Shared Decision-Making Needed to Address Environmental, Social Factors of Asthma Management

A shared decision-making approach for dialogue with patients with asthma and their caregivers is needed to best address and manage address the nonpharmacologic aspects of asthma management, including social and environmental factors.1

“Discussions around asthma management tend to focus on the therapeutic aspects… However, there are many other components of asthma management that are now receiving increased attention as we seek to make right on health disparities and strive towards health equity,” Mitchell Grayson, MD, editor in chief of Annals of Allergy, Asthma, and Immunology and Chair in Pediatric Research, Professor of Pediatrics, and Chief of the Division of Allergy at Nationwide Children's Hospital, said in a statement.2 “On the other hand, 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 co-morbidities. We continue to learn about methods to identify these issues and draw them into a shared decision-making approach to dialogue with patients and their caregivers. In this review, we provide information and available tools to address these non-pharmacologic aspects of asthma management.”

Nonpharmacologic aspects of asthma management, including environmental exposures, social determinants of health, and risk-taking behaviors, as well as a framework for shared decision making, were explored in a review published in Annals by primary investigator Emily H. Skeen, MD, Pediatric Pulmonary and Sleep Medicine Section, Department of Pediatrics, Breathing Institute, Anschutz Medical Campus, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, and colleagues.1

Skeen and colleagues compiled recent guidelines and recommendations, including from the Expert Panel Report 3 Guidelines and the United States Environmental Protection Agency (EPA), for managing asthma. Among these recommendations, clinicians should assess each patient's environmental exposures and tailor mitigation strategies to their specific sensitivities and living conditions. The review found that current guidelines stress that single interventions are often ineffective and a multifaceted approach addressing known triggers, including indoor allergens, tobacco smoke, and air pollutants, is favorable. Additionally, integrated pest management, mold reduction, use of HEPA filters, and smoke-free homes can significantly improve outcomes in sensitized patients.

Clinicians should also advise on reducing exposure to outdoor air pollution, particularly during high-risk events like wildfires or dust storms, and utilizing air purifiers and highly rated filtered ventilation systems.

Clinicians must also proactively consider social determinants of health (SDOH) such as poverty, racism, poor housing, and environmental exposures, all of which drive disparities in asthma prevalence, severity, and outcomes. Clinicians should incorporate validated SDOH screening tools into routine care and ensure resource referrals are available to address unmet social needs, ideally supported by integrated care teams or local networks.

Special considerations for pediatric patients are shaped by developmental stage, caregiver involvement, and family dynamics and include health behaviors, including medication adherence, avoidance of triggers, physical activity, sleep quality, and nutrition. Pediatric patients may especially benefit from shared decision making with caregivers to set realistic behavior change goals.

“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,” Skeen and colleagues wrote.1

REFERENCES

1. Skeen EH, Hamlington KL, De Keyser HH, Liu AH, Szefler SJ. Managing childhood asthma with an eye toward environmental, social, and behavioral features. Ann. Allergy Asthma Immunol. 2025; 134(5): 516-524. DOI: 10.1016/j.anai.2025.02.013

2. Chronic illnesses such as asthma and allergies have psychological impacts. News release. American College of Allergy, Asthma, and Immunology. May 7, 2025. https://www.eurekalert.org/news-releases/1082894