Infectious Disease

Neighborhoods with more opportunity associated with fewer ED visits for pediatric asthma

October 31, 2023

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Key takeaways:

  • Higher overall, social/economic and educational scores were associated with lower risks for ED encounters for asthma.
  • Neighborhood opportunity showed no associations with asthma hospitalization risk.

Lower census tract Child Opportunity Index scores were associated with higher risks for ED visits among children with asthma aged younger than 5 years, according to a study published in The Journal of Allergy and Clinical Immunology.

But these lower scores were not associated with higher risks for hospitalization, Jordan Tyris, MD, MSHS, hospitalist at Children’s National Hospital, and colleagues found.

Improvements in social, economic and educational opportunities may reduce asthma-related morbidity. Image: Adobe Stock

“A number of studies have found associations between community characteristics (social determinants of health) and asthma health among children of all ages,” Tyris told Healio. “We hoped to understand these associations in early childhood, when asthma-related morbidity is highest.”

Study design

The researchers used 2018 to 2019 data from the D.C. Pediatric Asthma Registry to identify 3,806 children (60% boys) with asthma aged younger than 5 years (mean age, 2.4 ± 1.4 years) living in 131 U.S. Census tracts in Washington, D.C. A total of 78% of the children were on public insurance and 53% had a prescription for an asthma controller medication.

Jordan Tyris

Also, 2,132 (56%) of the children had 5,852 ED encounters during the previous 24 months, including 1,326 (35%) with one or more ED encounters (median per child, 2; interquartile range [IQR], 1-3).

Similarly, 821 (22%) children had 1,418 hospitalizations in the previous 24 months, including 312 (8%) who had more than one hospitalization during the study period (median per child, 1; IQR, 1-2).

With a mean population of children with asthma aged younger than 5 years per census tract of 29 ± 23, at-risk rates (ARRs) for ED encounters spanned from 362 to 3,439 per 1,000 children (median, 1,337; IQR, 1,133-1,642) and ARRs for hospitalizations ranged from 121 to 797 per 1,000 children (median, 339; IQR, 308-398).

Child Opportunity Index

Child Opportunity Index (COI) scores use a composite of 29 individual social determinants of health (SDOHs) to describe how well an area encourages healthy childhood development in educational, health/environmental and social/economic domains, with higher scores on a scale of 0 to 100 indicating increased opportunity.

Researchers observed wide variations in COI scores based on census tract, with mean overall scores of 48 ± 24 (range, 1-100), 48 ± 24 (range, 1-96) for the educational domain, 47 ± 25 (range, 2-100) for the health/environmental domain, and 49 ± 26 (range, 1-100) for the social/economic domain.

The study showed a significant association between increased overall COI scores and decreased ED ARRs (regression coefficient [RC] = –8.6; standard error [SE] = 1.23; P < .0001).

Significant negative associations occurred for the educational (RC = –8.6; SE = 1.42; P < .001), health/environmental (RC = –5.7; SE = 1.5; P = .0002) and social/economic (RC = –10.4; SE = 1.18; P < .001) domains as well.

The researchers also found significant increases in ED ARRs with increases in violent crime (P = .02) and with increased percentages of children with asthma with public insurance (P < .001) and with prescriptions for asthma controller medications (P = .002), whereas

increased percentages of boys with asthma per census tract were linked to decreases in ED ARRs (P = .002).

Multivariable linear regression showed ED ARRS significantly decreased with increased overall COI (RC = –7.8; SE = 1.97; P = .0001) and greater scores for the educational (RC = –3.9; SE = 1.58; P = .02) and social/economic (RC = –7.7; SE = 1.91; P < .0001) domains.

Further, each one-point increase in overall COI conferred a 7.8 lower rate of ED encounters for 1,000 children aged younger than 5 years with asthma, with corresponding decreases of 7.7 for the social/economic score and 3.9 for the educational score.

However, the researchers did not find any significant associations between any exposure variables or covariates and ARRs for hospitalization.

Conclusions, next steps

“The most significant overall finding was that even starting in early childhood, lower neighborhood opportunity (measured by the Child Opportunity Index) was associated with increased asthma-related ED use, but not hospitalizations, among children with asthma,” Tyris said.

This association could indicate that adverse SDOHs could contribute to increased asthma morbidity, she continued, or it could indicate decreased health care access and increased ED use for primary asthma care. Further, Tyris said, these findings add context and possible mechanisms for why some children may have increased ED utilization.

“For children with increased ED utilization for their asthma, these findings might prompt a discussion or consideration of which broader factors at the community level that child and their family may be experiencing, and how they might be contributing to their asthma health,” Tyris said.

Based on these findings, the researchers said that improvements in community-level SDOHs including social, economic and educational opportunities may reduce asthma-related morbidity in early childhood.

“These findings underscore existing associations between place (or the characteristics of where a child lives) and asthma health among children, indicating that policies aiming to improve socioeconomic and educational factors for communities experiencing concentrated disadvantage may also have benefit for the asthma health of children living in those areas,” Tyris said.

Next, Tyris said that she and her colleagues will partner with families of children with asthma to consider how the social factors that they experience that impact asthma health can be addressed in the delivery of asthma care delivery, along with evaluating if these types of interventions affect pediatric asthma morbidity.




Tyris reports support from the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development through the Pediatric Scientist Development Program. Please see the study for all other authors’ relevant financial disclosures.


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Izzuddin M. Aris, PhD)

Izzuddin M. Aris, PhD

The study’s findings add to the increasing body of literature showing links between neighborhood environments and child asthma. Few studies have detailed this relationship among children aged younger than 5 years, and this study addresses this key research gap.

However, it is important to note that the study is cross sectional; in other words, both the COI and child asthma were measured at the same point in time. In this regard, it is difficult to disentangle any cause-and-effect relationships. The study was also only conducted among children in Washington, D.C. and, thus, it would be difficult to extrapolate the findings to children living in other cities or states.

These findings additionally are consistent with a recent study that also showed residence in neighborhoods with higher opportunity during early life was associated with lower subsequent asthma incidence.

Clinicians could potentially use the COI to identify children at high risk for developing asthma and potentially develop intervention strategies to prevent asthma.

This foundational information also may inform place-based initiatives or policies to reduce neighborhood barriers and improve access to health and environmental or social and economic resources and, in turn, provide families with optimal environments needed to support their children’s well-being.

Additional research is warranted to investigate whether strategies that alter specific neighborhood components would be effective in preventing childhood asthma.


Aris M, et al. JAMA Pediatr. 2023;doi:10.1001/jamapediatrics.2023.3133.

Izzuddin M. Aris, PhD

Assistant Professor of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School

Disclosures: Aris reports no relevant financial disclosures.

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