Study Examines Effects of Socioeconomics on Health of Youngsters

Children with cystic fibrosis (CF) who live in more socioeconomically disadvantaged areas of the U.S. tend to have worse lung function and health outcomes than their counterparts in more affluent areas, a new study shows.

The study, “The Association of Area Deprivation and State Child Health with Respiratory Outcomes of Pediatric Patients with Cystic Fibrosis in the United States,” was published in the journal Pediatric Pulmonology.

Health outcomes are not influenced by only medical and biological factors. Socioeconomics, which can affect environmental exposures and access to care, among other factors, also play a role.

Researchers based in Alabama and Virginia conducted statistical analyses to explore connections between socioeconomics and health outcomes in children with CF.

Specifically, the researchers assessed the Area Deprivation Index (ADI), which assesses socioeconomic status based on where a person lives, taking into account factors like income, education, employment, and housing in that area. ADI was scored from zero to 10, in which higher scores indicate greater socioeconomic deprivation (i.e., poorer socioeconomic status).

The team also analyzed Child Health Index (CHI) in each state. CHI is an indicator of overall child health based on parameters like annual low birth weight, child death rate, teen death rate, and teen pregnancy rate. For this study, CHI scores were measured on a scale of 1 to 10, with higher values indicating worse child health in the state.

For their analysis, the researchers used data from the national CF Foundation Patient Registry. They included all children with CF who were 6 to 18 years old in 2016.

In total, the study included 9,934 people with CF living in all 50 states. The average age of the group was 12.5 years, and the majority of the population was white (90.3%) and had public health insurance (53.9%).

In the most deprived areas (highest ADI scores), there were fewer white non-Hispanic children (86.8% vs. 91.5%) and more children with public health insurance (72.0% vs. 37.2%), compared to the least deprived areas. However, there were no significant differences in race, sex, age, or health insurance based on CHI.

Every clinical characteristic assessed differed significantly based on both ADI and CHI. The only exception was newborn screening, which was associated significantly with CHI but not with ADI. Specifically, states with the best child health had significantly more children diagnosed through newborn screening compared to those with the worst child health (39% vs. 24.2%).

Statistical analyses showed that, for every one-point increase in ADI, there was an average 0.4% decrease in percent predicted forced expiratory volume (ppFEV1), which is a common measure of lung function. Each one-point increase in ADI also was associated with 0.3 more nights undergoing intravenous (IV) treatment (medication administered directly into the bloodstream).

Similarly, each one-point increase in CHI was associated with a 0.3% decrease in ppFEV1 and 0.3 more IV treatment nights. These analyses accounted for factors like age, sex, race, health insurance, and Pseudomonas aeruginosa bacterial infection.

Further statistical analyses generally found comparable results. In analyses that included both ADI and CHI, both measurements had statistically significant associations with ppFEV1 and IV treatment nights, but the magnitude of the effect was decreased, indicating that the two measurements partially accounted for each other’s effect.

The effect sizes of ADI and CHI — both individually and together — were larger than those of age, sex, race/ethnicity, and newborn screening diagnosis. The only assessed factors with larger effects were health insurance and P. aeruginosa infection.

Children in areas with the worst ADI scores were about 20% more likely to have two or more pulmonary exacerbations (times when lung function suddenly gets worse) than those in less-deprived areas. Children in areas with the worst CHI scores were 40% more likely to have multiple exacerbations. In models combining the two measurements, the association with CHI remained significant, but ADI did not, “indicating that [the] association with increased pulmonary exacerbations is accounted for by CHI,” the researchers wrote.

“The residual association of overall child health with CF outcomes after controlling for area deprivation reflects the ability of state programs to ameliorate the effect of poverty,” the researchers added.

According to the team, “further research should investigate the effect of specific public health policy measures (e.g., policies related to tobacco control, Medicaid and state child health insurance programs, food assistance and school meal programs, housing, and air and water quality monitoring, among others) on both overall child health and CF-specific health outcomes.”

The researchers noted that these findings overall mirror previous research done in the general population.

“Children raised in worse socioeconomic circumstances have worse health. Children with CF are not an exception when exposed to the health risks of deprivation and social disadvantage,” the team wrote.

A notable limitation of this study is that socioeconomics were assessed based on where each person resides (by ZIP codes), which is necessarily imprecise.

“Future research should use smaller-area measures for more precise estimates,” the researchers wrote.