Social support network and family resilience among parents of school-age children with asthma: a cross-sectional study of current status and influencing factors

Abstract

Background

Parents of school-age children with asthma face prolonged caregiving burdens and multiple challenges. Understanding their social support networks and family resilience is essential for developing effective interventions, yet systematic investigations integrating both constructs in this specific population remain scarce.

Objective

This study aimed to investigate the current status of social support network and family resilience among parents of school-age children with asthma, identify independent influencing factors, and provide evidence for clinical intervention strategies.

Methods

A cross-sectional survey was conducted among 306 parents of school-age children (6–12 years) with asthma at a tertiary grade A children’s hospital from June 2025 to March 2026. A self-developed, pilot-tested questionnaire, grounded in Walsh’s family resilience framework and the stress buffering model of social support, was used to collect general information, family resilience (6 items), social support network (8 items), and disease coping and caregiving behaviors (6 items). The questionnaire demonstrated satisfactory content validity (S-CVI = 0.92), construct validity (three factors explaining 68.42% of variance), and reliability (Cronbach’s α = 0.894). The total score ranged from 0 to 100, with higher scores indicating better support and resilience. Univariate analysis, correlation analysis, and multiple linear regression were performed to identify influencing factors. Clinical trial number: not applicable.

Results

The effective response rate was 87.4% (306/350). The mean total score of social support network and family resilience was 58.90 ± 6.44, with 52.3% of participants scoring below 60 (the theoretical midpoint), indicating a moderately low overall level. The regression model explained 49.9% of the variance (adjusted R²=0.499). Among the three dimensions, social support network scored the lowest (mean item score 2.93 ± 0.52), whereas disease coping and caregiving behaviors scored the highest (3.04 ± 0.59). Parental age (β = 0.247), education level (β = 0.292), monthly household income per capita (β = 0.318), asthma duration (β = 0.219), and number of acute exacerbations in the past year (β=−0.269) were independent influencing factors (all P < 0.001). Child’s age, parental role, and child’s sex showed no significant associations.

Conclusion

The level of social support network and family resilience among parents of school-age children with asthma is moderately low, with notable deficiencies in external support utilization and intra-family communication. Household economic status exerts the strongest influence. Based on these findings, targeted strategies are proposed, including stratified empowerment education, family resilience workshops, hospital-school linkage mechanisms, and policy support to reduce financial burdens. Future prospective multicenter studies integrating objective clinical indicators and parental mental health variables are needed to validate associations and causal pathways.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-026-04366-0.

Background

Asthma is the most common chronic airway inflammatory disease in children, affecting approximately 80–95 million children worldwide, with an overall prevalence of about 9%–14% and exceeding 20% in some regions [1, 2]. In China, the total number of asthma cases among children and adolescents has reached 8.69 million, and the cumulative prevalence of asthma among children under 14 years of age in major cities has reached 3.02%, with the number of affected individuals continuing to increase [3, 4]. Although the prevalence and disease burden of asthma in Chinese children aged 0–14 years showed a declining trend from 1990 to 2021, projections based on the Bayesian age-period-cohort model indicate that the prevalence will rise to 5,143.35 per 100,000 by 2035, and the disease burden remains substantial [5]. The school-age period (6–12 years) represents a critical window for lung function development, during which children must also independently face academic pressures and social challenges in the school environment [6, 7]. However, more than 20% of children with asthma still do not achieve good control, with inadequate disease awareness and poor medication adherence being important contributors to suboptimal control [8]. Asthma is characterized by a long disease course, frequent exacerbations, and high long-term care needs, imposing persistent psychological and physical burdens on affected families [9]. As the primary caregivers of school-age children with asthma, parents perform multiple roles in disease management, including daily monitoring, medication supervision, and emergency management, while also addressing secondary issues such as school absences and activity limitations caused by asthma exacerbations [10]. Thus, understanding how to enhance the coping capacity of families of school-age children with asthma has become a central concern in the field of pediatric chronic disease management.

Family resilience refers to the dynamic process through which families mobilize internal resources and promote positive adaptation in the face of adversity [11]. Walsh’s family resilience framework explains the mechanisms underlying family resilience from three core dimensions – family belief systems, organizational patterns, and communication processes – and highlights the importance of assessing and intervening in family resilience for families of children with chronic diseases [12]. In the context of caring for school-age children with asthma, the role of family resilience is receiving increasing attention. Research [13] has shown that stable family belief systems and sustained emotional support are key factors facilitating positive family adaptation. Among parents of school-age children with asthma, fear of disease progression can be classified into two latent categories: a psychological state anxiety group (46.7%) and a psychological state resilience group (53.3%), with social support being a significant factor distinguishing these two groups. Nevertheless, research on family resilience in families of school-age children with asthma remains relatively limited, particularly for this specific developmental stage. Meanwhile, social support networks – encompassing multi-level support from spouses, family members, friends, healthcare providers, schools, and communities – play an irreplaceable buffering role in the formation of family resilience and disease coping [14]. Studies have shown that seeking social support, as a coping strategy, partially mediates the relationship between caregiving burden and quality of life among parents of school-age children with asthma [15, 16]. The family management styles of parents of children with difficult-to-treat asthma can be classified into three latent profiles, with the negative family management group accounting for 29.36%, and both family hardiness and social support are independent influencing factors of family management style [17]. However, existing research has mostly focused on single dimensions, and systematic studies that integrate social support networks and family resilience remain lacking.

Understanding the current state and associated factors of social support networks and family resilience among parents of school-age children with asthma is important for informing targeted, individualized interventions. Accordingly, this study aimed to examine these constructs, identify their key correlates, and propose tailored strategies, thereby providing evidence-based references for clinical nursing practice and the optimization of family support programs.

Methods

Research design

This study adopted a cross-sectional survey design aimed at systematically assessing the current status of social support network and family resilience among parents of school-age children with asthma and analyzing factors associated with these outcomes. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [18] and a completed STROBE checklist is provided as supplementary material. The survey was conducted from June 2025 to March 2026 in the respiratory outpatient clinics and inpatient wards of a tertiary grade A children’s hospital. Clinical trial number: not applicable.

Ethical approval

This study strictly adhered to the ethical principles of the Declaration of Helsinki. The study protocol was approved by the Children’s Hospital of Nanjing Medical University’s Ethics Review Committee (approval No. 202408008-1). All participants were informed of the study purpose, content, voluntary participation principle, and anonymous confidentiality commitment before enrollment, and written informed consent was obtained. For other family members who also cared for the child but did not directly complete the questionnaire, the study only collected information from the primary caregiver (father or mother). No invasive procedures or interventions were performed on the children or their families during the study.

Sample size calculation

The sample size was determined using two approaches. First, according to the rule of thumb for multivariable regression [19], the sample should be 10–20 times the number of independent variables. With eight planned predictors, 80–160 participants were required. Second, a precision-based calculation was performed: assuming a 95% confidence level, a 5% margin of error, and an estimated population proportion of 50%, the minimum required sample size was 385. The final sample of 306 valid cases slightly falls below this precision-based threshold, which may affect the precision of estimates; this limitation is addressed later. Considering potential invalid questionnaires (approximately 10%–15%), we aimed to recruit at least 350 participants.

Study population

A convenience sampling method was used to recruit school-age children with asthma and their parents who attended the respiratory department of a tertiary grade A children’s hospital. Inclusion criteria were: (1) children aged 6–12 years with a documented diagnosis of asthma according to the Chinese Guidelines for the Diagnosis and Prevention of Childhood Bronchial Asthma, confirmed by a respiratory physician and verified through electronic medical records; (2) the primary caregiver was the father or mother and self-reported having assumed the main caregiving responsibilities in the past six months; (3) parents had basic reading and comprehension skills, operationally screened by their ability to read and verbally confirm understanding of the informed consent form; (4) parents provided informed consent and voluntarily participated. Exclusion criteria were: (1) children with other serious chronic diseases (e.g., congenital heart disease, diabetes, malignant tumors) or intellectual disability; (2) parents with a documented diagnosis of severe mental illness or cognitive impairment recorded in their medical history that prevented them from understanding the questionnaire content.

Questionnaire development and psychometric testing

Questionnaire development

A self-developed Questionnaire on the Current Status of Social Support Network and Family Resilience Among Parents of School-Age Children With Asthma was used (see Supplementary File 1 for the full instrument). Item generation was based on: (a) a systematic literature review of validated scales including the Walsh Family Resilience Questionnaire, Social Support Rating Scale, and asthma self-management instruments; (b) semi-structured interviews with 12 parents of school-age children with asthma to capture context-specific caregiving challenges; and (c) iterative review by an expert panel. Redundancy across domains was minimized through content mapping and expert consensus. Because no existing instrument simultaneously captured family resilience, social support network, and disease coping behaviors in the specific context of school-age asthma caregiving, a new composite questionnaire was developed. The instrument was grounded in Walsh’s family resilience framework (family belief systems, organizational patterns, communication processes) and the stress buffering model of social support. The questionnaire consisted of four parts: Part I general information (8 items, not scored); Part II family resilience (6 items, maximum 30 points); Part III social support network (8 items, maximum 40 points); Part IV disease coping and caregiving behaviors (6 items, maximum 30 points). A 5-point Likert scale was used (1 = “very untrue/very unsupportive/almost never” to 5 = “very true/very supportive/always”). The total score ranged from 0 to 100, with higher scores indicating better social support networks and higher levels of family resilience. The three dimensions are conceptually linked through the stress-buffering model: social support facilitates adaptive coping, which in turn strengthens family resilience; thus, the total score represents an overall index of family psychosocial adaptation. For descriptive interpretation, a total score below 60 was provisionally classified as “moderately low” based on the theoretical midpoint and empirical tertile distribution from the pilot survey, while 60–80 indicates “moderate” and above 80 “high.”

Psychometric testing

A pilot survey was conducted among 30 parents from March to April 2025. (1) Content validity: Five experts evaluated the questionnaire; the item-level content validity index (I-CVI) ranged from 0.80 to 1.00, and the average scale-level CVI (S-CVI) was 0.92. (2) Construct validity: Exploratory factor analysis (principal component analysis, varimax rotation) yielded a KMO of 0.876, Bartlett’s χ²=1245.36 (df = 190, P < 0.001), and three factors with eigenvalues > 1 explaining 68.42% of cumulative variance. Factor loadings ranged from 0.52 to 0.84, generally consistent with the hypothesized structure. Confirmatory factor analysis (CFA) was not performed in this pilot phase; this limitation is noted in the Discussion. (3) Reliability: Cronbach’s α for the total scale was 0.894, and for the three dimensions were 0.852, 0.876, and 0.833. Two-week test-retest reliability (n = 15) was 0.86 (P < 0.01).

Data collection

Two uniformly trained pediatric respiratory nurses served as survey administrators. Questionnaires were distributed to eligible parents during outpatient visits or hospitalization. Before the survey, the administrators explained the study purpose, completion method, and precautions, emphasizing anonymity and confidentiality. A total of 350 questionnaires were distributed. Three hundred fifteen were returned, and after excluding 9 with a missing rate ≥ 5%, 306 valid questionnaires were retained, yielding an effective response rate of 87.4%. The questionnaires were completed independently by the parents. If a parent had difficulty reading due to low education or vision problems, the administrator read the items aloud in a neutral tone and recorded answers without prompts. Completed questionnaires were checked for missing items on the spot. If missing items were found, parents were informed of the option to complete the item or to leave it blank, and they were reassured that declining to answer any specific question would not affect their child’s care. When a parent chose not to respond, the missing value was handled during analysis.

Statistical analysis

Data were analyzed using SPSS version 26.0. All tests were two-tailed (α = 0.05). The analysis proceeded in three stages: (1) descriptive statistics, (2) univariate analysis (group comparisons and correlations), and (3) multivariable regression.

Descriptive statistics

Normally distributed continuous variables were expressed as mean ± standard deviation; non-normally distributed variables as median (interquartile range). Categorical variables were expressed as frequencies and percentages.

Univariate analysis

Group comparisons were performed using independent-samples t-test (two groups) or one-way ANOVA (multiple groups) with LSD or Games-Howell post-hoc tests as appropriate. Correlation analyses were conducted using Pearson correlation for normally distributed continuous variables and Spearman’s rank correlation for ordinal or non-normal variables. Point-biserial correlation was not reported separately because group comparisons already covered binary variables.

Multivariable analysis

Variables statistically significant in univariate analysis (P < 0.05) were entered as independent variables, with the total score as the dependent variable. Multiple linear regression (Enter method) was used. Child’s age, parental role, and child’s sex, although non-significant in univariate analysis, were retained as adjusting variables based on theoretical and clinical relevance as potential confounders identified in prior literature. Before regression, assumptions were tested: normality of residuals (P-P plot and Kolmogorov-Smirnov test), homoscedasticity (scatterplot of residuals vs. predicted values), and independence of residuals (Durbin-Watson statistic = 1.94). All assumptions were met. Multicollinearity was assessed using variance inflation factor (VIF), with values < 2.0 indicating no serious multicollinearity.

Handling of missing data

The item missing rate in valid questionnaires was < 3%. Missing values were imputed using sequential mean substitution. Although this method may slightly reduce variance, its impact is minimal given the very low missing rate. We acknowledge this as a limitation and recommend multiple imputation for future studies.

Variable assignment

Parental age and child’s age were entered as continuous variables. Education level was coded as 1 = Junior high school or below, 2 = High school/vocational, 3 = Associate degree, 4 = Bachelor’s degree or above. Monthly household income per capita was coded as 1 = < 5,000 CNY, 2 = 5,000–10,000 CNY, 3 = > 10,000 CNY. Asthma duration was coded as 1 = < 1 year, 2 = 1–3 years, 3 = 3–5 years, 4 = > 5 years. Number of acute exacerbations in the past year was coded as 1 = 0, 2 = 1–3, 3 = 4–6, 4 = > 6. Parental role was coded 0 = Mother, 1 = Father; child’s sex was coded 0 = Female, 1 = Male.

Results

Descriptive characteristics and total score

A total of 306 parents were included. The mean total score of social support network and family resilience was 58.90 ± 6.44 (observed range 38–82), with 52.3% (160/306) scoring below 60, indicating a moderately low level overall. Table 1 summarizes baseline characteristics and univariate comparisons. Mothers accounted for 67.97% and fathers for 32.03%. The majority of parents were aged 31–40 years (54.90%). The largest education categories were high school/vocational (36.60%) and junior high school or below (28.76%). Nearly half reported a monthly household income per capita of 5,000–10,000 CNY (48.37%). Children’s ages were relatively evenly distributed, 57.19% were male. Asthma duration of 1–3 years was most common (46.41%), and 51.63% had 1–3 acute exacerbations in the past year.

Table 1.

Baseline characteristics of participants and univariate analysis of total score (N = 306)

Variable	Subgroup	n	(%)	Total score	Statistic	P-value
Parental role	Father	98	32.03	59.12 ± 6.21	t = 0.382	0.703
	Mother	208	67.97	58.79 ± 6.56
Parental age (years)	≤ 30	74	24.18	54.32 ± 5.87	F = 15.873	< 0.001
	31–40	168	54.90	58.95 ± 5.92
	> 40	64	20.92	63.14 ± 6.03
Education level	Junior high or below	88	28.76	53.41 ± 5.63	F = 21.432	< 0.001
	High school/vocational	112	36.60	57.85 ± 5.91
	Associate degree	66	21.57	62.13 ± 5.47
	Bachelor’s or above	40	13.07	66.18 ± 6.22
Monthly household income per capita (CNY)	< 5,000	102	33.33	54.02 ± 5.76	F = 28.106	< 0.001
	5,000–10,000	148	48.37	59.91 ± 5.89
	> 10,000	56	18.30	65.23 ± 6.08
Child’s age (years)	≤ 7	130	42.48	58.46 ± 6.38	F = 0.564	0.570
	8–10	118	38.56	59.12 ± 6.57
	11–12	58	18.96	59.41 ± 6.29
Child’s sex	Male	175	57.19	58.74 ± 6.52	t = 0.486	0.627
	Female	131	42.81	59.10 ± 6.35
Asthma duration	< 1 year	68	22.22	54.21 ± 5.94	F = 14.125	< 0.001
	1–3 years	142	46.41	58.43 ± 6.11
	3–5 years	62	20.26	61.85 ± 6.03
	> 5 years	34	11.11	64.97 ± 6.48
Number of exacerbations in past year	0	46	15.03	64.57 ± 6.27	F = 20.831	< 0.001
	1–3	158	51.63	59.88 ± 5.92
	4–6	72	23.53	56.31 ± 5.84
	> 6	30	9.80	52.73 ± 5.61

Statistical methods: independent-sample t-test for two groups, one-way ANOVA for multiple groups

Table 2 presents the dimension scores. The mean item score was highest for disease coping and caregiving behaviors (3.04 ± 0.59) and lowest for social support network (2.93 ± 0.52). All dimension scores and the total score were normally distributed (Kolmogorov-Smirnov test, P > 0.05).

Table 2.

Dimension scores of social support network and family resilience (N = 306)

Dimension	Items	Max	Observed range	Total score	Mean item score
Family resilience	6	30	10–28	17.23 ± 3.85	2.87 ± 0.64
Social support network	8	40	12–36	23.45 ± 4.12	2.93 ± 0.52
Disease coping and caregiving behaviors	6	30	9–27	18.22 ± 3.56	3.04 ± 0.59
Total score	20	100	38–82	58.90 ± 6.44	2.95 ± 0.32

Univariate associations and correlations

Univariate ANOVA and t-test results (Table 1) showed that parents who were older than 40 years, had a bachelor’s degree or above, monthly household income > 10,000 CNY, asthma duration > 5 years, or no exacerbations in the past year had significantly higher total scores (all P < 0.001), while parental role, child’s age, and child’s sex were not significant.

Correlation analysis (Table 3) revealed that parental age (r = 0.428), education level (Spearman’s ρ = 0.462), household income (ρ = 0.504), and asthma duration (ρ = 0.413) were positively correlated with the total score, while number of exacerbations was negatively correlated (ρ=−0.479), all P < 0.001. Child’s age was not significantly correlated (r = 0.068, P = 0.234).

Table 3.

Correlation analysis between baseline characteristics and total score (N = 306)

Variable	Statistical method	Correlation coefficient	P-value
Parental age	Pearson	0.428	< 0.001
Education level	Spearman	0.462	< 0.001
Monthly household income per capita	Spearman	0.504	< 0.001
Child’s age	Pearson	0.068	0.234
Asthma duration	Spearman	0.413	< 0.001
Number of exacerbations in past year	Spearman	−0.479	< 0.001

Multivariable regression

Multiple linear regression (Table 4) showed the model was significant (F = 39.214, P < 0.001) and explained 49.9% of the variance (adjusted R²=0.499). Parental age (β = 0.247), education level (β = 0.292), household income (β = 0.318), asthma duration (β = 0.219), and number of exacerbations (β=−0.269) were independent predictors (all P < 0.001). Child’s age, parental role, and child’s sex were not significant (P > 0.05). Household income had the largest standardized effect. All VIF values were < 2.0. The Durbin-Watson statistic was 1.94, confirming independence of residuals.

Table 4.

Multiple linear regression analysis of factors influencing total score (N = 306)

Variable	B	SE	Beta (β)	t	P-value	95% CI
(Constant)	41.273	2.856	-	14.452	< 0.001	35.656–46.890
Parental age	0.215	0.048	0.247	4.479	< 0.001	0.121–0.309
Education level	2.016	0.351	0.292	5.744	< 0.001	1.326–2.706
Monthly household income per capita	2.847	0.456	0.318	6.243	< 0.001	1.951–3.743
Asthma duration	1.438	0.352	0.219	4.085	< 0.001	0.746–2.130
Number of exacerbations in past year	−1.772	0.347	−0.269	−5.107	< 0.001	−2.454– −1.090
Child’s age	0.102	0.089	0.058	1.146	0.253	−0.073–0.277
Parental role	−0.481	0.726	−0.035	−0.662	0.508	−1.910–0.948
Child’s sex	0.295	0.715	0.022	0.413	0.680	−1.112–1.702

R²=0.512, adjusted R²=0.499, F = 39.214, P < 0.001. All VIF < 2.0. Regression assumptions were met

Discussion

This study found that parents of school-age children with asthma had a mean total score of 58.90 ± 6.44 on a 100-point social support network and family resilience scale, with 52.3% scoring below 60, indicating a moderately low level of psychosocial adaptation. This finding underscores the substantial caregiving challenges faced by these families. The school-age period is a critical window for lung function development and self-management skill formation, and parents must manage medication, monitoring, and acute episodes while addressing school absenteeism and activity limitations [20–23]. The proportion of families with monthly per capita income below 5,000 CNY in our sample (33.3%) was slightly higher than the national urban average, which may reflect both the hospital’s catchment area and the financial strain associated with chronic childhood illness, limiting generalizability to more affluent populations. The overall pattern suggests a need for routine family resilience assessment in pediatric asthma care.

Within the family resilience dimension, families performed relatively well in mutual encouragement but showed weaknesses in “openly expressing concerns about the child’s illness” and “flexibly adjusting role division.” This suggests that many families cope using fixed patterns with limited emotional openness and role flexibility, consistent with Walsh’s emphasis on communication and organizational adaptability [24]. The unpredictable course of asthma requires families to possess the capacity for continuous learning and adaptation. In this study, families with shorter disease duration had significantly lower resilience scores than those with longer duration, indicating that newly diagnosed families have not yet established mature coping mechanisms [25, 26]. Therefore, we propose that nursing interventions for newly diagnosed families should incorporate family meetings, role-playing, and emotional expression training to accelerate resilience formation.

The social support network dimension had the lowest score among all dimensions, with marked deficiencies in support from communities, schools, and peer groups. Although spouses or family members provided some emotional support, parents faced significant barriers in actively utilizing external resources, such as rarely participating in patient support groups or receiving substantial assistance from schools. Children with asthma have special needs at school, including medication storage, acute exacerbation management, and restrictions on physical education classes. Without a systematic school management plan, parents are forced to take frequent leaves from work or endure additional psychological stress [27, 28]. In this study, parents of children with frequent exacerbations in the past year had lower total scores, which may be related to the increased communication burden with schools and heightened caregiving demands caused by frequent exacerbations. Meanwhile, parents’ low utilization of social support reflects a gap in health education regarding the cultivation of help-seeking skills [29]. Existing evidence shows that social support seeking partially mediates the relationship between caregiving burden and quality of life [30]. Therefore, healthcare providers should actively recommend reliable online support communities and promote hospital-school linkage mechanisms to expand accessible external support.

Although the dimension of disease coping and caregiving behaviors scored the highest among the three dimensions, in-depth analysis revealed that parents performed relatively well in identifying triggers and self-rated caregiving satisfaction, but had notable deficiencies in medication adherence and regular follow-up visits. This “knowing-doing gap” is common in chronic disease management, particularly among families with lower educational levels, where a disconnect exists between health information acquisition and sustained behavioral implementation. Globally, poor medication adherence among children with asthma is widespread, and in this study, parents with low socioeconomic status had even lower scores in disease coping behaviors, suggesting that financial stress and limited health literacy are major constraining factors. Therefore, health education for parents with low educational levels and low income should place greater emphasis on practicality and sustainability, such as using illustrated medication instructions, simplifying follow-up procedures, and employing community nurses for regular home visits and medication reminders, thereby transforming “knowledge transmission” into “behavioral formation” [31].

Multiple regression analysis showed that parental age, education level, household income, asthma duration, and number of acute exacerbations were all independent influencing factors, with household income having the largest standardized regression coefficient. This finding carries important theoretical and practical implications: household income not only directly determines the accessibility of medical resources but also indirectly shapes family resilience by affecting the flexibility of caregiving arrangements, parents’ sense of psychological security, and their capacity to withstand risks [32]. The influence of education level is primarily reflected in health literacy and information-seeking ability, as parents with higher education tend to actively seek and effectively utilize social support. The positive effect of parental age reflects the cumulative benefits of life experience and emotional maturity, while the positive effect of asthma duration suggests that “practice makes perfect” – as caregiving experience accumulates, families gradually develop effective management strategies [33, 34]. In contrast, the number of acute exacerbations, as a negative factor, not only increases caregiving load but may also lead to learned helplessness and decreased self-efficacy. These findings provide clear targets for stratified interventions: clinicians should prioritize identifying and providing higher-intensity support to parents who are young, have low education and low income, or have a child with a new diagnosis or frequent exacerbations.

Based on these results, we propose several strategies, distinguishing evidence-based findings from recommendations extending beyond the immediate data. At the clinical level, socioeconomic assessment should be integrated into treatment planning; for resource-limited families, simpler medication regimens should be prioritized, and rapid family resilience screening incorporated into quarterly follow-ups [35–37]. At the nursing level, stratified empowerment education and Walsh’s framework-based family resilience workshops are recommended, together with an “Asthma Home Emergency Guide” and simulation training [38, 39]. At the system level, hospital-school linkage mechanisms (personalized “School Asthma Management Recommendation Letter,” teacher training) and community-based chronic disease management with nurse home visits should be established [40, 41]. Peer support groups managed by respiratory nurses could also be valuable [42]. Additionally, given the strong association between household income and the total score, policy measures such as including asthma maintenance medications and pulmonary function tests in outpatient chronic disease reimbursement schemes may help alleviate financial burdens; however, this recommendation represents a policy implication rather than a direct finding of the study.

Limitations

Several limitations should be considered. First, the cross-sectional design precludes causal inference; observed associations may be bidirectional. Second, the sample was recruited from a single tertiary children’s hospital using convenience sampling, which may overrepresent families with greater healthcare access and more severe asthma; generalizability to rural areas and primary care settings is uncertain. Third, the sample size, while adequate for regression, fell slightly below the precision-based estimate of 385, which may affect precision. Fourth, self-reported data (e.g., exacerbation frequency) are subject to recall bias. Fifth, the questionnaire, although demonstrating satisfactory preliminary psychometric properties, lacked confirmatory factor analysis; future validation in independent samples is needed. The provisional cut-off score for “moderately low” was based on the theoretical midpoint and pilot distribution and requires further validation. Sixth, the mean substitution method for missing data, while having minimal impact due to very low missingness, is not optimal; multiple imputation is recommended in future research. Seventh, the study did not include objective asthma control indicators (e.g., Childhood Asthma Control Test (C-ACT), pulmonary function) or parental mental health variables (anxiety, depression, caregiver burden), which may confound the observed relationships. These omitted variables represent important avenues for future prospective studies.

Conclusion

In this sample of 306 parents of school-age children with asthma, the level of social support network and family resilience was moderately low, with 52.3% scoring below the midpoint. The main deficiencies were weak intra-family communication and flexible role allocation, and insufficient utilization of external social support. Parental age, education, monthly household income per capita, asthma duration, and number of acute exacerbations were independent influencing factors, with household economic status showing the strongest effect. These findings support the implementation of stratified empowerment education, family resilience workshops, and hospital-school-community linkage mechanisms. Policy measures to reduce financial burden, such as expanded outpatient chronic disease reimbursement, may also be beneficial. Future multicenter prospective cohort studies incorporating objective asthma control measures and parental mental health variables are needed to clarify causal pathways.

Authors’ contributions

Hui Chen: Conceptualization, Methodology, Software, Writing.Baidi Fu: Supervision, Software, Validation, Writing - Reviewing and EditingAll authors have read and approved the final manuscript.

Funding

This study did not receive any funding in any form.

Data availability

The data associated with the paper are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was conducted by the Ethics Committee of Children’s Hospital of Nanjing Medical University (Approval No. 202408008-1). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the purpose of the study, assured of confidentiality, and provided written consent prior to participation. Participation was voluntary, and respondents could withdraw at any time without consequence. Written informed consents were obtained from all the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.