Addressing the social determinants of ill health, such as asthma triggers in the home, requires not only courage but caution.
Homes should be safe and secure spaces that support our health and wellbeing. Our homes should provide us with shelter, access to efficient and healthy energy sources, sufficient space, as well as a sense of belonging, security and privacy.
The home environment should also protect us from things which are hazardous to our health. For people who have asthma or allergies this also includes many airborne substances and gases, which are prevalent in homes. These gases, nitrogen dioxide being the most potent culprit, can trigger asthma in those with established diagnoses and they may also increase the risk of a person developing the disease in the first place.
The recent TMR commentary on the clinical article by Dr Ben Ewald (University of Newcastle) and colleagues on the harms of gas cooking in Australian home was a useful contribution to this issue around which Asthma Australia has been advocating for several years.
In my practice, we regularly see people with asthma who are quite limited by their disease, with frequent symptoms and regular flare-ups. Part of a standard asthma consultation includes the identification of avoidable triggers which can be a difficult question for these patients, who can’t easily identify what is harming, and what is helping, their asthma.
Recent consumer research by Asthma Australia revealed that there are many asthma triggers in Australian homes. Their nationally representative survey of over 5000 people focused on indoor air pollution from cooking, gas or wood heating, mould and dampness and pests (including ants, spiders, mice, cockroaches and dust mites). They found that many people are exposed to these triggers in their homes and that some population groups are more likely to be exposed to certain triggers. Those most at risk include people with asthma, Aboriginal and Torres Strait Islander people, people living in social housing and people with children in their homes.
These findings align with the experiences of patients in my practice. In general, I find that people who seem to be facing the greater hardships with their social circumstances, finances, employment and housing setup are the ones most likely to be experiencing the most difficulties with their breathing.
This is why the AJGP article was especially important. Often doctors feel at a loss to deal with the myriad circumstances getting in the way of their patients’ health. The various determinants of a person’s health have been established for decades, but when faced with the question of what we can do about them, it can be a deterrent for many practitioners, as we are usually trained to focus on biomedical approaches.
I work in an Aboriginal Community Controlled Health Service, and this model has prioritised the social determinant approaches. We consider housing security, daily living expenses, and access to the range of social financial support to be as important, sometimes more important, than prescription of medicine or referral to diagnostic tests or specialist appointments.
The call by Dr Ewald and the team for doctors to consider engaging with landlords and social housing providers to advocate for improved housing conditions for those most vulnerable is potentially significant and realistic. We already regularly advocate for individual patients for improvements to their housing that impacts their health. Such improvements might now include installing or servicing appliances that are known to reduce risk and harm, like rangehoods, convection stoves, and overall ventilation. Having a diagnostic test or prescribing inhalers is ineffective if I am just sending people back to the conditions causing their problem in the first place.
However, it’s important that doctors and practices are aware of the potential risk of this approach: some Asthma Australia consumers have reported rent increases and even eviction. Consultation with our patients is paramount when considering such actions. Landlords may respond more to a doctor than to an individual request from a tenant. Making sure that patients have contact details for the state housing ombudsman and the Tenants Union can ensure that renters know their rights, and they are supported.
Asthma Australia’s research found that only six out of 10 people are confident to make changes to improve the air quality inside their home. And whilst this might seem surprisingly high, it is probably not representative of people who sit in the lower socioeconomic brackets in Australia for whom the problems are amplified. Common barriers surveyed consumers reported were cost, not owning the home, not being concerned, or not knowing what to do.
Additionally, while gas cooktops are associated with adverse health and environmental outcomes, they are the most common type of cooktop in Australia. Despite being so ubiquitous, just one quarter of Australians are aware that emissions from gas appliances can trigger their symptoms, compared to 82% of people for dust and 70% for mould.
Asthma Australia’s survey suggests triggers in Australian homes are likely to be worsening asthma and allergy symptoms with almost one third of people with asthma or allergies reporting worse symptoms when they are at home, regardless of whether they own their home, rent, or live in social housing.
This is the opposite of what we want, which is safe, healthy, and secure homes. Whilst some triggers in the home may be harder than others to avoid, we should consider the tangible actions we can take to support our patients to take action that we know can help them, protect their health and that of their loved ones.
Dr Senior is a member of Asthma Australia’s Professional Advisory Council. He works as a GP at the Aboriginal Community Controlled Health Service in southwest Sydney, and is a clinical senior lecturer at Western Sydney University; he is the Medical Advisor of the RACGP Aboriginal and Torres Strait Islander Health and founded the Environmental Impacts in General Practice network in the RACGP NFSI; he is also on the TMR editorial board.
