Neighborhood factors may drive racial disparities in pediatric cancer outcomes
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The issue of racial inequity in health care is complex and multifactorial, and researchers have been working to isolate specific factors involved in these disparities.
A study from researchers at Rutgers University suggests that in cases of pediatric cancer, the neighborhood in which a child lives has more of an effect on cancer outcomes than race and ethnicity alone.
“We have long known through multiple studies and an enormous amount of data that white children have an advantage when it comes to survivorship,” Beth Savage, PhD, RN, CPNP, CPON, assistant professor at Rutgers University School of Nursing and member of Rutgers Cancer Institute of New Jersey, told Healio. “Because I’ve been a bedside nurse for so long, I was curious if that inequity trickled down to specific reasons.”
Savage and her team assessed 2018 medical data from the State Inpatient Databases of California, Florida, Maryland, Michigan, New Jersey, North Carolina, Rhode Island, Washington and Wisconsin. In all cases, these records included the patient’s home ZIP code, which allowed the researchers to evaluate health outcomes in relation to racial demographics from 24,786 hospital stays by juvenile patients with cancer. They conducted this analysis using the Child Opportunity Index 2.0 (COI) rank of each child’s home neighborhood. COI ranks combine 29 measures of neighborhood quality in areas such as education, environment and socioeconomic resources.
Savage spoke with Healio about the results of the study, published in Cancer Nursing, the need for further research in this area and the importance of improving opportunities for children with cancer.
Healio: Why did you use COI to assess neighborhoods in your study?
Savage: COI is a measurement of a neighborhood that doesn’t really focus so much on vulnerability as it does on opportunity through resources. Certainly, it’s important to know how many adults are employed, but it’s also important to know how many playgrounds are available. I liked it because it had a positive focus — instead of simply looking at who is not doing well, it also looks at who is doing well, so we can change policy to raise the bar for everyone.
Healio: What did you find?
Savage: A significantly higher percentage of Black and Hispanic children had life-threatening complications during hospitalizations in 2018 in those nine states. Then we evaluated the COI for their town or ZIP code area. At that point we knew that the average COI for a white child in our cohort was 60, with zero representing no opportunity and 100 being the best you can get. On average, Black children lived in neighborhoods ranked at 33, and Hispanic children lived in neighborhoods ranked at 36.
When we put COI into our regression model, Hispanic children were no longer at increased risk for life-threatening complications compared with non-Hispanic white children.
Healio: What opportunities do you think are missing in the neighborhoods with low COI?
Savage: The researchers who developed this index refer to something called “hoarding,” which tends to happen in non-Hispanic white neighborhoods due to systematic and structural policies. The result is a clustering of resources at the expense of the neighborhoods in which children of color are living. For example, less money is going into the schools where children of color live because the property taxes are lower. Because more people rent than own homes, there is more movement in and out of the neighborhood. There’s not that cohesiveness and building of opportunity for kids in the neighborhoods with low COI.
Healio: What did you find in terms of differences between age groups?
Savage: We hypothesized that as children get older, the influence of neighborhood on that direct relationship between race and the risk for outcomes becomes stronger. So, we looked at the interaction between race and age at three different time points — the mean and one standard deviation below and above it. We found that as children get older, neighborhood opportunity becomes a stronger mediator. There were no significant racial differences in serious cancer complications among children aged under 4 years, but outcomes started to diverge as they got older.
Healio: What is next for this research?
Savage: We plan to compare health outcomes among individual census tracts, which are much smaller than ZIP code areas, and to find other location data that might help us determine what factors in different neighborhoods might drive higher complication rates. Is it epigenetic? Is it inflammation? We know that asthma in these low-opportunity areas puts a lot more children into the ER and the hospital than it does in the high-opportunity areas. It could be pollution, or overcrowding, or housing conditions. However, we tend not to think this way when it comes to cancer, and I believe we have to. We need to take some of the public health information we’ve learned in other areas and apply these factors to cancer.
For more information:
Beth Savage, PhD, RN, CPNP, CPON, can be reached at savagebe@sn.rutgers.edu.
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