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The Health-Housing Nexus: New Answers to Key Questions

The importance of housing to create health is increasingly proven.

The link between housing and health is far-reaching and complex. Historically, the housing-health nexus has been primarily associated with physical exposures and dilapidated housing; however, recent studies suggest that adverse health outcomes are also linked to housing rental assistance status, housing insecurity, a lack of affordable housing, and neighborhood quality.

Substandard, unaffordable housing and stalled community development affects the health of millions of American families. Policymakers must disentangle the complex relationships between housing and health to effectively address this public health challenge. A recent special issue of Cityscape magazine adds to the current body of evidence highlighting the relationship between health and housing. Throughout the issue, the authors examine innovative approaches, cross-sector poli­cies, and programs that promote the utilization of housing as a platform to improve quality of life. Below we summarize their main findings and include links to the original article for those interested in reading further.

Evaluations of the Health Impact of Housing-Based Interventions

The first group of articles present evaluations of the health impact of housing-based interventions. The authors Kandilov and colleagues asked: Does providing supportive services in housing developments reduce Medicare spending? Using Medicare claims data and a difference-in-difference study design, they found that the Vermont’s Supportive and Services at Home program was not associated with lower healthcare spending overall, but Medicare expenditures did decline in a subset of developments. (click here for full text)

Freeman et al. investigate: Does the placement of community health workers in assisted housing developments promote positive health outcomes? By studying the implementation of a community health worker program in two subsidized housing developments in the Lower East Side neighborhood of Manhattan, NY, the authors found that a large majority of residents reported meeting their goals, expressed improved overall well-being, and stated satisfaction with the community health worker program. (click here for full text)

And Frescoln and colleagues ask: Can work requirements promote self-sufficiency? What are the health consequences of these requirements? Using a mixed-methods approach, the authors suggest that when work requirements are implemented alongside case management, these initiatives can increase residents’ employment. However, this employment had the potential to lead to negative impacts on receipt of food assistance and Medicaid enrollment. (click here for full text)

State and Local Efforts To Bridge the Divide Between Housing and Health

The next section of the special Cityscape issue highlights state and local efforts designed to bridge the divide between housing and health. The first article by Bailey and colleagues asks: How do state and local housing programs address the relationship between housing assistance and health? The researchers provide an in-depth analysis of the development of 19 state- and locally-funded rental assistance programs in two cities (District of Columbia and San Francisco) and eight states (Connecticut, Illinois, Iowa, Maryland,

Minnesota, Nebraska, New Jersey, and Oregon) showing how these programs promote housing affordability and address the complex housing and health relationship. Researchers found that most programs targeted populations served by state or local health and human services programs; served a growing number of households over time; generally increased their funding over time from general revenue; and involved collaboration between housing and health and human services.  Bailey and colleagues concluded that rental assistance plays a critical role in helping states and localities achieve better health outcomes for key populations, such as families with children, or those experiencing homelessness or mental health challenges (click here for full text).

Next De Scisciolo and colleagues explore the role of public health in the design process: How can housing developers incorporate public health throughout the design process? They report on a pilot study in which five community development corporations partnered with public health professionals to create Health Action Plans. They found that all CDC partners gained a deeper understanding of how the built environment can impact health and were likely to engage public health professionals in the future, indicating that Health Action Plans could be important frameworks to help CDCs conceptualize development as a mechanism to promote resident health outcomes(click here for full text)

And Lucas explored the question: To what extent are public housing authorities currently partnering to support the health and well-being of HUD-assisted individuals and families? Through a survey of housing authorities, he found that large public housing authorities reported high engagement with public health entities and community-based social and human service providers, but housing authorities also reported limitations in funding, staffing, and data sharing (click here for full text).

New Qualitative and Quantitative Evidence Examining the Link Between Housing and Health

The last four articles of the issue provide new evidence exploring the link between housing and health. Using qualitative interviews, Keene and colleagues sought to answer the question: What are the mechanisms through which subsidized housing might impact chronic disease management?  Specifically, authors studied low-income residents with type 2 diabetes diagnoses andfound that receipt of rental assistance was accompanied by improvements in diabetes self-management through greater control of factors influencing the ability to follow a diabetes routine and the ability to afford diabetes-related expenses and mitigate financial stress (click here for full text).

Cutts et al. ask: How does homelessness during infancy impact maternal and child health? The authors identified that homelessness during infancy was significantly associated with higher developmental risk and, for mothers, worse overall health and depressive symptoms and concluded that interventions providing housing and other health-related resources to homeless families with infants may improve health and family hardship (click here for full text).

Through the analysis of panel survey data, Antonakos and Colabianchi examined: Does receipt of housing assistance impact health behaviors? The study found that receipt of rental assistance was linked with higher rates of smoking and obesity at two-year follow-up, but not at long-term follow-up. No association was observed for several other health behaviors or risk factors, including body mass index, alcohol consumption, or physical activity (click here for full text).

Finally, Wang and Immergluck explored: How does housing vacancy impact population health? They found that higher numbers of vacant homes is significantly associated with adverse health outcomes such as stroke, coronary heart disease, etc.  in the neighborhood. However, this link between housing vacancy and neighborhood health varied according to whether the metropolitan area was experiencing strong or weak growth (click here for full text).

Conclusion

Taken together, the research presented in the Cityscape, spanning housing-based interventions; state and local efforts and partnerships; and new evidence on the link between housing, health behaviors, and health outcomes adds to our growing understanding through evaluation of health impact of housing interventions, review of state and local efforts to bridge health and housing, and new evidence linking health and housing. We hope that this special issue will stimulate innovative ideas about how the housing and health sectors can partner at the national, state, and local levels to promote secure housing and foster both individual and population health.

About the Author

Veronica Helms Garrison and Craig Evan Pollack

Veronica Helms Garrison is a social science analyst at the U.S. Department of Housing and Urban Development, Office of Policy Development and Research, and a doctoral student at the Johns Hopkins Bloomberg School of Public Health.

Craig Evan Pollack is an associate professor of medicine, epidemiology, and health policy and management at the Johns Hopkins School of Medicine and the Bloomberg School of Public Health.