Housing and health: intersection of poverty and environmental exposures

Outcomes of Asthma Education and Healthy Homes Curriculum Provided Through Community Health Workers in South Texas Colonias

Background. Childhood asthma rates are highest among minorities and among those who reside in low-income communities. This is especially true of children who reside in colonias, which are defined as substandard housing communities in irregular rural settlements located along the US-Mexico border. This study aimed to evaluate the knowledge acquired by participants before and after an educational intervention was provided. Methods. This study used the healthy homes training approach, including integrated pest management, identification of asthma triggers, and asthma case management, to increase asthma management awareness and control. This dual training approach combined a healthy homes module with asthma education and was implemented by certified promotoras (community health workers) in South Texas colonias. Promotoras are generally trusted and respected individuals who live in or around the communities in which they work. The promotoras identified and trained 108 parents of children aged between 5 and 12 years in households in Hidalgo County with lifetime asthma diagnosed by his/her physician and of children who may not have been diagnosed by a health professional with asthma but suffer from symptoms of asthma. Results. Asthma management and healthy homes knowledge, including attitudes and practices, significantly improved among parents after the implementation of the dual training program. Of the 108 participants, 78% had never received asthma education, 78% had a child with lifetime asthma diagnosed by his/her physician, and 32% reported having medical insurance. Pretest and posttest comparison results based on 9 out of 14 questions related to asthma triggers and healthy home principles showed a significant improvement in knowledge gained among the participants. Regardless of the study limitations (self-report instrument for the pretest and the posttest), the results showed that families in colonias living with asthma benefit from an integrated training approach.

Moving environmental justice indoors: understanding structural influences on residential exposure patterns in low-income communities

OBJECTIVES

The indoor environment has not been fully incorporated into the environmental justice dialogue. To inform strategies to reduce disparities, we developed a framework to identify the individual and place-based drivers of indoor environment quality.

METHODS

We reviewed empirical evidence of socioeconomic disparities in indoor exposures and key determinants of these exposures for air pollutants, lead, allergens, and semivolatile organic compounds. We also used an indoor air quality model applied to multifamily housing to illustrate how nitrogen dioxide (NO(2)) and fine particulate matter (PM(2.5)) vary as a function of factors known to be influenced by socioeconomic status.

RESULTS

Indoor concentrations of multiple pollutants are elevated in low-socioeconomic status households. Differences in these exposures are driven by the combined influences of indoor sources, outdoor sources, physical structures, and residential activity patterns. Simulation models confirmed indoor sources' importance in determining indoor NO(2) and PM(2.5) exposures and showed the influence of household-specific determinants.

CONCLUSIONS

Both theoretical models and empirical evidence emphasized that disparities in indoor environmental exposure can be significant. Understanding key determinants of multiple indoor exposures can aid in developing policies to reduce these disparities.

Migrant farmworkers' housing conditions across an agricultural season in North Carolina

BACKGROUND

Several studies have documented poor housing conditions for farmworkers but none has focused on migrant farmworker housing, which is often provided as a condition of employment. Farmworker housing quality is regulated, but little documentation exists of compliance with regulations.

METHODS

A 2007 survey of 43 randomly selected farmworker camps and a 2008 survey of 27 camps randomly selected from the 2007 sample documented housing conditions via interviewer administered questionnaire and housing checklist.

RESULTS

Substandard conditions are common in migrant housing. All camps had at least one exterior housing problem; 93% had at least one interior problem. Housing conditions worsen across the agricultural season. Characteristics including no residents with H2A visa and 11 or more residents are associated with poorer conditions.

CONCLUSIONS

Housing standards are not adequately enforced. An increase in post-occupancy inspections and targeting camps with characteristics that place them at increased risk for substandard conditions are recommended.

Systematic neighborhood observations at high spatial resolution: methodology and assessment of potential benefits

There is a growing body of public health research documenting how characteristics of neighborhoods are associated with differences in the health status of residents. However, little is known about how the spatial resolution of neighborhood observational data or community audits affects the identification of neighborhood differences in health. We developed a systematic neighborhood observation instrument for collecting data at very high spatial resolution (we observe each parcel independently) and used it to collect data in a low-income minority neighborhood in Dallas, TX. In addition, we collected data on the health status of individuals residing in this neighborhood. We then assessed the inter-rater reliability of the instrument and compared the costs and benefits of using data at this high spatial resolution. Our instrument provides a reliable and cost-effect method for collecting neighborhood observational data at high spatial resolution, which then allows researchers to explore the impact of varying geographic aggregations. Furthermore, these data facilitate a demonstration of the predictive accuracy of self-reported health status. We find that ordered logit models of health status using observational data at different spatial resolution produce different results. This implies a need to analyze the variation in correlative relationships at different geographic resolutions when there is no solid theoretical rational for choosing a particular resolution. We argue that neighborhood data at high spatial resolution greatly facilitates the evaluation of alternative geographic specifications in studies of neighborhood and health.

Environmental health disparities in housing

The physical infrastructure and housing make human interaction possible and provide shelter. How well that infrastructure performs and which groups it serves have important implications for social equity and health. Populations in inadequate housing are more likely to have environmental diseases and injuries. Substantial disparities in housing have remained largely unchanged. Approximately 2.6 million (7.5%) non-Hispanic Blacks and 5.9 million Whites (2.8%) live in substandard housing. Segregation, lack of housing mobility, and homelessness are all associated with adverse health outcomes. Yet the experience with childhood lead poisoning in the United States has shown that housing-related disparities can be reduced. Effective interventions should be implemented to reduce environmental health disparities related to housing.

Housing and health in three contrasting neighbourhoods in Accra, Ghana

Although the literature on housing and health is extensive, most research comes from developed countries. Relatively little work on the topic has been done in developing countries such as Ghana where socio-economic and cultural characteristics are generally different. This paper reports on primary research that investigates the relationship between housing and self reported general and mental health in Accra, Ghana. The study focused on how the social and economic dimensions of housing, specifically, demand, control and material attributes (affordability, dwelling type) influence individuals' attachment to their home as a refuge for daily living. A cross-sectional survey was administered to a randomly selected sample (n = 562) in three contrasting neighbourhoods. Overall, housing conditions, demand and control residents have to where they live, emerged as significant predictors of self reported general and mental health status. The influence of these variables superseded well known correlates of health status, income and educational attainment, attesting to their importance in a worsening housing environment. The findings point to the need for policy that recognizes that housing is not only a physical shelter but also an important health resource.

Housing circumstances are associated with household food access among low-income urban families

Household food insecurity is a pervasive problem in North America with serious health consequences. While affordable housing has been cited as a potential policy approach to improve food insecurity, the relationship between conventional notions of housing affordability and household food security is not well understood. Furthermore, the influence of housing subsidies, a key policy intervention aimed at improving housing affordability in Western countries, on food insecurity is unclear. We undertook a cross-sectional survey of 473 families in market rental (n = 222) and subsidized (n = 251) housing in high-poverty urban neighborhoods to examine the influence of housing circumstances on household food security. Food insecurity, evident among two thirds of families, was inversely associated with income and after-shelter income. Food insecurity prevalence did not differ between families in market and subsidized housing, but families in subsidized housing had lower odds of food insecurity than those on a waiting list for such housing. Market families with housing costs that consumed more than 30% of their income had increased odds of food insecurity. Rent arrears were also positively associated with food insecurity. Compromises in housing quality were evident, perhaps reflecting the impact of financial constraints on multiple basic needs as well as conscious efforts to contain housing costs to free up resources for food and other needs. Our findings raise questions about current housing affordability norms and highlight the need for a review of housing interventions to ensure that they enable families to maintain adequate housing and obtain their other basic needs.

Social factors associated with nitrogen dioxide (NO2) exposure during pregnancy: the INMA-Valencia project in Spain

Numerous studies have focused on the effects of exposure to air pollution on health; however, certain subsets of the population tend to be more exposed to such pollutants depending on their social or demographic characteristics. In addition, exposure to toxicants during pregnancy may play a deleterious role in fetal development as fetuses are especially vulnerable to external insults. The present study was carried out within the framework of the INMA (Infancia y Medio Ambiente or Childhood and the Environment) multicenter cohort study with the objective of identifying the social, demographic, and life-style factors associated with nitrogen dioxide (NO(2)) exposure in the subjects in the cohort. The study comprised 785 pregnant women who formed part of the INMA cohort in Valencia, Spain. Outdoor levels of NO(2) were measured at 93 sampling sites spread over the study area during four different sampling periods lasting 7 days each. Multiple regression models were used for mapping outdoor NO(2) throughout the area. Individual exposure was assigned as: 1) the estimated outdoor NO(2) levels at home, and 2) the average of estimated outdoor NO(2) levels at home and work, weighted according to the time spent in each environment. The subjects' socio-demographic and life-style information was obtained through a questionnaire. In the multiple linear analyses, the outdoor NO(2) levels assigned to each home were taken to be the dependent variable. Other variables included in the model were: age, country of origin, smoking during pregnancy, parity, season of the year, and social class. These same variables remained in the model when the dependent variable was changed to the NO(2) levels adjusted for the subjects' time-activity patterns. We found that younger women, those coming from Latin American countries, and those belonging to the lower social strata were exposed to higher NO(2) levels, both as measured outside their homes as well as when time-activity patterns were taken into account. These subgroups also have a higher probability of being exposed to NO(2) levels over 40 μg/m(3), which is the annual limit for maximum safe exposure, as established by European Directive 2008/50/EC.

The impact of densification by means of informal shacks in the backyards of low-cost houses on the environment and service delivery in cape town, South Africa

This paper investigates the state-sponsored low cost housing provided to previously disadvantaged communities in the City of Cape Town. The strain imposed on municipal services by informal densification of unofficial backyard shacks was found to create unintended public health risks. Four subsidized low-cost housing communities were selected within the City of Cape Town in this cross-sectional survey. Data was obtained from 1080 persons with a response rate of 100%. Illegal electrical connections to backyard shacks that are made of flimsy materials posed increased fire risks. A high proportion of main house owners did not pay for water but sold water to backyard dwellers. The design of state-subsidised houses and the unplanned housing in the backyard added enormous pressure on the existing municipal infrastructure and the environment. Municipal water and sewerage systems and solid waste disposal cannot cope with the increased population density and poor sanitation behaviour of the inhabitants of these settlements. The low-cost housing program in South Africa requires improved management and prudent policies to cope with the densification of state-funded low-cost housing settlements.

Living in low-cost housing settlements in cape town, South Africa-the epidemiological characteristics associated with increased health vulnerability

The aim of this study was to assess the epidemiological characteristics of a representative sample of subsidized low-cost housing communities in the City of Cape Town in relation to their living conditions and their health status. Four subsidized low-cost housing communities were selected within the City of Cape Town in this cross-sectional survey. Structured interviews were administered in 336 dwellings on 173 plots. Data was obtained from 1,080 persons with a response rate of 100%. Almost all of the state-subsidized houses had one or more shacks in the backyard, increasing the occupation density and putting the municipal sanitation infrastructure under pressure. In 40% of main houses, one or more cases of diarrhea were reported during the two weeks preceding the survey, in contrast to 23% of shacks (p < 0.0007). Of the total group, 1.7% willingly disclosed that they were HIV positive, while 3.5% reported being tuberculosis (TB) positive. One of them reported having multiple drug-resistant TB. None of the HIV positive or TB positive persons was on any treatment. A reported 6.3% of the families admitted regularly eating only one meal per day, whereas 18.5% reported having only two meals per day. The shack dwellers had significantly higher education and employment status (p < 0.01), since they had to pay rent. Improvements in health intended by the rehousing process did not materialize for the recipients of low-cost housing in this study. The health vulnerability of individuals in these communities had considerable implications for the curative health services. Sanitation failures, infectious disease pressure, and environmental pollution in these communities represent a serious public health risk. The densification caused by backyard shacks, in addition, has municipal service implications and needs to be better managed. Urgent intervention is needed to allow the state-funded housing schemes to deliver the improved health that was envisaged at its inception.

Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children

Asthma disproportionately affects non-whites in urban areas and those of low socioeconomic status, yet asthma's social patterning is not well-explained by known risk factors. We hypothesized that disadvantaged urban populations experience acute and chronic housing stressors which produce psychological stress and impact health through biological and behavioral pathways. We examined eight outcomes: six child respiratory outcomes as well as parent and child general health, using data from 682 low-income, Chicago parents of diagnosed and undiagnosed asthmatic children. We created a continuous exposure, representing material, social and emotional dimensions of housing stressors, weighted by their parent-reported difficulty. We compared the 75th to the 25th quartile of exposure in adjusted binomial and negative binomial regression models. Higher risks and rates of poor health were associated with higher housing stressors for six of eight outcomes. The risk difference (RD) for poor/fair general health was larger for children [RD = 6.28 (95% CI 1.22, 11.35)] than for parents [RD = 3.88 (95% CI -1.87, 9.63)]. The incidence rate difference (IRD) for exercise intolerance was nearly one extra day per 2 weeks for the higher exposure group [IRD = 0.88 (95% CI 0.41, 1.35)]; nearly one-third extra day per 2 weeks for waking at night [IRD = 0.32 (95% CI 0.01, 0.63)]; and nearly one-third extra day per 6 months for unplanned medical visits [IRD = 0.30 (95% CI 0.059, 0.54)]. Results contribute to the conceptualization of urban stress as a "social pollutant" and to the hypothesized role of stress in health disparities. Interventions to improve asthma outcomes must address individuals' reactions to stress while we seek structural solutions to residential stressors and health inequities.

Life-course financial strain and health in African-Americans

Differential exposure to financial strain may explain some differences in population health. However, few studies have examined the cumulative health effect of financial strain across the life-course. Studies that have are limited to self-reported health measures. Our objective was to examine the associations between childhood, adulthood, and life-course, or cumulative, financial strain with disability, lung function, cognition, and depression. In a population-based cross-sectional cohort study of adult African-American twins enrolled in the US Carolina African American Twin Study of Aging (CAATSA), we found that participants who reported financial strain as children and as adults are more likely to be physically disabled, and report more depressive symptoms than their unstrained counterparts. Participants who reported childhood financial strain had lower cognitive functioning than those with no childhood financial strain. We were unable to detect a difference in lung function beyond the effect of actual income and education in those who reported financial strain compared to those who did not. Financial strain in adulthood was more consistently associated with poor health than was childhood financial strain, a finding that suggests targeting adult financial strain could help prevent disability and depression among African-American adults.

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.

Environmental justice and the health of children

Environmental injustice is the inequitable and disproportionately heavy exposure of poor, minority, and disenfranchised populations to toxic chemicals and other environmental hazards. Environmental injustice contributes to disparities in health status across populations of differing ethnicity, race, and socioeconomic status. Infants and children, because of their unique biological vulnerabilities and age-related patterns of exposure, are especially vulnerable to the health impacts of environmental injustice. These impacts are illustrated by sharp disparities across children of different racial and ethnic backgrounds in the prevalence of 3 common diseases caused in part by environmental factors: asthma, lead poisoning, and obesity. Documentation of linkages between health disparities and environmental injustice is an important step toward achieving environmental justice.

Social and environmental stressors in the home and childhood asthma

BACKGROUND

Both physical environmental factors and chronic stress may independently increase susceptibility to asthma; however, little is known on how these different risks may interact. The authors examined the relationship between maternal intimate partner violence (IPV), housing quality and asthma among children in the Fragile Families and Child Wellbeing Study (N=2013).

METHODS

Maternal reports of IPV were obtained after the child's birth and at 12 and 36 months. At the 36-month assessment, interviewers rated indoor housing conditions, regarding housing deterioration (ie, peeling paint, holes in floor, broken windows) and housing disarray (ie, dark, cluttered, crowded or noisy house). At the same time, mothers reported on housing hardships (ie, moving repeatedly, and hardships in keeping house warm). Maternal-report of physician-diagnosed asthma by age 36 months which was active in the past year was the outcome.

RESULTS

Asthma was diagnosed in 10% of the children. In an adjusted analysis, an increased odds of asthma was observed in children of mothers experiencing IPV chronically (OR 1.8, 95% CI 1.0 to 3.5) and in children experiencing housing disarray (OR 1.5, 95% CI 1.1 to 2.0) compared with those not exposed to these risks. In stratified analyses, a greater effect of IPV on asthma was noted among children living in disarrayed or deteriorated housing or among children whose mothers were experiencing housing hardship.

CONCLUSIONS

IPV and housing disarray are associated with increased early childhood asthma. Exposure to cumulative or multiple stressors (ie, IPV and poor housing quality) may increase children's risk of developing asthma more than a single stressor.

Geographic analysis of low birthweight and infant mortality in Michigan using automated zoning methodology

BACKGROUND

Infant mortality is a major public health problem in the State of Michigan and the United States. The primary adverse reproductive outcome underlying infant mortality is low birthweight. Visualizing and exploring the spatial patterns of low birthweight and infant mortality rates and standardized incidence and mortality ratios is important for generating mechanistic hypotheses, targeting high-risk neighborhoods for monitoring and implementing maternal and child health intervention and prevention programs and evaluating the need for health care services. This study investigates the spatial patterns of low birthweight and infant mortality in the State of Michigan using automated zone matching (AZM) methodology and minimum case and population threshold recommendations provided by the National Center for Health Statistics and the US Census Bureau to calculate stable rates and standardized incidence and mortality ratios at the Zip Code (n = 896) level. The results from this analysis are validated using SaTScan. Vital statistics birth (n = 370,587) and linked infant death (n = 2,972) records obtained from the Michigan Department of Community Health and aggregated for the years 2004 to 2006 are utilized.

RESULTS

For a majority of Zip Codes the relative standard errors (RSEs) of rates calculated prior to AZM were greater than 20%. Spurious results were the result of too few case and birth counts. Applying AZM with a target population of 25 cases and minimum threshold of 20 cases resulted in the reconstruction of zones with at least 50 births and RSEs of rates 20-22% and below respectively, demonstrating the stability reliability of these new estimates. Other AZM parameters included homogeneity constraints on maternal race and maximum shape compactness of zones to minimize potential confounding. AZM identified areas with elevated low birthweight and infant mortality rates and standardized incidence and mortality ratios. Most but not all of these areas were also detected by SaTScan.

CONCLUSION

Understanding the spatial patterns of low birthweight and infant deaths in Michigan was an important first step in conducting a geographic evaluation of the State's reported high infant mortality rates. AZM proved to be a useful tool for visualizing and exploring the spatial patterns of low birthweight and infant deaths for public health surveillance. Future research should also consider AZM as a tool for health services research.