Caregiver awareness of pediatric respiratory red-flag signs and emergency activation intentions: a province-wide cross-sectional study in China

TL;DR

This study finds that most caregivers in China poorly recognize critical pediatric respiratory symptoms, despite knowing when to seek emergency help.

Contribution

The study identifies specific gaps in caregiver recognition of red-flag respiratory symptoms and quantifies predictors of appropriate emergency response.

Findings

Only 22.9% of caregivers had adequate awareness of pediatric respiratory red-flag signs.

Caregivers with higher education and health literacy were more likely to recognize critical symptoms.

Emergency activation intentions were appropriate in 65% of cases, but varied by clinical setting.

Abstract

Caregiver recognition of pediatric respiratory red-flag signs remains suboptimal despite established international guidelines. The purpose of this study was to investigate caregiver awareness of pediatric respiratory red-flag signs and their intended emergency activation behaviors in China.

We conducted a cross-sectional, mixed-mode survey involving 2,702 caregiver–child dyads across pediatric outpatient departments, emergency departments, and wards in Hubei Province, China. Data were collected using a validated questionnaire that measured awareness of 12 red-flag respiratory signs and emergency activation intentions across 5 clinical vignettes. Primary outcomes were adequate awareness (Awareness Index ≥0.70) and high emergency activation intention (Emergency Activation Intention Score (EAIS) ≥ 20). Data were analyzed using multivariable logistic regression.

Adequate awareness was achieved by only 22.9% (n = 618) of the caregivers. Notably, symptom recognition varied substantially: identification rates were relatively high for cyanosis (71.0%) and severe chest indrawing (68.4%), but markedly lower for very low oxygen saturation (36.6%) and apnea (40.7%). Conversely, a majority of the cohort (n = 1,756, 65.0%) demonstrated appropriate emergency activation intentions. Caregivers exhibited a high propensity to contact emergency services during urgent scenarios (86–89%) while exercising suitable restraint during non-urgent presentations (12.3%). Multivariable analysis identified college education as the most robust predictor of adequate awareness (aOR = 3.41, 95% CI: 2.75–4.23, p < 0.001), followed by knowledge of the emergency number 120 (aOR = 1.67, p = 0.004) and a history of prior respiratory hospitalization (aOR = 1.34, p = 0.015). Furthermore, a distinct dose–response relationship regarding health literacy was observed, with adequate awareness being significantly more prevalent among caregivers with high health literacy compared to those with low health literacy (29.8% vs. 15.1%, p < 0.001). Finally, emergency activation rates were influenced by the clinical setting, as caregivers in the emergency department demonstrated significantly higher rates than those in outpatient environments (70.7% vs. 62.8%, p < 0.001).

Despite appropriate emergency activation intentions, caregivers’ limited recognition of red-flag symptoms highlights a critical knowledge–behavior gap. Targeted educational interventions addressing these specific deficits are essential to improving pediatric respiratory emergency outcomes.

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