Introduction
At the end of 2021, it was estimated that more than 24% of children in
Eastern Europe and Asia live in poverty due the effects of the COVID-19
pandemic, climate change, high inflation, the energy crisis and numerous
humanitarian crises, and these numbers further increased in 2022 due to
the war in Ukraine1,2. Although often overlooked,
poverty has a large impact on a child’s (respiratory) health. Living in
poverty influences all social determinants of health (SDH), which can be
divided into material, psychosocial, behavioral and structural
determinants3. Material SDH might be the most visible
and may have a direct impact on a child’s health, which was also seen
after the recession of 2008-20134. Increased prices of
food lead to poorer nutritional status whereas the energy crisis leads
to cold houses. Children in cold houses are at increased risk of asthma
attacks and respiratory infections. This is not only caused by
overcrowded houses when people stay indoors, but also by poor
ventilation, formation of mold and growth of house dust
mite5. An indirect effect of poverty can be seen in
parents who experience financial strain, who are less likely to quit
smoking and more likely to relapse6. Furthermore,
economic recession and unemployment induces a higher probability for
smoking by these parents, leading to increased exposure to possible
triggers for children with asthma living under those
circumstances7,8. Gaffney et al. found that over the
past four decades asthma prevalence increased among children but rose
more sharply in children with parents in a lower income
group9. Additionally, structural SDH may influence
health as well, and is defined as socioeconomic, political, cultural and
commercial structures that for instance influence accessibility of
resources and services across the population such as pediatric health
services, childcare, schools, welfare systems but also food marketing.
The effect of socioeconomic circumstances (SEC) on childhood respiratory
diseases are especially clear in the development of persistent asthma.
In the UK, disadvantages in early-life are associated with a 70%
greater risk of persistent asthma in adolescents, with almost two-thirds
of the excess risk being explained by both perinatal and environmental
mediators, with home environment being more important than more distal
exposures outside the home10. Also, early-life risk
factors such as maternal smoking during pregnancy and lower rates of
breastfeeding in disadvantaged groups have been shown to be mediators
for persistence of wheezing11. Similar findings are
reported in Australia and the USA12. In a study done
in the USA by Case et al, it was found that disadvantaged children with
asthma were more likely to have severe asthma compared to more
advantaged children13. In another study examining risk
factors for life threatening asthma in the USA in minority inner city
children, there was a high rate of previous pediatric intensive care
(PICU) admissions and growing up in an extremely poor household even
doubled the risk for a PICU admission for severe acute
asthma14. Interestingly, in the whole study
population, only 27.4% of the children previously admitted to a PICU
for asthma had been seen by an asthma specialist14.
Another important finding in this study group was that 30.5% of the
caregivers had symptoms of depression and 56.4% of the caregivers
perceived their child’s asthma as well controlled14.
Accessibility to a health care system, part of structural SDH, seems to
be even more important for this vulnerable minority group.
Similar to asthma, it may be expected that healthcare inequities (HI)
also exist for other respiratory diseases at the PICU. Several studies
have shown that children from families with a lower income are not only
more likely to be admitted to a PICU but are also more severely ill and
more likely to die before discharge15-18. This
inequality transcends patient-level, since it has been shown that PICU
use and PICU length of stay (LOS) is higher when coming from a
neighborhood with higher poverty rates compared to neighborhoods with
low poverty rates19. It has been suggested that these
higher-poverty neighborhoods have less accessibility to the health care
system, poor living conditions and a distressed social environment.
Indeed, Brown et al showed that in the USA, the physical distance to a
PICU increases with poverty20. Besides the
psychological effects on a child and its caregivers after a PICU
admission, medical (in the case of uninsured patients) but also
non-medical costs (transportation, meals) and the necessity to take
leave of absence from their jobs can give a huge strain on already
financially distressed families21,22. Both the risk of
a post-PICU syndrome as well as the financial effects increase with a
longer PICU LOS. To our knowledge, only scarce data are available on
effects of socioeconomic, environmental and ethnic factors on PICU
outcomes in childhood respiratory diseases. Our hypothesis is that
disparities in these factors also negatively influence the outcomes of
children’s respiratory diseases treated at the PICU.