The Correlation Between Skin Health and Housing Disparities

Americans spend more money on health than any other country in the world, yet the life expectancy of the American population is shorter than in other countries that spend far less.¹ "Despite our earliest efforts, preventable illnesses in infants, children and adolescents result from the environment around them. Housing is inseparable from health," said George Hightower, MD, PhD, assistant clinical professor at the University of California San Diego, pediatric dermatologist at Rady Children's Hospital.

George Hightower, MD, PhD

Hightower did a deep dive into the correlation between skin health and housing disparities during the session "Housing, Health, and Pediatric Dermatology" at the 2023 Society for Pediatric Dermatology Meeting in Asheville, North Carolina, July 13-16.²

Health disparities result from multiple factors including poverty, environmental threats, inadequate access to health care, individual and behavioral factors, and educational inequities.³ There are 4 conversations Hightower believes need to be more common among those providing dermatologic care.

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Conversation #1: Race, Health, and Housing Discrimination

The Civil Rights Act of 1968, known as the Fair Housing Act through its titles VII and IX, was designed to address fundamental problems related to housing not solved previously by constitutional amendment (13th, 14th, and 15th) and the Civil Rights Act of 1866.⁴

A child’s well being requires secure, safe, and affordable housing. Housing discrimination harms children and has lifelong health effects. Adverse early life experiences such as racism, stigma, housing instability, and exposure to health hazards contribute to mistrust of health care providers, incongruous use of health services, and high risk behaviors.⁵

There are plenty of opportunities and challenges to address in fair housing. Materials for professionals are written by fair housing legal experts, which make them difficult to understand. Those new in health professions oftentimes do not have an extensive knowledge in fair housing policies. Hightower also cited that the connections between fair housing and clinical practice may appear to be tenuous and inconsequential to physicians and health care providers.

"There are several problems that can result from diminished access to affordable housing that affect dermatology professionals," Hightower said. "Those living in underserved neighborhoods have increased exposure to environmental toxins, tend to miss appointments, fail to schedule visits, depend on the emergency department for care, do not follow regimen adherence, diminish patient self-esteem, and increase physician-patient-family conflict.

Conversation #2: Moving Beyond Despair

Hightower participated in a study overseeing the impact of performing art in a underserved communities, which proved how important it is to explore how individual personal identities and shared experiences can make visible what it means to live in a marginalized neighborhood. Clinicians have an opportunity to learn about the identities and shared experiences of their patients by enhancing patient-provider communication.

Structural humility is key to enhancing the communication before it starts. Having structural humility is the willingness to explore how the practice of medicine may limit one’s understanding of a condition because it fails to account for gender, neighborhood, social exclusion/inclusion, or other aspects of a patient’s life shaped by social determinants of health. The use of shared experiences to better understand health, disease, and resilience can provide hope in marginalized communities.

Conversation #3: Participatory Action and Problem Solving

Participatory Action Research is a framework for creating knowledge rooted in the belief that those most impacted by research should take the lead in framing the study from questions to methods, and determining which products/actions may be most useful in upcoming change. A few questions to ask ahead of solving for a solution include:

• Who should be part of the research collective?
• Does research necessitate same-only focus groups or research teams?
• How do different collective members and allies to the research use the data in distinct ways?
• How does the project connect to ongoing social justice?
• Whom does the research want to reach, education, provoke to act?

Conversation #4: Bridging Divides

The final conversation to address housing disparity's impact on skin health means advocating and taking action with tangible research conducted. One example of this Hightower presented was about a rising student at Harvard named Daniela. Daniela is a Harvard studient and has lived with hidradenitis suppurativa (HS) for 8 years. In high school, she began the work of talking to the public about what HS is. Then, she advocated a need for clinicians to help their patients better plan for futures where their chronic illness does not derail future aspirations. With this in mind, Hightower and colleagues performed an IRB-approved retrospective chart review of Rady Children's Hospital San Diego patients 15 to 19 (n = 591) diagnosed with HS, with a spotlight on neighborhoods patients come from. Data was organized by census-tracks.

The results of that review showed a high prevalence of HS among patients identified as Latino/Hispanic in specific San Diego nighborhoods. Investigators found discriminatory housing practices are a potential explanation for the neighborhood variation. Future studies with the same data could examine early life exposures and environmental triggers associated with structural inequalities. Hightower noted that while the study demonstrated important association, it provides no evidence of causation.⁶

References

1. Roser M. Why is life expectancy in the US lower than in other rich countries? Our World in Data. June 21, 2023. Accessed July 15, 2023. https://ourworldindata.org/us-life-expectancy-low.

2. Hightower G. Housing, health, and pediatric dermatology. Session presented at the 2023 Society for Pediatric Dermatology Meeting; July 13-16, 2023; Asheville, NC.

3. Health disparities. Centers for Disease Control and Prevention. May 26, 2023. Accessed July 15, 2023. https://www.cdc.gov/healthyyouth/disparities/index.htm.

4. History of fair housing - HUD. U.S. Department of Housing and Urban Development (HUD). Accessed July 16, 2023. https://www.hud.gov/program_offices/fair_housing_equal_opp/aboutfheo/history.

5. Weinstein JN, Geller A, Negussie Y, Baciu A. Communities in Action: Pathways to Health Equity. The National Academies Press; 2017.

6. Vuong CL, Park HH, Zhang S, et al. Neighborhood-based analysis of adolescent hidradenitis suppurativa prevalence in a large metropolitan area. JAAD Int. 2022 Aug 30;9:80-81. doi: 10.1016/j.jdin.2022.08.015. PMID: 36248206; PMCID: PMC9557723