O1017: Community-Level Stressors of Structural Racism, Food and Housing Insecurity, and Emergency Healthcare Utilization among Pediatric Patients and Caregivers

Background: Social determinants of health (SDOH) such as food and housing insecurity as well as adverse childhood experiences (ACEs) have been associated with increased non-preventive (emergency) healthcare resource utilization. Racial disparities in economic, neighborhood, and educational opportunity are downstream to structural racism, as described in the Racism + Resilience + Resistance Integrative Study of Childhood Ecosystem framework. A recently established ACE subset at the community-level – neighborhood violence, family member incarceration, and interpersonal racism – likely stem from these racial disparities. We hypothesize that community-level ACEs moderate the relationship between food/housing insecurity and emergency healthcare resource utilization.

Methods: We collected data via a purposive sampling approach in an urban, high volume pediatric emergency department (ED). Caregivers completed a tablet-based survey on food and housing insecurity, as well as a separate survey on ACEs. ED visits and hospitalizations 12 months prior to and 6 months after the ED index visit (for a total of 18 month follow-up period) were retrospectively collected. Geospatial data were used to derive the childhood opportunity index (COI 3.0) at the census tract level. The COI, with indicators spanning socioeconomic, environmental, and educational domains, was utilized as a proxy of structural racism. Multivariate linear regression models estimated the adjusted associations between food/housing insecurity, ACEs, and healthcare utilization, controlling for the time period of the strict California lock-down during the COVID pandemic (March 13, 2020 to May 08, 2020) and post-lockdown (May 08, 2020 and onwards). ED utilization was defined as low (1 visit), medium (2 visits), or high (≥3 visits) over an 18-month period.

Results: From March 2021 to May 2023, a total of 5,078 caregivers completed both screeners and had 18 months of patient follow-up and were included in the final analysis. The patient sample median age was 5.9 years (mean=7.1, SD=5.4, range=0-23), 51% male, 67% Hispanic, 62% White, 6% Asian, 2% Black, 69% publicly insured, and 50% of households had an annual income below $60,000. Food insecurity (p=0.044), housing insecurity (p < 0.001), one or more items of the ACE subset (p=0.012), and very low COI (p=0.014) were all independently associated with high ED utilization (but not hospitalization) over 18 months. The ACE subset of neighborhood violence, family member incarceration, and interpersonal racism did not demonstrate an interaction term with food/housing security on healthcare utilization. There was a decrease in ED (p=0.005) and inpatient utilization (p=0.035) per day during the COVID pandemic lockdown.

Conclusion: Community-level ACEs of neighborhood violence, family member incarceration, and interpersonal racism are independently associated with ED utilization, but do not appear to moderate the effect of housing and food inequities on utilization. The impact of structural racism and neighborhood conditions and resources on children’s health continue to shape inequities in pediatrics while defining areas for action.