Linking social and built environmental factors to the health of public housing residents: a focus group study

The absence or presence of environmental pollutants, general cleanliness of the community, and civic engagement have been key determinants in perception of a community as healthy or unhealthy [12]. Residents in our study perceived a connection between unsanitary and hazardous home conditions with negative health consequences, especially respiratory health. Their perceptions align with findings from a prior study of building characteristics and indoor allergens that found cockroach and mouse allergens were more likely to be present in public housing units than other types housing [13]. Similarly, another study found that children living in public housing had a significantly increased risk of asthma as compared to those living in private family homes. In this study, self-reported presence of cockroaches and rats were linked with current asthma [14]. We build upon these prior studies among public housing residents by identifying factors perceived to exacerbate these conditions, including housing authority enforcement of lease terms and the behaviors of other residents. Changes in property management practices, such as improving maintenance and pest control or creating leasing agreements that regulate home and neighborhood sanitation, may improve environmental conditions and health.

In addition to the home environment, residents believed that the surrounding neighborhood environment limited their opportunities to make healthy lifestyle choices. Specifically, focus group participants reported that recreation center fees often limited their access and their children’s access to these facilities and that local crime prevented them from using outdoor spaces around their homes. McAlexander and colleagues observed that public housing residents with greater access to physical activity resources had decreased body fat [15]. These researchers hypothesized that residents would be deterred from using sidewalks for exercise or to access physical activity resources if they lived in neighborhoods where the majority of crimes took place on streets or sidewalks. In general, neighborhood safety has been associated with physical and mental health [12], and a prior study found that low-income residents perceived that threats to their safety were coming from others within their local area [16]. Yet, the built environment can aid crime reduction and improved quality of life by selecting certain design strategies. This concept – Crime Prevention through Environmental Design (CPTED) – promotes higher density neighborhoods, surveillance, mixed-use development, and elimination of derelict or vacant buildings to reduce the opportunities for crime to occur [17]. Our results suggest that changes in city policies such as lower recreation center fees and routine police presence in these neighborhoods may increase residents’ engagement in exercise and recreation activities. In addition, though we recognize that substantial fiscal barriers are likely to exist, the city may need to consider employing some CPTED strategies like eliminating the nearby vacant row homes and promoting more businesses to come into the area to create a more mixed-use neighborhood.

Several participants in our focus groups described feeling socially isolated, due in part to lack of trust in interpersonal relationships. This may be an additional factor contributing to poor health, as social isolation has been linked with increased risk of death and chronic disease, including cardiovascular disease [18]. However, our results contrast with prior studies of public housing residents. Keene and Geronimus found that public housing residents were significantly more likely to report a supportive neighborhood environment where neighbors rely on one another and watch out for each other’s children [19]. Another study observed that Atlanta public housing residents had a sense of community attachment that was linked to collective efficacy and social support [20]. Increased social cohesion has been associated with increased perceived safety in a community [21]. A prior study showed that residents of a less cohesive and safe low-income neighborhood had significantly worse self-rated health than residents of other neighborhoods [16]. We suspect that the lack of trust in neighbors, which was commonly reported among our participants, may adversely affect community attachment in public housing neighborhoods. Additional studies are needed to determine whether or not social isolation occurs commonly among public housing residents, and if so, the factors that contribute to its development, as this could be an important target for future interventions.

Several subthemes that we identified highlight how the built and social environments may influence one another. Many residents identified unsanitary conditions within the physical environment as negatively contributing to health; however, these conditions occurred due to the actions of other community members. Social control has been identified as a powerful influence to regulate these behaviors [22]. Many residents did not feel empowered to talk to their neighbors about not littering or keeping a clean house, and therefore, social regulation may not develop. In addition, we noted that residents in different courts display different relationships, which might suggest that how the neighborhood is designed might have an effect on sense of community. For example, a prior study in Atlanta found that communities with more walkable site designs (higher commercial floor space to land area ratio) and urban designs with pedestrian-friendly commercial areas were associated with a greater sense of community [23]. In this study, we are unable to explore possible environmental design features of public housing courts with varying degrees of cohesiveness, as we did not obtain address information from participants due to confidentiality protections. We believe that future studies should consider obtaining this information in order to understand what design factors promote a more socially cohesive housing court.

Finally, the participants in our study believed that increased neighborhood social capital could facilitate improved environmental conditions that translate into increased wellbeing. A framework for implementing a social capital approach to promote health equity has been developed, which provides recommendations for policymakers, local practitioners, and communities [24]. In this framework, social capital is posited to aid communities in developing networks of support and social action, and as a result, gain economic and other resources. Our findings suggest that an effective strategy to improve neighborhood-level health may involve interventions to improve neighborhood environment by fostering social cohesion among community members. Social cohesion depends upon the buy-in and participation of the local community. Prior interventions that successfully promoted cohesion have led to positive impacts on health and lifestyle. One initiative increased exercise rates within a multicultural public housing development through the creation of social walking groups within the community [25]. Other successful interventions have focused on a community’s common values or priorities to address health outcomes. For example, one initiative improved social cohesiveness by uniting low-income community members around activities to promote their children’s wellbeing [26]. Improved social cohesiveness has been observed to be an important factor in environmental improvements, including lower levels of violence at the community level [27] and greater perceived safety in public housing [21]. Having a larger social network has been linked with increased physical activity among adults in public housing [28].

Our study has important strengths. Our sample was predominantly female, which is consistent with population statistics for public housing residents. We recruited participants with a wide age range who had lived in public housing for varying amounts of time to capture the diverse experiences of different populations. We used an iterative and consensus-driven process during coding to increase reliability. We had a diverse team – healthcare providers and a community member – to code text and generate themes and subthemes. Nonetheless, our study has several limitations, among them that all participants were recruited from a single housing development in Baltimore. Residents of other developments in Baltimore, or those in other cities that are managed by different housing authorities, may express different views. Our sample may represent the voices of more activated community members, as they responded to a flyer and were willing to participate in a group discussion. We were unable to explore possible environmental design features of public housing courts with varying degrees of cohesiveness. We limited our conceptualization of social environment to neighborhood social structure and interpersonal relationships, and did not focus on cultural factors. Despite these limitations, we believe this qualitative study provides deeper insights into residents’ perceptions of environmental factors that influence their health.