# 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.

## Key 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.