Managing childhood asthma with an eye toward environmental, social, and behavioral features

Abstract

Discussions on asthma management tend to focus on the therapeutic aspects when updates on asthma strategies are released. However, many other components of asthma management are now receiving increased attention, as we seek to make right on health disparities and strive toward health equity. In addition, with the therapeutic aspects of asthma, we now realize that our anti-inflammatory approaches largely address the high T2 component of airway inflammation. However, we know very little about what we can do to control the other inflammatory features that contribute to asthma. Factors, such as environmental exposures, social determinants of health, and risk-taking behaviors may be at the root of asthma persistence, progression, and comorbidities. We will continue to learn methods to identify these issues and draw them into a shared decision-making approach for dialogue with patients and their caregivers. This review provides information and tools to address the nonpharmacologic aspects of asthma management.

Introduction

Current asthma management and discussion focus on therapeutic intervention to achieve asthma control, as indicated by the evolving medication tables.¹ Consequently, less attention may be paid to other key components of asthma management, including asthma education, care coordination, environmental control, and climate events.² Events such as extreme heat, wildfires, and floods can increase exposure to asthma triggers, and these disasters can affect access to asthma medications and care.³ Persistent asthma can be classified as mild, moderate, and severe.¹ However, asthma is a dynamic process that can emerge at a very young age and follow various courses, including never again to wheeze, wheezing with viral infections, persistent asthma, spontaneous remission, and relapse.^4–8 Elucidating the heterogeneous molecular pathways (T2, T1, and T17) and their environmental drivers (viruses, allergens, and pollutants) that under-lie the clinical manifestations of asthma can lead to targeted care.^9–12

For many patients, common asthma therapies are useful in pro-viding bronchodilation through short- and long-acting b-agonists, short- and long-acting muscarinic antagonists, and leukotriene modifiers, and in reducing airway inflammation through inhaled corticosteroids. New approaches, such as maintenance and reliever therapy of combination inhaled corticosteroid with long-acting b-agonist formoterol, have emerged as the cornerstone of asthma therapy.¹ Asthma biologics can address some types of asthma that cannot be controlled by these readily available strategies, particularly T2-high allergic asthma.¹³ However, we do not have many options for the treatment of severe asthma with T2-low airway inflammation. Therefore, it is important to consider all components of asthma management. There may be underlying features that serve as the driving force for asthma inflammation and exacerbation that are not adequately addressed with current therapies and could play a role in asthma progression.

In adults with severe asthma, attention is now being directed to the concept of remission with asthma biologics.¹³ However, asthma biologics are reserved for later steps in asthma management, limiting their consideration to altering the emergence and natural progression of asthma in young children. It is not clear whether current medications can effectively alter the course of asthma in children, considering that several medications, such as inhaled corticosteroids, have failed (eg, Prevention of Early Asthma in Kids (PEAK) study).¹⁴ Nevertheless, guidelines such as the Pediatric Asthma Yardstick¹⁵ for stepping up asthma therapies do include considerations for asthma biologics to prevent the consequences of severe asthma, such as adverse effects related to high-dose inhaled corticosteroids and frequent use of systemic corticosteroids.

For this review, we have purposely limited the discussion on medications and instead focus on aspects of environmental assessment and control, socioeconomic factors that influence the course of asthma, and behavioral factors that affect asthma management. All these factors should lead to a true shared decision-making process between children with asthma and their clinicians and caregivers, which includes seldom discussed components of asthma management.

Environmental Management Tools for Childhood Asthma

National and international guidelines strongly state the importance of evaluating and addressing environmental triggers that can make asthma worse and cause exacerbations.^1,16–18 However, although environmental control is considered the standard of care both in practice and in public health settings, we recognize that comprehensive environmental history-taking and the implementation of multifaceted strategies to reduce triggering exposures can be burdensome for both providers and patient-families. In addition, environmental exposures related to climate change are increasing, requiring a proactive approach toward ensuring safe indoor spaces.¹⁹ Here, we describe current tools available to clinicians to assess and manage environmental exposures in practice (Fig 1).

Figure 1.

Assessment and management of asthma triggers and the patient’s environment. VOC, volatile organic compound.

Evidence linking indoor and outdoor environmental exposures to childhood asthma control, severity, and exacerbations has been extensively reviewed elsewhere in the past year. Radbel et al²⁰ highlighted tobacco smoke, volatile organic compound–containing aerosols (eg, scented products with phthalates), gas stoves, wood smoke, and wildfire smoke infiltrating from outdoors as important sources of indoor air pollution that affect respiratory health. Socioeconomic and race/ethnicity disparities, age, genetics, diet, and obesity are factors that increase susceptibility to these pollutants. Agache et al²¹ reviewed the evidence linking primary outdoor pollutants (carbon monoxide, nitrogen dioxide, ozone, particulate matter 2.5, particulate matter 10, and sulfur dioxide) to increased risk of hospitalizations for asthma.²²

The Expert Panel Report 3 Guidelines recommend that all patients with asthma be asked about exposures to indoor allergens, tobacco smoke, and other irritants and be informed of their potential effects on the patient’s asthma.^16,17 These guidelines also specify that “allergen avoidance requires a multifaceted, comprehensive approach that focuses on the allergens and irritants to which the patient is sensitive and exposed—individual steps alone are generally ineffective.”¹⁷ This advice continues to be echoed in recent literature along with an emphasis that there is no one-size-fits-all approach to mitigate asthma symptoms and exacerbation triggers.²³

The US Environmental Protection Agency’s asthma website provides numerous free resources and publications in English and Spanish for families and health care professionals on reducing asthma triggers and developing in-home interventions.²⁴ Short descriptions along with actions and infographics are provided for asthma triggers, including secondhand smoke, dust mites, molds, cockroaches and pests, pets, nitrogen dioxide, outdoor air pollution, chemical irritants, and wood smoke.²⁵ The website also provides easy-to-read publications for parents, caregivers, and children (eg, 1-page document with 10 steps for an asthma-friendly home and picture books about asthma triggers and air quality). In-depth guidance for health care professionals is also provided, including a home environment checklist, training, and scripts for home visitors to assess asthma triggers as part of an asthma home-visit program developed by the US Environmental Protection Agency, Centers for Disease Control and Prevention, and Department of Housing and Urban Development.²⁶

Asthma home-visit programs have been found to be an effective approach within health care systems and community public health programs to personalize asthma management and improve asthma symptoms.²⁷ Such programs include home environment assessments to identify and remove asthma triggers, asthma education, and care coordination. Basnet et al²⁸ reported the success of a community health worker home-visit program implemented in South Side Chicago. The program enrolled children aged 2 to 18 years with high-risk asthma and resulted in significant reductions in day and night symptoms, rescue medication use, emergency department (ED) visits, and missed school and work days.²⁸ Asthma home-visit programs may also be effective in a virtual format. A pilot study of virtual home visits for high-risk patients with asthma in low-income Black communities in Louisiana resulted in improved symptoms and identification of new asthma triggers at home.²⁹

Effective home environment remediation strategies that can be advised as part of clinical care or addressed through home-visit programs are multifaceted and tailored to the patient. Guidelines recommend against indoor allergen mitigation unless there is evidence that the patient is sensitized or has allergy symptoms.¹⁸ When warranted, allergen-reduction approaches highlighted by Patti et al²³ include the following:

• Integrated pest management to reduce mouse and cockroach allergen exposure.

• Reduce moisture, remove mold contamination, and limit use of window air conditioners that can harbor molds.

• Remove carpet and frequently vacuum to reduce dust mites and pet dander.

• Use pillow and mattress encasings and air purifiers with high-efficiency particulate air filters.

Additional recommendations based on the evidence reviewed by Robertson et al³⁰ to improve indoor air and asthma symptoms that can be addressed at the patient level include the following:

• Reduce exposure to secondhand smoke and encourage smoke-free homes.

• Reduce exposure to volatile organic compounds and encourage scent-free homes/indoor spaces.

• Encourage the use of exhaust fans that vent to the outside when cooking or doing other indoor activities that emit indoor air pollutants.

• Encourage use of electric stoves and appliances over gas stoves and appliances.

Outdoor ambient pollutants and episodic events that affect air quality, such as wildfires and dust storms, pose additional risks for respiratory health in general and for patients with asthma in particular.¹⁹ However, evidence of interventions that reduce the health impact of outdoor environmental exposures is limited and urgently needed. A recent randomized controlled trial of children with asthma in Greece tested outdoor and indoor interventions aimed at reducing exposures during dust storm events.³¹ The group receiving both the outdoor intervention (air quality alerts and instructions to stay indoors) and the indoor intervention (continuous use of an indoor high-efficiency particulate air purifier and instructions to keep doors and windows closed and seal cracks to reduce indoor-outdoor air exchange) during dust storm events had greater improvement in asthma control scores than the group receiving the outdoor intervention only and the control group.³¹

Especially in areas prone to high ambient air pollution, pollens, and/or episodic exposure events, such as wildfires and dust storms, it would be prudent to counsel patients with asthma on strategies to minimize outdoor air infiltration by keeping doors and windows closed and sealed and using filtered ventilation (heating or cooling) systems and air purifiers. The recommended filter efficiency for heating and cooling systems is a Minimum Efficiency Reporting Value-13 or better.³² In the United States, air quality information and alerts are attainable through the AirNow.gov website³³ and several smart-phone applications. Recommendations on safety for outdoor activities are provided with a distinction between health risks in those who may be more sensitive to poor air quality due to conditions such as asthma vs the general public.³⁴ As explored in the subsequent section, it is important to consider disparities in access to safe climate-controlled indoor spaces during times of extreme heat or cold and poor ambient air quality due to pollution or pollen.

Social Determinants of Health

Defined broadly by the World Health Organization, social determinants of health (SDOH) are the “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”³⁵ These include socioeconomic status (SES), systemic discrimination, access to opportunities, differential exposure to stress, and built environment. The study of SDOH disparities in asthma is an expanding area of investigation, with current evidence linking SDOH at both the individual and com-munity levels to asthma outcomes.^36–38

Key Social Determinants of Disparities in Childhood Asthma

Racism and Discrimination

There are marked disparities in both asthma incidence and outcomes across racial and ethnic groups, and these disparities have persisted over time.^39–41 Among Black individuals, asthma is more prevalent, and asthma mortality is substantially higher.⁴² Black children are hospitalized for asthma at 4 to 5 times the rate of their White peers, and this Black/White disparity has not lessened despite an overall reduction in childhood asthma hospitalizations.^41,43 Researchers have historically attempted to understand these disparities through the lens of biology; however, racial categories are a social construct and cannot be conflated with ancestry and biologic differences.⁴⁴ Much of the racial difference in asthma outcomes can be explained by differential exposure to negative SDOH, such as tobacco exposure, air pollution, household pests, mold, financial resources, and health care access.

More recent research suggests that racism itself (both current and historic) may be a key root cause of asthma disparities.⁴⁵ For example, the racist historical practice of redlining has had lasting down-stream consequences at the neighborhood level, including poor housing, increased violence, and community-level poverty. Individuals living in historically redlined communities have an increased risk of asthma and its complications.^46,47 Other studies have revealed that racism contributes to worse asthma outcomes in children.^48,49

Disparities also exist in other marginalized groups. Among adults, those who identify as bisexual, gay, or lesbian are significantly more likely to be diagnosed with asthma and have had a recent asthma attack than those who identify as straight.⁵⁰ The etiology of these disparities remains unclear. There has been limited research understanding asthma risk factors in sexual minorities, although differences in exposure to stress, smoking rates, and obesity may play a part.⁵¹

Socioeconomic Position

Both the prevalence and severity of asthma are directly correlated with poverty.^42,52,53 People living below the poverty line are 50% more likely to have current asthma than those living 450% above the poverty level.⁴² Beyond income, SES is intertwined with health care access, educational attainment, neighborhood/housing quality, and household stability, all of which have been found to affect asthma outcomes.^54–60

There are indirect effects of low SES as well. Decreased education levels are associated with lower health literacy, which can affect disease understanding and asthma control.⁶¹ In addition, low-income groups are often exposed to higher levels of outdoor pollutants known to contribute to asthma morbidity. This disparity has been worsening over time.⁶² The impact of decreased SES also varies with geography. Although urban populations with asthma have been well studied, rural populations face unique challenges, such as lack of sub-specialty care and fewer community programs, which can lead to less evidence-based treatment and higher hospitalization rates.^63,64

Stress and Trauma

Multiple studies have linked chronic psychosocial stress to both the development and severity of asthma.^65,66 For example, exposure to violence can lead to the development of asthma and worsen morbidity, even after controlling for other social risk factors.^54,67–69 The mechanism of this association between stress and violence in asthma is likely multifactorial. Changes in DNA methylation in the airway epithelium have been associated with atopy in patients with higher levels of stress, indicating a molecular mechanism.⁷⁰ Prenatal stress may also increase the risk of childhood asthma through these processes as well.^71,72 Poverty and exposure to chronic discrimination are significant and continuing stressors linked to health inequities.

Social Determinants of Health Assessment in Asthma

Addressing these social determinants of asthma begins with an understanding of the psychosocial needs of individual patients. There is no consensus screening tool for SDOH; however, there are multiple validated screeners that can be used in clinical practice.⁷³ The “WE CARE” survey^74,75 and the Safe Environment for Every Kid parent screening questionnaire^76,77 are examples of frequently used pediatric screeners. In adult patients, both the American Academy of Family Physicians^78,79 and the Center for Medicare and Medicaid Innovation^80,81 have developed social needs screening tools. These screeners were intentionally designed to be brief and easily incorporated into the clinical visits. Regardless of the tool chosen, SDOH screening is the most beneficial and ethical if resources can be offered to address unmet needs. Confidentiality must be maintained, and the rationale for screening and resource referral must be explained to avoid exacerbating health care distrust, which could then worsen existing inequities.^82,83

In recent years, new tools have emerged to assess SDOH at the community level. These census-tract level indices integrate multiple interrelated factors into a single score calculated by geocoding a patient’s home address. Although not a replacement for individual-level assessment, these indices can be a powerful advocacy tool for identifying communities that may benefit from intervention and offer a less time-intensive way of identifying patients who may need more social support. The most well-studied index in pediatrics is the Child Opportunity Index (COI),⁸⁴ which is a publicly available composite index with accessible maps and data sets. The COI comprises multiple factors known to affect child health outcomes, ranging from the quality of early childhood education to pollutant exposures to adult employment rates. Low COI scores have been consistently associated with adverse asthma outcomes, including increased asthma prevalence, exacerbation rates, and intensive care unit admissions.^85–88 Other available indices with interactive maps and downloadable data sets include the Area Deprivation Index,^89,90 the Social Vulnerability Index,⁹¹ and the Environmental Justice Index.⁹²

Practical Management Considerations

Asthma providers should be proactive in SDOH screening in their patients, as patients may not otherwise volunteer for this information due to stigma or may not recognize its relevance to asthma management. Screening can be integrated into electronic previsit questionnaires or conducted in person by a member of the health care team. The electronic health record can be a useful tool in this regard, and many electronic health records have the capability to record and display social needs data and track screening and resource coordination. “Z-codes” are International Classification of Diseases, 10th Revision codes created to identify SDOH.^93,94 These can be used to communicate within the health care team, but it can also be used in aggregate across a practice to better understand the SDOH needs of that patient population. Screening should be coupled with resource referral to address social needs. Some practice settings have embedded social workers and family health navigators to serve this role; however, in the absence of this, practitioners can keep an updated list of available local resources through websites such as 2–1-1, findhelp.org, the American Academy of Family Physicians EveryONE Project Neighbor-hood navigator, and state- and municipal-level health organizations, including those funded by the Centers for Disease Control and Prevention’s National Asthma Control Program.⁹⁵

Many of the SDOH discussed here are best addressed at the policy level, and medical professionals can leverage their asthma expertise for advocacy. Continued research is needed to understand the best ways to address these disparities. However, existing programs have made meaningful differences in asthma outcomes. For example, increased Supplemental Nutritional Assistance Program benefits are associated with a reduction in asthma-related ED visits.⁹⁶ The CAPP+ Home Repairs program (Children’s Hospital of Philadephia’s Community Asthma Prevention Program) has addressed structural problems in more than 100 homes to reduce asthma triggers.⁹⁷ A voucher program enabling families to move out of high poverty neighborhoods resulted in a significant decrease in asthma exacerbations and symptom days.⁹⁸

The Impact of Behaviors on Asthma Management in Children

In many ways, asthma is a behavior-driven disease. Asthma-related health behaviors range from avoidance of triggers to risky behaviors, such as smoking, medication adherence, maintaining adequate sleep, healthy eating, physical activity, and weight management. Management of asthma-related health behaviors in children adds layers of complexity, with developmentally appropriate levels of self-efficacy mingling with varying levels of parent/caregiver involvement and caregiver/family overall health. Often, caregivers rely on children to manage their own asthma at ages that are not developmentally appropriate. One study found that 20% of 7-year-old children were responsible for their own asthma medication use, with that number rising to 75% by age 15 years.⁹⁹ The matter is further complicated by the fact that there is not necessarily a direct correlation between age and developmental stage,¹⁰⁰ leaving clinicians to decipher not only how much responsibility the family is placing on the child but also how much of that responsibility is appropriate, without significant guidance on how to do so.

Perhaps the easiest health behavior to directly tie to asthma outcomes is medication adherence. Adherence to daily controller medication in children with asthma is poor, with most rates ranging from 30% to 60%.¹⁰¹ In addition, adherence rates decline with age, with a nadir in early adulthood,¹⁰² likely reflecting decreased care-giver involvement and oversight and transitioning to greater independence. Poor adherence to asthma controller medications has been associated with decreased levels of asthma control in children¹⁰³ and an increased risk of asthma exacerbations.¹⁰⁴ The reasons for poor medication adherence are multifactorial, ranging from medication beliefs, challenges with cost and access, educational gaps, stigma, and simply forgetting.¹⁰⁵ This is further complicated by poor technique with the use of asthma inhalers.¹⁰⁶

Health-related behaviors are also common drivers of comorbidities that complicate the care of children with asthma. Studies have revealed that obesity often predates asthma diagnosis and that children with an asthma diagnosis may have an even higher rate of subsequent weight gain than children without asthma.¹⁰⁷ Children with both asthma and obesity have been found to have increased asthma severity, worsened control, and poorer scores on measures of asthma-related quality of life.¹⁰⁸ Dietary interventions that increase fruit and vegetable intake and those that promote weight loss have improved asthma control and quality of life in pediatrics.¹⁰⁹ Nevertheless, such studies are relatively scarce and further studies are needed. Children with asthma may also be more sedentary than their peers, and poor asthma control is associated with deficits in physical activity in children as young as preschool age.¹¹⁰ In addition, children most often function within a family unit, and the health behaviors of their parents or caregivers exert significant influence on their own. Positive modeling of physical activity behaviors by parents has been found to significantly influence physical activity rates in children.¹¹¹

Sleep is another often forgotten health behavior associated with asthma outcomes. Obesity is associated with both asthma and obstructive sleep apnea. Sleep-related behaviors, such as nonadherence to nighttime positive pressure, poor sleep hygiene, short sleep duration, and poor sleep quality, may also be associated with poorer asthma-related outcomes.¹¹² The association is likely bidirectional, with poor asthma control leading to poor sleep and poor sleep leading to poor asthma control. Furthermore, poor sleep is associated with decreased physical activity and the likelihood of obesity, further complicating the aforementioned comorbidities.^113,114

Adolescence is a particularly high-risk period for asthma, partially due to the reasons described previously. However, another key feature of adolescence is the increased incidence of other risky health behaviors. One study evaluating more than 24,000 high school students found that marijuana use was associated with an increased odds of asthma diagnosis.⁶⁷ Although not a health behavior in itself, mental health is the factor underpinning essentially all health behaviors. An association between mental health and asthma and/or atopy has been described in children as young as preschool age.¹¹⁵ Psychosocial stressors, including depressive feelings and suicidal ideation, have been associated with a current asthma diagnosis in adolescents.⁶⁷ A complicating factor in children is that it is not only the child’s mental health that could potentially affect asthma management. Studies have found an increased risk of incident asthma in children whose parents have even minor mental health conditions.¹¹⁶ In adults with asthma, concurrent mental health disorders are associated with increased hospitalization, ED visits, and outpatient visits.¹¹⁷ Clearly, there are numerous ways in which health behaviors are associated with both incident asthma and asthma morbidity. Furthermore, patient-centered strategies, such as shared decision-making, can be used to identify health behaviors in need of change and to set goals with children and their caregivers to enact changes (Fig 2). However, shared decision-making is not always used in the clinical setting, with barriers such as insufficient visit time, power imbalances, and perceived lack of skill on the part of the health care provider.¹¹⁸ Further work is needed to both identify and enact strategies to educate and assist health care providers in having these, sometimes difficult, conversations with families to optimize their care.

Figure 2.

Asthma-related health behavior priorities and strategies.

Future Directions

Multiple factors must be considered when developing a holistic asthma management plan and adjusting it with time. For clinicians, it is impossible to address all these at once, especially in solo, small groups, and/or general practice settings. One must take steps simultaneously and work with partners in the health care system to assist in identifying problems. Allergists should be particularly aware of allergen sensitivity and address potential environmental triggers. However, a home that has significant mold issues or pest infestation may require the assistance of a specialty center that can provide remediation. A family affected by multiple SDOH that affect the family support structure may require the assistance of a social worker. Asthma specialists could play a significant role in identifying these issues, especially if they have developed a trusting relationship with the family and provided them with information about programs offered by state and local health departments and other entities.

Multiple underlying reasons for poor adherence to the management plan may be revealed once the clinician starts to peel away at the possible issues. Reviewing prescriptions and rescue inhaler refills can provide valuable information. Measuring day-to-day controller and rescue medication use through electronic medication monitoring could provide a more comprehensive view of patient behavior regarding medication adherence. Gathering this information supports a shared decision-making approach for addressing key issues. This approach is important before moving toward asthma biological therapy when optimal asthma control cannot be attained. The tools and strategies available to assist in gathering this information are summarized in Figure 3.^{23–26,30,33,74–81,84,89–92,119–123}

Figure 3.

Useful resources and strategies for assessing and managing environmental, social, and behavioral risk factors in pediatric patients with asthma. AAFP, American Academy of Family Physicians; HEPA, high-efficiency particulate air; MERV-13, Minimum Efficiency Reporting Value-13; SEEK, Safe Environment for Every Kid.

Conclusion

The challenge for the future is to bring all this information together in a compact manner so that the clinician can see it in a capsule format before entering the room for the patient’s visit. Hopefully, our movement toward digital health and the opportunities provided with artificial intelligence will assemble such a picture in the future. Digital health and telemedicine will help address the need for asthma specialty access in rural communities. Asthma specialty centers in large urban settings can provide personnel resources to address the complex social and environmental challenges in managing patients with severe asthma. Being aware of community resources to address each of the issues identified in an efficient manner will also be important.

Key Messages.

• Environmental exposures related to climate change are increasing, requiring a proactive approach toward ensuring safe indoor spaces.

• Outdoor ambient pollutants and episodic events that affect air quality, such as wildland fires and dust storms, pose additional risks for respiratory health in general and for patients with asthma in particular.

• Much of the racial difference in asthma outcomes can be explained by differential exposure to negative social determinants of health, such as tobacco exposure, air pollution, household pests, mold, financial resources, community and/or neighborhood-level effects, and health care access.

• Although urban populations with asthma are most well studied, rural populations face unique challenges, such as lack of subspecialty care and fewer community programs, which can lead to less evidence-based treatment and higher hospitalization rates. Rural communities also have problematic exposures related to rural living, such as farming/agriculture-related exposures, biomass burning stoves for heat, and dust storms.

• Health related behaviors are also common drivers of comorbidities that complicate the care of children with asthma.

• Patient-centered strategies, such as shared decision-making, can be used to both identify health behaviors in need of change and set goals to enact changes in patients with asthma.