When home is where the stress is: Expanding the dimensions of housing that influence asthma morbidity

Article (PDF Available)inArchives of Disease in Childhood 91(11):942-8 · December 2006with143 Reads
DOI: 10.1136/adc.2006.098376 · Source: PubMed
Abstract
The influence of physical housing quality on childhood asthma expression, especially the effect of exposure to moulds, allergens, and pollutants, is well documented. However, attempts to explain increasing rates and severity of childhood asthma solely through physical environmental factors have been unsuccessful, and additional exposures may be involved. Increasing evidence has linked psychological stress and negative affective states to asthma expression. At the same time, recent scholarship in the social sciences has focused on understanding how social environments, such as housing, "get under the skin" to influence health, and suggests that psychological factors play a key role. While there is relevant overlapping research in social science, psychology, economics, and health policy in this area, findings from these disciplines have not yet been conceptually integrated into ongoing asthma research. We propose to expand the dimensions of housing considered in future asthma research to include both physical and psychological aspects which may directly and indirectly influence onset and severity of disease expression. This synthesis of overlapping research from a number of disciplines argues for the systematic measure of psychological dimensions of housing and consideration of the interplay between housing stress and physical housing characteristics in relation to childhood asthma.

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Available from: Megan Sandel
CHILD HEALTH SERIES
When home is where the stress is: expanding the
dimensions of housing that influence asthma morbidity
M Sandel, R J Wright
...............................................................................................................................
Arch Dis Child 2006;91:942–948. doi: 10.1136/adc.2006.098376
The influence of physical housing quality on childhood
asthma expression, especially the effect of exposure to
moulds, allergens, and pollutants, is well documented.
However, attempts to explain increasing rates and severity
of childhood asthma solely through physical environmental
factors have been unsuccessful, and additional exposures
may be involved. Increasing evidence has linked
psychological stress and negative affective states to asthma
expression. At the same time, recent scholarship in the
social sciences has focused on understanding how social
environments, such as housing, ‘‘get under the skin’’ to
influence health, and suggests that psychological factors
play a key role. While there is relevant overlapping
research in social science, psychology, economics, and
health policy in this area, findings from these disciplines
have not yet been conceptually integrated into ongoing
asthma research. We propose to expand the dimensions of
housing considered in future asthma research to include
both physical and psychological aspects which may
directly and indirectly influence onset and severity of
disease expression. This synthesis of overlapping research
from a number of disciplines argues for the systematic
measure of psychological dimensions of housing and
consideration of the interplay between housing stress and
physical housing characteristics in relation to childhood
asthma.
...........................................................................
See end of article for
authors’ affiliations
.......................
Correspondence to:
Dr M Sandel, 91 E.
Concord St, Boston, MA
02118, USA; megan.
sandel@bmc.org
Accepted 12 June 2006
.......................
‘‘Experts agree: The blight of poverty housing
reaches beyond rotting roofs and insufficient
sanitation systems. It casts low-income
families into an unforgiving cycle of physical
and emotional duress, compromising their
health, academic achievement and sense of
security.’’ (Habitat World, June/July 2002)
1
A
growing asthma epidemic has been docu-
mented worldwide over the past three
decades. As the epidemic has grown, the
burden of disease has also shifted based on
demographic and socioeconomic indicators,
where asthma outcomes are socially patterned
and clustered by areas of residence.
2
In the USA,
asthma disproportionately affects non-white
children living in urban areas and children living
in poverty. However, variation in asthma mor-
bidity across urban neighbourhoods cannot be
explained by economic factors alone. All urban
communities do not have elevated asthma
morbidity despite the fact that they are compar-
ably low on many economic indicators and have
seemingly similar physical environmental expo-
sures as identified high risk neighbourhoods.
Among urban low socioeconomic status neigh-
bourhoods, those with predominantly minority,
segregated populations appear less burdened
than more integrated neighbourhoods.
While traditional asthma epidemiological stu-
dies suggest the importance of physical char-
acteristics of the inner-city environment on
asthma morbidity (including greater outdoor air
pollution (e.g. diesel buses); crowding, which
may predispose to viral respiratory illness; poor
housing stock of the inner-city, which may
increase exposure to indoor allergens; and
greater likelihood of tobacco smoke exposure),
these factors do not completely explain the
observed social disparities in asthma.
3
Efforts
are beginning to expand our thinking to consider
explanations that link asthma morbidity to social
and political forces that determine the distribu-
tion of physical characteristics of the urban
inner-city environment.
24
What remains largely
overlooked is that deprivation and disadvantage
related to the physical environment also exact an
emotional toll on residents that may further
impact health. In this light, it is useful to
reconsider the role of housing in asthma
research.
The link between housing and health has been
described for over a century.
5
Housing improve-
ments, sanitation, and slum clearance in the
19th and 20th centuries played an important role
in controlling tuberculosis, typhus, cholera, and
other infectious diseases.
6
Though in many parts
of the developing world problems of sanitation
and basic habitability persist, better housing has
resulted in reduction of morbidity and mortality,
improved life expectancy, and improved child
health in developed nations.
7
Even so, contem-
porary research shows persistent links between
the home environment and common childhood
diseases, in particular, asthma. Arguably, child-
hood asthma warrants specific attention in this
regard given recently documented trends of
increasing prevalence and morbidity.
8
Since
changes in genetic factors alone cannot explain
this rise, greater emphasis has been placed on
environmental factors to explain these trends.
Yet while asthma expression has been associated
with a variety of physical environmental expo-
sures, including chronic dampness,
9
vermin,
10
942
www.archdischild.com
dust mites,
11
and cockroaches,
12
recent reviews in this area
suggest that these known environmental exposures alone
cannot explain the asthma trends or observed disparities in
disease expression.
313
This has led to the consideration of as
yet unidentified factors that may be playing a role.
2
At the same time, mechanisms linking psychological stress,
negative affect, and emotion to atopic disorders including
asthma are being increasingly elucidated.
14
In overlapping
research, housing dimensions that may influence health and
wellbeing have been increasingly expanded to include the
psychological effects of poor housing.
15 16
Specifically, the
proposition that the influence of housing conditions on
health may be operating through psychological stress path-
ways has been explored in sociology, psychology, economics,
health policy, stress, and social epidemiological research. To
date, the knowledge gained from these disparate literatures
has scarcely been considered in asthma research. As we
continue to explore both physical and social factors that may
contribute to asthma disparities,
2
it is timely to consider more
fully all dimensions of housing risks in future asthma
research.
The known links between housing and health,
6
associa-
tions between indoor environmental exposures and asthma
morbidity,
13
and the gaps in our knowledge concerning
asthma disparities have been previously reviewed
23
and are
not within the scope of the present discussion. The aim of
this article is to synthesise the state of knowledge on the
psychological dimensions of housing from these traditionally
disparate areas of scholarship and then to frame their
relevance in the context of future asthma research. We first
review the evidence linking stress to asthma. We then review
the conceptualisation of psychological housing stress related
to a number of housing characteristics (e.g. lack of control
over housing, residential instability, high cost of housing,
presence of pests and dampness) that have been linked to
health. We consider how synthesis of the housing literature
may increase our understanding of asthma disparities.
Finally, we outline a conceptual model to provide direction
for future research considering the possible pathways linking
housing stress to asthma.
EVIDENCE LINKING STRESS AND ASTHMA
Psychological stress may have both direct and indirect effects
on asthma expression. Increasingly, asthma has been
conceptualised as an epidemic of dysregulated immunity.
14
Thus, psychological stress may directly influence asthma
expression. Asthma is regulated through immune phenom-
ena, in which many cells (i.e. mast cells, eosinophils,
T lymphocytes), and associated cytokines, chemokines, and
neuropeptides, play a role. Overlapping mechanisms of
inflammation central to the pathophysiology of asthma
involve a cascade of events, including the release of
immunological mediators. Hormones and neuropeptides
released into the circulation when individuals experience
stress are thought to be involved in regulating both immune
mediated and neurogenic inflammatory processes.
Dysregulation of normal homeostatic neural, endocrine,
and immunological mechanisms can occur in the face of
chronic stress, leading to chronic hyper-arousal and/or hypo-
responsiveness that may impact atopic disease expression.
Thus, psychological stress has been conceptualised as a
social pollutant that when ‘‘breathed into the body’’ may
disrupt these biological systems through inflammatory
processes.
14
An increasing number of studies have associated
psychological stress with asthma expression, whether experi-
enced directly or indirectly through parents and caretakers.
Prospective studies link early life caretaker stress
17
and
parenting difficulties
18
with early life wheeze and asthma
onset. Stressful life events have recently been shown to have
association with increased asthma attacks in children, up to
weeks after the event.
19
Among inner-city children with
asthma, parental psychosocial problems and distress are
associated with increased asthma morbidity.
20
Other evidence
has demonstrated the influence of psychological stress on the
dysregulation of known underlying neuro-immunological
factors related to asthma pathogenesis
21–23
and response to
known asthma triggers.
24
Moreover, stress may indirectly impact asthma morbidity
by influencing how children and families perceive asthma
and manage their disease. For families attending an asthma
specialty clinic, higher levels of life stressors (including
housing stressors) in caregivers was associated with higher
asthma morbidity perhaps because caregivers could not focus
adequately on asthma management because of these
stressors.
25
In one study of an inner-city population of
asthmatics, increased caregiver stress was associated with
more frequent asthma symptoms in the children, an effect
that was in part mediated through lower adherence to
asthma medications.
26
Another approach to examining the long term implica-
tions of housing stress is to document links between
housing and behaviours which may translate into later
health effects. Behavioural changes occurring as adaptations
or coping responses to stressors also influence asthma
morbidity. That is, persons exposed to stressors or viewing
themselves as under stress tend to engage in poor health
practices (e.g. they may smoke, eat poorly, exercise less, sleep
less, and be less compliant with prescribed medical treat-
ments). In turn, smoking, lack of sleep, and poor adherence
are established factors contributing to poorer asthma out-
comes.
Lastly, psychological stress may have independent effects,
but also may play a role through the enhancement of neuro-
immune responses to other physical environmental factors
operating through similar pathways.
14
That is, the effects of
environmental toxins (e.g. air pollution, tobacco smoke,
allergens) on atopy and asthma may be mediated through
common pathways (e.g. neuro-immune dysregulation or
oxidative stress). An individual’s response to allergens and
air pollutants may thus be potentiated by chronic psycholo-
gical stressors.
LINKING HOUSING CHARACTERISTICS AND
PSYCHOLOGICAL STRESS
Research to date has considered a number of housing
characteristics that may cause psychological distress, includ-
ing physical housing conditions that cause distress (e.g.
crowding, presence of pests, dampness in the home or noise),
financial strain, perceived housing dissatisfaction, lack of
privacy, lack of control over housing conditions (e.g. inability
to afford better housing, landlord unavailability), loss of
social supports, and other housing hardships. Research
linking housing characteristics to psychological stress and
co-morbidities are summarised in table 1.
Substandard physical housing conditions have been linked
to negative mental health among children and their adult
caregivers.
27
A number of housing characteristics, including
floor level, presence of pests, and dampness have been
associated with psychological distress, poor mental health,
and lower perceived health status.
28–30
Noise exposure in and
around housing has been associated with increased cortisol
levels and higher perceived stress.
31
McCarthy et al found that
housing age, type (flats versus single family houses), floor
level, and location affected both respiratory (i.e. cough,
wheeze, and self-reported asthma) and mental health out-
comes.
27 32
Another study
29
linked home dampness and being
unable to keep the house warm enough in the winter to
increased asthma prevalence among adults. In this study,
Housing and asthma morbidity 943
www.archdischild.com
inability to keep the house warm was significantly associated
with asthma, even after controlling for home dampness.
Although these authors touch on the notion that worry
about cold or damp housing may have contributed to the
observed effects, they were unable to test this directly. In
another study, Evans and colleagues
30
conducted a prospec-
tive longitudinal study linking physical housing quality to
mental health. Indeed, although housing characteristics
have been linked to mental health outcomes in numerous
studies to date, very few studies have systematically explored
the underlying mechanism or the mediators of these effects.
Of note, the demonstration of increased psychological
distress from substandard housing conditions is not unique
to the urban environment. For example, Evans and collea-
gues
33
have described similar findings in poor rural white
children.
Environmental psychologists and social scientists, among
others, suggest that housing also has a significant subjective
emotional dimension.
16
While the subjective or emotional
response to one’s housing can be positive, serving as a
reflection of positive personal identity, a site for the exercise
of control, and a source of social status,
34
it may also be
associated with psychological distress.
16
A number of
subjective housing characteristics have been linked to adverse
psychological outcomes.
Cost of housing
Housing cost has been linked to housing stress in many parts
of the world. Financial housing stress has been defined as
spending more than 30% of disposable income on housing
costs. In Australia, an estimated 1.7 million people have
financial housing stress.
35
Latest available evidence from the
European Union documents that most countries have been
able to keep average housing expenditures below 30% of
available income housing, though the distribution is wide,
with Ireland averaging 12% of available income whereas
Denmark averages close to 28% of available income.
36
In
contrast, in the United States, 3 in 10 families spend more
than 30% of their income on housing.
37
Overcrowding
High density living or overcrowding has been associated with
increased rates of infections
38
as well as psychological
distress.
6
Although it has been postulated that the tolerance
of crowding is different across cultural groups, high density
living conditions have been linked to psychological distress
among Asian, Indian, Latino, Anglo-American, and African
American cultures, even after controlling for income.
39 40
Crowding may result in a perceived lack of privacy, which
may have a greater impact on physical wellbeing than
housing quality itself.
41
Residential satisfaction
Other research argues that the subjective environment,
assessed through perceived residential satisfaction, has
greater influences on psychological wellbeing than the
objective environment. Residential satisfaction taps into an
individual’s appraisal of the conditions of their residential
environment, in relation to their needs and expectations.
42
A
recent study found that perceived residential satisfaction
mediated the effects of objective housing conditions on
psychological status among older adults living in Hong
Kong.
15
Residential instability
Residential instability can be defined as a lack of stable
housing, whether through frequent moving, living ‘‘doubled
up’’ with many families sharing one housing space, or
homelessness in shelter situations. Having a stable home has
been associated with better health ratings and lower
psychological distress. Research has consistently shown
home ownership to be associated with higher health
ratings.
42
Wong et al showed that perceived psychological
distress improved after homeless adults were placed in
permanent housing.
43
The influence of moving on health
may in part be mediated through an individual’s perception
of the change in their environment. One recent study found
that subjects who perceived improvement in environmental
quality of housing after moving reported improved self-
health ratings.
44
Social relationships, social supports, and
social networks may function as a buffering system which
can counteract the negative effects of environmental stres-
sors.
45
Housing instability and homelessness disrupt social
networks, which may have a negative impact on mental
health.
46
However, increased social support alone may not be
adequate to buffer the deterioration in mental health caused
by high levels of housing stressors.
34
Lack of control over housing
When the environment is perceived to be threatening, and
individuals lose the ability to cope or take control over life
events or their environment, they experience stress.
47
Therefore, the connection between housing and psychological
distress may be mediated through the perceived lack of
control over one’s life or circumstances, especially hous-
ing.
48 49
Many families have become aware through asthma
education programmes and communication with their
healthcare providers that exposure to cockroaches and
rodents in the home may adversely impact their own or their
child’s asthma. However, many lack the means to move, or to
remediate these potentially hazardous exposures.
The potential health effects of these circumstances are not
unlike those seen among individuals living near toxic waste
sites. Symptoms associated with living proximal to a toxic
Table 1 Housing stress factors, categories, and examples
Housing factors Categories Examples Health outcome examined References
Physical housing
conditions (material)
Substandard conditions Mould or dampness, infestations
Exposed wiring, cracks floors
Respiratory effects, mental health scores (GHQ30)
Children’s Behavior Inventory (CBI)
27, 28
59
Housing quality Rooms per person Demoralisation index (Psychiatric Epidemiology
Research Institute)
30
Noise Perceived Stress Index, cortisol measures 31, 33
Housing hardships No heat once in past 3 months Poorer health and respiratory status (SF-36) 29
Housing characteristic Flat versus house Poorer mental, respiratory health (GHQ30) 32
Emotional housing
conditions
(meaningful)
Overcrowding
Lack of control
Housing tenure
More child/parent conflicts
Landlord unavailable
Rent or own
Poorer mental health scores
Poor health status (Rand MHI)
Poor self-rated health status
40
16
42
Housing cost Fear of eviction Poor mental health scores, health status (Rand MHI) 16
Residential instability Homelessness Higher distress symptoms 13
944 Sandel, Wright
www.archdischild.com
waste site include depression, lack of control of the environ-
ment, increased family quarrels, increased health worries, and
increased intrusive and avoidant thoughts.
50–54
Long term
stress effects operating through lasting psychological, beha-
vioural, and physiological responses are thought to be
maintained through recurrent unwanted or ‘‘intrusive’’
thoughts about past events or circumstances.
55
Children
express increased stress which correlates with parental reports
of chronic distress from the uncertainty of toxic exposure.
51
Housing stress can be further mediated through perception
of control over housing conditions. Poor psychological health
status was found in Japanese women when they perceived
that housing was unhealthy for their children.
56
In another
study, control factors, like the presence of a tenants’ self-
management structure, was significantly associated with
improved mental health, self-rated health status, and
satisfaction with health.
16
Such partnerships may promote
new social support networks. Neighbours experiencing
similar stress can become effective sources of social support
for each other.
51 52
Rich et al
57
recommended a partnership
approach to community decision making to minimise the
disempowering impact of environmental threats. Community
groups can provide information and emotional support, and
engender a sense of empowerment.
58
CONSIDERING PHYSICAL AND EMOTIONAL
HOUSING DOMAINS
Findings that suggest independent health effects from both
the physical and emotional conditions of housing underscore
the need to consider both dimensions in future research on
housing and health. In a cross-sectional study of 12
neighbourhoods in Vancouver, Dunn et al showed an
independent association between poorer perceived health
ratings and poorer mental health from both physical
(material) and emotional (meaningful) aspects of housing.
16
In another Canadian study, housing quality, including
physical problems such as heating problems and cracks in
floors, and emotional stressors, such as crowding and fear
and insecurity related to housing, were significantly related
to parental ratings of children’s socioemotional health,
independent of other risk factors such as income and
education levels.
59
INFORMING SOCIAL DISPARITIES IN ASTHMA
Research linking housing characteristics to psychological
stress and asthma morbidities is summarised in table 2. Both
housing quality and life stressors, including psychological
distress related to housing characteristics, are not uniformly
distributed in the population. The negative effects of unequal
distribution of housing, overcrowding, and abandoned
housing on community health are well known.
60
Socioeconomic deprivation results in higher percentages of
income devoted to rent and more substandard conditions,
37
potentially modifying the relationship between housing
stress and health. Persons of lower socioeconomic status
experience negative life events more frequently, including
housing hardship.
61
While most contemporary life event
measures do not include items related to housing stress or
hardship,
62
there are some notable exceptions.
63 64
The social,
political, and economic forces that result in marginalisation
of certain populations in disadvantaged neighbourhoods and
communities also influence housing quality in these areas.
2
The legacy of racism, discrimination, and segregation under-
lies many families’ selection of where to live, both historically
and currently.
65–67
Families that are residentially unstable
have higher levels of cockroach allergen, even after control-
ling for income and ethnicity.
12
Some investigators concluded
from the available information that frequency of moving may
be a risk factor in developing asthma,
68
while others thought
moving was a marker for other factors, such as chronic
dampness in homes.
9
Future research should more system-
atically explore these associations.
Though a thorough discussion of disparities in housing
distribution is beyond the scope of this overview, it is clear
that housing dimensions cannot be fully separated from the
physical and social dimensions of the neighbourhoods and
communities in which housing is nested. Community level
variables are receiving increased attention for their critical
role in determining health inequalities between racial/ethnic
and socioeconomic groups, conceivably because they mediate
the effects of living in low socioeconomic status neighbour-
hoods. One potential mediating feature of community life
that has attracted considerable attention is the notion of
social capital and social cohesion, defined as those features of
social organisation (e.g. the extent of interpersonal trust
between citizens, norm of reciprocity, and the vibrancy of
civic associations) that facilitate cooperation for mutual
benefit.
69 70
Social capital can influence opinions and invest-
ment in housing, and plays a large role in how communities
deal with issues of crime, poverty, and inadequate housing.
71
Other housing policies, such as ones that promote residential
stability, have the potential to influence social organisation
and diminish crime.
72
While it may be challenging to
disentangle the effects of housing and neighbourhood, there
are studies that suggest independent housing effects.
Fullilove et al found that housing quality and overall health
could be improved if families moved to better, recently
renovated housing, even when neighbourhood conditions
remained poor.
73
Housing quality and health disparities
Housing may also exert effects independent of socioeconomic
factors. Housing tenure is related to overall health despite
controlling for income and self-esteem.
74
In comparing low
and middle income white children, Evans et al found home
environmental risk scores correlated with changes in
norepinephrine, epinephrine, and cortisol levels in the low
income group, even after controlling for income, maternal
education, family structure, age, and gender.
33
Race, income,
and housing may also be linked, since studies of the possible
role of discrimination in racial differences in hypertension
found chronic strains, such as housing discrimination, as
potentially important.
75
Relative deprivation of specific
factors, including housing, may be important in mediating
effects of low income on poor health.
76
Table 2 Housing stress factors, categories, and examples in asthma
Housing factors Categories Examples References
Physical housing conditions Substandard conditions Pest infestation (mice, roaches) 10
Emotional housing conditions Overcrowding Lack of privacy 38
Lack of control Caretaker stress 20
Residential instability Moving 68
Housing and asthma morbidity 945
www.archdischild.com
CONCEPTUALISATION OF HOUSING STRESS IN
FUTURE ASTHMA RESEARCH
Figure 1 demonstrates a conceptual model depicting path-
ways linking housing stress to asthma expression. Here, the
emotional conditions of housing are considered equally with
the physical conditions of housing, which have been more
extensively recognised and studied. The emotional and
physical housing conditions may interact, with physical
conditions such as dampness causing emotional distress
and emotional conditions, such as lack of control of housing
causing families to be less vigilant about housekeeping and
have more pest problems as a result. These pathways,
through physical and emotional housing conditions, will
lead to housing stress. Housing stress may also be con-
ceptualised as a social pollutant that when ‘‘breathed’’ into
the body may interact with other physical factors within
housing (e.g. allergens, environmental tobacco smoke) and
surrounding housing (e.g. air pollution, diesel fumes) to
disrupt similar biological pathways to influence asthma
expression.
14
Furthermore, neighbourhood level factors may
be related to housing quality but also interact with the effects
of housing stress as discussed above. For example, housing
instability, or frequent moving, may be influenced by housing
quality, but also may be related to other factors, such as
neighbourhood violence, which has been linked with higher
rates of asthma morbidity.
26
MOVING TO ACTION
Physical housing issues are universal, whether from Eastern
European block housing,
77
dilapidated public housing in the
United States,
78
or council housing in the UK.
79
Changing
someone’s housing situation has been shown to help mental
health after moving from substandard housing stock.
80
Other
relocation studies have shown mental health can be
improved by moving from a high poverty to a low poverty
neighbourhood, suggesting that neighbourhood factors, in
addition to housing, may also play a role.
81
Rental support
through the use of housing vouchers has enough evidence to
support wider use,
82
though programmes aimed to promote
mixed income or less racial segregation have less evidence to
support them.
83
To date, housing interventions may not have
adequately accounted for social capital in determining health
benefits. Often, they focus only on brief time spans, and
single housing units, instead of viewing housing on a broad
social and ecological scale.
84
Though the relationships proposed in this paper are still at
the theoretical level, pilot interventions should be designed to
improve both physical and emotional aspects of housing.
84
Future housing studies should measure the impact on quality
of life with changes in the physical environment.
85
Though
large housing interventions have been few in number
86
and
therefore the full health impact of housing interventions is
difficult to assess,
87
mental health should be considered among
the potential benefits of housing policies and thus examined in
future work. It would be important to design future studies,
for example, to examine potential independent effects of
psychological distress related to residential instability or other
housing conditions, controlling for physical factors like
cockroach exposure. Such findings would inform an interven-
tion quite different from the mere elimination of cockroach
allergen in these homes, and thus may prove more effective in
finding potential health benefits.
88
Disentangling the effects of socioeconomic status, educa-
tion, and race on housing and health will always be difficult.
Through more focus on housing stress, large cohort studies
can further illuminate relationships between social depriva-
tion and housing conditions and their potential role in the
development and severity of asthma.
89
This research can
inform future intervention points in housing that may reap
both physical and psychological benefits. Housing goes
beyond shelter and community.
90
The creation of a home,
free from housing stress, may be the best prescription for the
physical and mental health of all children, and particularly
those with asthma.
Authors’ affiliations
.....................
M Sandel, Boston University School of Medicine, Boston MA, Center for
Healthy Homes and Neighborhoods, Boston University School of Public
Health and Boston Medical Center, Boston, MA, USA
R J Wright, Channing Laboratory, Brigham and Women’s Hospital,
Harvard Medical School, and Department of Society, Human
Development, and Health, Harvard School of Public Health, Boston, MA,
USA
Emotional housing conditions:
– Fear of eviction
– Landlord unavailable
– Desire to but unable to move
Housing
quality
Physical housing conditions:
– Allergens/infestations
– Environmental tobacco smoke
– Housing quality
– Noise
Physical confounding/modifying
factors:
– Air pollution/diesel fumes
– Infections
Neighbourhood level confounding/
modifying factors:
– Social cohesion
– Violence
– Indicators of socioeconomic deprivation
Housing
stress
Increased wheeze or
asthma syndromes
Figure 1 Theoretical model for housing quality, housing stress, and asthma risk.
946 Sandel, Wright
www.archdischild.com
Funding: Dr Sandel is supported by a grant from the Medicine as
Profession Open Society Institute, Soros Foundation, and the National
Institutes of Health, 1K23 ES013173-02. During preparation of this
manuscript Dr Wright was supported by the National Heart, Lung, and
Blood Institute, U01 HL072494, and the National Institutes of
Environmental Health Sciences, R01 ES10932.
Competing interests: None.
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ARCHIVIST..........................................................................................................
Non-invasive testing for severe fetal anaemia
T
he fetus with severe rhesus haemolytic disease may be at risk of dying from severe
anaemia and in need of intrauterine blood transfusion. Standard testing includes
repeated amniocentesis with spectrophotometric measurement of amnioticfluid
bilirubin levels using change in optical density at wavelength 450 nm (DOD
450
). The risks
of repeated amniocentesis make non-invasive monitoring attractive, and many centres have
turned to measurement of blood flow in the middle cerebral artery using Doppler ultrasound
(high flow indicating severe anaemia). Now, researchers in North America and Europe
(D Oepkes and colleagues, N Engl J Med 2006;355:15664; also see Editorial, ibid: 1924)
have compared the two methods. The study included 164 women with rhesus
alloimmunisation and an indirect Coombs test titre of at least 1/64. Of the 165 fetuses
(one pair of twins), 74 had severe anaemia on intrauterine or postnatal testing of umbilical
cord blood. Doppler ultrasound assessment of the middle cerebral artery blood flow was
carried out before the first amniocentesis using DOD
450
. The sensitivities, specificities and
accuracies for the detection of severe fetal anaemia were 88%, 82% and 85% (Doppler
ultrasound) and 76%, 77% and 76% (amniocentesis), respectively. The non-invasive method
was considerably more sensitive and accurate than the invasive method.
Women with severe rhesus alloimmunisation should be cared for in specialised centres
where expertise is available in the management of this condition and the use of Doppler
ultrasound. Non-invasive detection of fetal anaemia may replace amniocentesis and
measurement of DOD
450
.
948 Sandel, Wright
www.archdischild.com
    • "Regarding the interplay between parenting stress and asthma severity, some previous studies in asthma did indicate that greater parenting stress was associated with higher asthma severity (Kaugars, Klinnert, & Bender, 2004; Sandel & Wright, 2006), poorer illness management, poorer adherence to medication (Celano, Klinnert, Holsey, & McQuaid, 2011), and poor house dust mite control (Joseph, Adams, Cottrell, Hogan, & Wilson, 2003). Moreover, it has been indicated that negative life events increase the risk of children's asthma attacks (Sandberg et al., 2000) and that caregiver stress predicts wheeze in early childhood (Wright, Cohen, Carey, Weiss, & Gold, 2002). "
    File · Data · Sep 2015 · Energy Policy
    • "The mediator domains (and component variables) include: mental health (psychological distress scale, behavior problems index; see (Osypuk et al., 2012a, 2012b) for details on items and construction of these measures); smoking (adult in home smokes, youth ever smoked); housing disarray (cluttered rooms, presence of pet fur, index of negative interior-of-home characteristics); interviewer-observed housing quality (wall-to-wall carpeting, broken plaster/peeling paint, cracks/holes in windows or walls, general condition of housing unit, index of negative exterior-of-home characteristics); adult-reported housing quality (broken locks, peeling paint/wallpaper , vermin, broken windows, count of housing problems, rating of housing as good or excellent); housing hardship (problems with heating, problems with plumbing, utilities were shut off, household head was evicted, household head was homeless/doubled up, problems paying rent/mortgage, problems paying for utilities); housing mobility (moved once since baseline, moved two or more times since baseline). The housing measures were grouped together into 5 domains based on prior empirical evidence (Sandel and Wright, 2006; Suglia et al., 2010). We tested health care access and neighborhood domains (i.e., neighborhood disorder, safety, and satisfaction, and census variables) as mediators, yet none was significant (results not shown). "
    [Show abstract] [Hide abstract] ABSTRACT: Literature on neighborhood effects on health largely employs non-experimental study designs and does not typically test specific neighborhood mediators that influence health. We address these gaps using the Moving to Opportunity (MTO) housing voucher experiment. Research has documented both beneficial and adverse effects on health in MTO, but mediating mechanisms have not been tested explicitly. We tested mediation of MTO effects on youth asthma (n = 2829). MTO randomized families living in public housing to an experimental group receiving a voucher to subsidize rental housing, or a control group receiving no voucher, and measured outcomes 4–7 years following randomization. MTO had a harmful main effect vs. controls for self-reported asthma diagnosis (b = 0.24, p = 0.06), past-year asthma attack (b = 0.44, p = 0.02), and past-year wheezing (b = 0.17, p = 0.17). Using Inverse Odds Weighting mediation we tested mental health, smoking, and four housing dimensions as potential mediators of the MTO–asthma relationship. We found no significant mediation overall, but mediation may be gender-specific. Gender-stratified models displayed countervailing mediation effects among girls for asthma diagnosis by smoking (p = 0.05) and adult-reported housing quality (p = 0.06), which reduced total effects by 35% and 42% respectively. MTO treatment worsened boys' mental health and mental health reduced treatment effects on asthma diagnosis by 27%. Future research should explore other potential mediators and gender-specific mediators of MTO effects on asthma. Improving measurement of housing conditions and other potential mediators may help elucidate the “black box” of neighborhood effects.
    Full-text · Article · Apr 2014
    • "Consistent with this idea, household energy efficiency interventions have been shown to result in a diverse range of positive health impacts (for reviews, see Thomson et al., 2009 Thomson et al., , 2013), including children's respiratory health, weight and susceptibility to illness, the mental health of adults (rarely assessed for children) (Liddell and Morris, 2010 ), better selfreported health, and reduced respiratory symptoms and school absences due to asthma (PHIS, 2006). Indirect evidence was also provided by Sandel and Wright (2006) who noted that stress caused by housing problems, including damp and mould, can exacerbate asthma in children. There is also evidence that improved domestic space heating can reduce school absences and health service use for children with asthma (Preval et al., 2010). "
    [Show abstract] [Hide abstract] ABSTRACT: Thirty-six studies, with over 33,000 participants, were meta-analysed. The sample-weighted average effect was d þ ¼0.08. Energy efficiency interventions, therefore, had a small, positive effect on health. Participants with low incomes saw greater benefits. Larger effects were found in more recent studies and where medical tests were used. a b s t r a c t It is widely accepted that interventions designed to promote household energy efficiency, like insulation, central heating and double glazing, can help to reduce cold-related illnesses and associated stress by making it easier for residents to keep their homes warm. However, these interventions may also have a detrimental effect on health. For example, the materials used or lower ventilation rates could result in poorer indoor air quality. The present research sought to systematically quantify the impact of household energy efficiency measures on health and wellbeing. Thirty-six studies, involving more than 33,000 participants were meta-analysed. Effect sizes (d) ranged from À 0.43 (a negative impact on health) to 1.41 (a substantial positive impact on health), with an overall sample-weighted average effect size (d þ) of 0.08. On average, therefore, household energy efficiency interventions led to a small but significant improvement in the health of residents. The findings are discussed in the context of the health improvements experienced by different groups of participants and the study design factors that influence health outcomes. The need for future studies to investigate the long term health benefits of interventions designed to promote household energy efficiency is identified.
    Full-text · Article · Jan 2013
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