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A systematic review of socioeconomic position in relation to asthma and allergic diseases

Eleonora Uphoff, Báltica Cabieses, Mariona Pinart, Macarena Valdés, Josep Maria Antó, John Wright
European Respiratory Journal 2015 46: 364-374; DOI: 10.1183/09031936.00114514
Eleonora Uphoff
1Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.
2Dept of Health Sciences, University of York, York, UK.
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  • For correspondence: noortjeuphoff@gmail.com
Báltica Cabieses
1Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.
2Dept of Health Sciences, University of York, York, UK.
3Universidad del Desarrollo, Clínica Alemana, Santiago, Chile.
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Mariona Pinart
4Centre for Research in Environmental Epidemiology, Barcelona, Spain.
5IMIM (Hospital del Mar Research Institute), Barcelona, Spain.
6CIBER Epidemiología y Salud Pública, Barcelona, Spain.
7Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain.
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Macarena Valdés
8PhD in Public Health Programme, Universidad de Chile, Santiago, Chile.
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Josep Maria Antó
4Centre for Research in Environmental Epidemiology, Barcelona, Spain.
5IMIM (Hospital del Mar Research Institute), Barcelona, Spain.
6CIBER Epidemiología y Salud Pública, Barcelona, Spain.
7Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain.
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John Wright
1Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.
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Abstract

The role of socioeconomic position (SEP) in the development of asthma and allergies is unclear, with some pointing to the risks of low SEP and other research pointing in the direction of higher SEP being associated with higher prevalence rates. The aim of this systematic review is to clarify associations between SEP and the prevalence of asthma and allergies. Out of 4407 records identified, 183 were included in the analysis. Low SEP was associated with a higher prevalence of asthma in 63% of the studies. Research on allergies, however, showed a positive association between higher SEP and illness in 66% of studies. Pooled estimates for the odds ratio of disease for the highest compared with the lowest SEP confirmed these results for asthma (unadjusted OR 1.38, 95% CI 1.37–1.39), allergies in general (OR 0.67, 95% CI 0.62–0.72), atopic dermatitis (unadjusted OR 0.72, 95% CI 0.61–0.83) and allergic rhinoconjunctivitis (unadjusted OR 0.52, 95% CI 0.46–0.59). Sensitivity analyses with a subsample of high-quality studies led to the same conclusion. Evidence from this systematic review suggests that asthma is associated with lower SEP, whereas the prevalence of allergies is associated with higher SEP.

Abstract

Lower socioeconomic position associated with higher prevalence of asthma and lower prevalence of allergies http://ow.ly/Oroan

Introduction

Decades of research on the aetiology of asthma and allergic diseases have led to the development of plausible theories on causal pathways. Nonetheless, this has made only a minor contribution to solving a complex multifactorial puzzle [1]. For many of the proposed prevention strategies related to hygiene, diet, pets, pollution and other environmental factors, the evidence is weak at best [2].

Spatial patterns in the global burden of disease

Prevalence rates of asthma and allergies have been on the rise in recent decades across the globe. The International Study of Asthma and Allergies in Childhood (ISAAC) phase III study conducted between 2001 and 2003 reported that the global prevalence rate of wheezing was 11.6% for 6–7-year-old children, and 13.7% for 13–14-year old children [3]. In Western countries, the prevalence rates of asthma, allergic diseases and associated symptoms are generally higher than in other countries. Pearce et al. [4] concluded that the prevalence rate of asthma symptoms is particularly high in English-speaking countries, Western Europe and some of the more affluent Asian countries. The prevalence rate of ever having had asthma among 13–14-year old children was 16.3% in Western Europe, 22.5% in North America, and 32.4% in New Zealand and Australia, while the global average was 13.8%. Apart from these high-income countries, Latin America is characterised by high prevalence rates. Other low- and middle-income countries, such as most of the African continent, Asia and Eastern Europe, have the lowest reported prevalence rates. Ever having had asthma or having a current wheeze was reported by 5.2% of 13–14-year-olds in Africa, 4.0% in the Asia-Pacific region and 3.1% on the Indian subcontinent, compared with the global prevalence rate of 6.2% [3]. These spatial patterns suggest a causal role for the environment, perhaps mediated through exposure to allergens, hygiene, air pollution and nutrition [5]. More recently, however, time trends have started to emerge, challenging the main theories on asthma causation.

Time trends in the global burden of disease

The global burden of asthma and allergic diseases is still increasing, at a time when the differences in the prevalence rates of asthma symptoms between countries seem to be decreasing [3]. This observation can partly be attributed to the rising prevalence rates of reported asthma and allergic diseases in many low- and middle-income countries. From 1994–1995 to 2001–2003, the upward trend in the prevalence rates of asthma and allergies has been particularly strong in Latin America, Northern and Eastern Europe, Africa, North America, and the Eastern Mediterranean [3]. In some high-income countries, however, and in particular those which are English speaking, the prevalence rates of reported asthma and allergies have now been reported to fall or at least plateau [2, 3, 6–8]. At this time, study findings contradict each other and not all researchers are convinced that the plateaus or decreases in prevalence rates observed in some studies indicate a trend [9–11]. Part of the change may be related to better awareness, improved diagnostic methods and changing diagnostic criteria that have uncovered undiagnosed cases in previous decades. However, this does not explain a decrease of prevalence rates in some populations. Even a stabilisation of new cases in Western countries challenges ideas about the causal role of factors such as obesity, hygienic environments and air pollution [3].

Socioeconomic position in relation to asthma and allergies

Spatial patterns in combination with changing trends over time may provide clues to understanding the causal pathways involved in the development of asthma and allergic diseases [12]. In relation to socioeconomic position (SEP), the “hygiene hypothesis” is the theory that features most prominently in the explanation of higher prevalence rates in more affluent Western countries: maternal exposure to microorganisms during pregnancy and early childhood exposure, which are thought to be higher in less “hygienic” and poorer environments such as farms and more crowded houses, would protect against the sensitisation to allergens later in life [13]. Despite being a popular theory, the hygiene hypothesis has been widely criticized, and results for various types of exposure and in different populations contradict each other [14, 15]. In addition, the evidence on the relationship between SEP and asthma and allergies has been conflicting, with both low and high SEP being reported as a risk factor.

A nonsystematic review published in 1996 summarised results from Australia, the USA, the UK and New Zealand, and found no consistent association between SEP and childhood asthma [16]. Although many factors associated with SEP, such as environmental tobacco smoke, housing, air pollution and obesity, have been studied in relation to asthma and allergic diseases, there has been no worldwide systematic review of the evidence of associations between SEP and asthma and allergies. We aim to review the evidence on the associations between SEP and the prevalence rates of asthma and allergic diseases by presenting an up-to-date overview of the international scientific literature.

Methods

Search strategy

We conducted a systematic review on asthma and allergies and SEP in accordance with the guidelines set by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [17]. The protocol can be accessed at PROSPERO (www.crd.york.ac.uk/PROSPERO/, registration number CRD42014008883). In step 1, the search was conducted in the PubMed database in November 2012. We chose broad string and MeSH (Medical Subject Heading) terms in our search to include any definition of asthma and allergies, and SEP (fig. 1). In addition to allergic disease in general, specific health outcomes included in the search were asthma, wheeze, allergic rhinitis, rhinoconjunctivitis, food allergy, food hypersensitivity, atopic dermatitis, anaphylaxis and urticaria. Variations for SEP used in the search were socioeconomic status, social class, poverty, social disadvantage and deprivation. In order to include all relevant evidence available on this topic, we applied no timeframe or language filter.

FIGURE 1
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FIGURE 1

Search terms and equations used for this review in the PubMed database. The term “IgE sensitization” was not included in the search but was described in the results section if it emerged as relevant during analysis.

Article selection and retrieval process

In step 2, all titles and abstracts were screened by two members of the research team (B. Cabieses and E. Uphoff) for keywords related to asthma and/or allergies and SEP. A random sample of 20% of the studies was selected for double-checking and agreement between independent reviewers was high (>98%). In step 3, full texts of the articles were retrieved or, for those manuscripts not accessible via institutional subscriptions, the authors were contacted via e-mail. In step 4, all full-text articles were reviewed by one author (M. Valdés) and a final decision on their inclusion in or exclusion from this review was made based on the criteria in table 1.

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TABLE 1

Inclusion and exclusion criteria

Discussion papers and reviews provided background to our systematic review but were not included in the data extraction form as they did not provide primary data. Studies that, upon extraction of the data in step 5, were found not to fit the inclusion criteria were not included in the results of this review. The search was updated in January 2014 to include recently published articles.

Data extraction

The data extraction form was designed in Microsoft Access (Microsoft Corp., Redmond, WA, USA), assessed by one of the authors not involved in the data extraction (M. Pinart) and piloted with 10 articles, which lead to minor modifications (online supplementary material). One of the reviewers performed the data extraction and quality assessment of each study (M. Valdés). Assessment of quality was based on version 4 of the STOBE (Strengthening the Reporting of Observational Studies in Epidemiology) guideline and the 2011 version of the MMAT (Mixed Methods Appraisal Tool), and incorporated into the data extraction form [18, 19]. A score from 0 to 6 was assigned to each study based on six quality criteria: “sample is representative of the population under study”, “sample size is adequate”, “measures are adequately described and the rationale for their use is justified”, “the method of data analysis is appropriate to answer the research question” and “analyses are adjusted for confounders or differences between groups”. Studies that fulfilled zero to two criteria were labelled “poor quality”, three to five was considered “average quality” and all six criteria met indicated “good quality”.

Pooled estimates

Pooled estimates were based on 147 unadjusted and 153 adjusted odds ratios or similar measures of association from 86 studies, as not all studies provided the necessary information. Inverse variance weights were used to take into account sample sizes of individual studies. Studies based on hospitalisations for asthma or allergies were excluded from the pooled estimate, as were country-level analyses (online supplementary material).

Results

A total of 4407 hits were retrieved from the literature search, of which 183 were finally selected for inclusion in the analysis (fig. 2). Most studies were excluded because no analysis on SEP was performed or because the exacerbation or severity of disease rather than the development of asthma and allergies was the focus of the study. All 183 studies included in this review can be found in the summary table in the online supplementary material.

FIGURE 2
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FIGURE 2

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. SES: socioeconomic status.

Overview of studies

Many studies were based on data from the ISAAC phase 1, 2 or 3 surveys, and others either adapted the ISAAC questionnaire for their own use or applied it without changes. The map in figure 3 shows the countries represented in these surveys. Excluded from the map are two studies using subsamples from international surveys without specifying which countries were included [20, 21]. The map shows that the Americas and Europe were well represented, while African countries were poorly represented. Ecuador and Brazil were overrepresented in Latin America, and data from the Middle East were disproportionally collected from Turkey. For some countries, the large number of studies is explained by national or regional birth cohorts, such as the Pelotas birth cohort study in Brazil, from which seven out of 17 studies drew data. In Turkey, however, all six studies were based on cross-sectional data collected from different parts of the country. A total of 32 countries not represented in the ISAAC surveys were covered by other surveys or cross-sectional studies.

FIGURE 3
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FIGURE 3

Setting of research conducted on asthma/allergies and socioeconomic position. ISAAC: International Study of Asthma and Allergies in Childhood.

The majority of included studies applied a cross-sectional design (n=124), followed by 42 prospective longitudinal studies, eight case–control studies, five retrospective longitudinal studies and four time series designs. Table 2 presents an overview of study characteristics. Studies included in this review were largely published after 2000, which partly reflects the growing interest in social determinants of health and partly the limited availability of older papers. This synthesis of results shows a preference for parental education and income as measures of SEP. The main source of information on SEP tended to be self-reported or parent-reported data, with census data and medical records also being used to extract this information. The measurement of health outcomes varied from parent-reported asthma and allergies to doctor-diagnosed medical illnesses extracted from medical records. Allergic disease indicated by tests for allergen-specific IgE generally lead to higher prevalence rates than medically diagnosed or self-reported allergies. In the study by Hoffmann et al. [22], for example, the parent-reported prevalence of ever having had allergies was 12.5%, while tests showed allergic sensitisation in 58.4% of cases.

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TABLE 2

Characteristics of studies included in the systematic review

Quality of studies

Detailed information about the quality of each study can be found in the online supplementary material. 24 studies were classified as poor quality, 41 were considered good quality and the remaining 118 were rated as average quality. The transparency of publications was affected by main aspects of the study design and execution not being reported. Most common was the lack of a discussion of the generalisability of study results (n=9) and a statement of funding received (n=43). Furthermore, 42 studies did not adjust for any confounders and 12 studies did not describe clearly the rationale for certain measures used. Two studies, for example, did not specify how their SEP variables were defined or measured [23, 24]. Three studies used the UK system of classification of occupations but did not make this explicit [25–27]. In addition, 18 studies were underpowered for the analyses performed, resulting in very wide confidence intervals for the risk estimates.

Association between asthma and SEP

A positive relationship between SEP and the prevalence rate of asthma or wheeze was found in only 9% of the studies, whereas 63% reported lower SEP to be associated with higher odds of asthma. The association between lower SEP and a higher prevalence of asthma was found in studies with children and adults, and across world regions. The pooled unadjusted odds ratio for the prevalence of asthma for people of the lowest SEP compared with the highest SEP was 1.38 (95% CI 1.37–1.39) and the odds ratio adjusted for a wide range of covariates was 1.11 (95% CI 1.09–1.14) (online supplementary material). Some studies found that the relationship between asthma and SEP varied by measure of SEP. In a study among US children, for example, lower prevalence rates of asthma were associated with low family income (OR 0.33, 95% CI 0.20–0.54) but not with unemployment (OR 1.35, 95% CI 0.84–2.17) [28]. A study among children in Cuba found that those exposed to an economic crisis had lower odds of asthma than unexposed children (OR 0.40, 95% CI 0.17–0.95) [29]. The association between self-reported or doctor-diagnosed asthma and SEP was more evident than the association between symptoms of wheeze and SEP (unadjusted OR 1.02, 95% CI 0.99–1.06; adjusted OR 1.33, 95% CI 1.29–1.37) (online supplementary material).

Association between allergic diseases and SEP

In contrast to asthma, of the studies that used allergies as an outcome measure, 66% found higher individual SEP to be associated with a higher prevalence rate and 12% reported that lower SEP was associated with higher rates of allergies (table 3). The pooled unadjusted odds ratio for the prevalence of allergies or atopy in general, for people of the lowest SEP compared with the highest SEP, was 0.67 (95% CI 0.62–0.72), and the odds ratio adjusted for a wide range of covariates was 0.69 (95% CI 0.60–0.79) (online supplementary material). A lower SEP was also associated with a lower prevalence rate of atopic dermatitis (unadjusted OR 0.72, 95% CI 0.61–0.83; adjusted OR 0.79, 95% CI 0.73–0.85) and allergic rhinoconjunctivitis (unadjusted OR 0.52, 95% CI 0.46–0.59; adjusted OR 0.79, 95% CI 0.78–0.80) (online supplementary material). Reported associations between higher prevalence rates of allergic diseases and lower SES were not consistent, and varied according to the measures of SEP or the health outcomes used in the analysis.

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TABLE 3

Evidence on the associations between socioeconomic position (SEP) and allergic diseases

Area-level SEP in relation to asthma and allergic diseases

A total of 19 studies reported on the association between area-level measures of SEP and either individual- or area-level health outcomes. 11 of these, most of which used measures of area deprivation or average household income, found that lower area SEP was associated with hospital admissions for asthma (n=6) [30–35], admission for anaphylactic shock [36] and the prevalence of asthma/wheeze (n=4) [37–40]. Only one study of the associations between asthma and area-level income found no significant result [41], and a study among UK adults showed an association between higher area deprivation and asthma for women but not for men [42]. Two studies using data on gross national income concluded that more affluent countries had higher prevalence rates of asthma, wheeze and atopic sensitisation [43, 44]. An ecological study making use of the ISAAC study data found a weak linear association between gross national product and wheeze and eczema, although this association was most prominent in non-European countries [45]. The remaining three studies reported mixed results [46–48].

Sensitivity analysis with high-quality studies

Including only high-quality studies confirms the relationships found between lower SEP and higher prevalence rates of asthma, and reproduces the evidence of the association between higher SEP and allergic diseases. 36 studies rated as good quality included asthma or wheezing as a health outcome (online supplementary material). Of these studies, 17 suggested asthma or wheezing were associated with lower SEP and only two studies found the opposite association. The remaining 17 studies either did not study this particular association (n=6) or reported mixed results depending on measures of health and subgroups within the population under study (n=11).

Aligne et al. [49] studied a sample of black and white Americans, and found that the prevalence of asthma was not related to poverty or ethnicity but to living in an urban setting. Another US study concluded that higher odds of asthma were associated with a lower SEP for African-American children and a higher SEP for Mexican-American children, while results for the “other Latino” group were not significant [50].

Eight studies on the relationship between individual SEP and allergies were rated high quality. Together, these studies reported on 11 relationships between SEP and different allergies, of which nine results in seven studies pointed towards a higher prevalence for people of higher SEP [51–57]. One study found no relationship between SEP and doctor-diagnosed atopic eczema in Japanese children [58].

Discussion

In this review of studies from mainly high- and middle-income countries, we found evidence confirming an association between lower SEP and a higher prevalence rate of asthma for children and adults. Area deprivation was also consistently associated with higher prevalence rates and hospital admission rates for asthma. In contrast, the evidence for the association between SEP and allergic diseases points in the opposite direction, with higher SEP being associated with a higher prevalence of allergies. This relationship was found for allergies or atopy in general, atopic dermatitis, allergic rhinoconjunctivitis and food allergies.

Study limitations

The findings of this systematic review are likely to be affected by bias within studies as well as bias in the pooled estimates of studies. Some studies did not provide a rationale for their choice of measures, and it is likely that measures of SEP chosen for reasons of convenience and availability may not always be the most suitable measures to detect social inequalities in health. Most studies used income or education of the parents as a proxy for SEP (table 2). Although these are often used and therefore facilitate comparison between studies, education of the parents in particular does not necessarily reflect the SEP of children in the household. In studies focussing on asthma or wheezing in children, measures of parental SEP may account for only part of the effects of social disadvantage on child health. This life-course perspective on childhood asthma was rarely considered in any of the studies. Due to the suboptimal quality of many studies, we analysed the sample rated as high quality separately. This did not lead to different conclusions on the relationships between SEP and asthma and allergies.

The generalisability of our findings may be affected by the study settings in which the data were collected. The results draw heavily upon data from Europe and the Americas, and the regions of Africa and Oceania were included in only 20% of the articles (table 2). The majority of African countries did not participate in the ISAAC surveys upon which many studies relied for their data collection (fig. 3).

Despite the large number of studies reviewed, by limiting the literature search to one electronic database, we might have not included all relevant literature. Furthermore, funnel plots indicate that not all relevant studies might have been published. There was a lack of smaller studies reporting results that contradict the main findings; in other words, a higher SEP being associated with higher prevalence rates of asthma or a lower SEP being associated with lower prevalence rates of allergies (online supplementary material).

We calculated pooled measures of association to aid the interpretation of the vast amount of data collected from the studies included in this review, despite large differences between studies in measurement of SEP, and health, setting, focus and statistical analyses. Higgins' I2-tests indicated considerable heterogeneity in studies of all groups of health outcomes [59] (online supplementary material). We stress that this systematic review is no more than a summary of previous findings and ask that results are interpreted with caution. Although we are confident that the pooled estimates give a reliable indication of the nature of the associations between SEP and allergic diseases for the studies included in this review, this information by no means quantifies the relationship between SEP and allergic diseases in the general population.

Implications for research and policy

The evidence for an association between lower SEP and a higher prevalence rate of asthma suggests that social and economic determinants of health associated with deprivation may play a role in the aetiology of asthma. Examples of such determinants from recent research include obesity, tobacco smoking, and indoor and outdoor pollution [14, 60, 61]. People with a lower SEP may be more exposed to these factors than those with a higher SEP. However, this does not explain why the prevalence of asthma is generally lower in low-income countries, where especially residents in urban areas in tropical climates may be more exposed to indoor and outdoor pollution than in higher income countries. Research on migrants has shown that the prevalence of asthma in people migrating to high-income countries rises over time, with increased length of exposure to determinants of health in the host country [62]. More research is needed to determine which environmental factors in westernised societies drive this change in susceptibility to asthma.

Lower SEP is associated with poorer health for almost every health outcome, and our results indicate that the association between higher SEP and allergies is a notable exception. For other health outcomes, the inverse social gradient can usually be explained by demographic characteristics and health behaviour (breast cancer and skin cancer). Higher prevalence rates of allergies in higher social groups have been considered consistent with the hygiene hypothesis, which has also been linked to the lack of a social gradient or inverse social gradient for other immune disorders (e.g. type 1 diabetes) [63, 64]. In contrast to evidence supporting the hygiene hypothesis, a Korean study found higher rates of sensitisation to most allergies in children with a higher household income, while sensitisation to cockroach allergen was more common in children of lower SEP [65]. Evidence on cockroach allergy not included in this review confirms that higher exposure to cockroach allergens in people with a lower SEP is associated with higher, rather than lower, prevalence rates of allergy [66, 67]. We cannot draw final conclusions on the hygiene hypothesis in relation to allergies, as most studies included in this review did not measure exposure to allergens in addition to the diagnosis of allergy.

Another explanation for an inverse social gradient in allergies is that people of higher SEP would be more likely to report allergy symptoms. One study found that the prevalence of self-reported allergies was significantly higher in people of higher SEP, while laboratory results on allergic sensitisation did not reach statistical significance [22]. Two studies showed a significant inverse social gradient in parent-reported as well as clinically diagnosed atopic dermatitis, with symptoms of illness being more common among children of higher SEP [68, 69].

Although we do not provide causal evidence, this review suggests it could be useful to treat asthma and different types of allergy as separate health outcomes, particularly when investigating the social determinants of health. In addition to a well-considered health outcome, using a combination of SEP measures increases the likelihood that the effects of SEP are captured accurately for children and adults, men and women, and different ethnic groups. This nuanced approach to the examination of determinants of asthma and allergies is likely to improve our understanding of causal pathways, in order to inform clinical practice and evidence-based policy on the prevention of asthma and allergies.

Conclusion

The evidence from this systematic review suggests that the association with SEP differs for asthma and allergic diseases. Asthma is associated with lower SEP, whereas allergies are more often associated with higher SEP.

Acknowledgements

We thank all authors who kindly sent us their manuscripts upon request during the retrieval and selection process. We are grateful to Kate Pickett (University of York, York, UK) for her comments.

Footnotes

  • This article has supplementary material available from erj.ersjournals.com

  • Support statement: This review was funded by the MeDALL project and the UK National Institute for Health Resarch (NIHR) Collaboration for Applied Health Research and Care for Yorkshire and Humberside. MeDALL is a collaborative project funded by the Health Cooperation Work Programme of the European Union Seventh Framework programme (grant agreement number 261357). The views expressed are those of the author(s) and not necessarily those of the UK National Health Service, the NIHR or the UK Dept of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Conflict of interest: None declared.

  • Received June 23, 2014.
  • Accepted November 24, 2014.
  • Copyright ©ERS 2015

References

  1. ↵
    1. Gold DR,
    2. Wright R
    . Population disparities in asthma. Annu Rev Public Health 2005; 26: 89–113.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    1. Eder W,
    2. Ege MJ,
    3. von Mutius E
    . The asthma epidemic. N Engl J Med 2006; 355: 2226–2235.
    OpenUrlCrossRefPubMedWeb of Science
  3. ↵
    1. Pearce N,
    2. Aït-Khaled N,
    3. Beasley R, et al.
    Worldwide trends in the prevalence of asthma symptoms: phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax 2007; 62: 758–766.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Pearce N,
    2. Sunyer J,
    3. Cheng S, et al.
    Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420–426.
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Marks GB
    . Geographical heterogeneity of asthma. Int J Epidemiol 2001; 30: 179–180.
    OpenUrlFREE Full Text
  6. ↵
    1. Akinbami LJ,
    2. Schoendorf KC
    . Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics 2002; 110: 315–322.
    OpenUrlAbstract/FREE Full Text
    1. Anderson HR,
    2. Ruggles R,
    3. Strachan DP, et al.
    Trends in prevalence of symptoms of asthma, hay fever, and eczema in 12–14 year olds in the British Isles, 1995–2002: questionnaire survey. BMJ 2004; 328: 1052.
    OpenUrlFREE Full Text
  7. ↵
    1. Zöllner I,
    2. Weiland S,
    3. Piechotowski I, et al.
    No increase in the prevalence of asthma, allergies, and atopic sensitisation among children in Germany: 1992–2001. Thorax 2005; 60: 545–548.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Anandan C,
    2. Nurmatov U,
    3. Van Schayck O, et al.
    Is the prevalence of asthma declining? Systematic review of epidemiological studies. Allergy 2010; 65: 152–167.
    OpenUrlCrossRefPubMedWeb of Science
    1. Downs S,
    2. Marks G,
    3. Sporik R, et al.
    Continued increase in the prevalence of asthma and atopy. Arch Dis Child 2001; 84: 20–23.
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Barnes PJ
    . Asthma: what is there left to find out? BMJ 1993; 307: 814.
    OpenUrlFREE Full Text
  10. ↵
    1. Partridge MR
    . Has ISAAC told us as much as it can? Where now? Thorax 2009; 64: 462–463.
    OpenUrlFREE Full Text
  11. ↵
    1. Okada H,
    2. Kuhn C,
    3. Feillet H, et al.
    The “hygiene hypothesis” for autoimmune and allergic diseases: an update. Clin Exp Immunol 2010; 160: 1–9.
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    1. Platts-Mills T,
    2. Erwin E,
    3. Heymann P, et al.
    Is the hygiene hypothesis still a viable explanation for the increased prevalence of asthma? Allergy 2005; 60: Suppl.79, 25–31.
  13. ↵
    1. Brooks C,
    2. Pearce N,
    3. Douwes J
    . The hygiene hypothesis in allergy and asthma: an update. Curr Opin Allergy Clin Immunol 2013; 13: 70–77.
    OpenUrlCrossRefPubMed
  14. ↵
    1. Mielck A,
    2. Reitmeir P,
    3. Wjst M
    . Severity of childhood asthma by socioeconomic status. Int J Epidemiol 1996; 25: 388–393.
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Moher D,
    2. Liberati A,
    3. Tetzlaff J, et al.
    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535.
    OpenUrlFREE Full Text
  16. ↵
    1. von Elm E,
    2. Altman DG,
    3. Egger M, et al.
    The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Prev Med 2007; 45: 247–251.
    OpenUrlCrossRefPubMedWeb of Science
  17. ↵
    1. Pluye P,
    2. Robert E,
    3. Cargo M, et al.
    Proposal: a mixed methods appraisal tool for systematic mixed studies reviews. Montréal, McGill University, 2011.
  18. ↵
    1. Ellison-Loschmann L,
    2. Sunyer J,
    3. Plana E, et al.
    Socioeconomic status, asthma and chronic bronchitis in a large community-based study. Eur Respir J 2007; 29: 897–905.
    OpenUrlAbstract/FREE Full Text
  19. ↵
    1. Brunekreef B,
    2. Von Mutius E,
    3. Wong GK, et al.
    Early life exposure to farm animals and symptoms of asthma, rhinoconjunctivitis and eczema: an ISAAC Phase Three Study. Int J Epidemiol 2012; 41: 753–761.
    OpenUrlAbstract/FREE Full Text
  20. ↵
    1. Hoffmann B,
    2. Kolahgar B,
    3. Rauchfuss K, et al.
    Childhood social position and associations between environmental exposures and health outcomes. Int J Hyg Environ Health 2009; 212: 146–156.
    OpenUrlCrossRefPubMedWeb of Science
  21. ↵
    1. Klinnert MD,
    2. Nelson HS,
    3. Price MR, et al.
    Onset and persistence of childhood asthma: predictors from infancy. Pediatrics 2001; 108: e69–e69.
    OpenUrlAbstract/FREE Full Text
  22. ↵
    1. Desalu OO,
    2. Salami AK,
    3. Iseh KR, et al.
    Prevalence of self reported allergic rhinitis and its relationship with asthma among adult Nigerians. J Investig Allergol Clin Immunol 2009; 19: 474–480.
    OpenUrlPubMed
  23. ↵
    1. Sibbald B,
    2. Rink E
    . Labelling of rhinitis and hayfever by doctors. Thorax 1991; 46: 378–381.
    OpenUrlAbstract/FREE Full Text
    1. Butland BK,
    2. Strachan DP,
    3. Lewis S, et al.
    Investigation into the increase in hay fever and eczema at age 16 observed between the 1958 and 1970 British birth cohorts. BMJ 1997; 315: 717–721.
    OpenUrlAbstract/FREE Full Text
  24. ↵
    1. Duran-Tauleria E,
    2. Rona RJ
    . Geographical and socioeconomic variation in the prevalence of asthma symptoms in English and Scottish children. Thorax 1999; 54: 476–481.
    OpenUrlAbstract/FREE Full Text
  25. ↵
    1. Wilhelm M,
    2. Qian L,
    3. Ritz B
    . Outdoor air pollution, family and neighborhood environment, and asthma in LA FANS children. Health Place 2009; 15: 25–36.
    OpenUrlCrossRefPubMedWeb of Science
  26. ↵
    1. van der Werff SD,
    2. Polman K,
    3. Ponce MC, et al.
    Childhood atopic diseases and early life circumstances: an ecological study in Cuba. PLoS One 2012; 7: e39892.
    OpenUrlCrossRefPubMed
  27. ↵
    1. Carr W,
    2. Zeitel L,
    3. Weiss K
    . Variations in asthma hospitalizations and deaths in New York City. Am J Public Health 1992; 82: 59–65.
    OpenUrlCrossRefPubMedWeb of Science
    1. Walters S,
    2. Phupinyokul M,
    3. Ayres J
    . Hospital admission rates for asthma and respiratory disease in the West Midlands: their relationship to air pollution levels. Thorax 1995; 50: 948–954.
    OpenUrlAbstract/FREE Full Text
    1. Watson JP,
    2. Cowen P,
    3. Lewis RA
    . The relationship between asthma admission rates, routes of admission, and socioeconomic deprivation. Eur Respir J 1996; 9: 2087–2093.
    OpenUrlAbstract/FREE Full Text
    1. Babin SM,
    2. Burkom HS,
    3. Holtry RS, et al.
    Pediatric patient asthma-related emergency department visits and admissions in Washington, DC, from 2001–2004, and associations with air quality, socio-economic status and age group. Environ Health 2007; 6: 9.
    OpenUrlCrossRefPubMed
    1. Lin S,
    2. Liu X,
    3. Le LH, et al.
    Chronic exposure to ambient ozone and asthma hospital admissions among children. Environ Health Perspect 2008; 116: 1725–1730.
    OpenUrlCrossRefPubMedWeb of Science
  28. ↵
    1. Wissow LS,
    2. Gittelsohn AM,
    3. Szklo M, et al.
    Poverty, race, and hospitalization for childhood asthma. Am J Public Health 1988; 78: 777–782.
    OpenUrlCrossRefPubMedWeb of Science
  29. ↵
    1. Sheikh A,
    2. Alves B
    . Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clin Exp Allergy 2001; 31: 1571–1576.
    OpenUrlCrossRefPubMedWeb of Science
  30. ↵
    1. Shankardass K,
    2. Jerrett M,
    3. Milam J, et al.
    Social environment and asthma: associations with crime and No Child Left Behind programmes. J Epidemiol Community Health 2011; 65: 859–865.
    OpenUrlAbstract/FREE Full Text
    1. da Cunha SS,
    2. Pujades-Rodriguez M,
    3. Barreto ML, et al.
    Ecological study of socio-economic indicators and prevalence of asthma in schoolchildren in urban Brazil. BMC Public Health 2007; 7: 205.
    OpenUrlCrossRefPubMed
    1. Digenis-Bury EC,
    2. Brooks DR,
    3. Chen L, et al.
    Use of a population-based survey to describe the health of Boston public housing residents. Am J Public Health 2008; 98: 85–91.
    OpenUrlCrossRefPubMedWeb of Science
  31. ↵
    1. Duran-Tauleria E,
    2. Rona RJ
    . Geographical and socioeconomic variation in the prevalence of asthma symptoms in English and Scottish children. Thorax 1999; 54: 476–481.
    OpenUrlAbstract/FREE Full Text
  32. ↵
    1. Cesaroni G,
    2. Farchi S,
    3. Davoli M, et al.
    Individual and area-based indicators of socioeconomic status and childhood asthma. Eur Respir J 2003; 22: 619–624.
    OpenUrlAbstract/FREE Full Text
  33. ↵
    1. Eachus J,
    2. Williams M,
    3. Chan P, et al.
    Deprivation and cause specific morbidity: evidence from the Somerset and Avon survey of health. BMJ 1996; 312: 287–292.
    OpenUrlAbstract/FREE Full Text
  34. ↵
    1. Weinmayr G,
    2. Weiland SK,
    3. Björksten B, et al.
    Atopic sensitization and the international variation of asthma symptom prevalence in children. Am J Respir Crit Care Med 2007; 176: 565–574.
    OpenUrlCrossRefPubMedWeb of Science
  35. ↵
    1. Lai CK,
    2. Beasley R,
    3. Crane J, et al.
    Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax 2009; 64: 476–483.
    OpenUrlAbstract/FREE Full Text
  36. ↵
    1. Stewart AW,
    2. Mitchell EA,
    3. Pearce N, et al.
    The relationship of per capita gross national product to the prevalence of symptoms of asthma and other atopic diseases in children (ISAAC). Int J Epidemiol 2001; 30: 173–179.
    OpenUrlAbstract/FREE Full Text
  37. ↵
    1. Mullins RJ,
    2. Clark S,
    3. Camargo CA Jr.
    . Socio-economic status, geographic remoteness and childhood food allergy and anaphylaxis in Australia. Clin Exp Allergy 2010; 40: 1523–1532.
    OpenUrlCrossRefPubMed
    1. Sembajwe G,
    2. Cifuentes M,
    3. Tak SW, et al.
    National income, self-reported wheezing and asthma diagnosis from the World Health Survey. Eur Respir J 2010; 35: 279–286.
    OpenUrlAbstract/FREE Full Text
  38. ↵
    1. Yura A,
    2. Shimizu T
    . Trends in the prevalence of atopic dermatitis in school children: longitudinal study in Osaka Prefecture, Japan, from 1985 to 1997. Br J Dermatol 2001; 145: 966–973.
    OpenUrlCrossRefPubMed
  39. ↵
    1. Aligne CA,
    2. Auinger P,
    3. Byrd RS, et al.
    Risk factors for pediatric asthma. Contributions of poverty, race, and urban residence. Am J Respir Crit Care Med 2000; 162: 873–877.
    OpenUrlCrossRefPubMedWeb of Science
  40. ↵
    1. Thakur N,
    2. Oh SS,
    3. Nguyen EA, et al.
    Socioeconomic status and childhood asthma in urban minority youths. The GALA II and SAGE II studies. Am J Respir Crit Care Med 2013; 188: 1202–1209.
    OpenUrlCrossRefPubMedWeb of Science
  41. ↵
    1. Ben-Shoshan M,
    2. Harrington DW,
    3. Soller L, et al.
    Demographic predictors of peanut, tree nut, fish, shellfish, and sesame allergy in Canada. J Allergy 2012; 2012: 858306.
    OpenUrl
    1. du Prel X,
    2. Kramer U,
    3. Behrendt H, et al.
    Preschool children's health and its association with parental education and individual living conditions in East and West Germany. BMC Public Health 2006; 6: 312.
    OpenUrlCrossRefPubMed
    1. Patel S,
    2. Henderson J,
    3. Jeffreys M, et al.
    Associations between socioeconomic position and asthma: findings from a historical cohort. Eur J Epidemiol 2012; 27: 623–631.
    OpenUrlCrossRefPubMed
    1. Victorino CC,
    2. Gauthier AH
    . The social determinants of child health: variations across health outcomes – a population-based cross-sectional analysis. BMC Pediatr 2009; 9: 53.
    OpenUrlCrossRefPubMed
    1. Lee YL,
    2. Li CW,
    3. Sung FC, et al.
    Increasing prevalence of atopic eczema in Taiwanese adolescents from 1995 to 2001. Clin Exp Allergy 2007; 37: 543–551.
    OpenUrlCrossRefPubMed
    1. Hammer-Helmich L,
    2. Linneberg A,
    3. Thomsen SF, et al.
    Association between parental socioeconomic position and prevalence of asthma, atopic eczema and hay fever in children. Scand J Public Health 2013; 42: 120–127.
    OpenUrlPubMedWeb of Science
  42. ↵
    1. Metsala J,
    2. Lundqvist A,
    3. Kaila M, et al.
    Maternal and perinatal characteristics and the risk of cow's milk allergy in infants up to 2 years of age: a case-control study nested in the Finnish population. Am J Epidemiol 2010; 171: 1310–1316.
    OpenUrlAbstract/FREE Full Text
  43. ↵
    1. Miyake Y,
    2. Tanaka K,
    3. Sasaki S, et al.
    Parental employment, income, education and allergic disorders in children: a prebirth cohort study in Japan. Int J Tuberc Lung Dis 2012; 16: 756–761.
    OpenUrlPubMed
  44. ↵
    1. Higgins J,
    2. Thompson SG,
    3. Deeks JJ, et al.
    Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–560.
    OpenUrlFREE Full Text
  45. ↵
    1. Beuther DA,
    2. Sutherland ER
    . Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med 2007; 175: 661.
    OpenUrlCrossRefPubMedWeb of Science
  46. ↵
    1. von Mutius E
    . The environmental predictors of allergic disease. J Allergy Clin Immunol 2000; 105: 9–19.
    OpenUrlCrossRefPubMedWeb of Science
  47. ↵
    1. Cabieses B,
    2. Uphoff E,
    3. Pinart M, et al.
    A systematic review on the development of asthma and allergic diseases in relation to international immigration: the leading role of the environment confirmed. PLoS One 2014; 9: e105347.
    OpenUrlCrossRefPubMed
  48. ↵
    1. Connolly V,
    2. Unwin N,
    3. Sherriff P, et al.
    Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health 2000; 54: 173–177.
    OpenUrlAbstract/FREE Full Text
  49. ↵
    1. Liese AD,
    2. Puett RC,
    3. Lamichhane AP, et al.
    Neighborhood level risk factors for type 1 diabetes in youth: the SEARCH case-control study. Int J Health Geogr 2012; 11: 1.
    OpenUrlCrossRefPubMed
  50. ↵
    1. Kim J,
    2. Hahm MI,
    3. Lee SY, et al.
    Sensitization to aeroallergens in Korean children: a population-based study in 2010. J Korean Med Sci 2011; 26: 1165–1172.
    OpenUrlCrossRefPubMed
  51. ↵
    1. Salo PM,
    2. Arbes SJ Jr.,
    3. Jaramillo R, et al.
    Prevalence of allergic sensitization in the United States: Results from the National Health and Nutrition Examination Survey (NHANES) 2005–2006. J Allergy Clin Immunol 2014; 132: 350–359.
    OpenUrl
  52. ↵
    1. Sarpong SB,
    2. Hamilton RG,
    3. Eggleston PA, et al.
    Socioeconomic status and race as risk factors for cockroach allergen exposure and sensitization in children with asthma. J Allergy Clin Immunol 1996; 97: 1393–1401.
    OpenUrlCrossRefPubMedWeb of Science
  53. ↵
    1. Harris JM,
    2. Cullinan P,
    3. Williams HC, et al.
    Environmental associations with eczema in early life. Br J Dermatol 2001; 144: 795–802.
    OpenUrlCrossRefPubMedWeb of Science
  54. ↵
    1. Williams HC,
    2. Strachan DP,
    3. Hay RJ
    . Childhood eczema: disease of the advantaged? BMJ 1994; 308: 1132–1135.
    OpenUrlAbstract/FREE Full Text
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A systematic review of socioeconomic position in relation to asthma and allergic diseases
Eleonora Uphoff, Báltica Cabieses, Mariona Pinart, Macarena Valdés, Josep Maria Antó, John Wright
European Respiratory Journal Aug 2015, 46 (2) 364-374; DOI: 10.1183/09031936.00114514

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A systematic review of socioeconomic position in relation to asthma and allergic diseases
Eleonora Uphoff, Báltica Cabieses, Mariona Pinart, Macarena Valdés, Josep Maria Antó, John Wright
European Respiratory Journal Aug 2015, 46 (2) 364-374; DOI: 10.1183/09031936.00114514
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