The Boston Public Health Commission, Massachusetts, identified insecure housing as having a major impact on stress, birth outcomes, and maternal health. They worked with the Boston Housing Authority to develop a new policy and program to ensure public housing slots for housing-insecure pregnant women.
Who Took This On
Boston, MA, Public Health Commission, Bureau of Child, Adolescent and Family Health
Ways You Can Get Started
- Meet with local housing authority and/or housing department to discuss shared goals and potential collaborations
- Include housing status and security questions on clinical intake forms
- Connect health care providers to affordable and public housing resources
See Advice for Local Health Departments below for more ways to take action.
What Sparked This?
Boston Public Health Commission forms Center for Health Equity
In 2008, the Boston Public Health Commission (BPHC) founded the Center for Health Equity and Social Justice (CHESJ) to further the Commission’s commitment to improving the health of communities of color. In its early years, CHESJ supported a network of public health organizations in Boston and across New England working toward health equity through community mobilization, participatory research, and program development.
During this time, there was growing national attention to the social determinants of health with the release of the WHO Report on Social Determinants of Health, the documentary Unnatural Causes, the National Racial and Ethnic Approaches to Community Health (REACH) coalition, and the Place Matters Initiative (now known as the Collaboratives for Health Equity). BPHC leveraged this national work and developed a Boston Place Matters team and the Boston REACH Coalition and coordinated numerous facilitated screenings of Unnatural Causes. Like other institutions across the nation involved in these initiatives, BPHC began to shift away from using the terms disparities and inequalities toward using the term inequities to describe the avoidable, unnecessary, unjust, and unfair differences in health outcomes and life opportunities. They also began to more explicitly name racism as a significant root cause of health inequities.
Over time, the Commission’s focus on eliminating health inequities expanded beyond CHESJ’s work. As described in the other BPHC case study, all bureaus and programs now ensure that social and racial justice values and practices are implemented throughout the Commission’s culture. Although CHESJ no longer exists as a separate entity, its work has largely been merged into the Commission’s Office of Health Equity.
BPHC establishes health equity goals
BPHC established 3 health equity goals in 2012 to reduce the gap in health outcomes between Boston residents of color and White residents. By 2016, BPHC sought to:
- Reduce low birthweight births among Boston infants and reduce the gap between White and Black low birthweight births by 25%
- Reduce chlamydia rates among Boston residents 15–24 years of age, and reduce the gap between White and Black/Latino chlamydia rates for residents 15–24 years of age by 25%
- Reduce obesity/overweight rates among Boston residents and reduce the gap between White and Black/Latino obesity/overweight rates by 20% for adults and 30% for school-aged children
BPHC worked within each bureau, across bureaus, and with other government and community partners to achieve these goals.
Home visitors identify housing insecurity as social determinant of health
Similar to other large cities, Boston has home visiting programs that provide pregnant women and parents of children under 5 years old with health education tools and care coordination to access services. The Healthy Baby/Healthy Child program is comprised of nurses, social workers, and advocates who visit homes to provide health, prenatal, parenting, child assessment, and early childhood education and counseling on nutrition, breastfeeding, family planning, and injury prevention. BPHC home visitors found that many of their clients were overwhelmed by the cost of housing and the struggle to retain housing in the face of rising rents and eviction rates.
Leverage existing partnership with Housing Authority
For years, BPHC and Boston Housing Authority (BHA) leadership met to discuss issues of homelessness and developed collaborative programs to address housing and health. At one meeting, BPHC leadership brought up the particular challenge of finding housing for housing-insecure pregnant women. BHA acknowledged the need and agreed to make 75 units of housing available if BPHC could design a program.
In 2011, BPHC and BHA signed a memorandum of agreement to launch the Healthy Start in Housing Program (HSiH), which prioritizes access to public housing for homeless and housing-insecure pregnant women who have medical risks associated with poor birth outcomes. Initially designed as a pilot program, HSiH tested the feasibility and effectiveness of a model combining intensive BPHC case management with timely provision of public housing to eligible women.
BPHC staff training and capacity building
A subset of the Healthy Baby/Healthy Child home visitors received training on the BHA application process and enhanced case management techniques. They also received training on common issues confronting homeless families, the factors most implicated in the eviction of young families from public housing, and how to increase client capacity to buffer the impact of negative life stressors. Staff also received certification in problem-solving education, an evidence-based model of cognitive behavioral therapy. This model is used as a framework for client case management to address both the stressors and opportunities of parenthood and tenancy.
Intensive training in trauma-informed care has been critical for staff working with women in HSiH. Program coordinators note that the experiences of housing insecurity and homelessness leave a mark on female clients and that it is critical for staff to recognize the stress experienced by the women they serve and to use a nonjudgmental approach to help them work through it.
BPHC also adjusted home visitor caseloads from 30 clients to 25 clients so they would have more time to address the complex health and psychosocial needs of their clients, the complex BHA application process, and the follow up needed to support program success. Because enrollment in case management was required of HSiH participants, changes in staff work hours were negotiated to include one evening a week and time on Saturdays, ensuring that clients would not have to give up work or school time to reap the benefits of the program. In total, BPHC allocated .7 FTE administrative staff time and 4.5 FTE of home visitor time to the program.
Clear eligibility requirements established
Potential HSiH applicants are required to attend a pre-enrollment meeting to understand eligibility and program requirements. To be eligible, pregnant women and mothers need to have been Boston residents for at least 3 years, not have a disqualifying criminal history, have a housing need, and meet at least 1 of the following 3 criteria:
- The mother has a chronic health condition
- The mother has had a previous poor birth outcome like preterm birth or low birthweight birth
- The family includes a child under age 5 with a complex condition requiring specialty care
Housing need was defined as being homeless or having insecure housing (e.g., doubling up with others, living in a short-term residence, or paying more than 50% of income on rent).
If women believe they are eligible, they attend 1 of 8 annual “application clinics” to complete the BHA housing application and sign an agreement with BPHC confirming their awareness of and intent to comply with program requirements, including ongoing case management for at least 1 year following placement in BHA housing.
Agency roles defined
As described above, BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Case management includes a 6-session course of problem-solving education and the development and implementation of a longer-term family plan that includes goals related to education, economic self-sufficiency, and promotion of maternal and child health.
The Boston Housing Authority expedites the processing of Healthy Start in Housing applications, and BHA managers at public housing sites work with BPHC case managers to resolve client problems. The 2 agencies also work together to mark client successes — for example, celebrating client achievement of stable tenancy, progress on school or employment plans, and moving on from client status to regular BHA tenancy.
BPHC staff worked with researchers from the Boston University Schools of Public Health and Medicine to evaluate the pilot project. The evaluators assessed program reach and impact related to changes in behavioral risks, problem-solving skills, and parenting practices to promote healthy child development. The evaluation found that of the initial 130 women referred to HSiH in the program’s first 6 months, 53 were ineligible, 59 submitted applications, 13 were preparing applications, 5 dropped out, and 19 received housing. Among eligible women, 58% had medical conditions, 56% had mental health conditions, 14% had prior adverse outcomes, 30% had multiple risks, and 41% had symptoms consistent with post-traumatic stress disorder. More details on the population at baseline and early evaluation outcomes can be found in the Maternal and Child Health Journal article about the program. Follow-up evaluation continues to show significant improvements in mothers’ mental health and social functioning, which are critical factors in child health and development.
Outcomes and Impacts
75 housing slots dedicated to housing insecure pregnant women
Seventy-five slots are now dedicated to housing-insecure pregnant woman, who are provided with housing as well as intensive case management aimed at housing retention and participant engagement in services and interventions that contribute to achievement of identified goals. As the women become more self-sufficient and acquire new skills and maturity as tenants, they graduate from the case management program and become permanent or regular BHA tenants, and their spot in HSiH opens for another pregnant woman.
Participants experience improved mental health, reduced stress
Evaluations of the Healthy Start in Housing Program found that program participants experienced reduced stress and depression and improved mental health outcomes.
Housing security enables action on other social determinants
Housing becomes a foundation in the participants’ lives. Once instability is addressed, the women are able to successfully take on other problems such as finding employment, going back to school, addressing chronic health problems, and other goals.
Ongoing interdepartmental collaboration
Evaluations also found that mutually shared goals between BPHC and BHA, previous interagency collaboration, and the need for interdependence contributed to the successful development of the Healthy Start in Housing collaboration.
While BPHC continues to work on quality improvement in HSiH — focusing on continuing to speed up the application and enrollment process and on the effectiveness of case management — they are also looking for new opportunities to build BHA-BPHC collaboration around the health of young families. A major new initiative will be the allocation of 5 HSiH slots to housing for fathers whose ability to serve as primary caregivers for their children is compromised by housing insecurity.
Advice for Local Health Departments
Use life course theory to emphasize investment in the future
It’s important to know the arguments in favor of prioritizing pregnant women for public housing, particularly when it is a scarce resource. Life course theory and the underlying research about early life exposures helped BPHC demonstrate that reducing stress during pregnancy can improve long-term health outcomes for 2 generations, showing that housing for mothers is a worthwhile investment.
Provide support in addition to housing
BHA was interested in this program because they had experienced challenges retaining families with young children. BPHC case managers provided problem-solving education to clients, and this approach helped women stay in housing by teaching them to confront problems effectively and directly.
Make support easily accessible
BPHC conducted application clinics to help women fill out the necessary forms for public housing. Multiple trained staff attended each clinic, bringing laptops and portable printers with them to make it easier for clients to complete the extensive paperwork. They negotiated with the local nurses’ union to make sure case managers could be available nights and weekends for women who worked, and gave clients staff phone numbers so they could call their case managers when problems arose.