Neighborhood Social Conditions, Family Relationships, and Childhood Asthma

Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study

PURPOSE

Low-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families.

METHODS

We conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.

RESULTS

We analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 - 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 - 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network.

CONCLUSION

Economic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.

Factors Contributing to the Health of 0- to 5-Year-Old Low-Birth-Weight Children in the United States: Application of the Multiple Disadvantage Model

This secondary data analysis of 1731 low-birth-weight children and their parents in the United States investigated children's health and its associations with social disorganization, social structural factors, social relationships, health/mental health, and access to health insurance/services. The study drew on data from the 2021 National Survey of Children's Health. Logistic regression yielded results showing low-birth-weight children's excellent/very good/good health to be associated positively with parents' education and health. In turn, child health was associated negatively with being Black, having a family income at or below the 100% federal poverty level, difficulty parenting the child, child chronic health condition(s), parent mental health, and substance use in the family. The implications of the present findings in terms of interventions promoting maternal and child health as well as participation in government assistance programs for low-income families are discussed.

Testing the Multiple Disadvantage Model of Health with Ethnic Asian Children: A Secondary Data Analysis

This study of ethnic Asian children in the United States asked whether their health exhibited relationship with any of six factors: social disorganization, social structural factors, social relationships, the health of their parents, their access to medical insurance, acculturation. The sample of 1350 ethnic Asian children was extracted from the 2018 National Survey of Children's Health. Logistic regression results showed that these children's excellent/very good/good health was associated positively with safe neighborhoods, family incomes, family cohesiveness, family support, and receipt of Temporary Assistance for Needy Families (TANF). In turn, health was associated negatively with single-mother households. Implications of the present results in terms of interventions promoting family support, TANF participation, safe neighborhoods, and professionals' cultural competency are discussed.

Impact of caregiver depression on child asthma outcomes in Mexicans and Puerto Ricans

OBJECTIVE

Examine whether caregiver depressive symptoms at baseline predict longitudinal child asthma outcomes in the two populations with the largest asthma disparities: Mexicans and Puerto Ricans.

METHODS

Two hundred and sixty-seven Hispanic caregiver-child dyads (Mexican = 188, Puerto Rican = 79; children 5-12 years) were recruited from clinics and hospitals in Phoenix, AZ and the Bronx, NY. The Center for Epidemiological Studies Depression Scale assessed caregiver depressive symptoms; higher scores indicate greater depressive symptomology. Medical records verified child asthma diagnosis. Assessments for outcome variables occurred at baseline, 3, 6, 9, and 12-month follow-ups. Pulmonary function was measured by spirometry, asthma control was measured by the Asthma Control Test, steroid bursts and acute healthcare utilization were assessed by caregiver report and medical records, and adherence was measured by doser devices on controller medications. Structural equation modeling analyzed baseline caregiver depressive symptoms as a predictor of longitudinal child asthma outcomes, and differences between subgroups.

RESULTS

Higher caregiver depressive symptoms predicted better pulmonary function (β = .02, p = .001) in Mexican children, and fewer steroid bursts (β = -.41, p = .01) and better medication adherence (β = .02, p = .07) in Puerto Rican children. Caregiver depressive symptoms did not predict pediatric asthma control or acute healthcare utilization in either subgroup.

CONCLUSIONS

Caregiver depressive symptomology had unexpected effects on child asthma outcomes. Results may be explained by the Hispanic paradox, caregiver resilience, acculturation, and the study's longitudinal nature. Further research is needed on social determinants of health that may influence differences in child asthma outcomes in heterogeneous Hispanic communities.

What caregivers believe affected the quality of implementation of asthma-related family management models (AFMM) during COVID-19: A phenomenological qualitative study

PURPOSE

The recurrent COVID-19 epidemic in China has disrupted many aspects of daily life for children with asthma and their caregivers, while negatively impacting their asthma family management models (AFMM). This phenomenological qualitative study identifies what affects the quality of implementation of AFMM in this population and outlines potential coping strategies for the caregivers.

METHODS

We used purposive sampling to conduct semistructured interviews with primary caregivers of school-age children with asthma from community healthcare centers (CHCs), which focused on understanding what factors influenced caregivers' implementation of AFMM during quarantine. The Colaizzi seven-step method was used to independently code and categorize the transcript and to generate themes and identify associated key subthemes.

RESULTS

Twenty-four caregivers were interviewed, and they provided greater insight into barriers and motivators to implement AFMM. The three themes and nine relevant subthemes generated, (a) the "individual-family" internal-level factors: weak health literacy and beliefs, quietly changing family relationships, the dramatic increase in the care burden, gradual adjustment of negative psychology; (b) the "hospital-community" external-level factors: the endless power of peer support, strict community quarantine policy; and (c) the "health system-public" social-level factors: the enormous potential of internet-based telemedicine, improved public awareness of prevention, government's prompt assistance.

CONCLUSIONS

This qualitative study reveals that the quality of AFMM implementation during pandemic is impacted by three different levels. Therefore, a targeted and comprehensive caring model that provides caregivers with the necessary coping strategies around these three levels is needed to achieve better asthma control outcomes.

Association of Neighborhood Characteristics With Pediatric Asthma

OBJECTIVE

To examine associations between neighborhood characteristics and asthma prevalence and severity among low-income children in a large nationally representative sample.

METHODS

Data source: 2018 National Survey of Children's Health, limited to low-income children, ages 0-17 years. We grouped parent responses about neighborhood characteristics into 5 scores: neighborhood support, safety, resources and quality, and a total score. Logistic regression compared rates and severity of asthma by neighborhood scores, adjusting for age, sex, race, and income.

RESULTS

Of 8,653 low-income children, those living in neighborhoods with better total neighborhood scores were significantly less likely to have parent-reported asthma; OR = 0.9, 95% CI: 0.8-1.0; P = .02, with similar findings for children living in neighborhoods with higher support, safety, and quality scores. We found no associations between neighborhood scores and asthma severity in this population.

CONCLUSIONS

Favorable neighborhoods are associated with lower parent-reported asthma prevalence in low-income children but not asthma severity. These data may support providers and policy makers interested in child asthma in addressing neighborhood improvement.

Harshness and unpredictability: Childhood environmental links with immune and asthma outcomes

The environment has pervasive impacts on human development, and two key environmental conditions - harshness and unpredictability - are proposed to be instrumental in tuning development. This study examined (1) how harsh and unpredictable environments related to immune and clinical outcomes in the context of childhood asthma, and (2) whether there were independent associations of harshness and unpredictability with these outcomes. Participants were 290 youth physician-diagnosed with asthma. Harshness was assessed with youth-reported exposure to violence and neighborhood-level murder rate. Unpredictability was assessed with parent reports of family structural changes. Youth also completed measures of asthma control as well as asthma quality of life and provided blood samples to assess immune profiles, including in vitro cytokine responses to challenge and sensitivity to inhibitory signals from glucocorticoids. Results indicated that harshness was associated with more pronounced pro-inflammatory cytokine production following challenge and less sensitivity to the inhibitory properties of glucocorticoids. Furthermore, youth exposed to harsher environments reported less asthma control and poorer quality of life. All associations with harshness persisted when controlling for unpredictability. No associations between unpredictability and outcomes were found. These findings suggest that relative to unpredictability, harshness may be a more consistent correlate of asthma-relevant immune and clinical outcomes.

Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated with Pediatric Intensive Care Use for Life-threatening Asthma

BACKGROUND

Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear.

OBJECTIVE

Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma.

METHODS

Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots.

RESULTS

A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days.

CONCLUSIONS

Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally in children with asthma.

Elements of Neuroanthropology

Neuroanthropology is the integration of neuroscience into anthropology and aims to understand “brains in the wild.” This interdisciplinary field examines patterns of human variation in field settings and provides empirical research that complements work done in clinical and laboratory settings. Neuroanthropology often uses ethnography in combination with theories and methods from cognitive science as a way to capture how culture, mind, and brain interact. This article describes nine elements that outline how to do neuroanthropology research: (1) integrating biology and culture through neuroscience and biocultural anthropology; (2) extending focus of anthropology on what people say and do to include what people process; (3) sizing culture appropriately, from broad patterns of culture to culture in small-scale settings; (4) understanding patterns of cultural variation, in particular how culture produces patterns of shared variation; (5) considering individuals in interaction with culture, with levels of analysis that can go from biology to social structures; (6) focusing on interactive elements that bring together biological and cultural processes; (7) conceptual triangulation, which draws on anthropology, psychology, and neuroscience in conjunction with field, clinic, and laboratory; (8) critical complementarity as a way to integrate the strengths of critical scholarship with interdisciplinary work; and (9) using methodological triangulation as a way to advance interdisciplinary research. These elements are illustrated through three case studies: research on US combat veterans and how they use Brazilian Jiu Jitsu as a way to manage the transition to becoming civilians, work on human-raptor interactions to understand how and why these interactions can prove beneficial for human handlers, and adapting cue reactivity research on addiction to a field-based approach to understand how people interact with cues in naturalistic settings.

Recalled Neighborhood Environments, Parental Control, and Cytokine-Mediated Response to Viral Challenge

OBJECTIVE

Neighborhood risk in childhood is associated with poor health across the life span. However, many people who are reared in risky neighborhoods remain healthy in adulthood. In the context of high-risk neighborhoods, parenting practices that are controlling might promote better physical health outcomes later in life. The current study used a viral challenge paradigm to examine whether parental control throughout childhood moderated the association between recalled neighborhood risk and cytokine-mediated cold susceptibility.

METHODS

A sample of 209 healthy adults completed questionnaires to assess recalled neighborhood risk and parental control over the first 15 years of life, were exposed to a common cold virus, and were quarantined for 6 days. Researchers assessed nasal proinflammatory cytokine production and objective markers of illness. Participants were diagnosed with a clinical cold if they met the infection and objective illness criteria.

RESULTS

A significant Neighborhood Risk by Parental Control interaction emerged to predict proinflammatory cytokine production. Furthermore, parental control moderated the cytokine-mediated association between neighborhood risk and cold diagnosis (index = -0.073, 95% confidence interval [CI] = -0.170 to -0.016), likelihood of infection (index = -0.071, 95% CI = -0.172 to -0.015), and meeting the objective symptom criteria (index = -0.074, 95% CI = -0.195 to -0.005). Specifically, there was a negative association between neighborhood risk and objective cold diagnosis and infection status at higher levels of parental control, but a nonsignificant association at lower levels of parental control.

CONCLUSIONS

Findings suggest that the degree to which recalled neighborhood risk is related to adult health varies as a function of parental control throughout childhood.

Mobility and social deprivation on primary care utilisation among paediatric patients with asthma

OBJECTIVE

Asthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting.

DESIGN

In this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

SETTING

We used data from community health centres in 15 OCHIN states.

PARTICIPANTS

The sample included 23 773 children with asthma aged 3-17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.

RESULTS

Clinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation.

CONCLUSIONS

Movement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.

Exacerbation-Prone Asthma: A Biological Phenotype or a Social Construct

Asthma is a complex syndrome with multiple phenotypes and endotypes. Asthma exacerbations are not only the clearest indictor of the morbidity of asthma and of the risk for mortality due to asthma, but also comprise a significant amount of the cost to care for poorly controlled asthma. There continues to be significant disparity in the prevalence, mortality, and morbidity due to asthma. Patients with asthma who suffer recurrent exacerbations are considered to have exacerbation-prone asthma (EPA). Efforts to characterize patients with frequent exacerbations show that the etiology is likely multifactorial. Research to determine the intrinsic risk factors for EPA include studies of both genetic and inflammatory biomarkers. External factors contributing to exacerbations have been extensively reviewed and include viral infection, environmental exposures, air pollution, and psychosocial and economic barriers to optimizing health. It is likely that EPA occurs when patients who have an increased underlying intrinsic/biological risk are placed in a given exposome (environments with a variety of exposures and triggers including allergens, pollution, stress, barriers, and occupational exposures). It is the social construct combined with underlying biology that frequently drives an EPA phenotype.

Chronic stress and asthma in adolescents

OBJECTIVE

First, to review and critically discuss published evidence on psychosocial stressors, stress, and asthma in adolescents and, then, discuss potential future directions in this field.

DATA SOURCES

The data source is the National Library of Medicine (PubMed database).

STUDY SELECTIONS

A literature search was conducted for human studies on stressors or stress and asthma between 2000 and 2020. Studies that were published in English, contained a full text, and included adolescents were considered for inclusion in this review.

RESULTS

Compared with the available body of evidence in children and adults, relatively few studies have been published in adolescents. Current evidence suggests that exposure to stressors (at the individual, family, and community levels) or stress (acute and chronic) is associated with asthma and worse asthma outcomes, but such evidence must be cautiously interpreted owing to limitations in the design or the analytical approach of the published studies.

CONCLUSION

Future large studies with a prospective design should determine whether and how stressors or stress causes or worsens asthma in adolescents. At present, clinicians should assess exposure to stressors (eg, violence or abuse) and screen for anxiety and depressive disorders when caring for adolescents with asthma in addition to providing referrals to social workers or mental health professionals when appropriate. Public health policies are needed to reduce psychosocial stressors, such as gun violence and racism, in adolescents.

The Impact of Social Determinants of Health on Children with Asthma

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.