Understanding the highs and lows of socioeconomic status

Abstract

Socioeconomic status (SES), which has traditionally been reported with education, income, and occupation,1Forno C. Celedon J.C. Asthma and ethnic minorities: socioeconomic status and beyond.Curr Opin Allergy Clin Immunol. 2009; 9: 154-160Crossref PubMed Scopus (109) Google Scholar was thought to influence health through ability to pay for services and treatments; establishment of early health habits; and resultant education, job opportunities, and income potential. Extensive research over the past 5 decades has underscored the gradient in health associated with differences in SES, and such a gradient has never been more relevant than today, when marked inequities in health are being observed in a public way through the effects of the COVID-19 pandemic.2Ogbogu P.U. Matsui E.C. Apter A.J. COVID-19, health disparities, and what the allergist immunologist can do.J Allergy Clin Immunol. 2021; 148: 172-175Abstract Full Text Full Text PDF Scopus (1) Google Scholar Addressing disparities resulting from differences in SES seems as if it would be especially relevant for asthma, the most prevalent chronic disease in pediatrics. Lower SES has been shown to be related to a higher prevalence of asthma. The current rate of asthma among children living below the poverty threshold is estimated at 11.1% compared with 7.7% to 8.5% among those not living in poverty.1Forno C. Celedon J.C. Asthma and ethnic minorities: socioeconomic status and beyond.Curr Opin Allergy Clin Immunol. 2009; 9: 154-160Crossref PubMed Scopus (109) Google Scholar For asthma, there are multiple precipitating or exacerbating factors related to SES, including allergen exposures, cigarette smoking, air pollutants, access to health care, stress and violence, obesity, and depression. The complex interactions between these internal and external influences makes analysis of the relationship between SES and asthma challenging, but the overall gradient is well established. In an article in this issue of the Journal of Allergy and Clinical Immunology, Redmond et al have performed a systematic review of the effect of SES on asthma outcomes internationally.3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar Studies were identified by including terms for asthma and terms related to SES (ie, income, poverty, education, employment status, and health care insurance coverage). After exclusions, Redmond et al3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar selected 61 studies (40 from the United States) that together included 1,145,704 patients and some measure of SES. They performed quality assessment of the studies, conducted data extraction, and used meta-analysis to pool the results. They concluded that patients with lower SES have increased secondary care health care utilization by emergency department (ED) visits, hospital admission, and hospital readmission than do those in the highest SES category used in a given study. However, the association between lower SES and increased exacerbations and mortality was not strong in their analysis. The drivers of SES (ie, jobs, transportation, and access to care) were not investigated; nor were the effects of SES on asthma incidence and diagnosis assessed. Given the numerous prior studies of asthma and SES from individual sites, the results of the systematic review may have been surprising; it is expected that there would be large differences in asthma ED and inpatient care based on SES, but the size of the differences across numerous comparisons were modest at best and did not always reach statistical significance. The most likely reason for this lower-than-expected level of association between asthma morbidity and SES is likely the failure of many of these studies to capture the extreme variation of SES in their original data. Redmond et al3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar compared the highest SES in each study with the lowest SES, but many of the studies, especially those from the United States, used insurance status to capture the range of SES values (Fig 1). Of course, this means that, for example, unlike commercially or privately insured children, those children who are covered by Medicaid would all be lumped into the lowest SES. Although such methods have been standard research practice for years, new studies on extreme neighborhood variation in outcomes even within overall poor neighborhoods underscore the need to study SES at a more refined level than at the level of entire states or countries or insurance groups. Differences in life expectancy of 20 years between proximate neighborhoods can be found in most major US cities because of decades of structural racism and redlining with associated disinvestment,2Ogbogu P.U. Matsui E.C. Apter A.J. COVID-19, health disparities, and what the allergist immunologist can do.J Allergy Clin Immunol. 2021; 148: 172-175Abstract Full Text Full Text PDF Scopus (1) Google Scholar and even some neighborhoods with relatively similar rates of poverty have marked differences in quality of life and violence. Racial differences were not considered in all of the studies included in the analysis. Although Redmond et al3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar identified this to be an important measure of study quality, only 34% of the studies included accounted for ethnicity and/or race. Although this issue must be addressed carefully to account for the extensive historic biases, particularly because of the inclusion of international studies, there are several lines of evidence supporting the importance of racial differences separate from SES as an explanation for asthma variation.3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar First, studies of people of different races living in the same communities show differences in asthma prevalence and severity such that the same environmental or external factors cannot entirely explain variation. Also, epigenetic changes during pregnancy and early childhood may make some groups particularly vulnerable to environmental triggers.1Forno C. Celedon J.C. Asthma and ethnic minorities: socioeconomic status and beyond.Curr Opin Allergy Clin Immunol. 2009; 9: 154-160Crossref PubMed Scopus (109) Google Scholar As we interpret study results, it is important to consider the impact of epigenetic variation and its interaction with SES. The review did not show a convincing difference in asthma exacerbations, which means that existing studies do not seem to be able to capture the reasons why wide differences in secondary health care utilization are observed. The authors suggest that patient differences in health care–seeking behavior, health literacy, or views of higher-quality emergency care may be the explanation. We beg to differ. Assigning responsibility to patients and their families for higher use of urgent or emergent care is not appropriate, especially without careful consideration of the extreme ends of the spectrum in SES. In some countries (such as the United States) with historically documented racism in diagnostic and treatment practices, decreased access to a regular source of high-quality primary care for poor families, large numbers of private practices refusing to accept Medicaid payments, limited time off work for workers at the lowest end of the pay spectrum, transportation systems that are often avoidant of the persons most in need, and underinsured or uninsured patients, the ED becomes the logical choice for a child with asthma or other acute condition.2Ogbogu P.U. Matsui E.C. Apter A.J. COVID-19, health disparities, and what the allergist immunologist can do.J Allergy Clin Immunol. 2021; 148: 172-175Abstract Full Text Full Text PDF Scopus (1) Google Scholar For many patients seen in such settings, hospitalizations may be more common when the home is not safe during a period of illness. In short, such differences would be expected among communities of concentrated disadvantage or those subject to a history of lack of access. In a separate review that included patient perspectives, these types of reasons were underscored.4Coster J.E. Turner J.K. Bradbury D. Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis.Acad Emerg Med. 2017; 24: 1137-1149Crossref PubMed Scopus (115) Google Scholar In that study, 6 patient-derived reasons were identified. They included access to and confidence in primary care, perceived urgency, belief that hospital resources were needed, advice of friends or health care personnel, convenience, out-of-pocket costs, and limited transport options. We are unlikely to be able to detect these community or neighborhood differences when national or statewide studies use large categories of SES such as Medicaid-insured versus commercially insured (Fig 1). Because so much health morbidity (asthma and otherwise) is concentrated in a few neighborhoods in most cities, investigators at our institution have shifted to a community population health approach to address gaps or disparities resulting from poverty, toxic stress, and racism. To address “neighborhood health” symptoms of poverty, racial segregation, trauma, violence, environmental toxins, low social support, and low school performance, we have aimed to improve neighborhood conditions.5Kelleher K. Reece J. Sandel M. The healthy neighborhood, healthy families initiative.Pediatrics. 2018; 142e20180261Crossref PubMed Scopus (35) Google Scholar With the support of Nationwide Children’s Hospital, we partnered with residents, a church, and United Way to improve family health through home repair, expansion of ownership, and increased amounts of high-quality housing and affordable rentals. The early outcomes show improvement in home sales, high school graduation rate, and safety. Data are being collected to assess the effect on health outcomes, but ED visits appear to be declining.6Chisholm D. Jones C. Root E. Dolce M. Kelleher K. A community development program and reduction in high-cost health care use.Pediatrics. 2020; 146e20194053Google Scholar Other investigators have also turned to community interventions to effect change. In western New York, regional economic development reduced the relative risk of ED visits for pediatric asthma (coefficient -1.5) when accounting for physical environment; temporal effects; and the contributing factors education, income, health insurance, race, and pollution.7Eum Y. Yoo E. Bowen E. Socioeconomic determinants of pediatric asthma emergency department visits under regional economic development in western New York.Soc Sci Med. 2019; 222: 133-144Crossref PubMed Scopus (12) Google Scholar In Massachusetts, the Reducing Ethnic/Racial Asthma Disparities in Youth (READY) study investigators used a 6-month program of in-home asthma management, trigger remediation, and education.8Marshall E.T. Guo J. Flood E. Sandel M.T. Sadof M.D. Zotter J.M. Home visits for children with asthma reduce Medicaid costs.Prev Chronic Dis. 2020; 17: E11Crossref PubMed Google Scholar The study showed a decrease in number of days with asthma symptoms and fewer ED visits. SES remains a critical variable in the study of asthma. The article by Redmond et al3Redmond C. Akinoso-Imran A.Q. Heaney L.G. Sheikh A. Kee F. Busby J. Socioeconomic disparities in asthma healthcare utilization, exacerbations and mortality: A systematic review and meta-analysis.J Allergy Clin Immunol. 2022; 149: 1617-1627Abstract Full Text Full Text PDF Scopus (1) Google Scholar reminds us of this, but the studies included did not consider the wide range of poverty and experiences of persons in the lowest-resource communities. Future studies conducted with innovations such as the Child Opportunity Index 2.09Singh G.K. Area deprivation and widening inequalities in US mortality, 1969-1998.Am J Public Health. 2003; 93: 1137-1143Crossref PubMed Scopus (476) Google Scholar or the Area Deprivation Index,10Acevedo-Garcia D. McArdle N. Hardy E.F. Crisan U.I. Romano B. Norris D. et al.The child opportunity index: improving collaboration between community development and public health.Health Aff. 2014; 33: 1948-1957Crossref PubMed Scopus (79) Google Scholar which capture the highs and lows of SES, are likely to be important to advancing our understanding further. On the intervention side, it seems clear that meaningful change will take thoughtful and creative approaches with collaboration between providers, health care systems, community partners, and advocacy groups. Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysisJournal of Allergy and Clinical ImmunologyVol. 149Issue 5PreviewPrior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used. Full-Text PDF