Infectious Disease

Children who move out of distressed neighborhoods see improved asthma outcomes

Source/Disclosures

Disclosures:
Matsui reports no relevant financial disclosures. Please see the full study for all other authors’ relevant financial disclosures.

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Key takeaways:

  • Odds for asthma exacerbations fell by 54% after moving.
  • Odds for an asthma symptom day fell by 59% after moving.
  • Average asthma controller treatment steps fell from 1.4 to 1.3.

Children with asthma who moved from distressed neighborhoods and into low-poverty neighborhoods experienced significant improvements in symptom days and exacerbations, according to a study published in JAMA.

Based on these findings, programs that counter housing discrimination may reduce asthma morbidity, Elizabeth C. Matsui, MD, MHS, professor of population health, Dell Medical School at the University of Texas at Austin, and colleagues wrote.

Moving proved more successful in improving asthma outcomes among children than individual-level and household-level interventions. Image: Adobe Stock

“Black children and other children of color with asthma have continued to experience much higher rates of severe asthma attacks than their white counterparts despite major advances in the treatment of asthma. More and more evidence points to their environments being a major factor,” Matsui told Healio.

Elizabeth C Matsui

“Children of color often live in disadvantaged neighborhoods because of historical and current day housing discrimination. If children moved and their asthma improved, this would suggest that where they were living did, indeed, matter a lot in terms of their high burden of asthma,” she continued.

Study design, results

The Baltimore Regional Housing Partnership (BRHP) helps families move into low-poverty neighborhoods by offering workshops, counseling, vouchers and other assistance including collaborations with landlords.

The Mobility Asthma Project recruited 123 children aged 5 to 17 years (median age, 8.4 years; 47.2% girls; 97.6% Black; 60% sensitized to at least one allergen) with persistent asthma or an asthma exacerbation in the previous 12 months during BRHP before move workshops.

Also, 110 of these children with data from before their move had lived in their neighborhood for a median of 3 years (interquartile range [IQR], 1.3-8 years), and 89 (80.9%) of them lived in high-poverty census tracts defined as more than 20% of their families below the federal poverty limit. By census tract, median household income was $32,542, and 87.3% of these residents were Black.

During the follow-up period (median, 12.8 months; IQR, 7.6-14 months), 106 (86%) of these children moved to census tracts with a median household income of $83,333 and a 19.1% proportion of Black residents.

The patients experienced at least one asthma exacerbation in 15.1% (standard deviation [SD]35.8%) of the 3-month periods before their movies and in 8.5% (SD, 28%) of their after-move periods.

Models adjusted for age and sex found 54% reduced odds for asthma exacerbations associated with moving (adjusted OR = 0.46; 95% CI, 0.28-0.76). Exacerbation rates fell from 0.88 per person-year before moving to 0.4 per person-year after moving.

A Poisson model adjusted for age and sex similarly found a 70% decrease in exacerbation rates (incidence rate ratio = 0.3; 95% CI, 0.2-0.46) associated with moving.

Maximum symptom days per 2 weeks fell from an average of 5.1 (SD, 5) before moving to 2.7 (SD, 3.8) after moving (difference, -2.4; 95% CI, -3.1 to -1.6) for 59% (aOR = 0.41; 95% CI, 0.32-0.53) lower odds of a symptom day associated with moving in adjusted models.

The average asthma controller medication treatment step fell from 1.4 (SD, 2) before moving to 1.3 (SD, 1.9) after moving (difference, -0.2; 95% CI, -0.1 to -0.5), indicating that these reductions in exacerbations and maximum symptom days were not due to more intense asthma medication regimens, the researchers said.

These relationships between moving and asthma outcomes remained similar whether the household received housing assistance before enrolling in BRHP, the researchers continued, with consistent results after adjusting for seasonality and excluding after-move visits when outcome look-back periods overlapped with move dates as well.

After comparing these changes with the Urban Environment and Childhood Asthma cohort to see if they were due to aging or regression to the mean, the researchers said moving continued to be associated with reductions in exacerbation likelihood and maximum number of symptom days, with statistically significant differences between the groups.

Before moving, the median cockroach allergen concentration was 0.3 U/g (IQR, below detection to 3.1). After moving, concentrations were below detection (change, -0.25 U/g; 95% CI, -0.43 to -0.07). However, the researchers said reductions in cockroach and other allergens did not mediate decreases in exacerbations or symptoms associated with moving.

Concentrations of indoor particulate matter at 2.5 µm or less and 10 µm or less in diameter did not change from before to after moving, although the mean number of cigarettes smoked in the home per day fell by 1 (95% CI, –1.7 to – 0.3).

The researchers also attributed 7.1% (95% CI, 3.8% to 29.3%) of the association between moving and asthma exacerbations and 1.4% (95% CI, 1% to 2%) of the association between moving and maximum symptom days to changes in second-hand smoke exposure.

Moving was associated with all measures of perceived social cohesion, daytime and nighttime safety and parent/caregiver stress, the researchers said, and these measures were highly correlated with one another as well.

The researchers further found that perceived social cohesion, daytime and nighttime neighborhood safety and urban stress mediated approximately 28.7% to 34.9% of the association between moving and asthma exacerbations and 12.9% to 34.3% of the reduction in symptoms.

These overall improvements were greater than those found with individual-level and household-level interventions for asthma in racialized populations, the researchers said, including those achieved with corticosteroids, and similar to those achieved with biologic agents.

Conclusions, next steps

Relocation programs have significant potential for improving asthma morbidity among children in distressed neighborhoods, as indicated by two key findings from the study, Matsui said.

“First, the size of the improvement in asthma was larger than we expected and larger than the improvement from asthma medications. This finding underscores just how important where a child lives is for their asthma,” she said.

“Second, it seems that one of the differences between neighborhoods that the children lived in prior to moving and those that they lived in after moving that explained a lot of the improvement in asthma was the decrease in neighborhood stressors,” she continued. “This finding suggests that neighborhood stressors might be more important in asthma than previously thought.”

These results also indicate how doctors may go beyond providing treatment to improve outcomes.

“It’s important for pediatricians and other primary care providers to understand where their patient lives and whether the environment might be contributing to their asthma symptoms and/or exacerbations,” Matsui said. “And if it might be, it’s important to connect their family to resources to help address their environment.”

Policy changes can play a role as well.

“Expansion of programs that support families in moving from disadvantaged to better resourced neighborhoods would be expected to substantially reduce asthma morbidity among children of color, likely shrinking disparities in asthma morbidity,” Matsui said.

“More broadly, programs that are explicitly designed to counter housing discrimination have great promise for meaningfully shrinking racial and ethnic asthma disparities,” she said.

Yet there are still many questions to answer, Matsui said.

“For example, understanding if there are specific neighborhood factors that are most impactful for asthma would be helpful for designing new interventions and refining existing ones so that they are most impactful and also scalable,” she said.

“Another question is whether the improvements we saw are sustained long term, and we are continuing to follow the cohort to answer this specific question,” she said.

For more information:

Elizabeth C. Matsui, MD, MHS, can be reached at elizabeth.matsui@austin.utexas.edu.

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