Examining mediators of housing mobility on adolescent asthma: results from a housing voucher experiment

Housing typologies and asthma: a scoping review

Asthma is related to triggers within the home. Although it is recognised that triggers likely occur due to characteristics of housing, these characteristics have not been comprehensively reviewed, and there is a paucity of housing-focused interventions to reduce asthma and asthma symptoms. Following five steps identified by Arksey and O'Malley, we conducted a scoping review of published evidence on the associations between asthma and housing characteristics. We searched three electronic databases (PubMed, Scopus, Web of Science), identifying 33 studies that met our inclusion criteria. Through an iterative approach, we identified nine housing characteristics relevant to asthma onset or exacerbation, categorised as relating to the surrounding environment (location), the house itself (dwelling), or to conditions inside the home (occupancy). We conceptualise these three levels through a housing typologies framework. This facilitates the mapping of housing characteristics, and visualises how they can cluster and overlap to exacerbate asthma or asthma symptoms. Of the three levels in our framework, associations between asthma and locational features were evidenced most clearly in the literature reviewed. Within this category, environmental pollutants (and particularly air pollutants) were identified as a potentially important risk factor for asthma. Studies concerning associations between dwelling features and occupancy features and asthma reported inconsistent results, highlighting the need for greater research in these areas. Interpreting housing-related asthma triggers through this framework paves the way for the identification and targeting of typologies of housing that might adversely affect asthma, thus addressing multiple characteristics in tandem rather than as isolated elements.

The Benefits of Rental Assistance for Children's Health and School Attendance in the United States

Programs that provide affordable and stable housing may contribute to better child health and thus to fewer missed days of school. Drawing on a unique linkage of survey and administrative data, we use a quasi-experimental approach to examine the impact of rental assistance programs on missed days of school due to illness. We compare missed school days due to illness among children receiving rental assistance with those who will enter assistance within two years of their interview, the average length of waitlists for federal rental assistance. Overall, we find that children who receive rental assistance miss fewer days of school due to illness relative to those in the pseudo-waitlist group. We demonstrate that rental assistance leads to a reduction in the number of health problems among children and thus to fewer days of school missed due to illness. We find that the effect of rental assistance on missed school days is stronger for adolescents than for younger children. Additionally, race-stratified analyses reveal that rental assistance leads to fewer missed days due to illness among non-Hispanic White and Hispanic/Latino children; this effect, however, is not evident for non-Hispanic Black children, the largest racial/ethnic group receiving assistance. These findings suggest that underinvestment in affordable housing may impede socioeconomic mobility among disadvantaged non-Hispanic White and Hispanic/Latino children. In contrast, increases in rental assistance may widen racial/ethnic disparities in health among disadvantaged children, and future research should examine why this benefit is not evident for Black children.

Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY

This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types—public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.

Do peer social relationships mediate the harmful effects of a housing mobility experiment on boys' risky behaviors?

PURPOSE

The purpose of this study was to understand why a housing mobility experiment caused harmful effects on adolescent boys' risky behaviors.

METHODS

Moving to Opportunity (MTO) (1994-2010) randomly assigned volunteer families to a treatment group receiving a Section 8 rental voucher or a public housing control group. Our outcome was a global risky behavior index (RBI; measured in 2002, n = 750 boys) measuring the fraction of 10 items the youth engaged in, 6 measuring past 30-day substance use and 4 measuring recent risky sexual behavior. Potential mediators (measured in 2002) included peer social relationships (e.g., peer drug use, peer gang membership).

RESULTS

The voucher treatment main effect on boys' RBI was harmful (B (SE) = 0.05 (0.02), 95% CI 0.01, 0.08), and treatment marginally increased having friends who used drugs compared to controls (B (SE) = 0.67 (0.23), 95% CI 0.22, 1.12). Having friends who used drugs marginally mediated the MTO treatment effect on RBI (indirect effect: B (SE) = 0.02(.01), 95% CI -0.002, 0.04), reducing the total treatment effect by 39%.

CONCLUSIONS

Incorporating additional supports into housing voucher programs may help support teenage boys who experience disruptions to their social networks, to buffer potential adverse consequences of residential mobility.

Association of Childhood Asthma With Federal Rental Assistance

Importance

Millions of low-income children in the United States reside in substandard or unaffordable housing. Relieving these burdens may be associated with changes in asthma outcomes.

Objectives

To examine whether participation in the US Department of Housing and Urban Development's (HUD) rental assistance programs is associated with childhood asthma outcomes and to examine whether associations varied by program type (public housing, multifamily housing, or housing choice vouchers).

Design, Setting, and Participants

This survey study used data from the nationally representative National Health Interview Survey linked to administrative housing assistance records from January 1, 1999, to December 31, 2014. A total of 2992 children aged 0 to 17 years who were currently receiving rental assistance or would enter a rental assistance program within 2 years of survey interview were included. Data analysis was performed from January 15, 2018, to August 31, 2019.

Exposures

Participation in rental assistance provided by HUD.

Main Outcomes and Measures

Ever been diagnosed with asthma, 12-month history of asthma attack, and 12-month history of visiting an emergency department for the treatment of asthma among program participants vs those waiting to enter a program. Overall participation was examined, and participation in public or multifamily housing was compared with participation in housing choice vouchers.

Results

This study included 2992 children who were currently participating in a HUD program or would enter a program within 2 years. Among children with an asthma attack in the past year, participation in a rental assistance program was associated with a reduced use of emergency departments for asthma of 18.2 percentage points (95% CI, -29.7 to -6.6 percentage points). Associations were only found after entrance into a program, suggesting that they were not confounded by time-varying factors. Statistically significant results were found for participation in public or multifamily housing (percentage point change, -36.6; 95% CI, -54.8 to -18.4) but not housing choice vouchers (percentage point change, -7.2; 95% CI, -24.6 to 10.3). No statistically significant evidence of changes in asthma attacks was found (percentage point change, -2.7; 95% CI, -12.3 to 7.0 percentage points). Results for asthma diagnosis were smaller and only significant at the 10% level (-4.3; 95% CI, -8.8 to 0.2 percentage points).

Conclusions and Relevance

Among children with a recent asthma attack, rental assistance was associated with less emergency department use. These results may have important implications for the well-being of low-income families and health care system costs.

The price of admission: does moving to a low-poverty neighborhood increase discriminatory experiences and influence mental health?

PURPOSE

The Moving to Opportunity (MTO) study is typically interpreted as a trial of changes in neighborhood poverty. However, the program may have also increased exposure to housing discrimination. Few prior studies have tested whether interpersonal and institutional forms of discrimination may have offsetting effects on mental health, particularly using intervention designs.

METHODS

We evaluated the effects of MTO, which randomized public housing residents in 5 cities to rental vouchers, or to in-place controls (N = 4248, 1997-2002), which generated variation on neighborhood poverty (% of residents in poverty) and encounters with housing discrimination. Using instrumental variable analysis (IV), we derived two-stage least squares IV estimates of effects of neighborhood poverty and housing discrimination on adult psychological distress and major depressive disorder (MDD).

RESULTS

Randomization to voucher group vs. control simultaneously decreased neighborhood % poverty and increased exposure to housing discrimination. Higher neighborhood % poverty was associated with increased psychological distress [B_IV = 0.36, 95% confidence interval (CI) 0.03, 0.69] and MDD (B_IV = 0.12, 95% CI - 0.005, 0.25). Effects of housing discrimination on mental health were harmful, but imprecise (distress B_IV = 1.58, 95% CI - 0.83, 3.99; MDD B_IV = 0.57, 95% CI - 0.43, 1.56). Because neighborhood poverty and housing discrimination had offsetting effects, omitting either mechanism from the IV model substantially biased the estimated effect of the other towards the null.

CONCLUSIONS

Neighborhood poverty mediated MTO treatment on adult mental health, suggesting that greater neighborhood poverty contributes to mental health problems. Yet housing discrimination-mental health findings were inconclusive. Effects of neighborhood poverty on health may be underestimated when failing to account for discrimination.

The Use of Geographic Data to Improve Asthma Care Delivery and Population Health

The authors examine uses of geographic data to improve asthma care delivery and population health and describe potential practice changes and areas for future research.

Modification of Housing Mobility Experimental Effects on Delinquency and Educational Problems: Middle Adolescence as a Sensitive Period

Residential mobility is one documented stressor contributing to higher delinquency and worse educational outcomes. Sensitive period life course models suggest that certain developmental stages make individuals more susceptible to the effects of an exposure, like residential mobility, on outcomes. However, most prior research is observational, and has not examined heterogeneity across age or gender that may inform sensitive periods, even though it may have important implications for the etiology of adolescent development. Moreover, there are important translational implications for identifying the groups most vulnerable to residential mobility to inform how to buffer adverse effects of moving. In this study, low-income families were randomized to residential mobility out of public housing into lower poverty neighborhoods using a rental subsidy voucher ("experimental voucher condition"), and were compared to control families remaining in public housing. The sample was comprised of 2829 youth (51% female; 62% Non-Hispanic Black, 31% Hispanic, 7% other race). At baseline, youth ranged from 5 to 16 years old. This study hypothesized that random assignment to the housing voucher condition would generate harmful effects on delinquency and educational problems, compared to the control group, among boys who were older at baseline. The results confirmed this hypothesis: random assignment to the experimental voucher condition generating residential mobility caused higher delinquency among boys who were 13-16 years old at baseline, compared to same-age, in-place public housing controls. However, residential mobility did not affect delinquency among girls regardless of age, or among boys who were 5-12 years old at baseline. The pattern of results for educational problems was similar but weaker. Families with teenage boys are particularly vulnerable to residential transitions. Incorporating additional supports into housing programs may help low-income, urban families to successfully transition to lower poverty neighborhoods.

Housing Assistance and Child Health: A Systematic Review

CONTEXT

Given a large and consistent literature revealing a link between housing and health, publicly supported housing assistance programs might play an important role in promoting the health of disadvantaged children.

OBJECTIVE

To summarize and evaluate research in which authors examine housing assistance and child health.

DATA SOURCES

PubMed, Web of Science, PsycInfo, and PAIS (1990-2017).

STUDY SELECTION

Eligible studies were required to contain assessments of public housing, multifamily housing, or vouchers in relation to a health outcome in children (ages 0-21); we excluded neighborhood mobility interventions.

DATA EXTRACTION

Study design, sample size, age, location, health outcomes, measurement, program comparisons, analytic approach, covariates, and results.

RESULTS

We identified 14 studies, including 4 quasi-experimental studies, in which authors examined a range of health outcomes. Across studies, the relationship between housing assistance and child health remains unclear, with ∼40% of examined outcomes revealing no association between housing assistance and health. A sizable proportion of observed relationships within the quasi-experimental and association studies were in favor of housing assistance (50.0% and 37.5%, respectively), and negative outcomes were less common and only present among association studies.

LIMITATIONS

Potential publication bias, majority of studies were cross-sectional, and substantial variation in outcomes, measurement quality, and methods to address confounding.

CONCLUSIONS

The results underscore a need for rigorous studies in which authors evaluate specific housing assistance programs in relation to child outcomes to establish what types of housing assistance, if any, serve as an effective strategy to reduce disparities and advance equity across the lifespan.

Using Address Information to Identify Hardships Reported by Families of Children Hospitalized With Asthma

OBJECTIVE

Socioeconomic hardship is common among children hospitalized for asthma but often not practically measurable. Information on where a child resides is universally available. We sought to determine the correlation between neighborhood-level socioeconomic data and family-reported hardships.

METHODS

Caregivers of 774 children hospitalized with asthma answered questions regarding income, financial strain, and primary care access. Addresses were geocoded and linked to zip code-, census tract-, and block group-level (neighborhood) data from the US Census. We then compared neighborhood median household income with family-reported household income; percentage of neighborhood residents living in poverty with family-reported financial strain; and percentage of neighborhood households without an available vehicle with family-reported access to primary care. We constructed heat maps and quantified correlations using Kendall rank correlation coefficient. Receiver operator characteristic curves were used to assess predictive abilities of neighborhood measures.

RESULTS

The cohort was 57% African American and 73% publicly-insured; 63% reported income <$30,000, 32% endorsed ≥4 financial strain measures, and 38% reported less than adequate primary care access. Neighborhood median household income was significantly and moderately correlated with and predictive of reported household income; neighborhood poverty was similarly related to financial strain; neighborhood vehicle availability was weakly correlated with and predictive of primary care access. Correlations and predictions provided by zip code measures were similar to those of census tract and block group.

CONCLUSIONS

Universally available neighborhood information might help efficiently identify children and families with socioeconomic hardships. Systematic screening with area-level socioeconomic measures has the potential to inform resource allocation more efficiently.

The effects of a housing mobility experiment on participants' residential environments

We used the Moving to Opportunity (MTO) housing experiment to inform how housing choice vouchers and housing mobility policies can assist families living in high-poverty areas to make opportunity moves to higher quality neighborhoods, across a wide range of neighborhood attributes. We compared the neighborhood attainment of the three randomly-assigned MTO treatment groups (Low Poverty voucher, Section 8 voucher, Control group) at 1997 and 2002 locations (4-7 years after baseline), by using survey reports, and by linking residential histories to numerous different administrative and population-based datasets. Compared to controls, families in Low-Poverty and Section 8 groups experienced substantial improvements in neighborhood conditions across diverse measures, including economic conditions, social systems (e.g., collective efficacy), physical features of the environment (e.g., tree cover) and health outcomes. The Low-poverty voucher group moreover achieved better neighborhood attainment compared to Section 8. Treatment effects were largest for New York and Los Angeles. We discuss the implications of our findings for expanding affordable housing policy.

Building a National Neighborhood Dataset From Geotagged Twitter Data for Indicators of Happiness, Diet, and Physical Activity

Background

Studies suggest that where people live, play, and work can influence health and well-being. However, the dearth of neighborhood data, especially data that is timely and consistent across geographies, hinders understanding of the effects of neighborhoods on health. Social media data represents a possible new data resource for neighborhood research.

Objective

The aim of this study was to build, from geotagged Twitter data, a national neighborhood database with area-level indicators of well-being and health behaviors.

Methods

We utilized Twitter’s streaming application programming interface to continuously collect a random 1% subset of publicly available geolocated tweets for 1 year (April 2015 to March 2016). We collected 80 million geotagged tweets from 603,363 unique Twitter users across the contiguous United States. We validated our machine learning algorithms for constructing indicators of happiness, food, and physical activity by comparing predicted values to those generated by human labelers. Geotagged tweets were spatially mapped to the 2010 census tract and zip code areas they fall within, which enabled further assessment of the associations between Twitter-derived neighborhood variables and neighborhood demographic, economic, business, and health characteristics.

Results

Machine labeled and manually labeled tweets had a high level of accuracy: 78% for happiness, 83% for food, and 85% for physical activity for dichotomized labels with the F scores 0.54, 0.86, and 0.90, respectively. About 20% of tweets were classified as happy. Relatively few terms (less than 25) were necessary to characterize the majority of tweets on food and physical activity. Data from over 70,000 census tracts from the United States suggest that census tract factors like percentage African American and economic disadvantage were associated with lower census tract happiness. Urbanicity was related to higher frequency of fast food tweets. Greater numbers of fast food restaurants predicted higher frequency of fast food mentions. Surprisingly, fitness centers and nature parks were only modestly associated with higher frequency of physical activity tweets. Greater state-level happiness, positivity toward physical activity, and positivity toward healthy foods, assessed via tweets, were associated with lower all-cause mortality and prevalence of chronic conditions such as obesity and diabetes and lower physical inactivity and smoking, controlling for state median income, median age, and percentage white non-Hispanic.

Conclusions

Machine learning algorithms can be built with relatively high accuracy to characterize sentiment, food, and physical activity mentions on social media. Such data can be utilized to construct neighborhood indicators consistently and cost effectively. Access to neighborhood data, in turn, can be leveraged to better understand neighborhood effects and address social determinants of health. We found that neighborhoods with social and economic disadvantage, high urbanicity, and more fast food restaurants may exhibit lower happiness and fewer healthy behaviors.

Heterogeneous Effects of Housing Vouchers on the Mental Health of US Adolescents

OBJECTIVES

To assess the mental health effects on adolescents of low-income families residing in high-poverty public housing who received housing vouchers to assist relocation.

METHODS

We defined treatment effects to compare 2829 adolescents aged 12 to 19 years in families offered housing vouchers versus those living in public housing in the Moving to Opportunity experiment (1994-1997; Boston, MA; Baltimore, MD; Chicago, IL; Los Angeles, CA; New York, NY). We employed model-based recursive partitioning to identify subgroups with heterogeneous treatment effects on psychological distress and behavior problems measured in 2002. We tested 35 potential baseline treatment modifiers.

RESULTS

For psychological distress, Chicago participants experienced null treatment effects. Outside Chicago, boys experienced detrimental effects, whereas girls experienced beneficial effects. Behavior problems effects were null for adolescents who were aged 10 years or younger at baseline. For adolescents who were older than 10 years at baseline, violent crime victimization, unmarried parents, and unsafe neighborhoods increased adverse treatment effects. Adolescents who were older than 10 years at baseline without learning problems or violent crime victimization, and whose parents moved for better schools, experienced beneficial effects.

CONCLUSIONS

Health effects of housing vouchers varied across subgroups. Supplemental services may be necessary for vulnerable subgroups for whom housing vouchers alone may not be beneficial.

Racial disparity in the association between body mass index and self-reported asthma in children: a population-based study

OBJECTIVE

To examine the racial disparity in the association between obesity and asthma in US children and adolescents.

METHODS

This study was based on a nationally representative, random-digit-dial sample of US households with children less than 18 years of age from the National Survey of Children's Health in 2011/2012 and 2007. The study sample included 88,668 children ages 10-17 with data on body mass index (BMI), parental reporting of asthma diagnosis, and potential confounders. Multiple logistic regression analysis was performed to estimate the crude and adjusted odds ratios stratified by child race/ethnicity.

RESULTS

The prevalence of overweight was 15.2% and obesity was 14.1%. Self-reported asthma diagnosis was 16.7% in our study sample. Obese children were 51% more likely to have asthma compared to normal weight children after controlling for child's sex, child age, socioeconomic status, environmental tobacco smoke (ETS), and neighborhood conditions. Our study also shows that the strength of this association varied by race/ethnicity after stratification. Being male, being non-Hispanic Black or Multi-racial, below the Federal Poverty Level, ETS and having detracting neighborhood elements were also significantly associated with higher odds of having a self-reported asthma diagnosis.

CONCLUSION

We observed a racial difference in the association between BMI and asthma in US children. Our findings have significant public health implications and may help public health practitioners to target children and adolescents at higher risk of prevention and intervention efforts.