Association Between Parental Asthma Knowledge and Perceptions of Asthma Control in Children: A Cross-Sectional Study in a Malaysian Tertiary Hospital

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ABSTRACT Introduction: Parental knowledge and perceptions about asthma are core factors influencing the better management and control of their children’s asthma, as parents are the primary caretakers. The association between these factors and childhood asthma control is not well characterised in Malaysia. Objective: This study aimed to investigate the association between asthma knowledge and perceptions among parents of asthmatic children and their children’s asthma control level. Method: A cross-sectional study with a sample size of 131 participants was conducted in the paediatric medical outpatient clinic of Sarawak General Hospital from January to March 2019. Face-to-face interviews were conducted with parents of asthmatic children using a validated questionnaire to determine socio-demographic characteristics of both parents and children, as well as parental asthma knowledge and perceptions. The internal consistency (Cronbach’s α) of the knowledge and perception constructs were 0.631 and 0.647, respectively. Children’s asthma control levels were assessed using two rating systems: the C-ACT score and the GINA-defined asthma control questionnaire. Data were analysed using non-parametric tests (Mann-Whitney U and Kruskal-Wallis tests) and Spearman’s correlation. Results: Parents averaged an asthma knowledge score of 8.8 out of 15, with those aged between 41-50 years old (p=0.006), those with tertiary education (p=0.001), and families with an income of ≥RM5000 (p<0.001) achieving significantly higher scores. The knowledge score was positively correlated with parental perceptions regarding the timeline of childhood asthma (r=0.184, p=0.035), but did not significantly correlate with their children’s asthma control level (r=0.024, p=0.783). C-ACT scores were significantly higher among parents living in urban areas (p=0.029) and those who were well educated (p=0.001), but negatively correlated with parental perceptions regarding the timeline of childhood asthma (r=-0.285, p=0.001). Conclusion: Despite a positive correlation between asthma knowledge scores and the education level of parents, their asthma knowledge and perceptions did not significantly influence the control of their children’s asthma. Other factors should be investigated.

INTRODUCTION

Asthma is a common respiratory disease affecting around 300 million individuals worldwide [1]. According to the 2006 National Health and Morbidity Survey (NHMS), the overall asthma prevalence among children (below 18 years) was 7.1% in Malaysia [2]. Additionally, 32.3% of those with asthma sought care at the emergency department (ED) due to exacerbations, 14.3% required hospitalisation, and 82.1% had clinic visits for asthma exacerbations [2]. Consequently, asthma is associated with significant morbidity, resulting in increased hospitalisation rates and ED visits among the paediatric population. Conversely, asthma symptoms and treatment can impact the daily lives of individuals with asthma and their families, leading to missed school days, reduced quality of sleep, and limitations in physical and social activities [3][4]. Therefore, managing childhood asthma should involve the implementation of asthma action plans, suitable pharmacological treatments, and asthma education for both parents and children with asthma [5].

Most asthma management guidelines emphasise the crucial role of families in handling childhood asthma. Caregivers must closely monitor symptoms and address them daily due to the condition’s variable nature [6][7]. Numerous studies have stated that the control of childhood asthma can be greatly affected by family factors [7][8]. Factors like parental knowledge, attitudes, education, income, healthcare access, and medications influence asthma management for parents of asthmatic children.  Adherence to asthma treatment plans is a primary family responsibility in asthma management [9]. A study by Faber HJ et al. revealed that parental misunderstanding of inhaled corticosteroids correlated with reduced daily usage [10]. Moreover, asthma management is often influenced by parents’ perceptions of their children’s symptoms. Some studies have shown that many parents struggle to accurately assess the severity of their children’s asthma, relying on the frequency of symptoms and the use of bronchodilator inhalers [11][12]. This misunderstanding can eventually lead to uncontrolled asthma and severe consequences. Thus, understanding the importance of asthma knowledge and perceptions for parental asthma management is essential for improving asthma control in children.  

In Malaysia, a study evaluated parental knowledge of childhood asthma and its management in an outpatient setting at a state hospital. The findings revealed that parents had adequate knowledge of asthma’s causes and symptoms but were less informed about its management [13]. In contrast, another local study conducted in 1998 at Hospital Kuala Lumpur reported a low asthma knowledge level and its association with steroid use and economic status [14].

Given the conflicting results from local studies and the scarcity of research on the relationship between parental knowledge of asthma and perceptions of asthma control in children, this study aims to investigate the association between parental asthma knowledge and perceptions among parents of asthmatic children, as well as their children’s levels of asthma control.

METHOD

Study type and design

This was a cross-sectional study that assessed the parent’s asthma knowledge and perceptions, along with asthma control assessment via a validated questionnaire in Sarawak General Hospital (SGH).

Study population and sampling method

A convenience sampling method was used in this study, targeting all the parents aged 18 years old and above who have at least one child with a doctor-confirmed diagnosis of asthma, aged between 4 and 11 years, and followed up in the paediatric medical clinic at SGH during the period from 28 January 2019, to 8 March 2019. Children with significant developmental delays or other chronic conditions requiring extensive medical care were excluded from this study.

Sample size

The required sample size for this study was determined based on a study conducted by Zhao J et al. [15]. The monthly average number of asthma patients following up in SGH paediatric medical clinic was 168, which served as a guide to estimate the minimum effective sample size needed for this study. Using a 95% confidence interval and a 5% error margin, the estimated sample size was 98 participants. However, the final sample size should be at least 108 participants to account for a 10% non-response rate. The sample size required for a given significance level and margin was calculated by using the formula below [16]:

Where,

N = Population size (168),

p = Expected proportion (18.3%),

d = Precision (5%),

Z = Z statistic for a confidence level of 95% (Z = 1.96)

Data collection

The questionnaires were divided into five sections: (1) parent’s and children’s socio-demographic information, (2) parental perceptions of childhood asthma, (3) asthma knowledge questionnaire (AKQ) with 15 items, (4) Childhood Asthma Control Test (C-ACT) scores in the past 4 weeks (assessed by research investigators), and (5) asthma control level in the past 4 weeks according to GINA guidelines (assessed by doctors). The self-administered questionnaires were then answered by the participants under the supervision of the researchers to ensure clarity and limit response bias. After that, all of the participants’ children were assessed by the researchers based on C-ACT to determine their asthma control level before being reviewed by the doctors in the paediatric medical clinic. Finally, the doctors evaluated the asthma control level of the children based on GINA guideline criteria. The doctors were blinded to the C-ACT scores assessed by the researchers to avoid any forms of bias.

Parental asthma knowledge questionnaires

The parental asthma knowledge questionnaire was used to measure components of parental asthma knowledge particularly relevant for paediatric asthma management, including knowledge about aetiology, symptoms, and asthma management. This questionnaire was adapted from previously published questionnaires, with modifications made to suit the local population [13][14][17][18][19][20]. The questionnaire was written in the Malay language and consisted of 15 items requiring answers of “True”, “False,” or “Don’t Know”. Each correct answer was allocated 1 point, whereas a wrong answer or an item with no response (don’t know) was given 0 points. The total score was 15, with higher scores indicating better knowledge of asthma. The questionnaire was reviewed by a panel of experts in the clinical pharmacy field for face validation and modifications were made based on their feedback. The reliability of the questionnaire was assessed using the internal consistency reliability test.

Parental asthma perceptions questionnaires

Parental asthma perceptions questionnaire was used to assess the perceptions of childhood asthma among parents with asthmatic children. The questionnaire was adapted from the Malay version of a brief illness perceptions questionnaire (MBIPQ), with permission granted by the authors [21][22]. A total of 8 items are rated using a 0-to-10 scale. This questionnaire was divided into 3 sections: (1) Five items assessing cognitive illness aspects: consequences, timeline (acute or chronic), parental control, treatment control, and presence of asthma symptoms. (2) Two items assessing emotional aspects: concern and emotions regarding asthma. (3) One item assessing asthma comprehensibility. The reported test-retest reliability correlation coefficients of the MBIPQ ranged from 0.39 to 0.70 at 2 weeks and from 0.58 to 0.78 at 4 weeks [22].

Asthma control assessment tools

The C-ACT was designed to assess asthma control in asthmatic children aged 4 to 11 years. It comprised 4 child-reported and 3 parent-reported items, and requiring both parent and child presence simultaneously [23][24]. The total score of C-ACT ranged from 0 to 27, with higher scores representing better asthma control. The validity and reliability study of C-ACT scores showed a Cronbach’s alpha coefficient of 0.79, indicating high internal consistency [23]. On the other hand, the asthma control level of participants determined by doctors was based on GINA guidelines. According to GINA guidelines, the level of asthma symptom control can be categorized into three categories: “well controlled,” “partly controlled,” or “uncontrolled,” based on the frequency of daytime and nocturnal asthma symptoms, limitations of activities, and the use of rescue medication [1].

Statistical analysis plan

The collected data were tabulated and analysed using the Statistical Package for Social Sciences (SPSS, version 24, Chicago, IL, US). A descriptive analysis was conducted to show the distribution of participants’ socio-demographic characteristics. In addition, the results of each item in the asthma knowledge questionnaire were presented in percentages and frequencies, whereas the parental asthma perception scales were presented in the median ± interquartile range (IQR).

As AKQ’s total scores followed a non-parametric distribution, Mann-Whitney U and Kruskal-Wallis tests were utilized to assess the influence of demographic characteristics on the AKQ’s total scores and C-ACT scores. On the other hand, Spearman’s Rank-Order correlation was used to assess the association among correlations of AKQ’s total scores with parents’ variables and C-ACT scores. Moreover, the relationship between parental asthma perceptions scores and AKQ’s total scores and C-ACT scores were also examined. A statistically significant difference was defined at p < 0.05.

Ethical considerations

The ethical approval of this study was obtained from the Medical Research Ethics Committee (MREC), Ministry of Health Malaysia (NMRR Registration Number: NMRR-18-2999-44497). Moreover, written informed consent was obtained from all participants who met the inclusion criteria of this study when the questionnaire was distributed.

RESULTS

One hundred thirty-one of 135 respondents completed the questionnaires, resulting in a response rate of 97%. The socio-demographic characteristics of the participants are summarized in Table I. More than half of the respondents were in the age group of 31-40 years, contributing about 57.3 % (n=75) of the total respondents, while parents aged 50 years and above constituted only 1.5% (n=2). Most respondents were mothers (80.9%; n=106), whereas fathers made up 19.1% (n=25) of the total respondents. Regarding education level, almost two-thirds of the respondents had education up to secondary school (64.9%; n=85), followed by 27.5% (n=36) who received tertiary education. Most respondents reported a household income of less than RM 2000 per month (46.6 %; n=61), despite 61.8% (n=81) being employed. More than half of the respondents’ children with asthma were boys (55%; n=72), and almost half of the respondents’ children were diagnosed at the age of 2 to 5 years (51.9%; n=68). Nevertheless, nearly 40% of asthmatic children did not have any episodes of hospitalisation due to asthma exacerbations in 2018(≥3; n=13, 9.9%).

Table II displays the median scores of parental perceptions of childhood asthma. The parental perception of treatment control (ranging from zero to ten scores) had the highest median ± interquartile range scores (9.0 ± 2.0) among parental asthma perceptions.  Whereas, the parental perception of asthma timeline had the lowest median ± interquartile range scores (4.0 ± 2.0), as most perceived that their children’s asthma condition would recover in a short period. The overall Cronbach’s alpha coefficient of the parental asthma perceptions questionnaire was 0.647, indicating moderate internal consistency and an acceptable level.

Table III illustrates the 15 statements of asthma knowledge. Overall, parents averaged an asthma knowledge score of 8.8 out of 15, indicating a moderate level of knowledge.  When asked whether smoking at home would worsen their child’s asthma, a vast majority (97%; n=127) answered correctly. Similarly, most respondents (94.7%; n=124) agreed that inhalation of paint fumes, gasoline, smoke, or haze would trigger an asthma attack. However, half of the respondents (51.1%; n=67) failed to recognize coughing as one of the asthma symptoms, although three-quarters agreed that asthma can be inherited from parents and that asthma is due to inflammation in the lungs. On the other hand, the majority (90.1%; n=118) had a misconception about the roles of rescue inhalers in managing asthma attack, believing that rescue inhalers reduce inflammation in the lungs instead of dilating the bronchial airways. Furthermore, only 24.4% of the respondents (n=32) were aware that the side effects of asthma inhalers are lesser than the oral form of anti-asthmatic medications. The overall Cronbach’s alpha coefficient of the parental asthma knowledge questionnaire was 0.631, indicating moderate internal consistency and an acceptable level.

Table IV shows the differences in total asthma knowledge scores related to the parents’ socio-demographic characteristics. At a significance level of 5%, median asthma knowledge scores differed among in these groups: parents’ age, education level, and family income. Higher asthma knowledge scores were achieved by parents aged 41–50 years, those with tertiary education level, and those with a family income of more than RM5,000.

Table V outlines the differences in C-ACT scores related to the parents’ socio-demographic characteristics. At a significance level of 5%, median C-ACT scores differed in two groups: places of living (p = 0.029) and education level (p = 0.001). Parents living in urban areas and those with tertiary education had higher C-ACT scores.

Table Ⅰ. Socio-demographic Characteristics of Participants (n=131)

Socio-demographic informationn (%)
Age 
20-30 years old29 (22.1)
31-40 years old75 (57.3)
41-50 years old25 (19.1)
> 50 years old2 (1.5)
Parents 
Father25 (19.1)
Mother106 (80.9)
Marital status 
Married123 (93.9)
Divorced2 (1.5)
Widow/ Widower2 (1.5)
Single parent4 (3.1)
Races 
Malay59 (45.0)
Chinese14 (10.7)
Sarawak Dayak52 (39.7)
Others6 (4.6)
Place of living 
Rural23 (17.6)
Urban108 (82.4)
Education level 
No formal education2 (1.5)
Primary school8 (6.1)
Secondary school85 (64.9)
Tertiary school36 (27.5)
Employment status 
Employed81 (61.8)
Unemployed50 (38.2)
Family income 
Less than RM 200061 (46.6)
RM 2000 – RM 500049 (37.4)
RM 5000 – RM 800013 (9.9)
More than RM 80008 (6.1)
Family history of asthma 
Yes63 (48.1)
No68 (51.9)
Children age 
4-6 years old70 (53.5)
7-9 years old43 (32.8)
10-11 years old18 (13.7)
Children gender 
Male72 (55.0)
Female59 (45.0)
Age diagnosed with asthma 
< 2 years old45 (34.4)
2-5 years old68 (51.9)
6-10 years old18 (13.7)
No. of hospitalisation due to asthma exacerbation (in last year) 
None53 (40.5)
143 (32.8)
222 (16.8)
≥313 (9.9)

Table Ⅱ. Median Scores of Parental Childhood Asthma Perceptions

Parental Asthma PerceptionsMedian ScoresInterquartile range (IQR)
How much does your child asthma affect your life?5.03.0
How long do you think your child asthma will continue?4.02.0
How much control do you feel you have over your child asthma?8.04.0
How much do you think your child treatment can help in his or her asthma?9.02.0
How much do your child experience symptoms of asthma?5.03.0
How concerned are you about your child asthma?8.03.0
How well do you feel you understand your child asthma?8.03.0
How much does your child asthma affect you emotionally? (e.g.: does it make you angry, scared, upset or depressed?)  6.05.0

Table Ⅲ. Correct and Incorrect Answers to the Asthma Knowledge Test

StatementsCorrect ResponseFrequency; n (%)
Correct AnswerIncorrect Answer
1. Asthma can be inherited from parents to children.T99 (75.6)32 (24.4)
2. Coughing is not one of the symptoms of asthma.F64 (48.9)67 (51.1)
3. Asthma is due to inflammation in the lungs.T99 (75.6)32 (24.4)
4. Smoking at home can make a child’s asthma worse.T127 (97)4 (3.0)
5. Inhalation of paint fumes, gasoline, smoke or haze will trigger an asthma attack.T124 (94.7)7 (5.3)
6. Asthmatic attack is more common at night time than daytime.T102 (77.9)29 (22.1)
7. Anger, crying or laughing can cause an asthma attack.T41 (31.3)90 (68.7)
8. Most of the asthmatic children have to go to the hospital for the management of asthma attacks.F105 (80.2)26 (19.8)
9. Wheezing after exercise suggests a sign of asthma.T97 (74.0)34 (26.0)
10. Asthmatic children should not play sports in which involved a lot of running.F51 (38.9)80 (61.1)
11. Asthma can be treated with antibiotics.F59 (45.0)72 (55.0)
12. Inhalers for asthma have lesser side effects than tablets/ syrup form of medications for asthma.T32 (24.4)99 (75.6)
13. A rescue inhaler (i.e.: reliever inhaler) is used to reduce inflammation in the lungs.F13 (9.9)118 (90.1)
14. You don’t need to shake most of the asthma medication inhalers before using them.F123 (93.9)8 (6.1)
15. A preventer inhaler (i.e.: steroid inhaler) doesn’t work unless you use them every day.T105 (80.2) 26 (19.8)

As shown in Table VI, there was a significant positive correlation between asthma knowledge, measured by AKQ, and the parental perception of the timeline of childhood asthma (r = 0.184, p = 0.035). However, other parental perceptions regarding childhood asthma were not significantly correlated with asthma knowledge scores.

In addition, another correlation analysis was conducted to examine the association between the C-ACT scores and the mean scores of parental perceptions of childhood asthma. Based on the correlations analysis shown in Table VII, the p-value was less than 0.05, indicating a significant association between the C-ACT scores and perceptions of the timeline of asthma, parental control over asthma, and asthma symptoms. However, the C-ACT scores were found to be negatively correlated with perceptions of the timeline of asthma (r = -0.285, p = 0.001) and asthma symptoms (r = -0.383, p < 0.001). On the other hand, there was a significant positive correlation between C-ACT scores and parental perception on parental of asthma control (r = 0.186, p = 0.033), indicating that C-ACT

scores moderately increased as parents perceived themselves to have better control over their children’s asthma at home.

As presented in Table VIII, there was a significant positive correlation between asthma knowledge scores and the education level of parents (r = 0.338, p < 0.001). Additionally, parents with higher monthly family incomes had better knowledge of the disease (r = 0.394, p < 0.001). Surprisingly, an analysis of the association between parents’ asthma knowledge and asthma control level demonstrated that AKQ scores were not significantly correlated with C-ACT scores (r = 0.024, p = 0.783). On the other hand, parents of children with a longer duration of asthma diagnosis were not significantly associated with AKQ total scores (r = 0.045, p = 0.607).

Table Ⅳ. Total Asthma Knowledge Scores Differences between Parents’ Socio-demographic Characteristics

Socio-demographic informationn (%)Median (IQR)Z-statistics*χ2-statistics (df)#p-value
Age  12.593 (3)0.006
20-30 years old29 (22.1)8.00 (2.50)  
31-40 years old75 (57.3)9.00 (3.00)  
41-50 years old25 (19.1)10.00 (2.50)  
> 50 years old2 (1.5)6.00  
Parents  -1.2500.211
Father25 (19.1)8.00 (2.50)  
Mother106 (80.9)9.00 (2.00)  
Marital status  3.493(3)0.322
Married123 (93.9)9.00 (2.00)  
Divorced2 (1.5)6.50  
Widow/ Widower2 (1.5)7.00  
Single parent4 (3.1)8.50 (8.00)  
Races  5.898 (3)0.117
Malay59 (45.0)9.00 (3.00)  
Chinese14 (10.7)9.00 (5.25)  
Sarawak Dayak52 (39.7)9.00 (2.00)  
Others6 (4.6)11.00 (3.00)  
Places of living  -0.8440.398
Rural23 (17.6)8.00 (3.00)  
Urban108 (82.4)9.00 (2.00)  
Education level  17.067 (3)0.001
No formal education2 (1.5)8.50  
Primary school8 (6.1)8.00 (2.50)  
Secondary school85 (64.9)8.00 (2.50)  
Tertiary school36 (27.5)10.00 (3.00)  
Employment status  -0.3470.728
Employed81 (61.8)9.00 (4.00)  
Unemployed50 (38.2)9.00 (2.00)  
Family income  21.761 (3)<0.001
Less than RM 200061 (46.6)8.00 (2.00)  
RM 2000 – RM 500049 (37.4)9.00 (3.00)  
RM 5000 – RM 800013 (9.9)11.00 (3.00)  
More than RM 80008 (6.1)10.00 (3.75)  
Family history of asthma  -0.8290.407
Yes63 (48.1)9.00 (2.00)  
No68 (51.9)9.00 (2.75)  

*Mann-Whitney U, #Kruskal-Wallis, p < 0.05

Multivariable analysis (i.e.: ANCOVA) was not conducted due to violation some of the assumptions.

IQR – Interquartile range

Table Ⅴ. C-ACT Scores Differences between Parents’ Socio-demographic Characteristics

Socio-demographic informationn (%)Median (IQR)Z-statistics*χ2-statistics (df)#p-value
Age  1.971 (3)0.579
20-30 years old29 (22.1)21.0 (7)  
31-40 years old75 (57.3)23.0 (5)  
41-50 years old25 (19.1)22.0 (4)  
> 50 years old2 (1.5)21.5  
Parents  -1.7860.074
Father25 (19.1)20.0 (5)  
Mother106 (80.9)22.5 (5)  
Marital status  0.994 (3)0.803
Married123 (93.9)22.0 (5)  
Divorced2 (1.5)22.0  
Widow/ Widower2 (1.5)21.5  
Single parent4 (3.1)20.0 (3)  
Races  6.727 (3)0.081
Malay59 (45.0)22.0 (5)  
Chinese14 (10.7)24.0 (4)  
Sarawak Dayak52 (39.7)23.0 (5)  
Others6 (4.6)24.0 (10)  
Places of living  -2.1790.029
Rural23 (17.6)21.0 (5)  
Urban108 (82.4)23.0 (5)  
Education level  15.591 (3)0.001
No formal education2 (1.5)19.0  
Primary school8 (6.1)18.0 (4)  
Secondary school85 (64.9)22.0 (5)  
Tertiary school36 (27.5)23.0 (6)  
Employment status  -0.0070.994
Employed81 (61.8)22.0 (5)  
Unemployed50 (38.2)22.0 (5)  
Family income  0.956 (3)0.812
Less than RM 200061 (46.6)22.0 (5)  
RM 2000 – RM 500049 (37.4)22.0 (6)  
RM 5000 – RM 800013 (9.9)23.0 (5)  
More than RM 80008 (6.1)23.0 (5)  
Family history of asthma  -1.8790.060
Yes63 (48.1)22.0 (5)  
No68 (51.9)22.5 (5)  

*Mann-Whitney U, #Kruskal-Wallis, p < 0.05

Multivariable analysis (i.e.: ANCOVA) was not conducted due to violation some of the assumptions.

IQR – Interquartile range

Table Ⅵ. Correlations between mean Parental Perceptions of Childhood Asthma Scores with mean Asthma Knowledge Scores

Parental Asthma PerceptionsTotal Asthma Knowledge Scores
Correlation (r)P-value*
Consequences0.0810.358
Timeline (acute/chronic)0.1840.035
Parental Control0.0660.455
Treatment Control-0.0050.959
Symptoms0.0580.507
Concern-0.0480.589
Illness Coherence0.0580.509
Emotional0.0930.292

*Spearman Correlation, p < 0.05

Table Ⅶ. Correlations between mean Parental Perceptions of Childhood Asthma Scores with C-ACT Scores

Parental Asthma PerceptionsC-ACT Scores
Correlation (r)P-value*
Consequences-0.0630.472
Timeline (acute/chronic)-0.2850.001
Parental Control0.1860.033
Treatment Control-0.0440.618
Symptoms-0.383<0.001
Concern-0.1290.143
Illness Coherence-0.0360.682
Emotional-0.0770.383

*Spearman Correlation, p < 0.05

Table Ⅷ. Correlations of Total Asthma Knowledge Scores with Parents’ and Clinical Variables

VariablesTotal Asthma Knowledge Scores
Correlation (r)P-value*
Marital status-0.1200.172
Races0.1690.054
Living place0.0740.401
Parent’s education level0.338<0.001
Parent’s employment status-0.0300.730
Family income0.394<0.001
Family history of asthma-0.0730.409
Children age diagnosed with asthma0.0450.607
No. of hospitalisation due to asthma exacerbation in last year-0.0250.778
C-ACT total scores0.0240.783

*Spearman Correlation, p < 0.05

DISCUSSION

The Parental Asthma Perceptions Questionnaire offers a rapid and fairly effective evaluation of parents’ views on their children’s asthma. Thus, it can be valuable in clinical settings as an initial discussion point during counselling sessions to address parental concerns regarding their children’s asthma, feelings of being overwhelmed, and beliefs about asthma treatment. Within parental asthma perceptions, the highest score was in “treatment control,” while the lowest was in “timeline.” This suggests that most parents perceived asthma treatment from the hospital as effective in managing their children’s asthma. Conversely, responses to “timeline” suggest that many parents believed their children would recover quickly from asthma, perceiving it as a short-term disease rather than a chronic respiratory condition that might persist throughout their lives. This aligns with previous studies where parents viewed asthma as a series of acute episodes [25][26][27]. One possible explanation for this perception is a lack of asthma knowledge among parents, potentially influenced by their educational backgrounds. However, the “illness coherence” score in the illness representation dimension was moderately high (8 out of 10) in this study. This suggests that parents of asthmatic children feel they had a good understanding of the disease. Interestingly, this contrasts with their belief in asthma’s acute nature. They believed their understanding of asthma aided in managing their child’s asthma at home, likely contributing to their high score in the “parental control” aspect of illness representation.

Asthma education plays a crucial role in managing asthma. Studies have shown that effective education programmes can significantly reduce asthma morbidity, hospitalisations, and emergency room visits due to asthma exacerbations [28][29][30][31]. Parents, being the primary link between doctors and asthmatic children, need to grasp basic asthma concepts. However, in this study, the parents had only moderate knowledge about asthma, especially regarding the roles of asthma medications. For instance, approximately 90% of the respondents were unaware of the specific functions of controller and rescue inhalers in asthma management. This lack of clarity mirrors findings from other studies where confusion existed among parents about these medication roles [26][32][33].

Moreover, parental concerns about the side effects of asthma medications, particularly controller inhalers used daily, are well-documented [34][35][36][37][38]. Surprisingly, in this study, most parents could not identify these side effects. This lack of awareness aligns with previous research where a high percentage of parents were unaware of asthma medication’s adverse effects [38]. Only a small fraction of parents correctly answered a question about the comparative side effects of salbutamol inhalers versus oral salbutamol. Many parents in this study claimed they had not been adequately informed about the adverse effects of different routes of asthma drug administration during medical consultations or counselling sessions. This misinformation could lead to non-adherence to inhaler treatments, especially among parents who are overly concerned about the side effects of inhaled therapy compared to oral asthma medications. These findings are consistent with a study conducted in Kuala Lumpur, which indicated that parents concerned about inhaled therapies were more likely to perceive the oral route as superior and preferable for treatment [36]. Addressing these parental misconceptions through proper asthma education is vital for achieving better asthma control.

The vast majority of our respondents (97%) knew that exposing asthmatic children to cigarette smoke at home worsened their asthma. This finding aligns with three other studies supporting our results [39][40][41]. Many studies have explored the harmful effects of environmental cigarette smoke on asthma control in children, with the negative effects of tobacco smoke exposure highlighted by extensive media campaigns in Malaysia [42][43]. Additionally, most respondents (94.7%) agreed that inhaling paint fumes, gasoline, smoke, or haze can trigger asthma attacks, indicating a good understanding of asthma’s causes. 

Moreover, about three-quarters of respondents agreed that asthma can be inherited and linked to lung inflammation. Similar perceptions were found in studies from the United States and India, where asthma was often seen as hereditary, while a study from Pakistan portrayed it as contagious [37][44][45]. Differences in asthma perceptions across populations may stem from varying levels of education, quality of healthcare information, and healthcare system structures. To ensure optimal treatment for childhood asthma, it is crucial to educate parents that asthma is not solely hereditary; environmental factors also play a significant role in asthma susceptibility and triggering attacks.

This study indicates that parents’ demographics like gender, marital status, race, location, job status, and family asthma history did not affect their awareness of childhood asthma. However, notable differences in asthma knowledge scores were observed based on parents’ education levels, family income, and ages. Consistent with prior research, the results suggest that parents with higher education had a deeper understanding of asthma compared to those with lower education [17][25][30]. Educated parents appeared to leverage their educational background to grasp and assimilate asthma knowledge, understanding the core aspects of the condition. Conversely, parents with lower socioeconomic status exhibited lower asthma knowledge scores, possibly due to their lower educational attainment. This was evident as most parents with low income had only completed secondary education, potentially explaining the lower asthma knowledge scores among this demographic.

The study highlights significant variations in C-ACT scores based on parents’ living environment and education levels. These findings align with a study from Canada, which found that children’s asthma control in rural areas was inferior to that in urban areas [46]. One plausible explanation is that urban parents have easier access to medical facilities like government hospitals or private clinics, enabling better asthma care for their children compared to those in rural areas. Furthermore, children of parents with higher education levels tended to have higher C-ACT scores. This corresponds with a study by Strömberg Celind F et al., which associated parents’ higher education levels with improved asthma control in children [47].

The study’s results indicated a significant albeit weak positive relationship between overall asthma knowledge scores and parental perceptions of the illness duration (r = 0.184, p = 0.035). This implies that parents with greater asthma knowledge perceived their child’s asthma to be of longer duration. This association can be attributed to parents who have a better understanding of asthma and recognize it as a chronic, incurable respiratory condition. They viewed childhood asthma as likely to be permanent rather than temporary in their children’s lifetime. This finding aligns with prior research [48][49]. Conversely, other parental perceptions about childhood asthma did not show a significant correlation with asthma knowledge scores in this study.

Further analysis reveals a significant inverse correlation between C-ACT scores and parental perceptions of asthma duration (r = -0.285, p = 0.001) and symptoms (r = -0.383, p < 0.001). This indicates that parents with higher C-ACT scores for their asthmatic children believed that their children would experience a shorter duration of asthma and fewer symptoms at home. Most parents believed that asthma duration could be reduced if their children’s asthma was completely under control. Likewise, parents reported fewer asthma symptoms at home when their children’s asthma was well-controlled. Conversely, there was a notable positive correlation between C-ACT scores and parental perception of asthma control, where higher C-ACT scores were directly linked to parents’ belief in their ability to help their children manage their asthma at home. This can be explained by the heightened awareness of parents who understand the importance of avoiding triggers in managing childhood asthma, leading to better disease control and higher C-ACT scores [49].

Several studies indicate a correlation between parents’ asthma knowledge and their educational background. In line with these findings, our study reveals a significant association between parents’ education levels and their overall asthma knowledge scores (r = 0.338, p < 0.001) [17][25][30], suggesting that higher education was associated with better asthma knowledge. Nonetheless, no significant relationship was found between parents’ asthma knowledge and the duration of their child’s asthma diagnosis (r = 0.045, p = 0.607). This contrasts with a previous study suggesting that longer experience with a child’s asthma could lead to improved asthma knowledge, highlighting the importance of experience and communication with healthcare providers [25].

Interestingly, our study did not find a significant association between parents’ asthma knowledge and asthma control levels (r = 0.024, p = 0.783). This implies that higher knowledge scores among parents did not necessarily translate to better control of asthma symptoms in their children. This aligns with research by Silva CM et al., which also found no association between parents’ asthma knowledge and children’s asthma outcomes, such as nocturnal symptoms, asthma exacerbations, and missed school days [25]. This discrepancy may be attributed to parents with poor asthma knowledge who tended to underreport symptoms, particularly nocturnal symptoms, as they failed to recognise them as asthma symptoms during assessments. Consequently, higher C-ACT scores might be achieved even when a child’s asthma was poorly controlled.

Limitations of the Study

Despite this study representing an innovative attempt to explore how parents’ perceptions and knowledge of asthma impact childhood asthma control levels, several limitations should be acknowledged. As this study was conducted at a single-centre tertiary hospital, its findings may not be generalisable to all Malaysian parents’ asthma knowledge and perceptions. However, it could serve as a reference or basis for comparison with existing studies on parental asthma knowledge. Furthermore, this study did not include an objective measure, such as pulmonary function or peak expiratory flow rate, even though the evaluation of clinical control by the child’s doctors was included. As this study utilised a self-administered questionnaire, the possibility of recall bias cannot be excluded. Additionally, data provided by fathers, who are typically not the primary caregivers in asthma management, may be less reliable.

CONCLUSION

The study reveals that socio-demographic factors influenced asthma knowledge and control among parents. Parents aged 41-50, with tertiary education and higher income, tended to have better asthma knowledge while urban-dwelling and more educated parents showed improved asthma control. Parental perception of the asthma timeline was significantly associated with both asthma knowledge and control. Despite a positive correlation between asthma knowledge scores and the education level of parents, their asthma knowledge and perceptions did not significantly influence the control of their children’s asthma. Other factors should be further investigated. 

ACKNOWLEDGEMENT

We would like to thank the Director General of the Ministry of Health Malaysia for his permission to publish the article.

CONFLICT OF INTEREST

No conflict of interest declared.

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Please cite this article as:

Alvin Chok Leong Jong, Baharudin Ibrahim and Lee Gaik Chan, Association Between Parental Asthma Knowledge and Perceptions of Asthma Control in Children: A Cross-Sectional Study in a Malaysian Tertiary Hospital. Malaysian Journal of Pharmacy (MJP). 2024;10(2):21-30. https://mjpharm.org/association-between-parental-asthma-knowledge-and-perceptions-of-asthma-control-in-children-a-cross-sectional-study-in-a-malaysian-tertiary-hospital/

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