Impact of socioeconomic factors on allergic diseases

Abstract

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly impacted by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including healthcare access and quality, diagnosis, management, education, and disease prevalence and outcomes. On-going research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on healthcare disparities and outcomes among patients with allergic and immunologic diseases.

INTRODUCTION

The World Health Organization (WHO) defines social determinants of health (SDoH) as the “non-medical factors that influence health outcomes.”(1,2) SDoH include the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”(1) Studies have estimated SDoH may account for between 30–55% of all health outcomes.(1) Persons living in poverty and persons identified as racial and ethnic underrepresented minorities (URM) are more likely to experience the adverse health effects associated with negative SDoH. In Allergy and Immunology, SDoH have been shown to influence asthma, eczema, allergic rhinitis, food allergy, and immunodeficiency outcomes. Here we discuss the SDoH, specifically socioeconomic factors, which influence allergic and immunologic diseases, including healthcare access and quality, environmental injustices, and health education and literacy, and propose solutions to address and overcome these health inequities.

Multi-level Socioeconomic Determinants of Health

Socioeconomic factors influencing allergic and immunologic diseases are multifactorial. These factors ultimately impact healthcare access and quality and should be considered at many levels—patient, provider, community, and policy(3) (Figure 1). To gain better understanding of and propose solutions to address these multi-level determinants, this review will explore the contextual relationship between socioeconomic status (SES) and allergic and immunologic diseases. These contextual considerations include the individual- and community-level factors such as the social and environmental setting in which patients and families reside,(4,5) provider/research-level factors including availability of specialists, geographic accessibility and research inclusivity, and policy-level factors including laws and regulations.(6,7)

Figure 1.

The interplay between patient-, provider-, community- and policy-level determinants and the 5 dimensions of healthcare access and quality(7) (availability, affordability, accessibility, acceptability and accommodation).

Underdiagnosis and delayed diagnosis

Underdiagnosis of allergic and immunologic diseases is a significant barrier to both access and quality of care. Socioeconomic factors related to limited access to specialists, lack of primary care physician expertise, and limited allergy testing availability have been described, particularly among underrepresented minorities (URM).(8–10) In one study of Puerto Rican children, underdiagnosis of allergic rhinitis by primary care physicians was high.(8) Physician diagnosed allergic rhinitis was missed in >75% of children with asthma and >85% of children without asthma. Additionally, in studies of URM with allergic rhinitis and asthma, allergic sensitization appears to be more prevalent among patients from lower socioeconomic neighborhoods, including in one study that revealed Black and Hispanic women being more than twice as likely to be sensitized to three or more aeroallergens, and to have higher rates of asthma, but not allergic rhinitis.(9,10)

Differences in food allergy diagnosis and management have also been demonstrated between groups of school children.(11) In a study of New York city private and public-school students, higher rates of food allergy diagnosis among private school students was found, but among public school students, underdiagnosis by a physician was high (nearly half) despite symptoms related to severe reactions.(12) This was likely due to differences in access to care, differing awareness of food allergy (e.g. high rates of parental report of food allergies in private school children), and perhaps differences in feeding practices related to underlying social disparities. McGowan et. al. also found underdiagnosis of eosinophilic esophagitis among Black patients given differences in symptoms and endoscopic findings.(13)

In atopic dermatitis (AD) underdiagnosis is often related to lack of ability and training of providers to recognize these skin conditions in skin of color.(14–16) In URM patients, the pattern of skin eruptions (e.g. more difficult to discern erythema) in AD often differ from other populations, further leading to diagnostic challenges for patients and providers.(17,18) Consideration of contextual factors, including socioeconomic factors and physical environment, in addition to health care access and quality, are important in understanding disparities in AD diagnosis and management.(19)

Lastly, underdiagnosis and delays in diagnosis of inborn errors of immunity is widespread but higher rates are seen among Black and Hispanic populations.(20) This is likely due to limited access and barriers to health care or diagnostic bias (e.g. belief that immunodeficiency does not impact URM communities). Though many studies of inborn errors of immunity have found lower rates among URM, a scoring algorithm to identify potential patients with complications related to immunodeficiency, 86% of these patients were Black or Hispanic, highlighting a severely underdiagnosed patient population.(20,21)

Access to Specialty Care

A known barrier among patients with allergic and immunologic conditions experience is the lack of access to specialty care and the resulting decreased quality of care management. In asthma, subspecialty care is associated with knowledge of and improvements in adherence to evidence-based care plans, compared to care from a generalist.(22,23) This is most apparent in the disparity in asthma controller medication prescribing for patients with persistent asthma when cared for by specialists versus non-specialists.(24) Among patients with asthma, studies have shown that inhaled corticosteroid and biologic therapy is under-prescribed in URM patients, despite higher rates of asthma prevalence and disease severity.(25–27) This may reflect the differences in subspeciality referrals which has been shown to be lower for URM patients.(28)

Similarly, in allergic rhinitis, access to specialty care, and specifically to allergy testing, leads to diagnostic and management challenges for patients. Among primary care providers, limited skin testing availability in some under-resourced areas can lead to delays in diagnosis and limit management options (i.e. allergen immunotherapy). Additionally, the association between asthma and allergic rhinitis is often underappreciated as a part of evidence-based care by non-specialists, leading to poor management of these diseases.(29–31)

In food allergy, access to specialty care also impacts disparate groups and is a part of several other factors that impact diagnosis and management in these groups (e.g. - lack of awareness of food allergy, differences in feeding practice, and access to safe foods also relate to disparities).(32–35) Evidence-based recommendations to implement early food introduction as a food allergy prevention strategy may be impacted by disparities in food access and variations in care among low income and URM groups.(36)

Additional Access Issues.

Comorbid depression and anxiety have been linked to increased risk of allergic diseases such as asthma and allergic rhinitis.(37–41) Similarly, maternal depression and prenatal stress have been linked to increased risk of the development of asthma and atopic dermatitis in children, and atopic dermatitis has been associated with increased risk of depression and internalizing behaviors even among children with mild disease.(42–44) Control of comorbid mental health conditions is integral to improving atopic disease outcomes, yet access to mental health services is frequently inadequate in high risk populations such as those living in high poverty and URM communities.(45–48) Other access issues include the lack of reliable transportation and long-distance travel as barriers to care for many patients. In rural settings, limited public transportation options and longer distances to travel to care impact receipt of adequate care.(49,50) For low-income patients in urban settings, lack of reliable transportation and reliance on public transportation are also significant barriers.(50,51)

Underrepresentation in Research

Underpinning disparities in care is the issue of underrepresentation of URM in clinical trials for allergic and immunologic diseases. In general, White participants make up the majority of participants in clinical trials for all diseases, while Black and Hispanic participants make up 5% and <1% of participants, respectively.(52) In one study of pediatric asthma trials conducted over a decade, a review of the demographic information revealed that 69% of clinical trials participants were White and 13% were Black.(53) Another example includes the PALISADE phase III trial of Palforzia(54) in which the reported demographics showed that 9 of the 551 participants identified as Black, and Hispanic participants were not reported on. In a recent study, Black children had the highest rates of peanut allergy (3.0% [95% CI, 2.4–3.8%]) compared to all other race and ethnicity categories.(32) Previous investigations focusing on recruitment of URM and impoverished atopic populations have primarily been conducted among urban children with asthma such as the Inner-City Asthma Consortium and Breathmobile Program.(55,56) These investigations have led to important discoveries in urban minority populations and emphasize the importance of adequate representation in clinical trials. Inclusivity in research is important in increasing scientific validity, inclusion of the most affected populations, generalizability, equity, and trust.(32,53,57–60)

Environmental Injustice

Associations between socioeconomic status (SES) and housing policies, environmental exposures and asthma/allergy outcomes

Low-income children and URM children are at increased risk for exposure to multiple environmental factors which have been associated with an increased risk of allergen sensitization, asthma prevalence, and asthma morbidity.(61,62) In the United States, Black families are more likely to live in housing that is considered substandard or in poor repair compared with White families, with a 2011 study reporting 2.6 million (7.5%) non-Hispanic Blacks versus 5.9 million Whites (2.8%) living in housing considered substandard.(62) This racial housing inequity has been sustained by systemically racist policies and historical lending practices.(63)

Living in substandard housing directly affects risk of allergic sensitization, risk of asthma and asthma morbidity as housing that is in poor repair is a risk factor for exposure to pests and mold.(64–67) Additionally, URM residents living in low-income housing and urban centers are also more likely to be exposed to pests.(68–70) In turn, mouse, cockroach, and mold exposure in Black, urban, and low-income children has been extensively associated with asthma outcomes, including risk of asthma and asthma prevalence, poor asthma control, increased healthcare utilization for asthma, increased asthma severity, abnormal lung function, reduced lung function growth, and air trapping.(70–77)

Given the known adverse asthma risks of poor housing quality and its associated exposures, there has been great interest in reduction of allergen exposure in urban children with asthma to improve asthma morbidity. Disappointingly, allergen exposure reduction trials have yielded mixed results, with recent trials unable to demonstrate a reduction in allergen exposure by group and/or an improvement in asthma outcomes.(78–81) One possible explanation for the lack of consistent clinical results is the difficulty in sustaining allergen reduction in urban centers due to neighborhood-level disrepair and disinvestment. It is possible that community-level rather than individual-level improvements in housing are needed.

Newer interest has turned to following participants who move from low-opportunity/high-poverty to high-opportunity/low-poverty neighborhoods. A 2023 secondary analysis of the “Moving To Opportunity” study found a reduction in pediatric hospitalizations for asthma (36% lower admission rates for asthma) for children whose families had received a housing voucher.(82) Another 2023 study, the “Mobility Asthma Project” (MAP), followed families of children with asthma who moved to low-poverty neighborhoods through receipt of a housing voucher found children with asthma had an improvement in asthma symptom days (2.4 fewer symptom days in the previous 2 weeks) and fewer asthma exacerbations (70% decrease in the rate of exacerbations) post move.(83) Approximately one third of the reduction in exacerbations was estimated to be mediated by improvements in measures of stress.(83) These critical studies provide evidence that housing policies aimed at reducing neighborhood-level poverty could improve asthma outcomes at the individual level and possibly community level.

Impact of historical and systemic racism with present-day reduction in air quality and worse asthma

Outdoor air pollution has been extensively linked to impaired lung development, lower lung function, risk of asthma, and increased asthma morbidity.(84–88) Specifically, traffic-related air pollution (TRAP) has been repeatedly associated with the risk of development of childhood asthma through meta-analysis.(89) Due to persistent racial, ethnic and socioeconomic inequities, Black persons, persons living in poverty, and persons with lower education are more likely to live in areas with higher exposure to outdoor air pollution.(90–92) One of the principal causes of these modern-day racial inequities is historically racist housing lending policy that existed throughout the early-to-mid 1900s known as redlining. Redlining systematically discriminated against non-White residents by placing Black home loan borrowers in the highest risk lending category.(63,93) As a result, Black residents were unable to secure mortgages and build wealth, and were forced to live in segregated neighborhoods with lower property values, older homes, and closer proximity to industrial areas and roadways. Subsequently, historically redlined neighborhoods experience higher exposure to present-day air pollution,(94) specifically with higher concentrations of nitrogen dioxide (NO₂) and fine particulate matter (PM_2.5) compared with non-redlined communities.

There is increasing awareness of the association between redlining and numerous adverse health outcomes, including preterm birth, mental illness, maternal depression, heat-related outcomes, gunshot-related injuries, cancer, and increased asthma morbidity.(63,93,95) Two recent studies have demonstrated the longstanding effects of the racist practice of redlining on asthma morbidity. First, a 2020 ecologic study of eight cities in California found higher diesel particle emissions in historically redlined communities.(96) Residents living in these historically relined communities were found to have a 2.4-fold increase in age-adjusted emergency room visits for asthma compared with communities previously designated as the lowest lending risk.(96) Second, a 2022 registry study out of Pittsburgh/Allegheny County, Pennsylvania also found that the highest levels of carbon monoxide, PM_2.5, sulfur dioxide, and volatile organic compounds were measured in historically redlined communities.(97) Residents living in these Pennsylvanian, historically relined communities reported a higher prevalence of uncontrolled and/or severe asthma,(97) the primary outcome of the study. Widening the gap in care along racial lines, asthma-related health outcomes varied by race with Black adults living in the historically redlined communities reporting more exacerbation-prone asthma, rescue inhaler use, current eczema, and having lower lung function.(97) Despite the higher disease burden and morbidity, these Black adults were less likely to be prescribed allergen immunotherapy and/or anti-IgE therapy compared with White adults living in historically relined communities.(97) These studies highlight the enduring adverse health effects of 20^th century, systematically racist lending practices on lung health of Black Americans today.

Neighborhood walkability and green space

The interaction between the physical environment (i.e. - walkability and green space) and health outcomes is complex and likely influenced by multiple factors, including neighborhood socioeconomic disadvantage, the social environment, and the built environment.(98,99) Studies have shown conflicting results when examining the relationship between sociodemographic factors (such as race and poverty) and neighborhood walkability, and there is significant variability among US cities.(100,101)

There is limited information and mixed results about the relationship of walkability and green space and atopic conditions,(102–105) with the most information being related to asthma. A cohort study of Toronto children found low walkability to be associated with increased incidence of asthma (hazard ratio: 1.11, 95% confidence interval: 1.08–1.14).(102) A review by Rigolon et al found that green space exposure, particularly public green space/parks, had more beneficial health effects in people with lower SES compared to the high SES group.(103) Studies in Europe showed a stronger difference in protective effect between SES groups than did studies in North America. Further studies are needed to better understand the relationship between green space, walkability, air pollution, and asthma or wheezing. There are few studies examining the relationship between greenspace and allergic rhinitis, AD, and food allergy. Proximity to greenness may be inversely associated with allergic rhinitis (106,107) and risk of sensitization to inhalant allergens in children. (108,109) The limited studies on AD and food allergy have shown inconsistent results.(106)

Access to safe and healthy food.

Access to food is an important issue for the health and happiness all families, but the interplay between food insecurity, access to safe food, access to non-allergenic foods, and atopic diseases is an understudied area. Food insecurity (a “household-level economic and social condition of limited or uncertain access to food”(110)) can have a wide impact on families and can pose unique challenges for minority and lower income communities. In the United States, approximately 11% of households were food insecure prior to the COVID-19 pandemic and data indicates that this increased during the pandemic. (111)

Food insecurity and access to safe foods can have particular challenges in those with food allergies. There is a growing body of evidence that households with food allergy are at higher risk for food insecurity,(112–114) particularly those with an allergy to milk and egg.(115) Allergen-free products have been found to cost two to four times more than foods containing the common allergens and gluten.(116) Access to safe, allergen-free food is a key component of food allergy management. However, studies have shown disparities in safe-food access based on race and SES.(117) One study showed that children with food allergy and food insecurity who rely on nutrition assistance programs are at increased risk of exposure to allergens and have more frequent reactions.(118) Furthermore, among patients with food allergy, food insecurity is associated with higher caregiver stress, higher perceived risk of accidental exposure, and worse overall quality of life compared to food-secure households.(115,117,119)

Additionally, studies have also found a relationship between food insecurity and asthma prevalence and poorer asthma control in children and adults.(120–124). Using a cross-sectional survey of US adults with asthma, Grande et al found that participants with high food insecurity were more likely to have uncontrolled asthma (74.38%) compared with those with lower food insecurity (34.99%; P < .01). (124) The relationship remained significant after adjusting for age, education, sex, race, anxiety, and living stability concerns due to the pandemic (survey launched in May 2020). A thorough review by Jones et. al. is published in this journal issue highlighting the impact of food insecurity on allergic diseases. [Jones et al]

Exposure to violence and stress.

Adverse childhood experiences (ACEs), including exposure to violence and mental illness, are prevalent, but unequally distributed in the United States, with those with low SES and URM being more likely to experience them.(125,126) ACEs have been associated with adverse health outcomes(126), including asthma and immune dysregulation.(127,128) ACEs may impact the prevalence and onset of child and adult asthma.(127) Some studies have found that ACES may have an independent effect and also increase the impact of other factors, such as TRAP and housing disarray, suggesting that exposure to multiple stressors may increase the risk of asthma more than exposure to a single stressor.(128–130)

Maternal stress and anxiety may increase the risk of asthma in the child.(131,132) Guxens et al looked at maternal psychological distress during pregnancy and wheezing in preschool children (n=4848). Maternal psychological distress during pregnancy was associated with increased odds of wheezing in their children during the first 6 years of life independent of paternal psychological distress during pregnancy and maternal and paternal psychological distress after delivery.(131) Similarly, Cookson et al found an increased risk of physician-diagnosed asthma at 7.5 years follow-up in children with mothers in the highest compared with lowest quartile of anxiety scores at 32 weeks of gestation with evidence of a dose-response(132). Nash et al examined the association between domestic violence and abuse and subsequent development of atopy.(133) The results to this population-based, retrospective study found that domestic violence was associated with increased risk of developing asthma (adjusted HR 1.69, 95% CI 1.44–1.99), AD (aHR 1.40, 95% CI 1.26–1.56), and allergic rhinoconjunctivitis (aHR 1.63, 95% CI 1.45–1.84).

Education and Health Literacy

Health literacy is the ability to find, understand, evaluate, and apply relevant health information in order to help patients make health-related judgments and decisions in their everyday lives.(134) Low health literacy is experienced at higher rates in those with other social disparities (i.e. low English proficiency, refugee status, low income earners, undocumented immigrants, and URM communities).(134–138) In the field of allergy and immunology, few studies have been published to highlight the impact of health literacy on outcomes. A Dutch study identified that approximately 25% of patients with atopic diseases have functional health literacy;(139) and, importantly, they observed that a large portion of patients with communicative and critical health literacy never or occasionally talked about their medical complaints and rarely collected information to help make health-related decisions. The study also correlates the lack of health literacy with low socioeconomic status, specifically related to low income and educational attainment. Another study evaluating the efficacy of inhaler technique education revealed that despite no baseline differences in inhaler technique, patients with asthma and COPD with low health literacy experienced 2.5–3 times the rate of MDI misuse as those with adequate health literacy after inhaler education using assessment and demonstration repetition (teach-to-goal).(140) This correlates with findings from a Turkish study in adolescents with asthma that found that poor asthma control was associated with low health literacy.(141)

Educational attainment also impacts outcomes differentially based on socioeconomic status and access to resources. Higher educational levels in patients and their caregivers correlates with higher rates of health literacy, lower rates of health disparities, and increased health outcomes which is not equally beneficial to Black patients.(142) This disparity is the result of biased systems, systemic disinvestments, and residential segregation and has led to a cycle of stagnant socioeconomic advancement in various Black, Hispanic, and Indigenous communities.(137) As true in other disease, patients and caregivers with atopic and immunologic conditions experience lower health literacy and educational attainment have worse health outcomes, increased health utilization, and reduced health-related quality of life. (143–149) This is due to their impaired ability to interpret health problems, decipher medical results, follow care recommendations, adhere to healthy lifestyles, and engage with the healthcare system.

Overcoming Barriers to Health Disparities

In recent years, several published works have highlighted the disparities within the field of Allergy and Immunology and the specific barriers to achieving health equity. Key amongst these being the Work Group Report of the AAAAI Committee on the Underserved (now renamed the Diversity, Equity, and Inclusion Committee).(11) Beyond describing the current extent of health disparities in the field and their impact on those who are socially disadvantaged, it is also important to detail solutions to address those disparities. Multiple examples and guidance have been published in recent years that focus on ways to mitigate, educate, and advocate for health equity in Allergy and Immunology. These evidence-based examples for interventions can be taken by providers and individuals regardless of specialty and experience, but they should be tailored and adjusted to suit the specific community of interest to improve atopic and immunologic disparities. A short list of specific examples of interventions are detailed in Figure 2.

Figure 2.

Multi-level interventions for addressing health disparities.

At the provider level, efforts at varying levels of engagement can be adopted or employed to prepare both trainees and providers to recognize and address health disparities. A toolkit including resources to enhance educational efforts to raise awareness of disparities and biases with disease-specific interventions for mitigating HD has been developed.(150) Structural competencies and key topics that should be addressed when educating allergy/immunology clinicians and trainees about HD have been outlined.(150,151) Evidence-based approaches and interventions to improve gaps in care within Allergy and Immunology have been thoughtfully categorized and detailed including recommendations to enhance DEI in research participation, employ treatment and evaluation strategies that reduce bias, and engage with other disadvantaged groups (i.e. - LGBTQI+ and persons with disabilities).(152) Additional work focusing on antiracist frameworks for research and care, as well as methods for enhancing provider-patient communication have also been published.(138,153,154) And an imperative to improve diversity efforts for research participants, providers, and trainees has been detailed as an important step in addressing inequities.(151,155,156)

Beyond educational tools, Ogbugu et al describe ways in which a provider can address cultural beliefs, societal attitudes, and the larger systems at play. A tool to assess HL in patients with asthma was developed during the COVID pandemic,(157) and a pilot program that used mobile health and web applications, wearables, and other personal monitoring devices showed promise as an intervention to increase HL and enhance asthma management.(158) Additionally, several structured programs have been developed to address HL as it relates to food allergies, which focus on educational interventions for parents, caregivers, and school personnel. These programs not only enhance health knowledge, but address awareness, confidence in self-management, and the promotion of coping skills for disease-related stress.(159) To better address disparities in Allergy and Immunology, the entire care team, as well as healthcare leadership, should work to increase the readability, quality, accuracy, clarity, and actionability of educational tools being used, as well as individualize them to the needs of the communities they serve. Doing so could play an important role in addressing an under-emphasized contributor to health disparities in the field.

At the patient and community level, several key elements have been identified as targets for health equity interventions. Improving access to care can be done through school-based clinics and programs, as well as telehealth. School or community-based and telehealth programs are also important ways to improve care coordination between Allergy and Immunology specialists and primary care colleagues, particularly in areas where specialists are unavailable. These efforts should be scaled up to address a broader group of patients in need of more evidence-based and equitable care.(11,160–162) Using community health workers, patient educators, and multidisciplinary clinics can help reduce the burden of repeat clinic visits and associated copays, while enhancing community-focused messaging and improving patient-centered care aid.(11,163,164) Educational programs and adaptive tools to enhance caregiver and patient health literacy serve as key elements for advancing health equity. It is important to note, though, that there are additional factors that exist outside of the control of the marginalized communities that are differentially impacted by health disparities. These factors (housing quality, air pollution, racist/biased care, insurance coverage, income, food security, etc.) are best mitigated by legislative action and institutional policies.

Legislative efforts to address systemic policies or practices that perpetuate social inequities is another important step in addressing health disparities in allergy/immunology. Programs and policies at the federal, regional, and local levels are needed to reverse the detrimental effects of decades of housing discrimination and impoverished living environments among patients with allergic diseases living in high-poverty neighborhoods. Similar efforts are needed to address food insecurity and education disparities in low-income and URM populations. Although health professionals have more direct and regular contact with SDoH and their impact on allergic and immunologic disease outcomes, researchers and funding agencies can also play an important role in legislative efforts. Like clinicians, researchers can leverage their expertise and credibility to engage with policymakers. They can help translate the barriers patients face and identify interventions through scholarly work so that policies can be developed to address those barriers. Efforts to support training in how to successfully engage in health advocacy have been described.(165)

Allergy/Immunology physicians and other healthcare professionals can also partner with nonprofit and professional organizations that have more seasoned experiences with engaging in policy work, in order to gain advocacy skills and amplify their voices. To impact change for allergy/immunology patients, health advocacy for the advancement of health equity should focus on key areas, such as: revised housing regulations and policies regarding allergen and pest remediation for under-resourced communities, improved standards for reducing air pollution and enhancing air quality, revisiting allocation of safe food, financial support, insurance coverage, educational support, and provider placement in under resourced and underserved communities.

Conclusion

Herein, we have described the profound impact of socioeconomic factors on allergic and immunologic diseases. Socioeconomic factors impact every aspect of patients’ lives from the opportunity to obtain high-quality specialty healthcare to the potential for acquiring nutritious food or safe and affordable housing free from exacerbating triggers. There is irrefutable scientific evidence that socioeconomically disadvantaged patients, primarily those living in poverty and/or those with identified URM status, have significantly poorer allergic and immunologic disease health outcomes. It is past time for action to mitigate the underlying and disparate social conditions in which many of our patients live, work, learn and play. Addressing these gaps will require intentional and collective commitment from stakeholders at the local, state, and federal level. Moreover, deliberate investments in socioeconomically disadvantaged populations and collaborations between advocacy groups, healthcare providers, healthcare systems, public health entities, educators, policy makers, and funding agencies is imperative to impact change.

Abbreviations

AD

atopic Dermatitis

SES

socioeconomic status

SDoH

social determinants of health

TRAP

traffic-related air pollution

URM

underrepresented minorities

NO2

nitrogen dioxide

PM_2.5

fine particulate matter 2.5 microns or less in diameter