Case Study Part 3: Home Safe Home
Economic stability is a social determinant of health. Per Healthy People 2020, housing instability is a key influencing factor for economic stability. The United States Department of Health and Human Services (DHHS) defines housing insecurity as high housing costs in proportion to income, poor housing quality, unstable neighborhoods, overcrowding, or homelessness. The DHHS definition combines the Healthy People 2020 social determinants of health key influencing factors of housing instability and quality of housing. Quality of housing as an influencing factor is found within the key area neighborhood and built environment social determinant of health. Healthy People 2030 is now available.
The terms housing instability, housing insecurity, quality of housing, and even homelessness may be used interchangeably in the literature, which can be confusing. Nurses need to understand that housing inadequacy in any form affects health outcomes for individuals, children, and families. It is also important to comprehend that a shelter bed in a homeless shelter is not housing. Shelter beds prevent people from having to sleep outdoors. Whereas, housing ends homelessness. Infants under age 12 months are the population most likely to be homeless (Child Trends; Stewart, 2019).
Keywords: economic stability, homelessness, housing insecurity, housing instability, neighborhood and built environment, quality of housing, social determinants of health
Learning Objective: Demonstrate how population data informs clinical practice
Further Case Study Dialogue
“Our living situation? It has been challenging. We had a place, an apartment, but the building was condemned after the fire. We lost everything. We still have not gotten back our security deposit. At first, we got help with a motel but since then we have been moving around a lot: friends places, relatives, people’s couches, a couple of times we slept in the park, it all is really hard. Scary. We could have gone to a homeless shelter. I stayed in a few after I aged out of foster care. But at best most are loud and not so clean. Leah is just so new. Jonathan is just so set in his ways. Just thinking about not having a permanent place to stay gets me stressed and emotional. For the last week or so we have been staying with Andrew’s grandmother. Her house is small. Yes, this is a big worry for us. So no, we do not really have a regular place to call home. ” ~ Emma (Leah and Jonathan’s mother)
How does Bright Futures suggest incorporating social determinants of health screening in health supervision visits?
The American Academy of Pediatrics supported Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents endorses priority attention to social determinants of health at each well-child health supervision visit prenatally through 21 years of age. Bright Futures identifies risk factors in social determinants including abuse and neglect, homelessness, parental dysfunction, poverty, and separation or divorce. Bright Futures also recognizes that social determinants found beyond the immediate household have an impact on children and families in both the current and longer timeframes. These determinants include neighborhood conditions; the built environment including safe and green play spaces; the availability of affordable, nutritious food; geographic access to quality health care services; and quality education starting with early childhood developmental programs.
There are many social determinants of health assessment/screening tools available. However, the accuracy of social determinant of health screening tools is largely unevaluated (Sokol et al, 2019). Social determinants of health screening should be population-sensitive, i.e., the questions you ask should reflect the circumstances and priorities of the people you most frequently professionally encounter.
No specific social determinants of health-related screening tools are recommended in the Bright Futures guidelines as sufficient evidence to endorse a specific tool is lacking. However, there are broad-based screening tools that can identify unmet basic needs and condition-specific tools to detect concerns such as maternal depression and intimate partner violence. Potentially useful tools include the following:
WE CARE survey,
Pediatric Intake Form,
SEEK parent screening questionnaire,
Edinburgh Post-Natal Depression Screening tool,
Survey of Wellbeing of Young Children,
Whole Child Assessment, and
2-Item Screen to Identify Families at Risk for Food Insecurity.
In addition, to evaluating the accuracy of social determinants of health screening tools, evaluation of referrals and interventions to address social determinant of heath are also needed (Gold & Gottlieb, 2019; Sokol et al, 2019). One example of such an evaluation is from Gottlieb (2020) who found that both in-person verbal and personalized written resources reduced social risks and improved child and caregiver health six months after. This underscores the importance of providing up-to-date personalized written resources to individuals and families experiencing social risk factors.
What does Bright Futures recommend as priority areas for the six-month well child health supervision visit?
The Bright Futures Guidelines are available for download from the American Academy of Pediatrics https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx.
Social determinants of health is given priority in all Bright Futures Health Supervision visits. For the 6-month health supervision visit, consider a discussion about
The family living situation
Food security
Alcohol, tobacco and other drug use
Parental depression (p. 458).
How common is housing insecurity?
The rate of housing insecurity when screened in pediatric primary care ranges from 2% (homelessness only) through 14–56% for more comprehensive screening tools that ask about housing problems such as crowding (41%) and multiple moves (5%) (Cutts et al, 2011; Fleegler et al, 2007; Porter et al, 2019; Zielinski et al, 2017). Often, housing insecurity screening tools do not address high housing costs in proportion to income, poor housing quality in general, or unstable neighborhoods.
How does housing insecurity affect child health and development?
Homelessness and poverty are among the social conditions most consistently associated with poor health outcomes and higher costs. Housing insecurity is associated with poor health, lower weight, and developmental risk in infants and young children. Households behind on rent have higher odds of child lifetime hospitalizations and fair/poor child health. Similar adverse child outcomes are found for families with multiple moves and a history of homelessness (Sandel et al, 2018). Homeless infants are known to have poor birth outcomes and poorer outcomes in asthma diagnosis, higher emergency department use and healthcare costs (Clark et al, 2019). Federal rental assistance for families with low incomes may reduce emergency department visits for asthma (Boudreaux, Slopen, & Newman, 2020).
Where can you find population level data for populations of interest?
Social determinants of health screening should be population-sensitive, i.e., the questions you ask should consider the circumstances and priorities of the people you most frequently professionally encounter.
PLACES: Local Data for Better Health https://www.cdc.gov/places/index.html
County Health Rankings https://www.countyhealthrankings.org/
Kids Count 2021 https://www.aecf.org/resources/2021-kids-count-data-book
Sources for social determinants of health data https://www.cdc.gov/socialdeterminants/data/index.htm
United States Census Bureau https://www.census.gov/
United States Interagency Council on Homelessness https://www.usich.gov/tools-for-action/map/#fn[]=1400&fn[]=2800&fn[]=6200&fn[]=10000&fn[]=13200
Zero to Three State of Babies Yearbook 2020 https://stateofbabies.org/
What are some examples of Federal programs that address the health and housing link?
Centers for Disease Control and Prevention https://www.cdc.gov/nceh/information/healthy_homes_lead.htm
Healthy Choice Vouchers Fact Sheet https://www.hud.gov/topics/housing_choice_voucher_program_section_8
Housing and Urban Development https://www.hud.gov/program_offices/healthy_homes/hhi
National Center for Healthy Housing https://nchh.org/
United States Department of Agriculture National Institute of Food and Agriculture
https://nifa.usda.gov/healthy-homes-initiative
Healthy Homes Portal https://extensionhealthyhomes.org/
How may population level health data influence clinical practice?
Population-level health data helps nurses determine which issues are quantitatively most important to address in clinical practice. For example, knowing that substance use disorder or syphilis is increasing may guide resource allocation in a particular practice or community. The same knowledge may encourage the individual nurse to seek out more evidence on the topic or attend a continuing education event. Knowing that a particular census tract or other geographic area has a high prevalence of a condition may assist health planners and urban planners on where to locate new or specific services. Policy initiatives developed based on population level data (e.g., Census) may influence resource and services allocation.
Thinking population health, what are some upstream and midstream approaches the nurse may take to address housing insecurity and quality of housing?
Ascertain the population level prevalence of a particular condition of interest.
Collaborate with community members, other healthcare professionals, and additional stakeholders to determine priorities and issues of concern.
Gather evidence to inform and guide clinical practice.
Pilot test a process that can be used in the clinical setting to assess for housing insecurity and quality of housing.
As appropriate, expand the above process to the practice setting or to the entire health care system. For example, implement universal screening for housing insecurity and quality of housing for all new and follow-up individuals including individuals being discharged.
Create and share related education and resource materials.
Advocate with policymakers to allocate additional resources to the prioritized issues of concern.
Support quality resource options through volunteering time and expertise.
Supplemental document
Social Determinants of Health (SDoH) ‘Screening’ Tools
References/Resources
American Institutes for Research. National Center on Family Homelessness. https://www.air.org/center/national-center-family-homelessness
Boudreaux, M., Fenelon, A., Slopen, N., Newman. S.J. (2020). Association of childhood asthma with federal rental assistance. JAMA Pediatr. 2020;174(6):592–598. doi:10.1001/jamapediatrics.2019.6242
Child Trends. (2019). Children and Youth Experiencing Homelessness. Retrieved from https://www.childtrends.org/indicators/homeless-children-and-youth.
Clark, R.E., Weinreb, L., Flahive, J.M., & Seifert, R.W. (2019). Infants exposed to homelessness: Health, health care use, and health spending from birth to age six. Health Aff (Millwood). 2019;38(5):721‐728. doi:10.1377/hlthaff.2019.00090
Cutts, D.B., Meyers, A.F., Black, M.M., Casey, P.H., Chilton, M., Cook, J.T., Geppert, J., Ettinger de Cuba, S., Heeren, T., Coleman, S., Rose-Jacobs, R., & Frank, D.A. (2011). US Housing insecurity and the health of very young children. American Journal of Public Health August 2011 101 8 1508-1514.
Fleegler, E.W., Lieu, T.A., Wise, P.H., & Muret-Wagstaff, S. (2007). Families’ health-related social problems and missed referral opportunities. Pediatrics. 119 6 e1332-1341
Hagan, J., Shaw, J., & Duncan, P. (2017). Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. ISBN (paper): 978-1-61002-022-0 ISBN (electronic): 978-1-61002-023-7 https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx
Garg, A., Byhoff, E., & Wexler, M.G. (2020). Implementation considerations for social determinants of health screening and referral interventions. JAMA Netw Open. 2020;3(3):e200693. Published 2020 Mar 2. doi:10.1001/jamanetworkopen.2020.0693
Garg, A., Toy, S., Tripodis Y, Silverstein, M., Freeman, E. (2015). Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–e304. doi:10.1542/peds.2014-2888
Gold, R., & Gottlieb, L. (2019). National data on social risk screening underscore the need for implementation research. JAMA Netw Open. 2019;2(9):e1911513. Published 2019 Sep 4. doi:10.1001/jamanetworkopen.2019.11513
Gottlieb, L.M, Hessler, D., Long, D., et al. (2016). Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521. doi:10.1001/jamapediatrics.2016.2521
Porter, S., Qureshi, R., Echevarria, M., Mahat, G., & Watkins, A.V. (2019). National Best Practices: Screening Tools for Economic Instability in Pediatric Primary Care. Report to Caplan Foundation for Early Childhood.
Sandel, M.T., & Bovell-Ammon, A. (2020). Associations between federal rental housing assistance and childhood asthma-A renewed call for investing in housing for health [published online ahead of print, 2020 Mar 9]. JAMA Pediatr. 2020;10.1001/jamapediatrics.2019.6272. doi:10.1001/jamapediatrics.2019.6272
Sandel, M., Sheward, R., Ettinger de Cuba, S., et al. (2018). Unstable housing and caregiver and child health in renter families. Pediatrics. 2018;141(2):e20172199. doi:10.1542/peds.2017-2199
Stewart, N. (2018). Baby Antonio: 5 pounds, 12 ounces and homeless since birth. New York Times October 30, 2018 https://www.nytimes.com/interactive/2018/10/30/nyregion/homeless-children.html
U.S. Census Bureau. Housing https://www.census.gov/topics/housing.html
Zielinski, S., Paradis, H.A., Herendeen, P., & Barbel, P. (2017). The identification of psychosocial risk factors associated with child neglect using the WE-CARE screening tool in a high-risk population. Journal of Pediatric Health Care 31 470-475.
The post Case Study Part 3: Home Safe Home Economic stability is a social appeared first on essayfab.