Abstract

Background: Asthma is a major public health burden causing high mortality, economic strain, and reduced quality of life. Patients with asthma frequently navigate a complex constellation of experiences that may stimulate feelings of fear, worry or distress, including aversion to steroids, fear of movement or even breathlessness itself. Traditional research often treats anxiety as a homogenous condition, and conventional management fails to consider how emotional drivers dictate self-regulatory behaviour. However, constructs such as fear, worry, and phobia are arguably more proximal to the daily self-management of asthma than generalised anxiety.

Objective: This systematic review seeks to understand the relationship between the specific emotional constructs of asthma fear, worry, and phobia in relation to management outcomes.

Methods: A systematic search of PubMed, EMBASE, and PsycINFO was conducted (1990-2025). Eligible studies were English-language quantitative prospective or cross-sectional studies on adults or adolescents (aged ≥13 years), investigating the impact or associations of at least one of fear, worry or phobia in relation to the following defined outcomes: asthma control (clinical symptom suppression), adherence (medication regimen alignment), quality of life (subjective impact on daily functioning), or healthcare utilisation (emergency department visits or hospitalisations).

Results: Thirteen studies met all inclusion criteria (nine cross-sectional and four prospective longitudinal studies). Fear of medication side effects (n=4), fear of movement (n=2), fear of breathlessness (n=3) and generalized asthma fear (n=2) were the most frequently assessed constructs. Notably fear related to steroids, including fear of addiction, was consistently associated with poorer adherence. Fear related to movement was also associated with reduced physical activity and quality of life. Prospective evidence demonstrated that high baseline asthma-related worry significantly predicted negative trajectories characterised by lower quality of life and increased emergency healthcare utilisation. Two intervention studies suggested targeting asthma specific fears could improve clinical outcomes.

Conclusion: This systematic review identifies that specific emotional constructs are a proximal driver of asthma self-management, but there is a limited body of evidence. Understanding specific emotional drivers may explain differences in clinical outcomes and provide opportunities for more emotion-based interventions. Future studies could benefit from understanding specific fears rather than just focusing on generalised anxiety.