Social Determinants of Health and At-Risk Rates for Pediatric Asthma Morbidity

Abstract

BACKGROUND AND OBJECTIVES Compared with population-based rates, at-risk rates (ARRs) account for underlying variations of asthma prevalence. When applied with geospatial analysis, ARRs may facilitate more accurate evaluations of the contribution of place-based social determinants of health (SDOH) to pediatric asthma morbidity. Our objectives were to calculate ARRs for pediatric asthma-related emergency department (ED) encounters and hospitalizations by census-tract in Washington, the District of Columbia (DC) and evaluate their associations with SDOH. METHODS This population-based, cross-sectional study identified children with asthma, 2 to 17 years old, living in DC, and included in the DC Pediatric Asthma Registry from January 2018 to December 2019. ED encounter and hospitalization ARRs (outcomes) were calculated for each DC census-tract. Five census-tract variables (exposures) were selected by using the Healthy People 2030 SDOH framework: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty. RESULTS During the study period, 4321 children had 7515 ED encounters; 1182 children had 1588 hospitalizations. ARRs varied 10-fold across census-tracts for both ED encounters (64–728 per 1000 children with asthma) and hospitalizations (20–240 per 1000 children with asthma). In adjusted analyses, decreased educational attainment was significantly associated with ARRs for ED encounters (estimate 12.1, 95% confidence interval [CI] 8.4 to 15.8, P <.001) and hospitalizations (estimate 1.2, 95% CI 0.2 to 2.2, P = .016). Violent crime was significantly associated with ARRs for ED encounters (estimate 35.3, 95% CI 10.2 to 60.4, P = .006). CONCLUSION Place-based interventions addressing SDOH may be an opportunity to reduce asthma morbidity among children with asthma.

The prevalence of childhood asthma: interpreting falling rates in the context of shifting measurement and the COVID-19 pandemic

“…Analyses that favour at-risk rates over populationrisk rates also provide greater insight into the social determinants of health that drive disparities, so that targeted interventions can be developed to promote equity in health outcomes [45]. This is the importance of accurate prevalence information: we cannot appropriately study or address disparities without a clear understanding of who is at the greatest risk.…”

“…Children from historically marginalized groups, including those with non-Hispanic Black or Puerto Rican ancestry, are more likely to develop asthma [ 1 ]. Differences in asthma prevalence rates between sub-groups of the larger U.S. population are informed by structural racism and inequities in American society [ 44 ▪▪ ], factors which also contribute to morbidity and confound analyses that rely on census-based population data [ 45 ]. When outcomes comparisons are limited to children who are at-risk for asthma morbidity (based on NHIS prevalence data), a different picture emerges, and indicates that disparities for black children may be improving [ 1 ].…”

“…When outcomes comparisons are limited to children who are at-risk for asthma morbidity (based on NHIS prevalence data), a different picture emerges, and indicates that disparities for black children may be improving [ 1 ]. Analyses that favour at-risk rates over population-risk rates also provide greater insight into the social determinants of health that drive disparities, so that targeted interventions can be developed to promote equity in health outcomes [ 45 ]. This is the importance of accurate prevalence information: we cannot appropriately study or address disparities without a clear understanding of who is at the greatest risk.…”

Socioeconomic determinants of asthma health

“…This suggests that the racist public policies and practices implemented almost 100 years ago continue to create areas of social vulnerability, limited opportunity, and poor health outcomes. Several studies have further explored the structural and social risks associated with adverse asthma outcomes [53,54 ▪▪ ,55 ▪▪ ,56]. Experiencing discrimination, along with markers of poverty, exposure to violent crime, and caregiver educational attainment, are all associated with increased healthcare utilization for children with asthma.…”

Extreme temperature and storm exacerbations of pediatric asthma: evidence and prevention strategies

“…A longitudinal analysis of 544 children in the Chicago Initiative to Raise Asthma Health Equity found that health literacy and education were important mediators of racial and ethnic disparities in asthma [15]. Another study of 4321 children in the D.C. Pediatric Asthma Registry found that decreased educational attainment and violent crime were the social determinants of health most significantly associated with risk of asthma emergency department visits and hospitalizations [16]. These findings must be considered when implementing community education and warning systems.…”