Multi-Level Influences of Smoke-Free Policies in Subsidized Housing: Applying the COM-B Model and Neighborhood Assessments to Inform Smoke-Free Policies.

Smoke-free policies in multi-unit housing are associated with reduced exposure to secondhand smoke (SHS); however, attitudes toward comprehensive smoke-free policies among residents in subsidized multi-unit housing are unknown. In this mixed-methods study, we explored the socio-ecological context for tobacco and cannabis use and attitudes toward policies restricting indoor use of these products through interviews with residents (N = 134) and staff (N = 22) in 15 federally subsidized multi-unit housing in San Francisco, California. We conducted a geo-spatial and ethnographic environmental assessment by mapping alcohol, cannabis, and tobacco retail density using ArcGIS, and conducted systematic social observations of the neighborhood around each site for environmental cues to tobacco use. We used the Capability, Opportunity, and Motivation behavior (COM-B) model to identify factors that might influence implementation of smoke-free policies in multi-unit housing. Knowledge and attitudes toward tobacco and cannabis use, social norms around smoking, neighborhood violence, and cannabis legalization were some of the social-ecological factors that influenced tobacco use. There was spatial variation in the availability of alcohol, cannabis, and tobacco stores around sites, which may have influenced residents' ability to maintain smoke-free homes. Lack of skill on how to moderate indoor smoking (psychological capability), lack of safe neighborhoods (physical opportunity), and the stigma of smoking outdoors in multi-unit housing (motivation) were some of the barriers to adopting a smoke-free home. Interventions to increase adoption of smoke-free policies in multi-unit housing need to address the co-use of tobacco and cannabis and commercial and environmental determinants of tobacco use to facilitate smoke-free living.

Disaster Preparedness and Housing Tenure: How Do Subsidized Renters Fare?

Homeowners are significantly more prepared for disasters than renters. However, disaster preparedness among subsidized renters is an understudied topic despite their increased vulnerability to negative disaster outcomes. Previous research shows that one in three subsidized units is at risk for exposure to disasters, relative to one in four unsubsidized rental units, and one in seven owner-occupied units. Subsidized housing residents often fall into many vulnerable statuses that would make them less prepared than renters and owners. Using 2017 American Housing Survey data, we examine differences in household disaster preparedness by housing tenure, with and without controls for such factors. Logistic regression analyses indicate that subsidized renters are significantly less prepared than unsubsidized renters, and both renter types are significantly less prepared than homeowners, controlling for demographic and neighborhood characteristics. The policy implications of this research are considered as they relate to the location and management of subsidized housing in an era of climate change.

The role of housing characteristics in racial and ethnic disparities in SARS-CoV-2 antibody seropositivity among New York City adults: A population representative study.

Black and Latino populations have been disproportionately burdened by COVID-19 morbidity and mortality. Subsidized housing, crowding, and neighborhood poverty might be associated with increased COVID-19 transmission and play a role in observed racial and ethnic disparities, yet research is limited. Our study investigated whether these housing variables mediate the relationship between race and ethnicity and SARS-CoV-2 antibody seropositivity among New York City (NYC) adults. We analyzed data from a SARS-CoV-2 serosurvey (n = 1074), nested within the 2020 cross-sectional NYC Community Health Survey (June-October 2020). We defined SARS-CoV-2 seropositivity as either a positive blood test for SARS-CoV-2 antibodies or a self-reported positive test result. We used causal mediation analyses to test whether subsidized housing, crowding, and neighborhood poverty mediate a relationship between race and ethnicity and seropositivity. After controlling for potential confounding, we found elevated prevalence ratios of SARS-CoV-2 seropositivity among Black (APR = 1.74, 95% CI = 1.10-2.73) and Latino (APR = 1.58, 95% CI = 1.05-2.37) residents compared with White residents and for those living in crowded housing (APR = 1.48, 95% CI = 1.03-2.12) and high-poverty neighborhoods (APR = 1.54, 95% CI = 1.12-2.11) but not for subsidized housing. We observed statistically significant natural direct effects for all three mediators. While living in crowded housing and high-poverty neighborhoods contributed to racial and ethnic disparities in seropositivity the estimated contribution from living in subsidized housing was -9% (Black) and - 14% (Latino). Our findings revealed racial and ethnic disparities in seropositivity of SARS-CoV-2 antibodies among NYC adults. Unlike crowding and neighborhood poverty, living in subsidized housing did not explain racial and ethnic disparities in COVID-19.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada.

BACKGROUND: Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Detecting dementia among older, ethnically diverse residents of rural subsidized housing.

Rural, ethnically diverse residents face at least twice the risk of Alzheimer's disease than urban residents. Chronic diseases such as diabetes and hypertension which increase dementia risk are more prevalent in rural areas with less access to specialty providers. A home-based approach for increasing dementia detection and treatment rates was tested among rural residents of government-assisted independent living facilities (N = 139; 78% non-White, and 70% with health literacy below 5th grade). Of 28 residents identified at risk during cognitive screening, 25 agreed to further in-depth assessment by adult gerontological nurse practitioners (AGNP). Fifteen of 25 (60%) completing consequent primary provider referrals were diagnosed with dementia and receiving new care (statistically significant; [χ2(1) = 76.67, p < .001, Phi = 0.743]). Home-based dementia management through a community engagement approach can help to meet the Healthy People 2030 goals of earlier detection and treatment and reduce the length of costly institutionalizations.

Subsidized Households and Wildfire Hazards in California.

As deadly and destructive wildfires become increasingly common in the western United States due to climate change, low-income households face particular difficulties recovering from these disasters. Despite this threat, surprisingly little empirical evidence exists about the exposure and vulnerability to wildfire hazards of residents of subsidized housing. This study focuses on the subsidized housing population for several reasons: residents generally have less adaptive capacity to respond to wildfires; the locations of subsidized housing units reflect relatively stable locations of low-income households for decades; and policymakers can intervene to retrofit existing housing as well as shape future housing siting and design. The dataset created for this study includes all Census tracts in California with housing units by type, wildland-urban interface (WUI) coverage, and an index of social vulnerability. Using a combination of descriptive statistics and spatial regression models, the analysis focuses on the intersection of subsidized housing and wildfire hazards. Results show that subsidized housing is disproportionately located outside the WUI in California's metropolitan and nonmetropolitan areas. However, policy interventions are necessary because many vulnerable households-including those residing in the 140,000 subsidized units in the WUI-live in harm's way.

Subsidized Housing and the Transition to Adulthood.

Despite abundant evidence about the effect of children's socioeconomic circumstances on their transition to adulthood, we know much less about the effect of social policy programs aimed at poor families with children in facilitating how and when children become adults. This issue is particularly important for the U.S. federal subsidized housing program given its long history of placing subsidized units in some of the poorest and most racially segregated neighborhoods. Using counterfactual causal methods that adjust for the length of receipt of subsidized housing, I estimate the effect of subsidized housing on teenage parenthood, household formation, and educational attainment. I find that the subsidized housing program has either null or positive effects on the transition to adulthood and that these effects vary by both race and gender. These results underscore the importance of considering whether social programs have differential effects on the life chances of individuals based on both race and gender.

Navigating Limited and Uncertain Access to Subsidized Housing After Prison.

An emerging literature has documented the challenges that formerly incarcerated individuals face in securing stable housing. Given the increasingly unaffordable rental market, rental subsidies represent an important and understudied source of stable housing for this population. The existing literature has described substantial discretion and a varied policy landscape that determine former prisoners' access to housing subsidies, or subsidized housing spaces that are leased to members of their social and family networks. Less is known about how former prisoners themselves interpret and navigate this limited and uncertain access to subsidized housing. Drawing on data from repeated qualitative interviews with 44 former prisoners, we describe the creative and often labor-intensive strategies that participants employed to navigate discretion and better position themselves for subsidized housing that was in high demand, but also largely out of reach. Our findings also illustrate the potential costs associated with these strategies for both participants and members of their social and family networks.

Barriers and facilitators to healthy eating and disease self-management among older adults residing in subsidized housing.

BACKGROUND: As adults transition into older ages, meeting age-specific dietary recommendations can become increasingly challenging, especially for low-income seniors who reside in publicly subsidized rental housing. AIM: The primary objectives of this study were to: 1) identify barriers and facilitators to healthy eating and self-management of nutrition-related chronic illnesses experienced by low-income seniors residing in a subsidized housing setting; and 2) assess the interest in community nutrition programming among low-income seniors residing in a subsidized housing setting. METHOD: A qualitative study design, using food focus groups and food pantry observations, was used. Participants included 24 male and female senior adults, between 65 and 75 years of age, residing in a subsidized housing community in Philadelphia, PA. This setting also included the unique features of a community garden and food pantry. Data were manually analyzed using a content analysis approach, which included familiarization, identification of themes, categorization and interpretation; and verified using NVivo 10. RESULTS: Personal barriers, including food cost and accessibility, physical limitations, desire for convenience, and low self-efficacy to change dietary habits, inhibited motivation to change. External barriers in the food environment, including lack of transportation and distance of markets to access fresh produce, were commonly cited; as well as negative influences of the internal environment, such as the presence of vending machines, common cultural cooking and eating practices, and the lack of social cohesion. Facilitators focused on food preparation and recipe adaptation. CONCLUSIONS: Participants expressed an interest in learning more about food, nutrition, and health through community-based programming.

State Tobacco Control Program Implementation Strategies for Smoke-Free Multiunit Housing.

Multiunit housing residents are at risk of secondhand smoke exposure from adjoining units and common areas. We developed this case study to document state-level strategies undertaken to address this risk. We explored program documents to identify facilitators, barriers, and outcomes. Three states (Montana, Michigan, and Nebraska) provided detailed information on multiunit housing efforts in the study time frame. We conducted a qualitative analysis using inductive coding to develop themes. Several facilitators relating to existing infrastructure included traditional and nontraditional partnerships, leadership and champions, collecting and using data, efficient use of resources, and strategic plans. We also report external catalysts, barriers, and outcomes. Significant state leadership and effort were required to provide local-level technical assistance to engage traditional and nontraditional partners. Information needs were identified and varied by stakeholder type (i.e., health vs. housing). States recommend starting with public housing authorities, so they can become resources for affordable and subsidized housing. These lessons and resources can be used to inform smoke-free multiunit housing initiatives in other states and localities.

The Effect of Microneighborhood Conditions on Adult Educational Attainment in a Subsidized Housing Intervention.

The ACHIEVEability model of affordable housing aims to promote self-sufficiency by requiring enrollment in postsecondary education in exchange for subsidized housing. In this study, we exploit the quasi random assignment of ACHIEVEability participants (N = 84) to subsidized housing units to evaluate whether microneighborhood environments moderated participants' progress in postsecondary education. Participants progressed in their educational pursuits in line with program requirements, earning about 12 college credits per year. Neighborhood block group characteristics moderated this progress. Participants who were assigned to housing located in poorer, more violent, and less educated block groups earned credits at a significantly slower rate than participants assigned housing in more advantaged block groups. Our results suggest that the micro environments immediately surrounding residents of subsidized housing matter, even if they are situated within broader contexts of spatial and personal disadvantage.

Preserving Neighborhood Opportunity: Where Federal Housing Subsidies Expire.

Rent burdens are increasing in U.S. metropolitan areas while subsidies on privately owned, publicly subsidized rental units are expiring. As a result, some of the few remaining affordable units in opportunity neighborhoods are at risk of being converted to market rate. Policy makers face a decision about whether to devote their efforts and scarce resources toward developing new affordable housing, recapitalizing existing subsidized housing, and/or preserving properties with expiring subsidies. There are several reasons to preserve these subsidies, one being that properties may be located in neighborhoods with greater opportunity. In this article, we use several sources of data at the census tract level to learn how subsidy expirations affect neighborhood opportunity for low-income households. Our analysis presents several key findings. First, we find that units that left the project-based Section 8 program were - on average - in lower opportunity neighborhoods, but these neighborhoods were improving. In addition, properties due to expiry from the Section 8 program between 2011 and 2020 are in higher opportunity neighborhoods than any other subsidy program. On the contrary, new Low-Income Housing Tax Credit (LIHTC) units were developed in tracts similar to those where LIHTC units are currently active, which tend to be lower opportunity neighborhoods.

Promoting Sustainability in Housing with Services: Insights From the Right Care, Right Place, Right Time Program.

Despite the widely-acknowledged potential of housing with services for improving the lives of low-income older adults, ensuring their financial sustainability has been challenging. This study aimed to address this issue, drawing on 31 key informant interviews and three focus groups with payers, housing providers, and community partners involved in the Boston-area Right Care, Right Place, Right Time Program, which enrolled about 400 older adults. Transcripts were qualitatively analyzed using thematic coding. Participants agreed on the program's value, but there was little consensus on mechanisms for securing ongoing funding. The broadly distributed responsibility for individuals in housing sites, which involves health insurers, hospitals, and community service providers, provides little incentive for investment by these entities. Findings suggest that governmental mechanisms, probably at the federal level, are needed to channel funding toward these supportive services. Without such reliable funding sources, replication of supportive housing models for low-income older people will prove difficult.

Geriatric conditions and healthcare utilization among older adults living in subsidized housing.

BACKGROUND: Nearly 2.9 million older Americans with lower incomes live in subsidized housing. While regional and single-site studies show that this group has higher rates of healthcare utilization compared to older adults in the general community, little is known about healthcare utilization nationally nor associated risk factors. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries aged ≥65 enrolled in the National Health and Aging Trends Study in 2011, linked to Medicare claims data, including individuals living in subsidized housing and the general community. Participants were followed annually through 2020. Outcomes were hospitalization, short-term skilled nursing facility (SNF) utilization, long-term care utilization, and death. Fine-Gray competing risks regression analysis was used to assess the association of subsidized housing residence with hospitalization and nursing facility utilization, and Cox proportional hazards regression analysis was used to assess the association with death. RESULTS: Among 6294 participants (3600 women, 2694 men; mean age, 75.5 years [SD, 7.0]), 295 lived in subsidized housing at baseline and 5999 in the general community. Compared to older adults in the general community, those in subsidized housing had a higher adjusted subdistribution hazard ratio [sHR] of hospitalization (sHR 1.21; 95% CI, 1.03-1.43), short-term SNF utilization (sHR 1.49; 95% CI, 1.15-1.92), and long-term care utilization (sHR 2.72; 95% CI, 1.67-4.43), but similar hazard of death (HR, 0.86; 95% CI, 0.69-1.08). Individuals with functional impairment had a higher adjusted subdistribution hazard of hospitalization and short-term SNF utilization and individuals with dementia and functional impairment had a higher hazard of long-term care utilization. CONCLUSIONS: Older adults living in subsidized housing have higher hazards of hospitalization and nursing facility utilization compared to those in the general community. Housing-based interventions to optimize aging in place and mitigate risk of nursing facility utilization should consider risk factors including functional impairment and dementia.

"I make myself get busy": Resilience and social connection among low-income older adults living in subsidized housing.

BACKGROUND: Social isolation and loneliness are pervasive issues among older adults in the United States, carrying significant health risks. Low-income older adults are particularly vulnerable to these challenges compared with their higher-income counterparts due to their limited access to resources and social networks. Many low-income older adults live in subsidized housing, which has the potential to offer unique support tailored to their needs. The intersection of aging and the unique social circumstances faced by low-income older adults significantly influences how they navigate crises. METHODS: We conducted semi-structured interviews with 24 older adults aged 63-86 residing in subsidized housing communities in the United States. The data were collected from August 2021 to November 2022 and subsequently analyzed using a thematic constant comparison analysis approach. RESULTS: Many participants felt connected to their housing community. Participants reported that their lives changed substantially due to the pandemic: communal activities ceased leading to isolation and feelings of loneliness. Amid this challenge, participants were resourceful and found creative ways to manage. Many emphasized the crucial role of technology in maintaining emotional support despite physical separation. CONCLUSIONS: Participants in subsidized housing shared their experiences before and during this unique crisis highlighting the challenges they face, as well as their resilience and adaptability when facing challenges. Our findings underscore the significance of community activation, demonstrating that activities motivated older adults to improve their well-being. Additionally, the role of technology in maintaining connections proved to be crucial.

Disability and subsidized housing residency: The adverse impacts of Winter Storm Uri in metropolitan Texas.

BACKGROUND: While natural disasters have been found to affect both disabled and subsidized rental housing residents negatively and disproportionately, previous studies have not examined if adverse disaster impacts experienced by disabled individuals in subsidized housing developments differ from those living in other housing. OBJECTIVE: We focused on Winter Storm Uri in Texas, USA, which lasted from February 10-20, 2021. We sought to: (1) compare differences in adverse impacts suffered by households with and without disabled persons; and (2) examine how residency in US Department of Housing and Urban Development (HUD)-assisted rental housing influences the severity of impacts for households with disabled persons. METHODS: We collected data from 790 randomly selected households in eight Texas metropolitan areas through a bilingual phone survey. Bivariate and multivariable statistical methods were utilized to compare adverse impacts suffered by households, based on both disability status and HUD-assisted housing residency. RESULTS: Households with disabled persons were more severely impacted by Uri than households without disabled persons, in terms of service disruptions, colder temperatures, slower recovery, and adverse experiences that have important health implications. Households with disabled persons residing in HUD-assisted housing were more negatively impacted and suffered more adverse experiences than those living in other housing. CONCLUSIONS: Residency in federally-assisted rental housing can worsen severity of adverse impacts and amplify disaster vulnerability for disabled individuals. These disparities based on disability and subsidized housing status emphasize the need for additional research to understand the impacts of disasters on disabled residents and formulate interventions that provide equitable protections.

Social Networks and Chronic Illness Management among Low-Income Tenants in Publicly Subsidized Housing: Findings from a Pilot Study.

Low-income tenants in publicly subsidized housing (PSH) have higher rates of chronic illnesses than non-PSH-based residents, making the implementation of chronic illness management (CIM) essential. Based on the person-in-environment framework used in social work practice, which emphasizes the importance of interactions between clients and their social environment, this pilot study used personal network analysis (PNA), a variant of social network analysis, to explore what attributes of social networks are relevant to CIM among 26 low-income tenants independently living in a PSH in the Southwest United States. Tenants with a smaller network size and effective size presented better self-efficacy to manage chronic disease (SEMCD) and lower levels of depressive symptoms. Being connected to a higher proportion of alters (i.e., network members) with whom they discussed health matters was also associated with high SEMCD. As for CIM implementation, being connected to a doctor and a lower proportion of alters who have chronic illnesses were associated with doing aerobic exercise. Tenants with a larger proportion of alters serving multiple functions reported more frequent vegetable and fruit consumption, while those with a higher share of kin alters and lower share of alters living in the same PSH reported less frequent high-fat food consumption. Our findings help social workers discover relevant social networks and dynamics that low-income tenants at PSH capitalize to locate resources for CIM. Further studies are recommended to adopt PNA to expand practice-related knowledge that social workers can use for health promotion among low-income tenants with chronic illness.

Health disparities among Social Security Disability Insurance and Supplemental Security Income beneficiaries who participate in federal rental housing assistance programs.

BACKGROUND: Approximately 1.2 million non-elderly adults jointly participate in U.S. Department of Urban Development (HUD) rental housing assistance and Social Security Administration (SSA) disability programs (Social Security Disability Insurance (DI) and Supplemental Security Income (SSI), yet information about the health of these program participants is limited. OBJECTIVE: /Hypothesis. Non-elderly DI and/or SSI participants participating in HUD-assisted rental housing programs face unique health disparities. METHODS: Using newly available 2013-2016 National Health Interview Survey (NHIS) data linked with U.S. Department of Housing and Urban Development (HUD) administrative records on public and assisted housing programs, multivariate analyses were used to highlight differences in health status, health behaviors, health care utilization, and financial worry about health and housing costs between non-elderly persons participating in HUD rental housing assistance programs who were and who were not also participating in DI and/or SSI. RESULTS: The focal population had higher predicted probabilities of fair or poor health status, chronic condition diagnoses (hypertension, asthma, diabetes), and obesity than others but a lower probability of smoking (p < .05). Engagement with the health care system is high, yet 32% needed but could not afford services in the past year. CONCLUSIONS: Opportunities for joint intervention between HUD and SSA to improve the health of their program participants are discussed.

In the Eyes of Those Who Were Randomized: Perceptions of Disadvantaged Older Adults in a Tai Chi Trial.

BACKGROUND AND OBJECTIVES: Older adults living in subsidized housing have typically been excluded from exercise intervention studies. We conducted a qualitative study to explore the perceived physical, psychological, social, and economic factors that influenced participation in and adherence to a year-long Tai Chi intervention within an ongoing cluster-randomized controlled trial (RCT) for older adults living within subsidized housing facilities. RESEARCH DESIGN AND METHODS: Focus groups were held with participants of the RCT who were allocated to the trial's Tai Chi intervention. Individual phone interviews were conducted with those allocated to Tai Chi who had low adherence or who had withdrawn their participation from the study. Emergent themes were extracted using grounded-theory methods. RESULTS: In this qualitative study, we enrolled 41 participants who were allocated to the RCT's Tai Chi intervention: 38 completed and 3 withdrew from the study. Average Tai Chi class attendance was 64.3%. Pragmatic factors that led to higher adherence and retention included: locating classes within each facility; providing programs at no cost; and deployment of a skilled research support team. In addition, the use of an accessible, simplified Tai Chi program improved confidence, social support, self-efficacy, and self-reported improvements in physical and psychological well-being. DISCUSSION AND IMPLICATIONS: Perceived physical, psychological, social benefits, and self-efficacy likely enhance adherence and retention to research-based Tai Chi interventions for older adults. Delivering an on-site, no cost, and supportive program appears critical to overcoming financial and environmental barriers to participation for those living within subsidized housing.

"I Felt Safe": The Role of the Rapid Rehousing Program in Supporting the Security of Families Experiencing Homelessness in Salt Lake County, Utah.

Homelessness is a public health issue that many organizations are addressing through a Housing First Model. One such organization is The Road Home (TRH), which provides services to homeless individuals and families in Salt Lake County. TRH is perhaps best known for their emergency shelters, but the organization also administers the Rapid Rehousing Program (RRHP), designed to help families experiencing homelessness transition back into stable housing. Those experiencing homelessness tend to have high rates of chronic mental/physical disabilities as well as issues related to substance abuse. Having a home is the first step toward achieving some kind of stability in their lives. The RRHP allows families to find housing in the private rental market and will cover the initial costs and several months of rent for clients. While the program has been praised by policymakers and social service providers for helping homeless families find rental housing, there is no empirical research about participant perspectives regarding their residential (in)security. The research question of this article is: what is the role of the RRHP in supporting the security of families experiencing homelessness? Researchers collected qualitative data through focus groups and interviews with 31 participants, 23 families experiencing homelessness, two landlords, six case managers, and service providers. Lastly, we identify recommendations for program improvements based on information gathered from research participants. It is our hope that the information presented in this article can and will be used in a way that improves public health by increasing the residential security of families experiencing homelessness.