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This article first appeared on the Grantmakers In Health blog in August 2016.
We have more evidence than ever before that housing is one of the most important social determinants of health and one of the most efficient platforms for improving health outcomes. In February, Enterprise Community Partners released new research conducted in conjunction with the Center for Outcomes Research and Education, which provided quantitative evidence of the long-term positive impact that affordable housing has on health outcomes for the most vulnerable and difficult to serve. The study found that health outcomes improved and health care costs declined after people moved into affordable housing and continued over time. It also found that the decline in costs was even greater when people lived in housing that included integrated health services. This reduction in cost was associated with an increase in primary care and a decrease in emergency care among the study participants (Saul et al, 2016).
This research is the not the first of its kind. Similar studies have been published that provide rich evidence of the important relationship between healthy housing and improved health outcomes, across a wide range of chronic diseases and populations (Takaro et al, 2011). Enterprise’s 2014 report, The Impact of Affordable Housing on Families and Communities: A Review of the Evidence Base, offers a useful summary of much of this evidence (Brisson et al, 2014) and a more recent paper by the Center for Housing Policy builds on that work (Viveiros et al, 2015).
While the research evidence about the role that quality, affordable housing can play in changing the trajectory of people’s lives is clear, public understanding of this relationship often runs counter to the research evidence. New research commissioned by Enterprise and conducted by the FrameWorks Institute tests the effectiveness of messages aimed at increasing public engagement and shows important gaps.
What the Public Understands about the Connection between Housing and Health
Researchers at FrameWorks worked to synthesize the core evidence-base around healthy housing and found significant differences between how health and housing experts think and talk about these issues, and how the public thinks and talks about these same issues. The research identifies areas where public understanding diverges from the evidence-base and highlights the implications of these differences on our ability to elevate the public discourse on these issues.
Health Promotion vs. Do No Harm. While health and housing experts focus attention on the ways in which healthy housing can promote positive health, the public assumes that housing is healthy as long as it does not explicitly cause harm. This perception renders invisible the important role that housing plays in health promotion and disease prevention.
Healthy Housing as a Citizen Right vs. Consumer Good. Health and housing experts think of healthy housing as a right of all citizens, while the public understands housing quality as a consumer good—something that some people can rightfully aﬀord and others cannot. In this way, the fact that some people have healthy housing and others do not is understood as a natural feature of a functioning marketplace.
Toxins in the Home as a Current Problem vs. In the Past. Health and housing experts explain that toxins such as lead, asbestos, mold, radon, and carbon monoxide constitute a significant health threat for Americans. The public assumes that toxins in the home are a problem of the past and that due to regulations, toxins no longer pose a danger to people’s health. This makes it more difficult for them to see our continued advocacy on regulation and abatement as important, relevant and timely.
Dangerous Contaminants in the Home as Invisible vs. Visible. Health and housing experts are highly concerned about invisible toxins such as radon and carbon monoxide, and can identify the specific causal mechanisms by which these toxins compromise health. The public focuses on the threats to health posed by visible contaminants such as trash, dirt, and pests and not on less visible contaminants. Both issues are important, but the public’s exclusive focus on visible contaminants makes it difficult to raise support for less visible health risks.
Who is Responsible for Addressing these issues – Policymakers vs. Individuals. To explain problems with housing (problems of quality, disparities or aﬀordability), health and housing experts emphasize systemic factors, such as policies that disadvantage certain populations or that fail to stimulate a larger supply of aﬀordable, healthy housing. Members of the general public tend to attribute housing quality problems to individuals and their choices in the housing market – primarily renters, landlords and homeowners.
Poverty vs. Choices. Health and housing experts view poverty, housing, and poor health as interconnected. Experts explain deteriorating housing conditions, poverty, and poor health as a bundle of cascading eﬀects, as problems in one area lead to problems in others, producing a spiral of eﬀects that often go beyond the control of individuals. The public often reasons that people need more willpower to pull themselves out of these challenging situations and need to make the “choice” to seek employment in order to secure quality housing. This perception makes it difficult to engage the public as advocates on behalf of families that are more vulnerable to challenges in the housing market.
Government Support vs. Ambivalence. Health and housing experts see government policy interventions aimed at structures and systems as the most eﬀective way to solve housing problems. While the public can acknowledge that government has some responsibility for improving housing conditions and has a regulatory role to play in the rental market in particular, they also view government intervention as ineﬃcient, ineﬀective, and in some cases even counterproductive.
Why Should We Care About Public Perception?
As the report makes clear, “the public’s lack of understanding about the connections between housing and health outcomes is a major impediment to public support for eﬀective solutions.” Finding ways to fill out public understanding of these connections is a precondition for increasing support for needed policies and interventions.” In essence, to catalyze greater support for programs, investments, and policies that support promote health through housing, we need to build public will and engage broader stakeholders in the work. This requires both better use of the research evidence and more effective ways to communicate about health and housing as an important public concern.
In essence, to catalyze greater support for programs, investments, and policies that support promote health through housing, we need to build public will and engage broader stakeholders in the work.
What Works to Shift Public Understanding in Directions More Consistent with the Research Evidence?
Research evidence shows how quality affordable housing (especially health service-enriched housing) can reduce the prevalence of health problems people in poor-quality housing face. Health and housing experts must rethink how we communicate research findings to broader public audiences to ensure those findings are well-received and understood. FrameWorks research offers up some important recommendations for how we might begin to better engage the public around these issues.
As the report makes clear, “the public’s lack of understanding about the connections between housing and health outcomes is a major impediment to public support for eﬀective solutions.”
Where You Live Affects You
The places where we live shape our lives and our health. Our communities and neighborhoods aﬀect our health in important ways. When people’s homes are near parks and bike paths, exercise is easier. When people live near grocery stores where good food is available, it’s easier to eat healthy. Things within our homes, like lead, mold, and other toxins can make us sick. And when housing is really expensive, it makes it hard to aﬀord to go to the doctor, join sports leagues, or eat well, which harms our health.
For example, researchers at FrameWorks found that framing the connection between health and housing in terms of the idea that “where you live affects you,” helped people to see health as being shaped by aspects of the built environment. Moreover, this meta-frame helped people to understand the connections between specific features of housing and specific health outcomes. Perhaps most important, this meta-frame made people less apt to blame poor health and housing conditions on individuals and more likely to see how community-level factors shape health – making systems and policy solutions more visible.
Health and Housing Experts Getting to a Common Frame
While the research provides additional messaging advice and reframes, this particular frame is particularly interesting because it connects well to a frame that is already in heavy rotation in the health space. Health experts are increasingly raising up the idea that place or “zip code” often determines health outcomes and, as a result, that we need to be much more thoughtful about how community-level factors shape health.
The cross-sector collaboration that could result from common messaging is exciting. Perhaps together, those working in the health and housing sectors can more effectively describe the dividends of a healthier population when they are safely and affordably housed.
Baran, M., N. Kendall-Taylor, A. Haydon, and A. Volmert. A House, a Tent, a Box: Mapping the Gaps Between Expert and Public Understandings of Healthy Housing. FrameWorks Institute, Washington, D.C. (2016). www.FrameWorksInstitute.org
Brisson, A., and L. Duerr. Impact of Affordable Housing on Families and Communities: A Review of the Evidence Base. Enterprise Community Partners, Columbia, MD (2014). www.enterprisecommunity.com/resources
Saul, A., C. Gladstone, M. Weller, K. Vartanian, B. Wright, G. Li, Center for Outcomes Research and Education (CORE). Health in Housing: Exploring the Intersection between Housing and Health Care. Enterprise Community Partners, Columbia, MD (2016). www.enterprisecommunity.com/resources.
Takaro, T., J. Krieger, L. Song, D. Sharify, and N. Beaudet. “The breathe-easy home: The impact of asthma-friendly home construction on clinical outcomes and trigger exposure.” American Journal of Public Health: 101(1) (2011): 55–62.
Viveiros, Janet, N. Maqbool, and M. Ault. The Impacts of Affordable Housing on Health: A Research Summary. Center for Housing Policy Washington, D.C. (2015). http://media.wix.com/ugd/19cfbe_d31c27e13a99486e984e2b6fa3002067.pdf