Association of Promoting Housing Affordability and Stability With Improved Health Outcomes: A Systematic Review.

Importance: Housing insecurity-that is, difficulty with housing affordability and stability-is prevalent and results in increased risk for both homelessness and poor health. However, whether interventions that prevent housing insecurity upstream of homelessness improve health remains uncertain. Objective: To review evidence characterizing associations of primary prevention strategies for housing insecurity with adult physical health, mental health, health-related behaviors, health care use, and health care access. Evidence Review: Pairs of independent reviewers systematically searched PubMed, Web of Science, EconLit, and the Social Interventions Research and Evaluation Network for quantitative studies published from 2005 to 2021 that evaluated interventions intended to directly improve housing affordability and/or stability either by supporting at-risk households (targeted primary prevention) or by enhancing community-level housing supply and affordability in partnership with the health sector (structural primary prevention). Risk of bias was appraised using validated tools, and the evidence was synthesized using modified Grading of Recommendations Assessment, Development, and Evaluation criteria. Findings: A total of 26 articles describing 3 randomized trials and 20 observational studies (16 longitudinal designs and 4 cross-sectional quasi-waiting list control designs) were included. Existing interventions have focused primarily on mitigating housing insecurity for the most vulnerable individuals rather than preventing housing insecurity outright. Moderate-certainty evidence was found that eviction moratoriums were associated with reduced COVID-19 cases and deaths. Certainty of evidence was low or very low for health associations of other targeted primary prevention interventions, including emergency rent assistance, legal assistance with waiting list priority for public housing, long-term rent subsidies, and homeownership assistance. No studies evaluated health system-partnered structural primary prevention strategies. Conclusions and Relevance: This systematic review found mixed and mostly low-certainty evidence that interventions that promote housing affordability and stability were associated with improved adult health outcomes. Existing interventions may need to be paired with other efforts to address the structural determinants of health. As health care systems and insurers respond to increasing opportunities to invest in housing as a determinant of health, further research is needed to clarify where along the housing insecurity pathway interventions should focus for the most effective and equitable health impact.

Variation in State-Level Eviction Moratorium Protections and Mental Health Among US Adults During the COVID-19 Pandemic.

Importance: Although evictions have been associated with adverse mental health outcomes, it remains unclear which stages of the eviction process are associated with mental distress among renters. Variation in COVID-19 pandemic eviction protections across US states enables identification of intervention targets within the eviction process to improve renters' mental health. Objective: To measure the association between the strength of eviction protections (ie, stages blocked by eviction moratoriums) and mental distress among renters during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study used individual-level, nationally representative data from the Understanding Coronavirus in America Survey to measure associations between state eviction moratorium protections and mental distress. The sample of 2317 respondents included renters with annual household incomes less than $75 000 who reported a state of residence and completed surveys between March 10 and September 3, 2020, prior to the federal eviction moratorium order by the Centers for Disease Control and Prevention. Exposures: Time-varying strength of state moratorium protections as a categorical variable: none, weak (blocking court hearings, judgments, or enforcement without blocking notice or filing), or strong (blocking all stages of the eviction process beginning with notice and filing). Main Outcomes and Measures: Moderate to severe mental distress was measured using the 4-item Patient Health Questionnaire. Linear regression models were adjusted for time-varying state COVID-19 incidence and mortality, public health restrictions, and unemployment rates. Models included individual and time fixed effects as well as clustered standard errors. Results: The sample consisted of 2317 individuals (20 853 total observations) composed largely (1788 [78%] weighted) of middle-aged adults (25-64 years of age) and women (1538 [60%]); 640 respondents (23%) self-reported as Hispanic or Latinx, 314 respondents (20%) as non-Hispanic Black, and 1071 respondents (48%) as non-Hispanic White race and ethnicity. Relative to no state-level eviction moratorium protections, strong protections were associated with a 12.6% relative reduction (risk ratio, 0.87; 95% CI, 0.76-0.99) in the probability of mental distress, whereas weak protections were not associated with a statistically significant reduction (risk ratio, 0.96; 95% CI, 0.86-1.06). Conclusions and Relevance: This analysis of the Understanding Coronavirus in America Survey data found that strong eviction moratoriums were associated with protection against mental distress, suggesting that distress begins early in the eviction process with notice and filing. This finding is consistent with the idea that to reduce mental distress among renters, policy makers should focus on primary prevention of evictions.

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.

Transportation Access to Health Care During the COVID-19 Pandemic: Trends and Implications for Significant Patient Populations and Health Care Needs

Since March 2020, COVID-19 transportation system disruptions have altered how Americans access routine health care. This report examines current knowledge about disparities in transportation and access to health care for people with various health conditions and health care needs. The authors highlight evidence related to end-stage kidney disease, pregnancy, cancer, mental health and substance use, disabilities, multiple chronic conditions, and preventive care to discuss population-specific transportation needs and challenges, COVID-19 health risks, and impacts of transportation system disruption on health outcomes during the pandemic. The report concludes with policy recommendations for how leaders in transportation, public health, and health care can improve transportation access to care during the COVID-19 pandemic.

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.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Association of the Timing of School Closings and Behavioral Changes With the Evolution of the Coronavirus Disease 2019 Pandemic in the US.

Importance: The consequences of school closures for children's health are profound, but existing evidence on their effectiveness in limiting severe acute respiratory syndrome coronavirus 2 transmission is unsettled. Objective: To determine the independent associations of voluntary behavioral change, school closures, and bans on large gatherings with the incidence and mortality due to coronavirus disease 2019 (COVID-19). Design, Setting, and Participants: This population-based, interrupted-time-series analysis of lagged independent variables used publicly available observational data from US states during a 60-day period from March 8 to May 18, 2020. The behavioral measures were collected from anonymized cell phone or internet data for individuals in the US and compared with a baseline of January 3 to February 6, 2020. Estimates were also controlled for several state-level characteristics. Exposures: Days since school closure, days since a ban on gatherings of 10 or more people, and days since residents voluntarily conducted a 15% or more decline in time spent at work via Google Mobility data. Main Outcomes and Measures: The natural log of 7-day mean COVID-19 incidence and mortality. Results: During the study period, the rate of restaurant dining declined from 1 year earlier by a mean (SD) of 98.3% (5.2%) during the study period. Time at work declined by a mean (SD) of 40.0% (7.9%); time at home increased by a mean (SD) of 15.4% (3.7%). In fully adjusted models, an advance of 1 day in implementing mandatory school closures was associated with a 3.5% reduction (incidence rate ratio [IRR], 0.965; 95% CI, 0.946-0.984) in incidence, whereas each day earlier that behavioral change occurred was associated with a 9.3% reduction (IRR, 0.907; 95% CI, 0.890-0.925) in incidence. For mortality, each day earlier that school closures occurred was associated with a subsequent 3.8% reduction (IRR, 0.962; 95% CI, 0.926-0.998), and each day of advance in behavioral change was associated with a 9.8% reduction (IRR, 0.902; 95% CI, 0.869-0.936). Simulations suggest that a 2-week delay in school closures alone would have been associated with an additional 23 000 (95% CI, 2000-62 000) deaths, whereas a 2-week delay in voluntary behavioral change with school closures remaining the same would have been associated with an additional 140 000 (95% CI, 65 000-294 000) deaths. Conclusions and Relevance: In light of the harm to children of closing schools, these findings suggest that policy makers should consider better leveraging the public's willingness to protect itself through voluntary behavioral change.

Estimation of US Children's Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic.

Importance: United States primary school closures during the 2020 coronavirus disease 2019 (COVID-19) pandemic affected millions of children, with little understanding of the potential health outcomes associated with educational disruption. Objective: To estimate the potential years of life lost (YLL) associated with the COVID-19 pandemic conditioned on primary schools being closed or remaining open. Design, Setting, and Participants: This decision analytical model estimated the association between school closures and reduced educational attainment and the association between reduced educational attainment and life expectancy using publicly available data sources, including data for 2020 from the US Centers for Disease Control and Prevention, the US Social Security Administration, and the US Census Bureau. Direct COVID-19 mortality and potential increases in mortality that might have resulted if school opening led to increased transmission of COVID-19 were also estimated. Main Outcomes and Measures: Years of life lost. Results: A total of 24.2 million children aged 5 to 11 years attended public schools that were closed during the 2020 pandemic, losing a median of 54 (interquartile range, 48-62.5) days of instruction. Missed instruction was associated with a mean loss of 0.31 (95% credible interval [CI], 0.10-0.65) years of final educational attainment for boys and 0.21 (95% CI, 0.06-0.46) years for girls. Summed across the population, an estimated 5.53 million (95% CI, 1.88-10.80) YLL may be associated with school closures. The Centers for Disease Control and Prevention reported a total of 88 241 US deaths from COVID-19 through the end of May 2020, with an estimated 1.50 million (95% CI, 1.23-1.85 million) YLL as a result. Had schools remained open, 1.47 million (95% credible interval, 0.45-2.59) additional YLL could have been expected as a result, based on results of studies associating school closure with decreased pandemic spread. Comparing the full distributions of estimated YLL under both "schools open" and "schools closed" conditions, the analysis observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure. Conclusions and Relevance: In this decision analytical model of years of life potentially lost under differing conditions of school closure, the analysis favored schools remaining open. Future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children's health.