Building health equity through housing policies: critical reflections and future directions for research

Housing assistance among patients with cancer: SEER-Medicare US Department of Housing and Urban Development data linkage

BACKGROUND

Lack of stable, affordable housing is an important social determinant of health. Federal housing assistance may buffer against housing vulnerabilities among low-income households, but research examining the association of housing assistance and cancer care has been limited. We introduce a new linkage of Surveillance, Epidemiology, and End Results (SEER) program-Medicare and US Department of Housing and Urban Development (HUD) administrative data.

METHODS

Individuals enrolled in HUD public and assisted housing programs between 2006 and 2021 were linked with cancer diagnoses between 2006 and 2019 identified in the SEER-Medicare data from 16 states using Match*Pro (National Institutes of Health, Bethesda, MD) probabilistic linkage software. HUD administrative data include timing and type of housing assistance as well as verified household income. Medicare administrative data are available through 2020.

RESULTS

A total of 335 490 unique individuals who received housing assistance at any time point, including 156 794 who received housing assistance around the time of their diagnosis (at least 6 months before diagnosis until 6 months after diagnosis or death), were matched to SEER-Medicare data. A total of 63 251 individuals receiving housing assistance at the time of their diagnosis were aged 66 years and older and continuously enrolled in Medicare parts A and B fee for service; 12 035 had a diagnosis of lung cancer, 8866 of breast cancer, 7261 of colorectal cancer, and 4703 of prostate cancer.

CONCLUSIONS

This novel data linkage will be available through the National Cancer Institute and can be used to explore the ways in which housing assistance is associated with cancer diagnosis, care, and outcomes, including the role of housing assistance status in potentially reducing or contributing to inequities across racialized and ethnic groups.

Moving Because of Unaffordable Housing and Disrupted Social Safety Net Access Among Children

OBJECTIVES

To measure associations between residential moves because of unaffordable housing costs and disruptions in access to the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and Medicaid in a health care-based sample of families with young children.

METHODS

We used cross-sectional survey data on social safety net-eligible caregivers and children recruited into the Children's HealthWatch study from emergency departments and primary care clinics in Baltimore and Philadelphia (2011-2019). Children's HealthWatch measured residential moves (cost-driven and noncost-driven) in the past year and disruptions in safety net access. We used logistic regression to estimate associations between each type of move and disrupted access to social safety nets.

RESULTS

Across 9344 children, cost-driven residential moves were associated with higher odds of disrupted access to at least 1 safety net program (Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; or Medicaid; adjusted odds ratio 1.44; 95% confidence interval 1.16-1.80), as well as higher odds of disruption to each program separately. Noncost-driven moves were also associated with disruptions to at least 1 safety net program, but less strongly so (adjusted odds ratio 1.14; confidence interval 1.01-1.29; P value for comparison with cost-driven = .045).

CONCLUSIONS

Residential moves, particularly cost-driven moves, are associated with social safety net benefit disruptions. The association between these events suggests a need for action to ensure consistent safety net access among children facing cost-driven moves and vice versa (ie, access to housing supports for children with disrupted safety net access).

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.

Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations

On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.

The impacts of rent burden and eviction on mortality in the United States, 2000-2019

Investments in stable, affordable housing may be an important tool for improving population health, especially in the context of rising costs and evictions for American renters. Still, a lack of longitudinal data linking these exposures to health outcomes has limited prior research. In this study, we use linked administrative data to estimate the associations of rent burden and eviction with all-cause mortality. We constructed a novel dataset linking renters in the long-form 2000 Census (N = 6,587,000) to mortality follow-up through 2019 from the Census Numident file. To measure exposure to eviction, we further linked this dataset to 38 million eviction records between 2000 and 2016 using names and addresses. For a subsample of renters, we also measured within-individual changes in rent burden between 2000 and 2008-2012 by linking to the American Community Survey. We estimated the associations of rent burden and eviction with mortality using Cox proportional-hazards models and discrete-time hazard models adjusted for individual, household, neighborhood, and state characteristics, examining varying associations by cohort, race, gender, and eviction risk. Higher baseline rent burden, increases in rent burden during midlife, and evictions were all associated with increased mortality. Compared to a baseline rent burden of 30%, a burden of 70% was associated with 12% (95% confidence interval = 11-13%) higher mortality. A 20-point increase in rent burden between 2000 and 2008-2012 was associated with 16% (12-19%) higher mortality through 2019. An eviction filing without judgment was associated with a 19% (15-23%) increase in mortality and an eviction judgment was associated with a 40% (36-43%) increase. Associations were larger for those at lower predicted risk of eviction. These findings reveal how rising costs and evictions are shaping mortality for American renters. Policies designed to increase the supply of affordable housing and prevent eviction may lead to widespread improvements in population health.

Eviction as a community health exposure

Evidence suggests that being evicted harms health. Largely ignored in the existing literature is the possibility that evictions exert community-level health effects, affecting evicted individuals' social networks and shaping broader community conditions. In this narrative review, we summarize evidence and lay out a theoretical model for eviction as a community health exposure, mediated through four paths: 1) shifting ecologies of infectious disease and health behaviors, 2) disruption of neighborhood social cohesion, 3) strain on social networks, and 4) increasing salience of eviction risk. We describe methods for parsing eviction's individual and contextual effects and discuss implications for causal inference. We conclude by addressing eviction's potentially multilevel consequences for policy advocacy and cost-benefit analyses.

Association of Housing Status With Types of Operations and Postoperative Health Care Utilization

OBJECTIVE

To analyze the association between housing status and the nature of surgical care provided, health care utilization, and operational outcomes.

BACKGROUND

Unhoused patients have worse outcomes and higher health care utilization across multiple clinical domains. However, little has been published describing the burden of surgical disease in unhoused patients.

METHODS

We conducted a retrospective cohort study of 111,267 operations from 2013 to 2022 with housing status documented at a single, tertiary care institution. We conducted unadjusted bivariate and multivariate analyses adjusting for sociodemographic and clinical characteristics.

RESULTS

A total of 998 operations (0.8%) were performed for unhoused patients, with a higher proportion of emergent operations than housed patients (56% vs 22%). In unadjusted analysis, unhoused patients had longer length of stay (18.7 vs 8.7 days), higher readmissions (9.5% vs 7.5%), higher in-hospital (2.9% vs 1.8%) and 1-year mortality (10.1% vs 8.2%), more in-hospital reoperations (34.6% vs 15.9%), and higher utilization of social work, physical therapy, and occupational therapy services. After adjusting for age, sex, comorbidities, insurance status, and indication for operation, as well as stratifying by emergent versus elective operation, these differences went away for emergent operations.

CONCLUSIONS

In this retrospective cohort analysis, unhoused patients more commonly underwent emergent operations than their housed counterparts and had more complex hospitalizations on an unadjusted basis that largely disappeared after adjustment for patient and operative characteristics. These findings suggest issues with upstream access to surgical care that, when unaddressed, may predispose this vulnerable population to more complex hospitalizations and worse longer term outcomes.

The effect of housing tenure on health status of migrant populations in China: are health service utilization and social integration mediating factors?

BACKGROUND

Current research suggests that there is an association between housing tenure and the health status of migrant populations, but the potential mediators of this association remain to be explored. We aimed to examine the effect of housing tenure on migrant populations' health in China and how this effect is mediated by health service utilization and social integration.

METHODS

Data from the 2017 China Migrants Dynamic Survey of 47,459 participants was used. Logistic regression models were used to explore the effects of housing tenure, health service utilization, and social integration on the health status of migrant populations. Mediated effects models were used to explore the association among them. This study used the bootstrap method and KHB method to test the mediating effect of health service utilization and social integration.

RESULTS

Compared to private renters, owners with mortgages (OR: 0.828, 95% CI: 0.765-0.896) were significantly associated with a higher risk of poor health. Compared with private renters, outright owners were associated with a lower risk of poor health (OR: 1.016, 95% CI: 0.935, 1.104), but the association was not statistically significant (p > 0.05). Moreover, health service utilization (OR: 1.422, 95% CI: 1.268, 1.594) and social integration (OR: 4.357, 95% CI: 3.555, 5.341) were both significantly associated with a higher probability of good health (p < 0.001).

CONCLUSION

Among migrant populations, homeowners with mortgages had a lower likelihood of good health than private renters, while there was no significant difference in the health status between outright owners and private renters. Moreover, health service utilization and social integration mediate the effect of housing tenure on the health status of migrant populations. Policies and interventions can be designed to improve the health service utilization and social inclusion of migrant populations to reduce health disparities across housing tenure types.

The impact of place-based contextual social and environmental determinants on preterm birth: A systematic review of the empirical evidence

The objective of this study was to systematically review the available empirical evidence examining associations between preterm birth (PTB) and five domains of place-based contextual social and environmental determinants, including (1) physical environment, (2) residential greenness, (3) neighborhood violence/crime, (4) food accessibility and availability, and (5) health services accessibility, among adult mothers in high-income countries. The evidence in this review suggests an adverse association between damaged physical environment, neighborhood violence/crime, lack of health services accessibility, and PTB. The existing evidence also suggests a beneficial effect of residential greenness on PTB. Further studies are needed to investigate these associations for more understanding of the direction and magnitude of these association and for potential heterogeneity by factors such as race/ethnicity, urban vs rural residence, immigration status, and social class.

The Relationship Between Homeownership and Health by Race/Ethnicity Since the Foreclosure Crisis: California Health Interview Survey 2011-2018

BACKGROUND

US housing policy places a high priority on homeownership, providing large homeowner subsidies that are justified in part by homeownership's purported health benefits. However, studies conducted before, during, and immediately after the 2007-2010 foreclosure crisis found that while homeownership is associated with better health-related outcomes for White households, that association is weaker or non-existent for African-American and Latinx households. It is not known whether those associations persist in the period since the foreclosure crisis changed the US homeownership landscape.

OBJECTIVE

To examine the relationship between homeownership and health and whether that relationship differs by race/ethnicity in the period since the foreclosure crisis.

DESIGN

We conducted a cross-sectional analysis of 8 waves (2011-2018) of the California Health Interview Survey (n = 143,854, response rate 42.3 to 47.5%).

PARTICIPANTS

We included all US citizen respondents ages 18 and older.

MAIN MEASURES

The primary predictor variable was housing tenure (homeownership or renting). The primary outcomes were self-rated health, psychological distress, number of health conditions, and delays in receiving necessary medical care and/or medications.

KEY RESULTS

Compared to renting, homeownership is associated with lower rates of reporting fair or poor health (OR = 0.86, P < 0.001), fewer health conditions (incidence rate ratio = 0.95, P = 0.03), and fewer delays in receiving medical care (OR = 0.81, P < 0.001) and medication (OR = 0.78, P < 0.001) for the overall study population. Overall, race/ethnicity was not a significant moderator of these associations in the post-crisis period.

CONCLUSIONS

Homeownership has the potential to provide significant health-related benefits to minoritized communities, but this potential may be threatened by practices of racial exclusion and predatory inclusion. Further study is needed to elucidate health-promoting mechanisms within homeownership as well as potential harms of specific homeownership-promoting policies to develop healthier, more equitable housing policy.

"It's Stable but Not Stable": A Conceptual Framework of Subjective Housing Stability Definition Among Individuals with Co-occurring Mental Health and Substance Use Disorders

Objective: Despite increasing efforts to improve housing stability, research has largely defined housing stability in a narrow sense and heavily relied on objective measures, such as housing types and housing duration. The present study constructed a conceptual framework for a subjective housing stability definition from the perspectives of individuals with co-occurring mental health and substance use disorders and their behavioral health service providers. Methods: Following the principles of grounded theory, we collected and analyzed qualitative data through semistructured interviews with 24 individuals with serious mental illness and substance use problems and three focus groups with 22 behavioral health service providers. Results: We developed a conceptual framework with two domains of subjective housing stability: functional stability and experiential stability. The functional stability domain includes four theoretical concepts: meeting basic needs, housing quality, housing affordability, and housing permanence. The experiential stability domain includes four theoretical concepts: autonomy and independence, connectedness, safety, and supportiveness. Conclusions: The conceptual framework can inform future research, practices, and policies to move beyond focusing on merely providing housing to consider the diverse and underlying needs in improving housing stability and well-being among those experiencing or at risk of housing instability.

The smoke-free home study: study protocol for a cluster randomized controlled trial of a smoke-free home intervention in permanent supportive housing

Background

Formerly chronically homeless adults who live in permanent supportive housing (PSH) have high prevalence of smoking. It is uncommon to find smoke-free policies in PSH because of the concern that such policies contradict PSH’s harm reduction framework and could increase homelessness should residents lose their housing because of the policy. However, in the absence of such policies, non-smoking PSH residents face the harmful effects of secondhand smoke exposure while residents who smoke see increased risks from high rates of smoking throughout their residence. Our pilot work highlighted the feasibility and acceptability of an intervention designed to promote voluntary adoption of a smoke-free home. Here we report a protocol for a cluster randomized controlled trial of the smoke-free home intervention for formerly chronically homeless residents in PSH.

Methods

The smoke-free home intervention provides face-to-face counseling and instruction to PSH residents on how to adopt a smoke-free home and offers training for PSH staff on how to refer residents to tobacco cessation services. We will randomize 20 PSH sites in the San Francisco Bay Area to either the intervention or wait-list control arms. We will enroll 400 PSH residents who smoke cigarettes in their housing unit and 120 PSH staff who work at the sites. At baseline, three- and six-months follow-up, we will ask residents to report their tobacco use and cessation behaviors and adoption of smoke-free homes. We will ask staff to answer questions on their knowledge, attitudes, practices, and barriers related to supporting residents’ smoking cessation. The primary outcome for PSH residents is adoption of smoke-free homes for 90 days or more at six-months follow-up, and the secondary outcome is point prevalence tobacco abstinence. The primary outcome for PSH staff is change in Smoking Knowledge Attitudes Practices survey score.

Discussion

Voluntary adoption of smoke-free homes is a promising approach for reducing exposure to secondhand smoke and reducing tobacco use among a population facing high rates of tobacco-related disease, and is aligned with PSH’s harm reduction framework. Findings from this study have the potential to inform adoption of tobacco control policies among vulnerable populations most at risk for smoking-related harms.

Trial registration

This study was registered with the U.S. National Institute of Health Clinical Trials register on April 22, 2021: NCT04855357.