**4. Discussion**

The family, as the core of society, is responsible for providing adequate care for children. Besides, it should have correct information and perception of the child's disease [28]. According to Piaget's theory, school-aged children (7 to less than 12) gain the ability to solve concrete problems [25]. For that, they can manage and control asthma by themselves and with their parents' supervision through education and

support. The fact of being responsible for asthma management as a school-age child is a huge development, which provides strength and command over the disease. The National Heart, Lung and Blood Institute (NHLBI), and the Global Initiative for Asthma (GINA) strictly emphasize educating asthmatic children, their parents, and health care professionals [1, 29]. Family education has a crucial role in empowering children and their families to effectively control and manage asthma. Evidence supported pediatric nurses to educate children with asthma and their families [8, 9]. The British guideline on asthma management suggested that family therapy may be a useful adjunct to medication use in children with asthma [30].

In this study, we reviewed the characteristics and the impact of family education on asthma outcomes. The reported asthma clinical outcomes were QOL, asthma symptom control, pulmonary function, ED use/hospitalization, medication adherence, and inhalation technique. This literature review revealed that home- and clinic-based family education was significantly effective in enhancing the QOL of children with asthma and their parents and asthma symptom control. Five family interventions improved pulmonary function, medication adherence, and inhalation technique [15, 18, 21, 24, 26]. One family education program reduced ED use [13].

Indeed, family interventions are needed to develop empowerment skills in families to take care of asthmatic children [21, 25]. The literature revealed that family empowerment education based on empowerment theories enhanced the QOL of children and parents, asthma symptom control, and pulmonary function in asthmatic children, as well as reduced parental stress [16, 17, 21, 22, 25]. Moreover, the use of predetermined open-ended communication, meaningful learning, art therapy, problem-solving, and goal setting principles was advantageous for better medication use, parent's QOL, and asthma symptom control [18]. Besides, the multidisciplinary intervention that included a pediatrician, a pediatric pulmonologist, a pediatric psychologist, and two experts in the field of Information and Communication Technologies-based tools had a crucial role in improving the QOL of children, forced expiratory maneuvers, and asthma symptom control [24].

The synthesis of the literature demonstrated that it is beneficial to educate children and their parents about the different asthma aspects in group sessions at home, school, or in clinical settings. Asthma aspects can include asthma pathophysiology, triggers identification, symptoms recognition, effective response during exacerbations, asthma action plan, types of asthma medications and their correct use, and communication with care providers. The interventions must be age-appropriate, culture-tailored, and well-designed to satisfy the unmet health care needs of families of children with asthma. These data suggested that family interventions can promote the health of asthmatic children in diverse settings. Furthermore, this study revealed that family asthma educational interventions were widely and successfully implemented in lower- and upper-middle income countries, including Tunisia, India, Egypt, Iran, and Turkey [31].

This literature review presented several limitations. First, articles published in languages other than English were not considered. Second, only three databases were used for data search. Due to these facts, some of the relevant articles may not be included in this literature review. Besides, half of the studies included (11 of 22 studies) had small samples, which can limit the generalizability of the results. However, this literature review reported recent interventions in detail. The practice implication for pediatric nurses was noticeable and fitted the guidelines of the National Heart, Lung and Blood Institute, and the Global Initiative for Asthma.
