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.

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.

Switching Schools: Reconsidering the Relationship Between School Mobility and High School Dropout.

Youth who switch schools are more likely to demonstrate a wide array of negative behavioral and educational outcomes, including dropping out of high school. However, whether switching schools actually puts youth at risk for dropout is uncertain, since youth who switch schools are similar to dropouts in their levels of prior school achievement and engagement, which suggests that switching schools may be part of the same long-term developmental process of disengagement that leads to dropping out. Using data from the National Longitudinal Survey of Youth 1997, this study uses propensity score matching to pair youth who switched high schools with similar youth who stayed in the same school. We find that while over half the association between switching schools and dropout is explained by observed characteristics prior to 9th grade, switching schools is still associated with dropout. Moreover, the relationship between switching schools and dropout varies depending on a youth's propensity for switching schools.

Fifteen years later: can residential mobility programs provide a long-term escape from neighborhood segregation, crime, and poverty?

We examined whether the Gautreaux residential mobility program, which moved poor black volunteer families who were living in inner-city Chicago into more-affluent and integrated neighborhoods, produced long-run improvements in the neighborhood environments of the participants. We found that although all the participants moved in the 6 to 22 years since their initial placements, they continued to reside in neighborhoods with income levels that matched those of their placement neighborhoods. Families who were placed in higher-income, mostly white neighborhoods were currently living in the most-affluent neighborhoods. Families who were placed in lower-crime and suburban locations were most likely to reside in low-crime neighborhoods years later.