The Relationship Between Homeownership and Health by Race/Ethnicity Since the Foreclosure Crisis: California Health Interview Survey 2011-2018.

BACKGROUND: US housing policy places a high priority on homeownership, providing large homeowner subsidies that are justified in part by homeownership's purported health benefits. However, studies conducted before, during, and immediately after the 2007-2010 foreclosure crisis found that while homeownership is associated with better health-related outcomes for White households, that association is weaker or non-existent for African-American and Latinx households. It is not known whether those associations persist in the period since the foreclosure crisis changed the US homeownership landscape. OBJECTIVE: To examine the relationship between homeownership and health and whether that relationship differs by race/ethnicity in the period since the foreclosure crisis. DESIGN: We conducted a cross-sectional analysis of 8 waves (2011-2018) of the California Health Interview Survey (n = 143,854, response rate 42.3 to 47.5%). PARTICIPANTS: We included all US citizen respondents ages 18 and older. MAIN MEASURES: The primary predictor variable was housing tenure (homeownership or renting). The primary outcomes were self-rated health, psychological distress, number of health conditions, and delays in receiving necessary medical care and/or medications. KEY RESULTS: Compared to renting, homeownership is associated with lower rates of reporting fair or poor health (OR = 0.86, P < 0.001), fewer health conditions (incidence rate ratio = 0.95, P = 0.03), and fewer delays in receiving medical care (OR = 0.81, P < 0.001) and medication (OR = 0.78, P < 0.001) for the overall study population. Overall, race/ethnicity was not a significant moderator of these associations in the post-crisis period. CONCLUSIONS: Homeownership has the potential to provide significant health-related benefits to minoritized communities, but this potential may be threatened by practices of racial exclusion and predatory inclusion. Further study is needed to elucidate health-promoting mechanisms within homeownership as well as potential harms of specific homeownership-promoting policies to develop healthier, more equitable housing policy.

Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring.

Policy Points Social indicators of young peoples' conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being. There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators. Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

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.

Unmet Medical Needs Among Adults Who Move due to Unaffordable Housing: California Health Interview Survey, 2011-2017.

BACKGROUND: Stable, affordable housing is an established determinant of health. As affordable housing shortages across the USA threaten to displace people from their homes, it is important to understand the implications of cost-related residential moves for healthcare access. OBJECTIVE: To examine the relationship between cost-related moves and unmet medical needs. DESIGN: We performed a cross-sectional analysis of 7 waves (2011-2017) of the California Health Interview Survey. PARTICIPANTS: We included all respondents ages 18 and older. MAIN MEASURES: The primary predictor variable was residential move history in the past 5 years (cost-related move, non-cost-related move, or no move). The primary outcome was unmet medical needs in the past year (necessary medications and/or medical care that were delayed or not received). KEY RESULTS: Our sample included 146,417 adults (42-47% response rate), representing a weighted population of 28,518,590. Overall, 20.3% of the sample reported unmet medical needs in the past year, and 4.9% reported a cost-related move in the past 5 years. In multivariable logistic regression models, adjusted risk of unmet medical needs increased for adults with both cost-related moves (aOR 1.38; 95% CI 1.19-1.59) and non-cost-related moves (aOR 1.17; 95% CI 1.09-1.26) compared to those with no moves. Among people who had moved, those with cost-related moves were more likely to report unmet medical needs compared to people with non-cost-related moves (p = 0.03). CONCLUSIONS: People who have moved due to unaffordable housing represent a population at increased risk for unmet medical needs. Policy makers seeking to improve population health should consider strategies to limit cost-related moves and to mitigate their adverse effects on healthcare access.

Population Health Science: Fulfilling the Mission of Public Health.

Policy Points The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized-control trials, a lack of formal theoretical models, and a fear of politics. The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.

Firearm laws and the network of firearm movement among US states.

BACKGROUND: The movement of firearm across state lines may decrease the effectiveness of state-level firearm laws. Yet, how state-level firearm policies affect cross-state movement have not yet been widely explored. This study aims to characterize the interstate movement of firearms and its relationship with state-level firearm policies. METHODS: We analyzed the network of interstate firearm movement using Bureau of Alcohol, Tobacco, Firearms, and Explosives firearm trace data (2010-2017). We constructed the network of firearm movement between 50 states. We used zero-inflated negative binomial regression to estimate the relationship between the number of a state's firearm laws and number of states for which it was the source of 100 or more firearms, adjusting for state characteristics. We used a similar model to examine the relationship between firearm laws and the number of states for which a given state was the destination of 100 or more firearms. RESULTS: Over the 8-year period, states had an average of 26 (Standard Deviation [SD] 25.2) firearm laws. On average, a state was the source of 100 or more crime-related firearms for 2.2 (SD 2.7) states and was the destination of 100 or more crime-related firearms for 2.2 (SD 3.4) states. Greater number of firearm laws was associated with states being the source of 100 or more firearms to fewer states (Incidence Rate Ratio [IRR] 0.58 per SD, p < 0.001) and being the destination of 100 or more firearms from more states (IRR1.73 per SD, p < 0.001). CONCLUSIONS: Restrictive state-level firearm policies are associated with less movement of firearms to other states, but with more movement of firearms from outside states. The effectiveness of state-level firearm-restricting laws is complicated by a network of interstate firearm movement.

Trends in Health Equity Among Children in the United States, 1997-2018.

OBJECTIVES: Health equity is crucial to population health. To achieve this aim, extensive monitoring efforts beyond traditional disparities research are required. This analysis assesses trends in health equity for children from 1997 to 2018. METHODS: Health equity in a given year is calculated using a previously developed measure as the mean weighted departure of individual health from the best achievable level of health. This criterion is defined as the median health of the most socially privileged identifiable group: white, non-Latinx boys in upper-income households. Using more than 20 years of data from the National Health Interview Survey, we apply this methodology to six measures of child health: parent-reported health status, school days missed due to illness or injury in the past year, a strength and difficulties questionnaire score, emotional difficulties, a toddler mental health indicator score, and toddler depression. We separately calculate racial/ethnic and income disparities. Monte Carlo simulation is used to assess whether trends are statistically significant. RESULTS: Health equity among children increased gradually over the past 2 decades, with five of the six measures demonstrating upward trends. Improvements in health equity are stronger among younger children (age 0-3 and 4-7). Unlike previous work examining adults, both types of disparities narrowed over the study period. CONCLUSIONS FOR PRACTICE: Progress on health equity requires accountability to an objective metric. This analysis suggests some improvement over the past two decades, although these gains are under threat from potential decreases in government spending on programs affecting children and the COVID-19 pandemic.

Passing a Healthy Homes Initiative: Using Modeling to Inform Evidence-Based Policy Decision Making in Kansas City, Missouri.

CONTEXT AND SETTING: Kansas City, Missouri, experiences substantial racial/ethnic health disparities, particularly associated with that city's high level of residential segregation. Among the risk factors for poor health are substandard housing, particularly common in African American neighborhoods, which lead to asthma and therefore to school absences. A 2018 ballot initiative in Kansas City, Missouri, would allow health inspectors to investigate complaints of poor or hazardous conditions in rental housing. OBJECTIVES: Because the Kansas City, Missouri Health Department cannot legally advocate directly for voter support of public health policies, department staff used outside consultants to demonstrate the potential positive impact of environmental initiatives. DESIGN: The Win-Win model provides a standardized, unbiased economic analysis of interventions to help public health officials make informed policy and program decisions and engage in cross-sectoral collaboration. RESULTS: The Win-Win model found that if an asthma home remediation program were provided for almost 7000 low-income children in Kansas City, it would result in 55 000 fewer days of missed school annually among other promising outcomes. The model also showed a $1.67 return-on-investment to local and state government for each dollar spent and a 3-year breakeven point. The results from the Win-Win model were integrated into Kansas City's Community Health Improvement Plan and made available on the Win-Win Project Web site. The proposed law to promote rental inspections passed with 57% of the vote. CONCLUSIONS: The model results allowed for an informed, unbiased point of evidence that the health department could present to community groups and elected officials leading up to the vote on the health inspection initiative.

Longitudinal Associations Between Healthcare Resources, Policy, and Firearm-Related Suicide and Homicide from 2012 to 2016.

BACKGROUND: Firearm-related violence is a leading cause of mortality in the United States (US). Prior research suggests that public policy plays a role in firearm mortality, but the role of healthcare resources (physicians, insurance coverage) within the US policy context has not yet been studied. OBJECTIVE: To examine how healthcare resources and social/firearm policy affect firearm-related suicide and homicide rates in the US. DESIGN: Longitudinal, ecological study. SETTING: US. PARTICIPANTS: US states from 2012 to 2016 (N = 242). MEASUREMENT: The outcome variables were age-adjusted, firearm-related suicide and homicide rates. Predictor variables were healthcare resources (physicians, Medicaid benefits generosity) and policy context (social policy, firearm policy) with covariates for sociodemographic factors. RESULTS: Healthcare provider variables did not have significant associations to firearm-related suicide or homicide. In fully saturated models, more worker protection laws, greater average population density, more alcohol regulation, and more firearm prohibition policies were associated with fewer firearm-related suicides. Higher generosity of Medicaid benefits was associated with fewer firearm-related homicides. Poverty rate was a predictor of both outcomes. LIMITATIONS: This state-level study cannot make individual-level inferences. Only proxy variables were available for measuring gun ownership and actual gun ownership rates may not have been ideally captured at the state level. CONCLUSIONS: At the state level, there are protective associations of certain social, healthcare, and firearm policies to firearm-related suicide and homicide rates. Healthcare resources play a role in population-level firearm outcomes but alone are not sufficient to decrease firearm-related homicide or suicide.

The relationship of nursing practice laws to suicide and homicide rates: a longitudinal analysis of US states from 2012 to 2016.

BACKGROUND: Nursing resources can have a protective effect on patient outcomes, but nurses and nursing scope of practice have not been studied in relation to injury outcomes. The purpose of this study was to examine whether scope of practice and ease of practice laws for nurse practitioners and registered nurses are associated with suicide and homicide rates in the United States. METHODS: This state-level analysis used data from 2012 to 2016. The outcome variables were age-adjusted suicide and homicide rates. The predictor variables were NP scope of practice by state (limited, partial, or full) and RN ease of practice (state RN licensure compact membership status). Covariates were state sociodemographic, healthcare, and firearm/firearm policy context variables that have a known relationship with the outcomes. RESULTS: Full scope of practice for NPs was associated with lower rates of suicide and homicide, with stronger associations for suicide. Likewise, greater ease of practice for RNs was associated with lower suicide and homicide rates. CONCLUSIONS: Findings suggest that nurses are an important component of the healthcare ecosystem as it relates to injury outcomes. Laws supporting full nursing practice may have a protective effect on population health in the area of injuries and future studies should explore this relationship further.

Examining the association of changes in minimum wage with health across race/ethnicity and gender in the United States.

BACKGROUND: The minimum wage creates both winners (through wage increases) and-potentially-losers (through job losses). Research on the health effects of minimum wage policies has been sparse, particularly across gender and among racial/ethnic minorities. We test the impact of minimum wage increases on health outcomes, health behaviors and access to healthcare across gender and race/ethnicity. METHODS: Using 1993-2014 data from the Behavioral Risk Factor Surveillance System, variables for access to healthcare (insurance coverage, missed care due to cost), health behavior (exercise, fruit, vegetable and alcohol consumption) and health outcomes (self-reported fair/poor health, hypertension, poor physical health days, poor mental health days, unhealthy days) were regressed on the product of the ratio of the 1-year lagged minimum wage to the state median wage and the national median wage, using Linear Probability Models and Poisson Regression Models for dichotomous and count outcomes, respectively. Regressions (total population, gender-stratified, race/ethnicity stratified (white, black, Latino), gender/race/ethnicity stratified and total population with interaction terms for race/ethnicity/gender) controlled for state-level ecologic variables, individual-level demographics and fixed-effects (state and year). Results were adjusted for complex survey design and Bonferroni corrections were applied to p-values such that the level of statistical significance for a given outcome category was 0.05 divided by the number of outcomes in that category. RESULTS: Minimum wage increases were positively associated with access to care among white men, black women and Latino women but negatively associated with access to care among white women and black men. With respect to dietary quality, minimum wage increases were associated with improvements, mixed results and negative impacts among white, Latino and black men, respectively. With respect to health outcomes, minimum wage increases were associated with positive, negative and mixed impacts among white women, white men and Latino men, respectively. CONCLUSIONS: While there is enthusiasm for minimum wage increases in the public health community, such increases may have to be paired with deliberate strategies to protect workers that might be vulnerable to economic dislocation. Such strategies may include more robust unemployment insurance or increased access to job training for displaced workers.

Making Strides Toward Health Equity: The Experiences of Public Health Departments.

OBJECTIVES: We explored the definition of health equity being used by public health departments and the extent of engagement of public health departments in activities to improve health equity, as well as facilitators and barriers to this work. DESIGN: We conducted 25 semistructured qualitative interviews with lead public health officials (n = 20) and their designees (n = 5). All interviews were transcribed and thematically analyzed. SETTING: We conducted interviews with respondents from local public health departments in the United States (April 2017-June 2017). PARTICIPANTS: Respondents were from local or state public health departments that were members of the Big Cities Health Coalition, accredited or both. RESULTS: Many departments were using a definition of health equity that emphasized an equal opportunity to improve health for all, with a special emphasis on socially disadvantaged populations. Improving health equity was a high priority for most departments and targeting the social determinants of health was viewed as the optimal approach for improving health equity. Having the capacity to frame issues of health equity in ways that resonated with sectors outside of public health was seen as a particularly valuable skill for facilitating cross-sector collaborations and promoting work to improve health equity. Barriers to engaging in work to improve health equity included lack of flexible and sustainable funding sources as well as limited training and guidance on how to conduct this type of work. CONCLUSIONS: Work to improve health equity among public health departments can be fostered and strengthened by building capacity among them to do more targeted framing of health equity issues and by providing more flexible and sustained funding sources. In addition, supporting peer networks that will allow for the exchange of resources, ideas, and best practices will likely build capacity among public health departments to effectively do this work.

Quantifying the Value of Prevention: A Survey of Public Health Departments' Quantitative and Economic Modeling Capacity.

OBJECTIVE: To improve the understanding of local health departments' (LHDs') capacity for and perceived barriers to using quantitative/economic modeling information to inform policy and program decisions. DESIGN: We developed, tested, and deployed a novel survey to examine this topic. SETTING: The study's sample frame included the 200 largest LHDs in terms of size of population served plus all other accredited LHDs (n = 67). The survey was e-mailed to 267 LHDs; respondents completed the survey online using SurveyMonkey. PARTICIPANTS: Survey instructions requested that the survey be completed from the perspective of the entire health department by LHD's top executive or designate. A total of 63 unique LHDs responded (response rate: 39%). MAIN OUTCOME MEASURE(S): Capacity for quantitative and economic modeling was measured in 5 categories (routinely use information from models we create ourselves; routinely use information from models created by others; sometimes use information from models we create ourselves; sometimes use information from models created by others; never use information from modeling). Experience with modeling was measured in 4 categories (very, somewhat, not so, not at all). RESULTS: Few (9.5%) respondents reported routinely using information from models, and most who did used information from models created by others. By contrast, respondents reported high levels of interest in using models and in gaining training in their use and the communication of model results. The most commonly reported barriers to modeling were funding and technical skills. Nearly all types of training topics listed were of interest. CONCLUSIONS: Across a sample of large and/or accredited LHDs, we found modest levels of use of modeling coupled with strong interest in capacity for modeling and therefore highlight an opportunity for LHD growth and support. Both funding constraints and a lack of knowledge of how to develop and/or use modeling are barriers to desired progress around modeling. Educational or funding opportunities to promote capacity for and use of quantitative and economic modeling may catalyze use of modeling by public health practitioners.

Early Child Development, Residential Crowding, and Commute Time in 8 US States, 2010-2017.

OBJECTIVES: To examine relationships of residential crowding and commute time with early child development. METHODS: We used the Early Development Instrument (EDI), a teacher-reported, population-health measure of child development. The sample included child-level observations spanning 8 US states from 2010 to 2017 (n = 185 012), aggregated to the census tract (n= 2793), stratified by percentage of households in poverty. To test the association of commute times, crowding, and child development, we tested overall readiness and 5 EDI domains by using adjusted census tract-level multivariate regression with fixed effects. RESULTS: In the full sample, a 1-standard-deviation increase in crowding was associated with 0.064- and 0.084-point decreases in mean score for cognitive development and communication skills, respectively. For the high-poverty subsample, a 1-standard deviation increase in commute time was associated with 0.081- and 0.066-point decreases in social competence and emotional maturity. CONCLUSIONS: In neighborhoods with increased crowding or commute time, early child development suffers. POLICY IMPLICATIONS: This study suggests a potential relationship between the changing urban landscape and child health. Children would benefit from more multisector collaboration between urban planning and public health.

Weighing in: the taste-engineering frame in obesity expert discourse.

OBJECTIVES: We sought expert opinion on the problems with 2 dominant obesity-prevention discourse frames-personal responsibility and the environment-and examined alternative frames for understanding and addressing obesity. METHODS: We conducted 60-minute, semistructured interviews with 15 US-based obesity experts. We manually coded and entered interview transcripts into software, generating themes and subthematic areas that captured the debate's essence. RESULTS: Although the environmental frame is the dominant model used in communications with the public and policymakers, several experts found that communicating key messages within this frame was difficult because of the enormity of the obesity problem. A subframe of the environmental frame--the taste-engineering frame--identifies food industry strategies to influence the overconsumption of certain foods and beverages. This emerging frame deconstructs the environmental frame so that causal attributes and responsible agents are more easily identifiable and proposed policies and public health interventions more salient. CONCLUSIONS: Expert interviews are an invaluable resource for understanding how experts use frames in discussing their work and in conversations with the public and policymakers. Future empirical studies testing the effectiveness of the taste-engineering frame on public opinion and support for structural-level health policies are needed.

Local public health department adoption and use of electronic health records.

CONTEXT: Electronic health records (EHRs) may help local health departments (LHDs) to improve services and thereby promote and protect population health. Yet, little is known about nationwide trends and correlates of EHR use by LHDs. OBJECTIVE: We examine relative contributions of LHD finances, leadership, and governance to EHR adoption and use from 2010 to 2013. The impact of LHD service provision and meaningful use factors on EHR use is explored in depth. DESIGN: Combining data from the National Association of County & City Health Officials Profile survey and the Area Health Resource File, logistic regression models were used to examine EHR use in 2013. Multinomial logistic models examined EHR adoption, use, or discontinuation from 2010 to 2013. PARTICIPANTS: EHR usage data were available for 514 and 488 LHDs in 2010 and 2013, respectively. A total of 117 LHDs had data for both 2010 and 2013. MAIN OUTCOME MEASURES: Outcomes included dichotomized measures of LHD self-reported use of EHRs in 2010 and 2013. For LHDs with 2 years of data, a 4-category variable measuring self-reported EHR use, nonuse, adoption, or discontinuation was analyzed. RESULTS: Overall LHD EHR use did not increase significantly between 2010 (19.3%) and 2013 (22.0%). While 15% of LHDs reported adopting EHRs from 2010 to 2013, another 8.5% reported discontinuing use of EHRs during this time. Likelihood of EHR use was strongly associated with LHD clinical service characteristics, per capita expenditures, and state governance structure. CONCLUSIONS: EHRs do not appear to be rapidly diffusing across LHDs, and retention of current systems may be a concern. Given trends away from clinical service provision and other pressing demands for LHD resources, the benefits of EHR adoption are unclear.

Impact of different policies on unhealthy dietary behaviors in an urban adult population: an agent-based simulation model.

OBJECTIVES: Unhealthy eating is a complex-system problem. We used agent-based modeling to examine the effects of different policies on unhealthy eating behaviors. METHODS: We developed an agent-based simulation model to represent a synthetic population of adults in Pasadena, CA, and how they make dietary decisions. Data from the 2007 Food Attitudes and Behaviors Survey and other empirical studies were used to calibrate the parameters of the model. Simulations were performed to contrast the potential effects of various policies on the evolution of dietary decisions. RESULTS: Our model showed that a 20% increase in taxes on fast foods would lower the probability of fast-food consumption by 3 percentage points, whereas improving the visibility of positive social norms by 10%, either through community-based or mass-media campaigns, could improve the consumption of fruits and vegetables by 7 percentage points and lower fast-food consumption by 6 percentage points. Zoning policies had no significant impact. CONCLUSIONS: Interventions emphasizing healthy eating norms may be more effective than directly targeting food prices or regulating local food outlets. Agent-based modeling may be a useful tool for testing the population-level effects of various policies within complex systems.

The effects of food advertising and cognitive load on food choices.

BACKGROUND: Advertising has been implicated in the declining quality of the American diet, but much of the research has been conducted with children rather than adults. This study tested the effects of televised food advertising on adult food choice. METHODS: Participants (N = 351) were randomized into one of 4 experimental conditions: exposure to food advertising vs. exposure to non-food advertising, and within each of these groups, exposure to a task that was either cognitively demanding or not cognitively demanding. The number of unhealthy snacks chosen was subsequently measured, along with total calories of the snacks chosen. RESULTS: Those exposed to food advertising chose 28% more unhealthy snacks than those exposed to non-food-advertising (95% CI: 7% - 53%), with a total caloric value that was 65 kcal higher (95% CI: 10-121). The effect of advertising was not significant among those assigned to the low-cognitive-load group, but was large and significant among those assigned to the high-cognitive-load group: 43% more unhealthy snacks (95% CI: 11% - 85%) and 94 more total calories (95% CI: 19-169). CONCLUSIONS: Televised food advertising has strong effects on individual food choice, and these effects are magnified when individuals are cognitively occupied by other tasks.