Housing quality as a social determinant of developmental & behavioral health

Housing quality (HQ) is a likely determinant of children's physical and socioemotional health. In the United States, structural racism and residential segregation have concentrated poverty and substandard housing in predominantly Black communities, particularly in urban centers such as Washington, DC, where families with low incomes are more likely to experience conditions such as mold, pests, leaks, and peeling paint. While there are several studies showing associations between housing conditions and child health, socioemotional and developmental outcomes, there are no studies to our knowledge examining universal screening for housing quality and associated developmental and behavioral health outcomes in the pediatric primary care setting. The objective of this study is to quantify housing quality through a screening question integrated into routine pediatric primary care in historically marginalized children served by a mobile medical clinic and quantify the association between poor housing quality and adverse behavioral and developmental outcomes.

This retrospective study utilized data from universal screenings at preventive care visits of 800 children ages 0-17 years old (yo) between January 2019 and June 2023 at an urban clinic in Washington, D.C., with families predominantly on Medicaid or uninsured. HQ is derived from the following question: "Have you seen mold, bugs, mice, rats, peeling paint or water leaking where you live?" with "Yes" or "Maybe" classified as positive. Dependent variables include adverse behavioral and developmental outcomes: International Classification of Diseases Tenth Revision (ICD-10) codes for adverse behavioral or developmental diagnoses and for ages 4-17yo the Strengths and Difficulties Questionnaire. Statistics included prevalence (%) and Odds Ratios (OR), unadjusted and adjusted for food insecurity, sex, and age.

The prevalence of reported poor HQ was 41%, adverse developmental outcomes 13%, adverse behavioral outcomes 25%, and either adverse behavioral or developmental diagnoses 37%. After adjustment, poor HQ was significantly associated with adverse behavioral outcomes (aOR = 1.7, p < 0.05), developmental outcomes (aOR = 1.6, p < 0.05), and a combined outcome (aOR = 1.9, p < 0.05). Additionally, 0-3yo with poor housing quality had 3.3-fold higher adjusted odds of adverse developmental outcomes (95% CI: 1.6-7.0).

Poor HQ may be an important and modifiable social determinant of health (SDOH) that can be screened for in pediatric clinical settings. Limitations included self-reported HQ and potential confounders. This study can inform efforts to include housing quality in pediatric screening tools, health system innovations, and cross-sector interventions and policy.