Pilot Study of Bronx-Lebanon Pediatrics Screening Program for Social Determinants of Health (SDOH)

Pilot Study of Bronx-Lebanon Pediatrics Screening Program for Social Determinants of Health (SDOH):

Focus on Asthma, Housing Conditions, and Food Insecurity

Abstract

Objectives: The present study is a pilot study for a Bronx-Lebanon (BronxCare) Health System pediatrics screening program for social determinants of health (SDOH). The screening questionnaire targets multiple social determinants, with a focus on asthma and asthma-related risk factors such as poor housing conditions. In addition, the questionnaire examined housing insecurity, food insecurity, financial strain, and the need for child care services, among other parameters. The long-term goal of the screening program and questionnaire is to identify, using a technology-based platform, specific needs of parents of pediatrics patients, then provide parents with targeted resources that can help them and their children.

Methods: The screening questionnaire was designed by adapting existing, validated assessment tools found in the literature. Team meetings with community health workers and pediatricians identified the critical needs of our BronxCare Primary Service Area (PSA) population. Screening questions focused on these needs. The survey was piloted in the pediatrics clinic waiting room; completed questionnaires from 28 respondents were analyzed in this study.

Results: More than half (53.8%) of respondents had at least four people living in their homes, with most respondents (76%) bringing their own children into the clinic, but some respondents (20%) bringing their grandchildren into the clinic. 18.5% of respondents screened positive for housing insecurity, but a larger percentage (30.8%) said they need help moving into a new home. 42.9% of respondents screened positive for at least one poor housing condition. 35.3% had someone in their home with asthma. 60.7% of respondents screened positive for financial strain, and 67.9% requested child care assistance. 75% of parents screened positive for food insecurity.

Conclusions: Asthma, and its related risk factors, is a major problem for households in which Bronx-Lebanon pediatrics patients live. The progression and severity of pediatric asthma may be decreased with an improvement in housing conditions. Housing insecurity is not a major problem, although it may be under-represented in the survey. Food insecurity is a startling problem, according to this study population. Future studies must be undertaken to confirm this percentage, but technology-based interventions to connect patients to food pantries can be considered as part of the screening program.

Introduction

 The Bronx-Lebanon Hospital Center in the southwest Bronx, renamed the BronxCare Health System, services a socioeconomically disadvantaged area that is among the poorest in the nation. The primary service area (PSA) for the hospital includes south and central regions of the Bronx, including Highbridge-Morrisania, Hunts Point-Mott Haven, and Crotona-Tremont (Figure 1).^[1] Demographically, most of the PSA population is comprised of ethnic/racial minorities. One out of three Bronx residents is foreign born, with 55% form Latin America.^[2] Puerto Ricans comprise the largest ethnic/nationality group in the PSA; 67% of the population is Hispanic, versus 29% for NYC.^[3] The PSA contains 13 geographic areas designated by the Health Resources and Service Administration (HRSA) as Health Professional Shortage (HPSA) or Medically Underserved Areas (MUA) for primary care.^[4] This is particularly relevant when considering the complex needs of Bronx city youth, who require extensive pediatrics primary care services, as well as health education and mental health services. Furthermore, BronxCare is designated as a “safety-net” provider, providing services to a large number of Bronx residents who are covered by public insurance programs, such as Medicaid. In 2014, 62% of acute care discharges from the main hospital center (excluding newborns) were Medicaid patients, compared to 36% from other NYC hospitals.^[5] Considering the underserved population in the service area of BronxCare, some grim statistics have been published, especially pertaining to children. For instance, 43% of children are living in poverty; and 63% of children live in single-parent households. In addition, 29% of the population is in “poor” or “fair” health, with the Bronx ranking lowest or near-bottom for overall mortality and morbidity, socioeconomics, and the physical (built) environment.^[6] In fact, the neighborhoods comprising the BronxCare PSA are among the most economically stressed neighborhoods in NYC, with 42% of adults in the PSA living in poverty, compared to 21% in NYC. To make matters worse, 61% of adults experience rent burden, with Highbridge-Concourse and Morrisania-Crotona ranking 4th and 5th most burdened in NYC.^[7]

In terms of quality of life and preventive care, 58 of 100,000 hospital stays were considered preventable, compared to 38 for New York State.^[8] According to the NYC Department of Health and Mental Hygiene, and averaging statistics from four neighborhoods in the BroxCare PSA, 24% of adults have no health insurance ‒ similar to the NYC average of 20%. Two neighborhoods (Hunts Point and Mott Haven) rank first in NYC for the percent of adults who went without needed medical care (17%).^[9] Morrisania ranks fifth in NYC in percent of adults who currently smoke (20%)^[10], with the PSA average standing at 19%.^[11] With regard to air quality, measured as micrograms of fine particulate matter per cubic meter, the BronxCare PSA is among the most polluted in NYC, averaging 9.8 µg/m^3, higher than the NYC average of 8.6.^[12] Perhaps not surprisingly, the BronxCare PSA also ranks among the poorest in NYC for housing quality, with Mott Haven and Hunts Point ranking second highest for the percent of renter-occupied homes experiencing at least one maintenance defect (79%).^[13] Maintenance defects include water leaks, cracks and holes, presence of mice or rats, toilet breakdowns, and peeling paint.

Childhood asthma is a serious public health issue that has been associated with characteristics of the home environment, like the housing quality defects mentioned previously.^[14] Multiple biologic agents have been implicated as environmental factors in the morbidity of asthma ‒ these include allergens from cockroaches, rodents, dust mites, and fungi, as well as other respiratory irritants.^[15] Perhaps related to poor air quality and housing conditions are the startling child asthma statistics in the Bronx, with Mott Haven leading NYC at 112 asthma hospitalizations per 10,000 children ages 5-14, compared to 36 for NYC. Other neighborhoods in the PSA have concerning statistics as well, standing at 88 and 89 hospitalizations per 10,000 for Hunts Point and Morrisania, respectively.^[16] Adult asthma hospitalizations are also disproportionately high in the BronxCare PSA, with Morrisania ranking second in NYC at 769 hospitalizations per 100,000 adults, and Mott Haven ranking 3rd, at 749. This compares to a Bronx average of 508 and a NYC average of 249 per 100,000 adults.^[17]

One cross-sectional, multi-state study of 1,772 children ages 5-11 with persistent asthma examined parental responses to the Child Asthma Risk Assessment Tool. Results for 265 Bronx children were compared to those of 1,507 children from seven other US inner-city areas.^[18] Investigators found that Bronx children were significantly more likely to be sensitized to reported aeroallergens in their homes than children from other inner cities. Moreover, Bronx parents more frequently reported household cockroaches, mice, and rats; in addition, they more frequently reported using a gas stove, and having visible mold in the home.^[19] In terms of attitude, and perhaps related to poor housing conditions, Bronx parents were also more likely to report pessimistic beliefs about controlling their children’s asthma.^[20]

In another study on the role of housing quality in urban children with asthma, investigators found, after adjusting for individual and community-level demographic and economic factors, that residents of public housing had the highest odds of current asthma, compared to residents of private housing.^[21] The clustering of asthma in public housing could be explained by poor housing conditions, in which 68.7% of public housing residents reported the presence of cockroaches, compared to 21% of private houses. Reported cockroaches, rats, and water leaks associated independently with current asthma.^[22]

Another study, recognizing the well documented contribution of indoor allergens to asthma, attempted to link socioeconomic disadvantage to indoor allergen levels. Investigators determined whether the distribution of allergens in NYC exists as a function of housing deterioration, measured by the presence and number of physical housing problems.^[23] Results demonstrated that household allergen levels, which would exacerbate asthma in young children, are related to the degree of household disrepair, after adjusting for individual family attributes.^[24] Extending the critical nature of considering such allergen levels, one study found that 36.8% of inner city children were allergic to cockroach allergen, 34.9% to dust-mite allergen, and 22.7% to cat allergen.^[25] Children who were both allergic to cockroach allergen and exposed to it had 0.37 asthma hospitalizations a year, compared to 0.11 for other children. Moreover, they had significantly more days of wheezing, missed school days, and nights with lost sleep.^[26]

Most studies recognize that there are limits to income as a measure of socioeconomic status and have instead used “material hardship” as an umbrella term for poverty-related conditions that can lead to known asthma triggers. One such study found that measures related to housing quality were strongly and independently associated with asthma diagnosis and ED visits, whereas measures indirectly related to housing quality, such as crowding, were not independently associated with asthma diagnosis and control.^[27] Households with poor housing quality had 50% higher odds of an asthma-related ED visit in the past year. Moreover, although the study found that non-Hispanic Black heads of household had higher odds of having a child diagnosed with asthma in the home than a non-Hispanic White head of household, investigators found that this apparent racial/ethnic disparity is reduced after controlling for financial and social hardships such as housing insecurity and poor housing conditions (cracks in walls and broken plumbing).^[28]

One recent study examined secondhand smoke (SHS) exposures and asthma outcomes among African-American and Latino children with asthma. Investigators assessed dose-response relationships between plasma cotinine-determined SHS exposure (a biomarker of SHS exposure) and asthma outcomes in minority children. Investigators found, upon analysis of dose-response relationships, that increasing odds of asthma outcomes correlated with increasing exposure to SHS, even at “light” levels of SHS.^[29]

Provided that asthma disparities are complex and multifaceted, clinical strategies to address these disparities, particularly hospital-wide interventions, must be just as complex and wide-reaching in their approach. At the provider level, clinical strategies that address asthma control, as well as interventions designed to improve provider-patient communication and barriers to care, are promising strategies for addressing the disparity of housing conditions and prevalence of asthma.^[30]

In addition to asthma and its associated poor housing conditions, food insecurity is another major problem that plagues the Bronx. Food insecure households are defined by the U.S. Department of Agriculture (USDA) as households in which “access to adequate food is limited by a lack of money or other resources.” ^[31] According to a study conducted by Hunger Free America, nearly half of all NYC and NYS residents who can’t afford enough food live in employed households.^[32] 31.46% of Bronx residents lived in food insecure households in 2013-2015. Upon stratification of the study population, investigators found that, in the same time period, 37% of children lived in food insecure homes.^[33] Furthermore, the organization Public Health Solutions reports that, as of June 2018, more than 375,000 people in the Bronx experience food insecurity, a figure that represents 26% of the city’s food insecure population.^[34] One study of food insecurity and obesity in NYC primary care clinics found that 55% of patients were receiving some form of food assistance, with more than half (57.1%) reporting some degree of food insecurity.^[35] According to the NYC Food Policy Center at Hunter College, 51% of South Bronx households receive Supplemental Nutrition Assistance Program (SNAP) benefits, commonly known as food stamps.^[36] This is 30% greater than the citywide level. The use of SNAP benefits is an indicator of food insecurity, because most households that receive SNAP are food insecure.^[37] According to the American Association of Pediatrics (AAP), food insecurity can negatively affect behavior and development of children, as well as lifelong health outcomes.^[38] Children living in food-insecure households are more likely to have worse overall health and more frequent hospitalizations prior to the age of three.^[39]

The present study is a pilot for a community health outreach project that aims to screen BronxCare patients, specifically the parents of children seen at our pediatrics clinic, for certain risk factors in the realm of the social determinants of health (SDOH). The screening program will identify pediatrics patients, both children and adolescents, who may be at risk of worsening health conditions, including asthma. We will be designing a technology-based and resource-intensive form of our questionnaire that will be implemented as “resource table” in Bronx-Lebanon patient waiting areas. Ultimately, this will serve as part of the hospital’s standard of care, improving outcomes for pediatrics patients and their families.

Methods

Social determinants of health (SDOH) have been thoroughly established as powerful etiological agents of an array of health outcomes. SDOH include housing security, quality of housing, food security, income, access to healthy food, health coverage, transportation, and many other variables.^[40] When designing our screening survey for SDOH, our most important consideration was the validity of each screening question. In addition, we selected only the screening parameters that were relevant and ‘comfortable’ to our population of interest ‒ the BronxCare PSA population. We participated in multiple team meetings to discuss the design of the screening survey; these meetings included community health workers, residents on their community health rotations, and physicians. With their advice and expertise, we selected screening parameters that are important to our study population, such as food and housing insecurity, housing conditions, financial support, and the need for childcare services. Our questions were pediatrics-focused; any sensitive or stigmatized topics, such as domestic violence, STDs, and substance abuse, were left as check-boxes in a generic question asking the individual what they would like more information about (Appendix A).

Upon recognition of the complex needs of our service population, our questionnaire was designed using pre-existing, validated screening tools. In fact, adapting existing assessment tools for SDOH has been established as an effective means of implementing a screening program for social determinants.^[41] Many successful screening programs, such as the one at the Redwood Community Health Coalition, have established a standard set of questions but allowed other centers to adapt the questionnaire with optional questions examining additional metrics.^[42] Our screening survey includes questions from “The Accountable Health Communities Health-Related Social Needs Screening Tool” by the Center for Medicare and Medicaid Services, the Health Leads “Social Needs Screening Toolkit,” and the “PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences.” These screening tools have all been validated in studies, and thus guarantee that our results can be accurate. To screen for food insecurity, we used a two-question screening tool from the AAP, known as The Hunger Vital Sign (Appendix A).This tool has been shown to have a 97% sensitivity and an 83% specificity for food insecurity, when compared to an 18-item Household Food Security Scale used by the USDA.^[43]

One final, but critical, consideration was the literacy level of a significant percentage of our BronxCare PSA population. We were instructed by our team members to avoid complex language and wordy terminology ‒ to keep our use of language at a third-grade reading level. This is especially important when considering health literacy ‒ patients with low health literacy are less likely to comply with medications and other prescribed treatments from their physician.^[44] While we do not have control over patient-physician interaction in the clinic, we can ensure that the preliminary screening of a patient for SDOH requires a very low health literacy and reading literacy score so as not to alienate any portion of our target population from our study.

The screening survey was piloted in the waiting room of the pediatrics clinic at the BronxCare main hospital building at Concourse, between the hours of 10AM and 12PM and 1PM and 3PM. Teams of three went into the patient waiting rooms and asked parents of patients to fill out the questionnaire. No volunteer was scripted, but every volunteer had to address a few main talking points, including asking the parent for feedback on the screening program. Parent responses to the survey (n = 28) were recorded, then analyzed in an excel workbook.

We recognize that the scope and external validity of our screening survey is limited because we did not ask for demographic information such as race and ethnicity. However, this was done intentionally, as advised by our team, because this phase of our project is a pilot study in anticipation of a more comprehensive screening program. We did not want to alienate any patients by asking for their demographic in this early phase of the project.

Results

 Of the 28 respondents who took our screening survey questionnaire, 27 provided their zip-codes; of those 27, 21 were residents of the Bronx (77.8%), their zip-codes aligning with the BronxCare PSA and its surrounding neighborhoods. Furthermore, 96.4% (27/28) of respondents had children of their own, but all respondents had children with them. Of the 27 respondents with children, 22.2% (6/27) have one child, 44.4% (12/27) have two children, 18.5% (5/27) have three children, 7.4% (2/27) have four children, and 7.4% (2/27) have five or more children. The average age of the children was 5.25 years. Children were brought into the pediatrics clinic by their mother or father most of the time (76%), but not always. In some cases (20%), the child was brought into the clinic by his/her grandmother or grandfather. Out of 25 respondents to the question, an aunt or uncle was encountered only once, and no foster parent was encountered. Out of 26 respondents, 26.9% (7/26) said that five or more people, including themselves, live in their home (Figure 2). 26.9% also said that four people live in their home, while the majority (34.6%, 9/26) said that two people live in their home. Based on these results, 53.8% of respondents have at least four people living in their home.

In terms of housing security, most respondents (81.5%, 22/27) were secure in their housing, while 18.5% (5/27) screened positive for housing insecurity. The latter set of respondents would require follow-up and support (Figure 3A). Out of 26 respondents, however, a larger percentage (30.8%, 8/26) said they need help moving into a new home (Figure 3B). Interestingly, of these 8 respondents, only two of the eight (2/8, 25%) also screened positive for housing insecurity. This sheds light on other motivations for wanting to change housing, such as poor housing quality and living conditions. In fact, nearly half of the respondents indicated that they have problems with at least one poor housing condition ‒ most of which are risk factors for asthma (Figure 4). Of the poor housing conditions listed in our survey, the most frequent complaint was water leaks (8/12), followed by pests (7/12), mold (6/12), and lead pipes (4/12). While 12 respondents screened positive for at least one poor housing condition, 8/12 had at least two poor housing conditions, and 6/12 had at least four poor housing conditions. Moreover, 17 parents were asked directly in a modified survey whether they, or anyone who lives in their home, have asthma. Six of these parents (6/17, 35.3%) answered yes to that question. Half of them (3/6) have problems with mold in their homes; two of those three (2/3) also had water leaks and lead paint; one of the three (1/3) also had pests. Interestingly, all four individuals who wanted more information on quitting smoking also had asthma, and 75% of them (3/4) also had children with asthma.

Looking at other parameters of SDOH, 60.7% (17/28) of parents screened positive for financial strain by marking down at least one item they need help paying for (Figure 5A). The most frequent selections for financial assistance were transportation (8/17), phone (6/17), and clothing (6/17). 67.9% (19/28) of parents also requested child care assistance (Figure 5B).

Regarding food insecurity, 57.1% (16/28) of parents tested positive in response to the first question (Figure 6A), whereas 64.3% (18/28) tested positive in response to the second question (Figure 6B). However, AAP’s screening tool requires that only one of the two questions be answered “yes” for an individual to screen positive for food insecurity – such that 75% of respondents were identified as having children in food insecure households. In other words, in 75% of cases, respondents had limited access to adequate food due to a lack of money or other resources.

Discussion

Considering that 77.8% of our respondents had zip-codes of residence aligning with the BronxCare PSA and its surrounding neighborhoods, we can rest assured that our method of data collection in pediatrics patient waiting rooms is effectively targeting our population of interest – at least on a geographic level. Although we could not make any assumptions about the marital status of our respondents, knowing that 63% of children in the Bronx live in single-parent households^[45] and observing that 33.3% (9/27) of respondents had three or more children is an alarming statistic. It is possible that many of the parents who responded to our survey are single-handedly raising three or more children. Thus, they may experience many of the social determinants that we are screening for, such as financial stress, need for child care services, food and housing insecurity, and poor housing conditions. In fact, we did find that this was true, with 60.7% of parents screening positive for financial strain, and 67.9% requesting child care assistance. It is concerning that the most frequent need was “transportation.” Lack of money to afford transportation is a barrier to health care, because parents may not be able to make it to medical appointments. It was interesting to learn that, in 20% of cases, children were brought into the pediatrics clinic by their grandparents. This is relevant for our consideration of how to address the individual who brought the child into the clinic (i.e. asking, “do you have a child with you today?” rather than “do you have your child here today?).

We were able to obtain a sense of the crowding of the home in which the children live. Finding that 53.8% of respondents have at least four people living in their home may be concerning for exacerbation of asthma (more crowding, potentially exacerbated asthma.) However, studies have shown that crowding is not independently associated with asthma.^[46]

Our study found that only 18.5% of patients screened positive for housing insecurity. In other words, only 5/27 respondents worried that they would lose their housing. This is concerning, but not startling. According to a March 2017 study by the Regional Plan Association, however, households in 71% of the Bronx borough census tracts are in danger of an impending displacement.^[47] With this figure, Bronx residents lead NYC with being at the greatest risk of displacement. Thus, we speculate that a far greater percentage (>18.5%) of respondents are at risk of displacement but are unaware of this reality. This could potentially shed light on the need to educate these parents on the geo-political reality of their residence.

Because 42.9% of parents screened positive for at least one poor housing condition, and 21.4% of parents had at least four poor housing conditions, we became concerned that this could exacerbate their asthma, which 35.3% of respondents identified as a problem someone in their home has. Studies have shown that 15.5% of 4-5-year-old Bronx children have asthma, compared with 9.2% for NYC.^[48] Studies have also shown that these poor housing conditions, including pests, mold, and water leaks, are associated independently with current asthma.^[49]

Regarding food insecurity, our finding that 75% of parents screened positive for food insecurity is a shocking statistic. This finding is at odds with findings from other studies, which found that 31% of Bronx residents, and 37% of Bronx children, live in food insecure households.[50] Even if we consider every household receiving SNAP benefits to be food-insecure, this figure would stand at 51% of residents in the South Bronx[51], still significantly lower than our result. Considering that the AAP screening tool, The Hunger Vital Sign, has a 97% sensitivity and 83% specificity[52] we can calculate its positive predictive value (PPV) to be 85%. This means that, of 21 respondents who screened positive for food insecurity, the lower limit of the percentage of those respondents who are actually food insecure is 85% of 21, which is 18. Thus, even at the lower limit of the screening tool’s validity, 64.3% (18/28) of respondents screen positive for food insecurity. This statistic needs to be validated with a larger sample size. It is possible that patients who visit Bronx-Lebanon are more food insecure than the South Bronx population as a whole. Clearly, however, food insecurity is a serious problem in the South Bronx. Our goal is to cast our validated screening survey onto a digital platform, then link it directly to a food pantry application known as Plentiful, as well as to other NYC resources and screening tools.

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^[1] Bronx-Lebanon Hospital Center. (2016). Bronx-Lebanon Hospital Center 2016 Community Service Plan [PDF]. New York.

^[2] Claritas Inc. (2016). Demographics of the South Bronx. Retrieved July 11, 2018, from Claritas Inc.

^[3] Bronx-Lebanon Hospital Center 2016 Community Service Plan [PDF].

^[4] “HRSA Data Warehouse,” HRSA. (2018). U.S. Department of Health and Human Services, accessed July 24^th, 2018, https://datawarehouse.hrsa.gov/.

^[5] Bronx-Lebanon Hospital Center. (2014). Bronx-Lebanon Hospital Center 2014 Institutional Cost Reports (ICRs).

^[6] Robert Wood Johnson Foundation. (2016). Robert Wood Johnson County Health Rankings (Rep.). Princeton, NJ: Robert Wood Johnson Foundation. Retrieved July 24, 2018.

^[7] NYC Department of Health. (2015). New York City Community Health Profiles. Retrieved June 11, 2018, from https://www1.nyc.gov/site/doh/data/data-publications/profiles.page#qn.

^[8] Robert Wood Johnson Foundation. (2016).

^[9] NYC Department of Health. (2015).

^[10] Ibid.

^[11] Robert Wood Johnson Foundation. (2016).

^[12] NYC Department of Health. (2015).

^[13] Ibid.

^[14] Virginia A. Rauh, Philip J. Landrigan, and Luz Claudio, “Housing and Health: Intersection of Poverty and Environmental Exposures,” Annals of the New York Academy of Sciences 1136, no. 1 (2008): , accessed July 24, 2018, doi:10.1196/annals.1425.032.

^[15] Institute of Medicine. Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National Academy Press; 2000.

^[16] Ibid.

^[17] Ibid.

^[18] Karen Warman, Ellen Johnson Silver, and Pam R. Wood, “Modifiable Risk Factors for Asthma Morbidity in Bronx Versus Other Inner-City Children,” Journal of Asthma 46, no. 10 (2009): , accessed July 24, 2018, doi:10.3109/02770900903350481.

^[19] Ibid.

^[20] Ibid.

^[21] Jennifer Northridge et al., “The Role of Housing Type and Housing Quality in Urban Children with Asthma,” Journal of Urban Health 87, no. 2 (2010): , accessed July 24, 2018, doi:10.1007/s11524-009-9404-1.

^[22] Ibid.

^[23] Virginia A. Rauh, Ginger L. Chew, and Robin S. Garfinkel, “Deteriorated Housing Contributes to High Cockroach Allergen Levels in Inner-City Households,” Environmental Health Perspectives 110, no. S2 (2002): , accessed July 24, 2018, doi:10.1289/ehp.02110s2323.

^[24] Ibid.

^[25] David J. Birnkrant, “The Role of Cockroach Allergy and Exposure to Cockroach Allergen in Causing Morbidity Among Inner-City Children With Asthma,” Clinical Pediatrics 36, no. 12 (1997): , accessed July 24, 2018, doi:10.1177/000992289703601213.

^[26] Ibid.

^[27] Helen K. Hughes et al., “Pediatric Asthma Health Disparities: Race, Hardship, Housing, and Asthma in a National Survey,” Academic Pediatrics 17, no. 2 (2017): , accessed July 24, 2018, doi:10.1016/j.acap.2016.11.011.

^[28] Ibid.

^[29] Neophytou AM, Oh SS, White MJ, et al Secondhand smoke exposure and asthma outcomes among African-American and Latino children with asthma Thorax Published Online First: 13 June 2018. doi: 10.1136/thoraxjnl-2017-211383

^[30] G. Canino, El McQuaid, and CS Rand, “Addressing Asthma Health Disparities: A Multilevel Challenge,” Journal of Allergy and Clinical Immunology 123, no. 6 (2009): , accessed July 24, 2018, doi:10.1016/j.jaci.2009.04.012.

^[31] “Definitions of Food Security,” Economic Research Service, United States Department of Agriculture, last modified October 04, 2017, https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security/.

^[32] “New York City and State Hunger Report, 2016,” [PDF], Hunger Free America, accessed July 24, 2018

^[33] Ibid.

^[34] “PHS Awarded OneCity Health Innovation Award to Address Food Insecurity in the Bronx,” Public Health Solutions, last modified June 13, 2018, https://www.healthsolutions.org/blog/addressing-food-insecurity-in-bronx/

^[35] Arati Karnik et al., “Food Insecurity and Obesity in New York City Primary Care Clinics,” Medical Care 49, no. 7 (2011): , accessed July 24, 2018, doi:10.1097/mlr.0b013e31820fb967.

^[36] “A Foodscape of the South Bronx,” New York City Food Policy Center at Hunter College, March, 2017

^[37] Executive Office of the President of the United States. (2015) Long-Term Benefits of the Supplemental Nutrition Assistance Program

^[38] “Identifying food insecurity: Two-question screening tool has 97% sensitivity,” AAP News, AAP

^[39] Ibid.

^[40] Samantha Artiga and Elizabeth Hinton, “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,” Henry J. Kaiser Family Foundation, May 10, 2018, , accessed July 24, 2018.

^[41] Caitlin Thomas-Henkel and Meryl Schulman, “Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations,” Center for Health Care Strategies, October 2017, , accessed July 20, 2018.

^[42] Ibid.

^[43] “Identifying food insecurity: Two-question screening tool has 97% sensitivity,” AAP News, AAP

^[44] US Department of Health and Human Services. (2010, May). National Action Plan to Improve Health Literacy [PDF]. US Department of Health and Human Services.

^[45] Robert Wood Johnson Foundation. (2016).

^[46] Helen K. Hughes et al., “Pediatric Asthma Health Disparities…”

^[47] “Pushed Out: Housing Displacement in an Unaffordable Region,” Regional Plan Association (2017)

^[48] Karen Warman, Ellen Johnson Silver, and Pam R. Wood, “Modifiable Risk Factors…”

^[49] Jennifer Northridge et al., “The Role of Housing Type and Housing Quality in Urban Children with Asthma,”

[50] “New York City and State Hunger Report, 2016,” [PDF], Hunger Free America, accessed July 24, 2018

[51] A Foodscape of the South Bronx,” New York City Food Policy Center at Hunter College, March, 2017

[52] “Identifying food insecurity: Two-question screening tool has 97% sensitivity,” AAP News, AAP