Mapping inequality: Childhood asthma and environmental injustice, a case study of St. Louis, Missouri

Factors Associated With Recurrent Pediatric Firearm Injury : A 10-Year Retrospective Cohort Analysis

BACKGROUND

Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States.

OBJECTIVE

To examine the factors associated with recurrent firearm injury among children who presented with acute (index) nonfatal firearm injury in the St. Louis region.

DESIGN

Multicenter, observational, cohort study.

SETTING

2 adult and 2 pediatric level I trauma hospitals in St. Louis, Missouri.

PARTICIPANTS

Pediatric patients aged 0 to 17 years presenting with an index firearm injury between 2010 and 2019.

MEASUREMENTS

From the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, we collected data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and mortality. The Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the cumulative incidence of experiencing a recurrent firearm injury.

RESULTS

During the 10-year study period, 1340 children presented with an index firearm injury. Most patients were Black (87%), non-Hispanic (99%), male (84%), and between the ages of 15 and 17 years (67%). The estimated risk for firearm reinjury was 6% at 1 year and 14% at 5 years after initial injury. Male children and those seen at an adult hospital were at increased risk for reinjury.

LIMITATION

Our data set does not account for injuries occurring outside of the study period and for reinjuries presenting to nonstudy hospitals.

CONCLUSION

Children who experience an initial firearm injury are at high risk for experiencing a recurrent firearm injury. Interventions are needed to reduce reinjury and address inequities in the demographic and clinical profiles within this cohort of children.

PRIMARY FUNDING SOURCE

National Institutes of Health.

A novel tool using social and environmental determinants of health to assess pediatric asthma in the emergency department

Asthma, the most common chronic disease in children, affects more than 4 million children in the United States, disproportionately affecting those who are economically disadvantaged and racial and ethnic minorities. Studies have shown that the racial and ethnic disparities in asthma outcomes can be largely explained by environmental, socioeconomic and other social determinants of health (SDoH). Utilizing new approaches to stratify disease severity and risk, which focus on the underlying SDoH that lead to asthma disparity, provides an opportunity to disentangle race and ethnicity from its confounding social determinants. In particular, with the growing use of geospatial information systems, geocoded data can enable researchers and clinicians to quantify social and environmental impacts of structural racism. When these data are systematically collected and tabulated, researchers, and ultimately clinicians at the bedside, can evaluate patients' neighborhood context and create targeted interventions toward those factors most associated with asthma morbidity. To do this, we have designed a view (mPage in the Cerner electronic health record) that centralizes key clinical information and displays it alongside SDoH variables shown to be linked to asthma incidence and severity. Once refined and validated, which is the next step in our project, our goal is for emergency medicine clinicians to use these data in real time while caring for patients with asthma. Our multidisciplinary, patient-centered approach that leverages modern informatics tools will create opportunities to better triage patients with asthma exacerbations, choose the best interventions, and target underlying determinants of disease.

Community violence and asthma: A review

Over the past 2 decades, epidemiologic studies have identified significant associations between exposure to violence, as a psychosocial stressor, and the incidence or exacerbation of asthma. Across diverse populations, study designs, and measures of community violence, researchers have consistently identified adverse associations. In this review, the published epidemiologic evidence is summarized with special attention to research published in the last 5 years and seminal papers. Hypothesized mechanisms for the direct effects of violence exposure and for how such exposure affects susceptibility to physical agents (eg, air pollution and extreme temperature) are discussed. These include stress-related pathways, behavioral mechanisms, and epigenetic mechanisms. Finally, clinical implications and recommendations are discussed.

Interpersonal comparison among caregivers of children with asthma

Objective: We examined the extent to which caregivers of children with asthma used interpersonal comparisons-a novel comparison process that parallels social comparison and temporal comparison-to form judgments about their child. Methods & Measures: Using semi-structured interviews adapted from the McGill Illness Narrative Interview, we examined the interpersonal comparisons that caregivers of a child with asthma (n = 41) made regarding their child. Results: Interpersonal comparisons influenced caregiver thoughts, feelings, and behavior. They helped caregivers distinguish asthma from other breathing problems, evaluate the severity of the asthma, and understand their child's experience. However, they also created uncertainty by highlighting the complex, unpredictable nature of asthma. Interpersonal comparisons were a source of gratitude and hope, but also worry and frustration. Finally, interpersonal comparisons influenced caregivers' decisions and actions, resulting in decisions that aligned with and, at times, ran counter to biomedical models of asthma care. In some instances, caregivers used interpersonal comparisons to motivate their child's behavior. Conclusion: The interpersonal comparisons served as a source of information for caregivers trying to understand and manage their child's asthma. Investigating these comparisons also expands how we think about other comparison theories.

Social deprivation and spatial clustering of childhood asthma in Australia

BACKGROUND

Asthma is the most common chronic respiratory illness among children in Australia. While childhood asthma prevalence varies by region, little is known about variations at the small geographic area level. Identifying small geographic area variations in asthma is critical for highlighting hotspots for targeted interventions. This study aimed to investigate small area-level variation, spatial clustering, and sociodemographic risk factors associated with childhood asthma prevalence in Australia.

METHODS

Data on self-reported (by parent/carer) asthma prevalence in children aged 0-14 years at statistical area level 2 (SA2, small geographic area) and selected sociodemographic features were extracted from the national Australian Household and Population Census 2021. A spatial cluster analysis was used to detect hotspots (i.e., areas and their neighbours with higher asthma prevalence than the entire study area average) of asthma prevalence. We also used a spatial Bayesian Poisson model to examine the relationship between sociodemographic features and asthma prevalence. All analyses were performed at the SA2 level.

RESULTS

Data were analysed from 4,621,716 children aged 0-14 years from 2,321 SA2s across the whole country. Overall, children's asthma prevalence was 6.27%, ranging from 0 to 16.5%, with significant hotspots of asthma prevalence in areas of greater socioeconomic disadvantage. Socioeconomically disadvantaged areas had significantly higher asthma prevalence than advantaged areas (prevalence ratio [PR] = 1.10, 95% credible interval [CrI] 1.06-1.14). Higher asthma prevalence was observed in areas with a higher proportion of Indigenous individuals (PR = 1.13, 95% CrI 1.10-1.17).

CONCLUSIONS

We identified significant geographic variation in asthma prevalence and sociodemographic predictors associated with the variation, which may help in designing targeted asthma management strategies and considerations for service enhancement for children in socially deprived areas.

Managing children's asthma: what role do caregivers' mental representations of trigger and symptom management behaviors play?

OBJECTIVE

Pediatric asthma management is challenging for parents and guardians (hereafter caregivers). We examined (1) how caregivers mentally represent trigger and symptom management strategies, and (2) how those mental representations are associated with actual management behavior.

METHODS

In an online survey, N = 431 caregivers of children with asthma rated 20 trigger management behaviors and 20 symptom management behaviors across 15 characteristics, and indicated how often they engaged in each behavior.

RESULTS

Principal components analysis indicated 4 dimensions for trigger management behaviors and 3 for symptom management behaviors. Bayesian mixed-effects models indicated that engagement in trigger management behavior was more likely for behaviors rated as affirming caregiver activities. However, trigger management behavior did not depend on how highly the behavior was rated as challenging for caregiver, burdensome on child, or routine caregiving. Engagement in symptom management behavior was more likely for behaviors rated as affirming and common and harmless to the child, but was unrelated to how highly a behavior was rated as challenging for caregivers.

CONCLUSION

These results suggest that interventions might be particularly useful if they focus on the affirming nature of asthma management behaviors. However, such interventions should acknowledge structural factors (e.g. poverty) that constrain caregivers' ability to act.

Linking cognitive and affective heuristic cues to interpersonal risk perceptions and behavior

People often use cognitive and affective heuristics when judging the likelihood of a health outcome and making health decisions. However, little research has examined how heuristics shape risk perceptions and behavior among people who make decisions on behalf of another person. We examined associations between heuristic cues and caregivers' perceptions of their child's asthma risk, the frequency of caregivers' asthma management behaviors, and child health outcomes. We used Ipsos KnowledgePanel to recruit 814 U.S. adult caregivers of children with asthma of the age <18 years. Participants completed a survey at baseline (T1) and 3 months later (T2). Caregivers who, at T1, reported greater negative affect about their child's asthma (affect heuristic cue), greater ease of imagining their child experiencing asthma symptoms (availability heuristic cue), and greater perceived similarity between their child and a child who has ever experienced asthma symptoms (representativeness heuristic cue) reported statistically significantly (p < 0.05) higher interpersonal perceived risk of their child having an exacerbation or uncontrolled asthma at T1. They also indicated at T2 that their child had poorer asthma control and more frequent exacerbations. Greater T1 negative affect was associated with more frequent T2 actions to reduce inflammation, manage triggers, and manage symptoms, and with poorer T2 child health outcomes. Heuristic cues are likely important for interpersonal-not just personal-risk perceptions. However, the interrelationship between caregivers' ratings of heuristic cues (in particular, negative affect) and risk judgments may signify a struggle with managing their child's asthma and need for extra support from health care providers or systems.

Monitoring Social Determinants of Health Assessing Patients and Communities

Because of the devastating health effects of social determinants of health (SDoH), it is important for the primary care provider to assess and monitor these types of stressors. This can be done via surveys, geomapping, or various biomarkers. To date, however, each of these methods is fraught with obstacles. There are currently are no validated "best" SDoH screening tools for use in clinical practice. Nor is geomapping, a perfect solution. Although mapping can collect location specific factors, it does not account for the fact that patients may live in one area, work in another and travel frequently to a third.

Economic Determinants of Health Disparities and the Role of the Primary Care Provider

The economic determinants of adverse personal health outcomes and population level disparities pose a daunting challenge for primary care providers in promoting health for persons experiencing poverty and neighborhood deprivation. Until they are addressed, however, the health and economic well-being of persons experiencing neighborhood deprivation is not likely to be improved. There is growing evidence of effective interventions that primary care providers can adopt to address social and economic determinants of health. Primary care providers can participate in clinic and community-based approaches that target individual, neighborhood and social level drives of health and disparities.

Social Determinants of Health, Chronic Disease Management, and the Role of the Primary Care Provider-to Include Cardiovascular Disease, Cancer, Diabetes, Major Causes of Morbidity and Mortality as Affected by Social Determinants of Health

Despite advances in health science and medical technology, health outcomes continue to fall behind in certain communities. A recent study linking health outcomes to zip code may explain part of this disparity, social determinants of health. Although well known that patients in resource-poor environments have worse outcomes than patients with advantages, the exact reason for this disparity may not be so well known. This article aims to explore the physiologic basis for worsening disease states in patients with poor social determinants of health, as well as start a discussion surrounding possible screening and interventions that can be performed in a primary care office to promote patient health.

Beginning to Address an Implementation Gap in Asthma: Clinicians' Views of Prescribing Reliever Budesonide-Formoterol Inhalers and SMART in the United States

BACKGROUND

The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored.

OBJECTIVE

To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States.

METHODS

Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation.

RESULTS

Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making.

CONCLUSIONS

Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.

How are mental representations of asthma triggers and symptoms related to interpersonal risk perceptions? A psychometric investigation of caregivers of children with asthma

OBJECTIVE

Parents and guardians (hereafter caregivers) make decisions for their children's medical care. However, many caregivers of children with asthma struggle to understand their child's illness. We used the psychometric paradigm to investigate how caregivers conceptualize, or mentally represent, asthma triggers and symptoms and how these representations are linked to perceived asthma exacerbation risk.

METHODS

We asked 377 caregivers of children with asthma across the U.S. to rate 20 triggers or 20 symptoms along 15 characteristics. Caregivers also indicated their perceived risk of their child having an asthma exacerbation (hereafter interpersonal risk perceptions). Using principal components analysis, we extracted key dimensions underlying caregivers' ratings on the characteristics. Then we related the triggers' and symptoms' scores on the dimensions to caregivers' interpersonal risk perceptions.

RESULTS

Interpersonal risk perceptions were higher for triggers with high ratings for the dimensions severe and relevant, and negative affect-yet manageable, but not chronic-yet unpredictable. Risk perceptions were also higher for symptoms with high ratings for the dimensions severe and unpredictable, and relevant and common, but not self-blame or manageable despite unknown cause.

CONCLUSION

By identifying key dimensions underlying caregivers' mental representations of asthma triggers and symptoms, these findings can inform a new approach to asthma education.

Through the Zoom window: How children use virtual technologies to navigate power dynamics in research

Virtual technologies gained popularity during the COVID-19 pandemic for use in research, including research with children. As scholarship from the field of science, technology and society (STS) suggests, technologies are never neutral, but embedded with social values and, as such, used by people to navigate identities and relationships. Building on childhood studies research that has shown how children appropriate and use research tools, this article asks: How do child research participants use this virtual "window" into their homes and their lives? Using observations from a virtual and in-person study in the United States, we show how children used virtual technologies to manage relationships, filter what researchers saw of their lives, and navigate issues of privacy and self-disclosure. We conclude that analysing children's interactions with research technologies offers important indicators to guide researchers attending to ethical issues of power for both in-person and virtual research with children.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Breathing Together: Children Co-constructing Asthma Self-Management in the United States

Pediatric asthma management in the U.S. is primarily oriented around caregivers. As evident in policy, clinical literature and provider practices, this caregiver-centric approach assumes unidirectional transfer of practices and knowledge within particular relational configurations of physicians, caregivers, and children. Reflecting broader societal values and hierarchies, children are positioned as passive recipients of care, as apprentices for future citizenship, and as the responsibility of parents who will train them in the knowledge and labor of asthma management. These ideas, though sometimes contradictory, contribute to a systemic marginalization of children as participants in their health care, leaving a conceptual gap regarding children's inclusion in chronic illness management: what children's roles in their health care are or should be. We address this conceptual gap by asking, what does pediatric asthma management look like when we center children, rather than caregivers in our lens? We draw data from a study of asthma management in St. Louis, Missouri, and Gainesville, Florida, which included 41 caregivers, 24 children, and 12 health-care providers. By asking children to show us how they manage asthma, we find that children actively co-construct health practices within broader interdependencies of care and the structural constraints of childhoods.

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

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.

Housing and health in vulnerable social groups: an overview and bibliometric analysis

Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.

Towards emplaced understandings of risk: How caregivers of children with asthma identify and manage asthma-related risk across different places

In the United States, pediatric asthma is distributed geographically across lines of racialized segregation. We draw on emplacement, or the theory that embodied experiences and the material world are mutually informed, to situate such geographic trends within the narratives of 41 caregivers of children with asthma. Results suggest that caregivers identified and managed asthma-related risk with regard to the relational and structural conditions of three categories of locations: (1) houses, (2) neighborhoods, and (3) schools and other childhood institutions. Within each type of location, caregivers used emplaced knowledge and emplaced caregiving tactics to respond to asthma-related risk. Based on our findings, we identify critical intervention topics that are consistent with families' everyday lived experiences of place.

Evaluation of a Program to Reduce Home Environment Risks for Children with Asthma Residing in Urban Areas

Pediatric asthma morbidity is often linked to challenges including poor housing quality, inability to access proper medical care, lack of medications, and poor adherence to medical regimens. Such factors also propagate known disparities, by race and income, in asthma-related outcomes. Multimodal home visits have an established evidence base in support of their use to improve such outcomes. The Collaboration to Lessen Environmental Asthma Risks (CLEAR) is a partnership between the Cincinnati Children's Hospital Medical Center and the local health department which carries out home visits to provide healthy homes education and write orders for remediation should code violations and environmental asthma triggers be identified. To assess the strengths and weaknesses of the program, we obtained qualitative feedback from health professionals and mothers of children recently hospitalized with asthma using key informant interviews. Health professionals viewed the program as a positive support system for families and highlighted the potential benefit of education on home asthma triggers and connecting families with services for home improvements. Mothers report working to correct asthma triggers in the home based on the education they received during the course of their child's recent illness. Some mothers indicated mistrust of the health department staff completing home visits, indicating a further need for research to identify the sources of this mistrust. Overall, the interviews provided insights into successful areas of the program and areas for program improvement.

Revealing the racial and spatial disparity in pediatric asthma: A Kansas City case study

Black and other socially disadvantaged children are disproportionately burdened by high rates of pediatric asthma. Intraurban variation in environmental risk factors and limited access to high-resolution health data make it difficult to identify vulnerable patients, communities, or the immediate exposures that may contribute to pediatric asthma exacerbation. This article presents a novel, interdisciplinary health disparities research and intervention strategy applied to the problem of pediatric asthma in Kansas City. First, address-level electronic health records from a major children's hospital in the Kansas City region are used to map the distribution of asthma encounters in 2012 at a high spatial resolution. Census tract Environmental Justice Screening Method (EJSM) indicators are then developed to scan for patterns in both the population health risks and vulnerabilities that may contribute to the burden of asthma in different communities. A Bayesian Profile Regression cluster analysis is used to systematically explore the complex relationships between census tract EJSM indicators and pediatric asthma incidence rates, helping to identify population characteristics and risk factors associated with both high and low rates of pediatric asthma throughout the region. The EJSM scanning exercise and BPR analysis demonstrate that each community faces a distinct set of risks and vulnerabilities that can contribute to the rate of acute pediatric asthma acute care encounters, providing targets for research and intervention. It is clear, however, that different forms of social disadvantage are driving high rates of pediatric asthma, which is closely tied to uneven development patterns and racial residential segregation. The results provide a starting point for designing place-based health disparities research and intervention strategies catered to the unique needs of vulnerable patients and communities; disparities-focused research and intervention strategies that leverage local knowledge and resources through community-based practices.

Not Breathing Easy: "Disarticulated Homework" in Asthma Management

Recent health policy in the United States encourages an outsourcing of labor from professional practice into domestic spaces, where in theory, medical professionals supply the training, technologies, and guidance needed to discharge responsibility for care to patients or caregivers. Mattingly et al. (2011) term this labor "chronic homework," describing the relationship between the assigning and undertaking of medical care at the borders of professional and domestic domains. This is a system predicated on relationships between professional and caregiver. However, in our research with families and providers in two U.S. sites, we observed a "disarticulation" of asthma care from professional medicine. Caregivers may undertake routine asthma management with little physician oversight, transforming chronic homework into what we term "disarticulated homework." We argue that expanding the concept of chronic homework to theorize disarticulation processes can help elucidate how health disparities are reproduced in the gap between medical systems and domestic life. [asthma, self-management, caregiving pharmaceuticalization, health disparities].

Inequalities and Inequities in Pediatric Respiratory Diseases

Social inequality refers to disparities in society that have the effect of limiting a group's socioeconomic, educational, and intellectual potential. Inequity in health means any limitation to access comprehensive health services that also hinders the achievement of well-being and favorable health outcomes. Strategies for more equitable growth to eradicate global poverty would contribute to reducing health inequities and improve health care outcomes. Coordinated efforts between governments, private sector, families, and interested stakeholders are needed. This article discusses inequality and inequity in pediatric respiratory diseases, the challenges confronted, and the strategies needed to mitigate these disparities.

The impact of nature-based education on health-related quality of life among low-income youth: results from an intervention study

BACKGROUND

Nature experiences have been shown to promote physical, emotional, mental and overall health. However, low-income youth often face inequities in access to nature. The purpose of this study was to evaluate the impact of a 15-week nature-based education (NBE) intervention on health-related quality of life (HRQoL) of low-income youth.

METHODS

A total of 362 low-income youth (ages 9-15) in St. Louis, MO, USA, participated in this study. Study participants completed a pre- and post-intervention survey that included validated measures of six HRQoL domains (Physical Activity, Emotional Health Functioning, School Functioning, Social Functioning, Family Functioning and overall HRQoL). Random effects analysis of covariance was used to test for significant differences in HRQoL scores between the intervention and control groups, after adjusting for school, age, previous nature exposure, and Science, Technology, Engineering and Mathematics capacity.

RESULTS

After the intervention period, youth in the NBE intervention group experienced improvements in all HRQoL domain scores (P < 0.001), whereas youth in the control group experienced declines in HRQoL domain scores (P < 0.001).

CONCLUSIONS

NBE may have a positive impact on the HRQoL of low-income youth. Further investigations examining the influence of nature-based activities on youth health outcomes are warranted.

Social Determinants of Placental Health and Future Disease Risks for Babies

Birthweight is a well-known predictor of adult-onset chronic disease. The placenta plays a necessary role in regulating fetal growth and determining birth size. Maternal stressors that affect placental function and prenatal growth include maternal overnutrition and undernutrition, toxic social stress, and exposure to toxic chemicals. These stressors lead to increased vulnerability to disease within any population. This vulnerability arises from placental and fetal exposure to stressors during fetal life. The biological drivers linking various social determinants of health to compromised placental function and fetal development have been little studied.

Situating household management of children's asthma in the context of social, economic, and environmental injustice

BACKGROUND

Structural determinants of health are social, economic, and environmental forces that generate unequal opportunities for resources and unequally distribute exposure to risk. For example, economic constraint, racial discrimination and segregation, and environmental injustice shape population-level asthma prevalence and severity. Structural determinants are especially relevant to consider in clinical settings because they affect everyday household asthma management.

OBJECTIVE

To examine how structural determinants shape everyday household management of pediatric asthma and offer a framework for providers to understand asthma management in social context.

DESIGN

Qualitative interviews of caregivers for children with asthma.

PARTICIPANTS

Participants included 41 caregivers in two U.S. cities: St. Louis, Missouri (n = 25) and Gainesville, Florida (n = 16). Most caregivers were women (83%), Black (73%) and/or had low socioeconomic status (SES; 78%). Caregivers cared for children with asthma aged 0-4 (32%), 5-11 (68%) and 12-17 (54%).

APPROACH

We carried out narrative interviews with caregivers using an adapted McGill Illness Narrative Interview and using qualitative analysis techniques (e.g. inductive and deductive coding, constant comparison).

KEY RESULTS

Caregivers highlighted three ways that structural determinants complicated asthma management at home: 1) housing situations, 2) competing household illnesses and issues, and 3) multi-household care.

CONCLUSIONS

By connecting social, economic, and environmental injustices to the everyday circumstances of asthma management, our study can help providers understand how social contexts challenge asthma management and can open conversations about barriers to adherence and strategies for supporting asthma management at home. We offer recommendations for medical system reform, clinical interactions, and policy advocacy.

Neighborhood Environment and Asthma Exacerbation in Washington, DC

Approximately one in eight people in the United States have been diagnosed with asthma. Asthma is associated with significant medical expenditure and has been implicated as a leading reason for chronic school absences. Environmental risk factors such as access to green space and exposure to poor air quality are patterned such that some vulnerable populations may be at higher risk. Using data from DC Health, the Washington, DC, department of public health, this study investigated associations between neighborhood social, built, and natural environments and rates of asthma-related healthcare encounters by ZIP code between 2014 and 2017. We found that significant differences in rates exist between ZIP codes and for different subpopulations. Black boys had the highest overall rate, with 58.49 visits per 1,000 population, ranging by ZIP code from 0 to 88.56 visits. We found that the ZIP code Social Vulnerability Index was consistently associated with rates of healthcare encounters, but not access to green/open space or exposure to high traffic. However, we discuss how the ZIP code level may not be an appropriate level at which to investigate such built/natural environment features because of the proportion of variability that is found within rather than between ZIP codes. We end with a short discussion of ways that nurses, in particular school nurses, could help to address neighborhood environmental risk factors.