The relationships among family management behaviors and asthma morbidity in maternal caregivers of children with asthma.

552845 research-article2014

JFNXXX10.1177/1074840714552845Journal of Family NursingGibson-Young et al.

Article

The Relationships Among Family Management Behaviors and Asthma Morbidity in Maternal Caregivers of Children With Asthma

Journal of Family Nursing 2014, Vol. 20(4) 442–461 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1074840714552845 jfn.sagepub.com

Linda Gibson-Young, PhD, ARNP, CNE1, Anne Turner-Henson, DSN, RN, FAAN2, Lynn B. Gerald, PhD, MSPH3, David E. Vance, PhD, MGS2, and David Lozano, MD2

Abstract Numerous studies have identified the relationship of the family caregiver’s perception regarding asthma management and the child’s asthma outcomes, although few have examined family caregiver asthma management behaviors. The primary aim of this study was to examine the relationship among family management behaviors and asthma morbidity as perceived by maternal caregivers. The Family Management Style Framework was used to guide the research. Maternal caregivers (N = 101) with school-aged children diagnosed with persistent asthma and living in the United States were recruited from a specialty asthma clinic. When caregivers perceived they were expending much effort on their child’s asthma management and were not confident in 1University

of Central Florida, Orlando, FL, USA of Alabama at Birmingham, AL, USA 3University of Arizona, Tucson, AZ, USA 2University

Corresponding Author: Linda Gibson-Young, Assistant Professor and Nurse Practitioner Program Director, College of Nursing, University of Central Florida, 12201 Research Parkway, Suite 489, Orlando, FL 32826, USA. Email: [email protected]

Downloaded from jfn.sagepub.com at NORTHERN ARIZONA UNIVERSITY on May 29, 2015

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their ability to perform management activities, the child’s asthma outcomes were worse. This is the first study to examine family management behaviors with maternal caregivers of school-aged children with asthma. Findings from this study encourage health care providers to tailor each educational opportunity with families to improve child asthma outcomes. An ongoing effort must be made to include families in asthma management. Health care partnerships between provider and family can lead to improved asthma management. Keywords Family Management Style Framework, family management, asthma, childhood, outcomes More than 15% of children in the United States have a chronic health condition and because of the requirements of managing a chronic condition, families are greatly influenced and affected (Cohen et al., 2011). Families of children with chronic conditions often struggle with the daily requirements of the condition and most families are influenced by the condition each day (Knafl et al., 2013). Chronic conditions require administration of medications, symptom monitoring, and actions related to abnormal symptoms (Checton, Greene, Magsamen-Conrad, & Venetis, 2012; Sato et al., 2013). There is sufficient evidence of the problems that arise for families managing chronic conditions, but direction for family-based interventions is often lacking (Dalheim-England & Rydstrom, 2012). Approximately 10 million school-aged children (14% of all U.S. children) have been diagnosed with the chronic condition of asthma (Bloom, Cohen, & Freeman, 2012). Asthma is the most common chronic childhood condition, the largest public health burden for children, and has a significant impact on life for families (Akinbami, Moorman, & Liu, 2011; Dalheim-England, Rydstrom, Rasmussen, Moller, & Sandman, 2004; Everhart et al., 2014). Childhood asthma is associated with high rates of asthma morbidity, including frequent emergency department visits, hospitalizations, and school days missed significantly affecting families with costs and time (Centers for Disease Control and Prevention [CDC], 2011; Cloutier, Wakefield, Hall, & Bailit, 2002; Warman, Silver, & Stein, 2001). Everhart and colleagues (2014) addressed a clear need for families to balance life with childhood asthma management and other family needs. Because family-based interventions are often deficient with management of chronic conditions, this article will examine the perceptions of daily asthma management from the perspective of


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the maternal caregiver and will focus on the child-specific outcomes, such as emergency department visits, hospitalizations, and school days missed. Morawska, Stelzer, and Burgess (2008) examined the challenges parents of children with asthma face when managing the condition on a daily basis. Primarily, these researchers found that parents identified specific tasks associated with entrusting schools and caregivers, identifying symptoms, and avoiding triggers when the child is diagnosed with asthma. In particular, parents associated specific allergies and triggers with their child’s asthma and often tried to deter the child’s interaction with associated triggers. Families are even more affected by childhood asthma when limited by income and environments that are less than ideal for a child with respiratory conditions (Checton et al., 2012). Children with asthma are frequently affected by allergies that trigger asthma symptoms. It is often the caregiver who must respond when symptoms occur, and often, health care professionals strive to educate families about specific triggers affecting childhood asthma (Horner & Fouladi, 2003). Management of childhood asthma requires family caregivers to monitor daily for symptoms, administer medications, make home environmental modifications, coordinate health care visits, and purchase health supplies, as well as manage the child’s other day to day needs such as school and family activities (Butz et al., 2004; Everhart et al., 2014; Horner, 2004; Horner & Fouladi, 2003; McQuaid et al., 2006; Sato et al., 2013). McQuaid and colleagues (2006) evaluated 122 children diagnosed with asthma and found the family response to child asthma symptoms mediates the relationship between child symptom perception and child asthma morbidity outcomes. In this study, the family response was examined from the primary caregiver of the child with asthma and this was typically the mother (92%). This study reported an underestimation of symptoms by families of an asthmatic child and found family response mediated the child perception and ultimately the child’s outcomes. Another study by Sato and colleagues (2013) found the environment, including family structure and support, links directly with asthma outcomes. Consequently, if the family had ineffective responses to the child’s symptoms, then the child had worse asthma outcomes (McQuaid et al., 2006). This study used the Family Management Style Framework, which helps explain how families manage the care of children with chronic conditions (Knafl & Deatrick, 2003; Knafl et al., 2013). Knafl, Deatrick, and Gallo (2009) recognized family management behaviors are incorporated in daily requirements of the family (roles, responsibilities) with specific necessities for a child with a chronic condition. Two specific types of family management behaviors, known as condition management ability (ability) and condition management effort (effort), focus on the family’s response toward


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managing a chronic condition. The condition management ability focuses on parental perceptions regarding the family’s competency in managing the child’s condition, whereas the condition management effort focuses on the work required of the family when managing the chronic condition (Knafl et al., 2009; Knafl et al., 2013). The purpose of this study was to examine family management perceptions of ability and effort with asthma morbidity (emergency department visits, hospitalizations, and school days missed) from the maternal caregiver perspective.

Specific Aims The specific aims of this study included the following: (a) to examine the relationships between maternal caregiver perceptions of condition management ability and condition management effort with child, maternal caregiver, and family characteristics, and (b) to examine the relationship between maternal caregiver self-report of family management behaviors (ability, effort) and children’s emergency department visits, hospitalizations, and school days missed.

Method A cross-sectional design was used to describe the family management behaviors (ability, effort) reported by 101 maternal caregivers of children with asthma, ages 5 to 12 years, and to examine the relationship between family management behaviors and children’s asthma morbidity outcomes. The rationale for assessing the maternal caregiver was appropriate given that maternal caregivers are the primary caregivers of childhood chronic conditions (McQuaid et al., 2006). School-aged children are examined because the daily management is most often the responsibility of the primary caregiver. The predictor variables of the study were demographic factors (i.e., maternal caregiver work status, child age) and family management behaviors (ability, effort). The criterion variables were maternal self-report of the child’s asthma morbidity outcomes including emergency department visits, hospitalizations, and school days missed. For a medium effect size and alpha of .05, the suggested sample size was 91 with a power of .87. Also, by using test–retest, the demographic coefficients had Cronbach’s alpha of .73 and Family Management Measure (FaMM) coefficients indicating .84 to .94 reliability.

Sample and Setting A convenience sample of maternal caregivers of school-aged children with asthma was recruited from an interdisciplinary pediatric pulmonary clinic.


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Inclusion criteria for the sample included maternal caregivers of children who were (a) diagnosed with asthma for 1 year or more, (b) on preventive medication for persistent asthma, and (c) enrolled in kindergarten through sixth grade. Maternal caregivers for this study were defined as the female caregiver who acknowledged self as the primary responsible family caregiver for the child with asthma. Exclusion criteria included maternal caregivers who could not read and speak English or had a child with any comorbid conditions. Comorbid conditions (e.g., diabetes, hyperactivity disorders) were defined as a medical diagnosis of a chronic condition that may require daily responsibilities potentially affecting daily asthma care. Maternal caregivers with more than one child meeting inclusion criteria were asked to focus the responses on one particular child meeting the inclusion criteria. The setting for the study was a freestanding asthma care clinic in the Southeastern U.S. freestanding pediatric facilities. The clinics use an interdisciplinary model of care, with providers including physicians, nurse practitioners, social workers, nurses, nutritionists, and respiratory therapists. Approval to conduct the study was obtained from Institutional Review Board (IRB) of the researchers’ study institution. The researchers ensured Health Insurance Portability and Accountability Act (HIPAA) policies were adequately followed. The principal investigator reviewed research protocols with the maternal caregivers and gained informed consent. All data were collected fall 2009 through spring 2010.

Demographic Data Questionnaire A demographic data questionnaire was used to assess maternal caregiver selfreport of key demographic variables associated with the child diagnosed with asthma, the maternal caregiver, and the family of the child with asthma. The demographic data questionnaire was developed after exploration of the Family Background Questionnaire used in family studies (Morawska et al., 2008) and an extensive review of the literature focusing on family management with chronic childhood conditions. The principal investigator examined feasibility and adequate fourth-grade reading level for the demographic measure in a pilot test and by use of the Flesch Reading Ease instrument (Microsoft, 2007). Demographic data related to the child with asthma included the child’s current age, when diagnosed with asthma in years/months, school grade, gender, and minority status. For minority status, maternal caregivers were asked to categorize their child’s ethnicity as Caucasian, African American, Hispanic, or other. The status was then recoded as minority or non-minority. Demographic information regarding maternal caregivers included family


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role of maternal caregiver (mother, grandmother, or guardian) and work status (employed full-time, part-time, or no employment). Additional information obtained on family characteristics included type of insurance information (private, public, or no insurance) and family structure (single parent, nuclear, or blended). Asthma morbidity outcomes were self-reported by maternal caregivers. Maternal caregivers reported the number of emergency department visits, hospitalizations, and school days missed for the child in the previous school year (2009-2010) due to asthma.

FaMM The FaMM was designed to assess the family’s perception of management behaviors with chronic childhood conditions (Knafl & Deatrick, 2003). This measure, consisting of 6 subscales (a total of 53 items), is an overall measure of family caregiver self-report of chronic condition management behaviors, including the child’s daily life, condition management ability, condition management effort, family life difficulty, view of condition impact, and parental mutuality. The FaMM has undergone extensive validation and has been evaluated and compared with several chronic conditions, test/retest, and three established family measures (Knafl et al., 2011). Understanding the family perceptions and responses offers a greater interpretation of a child’s outcomes when managing chronic conditions (Knafl et al., 2013). Two particular subscales of the FaMM were chosen for this study including the condition management ability (ability) and condition management effort (effort) subscales. These subscales were selected because the items focus on the perception of management ability and how much effort is required with chronic conditions, particularly of interest to maternal caregivers when managing childhood chronic conditions. Condition management ability is measured using 12 items (possible score range = 12-60) with higher responses indicating the chronic condition is viewed as more manageable. This subscale measures the maternal caregiver’s perception of the overall management of the child’s condition and addresses knowledge, ability, and competency to manage the child’s condition. It also identifies how the family caregiver views the child’s chronic condition as manageable now and into the future (Knafl & Deatrick, 2006). Condition management effort is evaluated using four items (possible score ranges = 4-20) with higher responses indicating greater time and work involved with managing the chronic condition. This subscale of the FaMM measures the maternal caregiver’s perception of time and work required to manage the child’s condition (Knafl & Deatrick, 2006).


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Data Analysis Data were analyzed using SPSS 18.0 software. The level of significance was set at an alpha of .05. Frequency analysis was used to describe the sample and evaluate demographics. A correlation table was created to evaluate relationships with predictor variables (ability and effort) with criterion variables (emergency department visits, hospitalizations, and school days missed). Variables appearing to have a correlation (α ≤ .10) with ability and effort were identified from the correlation table and used in step-wise multiple regressions. These step-wise multiple regression methods were then used to identify predictor variables that may predict asthma morbidity (emergency department visits, hospitalizations, and school days missed).

Results Demographics Descriptive characteristics of the sample are reviewed in Table 1. The children in this sample (N = 101) had a mean age of 8.9 years with a range of 5 to 12 years. The mean age at which children were diagnosed with asthma was 36.62 months (3 years of age). Children were 53% male and 66% minority. Mothers made up the majority of maternal caregivers (94%) and most worked outside the home (57%). Single-parent families accounted for the largest proportion (47%) of families, followed by the nuclear family (37%), and then the blended family (16%). The highest percentage of income for the sample participants was US$10,000 to US$50,000 per year. No child was identified as lacking insurance, and the majority had public insurance (96%). With a sample size of 101, the observed power is .845.

Family Management FaMM ability subscale scores ranged from 12 to 60 with a mean of 32.4 (SD = 5.8) and the effort subscale scores ranged from 4 to 20 with a mean of 13.0 (SD = 3.7). Table 2 provides the self-reported asthma morbidity variables: emergency department visits, hospitalizations, and school days missed. Table 3 provides correlational findings of the study variables, including the relationship between the two subscales, ability and effort. When examined no significant correlation was identified (r = −.08, p = .44), thus distinguishing ability and effort as two different constructs. However, significant findings were found among the predictor and criterion variables. Effort positively correlated with school days missed (r = .26, p = .01) whereas ability negatively correlated with hospitalizations (r = −.21, p = .04).


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Gibson-Young et al. Table 1. Demographic Characteristics of the Sample (N = 101). Variable Age at data collection (years) 5 6 7 8 9 10 11 12 Child’s school grade Kindergarten 1st 2nd 3rd 4th 5th 6th Child’s minority status Minority Non-minority Child’s gender Male Female Maternal work status Full-time Part-time No work outside home Family Structure Single parent Nuclear Blended

n

%

17 11 6 15 15 17 14 6

16.8 10.9 5.9 14.9 14.9 16.8 13.9 5.9

16 10 8 20 9 20 18

15.8 9.9 7.9 19.8 8.9 19.8 17.8

67 34

66.3 33.7

54 47

53.5 46.5

41 17 43

40.6 16.8 42.6

47 37 16

46.5 36.6 15.8

The child minority status (N = 101; 0 = non-minority, 1 = minority) positively correlated with effort (r = .30, p = .00), emergency department visits (r = .33, p = .00), and hospitalizations (r = .25, p = .01); if the child was of minority status, then maternal caregivers reported greater perceived effort, more emergency department visits, and more hospitalizations. The child’s minority status negatively correlated with ability (r = −.36, p = .00); less perceived ability was noted by minority maternal caregivers.


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Table 2. Descriptive Statistics of Independent Variables. Variable

%

Ability (possible range 12-60) Effort (possible range 4-20) Emergency Department Visit 0 1-2 3-5 6-10 >10 Hospitalizations 0 1-2 3-5 >5 School days missed 0 1-5 6-10 11-15 >15

Range

M (SD)

12-60 4-20 0-30

32.4 (5.77) 13.0 (3.69)

38.8 29.8 20.8 7.9 2.9 0-14 72.3 19.8 2.9 4.9 0-84 12.9 31.7 18.8 13.9 19.8

Note. Due to rounding, percentages may not total 100.

The child’s gender (0 = male, 1 = female) negatively correlated with emergency department use (r = −.25, p = .03). Maternal caregivers of male children in this study were more likely to report increased emergency department visits for asthma. The maternal caregiver work status (employed full-time, part-time, or no employment) positively correlated with emergency department visits (r = .24, p = .02). When the maternal caregiver was employed (full-time or parttime), more emergency department visits were reported. Family income was positively correlated with ability (r = .32, p = .00), indicating a greater perception of the ability to manage asthma with higher family income. However, family income was negatively correlated with effort (r = −.20, p = .04), school days missed (r = −.24, p = .02), and hospitalizations (r = −.23, p = .02); lower family incomes were associated with greater perceived effort, more school days missed, and more hospitalizations. In addition, there was a strong correlation between maternal work status, minority status (r = .31, p < .001), and income (r = −.44, p < .001).


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Gibson-Young et al. Table 3. Correlation Matrix of the Study Variables. Variable

Grade

Minority status

Grade Minority status Child’s gender Work Income ED Hospitalization SDM Effort Ability

— .31** .07 .03 −.11 .01 −.07 −.10 .05 −.14

— .04 .36** −.44** .33** .25* .20 .30** −.36**

Child’s gender

— −.15 .18 −.25* −.09 −.11 .04 −.01

Work

— −.50** .24* .19 .17 .19 −.16

Income

ED

— −.18 — −.30* .15 −.24* .58** −.20* .17 .32** −.09

Hospitalization

— .07 .00 −.21*

SDM

Effort

— .26** .04

— −.08

Note. N = 101 for all correlations. ED = emergency department visits; SDM = School days missed. *p ≤ .05. **p ≤ .01.

More than one emergency department visit during the past year was reported by 61.2% of the sample. The range for emergency department visits was 0 to 30 visits in the previous year, with 30% of maternal caregivers reporting children had greater than three emergency department visits. Seventy-two percent of the children (n = 73) did not require a hospitalization for asthma during the previous school year. The average number of hospitalizations for this sample was 0.52 (range = 0-14). Maternal caregivers reported children missing an average of 6.5 school days per school year. The range was 0 to 84 school days missed with 19.8% noting more than 15 days in the previous year (see Table 1). Step-wise multiple regression methods were used to identify predictor variables that may predict asthma morbidity outcomes. In each step-wise regression analysis, condition management ability and condition management effort were entered in the first step, child’s age at diagnosis in the second step, and demographic control variables in the third step. To minimize degrees of freedom and maximize power with predictive statistics, only predictor variables with significant correlations between variables (p < .10) on the initial correlation chart were included in the regression analyses. Demographic control variables were defined by using the correlation chart to recognize p values less than .10; all variables with p greater than or equal to .10 were removed from the model. The control variables for the regression analyses included minority status, family income, maternal work status, child’s grade, and child’s gender. Step-wise regression analysis was used to identify whether ability and effort were predictors of emergency department visits, and neither were predictive. Yet, when control variables were utilized, minority status and child’s gender were predictive of emergency department


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Table 4. Step-Wise Regression Analysis Predicting Hospitalizations. Variable Constant Minority Status Family Income Age Dx Effort Ability

Model 1

p value

−0.97 1.09 −0.15 0.04 −0.08 −0.13

.19 .01 .17 .69 .44 .20

Table 5. Step-Wise Regression Analysis Predicting School Days Missed From Family Management Behavior Perceptions: Ability and Effort. Variable Constant Minority Status Family Income Work Status Age Dx Effort Ability

Model 1

Model 2

p value

17.67 0.12 −3.62 0.07 −.16 0.22 0.14

5.88 0.06 −2.98 0.05 −.13 0.82 0.14

.33 .57 .05 .67 .21 .03 .17

visits. In relation to hospitalizations, step-wise regression did identify ability as a significant predictor of hospitalizations; and when controlling for ability, effort, and child’s age at diagnosis, family income and minority status were also predictive of hospitalizations (see Table 4). Furthermore, effort was identified as a significant predictor of school days missed (see Table 5).

Discussion The findings of this study confirm and extend results from other studies of maternal caregivers who have school-aged children diagnosed with asthma. This study found that children of minority status were more likely to be hospitalized and had significantly higher emergency department visits. Previous studies have reported relationships between demographic characteristics (such as minority status, child’s gender, work status, and family income) and child asthma morbidity including emergency department visits, hospitalizations, and school days missed (Butz et al., 2004; Horner, 2004; Suglia, Duarte, Sandel, & Wright, 2010; Ungar et al., 2011). A new finding focused on the


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self-reported number of emergency department visits with male asthma children. Lara et al. (2003) found higher prevalence of males in the emergency department visits, and this study found maternal caregivers of male children with asthma reporting higher numbers of annual visits for asthma. This result should be examined further. Furthermore, a negative relationship was identified between family income and asthma morbidity outcomes. Often, lower income families struggle with balancing resource needs, such as purchasing daily preventative medications or transportation to scheduled acute care visits, thus potentially leading to poorer asthma outcomes (Horner, 2004; Kruse, Deshpande, & Vezina, 2007). Previous research has also indicated that lower income families have a greater need for education with regard to asthma (Horner, 2004; Horner & Fouladi, 2003; Velsor-Friedrich, Pigott, & Louloudes, 2004). Maternal caregivers working outside the home (part-time or full-time) were more likely to have children with increased emergency room visits and poor asthma control, findings not previously reported in the literature. On a daily basis, maternal caregivers balance chronic conditions and family demands; however, working maternal caregivers must further shift their roles when balancing parental time and medical treatments (Knafl & Deatrick, 2006). Working maternal caregivers may have a difficult time balancing these roles as they attempt to adequately manage treatment of childhood asthma (Horner, 2004; Yoos, Kitzman, McMullen, & Sidora, 2003). More research is required with working caregivers with family-based interventions needed for educating these working caregivers. Overall, high rates of asthma morbidity were reported for the study sample, and thus reflect the patient population that is generally found in pediatric pulmonary clinics (Butz et al., 2004; Gerald et al., 2009). Families of children with asthma frequently utilize the emergency room for various minor symptoms of asthma (e.g., cough, wheeze; Lara et al., 2003). High rates of emergency department use frequently cited in the literature continue to demonstrate the critical health disparities in asthma and suggest the need for further research related to use of emergency department versus primary care clinics (Lara et al., 2003; McQuaid et al., 2006). In school-aged populations, asthma morbidity greatly affects children by emergency department visits, hospitalizations, and school days missed (Akinbami et al., 2011; Horner, 2004). Regression analysis indicated effort was a significant predictor of school days missed. Children with a chronic condition miss 3 times more school days than a child without a chronic condition (Lara et al., 2003). Ability negatively correlated with hospitalizations; that is, the lower the maternal perception of ability to manage the child’s asthma, the greater the number of hospitalizations. After examining maternal


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caregiver perceptions of family management with chronic conditions and assessing the relationship with child-specific outcomes, it is clear that health care providers must include the family in the education and treatment of the chronic condition. It is well documented that children of minority status have increased prevalence of asthma (Lara et al., 2003; Velsor-Friedrich et al., 2004). This study is limited by grouping ethnicity into minority and non-minority, and must be re-examined with categorical information with a larger sample size. In addition, it is evident that family demographics must be further assessed when seeking to answer questions associated with family management (DalheimEngland & Rydstrom, 2012; Dalheim-England et al., 2004). Substantial research has reported that maternal caregivers of minority children often perceive asthma as requiring increased time and work (Butz et al., 2004; Horner, 2004; Lara et al., 2003; Sterling & Peterson, 2003). In this study, there was a positive association between minority status and effort indicating that if the child was of minority status, maternal caregivers reported more time and work required in the daily management of the child’s asthma. More research is required in relation to home management of chronic conditions and caregivers must be involved when examining school-aged children. Interventions are required for caregivers managing asthma in the home setting and a focus must involve decreasing time and work involved with daily management. A negative correlation was found between children’s minority status and maternal caregiver report of ability. To enhance, if the child was of minority status, the maternal caregiver reported lower perceived ability to manage the child’s asthma condition. Ability focuses on the confidence in managing a child’s asthma. When minority caregivers report low confidence, health care providers must investigate ways to increase caregiver confidence in management. One example is to examine how the child asthma management plans or asthma action plans could be adjusted to meet the needs of the family. Based on the maternal caregiver’s perceived ability, health care providers could intercede with family management interventions in the home setting to help families better manage asthma (Horner & Fouladi, 2003). Moreover, Morawska and colleagues (2008) recognized that family home asthma management is the key toward reducing asthma morbidity as it associated varieties of parenting styles with child asthma outcomes. Morawska et al. (2008) identified that in families of children with more than one child with asthma, parenting styles may differ according to previous experience. Everhart et al. (2014) found caregivers with certain ethnicities had more difficulty balancing childhood asthma with other tasks and family responsibilities. The current study did not assess prior experience, which may limit findings. Further research is required to examine potential influences of


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ability and effort within families, while further exploring minority caregiver perceptions. Another option to increase this ability is to implement tailored approaches with specific family interventions in the home setting with minority caregivers to improve child asthma outcomes.

Implications for Practice The FaMM (Knafl & Deatrick, 2006) is a novel tool designed for measuring family measurement behaviors in maternal caregivers of children with chronic conditions. By utilizing the FaMM, researchers examined the relationships among the perceptions of family management behaviors (ability, effort) with asthma morbidity outcomes in maternal caregivers of schoolaged children diagnosed with persistent asthma. This incorporation improved exploration of family management with a chronic childhood condition of asthma. Providers must move toward interventions with families to improve the perceived ability and effort when managing chronic conditions. Specifically, it is imperative to intervene with an individual focus on the family. The FaMM score for perceived ability or effort could be the outcome variable with the intervention. Second, this understanding can guide researchers in advancing interventions for families affected by a chronic condition. Health care providers should consider interventions that recognize and encourage family responses and praise families in learning effort. Standard health education (knowledge, skill demonstrations) may not address caregiver ability (confidence) in chronic condition management. Although this study did not address the caregiver education, further information is warranted as to what education families have with asthma management and what is lacking. Families vary and not all families communicate with the same abilities (Dalheim-England & Rydstrom, 2012; Gonzalez et al., 2012). Education and actual knowledge of asthma may influence caregiver perceptions of ability and effort. This sample did not examine educational level or available hours to manage the chronic condition, both of which may influence family management. Providers must begin to take demographic characteristics into effect when creating a home asthma management plan. Other caregiver interventions, such as problem solving or ways to improve caregiver confidence should be examined to adequately prepare maternal caregivers for asthma management. Encouraging maternal caregivers to communicate goals for asthma management and identifying how management occurs in the home setting must be included. Furthermore, health care providers must regularly provide asthma education and resources for families


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of children with asthma at every visit, and essentially must recognize family responses and praise families when effort is observed. The maternal caregiver’s perception of the effort it takes to manage asthma and the perception of their ability to manage asthma are related to poorer asthma outcomes. When perceived effort is higher, health care providers must begin to work more closely with these caregivers to assess the causes of these perceptions. Time must focus on the specific needs within families to lessen the perceived effort and improve family-based care. Likewise, when condition management ability is perceived to be lower, health care providers may promote educational interventions to improve the ability of maternal caregivers to manage the child’s asthma.

Conclusion In conclusion, this is the first study to examine family management behaviors with maternal caregivers of school-aged children with asthma. Because maternal caregiver perception of increased effort (time and work) was found to be associated with children’s poor asthma outcomes, it is essential for health care providers to address asthma needs and work to reduce required time when managing this condition. Further research is needed to examine current education and children’s asthma management plans, to determine whether management complexity, time, or work to implement plans places increased burdens or stress on maternal caregivers. Additional research can incorporate specific interventions to improve time and work efficiency for maternal caregivers of children with asthma. This study demonstrated that health care providers must utilize each opportunity with families of childhood asthma to examine family management behaviors to improve asthma outcomes. The FaMM proved to be a valuable measure when assessing maternal caregivers of children with asthma. In particular, the FaMM concepts of effort and ability, along with other components of the framework, are helpful in designing interventions to improve asthma outcomes. As with effort, ability may be related to maternal caregiver knowledge. Future studies are needed to examine whether maternal caregiver perception of ability is related to asthma management knowledge. Health care researchers should examine how perception of ability may be related to actual knowledge or stressors in families with children diagnosed with asthma. In addition, health care providers must recognize how perception of ability may be related to actual knowledge or competence in families with children diagnosed with asthma, or whether knowledge and actions are measured in a different way.


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The findings from this study offer insights into maternal caregiver perception with childhood conditions and questions whether the current practice of education is enough for families. Standard health education, that is providing traditional classes on disease processes, symptoms, risk factors, environmental modifications, and technical skills in medication administration alone may not be effective. It is imperative for health care providers to recognize family responses and praise families to encourage the learning effort. Acknowledgment I thank my dissertation team for the guidance and dedication to my education.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Linda Gibson-Young, PhD, ARNP, is an assistant professor in the College of Nursing, University of Central Florida. She has 15 years of experience working with pediatric pulmonary patients, and a priority focus of her practice has been family management of childhood asthma. As a nurse, nurse educator, and family nurse practitioner, she has


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worked with countless families managing childhood asthma within the home setting. Her overall goal for research is to increase family management and decrease child asthma morbidity. Her recent publications include “Are Students With Asthma at Increased Risk for Being a Victim of Bullying in School or Cyberspace? Findings From the 2011 Florida Youth Risk Behavior Survey” in Journal of School Health (2014, with M. P. Martinasek, M. O. Clutter, & J. Forrest), “Peak Flow Measurements in Children With Asthma: What Happens at School?” in Journal of Asthma (2009, with R. Grad, J. Mangan, L. McClure, & L. Gerald), and “Increasing Adherence to Inhaled Steroids Among School Children: Effectiveness of a School Based Supervised Asthma Therapy Program” in Pediatrics (2009, with L. Gerald, L. A. McClure, J. M. Mangan, K. F. Harrington, S. Erwin, A. Atchison, & R. Grad). Anne Turner-Henson, DSN, RN, FAAN, is a professor, University of Alabama at Birmingham School of Nursing, and holds joint faculty appointments in the Schools of Medicine (General Pediatrics and Adolescent Medicine) and Public Health (Maternal Child Health). Her research program focuses on children’s health, from the perspective of respiratory health (specialty focus on secondhand smoke exposure, asthma, and parental caregiving) and environmental health concerns. Empowering communities through building grassroots initiatives to reduce children’s environmental risk and promote healthy communities is a key focus of her work. Her recent publications include “Position Statement on Tobacco Exposures in Children and Families [Society of Pediatric Nurses]” in Journal of Pediatric Nursing (in press), “Stress and Inflammation: A Biobehavioral Approach for Nursing Research” in Western Journal of Nursing Research (2010, with D. H. Kang, M. Rice, N. J. Park, & C. Downs), “Back to the Future: H1N1 and Public Health” in Journal of Pediatric Nursing (2010, with J. Vessey). Lynn B. Gerald, PhD, MSPH, is the associate dean for research, Canyon Ranch Endowed Chair and professor in the Health Promotion Sciences Division, College of Public Health, at the University of Arizona and a member of the Arizona Respiratory Center. She is a nationally known expert in the area of asthma and community based clinical trials. She also has extensive experience in the areas of clinical, behavioral, and epidemiological research in respiratory medicine. Her recent publications include “Validation and Psychometric Properties of the Asthma Control Questionnaire Among Children” in Journal of Allergy and Clinical Immunology (2014, with J. M. Nguyen, J. T. Holbrook, C. Y. Wei, W. G. Teague, & R. A. Wise), “Sex Differences in Asthma Symptom Profiles and Control in the American Lung Association Asthma Clinical Research Centers” in Respiratory Medicine (2013, with J. W. McCallister, J. T. Holbrook, C. Y. Wei, J. P. Parsons, C. G. Benninger, A. E. Dixon, & J. G. Mastronarde), and “Parent Report and Electronic Medical Record Agreement on Asthma Education Provided and Children’s Tobacco Smoke Exposure” in Journal of Asthma (2013, K. F. Harrington, K. M. Haven, V. L. Nuño, T. Magruder, & W. C. Bailey). David E. Vance, PhD, MGS, is an associate professor in the School of Nursing at the University of Alabama at Birmingham. He has published in a variety of areas including structural equation modeling, cognitive aging, successful aging, aging with HIV, and the neuropsychology of HIV. He is currently funded to study transcranial direct


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current stimulation to improve cognitive functioning in normal community-dwelling older adults. Her recent publications include “Speed of Processing Training With Middle-Aged and Older Adults With HIV: A Pilot Study” in Journal of the Association of Nurses in AIDS Care (2012, with P. L. Fazeli, L. Ross, V. G. Wadley, & K. K. Ball), “Sleep and Cognition on Everyday Functioning in Older Adults: Implications for Nursing Practice and Research” in Journal of Neuroscience Nursing (2011, with K. Heaton, Y. Eaves, & P. L. Fazeli), and “Aging With HIV: A Cross-Sectional Study of Co-Morbidity Prevalence and Clinical Characteristics Across Decades of Life” in Journal of the Association of Nurses in AIDS Care (2011, with M. Mugavero, J. Willig, J. L. Raper, & M. Saag). David Lozano, MD, is a pediatric, pulmonary physician at the University of Alabama in Birmingham and practices at Children’s of Alabama. Dr. Lozano specializes in Pediatric Sleep Medicine, Asthma, home ventilator patients, and neuromuscular disease.


The influence of caregivers' knowledge and understanding of asthma aetiology on domiciliary management of children with asthma.

Disparities in Asthma Care, Management, and Education Among Children With Asthma.

Association of FEF25%-75% and bronchodilator reversibility with asthma control and asthma morbidity in inner-city children with asthma.

Asthma mortality and morbidity.

Prenatal Maternal Stress and the Risk of Asthma in Children.

Family Functioning, Eosinophil Activity, and Symptoms in Children With Asthma.

Structural and Functional Support in the Prediction of Smoking Cessation in Caregivers of Children with Asthma.

Maternal socioeconomic status and the risk of asthma among offspring.

Management of asthma in pre-school children.

Effects of socioeconomic status on maternal and child positive behaviors in daily life among youth with asthma.

Morbidity due to asthma.

Mexican-American caregivers' perceptions about asthma management: a photovoice study.

Systematic Review and Meta-Analysis of Anxious and Depressive Symptoms in Caregivers of Children With Asthma.

Age at asthma onset and asthma self-management education among adults in the United States.

Changing Trends in Asthma Prevalence Among Children.

Home renovation, family history of atopy, and respiratory symptoms and asthma among children living in China.

Factors impacting the mental health of the caregivers of children with asthma in china: effects of family socioeconomic status, symptoms control, proneness to shame, and family functioning.

Global burden of asthma among children.

Acculturation and quality of life in urban, African American caregivers of children with asthma.

The relationships among sleep efficiency, pulmonary functions, and quality of life in patients with asthma.

The Stress of Caring for Children With Asthma: A Qualitative Study of Primary Caregivers.

Reducing Racial Disparities in Influenza Vaccination Among Children With Asthma.

Correlates of asthma morbidity in primary care.

Asthma characteristics among older adults: using the California health interview survey to examine asthma incidence, morbidity and ethnic differences.