Faculty Bibliography

INTRODUCTION/BACKGROUND:In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein 'Section 8'). METHODS:We invited participants from non-smoking households (NYCHA n=157, Section 8 n=118) to enroll into a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bi-sulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n=91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. RESULTS:After three years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section 8, [difference-in-difference (DID) = -1.92 µg/m 3 (95% CI -2.98, -0.87), p=0.001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m 3 (95% CI -2.40, 0.18), p=0.089]. In households, there was no differential change in nicotine concentration (p=0.093) or in PM2.5 levels (p=0.385). CONCLUSIONS:Nicotine concentration reductions in NYCHA common areas over three years may be attributable to the SFH policy, reflecting its gradual implementation over this time. IMPLICATIONS/CONCLUSIONS:Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings.

INTRODUCTION/BACKGROUND:Research has focused on developing methods to facilitate screening and tracking data on social risk factors in healthcare settings. Less is known about the multiple factors that shape patients' acceptance of healthcare-based social risk programs. This qualitative study sought to elucidate the multilevel (individual, interpersonal, family/community, system, policy) factors that influence patients' acceptance of a healthcare-based social risk program within a Federally Qualified Health Center in New York City. METHODS:Participants included 5 patients receiving care at the Federally Qualified Health Center who screened positive for social risks, 4 nurses who are responsible for conducting social risk screenings, and 5 Family Support Services counselors who conduct outreach to patients who screened positive. Interviews were conducted from March to June 2021 and analyzed from July to September 2021 using the constant comparative method. RESULTS:Analyses of the transcripts identified the following 3 themes: (1) Patients appreciated being asked about social risk factors, but there was a mismatch between their understanding of the screening process, their desire for assistance, and the support received. Although nurses and counselors described relationship-centered approaches to involve patients in the process, patients reported feeling initial discomfort and confusion; (2) Multilevel barriers inhibit patients' acceptance of assistance; and (3) Patient trust in the physician and healthcare organization serves as facilitators to acceptance. CONCLUSIONS:Patients' views about the purpose of a healthcare-based social risk program differed from nurses' and counselors' perspectives of the process. Although patients face multilevel challenges, strong trust in the physician and Family Health Centers served as facilitators to accepting healthcare-based assistance.

In 2018, the U.S. Department of Housing and Urban Development required public housing authorities to implement a smoke-free housing (SFH) policy that included individual apartments. We analyzed the policy implementation process in the New York City Public Housing Authority (NYCHA). From June-November 2019, we conducted 9 focus groups with 64 NYCHA residents (smokers and nonsmokers), 8 key informant interviews with NYCHA staff and resident association leaders, and repeated surveys with a cohort of 130 nonsmoking households pre- and 12-month post policy. One year post policy implementation, participants reported widespread smoking violations and multi-level factors impeding policy implementation. These included the shared belief among residents and staff that the policy overreached by "telling people what to do in their own apartments". This hindered compliance and enforcement efforts. Inconsistent enforcement of illegal marijuana use, staff smoking violations, and a lack of accountability for other pressing housing issues created the perception that smokers were being unfairly targeted, as did the lack of smoking cessation resources. Resident support for the policy remained unchanged but satisfaction with enforcement declined (60.1% vs. 48.8%, p = 0.047). We identified multilevel contextual factors that are influencing SFH policy implementation. Findings can inform the design of strategies to optimize policy implementation.

Importance/UNASSIGNED:Secondhand smoke (SHS) exposure is associated with many health conditions in children and adults. Millions of individuals in the US are currently exposed to SHS in their homes. Objective/UNASSIGNED:To investigate whether a federal ban on smoking in public housing settings was associated with a decrease in indoor SHS levels in New York City public housing developments 12 months after the policy's implementation. Design, Setting, and Participants/UNASSIGNED:This cohort study tracked indoor air quality longitudinally from April 2018 to September 2019 and used difference-in-differences analysis to examine SHS exposure before vs after implementation of the 2018 federal smoke-free housing (SFH) policy in 10 New York City Housing Authority (NYCHA) buildings vs 11 matched low-income buildings not subject to the SFH policy (ie, Section 8 buildings). Exposures/UNASSIGNED:Federal SFH policy implementation, beginning July 30, 2018. Main Outcomes and Measures/UNASSIGNED:Comparison of nicotine concentration levels from passive, bisulfate-coated filters before vs 12 months after implementation of the federal SFH policy. Secondary outcomes included changes in particulate matter less than 2.5 μm in diameter, measured with low-cost particle monitors, and counts of cigarette butts in common areas. Results/UNASSIGNED:Air quality was measured repeatedly in a total of 153 NYCHA and 110 Section 8 nonsmoking households as well as in 91 stairwells and hallways. Before the SFH policy implementation, air nicotine was detectable in 19 of 20 stairwells (95.0%) in NYCHA buildings and 15 of 19 stairwells (78.9%) in Section 8 buildings (P = .19) and in 17 of 19 hallways (89.5%) in NYCHA buildings and 14 of 23 hallways (60.9%) in Section 8 buildings (P = .004). Nicotine was detected less frequently inside nonsmoking apartments overall (26 of 263 [9.9%]) but more frequently in NYCHA apartments (20 of 153 [13.1%]) than in Section 8 apartments (6 of 110 [5.5%]) (P = .04). One year after policy implementation, there was no differential change over time in nicotine concentrations measured in stairwells (DID, 0.03 μg/m3; 95% CI, -0.99 to 1.06 μg/m3) or inside nonsmoking households (DID, -0.04 μg/m3; 95% CI, -0.24 to 0.15 μg/m3). Larger decreases in nicotine concentration were found in NYCHA hallways than in Section 8 hallways (DID, -0.43 μg/m3; 95% CI, -1.26 to 0.40 μg/m3). Conclusions and Relevance/UNASSIGNED:The findings suggest that there was no differential change in SHS in NYCHA buildings 12 months after SFH policy implementation. Additional support may be needed to ensure adherence to SFH policies.

Health and housing consortia in New York City offer a model for bridging the divide between the health care and housing sectors. While staff in these sectors often recognize the need to better integrate their services, there are few models for doing so. In this article we describe the formation of a health and housing consortium in the Bronx, New York City, as well as the successful replication of its model in Brooklyn. While each consortium has some features specific to its service area, the primary goal of both is the same: to provide a neutral space for health care and housing organizations to collaborate in what is otherwise often competitive and fragmented territory. In addition, the work of both consortia coalesces around training and resource development, cross-sector communication, and research and advocacy. We provide examples of the Bronx Consortium's activities in each of these core areas, highlight tangible results to date, and offer recommendations for people interested in undertaking similar efforts.

From April 2016 to June 2017, the Health + Housing Project employed four community health workers who engaged residents of two subsidized housing buildings in New York City to address individuals' broadly defined health needs, including social and economic risk factors. Following the intervention, we observed significant improvements in residents' food security, ability to pay rent, and connection to primary care. No immediate change was seen in acute health care use or more narrowly defined health outcomes. (Am J Public Health. Published online ahead of print March 19, 2020: e1-e4. doi:10.2105/AJPH.2019.305544).

BACKGROUND:Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE:To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN/METHODS:Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS/METHODS:15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES/METHODS:Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS/RESULTS:Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS:Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

As the Internal Revenue Service strengthens the public health focus of community benefit regulations, and many states do the same with their tax codes, hospitals are being asked to look beyond patients in their delivery system to understand and address the needs of geographic areas. With the opportunities this affords come challenges to be addressed. The regulations' focus on population health is not limited to a defined clinical population-and the resulting emphasis on upstream determinants of health and community engagement is unfamiliar territory for many healthcare systems. At the same time, for many community residents and community-based organizations, large medical institutions can feel complicated to engage with or unwelcoming. And for neighborhoods that have experienced chronic underinvestment in upstream determinants of health-such as social services, housing and education-funds made available by hospitals through their community health improvement activities may seem insufficient and unreliable. Despite these regulatory requirements, many hospitals, focused as they are on managing patients in their delivery system, have not yet invested significantly in community health improvement. Moreover, although there are important exceptions, community health improvement projects have often lacked a strong evidence base, and true health system-community collaborations are relatively uncommon. This article describes how a large academic medical center tapped into the expertise of its population health research faculty to partner with local community-based organizations to oversee the community health needs assessment and to design, implement and evaluate a set of geographically based community-engaged health improvement projects. The resulting program offers a paradigm for health system investment in area-wide population health improvement.

BACKGROUND:Tobacco remains the leading cause of preventable death in the United States, with 41,000 deaths attributable to secondhand smoke (SHS) exposure. On July 30, 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. OBJECTIVES/OBJECTIVE:Prior to SFH policy implementation, we measured self-reported and objective SHS incursions in a purposeful sample of 21 high-rise buildings (>15 floors) in New York City (NYC): 10 public housing and 11 private sector buildings where most residents receive federal housing subsidies (herein 'Section 8' buildings). METHODS:) from low-cost particle monitors. SHS was measured for 7-days in non-smoking households (NYCHA n = 157, Section 8 n = 118 households) and in building common areas (n = 91 hallways and stairwells). RESULTS:was observed between and within buildings; on average nicotine concentrations were higher in NYCHA apartments and hallways than in Section 8 buildings (p < 0.05), and NYCHA residents reported seeing smokers in common areas more frequently. CONCLUSIONS:SFH policies may help in successfully reducing SHS exposure in public housing, but widespread pre-policy incursions suggest achieving SFH will be challenging.