Compounding Stress: The Timing and Duration Effects of Homelessness on Children's Health

New research from Children's HealthWatch illustrates there is no safe level of homelessness. The timing (pre-natal, post-natal) and duration of homelessness (more or less than six months) compounds the risk of harmful child health outcomes. The younger and longer a child experiences homelessness, the greater the cumulative toll of negative health outcomes, which can have lifelong effects on the child, the family, and the community.Researchers from Children's HealthWatch collected data from over 20,000 caregivers of low-income children under the age of four with public or no health insurance. These caregivers were interviewed in urban pediatric clinics and emergency departments in five U.S. cities from 2009 through 2014. Interview data were analyzed to assess children's health and development and to compare outcomes for children who experienced homelessness at some point in their lives with children who were never homeless

Applying Failure Modes and Effects Analysis to Public Health Models: The Breathe Easy at Home Program

Failure Modes and Effects Analysis (FMEA) is a structured process used to identify and prioritize risks by ranking them based on severity, occurrence, and detectability. Historically, FMEA has been used within industries, including automotive and health care. This project explored the adaption of the FMEA template to a small public health program designed to improve asthma outcomes. The Breathe Easy at Home (BEAH) program is a multi-sector partnership that uses a web-based system to link clinical sites with housing code inspections and enforcement for patients with asthma. In July and August 2014, an FMEA was conducted to uncover risks within the BEAH process, and failures were prioritized for corrective action. The FMEA team prioritized risk based on severity, occurrence, and detectability to apply the FMEA process to a public health program. The FMEA team developed an action plan to improve failure modes that received the highest rankings. To fit the needs of a relatively small public health program, Joint Health Commission and U.S. Veterans Administration rating scales were adapted. The FMEA process can be adapted to a public health systems evaluation framework in order to prioritize areas for improvement

Public Health Legal Services: A New Vision

In recent years, the medical profession has begun to collaborate more and more with lawyers in order to accomplish important health objectives for patients. That collaboration invites a revisioning of legal services delivery models and of public health constructs, leading to a concept we develop in this article, and call public health legal services. The phrase encompasses those legal services provided by non-government attorneys to low-income persons the outcomes of which when evaluated in the aggregate using traditional public health measures advance the public\u27s health. This conception of public health legal services has emerged most prominently from innovative developments in Los Angeles (the HIV Legal Checkup model), Boston (Medical-Legal Partnership for Children) and New York (LegalHealth). It departs from the commonplace understanding about public health law as concerned with the exercise of the state\u27s public health power. It extends that understanding to include the exercise of individual rights by private lawyers that also advances the public\u27s health. Just as it was once discovered that communities need access to health information, clean water, inoculation, and regulation of hazardous activities and products as part of a comprehensive scheme for promoting and achieving health, so too the emerging vision suggests that community health promotion also requires affordable access to effective legal information and assistance. The idea of public health legal services offers a rich and powerful incentive for public and private agencies to increase free and subsidized legal services. At the same time, the legal services necessary from a public health perspective may not be the ones currently emphasized by providers. The vision of public health legal services in many ways favors prevention over crisis management, and therefore calls upon traditional legal services providers to rethink their customary resource allocation models. The vision may call for painful short-term choices between the new model and the always urgent demand for litigation and crisis-driven work. This Article engages that tension in an effort to understand, if not resolve, its dimensions

The Effects of Indoor Environmental Exposures on Pediatric Asthma: A Discrete Event Simulation Model

Background: In the United States, asthma is the most common chronic disease of childhood across all socioeconomic classes and is the most frequent cause of hospitalization among children. Asthma exacerbations have been associated with exposure to residential indoor environmental stressors such as allergens and air pollutants as well as numerous additional factors. Simulation modeling is a valuable tool that can be used to evaluate interventions for complex multifactorial diseases such as asthma but in spite of its flexibility and applicability, modeling applications in either environmental exposures or asthma have been limited to date. Methods: We designed a discrete event simulation model to study the effect of environmental factors on asthma exacerbations in school-age children living in low-income multi-family housing. Model outcomes include asthma symptoms, medication use, hospitalizations, and emergency room visits. Environmental factors were linked to percent predicted forced expiratory volume in 1 second (FEV1%), which in turn was linked to risk equations for each outcome. Exposures affecting FEV1% included indoor and outdoor sources of $NO_2$ and $PM_{2.5}$, cockroach allergen, and dampness as a proxy for mold. Results: Model design parameters and equations are described in detail. We evaluated the model by simulating 50,000 children over 10 years and showed that pollutant concentrations and health outcome rates are comparable to values reported in the literature. In an application example, we simulated what would happen if the kitchen and bathroom exhaust fans were improved for the entire cohort, and showed reductions in pollutant concentrations and healthcare utilization rates. Conclusions: We describe the design and evaluation of a discrete event simulation model of pediatric asthma for children living in low-income multi-family housing. Our model simulates the effect of environmental factors (combustion pollutants and allergens), medication compliance, seasonality, and medical history on asthma outcomes (symptom-days, medication use, hospitalizations, and emergency room visits). The model can be used to evaluate building interventions and green building construction practices on pollutant concentrations, energy savings, and asthma healthcare utilization costs, and demonstrates the value of a simulation approach for studying complex diseases such as asthma

Bringing Children in from the Cold: Solutions for Boston's Hidden Homeless

This report describes a population of "hidden homeless" families and new research showing that children in these families are more likely to be hungry and in poor health. Unrecorded by any homeless census, these families move frequently, often into overcrowded apartments, or double up with another family never knowing how long they can stay. The report estimates that there are over 14,800 hidden homeless families in Boston and that this number is likely to grow as the economy declines

Rx for Hunger: Affordable Housing

This report by Children's HealthWatch and the Medical-Legal Partnership | Boston finds that housing plays a significant role in protecting young children from food insecurity and the health risks of being seriously underweight. This report confirms that increased support for subsidized housing must be part of the strategy for ending childhood hunger

Co-enrollment for Child Health: How Receipt and Loss of Food and Housing Subsidies Relate to Housing Security and Statutes for Streamlined, Multi-Subsidy Application

In light of recent policy debates around funding food and housing subsidies, the combined influence of these programs on housing security (HS), defined as housing without crowding or frequent moves, remains unstudied. In a multi-city study of young children, federal nutrition and housing subsidies together increased the odds of HS, whereas loss of nutrition subsidies lowered the odds of HS even after controlling for housing subsidy receipt. Ensuring eligible families’ access to both nutrition and housing subsidies may sustain HS. The results of this study inform and support current efforts by states to streamline online applications for social services and remove statutory legal barriers to accessing these subsidies simultaneously

Trends in Household and Child Food Insecurity Among Families with Young Children from 2007 to 2013

Background: 2007-2013 spanned an economic downturn with rising food costs. While Supplemental Nutrition Assistance Program (SNAP) benefits increased during those years by 13.6% from the 2009 American Recovery Reinvestment Act (ARRA), the impact of these competing conditions on household food insecurity (HFI, household food insecure but child food secure) and child food insecurity (CFI, household and child food insecure) in households with infants and toddlers has not been investigated. Objective: To describe HFI and CFI in households participating in SNAP vs. households likely eligible but not participating (No SNAP). Design: Repeat cross-sectional Participants/Setting: 19,999 caregivers of childrenChildren’s HealthWatch survey in emergency and primary care departments in 5 US cities. Main Outcome Measures: The 18-item U.S. Household Food Security Survey (HFSS) measured HFI (≥3 affirmative responses on non-child-specific questions) and CFI (≥2 affirmative responses to eight child-specific questions). Statistical analyses performed: The sample was stratified by SNAP/ No SNAP. Multinomial logistic regression analyses examined the association between SNAP receipt and HFI and CFI. Results: Across the study period, controlling for confounders including year, households with SNAP were 17% less likely to experience HFI (AOR 0.83; 95% CI,0 .75, 0.91; p Conclusions: Receipt of SNAP vs. No SNAP was associated with decreased prevalence of HFI and CFI during much of the economic downturn; this impact waned as the buying power of the boost in benefit amounts during the ARRA period eroded

Association of the infant gut microbiome with early childhood neurodevelopmental outcomes: An ancillary study to the VDAART randomized clinical trial

Importance: In animal models, the early life gut microbiome influences later neurodevelopment. Corresponding data in human populations are lacking. Objective: To study associations between the gut microbiome in infants and development at preschool age measured by the Ages and Stages Questionnaire, third edition (ASQ-3). Design, Setting, and Participants: This ancillary cohort study of the Vitamin D Antenatal Asthma Reduction Trial (VDAART) used data from 715 participants who had development assessed at 3 years of age by the ASQ-3, which included scores in 5 domains (gross motor skills, fine motor skills, problem solving, communication, and personal and social skills). A total of 309 stool samples were collected from infants aged 3 to 6 months for microbiome analysis using 16S rRNA gene sequencing. Exposures: Infant gut microbiome. Main Outcomes and Measures: Continuous ASQ-3 scores and typical vs potential delay in the 5 developmental domains. Factor scores for bacterial coabundance groups were used as predictors in regression models of continuous ASQ-3 scores. Logistic regression was used to examine bacterial coabundance scores and odds of scoring below the threshold for typical development. Multivariate analysis examined the abundance of individual taxa and ASQ-3 scores. Results: The 309 participants (170 [55.0%] male) with ASQ-3 scores and stool samples were ethnically diverse (136 [44.0%] black, 41 [13.3%] Hispanic, 86 [27.8%] white, and 46 [14.9%] other race/ethnicity); the mean (SD) age at ASQ-3 assessment was 3.0 (0.07) years. Coabundance scores dominated by Clostridiales (Lachnospiraceae genera and other, unclassified Clostridiales taxa) were associated with poorer ASQ-3 communication (β, -1.12; 95% CI, -2.23 to -0.01; P = .05) and personal and social (β, -1.44; 95% CI, -2.47 to -0.40; P = .01) scores and with increased odds of potential delay for communication (odds ratio [OR], 1.69; 95% CI, 1.06 to 2.68) and personal and social skills (OR, 1.96; 95% CI, 1.22 to 3.15) per unit increase in coabundance score. The Bacteroides-dominated coabundance grouping was associated with poorer fine motor scores (β, -2.42; 95% CI, -4.29 to -0.55; P = .01) and with increased odds of potential delay for fine motor skills (OR, 1.52; 95% CI, 1.07 to 2.16) per unit increase in coabundance score. Multivariate analysis detected similar family-level and order-level associations. Conclusions and Relevance: These findings suggest an association between infant gut microbiome composition and communication, personal and social, and fine motor skills at age 3 years. The majority of associations were driven by taxa within the order Clostridiales