The primary goal of asthma treatment emphasized in the national and international asthma guidelines is to control asthma symptoms and prevent asthma flares making it imperative to evaluate asthma control status for every patient [9, 10]. Our results, reflecting and expanding previous studies [13–15], indicate that good asthma control status is associated with better HRQoL. While previous work has examined the association between asthma control and HRQoL in children [15, 38], these studies did not explicitly test which parental factors influence asthma control status, in turn affecting asthma-specific HRQoL. The present study shows how the parental factors such as health literacy, satisfaction with SDM, and perceived self-efficacy with patient-physician interaction directly and indirectly affect asthma control through different pathways, which in turn influences pediatric asthma-specific HRQoL. Notably, the association between asthma control and asthma-specific HRQoL remained strong after taking into account the influence of these factors. Understanding and accounting for these factors may help practitioners identify patients at an increased risk of poor asthma control to better manage their asthma symptoms and improve asthma-specific HRQoL.
One of the specific aims of the present study was to examine how parental health literacy, perceived self-efficacy with patient-physician interaction and satisfaction with SDM can contribute to children’s asthma control and asthma-specific HRQoL. Interestingly, we found a lack of association between health literacy and perceived self-efficacy with patient-physician interaction, which is consistent with a previous study , but in contrast to another study . The reasons behind this lack of association may be confounded due to the increased self-confidence in parents who have established a long-term open and trusting relationship with their physicians . On the other hand, it is possible that perceived self-efficacy with patient-physician interaction may be explained by personality traits (e.g., optimism), which is not influenced by one’s level of health literacy. Lastly, we had very few parents with low health literacy and that may have limited our ability to detect small, but important relationships between health literacy and perceived self-efficacy with patient-physician interaction.
Evidence is limited about the relationship between health literacy and satisfaction with SDM. Some studies reported that patients with lower health literacy were less likely to take part in the medical decision-making process [22, 40]. The present study extends the previous findings, showing that parents with higher levels of health literacy had greater satisfaction with SDM. It is plausible that parents with high literacy levels were likely to take an active role and intensively engage in the shared-decision process, leading to an increase in their satisfaction with SDM. Designing appropriate interventions to improve health literacy levels, particularly asthma-relevant literacy, may foster the patient-physician communication, and increase the involvement of parents in the SDM .
The association between self-efficacy and asthma outcomes, especially asthma control and HRQoL, remains unclear. While the present study found that perceived self-efficacy was not directly associated with asthma control and asthma-specific HRQoL, others have previously noted this association [25, 27]. From a design perspective, the discrepant findings may be due to the fact that previous studies investigated the influence of self-efficacy as part of the psychosocial coping resource  or as self-efficacy on HRQoL ; instead, our study tested the influence of perceived self-efficacy with patient-physician interaction on both asthma control and asthma-specific HRQoL.
This study identified several important pathways involved in good asthma control and asthma-specific HRQoL. The findings highlight the need for appropriate interventions to improve asthma control and asthma-specific HRQoL in children through the needs and strengths of their parents. Higher perceived self-efficacy with patient-physician interaction would be indirectly associated with good asthma control through the satisfaction with shared decision-making. This implies that if clinicians can improve the patient-doctor interactions through assuring that patients understand the asthma treatment plan and are satisfied with the interaction process, the likelihood of achieving good asthma control is high. On the other hand, higher perceived self-efficacy was indirectly associated with better asthma-specific HRQoL through satisfaction with SDM and asthma control. It thus seems appropriate that interventions targeted at increasing perceived self-efficacy and/or satisfaction with SDM will increase the likelihood of improving asthma outcomes.
The study is not without limitations. We utilized a cross-sectional study design to investigate the interrelationships among variables. This limits our ability to interpret the causal relationships among these variables. Our path analysis did, however, allow us to establish which of the potential mediator variables were most important in explaining the overall association with the asthma outcomes. The path analysis that we used in this study provides evidence whether the observed data were consistent with a priori hypotheses based on evidence available from several studies. We recognize that the causality in cross-sectional studies can only be speculated and be accepted with caution; longitudinal studies are needed to examine those associations. Second, participants were recruited from five pediatric clinics of a single university medical center, which may limit the generalizability of these findings to other populations. Third, we did not distinguish the role of parental health literacy on asthma-specific outcomes in children compared to adolescents. Oftentimes adolescents are more mature, have different cognitive abilities and are more responsible than children which may potentially influence their role in the decision making process . Future studies should investigate the role of health literacy in adolescents and its relationship with self-efficacy, satisfaction with SDM, and asthma outcomes and how it differs to the role of parental health literacy in children for the said relationships. Fourth, we rely on parent report to collect child’s asthma control status because our clinical experience informs us that parents would better understand and recognize the types of medication than children did. Nevertheless, previous studies have shown that the discrepancy in parent and child reports were not different [43, 44]; and parents and children tend to overstate asthma medication adherence compared to the use of asthma inhaler canister weight checks  and electronic canister measures that recorded daily adherence through a microchip . More research is needed to test the accuracy and discrepancy in child self- or parent proxy-report of the medication use. Lastly, the small number of respondents may have influenced the model fit in the path analyses. Nevertheless, we used procedures noted to optimize use of SEM procedures in studies with small sample sizes [36, 45].