Social and structural barriers to housing among street-involved youth who use illicit drugs

In Canada, approximately 150,000 youth live on the street. Street-involvement and homelessness have been associated with various health risks, including increased substance use, blood-borne infections and sexually transmitted diseases. We undertook a qualitative study to better understand the social and structural barriers street-involved youth who use illicit drugs encounter when seeking housing. We conducted 38 semi-structured interviews with street-involved youth in Vancouver, Canada from May to October 2008. Interviewees were recruited from the At-risk Youth Study (ARYS) cohort, which follows youth aged 14 to 26 who have experience with illicit drug use. All interviews were thematically analyzed, with particular emphasis on participants' perspectives regarding their housing situation and their experiences seeking housing. Many street-involved youth reported feeling unsupported in their efforts to find housing. For the majority of youth, existing abstinence-focused shelters did not constitute a viable option and, as a result, many felt excluded from these facilities. Many youth identified inflexible shelter rules and a lack of privacy as outweighing the benefits of sleeping indoors. Single-room occupancy hotels (SROs) were reported to be the only affordable housing options, as many landlords would not rent to youth on welfare. Many youth reported resisting moving to SROs as they viewed them as unsafe and as giving up hope for a return to mainstream society. The findings of the present study shed light on the social and structural barriers street-involved youth face in attaining housing and challenge the popular view of youth homelessness constituting a lifestyle choice. Our findings point to the need for housing strategies that include safe, low threshold, harm reduction focused housing options for youth who engage in illicit substance use.

The role of housing type and housing quality in urban children with asthma

The goal of this study was to assess the relationship between type and quality of housing and childhood asthma in an urban community with a wide gradient of racial/ethnic, socioeconomic, and housing characteristics. A parent-report questionnaire was distributed in 26 randomly selected New York City public elementary schools. Type of housing was categorized using the participants' addresses and the Building Information System, a publicly-accessible database from the New York City Department of Buildings. Type of housing was associated with childhood asthma with the highest prevalence of asthma found in public housing (21.8%). Residents of all types of private housing had lower odds of asthma than children living in public housing. After adjusting for individual- and community-level demographic and economic factors, the relationship between housing type and childhood asthma persisted, with residents of private family homes having the lowest odds of current asthma when compared to residents of public housing (odds ratio: 0.51; 95% confidence interval, 0.22, 1.21). Factors associated with housing quality explain some of the clustering of asthma in public housing. For example, the majority (68.7%) of public housing residents reported the presence of cockroaches, compared to 21% of residents of private houses. Reported cockroaches, rats, and water leaks were also independently associated with current asthma. These findings suggest differential exposure and asthma risk by urban housing type. Interventions aimed at reducing these disparities should consider multiple aspects of the home environment, especially those that are not directly controlled by residents.

Housing and health in Ghana: the psychosocial impacts of renting a home

This paper reports the findings of a qualitative study investigating the impacts of renting a home on the psychosocial health of tenants in the Accra Metropolitan Area (AMA) in Ghana. In-depth interviews (n = 33) were conducted with private renters in Adabraka, Accra. The findings show that private renters in the AMA face serious problems in finding appropriate and affordable rental units, as well as a persistent threat of eviction by homeowners. These challenges tend to predispose renters to psychosocial distress and diminishing ontological security. Findings are relevant to a range of pluralistic policy options that emphasize both formal and informal housing provision, together with the reorganization and decentralization of the Rent Control Board to the district level to facilitate easy access by the citizenry.

PROJECT NEW HOPE: A FAITH-BASED EFFORT TO PROVIDE HOUSING FOR PERSONS WITH HIV/AIDS

Housing has long been the single largest area of unmet need for people living with HIV/AIDS, and there are few published descriptions of programs that address this need. This paper describes Project New Hope in Los Angeles, California, a faith-based program that may be the nation's first housing program exclusively designed for people with HIV/AIDS. We discuss why housing is important for HIV positive people; then we describe the project, including how it got started, how it operates, its linkage with the Episcopal Church, and its principal accomplishments and challenges; finally, we conclude with lessons learned that might be applied elsewhere.

The Columbia-Harlem Homeless Medical Partnership: a new model for learning in the service of those in medical need

Though altruism and patient advocacy are promoted in medical education curricula, students are given few opportunities to develop these skills. Student-run clinics focusing on the health needs of the underserved can provide important health services to needy patients while providing students with career-influencing primary care experiences. The Columbia-Harlem Homeless Medical Partnership (CHHMP)-a project initiated by medical students to provide primary care to Northern Manhattan's homeless population-serves as a new model of service learning in medical education. Unlike many other student-run clinics, CHHMP has developed direct patient outreach, continuous care (stable "student-patient teams" and a weekly commitment for all volunteers), and regular internal data review. Chart review data presented demonstrate the project's success in providing care to the clinic's target population of homeless and unstably housed patients. Targeted outreach efforts among clients have increased rates of patient follow-up at each subsequent review period. Additionally, CHHMP has used review data to develop services concordant with identified patient needs (psychiatric care and social services). CHHMP has recruited a committed group of volunteers and continues to engender an interest in the health needs of the underserved among students. Not only does CHHMP provide a "medical home" for homeless patients, it also provides a space in which students can develop skills unaddressed in large teaching hospitals. This project, a "win-win" for patients and students, serves as a unique model for community health-based service learning in medical education.

Evaluating life in foster homes for persons with serious mental illness: Resident and caregiver perspectives

BACKGROUND

In Montreal Canada, the majority of persons with serious mental illness discharged from psychiatric hospitals were placed into foster homes. Very little updated information exists on life in foster homes, and the level of autonomy allowed in this residential setting.

AIMS

The purpose of the study was to elicit the foster home residents' opinions about their lives in this setting and their caregiver's perception of the level of autonomy allowed.

METHOD

Two questionnaires were administered to 102 foster home residents and their caregivers: (1) Patient Attitude Questionnaire and (2) Hospital and Hostel Practices Profile Survey.

RESULTS

Consumers are satisfied living in this type of milieu and do not desire to change their housing. The foster home provides residents with a sense of security and well being. Foster homes rank second in terms of autonomy when compared to hospitals and hostels. Only supported apartments rank higher.

CONCLUSION

These findings shed a new light on this type of residential milieu. Over time the structure of foster homes has evolved. This study points to the need to value the opinions of consumers and not force people to move onto other types of housing.

Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control

BACKGROUND

This study is a cost-benefit analysis that quantifies the social and economic benefits to household lead paint hazard control compared with the investments needed to minimize exposure to these hazards.

OBJECTIVES

This research updates estimates of elevated blood lead levels among a cohort of children < or = 6 years of age and compiles recent research to determine a range of the costs of lead paint hazard control ($1-$11 billion) and the benefits of reduction attributed to each cohort for health care ($11-$53 billion), lifetime earnings ($165-$233 billion), tax revenue ($25-$35 billion), special education ($30-$146 million), attention deficit-hyperactivity disorder ($267 million), and the direct costs of crime ($1.7 billion).

RESULTS

Each dollar invested in lead paint hazard control results in a return of $17-$221 or a net savings of $181-269 billion.

CONCLUSIONS

There are substantial returns to investing in lead hazard control, particularly targeted at early intervention in communities most likely at risk. Given the high societal costs of inaction, lead hazard control appears to be well worth the price.

Population development and the need for housing for elderly people in Sweden

Introduction

The need for housing adapted to the needs of elderly people will increase during the forthcoming years due to the increase of the proportion of elderly people from 2020 and onwards. This need cannot be resolved by means of a single limited initiative.

Description of situation

Most elderly people live in houses, farms and apartments which have to be adapted to disabilities. There is an increasing interest in senior housing which is intended for people over a certain age. For very old and frail people who feel anxious and insecure in their present accommodation ask for a new type of housing—sheltered housing. Here, the residents should have access to communal premises with the option of meals, staff and activities. There is a lack of residential care homes. This is a form of housing for elderly people who live there permanently and suffer from dementia or multiple illnesses. They are in need of social and health care round the clock.

Conclusion

The interplay between the design of the physical environment and social and medical thinking in health and social care for the elderly needs to be improved and more interdisciplinary research on housing for the elderly has to be initiated.

Housing first for homeless persons with active addiction: are we overreaching?

CONTEXT

More than 350 communities in the United States have committed to ending chronic homelessness. One nationally prominent approach, Housing First, offers early access to permanent housing without requiring completion of treatment or, for clients with addiction, proof of sobriety.

METHODS

This article reviews studies of Housing First and more traditional rehabilitative (e.g., "linear") recovery interventions, focusing on the outcomes obtained by both approaches for homeless individuals with addictive disorders.

FINDINGS

According to reviews of comparative trials and case series reports, Housing First reports document excellent housing retention, despite the limited amount of data pertaining to homeless clients with active and severe addiction. Several linear programs cite reductions in addiction severity but have shortcomings in long-term housing success and retention.

CONCLUSIONS

This article suggests that the current research data are not sufficient to identify an optimal housing and rehabilitation approach for an important homeless subgroup. The research regarding Housing First and linear approaches can be strengthened in several ways, and policymakers should be cautious about generalizing the results of available Housing First studies to persons with active addiction when they enter housing programs.

The relationship of housing and population health: a 30-year retrospective analysis

OBJECTIVE

We analyzed the relationship between health status and housing quality over time.

METHODS

We combined data from two nationally representative longitudinal surveys of the U.S. population and its housing, the National Health and Nutrition Examination Survey and the American Housing Survey, respectively. We identified housing and health trends from approximately 1970 to 2000, after excluding those trends for which data were missing or where we found no plausible association or change in trend.

RESULTS

Changes in housing include construction type, proportion of rental versus home ownership, age, density, size, moisture, pests, broken windows, ventilation and air conditioning, and water leaks. Changes in health measures include asthma, respiratory illness, obesity and diabetes, and lead poisoning, among others. The results suggest ecologic trends in childhood lead poisoning follow housing age, water leaks, and ventilation; asthma follows ventilation, windows, and age; overweight trends follow ventilation; blood pressure trends follow community measures; and health disparities have not changed greatly.

CONCLUSIONS

Housing trends are consistent with certain health trends over time. Future national longitudinal surveys should include health, housing, and community metrics within a single integrated design, instead of separate surveys, in order to develop reliable indicators of how housing changes affect population health and how to best target resources. Little progress has been made in reducing the health and housing disparities of disadvantaged groups, with the notable exception of childhood lead poisoning caused by exposure to lead-based paint hazards. Use of these and other data sets to create reliable integrated indicators of health and housing quality are needed.

Housing and demographic factors

BACKGROUND

Lead-contaminated house dust is a major source of lead exposure for children in the United States. In 1999-2004, the National Health and Nutrition Examination Survey (NHANES) collected dust lead (PbD) loading samples from the homes of children 12-60 months of age.

OBJECTIVES

In this study we aimed to compare national PbD levels with existing health-based standards and to identify housing and demographic factors associated with floor and windowsill PbD.

METHODS

We used NHANES PbD data (n=2,065 from floors and n=1,618 from windowsills) and covariates to construct linear and logistic regression models.

RESULTS

The population-weighted geometric mean floor and windowsill PbD were 0.5 microg/ft2 [geometric standard error (GSE)=1.0] and 7.6 microg/ft2 (GSE=1.0), respectively. Only 0.16% of the floors and 4.0% of the sills had PbD at or above current federal standards of 40 and 250 microg/ft2, respectively. Income, race/ethnicity, floor surface/condition, windowsill PbD, year of construction, recent renovation, smoking, and survey year were significant predictors of floor PbD [the proportion of variability in the dependent variable accounted for by the model (R2)=35%]. A similar set of predictors plus the presence of large areas of exterior deteriorated paint in pre-1950 homes and the presence of interior deteriorated paint explained 20% of the variability in sill PbD. A companion article [Dixon et al. Environ Health Perspect 117:468-474 (2009)] describes the relationship between children's blood lead and PbD.

CONCLUSION

Most houses with children have PbD levels that comply with federal standards but may put children at risk. Factors associated with PbD in our population-based models are primarily the same as factors identified in smaller at-risk cohorts. PbD on floors and windowsills should be kept as low as possible to protect children.

Exposure of U.S. children to residential dust lead, 1999-2004: II. The contribution of lead-contaminated dust to children's blood lead levels

BACKGROUND

The U.S. Centers for Disease Control and Prevention collected health, housing, and environmental data in a single integrated national survey for the first time in the United States in 1999-2004.

OBJECTIVES

We aimed to determine how floor dust lead (PbD) loadings and other housing factors influence childhood blood lead (PbB) levels and lead poisoning.

METHODS

We analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES), including 2,155 children 12-60 months of age with PbB and PbD measurements. We used linear and logistic regression models to predict log-transformed PbB and the odds that PbB was >or=5 and >or=10 microg/dL at a range of floor PbD.

RESULTS

The population-weighted geometric mean (GM) PbB was 2.0 microg/dL (geometric standard error=1.0). Age of child, race/ethnicity, serum cotinine concentration, poverty-to-income ratio, country of birth, year of building construction, floor PbD by floor surface and condition, windowsill PbD, presence of deteriorated paint, home-apartment type, smoking in the home, and recent renovation were significant predictors in either the linear model [the proportion of variability in the dependent variable accounted for by the model (R2)=40%] or logistic model for 10 microg/dL (R2=5%). At floor PbD=12 microg/ft2, the models predict that 4.6% of children living in homes constructed before 1978 have PbB>or=10 microg/dL, 27% have PbB>or=5 microg/dL, and the GM PbB is 3.9 microg/dL.

CONCLUSIONS

Lowering the floor PbD standard below the current standard of 40 microg/ft2 would protect more children from elevated PbB.

The relationship between housing status and HIV risk among active drug users: a qualitative analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004-2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001-2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.

A clean and sober place to live: philosophy, structure, and purported therapeutic factors in sober living houses

The call for evidence-based practices (EBPs) in addiction treatment is nearly universal. It is a noteworthy movement in the field because treatment innovations have not always been implemented in community programs. However, other types of community-based services that may be essential to sustained recovery have received less attention. This article suggests that sober living houses (SLHs) are a good example of services that have been neglected in the addiction literature that might help individuals who need an alcohol- and drug-free living environment to succeed in their recovery. It begins with an overview of the history and philosophy of this modality and then describes our five-year longitudinal study titled, "An Analysis of Sober Living Houses." Particular attention is paid to the structure and philosophy of SLHs and purported therapeutic factors. It ends with the presentation of baseline data describing the residents who enter SLHs and six-month outcomes on 130 residents.

Building life around foster home versus moving on: the competing needs of people living in foster homes

OBJECTIVE

This article reports findings on the competing needs of people living in psychiatric foster homes in Montreal, Canada.

METHODS

Semi-structured interviews were conducted with 33 residents. Consumers describe the tensions associated with foster home life.

RESULTS

Two overall competing needs emerged: the need to build their lives around the foster home and the need to build life beyond the foster home. Residents describe their need for security and support versus their need for greater personal autonomy, the dilemmas associated with communal living, and their struggle to envisage a positive future.

CONCLUSIONS

These findings have important implications for mental health professionals mandated to dismantle foster homes for more autonomous housing.

The role of neurocognition and social context in predicting community functioning among formerly homeless seriously mentally ill persons

OBJECTIVE

To test the influence of neurocognitive functioning on community functioning among formerly homeless persons with serious mental illness and to determine whether that influence varies with social context, independent of individual characteristics.

METHODS

In metropolitan Boston, 112 persons in Department of Mental Health shelters were administered a neuropsychological test battery and other measures and then randomly assigned to empowerment-oriented group homes or independent apartments, as part of a longitudinal study of the effects of housing on multiple outcomes. Subjects' case managers completed Rosen's 5-dimensional Life Skills Inventory at 3, 6, 12, and 18 months and subjects reported on their social contacts at baseline, 6, 12, and 18 months. Subject characteristics are controlled in the analysis.

RESULTS

Three dimensions of neurocognitive functioning--executive function, verbal declarative memory, and vigilance--each predicted community functioning. Better executive function predicted improved self-care and less turbulent behavior among persons living alone, better memory predicted more positive social contacts for those living in a group home, and higher levels of vigilance predicted improved communication in both housing types.

CONCLUSION

Neurocognition predicts community functioning among homeless persons with severe mental illness, but in a way that varies with the social context in which community functioning occurs.

Linking public health, housing, and indoor environmental policy: successes and challenges at local and federal agencies in the United States

We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of "shared commons" and the "polluter pays" is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities.

When home is where the stress is: expanding the dimensions of housing that influence asthma morbidity

The influence of physical housing quality on childhood asthma expression, especially the effect of exposure to moulds, allergens, and pollutants, is well documented. However, attempts to explain increasing rates and severity of childhood asthma solely through physical environmental factors have been unsuccessful, and additional exposures may be involved. Increasing evidence has linked psychological stress and negative affective states to asthma expression. At the same time, recent scholarship in the social sciences has focused on understanding how social environments, such as housing, "get under the skin" to influence health, and suggests that psychological factors play a key role. While there is relevant overlapping research in social science, psychology, economics, and health policy in this area, findings from these disciplines have not yet been conceptually integrated into ongoing asthma research. We propose to expand the dimensions of housing considered in future asthma research to include both physical and psychological aspects which may directly and indirectly influence onset and severity of disease expression. This synthesis of overlapping research from a number of disciplines argues for the systematic measure of psychological dimensions of housing and consideration of the interplay between housing stress and physical housing characteristics in relation to childhood asthma.

Public health care utilization in a cohort of homeless adult applicants to a supportive housing program

Supportive housing is subsidized housing with on-site or closely linked services for chronically homeless persons. Most literature describing the effects of supportive housing on health service utilization does not describe use across multiple domains of services. We conducted a retrospective cohort study of 249 applicants to a supportive housing program; 114 (45.7%) were housed in the program. We describe the pattern of service use across multiple domains (housing, physical health care, mental health care, substance abuse treatment). We examine whether enrollment in supportive housing was associated with decreased use of acute health services (emergency department (ED) and inpatient medical hospitalizations) and increased use of ambulatory services (ambulatory medical and generalist care, mental health, and substance abuse treatment) as compared to those eligible but not enrolled. Participants in both groups exhibited high rates of service utilization. We did not find a difference in change in utilization patterns between the two groups [those that received housing (intervention) and those that applied, were eligible, but did not establish residency (usual care group)] comparing the two years prior to the intervention to the two years after. The finding of high rates of maintenance of housing is, in itself, noteworthy. The consistently high use of services across multiple domains and across multiple years speaks to the level of infirmity of this population and the costs of caring for its members.

Housing and health: beyond disciplinary confinement

There is a need for innovative research on housing and health. In contrast to traditional disciplinary studies, which are sector-based, interdisciplinary and transdisciplinary contributions offer a broader approach. Interdisciplinary approaches highlight the difference between a biomedical model that often adopts a symptom-treatment interpretation of housing and health and a holistic or integrated model that combines biological, cultural, economic, political, psychological and social factors in a new way. This article illustrates the pertinence of interdisciplinary contributions to develop a more holistic understanding of housing density and how it can be interpreted to understand the complex relationship between housing conditions and health status.

Airborne endotoxin is associated with respiratory illness in the first 2 years of life

To determine the influence of endotoxin on the incidence of acute respiratory illness during the first 2 years of life, we carried out a longitudinal follow-up study, beginning at birth, of 332 children born in Prince Edward Island, Canada. We measured 5-day averaged air endotoxin in the homes of children, whose parents provided information by daily symptom diaries and twice-monthly telephone contact for up to 2 years. Endotoxin concentration was 0.49 +/- 3.49 EU/m3 (geometric mean +/- geometric SD), and number of annualized illness episodes was 6.83 +/- 2.80 (mean +/- SD). A doubling of the air endotoxin concentration was associated with an increase of 0.32 illness episodes per year (p = 0.0003), adjusted for age, year of study, breast-feeding, environmental tobacco smoke, child care attendance, indoor temperature, and income. Indoor mold surface area and fungal ergosterol were not significantly associated with endotoxin. Airborne endotoxin appears to be a risk factor for clinically symptomatic respiratory illnesses during the first 2 years of life independent of indoor fungus.

Community experiences and perceptions related to demolition and gut rehabilitation of houses for urban redevelopment

Reports about current residential demolition practices received from residents and plans for large-scale urban redevelopment in East Baltimore provided impetus for this study to assess community concerns and develop approaches to addressing them. This article describes the following themes regarding residents' experiences with demolition and gut rehabilitation of older housing performed as part of urban redevelopment: (1) lack of notification and awareness about protective measures; (2) concerns about environmental and safety hazards; (3) psychosocial impact from displacement, disruption in daily life, and inattention to community concerns; and (4) recommendations to improve redevelopment practices, including ideas to control neighborhood exposure to environmental hazards potentially exacerbated by residential demolition and gut rehabilitation. The findings from focus groups substantiated and deepened our understanding of earlier anecdotal reports of residents' concerns and emphasized the need for including community perceptions and ideas in addressing environmental and psychosocial issues related to urban redevelopment.

Racial differences in exposure to environmental tobacco smoke among children

Exposure to environmental tobacco smoke (ETS) is a major cause of morbidity and mortality among U.S. children. Despite African-American children's having a lower reported exposure to tobacco compared to whites, they suffer disproportionately from tobacco-related illnesses and have higher levels of serum cotinine than white children. The goal of this study was to test whether African-American children have higher levels of serum and hair cotinine, after accounting for ETS exposure and various housing characteristics. We investigated the level of cotinine in both hair and serum in a sample of 222 children with asthma. Using a previously validated survey for adult smokers, we assessed each child's exposure to ETS. We collected detailed information on the primary residence, including home volume, ventilation, and overall home configuration. Despite a lower reported ETS exposure, African-American children had higher mean levels of serum cotinine (1.41 ng/mL vs. 0.97 ng/mL; p = 0.03) and hair cotinine (0.25 ng/mg vs. 0.07 ng/mg; p < 0.001) compared with white children. After adjusting for ETS exposure, housing size, and other demographic characteristics, serum and hair cotinine levels remained significantly higher in African-American children (ss = 0.34, p = 0.03) than in white children (ss = 1.06, p < 0.001). Housing volume was significantly associated with both serum and hair cotinine but did not fully explain the race difference. Our results demonstrate that, despite a lower reported exposure to ETS, African-American children with asthma had significantly higher levels of both serum and hair cotinine than did white children. Identifying causes and consequences of increased cotinine may help explain the striking differences in tobacco-related illnesses.

Geographic analysis of blood lead levels in New York State children born 1994-1997

We examined the geographic distribution of the blood lead levels (BLLs) of 677,112 children born between 1994 and 1997 in New York State and screened before 2 years of age. Five percent of the children screened had BLLs higher than the current Centers for Disease Control and Prevention action level of 10 microg/dL. Rates were higher in upstate cities than in the New York City area. We modeled the relationship between BLLs and housing and socioeconomic characteristics at the ZIP code level. Older housing stock, a lower proportion of high school graduates, and a higher percentage of births to African-American mothers were the community characteristics most associated with elevated BLLs. Although the prevalence of children with elevated BLLs declined 44% between those born in 1994 and those born in 1997, the rate of improvement may be slowing down. Lead remains an environmental health problem in inner-city neighborhoods, particularly in upstate New York. We identified areas having a high prevalence of children with elevated BLLs. These communities can be targeted for educational and remediation programs. The model locates areas with a higher or lower prevalence of elevated BLLs than expected. These communities can be studied further at the individual level to better characterize the factors that contribute to these differences.

The cost-effectiveness of independent housing for the chronically mentally ill: do housing and neighborhood features matter?

OBJECTIVE

To determine the effects of housing and neighborhood features on residential instability and the costs of mental health services for individuals with chronic mental illness (CMI).

DATA SOURCES

Medicaid and service provider data on the mental health service utilization of 670 individuals with CMI between 1988 and 1993 were combined with primary data on housing attributes and costs, as well as census data on neighborhood characteristics. Study participants were living in independent housing units developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness in four of nine demonstration cities between 1988 and 1993.

STUDY DESIGN

Participants were assigned on a first-come, first-served basis to housing units as they became available for occupancy after renovation by the housing providers. Multivariate statistical models are used to examine the relationship between features of the residential environment and three outcomes that were measured during the participant's occupancy in a study property: residential instability, community-based service costs, and hospital-based service costs. To assess cost-effectiveness, the mental health care cost savings associated with some residential features are compared with the cost of providing housing with these features.

DATA COLLECTION/EXTRACTION METHODS

Health service utilization data were obtained from Medicaid and from state and local departments of mental health. Non-mental-health services, substance abuse services, and pharmaceuticals were screened out.

PRINCIPAL FINDINGS

Study participants living in newer and properly maintained buildings had lower mental health care costs and residential instability. Buildings with a richer set of amenity features, neighborhoods with no outward signs of physical deterioration, and neighborhoods with newer housing stock were also associated with reduced mental health care costs. Study participants were more residentially stable in buildings with fewer units and where a greater proportion of tenants were other individuals with CMI. Mental health care costs and residential instability tend to be reduced in neighborhoods with many nonresidential land uses and a higher proportion of renters. Mixed-race neighborhoods are associated with reduced probability of mental health hospitalization, but they also are associated with much higher hospitalization costs if hospitalized. The degree of income mixing in the neighborhood has no effect.

CONCLUSIONS

Several of the key findings are consistent with theoretical expectations that higher-quality housing and neighborhoods lead to better mental health outcomes among individuals with CMI. The mental health care cost savings associated with these favorable features far outweigh the costs of developing and operating properties with them. Support for the hypothesis that "diverse-disorganized" neighborhoods are more accepting of individuals with CMI and, hence, associated with better mental health outcomes, is mixed.

Are general practitioners' assessments of housing applicants' health accurate?

Public sector housing is often allocated on the basis of the 'vulnerability' of applicants. As part of assessing vulnerability, housing departments request assessments from applicants' general practitioners (GPs). GP assessments submitted over 3 years to a local authority housing department were analysed. The nature of the patient group and format of the GP report discriminate against accurate reporting and hence fair assignment of housing.

The effect of matching comprehensive services to patients' needs on drug use improvement in addiction treatment

AIMS

To examine whether need-service matching in addiction treatment leads to improvements in drug use, and whether treatment duration mediates those improvements.

DESIGN, PARTICIPANTS, MEASUREMENTS

This analysis utilizes prospective data from a US cohort of addiction treatment patients who reported service needs beyond core rehabilitative services (n = 3103). 'Drug use improvement' is the difference between the patient's peak drug use frequency (in days per month) in the year before intake and in the year after treatment. Overall and primary use of the major illicit drugs (heroin, powder or crack cocaine and marijuana) are considered separately. 'Need-service match' means that a patient rated a service as important at intake and reported its receipt during treatment. 'Percentage of needs matched' indicates the proportion of five service domains (medical, mental health, family, vocational and housing) so matched.

FINDINGS

In mixed regression models controlling for multiple factors, a greater percentage of needs matched tended to improve primary (beta = 0.028, P = 0.09) and overall (beta = 0.049, P = 0.05) drug use in the follow-up year. Exclusion of treatment duration as a covariate doubled the magnitude of these coefficients. The benefits of matching were concentrated among the half of patients reporting needs in four to five rather than one to three domains, and were strongest among patients in long-term residential facilities. Addressing vocational and housing needs exerted the greatest effects.

CONCLUSIONS

Matching comprehensive services to needs is a useful addiction treatment practice, especially for high-need patients. Treatment duration might partially mediate its effect.

Tuberculosis prevention versus hospitalization: taxpayers save with prevention

This study describes who pays for inpatient tuberculosis (TB) care and factors associated with payer source. The authors analyzed TB hospitalization costs for a prospective cohort of active TB patients at 10 U.S. sites. Private insurance paid for 9 percent and private hospitals for 6 percent of TB hospitalization costs. Public sources (federal, state, and local governments and public hospitals) paid more than 85 percent of TB hospitalization costs. Preventive services (treatment for latent TB infection; housing, food, and social work for homeless persons; substance abuse treatment for substance abusers; and antiretroviral medication for HIV-infected persons) targeted to those at high risk for TB hospitalization could save taxpayers between $4 million and $118 million. Since public resources are used to pay nearly all the costs of late-stage TB care, the public sector could save by shifting resources currently used for inpatient care to target preventive services to persons at high risk for TB hospitalization.

Social isolation modifies nicotine's effects in animal tests of anxiety

1. These experiments determined whether the housing conditions of rats influenced the effects of nicotine in two animal tests of anxiety, social interaction and elevated plus-maze tests. 2. In animals housed singly for 7 days, (-)nicotine (0.025 mg kg(-1) s.c.) was ineffective, but 0.05, 0.1 and 0.25 mg kg(-1) (s.c.) significantly increased the time spent in social interaction, without changing locomotor activity, thus indicating anxiolytic actions. (-)Nicotine (0.45 mg kg(-1) s.c.) significantly reduced social interaction, indicating an anxiogenic effect. 3. However, in group-housed animals, (-)nicotine (0.025 mg kg(-1) s.c.) had a significant anxiolytic effect in the social interaction test, but 0.01, 0.05, 0.1, 0.25 and 0.45 mg kg(-1) were ineffective. (-)Nicotine (1 mg kg(-1)) reduced motor activity and social interaction in the group-housed animals. 4. In the elevated plus-maze, the time-course and the dose-response curve to nicotine were investigated. In both singly- and group-housed rats, (-) nicotine (0.1 - 0.45 mg kg(-1) s.c.) decreased the per cent entries into, and per cent time spent on, the open arms, indicating anxiogenic effects. 5. The housing condition influenced the time course, with significant effects at 5 and 30 min after injection in group-housed rats, and significant effects at 30 and 60 min in singly-housed rats. 6. In the social interaction test there was no difference in the scores of the first and last rats removed from group cages, whereas the order of removal from the cages did affect the scores in the elevated plus-maze. 7. These results provide further evidence that the two animal tests model distinct states of anxiety, and show how social isolation powerfully modifies both anxiolytic and anxiogenic effects of nicotine.

Housing status and health care service utilization among low-income persons with HIV/AIDS

OBJECTIVE

To examine the impact of housing status on health service utilization patterns in low-income HIV-infected adults.

DESIGN

A survey of 1,445 HIV-infected Medicaid recipients in New York State between April 1996 and March 1997.

MAIN RESULTS

Six percent of study participants were homeless, 24.5% were "doubled-up," and 69.5% were stably housed. Compared with the stably housed, doubled-up and homeless participants were less likely to be seeing a physician regularly (P = .0001), and if seeing a physician, they were likely to have been doing so for a significantly shorter time (P = .02). The homeless were also less likely than either stably housed or doubled-up individuals to see the same physician or group of physicians at each ambulatory visit (P = .007). In addition, a higher proportion of the homeless had made one or more hospital visits over the prior 3 months than the nonhomeless. After multivariate adjustment, doubled-up participants were found to make more emergency room visits, the homeless were less likely to be taking prophylaxis for Pneumocystis carinii pneumonia, and both the doubled-up and the homeless were shown to use slightly more outpatient care than the stably housed.

CONCLUSION

Our study documents differences in health care utilization patterns across stably housed, doubled-up, and homeless HIV-infected persons after controlling for health insurance coverage. These differences, especially those pertaining to outpatient services, suggest that the unstably housed may be receiving less adequate health care than the stably housed, and hence may be more likely to experience adverse clinical outcomes.

Housing and health--current issues and implications for research and programs

This article provides an overview of the ways in which the home environment can affect human health, describes how specific health hazards in housing are related, and considers implications of these concerns for research and programs to address the health-housing connection. The widespread availability of decent housing has contributed greatly to improvements in health status in developed countries through, for example, provision of safe drinking water, proper sewage disposal, and protection from the elements. However, a lack of decent housing and homelessness among a significant number of Americans remains a significant public health concern. In addition, a number of specific health hazards can be found even in housing that is in good condition and provides all basic amenities. Specific health hazards related to housing include unintentional injuries, exposure to lead, exposure to allergens that may cause or worsen asthma, moisture and fungi (mold), rodent and insect pests, pesticide residues, and indoor air pollution. A number of these specific hazards share underlying causes, such as excess moisture, and all may be influenced by factors in the community environment or by occupant behaviors. We make recommendations for developing programs and research efforts that address multiple housing problems in an integrated way, rather than categorically, and for closer collaboration between housing and public health programs.

The social determinants of emergency department and hospital use by injection drug users in Canada

OBJECTIVE

The aim of this study was to describe the relationship between sociodemographic characteristics and human immunodeficiency (HIV) status of a cohort of injection drug users (IDUs) on their self-reported health service utilization.

DESIGN

Interviewer-administered questionnaire.

METHODS

IDUs who had injected illicit drugs within the previous month were recruited through street outreach. They underwent serology for HIV-1 and questionnaires on demographics, drug using behaviors, housing status, and health service utilization (hospitalization overnight and emergency department visits) in the previous 6 months. Logistic regression analysis was used to identify independent associations with the use of health services.

RESULTS

Of 1,103 cohort participants, 65% were male, 63% were white, and 23% were HIV positive. Cocaine was the most frequently injected drug used. Almost half (47%) had used health services in the previous 6 months. The following variables were associated independently with health service utilization (adjusted odds ratio; 95% confidence interval): unstable housing, defined as living primarily in a hotel, boarding room, or transition house or on the street in the past 6 months (1.44; 1.11-1.86); female gender (1.45; 1.11-1.89); HIV-positive status (1.43; 1.06-1.92); injection of cocaine (1.50; 1.12-2.02); and primary care I physician visit in past 6 months (1.91; 1.39-2.64).

CONCLUSION

IDUs with unstable housing were more likely to report emergency department and hospital use, which may be a reflection of their disorganized lifestyle or poorer health status. Further studies are required to assess the effect on the health status and health care use of IDUs of interventions that increase the availability of safe, affordable housing.

Housing issues of persons with AIDS

The housing status of persons with HIV/AIDS is a central issue in their care and prognosis. We conducted eight focus groups to explore the housing needs of special populations of persons with HIV/AIDS in New York State; these populations included substance users, ex-offenders, persons with documented histories of homelessness, and rural dwellers/migrant workers. For the focus groups, 52 participants were recruited from the clientele of health and social service agencies. A major theme was the potent effect that housing situations had on participants' health. Participants frequently attributed lowered T-cell counts and increased lethargy to the stress associated with governmental rules and paperwork. Lack of money, inadequacy of entitlements, and high costs of housing were the major barriers to securing stable and appropriate housing. Furthermore, participants experienced housing discrimination based on HIV status and experience with the criminal justice system or drugs.

Comparison of ketosis, clinical mastitis, somatic cell count, and reproductive performance between free stall and tie stall barns in Norwegian dairy herds with automatic feeding

Differences in ketosis and clinical mastitis rates, mean somatic cell counts (SCC) and reproductive performance scores (fertility status index = FS-index) between herds housed in free stall (n = 533) and tie stall (n = 59) barns were measured in relation to management and environmental factors in a retrospective cohort study of Norwegian dairy farms with automatic grain feeding systems. Herds with tie stalls were found to have a higher clinical mastitis rate, (61.6 cases per 100 cow-years versus 46.4 cases per 100 cow-years (p < 0.01)); a significantly higher proportion of herds with ketosis, (relative risk = 1.59, (p < 0.01)); and a lower mean fertility status index, (67.3 versus 82.8 (p < 0.01)). No significant difference in mean SCC was found between the 2 groups of dairies (p = 0.32). Large herds had higher Loge geometric mean SCC than small herds (p < 0.01) and herds with high SCC had lower milk production than herds with low SCC (p < 0.01). Herds that scored "very good" on cow cleanliness had significantly lower adjusted mean SCC than herds with scores of "average" or "good" (p < 0.05). Herds in barns with a concrete floor had an adjusted mean number of cases of clinical mastitis of 51.4 per 100 cow-years, 14 per cent higher than herds in barns with rubber mats, litter bed or wood (45.2 cases per 100 cow-years) (p < 0.05). Herds with high milk production level had higher FS-index than herds with low milk production (p < 0.01). Lower disease rates and the higher fertility status measured in the present study favor free stall herds over tie stall herds.

Long-term use of televisions, balls, and mirrors as enrichment for paired and singly caged chimpanzees

The evaluation of environmental enrichment techniques for nonhuman primates over long periods of time has had mixed results. Some studies report rapid habituation to new enrichment items, while others note continued use. We have investigated the use of three different enrichments that had been available to paired and singly caged chimpanzees for several years. Twenty subjects were observed during 200 hr of scan sampling while singly caged and while pair housed. Each subject had a variety of enrichments available and their use of a television, ball, and mirror were recorded. The chimpanzees had previous exposure to all of the items: televisions had been available for a mean of 22.75 months, balls had been available for 55.9 months, and mirrors had been available for 25.9 months. The results indicated that the chimpanzees continued to use the enrichments for small amounts of time (0.27%-1.53% of the observations) even after such prolonged exposure. Television and ball use were significantly higher than mirror use. Housing condition was not a significant factor in the analyses, contrary to expectations. We concluded that several simple enrichment items may be effective in offering variety and choices to the nonhuman primate and can be one element in a comprehensive environmental enhancement plan. © 1996 Wiley-Liss, Inc.

Effects of housing and colostrum feeding on serum immunoglobulins, growth, and fecal scores of Jersey calves

Ninety-six Jersey calves were used to evaluate the effects of housing and method of colostrum feeding on serum Ig concentrations, incidence and severity of scours, intake, and BW changes from birth to 35 d of age. Calves were separated from the dam and fed 2 L of colostrum in nipple-bottles or allowed to nurse the dam for 3 d. Calves were housed in individual hutches or wooden pens in a barn. Intake of colostrum by calves allowed to nurse the dam was not controlled. Serum IgG and IgM concentrations at 24 h of age were greater for calves that nursed the dam. Scours were less severe when calves were housed in hutches, but number of days scouring was unaffected by treatment. Calves fed colostrum in nipple-bottles and housed in the barn consumed more starter than did other calves from 3 to 5 wk of age. The BW were greater for calves allowed to nurse the dam and housed in hutches. Feed efficiency over the 35-d study was improved when calves nursed the dam. Optimal transfer of passive immunity and housing in hutches appeared to maximize health and growth in this study.

Effects of housing and colostrum feeding on the prevalence of selected infectious organisms in feces of Jersey calves

Neonatal Jersey calves (n = 96) were used to evaluate effects of housing (individual hutches or wooden pens in a barn) and colostrum feeding (calves were separated from the dam and fed 2 L of colostrum in nipple-bottles or allowed to nurse the dam for 3 d) on the prevalence of selected organisms in feces. Prevalence of Cryptosporidium and Eimeria were reduced, and prevalence of rotavirus tended to be reduced, when calves were housed in hutches. Prevalence of coronavirus was unaffected by treatment. Weekly prevalence of Giardia was increased when calves were left to nurse the dam for 3 d. Mean prevalence of Cryptosporidia (wk 1 to 4), Eimeria (wk 4 to 5), Giardia, rotavirus, and coronavirus (wk 1 to 5) were 34.7, 20.6, 27.1, 15.8, and 4.9%, respectively. Escherichia coli (K99 positive) were observed in 3 of 174 samples cultured. Methods of housing and colostrum feeding affected acquisition of enteropathogens in this study.