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Housing and Health: A Comprehensive Solution . Presented by Mary E. Homan, MA Saint Louis University School of Public Health 28 January 2008.

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    1. Housing and Health: A Comprehensive Solution Presented by Mary E. Homan, MA Saint Louis University School of Public Health 28 January 2008

    2. “A comprehensive, holistic and systems approach to the health and safety-related problems of substandard housing is more efficient and effective than a categorical approach.” (Tsou, 2005)

    3. Healthy People 2010: Understanding and Improving Health • Part of the Healthy People 2010 initiative sponsored by the U.S. Department of Health and Human Services. • Healthy People 2010 is grounded in science, built through public consensus, and designed to measure progress.

    4. Determinants of health 1. Heredity 2. Social environment 3. Physical environment 4. Behavior

    5. Housing as determinant of health • Access to fair, safe, and adequate housing leads to lower rates of acute care utilization, fewer preventable emergency department visits, provides stability to larger social environment.

    6. Fair Housing Act • Title VIII of the Civil Rights Act of 1968, with the Fair Housing Amendments Act of 1988, is called the Fair Housing Act. • These combined laws make it illegal to discriminate in housing sales or rentals or in housing lending, advertising, insurance, appraisals and zoning

    7. It is illegal to discriminate on the basis of • Race, color, or national origin • Familial status • Disability • Sex • Religion • Additionally, the City of Saint Louis prohibits discrimination on the basis of • Sexual Orientation • Source of Income • Marital Status (lending)

    8. The Threat of Housing Instability: Vulnerable Populations • On average, homeless women are disproportionately young and non-white (Phinney et al, 2007) • single-mothered families are much more likely to be poor and to have fewer economic resources upon which to call upon in times of need • domestic violence may increase the risk of eviction and homelessness • Discrimination may amplify housing instability among members of minority groups • Young adults may be vulnerable to housing instability because they have not developed the economic and social resources to help them obtain and retain housing

    9. Human capital (work experience, work skills, and education) deficiencies may foster housing instability if those who are job-less or working low-paying jobs have difficulty making monthly rental payments

    10. Housing Instability as Barrier to Care

    11. The National Survey of American Families (NASF) • Household survey conducted by the Urban Institute, was designed to provide a nationally representative sample of the civilian, non-institutionalized US population under the age of 65 years. • Interviews were conducted between Feb and Oct 1999. • 1999 public use data files provide data on over 100,000 non-elderly persons from over 42,000 households sampled from 13 states.

    12. NASF Continued • In order to obtain information on the low income population, researchers over sampled families with incomes less than 200% of the federal poverty level and did not include homeless or institutionalized persons.

    13. Kushel et al, 2005 • Secondary data analysis of NASF • Reported • 16,651 subjects • median age: 37 • 56.7% female • 57.1% white • less than one-fifth of the respondents reported their HHI to be less than 50% FPL; the remainder was evenly divided between 50-100%FPL, 100-150% FPL, and 150-200% FPL

    14. Choosing to pay rent, buy food or seek medical care • Nearly half (42.7%) of low-income adults reported food insecurity: cutting the size of or skipping meals (21.4%), running out of food (38.0%), or worrying about running out of food because of lack of money. • One quarter (23.6%) reported housing instability: difficulty paying rent, mortgage, or utilities. • Among those with housing instability, 76.7% reported food insecurity. • Among those with food insecurity, 42.4% reported housing instability.

    15. Housing instability and food insecurity are associated with poor access to ambulatory care and high rates of acute care (Kushel et al, 2005). • Individuals reporting food insecurity or housing instability were more likely to delay seeking needed care or taking necessary medications.

    16. Housing instability was associated with: • Not having a usual source of care (AOR* 1.31, 95% CI 1.08 to 1.59), • Postponing needed health care (AOR 1.84, 95% CI 1.46 to 2.31), and • Postponing needed medications (AOR 2.16, 95% CI 1.70 to 2.74). • Housing instability was a barrier to having a usual source of care, thus impeding continuity of care. *Adjusted Odds Ratio

    17. Food insecurity was associated with: • Postponing needed health care (AOR 1.74, 95% CI 1.38 to 2.21) and • Postponing medications (AOR 2.15, 95% CI 1.62 to 2.85).

    18. Acute Care Utilization • Both housing instability and food insecurity were associated with increasing numbers of ED visits and having had an non-pregnancy related hospitalization in the previous year • Housing instability (AOR: 1.43, 95% CI 1.20 to 1.70) and food insecurity (AOR 1.40, 95% CI 1.17 to 1.66) were associated with a single category increase in ED use. • In a multivariate model, housing instability (AOR 1.30, 95% CI 1.01 to 1.67) and food insecurity (AOR 1.42, 95% CI 1.09 to 1.85) were both associated with hospitalizations.

    19. Chronic medical problems due to poor housing • Increased rates of infectious diseases as well as chronic medical conditions have been reported, ranging from community-acquired pneumonia, tuberculosis, and HIV to cardiovascular disease and chronic obstructive lung disease (Schanzer, 2007).

    20. Housing Instability and Children (CCHS, 2005) • After controlling for potential explanatory factors, homeless children remained more likely to experience fair or poor health status. • School-related problems are common among homeless children and include sporadic attendance or nonattendance, grade repetition, and below-average performance.

    21. Homeless children have a higher incidence of trauma-related injuries, developmental delays, sinusitis, anemia, asthma, bowel dysfunction, eczema, and visual and neurological deficits. Obesity and hunger are also common among homeless children. • Runaway youth or young people living on the streets are at significant risk of violence and victimization, substance abuse, pregnancy and sexually transmitted diseases, including HIV infection and AIDS.

    22. Health Issues in the Saint Louis Area • In the five census tracts** with the highest screening prevalence rates of lead poisoning, over 1/3 of the children tested are lead-poisoned. • Over 90% of the housing stock in those five census tracts is pre-1950 which means that almost every child resides in a lead-infested house and cannot afford to move because 63.41% rent housing§. **Census Tracts 111400, 116400, 118600, 124100, and 126700

    23. Pediatric Asthma in Saint Louis • Current asthma prevalence among children is 9.1% in the St. Louis region, compared to 8% for all children in Missouri. • Children under the age of 15, with asthma complications, accounted for 45% of ED visits in St. Louis City and 50% of ED visits in St. Louis City.

    24. Missouri Housing Trust Fund Coalition • During the 2006 project year the Missouri Housing Trust Fund provided housing assistance to families and individuals, veterans and the elderly • 7,350 received assistance to prevent eviction and foreclosure • 1,550 received assistance with first month’s rent and deposit to obtain affordable housing • 351 were assisted with repairs that made their homes accessible and safe • 96 affordable housing units were created through new construction or rehabilitation • Unfortunately, in 2006 Missouri Housing Trust Fundswere available for only 25% of requested needs

    25. Changing Policy to Reflect Evidence-Based Practices

    26. General Policy Implications • Risk factors should be given more attention to by policymakers and practitioners • screening welfare recipients for health, mental health, drug uses and domestic violence problems could identify many of the women facing the greatest risks of homelessness • caseworkers might investigate housing concerns among welfare recipients with exposure to domestic violence

    27. Federal Housing Policy • Federal housing programs are not entitlements • relatively few low-income households receive housing assistance • Policies that improve housing stability (such as rent support programs, housing vouchers, and expansion of low-income housing availability) and food security (such as through the expansion of the food stamp program) may improve access to health care and health care outcomes§

    28. CDC and HUD • The Centers for Disease Control and Prevention and the U.S. Department of Housing and Urban Development are strongly promoting the "Healthy Homes Initiative” and • Establishing the National Healthy Homes Training Center and Network

    29. Healthy Homes Initiative • Promotes • the use of research to determine causal relations between housing and health and safety • the collection of local data to define problems and monitor progress toward reducing or eliminating housing deficiencies and hazards • the development of guidelines to assess, identify and reduce or eliminate risks • the identification and implementation of low-cost, reliable and practical solutions to housing deficiencies.

    30. National Healthy Homes Training Center and Network • Its purpose is to encourage public health and housing programs to address housing deficiencies and health hazards. • Environmental health practitioners, public health nurses, housing specialists and others are being cross-trained to build their capacity and competency across multiple disciplines.

    31. Medical Trainees as Community Advocates • Three educational strategies (Oandasan, 2003) • Student exposure to marginalized populations • Exposure to role models • Explicitness about how current learning activities help in the development of the physician as community advocate role

    32. Student exposure to marginalized populations • Provide or require clinical exposure to marginalized and underserved populations is supported by the impact such exposure had on the community-responsive physicians in their decisions regarding where to practice after training. • Students who had formal learning opportunities working with communities were more likely to incorporate this learning into their medical practices after graduation.

    33. Student exposure to role models • Involves communicating to students that their medical schools regard advocacy an important educational domain. • This communication can be achieved by appointing faculty who personify responsiveness, which may be role modeled to students. • Students learn not merely what they are taught, but also what they gather from the behavior of teachers who serve as role models.

    34. Current learning activities help in the development of the physician • Curricula should ensure that specific goals are infused into learning activities for students to aspire to attain. • To develop socially accountable or community-responsive physicians, the educational component should include a continuum of learning activities from undergraduate education to residency and into practice.

    35. Creating a clear link between existing areas of study in medical school (related to the social determinants of health, medical ethics, and community health electives) and the knowledge, skills, and attitudes needed to become a community advocate would improve the opportunities educators have in assisting trainees to develop community responsiveness and advocacy.

    36. In the words of two physicians from this study • “Advocacy is a basic responsibility of a physician.” • “You don’t arrive as an advocate—you develop into an advocate.”

    37. Housing Resources Coalition for the Missouri Housing Trust Fund Ensuring Access to Affordable Housing for Missourians Liz Hagar-Mace (573) 522-6519 liz.hagar-mace@dmh.mo.gov Sandy Wilson (573) 634-2901 wilson@masw.org Missouri Department of Mental Health Housing Team www.dmh.mo.gov/ada/housing/housingindex.htm Doorways4385 Maryland AvenueSt. Louis, MO 63108-2703 tel: 314-535-1919 http://www.doorwayshousing.org Catholic Charities Housing Resource Center Hotline:(314)802-5444, (314)241-5600 4100 Lindell Blvd. St. Louis, MO 63108(314) 531-4770TDD 286-4223 Section 8 Waiting List314/286-4361 Kansas City: (816) 759-6600 Saint Louis: (314) 877-1350 http://www.mhdc.com/

    38. References • Barrow, S. M., D. B. Herman, P. Cordova, and E. L. Struening. 1999. Mortality among homeless shelter residents in new York city. American Journal of Public Health 89, no. 4: 529-34. • Duchon, L. M., B. C. Weitzman, and M. Shinn. 1999. The relationship of residential instability to medical care utilization among poor mothers in new York city. Med Care 37, no. 12: 1282-93. • DuPlessis, H. M. and D. Cora-Bramble. 2005. Providing care for immigrant, homeless, and migrant children. Pediatrics 115, no. 4: 1095-100. • Kushel, M. B., R. Gupta, L. Gee, and J. S. Haas. 2006. Housing instability and food insecurity as barriers to health care among low-income americans.[see comment]. Journal of General Internal Medicine 21, no. 1: 71-7. • Kushel, M. B., S. Perry, D. Bangsberg, R. Clark, and A. R. Moss. 2002. Emergency department use among the homeless and marginally housed: Results from a community-based study. American Journal of Public Health 92, no. 5: 778-84. • Kushel, M. B., E. Vittinghoff, and J. S. Haas. 2001. Factors associated with the health care utilization of homeless persons. JAMA 285, no. 2: 200-6. • Ma CT, Gee L, Kushel MB. 2008. Associations between housing instability and food insecurity with health care access in low-income children. Ambulatory Pediatrics 8, no. 1: 50-57. • Martell, J. V., R. S. Seitz, J. K. Harada, J. Kobayashi, V. K. Sasaki, and C. Wong. 1992. Hospitalization in an urban homeless population: The honolulu urban homeless project. Annals of Internal Medicine 116, no. 4: 299-303. • Montauk, S. L. 2006. The homeless in america: Adapting your practice. Am Fam Physician 74, no. 7: 1132-8. • Oandasan, Ivy, Barker, Keegan. 2003. Educating for advocacy: Exploring the source and substance of community-responsive physicians. Academic Medicine 78, no. 10: (Supplement):S16-S19. • Phinney, R., S. Danziger, H. A. Pollack, and K. Seefeldt. 2007. Housing instability among current and former welfare recipients. American Journal of Public Health 97, no. 5: 832-7. • Salit, S. A., E. M. Kuhn, A. J. Hartz, J. M. Vu, and A. L. Mosso. 1998. Hospitalization costs associated with homelessness in new york city.[see comment]. New England Journal of Medicine 338, no. 24: 1734-40. • Schanzer, Bella; Dominguez, Boanerges; Shrout, Patrick E.;Caton, Carol L.M. 2007. Homelessness, health status, and health care use. American Journal of Public Health 97, no. 3: 464-9. • Services, Committee on Community Health. 2005. Providing care for immigrant, homeless, and migrant children. Pediatrics 115: 1095-1100. • Tsou, Walter. 2005. Safer housing: A key step to overcoming health disparities. The Nation's Health 35, no. 4: 3. • Wood, D. and R. B. Valdez. 1991. Barriers to medical care for homeless families compared with housed poor families. Am J Dis Child 145, no. 10: 1109-15.