Subsidized Housing and Adult Asthma in Boston, 2010-2015

Patterns and drivers of disparities in pediatric asthma outcomes among Medicaid-enrolled children living in subsidized housing in NYC

OBJECTIVE

There are persistent disparities in pediatric asthma morbidity in the U.S. We linked claims data with information on neighborhood-level risk factors to explore drivers of asthma disparities among Medicaid-enrolled children in New York City subsidized housing.

METHODS

We constructed a cohort of Medicaid-enrolled children living in public or other subsidized housing, based on residential address, in NYC between 2016 and 2019 (n = 108,969). We examined claims-derived asthma prevalence across age and racial and ethnic groups, integrating census tract-level information and using the Bayesian Improved Surname Geocoding (BISG) algorithm to address high rates of missing data in self-reported race and ethnicity. We used inverse probability weighting (IPW) to explore the extent to which disparities persisted when exposure to asthma risk factors - related to the built environment, neighborhood poverty, and air quality - were balanced across groups. This analysis was conducted in 2022-2023.

RESULTS

Claims-derived asthma prevalence was highest among children <7 years at baseline and among non-Hispanic Black and Hispanic children. For example, among children aged 3-6 years at baseline, claims-derived prevalence was 17.3% and 18.1% among non-Hispanic Black and Hispanic children, respectively, compared to 9.3% and 9.0% among non-Hispanic White and non-Hispanic Asian American/Pacific Islander children. Using IPW to balance exposure to asthma risk factors across racial and ethnic groups attenuated, but did not eliminate, disparities in asthma prevalence.

CONCLUSIONS

We found high asthma burden among children living in subsidized housing. Modifiable place-based characteristics may be important contributors to pediatric asthma disparities.

Housing Insecurity and Asthma Outcomes

Asthma is a chronic respiratory disease with widespread prevalence that affects children, adolescents, and adults. Asthma morbidity and mortality can be exacerbated in the setting of housing insecurity. In this Grand Rounds Review article, we present a case and discuss the implications that housing insecurity has on asthma outcomes in the United States. We then highlight ways in which providers can advocate for patients with asthma and housing insecurity.

Housing and Inequalities in US Life Expectancy, Child and Youth Mortality, and All-Cause and Cause-Specific Mortality, 1979-2020: Results from the National Longitudinal Mortality Study and the National Vital Statistics System

Background

Limited research exists on the association between housing, life expectancy, and mortality disparities in the United States (US). Using longitudinal individual-level and pooled county-level mortality data from 1979 to 2020, we examine disparities in life expectancy, child and youth mortality, and all-cause and cause-specific mortality in the US by several housing variables.

Methods

Using the 1979-2011 National Longitudinal Mortality Study (N=1,313,627) and the 2011-2020 linked county-level National Mortality Database and American Community Survey, we analyzed disparities in life expectancy and all-cause and cause-specific disparities by housing tenure, household crowding, and housing stability. Multivariate Cox proportional hazards regression was used to analyze individual-level mortality differentials by housing tenure. Age-adjusted mortality rates and rate ratios were used to analyze area-level disparities in mortality by housing variables.

Results

US homeowners had, on average, a 3.5-year longer life expectancy at birth than renters (74.22 vs. 70.76 years), with advantages in longevity associated with homeownership being greater for males than for females; for American Indians/Alaska Natives, non-Hispanic Whites, and non-Hispanic Blacks than for Asian/Pacific islanders and Hispanics; and for the US-born than for immigrants. Compared with renters, homeowners had 22% lower risks of all-cause mortality, 15% lower child mortality, 17% lower youth mortality, and significantly lower mortality from cardiovascular diseases, all cancers combined, stomach, liver, esophageal and cervical cancer, diabetes, influenza and pneumonia, COPD, cirrhosis, kidney disease, HIV/AIDS, infectious diseases, unintentional injuries, suicide, and homicide.

Conclusion and Global Health Implications

Several aspects of housing are strongly associated with life expectancy, child and youth mortality, and all-cause and cause-specific mortality in the US. Policies that aim to provide well-designed, accessible, and affordable housing to residents of both developed and developing countries are important policy options for addressing one of the most fundamental determinants of health for disadvantaged individuals and communities and for reducing health inequities globally.

Asthma disparities among U.S. children and adults

OBJECTIVE

To assess factors that are associated with asthma prevalence and asthma attacks among children (0-17 years) and adults (18 years and over) in the United States of America.

METHODS

The 2019-2021 National Health Interview Survey data were analyzed using multivariable logistic regression models to determine associations between health outcomes (i.e. current asthma and asthma attacks) and demographic and socioeconomic factors. Each health outcome was regressed over each characteristic variable, adjusting for age, sex, and race/ethnicity for adults and sex and race/ethnicity for children.

RESULTS

Asthma was more common among children who were male, blacks, parental education less than bachelor's, or had public health insurance, and among adults who had less than a bachelor's degree, do not own a home, or not in the workforce. Persons in families facing difficulty paying medical bills were more likely to have current asthma (children: aPR = 1.62[1.40-1.88]; adults: aPR = 1.67[1.55-1.81]) and asthma attacks (children: aPR = 1.34[1.15-1.56]; adults: aPR = 1.31[1.20-1.43]). Persons with family income <100% federal poverty threshold (FPT) (children: aPR = 1.39[1.17-1.64]; adults: aPR = 1.64[1.50-1.80]) or adults 100-199% FPT (aPR = 1.28[1.19-1.39]) were more likely to have current asthma. Children and adults with family income <100% FPT and adults 100-199% FPT were also more likely to have asthma attacks. Having asthma attacks was common among adults not in the workforce as well (aPR = 1.17[1.07-1.27]).

CONCLUSIONS

Asthma affects certain groups disproportionately. The findings of this paper suggesting asthma disparities continue to persist may increase public health programs awareness to better deliver effective and evidence-based interventions.

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.

Questions in Mild Asthma: An Official American Thoracic Society Research Statement

Background: Patients with mild asthma are believed to represent the majority of patients with asthma. Disease-associated risks such as exacerbations, lung function decline, and death have been understudied in this patient population. There have been no prior efforts from major societies to describe research needs in mild asthma. Methods: A multidisciplinary, diverse group of 24 international experts reviewed the literature, identified knowledge gaps, and provided research recommendations relating to mild asthma definition, pathophysiology, and management across all age groups. Research needs were also investigated from a patient perspective, generated in conjunction with patients with asthma, caregivers, and stakeholders. Of note, this project is not a systematic review of the evidence and is not a clinical practice guideline. Results: There are multiple unmet needs in research on mild asthma driven by large knowledge gaps in all areas. Specifically, there is an immediate need for a robust mild asthma definition and an improved understanding of its pathophysiology and management strategies across all age groups. Future research must factor in patient perspectives. Conclusions: Despite significant advances in severe asthma, there remain innumerable research areas requiring urgent attention in mild asthma. An important first step is to determine a better definition that will accurately reflect the heterogeneity and risks noted in this group. This research statement highlights the topics of research that are of the highest priority. Furthermore, it firmly advocates the need for engagement with patient groups and for more support for research in this field.

Subsidised housing and diabetes mortality: a retrospective cohort study of 10 million low-income adults in Brazil

INTRODUCTION

Housing-related factors can be predictors of health, including of diabetes outcomes. We analysed the association between subsidised housing residency and diabetes mortality among a large cohort of low-income adults in Brazil.

RESEARCH DESIGN AND METHODS

A cohort of 9 961 271 low-income adults, observed from January 2010 to December 2015, was created from Brazilian administrative records of social programmes and death certificates. We analysed the association between subsidised housing residency and time to diabetes mortality using a Cox model with inverse probability of treatment weighting and regression adjustment. We assessed inequalities in this association by groups of municipality Human Development Index. Diabetes mortality included diabetes both as the underlying or a contributory cause of death.

RESULTS

At baseline, the mean age of the cohort was 40.3 years (SD 15.6 years), with a majority of women (58.4%). During 29 238 920 person-years of follow-up, there were 18 775 deaths with diabetes as the underlying or a contributory cause. 340 683 participants (3.4% of the cohort) received subsidised housing. Subsidised housing residents had a higher hazard of diabetes mortality compared with non-residents (HR 1.17; 95% CI 1.05 to 1.31). The magnitude of this association was more pronounced among participants living in municipalities with lower Human Development Index (HR 1.30; 95% CI 1.04 to 1.62).

CONCLUSIONS

Subsidised housing residents had a greater risk of diabetes mortality, particularly those living in low socioeconomic status municipalities. This finding suggests the need to intensify diabetes prevention and control actions and prompt treatment of the diabetes complications among subsidised housing residents, particularly among those living in low socioeconomic status municipalities.

A Matched Analysis of the Association Between Federally Mandated Smoke-Free Housing Policies and Health Outcomes Among Medicaid-Enrolled Children in Subsidized Housing, New York City, 2015-2019

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory tract infections, and upper respiratory tract infections in the early post-policy intervention period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to the policy) to children living in lots with other subsidized housing (unexposed to the policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015, and December 31, 2019 (the policy was introduced on July 30, 2018). We also examined effect modification by baseline age group (≤2, 3-6, or 7-15 years). In New York City, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early postpolicy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient upper respiratory tract infection claims (incidence rate ratio = 1.05, 95% confidence interval: 1.01, 1.08), a result most pronounced among children aged 3-6 years. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

Housing environments and asthma outcomes within population-based samples of adults and children in NYC

Exposure to indoor environmental risk factors is associated with patterns of asthma morbidity. In this study, we assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). We used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma ("ever asthma") and experiencing a past-year asthma attack. We further examined whether associations were modified by smoking status (among adults), smoking within the home (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.35, 2.84), and past-year asthma attack (OR = 2.24; 95% CI 1.21,4.18). Living in rental assistance housing was also significantly associated with ever asthma (OR = 1.75; 95% CI 1.16, 2.66). Associations between public or rental assistance housing and ever asthma were marginally non-significant among children. Associations between living in public or rental assistance housing and ever asthma were more pronounced among ever smokers than among never smokers. Housing environments remain important predictors of both pediatric and adult asthma morbidity. Associations between living in subsidized housing and asthma outcomes among adults are most apparent among ever smokers.

Master Clinician and Public Health Practitioner: Selected Occupational and Environmental Pulmonary Cases

Occupational and environmental exposures contribute to the development and progression of most lung diseases, yet their impact is greatly under-recognized in clinical practice. Clinicians caring for patients with respiratory diseases should maintain a high index of suspicion for occupational and environmental contributing factors. Mastering occupational and environmental medicine clinical decision making requires specialized clinical skills. These skills include obtaining an appropriate work and exposure history; making an assessment of the magnitude and relevance of exposures and their contribution to a patient's respiratory disease; utilizing appropriate resources for evaluation and management of exposure-related disease; and considering socioeconomic and public health factors.

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.

Housing stability and diabetes among people living in New York city public housing

Public housing provides affordable housing and, potentially, housing stability for low-income families. Housing stability may be associated with lower incidence or prevalence and better management of a range of health conditions through many mechanisms. We aimed to test the hypotheses that public housing residency is associated with both housing stability and reduced risk of diabetes incidence, and the relationship between public housing and diabetes risk varies by levels of housing stability. Using 2004-16 World Trade Center Health Registry data, we compared outcomes (housing stability measured by sequence analysis of addresses, self-reported diabetes diagnoses) between 730 New York City public housing residents without prevalent diabetes at baseline and 730 propensity score-matched non-public housing residents. Sequence analysis found 3 mobility patterns among all 1460 enrollees, including stable housing (65%), limited mobility (27%), and unstable housing patterns (8%). Public housing residency was associated with stable housing over 12 years. Diabetes risk was not associated with public housing residency; however, among those experiencing housing instability, a higher risk of diabetes was found among public housing versus non-public housing residents. Of those stably housed, the association remained insignificant. These findings provide important evidence for a health benefit of public housing via housing stability among people living in public housing.

Affordable, Social, and Substandard Housing and Mortality: The EPIPorto Cohort Study, 1999-2019

Objectives. To examine the association between residence in different housing typologies and all-cause and cause-specific mortality, and to compare with the 25 × 25 risk factors defined by the World Health Organization.Methods. We used data from EPIPorto cohort (Porto, Portugal; n = 2485). We georeferenced and matched participants to a housing type-conventional, affordable, social, or substandard housing (locally called ilhas). We used Poisson regression models to estimate mortality rates and associations.Results. Age- and sex-adjusted mortality rates (per 100 000 person-years) were 713 (95% confidence interval [CI] = 584, 863) for individuals residing in conventional housing, and 1019 (95% CI = 637, 1551), 1200 (95% CI = 916, 1551), and 1239 (95% CI = 839, 1772) for individuals residing in affordable housing, social housing, and ilhas, respectively. After further adjustment, the associations between mortality and residence in social housing (rate ratio [RR] = 1.59; 95% CI = 1.22, 2.06) and in ilhas (RR = 1.64; 95% CI = 1.12, 2.33) remained. The association between disadvantaged housing and mortality was stronger than that observed for well-established risk factors such as hypertension, sedentariness, heavy drinking, manual occupation, or obesity.Conclusions. Disadvantaged housing is a major risk factor for mortality that should be accounted for by health policies and surveillance systems.

Residential mobility and chronic disease among World Trade Center Health Registry enrollees, 2004-2016

Residential mobility is hypothesized to impact health through changes to the built environment and disruptions in social networks, and may vary by neighborhood deprivation exposure. However, there are few longitudinal investigations of residential mobility in relation to health outcomes. This study examined enrollees from the World Trade Center Health Registry, a longitudinal cohort of first responders and community members in lower Manhattan on September 11, 2001. Enrollees who completed ≥2 health surveys between 2004 and 2016 and did not have diabetes (N = 44,089) or hypertension (N = 35,065) at baseline (i.e., 2004) were included. Using geocoded annual home addresses, residential mobility was examined using two indicators: moving frequency and displacement. Moving frequency was defined as the number of times someone was recorded as living in a different neighborhood; displacement as any moving to a more disadvantaged neighborhood. We fit adjusted Cox proportional hazards models with time-dependent exposures (moving frequency and displacement) and covariates to evaluate associations with incident diabetes and hypertension. From 2004 to 2016, the majority of enrollees never moved (54.5%); 6.5% moved ≥3 times. Those who moved ≥3 times had a similar hazard of diabetes (hazard ratio (HR) = 0.78; 95% Confidence Interval (CI): 0.40, 1.53) and hypertension (HR = 0.99; 95% CI: 0.68, 1.43) compared with those who never moved. Similarly, displacement was not associated with diabetes or hypertension. Residential mobility was not associated with diabetes or hypertension among a cohort of primarily urban-dwelling adults.

New Directions in Pediatric Asthma

Childhood asthma affects many children placing them at significant risk for health care utilization and school absences. Several new developments relevant to the field of pediatric asthma have occurred over the last 5 years; yet, there is much more to learn. It is poorly understood how to prevent the disease, optimally address environmental challenges, or effectively manage poor adherence. Moreover, it is not clear how to customize therapy by asthma phenotype, age group, high risk groups, or severity of disease. Highlights of advances in pediatric asthma are reviewed and multiple essential areas for further exploration and research are discussed.

The Effects of the Environment on Asthma Disease Activity

Asthma is highly prevalent and causes significant morbidity in children. The development of asthma depends on complex relationships between genetic predisposition and environmental modifiers of immune function. The biological and physical environmental factors include aeroallergens, microbiome, endotoxin, genetics, and pollutants. The psychosocial environment encompasses stress, neighborhood safety, housing, and discrimination. They all have been speculated to influence asthma control and the risk of developing asthma. Control of the factors that contribute to or aggravate symptoms, interventions to eliminate allergen exposure, guidelines-based pharmacologic therapy, and education of children and their caregivers are of paramount importance.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.