Question

Briefly describe the Quality and Safety Pathway by which Housing affects health status. Give one (1) example of how unsafe or poor-quality Housing may negatively affect the health status of a person or family.

Answer 1

pathways with examples

THE STABILITY PATHWAY

Observational studies have shown that being without a stable home is detrimental to one’s health. People who are chronically homeless face substantially higher morbidity in terms of both physical and mental health and of increased mortality. Many people experience traumas on the streets or in shelters, which has long-standing adverse impacts on psychological well-being. These and other challenges can result in persistently high health care expenditures due to emergency department and inpatient hospital use. Even children who experienced homelessness only while in utero are more likely to be hospitalized or suffer worse health, compared to their peers.

People who are not chronically homeless but face housing instability (in the form of moving frequently, falling behind on rent, or couch surfing) are more likely to experience poor health in comparison to their stably housed peers. Residential instability is associated with health problems among youth, including increased risks of teen pregnancy, early drug use, and depression. A review of twenty-five studies that examined the impact of foreclosure on mental health and health behaviors (including substance abuse) found that all of the studies reported that foreclosure was associated with worsened outcomes, including depression, anxiety, increased alcohol use, psychological distress, and suicide. Matthew Desmond’s recent ethnography, Evicted, illustrates how the stress of unstable housing can result in disruptions to employment, social networks, education, and the receipt of social service benefits. The lack of stable housing can also decrease the effectiveness of health care by making proper storage of medications difficult or impossible.

In contrast, providing access to stable housing can improve health and reduce health care costs. Within a population of nearly 10,000 people in Oregon with unstable housing, the provision of affordable housing decreased Medicaid expenditures by 12 percent. At the same time, use of outpatient primary care increased by 20 percent and emergency department use declined by 18 percent for this group. The health impacts of other means of stabilizing housing, including rental and foreclosure assistance, have also been rigorously studied in relation to mental health outcomes.

Housing the homeless has consistently been shown to improve health outcomes. In one of several randomized controlled trials of interventions to address homelessness, long-term housing subsidies had positive impacts on measures of psychological distress and intimate partner violence. Particularly among chronically homeless people, having a safe place to stay can both improve health and decrease health care costs. The extent to which the reductions in health care costs fully offset the costs of housing continues to be a subject of debate. The Housing First model, in which chronically homeless people with a diagnosis of a behavioral health condition receive supportive housing, has been shown to be particularly cost-effective, with one study finding that the provision of housing generated cost offsets of up to $29,000 per person per year, after accounting for housing costs.

THE SAFETY AND QUALITY PATHWAY

A number of environmental factors within homes are correlated with poor health. In-home exposure to lead irreversibly damages the brains and nervous systems of children. Substandard housing conditions such as water leaks, poor ventilation, dirty carpets, and pest infestation have been associated with poor health outcomes, most notably those related to asthma. Additionally, exposure to high or low temperatures is correlated with adverse health events, including cardiovascular events—particularly among the elderly. Residential crowding has also been linked to both physical illness (for example, infectious disease) and psychological distress.

A large number of interventional studies demonstrate the potential for improving health through improved housing quality and safety. Studies in which asthma triggers are removed have repeatedly demonstrated health improvements and cost reductions among both children and adults (see also here and here). Research on smoking bans in public and affordable housing has found reductions in the number of smokers, the number of cigarettes smoked per smoker, and secondhand smoke exposure among nonsmokers. Children in families participating in the federally funded Low Income Home Energy Assistance Program (LIHEAP), which provides financial assistance for home heating, medically necessary home cooling, and emergencies due to weather-related fuel shortages, were at a healthier weight and at less nutritional risk, compared to their nonparticipant peers. Among community-dwelling older adults, home modifications can reduce falls by 39 percent when delivered by occupational therapists, and a randomized controlled trial of a standardized package of home safety improvements to decrease fall risk is ongoing.

THE AFFORDABILITY PATHWAY

In 2015, 38.9 million American families spent more than 30 percent of their income on housing, earning them the designation of being “cost burdened” and inhibiting their ability to invest in health-generating goods. In the same year, 18.8 million households were “severely cost-burdened” because they spent more than 50 percent of their income on housing, with much of this burden falling on renters rather than owners. If both rents and incomes rise at the rate of inflation, the number of American households that are severely cost-burdened because of rent is expected to reach 13.1 million in 2025, an 11 percent increase from 2015.

In some cases, Americans may choose to spend substantially on housing to live in neighborhoods that provide access to health-promoting features such as schools and parks. However, a lack of affordable housing options can affect families’ ability to make other essential expenses and can create serious financial strains. Low-income families with difficulty paying their rent or mortgage or their utility bills are less likely to have a usual source of medical care and more likely to postpone needed treatment than those who enjoy more-affordable housing. Severely cost-burdened renters are 23 percent more likely than those with less severe burdens to face difficulty purchasing food. Homeowners who are behind in their mortgage payments are also more likely to lack a sufficient supply of food and to go without prescribed medications, compared to those who do not fall behind on payments. Conversely, New York City families with affordable rent payments were found to increase their discretionary income by 77 percent, freeing up funds to spend on health insurance, food, and education or to save for a future down payment on a home.

THE NEIGHBORHOOD PATHWAY

Research on the influence of physical surroundings on health has been ongoing since John Snow’s investigation of the Broad Street pump. In the modern era, researchers have found that the availability of resources such as public transportation to one’s job, grocery stores with nutritious foods, and safe spaces to exercise are all correlated with improved health outcomes. Living in close proximity to high-volume roads, in contrast, is a danger to health and can result in increased rates of respiratory diseases such as asthma and bronchitis and increased use of health care. In one study of neighborhood blight remediation, even walking past a vacant lot that had been “greened” decreased heart rate significantly, in comparison to walking past a nongreened vacant lot. The same authors also found that abandoned building and lot remediation significantly reduced firearm violence. Researchers evaluating the creation of a Safe Routes to School program in Texas found that the addition of sidewalks, bike lanes, and safe crossings reduced pedestrian and bicyclist injuries 43 percent among children ages 5–19.

Less visible but potentially even more important are neighborhoods’ social characteristics, including measures of segregation, crime, and social capital. Sociologists have conducted crucial research that describes the health impacts of social and institutional dynamics of communities. David Williams and Chiquita Collins, in particular, have documented the impact of neighborhood segregation on health, suggesting that segregation widens health disparities by determining access to schools, jobs, and health care; influencing health behaviors; and increasing crime rates in neighborhoods of color. Although the preponderance of evidence suggests that racial segregation has negative impacts on health, some researchers have reported health-protective effects among blacks living in “clustered black neighborhoods.”

An analysis of the Moving to Opportunity for Fair Housing Demonstration Program has offered some of most compelling data on the impact of neighborhoods on health. Under this landmark federally funded experiment, people were randomly assigned to groups that either did or did not receive financial and other assistance in moving to lower-poverty areas—a research design that overcame unobservable selection effects inherent in many previous studies. Adults who moved experienced improvements in long-term mental health and some aspects of physical health (for example, reductions in the prevalence of obesity and diabetes) in comparison to peers who remained in high-poverty areas. Nearly two decades after the experiment concluded, Raj Chetty and colleagues found that when children were younger than age thirteen when they moved to a low-poverty neighborhood, their likelihood of attending college and projected lifetime earnings were significantly improved.