Housing interventions and control of asthma-related indoor biologic agents: a review of the evidence.

Subject matter experts systematically reviewed evidence on the effectiveness of housing interventions that affect health outcomes, primarily asthma, associated with exposure to moisture, mold, and allergens. Three of the 11 interventions reviewed had sufficient evidence for implementation: multifaceted, in-home, tailored interventions for reducing asthma morbidity; integrated pest management to reduce cockroach allergen; and combined elimination of moisture intrusion and leaks and removal of moldy items to reduce mold and respiratory symptoms. Four interventions needed more field evaluation, 1 needed formative research, and 3 either had no evidence of effectiveness or were ineffective. The 3 interventions with sufficient evidence all applied multiple, integrated strategies. This evidence review shows that selected interventions that improve housing conditions will reduce morbidity from asthma and respiratory allergies.

The Latino Health Insurance Program: a pilot intervention for enrolling Latino families in health insurance programs, East Boston, Massachusetts, 2006-2007.

BACKGROUND: Thirteen percent of Latinos in Massachusetts lack health insurance, the highest rate of any ethnic or racial group. Families without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year. CONTEXT: The Latino Health Insurance Program is designed as a response both to the high rate of uninsurance among Latinos in Boston and to the multiple obstacles that keep Latino parents from applying for insurance for their families. METHODS: In 2006, we designed and implemented a culturally competent model of health insurance outreach, education, enrollment and maintenance, and referral for primary care and social services for Latino families. CONSEQUENCES: Year 1 results of the Latino Health Insurance Program are promising. Six community members were hired and trained as case managers. A total of 230 children and adults were enrolled or re-enrolled in health insurance programs and received other needed services. Retention was near 100% after 1 year. INTERPRETATION: The Latino Health Insurance Program may serve as a model health insurance access program that can be adapted by community-based organizations and also can be incorporated into public agency programs for Latinos and other immigrant and minority groups. The program continues to serve East Boston residents and was expanded in 2008.

Pesticides in urban multiunit dwellings: hazard identification using classification and regression tree (CART) analysis.

Many units in public housing or other low-income urban dwellings may have elevated pesticide residues, given recurring infestation, but it would be logistically and economically infeasible to sample a large number of units to identify highly exposed households to design interventions. Within this study, our aim was to devise a low-cost approach to identify homes in public housing with high levels of pesticide residues, using information that would allow the housing authority and residents to determine optimal strategies to reduce household exposures. As part of the Healthy Public Housing Initiative, we collected environmental samples from 42 public housing apartments in Boston, MA, in 2002 and 2003 and gathered housing characteristics; for example, household demographics and self-reported pesticide use information, considering information available with and without a home visit. Focusing on five organophosphate and pyrethroid pesticides, we used classification and regression tree analysis (CART) to disaggregate the pesticide concentration data into homogenous subsamples according to housing characteristics, which allowed us to identify households and associated networks impacted by the mismanagement of pesticides. The CART analysis demonstrated reasonable sensitivity and specificity given more extensive household information but generally poor performance using only information available without a home visit. Apartments with high concentrations of cyfluthrin, a pyrethroid of interest given that it is a restricted use pesticide, were more likely to be associated with Hispanic residents who resided in their current apartment for more than 5 yr, consistent with documented pesticide usage patterns. We conclude that using CART as an exploratory technique to better understand the home characteristics associated with elevated pesticide levels may be a viable approach for risk management in large multiunit housing developments.

Obesity, physical activity, and the urban environment: public health research needs.

Persistent trends in overweight and obesity have resulted in a rapid research effort focused on built environment, physical activity, and overweight. Much of the focus of this research has been on the design and form of suburbs. It suggests that several features of the suburban built environment such as low densities, poor street connectivity and the lack of sidewalks are associated with decreased physical activity and an increased risk of being overweight. But compared to suburban residents, inner city populations have higher rates of obesity and inactivity despite living in neighborhoods that are dense, have excellent street connectivity and who's streets are almost universally lined with sidewalks. We suggest that the reasons for this apparent paradox are rooted in the complex interaction of land use, infrastructure and social factors affecting inner city populations. Sometimes seemingly similar features are the result of very different processes, necessitating different policy responses to meet these challenges. For example, in suburbs, lower densities can result from government decision making that leads to restrictive zoning and land use issues. In the inner city, densities may be lowered because of abandonment and disinvestment. In the suburbs, changes in land use regulations could result in a healthier built environment. In inner cities, increasing densities will depend on reversing economic trends and investment decisions that have systematically resulted in distressed housing, abandoned buildings and vacant lots. These varying issues need to be further studied in the context of the totality of urban environments, incorporating what has been learned from other disciplines, such as economics and sociology, as well as highlighting some of the more successful inner city policy interventions, which may provide examples for communities working to improve their health. Certain disparities among urban and suburban populations in obesity and overweight, physical activity and research focus have emerged that are timely to address. Comparable research on the relationship of built environment and health is needed for urban, especially inner city, neighborhoods.

The effects of housing interventions on child health.

Housing hazards contribute to considerable morbidity and mortality among millions of children each year in the US, but few interventions are proven to control asthma and lead poisoning. Moreover, there is little evidence that many of the current recommendations to control residential hazards are safe and efficacious. The only interventions that have been found to work consistently are home visitation programs and home modification, such as installment of window guards and carpet removal. Altering the environment to protect the health of children requires pediatrician intervention. New models of cooperation between pediatricians and public health agencies must deal with residential hazards in an integrated manner and cannot be focused on one disease process or one method at a time. With research in more effective environmental interventions and pediatric-public-health partnerships, primary and secondary prevention of diseases from residential hazards may become a reality in the future.

Investigations into the indoor environment and respiratory health in Boston public housing.

The self-reported prevalence of asthma in the United States increased by 75% from 1980 to 1994, a trend found to be significant and evident in every region of the country. The increase was most marked in children from birth to 14 years of age; and growing evidence indicates that, as with lead poisoning, inner-city and urban populations are most at risk. Attention has turned to the role of indoor environmental risk factors, especially in homes and schools. Such factors include moisture and mold growth, pest infestation, dust mites, the building envelope, heating systems, inadequate ventilation, nitrogen dioxide, and environmental tobacco smoke. The Healthy Public Housing Initiative (HPHI) is a Boston-based community-centered research and intervention project designed to engage Boston Housing Authority residents in a collaborative process to improve respiratory health, quality of life, building conditions, and building maintenance in public housing. This article summarizes the significant research findings from four pilot studies in housing developments that laid the foundation for the larger HPHI asthma-related environmental intervention study. The research design for the pilot projects is informed by principles of community-collaborative research. The strengths of this model of research for our work are also discussed.

SPRAWL IN THE 1990S Measurement, Distribution, and Trends.

Although sprawl is a growing national debate, there have been few efforts to measure or monitor changes in degree of sprawl over time. By using a methodology that employs census data, this sprawl index allows computation of levels of sprawl and examination of temporal and geographic changes. The results show that sprawl has increased over the past decade in many metropolitan areas. There are important geographic variations in sprawl, implying that it is neither inevitable nor universal.

"Where does the damp come from?" Investigations into the indoor environment and respiratory health in Boston public housing.

The self-reported prevalence of asthma increased by 75% from 1980 to 1994, a trend found to be significant and evident in every region of the country. The increase has been most marked in children 0-14 years of age, and there is evidence that, as with lead poisoning, inner-city and urban populations are most at risk. Attention has turned to the role of indoor environment risk factors, especially in homes and schools. Such factors include moisture and mold growth, pest infestation, dust mites, the building envelope, heating systems, inadequate ventilation, NO2, and environmental tobacco smoke. The Healthy Public Housing Initiative (HPHI) is a Boston-based community-centered research and intervention project designed to engage Boston Housing Authority residents in a collaborative process to improve respiratory health, quality of life, building conditions, and building maintenance in public housing. This article summarizes the significant research findings from four pilot studies in housing developments that lay the foundation for the larger HPHI asthma-related environmental intervention study. The research design for the pilot projects is informed by principles of community-collaborative research. The strengths of this model of research to our work are also discussed.

Comment and controversies: since "Silent Spring": new voices, new analyses, and new movements.

Forty years ago, in the enormously praised and fiercely criticized book, "Silent Spring", Rachel Carson demonstrated the dangers of pesticides to humans and ecosystems and called for precaution in their use. Yet, the majority of environmental regulations passed since 1962 have primarily addressed pollutant discharge rather than cleaner products and technologies. The number of active ingredients in pesticides used in the United States has risen from 32 in 1939 to 860 in recent times, while the overall volume of agrochemicals applied has nearly doubled since the publication of Silent Spring. The last 40 years have brought significant changes with respect to environmental policies, agricultural technologies, urbanization, civil rights, women's rights, the roles of non-profit organizations and community development, and increased poverty, hunger, and economic inequality. In recent years, new voices, new analyses, and new movements have emerged offering fresh perspectives on how we can answer Carson's clarion call to protect our planet and ourselves.