Dr Seb Gray, Consultant Paediatrician. Twitter: @SebJGray
“Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age”
Prof. Sir Michael Marmot
Let’s get straight to the point: when we use the slightly sanitised sounding phrase ‘health inequalities’ we are really talking about poverty and deprivation. Poverty and deprivation are terrible for your health. Poverty makes people ill and shortens lives – the most deprived males and females born between 2014-16 expected to die 9.3 years and 7.4 years sooner than the least deprived.
As paediatricians, we must be aware of how poverty impacts health and how we can help improve outcomes for children. Five major areas of health inequality are asthma, diabetes, epilepsy, oral health and mental health; here we will look at how asthma and poverty are intertwined.
Firstly, it might be useful to know where your area stands in terms of deprivation. The Indices of Multiple Deprivation (IMD) is a scale which ranks relative deprivation from 1-10, where 1 is the most deprived decile.
Take a minute to look at where your local area stands – and read the rest of this piece with that in mind.
One of the many reasons that looking after children and young people with asthma is great, is that the majority grow out of it and get better. Only about 15% have asthma that persists beyond the age of 14. When asthma persists beyond this age, it is heavily associated with poverty. Lower maternal education level (a marker of early life socioeconomic circumstances) was found to account for 58.9% of the 1.7 times increased risk of persisting asthma – much more of an impact than any of the other factors assessed. This data is another reminder that the impact of poverty isn’t just in the here and now. Children born into deprivation right now will be more likely to have asthma that persists throughout adolescence. Investing to tackle poverty would save the later costs of treating these future patients. The longer we wait to join the dots and make societal meaningful change, the more difficult it will be – action is needed now.
We know from studies of the 1944-45 Dutch famine that extreme periods of deprivation have long-lasting effects. Women who were pregnant during the famine had offspring who developed an array of different health problems, depending on which trimester of pregnancy they were most deprived of food (asthma was more likely in those who were exposed to famine during the second trimester).
With the current cost of living crisis, it isn’t too far a stretch to imagine similar stories of a generation yet to be born who will be impacted by their parents’ struggle to afford food.
Let’s start with some pretty shocking statistics about asthma and poverty.
A British Lung Foundation report showed that the incidence of asthma is 36% higher in the most deprived communities versus the least deprived.
The UK national PICU database (PICAnet) reveals that children living in poverty represent the majority of asthmatics admitted to PICU, needing invasive ventilation and dying. 73% of those that died were from the fourth and fifth most deprived quintiles. It’s worth pointing out that this was looking at data from 2006 up until 2013 – since which the gaps have widened.
The CYP Transformation Programme for asthma has developed a dashboard which provides some really interesting data. Here is the national data trend for England:
You can clearly see the peaks every year in asthma admissions (note the difference during COVID) with the ethnic breakdown and then the IMD ranges. There is an absolutely clear correlation with the left to right numbering of 1-10. The poorer you are, the lower your IMD, the more likely you are to be admitted with an asthma exacerbation.
Does ethnicity play a part?
We know from larger population and epidemiological studies that internationally, populations living in economically developed countries have a higher prevalence of asthma. However, despite originating from lower risk countries, Afro-Caribbeans & South Asians residing in the UK have been shown to have worse outcomes than Caucasians. What’s more, their offspring have an increased risk of developing asthma compared to UK-born Caucasians. The reasons for this are complex and multi-factorial but with 14.4% of the UK’s population born outside the UK (2021 data), further exploration is required.
The 2011 Census data has conflicting findings relating to ethnicity and socioeconomic status. Whilst those of Indian ethnicity were significantly more represented in the ‘managerial and professional’ groups (33.1% of Indians), Black and minority ethnic individuals represented a higher-than-average proportion of ‘long term unemployed or never worked’ compared to White British. As asthma risk and socio-economic status is so strongly correlated, we need to untangle the extent to which poverty is responsible for the difference in outcomes.
Asthma is caused by a combination of genetic and environmental factors that Interplay with epigenetics across a whole lifetime. In other words – your environment can change your gene expression, and that of your offspring, and of future generations.
This amazing study found that having a mother who smokes increases a child’s risk of developing asthma – which absolutely makes sense. What’s really interesting is that if your grandmother smoked, you have an even higher relative risk of developing asthma than just your mother but if they both smoked then you get the double whammy. Protect your grandkids – don’t smoke!
Air Pollution
Ella Roberta Adoo-Kissi-Debrah tragically died aged 9 in 2013. It took many years and an inquest for her death certificate to have air pollution listed as a cause of death. Ella lived close to the heavily polluted South Circular Road
in Lewisham and her health deteriorated catastrophically in the two years prior to her death. Air pollution levels were persistently at illegal levels and spikes were associated with her worsening asthma symptoms.
Her mother, Rosamund, continues to fight in her daughter’s name and has set up The Ella Roberta Foundation campaigning for the RCPCH-backed Ella’s Law and Clean Air For All.
London has introduced Low Emission Zones (LEZ) to try and improve air quality in the most polluted areas. Introducing a LEZ does indeed improve air quality (the percentage of children living at addresses where the nitric dioxide (NO2) levels were above EU limits reduced from 99% to 34%) – still an unacceptable percentage of children exposed to toxic air. It’s also worth noting that despite the improvement in air quality, there was no discernible improvement in objective lung function testing. It is so important to report negative as well as positive outcomes from air quality interventions – the drive for improved air quality cannot lose momentum.
Mould and damp
Growing up in a home with mould and damp makes you 1.5 to 3 times more likely to develop wheezy symptoms. Mould and damp are associated with living in poverty and the health effects can be catastrophic. The incredibly sad story of Awaab Ishak demonstrates that.
Awaab presented to hospital over and over again with worsening respiratory symptoms until he died aged 2 years. An inquest found that his death was caused by exposure to mould in his home. The family repeatedly raised the issue with Rochdale Boroughwide Housing but not enough was done.
It shouldn’t take children and young people needlessly dying to make change happen but again, the outrage about the circumstances surrounding Awaab’s death has resulted in the Government pledge to deliver Awaab’s Law. Paediatricians continue to have to write letters advocating for their patients and reduce exposure to indoor air pollution. Joined-up, system-wide changes are required to identify children at risk at the earliest opportunity.
There is an excellent systematic review of the associations between environmental exposures and development of asthma published nearly 10 years ago. TL;DR: living in deprivation increases the risk of developing asthma. Whilst an organic diet and fish oil supplements didn’t impact on asthma, a lot of surrogate markers for affluency did.
Smoking and vaping
Second hand smoke is a big risk factor with both antenatal (including previous generations as already discussed) and postnatal exposure having a big impact. Smoking is heavily linked with poverty. 23% of those with a household income of less than £10,000 annually smoke, compared to 11% of those earning >£40,000. With the average cost of a 20-pack of cigarettes in the UK now £12.61, a 20-day habit would cost £4,602.65. That doesn’t leave much to provide everything else required to optimise a healthy start to life.
Vaping and e-cigarettes have been revolutionary in augmenting the smoking cessation rates in adult populations.
However, this is where things get tricky: the public health messaging has been solely adult focussed, so children and young people have inadvertently been put at risk. The effects of second-hand smoking are well known, and there is societal stigma in smoking near children. The same can’t be said for vaping – people seem comfortable vaping around children, and as we don’t yet know the long term effects of vape smoke, this is concerning. Evidence has shown second-hand nicotine vape exposure is associated with increased risk of bronchitis symptoms and shortness of breath in young adults. This effect is almost certainly reproducible in children, particularly as the impact was heightened in those who had never smoked or vaped.
Adults largely use vaping to cut down on tobacco smoking, but vapes are now very common for recreational use in young people (rather than smoking ‘normal’ cigarettes). There’s increasing evidence that there is a socioeconomic correlation with deprivation and vaping. We’ve previously written about the issues around vaping in young people (Vaping: No Smoke Without Fire) – since then, the rate of vape use in young people continues to rise in the UK. Recreational vaping has now been banned in Australia, Singapore and Thailand. You can’t get a vape without a prescription, the flavours are limited and there are strict rules around nicotine content.
It’s clear that public health messaging should balance the benefits (for adults) of vaping for smoking cessation with the risks (for children) of being exposed to vape smoke, or starting vaping. Smoking cessation and child health advocates need to be having this conversation!
So… What can we do?
1. Learn more about the issues
An excellent children and young people’s asthma education package has been developed, hosted on e-learning for health. It’s great because it’s targeted in a tiered way at anyone who may come across a young person with asthma:
The first 3 levels – which cover the vast majority of the asthma ‘iceberg’ – are free to access and a great resource.
That will tick the box of understanding and education of those looking after the CYP apart from one quite big elephant in the room and that is the CYP themselves and their parents and carers. To be fair, there is a lot of focus in the training packages of upskilling and educating CYP and families. Literacy, health literacy and poverty are all heavily linked. Communicating asthma management in a way that is tailored to individual educational and understanding levels is challenging. Ideally, a tailored CYP and parent/carer education package similar to that nationally developed would be ideal to ensure a universal, clear, easy to understand asthma public health message is communicated.
2. Tailor advice for your patients
One of the most simple things you can change in your consultations (which will help patients with their symptoms and also get them thinking about the impact of air quality) is to show patients and their families how to check the Daily Air Quality Index (DAQI).
The DAQI is an accurate and current measurement of local air pollution. You’ve probably seen it without realising, if you’ve checked the weather app on your phone and seen a number between 1-10. What many people don’t realise is that when the DAQI hits the higher numbers, the health advice is to reduce physical activity.
Reduced physical activity is associated with poorer controlled asthma so you get the double whammy of potential air pollutant triggers alongside reducing the respiratory resilience that can be built from meeting the recommended levels of physical activity.
If you want to check a forecast of your local DAQI, have a look here.
Engaging with young people themselves is the gold standard, and nobody does it better than the RCPCH ‘&Us’ team. The Asthma &Me team were awarded the HQIP Richard Driscoll Memorial Award for patient and public involvement for their work with NACAP in producing CYP asthma information leaflets.
3. Advocate for your patients
System-wide interventions are just as important as individual patient-focussed actions. Advocacy work is essential, and we need to ensure that the voice of young people is considered in every policy. Ideally, policy-makers should be invested long-term and not use policies as political footballs for short-term gains with short-term thinking.
‘System’ advocacy
Paediatricians need to engage more with politicians. The RCPCH parliamentary panel is a good place to start – keep your eyes peeled for media and parliamentary training courses that are great fun and will equip you with the skills and confidence to make your voice heard.
Often there is a disconnect between us – the paediatricians on the ‘shop floor’ who see the direct effects of poverty – and the people ‘out there’ in local authorities, trying to effect change. Putting your head above the parapet and offering real insight, is usually well received. So, get in touch with the public health leads at your local authority. Ask about their smoking cessation policy. Ask about how they are trying to prevent young people from vaping. Ask how you can help bridge the two. If you want more confidence in doing so, complete the Very Brief Advice training module from the National Centre for Smoking Cessation and Training. The Making Every Contact Count e-learning package is also a nice bite-size learning package that should be in the arsenal of every paediatrician (and is completely free).
The Wellbeing and Health Action Movement (WHAM) has been one of the pioneers in attempting to tackle child poverty and has numerous tips, tricks and tools on what you can do and how you can get involved. There is currently a lot of enthusiasm and will (a lot of overlap) between the likes of WHAM and the RCPCH Climate Change Working Group.
Patient level advocacy
Advocating for your individual patients begins with identifying those who are vulnerable. We need to consider that every patient we come into contact with might be living in poverty and actively screen for it. There is an excellent ADC Education & Practice piece from Guddi Singh and Hannah Zhu on how to do this using QI methodology.
For asthma care, there are some pilot schemes which have looked at triangulating areas of deprivation with poorer asthma outcomes, using the data to identify individual children who may be at risk of worsening asthma, and then targeting intervention at this level. Wider rollout of initiatives like this (funding dependent…) holds the possibility of transforming asthma care for patients and populations. Watch this space.
Hopefully this piece has shown you some new concepts and introduced you to some important pieces of work that are already going on in the health inequalities arena. There is still so much to do, and everyone in paediatrics has a part to play – the health of our patients, and the health of society depends on it.
Dr Seb Gray, Paediatric Consultant, Salisbury NHS Foundation Trust & CYP Asthma Lead for Bath, North East Somerset, Swindon & Wiltshire (BSW) Email: Sebastian.Gray@nhs.net