Projects – Hopkins Housing & Health Collaborative

Studies the impact of Baltimore’s housing mobility program on asthma exposures and outcomes. 

Background: Children living in poor-urban neighborhoods bear a high burden of asthma morbidity, and there is strong evidence that housing-related environmental exposures such as pest allergens are a major driver of this excess asthma morbidity. Historic residential discrimination together with systemic disinvestment in neighborhoods have contributed to poor neighborhood and housing conditions, which make successful mitigation of housing-related exposures difficult, and in many cases, impossible. In contrast, housing mobility programs, where families are supported in moving to less segregated communities, may address the root- causes of the exposures that drive asthma disparities, while also serving as a tool by which we can parse the role of various housing and neighborhood exposures and understand their long-term effects on asthma.

Approach: Working with the Baltimore Regional Housing Partnership, the Mobility Asthma Project (MAP) recruited children with asthma who move from higher- to lower-poverty neighborhoods. Through home visits and surveys, the study collects information on asthma symptoms, exposures, lung function growth, and stress.

Team: The study team includes Craig Pollack, Lauren Barrow, Syed Qasim Hussaini, and Amanda Blackford at Johns Hopkins. Robin Yabroff, Leticia Nogueira, and Qinjin Fan help lead the effort from the American Cancer Society.

Funding: The project is supported by the National Institute of Environmental Health Sciences (R0 ES026170).

Every child deserves a home that meets their health needs, regardless of their family’s means or child’s conditions. However, existing resources and housing-related policies appear wholly inadequate to address the housing accessibility challenges faced by families of children with disabilities (CWD) across the country. Our prior research in Maryland and Illinois shows that for many CWD, their current housing situation does not have the equipment, supplies, or adapted spaces they need for safe, independent, and developmentally appropriate life at home. Structural problems (e.g. inaccessible bathrooms) and lack of needed equipment (e.g., lifts or accessible bathing tubs) make it difficult for family caregivers to conduct care for their child, which in addition to impacting the child, negatively impacts parental well-being and physical health. While we found that families often relied on Medicaid and Title V programs for financial and planning supports, caregivers still identified cost, informational gaps, and wait lists as key barriers to making needed modifications. Additional barriers identified by families living in rental properties raise equity concerns about how well current housing policies support CWD living in lower-income or otherwise marginalized families.

Mixed methods study to explore the experience of housing and household expenses for families of children with medical complexity in Maryland.

Background: Children and Youth with Special Health Care Needs (CYSHCN) can have many home care requirements including medications, therapies, and medical equipment. Prior studies have shown that caring for CYSHCN can result in challenges with parental employment and family finances; yet, how the child’s care needs specifically impact housing adequacy or stability for families of CYSHCN has not been well-described. 

Approach: In partnership with Parent’s Place of Maryland and the Coordinating Center, we recruited parents/guardians of CYSHCN in Maryland to conduct surveys and semi-structured interviews focused on housing and household expenses. 

Team: The study team incudes Rebecca Seltzer, Pamela Donohue, Renee Boss, Karen Fratantoni, Kate Detweiler (Children’s National), Danielle Gaskin, Brandon Smith.

Funding: The project is supported by the Thomas Wilson Foundation.

Examines whether children whose families receive housing choice vouchers have different patterns of Medicaid enrollment and health care use compared to those on the voucher waitlist

Background: Housing vouchers, which subsidize the costs or rent and utilities and enable low-income families to rent homes on private market, are the nation’s largest housing assistance program. As policy-makers and practitioners consider ways to optimize the use of existing vouchers and seek support to expand the overall supply of affordable housing, there is a critical need for research that investigates the link between housing choice vouchers and health.  

Approach: Working with two public housing authorities (Seattle Housing Authority and King County Housing Authority) and a health department (Public Health –Seattle & King County), we are investigating the association between the receipt of a housing voucher on children’s enrollment in Medicaid and patterns of health care use. The proposal uses quasi-experimental difference-in-differences methods leveraging the fact that families who receive housing assistance are randomly selected from a long waitlist and takes advantage of administrative housing linked with Medicaid data.

Team: The study team incudes Craig Pollack (PI) Matthew Eisenberg, Amanda Blackford, and Justin Rose at Johns Hopkins and Alastair Matheson and Amy Laurent at Public Health –Seattle & King County.

Funding: The project is supported by the National Institute for Nursing Research (R21HD105143).

Background: In 2021, the federal government allocated $46 billion in Emergency Rental Assistance (ERA) to states and local governments, in order to mitigate widespread housing insecurity and prevent evictions during the COVID-19 pandemic. We hypothesize that, by bolstering families’ budgets, this substantial investment in housing supports might have mitigated food insecurity.

Approach: We are conducting a multi-method study that combines 1) a quantitative study leveraging states’ uneven ERA rollout as a natural experiment to measure associations between ERA and food insecurity [secondary outcomes: caregiver mental health and child preventive care] and 2) a qualitative study, using interactive timelines and semi-structured interviews to understand ERA participants’ lived experience with ERA. In both aims, we will explore differential impacts by race and ethnicity.

Team: The study team includes Eliana Perrin (mPI), Kate Leifheit (mPI), Craig Pollack, and Sabriya Linton

Funding: Robert Wood Johnson Foundation Healthy Eating Research Program (Grant # 119755)

Uses photovoice methodology to document barriers and facilitators to caring for children with medical complexity in the home environment.  

Background: There is a growing population of children with medical complexity (CMC), who have serious medical needs and require hospital-like care at home. In order to stay healthy and out of the hospital, these children require a home that is safe, stable, accessible, and spacious enough to meet their intensive daily care needs. Yet, for many CMC, their current housing situation falls short and does not promote optimal quality of life and independence.  

Approach: In this study, we use Photovoice methodology, a participatory research strategy combining photography, critical dialogue, and experiential knowledge of participants, to document barriers and facilitators to caring for CMC in the home and use this information to inform future family education and home-based interventions. Our goal is to understand, from the family’s lens, what barriers they experience to adequate housing and where we can begin targeting interventions to improve both the quality of life and the quality of homes for children with the greatest medical needs in Maryland.   

Team: The study team includes Rebecca Seltzer, Pamela Donohue, Brandon Smith, and Mona-Esmat Jarrah.

Funding: The project is supported by the Thomas Wilson Foundation.

Projects investigate the link between housing security and cancer across the continuum.

Background: Housing insecurity may worsen cancer outcomes and, conversely, cancer, including its treatment cost and impact on employment, may undermine housing security.  

Approach: Our team is exploring these relationships with current projects that include a systematic review of the research linking housing and cancer and investigating the impact of historic redline and contemporary mortgage discrimination on lung cancer mortality. The team has also been involved in the creation of the SEER-Medicare and U.S. Department of Housing and Urban Development (HUD) linked dataset which will, for the first time, enable researchers to study the impact of housing assistance using cancer registry together with claims data.  

Team: The study team includes Craig Pollack, Lauren Barrow, Syed Qasim Hussaini, and Amanda Blackford at Hopkins. Robin Yabroff, Leticia Nogueira, and Qinjin Fan help lead the effort from the American Cancer Society. 

Investigates the association between living in a property funded by the Low Income Housing Tax Credit (LIHTC) and child health.

Background: The Low-Income Housing Tax Credit (LIHTC)—the federal government’s largest program to increase the supply of new affordable housing—has supported the creation of over 3 million rental units since its inception in 1986. Little is known, however, about the health of low-income children living in LIHTC-financed housing.  

Approach: Using data from the National Health Interview Survey (2004-2016) linked to data on LIHTC properties, this study provides national estimates for health status and healthcare access among low-income children living in LIHTC housing. Prior work, led by Marc Shi, used qualitative interviews to explore how developers, government officials, and others involved in the LIHTC process consider the intersection of health with LIHTC developments and the allocation of tax credits. 

Team: The study team includes Craig Pollack (PI),  Matthew Eisenberg, Amanda Blackford, and Sarah Gensheimer. 

Funding: The study is funded by a grant from Eunice Shrive National Institute of Child Health and Human Development (R03HD098411) and the Johns Hopkins Population Center. 

Explores whether and how stakeholders in community land trusts (CLTs) perceive connections between CLTs and health and well-being and identifies mechanisms underlying those connections.

Background: Community land trusts (CLTs) have gained attention as a shared equity model to create perpetually affordable housing and achieve other community development goals. A CLT’s key strategy is to acquire land and set affordability requirements for the owners of residential or commercial buildings on that land. Given the growing awareness of affordable housing’s public health impacts, it is important to assess whether the theorized pathways between housing and health are relevant in the CLT setting, and to better understand how CLT leaders themselves think about these pathways. However, very little research exists on the potential health-related impacts of CLTs, despite a growing body of case studies.  

Approach: This is a cross-sectional qualitative study. Using theoretical sampling and semi-structured interviews, we aim to explore how CLT stakeholders understand general connections, as well as specific theorized mechanisms, between CLTs and health. We aim to interview at least 30 residents/lessees and staff members serving in leadership roles in CLTs across a range of regions. We will use a combination of inductive and deductive coding to identify emerging themes from participants. 

Team: The study team incudes Craig Pollack (PI), Justin Rose, and Loraine Arikat. 

Explores perspectives of older adults living in Mercy Housing properties regarding social connectedness experiences during the COVID-19 pandemic. 

Background: Mercy Housing Incorporated is one of the nation’s largest affordable housing organizations. Approximately one-quarter of all Mercy Housing residents are low-income older adults (65+). The Coronavirus pandemic has likely impacted prevalence and perceptions of social isolation, health, wellbeing, and healthcare utilization is this population.  

Approach: This study uses qualitative and quantitative methods with Mercy Housing residents (aged 62+) to explore the impact of the COVID-19 pandemic on social isolation and overall wellbeing. Along with a semi-structured interview, participants will complete a contextual survey that inquires building, site, and mobility factors.  

Team: Thomas Cudjoe, Marcela Blinka, Cynthia Boyd, Suzanne Greib, Carl Latkin, Laura Prichett, Harshini Devi, and Nicole Williams. 

Funding: This project is supported by the AARP Foundation. 

Examined whether household and neighborhood conditions partially account for associations between education and physical capacity in a population-based sample of older adults. 

Background: Socioeconomic resources, such as education, prevent disability but are not readily modifiable. However, household and neighborhood conditions may be modifiable and may account for some of the educational disparities in disability for older adults. 

Approach: The National Health and Aging Trends Study measured education, household and neighborhood conditions, and physical capacity, including lower extremity function, hand grip strength and lung function. Structural equation models were used to decompose total educational effects into direct effects and indirect effects via household and neighborhood conditions in 6874 community-dwelling participants. 

Findings: Education was directly associated with lower extremity function and lung function, but not hand grip strength. Indirect effects were found for household disorder with lower extremity function, hand grip strength and lung function and between street disorder with lower extremity function. Results show that these indirect effects accounted for approximately 35%, 27% and 14% of the total association between education and SPPB scores, grip strength level, and peak expiratory flow level, respectively. These results suggest that household and neighborhood conditions account for a non-trial proportion of educational disparities in disability among older adults.  

Team: The study team includes Laura Samuel, Thomas Glass, Roland Thorpe, Sarah Szanton and David Roth.  

 Funding: The project was supported by the National Institute on Aging (T32AG000247). 

 Media & Publications:  

Household and neighborhood conditions partially account for associations between education and physical capacity in the National Health and Aging Trends Study. 

Determines whether of housing cost burden and structural housing deficiencies are associated with adverse consequences of having unmet care needs (such as going without a hot meal, or without bathing).

Background: An important metric of LTSS delivery, quality, and access is the occurrence of unmet care needs, defined by going without needed assistance with activities of daily living, household activities, and mobility tasks. Unmet care needs are more prevalent among lower income older adults.The home environment is an increasingly important setting for the receipt of LTSS and while housing related risk-factors (e.g., housing cost burden and housing of inadequate quality) are relevant to health and function outcomes—such as accidental falls, the ability to perform self-care activities, and moving to a nursing home—it is not understood how housing related risk-factors affect LTSS outcomes among older adults. 

 Approach: A secondary analysis of data from 5,041 low and moderate income participants in the 2015 National Health and Aging Trends Study, a population-based national survey that comprehensively assesses characteristics of older adults (≥65 years) and their households in a two-hour in-home interview.  

Team: The study team incudes Safiyyah Okoye (PI), Sarah Szanton, Laura Samuel and Jennifer Wolff at Johns Hopkins. 

 Funding: The project is supported by a pilot award from Center for Innovative Care in Aging, School of Nursing, Johns Hopkins University, and the Training Program in Health Service and Outcomes Research for Aging Populations (NIA T32AG066576). 

Examine how low-income older adults handle financial challenges, the ways that those experiences affect their health and well-being and the social norms that may influence their decisions and/or constrain options for handling financial challenges.  

Background: About one-third of U.S. older adults report experiencing financial challenges, such as financial strain or a financial shock, each year. Although there are many programs intended to help these older adults, many programs are under-utilized and many programs have barriers to accessing them. As examples, less than half of older adults who are eligible for the Supplemental Nutrition Assistance Program use the benefits and many individuals who are eligible for housing assistance are placed on long waiting lists across the country. Overall, little is known about the day-to-day experiences of older adults facing financial challenges, the strategies that are useful to handle the challenges, and the social norms that may constrain their options for handling financial challenges.  

 Approach: Our team has explored these research questions through qualitative research in two phases. Phase 1 comprised in-depth individual interviews with low income older adults in Baltimore to understand their experiences with financial challenges, the strategies they employed to address the challenges and how the financial challenges affected their health and well-being. Phase 2 consisted of focus groups and sought to examine the social norms relevant to financial challenges, to better understand the role of stigma, perceptions of supportive resources and perceived best practices for handling financial challenges. 

Team: Laura Samuel, Rebecca Wright, Marianne Granbom (Lund University, Sweden), Janiece Taylor, Ciara Hupp (Boston University), Laken Roberts Lavigne, Sarah Szanton. 

Funding: The project is supported by the National Institute on Aging (K01AG054751) and pilot funding from Funded by the Center for Innovative Care in Aging.  

Media & Publications: 

Tests cross-lagged associations between financial strain, home disorder, relocation, home modifications and mobility. 

Background: Socioeconomic resources, such as education, prevent disability but are not readily modifiable. However, household and neighborhood conditions may be modifiable and may account for some of the educational disparities in disability for older adults. 

Approach: The National Health and Aging Trends Study measured education, household and neighborhood conditions, and physical capacity, including lower extremity function, hand grip strength and lung function. Structural equation models were used to decompose total educational effects into direct effects and indirect effects via household and neighborhood conditions in 6874 community-dwelling participants. 

Findings: Education was directly associated with lower extremity function and lung function, but not hand grip strength. Indirect effects were found for household disorder with lower extremity function, hand grip strength and lung function and between street disorder with lower extremity function. Results show that these indirect effects accounted for approximately 35%, 27% and 14% of the total association between education and SPPB scores, grip strength level, and peak expiratory flow level, respectively. These results suggest that household and neighborhood conditions account for a non-trial proportion of educational disparities in disability among older adults.  

Team: The study team includes Laura Samuel, Thomas Glass, Roland Thorpe, Sarah Szanton and David Roth.

Funding: The project was supported by the National Institute on Aging (T32AG000247).  

Media & Publications:  

Household and neighborhood conditions partially account for associations between education and physical capacity in the National Health and Aging Trends Study. 

Examines the joint contribution of financial resources, social environment, and functional abilities to the probability of living in a home with housing deficiencies, among older adults. 

Background: Housing quality is a recognized social determinant of health. Qualitative evidence suggests the ability of older adults to maintain their homes is affected by the domains of financial resources, social environment, and functional abilities, but this conceptualization has not been tested quantitatively. 

Approach: This cross-sectional study examined associations between financial resources, social environment, and functional abilities with deficient housing among 6,489 community-living adults ≥ 65 years participating in the nationally representative 2015 National Health and Aging Trends Study. 

Team: The study team incudes Safiyyah Okoye (PI), Sarah Szanton, Laura Samuel and Jennifer Wolff at Johns Hopkins. 

Funding: The project is supported by the Training Program in Health Service and Outcomes Research for Aging Populations (NIA T32AG066576). 

Develops a life course measure of structural racial discrimination and structural resilience.

Background: Most measures of racial discrimination are of interpersonal discrimination. The few measures of more systemic discrimination are cross-sectional.  This project is developing a life course measure of structural racial discrimination in the US.  

Approach: Using life course addresses of older adults and matching to multiple public data sources for each domain of structural discrimination (education, employment, income/credit/wealth, media, criminal justice, neighborhood) across the life course, we are iteratively developing and refining a measure of structural racial discrimination and structural resilience.  

Team: The study team includes Sarah Szanton (PI), Roland Thorpe, Deidra Crews, Gil Gee, Karen Bandeen-Roche, Laura Samuel, Melissa Hladek.  

Funding: The study is funded by a grant from National Institute on Aging (DP1AG069874).

Mixed methods study to examine the factors that affect social connections of older adults living in subsidized housing.  

Background: Social isolation in older adults has become a rising public health concern as it has been found to be correlated with deficits in physical and mental health. Low-income older adults are at increased risk of experiencing the consequences of social isolation as limited resources poses a threat to social mobility.  

Approach: Semi-structured qualitative interviews are conducted to explore perspectives and preferences in order to gain insights into how social connections are formed and maintained in these residential communities, facilitators and barriers of social connection, and resources that impact connections. A social network inventory is administered which includes validated social network and loneliness scales, an ADL and IADL assessment, record of physical health, list of community housing features, and a detailed account of members of the participant’s social network.   

Team: The study team includes Thomas Cudjoe, Nicole Williams, Sarah Szanton, Joe Gallo, Carl Latkin, Roland Thorpe, and Cynthia Boyd. 

Funding: The project is supported by the National Institute of Health.