Mechanisms to Improve Health Through Community Land Trusts.

Community land trusts (CLTs) provide long-term affordable housing and offer a range of mechanisms that may improve the health and well-being of low-income households. We sought to elucidate these mechanisms through thematic analysis of semi-structured interviews with a diverse sample of CLT staff and residents across the USA. Stakeholders most frequently identified improvements in mental health that come through increased housing stability and affordability. Other factors-including the ways that CLTs promote wealth generation, improvements in housing quality and neighborhood amenities, services and partnerships with healthcare organizations, and democratic governance-were raised by respondents though less frequently tied to health benefits. CLTs represent a promising area for future research on housing's impact on health.

Addressing housing-related social needs for Medicaid beneficiaries: a qualitative assessment of Maryland's Medicaid §1115 waiver program.

BACKGROUND: While health care payers are increasingly considering approaches that help support stable and affordable housing for their beneficiaries, experience with these initiatives is limited. Through its §1115 HealthChoice waiver, Maryland Medicaid has begun experimenting with programs designed to pay for housing and tenancy support/case management services. This study investigates barriers and facilitators to the success of Maryland's pilot program initiative - Assistance in Community Integration Services (ACIS). METHODS: The study focused on key stakeholders employed by the four Lead Entities that currently participate in the ACIS program. The stakeholders included members of each Lead Entity's administration, direct service providers, state and local government officials, and case managers from local hospitals. The convenience sample was selected through an initial list of stakeholders and was supplemented using snowball sampling methods. Interviews were audio recorded and turned into transcripts via Otter.ai and then analyzed using NVivo by two independent reviewers. RESULTS: A total of 23 interviews were conducted between February 2022 and May 2022, representing a broad range of stakeholders across different Maryland geographies. A total of 4 themes were identified through the course of the interviews. Stakeholders identified difficulty finding housing for the target population in a tight housing market, challenges with communication within the program and with its clients, and problems with non-healthcare providers documenting services for reimbursement. At the same time, ACIS was seen as creating opportunities for organizations to work together across siloes in meeting client needs. CONCLUSIONS: The findings of this study helps to highlight Medicaid §1115 waivers as a novel approach to using Medicaid funds to support tenancy-based services, such as ACIS and to improve the lives of individuals while reducing healthcare costs. Implementation of the ACIS program in Maryland has been a resounding success in helping individuals obtain and sustain stable housing. However, continued efforts to align capacity with demand, streamline billing and reimbursement and improve communication with clients and across partners will need to be prioritized. The program also highlights the growing need to address root causes of housing insecurity including the limited supply of affordable housing.

Association of a Housing Mobility Program With Childhood Asthma Symptoms and Exacerbations.

Importance: Structural racism has been implicated in the disproportionally high asthma morbidity experienced by children living in disadvantaged, urban neighborhoods. Current approaches designed to reduce asthma triggers have modest impact. Objective: To examine whether participation in a housing mobility program that provided housing vouchers and assistance moving to low-poverty neighborhoods was associated with reduced asthma morbidity among children and to explore potential mediating factors. Design, Setting, and Participants: Cohort study of 123 children aged 5 to 17 years with persistent asthma whose families participated in the Baltimore Regional Housing Partnership housing mobility program from 2016 to 2020. Children were matched to 115 children enrolled in the Urban Environment and Childhood Asthma (URECA) birth cohort using propensity scores. Exposure: Moving to a low-poverty neighborhood. Main Outcomes: Caregiver-reported asthma exacerbations and symptoms. Results: Among 123 children enrolled in the program, median age was 8.4 years, 58 (47.2%) were female, and 120 (97.6%) were Black. Prior to moving, 89 of 110 children (81%) lived in a high-poverty census tract (>20% of families below the poverty line); after moving, only 1 of 106 children with after-move data (0.9%) lived in a high-poverty tract. Among this cohort, 15.1% (SD, 35.8) had at least 1 exacerbation per 3-month period prior to moving vs 8.5% (SD, 28.0) after moving, an adjusted difference of -6.8 percentage points (95% CI, -11.9% to -1.7%; P = .009). Maximum symptom days in the past 2 weeks were 5.1 (SD, 5.0) before moving and 2.7 (SD, 3.8) after moving, an adjusted difference of -2.37 days (95% CI, -3.14 to -1.59; P < .001). Results remained significant in propensity score-matched analyses with URECA data. Measures of stress, including social cohesion, neighborhood safety, and urban stress, all improved with moving and were estimated to mediate between 29% and 35% of the association between moving and asthma exacerbations. Conclusions and Relevance: Children with asthma whose families participated in a program that helped them move into low-poverty neighborhoods experienced significant improvements in asthma symptom days and exacerbations. This study adds to the limited evidence suggesting that programs to counter housing discrimination can reduce childhood asthma morbidity.

Using the Moving To Opportunity Experiment to Investigate the Long-Term Impact of Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service.

We performed a secondary analysis of the Moving To Opportunity (MTO) social experiment to investigate the impact of different types of housing assistance and neighborhood environments on long-term patterns of health care use for specific conditions and across different types of health care services. MTO participants, who were randomized at baseline, were linked to up to 21 years of all-payer hospital discharge and Medicaid data. Among the 9,170 children at the time of randomization, those who received a voucher had subsequent hospital admissions rates that were 36% lower for asthma and 30% lower for mental health disorders compared to the control group; rates of psychiatric services, outpatient hospital services, clinic services and durable medical equipment were also lower among the voucher groups. Findings for adults were not statistically significant. The results suggest that housing policies that reduce neighborhood poverty exposure as a child are associated with lower subsequent healthcare use for specific clinical conditions and types of services.

The association between vacant housing demolition and safety and health in Baltimore, MD.

We measured the association between vacant housing demolitions and changes in crime and emergency department (ED) visits in Baltimore, MD. We included 646 block groups in Baltimore, 224 of which experienced at least one demolition from 2012 to 2019. The exposure was the number of demolitions completed in a block group during the previous quarter. Crime (all, property, and violent) and ED visits (all, adults, children, and for specific causes) were examined as the change in the rate per 1000 people from the previous quarter to the current quarter and analyzed using multivariable mixed effects regression models. Demolitions were associated with a small decrease in total ED visits (difference = -0.068 per 1000 people from the previous quarter to the current quarter, 95% CI -0.119, -0.018) but no significant change in crime. For each demolition, the rate of total child ED visits was 0.452 lower compared to the previous quarter (95% CI -0.777, -0.127). Demolitions were associated with small decreases in adult injury-related ED visits in the short term.

Expiring Eviction Moratoriums and COVID-19 Incidence and Mortality.

The coronavirus disease 2019 (COVID-19) pandemic and associated economic crisis have placed millions of US households at risk of eviction. Evictions may accelerate COVID-19 transmission by decreasing individuals' ability to socially distance. We leveraged variation in the expiration of eviction moratoriums in US states to test for associations between evictions and COVID-19 incidence and mortality. The study included 44 US states that instituted eviction moratoriums, followed from March 13 to September 3, 2020. We modeled associations using a difference-in-difference approach with an event-study specification. Negative binomial regression models of cases and deaths included fixed effects for state and week and controlled for time-varying indicators of testing, stay-at-home orders, school closures, and mask mandates. COVID-19 incidence and mortality increased steadily in states after eviction moratoriums expired, and expiration was associated with a doubling of COVID-19 incidence (incidence rate ratio = 2.1; 95% confidence interval (CI): 1.1, 3.9) and a 5-fold increase in COVID-19 mortality (mortality rate ratio = 5.4; CI: 3.1, 9.3) 16 weeks after moratoriums lapsed. These results imply an estimated 433,700 excess cases (CI: 365,200, 502,200) and 10,700 excess deaths (CI: 8,900, 12,500) nationally by September 3, 2020. The expiration of eviction moratoriums was associated with increased COVID-19 incidence and mortality, supporting the public-health rationale for eviction prevention to limit COVID-19 cases and deaths.

Association of Receipt of a Housing Voucher With Subsequent Hospital Utilization and Spending.

Importance: Although neighborhoods are thought to be an important health determinant, evidence for the relationship between neighborhood poverty and health care use is limited, as prior studies have largely used observational data without an experimental design. Objective: To examine whether housing policies that reduce exposure to high-poverty neighborhoods were associated with differences in long-term hospital use among adults and children. Design, Setting, and Participants: Exploratory analysis of the Moving to Opportunity for Fair Housing Demonstration Program, a randomized social experiment conducted in 5 US cities. From 1994 to 1998, 4604 families in public housing were randomized to 1 of 3 groups: a control condition, a traditional Section 8 voucher toward rental costs in the private market, or a voucher that could only be used in low-poverty neighborhoods. Participants were linked to all-payer hospital discharge data (1995 through 2014 or 2015) and Medicaid data (1999 through 2009). The final follow-up date ranged from 11 to 21 years after randomization. Exposures: Receipt of a traditional or low-poverty voucher vs control group. Main Outcomes and Measures: Rates of hospitalizations and hospital days, and hospital spending. Results: Among 4602 eligible individuals randomized as adults, 4072 (88.5%) were linked to health data (mean age, 33 years [SD, 9.0 years]; 98% female; median follow-up, 11 years). There were no significant differences in primary outcomes among adults randomized to receive a voucher compared with the control group (unadjusted hospitalization rate, 14.0 vs 14.7 per 100 person-years, adjusted incidence rate ratio [IRR], 0.95 [95% CI, 0.84-1.08; P = .45]; hospital days, 62.8 vs 67.0 per 100 person-years; IRR, 0.93 [95% CI, 0.77-1.13; P = .46]; yearly spending, $2075 vs $1977; adjusted difference, -$129 [95% CI, -$497 to $239; P = .49]). Among 11 290 eligible individuals randomized as children, 9118 (80.8%) were linked to health data (mean age, 8 years [SD, 4.6 years]; 49% female; median follow-up, 11 years). Receipt of a housing voucher during childhood was significantly associated with lower hospitalization rates (6.3 vs 7.3 per 100 person-years; IRR, 0.85 [95% CI, 0.73-0.99; P = .03]) and yearly inpatient spending ($633 vs $785; adjusted difference, -$143 [95% CI, -$256 to -$31; P = .01]) and no significant difference in hospital days (25.7 vs 28.8 per 100 person-years; IRR, 0.92 [95% CI, 0.77-1.11; P = .41]). Conclusions and Relevance: In this exploratory analysis of a randomized housing voucher intervention, adults who received a housing voucher did not experience significant differences in hospital use or spending. Receipt of a voucher during childhood was significantly associated with lower rates of hospitalization and less inpatient spending during long-term follow-up.

Association between physician characteristics and the use of 21-gene recurrence score genomic testing among Medicare beneficiaries with early-stage breast cancer, 2008-2011.

PURPOSE: We sought to determine whether physician-level characteristics were associated with 21-gene recurrence score (RS) genomic testing to evaluate recurrence risk and benefit of adjuvant chemotherapy in patients with estrogen receptor-positive, node-negative breast cancer. METHODS: Retrospective cohort study of a nationally representative sample of Medicare beneficiaries using Surveillance, Epidemiology, and End Results program-Medicare data linked with the American Medical Association physician master file. The main outcome was receipt of genomic testing within 1 year of diagnosis as a function of physician-level factors. RESULTS: A total of 24,463 patients met the study criteria; they received care from 3172 surgeons and 2475 medical oncologists. Of 4124 tests ordered, 70% were ordered by a medical oncologist and 16% by a surgeon. In multivariable regression models, multiple variables were associated with receipt of testing, including having a medical oncologist (odds ratio [OR] 2.77; 95% CI 2.00-3.82), a surgeon specializing in surgical oncology (OR 1.20; 95% CI 1.09-1.31), and a female medical oncologist (OR 1.10; 95% CI 1.02-1.20). Having a medical oncologist with 5 or more years in practice was associated with lower odds of testing (OR 0.83; 95% CI 0.76-0.92). Surgical procedures performed at academic centers were associated with higher odds of testing (OR 1.11; 95% CI 1.02-1.20). CONCLUSIONS: Although most RS testing was ordered by medical oncologists, physicians in other specialties ordered roughly one-third of the tests. Physician characteristics, including gender and time in practice, were associated with receiving testing, creating opportunities for targeting interventions to help patients receive optimal care.

Second opinions from urologists for prostate cancer: Who gets them, why, and their link to treatment.

BACKGROUND: Cancer patients are encouraged to obtain second opinions before starting treatment. Little is known about men with localized prostate cancer who seek second opinions, the reasons why, and the association with treatment and quality of care. METHODS: We surveyed men who were diagnosed with localized prostate cancer in the greater Philadelphia area from 2012 to 2014. Men were asked if they obtained a second opinion from a urologist, and the reasons why. We used multivariable logistic regression models to evaluate the relationship between second opinions and definitive prostate cancer treatment and perceived quality of care. RESULTS: A total of 2386 men responded to the survey (adjusted response rate, 51.1%). After applying exclusion criteria, the final analytic cohort included 2365 respondents. Of these, 40% obtained second opinions, most commonly because they wanted more information about their cancer (50.8%) and wanted to be seen by the best doctor (46.3%). Overall, obtaining second opinions was not associated with definitive treatment or perceived quality of cancer care. Men who sought second opinions because they were dissatisfied with their initial urologist were less likely to receive definitive treatment (odds ratio, 0.49; 95% confidence interval, 0.32-0.73), and men who wanted more information about treatment were less likely to report excellent quality of cancer care (odds ratio, 0.70; 95% confidence interval, 0.49-0.99) compared with men who did not receive a second opinion. CONCLUSIONS: Although a large proportion of men with localized prostate cancer obtained a second opinion, the reasons for doing so were not associated with treatment choice or perceived quality of cancer care. Future study is needed to determine when second opinions contribute to increasing the value of cancer care. Cancer 2017;123:1027-34. © 2016 American Cancer Society.

A multidimensional view of racial differences in access to prostate cancer care.

BACKGROUND: Racial disparities in prostate cancer treatment and outcomes are widespread and poorly understood. In the current study, the authors sought to determine whether access to care, measured across multiple dimensions, contributed to racial differences in prostate cancer. METHODS: The Philadelphia Area Prostate Cancer Access Study (P2 Access) included 2374 men diagnosed with localized prostate cancer between 2012 and 2014. Men were surveyed to assess their experiences accessing care (response rate of 51.1%). The authors determined appointment availability at 151 urology practices using simulated patient telephone calls and calculated travel distances using geospatial techniques. Multivariable logistic regression models were used to determine the association between 5 different domains of access (availability, accessibility, accommodation, affordability, and acceptability) and receipt of treatment, perceived quality of care, and physician-patient communication. RESULTS: There were 1907 non-Hispanic white and 394 black men in the study cohort. Overall, approximately 85% of the men received definitive treatment with no differences noted by race. Black men were less likely to report a high quality of care (69% vs 81%; P<.001) and good physician-patient communication (60% vs 71%; P<.001) compared with white men. In adjusted models, none of the 5 domains of access were found to be associated with definitive treatment overall or with radical prostatectomy. All access domains were associated with perceived quality of care and communication, although these domains did not mediate racial disparities. CONCLUSIONS: To the authors' knowledge, the current study presents the first comprehensive assessment of prostate cancer care access, treatment, and patient experience, demonstrating that although access was related to overall perceived quality of care and better physician-patient communication, it did not appear to explain observed racial differences. Cancer 2017;123:4449-57. © 2017 American Cancer Society.

Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey.

OBJECTIVE: To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. STUDY DESIGN: We conducted a mail-based survey of a nationally representative sample of 1000 children's primary care physicians (trained in pediatrics, family medicine, or medicine-pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. RESULTS: The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co-location of auxiliary services was the most frequently cited facilitator for the majority of issues. CONCLUSIONS: Children's primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice-related barriers. Co-location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

Racial Differences in Prostate Cancer Treatment: The Role of Socioeconomic Status.

OBJECTIVE: This study examines whether socioeconomic status (SES), measured at both the individual and neighborhood levels, is associated with receipt of definitive treatment for localized prostate cancer and whether these associations mediate racial differences in treatment between non-Hispanic White and non-Hispanic Black men. DESIGN: The Philadelphia Area Prostate Cancer Access Study (P2 Access) is a mailed, cross-sectional survey of men sampled from the Pennsylvania Cancer Registry, combined with neighborhood Census data. SETTING: Eight counties in southeastern Pennsylvania. PARTICIPANTS: 2,386 men with prostate adenocarcinoma. MAIN MEASURES: Receipt of definitive treatment, race, self-reported income, education, employment status, and neighborhood SES. RESULTS: Overall, Black and White men were equally likely to receive definitive treatment. Men living in neighborhoods with higher SES were more likely to receive definitive treatment (OR 1.57, 95%CI 1.01, 2.42). Among men who received definitive treatment, Black men were significantly less likely to receive radical prostatectomy compared with White men (OR .71, 95% CI .52, .98), as were men with some college education compared with those with a high school education or less (OR .66, 95% CI .47, .94). SES does not mediate racial differences in receipt of definitive treatment or the type of definitive treatment received, and associations with income or employment status were not significant. CONCLUSIONS: These results stress the importance of examining racial disparities within geographic areas and highlight the unique associations that different measures of SES, particularly neighborhood SES and education, may have with prostate cancer treatment.

Does Churning in Medicaid Affect Health Care Use?

BACKGROUND: Transitions into and out of Medicaid, termed churning, may disrupt access to and continuity of care. Low-income, working adults who became eligible for Medicaid under the Affordable Care Act are particularly susceptible to income and employment changes that lead to churning. OBJECTIVE: To compare health care use among adults who do and do not churn into and out of Medicaid. DATA: Longitudinal data from 6 panels of the Medical Expenditure Panel Survey. METHODS: We used differences-in-differences regression to compare health care use when adults reenrolled in Medicaid following a loss of coverage, to utilization in a control group of continuously enrolled adults. OUTCOME MEASURES: Emergency department (ED) visits, ED visits resulting in an inpatient admission, and visits to office-based providers. RESULTS: During the study period, 264 adults churned into and out of Medicaid and 627 had continuous coverage. Churning adults had an average of approximately 0.05 Medicaid-covered office-based visits per month 4 months before reenrolling in Medicaid, significantly below the rate of approximately 0.20 visits in the control group. Visits to office-based providers did not reach the control group rate until several months after churning adults had resumed Medicaid coverage. Our comparisons found no evidence of significantly elevated ED and inpatient admission rates in the churning group following reenrollment. CONCLUSIONS: Adults who lose Medicaid tend to defer their use of office-based care to periods when they are insured. Although this suggests that enrollment disruptions lead to suboptimal timing of care, we do not find evidence that adults reenroll in Medicaid with elevated acute care needs.

Effect of Patient Navigation on Breast Cancer Screening Among African American Medicare Beneficiaries: A Randomized Controlled Trial.

BACKGROUND: There is growing evidence that patient navigation improves breast cancer screening rates; however, there are limited efficacy studies of its effect among African American older adult women. OBJECTIVE: To evaluate the effect of patient navigation on screening mammography among African American female Medicare beneficiaries in Baltimore, MD. DESIGN: The Cancer Prevention and Treatment Demonstration (CPTD), a multi-site study, was a randomized controlled trial conducted from April 2006 through December 2010. SETTING: Community-based and clinical setting. PARTICIPANTS: The CPTD Screening Trial enrolled 1905 community-dwelling African American female Medicare beneficiaries who were ≥65 years of age and resided in Baltimore, MD. Participants were recruited from health clinics, community centers, health fairs, mailings using Medicare rosters, and phone calls. INTERVENTIONS: Participants were randomized to either: printed educational materials on cancer screening (control group) or printed educational materials + patient navigation services designed to help participants overcome barriers to cancer screening (intervention group). MAIN MEASURE: Self-reported receipt of mammography screening within 2 years of the end of the study. KEY RESULTS: The median follow-up period for participants in this analysis was 17.8 months. In weighted multivariable logistic regression analyses, women in the intervention group had significantly higher odds of being up to date on mammography screening at the end of the follow-up period compared to women in the control group (odds ratio [OR] 2.26, 95 % confidence interval [CI]1.59-3.22). The effect of the intervention was stronger among women who were not up to date with mammography screening at enrollment (OR 3.63, 95 % CI 2.09-6.38). CONCLUSION: Patient navigation among urban African American Medicare beneficiaries increased self-reported mammography utilization. The results suggest that patient navigation for mammography screening should focus on women who are not up to date on their screening.

Physician's peer exposure and the adoption of a new cancer treatment modality.

BACKGROUND: New technologies, often with limited evidence to support their effectiveness, frequently diffuse into clinical practice and increase the costs of cancer care. The authors studied whether physician peer exposure was associated with the subsequent adoption of a new approach to adjuvant radiotherapy (brachytherapy) for the treatment of women with early-stage breast cancer. METHODS: A retrospective cohort study was performed using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Data from 2003 through 2004 were used to classify surgeons as early brachytherapy adopters and, among non-early adopters, whether they shared patients with early adopters (peer exposure). Data from 2005 through 2006 were used to examine whether women were more likely to receive brachytherapy if their surgeons were exposed to early adopters. RESULTS: Overall, the percentage of women receiving brachytherapy increased from 3.2% in 2003 through 2004 to 4.7% in 2005 through 2006. In this latter period, a total of 2087 patients were assigned to 328 non-early adopting surgeons. In unadjusted analyses, patients whose surgeons were connected to early adopters during 2003 through 2004 were found to be significantly more likely to receive brachytherapy in 2005 through 2006 compared with those whose surgeons were not connected to early adopters (8.0% vs 4.1%; P = .003). In adjusted analyses, the predicted probability of receiving brachytherapy among patients whose surgeon did have an early-adopting peer was 3.9% versus 1.0% among those whose surgeons did not have an early-adopting peer (P = .03). CONCLUSIONS: Exposure to peers who were early adopters of brachytherapy was found to be associated with a surgeon's subsequent uptake of brachytherapy. The results of the current study provide an example of a novel approach to examining the diffusion of innovation in cancer care.

Fragmentation in specialist care and stage III colon cancer.

BACKGROUND: Patients with cancer frequently transition between different types of specialists and across care settings. This study explored how frequently the surgical and medical oncology care of stage III colon cancer patients occurred across more than 1 hospital and whether this was associated with mortality and costs. METHODS: This was a retrospective Surveillance, Epidemiology, and End Results-Medicare cohort study of 9075 stage III colon cancer patients diagnosed between 2000 and 2009 who had received both surgical and medical oncology care within 1 year of their diagnosis. Patients were assigned to the hospital at which they had undergone their cancer surgery and to their oncologist's primary hospital, and then they were characterized according to whether these hospitals were the same or different. Outcomes included all-cause mortality, subhazards for colon cancer-specific mortality, and costs of care at 12 months. RESULTS: Thirty-seven percent of the patients received their surgical and medical oncology care from different hospitals. Rural patients were less likely than urban patients to receive medical oncology care from the same hospital (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). Care from the same hospital was not associated with reduced all-cause or colon cancer-specific mortality but resulted in lower costs (8% of the median cost) at 12 months (dollars saved, $5493; 95% confidence interval, $1799-$9525). CONCLUSIONS: The delivery of surgical and medical oncology care at the same hospital was associated with lower costs; however, reforms seeking to improve outcomes and lower costs through the integration of complex care will need to address the significant proportion of patients receiving care at more than 1 hospital.

Intergenerational Social Networks and Health Behaviors Among Children Living in Public Housing.

OBJECTIVES: In a survey of families living in public housing, we investigated whether caretakers' social networks are linked with children's health status. METHODS: In 2011, 209 children and their caretakers living in public housing in suburban Montgomery County, Maryland, were surveyed regarding their health and social networks. We used logistic regression models to examine the associations between the perceived health composition of caretaker social networks and corresponding child health characteristics (e.g., exercise, diet). RESULTS: With each 10% increase in the proportion of the caretaker's social network that exercised regularly, the child's odds of exercising increased by 34% (adjusted odds ratio = 1.34; 95% confidence interval = 1.07, 1.69) after the caretaker's own exercise behavior and the composition of the child's peer network had been taken into account. Although children's overweight or obese status was associated with caretakers' social networks, the results were no longer significant after adjustment for caretakers' own weight status. CONCLUSIONS: We found that caretaker social networks are independently associated with certain aspects of child health, suggesting the importance of the broader social environment for low-income children's health.

Linking social and built environmental factors to the health of public housing residents: a focus group study.

BACKGROUND: Public housing residents have a high risk of chronic disease, which may be related to neighborhood environmental factors. Our objective was to understand how public housing residents perceive that the social and built environments might influence their health and wellbeing. METHODS: We conducted focus groups of residents from a low-income public housing community in Baltimore, MD to assess their perceptions of health and neighborhood attributes, resources, and social structure. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content using editing style analysis technique. RESULTS: Twenty-eight residents participated in six focus groups. All were African American and the majority were women. Most had lived in public housing for more than 5 years. We identified four themes: public housing's unhealthy physical environment limits health and wellbeing, the city environment limits opportunities for healthy lifestyle choices, lack of trust in relationships contributes to social isolation, and increased neighborhood social capital could improve wellbeing. CONCLUSIONS: Changes in housing and city policies might lead to improved environmental health conditions for public housing residents. Policymakers and researchers may consider promoting community cohesiveness to attempt to empower residents in facilitating neighborhood change.