uncontrolled asthma the most. The same conclusion was presented in the research of Banjari et al. [
50]. Parents of children with controlled asthma better understand and they are less concerned about their child’s disease.