Social Determinants of Health Associated With Asthma Morbidity in Children

At-risk rates of asthma morbidity in children varied across census tracts in Washington, DC, and were significantly correlated with social determinants of health in each area, according to a recent study.

Study results published in Pediatrics showed that adverse social determinants of health (SDOH) were significantly associated with increased at-risk rates (ARRs) of pediatric asthma morbidity and that these ARRs varied widely across census tracts in Washington, DC.1

Researchers aimed to evaluate the associations between pediatric asthma morbidity and SDOH in the different census tracts using ARRs, which account for underlying variations in asthma prevalence. They calculated ARRs for pediatric asthma-related emergency department (ED) visits and hospitalizations based on the number of children with asthma in each tract of the city. Examining the associations between census-tract ARRs and SDOH allows for the identification of specific place-based SDOH that could be targeted to reduce pediatric asthma morbidity.

ARRs are preferable to using population-based rates (PBRs) in geospatial analyses because the former divide ED visits and hospitalizations by only children with asthma in a particular area, whereas PBRs divide these encounters by all children in a particular area. As ARRs are calculated using only those at risk for pediatric asthma-related morbidity, census-tract ARRs may more accurately evaluate the effect of SDOH on disparities in pediatric asthma morbidity. To the researchers’ knowledge, this is the first study to use ARRs in order to evaluate associations between pediatric asthma morbidity and SDOH.

This population-based, cross-sectional study included children with asthma aged 2 to 17 years and residing in Washington, DC. Researchers pulled data from the DC Pediatric Asthma Registry. Health records from January 2018 to December 2019 were analyzed.

ARRs were calculated by dividing the number of ED encounters and hospitalizations by the number of children with asthma in each census tract.

Researchers used the Healthy People 2030 SDOH framework to determine 5 census-tract exposure variables: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty.

During the study, 4321 children with asthma had 7515 total ED encounters and 1182 children with asthma had 1588 total hospitalizations.

Across DC census tracts, ARRs for both ED encounters and hospitalizations varied greater than 10-fold. For ED encounters, ARRs ranged from 64 to 728 per 1000 children with asthma, depending on the census tract. ARRs for hospitalizations ranged from 20 to 240 per 1000 children with asthma, depending on the census tract.

Simple linear regression analyses showed that an increase in vacant housing, poverty, and violent crime and a decrease in educational attainment was associated with an increase in ARRs for ED encounters. These analyses also showed decreased educational attainment, poverty, and adults with limited English proficiency to be associated with increased ARRs for hospitalizations.

Multivariable linear regression analyses showed decreased educational attainment to be significantly associated with increased ARRs for ED encounters and for hospitalizations. Increased violent crime was significantly associated with increased ARRs for ED encounters.

Limitations of this study include the cross-sectional design, which prohibited researchers from evaluating potential causality between SDOH and pediatric asthma morbidity. Another limitation is that SDOH beyond the 5 evaluated in this study may be important factors related to pediatric asthma morbidity. In addition, the study population did not encompass all children with asthma in DC and asthma severity was not measured. Finally, ecological fallacy may have occurred, meaning that the aggregate data may not accurately reflect an individual living in a particular area.

Data from this study may be helpful in creating location-specific interventions to address SDOH in order to reduce pediatric asthma morbidity, the researchers concluded.

In an accompanying editorial, Lara J. Akinbami, MD, and Tyra Bryant-Stephens, MD, call the research “a renewed call to action,” noting that the authors’ work to identify contextual risk factors has provided “a more meaningful methodology for measuring and mapping risk and outcomes at the census tract level and working for change.”2


1. Tyris J, Gourishankar A, Ward MC, Kachroo N, Teach SJ, Parikh K. Social determinants of health and at-risk rates for pediatric asthma morbidity. Pediatrics. 2022;150(2).

2. Akinbami LJ, Bryant-Stephens T. Increasing the resolution and broadening the focus on childhood asthma disparities. Pediatrics. 2022;150(2). doi:10.1542/peds.2022-057206