Association of Promoting Housing Affordability and Stability With Improved Health Outcomes: A Systematic Review

The hidden crisis: Long COVID's association with housing stability and home accessibility among people with disabilities

BACKGROUND

The COVID-19 pandemic has given rise to the emerging phenomenon known as Long COVID, characterized by persistent symptoms long after the acute infection has passed. However, the relationship of Long COVID on housing stability and home accessibility remains underexplored.

OBJECTIVE

This manuscript aims to comprehensively examine the association of Long COVID on housing stability and accessibility, identifying challenges faced by people with Long COVID and potential strategies to address them.

METHODS

The study employs a cross-sectional mixed-methods approach, combining quantitative and qualitative methods. It analyzes data from 1533 people with disabilities, 514 with Long COVID and 1019 without Long COVID, to compare demographics, housing stability, financial concerns, housing problems, and home accessibility. Qualitative analysis extracts thematic insights from 13 participant narratives.

RESULTS

Individuals with Long COVID exhibit significantly higher rates of housing instability (21.1 % v. 8.1 %, p < 0.001) and financial concerns, such as worries about high rent or mortgage (50.4 % v. 40.0 %, p < 0.001), compared to those without Long COVID. They also report more frequent issues with pests (30.0 % v. 23.5 %, p < 0.01) and mold (22.0 % v. 12.7 %, p < 0.001) in their homes. Qualitative analysis reveals financial setbacks, difficulties in obtaining support, and the challenges of home accessibility.

CONCLUSIONS

Associations between Long COVID and challenges related to housing stability and home accessibility highlight the need for systemic changes, financial support, and advocacy. This research contributes to understanding Long COVID's challenges, informing policy development, and promoting compassionate responses, ensuring the well-being of people with Long COVID.

The impact of housing insecurity on mental health, sleep and hypertension: Analysis of the UK Household Longitudinal Study and linked data, 2009-2019

BACKGROUND

Housing insecurity is an escalating problem in the UK but there is limited evidence about its health impacts. Using nationally representative panel data and causally focussed methods, we examined the effect of insecure housing on mental health, sleep and blood pressure, during a period of government austerity.

METHODS

We used longitudinal survey data (2009-2019, n = 11,164 individuals with annual data) from the UK Household Longitudinal Study. Outcomes were probable common mental disorder (GHQ-12), sleep disturbance due to worry, and new diagnoses of hypertension. The primary exposure was housing payment problems in the past year. Using doubly robust marginal structural models with inverse probability of treatment weights, we estimated absolute and relative health effects of housing payment problems, and population attributable fractions. In stratified analyses we assessed potentially heterogeneous impacts across the population, and potential modifying effects of government austerity measures. A negative control analysis was conducted to detect bias due to unmeasured confounding.

RESULTS

Housing payment problems were associated with a 2.5 percentage point increased risk of experiencing a common mental disorder (95% CI 1.1%, 3.8%) and 2.0% increased risk of sleep disturbance (95% CI 0.7%, 3.3%). Estimates were larger for renters, younger people, less educated, households with children, and people living in areas most affected by austerity-related cuts to housing support services. We did not find consistent evidence for an association with hypertension (risk difference = 0.4%; 95% CI -0.1%, 0.9%). The negative control analysis was not indicative of unmeasured confounding.

CONCLUSIONS

Housing payment problems were associated with worse mental health and sleep disturbance in a large UK sample. Households at risk of falling into rent or mortgage arrears need more support, especially in areas where housing support services have been diminished. Substantial investment is urgently needed to improve supply of social and affordable housing.

Social Determinants of Health Needs and Health-related Quality of Life Among Surgical Patients: A Retrospective Analysis of 8512 Patients

OBJECTIVE

To assess associations between social determinants of health (SDOH) needs and health-related quality of life (HRQOL) among surgical patients.

BACKGROUND

Despite the profound impact of SDOH on health outcomes, studies examining the effect of SDOH needs on HRQOL among surgical patients are limited.

METHODS

A retrospective study was conducted using responses from the SDOH needs assessment and the Patient-Reported Outcomes Measurement Information Systems Global Health instrument of adults seen in surgical clinics at a single institution. Patient characteristics including socioeconomic status (insurance type, education level, and employment status) were extracted. Stepwise multivariable logistic regression analyses were performed to identify independent predictors of global health scores.

RESULTS

A total of 8512 surgical patients (mean age: 55.6±15.8 years) were included. 25.2% of patients reported one or more SDOH needs. The likelihood of reporting at least one SDOH need varied by patient characteristics and socioeconomic status variables. In fully adjusted regression models, food insecurity [odds ratio (OR), 1.53; 95% CI, 1.38-1.70 and OR, 1.49; 95% CI, 1.22-1.81, respectively], housing instability (OR, 1.27; 95% CI, 1.12-1.43 and OR, 1.39; 95% CI, 1.13-1.70, respectively) lack of transportation (OR, 1.46; 95% CI, 1.27-1.68 and OR, 1.25; 95% CI, 1.00-1.57, respectively), and unmet medication needs (OR, 1.31; 95% CI, 1.13-1.52 and OR, 1.61; 95% CI, 1.28-2.03, respectively) were independent predictors of poor physical and mental health.

CONCLUSIONS

SDOH needs are independent predictors of poor patient-reported physical and mental health among surgical patients. Assessing and addressing SDOH needs should be prioritized in health care settings and by policymakers to improve HRQOL.

Examining Excess Mortality Associated With the COVID-19 Pandemic for Renters Threatened With Eviction

Importance

Residential evictions may have increased excess mortality associated with the COVID-19 pandemic.

Objective

To estimate excess mortality associated with the COVID-19 pandemic for renters who received eviction filings (threatened renters).

Design, Setting, and Participants

This retrospective cohort study used an excess mortality framework. Mortality based on linked eviction and death records from 2020 through 2021 was compared with projected mortality estimated from similar records from 2010 through 2016. Data from court records between January 1, 2020, and August 31, 2021, were collected via the Eviction Lab's Eviction Tracking System. Similar data from court records between January 1, 2010, and December 31, 2016, also collected by the Eviction Lab, were used to estimate projected mortality during the pandemic. We also constructed 2 comparison groups: all individuals living in the study area and a subsample of those individuals living in high-poverty, high-filing tracts.

Exposures

Eviction filing.

Main Outcomes and Measures

All-cause mortality in a given month. The difference between observed mortality and projected mortality was used as a measure of excess mortality associated with the pandemic.

Results

The cohort of threatened renters during the pandemic period consisted of 282 000 individuals (median age, 36 years [IQR, 28-47]). Eviction filings were 44.7% lower than expected during the study period. The composition of threatened renters by race, ethnicity, sex, and socioeconomic characteristics during the pandemic was comparable with the prepandemic composition. Expected cumulative age-standardized mortality among threatened renters during this 20-month period of the pandemic was 116.5 (95% CI, 104.0-130.3) per 100 000 person-months, and observed mortality was 238.6 (95% CI, 230.8-246.3) per 100 000 person-months or 106% higher than expected. In contrast, expected mortality for the population living in similar neighborhoods was 114.6 (95% CI, 112.1-116.8) per 100 000 person-months, and observed mortality was 142.8 (95% CI, 140.2-145.3) per 100 000 person-months or 25% higher than expected. In the general population across the study area, expected mortality was 83.5 (95% CI, 83.3-83.8) per 100 000 person-months, and observed mortality was 91.6 (95% CI, 91.4-91.8) per 100 000 person-months or 9% higher than expected. The pandemic produced positive excess mortality ratios across all age groups among threatened renters.

Conclusions and Relevance

Renters who received eviction filings experienced substantial excess mortality associated with the COVID-19 pandemic.

The impact of housing-price-related indices on suicide rates in Taiwan

BACKGROUND

While certain socioeconomic factors have been studied in relation to suicide, housing-price-related indexes have rarely been investigated.

AIMS

This article aims to examine the impact of housing-price-related indexes on suicide rates in the general population of Taiwan, a country with high housing costs and suicide rates.

METHODS

The study utilized three national housing-price-related indexes from 2012 to 2019: (1) housing price index, (2) housing price to income ratio, and (3) housing rental index. Cause of Death Data was employed to calculate suicide rate. A linear regression model with autoregressive errors was used to analyze the association between housing-price-related indexes and suicide rates among different sex and age groups.

RESULTS

The findings revealed that higher housing rental index values were associated with increased suicide rates in young and middle-aged adults compared to the elderly population, regardless of sex. However, this association was not observed with the other two housing-price-related indexes (i.e. housing price index and housing price to income ratio).

CONCLUSION

These results offer valuable insights for policymakers, mental health professionals, and housing advocates to improve housing affordability and reduce the burden of suicide in the general population, particularly among younger generations.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Primary Care-Based Housing Program Reduced Outpatient Visits; Patients Reported Mental And Physical Health Benefits

Screening for housing instability has increased as health systems move toward value-based care, but evidence on how health care-based housing interventions affect patient outcomes comes mostly from interventions that address homelessness. In this mixed-methods evaluation of a primary care-based housing program in Boston, Massachusetts, for 1,139 patients with housing-related needs that extend beyond homelessness, we found associations between program participation and health care use. Patients enrolled in the program between October 2018 and March 2021 had 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year compared with those who were not enrolled, including fewer social work, behavioral health, psychiatry, and urgent care visits. Patients in the program who obtained new housing reported mental and physical health benefits, and some expressed having stronger connections to their health care providers. Many patients attributed improvements in mental health to compassionate support provided by the program's housing advocates. Health care-based housing interventions should address the needs of patients facing imminent housing crises. Such interventions hold promise for redressing health inequities and restoring dignity to the connections between historically marginalized patient populations and health care institutions.

"When I think about my future, I just see darkness": How youth exiting homelessness navigate the hazy, liminal space between socioeconomic exclusion and inclusion

OBJECTIVES

The overarching objective of this mixed methods longitudinal study was to understand whether and how rent subsidies and mentorship influenced socioeconomic inclusion outcomes for youth exiting homelessness. The focus of this paper is on the qualitative objectives, which evolved from a primary focus on exploring how study mentorship was working as a facilitator of socioeconomic inclusion to focusing on how participants navigated the hazy, liminal space between socioeconomic exclusion and inclusion.

METHODS

This was a convergent mixed methods study scaffolded by community-based participatory action axiology. The quantitative component is reported elsewhere and involved a 2-year pilot randomized controlled trial where 24 participants received rent subsidies and 13 were randomly assigned a study mentor; proxy indicators of socioeconomic inclusion were measured every 6 months for 2.5 years. Qualitative objectives were explored using a qualitative descriptive design and theoretically framed using critical social theory. The lead author interviewed 12 participants every 6 months for 2.5 years. Qualitative interviews were analyzed using reflexive thematic analysis with an emphasis on critical interpretation.

RESULTS

Navigating the liminal space between socioeconomic exclusion and inclusion was complex and non-linear, and the way youth navigated that journey was more strongly associated with factors like informal mentorship (naturally occurring "coach-like" mentorship) and identity capital (sense of purpose, control, self-efficacy, and self-esteem), rather than whether or not they were assigned a formal study mentor.

CONCLUSION

A holistic approach integrating coaching and attention to identity capital alongside economic supports may be key to helping youth exiting homelessness achieve socioeconomic inclusion.

In the wake of a crisis: Caught between housing and healthcare

Objective

To measure the association between housing insecurity and foregone medication due to cost among Medicare beneficiaries aged 65+ during the Recession.

Methods

Data came from Medicare beneficiaries aged 65+ years from the 2006-2012 waves of the Health and Retirement Study (HRS). Two-wave housing insecurity changes are evaluated as follows: (i) No insecurity, (ii) Persistent insecurity, (iii) Onset insecurity, and (iv) Onset security. We implemented a series of four weighted longitudinal General Estimating Equation (GEE) models, two minimally adjusted and two fully adjusted models, to estimate the probability of foregone medications due to cost between 2008 and 2012.

Results

Our study sample was restricted to non-proxy interviews of non-institutionalized Medicare beneficiaries aged 65+ in the 2006 wave (n = 9936) and their follow up visits (n = 8753; in 2008; n = 7464 in 2010; and n = 6594 in 2012). Results from our fully adjusted model indicated that the odds of foregone medication was 64% higher among individuals experiencing Onset insecurity versus No insecurity in 2008, and also generally larger for individuals experiencing Onset Insecurity versus Persistent Insecurity. Odds of foregone medication was also larger among females, minority versus non-Hispanic white adults, those reporting a chronic condition, those with higher medical expenditures, and those living in the South versus Northeast.

Conclusion

This study drew from nationally representative data to elucidate the disparate health and financial impacts of a crisis on Medicare beneficiaries who, despite health insurance coverage, displayed variability in foregone medication patterns. Our findings suggest that the onset of housing insecurity is most closely linked with unexpected acute economic shocks leading households with little time to adapt and forcing trade-offs in their prescription and other needs purchases. Both housing and healthcare policy implications exist from these findings including expansion of low-income housing units and rent relief post-recession as well as wider prescription drug coverage for Medicare adults.

Inequities in Mental Health Care Facing Racialized Immigrant Older Adults With Mental Disorders Despite Universal Coverage: A Population-Based Study in Canada

OBJECTIVES

Contemporary immigration scholarship has typically treated immigrants with diverse racial backgrounds as a monolithic population. Knowledge gaps remain in understanding how racial and nativity inequities in mental health care intersect and unfold in midlife and old age. This study aims to examine the joint impact of race, migration, and old age in shaping mental health treatment.

METHODS

Pooled data were obtained from the Canadian Community Health Survey (2015-2018) and restricted to respondents (aged ≥45 years) with mood or anxiety disorders (n = 9,099). Multivariable logistic regression was performed to estimate associations between race-migration nexus and past-year mental health consultations (MHC). Classification and regression tree (CART) analysis was applied to identify intersecting determinants of MHC.

RESULTS

Compared to Canadian-born Whites, racialized immigrants had greater mental health needs: poor/fair self-rated mental health (odds ratio [OR] = 2.23, 99% confidence interval [CI]: 1.67-2.99), perceived life stressful (OR = 1.49, 99% CI: 1.14-1.95), psychiatric comorbidity (OR = 1.42, 99% CI: 1.06-1.89), and unmet needs for care (OR = 2.02, 99% CI: 1.36-3.02); in sharp contrast, they were less likely to access mental health services across most indicators: overall past-year MHC (OR = 0.54, 99% CI: 0.41-0.71) and consultations with family doctors (OR = 0.67, 99% CI: 0.50-0.89), psychologists (OR = 0.54, 99% CI: 0.33-0.87), and social workers (OR = 0.37, 99% CI: 0.21-0.65), with the exception of psychiatrist visits (p = .324). The CART algorithm identifies three groups at risk of MHC service underuse: racialized immigrants aged ≥55 years, immigrants without high school diplomas, and linguistic minorities who were home renters.

DISCUSSION

To safeguard health care equity for medically underserved communities in Canada, multisectoral efforts need to guarantee culturally responsive mental health care, multilingual services, and affordable housing for racialized immigrant older adults with mental disorders.

A Novel Framework to Address the Complexities of Housing Insecurity and Its Associated Health Outcomes and Inequities: "Give, Partner, Invest"

The association between housing insecurity and reduced access to healthcare, diminished mental and physical health, and increased mortality is well-known. This association, along with structural racism, social inequities, and lack of economic opportunities, continues to widen the gap in health outcomes and other disparities between those in higher and lower socio-economic strata in the United States and throughout the advanced economies of the world. System-wide infrastructure failures at municipal, state, and federal government levels have inadequately addressed the difficulty with housing affordability and stability and its associated impact on health outcomes and inequities. Healthcare systems are uniquely poised to help fill this gap and engage with proposed solutions. Strategies that incorporate multiple investment pathways and emphasize community-based partnerships and innovation have the potential for broad public health impacts. In this manuscript, we describe a novel framework, "Give, Partner, Invest," which was created and utilized by the University of Pittsburgh Medical Center (UPMC) Insurance Services Division (ISD) as part of the Integrated Delivery and Finance System to demonstrate the financial, policy, partnership, and workforce levers that could make substantive investments in affordable housing and community-based interventions to improve the health and well-being of our communities. Further, we address housing policy limitations and infrastructure challenges and offer potential solutions.

Burden Of Health-Related Social Needs Among Dual- And Non-Dual-Eligible Medicare Advantage Beneficiaries

Little information exists to inform stakeholders' efforts to screen for, address, and risk-adjust for the health-related social needs (HRSNs) of Medicare Advantage (MA) enrollees, particularly those not dually Medicaid-Medicare eligible and those younger than age sixty-five. HRSNs can include food insecurity, housing instability, transportation issues, and other factors. We examined the prevalence of HRSNs in 2019 among 61,779 enrollees in a large, national MA plan. Although HRSNs were more common among dual-eligible beneficiaries, with 80 percent reporting at least one (average, 2.2 per beneficiary), 48 percent of non-dual-eligible beneficiaries reported one or more, indicating that dual eligibility alone would have inadequately captured HRSN risk. HRSN burden was unequally distributed across multiple beneficiary characteristics, notably with beneficiaries younger than age sixty-five more likely than those ages sixty-five and older to report having an HRSN. We also found that some HRSNs were more strongly associated with hospitalizations, emergency department visits, and physician visits than others. These findings suggest the importance of considering the HRSNs of dual- and non-dual-eligible beneficiaries, as well as those of beneficiaries of all ages, when exploring how to address HRSNs in the MA population.

Structural and Intermediary Social Determinants of Health and the Emotional and Behavioral Health of US Children

Children grow up in homes where varying environmental and socioeconomic contexts have a bearing on their emotional and behavioral health (EBH). This study used data from a representative sample of the child supplement of the US National Health Information Survey (NHIS) and applied the social determinants of health (SDoH) framework to explore factors associated with child EBH. We conducted a path analysis of the child's EBH measured by the strengths and difficulties questionnaire (SDQ) from their macro and socioeconomic contexts, e.g., policy, household, and other health system risk factors. For children in the sample, aged 4 to 17 years old (n = 9205), most path relationships to child SDQ scores were statistically significant. The total effects from a child's visit to a mental health specialist (0.28) and child's age (0.22) had the highest coefficients to child SDQ scores. A modified model showed a better fit with X2 (4) = 22.124, RMSEA = 0.021, and 90% CI [0.013-0.03], CFI = 0.98. Findings indicate that child factors such as being older, the use of mental healthcare services, and family socioeconomic status were significantly associated with EBH, calling attention to the need for more responsive policy and behavioral health interventions that address household/familial and child-level factors, critical determinants of child wellbeing.

Photo-Enhanced Health Promotion Messages to Target Reduction in Dietary Sugar among Residents of Public Housing

Interventions intended to reduce the consumption of dietary sugars among those population groups demonstrating disproportionately greater and more frequent consumption of sugar-sweetened beverages and foods (SSBF) would benefit from intervention strategies that are tailored to population-specific barriers and facilitators. The objective of this study was to develop and evaluate the acceptability of photo-enhanced and theory-based health promotion messages that target the reduction in SSBF among adult residents of public housing developments, a population known for their high rates of chronic disease. Using the message development tool as a framework, we developed a series of 15 SSBF reduction messages, using an iterative process with community member input. We then evaluated the acceptability of the messages and compared three delivery mechanisms: print, text, and social media. We recruited participants who were residents of urban public housing developments, and who spoke either English or Spanish. A majority of participants identified as being of Hispanic ethnicity (73%). The message acceptability scoring did not appear to differ according to the assigned delivery mechanism, despite some imbalances in participants' characteristics across delivery mechanisms. The messages that targeted motivation were least likely to be accepted. In conclusion, our findings suggest that engaging members of the community at all phases of the development process was a feasible method to develop SSBF reduction messages with a high perceived acceptability.

Housing instability and cardiometabolic health in the United States: a narrative review of the literature

Housing instability is variably defined but generally encompasses difficulty paying rent, living in poor or overcrowded conditions, moving frequently, or spending the majority of household income on housing costs. While there is strong evidence that people experiencing homelessness (i.e., lack of regular housing) are at increased risk for cardiovascular disease, obesity, and diabetes, less is known about housing instability and health. We synthesized evidence from 42 original research studies conducted in the United States examining the association of housing instability and cardiometabolic health conditions of overweight/obesity, hypertension, diabetes, and cardiovascular disease. The included studies varied widely in their definitions and methods of measuring housing instability, but all exposure variables were related to housing cost burden, frequency of moves, living in poor or overcrowded conditions, or experiencing eviction or foreclosure, measured at either the individual household level or at a population level. We also included studies examining the impact of receipt of government rental assistance, which serves as a marker of housing instability given that its purpose is to provide affordable housing for low-income households. Overall, we found mixed but generally adverse associations between housing instability and cardiometabolic health, including higher prevalence of overweight/obesity, hypertension, diabetes, and cardiovascular disease; worse hypertension and diabetes control; and higher acute health care utilization among those with diabetes and cardiovascular disease. We propose a conceptual framework for pathways linking housing instability and cardiometabolic disease that could be targeted in future research and housing policies or programs.

Better health through better housing - Current impact and future prospects of randomized trials

Safe and stable housing in integrated neighborhoods with access to basic amenities and social elements is indispensable for good health. Recent randomized controlled trials have demonstrated that improvements in the built environment have positive impacts on malaria, fall injuries, and gun violence outcomes. There are several challenges associated with performing studies that assess house improvement as an intervention for advancing human health and well-being, including ethical issues, lack of blinding, spillover effects, and differential behavior. Future research is warranted to evaluate the clinical benefits and cost-effectiveness of prototype houses or energyefficient prefabricated modular homes by employing more holistic strategies, such as integration of data analytics, peer support, and whole health coaching, addition of social contextual perspectives on mobile technology-supported community-based interventions, and combination of digital technology-informed community-engaged citizen science and participatory action programs with multi-sector partnerships. Gleaning stronger evidence from clinical trials and model-based economic analyses that ascertain the effects of multiple intersecting factors on individuals and communities would illuminate effective policymaking options in healthy housing and guide successful implementation of sustainable public health policies. Straightforward and cost-effective pathways should therefore be created based on highest-quality scientific data to lead the scaling up of novel housing interventions and capacity building for health-in-all-policies to support population health equity, thereby ensuring that everyone has access to housing and the chance to live a healthy and productive life.