Disparities in socioeconomic status
In this review we describe the influence of socioeconomic, environmental and ethnic disparities on PICU outcomes in childhood respiratory diseases. Children from families living in poverty or being minorities not only comprise a higher proportion of PICU admissions for respiratory diseases27,28, but there is an association with higher mortality rates as well29. A few possible proposed explanations for the higher prevalence of respiratory diseases and the higher proportion of deaths in this group are psychosocial processes, such as parental stress, overcrowding, illiteracy and malnutrition27,29. Socioeconomic inequalities tend to have an effect on the morbidity at the PICU as well: children from deprived neighborhoods have a higher severity of illness, a larger chance on respiratory failure and were mechanically ventilated more frequently16,27,30. Usually, being a minority and living in a neighborhood with other minorities tends to be protective, but these studies state otherwise, even after correcting for factors such as ethnicity, income and insurance16. This finding of increased morbidity may be explained by low acculturation and health illiteracy (e.g. parents or child only skilled in speaking native language in an English-speaking country, or lessened understanding of the health care system), which could in turn lead to decreased knowledge about medical care options16. Moreover, a low collective social capital could lead to neighborhoods where neighbors are not able to help each other and result in further impoverishment16. Finally, socioeconomic status may lead to a more severe disease course because of a lower parental education level, more exposure to indoor smoking, a limited access to healthcare, suboptimal medical care during emergencies, and structural problems in public health care services30. Previous studies describing the connection between poverty and outcomes in critically ill children derived these effects to limited knowledge about preventive primary care and an unhealthy lifestyle31. With the increasing food prices, the choice for unhealthier and often cheaper food is easily made.