Possibilities for health-conscious assisted housing mobility

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2008."June 2008."Includes bibliographical references.Many poor, segregated, urban neighborhoods are rife with risks to health, which contributes to stark racial and geographic disparities in health. Fighting health disparities requires buy-in from non-health professionals whose work directly impacts the way cities are designed and governed. This thesis provides a case study of one non-health initiative, assisted housing mobility, with clear relevance to health disparities. Research suggests that moving from high- to lower-poverty neighborhoods may confer a range of health benefits on individuals; however, assisted housing mobility programs are, to date, relocation-only interventions. Could these programs more deliberately promote health, and should they do so? Through interviews and a review of counseling materials, I examine. how nine assisted housing mobility programs are linked to health, how health is understood by program staff, and how managers might offer more health-conscious programming. Based on a review of pathways between health and housing and neighborhoods, I identified five areas of intervention around which managers could build healthful programs: housing units, neighborhoods, health behavior and awareness, social connectedness, and access to health services. For each area of intervention, I detail possibilities for active versus passive approaches, and document relevant practices from the profiled programs. I then explore practitioner attitudes towards integrating health into mobility programs. Although most practitioners see their work as disconnected from health, their programs actually play a promising mediating role. Concerns about mandate, privacy, legality, liability, and capacity hinder programs from exploring health. So does limited understanding of how to incorporate health appropriately.(cont.) Yet, most staff members are encouraged that their work may improve client health, and many want to do more. I recommend steps programs could take to provide better health-related information and discuss health more openly throughout housing counseling so families can make deliberate choices. I provide a preliminary assessment of relative costs and benefits of each step. I note that program managers will require technical and collegial support in order to implement the suggested changes well. The Poverty & Race Research Action Council, which helped guide my research, could provide needed support.by Mariana Clair Arcaya.M.C.P

Eviction as a community health exposure.

Evidence suggests that being evicted harms health. Largely ignored in the existing literature is the possibility that evictions exert community-level health effects, affecting evicted individuals social networks and shaping broader community conditions. In this narrative review, we summarize evidence and lay out a theoretical model for eviction as a community health exposure, mediated through four paths: 1) shifting ecologies of infectious disease and health behaviors, 2) disruption of neighborhood social cohesion, 3) strain on social networks, and 4) increasing salience of eviction risk. We describe methods for parsing evictions individual and contextual effects and discuss implications for causal inference. We conclude by addressing evictions potentially multilevel consequences for policy advocacy and cost-benefit analyses

Inequalities in health: definitions, concepts, and theories

Individuals from different backgrounds, social groups, and countries enjoy different levels of health. This article defines and distinguishes between unavoidable health inequalities and unjust and preventable health inequities. We describe the dimensions along which health inequalities are commonly examined, including across the global population, between countries or states, and within geographies, by socially relevant groupings such as race/ethnicity, gender, education, caste, income, occupation, and more. Different theories attempt to explain group-level differences in health, including psychosocial, material deprivation, health behavior, environmental, and selection explanations. Concepts of relative versus absolute; dose–response versus threshold; composition versus context; place versus space; the life course perspective on health; causal pathways to health; conditional health effects; and group-level versus individual differences are vital in understanding health inequalities. We close by reflecting on what conditions make health inequalities unjust, and to consider the merits of policies that prioritize the elimination of health disparities versus those that focus on raising the overall standard of health in a population

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. Methods and Findings: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. Conclusions: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors' Summar

Designing and Facilitating Collaborative Research Design and Data Analysis Workshops: Lessons Learned in the Healthy Neighborhoods Study

One impediment to expanding the prevalence and quality of community-engaged research is a shortage of instructive resources for collaboratively designing research instruments and analyzing data with community members. This article describes how a consortium of community residents, grassroots community organizations, and academic and public institutions implemented collaborative research design and data analysis processes as part of a participatory action research (PAR) study investigating the relationship between neighborhoods and health in the greater Boston area. We report how nine different groups of community residents were engaged in developing a multi-dimensional survey instrument, generating and testing hypotheses, and interpreting descriptive statistics and preliminary findings. We conclude by reflecting on the importance of balancing planned strategies for building and sustaining resident engagement with improvisational facilitation that is responsive to residents’ characteristics, interests and needs in the design and execution of collaborative research design and data analysis processes. Keywords: participatory action research; community engagement; instrument design; data analysis; urban development; community healt

Tailoring community-based wellness initiatives with latent class analysis--Massachusetts Community Transformation Grant projects

INTRODUCTION: Community-based approaches to preventing chronic diseases are attractive because of their broad reach and low costs, and as such, are integral components of health care reform efforts. Implementing community-based initiatives across Massachusetts\u27 municipalities presents both programmatic and evaluation challenges. For effective delivery and evaluation of the interventions, establishing a community typology that groups similar municipalities provides a balanced and cost-effective approach. METHODS: Through a series of key informant interviews and exploratory data analysis, we identified 55 municipal-level indicators of 6 domains for the typology analysis. The domains were health behaviors and health outcomes, housing and land use, transportation, retail environment, socioeconomics, and demographic composition. A latent class analysis was used to identify 10 groups of municipalities based on similar patterns of municipal-level indicators across the domains. RESULTS: Our model with 10 latent classes yielded excellent classification certainty (relative entropy = .995, minimum class probability for any class = .871), and differentiated distinct groups of municipalities based on health-relevant needs and resources. The classes differentiated healthy and racially and ethnically diverse urban areas from cities with similar population densities and diversity but worse health outcomes, affluent communities from lower-income rural communities, and mature suburban areas from rapidly suburbanizing communities with different healthy-living challenges. CONCLUSION: Latent class analysis is a tool that may aid in the planning, communication, and evaluation of community-based wellness initiatives such as Community Transformation Grants projects administrated by the Centers for Disease Control and Prevention

A Health Impact Assessment of Proposed Public Transit Service Cuts and Fare Increases in Boston, Massachusetts

Transportation decisions have health consequences that are often not incorporated into policy-making processes. Health Impact Assessment (HIA) is a process that can be used to evaluate health effects of transportation policy. We present a rapid HIA evaluating health and economic effects of proposed fare increases and service cuts to Boston, Massachusetts’ public transit system. We used transportation modeling in concert with tools allowing for quantification and monetization of multiple pathways. We estimated health and economic costs of proposed transit system changes to be hundreds of millions of dollars per year, exceeding the budget gap the transit authority was required to close. Significant health pathways included crashes, air pollution, and physical activity. The HIA enabled stakeholders to advocate for more modest fare increases and service cuts, which were eventually adopted. This HIA was among the first to quantify and monetize multiple pathways linking transportation decisions with health and economic outcomes, using approaches that could be applied in different settings. Including health costs in transportation decisions can lead to policy choices with both economic and public health benefits

Health selection into neighborhoods among patients enrolled in a clinical trial

Health selection into neighborhoods may contribute to geographic health disparities. We demonstrate the potential for clinical trial data to help clarify the causal role of health on locational attainment. We used data from the 20-year United Kingdom Prospective Diabetes Study (UKPDS) to explore whether random assignment to intensive blood-glucose control therapy, which improved long-term health outcomes after median 10 years follow-up, subsequently affected what neighborhoods patients lived in. We extracted postcode-level deprivation indices for the 2710 surviving participants of UKPDS living in England at study end in 1996/1997. We observed small neighborhood advantages in the intensive versus conventional therapy group, although these differences were not statistically significant. This analysis failed to show conclusive evidence of health selection into neighborhoods, but data suggest the hypothesis may be worthy of exploration in other clinical trials or in a meta-analysis. Keywords: Neighborhoods, Self-selection, Health, Equity, Socioeconomic statu

A Health Impact Assessment of a Proposed Bill to Decrease Speed Limits on Local Roads in Massachusetts (U.S.A.)

Decreasing traffic speeds increases the amount of time drivers have to react to road hazards, potentially averting collisions, and makes crashes that do happen less severe. Boston’s regional planning agency, the Metropolitan Area Planning Council (MAPC), in partnership with the Massachusetts Department of Public Health (MDPH), conducted a Health Impact Assessment (HIA) that examined the potential health impacts of a proposed bill in the state legislature to lower the default speed limits on local roads from 30 miles per hour (mph) to 25 mph. The aim was to reduce vehicle speeds on local roads to a limit that is safer for pedestrians, cyclists, and children. The passage of this proposed legislation could have had far-reaching and potentially important public health impacts. Lower default speed limits may prevent around 18 fatalities and 1200 serious injuries to motorists, cyclists and pedestrians each year, as well as promote active transportation by making local roads feel more hospitable to cyclists and pedestrians. While a lower speed limit would increase congestion and slightly worsen air quality, the benefits outweigh the costs from both a health and economic perspective and would save the state approximately $62 million annually from prevented fatalities and injuries

Role of health in predicting moves to poor neighborhoods among Hurricane Katrina survivors

In contrast to a large literature investigating neighborhood effects on health, few studies have examined health as a determinant of neighborhood attainment. However, the sorting of individuals into neighborhoods by health status is a substantively important process for multiple policy sectors. We use prospectively collected data on 569 poor, predominantly African American Hurricane Katrina survivors to examine the extent to which health problems predicted subsequent neighborhood poverty. Our outcome of interest was participants’ 2009-2010 census tract poverty rate. Participants were coded as having a health problem at baseline (2003-2004) if they self-reported a diagnosis of asthma, high blood pressure, diabetes, high cholesterol, heart problems, or any other physical health problems not listed, or complained of back pain, migraines, or digestive problems at baseline. While health problems were not associated with neighborhood poverty at baseline, those with baseline health problems ended up living in higher poverty areas by 2009-2010. Differences persisted after adjustment for personal characteristics, baseline neighborhood poverty, hurricane exposure, and residence in the New Orleans metropolitan area, with baseline health problem(s) predicting a 3.4 percentage point higher neighborhood poverty rate (95% CI: 1.41,5.47). Results suggest that better health was protective against later neighborhood deprivation in a highly mobile, socially vulnerable population. Researchers should consider reciprocal associations between health and neighborhoods when estimating and interpreting neighborhood effects on health. Understanding whether and how poor health impedes poverty deconcentration efforts may help inform programs and policies designed to help low income families move to, and stay in, higher opportunity neighborhoods.Sociolog