Socioeconomic Status and Asthma in Children

  • Edith Chen
  • Hannah M. C. Schreier
Part of the Allergy Frontiers book series (ALLERGY, volume 1)

Social factors have long been suggested to contribute to childhood asthma, and recently research has begun to provide some intriguing empirical evidence to support this hypothesis. Characteristics of a child's larger social environment, including neighborhoods with high levels of violence, occurrences of acute and chronic stress, and negative family environments have all been linked to asthma onset or morbidity in children [1–3]. These findings suggest that in addition to traditional risk factors such as genetics and environmental exposures, the social environment maybe an important component to a fuller understanding of asthma pathogenesis. For a graphical representation of how social contributors interact to shape asthma, see Fig. 1.

One broad social environment factor that maybe important to childhood asthma is socioeconomic status (SES). SES refers to a family's position within a larger social hierarchy, and can be defined in terms of prestige (e.g., parent's education or occupation) as well as resources (e.g., family income or assets) [4]. Across all social factors, SES exhibits one of the most robust and consistent associations with physical health outcomes. Individuals from lower SES families have poorer health than individuals from higher SES families. This relationship holds true across a variety of diseases, across many different countries, and throughout the life span [5, 6]. Despite this striking pattern, the relationship of SES with childhood asthma remains unclear. Asthma is one of the few diseases for which evidence of a reverse gradient (higher SES being associated with greater disease prevalence) has been presented. Thus the aims of the present chapter are to review evidence regarding the direction of association of SES with childhood asthma and to discuss plausible pathways between SES and asthma.


Allergy Clin Immunol Childhood Asthma Asthma Outcome Cockroach Allergen High Eosinophil Count 


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  1. 1.
    Wright RJ, Mitchell H, Visness CM, Cohen S, Stout J, Evans R, Gold DR (2004) Community violence and asthma morbidity: the inner-city asthma study. Am J Public Health 94:625–632PubMedCrossRefGoogle Scholar
  2. 2.
    Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR (2000) The role of acute and chronic stress in asthma attacks in children. Lancet 356:982–987PubMedCrossRefGoogle Scholar
  3. 3.
    Klinnert MD, Nelson HS, Price MR, Adinoff AD, Leung DY, Mrazek DA (2001) Onset and persistence of childhood asthma: Predictors from infancy. Pediatrics 108:e69PubMedCrossRefGoogle Scholar
  4. 4.
    Krieger N, Williams DR, Moss NE (1997) Measuring social class in US public health research: Concepts, methodologies, and guidelines. Ann Rev Public Health 18:341–378CrossRefGoogle Scholar
  5. 5.
    Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL (1993) Socioeconomic inequalities in health: No easy solution. JAMA 269:3140–3145.PubMedCrossRefGoogle Scholar
  6. 6.
    Chen E, Matthews KA, Boyce WT (2002) Socioeconomic differences in children's health: How and why do these relationships change with age? Psychol Bull 128:295–329PubMedCrossRefGoogle Scholar
  7. 7.
    Miller JE (2000) The effects of race/ethnicity and income on early childhood asthma prevalence and health care use. Am J Public Health 90:428–430PubMedCrossRefGoogle Scholar
  8. 8.
    Wood PR, Smith LA, Romero D, Bradshaw P, Wise PH, Chavkin W (2002) Relationships between welfare status, health insurance status, and health and medical care among children with asthma. Am J Public Health 92:1446–1452PubMedCrossRefGoogle Scholar
  9. 9.
    Simon PA, Zeng ZW, Wold CM, Haddock W, Fielding JE (2003) Prevalence of childhood asthma and associated morbidity in Los Angeles County: impacts of race/ethnicity and income. J Asthma 40:535–543PubMedCrossRefGoogle Scholar
  10. 10.
    Dales RE, Choi B, Chen Y, Tang M (2002) Influence of family income on hospital visits for asthma among Canadian school children. Thorax 57:513–517PubMedCrossRefGoogle Scholar
  11. 11.
    Maziak W, von Mutius E, Keil U, Hirsch T, Leupold W, Rzehak P, Behrens T, Weiland SK (2004) Predictors of health care utilization of children with asthma in the community. Pediatric Allergy and Immunology 15:166–171PubMedCrossRefGoogle Scholar
  12. 12.
    Amre DK, Infante-Rivard C, Gautrin D, Malo JL (2002) Socioeconomic status and utilization of health care services among asthmatic children. J Asthma 39:625–631PubMedCrossRefGoogle Scholar
  13. 13.
    Goodman DC, Stukel TA, Chang C (1998) Trends in pediatric asthma hospitalization rates: Regional and socioeconomic differences. Pediatrics 101:208–213PubMedCrossRefGoogle Scholar
  14. 14.
    Claudio L, Stingone JA, Godbold J (2006) Prevalence of childhood asthma in urban communities: The impact of ethnicity and income. Ann Epidemiol 16:332–340PubMedCrossRefGoogle Scholar
  15. 15.
    Castro M, Schechtman KB, Halstead J, Bloomberg G (2001) Risk factors for asthma morbidity and mortality in a large metropolitan city. J Asthma 38:625–635PubMedCrossRefGoogle Scholar
  16. 16.
    Persky VW, Slezak J, Contreras A, Becker L, Hernandez E, Ramakrishnan V, Piorkowski J (1998) Relationships of race and socioeconomic status with prevalence, severity, and symptoms of asthma in Chicago school children. Ann Allergy Asthma Immunol 81:266–271PubMedGoogle Scholar
  17. 17.
    Cesaroni G, Farchi S, Davoli M, Forastiere F, Perucci CA (2003) Individual and area-based indicators of socioeconomic status and childhood asthma. Eur Respir J 22:619–624PubMedCrossRefGoogle Scholar
  18. 18.
    Grant EN, Wagner R, Weiss KB (1999) Observations on emerging patterns of asthma in our society. J Allergy Clin Immunol 104:S1–S9PubMedCrossRefGoogle Scholar
  19. 19.
    Webber MP, Carpiniello KE, Oruwariye T, Appel DK (2002) Prevalence of asthma and asthmalike symptoms in inner-city elementary schoolchildren. Pediatr Pulmonol 34:105–111PubMedCrossRefGoogle Scholar
  20. 20.
    Ernst P, Demissie K, Joseph L, Locher U, Becklake MR (1995) Socioeconomic status and indicators of asthma in children. Am J Respir Crit Care Med 152:570–575PubMedGoogle Scholar
  21. 21.
    Saha C, Riner ME, Liu G (2005) Individual and neighborhood-level factors in predicting asthma. Arch Pediatr Adolesc Med 159:759–763PubMedCrossRefGoogle Scholar
  22. 22.
    Juhn YJ, St Sauver J, Katusic S, Vargas D, Weaver A, Yunginger J (2005) The influence of neighborhood environment on the incidence of childhood, asthma: a multilevel approach. Social Sci Med 60:2453–2464CrossRefGoogle Scholar
  23. 23.
    Yawn BP, Wollan P, Kurland M, Scanlon P (2002) A longitudinal study of the prevalence of asthma in a community population of school-age children. J Pediatr 140:576–581PubMedCrossRefGoogle Scholar
  24. 24.
    Graham PJ, Rutter ML, Yule W, Pless IB (1967) Childhood asthma: a psychosomatic disorder? Br J Prev Soc Med 21:78–85PubMedGoogle Scholar
  25. 25.
    Chung KF, Barnes PJ (1999) Cytokines in asthma. Thorax 54:825–857PubMedGoogle Scholar
  26. 26.
    Busse WW, Lemanske RF (2001) Asthma. N Engl J Med 344:350–362PubMedCrossRefGoogle Scholar
  27. 27.
    Bacharier LB, Geha RS (2000) Molecular mechanisms of IgE regulation. J Allergy Clin Immunol 105:S547–548PubMedCrossRefGoogle Scholar
  28. 28.
    Kamfar HZ, Koshak EE, Milaat WA (1999) Is there a role for automated eosinophil count in asthma severity assessment? J Asthma 36:153–158PubMedCrossRefGoogle Scholar
  29. 29.
    Ying S, Humbert M, Barkans J, Corrigan CJ, Pfister R, Menz G, Larché M, Robinson DS, Durham SR, Kay AB (1997) Expression of IL-4 and IL-5 mRNA and protein product by CD4+ and CD8+ T cells, eosinophils, and mast cells in bronchial biopsies obtained from atopic and nonatopic (intrinsic) asthmatics. J Immunol 158:3539–3544PubMedGoogle Scholar
  30. 30.
    Chen E, Fisher EB, Jr., Bacharier LB, Strunk RC (2003) Socioeconomic status, stress, and immune markers in adolescents with asthma. Psychosom Med 65:984–992PubMedCrossRefGoogle Scholar
  31. 31.
    Chen E, Hanson MD, Paterson LQ, Griffin MJ, Walker HA, Miller GE (2006) Socioeconomic status and inflammatory processes in childhood asthma: the role of psychological stress. J Allergy Clin Immunol 117:1014–1020PubMedCrossRefGoogle Scholar
  32. 32.
    Litonjua AA, Celedon JC, Hausmann J, Nikolov M, Sredl D, Ryan L, Platts-Mills TAE, Weiss ST, Gold DR (2005) Variation in total and specific IgE: effects of ethnicity and socioeconomic status. J Allergy Clin Immunol 115:751–757PubMedCrossRefGoogle Scholar
  33. 33.
    Lewis SA, Weiss ST, Platts-Mills TAE, Syring M, Gold DR (2001) Association of specific allergen sensitization with socioeconomic factors and allergic disease in a population of Boston women. J Allergy Clin Immunol 107:615–622PubMedCrossRefGoogle Scholar
  34. 34.
    Chen E, Miller GE (2007) Social context as an individual difference in psychoneuroimmunol-ogy. In: Irwin MR (ed.). Psychoneuroimmunology, 4th edn. Elsevier, Boston, MA, pp. 497–508Google Scholar
  35. 35.
    Wamboldt FS, Ho J, Milgrom H, Wamboldt MZ, Sanders B, Szefler SJ, Bender BG (2002) Prevalence and correlates of household exposures to tobacco smoke and pets in children with asthma. J Pediatr 141:109–115PubMedCrossRefGoogle Scholar
  36. 36.
    Jaakkola JJ, Nafstad P, Magnus P (2001) Environmental tobacco smoke, parental atopy, and childhood asthma. Environ Health Perspect 109:579–582PubMedCrossRefGoogle Scholar
  37. 37.
    Sarpong SB, Hamilton RG, Eggleston PA, Adkinson NF (1996) Socioeconomic status and race as risk factors for cockroach allergen exposure and sensitization in children with asthma. J Allergy Clin Immunol 97:1393–1401PubMedCrossRefGoogle Scholar
  38. 38.
    Togias A, Horowitz E, Joyner D, Guydon L, Malveaux F (1997) Evaluating the factors that relate to asthma severity in adolescents. Int Arch Allergy Immunol 113:87–95PubMedCrossRefGoogle Scholar
  39. 39.
    Rosenstreich DL, Eggleston P, Kattan M, Baker D, Slavin RG, Gergen P, Mitchell H, McNiff-Mortimer K, Lynn H, Ownby D, Malveaux F (1997) The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med 336:1356–1363PubMedCrossRefGoogle Scholar
  40. 40.
    Kunzli N, Kaiser R, Medina S, Studnicka M, Chanel O, Filliger P, Herry M, Horak F, Jr., Puybonnieux-Texier V, Quenel P, Schneider J, Seethaler R, Vergnaud JC, Sommer H (2000) Public-health impact of outdoor and traffic-related air pollution: a European assessment. Lancet 356:795–801PubMedCrossRefGoogle Scholar
  41. 41.
    Brunekreef B, Holgate ST (2002) Air pollution and health. Lancet 360:1233–1242PubMedCrossRefGoogle Scholar
  42. 42.
    Dockery DW, Pope CA, III, Xu X, Spengler JD, Ware JH, Fay ME, Ferris BG Jr, Speizer FE (1993) An association between air pollution and mortality in six U.S. cities. N Engl J Med 329:1753–1759PubMedCrossRefGoogle Scholar
  43. 43.
    Nicolai T (2002) Pollution, environmental factors and childhood respiratory allergic disease. Toxicology 181–182:317–21PubMedCrossRefGoogle Scholar
  44. 44.
    Belanger K, Gent JF, Triche EW, Bracken MB, Leaderer BP (2006) Association of indoor nitrogen dioxide exposure with respiratory symptoms in children with asthma. Am J Respir Crit Care Med 173:297–303PubMedCrossRefGoogle Scholar
  45. 45.
    Lin M, Chen Y, Villeneuve PJ, Burnett RT, Lemyre L, Hertzman C, McGrail KM, Krewski D (2004) Gaseous air pollutants and asthma hospitalization of children with low household income in Vancouver, British Columbia, Canada. Am J Epidemiol 159:294–303PubMedCrossRefGoogle Scholar
  46. 46.
    Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW (2002) School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med 165:1062–1067PubMedGoogle Scholar
  47. 47.
    Kang D, Coe C, McCarthy DO, Jarjour NN, Kelly EA, Rodriguez RR, Busse WW (1997) Cytokine profiles of stimulated blood lymphocytes in asthmatic and healthy adolescents across the school year. J Interferon Cytokine Res 17:481–487PubMedGoogle Scholar
  48. 48.
    Kang DH, Fox C (2001) Th1 and Th2 cytokine responses to academic stress. Res Nursing Health 24:245–257CrossRefGoogle Scholar
  49. 49.
    Wright RJ, Finn P, Contreras JP, Cohen S, Wright RO, Staudenmayer J, Wand M, Perkins D, Weiss ST, Gold DR (2004) Chronic caregiver stress and IgE expression, allergen-induced proliferation, and cytokine profiles in a birth cohort predisposed to atopy. J Allergy Clin Immunol 113:1051–1057PubMedCrossRefGoogle Scholar
  50. 50.
    Clougherty JE, Levy JI, Kubzansky LD, Ryan PB, Suglia SF, Jacobson Canner M, et al. (2007) Synergistic effects of traffic-related air pollution and exposure to violence on urban asthma etiology. Environ Health Perspect 115:1140–1146.PubMedGoogle Scholar
  51. 51.
    Yeatts K, Davis KJ, Sotir M, Herget C, Shy C (2003) Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without a diagnosis of asthma. Pediatrics 111:1046–1054PubMedCrossRefGoogle Scholar
  52. 52.
    Haas JS, Cleary PD, Guadagnoli E, Fanta C, Epstein AM (1994) The impact of socioeco-nomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma. J General Intern Med 9:121–126CrossRefGoogle Scholar
  53. 53.
    Kozyrskyj AL, Mustard CA, Simons ER (2001) Socioeconomic status, drug insurance benefits, and new prescriptions for inhaled corticosteroids in schoolchildren with asthma. Arch Pediatr Adolesc Med 155:1219–1224PubMedGoogle Scholar
  54. 54.
    Eggleston P, Malveaux F, Butz AM, Huss K, Thompson L, Lolodner K, Rand CS (1998) Medications used by children with asthma living in the inner city. Pediatrics 101:349–354PubMedCrossRefGoogle Scholar
  55. 55.
    Finkelstein JA, Barton MB, Donahue JG, Algatt-Bergstrom P, Markson LE, Platt R (2000) Comparing asthma care for Medicaid and non-Medicaid children in a health maintenance organization. Archives of Pediatrics & Adolescent Medicine 154:563–568Google Scholar
  56. 56.
    Blais L, Beauchesne MF, Levesque S (2006) Socioeconomic status and medication prescription patterns in pediatric asthma in Canada. J Adolesc Health 38:607.e9–16PubMedGoogle Scholar
  57. 57.
    Barr RG, Somers SC, Speizer FE, Camargo CA (2002) Patient factors and medication guideline adherence among older women with asthma. Arch Intern Med 162:1761–1768PubMedCrossRefGoogle Scholar
  58. 58.
    Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL (1998) Adherence with twice-daily dosing of inhaled steroids: Socioeconomic and health-belief differences. Am J Respir Crit Care Med 157:1810–1817PubMedGoogle Scholar
  59. 59.
    Lynd LD, Sandford AJ, Kelly EM, Pare PD, Bai TR, Fitzgerald M, Anis AH (2004) A cross-sectional study of the relationship between socioeconomic status and the magnitude of short-acting beta-agonist use in asthma. Chest 126:1161–1168PubMedCrossRefGoogle Scholar
  60. 60.
    Apter AJ, Reisine ST, Kennedy DG, Cromley EK, Keener J, ZuWallack RL (1997) Demographic predictors of asthma treatment site: Outpatient, inpatient, or emergency department. Ann Allergy Asthma Immunol 79:353–361PubMedCrossRefGoogle Scholar
  61. 61.
    Wright RJ (2005) Stress and atopic disorders. J Allergy Clin Immunol 116:1301–1306PubMedCrossRefGoogle Scholar
  62. 62.
    Wright RJ, Rodriguez M, Cohen S (1998) Review of psychosocial stress and asthma: An integrated biopsychosocial approach. Thorax 53:1066–1074PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2009

Authors and Affiliations

  • Edith Chen
    • 1
  • Hannah M. C. Schreier
    • 1
  1. 1.University of British ColumbiaVancouverCanada

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