Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Abstract

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Keywords: chronic kidney disease; health inequalities; health inequities; kidney replacement therapy; social determinants of health; socioeconomic status.

Figure 1

Conceptual illustration of SEP highlighting multiple hierarchical levels (individual, family/household, area/neighborhood) and domains (including income, education, occupation/employment, and others) that make up the construct of SEP. SEP, socioeconomic position.

Figure 2

Illustration of potential bidirectional relationships between health and SEP across life-course development and disease stages in pediatric CKD, highlighting the potential for accumulating disadvantage over time. Adapted from Adler and Stewart. The figure illustrates the way that health and socioeconomic disadvantage may accumulate across life stages for children with CKD, because low SEP in one stage may compromise health in the next, and poor health in one life stage may compromise SEP in the next. This is a simplified conceptual model, so does not include all possible associations between SEP and health over time (e.g., SEP at each stage is likely to impact SEP at later stages, and health at each stage is likely to impact health at later stages). The age of onset of CKD may vary across individuals; illustrative trajectories are included to highlight how impacts on health and SEP may vary according to whether CKD develops in the prenatal period, childhood, or adolescence, with compounding disadvantage potentially being greater for children presenting at earlier life stages. Accumulating disadvantage may also be impacted by interactions with other social, genetic, and environmental factors. CKD, chronic kidney disease; SEP, socioeconomic position.

Figure 3

Mechanisms for the generation and perpetuation of health inequities across the life-course among children with CKD, each of which represents a potential policy entry point for interventions, based on the Diderichsen model of health inequities. These include the following: (i) social stratification, (ii) differential exposure to harmful and protective factors, (iii) differential vulnerability to exposures, (iv) differential social consequences of illness, (v) further social stratification. Adapted from the Diderichsen model in Diderichsen et al. and its adaptations in Pearce et al. These mechanisms start at the upstream level with the broad social, economic, and political factors that drive social stratification into different levels of family SEP (mechanism i), moving through to differential exposure (mechanism ii) and vulnerability (mechanism iii) to risk and protective factors (across material, psychosocial, behavioral, healthcare, and biological domains) for children of lower SEP, and on to greater social consequences of CKD (e.g., adverse effects on caregiver employment or income, and child education) for children in lower SEP families. This in turn leads to further social stratification, moderated by broader structural factors. CKD, chronic kidney disease; SEP, socioeconomic position.

Figure 4

Potential mechanisms and pathways from SEP to health among children and adolescents with CKD, showing structural determinants and intermediary determinants, with intermediary factors ordered from more upstream to more downstream. Adapted from the Commission on Social Determinants of Health conceptual framework in Solar and Irwin and its adaptations in Bell. This figure “zooms in” on the intermediary factors between family SEP and child health across material, psychosocial, behavioral, healthcare, and biological domains, with examples relevant to childhood CKD. Children in more disadvantaged families may have greater exposure and vulnerability to harmful factors (and lower exposure to protective factors) across these domains. Although these intermediary determinants are all considered more downstream than the broader structural determinants on the left of the figure (social, economic and political factors, social stratification, and SEP itself), they can still be ordered from more upstream (material) to more downstream (biological) factors. This figure has been simplified to illustrate the most dominant direction of influence of these factors on each other and does not include all potential arrows between factors; in reality, there may be some influence of more downstream factors on more upstream factors. CKD, chronic kidney disease; SEP, socioeconomic position.