Gaps Between Use of Air Quality Information and Healthcare Provider Discussion in U.S. Children With Asthma and Their Caregivers

HIGHLIGHTS

• •Most participants reported checking air quality before outdoor activity.
• •Healthcare provider discussion of outdoor air pollution as an asthma trigger is low.
• •A phone app was the most frequently reported source of air quality information.
• •A weather app was the most common source, which may report various indices.
• •The Environmental Protection Agency AirNow app or website was infrequently reported as an air quality source.

Abstract

Introduction

The aim of this study was to determine whether and what air quality index products that children with asthma and their caregivers use and whether healthcare providers discuss outdoor air pollution as an asthma trigger or risk reduction strategies.

Methods

A questionnaire was administered to participants in The Transcript/Omics for Precision Medicine in Asthma Study, an observational study of transcriptomic profiles and severe asthma exacerbations in youth aged 6–21 years, recruited from 2023 to 2025. The Wilcoxon rank sum or chi-square test was used for bivariate analyses.

Results

Most caregivers (75%) were aware of alerts or an air quality index and reported learning about or checking it prior to going outdoors (64%), and most reported a behavior change (73%). The most common air quality index source was a phone app (75%, a weather app was most common), followed by TV, radio, or social media alerts (44%) or internet website (24%), with fewer reporting county services (14%). Few reported having discussions with a healthcare provider (41%), and fewer reported receiving recommendations during poor air quality (35%).

Conclusions

Children with asthma and their families report frequently using air quality information to make outdoor activity changes, most often using a weather app; however, they less often report discussing outdoor air pollution as an asthma trigger or recommendations for avoidance with healthcare providers.

INTRODUCTION

Outdoor air pollution is well known to worsen asthma symptoms in children.1, 2, 3 Despite this, few studies have examined whether and how healthcare providers discuss outdoor air pollution as part of asthma clinical management.4, 5, 6, 7

Although there has been a rise in commercially available products reporting an air quality index (AQI), not all such indices are the same as the U.S. Air Quality Index⁸ with regard to pollutants included (e.g., single versus multiple), measurement methods (e.g., monitors using Federal Reference or Equivalent Methods versus non–Federal Reference or Equivalent Methods), and averaging times (e.g., 10 minutes vs 12 hours).⁹ Thus, it is important to understand whether and how clinical counseling on outdoor air pollution is provided and how and which index(ices) are incorporated in asthma management by affected children and their caregivers. For this study, the hypothesis was that most children and their caregivers would obtain air quality information on a smartphone and that healthcare provider’s discussion would be limited.

METHODS

A 5-item questionnaire regarding the use of an AQI and healthcare provider’s discussion of outdoor air pollution was administered to participants of The Transcript/Omics for Precision Medicine in Asthma Study. The Transcript/Omics for Precision Medicine in Asthma Study is a cohort of 115 children with physician-diagnosed persistent asthma (≥1 severe asthma exacerbation in the year before enrollment,¹⁰ prescribed inhaled corticosteroids, and able to perform high-quality spirometry), aged 6–21 years, and recruited from UPMC Children's Hospital of Pittsburgh between 2023 and 2025. Exclusion criteria included chronic disease other than asthma; participation in an intervention study; reported smoking, vaping, or E-cigarette use in the past 4 weeks; or report of acute respiratory infection or systemic or nasal steroid use in the prior 4 weeks. Covariates were obtained through questionnaires (race and sex self-reported). Anthropometry and pulmonary function were measured by trained personnel. Wilcoxon rank sum or chi-square test was used for bivariate analyses, and answers of Don't know were coded as no (SAS 9.4, SAS Institute, Inc., Cary, NC.). The study was approved by the University of Pittsburgh IRB, and all participants provided consent and assent.

RESULTS

Of the 112 participants who completed the questionnaire, over half were male (56%), White (51%), and recipients of Medicaid (62%). Most had good asthma control (60%) and reported at least 10 minutes of vigorous or moderate outdoor physical activity $\ge$3 days in the prior week (61%). Close to one third of participants reported current second-hand smoke exposure, and half had at least 1 severe adverse event during the prior 6 months. Most caregivers (75%, n=84) had heard or read about the AQI or alerts, with 64% (n=72) reporting that they or their child had learned about or checked the air quality before going outside to be active in the past 12 months (Table 1). Of those who responded yes to learning about or checking an AQI, most made a change in outdoor activity in response (n=52, 72% [46% of the overall cohort]). Those who reported making a change were more likely to be White, to own their home than to renting, to have commercial or private health insurance, to have ever heard of an air quality alert, and to have made a change in outdoor activity on the basis of air quality perception (Table 2). Those who reported making a change in outdoor activity in response to learning or checking an AQI more often reported a healthcare provider recommendation for activity change (56% vs 32%) and had a higher forced expiratory volume in 1 second (80% vs 87%), although neither reached statistical significance (p=0.07 for each). No differences were found between asthma control or phenotypic markers among those who did versus did not report making an outdoor activity change in response to learning or checking the air quality.

Table 1.

Characteristics of TOPMAS Cohort (N=112)

Variables	n (%) or median (IQR)
Age (years)	12 (10, 15)
Female sex	51 (46%)
Race
Black	49 (44%)
Other	6 (5%)
White	57 (51%)
Medicaid (versus private or commercial) health insurance	69 (62%)
Perceived poverty (living check to check, almost poor, poor)	46 (41%)
Rent (versus own) home	52 (46%)
Gas stove for cooking	73 (65%)
At least 1 parent completed college	58 (52%)
Parental asthma	67 (62%)
Overweight or obese (BMI ≥85th)	35 (31%)
Current second-hand tobacco exposure	30 (27%)
Vigorous or moderate outdoor activity ≥3 days per weeka	68 (61%)
ACT scorea	20 (17, 22)
CACT score	20 (18, 23)
ACT or CACT score ≥20a (i.e., consistent with good control)	67 (60%)
Pediatric Asthma Quality of Life Questionnaire, scorea	6.1 (5.0, 6.7)
Fractional Exhaled Nitric Oxide, ppba	34 (15, 73)
Immunoglobulin E	531 (117, 883)
Serum absolute eosinophil count	372 (212, 642)
% predicted FEV1a	87 (78, 103)
% predicted FVCa	99 (90, 113)
% predicted FEV1/FVCa	89 (81, 95)
≥1 ED visit or hospitalization or use OCS owing to asthmab	56 (50%)
Ever heard or read about the air quality index or air quality alerts?	84 (75%)
Learned about or checked the air quality before going outside to be active, yes	72 (64%)
Change made in outdoor activity owing to perception of outdoor air quality (not index), yes	55 (49%)
Healthcare provider ever discussion of outdoor air pollution as an asthma trigger	46 (41%)
Healthcare provider ever recommendation for outdoor activity change when poor air quality	39 (35%)
Season of interviewa
September to November	15 (13%)
December to February	26 (23%)
March to May	41 (37%)
June to August	30 (27%)

^aMeasured at time of AQI questionnaire.

^bIncludes prior 6 months.

ACT, asthma control test; AQI, air quality index; CACT, childhood asthma control test; ED, emergency department; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; OCS, oral corticosteroid; TOPMAS, The Transcript/Omics for Precision Medicine in Asthma Study.

Table 2.

Differences Between Those Who Did Not Change and Those Who Did Change Outdoor Activity After Learning About or Checking Air Quality Prior to Going Outside (n=71)

Variables	No change (n=19)	Change (n=52)
Age (years)	12 (10, 13)	12 (9, 14)
Female sex	6 (32%)	24 (46%)
Race
Black	15 (79%)	17 (33%)
Other	1 (5%)	2 (4%)
White	3 (16%)	33 (64%)
Medicaid (versus private or commercial) health insurance	16 (84%)	29 (56%)
Perceived poverty (living check to check, almost poor, poor)	13 (72%)	29 (56%)
Rent (versus own) home	14 (74%)	19 (27%)
Gas stove for cooking	11 (58%)	33 (64%)
At least 1 parent completed college	8 (42%)	30 (58%)
Parental asthma	14 (74%)	30 (60%)
Overweight or obese (BMI ≥85th)	8 (42%)	11 (21%)
Current second-hand tobacco exposure	7 (37%)	9 (16%)
Vigorous or moderate outdoor activity ≥3 days per weeka	10 (53%)	33 (65%)
ACT scorea	20 (18,22)	20 (15, 22)
CACT score	19.5 (18, 21)	20 (17, 21.5)
ACT or CACT score ≥20a (i.e., consistent with good control)	10 (53%)	28 (54%)
Pediatric Asthma Quality of Life Questionnaire, scorea	6.1 (5.4, 6.5)	5.8 (4.8, 6.8)
Fractional Exhaled Nitric Oxide, ppba	23 (13, 40)	31 (13, 72)
Immunoglobulin E	480 (163, 742)	559 (106, 960)
Serum absolute eosinophil count	406 (370, 530)	405 (213, 676)
% predicted FEV1a	80 (68, 97)	87 (81, 102)
% predicted FVCa	92 (82, 105)	99 (92, 113)
% predicted FEV1/FVCa	86 (76, 92)	89 (81, 98)
≥1 ED visit or hospitalization or use OCS owing to asthmab	12 (63%)	26 (50%)
Ever heard or read about the air quality index or air quality alerts?	11 (58%)	51 (98%)
Change made in outdoor activity owing to perception of air quality (not index)	6 (31.6%)	42 (80.8%)
Healthcare provider ever discussion of outdoor air pollution as a trigger, yes	11 (58%)	28 (54%)
Healthcare provider ever recommendation for outdoor activity change when poor air quality, yes	6 (32%)	29 (56%)
Season of interviewa
September to November	5 (26%)	7 (13%)
December to February	3 (16%)	12 (23%)
March to May	7 (37%)	20 (38%)
June to August	4 (21%)	12 (25%)

Note: Data are shown as median (IQR) and n (%). *p<0.05 for comparison between groups, obtained through Wilcoxon rank sum or chi-square test.

^aMeasured at time of AQI questionnaire.

^bIncludes prior 6 months.

ACT, asthma control test; AQI, air quality index; CACT, childhood asthma control test; ED, emergency department; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; OCS, oral corticosteroid.

For those who reported learning or checking the air quality before going outside to be active, the follow-up question allowed participants to select all sources of information that applied: app on my phone; heard about an alert from the TV, radio, or social media; internet website; or Allegheny County Alert service (Appendix Table 1, available online). Most participants reported using a single source for information (n=48, 67%) (Appendix Figure 1, available online). The most common single source selected was a phone app only (n=30), followed by alerts from TV, radio, or social media only (n=11) and internet website only (n=7). No participants reported sole use of county alerts. Among those who selected 2 or more sources (n=24, 33% of those reporting learning or checking air quality), all reported using a phone app. Most multisource users reported 2 sources (n=11 of 24, 46%), with fewer reporting the use of 3 sources (n=9 of 24, 38%) and the least reporting the use of all 4 sources (n=4 of 24, 17%) (Appendix Figure 1, available online).

Overall, a phone app was the most frequently selected choice (n=54, 75%), followed by alerts (n=32, 44%), internet (n=17, 24%), and county alert service (n=10, 14%) (Figure 1). Among those reporting phone app usage, the weather app was the most frequently reported (83%), with few reporting the U.S. AirNow app (6%) or local news apps and IQAir (4% each) (Figure 1). Among the few reporting internet website usage, the most frequent response was do not know/not sure (n=6), followed by Allegheny County Health Department (n=3), with AirNow website, Google, and AccuWeather websites (n=2 each) (Figure 1).

Figure 1.

Source of air quality information in those who reported learning about or checking the air quality for themselves or their child with asthma. (A) Prior to going outside to be active. (B) App used among those reporting phone app. (C) Site used amongst those reporting internet/website.

Note: For Panel A, participants could select multiple answer choices. For Panels B and C, only 1 source could be selected.

DISCUSSION

In this cohort of 112 children with persistent asthma and their caregivers, 64% reported learning about or checking air quality prior to outdoor activity, yet healthcare provider’s discussion of outdoor air pollution was endorsed by only 41%, and 35% reported a provider’s recommendation to reduce or change outdoor activity when air quality is poor. These data suggest that more children with asthma and their families use air quality information than discuss air quality with healthcare providers. Notably, only half of all participants and their caregivers reported changing outdoor activities on the basis of air quality, despite outdoor air pollution being an asthma trigger and most children reporting at least 10 minutes of moderate or vigorous outdoor physical activity several days per week. There are few studies that have examined the rates of healthcare providers’ discussions of outdoor air pollution in general, with fewer specific to children with asthma. Current evidence supports overall low rates of healthcare provider’s discussion of outdoor air pollution during clinical encounters, with poor knowledge or confidence, lack of time, or lack of feasible interventions as potential barriers to implementation.^7,11, 12, 13, 14, 15, 16, 17

In this study, the primary source of air quality information was a phone app, specifically a weather app, with few participants utilizing the Environmental Protection Agency (EPA) source. On the basis of current evidence, this is the first study to report on the primary app source of air quality information used by children with asthma and their caregivers. The questionnaire did not capture the specific weather app used, which is important because not all AQIs provided by commercial products are the same as the NowCast AQI provided by the U.S. EPA AirNow product. For example, Breezometer provides the index on the iPhone weather app, Copernicus Atmosphere Monitoring Service provides it on The Weather Channel app, and Plume Labs provides it on the AccuWeather app, which are not all analogous with regard to input pollutants, time intervals, and AQI reporting. The benefits and risks of using various AQIs, mostly providing subdaily (<24-hour averages), are unknown and require evaluation. Although the source of air quality information in people with asthma is understudied, the findings are consistent with those of 2 studies demonstrating that phone apps are the most common source for younger people.^13,16 Of note, the findings of this study support overall low usage of EPA AirNow products and greater reported behavioral change in response to an AQI in families with greater resources.

Limitations

Several study limitations should be acknowledged, including the lack of a validated questionnaire, possible recall bias, and the use of a single-site cohort in a county with poor air quality because of particle pollution (Allegheny County). Nonetheless, these results suggest that healthcare providers caring for children with asthma should inquire about patient and caregiver outdoor air pollution self-management and provide guidance on the basis of the best current evidence, although more evidence is needed to determine the best use of the U.S. AQI in pediatric asthma management.¹⁷

Conclusions

Most children with asthma and their caregivers report checking an air quality index at least once in the prior year before going outside to be active. The most frequent source of air quality information was a weather app, with infrequent reported use of AirNow products. More research is needed to better understand how children with asthma and their caregivers select air quality index products and the facilitators and barriers to discussion of outdoor air pollution by healthcare providers.