Responses by subject

Angela Boque (Spain):

1. Acceptance and understanding that there are things that they cannot do or must do. For example, the child who loves football and has an exacerbation: it's extremely difficult for him to accept that this day, this week, he cannot play until he gets better.
2. Avoidance of certain things, for example, mite prevention, setting up the child's room in the best way.
3. Being faithful to treatment; the parent or the child, they are the ones who decide to stop medications when the child feels better.

Sandra Frateiacci (Italy):

1. School: Even in the best case scenario when parents are well-informed and have instituted all preventive steps at home so that asthma is well-controlled, children spend long days at school, up to 8 hours and starting at a young age. Italian schools are often in older and poorly maintained buildings; and the cleaning leaves a lot to be desired. Thus, all the steps taken at home are diminished if the school environment is not adequately cleaned. We don't succeed in ensuring an adequate environment at school because of the costs involved, both of money and time commitment.
2. Recreational structures and travel: It is difficult to protect the child from allergen exposure in recreation and travel because the public does not understand the importance of allergen avoidance. For example, dogs and cats are allowed in public places, on buses, ships, and trains, as well as in restaurants and hotels in Italy. Thus, people with animal allergies have problems travelling, in hotels, and in vacation rental homes. There is no mentality for the improvement of the environment.
3. Access to emergency services at hospitals: Even at hospitals, the seriousness of allergies, of an asthma attack is not taken into consideration. Children with asthma and/or allergies, even when severe, have to wait their turn in crowded waiting rooms, where people may be wearing perfume or come from homes with animals, and there is dust. If they go outside, they are exposed to people smoking and cannot hear their name called when it is their turn.
4. People do not understand the problem; for example, they say that the dog doesn't bite. Parents and children always have to fight to help people understand the problem of allergies and asthma. Frequently, at a certain age, children with these problems become tired of feeling different because it has to be told to others that they are a problem. It's a form of profound isolation because they become socially distanced because they can't do the same things that their friends do. They become excluded from the normal social life of their contemporaries.

Len Fromer (USA):

1. Trigger avoidance.
2. Adherence to controller medications.
3. The stigma of asthma in the social milieu; the challenge of not wanting to show that they have asthma. Children want to hide the fact that they have to take medications and have to avoid trigger factors. I teach them to say, "I'm allergic to it [a food]." Rather than "I can't eat it. I have asthma."

Svein Høegh Henrichsen (Norway):

1. The medication: both that they have to remember to take it even when they don't feel they have any problems and the fear of side effects.
2. They get very anxious if they have infections.

Chris Hogan (Australia):

1. Exposure to cigarette smoke has to be the top one.
2. Peer pressure--As far as children are concerned, it is the stigmatization associated with being different.
3. In Australia, there is a revolt against the concept of western medicine; western medicine is considered to be the status quo. It's part of the youth culture of rebellion; and there's a whole range of issues where western medicine is considered part of the establishment, the 'parentalistic' attitude of health care, and the lack of autonomy that being involved with the medicine brings.
4. Often we don't target the carers. For those people who come from a culture that doesn't have a concept of asthma-in fact a lot of our regional neighbours don't have a word for asthma in their language-the concept of chronic illness is not well understood.
5. . Difficulties are severe for patients with dual pathologies, such as an unstable family; tobacco or marijuana addiction; or chronic illness.

Alexandre Holanda (Brazil):

Alan Kaplan (Canada):

Sarath Paranavitane (Sri Lanka):

1. For parents: giving children inhaled medication through a spacer. Children are cooperative at the beginning, then parents almost have to "bribe" them to comply; for little children it's like a toy, the novelty soon wears off and they are disinterested thereafter.
2. Unfounded fears about inhaled medications, which I believe can be easily dispelled if one takes time to explain.

Dermot Ryan (UK):

1. Kids get fed up with taking their medication. Taking medication regularly is a big problem. Side effects do not seem to be a problem.
2. As kids get older, they worry whether it's fashionable enough or not.

Björn Ställberg (Sweden):

1. Problems for parents: Parents may be divorced, and one parent may have a cat, for example.
2. Allergic asthma is especially a problem: children may not be able to go to a friend's house or a relative's house. Also cat dander follows the clothes, and children who do well at home on the weekend may gradually do worse over the week at school. Many have eczema and are itching a lot; many have food allergies, and the parents are afraid of children getting a severe food allergy reaction.
3. Taking medications regularly.
4. When children are small, parents are afraid of the disease, of what may happen. They have medications but cannot travel without them. They are small problems, but together many small problems add up to a big problem.

Hakan Yaman (Turkey):

1. For the parents, anxiety about the health of the children and certainly about being successful in getting the children to take the medication.
2. For the children, the feeling of being handicapped with peers and at school, of being different-the stigmatization in society, at school, with friends.

Osman Yusuf (Pakistan):

1. Lack of education. Because if they haven't been educated they don't know when to continue or when to stop the medicine, they don't know the importance of taking it regularly.
2. Peer pressure. A lot of peer pressure. "Don't give him so many medicines, he won't grow up; don't give him these medicines, they will make his asthma worse, they can kill him, the side effects are too much." Peer pressure is the second thing that you really have to counteract.
3. Proper diagnosis and treatment. Parents and children are going to the physician, they are spending money, they are buying medicines, but it's the wrong medication and the wrong diagnosis. So we need the doctor to be up to the mark.