Infectious Disease

Neighborhoods with more opportunity associated with less pediatric asthma

August 31, 2023

4 min read


Aris reports no relevant financial disclosures. Please see the study for all other authors’ relevant disclosures.


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Key takeaways:

  • 20.6% of children lived in areas with very high Child Opportunity Index (COI) and very low Social Vulnerability Index scores.
  • High and very high COI was associated with lower asthma incidence.

Asthma was less common among children who lived in neighborhoods with high and very high opportunity during their early lives than among those who lived in areas with less opportunity, according to a study published in JAMA Pediatrics.

These associations were independent of sociodemographic characteristics, parental asthma history and parity, Izzuddin M. Aris, PhD, assistant professor of population medicine at Harvard Pilgrim Health Care Institute and Harvard Medical School, and colleagues wrote.

Children born into neighborhoods with very low opportunity had asthma incidence rates of 35.3 per 1,000 child-years. Image: Adobe Stock

“Asthma is one of the most prevalent chronic conditions in U.S. children, with adverse implications for long-term health outcomes,” Aris told Healio. “Neighborhood factors contribute to asthma in children by exposing them to health risks in their physical and social environments.”

Izzuddin M. Aris

However, he continued, most studies that have examined these questions have focused on single socioeconomic indicators of neighborhood disadvantage that may not adequately capture the totality of early-life social experiences.

Additionally, he continued, few studies have examined the extent to which neighborhood conditions at birth or early childhood are associated with asthma incidence.

“We sought to address these research gaps in this study by examining the associations of neighborhood opportunity and vulnerability with asthma incidence in racially, ethnically and geographically diverse children enrolled in cohorts participating in the Environmental influences on Child Health Outcomes (ECHO) Program,” he said.

Study design, results

The researchers used the Child Opportunity Index (COI), which incorporates 29 neighborhood attributes deemed necessary for healthy childhood development across education, health and environment, and social and economic domains.

They also used the Social Vulnerability Index (SVI), which measures 15 social factors that make a community more vulnerable in the aftermath of natural or human-caused disasters spanning socioeconomic status, household composition and disability, racial and ethnic minority and language status, and housing and transportation type domains.

The study comprised 10,516 children (median age at follow-up, 9.1 years; 47.8% girls; 65.3% white) from 46 cohorts in the ECHO program.

Based on the indices, 20.6% of these children lived in neighborhoods with very high COI scores and very low SVI scores, which the researchers called similar to nationwide distributions.

There were 23.3 cases of asthma per 1,000 child-years overall, with a median age of 6.6 years (interquartile range, 4.1-9.9 years) at diagnosis.

Areas with higher opportunities had lower crude asthma incidence rates, the researchers found.

Specifically, children born in low-opportunity neighborhoods experienced 27 cases per 1,000 child-years, and children born in very low-opportunity neighborhoods had 35.3 cases per 1,000 child-years.

After adjusting for socioeconomic characteristics, researchers observed lower asthma incidence with moderate (adjusted incidence rate ratio [aIRR] = 0.87; 95% CI, 0.75-1), high (aIRR = 0.87; 95% CI, 0.75-1) and very high (aIRR = 0.83; 95% CI, 0.71-0.98) COI at birth compared with very low COI at birth.

With adjustments for the same covariates, low, high and very high COI in infancy and early childhood were associated with similarly lower asthma incidence vs. very low COI.

“We found that residence in high and very high opportunity neighborhoods at birth, infancy or early childhood were associated with lower subsequent childhood asthma incidence, which appeared to be driven by the health and environmental and the social and economic domains of the Child Opportunity Index,” Aris said.

However, Aris noted, the researchers did not observe significant associations between SVI and childhood asthma incidence, although incidence rate ratios were in the hypothesized directions. Compared with very high SVI, adjusted IRR for asthma was 0.88 (95% CI, 0.75-1.02) for low SVI and 0.89 (95% CI, 0.76-1.03) for very low SVI at birth.

The researchers did not report any changes in IRR for associations between COI and asthma incidence with adjustments for prenatal characteristics, but IRRs were slightly attenuated with adjustments for early childhood BMI.

Conclusions, next steps

Associations between very high COI with lower incidences of asthma at each stage of life seemed to be attributable to the health and environmental domain and to the social and economic domain of the index, the researchers wrote, but not to the education domain.

This may be because children do not go to school until after they have aged out of their most developmentally vulnerable periods of asthma risk, even with known associations between exposures to school environments and asthma development.

Although there were no significant associations between each SVI domain and asthma incidence, Aris noted that the COI incorporates 29 neighborhood attributes that are more relevant for child health outcomes.

“In contrast, the SVI comprised only 15 neighborhood attributes and was developed primarily for emergency preparedness in the event of a disaster and might be less sensitive to child asthma,” Aris said.

The finding of lower asthma incidence in areas with very high health and environmental or social and economic COI supports this notion,” Aris said.

“Both domains include several indicators such as neighborhood walkability, access to healthy food choices and commute duration that are not contained in the SVI and have been previously associated with child asthma,” he said.

Aris also noted how the COI and SVI both had similar crude asthma incidence rates.

“This finding suggests that physicians may use either neighborhood index to potentially identify vulnerable children at high risk of developing asthma,” he said.

Decision-makers can use these findings to impact change at the system level as well, the researchers said.

“Our findings 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,” he said.

Future studies should examine whether investments in health and environmental or in social and economic resources during early life, as well as strategies that alter specific neighborhood components, can promote health equity in pediatric asthma, the researchers wrote.



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Payel Gupta, MD, FACAAI)

Payel Gupta, MD, FACAAI

I do not think that these findings are surprising. As an allergist, I see firsthand how someone’s environment can affect their health, and this underscores the importance of our environment and how this can play a significant role in the development of disease.  

Findings like this are significant because they will hopefully help shift policy on something that we intuitively know. To date we haven’t had data that show a difference in risk independent of sociodemographic characteristics, parental asthma history and parity, and these confounding factors are used to lessen the need for systemic changes that will actually make a difference.   

Working in New York City, I see patients who are living in housing that is infested with cockroaches, mice and mold, located near large highways. I see firsthand how these environments affect asthma. Exposure to these allergens at an early age in such high quantities most definitely affects my patients. The study findings are consistent with what I see on a regular basis. 

On a practice level, we can help to ensure that families are given the resources available to help mitigate these risks. I write letters to landlords regularly to try and help families get the resources they need in order to improve their living conditions. 

Practitioners should also be aware of the programs that are in their areas that help patients identify and improve potential triggers. The American Lung Association runs various training programs that focus on home visits for trigger reduction and asthma self-management education. 

On a policy level, we need to highlight the importance that environment plays in disease. Children are known to be a vulnerable population, and studies that show that they are affected by their environment such as this can be used as evidence for the importance of policy change. We need better air quality measures that the American Lung Association State of the Air report highlights every year. We also need better housing policies to ensure that everyone is living in a situation that is safe.  

Payel Gupta, MD, FACAAI

National Spokesperson, American Lung Association

Assistant Clinical Professor, SUNY Downstate Medical Center

Voluntary Clinical Instructor, Mount Sinai Medical Center

Medical Director of Allergy, Asthma, Immunology & ENT,

Owner, Ease Allergy

Chair, American College of Allergy, Asthma & Immunology Integrative Medicine Committee

Disclosures: Gupta reports no relevant financial disclosures.


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