Landlord Behavior After Receiving Pediatrician-Generated Letters to Address Poor Housing Conditions

This cohort study examines whether providing a pediatrician-generated letter regarding patients’ poor housing conditions can encourage landlords to improve those conditions.


Introduction
Indoor environmental exposures are detrimental to health outcomes and contribute to childhood morbidity; however, addressing these exposures remains a challenge in pediatric care. 1,2 To mitigate morbidity associated with poor housing conditions, interventions using community health workers, 3 mobility experiments relocating families, 4 and medical-legal partnerships have proven successful. 5 However, these interventions are often constrained by availability of funding, resources, and time. 1 Using physician-generated letters is 1 strategy applied in medical-legal partnerships that does not require additional funding or resources. 6 In this study, we examined the association between physician-generated housing letters and improvement of poor housing conditions.

Methods
In this cohort study conducted from April through December 2019, an electronic health recordbased social determinants of health screening tool and referral model was implemented in 3 urban hospital-based pediatric primary care sites (Pediatrics at 57th Street, Pediatrics at 7th Avenue, and  All patients at the pediatric primary care clinics who were screened for social determinants of health were eligible to participate in this study. Data on self-reported primary language were collected from the electronic health record rather than data on race and ethnicity because language affected the administration of the initial quality improvement surveys. Caregivers of patients who reported poor housing conditions and received a physician-generated letter between April and October 2019 were surveyed about the landlords' actions 2 to 6 months later. The outcomes of interest were (1) rates of poor housing conditions and (2) resolution of the poor conditions. χ 2 tests were performed, with 2-sided P < .01 deemed to be significant, and mean difference with 95% CIs were calculated. SPSS software, version 27 (IBM Corporation) was used to analyze the data.

Results
Between April and October 2019, 233 of 2480 (9%) families who were screened for social determinants of health needs had poor housing conditions. Of these families, 127 (55%) requested and received a physician-generated letter advocating for housing repairs. Demographic characteristics of participating families are reported in Table 1. reported that the landlord acted to resolve the issue, and 26 (74%) reported complete resolution of the concern. The families who received the housing letter were significantly more likely than families who did not receive housing letters to experience food insecurity (31.5% vs 17.3%; P < .001), child care or developmental concerns (26.8% vs 12.1%; P < .001), and problems with finances or benefits (26.0% vs 9.8%; P < .001) (

Discussion
Integrating the letter template into the electronic health record allows for a quick intervention, providing families with a simple way to attempt to remediate their housing conditions before resorting to more time-intensive solutions, such as moving or legal action. 6 Furthermore, most families who gave letters to their landlords reported that the process led to landlord action and improved housing conditions.
Limitations of this study include selection bias, response bias, and being a single-center study with a small sample size. In addition, this study was not designed to assess whether families who did not receive the letter had resolution of their conditions. Nevertheless, our findings suggest that physician-generated housing letters have the potential to be an effective intervention to address poor housing conditions.