INTRODUCTION
Asthma is a prevalent heterogeneous chronic airway disorder, typically characterized by reversible and recurring symptoms related to airflow obstruction due to underlying inflammation and airway hyper-responsiveness, affecting 262 million individuals globally in 2019 (GBD 2019 Diseases and Injuries Collaborators, 2020). The prevalence rate of asthma has been rising annually, particularly in developing countries. From 2012 to 2015, the overall prevalence rate of asthma among children in China was 4.2% (Huang et al., 2019), tripling the rate of 1.09% reported in the 2010 National Census (Liu et al., 2013). According to the Global Initiative on Asthma Prevention and Control 2020, the goal of asthma management is to achieve and maintain disease control or reduce future risks either by the therapies used or the disease itself (Global Initiative for Asthma, 2022). Despite the extensive use of inhaled corticosteroids (ICSs) and the emphasis on the progressive standardization of asthma treatment by Respiratory Group of Pediatric Branch of Chinese Medical Association (2020), an analysis of the asthma control status of 400 children in Guiyang City revealed that 72.5% had asthma exacerbations, 35.5% required emergency treatment, and 17.8% were hospitalized due to an asthma exacerbation within the past 12 months, indicating poor asthma control level (Luo & Zhu, 2017). Poor asthma control leads to children's school absenteeism (Fleming et al., 2019), caregivers' work absenteeism, impaired lung function (Jensen et al., 2016), and imposes a substantial economic burden on families and society (Nurmagambetov et al., 2018).
Both asthma itself and management issues contribute to poor asthma control. An increasing number of studies have demonstrated that childhood asthma presents a complex clinical phenotype with multiple triggers, resulting in varied responses to treatment and different clinical outcomes, complicating management (Kuo, et al., 2017). Therefore, there is an urgent need for precise and personalized management. The Global Initiative for Asthma (2022) highlights the importance of family management for children with asthma and calls for individualized patient care. The Guidelines for Diagnosis and Prevention of Bronchial Asthma in Children in China (Respiratory Group of Pediatric Branch of Chinese Medical Association & The editorial board of Chinese Journal of Pediatrics, 2016) also indicated that effective, individualized asthma management and prevention education contributed to symptoms control. The varied family management styles are reported to be associated with the child's ability to accomplish age-appropriate roles, the control level of asthma, and the overall quality of family functioning (Knafl et al., 2013; Zhang et al., 2017). As a result, identifying family management styles is essential to develop tailored interventions to provide individualized care to children with asthma, thus, to improve child and family functioning as well as the control of asthma.
BACKGROUND
Family management style is defined as the type of family responses to childhood chronic illness (Knafl et al., 1996). To achieve individualized management of children with asthma, it is necessary to effectively evaluate and comprehensively analyse differences in management styles and factors associated with these styles. Several researchers have described family management styles for families of children with chronic diseases. For example, Knafl et al. (1996) conducted a qualitive study and identified five different family management styles according to family members' subjective accounts of the illness experience: thriving, accommodating, enduring, struggling and floundering. They reflected differences in terms of definition of the illness experience, management goals and approach, and illness consequences. They presented a continuum of difficulty families experience in managing a child's chronic illness. Knafl et al. (2011) developed an evaluation tool, namely, the Family Management Measure (FaMM) and subsequently used it to quantitatively examine the family management styles of families with children experiencing chronic diseases (Knafl et al., 2013). Through cluster analysis, they validated four management style categories: family focused, somewhat family focused, somewhat condition focused and condition focused. These categories provided valuable insights into how families respond to childhood chronic conditions. However, as one of the most common chronic diseases among children, asthma constituted only 11.1% (Seven out of 63 families) and 4.8% of the chronic diseases in the two studies (Knafl et al., 1996, 2013). As noted by Knafl et al. (2013), the limited number of children with a specific chronic condition hindered efforts to investigate condition-specific aspects of family management. The specific family management styles for families of children with asthma remain unclear. Furthermore, compared to the Western culture, Chinese culture is more family-oriented, grandparents are usually living together with their children and grandchildren, filial piety plays a critical role in family dynamics (Ma, 2023). Due to differences in family culture between the USA and China, it is worthwhile to explore the categories of family management style for children with asthma within the Chinese cultural context and draw conclusions based on the target population.
Various factors have been reported to influence family management of children with asthma. At the individual level, a study found that the longer the disease duration, the better the family management of children was, partially due to the rich experience parents gained in disease management (Xu et al., 2015). At the family level, family economic status (Zhou et al., 2014), parents' education level (Wang et al., 2015), parents' health literacy (Harrington et al., 2015) and family functioning status (Zhou et al., 2014) were considered to affect family management. At the organizational level, medical resources were the direct resources available for the family management of children with asthma. It has been found that distributing health knowledge pamphlets to children and their parents played a crucial role in the management of children with asthma (Long, 2019). Regular follow-up visits as required by physicians were also beneficial to asthma management (Cheng et al., 2022). Nevertheless, there is still a lack of research regarding the predictors associated with the potential profiles of family management styles for children with asthma in China.
THE STUDY
Aims and hypotheses
We applied the latent profile analysis (LPA) in this study with two primary aims: (1) to identify the latent profiles of family management styles for children with asthma and (2) to explore predictors of family management styles for children with asthma. We hypothesize that family management styles for children with asthma are heterogeneous and exhibit distinct classification characteristics. Furthermore, each family management style is influenced by individual and family factors of the child, as well as factors associated with medical organizations. Identifying the latent profiles of family management styles and predictors will help precisely classify family management styles of children with asthma and provide individualized care.
METHODS
Design
This study is a secondary data analysis based on a cross-sectional study which was conducted from December 2015 to September 2016. The original study (Zhang & Duan, 2017) aimed to explore the relationship between asthma control and quality of life in children with asthma. During the data analysis, we found that family management was a key factor to achieve optimal control of asthma. Therefore, we performed a secondary data analysis to identify the latent profiles of family management styles, using the data from the Family Management Style Scale for Children with Asthma (FMSCA) and the demographic information collected in the original study. We hope to lay the foundation for stratified management, personalized care for children with asthma by this secondary data analysis.
Instrument with validity and reliability
The questionnaire included three sections: the demographic information section, and the Family Management Style Scale for Children with Asthma (FMSCA) and Children Asthma Control Test (C-ACT).
Demographic information section
This section was designed to gather information on individual, family, and organizational levels based on Social Ecosystem Theory (Bronfenbrenner, 1979). The individual factors included child's characteristics, such as gender, age, duration of asthma, presence of rhinitis, whether the child was the only child, and the level of schooling. The family-related factors included family history of asthma, marital status, parents' relationship, parents' education level, parents' employment, family income, residence and whether the child's disease influenced the parents' work and family life. The organizational factors included whether parents had read disease and health knowledge pamphlets, attended lectures on asthma, and had follow-up plans.
Family Management Style Scale for Children with Asthma (FMSCA)
The Family Management Scale for Children with Asthma (FMSCA) was developed by our research team (Xing et al., 2020) based on the Family Management Style Framework (FMSF) (Knafl et al., 2012). It includes eight subscales and a total of 57 items: Children identity (parents' views of the child and the extent to which those views focus on asthma or normalcy and capabilities or vulnerabilities, 6 items); View of condition (parental beliefs about the cause, seriousness, predictability, and course of asthma, 6 items); Management mindset (parental views of the ease or difficulty of carrying out the treatment regimen and their ability to manage asthma effectively, 4 items); Parental mutuality (caregivers' beliefs about the extent to which they have shared or discrepant views of the child, asthma, their parenting philosophy, and their approach to asthma management, 8 items); Parenting philosophy (parent's goals, priorities, and values that guide the overall approach and specific strategies for asthma management, 5 items); Management approach (parent's assessment of the extent to which they have developed a routine and related strategies for asthma management and incorporating it into family life, 19 items); Family focus (parent's assessment of the balance between asthma management and other aspects of family life, 4 items); and, Future expectations (parent's assessment of the implications of asthma for their child's and their family's future, 5 items). The scale is scored on a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree). Responses on all items were totaled to create a score of FMSCA. A higher score on the total scale indicated a better adaptive family management style. The scale has been used to measure the family management style of Chinese families who have children with asthma and has proved to have good reliability and validity (Cheng et al., 2022; Xing et al., 2020). The Cronbach's alpha coefficient of FMSCA was 0.918, ranging between 0.759 and 0.883 for the eight subscales. The item content validity index of the scale ranged from 0.83 to 1.00. The scale content validity index was 0.807 (Xing et al., 2020).
Children Asthma Control Test(C-ACT) (Wu, 2009)
C-ACT was used to evaluate the control level of asthma in this study. It is comprised of seven questions. The first four questions were finished by the child independently or with the help from the researcher. Each question is scored between 0 and 3. The last three questions were finished by parents. They ranked the frequency of asthma syndrome from Never (0) to Every day (5). The total score for C-ACT is 27. Score less than 19 indicates asthma is not controlled, 20–22 indicates asthma is partially controlled, and score no less than 23 indicates asthma is fully controlled.
Sampling and recruitment
A convenience sample of primary caregivers of the children (either mothers or fathers) who came for follow-up visit were recruited from four tertiary children's hospitals in Beijing, Gansu Province, and Shandong Province of China. A total of 528 primary caregivers were screened and eligible, 22 refused due to the tight schedule during the follow-up visits, with the refusal rate of 4.17%. Finally, 506 were enrolled.
Inclusion and exclusion criteria
Inclusion criteria for children were as follows: (1) diagnosed with asthma according to the diagnostic criteria for bronchial asthma in children formulated by the national collaboration group on prevention and treatment of childhood asthma (Respiratory Group of Pediatric Branch of Chinese Medical Association et al., 2008); (2) had a diagnosis of asthma for more than 3 months; (3) had asthma symptoms or used asthma medication during the past 12 months; and (4) aged between 4 and 17 years old. Exclusion criteria for children were as follows: (1) with other acute or chronic diseases, such as heart, liver, or kidney diseases, rheumatic diseases, bronchiolitis, cystic fibrosis, pneumonia, etc. or (2) who were treated for an acute asthma exacerbation during the past week. After the screening of eligible children, their primary caregivers who could read Chinese and communicate in Mandarin was invited to complete the questionnaire.
Data collection
First, we obtained permission to conduct the research from each medical institution. Then, with the assistance of medical staff, we selected children who met the inclusion criteria and whose parents were willing to participate in the study. Before the questionnaires were issued, the researcher introduced herself to the participants, and explained the purpose, significance and procedures of the study. After their informed consent, participants were included in the study.
To ensure the quality and uniformity of the questionnaire data, the researcher was responsible for all data collection and used standardized guidance to explain the process. The researcher used consistent language to provide detailed explanations of the method for filling out the questionnaire and any other matters needing attention. After the questionnaires were returned, the researcher checked for missing items, and followed up with participants if necessary to ensure the completeness and integrity of the data.
Data analysis
In this study, we used Mplus7.3 (Muthén & Muthén, 2017) for LPA and multiple logistic regression analyses. Data analysis mainly included two steps. The first step involved analysing the latent profiles. The analysis began with the initial model (assuming that there was only one class for all samples) and gradually increased the number of profiles in the model until the best fit for the data was found. In the second step, multiple logistic regression analyses were performed, incorporating covariates to analyse the impacts of children's characteristics, family factors, and organizational factors on the latent profiles.
LPA is a person-centred approach that categorizes samples according to various individual traits and homogenous grouping of continuum data that can separate groups with comparable symptoms into subgroups (Spurk et al., 2020). Test indicators for model adaptation mainly include the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and sample-corrected BIC (aBIC). Smaller values of AIC, BIC, and aBIC indicate a better model fit. The Entropy Index is also often used to evaluate the accuracy of classification. The value of Entropy ranges from 0 to 1. An Entropy value of 0.6 indicates that about 20% of individuals have classification errors, while a value of 0.8 indicates that the classification accuracy exceeds 90% (Nylund-Gibson & Choi, 2018). In addition, Mplus provides the likelihood ratio test index Lo–Mendell–Rubin (LMR), and the Bootstrap-based Likelihood Ratio Test (BLRT), which are used to compare the difference in fit of the latent category model. If the p-value of these two tests reaches a significant level of 0.05, it indicates that the k-category model is significantly better than the k-1 category model (Muthén & Muthén, 2017).
Ethical considerations
The original study was conducted in accordance with the principles and regulations of the Helsinki Declaration. Participants were informed that the questionnaires were anonymous and that their information would be kept confidentially, used only for the analysis of data for this study. They were informed that they had the right to participate voluntarily, and that refusal to participate in this study would not affect their medical treatment, rights or interests. As the original study was a questionnaire survey and had no harm to participants, oral informed consent was obtained from the legal guardians of children with asthma. The original study was reviewed and approved by the Ethics Committee of Beijing University of Chinese Medicine.
RESULTS
Subjects
Data from a total of 506 caregivers were entered into the analysis. Among the children, 352 (69.6%) were males and 154 (30.4%) were females. Fifty-two point eight percent of children were aged 7–11, 52.6% had asthma for more than 3 years, 51.8% were in kindergarten and primary school. Four-hundred and forty-five (87.9%) of the family reported they had no family history of asthma, 370 children had rhinitis. Majority were the only-child in the family (397, 78.5%). In terms of parents' relationship, 340 (67.2%) reported it was very good. Although most were core families, there was still 26.7% extended families. The parents' education was mostly senior high school and above. More than half of the parents reported that their work and family life were affected by their child's disease (255, 50.4%). Most of the families lived in big cities (237, 46.8%). Regarding organizational factors, the majority families had follow-up plans (325, 64.2%). Fifty-one point four percent parents had not read educational pamphlets about the disease (n = 260), most had not attended lectures regarding asthma (n = 420). For more details, please refer to Table 1.
TABLE 1 Demographic information drawn from the questionnaire (
| Demographic information (coding in the analysis) | Total sample n (%) | Profile 1 n (%) | Profile 2 n (%) | Profile 3 n (%) |
| Children's characteristics | ||||
| Child's gender | ||||
| Female (1) | 154 (30.4%) | 84 (35.0%) | 45 (24.2%) | 25 (31.2%) |
| Male (2) | 352 (69.6%) | 156 (65.0%) | 141 (75.8%) | 55 (68.8%) |
| Child's age (years old) | ||||
| <4 (1) | 13 (2.6%) | 6 (2.5%) | 3 (1.6%) | 4 (5.0%) |
| ≥4 but <7 (2) | 84 (16.6%) | 43 (17.9%) | 25 (13.5%) | 16 (20.0%) |
| ≥7 but <11 (3) | 267 (52.8%) | 133 (55.4%) | 94 (50.5%) | 40 (50.0%) |
| ≥11 (4) | 142 (28.0%) | 58 (24.2%) | 64 (34.4%) | 20 (25.0%) |
| Duration of disease (year) | ||||
| ≤1 (1) | 93 (18.3%) | 43 (17.9%) | 32 (17.2%) | 18 (22.5%) |
| >1 but ≤3 (2) | 147 (29.1%) | 78 (32.5%) | 49 (26.3%) | 20 (25.0%) |
| >3 (3) | 266 (52.6%) | 119 (49.6%) | 105 (56.5%) | 42 (52.5%) |
| Whether the only child in the family | ||||
| No (1) | 109 (21.5%) | 53 (22.1%) | 34 (18.3%) | 22 (27.5%) |
| Yes (2) | 397 (78.5%) | 187 (77.9%) | 152 (81.7%) | 58 (72.5%) |
| Level of schooling | ||||
| Pre-school age (1) | 244 (48.2%) | 123 (51.3%) | 79 (42.5%) | 42 (52.5%) |
| School age (2) | 262 (51.8%) | 117 (48.7%) | 107 (57.5%) | 38 (47.5%) |
| Whether had rhinitis | ||||
| No (1) | 136 (26.9%) | 76 (31.7%) | 45 (24.2%) | 15 (18.8%) |
| Yes (2) | 370 (73.1%) | 164 (68.3%) | 141 (75.8%) | 65 (81.2%) |
| Family factors | ||||
| Family history of asthma | ||||
| No (1) | 445 (87.9%) | 211 (87.9%) | 166 (89.2%) | 68 (85.0%) |
| Yes (2) | 61 (12.1%) | 29 (12.1%) | 20 (10.8%) | 12 (15.0%) |
| Marital status | ||||
| Divorced/ Widowed (1) | 11 (2.2%) | 6 (2.5%) | 3 (1.6%) | 2 (2.5%) |
| Married (2) | 495 (97.8%) | 234 (97.5%) | 183 (98.4%) | 78 (97.5%) |
| Parents' relationship | ||||
| Very good (1) | 340 (67.2%) | 162 (67.5%) | 120 (64.5%) | 58 (72.5%) |
| Good (2) | 120 (23.7%) | 58 (24.2%) | 48 (25.8%) | 14 (17.5%) |
| So-so/ bad (3) | 46 (9.1%) | 20 (8.3%) | 18 (9.7%) | 8 (10.0%) |
| Family structure | ||||
| One-parent family (1) | 13 (2.5%) | 6 (2.5%) | 4 (2.2%) | 3 (3.8%) |
| Core family (2) | 358 (70.8%) | 161 (67.1%) | 133 (71.5%) | 64 (80.0%) |
| Extended family (3) | 135 (26.7%) | 73 (30.4%) | 49 (26.3%) | 13 (16.2%) |
| Father's education level | ||||
| Junior high school and below (1) | 64 (12.7%) | 29 (12.1%) | 24 (12.9%) | 11 (13.7%) |
| Senior high school and above (2) | 441 (87.3%) | 210 (87.9%) | 162 (87.1%) | 69 (86.3%) |
| Mother's education level | ||||
| Junior high school and Below (1) | 84 (16.6%) | 38 (15.8%) | 32 (17.2%) | 14 (17.6%) |
| Senior high school and above (2) | 422 (83.4%) | 202 (84.2%) | 154 (82.8%) | 66 (82.4%) |
| Father's employment status | ||||
| Unemployed (1) | 163 (32.2%) | 68 (28.3%) | 66 (35.5%) | 29 (36.2%) |
| Employed (2) | 343 (67.8%) | 172 (71.7%) | 120 (64.5%) | 51 (63.8%) |
| Mother's employment status | ||||
| Unemployed (1) | 220 (43.7%) | 93 (38.9%) | 84 (45.2%) | 43 (54.3%) |
| Employed (2) | 286 (56.3%) | 147 (61.1%) | 102 (54.8%) | 37 (45.7%) |
| Residence | ||||
| Big cities (1) | 237 (46.8%) | 108 (45.0%) | 97 (52.2%) | 32 (40.0%) |
| Middle cities (2) | 89 (17.6%) | 49 (20.4%) | 24 (12.9%) | 16 (20.0%) |
| Small cities and towns (3) | 134 (26.5%) | 65 (27.1%) | 46 (24.7%) | 23 (28.8%) |
| Rural area (4) | 46 (9.1%) | 18 (7.5%) | 19 (10.2%) | 9 (11.2%) |
| Household average monthly income (RMB) | ||||
| <10,000 (1) | 110 (21.7%) | 51 (21.3%) | 39 (21.0%) | 20 (25.0%) |
| ≥10,000 but <40,000 (2) | 132 (26.1%) | 70 (29.2%) | 42 (22.6%) | 20 (25.0%) |
| ≥40,000 but <100,000 (3) | 177 (35.0%) | 78 (32.5%) | 70 (37.6%) | 29 (36.3%) |
| ≥100,000 (4) | 87 (17.2%) | 41 (17.0%) | 35 (18.8%) | 11 (13.7%) |
| Influence of illness on their parents' work and family life | ||||
| No (1) | 251 (49.6%) | 130 (54.2%) | 91 (48.9%) | 30 (37.5%) |
| Yes (2) | 255 (50.4%) | 110 (45.8%) | 95 (51.1%) | 50 (62.5%) |
| Organizational factors | ||||
| Whether they had follow-up plans | ||||
| No (1) | 181 (35.8%) | 75 (31.2%) | 72 (38.7%) | 34 (42.5%) |
| Yes (2) | 325 (64.2%) | 165 (68.8%) | 114 (61.3%) | 46 (57.5%) |
| Whether their parents had read disease and health knowledge pamphlets | ||||
| No (1) | 260 (51.4%) | 128 (53.3%) | 93 (50.0%) | 39 (48.8%) |
| Yes (2) | 246 (48.6%) | 112 (46.7%) | 93 (50.0%) | 41 (51.2%) |
| Whether their parents had attended lectures | ||||
| No (1) | 420 (83.0%) | 205 (85.4%) | 148 (79.6%) | 67 (83.8%) |
| Yes (2) | 86 (17.0%) | 35 (14.6%) | 38 (20.4%) | 13 (16.2%) |
Latent profiles of family management of children with asthma
One to four Latent Profile Models were extracted, respectively, for the study. The fitting indices are summarized in Table 2. As shown in the table, the information of the indices was not consistent. The best fitting LPA was the three-profile model, which had the lowest AIC (7462.01), BIC (7605.65) and aBIC (7497.73). The p-values of the LMR test (<0.0001) and BLRT (<0.0001) suggested that this model was statistically significant at α = 0.05 level. The entropy value was 0.863 for the three-profile model, which was the highest among the four profiles.
TABLE 2 Latent profile analysis models and fit indices.
| Model | K | Log(L) | AIC | BIC | aBIC | Entropy | LMR | BLRT |
| 1 profile | 16 | −4201.46 | 8434.92 | 8502.51 | 8451.73 | — | — | — |
| 2 profiles | 25 | −3810.23 | 7670.46 | 7776.08 | 7696.73 | 0.841 | <0.0001 | <0.0001 |
| 3 profiles | 34 | −3697.01 | 7462.01 | 7605.65 | 7497.73 | 0.863 | <0.0001 | <0.0001 |
| 4 profiles | 43 | −3626.03 | 7338.07 | 7519.72 | 7383.24 | 0.849 | 0.0152 | <0.0001 |
Scores of the family management style scale for children with asthma
The total score and the scores for each dimension of FMSCA are shown in Table 3. The total score on the scale ranged from 107 to 285, with an average of 239.8. Among the profile scores, the total score on the scale ranged from 182 to 285 in Profile 1, ranged from 181 to 280 in Profile 2, ranged from 107 to 285 in Profile 3. Profile 1 had the highest average score (257.7) while Profile 2 had the lowest average score (215.8). The average item scores for the three profiles across the eight dimensions of FMSCA are shown in Figure 1.
TABLE 3 Scores of FMSCA and the eight dimensions.
| Minimum | Maximum | P 50 | Mean | Standard deviation | |
| Total Sample | |||||
| Child identity | 7 | 30 | 29 | 27.3 | 3.204 |
| View of condition | 10 | 30 | 25 | 24.7 | 3.833 |
| Management mindset | 4 | 20 | 11 | 11.4 | 4.482 |
| Parental mutuality | 8 | 40 | 35 | 34.4 | 5.551 |
| Parenting philosophy | 5 | 25 | 20 | 20.5 | 3.341 |
| Management approach | 28 | 95 | 85 | 83.6 | 8.288 |
| Family focus | 5 | 20 | 16 | 15.7 | 3.710 |
| Future expectations | 5 | 25 | 23 | 22.1 | 3.393 |
| Entire scale | 107 | 285 | 242 | 239.8 | 23.083 |
| Profile 1 | |||||
| Child identity | 17 | 30 | 29 | 28.9 | 1.930 |
| View of condition | 10 | 30 | 25 | 26.1 | 3.124 |
| Management mindset | 4 | 20 | 11.5 | 13.6 | 4.288 |
| Parental mutuality | 8 | 40 | 36 | 36.7 | 4.305 |
| Parenting philosophy | 11 | 25 | 20.5 | 21.8 | 2.924 |
| Management approach | 63 | 95 | 86 | 88.2 | 5.080 |
| Family focus | 6 | 20 | 17 | 18.5 | 1.765 |
| Future expectations | 11 | 25 | 24 | 24.0 | 1.798 |
| Entire scale | 182 | 285 | 247.5 | 257.7 | 12.583 |
| Profile 2 | |||||
| Child identity | 8 | 30 | 28 | 25.4 | 3.452 |
| View of condition | 10 | 30 | 24.5 | 25.4 | 3.452 |
| Management mindset | 4 | 20 | 11 | 10.4 | 3.421 |
| Parental mutuality | 8 | 40 | 33 | 30.7 | 5.533 |
| Parenting philosophy | 10 | 25 | 20 | 18.2 | 2.889 |
| Management approach | 57 | 95 | 82 | 75.4 | 6.071 |
| Family focus | 7 | 20 | 16 | 14.2 | 2.824 |
| Future expectations | 9 | 25 | 22 | 19.1 | 3.265 |
| Entire scale | 181 | 280 | 230 | 215.8 | 14.251 |
| Profile 3 | |||||
| Child identity | 7 | 30 | 28 | 27.4 | 3.165 |
| View of condition | 12 | 30 | 25.5 | 27.4 | 3.165 |
| Management mindset | 4 | 20 | 9.5 | 7.15 | 3.106 |
| Parental mutuality | 14 | 40 | 36 | 36.5 | 3.999 |
| Parenting philosophy | 5 | 25 | 21 | 21.7 | 2.675 |
| Management approach | 28 | 95 | 86.5 | 89.0 | 4.790 |
| Family focus | 5 | 20 | 14.5 | 10.7 | 2.417 |
| Future expectations | 5 | 25 | 24.5 | 23.5 | 2.408 |
| Entire scale | 107 | 285 | 244 | 242.5 | 10.768 |
[IMAGE OMITTED. SEE PDF]
Relationship between latent profiles and the control level of asthma
Relationship between latent profiles and the control level of asthma was examined by chi squared. There is statistically significance between the various latent profiles and the control level of asthma (Table 4).
TABLE 4 Relationship between latent profiles and the control level of asthma.
| Control level | Profile 1 (n, %) | Profile 2 (n, %) | Profile 3 (n, %) | χ 2 | p |
| Not controlled | 36 (15.0%) | 58 (31.2%) | 15 (18.7%) | 59.86 | <0.001 |
| Partially controlled | 21 (8.8%) | 54 (29.0%) | 16 (20.0%) | ||
| Fully controlled | 183 (76.2%) | 74 (39.8%) | 49 (61.3) |
Results of multiple LOGSTIC regression analyses
After dividing 506 families of children with asthma into three potential profiles, the potential predictors were incorporated into multiple logistic regression analyses. As indicated in Table 5, the child's age, gender, mother's education level, family structure, influence of illness on parents' work and family life, whether they had follow-up plans, and whether their parents had read disease and health knowledge pamphlets were found to be the predictors of different styles.
TABLE 5 Predictors of latent profiles (Reference group: Profile 1).
| B | Std | Wald χ2 | OR | 95% CI | p | |
| Profile 2 | ||||||
| Children's characteristics | ||||||
| Child's age (years old) | 0.820 | 0.229 | 12.799 | 2.271 | 1.449–3.559 | <0.001 |
| <4 (1) | ||||||
| ≥4 but <7 (2) | ||||||
| ≥7 but <11 (3) | ||||||
| ≥11 (4) | ||||||
| Family factors | ||||||
| Influence of illness on parents' work and family life | −1.030 | 0.222 | 21.605 | 0.357 | 0.231–0.551 | <0.001 |
| No (1) | ||||||
| Yes (2) | ||||||
| Organizational factors | ||||||
| Whether they had follow-up plans | 0.528 | 0.225 | 5.501 | 1.696 | 1.091–2.636 | 0.019 |
| No (1) | ||||||
| Yes (2) | ||||||
| Whether their parents had read disease and health knowledge pamphlets | 0.859 | 0.233 | 13.592 | 2.361 | 1.495–3.728 | <0.001 |
| No (1) | ||||||
| Yes (2) | ||||||
| Profile 3 | ||||||
| Children's Characteristics | ||||||
| Child's gender | −0.719 | 0.331 | 4.718 | 0.487 | 0.255–0.932 | 0.030 |
| Female (1) | ||||||
| Male (2) | ||||||
| Family factors | ||||||
| Family structure | −1.176 | 0.385 | 9.339 | 0.308 | 0.145–0.656 | 0.002 |
| One-parent family (1) | ||||||
| Core family (2) | ||||||
| Extended family (3) | ||||||
| Influence of illness on parents' work and family life | −0.971 | 0.288 | 11.363 | 0.379 | 0.215–0.666 | 0.001 |
| No (1) | ||||||
| Yes (2) | ||||||
| Mother's education level | −0.454 | 0.222 | 4.190 | 0.635 | 0.411–0.981 | 0.041 |
| Junior high school and Below (1) | ||||||
| Senior high school and above (2) |
DISCUSSION
This study is among the first studies to employ LPA to reveal the family management styles of children with asthma, producing results consistent with our research hypothesis. LPA was selected over other exploratory approaches due to its model-based nature, relying on multiple dimensions. Its classification is entirely dependent on data rather than the subjective judgement of researchers (Muthén & Muthén, 2017; Nylund-Gibson & Choi, 2018). Using LPA, we identified three distinct profiles of families based on different scoring probabilities across the eight dimensions of the FMSCA (Cheng et al., 2022; Xing et al., 2020). The three profiles we identified were significantly linked to the control level of asthma, highlighting the significance of classifying family management profiles among Chinese children with asthma.
We characterize the first profile as ‘Thriving Family Management Style’. Families in Profile 1 endorsed high scores to most of the items in all eight dimensions. According to the definitions of eight dimensions, parents in this profile consider the child as normal. They had a high level of mastery about the cause, severity, prognosis, and course of asthma. They perceived carrying out the treatment regimen was easy. They were confident of their ability to manage asthma effectively. Parents had shared views of the child, asthma, their parenting philosophy, and their approach to asthma. They had a good understanding of the goals, priorities, and values of approach and specific strategies for asthma management, and believed that asthma would have little impact on the future life of the child and family. In addition, they could develop a routine and related strategies for asthma management and incorporate them into family life, especially keeping the balance between asthma management and other aspects of family life. The characteristics of this group is similar to the description of thriving family management style proposed by Knafl et al. (1996). Therefore, this profile was named the ‘Thriving group’. 47.4% of families belong to this group, indicating that almost half of the families in our study manage the disease effectively. The relatively high scores for the total and subscales of FMSCA, as displayed in Table 3, also echo this finding. This result is in line with the findings of Zhang and Duan (2017) and Cheng et al. (2022) research.
For families in Profile 2, as shown in Figure 1, the average scores in the eight dimensions were all lower than Profile 1(Thriving group). Parents in these group may view their situation more negatively and having more difficulty managing asthma than those in the thriving group. Parents' views toward the child, the disease itself, and parenting philosophy may need to be improved. Parents may perceive asthma management as relatively difficult, and their management strategies may need to be improved. They may face challenges in balancing disease management with family life, and the implications of the disease for their child and family in the future may remain unclear. This group was similar to families in the accommodating management style described by Knafl et al. (1996) and was named ‘Accommodating group’, which accounts for 36.8% of families.
For families in Profile 3, expect for ‘Management mindset’ and ‘Family focus’ dimensions, the other dimensions were about the same as those in Profile 1(Thriving group). The mean scores for these two dimensions in this profile were the lowest among the three profiles. Unlike parents in the Thriving group, parents in this group may perceive asthma management as a very difficult task to finish, and perceive asthma as having major negative consequences for their family life, and may fail to achieve a balance between asthma management and family life. This group was similar to families in the enduring management style described by Knafl et al. (1996) and was named ‘Enduring group’, which only accounts for 15.8% of families.
Struggling and floundering patterns were not derived from our study. According to Knafl et al. (1996), the overriding theme of struggling family management style is the parental conflict over how best to manage the child's illness. Our result does not support this, as the mean scores of parental mutuality were relatively high for all the three profiles. One explanation may be the high percentage of good parents' relationship in our study. Another explanation may be the avoidance of conflict in Chinese culture. An inconsistent or missing parenting philosophy may clearly set the parents in the floundering group apart from parents in all the other management styles (Knafl et al., 1996). The relatively high scores of parenting philosophy in all the three profiles do not support the floundering pattern.
In the investigation of individual factors related to the children, we found that an older child would be more likely in Profile 2 (Accommodating group) than in Profile 1(Thriving group). As children grow older, their increased awareness may lead to more conflict with intervention and management (Xiao, 2020). In daily life, parents may be more willing to consider their child's feelings and neglect disease management. At the same time, due to concerns about the side effects of the medication, parents may believe that long-term hormone therapy will have adverse effects on the children and therefore did not follow the doctor's order. According to a qualitative study (Liu et al., 2020), parents may judge the child's condition based on their own experience and reduce or even skip the ICSs to minimize adverse effects. In our study, we found the female children with asthma were more likely in Profile 3 (Enduring group) than in Profile 1 (Thriving group). Research supports that the most common allergens are pollen, fur and feather of pets (Qiu et al., 2019). Compared with boys, girls may be more likely to be exposed to plants and pets such as cats and dogs, which would be detrimental to the management of allergic asthma.
Surprisingly, we found that if parents' work was affected by the disease, the family is more likely in Profile 1 (Thriving group) than in Profile 2 (Accommodating group) and Profile 3 (Enduring group). It should be noted that our study is cross-sectional in nature. It may be that parents have to invest a lot of time and energy in order to achieve better understanding and management skills, which in turn affect their work. Longitudinal studies are needed to confirm this. Children in extended families were more likely to appear in Profile 1 (Thriving group), while those in one-parent families were more likely to appear in Profile 3 (Enduring group). One-parent families may be under a heavy burden of care and fail to meet their children's needs. Compared to the Western culture, extended family is still a major form of family structure in China. Grandparents also assume important roles in taking care of the children (Ma, 2023). As a qualitative study has showed (Liu et al., 2020), when there were conflicts between parents and grandparents regarding the child's asthma management, parents usually had to agree with grandparents' opinions and behaviours due to filial piety, even though parents believed that the grandparents' opinions and behaviours might not be beneficial to their children's asthma management. Interestingly, the current study indicated that grandparents' advice did not play a decisive role. As pointed out by Ma (2023), the authorities of grandparents have been decreasing gradually in recent decades due to the urbanization and economic independence of parents in China. Grandparents were increasingly aligned with parental management, leading to better family management. Given the influence of family structure on disease management of children with asthma, family related factors should be assessed by healthcare providers. In addition, between Profile 1(Thriving group) and Profile 3 (Enduring group), the more educated the mother, the more likely that children were in Profile 1(Thriving group). In China, the mother is usually the primary caregiver of the child and takes more responsibility for the children's daily life compared with other secondary caregivers. The higher education level of the mother, the greater the awareness of the disease, making it easier to integrate disease management into daily life.
As to the organizational factors, we found that if families had follow-up plans, they might be more likely in Profile 2 (Accommodating group) than in Profile 1 (Thriving group). Follow-up plans mean more follow-up visits. It is assumed that more follow-up visits would result in increased interaction between parents and clinicians, leading to the Thriving group and good-management behaviours. However, due to the cross-sectional nature of the study design, we were unable to decide the causal relationship between follow-up plans and management levels. In other words, instead of being the assumed antecedent of Thriving group with good-management behaviours, follow-up plans might actually the consequence of poor asthma management and recurrent refractory asthma. Therefore, the group with follow-up plans was actually the Accommodating group characterized by management difficulties, although their asthma management ability may have improved due to the follow-up plans. Interestingly, as one of the information resources, having read the disease and health knowledge pamphlets is a barrier to family management. We found they were more likely to be in Profile 2 (Accommodating group) than in Profile 1 (Thriving group), which is contrary to the findings of Long's study (2019). Usually, the pamphlets are conveniently displayed on shelves and ready to be picked up. It may be because only those who do not manage the disease well will pick up the pamphlets and read them. It may also be associated with refractory asthma. Despite carefully reading the health information pamphlets, parents in those families may still gradually lose confidence during the management process due to the incurable nature of asthma.
Strength and limitations of the work
To the best of our knowledge, this is one of the first studies aiming at the classification of heterogeneous subgroups of family management styles for children with asthma. While this is innovative and significant, there are several limitations in this study. First, although our study had a relatively large number of participants, it may fail to fully represent the common profiles of family management of children with asthma across China, as we used a convenience sampling, and the sample size of children with asthma in rural areas was small. Future research could use a different type of sampling approach to include more rural samples to make the sample more representative. Second, due to the cross-sectional nature of the study design, causal relationships cannot be drawn. Longitudinal studies could be conducted to confirm the results. Third, we labelled the family management patterns by referring to those which were derived qualitatively by Knafl et al. (1996). Although the names of the labels are the same, it should be cautious to conclude that they are identical, as we derived the labels quantitatively by using LCA and not from the narrative accounts. We can only refer to the characteristics of the five patterns and the eight dimensions of FMSF in the publications by Knafl et al. (1996, 2011) to label the profiles in our study. Hence, bias may exist. Lastly, the profiles we identified in this study may be only limited to those in China, as cultural norms are different globally.
Recommendations for clinical practice and further research
At present, research on precision medicine continues to deepen due to the development of genomics, proteomics technology, and precision medicine theory. In childhood asthma, the core of management is medication management and symptom monitoring, which is relevant to the genomics and proteomic-based context of precision medicine. However, the family management of children with asthma is lacking in this aspect. With the goal of providing precision health services to children with asthma in clinical practice, we accurately classified the family management styles of children with asthma and their associated factors. Based on the focus of asthma phenotype research within the context of precision medicine, our insights on the precise classification of family management styles in this study can serve as a guide to form multi-disciplinary teams of physicians and nurses to provide individualized care and conduct in-depth research to explore the mechanisms of biomedicine and the social psychology of asthma in the future. From research perspective, to ease the response burden of the 57-item FMSCA and facilitate the quick assessment of family management styles, association and correlation technique in data mining could be used to shorten the number of items in FMSCA and subsequently classify the potential categories of short form of FMSCA in future research, and validate it in clinical practice.
CONCLUSION
We applied LPA to investigate family management styles of 506 caregivers of children with asthma in China. We identified three types of family management styles based on the caregiver's responses to the Family Management Style Scale: (1) Thriving, (2) Accommodating and (3) Enduring. The majority of families were in the Thriving group. Predictors of family management styles include: characteristics of the children, such as the gender and age; family factors, such as family structure, influence of illness on parents' work and family life, and mother's education level; and organizational factors, such as whether the family had follow-up plans and whether their parents had read disease and health knowledge pamphlets. For different types of family management, medical staff should adopt different disease management and education approaches to improve family management capabilities.
AUTHOR CONTRIBUTIONS
Keke Lin: Conceptualization, Methodology, Software, Writing- Original draft preparation and editing. Yuying Zhang: Conceptualization, Methodology, Software, Writing- Original draft preparation and editing. Xudong He: Methodology, Software. Xiangyu Chen: Methodology, Software. Xianzhen Zhang: Data curation. Hongmei Duan: Conceptualization, Writing- Reviewing and Editing, Supervision.
ACKNOWLEDGEMENTS
We would like to thank Jim Stout, Indiana University, USA (retired) for his help in editing. We also thank Xiaoshang Lou and Yuexia Li from Capital Institute of Paediatrics, Beijing for their help in data collection and resource coordination.
FUNDING INFORMATION
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
STATISTICS STATEMENT
The authors have checked to make sure that our submission conforms as applicable to the Journal's statistical guidelines described here. The statistics has been checked prior to submission by Professor Jianzhou WANG, an expert statistician from School of Statistics, Dongbei University of Finance and Economics, Dalian, China. His email is
Bronfenbrenner, U. (1979). The ecology of human development. Harvard University Press.
Cheng, J., Wang, H., Zhang, X., Guo, H., & Duan, H. (2022). The factors of family management affecting asthma control status in school‐age children with asthma in China. The Journal of Asthma, 59(5), 1041–1050. [DOI: https://dx.doi.org/10.1080/02770903.2021.1895209]
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Abstract
Aim
To identify the latent profiles and predictors of family management styles for children with asthma.
Design
This is a secondary data analysis. The demographic data of 506 primary caregivers of children with asthma and their scores of the Family Management Scale in a cross‐sectional study were used. Latent profile analysis and multiple logistic regression analyses were employed.
Results
Three family management styles were identified: Thriving (Profile 1), Accommodating (Profile 2), and Enduring (Profile 3) Family Management Style. The child's age, gender, mother's education level, family structure, influence of illness on parents' work and family life, whether they had follow‐up plans and whether their parents had read disease and health knowledge pamphlets were found to be the predictors of different styles.
Conclusion
Three distinct family management styles exist for children with asthma. Future interventions designed to enhance family management for children with asthma should be based on their demographic characteristics and family management styles.
Implications for the Profession and Patient Care
The precise classification of family management styles in this study can serve as a guide to form multi‐disciplinary teams of physicians and nurses to provide individualized care and conduct in‐depth research to explore the mechanisms of biomedicine and the social psychology of asthma in the future.
Impact
Reporting Method
The article was reported according to the STROBE Checklist.
Patient or Public Contribution
No Patient or Public Contribution.
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Details
; Zhang, Yuying 2 ; He, Xudong 1 ; Chen, Xiangyu 1 ; Zhang, Xianzhen 3 ; Duan, Hongmei 1 1 School of Nursing, Beijing University of Chinese Medicine, Beijing, China
2 Department of VIP Clinic Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
3 Emergency Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China