According to the World Health Organization, health is “a state of physical, mental, and social well-being and not merely the absence of disease or infirmity.”1 Healthy children live in families, environments, and communities that provide them with the opportunity to reach their fullest developmental potential.1
In this issue of Pediatrics, Sakai-Bizmark et al2 share results of a large population-based study on asthma hospitalization rates among homeless youth in the state of New York. The investigators reviewed administrative data from 71 837 pediatric asthma hospitalizations over 5 years using the New York Healthcare Cost and Utilization Project’s Statewide Inpatient Database, compiled by the Agency for Healthcare Research and Quality.2 The authors of this study build on previous work by McLean et al3 in 2004 in which the authors reported a 39.8% increase in the prevalence of asthma among homeless children in New York city. Per the latest Centers for Disease Control and Prevention data, the national rate of childhood asthma is 8.3%.4 In their work, Sakai-Bizmark et al2 found a 31 times higher rate of asthma hospitalization among homeless youth compared with nonhomeless youth, as well as higher emergency department use rates. Not surprisingly, they found nonhomeless hospitalization rates to be highest among those living within the lowest income quartiles, and when compared with these low-income children, homeless youth were still hospitalized at a 13.6 times higher rate.2 These findings are consistent with a previous 2013 study by Hwang et al5 revealing that homeless individuals visit the emergency department at a rate of >8 times that of low-income age- and sex-matched controls.
As concluded by the authors, “homeless youth live under special conditions; therefore, more targeted efforts are needed to identify underlying causes of this discrepancy and develop effective interventions to improve well-being in homeless children with asthma.”2 Recognition of the high prevalence of asthma among young homeless children presents an opportunity to support the health and positive development of this and other at-risk populations. Although it is not completely clear what the main contributor of the increased rate of hospitalization found in this study population is, potential contributing factors identified by the authors include high minority representation, poor control of disease due to the lack of adherence to medication regimens or fragmented care, and environmental factors exacerbated in shelter environments.2 The issues facing families who are “literally homeless” based on the US Department of Housing and Urban Development’s (HUD) definition versus those who are living in multigenerational “doubled-up” housing differ, but both groups require support and opportunities to move to a more stable living situation.6
Our experience as pediatricians and the literature tell us there are socioeconomic and racial disparities related to both the diagnosis and treatment of asthma. Increased rates of exposure to risk factors in the physical environment, increased rates of respiratory infections in early life, and the effects on physiologic systems due to chronic or toxic stress early in life are all implications for these disparities.7,8 A deep understanding of these factors is needed to positively impact these differences. To best care for our patients, health systems and clinicians need to consider the environmental and other conditions that may be contributing to poor health outcomes. Providing access to health care alone, without addressing these social determinants of health as a continuum, is not enough. It is now well known that both the physical environments and communities in which children are raised play a significant role in their overall health.9 Both the quality and stability of these environments matter, with housing adequacy being particularly important.
HUD has recognized the importance of the care continuum as part of the solution to chronic homelessness by promoting innovative approaches such as Housing First.10 This model is targeted at individuals with chronic disease at risk for disability and places them directly into permanent supportive housing where, through voluntary participation, trauma-informed treatment services are readily available. By removing traditional barriers to housing entrance and focusing on convenient on-site health care services as well as intense home visitation and case management to engage residents in self-efficacy, this model decreases the use of expensive crisis-oriented systems like hospitals and jails.10,–12 Housing First supporters claim that housing is health care.12 As such, there are now more beds devoted to rapid rehousing and permanent supportive housing than to shelter projects. According to the HUD 2018 Annual Homeless Assessment Report, shelter inventory decreased by 8% between 2007 and 2018, whereas the permanent housing inventory increased considerably by 169%.13
Improvements to housing stability, quality, and affordability reduce the burden and stress on families to meet a basic need so that parents can focus on being responsive and nurturing caregivers for their developing children.14 With their findings, Sakai-Bizmark et al2 underscore the importance of developing effective interventions to decrease the long-term consequences of housing insecurity and homelessness in youth.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2769.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.