PRIMARY CARE MANAGEMENT OF CHILDHOOD ASTHMA: ADDRESSING
CAREGIVER QUALITY OF LIFE USING ASTHMA ACTION PLANS WITH
PRESCHOOL-AGED CHILDREN
by
Megan Ireland
BScN (Honours), University of Victoria, 2009

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE IN NURSING – FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August 2016
© Megan Ireland, 2016

ii

Abstract
As the leading chronic disease in children both worldwide and in Canada, the care and management
of paediatric asthma requires a significant amount of attention within health care delivery and research.
While these efforts have typically been directed at the affected children themselves, or at improving the
economic burden of this disease, there is substantial literature describing the effects childhood asthma
can have on caregivers and their overall quality of life (QOL). Because of the high level of caregiver
dependency among young children, such as preschoolers, it is clear that this effect is amplified with
asthma in this age group. Current guidelines stress the use of asthma action plans (AAPs) to improve
asthma outcomes in children, however there are few studies describing whether these tools may effect
caregiver QOL. The purpose of this project is to evaluate whether AAPs used in the primary care setting
can contribute to improved QOL in caregivers of preschool-aged children with asthma. Using an
integrative literature review approach, I conducted a thorough analysis of the literature on asthma in
preschoolers, the caregiver experience of childhood asthma, the primary care management of childhood
asthma, and the use of AAPs in paediatric asthma. The information obtained validates the hypothesis
that AAPs are valuable tools for promoting caregiver QOL in preschool-aged asthma. I close this paper by
reviewing recommendations for implementing AAPs and other interventions aimed at caregiver QOL,
along with suggestions for future research on this important topic.

iii

TABLE OF CONTENTS
Abstract

ii

Table of Contents

iii

List of Tables

v

List of Figures

vi

Acknowledgement

vii

Dedication

viii

Chapter One

Introduction

Chapter Two

Background and Context
4
Asthma in Preschoolers: Presentation, Pathophysiology, and Diagnostic
Criteria
5
7
The Caregiver Experience
Quality of Life and Primary Care Management
8
Asthma Action Plans
10

Chapter Three

Methods
Search Strategy and Preliminary Search
Focused Search
Analysis

12
12
14
16

Chapter Four

Findings
The Caregiver Context of Disease: Factors Influencing QOL
Caregiver-Provider Communication
Management Strategies to Promote Caregiver QOL.

18
18
22
24

Chapter Five

Discussion
Recommendations for Clinical Practice
Addressing factors influencing QOL
Addressing caregiver-provider communication concerns
Use of AAPs to promote improved caregiver QOL
Implications for Nurse Practitioner Practice
Limitations and Recommendations for Future Research

27
27
28
30
31
38
39

Chapter Six

Conclusion

41

References
Appendix A

1

43
Boolean Search Combinations

47

iv

Appendix B

PACQLQ

48

Appendix C

Literature Review Matrix

51

Appendix D

Asthma Action Plan Example

65

v

List of Tables
Table 1: Search Terms

13

Table 2: Inclusion and Exclusion Criteria

15

Table 3: Key Recommendations for Clinical Practice

37

vi

List of Figures
Figure 1: Search Strategy and Detailed Results

16

vii

Acknowledgement
My sincerest appreciation goes to my advisory committee members, Linda Van Pelt, MScN,
NP-F, and Amy Klepetar, BA, BScN, MScPH. Thank you both for the dedication and support
you have provided throughout this process, despite juggling many other commitments in your
lives. Your feedback and encouragement has played a major role in keeping me on track and
pushing me to complete this project within the aimed timeline.

viii

Dedication
This project is dedicated to the many people who have provided support and encouragement
as I have worked towards completion of this degree. First and foremost, to Rob, whose
unwavering support, love, and humour have kept me standing over the last two years. To my
family and friends, my own personal cheer section since day one, for your constant confidence in
me, and for being so understanding of my absence while I pursue this goal. Particularly, to my
incredible parents, whose hard work and unconditional love have provided me the opportunities
to get where I am today. To the UNBC faculty, and to my clinical preceptors Amber Reynolds,
Chantel Canessa, Dr. Clair Biglow, Rosemary Cashman, Natalie Manhard, and Colleen Regehr
for providing me with exceptional learning environments. And finally, to my classmates, who I
cannot thank enough for the laughs, the tears, and the friendship through these last few years.

1

Chapter One
Introduction
Asthma is a highly prevalent chronic disease experienced by people of all demographics
worldwide. It is estimated that 235 million people in the world have asthma, causing significant
burden on individuals, families, and health systems, and making it one of the most common noncommunicable diseases (World Health Organization, 2013). While childhood asthma is not a
different disease than asthma in adults, it presents unique challenges both physiologically and in
terms of approach to management. Most notably, as with any paediatric illness, the presence and
involvement of the family may be exaggerated from that of an adult.
In my practice as an acute care paediatric registered nurse, I have seen first-hand the
negative impact acute asthma exacerbations have on families—and particularly the caregivers—
of children with asthma. I can recall many caregivers describing significant emotional stress as a
result of their child’s health concerns. As I move into a role based in primary care, this
observation has led me to consider whether this impact on emotional well-being is situational
and limited to hospitalizations and acute exacerbations, or whether it transfers to the everyday
life of having a child with asthma.
Most individuals with asthma are treated in the primary care setting. A study by the
American College of Allergy, Asthma & Immunology (2015) found that 64% of study
participants with asthma were being treated by a primary care provider. As most nurse
practitioners in BC work in primary care, it can be assumed that many have some level of
involvement in the management of asthma in children. As such, I believe that primary care
providers, including nurse practitioners, are in a position to address the concerns of stress and
well-being in the caregivers of children with asthma.

2

My preliminary literature search for this project aimed at gathering information on the
caregiver experience of having a child with asthma, reviewing current primary care management
strategies and guidelines, and identifying barriers to care. From this initial review, I found that
concerns regarding the well-being of caregivers extend well beyond the context of acute
exacerbations and hospitalizations; effect on overall caregiver quality of life (QOL) is a welldocumented problem in paediatric asthma, particularly with younger children such as
preschoolers. Also standing out in this initial review, was the literature supporting the use of
asthma action plans (AAPs) to improve asthma outcomes. Thus, I developed the following
question to guide my research: “Can nurse practitioners, as primary care providers, use asthma
action plans to improve the quality of life in the caregivers of preschool-aged children with
asthma?” For the purpose of this paper, I will define “preschool-aged” as children between the
ages of one and five, based on the ages designated by the Canadian Thoracic Society (CTS)
guideline (Lougheed et al., 2012).
I hypothesize that the use of AAPs in this context would contribute to improved quality of
life in caregivers. In this paper, I aim to link together current literature available on caregiver
QOL, asthma in preschoolers, the primary care/NP role in asthma care, and the use of asthma
action plans in order to evaluate this hypothesis and further explore this topic. I will carry this
out using an integrative literature review format.
Chapter Two of this paper addresses the background and context relevant to the topic by
breaking down the research question into each of its elements. This includes further exploration
of childhood asthma, the caregiver experience of having a child with asthma, current
considerations for caregiver QOL in the primary care management of asthma, and the use of
asthma action plans in the management of childhood asthma. Chapter three outlines the approach

3

to this project, describing the literature review methods. Chapter four provides the findings from
the critical analysis and evidence synthesis of the literature. This section identifies themes found
to address the research question. Finally, chapter five provides a discussion of the findings,
including implications and recommendations for the primary care management of childhood
asthma.

4

Chapter Two
Background and Context
Beyond being a major chronic disease across all demographics worldwide, asthma is the
most common chronic disease in children, affecting 14% of children globally (Global Asthma
Network, 2014), and 10% of children ages 2 to 7 in Canada (Statistics Canada, 2010). With
prevalence this high, it is perhaps not surprising that major implications are seen in terms of
supporting the care of this disease. In Canada, asthma is the leading cause of hospitalization in
children (Ortiz-Alvarez & Mikrogianakis, 2012), and is estimated to cost over 1 billion dollars
annually in combined direct and indirect expenses (Asthma Society of Canada, 2014).
Consequently, research and major task forces are often focused on end-point results of
decreasing this economic burden. Thus, asthma in children continues to be well-researched in
terms of etiology, effective management, and treatment to decrease exacerbations and
hospitalization. However, the reality for those dealing with this disease, and those involved in its
management, stretch beyond the biomedical and economical concerns that arise. The medical
burden, along with the psychological and emotional impact of asthma have substantial effects on
quality of life (QOL) for both children with asthma and their families (Carpenter et al., 2013).
As asthma is so common, it may be assumed that many primary care practitioners will be
involved in the management of this disease. Practitioners involved in the management of asthma
have a big task at hand; not only can these providers have an effect on the symptomatic
management of the disease, but can also contribute to improving the quality of life in these
children and their families.

5

Asthma in Preschoolers: Presentation, Pathophysiology, and Diagnostic Criteria
Asthma is a chronic respiratory disease characterized by airway hypersensitivity,
intermittent or persistent airway inflammation, and resultant airflow limitations (Chesnutt &
Prendergast, 2015). It is associated with variable degrees of dyspnea, wheezing, cough, chest
tightness, and sputum production, from a variety of both endogenous and exogenous factors
(Lougheed et al., 2012). With over 100 genes identified as playing a role in asthma risk and
development, the disease is often familial in nature, but may also be influenced by allergen
exposure, urban residence, air pollution exposure, exposure to tobacco smoke, recurrent
respiratory infections, esophageal reflux, and obesity (Brashers & Huether, 2014a). The
pathophysiology of what occurs during an acute asthma response relates to an immune
hyperresponse to an antigen (i.e. an allergen). The antigen binds with IgE to mast cells, leading
to mast cell degranulation and the release of inflammatory mediators, such as histamine. These
mediators induce bronchospasm, airway edema, and mucus secretion from goblet cells. In
addition, the activation of eosinophils produces proteins that contribute to damaging the
respiratory epithelium, leading to further inflammation (Brashers & Huether, 2014a).
Though it affects individuals of all ages, asthma is highly prevalent in children, with highest
incidence occurring during preschool age (1-5 years old) (Ducharme et al., 2015). Consequently,
asthma is often viewed predominantly as a childhood disease. The pathophysiology of asthma in
children is similar to that of an adult, however young children often present with more severe
symptoms, and can deteriorate more quickly due to the smaller diameter of their airways, which
puts them at a higher risk for obstruction (Brashers & Huether, 2014b).
Diagnostic criteria for asthma involves assessment of clinical presentation and spirometry,
response to treatment, and consideration of risk factors. In preschoolers however, diagnosis can

6

be particularly challenging due to other respiratory conditions that may mimic asthma, such as
recurrent bronchiolitis or croup, and the difficulty in obtaining spirometry. This often leads to a
vague diagnosis, and inconsistent treatment of symptoms (Ducharme et al., 2015). The Canadian
Thoracic Society (CTS) has therefore developed operational criteria for diagnosing asthma in
this age group, with the aim of clarifying diagnoses, and guiding early treatment of symptoms
(Ducharme et al.). The CTS operational diagnostic criteria for asthma in children 1 to 5 years of
age requires:


Either recurrent asthma-like symptoms or exacerbations, and



Documented airflow obstruction, with wheeze being the most specific symptom, and



Documented reversible airflow obstruction with short acting-beta agonist and/or oral
corticosteroid, and



No evidence of alternative diagnosis



Heightened suspicion if personal atopy is present or with family history of asthma
(though not required for diagnosis)

Asthma severity is generally categorized into four classes: intermittent, mild persistent,
moderate persistent, and severe persistent. Current CTS Guidelines (Ducharme et al.) assume
this classification for preschool children as well, while acknowledging that this age group
experiences high individual variability in severity.
Treatment for asthma in preschool-aged children is primarily based on symptoms and
severity and includes both pharmacological and non-pharmacological approaches.
Pharmacological interventions generally begin with as-needed doses of an inhaled short-acting
ß2-agonist for intermittent symptoms, with the addition of an inhaled corticosteroid taken daily at
the lowest effective dose for persistent symptoms (Ducharme et al., 2015). Recommended non-

7

pharmacological interventions include asthma education, including a written AAP, avoidance of
triggers, and reassessment every 3-4 months (Ducharme et al.)
The Caregiver Experience
Literature on childhood asthma is highly focused on the pharmacological treatment and
management of symptoms. Though caregiver QOL has been reasonably addressed within this
context, it is often assumed that asthma control is the only indicator of quality of life in the
families of children with asthma. Asthma can present multiple challenges to the family of the
affected child that have the potential to affect QOL.
As asthma management often requires daily interventions, the majority of care for this
disease occurs in the home. As children are often dependent on their caregivers for even general
activities of daily living, it is perhaps not surprising that responsibility for day-to-day
management of asthma falls on them, causing significant effects on their lives. Major indicators
for QOL in parents may include feelings associated with the burden of management (e.g.
decision-making, medication administration, hospitalization), stress due to fears about the child’s
current and future health, and the stress due to consequences on the caregivers’ ability to carry
out work and household responsibilities (Bellin et al., 2013; Carpenter et al., 2013; Clark &
Chalmers, 2003; Kieckhefer & Ratcliffe, 2000). The Paediatric Asthma Caregiver’s Quality of
Life Questionnaire (PACQLQ) is a tool developed by Juniper et al. (1996) that is used
internationally to measure QOL in caregivers based on indicators of disease interference on
normal daily life. The PACQLQ indicators (see Appendix B) will be maintained when describing
quality of life in this paper.
I will focus specifically on the caregivers of preschool-aged children ages 1-5 with asthma in
this paper because this population presents with unique challenges in terms of the indicators for

8

QOL. Foremost, preschool-aged children are highly dependent on their caregivers for all aspects
of their care. This results in caregivers assuming the full burden of asthma management, whereas
an older child is often able participate in a degree of self-management. Additionally, at this age,
children and their caregivers are often dealing with a new diagnosis of asthma and the added
stressors associated with this new diagnosis. According to Clark and Chalmers (2003), these may
include stressors such as learning basic asthma management for their child, fear of the unknown,
and the perceived lifestyle changes following diagnosis. Finally, asthma in this age group is
associated with the highest rate of hospitalization, as well as high individual variability in
severity, requiring frequent treatment adjustments by health providers. Consequently, it is not
surprising that caregivers of preschool-aged children with asthma report significant stress and
negative effects on their QOL as a result of the responsibility of managing the disease.
Quality of Life and Primary Care Management
Unfortunately, in primary care management of childhood asthma, the well-being and QOL
of caregivers are often not a chief focus of care. Health visits predominantly focus on symptom
management, and the quality of life of the affected child. Further support is available beyond the
primary care provider, however broader initiatives such as asthma education programs are
limited in accessibility. These programs— offered through health authorities and nongovernmental organizations— are generally reserved for children with severe or uncontrolled
symptoms, and are primarily found in larger urban centres. Primary care providers are therefore
often tasked with providing comprehensive asthma care using what few resources are available
to them, such as clinical guidelines. Even within evidence-based practice guidelines for the care
of childhood asthma, the acknowledgement of caregiver care/QOL is negligible. For example, in
Canada and British Columbia, there are two major guidelines on the management of asthma for

9

health providers: one set through BC Guidelines (2014), and the other, the aforementioned CTS
guidelines (Ducharme et al., 2015; Lougheed et al., 2012). The BC Guidelines publication is
only indicated for those 6 years and older with asthma. Though this does not include the focus
population for this paper, it still includes the care of a large proportion of children with asthma,
and there is no mention of caregiver involvement anywhere in the document. The CTS
guidelines, particularly those focused on preschool-aged children (Ducharme et al.) are more
comprehensive and specific to the management of childhood asthma. While these guidelines
consider the involvement of caregivers in management, the only mention of caregiver quality of
life is in regards to referral to specialists, stating that “parental anxiety, need for reassurance,
additional education” are indications for referral to an asthma specialist (p. 31). Likewise, when
searching US-based guidelines (National Institutes of Health, 2012) I found a similar lack of
priority placed on the well-being of caregivers.
Though major guidelines on paediatric asthma management may not adequately address the
caregiver experience, there is substantial literature available on this topic. Within the literature I
collected on the caregiver experience of having a child with asthma, two consistent themes
emerged related to the health provider’s effect on caregiver quality of life: (a) caregiver-provider
communication, and (b) caregiver input on management. A study by Carpenter et al. (2013)
found that increased caregiver-provider communication (indicated by greater number of
questions asked by the provider) was directly associated with increased caregiver quality of life.
Likewise, a study by Sleath et al. (2011) addresses the significance of shared decision-making in
the management of asthma, and the effects on caregiver satisfaction. Alongside the essential
biomedical care needs of children with asthma and their families, these are aspects of care that

10

primary care providers must consider to promote the overall health of the patient and their
family.
Asthma Action Plans
There is an abundance of literature available on best approaches to asthma management in
primary care. Overall, asthma action plans (AAPs) are recognized as a gold standard in asthma
care. A systematic review of randomized controlled trials by Zemek, Bogal, and Ducharme
(2008) supports the use of AAPs to improve outcomes in childhood asthma. Most asthma
guidelines worldwide have adopted this approach as best-practice, yet it is estimated that fewer
than 25% of patients with asthma have a written AAP (Shah et al., 2011).
AAPs involve a written document provided to the patient or caregiver that usually includes
management goals, information on early symptom recognition, step by step instructions for
symptomatic treatment, and guidance in determining need for a higher level of care (Tan, Chen,
Soo, Ngoh, & Tai, 2013). The most common type of AAP involves a “traffic light” approach, in
which each colour (green, yellow, and red) represents a symptom set and the subsequent actions
recommended.
Understandably, most literature on AAPs has been focused on decreasing exacerbations of
asthma, and not necessarily on the how this translates to QOL in the caregivers of the children
with asthma. As AAPs are tools that support communication between providers and caregivers,
provide information on the disease, and allow for individualized care of asthma, I suspect that
their use could contribute to improved quality of life in caregivers. By completing an integrative
literature review, I hope to link together evidence to determine whether this is supported, guided
by the following research question: “Can nurse practitioners, as primary care providers, use
asthma action plans to improve the quality of life in the caregivers of preschool-aged children

11

with asthma?” The next step in this process involved a comprehensive literature search to gather
studies to review for final analysis. The methodology used in this process will be described in the
next chapter.

12

Chapter Three
Methods
An integrative review of current literature was executed to explore the use of asthma action
plans in pediatric populations, and determine how this may affect quality of life (QOL) for
caregivers. Torraco (2005) defines an integrative literature review as “a form of research that
reviews, critiques, and synthesizes representative literature on a topic in an integrative way such
that new frameworks and perspectives on the topic are generated” (p.356). Thus, prior to
deciding on a final research topic, I performed an initial search of the literature on pediatric
asthma management aimed at uncovering areas in which gaps in evidence remain. Accordingly,
the topic I chose to review is guided by the following question: “Can nurse practitioners, as
primary care providers, use asthma action plans to improve the quality of life of caregivers of
preschool-aged children with asthma?” Through a comprehensive examination of the themes
within this research question, I intend to develop recommendations for guiding future practice
and research on asthma management.
The literature search process for this integrative literature review occurred in three stages,
including (1) developing a search strategy and the preliminary search, (2) a focused search, and
(3) a detailed analysis of the final chosen articles.
Search Strategy and Preliminary Search
My preliminary literature search strategy involved a search of four electronic databases
through the University of Northern British Columbia library: CINAHL (EBSCOhost), Medline
(Ovid), Cochrane Database of Systematic Reviews (CDSR), and PsychINFO (EBSCOhost). I
chose these databases because they are specific to health care-related journals. In order to ensure
a thorough search of the literature, I began by using a concept map to break down my research

13

question and extract ideas, which I could develop into search terms. Each term was then searched
as a keyword, using appropriate truncation and wildcard functions, with the option to formulate
into MeSH terms used, when available (with CINAHL, MEDLINE, and PsychINFO). All MeSH
terms were exploded in order to decrease risk of omitting important literature. Table 1 outlines
the keyword terms entered, and the resulting subject headings used.
Table 1
Search Terms
Keyword Search
(?= Wildcard)
(*= Truncation)
“Quality of life”
or
“Stress”
“Parent*”
“Asthma”
“Chronic disease*”
“Child*”
Or
“P?ediatric*”
“Asthma action
plan*”
“Nurse
Practitioner*”

“Primary care”

CINAHL
(EBSCOhost)
 Quality of
Life
 Stress,
Psychological
 Parents
 Asthma
 Chronic
Disease
 No relevant
subject terms,
keywords
used
 No relevant
subject terms,
keywords
used
 Nurse
Practitioners
 Pediatric
Nurse
Practitioners
 Primary
Health Care

MeSH Terms Retrieved
MEDLINE
CDSR
(Ovid)
 Quality of
 Subject
Life
terms not
available
 Stress,
through
Psychological
this
 Parents
database,
 Asthma
keyword
 Chronic
terms
Disease
used
 Child
 Pediatrics

PsychINFO
(EBSCOhost)
 Quality of
Life
 Stress
 Parents
 Asthma
 Chronic
Illness
 Pediatrics

 No relevant
subject terms,
keywords
used
 Nurse
Practitioners

 Not relevant
for this
database

 Primary
Health Care

 Not relevant
for this
database

 Not relevant
for this
database

14

From these search terms, I formulated Boolean search combinations (see Appendix A)
aimed at finding available research on:


Current use of asthma action plans in paediatric populations



Management of asthma in primary care, or more specifically by nurse practitioners in
primary care



The experience of having a child with asthma or a chronic illness

Upon completing the preliminary searches, I removed literature that was unsuitable for the
purpose of this paper, by applying minor limiters including language (English), and type of
publication (peer-reviewed journal article).
Focused Search
Due to the high volume of results (1384 articles) following the preliminary search, my next
step involved narrowing the results by screening titles and abstracts for relevance. This was
carried out using a specific inclusion and exclusion criteria, depicted in Table 2.
The final part of this stage involved a full review of each article that met the requirements
following abstract and title screening to further narrow the results. In the end, I identified 18
studies eligible for inclusion in this integrative literature review. Figure 1 illustrates a summary
of the full search process.

15

Table 2
Inclusion and Exclusion Criteria
Inclusion
Published between 2000 and
2015

Exclusion
Published prior to 2000

May be qualitative or
quantitative research.

Non-peer-reviewed research
articles, opinion pieces,
editorials, news releases,
magazine articles.

May be any level of research
(e.g. original studies,
systematic reviews, metaanalyses)
Abstract available, or title
appears relevant if no abstract
is available.
Addresses at least one of the
following:
 Asthma in children,
with preference given
to those addressing
preschool aged
children
 Caregiver experience
of having a child with
asthma
 Primary care/NP
approaches to asthma
management
 Use of asthma action
plans in paediatrics
Studies based in any country,
provided that the
sociodemographic factors of
the country would not overtly
affect generalizability to
Canadian/BC populations.

Rationale
To reflect recent and current
practices. This period also
coincides with the major
implementation of NPs in
Canada.
Seeking credible sources
within the databases.

No abstract available and
title does not appear
relevant.
Specific focus on acute care
management or on the
pharmacological
management of asthma

To assist in limiting search
results to pertinent articles to
review.
As I have not found literature
that addresses all aspects of
my research topic, I am
looking for these pieces to
bridge the evidence together.

Studies specifically directed
at the
demographics/population or
health system of a country
outside of Canada

To limit to research pertinent
to Canadians and British
Columbians.

16

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17

these themes, though it should be noted that themes had a degree of crossover within articles.
The results of this analysis are presented in the next chapter.

18

Chapter Four
Findings
The main purpose of the literature review was to gather and integrate current evidence on
caregiver quality of life (QOL), primary care management, and the use of asthma action plans
(AAPs) within the context of preschool-aged children with asthma. I guided this analysis by the
research question: “Can nurse practitioners, as primary care providers, use asthma action plans to
improve the quality of life in the caregivers of preschool-aged children with asthma?” An
integrative literature review approach was used, with a final literature sample of 18 articles,
which were analyzed using a literature review matrix. The literature analysis revealed three main
themes relating to the research question: (a) the caregiver context of disease and factors that
influence QOL, (b) communication between caregivers and primary care providers, and (c)
evidence surrounding particular management strategies for childhood asthma that promote
caregiver QOL. In this chapter, I will focus on expanding on these themes as they are presented
within individual articles. Details on the quality, reliability, and utility of each article are
summarized in a shortened version of literature review matrix used in the literature analysis,
modified for this purpose (see Appendix C).
The Caregiver Context of Disease: Factors Influencing QOL
Understanding the caregiver context of childhood asthma emerged as an important theme
within the literature. The evidence to support the idea that caregiver QOL is affected in
childhood asthma— and particularly with preschool-aged children— was overwhelming. This
theme was important in my literature analysis, as in order to answer the research question about
improving QOL, it was necessary to understand what was leading to impaired QOL in

19

caregivers. Within this section, I will therefore discuss two sub-themes that emerged as factors
influencing QOL in caregivers: factors related to caregiver burden, and individual factors.
Caregiver burden refers to the caregiving demands that are beyond those a parent or
caregiver would typically be responsible for when raising a child. This may include various
degrees of routine rearrangement, symptom monitoring, medication administration, medical
visits, missed work and school, and avoidance of triggers. Individual factors include
sociodemographic influences, coping mechanisms, and self-efficacy in managing the disease. Of
the 18 articles chosen for review, nine articles considered disease burden, the caregiver context
of disease in asthma and how these can be related to caregiver QOL.
The first article chosen for review was a longitudinal study by Bellin et al (2013). In this
study, the researchers examined the stress and QOL in the caregivers of children with poorlycontrolled asthma. Disease burden was a primary focus, with the target population—children
with poorly controlled asthma— having presumably high caregiver burden. Using the Activity
Limitation Scale of the Paediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ)
as an indicator of QOL, the researchers found that perception of life stress and perception of
higher care demands by the caregiver during periods of poor asthma control correlated with
impaired QOL ratings (b = -0.19 to -0.26; p = 0.03). Verification of validity and reliability of the
Activity Limitation Scale of the PACQLQ is indicated by a Cronbach α value of 0.83, and an
intraclass correlation coefficient of 0.84. A major limitation to this study however, was in the
sample population. Most of the caregiver participants recruited were mothers, and were single,
unemployed, and low-income. The children were primarily African-American with poorlycontrolled asthma, limiting the generalizability of these results.

20

Studies by Cerdan, Alpert, Moonie, Cyrkiel, and Rue (2012), Silva, Crespo, Carona, and
Canavarro (2015), and Walker et al. (2008) also demonstrated an association between caregiver
burden and caregiver QOL. Cerdan et al. found that higher asthma severity in children, and the
resulting increased burden of this, reflect lower PACQLQ scores and thus, lower QOL in
caregivers (r = -0.34; p = 0.001). Again, the authors of the study indicate the validity and
reliability of the PACQLQ by reviewing the correlation data: indicators and QOL scores were
well-correlated with QOL, with r scores ranging from 0.22-0.51 and p values for particular
indicators ranging from < 0.1 to <0.0001. While this study had a fairly small sample size (101
caregivers), it included families of variable sociodemographic groups, allowing for better
generalizability than the study by Bellin et al. (2013). Likewise, the studies by Silva et al. and
Walker et al. reinforce the evidence that higher caregiver burden is associated with decreased
QOL using population samples from a variety of sociodemographic groups.
In considering the target age of this integrative literature review, three articles addressed the
connection between higher caregiver burden and having a preschool-aged child with asthma.
Clark and Chalmers (2003), and Silva et al. (2015) distinguish the increased dependency young
children have on their caregivers for asthma care compared to older children, thus speculating
greater caregiver burden. Kieckhefer and Ratcliffe (2000) found that the caregivers of children
under the age of five frequently experience a high level of discomfort and uncertainty around
recognizing and responding to asthma symptoms. Similarly, Trzcieniecka-Green, BargielMatusiewicz, Wilczynska, and Omar (2015) found that a new diagnosis of asthma, which is
often the case in preschoolers with asthma, may be associated with lower caregiver QOL when
compared to caregivers of children with an asthma diagnosis of over one year (χ2 = 5.17, p <
0.05). This may indicate that as caregivers adjust to the burden of care, QOL improves.

21

However, this finding was only demonstrated with statistical significance in caregivers 20-30
years of age, and the sample size of the study was small at only 60 caregivers.
Beyond findings related to disease burden, the literature sample revealed that there are
multiple factors that contribute to caregiver QOL related to the individual situations of
caregivers. Though the results of the studies above may indicate that QOL is affected regardless
of sociodemographic factors, it is apparent that factors—such as age, level of education attained,
household income, housing, and marital status—may contribute to the degree of effect asthma
has on a caregiver’s QOL. Data retrieved by both Cerdan et al. (2012), and Osman, Baxter-Jones,
and Helms (2001) demonstrated an association between certain high-risk sociodemographic
groups (e.g. low-income, young maternal age, poor housing) and lower overall QOL. Caregivers
with higher incomes reported higher QOL (r = 0.35; p < .001) (Cerdan et al.), and QOL scores
were significantly lower in mothers with a higher social deprivation score (8% lower; p = .05),
and in mothers under the age of 30 (10% lower; p < .02) (Osman et al.).
Individual coping mechanisms of caregivers may also have effects on QOL. In the study by
Silva et al. (2015), researchers found that a diagnosis of asthma in a child generally led
caregivers to assume one of two coping mechanisms: denial or acceptance. When comparing
QOL based on a caregiver denying or accepting the reality of the situation, acceptance marked a
positive correlation with QOL (β = 0.29; p = 0.01), leading to a conclusion that assisting the
caregiver to understand and accept the disease may promote better QOL.
Finally, it was repeatedly discovered within the literature that caregiver self-efficacy in
managing their child’s asthma has a tremendous effect on QOL. Carpenter et al. (2013) used the
Parent Asthma Self-Efficacy Scale (α = 0.87) to assess caregiver confidence in preventing and
managing asthma exacerbations, and followed with an assessment of QOL using the PACQLQ.

22

Within this study, the authors found that caregivers with higher levels of asthma self-efficacy
reported better overall QOL (r = .45, p = .01). Likewise, the studies by Clark and Chalmers
(2003), and Kieckhefer and Ratcliffe (2000) acknowledge the significance of caregiver selfefficacy in asthma management, as asthma interventions are largely carried out independently by
caregivers in the home. All three studies thus stress the importance of targeting caregiver selfefficacy when managing childhood asthma. Additionally, these findings correspond well to the
aforementioned idea that caregiver QOL is greater in children with a diagnosis for over one year
(versus a new diagnosis), assuming that experience with asthma management leads to greater
self-efficacy.
Caregiver-Provider Communication
The second major theme I found within my literature review emphasized caregiver-provider
communication. From the literature that explored the caregiver experience of childhood asthma,
it was apparent that caregivers often felt like “outsiders” during interactions with providers, and
felt as though they should have more input on their child’s asthma care. Likewise, in multiple
studies the authors concluded that there is a need for providers to better facilitate communication
with caregivers in order to gain an understanding of their experiences and better address
problems, including impaired caregiver QOL.
In three of the articles, researchers found that caregivers were not adequately involved in
discussions regarding their child’s asthma, whether due to low engagement on the part of the
caregiver, lack of inclusion or invitation by the provider, or possibly a combination of both.
Sleath et al. (2011) audio recorded and examined the interactions that occurred between
caregivers and providers during 333 paediatric asthma visits at five different clinics. They found
that discussions were largely dominated by providers, few questions were asked by caregivers,

23

and providers only asked for caregiver input into the management plan during 10% of the visits
recorded. Clark and Chalmers (2003) found that many caregivers of preschool-aged children
with a new diagnosis of asthma did not feel well-supported by health providers. These feelings
were found to be related to the quality of relationship held between the provider and caregiver,
which may fluctuate over time. Particular phases of these relationships included entrusting the
provider, becoming disillusioned by interactions, and learning the formal and informal rules or
“ways” of the health care system. The particular phase the caregiver was in within the
relationship contributed to their sense of participation and inclusion in care. In an article by
Kieckhefer and Ratcliffe (2000), the authors discuss the importance of acknowledging the
expertise of the caregiver, and encouraging shared-decision making in the care of the child.
Through focus groups, this study found that caregivers generally feel they have “important
information to share with the provider about living with a child with asthma” (p. 125), but do not
always feel comfortable initiating this conversation.
In addition to caregivers feeling like outsiders in the management of their child’s asthma, the
findings of this literature review indicates that there is a communication gap in discussing the
caregiver experience of having a child with asthma. In the study by Kieckhefer and Ratcliff
(2000), caregivers were asked “what is one thing that you would like health providers to know
about your experiences of living with a child who has asthma?” (p. 123). The results indicated
that 18.8% of caregivers wanted providers to know that they felt scared and fearful, 9.4% wanted
providers to know that having a child with asthma is difficult, stressful and affects the
caregiver’s behaviour, and 6.3% described wanting the provider to understand to degree of
burden due to disease monitoring requirements. These findings suggest that the caregiver
experience, including their QOL, is not adequately addressed during asthma visits with

24

providers. Kieckhefer and Ratcliffe also suggest that discussing these concerns, and
acknowledging that they are normal feelings may be reassuring to caregivers.
In terms of directly addressing QOL in caregivers of children with asthma, in the studies by
Stelmach et al. (2012), and Osman, Baxter-Jones, and Helms (2001), the authors recognize the
importance of discussing and assessing caregiver QOL in paediatric management. In both
studies, the authors recommend using the PACQLQ in asthma visits as a tool to better
acknowledge caregivers in the care of children with asthma.
Management Strategies to Promote Caregiver Quality of Life.
One purpose of this literature review was to explore the use of AAPs, determine whether
their use would address the caregiver context of disease, and more specifically, whether they can
promote improved QOL in caregivers. Thus, this final theme focuses on key strategies of asthma
management that can contribute to improvement of caregiver QOL, and explores how AAPs can
contribute to meeting these standards. Key strategies found within the literature focus on asthma
education and asthma self-efficacy by caregivers.
As previously mentioned, asthma self-efficacy and management have emerged as important
factors in promoting caregiver QOL in childhood asthma. In further review of the articles
focused on management strategies, authors acknowledged that education plays a role in a
caregiver’s ability to independently manage their child’s asthma. Shah, Roydhouse, and Sawyer
(2008) discuss this in their study, highlighting that asthma education is needed to teach
information and skills to caregivers in order to effectively manage their child’s asthma. Georgiou
et al. (2003) implemented a large-scale asthma education intervention involving written
information, videos, reminder aids, and telephone assistance, and found that these strategies
significantly lessened the burden of asthma on caregivers. Similarly, Bentley, Ludlow, Meier,

25

and Baydala (2005) reinforce the significance of education in the management of childhood
asthma. In this study, the authors not only found that detailed educational interventions increase
caregiver’s confidence in their ability to manage their child’s asthma, but also reveal significant
improvements in caregiver QOL (6.3-12% increase in QOL scores, p <0.05). However, it should
be noted that the educational intervention involved in this study was based out of a specialized
asthma clinic, thus limiting generalizability to primary care practices.
It is clear within the literature that caregivers see value in AAPs (MacGillivray & Flavin,
2014; Tan et al., 2013). A primary function of an AAP is to promote independence in asthma
management by reminding patients and caregivers of the treatment plan, and provide step-bystep instructions on how to carry out this treatment plan (Bhogal, Zemek, & Ducharme, 2009;
Dinakar, Van Osdol, & Wible, 2004). Tan et al. confirm in their study that AAPs increase
confidence in caregiver management of asthma and improved understanding of the illness. So,
while much of the literature on AAPs is focused on using them as a tool to decrease
exacerbations and hospitalizations (Bhogal et al., 2009; Dinakar et al., 2004), it is possible that
their role may indirectly contribute to caregiver QOL, based on the information gathered in this
literature review. Additionally, within the articles on AAPs, it was found that these tools
contribute to improved caregiver-provider communication and better individualization of care;
factors also found within this review to contribute to caregiver QOL.
Though AAPs may provide some education and information on asthma, an important subtheme that emerged within the literature specific to AAPs emphasized that they are only a tool,
and as such should only be used as a part of a larger educational intervention. Of the four studies
on AAPs from the literature sample, three reported the use of AAPs in conjunction with
educational interventions (Bhogal et al., 2009; Dinakar et al., 2004; Tan et al., 2013). These

26

recommendations, however, are postulated by the authors without sufficient evidence. This is
further addressed by Bhogal et al. (2009) in their systematic review of randomized controlled
trials, in which the authors acknowledge the lack of research addressing whether AAPs are
truthfully more effective with the addition of educational interventions, and implying that standalone use may offer equal benefit.
To summarize, this analysis has provided a critical review of common themes within the
literature gathered on current primary care management of childhood asthma, caregiver QOL,
and AAP use. In consideration of the research question, “Can nurse practitioners, as primary care
providers, use asthma action plans to improve the quality of life in the caregivers of preschoolaged children with asthma?”, this analysis considers the factors influencing caregiver QOL, the
dynamics involved in caregiver-provider communication, and particular strategies that can
promote improved caregiver QOL. The next chapter of this paper provides a discussion of these
findings. It includes recommendations for clinical practice, implications for NP practice, and
limitations and recommendations for future research.

27

Chapter Five
Discussion
Through this literature review, I was able to explore the topic of caregiver quality of life
(QOL) in childhood asthma. Guided by the question, “Can nurse practitioners, as primary care
providers, use asthma action plans to improve the quality of life in the caregivers of preschoolaged children with asthma?”, I have examined a combination of qualitative and quantitative
studies concerning the caregiver experience of childhood asthma, the primary care management
of childhood asthma, and the use of an asthma action plan (AAP), in this management. This
chapter is aimed at discussing how the assembled literature supports the hypothesis that the use
of the asthma action plans in primary care can contribute to improved QOL in caregivers of
preschoolers with asthma. I will begin by reviewing the key findings and discussing the proposed
recommendations for clinical practice. I will follow with a consideration of the implications for
practice, including specific inferences for NPs. Finally, I will conclude this chapter with a
discussion of the limitations of this project, and provide recommendations for future research on
the topic of preschool-aged asthma and caregiver QOL.
Recommendations for Clinical Practice
Three key findings were identified as paramount in answering the research question. First, it
was found that the factors influencing caregiver QOL are multifaceted, involving a combination
of external and personal factors related to the caregivers. Second, it was found that caregiverprovider communication practices are a barrier in both assessing caregiver QOL, and in
promoting practices that encourage improved QOL in caregivers. Lastly, it was found that AAPs,
along with other concurrent strategies, have the potential to support providers in improving low

28

caregiver QOL in childhood asthma. Each of these findings provided direction for making
recommendations for clinical practice.
Addressing factors influencing QOL
Through the literature analysis, it was found that low QOL in the caregivers of children with
asthma is associated with both external factors related to the caregiver burden in childhood
asthma, and the individual factors of the caregivers. The key external factors associated with low
caregiver QOL corresponded to those elements causing increased caregiver burden, which
subsequently led to decreased QOL. These included:


Having a child with a more severe form of asthma, and the increased demands this has on
the caregiver (Cerdan et al., 2012).



Having a child with poorly-controlled asthma, and managing acute asthma exacerbations
(Bellin et al., 2013; Silva et al., 2015; Walker et al., 2008).



Having a young child with asthma, specifically preschool-aged, and the associated higher
dependency on the caregiver (Clark & Chalmers, 2003; Silva et al., 2015).



Having a child with a new diagnosis of asthma, and the associated discomfort and
uncertainty in recognizing and responding to symptoms (Trzcieniecka-Green et al.,
2015).

Key individual factors associated with decreased QOL in caregivers corresponded to
sociodemographic factors, and the personal coping skills of the caregivers. These included:


Belonging to a sociodemographic group considered “high-risk” for health disparities. The
examples provided in the literature included young maternal age, low-income, and certain
places of residence (Cerdan et al., 2012; Osman et al., 2001).

29



Coping mechanisms; specifically, denial versus acceptance of the responsibilities
associated with managing their child’s asthma (Silva et al., 2015).



Confidence and self-efficacy in managing their child’s asthma (Carpenter et al., 2013;
Clark & Chalmers, 2003; Kieckhefer & Ratcliffe, 2000).

These factors suggest that actions aimed at improving asthma control, decreasing the demand
of care, increasing caregiver knowledge, improving confidence and self-efficacy in asthma
management, improving caregiver coping mechanisms, and addressing sociodemographic risk
factors could potentially improve caregiver QOL. Implementing AAPs into primary care asthma
management is a small step that may address several of these objectives. Typically, AAPs
include management goals, information for early symptom recognition, instructions for treatment
of specific symptoms, and guidance to assist caregivers in deciding whether a higher level of
care is needed (Tan et al., 2013). These characteristics are intended to provide the caregiver or
child with the information needed to independently manage symptoms, thus supporting selfefficacy and prevention of exacerbations, thus improving control and decreasing demands of
care. Many AAPs also contain simple, straightforward information on individual asthma triggers
and instructions for correct use of device (Province of British Columbia, n.d.), addressing the
need for information to increase caregiver knowledge. Furthermore, I would simply expect that
having a detailed, written AAP would contribute to comfort and confidence in care, based on an
assumption that AAPs provide reinforcement when a caregiver is feeling uncertain on how to
proceed with asthma management. However, the literature reviewed further supports this theory,
revealing explicit evidence that caregivers find comfort in having an AAP, and have an increased
sense of confidence as a result of their use (Tan et al.) Finally, while they are unquestionably
important contributors to caregiver QOL, the complex nature of addressing sociodemographic

30

risk factors and individual coping mechanisms to improve QOL places these indicators beyond
the scope of this paper.
Addressing caregiver-provider communication concerns
The main issues that emerged in this review related to caregiver-provider communication
involved poor inclusion of caregiver input in management planning, and inadequate
acknowledgement and support of the caregiver experience of childhood asthma.
Recommendations for practice related to these findings are therefore directed at the provider’s
role in facilitating caregiver-provider communication, involving the caregiver in developing the
management plan, and inquiring about QOL at health visits.
As reported by Sleath et al., (2011) it is not uncommon for providers to dominate the
discussion during asthma visits. Supporting reciprocal communication during these interactions
has the potential to provide a better understanding of the family’s individual situation, promote a
stronger caregiver-provider relationship, allow for more individualized and effective care, and
consequently contribute to improved QOL (Clark & Chalmers, 2003; Kieckhefer & Ratcliffe,
2000). Facilitating better communication may be as simple as directing more questions to
caregivers during visits, encouraging them to ask questions, and allowing mutual dialogue to
occur. Likewise, the provider can use the AAP as a tool to promote discussion by assuming a
collaborative approach with the caregiver in developing the home management plan. For
example, by developing the AAP together, the provider may learn that the caregiver is struggling
to remember to administer morning doses of the child’s twice-daily inhaled corticosteroid (ICS).
If appropriate, they could instead consider an ICS with available once-daily dosing. Hence,
AAPs are not only a tool that can directly effect caregiver quality of life, but has the potential to
be used as an indirect method by supporting communication.

31

Part of the provider’s role in facilitating better caregiver-provider communication should
also involve assessing caregiver QOL (Osman et al., 2001; Stelmach et al., 2012). Within the
literature on caregiver QOL, the PACQLQ stood out as a well-supported tool for measuring and
addressing the effects of childhood asthma on caregiver QOL. The tool is short, simple, and
provides an objective measure of caregiver QOL that can then be reassessed with subsequent
visits. This tool, along with other QOL assessment tools, can therefore be used to promote
communication and understanding between caregivers and providers.
Larger-scale interventions aimed at supporting providers may also be beneficial in
promoting improved caregiver-provider communication. As previously noted in this paper,
current guidelines for the management of childhood asthma offer little recognition of the
important role caregivers and families play. I would thus recommend that asthma guidelines
directed at paediatric populations include greater acknowledgement of this unique dynamic, with
guidance for practitioners, such as the use of tools like the PACQLQ.
Use of AAPs to promote improved caregiver QOL
While AAPs are by no means a novel concept in asthma care, it was found within the
literature that a large proportion of patients with asthma do not have AAPs (Shah et al., 2011). In
addition to the prevailing, well-documented reasons for their use, AAPs have been clearly
verified within this literature review as a tool providers may use to promote and contribute to
better QOL in caregivers. AAPs are therefore recommended to be implemented in the care of all
children with asthma.
It is not apparent in the literature why AAPs are often not included in a child’s management
plan, however I would suspect that this is either due to oversight, or related to time and resource
constraints in the primary care setting. I believe that increasing the use of AAPs is highly

32

dependent on uptake by primary providers, and thus it is necessary to consider AAP practices
that center on ease of use and efficiency. Integrating routine use into practice can be challenging,
however this can be supported using available resources and technology. AAP templates are
easily obtained online, and are most often free of charge. Providers can choose hard-copy
templates, or electronic templates that can completed online and either printed or emailed to the
family, depending on which they would consider more convenient. Having preprinted AAP
templates available may promote greater use. Likewise, some providers may prefer to have a
direct link on their desktop to an electronic template that can be completed and saved directly
into the patient’s electronic medical record (EMR), or printed and filed. With the growth of
EMRs, there are even programs like iAAP (Minnesota Department of Health, 2009), which draw
information from a patient’s EMR to provide individual AAP recommendations and allows for
easy development of the AAP, which is then automatically filed into the patient’s EMR.
When considering AAP use in practice, it is also important to recognize that not all AAPs
are created equal. While most AAPs are developed consistently, take an evidence-based
approach to guiding home-based management, and are clear and simple to use, there remains
considerable variation among those available.
The main variations seen amongst AAPs includes whether they are symptom or peak-flow
based plans, differences in treatment recommendations for each zone of asthma severity (i.e.
green, yellow, and red zones), and availability of additional reference information. Both
MacGillivray and Flavin (2014), and Zemek et al. (2008) found in their studies that symptombased plans are superior to peak-flow based plans for addressing exacerbations. Additionally, the
proper use of peak-flow meters is not realistic in preschool populations and therefore these
should not be used in this population. MacGillivray and Falvin also provide further

33

recommendations for AAPs used in Canada, based on alignment with current CTS guidelines.
The authors recommend that the descriptors defining each zone be clear and concise, provide
space for child-specific interventions, but also provide practitioners with treatment guidance for
each zone per the current CTS guidelines. For example, the authors found that many AAPs
provide a space for providers to write a step-up dose for inhaled corticosteroids (ICS) during
acute exacerbations, whereas current guidelines do not recommend increasing an ICS during
acute exacerbations due to a lack of data supporting this intervention. The other main
recommendation by the authors stressed the importance of including information on the child’s
individual asthma triggers in the plan. The AAP developed by the Province of British Columbia
(n.d.) is designed specifically for preschoolers and is an example of an AAP that meets all of the
the aforementioned recommendations (see Appendix D).
Beyond the use of AAPs, one of the most significant findings that emerged from this review
was the importance of providing caregivers with detailed education on asthma and asthma
management. In studies by Bentley et al. (2005) and Tan et al. (2013), comprehensive
educational interventions were directly associated with increased caregiver confidence and selfefficacy in managing their child’s asthma, and improved overall QOL. While this review has
established that AAPs are a tool that can promote improved QOL in the caregivers of preschoolaged children with asthma, it has also revealed that they are only one of many practices that
should be considered (Bhogal et al., 2009; Dinakar et al., 2004; Tan et al.). Thus, this
recommendation stresses the significance of using AAPs alongside educational interventions for
caregivers. I can appreciate that in the primary care setting this can be a challenge, as
appointment times are limited. If resources are available to support asthma teaching, providers
are then encouraged to make use of these options (e.g. access to asthma educators, group

34

learning sessions, online resources). Otherwise, it may be necessary to schedule follow-up
appointments to complete the adequate education with children and their caregivers. Overall,
however, an AAP is an excellent place to start, and should be provided regardless of whether
formal asthma education is available.
Interventions that go beyond the scope of individual providers, such as those implemented at
the community, health authority, or provincial level can also be beneficial in supporting the
educational component of asthma management, and contribute towards efforts for improved
caregiver QOL. Currently, programs are available through health authorities aimed at asthma
care and education for children and their families. BC Children’s Hospital (2016) provides
asthma consultation and education, however this service is aimed at children with poorlycontrolled or difficult to manage asthma, and no longer accepts referrals for education alone.
Throughout the province, educational services are available (Canadian Lung Association, 2015),
though are generally limited to larger urban centers, limiting access for many families. As this
review has established that caregiver QOL is affected in most cases of childhood asthma, making
formal educational interventions standard for all families experiencing childhood asthma may be
valuable for improving QOL. Furthermore, with the success and growth of programs using new
technologies like the videoconferencing used with the Provincial Health Services Authority
Telehealth Services (2016), such services may be deliverable through more cost-efficient and
convenient means.
Working towards improved QOL for caregivers of preschool-aged children with asthma is
best approached using multiple interventions and methods aimed at addressing the causes of
decreased QOL, current issues around caregiver-provider communication, and using evidence-

35

based approached to management. Table 3 summarizes the key recommendations for clinical
practice.

36

Table 3
Key Recommendations for Clinical Practice
Target Audience
Individual providers:
 NPs in
primary care
 General
practitioners
 Other
primary care
providers

Recommendations
1. Ensure all children,
especially preschoolers, with
a diagnosis of asthma or with
symptoms suggestive of
asthma are provided with an
individualized AAP
2. Work towards better
conscious facilitation of
reciprocal communication
with caregivers.
3. Promote the use of AAPs
concurrently with
comprehensive asthma
education when available.
4. Assess QOL in caregivers
throughout the course of the
disease.

Suggestions for Implementation
Have easy access to AAPs for primary care visits:
 Hard copies available
 Link to electronic version on computer desktops
 Program/template through EMR (e.g. iAAP)
 Ask caregivers questions during visits, and encourage
question-asking on their part.
 Develop AAPs collaboratively with parents (and children
when appropriate).
 If asthma education during a primary care visits is not
adequate, consider:
 Scheduling additional visits as needed to complete
education
 Referring to formal education programs if available
 Referring to online asthma resources, such as the Asthma
Society of Canada (2016) website, or the extensive list of
tools and resources available to caregivers on the Asthma
and Allergy Foundation of America (2016) website
 Use tools to regularly assess caregiver QOL:
 PACQLQ
 WHO Quality of Life assessment instrument
(WHOQOL): not limited to caregivers, or to the context
of asthma, but addresses cultural and value systems, and
individual considerations of QOL.
 As with AAPs, tools like the PACQLQ can be integrated
into EMRs to promote ease of use.


37

Target Audience
Other key
stakeholders:
 Community
programs
 Asthma
organizations
 Health
authorities
 Asthma
guideline
developers

Recommendations
1. Increase access to asthma
education programs.
2. Make formal asthma
education standard for all
preschool-aged children with
asthma, or with symptoms
suggestive of asthma.
3. Provide better inclusion of
issues affecting the caregivers
of children with asthma—
such as QOL—into current
management guidelines.

Suggestions for Implementation




Consider funding and implementation of cost-effective
asthma education delivery.
 Online education modules
 Telehealth services
Provider support: For example, NPs, GPs, asthma educators,
and other asthma care providers can advocate for such
services through project proposals to potential funders,
presenting at conferences, or even simply by discussing the
at health authority meetings or with other health
professionals.

38

Implications for Nurse Practitioner Practice
The findings from this literature review lead to many potential implications for NP practice.
In Canada— and in British Columbia in particular— NPs are emerging as important members of
the health care team. Many of the positions developed for NPs are in primary care; in 2013 56%
of NPs in BC were employed in community or primary health care settings (Sangster-Gormley et
al., 2014). While many children with asthma may receive specialty consultation for asthma— for
example through emergency departments, by respirologists, or in specialty asthma clinics— the
majority of health visits for asthma management occur in the primary care setting (American
College of Allergy, Asthma & Immunology, 2015). Additionally, in BC, asthma is classified as a
disease that can be independently diagnosed and managed by entry-level paediatric and family
NPs (College of Registered Nurses of British Columbia, 2015). Therefore, many NPs may be
responsible for the diagnosis and ongoing management of asthma in children, and thus have the
potential to play a key role in addressing the altered QOL of caregivers.
Though in this project I focused on NP and primary care management of childhood asthma,
it is not to say implications cannot extend to other health providers and other sectors of care. As
health care continues to adopt more collaborative approaches to disease management, children
with asthma and their families may see a variety of providers for their asthma needs. For
example, within a primary care centre, a child may be connected to a NP or physician primary
care provider, a social worker, a pharmacist, a respiratory therapist, and/or a physiotherapist.
Having common goals around interventions—like the use of AAPs—can provide consistency in
care and better address the needs of these families. Thus, any health provider working with
families affected by childhood asthma can use or promote the principles and recommendations
discussed in this review in order to support improved QOL in the caregivers.

39

Limitations and Recommendations for Future Research
The main limitations of this review were related to the narrow size and scope. Addressing
sociodemographic risk factors was mentioned in discussing the contributors to decreased
caregiver QOL, however the complexity of these factors extend beyond the scope of this paper.
Likewise, addressing the individual coping mechanisms of caregivers is another factor requiring
greater exploration than what was provided by the literature search and analysis of this review.
Thus, my first recommendation is for further depth of research regarding caregiver QOL in
relation to the sociodemographic risk factors and the individual coping mechanisms of caregivers
in order to better identify and support these groups.
While education was revealed as an important aspect for promoting caregiver QOL, this
review lacks detail on specific components of education that may be key in addressing this, and
whether formal education is an essential concomitant intervention with AAPs. Furthermore,
though the evidence in this paper upholds the hypothesis that AAPs improve QOL in caregivers,
the idea that they are an unrivaled solution is limiting, in that there are certainly other possible
interventions that may support QOL in caregivers. Consequently, I think it is not only important
to further explore specific educational interventions aimed at improving QOL in caregivers, but
to consider interventions beyond AAPs and educational interventions. While no specific
examples pertaining to this emerged in the literature review, this may include such interventions
as caregiver support groups, family or individual counselling services, or services to provide
asthma teaching to family members or other caregivers (e.g. daycare staff) so they may better
support the primary caregivers. This paper also considers the possible indirect effects of AAPs,
such as their use as a tool to improve communication between caregivers and providers. I believe

40

that this topic would benefit from further research on specific ways in which AAPs should be
utilized to promote caregiver QOL, including their role in supporting communication.
Finally, this review has focused solely on childhood asthma and the effects of this particular
chronic disease on caregivers. While depth has been provided to this very specific topic within
this review, I believe that it provides implications for other paediatric chronic illnesses (e.g. type
1 diabetes mellitus, epilepsy, severe allergies) and the similar challenges that may arise in these
illnesses for caregivers. I would therefore encourage further research on addressing QOL in
caregivers to encompass a greater range of health challenges affecting paediatric populations and
their families.

41

Chapter Six
Conclusion
As one of the most prevalent childhood chronic illnesses both worldwide and in Canada, the
overall effects of asthma are extensive. While efforts are often concentrated on addressing the
biomedical and economic issues associated with the disease, it is well known that asthma has
considerable effects on individual family units of children with asthma, particularly on
caregivers. Quality of life (QOL) of caregivers has emerged as an important concern within the
context of childhood asthma, with even greater emphasis when this concerns young children, like
preschoolers. The preceding chapters of this paper identified that current primary care
management strategies are not sufficient in addressing the caregiver experience of asthma in this
population.
Asthma action plans (AAPs) have been established as a key tool in asthma management for
improving asthma outcomes, and preventing exacerbations and hospitalizations, however there is
little documentation on the effects of AAPs on caregiver QOL. Thus, this integrative literature
review was aimed at answering the following research question: “Can nurse practitioners, as
primary care providers, use asthma action plans to improve the quality of life in the caregivers of
preschool-aged children with asthma?”
A comprehensive review of the literature was undertaken to explore this question. Eighteen
studies were selected for the final literature sample, allowing for an in-depth analysis of the
caregiver experience of childhood and preschool-aged asthma, current trends in primary care
management of childhood asthma, and the use of AAPs in childhood asthma. The analysis
revealed three main themes related to this topic in the literature. These included: 1) the specific
factors that contribute to decreased caregiver QOL, 2) issues regarding caregiver-provider

42

communication, and 3) evidence supporting particular asthma management strategies for
promoting improved caregiver QOL, including AAPs.
Overall, the results of this review not only support the hypothesis that nurse practitioners in
primary care can use AAPs to improve QOL in the caregivers of preschool-aged children with
asthma, but extend to recommend further applications, such as the use of educational
interventions, and the possibility of crossover to include other health providers beyond NPs.
Furthermore, this review provides insight for prospective research to build on the findings and
recommendations for QOL in caregivers of children with asthma, as well as the potential for
implications for other childhood chronic illnesses.

43

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47

Appendix A
Boolean Search Combinations


CINAHL (EBSCOhost): October 3, 2015



MEDLINE (Ovid): October 3, 2015



Cochrane Database of Systematic Reviews: October 4, 2015
1. Quality of Life/Stress

9. 3 OR 4

2. Parents

10. 6 OR 7

3. Asthma

11. 5 OR 9

4. Chronic Disease

12. 5 AND 3

5. Child/Paediatric

13. 1 AND 2 AND 11

6. Asthma Action Plans

14. 5 AND 6

7. Nurse Practitioner

15. 10 AND 12

8. Primary Care



PsychINFO (EBSCOhost): October 15, 2015
1. Quality of Life/Stress
2. Parents
3. Asthma
4. Chronic Illness
5. Pediatrics
6. 3 OR 4
7. 5 AND 6
8. 1 AND 2 AND 7

48

Appendix B
PACQLQ 1

Reprinted with permission from Elizabeth Juniper on behalf of QOL Technologies Limited

1

49

Reprinted with permission from Elizabeth Juniper on behalf of QOL Technologies Limited

1

50

Reprinted with permission from Elizabeth Juniper on behalf of QOL Technologies Limited

1

51

Appendix C
Literature Review Matrix
Article / Study Design and
Overview
(Bellin et al., 2013)

Strengths

Had a control group
receiving standard asthma
Longitudinal quantitative study education versus
examining changes in QOL over intervention group.
12 months related to a
behavioral/educational
Objective measures:
intervention. Part of a larger
Comparing PACQLQ
randomized controlled trial
scores at baseline, 6
(RCT)
months, and 12 months.
Intervention: Two home visits
by asthma nurse, and assistance
arranging follow up
appointment.

Size: caregivers of 300
children with asthma.
Sound statistical analysis.

Limitations

Utility/Important Findings

Generalizability: most caregiver
participants were female, single,
unemployed, and/or low-income.
All children had poorly-controlled
asthma.

Improved PACQLQ scores with
intervention group: Baseline
17.98; 6 months 22.75; 12
months 22.87. Both increases
statistically significant (p <
.001)

US-based; different health system
and potentially different caregiver
stressors.

Greater life stress associated
with lower QOL at all 3 data
collection points: At baseline b
= - .26 p = .03; at 6 months b =
- .19, p = .03; and at 12 months
b = - .21, p = .03.

52

Article / Study Design and
Overview
(Bentley et al., 2005)

Strengths

Limitations

Canadian study

Longitudinal study aimed at
evaluating effects of an asthma
program involving education
and AAPs on asthma severity
and QOL

Large sample: Caregivers
of 398 children with
asthma.

Sample recruited from one asthma Links components of AAPs and
specialty clinic. Did not describe
QOL, and education alongside
severity of asthma.
AAPs.

Variety of demographics
providing good
generalizability.
Sound statistical analysis.

(Bhogal et al., 2009)

Strength in being a
systematic review.

Systematic review of RCTs to
examine the impact of providing Size: Total of 355
AAPs in childhood asthma.
patients were represented
between the 4 studies
reviewed.
Samples provided
variation in child’s age,
gender, and asthma
severity. Recruited from a
variety of settings. Good
generalizability.

Often lacked clarity about who
the participant was (patient or
caregiver).
Intervention based on a
specialized clinic and
interventions by a pediatrician
and asthma educators.

Small sample: only 4 RCTs were
accepted for the final sample,
none of which provided a control
group in which no AAP was used.
Comparison was between
symptom-based AAPs and peakflow AAPs.

Utility/Important Findings

Statistically significant
improvement in caregiver QOL
(6.3-12.5% improvement; p <
.05) and confidence in selfmanagement (41.2% increase in
parents “quite confident” post
intervention [p < .05]), as well
as less contact with their family
physician (73.6-90% less, p <
.01), and decreased loss of
caregiver productivity (89.1%
decrease in days of productivity
lost; p < .01).
Focused on decreasing
exacerbations. Found relative
risk 27% lower for children
with AAPs based on symptoms.
Parents did not prefer one type
of AAP over the other.
Acknowledges the importance
of using AAPs only as a part of
the intervention; education is
paramount. Good overview of
the purpose of AAPs.

53

Article / Study Design and
Overview
(Carpenter et al., 2013)
Secondary analysis of data
gathered in a previous
longitudinal study (Sleath et al.,
2011). Examines whether there
is any association between
patient-provider communication
and QOL of children with
asthma and their caregivers.

Strengths

Limitations

Utility/Important Findings

Diverse, large sample
consisting of 296
families.

Caregiver QOL not measured
using PACQLQ (uses GEE
model).

Correlation between caregiver
asthma self-efficacy and QOL
(r = .45, p = .01).

Provides consistent,
appropriate methods of
data collection based on
participants (interviews
with children and
caregivers, followed by
surveys of caregivers).

Some of the study focus was on
communication between the child
(aged 8-16) and provider, not
necessarily the caregiver which
may not be transferable to
preschool populations.

Specifies AAPs as a tool for
improving self-efficacy

Thorough statistical
analysis of outcomes as
well as variables.

Stresses importance of asthma
education and engaging
families in discussions during
visits in order to promote selfPatients, caregivers, and providers efficacy/effective management.
were all aware they were being
audio-recorded, possibly
influencing interactions.
No control for baseline QOL.
Data was only collected at
baseline and 1 month later; short
duration.
Participant were referred to the
study based on interest; certain
populations/demographics may be
more likely to volunteer or show
interest.

54

Article / Study Design and
Overview
(Cerdan et al., 2012)

Strengths

Though all participants
were recruited from a
Cross-sectional study examining single clinic, there good
asthma severity and caregiver
variation in demographic
QOL using 3 surveys
information providing
(PACQLQ, asthma severity
generalizability.
questionnaire, and the
sociodemographic factors
Reasonable sample size:
questionnaire).
101 caregivers of children
with asthma.

Limitations

Utility/Important Findings

US-based; different health system
potentially providing different
variables that in Canada.

Provides quality data on
caregiver QOL based on the
PACQLQ.

Cross-sectional design provided
data on QOL only for that
particular time. Many variables
may contribute to QOL at a
particular snapshot of time.
Longitudinal study may have
been a more appropriate design.

Found that higher asthma
severity correlates with
significantly lower PACQLQ
scores and thus lower caregiver
QOL (Spearman rank
correlation = - .34; p = .001).

Considers how
Selection bias: certain populations sociodemographic influences
may volunteer and respond to
may impact caregiver QOL
surveys.
(e.g. parents with higher income
experienced better QOL
(Spearman rank correlation =
.35; p < .001)
Affirms the importance of
education in supporting
caregiver QOL.

55

Article / Study Design and
Overview
(Clark & Chalmers, 2003)
Exploratory descriptive study
aimed at examining how
providers can help caregivers of
children with asthma cope with
the disease.

Strengths

Limitations

Utility/Important Findings

Provides descriptive
qualitative data,
appropriate for evaluating
the caregiver experience
of childhood asthma.

Small sample size: 17 parents of
15 children with asthma along
with many variables (which
parent participated, age of
diagnosis, asthma severity)
possibly decreases
reproducibility.

Focus is on preschool-aged
children with asthma.

A Canadian study

Document retrieved did not
include tables, images, or graphs;
possibly omitting missing
valuable information.
Focus is on nursing (RN) role,
though may still be applicable to
primary care providers.

Provided qualitative data on the
caregiver experience of having
a preschool-aged child with
asthma. Found that caregivers
experience stress and disruption
as a result of the diagnosis.
Describes “stages” caregivers
experience in coping with the
diagnosis and management, and
how providers can assist them
based on each stage.
Stresses the role of the
caregiver in this age group and
importance of self-efficacy as
most asthma care is carried out
in the home.
Recommends individualized
care and management.

56

Article / Study Design and
Overview
(Dinakar et al., 2004)
Cross-sectional survey of
parents of children with asthma
covering possession/usefulness
of AAP, asthma severity, and
frequency of exacerbations.

Strengths

Limitations

Utility/Important Findings

Reasonable study size:
Caregivers of 75 children
with asthma.

US-based; different health system
and potentially different caregiver
stressors.
Convenience sampling: all were
recruited from one paediatric
clinic. Selection bias may limit
generalizability.

Describes trends in AAP use.

Good survey return: 95%
Variety of asthma
severity contributes to
generalizability.

75% had AAPs in this study.
9/10 parents found AAPs to be
of value in managing
symptoms.
Discussion section considers
the role education has in
supporting AAPs.

57

Article / Study Design and
Overview
(Georgiou et al., 2003)
Longitudinal study taken place
over 12 months examining the
effects of an asthma
management program on
children and their caregivers,
including child’s QOL,
caregiver’s asthma management
skills and knowledge, and lost
days of work/school.

Strengths

Limitations

Utility/Important Findings

Large, random sample:
401 families randomly
selected from 14 districts
involved in a large-scale
population-based
intervention program.

Mail-in surveys; certain
populations may be more likely to
respond. Response rate was 28%
for the baseline survey, then 40%
of the 28% completed the followup survey.

Though interventions were
mostly via telephone or
multimedia, the study, provides
data supporting education for
improved outcomes and
decreased caregiver burden.

Good variation in
demographics providing
generalizability.

US-based; different health system
potentially providing different
variables that in Canada (e.g. cost
of health care).

Found statistically significant
improvement in the caregivers’
understanding of asthma
management and ability to
control asthma triggers (16.7%
increase in proper symptom
management), improved
confidence in managing their
child’s asthma (8.6% increase
in parents feeling “very
confident” in self-management
abilities), and fewer missed
days of work (mean of 2 less
annual work days missed) (all p
values < .01).

58

Article / Study Design and
Overview
(Kieckhefer & Ratcliffe, 2000)
Qualitative study; data obtained
through focus groups. Aimed at
exploring the fears of
caregivers, and what caregivers
want provider to know about
having a child with asthma.

Strengths

Limitations

Utility/Important Findings

Provides descriptive
qualitative data,
appropriate for evaluating
the caregiver experience
of childhood asthma.

Large variation in age: sample
involved caregivers of children
ages 18 months to 19 years. The
caregiver experiences is likely
very different in a 19 year-old
child then in a preschool agedchild.

Applies findings to the use of
AAPs: encourages providers to
discuss fears and concerns with
caregivers, and integrate
individual concerns into AAPs.

Reasonable sample size
for a qualitative study: 52
caregivers of children
with asthma.

Acknowledges the “parent as
the expert” and the importance
Convenience sampling: caregivers of involving them in developing
were recruited from an asthma
the management plan.
education conference earlier that
day (possible selection bias).
Found that caregivers want
repeated education, not just at
Poor generalizability; participants diagnosis or with exacerbation.
were mainly middle-class, urban
families.
Discusses the importance of
education and communication
Focus groups: certain members
to promote caregiver selfcan influence the conversation
efficacy in managing their
and how others participate
child’s asthma.
discussion.
Acknowledges the unique
challenges parents of young
children (under 11 years-old)
experience.

59

Article / Study Design and
Overview
(MacGillivray & Flavin, 2014)

Strengths

Limitations

Utility/Important Findings

Canadian-focused

Review and comparison of the
different formats of AAPs used
in Canada.

Large sample: 17
different types of AAPs
were reviewed.

Assumes that variation in AAPs
causes confusion to users.

Literature review identifies that
patients find most value in
clear, specific AAPs for
managing symptoms.

(Osman et al., 2001)

Thorough statistical
analysis.

Longitudinal study aimed at
validating the use of the
PACQLQ with the caregivers of
preschool-aged children with
asthma.

Mixed demographics
from urban and rural
primary care practices.
Though study was
completed in Scotland
and there may be unique
variable as a result of
this, the health systems
are comparable.

Small sample size: 62 caregivers
Most children were found to have
relatively mild asthma, limiting
generalizability.

Provides recommendations for
types of AAPs and highlights
that parents find AAPs useful.
Focus on caregiver QOL in
preschool-aged children with
asthma.
Uses PACQLQ as measurement
tool. PACQLQ not previously
validated for children <7 years;
this study validates sensitivity
of the PACQLQ in preschoolaged children.
Also provided data supporting
the associations between
caregiver QOL and
sociodemographic factors
(maternal age <30 = 10% lower
QOL score [p= .02]; higher
social deprivation score = 8%
lower QOL score), and asthma
symptoms and QOL (as
symptoms reduced, QOL scores
improved; r= .69, p= .05).

60

Article / Study Design and
Overview
(Shah et al., 2008)

Strengths

Provides a good
description of the many
Literature review to examine the forms of education
impact of self-management
currently being provided
education on health outcomes.
(GP-led, nurse-led,
pharmacy-based, and
multidisciplinary).

(Silva et al., 2015)
Cross-sectional study aimed at
examining the links between
coping (via denial or
acceptance), disease burden, and
QOL in the caregivers of
children with asthma. Data
collected through questionnaires
during health visits.

Limitations

Utility/Important Findings

No description of
methods/approach to literature
review.

Importance of education for
caregivers in improving
independent management of
asthma.
Focused on primary care.

Sources used in review
appear reliable.
Reasonable study size:
Study completed in Portugal;
parents of 182 parents of potentially providing different
112 children with asthma. variables that in Canada
Retrieved a large amount
of data with a very
thorough analysis
(multivariate analyses
performed).

Found improved outcomes
using interdisciplinary approach
for asthma education.
Found that disease burden is
associated with decreased QOL,
speculating that measures to
ease burden may contribute to
improved QOL.

Cross-sectional design provides
data for that particular snapshot of
time.
Found that caregivers that
coped via acceptance (rather
Possible selection bias due to
than denial) demonstrated
convenience sampling, and
higher QOL (β= .29, p = .01).
recruitment taking place in 3
similar centres.
Affirms that there is increased
disease burden on caregivers of
Possibly low generalizability due younger children due to greater
to low variability in asthma
dependence for needs.
severity, and similar
socioeconomic status amongst
Does not use PACQLQ as QOL
participants (low/medium
measure, uses WHOQOL.
socioeconomic status).

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Article / Study Design and
Overview
(Sleath et al., 2011)

Strengths

Appropriate, thorough
methodology for data
Cross-sectional study examining collection; used
child and caregiver involvement interviews with tape
in asthma visits.
recording, then coding for
data interpretation.
Large sample: 333
families, 41 primary care
providers.

Limitations

Utility/Important Findings

Providers, caregivers, and
children knew they were being
audio-recorded, possibly affecting
interactions.

Involved primary care
practitioners, including NPs
(11%).

Convenience sample; possibility
that certain populations attend the
clinic and would agree to
participate in the study.

Found that providers do not
include caregiver input enough
while developing management
plan.

Only 33% of caregivers asked
US-based; different health system one or more questions during
Good variability in
potentially providing different
visits. Providers only asked for
demographics of children, variables then in Canada (e.g. cost caregiver input on the
caregivers, and providers. of health care).
management plan in 10% of the
Variation in asthma
visits recorded.
severity.
Discusses the importance of
communication and
collaboration between
caregivers and providers, of
education, and of
individualizing care (e.g. to fit
the lifestyle of the family).
Recommends providers take
steps to support caregiver
involvement in decision-making
and involvement in visits.

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Article / Study Design and
Overview
(Stelmach et al., 2012)
9-week cohort study aimed at
examining the usefulness of the
PACQLQ and whether there is
correlation between caregiver
QOL, child QOL and asthma
control.

(Tan et al., 2013)
A mixed-method study
evaluating the effects of AAPs
on caregiver understanding of
symptoms, use of medication,
and frequency of acute care
visits.
Involved focus groups to
explore the understanding and
management of asthma followed
by a survey to determine AAP
use.

Strengths

Limitations

Utility/Important Findings

Reasonable sample size:
110 caregiver/child
dyads.

Did not provide demographic
information, or detailed
information on recruitment. Not
clear on type of clinic participants
were recruited from. Unsure of
generalizability.

Provided evidence for
measuring caregiver QOL using
the PACQLQ.

Consistent measure used
throughout (PACQLQ).
Measured at multiple
points in care (weeks 1, 5, Study completed in Poland,
and 9).
potentially providing different
variables then in Canada.
Large sample size
recruited from various
sites: 169 caregivers from
9 primary care clinics.
Varied demographics.
Good generalizability.

Study completed in Singapore,
however AAPs and asthma
treatment and management
appeared similar to Canadian
standards.

Found that PACQLQ may be
valuable in indirectly assessing
child’s asthma control.
Significant improvement in
PACQLQ score when asthma
control was gained (7 point
increase in QOL score, p < .01)
AAP use was associated with
greater caregiver understanding
of the disease and improved use
of medications during
exacerbation (adjusted odds
ratio = .53-5.71; all p values in
these domains < .061, most <
.01).
Describes AAPs being of best
use alongside education.

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Article / Study Design and
Overview
(Trzcieniecka-Green et al.,
2015)
Non-experimental, crosssectional study examining QOL
in parents of children with
asthma. Compared 2 groups: (1)
Children with a new diagnosis
of asthma (< 3 months), and (2)
children diagnosed at least 1
year prior.

Strengths

Limitations

Utility/Important Findings

Used consistent methods
of data collection:
PACQLQ and
Satisfaction with Life
Scale (SWLS).

Study completed in Poland;
potentially providing different
variables then in Canada.

PACQLQ used as measure of
caregiver QOL. Consistent,
slight (not statistically
significant, values not reported)
increase in QOL was found
when the diagnosis was > 1
year, possibly indicating that
caregivers adapt to disease
burden.

Limited statistically significant
results. Did not report may
statistical values in article.
Small sample size: 60 parents of
children with asthma.
All participants were recruited
from one health centre, possibly
limiting generalizability and
increasing risk of selection bias.

Found that life satisfaction was
rated better in the caregivers of
children diagnosed at least one
year prior, compared to those
with a new diagnosis in
caregivers ages 20-30 years old
(chi-square = 5.17; p < .05).

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Article / Study Design and
Overview
(Walker et al., 2008)
Longitudinal study examining
the effects of an asthma
education intervention.
Intervention providing devices
and literature, and participation
in asthma workshops.

Strengths

Limitations

Utility/Important Findings

Compared intervention
group to control group.
Participants were
randomized into groups.

US-based; different health system
potentially providing different
variables then in Canada.

PACQLQ scores were highly
correlated with missed work
days and asthma severity.
Fewer missed days of work was
associated with higher mean
QOL scores (p < .001). High
asthma severity was associated
with decreased emotional QOL
(p = .009) and activity QOL (p
= .03).

Reasonable sample size:
221 children with asthma
and their families.
QOL measured with
consistent tool (PAQLQ
for children, PACQLQ
for caregivers).
Thorough data analysis:
analyzes QOL in relation
to both the variables and
the intervention.
Considers the different
elements of the PACQLQ
(e.g. emotional, activity),
not just overall QOL.

Participants were all from one
school, possibly contributing to
selection bias.
Limited variability in
demographics may decrease
generalizability; most caregivers
were white, had a high school
education, and most families were
rural and middle-income.
Reproducibility: findings around
educational interventions contrast
other studies (most have found a
relationship between education
and QOL).
Possible recall bias: long period
between QOL questionnaires (10
months).

No statistically significant
findings that the particular
educational intervention had
any effect on caregiver QOL.
Recommendations that
interventions and education
focus on decreasing asthma
severity and improving control
in order to improve caregiver
QOL.

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Appendix D
Asthma Action Plan Example2

Copyright (c) Province of British Columbia. All rights reserved. Reproduced with permission of the Province of
British Columbia.
2

66

Copyright (c) Province of British Columbia. All rights reserved. Reproduced with permission of the Province of
British Columbia.
2