Housing Intervention For Medically Complex Families Associated With Improved Family Health: Pilot Randomized Trial

Longitudinal relationships between early-life homelessness and school-aged asthma and wheezing

BACKGROUND

Homelessness is a disruptive life event with profound impacts on children's health. It remains unclear, however, whether homelessness in early life has an enduring association with asthma and wheezing among school-aged children.

OBJECTIVE

To test whether early-life homelessness is prospectively associated with asthma and wheezing during school-aged years.

METHODS

We draw on data from 9242 children from the Avon Longitudinal Study of Parents and Children. Children were categorised as 'ever' or 'never' homeless based on maternal reports from the prenatal period through age 5 years. Children were assigned a binary indicator of asthma/wheezing based on maternal reports of asthma and wheezing at ages 6.8, 7.6 and 8.6 years. We used multilevel logistic regression models to test the association of interest in both bivariate analyses and models adjusted for a broad set of potential confounders. We conducted sensitivity analyses using generalised estimating equations and considering asthma and wheezing separately to test the robustness of the results.

RESULTS

Between 12.1% and 14.3% of children had asthma or wheezing at ages 6.8, 7.6 and 8.6 years, and these conditions were more common among ever homeless participants. Ever-homeless children displayed higher odds of asthma or wheezing than never-homeless children (OR: 1.59, 95% CI 1.02 to 2.48) after adjustment for child, maternal and household risk factors. Sensitivity analyses yielded similar results.

CONCLUSION

Early-life homelessness is prospectively associated with asthma and wheezing among school-aged children and should be prioritised by interventions promoting healthy child development.

Barriers and facilitators to obtaining accessible housing among children, youth and young adults with disabilities and their families: a scoping review

PURPOSE

Accessible housing is a fundamental human right and yet many children and youth with disabilities live in inaccessible, insecure, unaffordable and poor quality housing. The aim of our study was to understand the barriers and facilitators to obtaining accessible housing among children, youth and young adults with disabilities and their families.

METHODS

We conducted a scoping review involving seven international literature databases from 2000 to 2022 that identified 38 studies meeting our inclusion criteria.

RESULTS

The reviewed studies involved 10 countries over a 22-year period. Our review emphasized the following key trends: (1) barriers to obtaining accessible homes (i.e. common types of accessibility barriers, rates of inaccessible housing, factors affecting home accessibility), and negative impacts of inaccessible housing; and (2) rates and facilitators to obtaining accessible housing (i.e., common types of home modifications, enablers of home modifications) and positive impacts of accessible housing.

CONCLUSIONS

Our findings highlight the barriers and enablers of obtaining accessible housing among children, youth and young adults with disabilities and their families and the critical need to support them in securing appropriate housing.

Evaluating Intensity, Complexity, and Potential for Causal Inference in Social Needs Interventions: A Review of a Scoping Review

Importance

Interventions that address needs such as low income, housing instability, and safety are increasingly appearing in the health care sector as part of multifaceted efforts to improve health and health equity, but evidence relevant to scaling these social needs interventions is limited.

Objective

To summarize the intensity and complexity of social needs interventions included in randomized clinical trials (RCTs) and assess whether these RCTs were designed to measure the causal effects of intervention components on behavioral, health, or health care utilization outcomes.

Evidence Review

This review of a scoping review was based on a Patient-Centered Outcomes Research Institute-funded evidence map of English-language US-based RCTs of social needs interventions published between January 1, 1995, and April 6, 2023. Studies were assessed for features related to intensity (defined using modal values as providing as-needed interaction, 8 participant contacts or more, contacts occurring every 2 weeks or more often, encounters of 30 minutes or longer, contacts over 6 months or longer, or home visits), complexity (defined as addressing multiple social needs, having dedicated staff, involving multiple intervention components or practitioners, aiming to change multiple participant behaviors [knowledge, action, or practice], requiring or providing resources or active assistance with resources, and permitting tailoring), and the ability to assess causal inferences of components (assessing interventions, comparators, and context).

Findings

This review of a scoping review of social needs interventions identified 77 RCTs in 93 publications with a total of 135 690 participants. Most articles (68 RCTs [88%]) reported 1 or more features of high intensity. All studies reported 1 or more features indicative of high complexity. Because most studies compared usual care with multicomponent interventions that were moderately or highly dependent on context and individual factors, their designs permitted causal inferences about overall effectiveness but not about individual components.

Conclusions and Relevance

Social needs interventions are complex, intense, and include multiple components. Our findings suggest that RCTs of these interventions address overall intervention effectiveness but are rarely designed to distinguish the causal effects of specific components despite being resource intensive. Future studies with hybrid effectiveness-implementation and sequential designs, and more standardized reporting of intervention intensity and complexity could help stakeholders assess the return on investment of these interventions.

Family perspectives on provider conversations about housing needs for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) have unique, and often unmet, housing needs that place them at risk for housing insecurity and poor health outcomes. Yet, little is known about how families with CMC discuss their housing needs with healthcare providers. We sought to understand: (1) how housing is currently discussed between CMC caregivers and healthcare providers, and (2) how CMC caregivers want such conversations to occur.

METHODS

From August to November 2020, we conducted semi-structured interviews with parents/guardians of CMC (<26 years old) in Maryland as part of a larger study to understand their housing experience. Four questions on communication with providers about housing were developed a priori and included in this analysis. Qualitative content analysis was applied to interview transcripts.

RESULTS

Among 31 completed interviews, most participants were female (90%), lived in single-family homes (68%) and were from a mix of neighbourhood types (urban 19%, suburban 58%, rural 22%). Their children ranged in age from 6 months to 22 years, had a mix of insurance types (public 65%, private 29%, both 6%) and nearly all required medical equipment or technology. Four themes emerged: (1) Current housing conversations are rare and superficial, (2) Ideal housing conversations would result in thoughtful care plans and concrete supports, (3) Frequency and initiation of housing conversations are best tailored to family preferences and (4) Value of housing conversations are limited by lack of provider knowledge and time.

CONCLUSIONS

Conversations about housing needs for CMC happen in limited ways with healthcare providers, despite a desire on the part of their caregivers. Such conversations can give meaningful insights into the family's specific housing challenges, allowing providers to appropriately tailor care plans and referrals. Future work is needed to capture provider perspectives, design CMC-specific housing screeners and develop interdisciplinary referral strategies.

The potential role of social care in reducing childhood obesity

PURPOSE OF REVIEW

This review evaluates the current evidence for relationships of social factors with childhood obesity and for a role of social care in reduction of childhood obesity.

RECENT FINDINGS

Most literature on the relationship between social factors and childhood obesity has examined food insecurity as a risk factor for obesity. Associations between food insecurity and excess weight in children are most consistent during infancy and among those with food insecurity at more than one time point. A few pilot food security interventions that link patients with produce or groceries show feasibility and potential promise for reducing childhood obesity risk factors. However, full-scale, randomized studies to examine interventions that reduce social needs and their effects on childhood obesity are lacking. Future research is needed to examine holistic social care approaches to effectively reduce childhood obesity risk factors.

SUMMARY

Food insecurity acts as a barrier to childhood obesity prevention and treatment. Patient-centered, validated measures of social needs and effective interventions to address social needs are needed to equitably prevent and treat childhood obesity.

Evaluation of Income and Food Insecurity as Risk Factors for Failure to Thrive: An Analysis of National Survey Data

Limited data exist regarding the relationship between socioeconomic risk factors and failure to thrive (FTT). Using data from the National Health and Nutrition Examination Survey (NHANES) from years 1999 to 2014, we sought to determine whether there was a higher prevalence of underweight (<5th percentile weight-for-age [WFA], weight-for-length [WFL], or body mass index-for-age [BFA]), and, therefore, likely a higher risk of FTT, in US children <3 years with low household income or food insecurity compared with children without these factors. Among 7356 evaluated children, there were no significant differences in the prevalence of underweight by adjusted household income quintile, food security, household Women, Infants, and Children (WIC) status, or federal poverty income ratio. These findings do not support a link between low income or food security and underweight in children and, therefore, do not provide support for an association between low income or food security and FTT.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Association Between Material Hardship in Families With Young Children and Federal Relief Program Participation by Race and Ethnicity and Maternal Nativity

Importance

Even brief periods of hardship during early childhood may have lifelong consequences. Prior cross-sectional research limited to respondents with English proficiency and internet access during the COVID-19 crisis documented families with young children that struggled to afford basic needs like food and rent. Few studies have examined experiences of families with young children by race and ethnicity and maternal nativity.

Objective

To examine the association of COVID-19 relief programs with the mitigation of household food insecurity among families with young children, as well as being behind on rent and disparities in program receipt.

Design, Setting, and Participants

This cohort study used data from the ongoing repeat cross-sectional Children's HealthWatch study comprising families surveyed at baseline (January 1, 2018, to March 20, 2020) and during the COVID-19 crisis (September 1, 2020, to June 30, 2021). Baseline questionnaires were administered face to face to caregivers of children aged 48 months or younger in English or Spanish in emergency departments or primary care clinics in 5 US cities. The follow-up questionnaires were administered via telephone.

Exposures

Supplemental Nutrition Assistance Program (SNAP) participation or receipt of at least 1 Economic Impact Payment (EIP; ie, stimulus check) during the COVID-19 crisis.

Main Outcomes and Measures

The primary outcomes were household food insecurity (assessed via the US Household Food Security Survey Module: Six-Item Short Form) and being behind on rent. Logistic and binomial regression models were used to calculate adjusted odds ratios (aORs) and unadjusted and adjusted prevalence ratios (PRs).

Results

Of 1396 caregiver-child dyads (20.3% response rate), race and ethnicity data were available for 1357 caregivers: 514 (37.9%) were Black, non-Latino; 558 (41.1%) were Latino; 230 (16.9%) were White, non-Latino; and 55 (4.1%) were of other non-Latino race or ethnicity. Among 1390 responses with nonmissing data, 417 children (30.0%) had an immigrant mother, and among 1388 responses, 1238 (33.5%) were publicly insured. During the crisis, 467 of 1395 respondents (33.5%) reported household food insecurity, and 567 of 1391 respondents (40.8%) reported being behind on rent. Families with immigrant mothers had lower odds of EIP and SNAP participation than families with US-born mothers (eg, aOR, 0.07 [95% CI, 0.05-0.12] for both EIP and SNAP vs neither), despite being more likely to report household food insecurity (adjusted PR [aPR], 1.48 [95% CI, 1.28-1.71]) and being behind on rent (aPR, 1.14 [95% CI, 1.00-1.30]). Families with Black (unadjusted PR [uPR], 1.40 [95% CI, 1.08-1.82]) or Latino (uPR, 1.54 [95% CI, 1.19-1.98]) caregivers or caregivers of other race and ethnicity (uPR, 1.67 [1.12-2.49]) were also more likely than families with White, non-Latino caregivers to experience household food insecurity or being behind on rent (families with Black caregivers: uPR, 2.02 [95% CI, 1.58-2.58]; families with Latino caregivers: 1.68 [95% CI, 1.30-2.16]; families with caregivers of other race or ethnicity: uPR, 1.94 [95% CI, 1.34-2.80]). Adjustment for covariates and differential participation in relief programs did not entirely account for these disparities.

Conclusions and Relevance

The results of this cohort study suggest that the COVID-19 crisis exacerbated preexisting inequities in food insecurity and difficulty paying rent according to race and ethnicity and maternal nativity and that equity-focused policy changes are needed to ensure that all children and their families in the US can afford basic needs for optimal health.

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review

IMPORTANCE

Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities.

OBJECTIVE

To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity.

EVIDENCE REVIEW

Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity).

FINDINGS

Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences.

CONCLUSIONS AND RELEVANCE

In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Equity Rx: Boston Medical Center's Work to Accelerate Racial Health Justice

In November 2021, after more than a year of investigating the racial health disparities across its organization, Boston Medical Center launched the Health Equity Accelerator, a system-wide approach to holistically address the root causes of health inequities among people of different races and ethnicities and speed improvements in health outcomes. This article discusses lessons learned during the institution's process of discovery, shares examples of the work to dismantle a structural narrative that impedes health justice, and outlines interventions that can be applied to other healthcare systems across the United States.

Association of Promoting Housing Affordability and Stability With Improved Health Outcomes: A Systematic Review

IMPORTANCE

Housing insecurity-that is, difficulty with housing affordability and stability-is prevalent and results in increased risk for both homelessness and poor health. However, whether interventions that prevent housing insecurity upstream of homelessness improve health remains uncertain.

OBJECTIVE

To review evidence characterizing associations of primary prevention strategies for housing insecurity with adult physical health, mental health, health-related behaviors, health care use, and health care access.

EVIDENCE REVIEW

Pairs of independent reviewers systematically searched PubMed, Web of Science, EconLit, and the Social Interventions Research and Evaluation Network for quantitative studies published from 2005 to 2021 that evaluated interventions intended to directly improve housing affordability and/or stability either by supporting at-risk households (targeted primary prevention) or by enhancing community-level housing supply and affordability in partnership with the health sector (structural primary prevention). Risk of bias was appraised using validated tools, and the evidence was synthesized using modified Grading of Recommendations Assessment, Development, and Evaluation criteria.

FINDINGS

A total of 26 articles describing 3 randomized trials and 20 observational studies (16 longitudinal designs and 4 cross-sectional quasi-waiting list control designs) were included. Existing interventions have focused primarily on mitigating housing insecurity for the most vulnerable individuals rather than preventing housing insecurity outright. Moderate-certainty evidence was found that eviction moratoriums were associated with reduced COVID-19 cases and deaths. Certainty of evidence was low or very low for health associations of other targeted primary prevention interventions, including emergency rent assistance, legal assistance with waiting list priority for public housing, long-term rent subsidies, and homeownership assistance. No studies evaluated health system-partnered structural primary prevention strategies.

CONCLUSIONS AND RELEVANCE

This systematic review found mixed and mostly low-certainty evidence that interventions that promote housing affordability and stability were associated with improved adult health outcomes. Existing interventions may need to be paired with other efforts to address the structural determinants of health. As health care systems and insurers respond to increasing opportunities to invest in housing as a determinant of health, further research is needed to clarify where along the housing insecurity pathway interventions should focus for the most effective and equitable health impact.

Housing Instability and Homelessness-An Undertreated Pediatric Chronic Condition

This Viewpoint discusses housing instability and homelessness among children as well as the significance of the Housing First model, with particular focus on children in families.

The impact of COVID-19 and housing insecurity on lower-income Black women

During the COVID-19 pandemic, multiple groups faced increased risks for negative health and mortality. Using an intersectional framework, the current study explores how the global pandemic impacted lower-income women living in the United States through access to housing. Findings indicate several challenges  remaining stably housed during the pandemic. Major themes included: (1) High-Risk Survival Economies, (2) Landlord Stress, Deception, and Exclusion, (3) Landlord Harassment, (4) Low Levels of Formal and Informal Support, (5) Housing as a Health Risk Factor, and (6) Resilience. These themes are explored through four in-depth narrative accounts. Implications for health and policy are discussed. Future research that examines and engages with both direct (e.g., material scarcity) and indirect (e.g., discrimination) pathways that connect housing to health are strongly encouraged.

Eviction and Household Health and Hardships in Families With Very Young Children

BACKGROUND

Families with versus without children are at greater eviction risk. Eviction is a perinatal, pediatric, and adult health concern. Most studies evaluate only formal evictions.

METHODS

Using cross-sectional surveys of 26 441 caregiver or young child (<48 months) dyads from 2011 to 2019 in emergency departments (EDs) and primary care clinics, we investigated relationships of 5 year history of formal (court-involved) and informal (not court-involved) evictions with caregiver and child health, history of hospitalizations, hospital admission from the ED on the day of the interview, and housing-related and other material hardships.

RESULTS

3.9% of 26 441 caregivers reported 5 year eviction history (eviction), of which 57.0% were formal evictions. After controlling for covariates, we found associations were minimally different between formal versus informal evictions and were, therefore, combined. Compared to no evictions, evictions were associated with 1.43 (95% CI: 1.17-1.73), 1.55 (95% confidence interval [CI]: 1.32-1.82), and 1.24 (95% CI: 1.01-1.53) times greater odds of child fair or poor health, developmental risk, and hospital admission from the ED, respectively, as well as adverse caregiver and hardship outcomes. Adjusting separately for household income and for housing-related hardships in sensitivity analyses did not significantly alter results, although odds ratios were attenuated. Hospital admission from the ED was no longer significant.

CONCLUSIONS

Demonstrated associations between eviction and health and hardships support broad initiatives, such as housing-specific policies, income-focused benefits, and social determinants of health screening and community connections in health care settings. Such multifaceted efforts may decrease formal and informal eviction incidence and mitigate potential harmful associations for very young children and their families.

Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review

OBJECTIVES

Housing is a social determinant of health that impacts the health and well-being of children and families. Screening and referral to address social determinants of health in clinical and social service settings has been proposed to support families with housing problems. This study aims to identify housing screening questions asked of families in healthcare and social services, determine validated screening tools and extract information about recommendations for action after screening for housing issues.

METHODS

The electronic databases MEDLINE, PsycINFO, EMBASE, Ovid Emcare, Scopus and CINAHL were searched from 2009 to 2021. Inclusion criteria were peer-reviewed literature that included questions about housing being asked of children or young people aged 0-18 years and their families accessing any healthcare or social service. We extracted data on the housing questions asked, source of housing questions, validity and descriptions of actions to address housing issues.

RESULTS

Forty-nine peer-reviewed papers met the inclusion criteria. The housing questions in social screening tools vary widely. There are no standard housing-related questions that clinical and social service providers ask families. Fourteen screening tools were validated. An action was embedded as part of social screening activities in 27 of 42 studies. Actions for identified housing problems included provision of a community-based or clinic-based resource guide, and social prescribing included referral to a social worker, care coordinator or care navigation service, community health worker, social service agency, referral to a housing and child welfare demonstration project or provided intensive case management and wraparound services.

CONCLUSION

This review provides a catalogue of housing questions that can be asked of families in the clinical and/or social service setting, and potential subsequent actions.

Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study

Screening for social needs during routine medical visits is increasingly common. To date, there are limited data on which social needs are most predictive of health outcomes. The aim of this study is to build a predictive model from integrated social needs screening and health data to identify individual or clusters of social needs that are predictive of chronic illnesses. Using the electronic medical record data from a Federally Qualified Health Center collected from January 2016 to December 2020, demographic, diagnosis, and social needs screening data were used to look at adjusted and unadjusted associations of individual unmet social needs with chronic illnesses (n = 2497). The least absolute shrinkage and selection operator (LASSO) model was used to identify which social need(s) were associated with overall burden of chronic illness, and individual diagnoses of hypertension, obesity, diabetes, and psychiatric illness. The LASSO model identified age, race, language, gender, insurance, transportation, and food insecurity as significant predictors of any chronic illness. Using these variables in a multivariable model, transportation (adjusted odds ratio [aOR] 1.66) was the only social need that remained significantly associated with chronic illness diagnosis. Transportation need was also significantly associated with diabetes (aOR 1.44) and psychiatric illness (aOR 1.98). Food insecurity was associated with obesity (aOR 10.21). Using LASSO models to identify significant social needs, transportation was identified as a predictor in 3 of the 5 models. Further research is warranted to evaluate if addressing patients' transportation needs has the potential to mitigate chronic disease sequelae for vulnerable adults to advance health equity.

Identifying Value-Added Population Health Capabilities to Strengthen Public Health Infrastructure

Policy Points While the coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in delivery systems. The results of our study suggest that the public health system structure can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities can help communities efficiently use limited time and resources and identify the most effective pathways for building a stronger public health system and improving health outcomes over time.

CONTEXT

While the novel coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in public health delivery systems. Information about the relative value in the implementation of recommended population health capabilities can help communities prioritize their use of limited time and resources and identify the most effective pathways for building a stronger public health system.

METHODS

We used a longitudinal cohort design with data from the National Longitudinal Survey of Public Health Systems to examine longitudinal and geographic trends in the delivery of population health capabilities and their impact on system strength across communities in the United States. We used linear probability models to ascertain whether the delivery of certain capabilities added value to public health system strength.

FINDINGS

Those communities with the strongest classification of public health system structure in both urban and rural areas implemented the largest set of population health capabilities. Results from the linear probability model indicate that a set of population health capabilities are associated with increased public health system strength. Key activities include allocating resources based on a community health plan, surveying the community for behavioral risk factors, analyzing the data on preventive services use, and engaging community stakeholders in health improvement planning (p < 0.01).

CONCLUSIONS

The results of this study suggest that public health systems can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities may help communities increase their public health system's capacity and improve health outcomes.

Relationship between housing insecurity, diabetes processes of care, and self-care behaviors

Background

The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity.

Methods

Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count.

Results

38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99).

Conclusions

Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

Further Inspection: Integrating Housing Code Enforcement and Social Services to Improve Community Health

As a result of working inside homes, city housing inspectors witness hidden and serious threats to public health. However, systems to respond to the range of problems they encounter are lacking. In this study, we describe the impact and enabling environment for integrating a novel Social Service Referral Program within the Inspectional Services Department in Chelsea, MA. To evaluate the first eight months of the program, we used a mixed-methods approach combining quantitative data from 15 referrals and qualitative interviews with six key informants (inspectors, a case manager, and city leadership). The most common services provided to residents referred by inspectors were for fuel, food, and rent assistance; healthcare; hoarding; and homelessness prevention. Half of referred residents were not receiving other social services. Inspectors reported increased work efficiency and reduced psychological burden because of the program. Interviewees described how quality of life improved not only for referred residents but also for the surrounding neighborhood. A simple referral process that made inspectors’ jobs easier and a trusted, well-connected service provider funded to carry out the work facilitated the program’s uptake and impact. Housing inspectors’ encounters with residents present a unique opportunity to expand the public health impact of housing code enforcement.

Pediatric Primary Care-Based Social Needs Services and Health Care Utilization

OBJECTIVE

To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services.

METHODS

This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not.

RESULTS

Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively).

CONCLUSIONS

Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.

Neighborhood Poverty and Child Health: Investing in Communities to Improve Childhood Opportunity and Well-Being

If ZIP code is more important than genetic code in determining one's health and opportunities, how can pediatricians enable healthy and opportunity-rich environments for all children? This paper introduces a broad network of organizations, policies, and financial resources that are working to improve ZIP codes by tackling poverty at the neighborhood level. The mission-driven US community development sector began with the War on Poverty in the 1960s and 70s and comprises a network of finance, real estate, and community-based organizations working together to overturn decades of racially motivated disinvestment, revitalize persistently marginalized, low-income communities, and enhance the lives of the people who live in them. Across the country, thousands of community development corporations, community development financial institutions, affordable housing developers, and regulated for-profit banks together invest over $300 billion annually in affordable housing, childcare and early learning facilities, recreation centers, community clinics, grocery stores, small businesses, and financial services for low-income families and neighborhoods. We present successful examples of community development efforts targeting child health and opportunity and highlight opportunities for pediatricians to advise, collaborate, and partner in order to accelerate and maximize the impact of billions of dollars invested in support of healthier neighborhoods where all children can grow and thrive.

Housing and Neighborhoods as Root Causes of Child Poverty

Understanding how housing inequities among families with children are rooted in structural racism is important for identifying opportunities to engage in ongoing and collective work as pediatricians to lift children out of poverty. This article discusses the complex mechanisms between housing and child and family health outcomes, and offers potential solutions linking housing, health programs, and policy solutions. Beginning with a review of historical antecedents of housing policy and their impact on health inequities, the authors outlines policies and structures directly linked to disproportionate housing instability and inequities in health outcomes among children. This article examines four key domains of housing - affordability, stability, quality, and neighborhood - and their relationship to child and family health. Finally, the authors present multidimensional solutions for advancing health equity.

Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force

IMPORTANCE

Evidence-based guidance is limited on how clinicians should screen for social risk factors and which interventions related to these risk factors improve health outcomes.

OBJECTIVE

To describe research on screening and interventions for social risk factors to inform US Preventive Services Task Force considerations of the implications for its portfolio of recommendations.

DATA SOURCES

Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Sociological Abstracts, and Social Services Abstracts (through 2018); Social Interventions Research and Evaluation Network evidence library (January 2019 through May 2021); surveillance through May 21, 2021; interviews with 17 key informants.

STUDY SELECTION

Individual-level and health care system-level interventions with a link to the health care system that addressed at least 1 of 7 social risk domains: housing instability, food insecurity, transportation difficulties, utility needs, interpersonal safety, education, and financial strain.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data from studies and a second investigator evaluated data abstractions for completeness and accuracy; key informant interviews were recorded, transcribed, summarized, and integrated with evidence from the literature; narrative synthesis with supporting tables and figures.

MAIN OUTCOMES AND MEASURES

Validity of multidomain social risk screening tools; all outcomes reported for social risk-related interventions; challenges or unintended consequences of screening and interventions.

RESULTS

Many multidomain social risk screening tools have been developed, but they vary widely in their assessment of social risk and few have been validated. This technical brief identified 106 social risk intervention studies (N = 5 978 596). Of the interventions studied, 73 (69%; n = 127 598) addressed multiple social risk domains. The most frequently addressed domains were food insecurity (67/106 studies [63%], n = 141 797), financial strain (52/106 studies [49%], n = 111 962), and housing instability (63/106 studies [59%], n = 5 881 222). Food insecurity, housing instability, and transportation difficulties were identified by key informants as the most important social risk factors to identify in health care. Thirty-eight studies (36%, n = 5 850 669) used an observational design with no comparator, and 19 studies (18%, n = 15 205) were randomized clinical trials. Health care utilization measures were the most commonly reported outcomes in the 68 studies with a comparator (38 studies [56%], n = 111 102). The literature and key informants described many perceived or potential challenges to implementation of social risk screening and interventions in health care.

CONCLUSIONS AND RELEVANCE

Many interventions to address food insecurity, financial strain, and housing instability have been studied, but more randomized clinical trials that report health outcomes from social risk screening and intervention are needed to guide widespread implementation in health care.

A Community Partnership to House and Care for Complex Patients with Unstable Housing

Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.

International Evidence on the Impact of Health-Justice Partnerships: A Systematic Scoping Review

Background: Health-justice partnerships (HJPs) are collaborations between healthcare and legal services which support patients with social welfare issues such as welfare benefits, debt, housing, education and employment. HJPs exist across the world in a variety of forms and with diverse objectives. This review synthesizes the international evidence on the impacts of HJPs.

Methods: A systematic scoping review of international literature was undertaken. A wide-ranging search was conducted across academic databases and grey literature sources, covering OECD countries from January 1995 to December 2018. Data from included publications were extracted and research quality was assessed. A narrative synthesis approach was used to analyze and present the results.

Results: Reported objectives of HJPs related to: prevention of health and legal problems; access to legal assistance; health improvement; resolution of legal problems; improvement of patient care; support for healthcare services; addressing inequalities; and catalyzing systemic change. There is strong evidence that HJPs: improve access to legal assistance for people at risk of social and health disadvantage; positively influence material and social circumstances through resolution of legal problems; and improve mental wellbeing. A wide range of other positive impacts were identified for individuals, services and communities; the strength of evidence for each is summarized and discussed.

Conclusion: HJPs are effective in tackling social welfare issues that affect the health of disadvantaged groups in society and can therefore form a key part of public health strategies to address inequalities.

More Than Shelter: Housing for Urban Maternal and Infant Health

Housing quality, stability, and affordability have a direct relationship to socioemotional and physical health. Both city planning and public health have long recognized the role of housing in health, but the complexity of this relationship in regard to infant and maternal health is less understood. Focusing on literature specifically relevant to U.S. metropolitan areas, I conduct a multidisciplinary literature review to understand the influence of housing factors and interventions that impact infant and maternal health. The paper seeks to achieve three primary goals. First, to identify the primary "pathways" by which housing influences infant and maternal health. Second, the review focuses on the role and influence of historical housing discrimination on maternal health outcomes. Third, the review identifies emergent practice-based housing interventions in planning and public health practice to support infant and maternal health. The literature suggests that the impact of housing on infant health is complex, multifaceted, and intergenerational. Historical housing discrimination also directly impacts contemporary infant and maternal health outcomes. Policy interventions to support infant health through housing are just emerging but demonstrate promising outcomes. Structural barriers to housing affordability in the United States will require new resources to foster greater collaboration between the housing and the health sectors.

Household material hardships impact emergency department reliance in pediatric patients with sickle cell disease

BACKGROUND

In sickle cell disease (SCD), high emergency department (ED) utilization is associated with worse outcomes and increased costs. A metric called ED reliance (EDr), the percentage of healthcare visits that occur in the ED, attempts to identify ED overutilization. It is unknown if household material hardships (HMH)-housing, utility, or food insecurity-impact reliance on the ED. As these may represent modifiable risk factors for high ED utilization, we aimed to estimate the association between HMH and EDr in pediatric patients with SCD.

METHODS

We reviewed the electronic medical records of pediatric patients with SCD who received care in the Boston Medical Center network in Massachusetts, USA, to collect data on HMH and healthcare utilization. Using linear regression to control for potential confounders, we modeled the association between material hardships and EDr.

RESULTS

Of 101 eligible patients, 60 (59%) reported one or more HMH. The mean EDr was 12% overall, with significant differences between those with and without HMH (15.9 vs 5.9, P = 0.0001). Each additional hardship experienced was associated with an increased average EDr of 7.7 percentage points (R²  = 0.34, P < 0.0001). Housing and utility hardships were each independently associated with increased EDr.

CONCLUSION

HMH are associated with significantly increased EDr in children with SCD, independent of transportation hardship or insurance type. Through screening for HMH, providers and health systems could identify at-risk patients with modifiable risk factors for high EDr in order to provide them additional support.

Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health

US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.