Longitudinal study of the housing and mental health outcomes of tenants appearing in eviction court

Evictions, legal counsel, and population health: A mixed methods study

BACKGROUND

Access to stable, affordable housing is critical for physical and mental health. As affordable housing has become increasingly inaccessible for many American households, eviction has become a common experience for renters. Existing eviction research has motivated an ongoing movement to provide universal legal counsel to evicted tenants through Right to Counsel (RTC) initiatives. While prior studies have explored the potential population health benefits of RTC programs, more research is needed to comprehensively understand the effectiveness of RTC as a public health intervention.

METHODS

Using a sequential exploratory design, this study first presents qualitative data from semi-structured interviews with evicted tenants who received legal aid from Washington State's first-in-the-nation statewide RTC program (n = 45). These results are supplemented with descriptive, quantitative analysis of case outcomes (n = 970 cases from January 2024) which tenants identified as being related to mental and physical health outcomes.

FINDINGS

Attorneys help their clients manage the psychological and logistical burdens of an eviction, resulting in the perception of reduced stress. Legal representation is linked to case outcomes which could improve short-term housing security and long-term housing trajectories. Findings also demonstrate that tenants are approximately half as likely as their landlords to have legal representation during their eviction proceedings despite the program's broad eligibility criteria.

CONCLUSIONS

Results demonstrate the potential health benefits of legal representation for tenants. While prior research has identified many health-related benefits of legal representation for tenants, policymakers may need to increase representation rates to maximize the population health benefits of RTC programs.

Expiration of a state level eviction moratorium in the first or second trimester of pregnancy and perinatal outcomes among Medicaid and uninsured people, 2020-2022

GOAL

Housing insecurity is associated with poor perinatal outcomes. However, we lack information on whether supportive housing policies improve perinatal health. Our goal was to estimate the effect of expiration of a state-level eviction moratoria on adverse maternal and infant outcomes among Medicaid insured individuals residing in states with a state-level moratorium in place at conception in the United States.

METHODS

We used data from the US natality files, 2020-2022 and the Eviction Moratoria & Housing Policy dataset to link individuals with moratoria. We compared those for whom the moratorium expired prior to conception, in the first trimester, or second trimester (exposed) with those fully protected through gestation (unexposed) We fit log binomial models to estimated risk ratios (RRs) and 95% confidence intervals (CIs) for each outcome separately (preterm birth (PTB), very preterm birth (VPTB), low birthweight birth (LBW), very low birthweight birth (VLBW), primary cesarean, maternal morbidity, or adequate/adequate plus prenatal care utilization) using generalized estimating equations, controlling for month/year of conception, state (unemployment, monthly covid death rates per 100,000, median household income, governor's party affiliation 2019), and individual (primiparity, age, race/ethnicity) confounders. We also fit difference in difference models as an alternate approach.

RESULTS

We included 2,562,067 births (PTB: 12.5%, LBW: 8.1%, primary cesarean:14.1%). All adverse outcomes were more common for births where the moratoria expired prior to conception or during the first trimester. Following adjustment, risk remained significantly elevated for primary cesarean (preconception v. fully protected: RR: 1.08, 95% CI: 1.02, 1.14; first trimester: 1.05, 95% CI: 0.99, 1.11) but not other outcomes. Results from difference in difference models were consistent with multilevel models.

CONCLUSIONS

Expiration of an eviction moratoria during the first or second trimester of pregnancy was not associated with increased risk of adverse birth outcomes, beyond ongoing state and temporal factors for people birthing in the United States during the COVID-19 global pandemic.

Spatiotemporal analysis of the association between residential eviction and fatal overdose in Rhode Island

Objective

Policy ramifications of the COVID-19 pandemic shape the concurrent housing and overdose crises in the USA. Housing insecurity is a known risk factor for overdose, yet how residential eviction may influence fatal overdose risk is understudied. We sought to evaluate the spatiotemporal relationship between neighbourhood-level residential eviction rates and overdose mortality in Rhode Island (RI) before and during a statewide eviction moratorium in response to COVID-19.

Methods

We conducted an ecological study at the census tract level in RI (N=240) by modelling the association between quintiles of eviction rates and fatal overdose rates from 2016 to 2021. We applied a Bayesian spatiotemporal approach using an integrated nested Laplace approximation and adjusted for an a priori determined set of time-varying demographic and policy covariates.

Results

Descriptively, we observed a direct, dose-response relationship between quintiles of eviction incidence rates over the full study period and fatal overdose. Prior to the implementation of a statewide eviction moratorium, census tracts in the highest eviction quintile had increased rates of overdose mortality, relative to those in the lowest quintile (posterior mean relative rate = 1.49, 95% credible interval: 1.05 to 2.13). Associations during the periods of eviction moratorium were non-significant.

Conclusion

This work highlights the neighbourhood-level relationship between residential eviction and fatal overdose risk in the absence of an eviction moratorium. Enhanced investment in eviction prevention policies, such as rent relief and limitations to the circumstances under which landlords can file for eviction, may complement harm reduction efforts to reduce neighbourhood-level overdose inequalities.

COVID-Related Stressors and Psychological Distress Among Chicago Residents: the Moderating Role of Race

BACKGROUND

Racial and ethnic minorities have been disproportionately affected by the COVID-19 pandemic and have experienced greater financial loss, housing instability, and food insecurity due to COVID-related restrictions. As a result, Black and Hispanic communities may be at greater risk of experiencing psychological distress (PD).

METHODS

Using data collected between October 2020 and January 2021from 906 Black (39%), White (50%), and Hispanic (11%) adults, we assessed racial/ethnic differences in the effect of three COVID-related stressors-employment stress, housing instability, and food insecurity-on PD using ordinary least square regression.

RESULTS

Black adults reported lower PD levels compared to White adults (β =  - 0.23, P < 0.001), but Hispanic adults did not differ significantly from White adults. COVID-related housing instability (β = 0.46, P < 0.001), food insecurity (β = 0.27, P < 0.001), and employment stress (β = 0.29, P < 0.001) were associated with higher PD. Employment stress was the only stressor to differentially affect PD by race/ethnicity. Among those that reported employment stress, Black adults had lower levels of distress compared to Whites (β =  - 0.54, P < 0.001) and Hispanics (β =  - 0.04, P = 0.85).

CONCLUSION

Despite relatively high exposure to COVID-related stressors, Black respondents had lower levels of PD compared to Whites and Hispanics which may reflect differences in race-specific coping mechanisms. Future research is needed to elucidate the nuances of these relationships and identify policies and interventions that prevent and minimize the impact of employment, food, and housing-related stressors and support coping mechanisms that promote mental health among minority populations, such as policies that support easier access to mental health and financial and housing assistance.

Prevalence of eviction, home foreclosure, and homelessness among low-income US veterans: the National Veteran Homeless and Other Poverty Experiences study

OBJECTIVES

Housing stability is essential for health and social well-being, and the United States is focused on preventing homelessness among veterans, so this study examined the prevalence of different events related to housing instability among low-income US veterans.

STUDY DESIGN

This was a nationally representative survey.

METHODS

Using a sample of 1004 low-income veterans in 2021, this study examined the lifetime prevalence and characteristics associated with eviction, home foreclosure, and homelessness among low-income US veterans.

RESULTS

In the total sample, 10.9% reported a lifetime history of eviction, 8.0% reported a lifetime history of home foreclosure, and 19.9% reported a lifetime history of homelessness. Among those with a history of homelessness, 39.2% also reported a history of eviction, and 13.9% reported a history of home foreclosure. Hierarchical logistic regression analyses found that for eviction, sociodemographic characteristics (e.g. being Hispanic, having private insurance, and being from the Northeast was associated with lower risk of eviction) together explained 26% of the variance, and clinical characteristics explained an incremental 12% additional variance. For homelessness, sociodemographic characteristics explained 18% of the variance, and clinical characteristics explained an incremental 20% (e.g. diagnosis of schizophrenia or bipolar disorder, any history of suicide attempt, and lower physical health scores were associated with higher risk of homelessness). For home foreclosure, sociodemographic, clinical, and psychosocial variables together only explained 14% of the variance.

CONCLUSION

Evictions, home foreclosures, and homelessness are discrete events and occur at relatively high rates among low-income veterans. In addition, homelessness was more associated with biosocial dysfunction, whereas eviction was more closely associated with socio-economic vulnerability, which may inform intervention efforts for both events.

The risk of eviction and the mental health outcomes among the US adults

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Perceived risk of eviction among people living with rent arrears is associated with elevated mental health problems.

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Prevalence of depression, anxiety, and pyschotropic medication use is higher in the at-risk of eviction group compared to the non-risk group.

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Addressing the housing crisis is crucial in decreasing the mental health burden among people living in rented residences.

Although past studies establish a link between residential instability and poor mental health, studies investigating the association between perceived risk of eviction and mental health with nationally representative data are largely lacking. This study examines the association between self-reported risk of eviction and anxiety, depression, and prescription medication use for mental or emotional health reasons. This is a retrospective observational study using the repeated-cross sectional data (n = 14548; unweighted) using the US Census Bureau’s Household Pulse Survey from July 2021 to March 2022. Survey respondents aged 18 years and above who lived in rented residences and were not caught up with the rent payments at the time of the survey were included in the analysis. The descriptive summary shows a higher prevalence of depression (59.33 % vs 37.01 %), anxiety (67.01 % vs 43.28 %), and prescription medication use (26.57 % vs 23.68 %) among the respondents who are likely to face eviction in the next two months compared to the reference group not at the risk of eviction. When adjusted for demographic characteristics, family context, and socioeconomic setting, the odds of depression, anxiety, and prescription medication use in the at-risk eviction group were significantly higher than in the reference group. Specifically, odds ratios (ORs) [95 % CI] for depression, anxiety, and prescription medication use are 2.366 [2.364, 2.369], 2.650 [2.648, 2.653], and 1.172 [1.171, 1.174], respectively. These results suggest that the perceived risk of eviction is associated with elevated mental health problems. Addressing the housing crisis may help decrease the mental health burden among rented households.

Characteristics of Tenants Who Delayed Rent Payments during Eviction Moratoria in 2020

This study examined the characteristics of US tenants who reported delaying rent payments during the eviction moratoria in 2020 in respond to the coronavirus disease 2019 (COVID-19) pandemic. A nationally representative sample of 3393 US tenants was assessed from May to June 2020 during a period that eviction moratoria were issued across the country. In the total sample, 22.9% of US tenants reported they delayed paying rent because of the eviction moratoria. Tenants who delayed paying rent were nearly 7 times as likely to be at risk of eviction, more than 3 times as likely to endorse recent suicidal ideation, and 1.6 times as likely to report recent illicit drug use compared to tenants who did not delay paying rent. These findings highlight the health and social needs of tenants in the aftermath of the COVID-19 pandemic.

Evictions and tenant-landlord relationships during the 2020-2021 eviction moratorium in the US

This study provisionally examined the effects of the US eviction moratorium instituted in response to the Coronavirus Disease 2019 (COVID-19) pandemic. Three waves of data collected May 2020-April 2021 from a nationally representative sample of middle- and low-income US tenants (n = 3393 in Wave 1, n = 1311 in Wave 2, and 814 in Wave 3) were analyzed. Across three waves, 4.3% of tenants reported experiencing an eviction during the moratorium and 6%-23% of tenants reported delaying paying rent because of the moratorium. Multivariable analyses found that tenants who delayed paying their rent, were female, or had a history of mental illness or substance use disorder were more likely to report the eviction moratorium had a negative effect on their landlord relationship. COVID-19 infection was not predictive of eviction but tenants with a history of homelessness were more than nine times as likely to report an eviction than those without such a history. Together, these findings suggest the eviction moratorium may have had some unintended consequences on rent payments and tenant-landlord relationships that need to be considered with the end of the federal eviction moratorium.

Variation in State-Level Eviction Moratorium Protections and Mental Health Among US Adults During the COVID-19 Pandemic

Importance

Although evictions have been associated with adverse mental health outcomes, it remains unclear which stages of the eviction process are associated with mental distress among renters. Variation in COVID-19 pandemic eviction protections across US states enables identification of intervention targets within the eviction process to improve renters' mental health.

Objective

To measure the association between the strength of eviction protections (ie, stages blocked by eviction moratoriums) and mental distress among renters during the COVID-19 pandemic.

Design, Setting, and Participants

This cohort study used individual-level, nationally representative data from the Understanding Coronavirus in America Survey to measure associations between state eviction moratorium protections and mental distress. The sample of 2317 respondents included renters with annual household incomes less than $75 000 who reported a state of residence and completed surveys between March 10 and September 3, 2020, prior to the federal eviction moratorium order by the Centers for Disease Control and Prevention.

Exposures

Time-varying strength of state moratorium protections as a categorical variable: none, weak (blocking court hearings, judgments, or enforcement without blocking notice or filing), or strong (blocking all stages of the eviction process beginning with notice and filing).

Main Outcomes and Measures

Moderate to severe mental distress was measured using the 4-item Patient Health Questionnaire. Linear regression models were adjusted for time-varying state COVID-19 incidence and mortality, public health restrictions, and unemployment rates. Models included individual and time fixed effects as well as clustered standard errors.

Results

The sample consisted of 2317 individuals (20 853 total observations) composed largely (1788 [78%] weighted) of middle-aged adults (25-64 years of age) and women (1538 [60%]); 640 respondents (23%) self-reported as Hispanic or Latinx, 314 respondents (20%) as non-Hispanic Black, and 1071 respondents (48%) as non-Hispanic White race and ethnicity. Relative to no state-level eviction moratorium protections, strong protections were associated with a 12.6% relative reduction (risk ratio, 0.87; 95% CI, 0.76-0.99) in the probability of mental distress, whereas weak protections were not associated with a statistically significant reduction (risk ratio, 0.96; 95% CI, 0.86-1.06).

Conclusions and Relevance

This analysis of the Understanding Coronavirus in America Survey data found that strong eviction moratoriums were associated with protection against mental distress, suggesting that distress begins early in the eviction process with notice and filing. This finding is consistent with the idea that to reduce mental distress among renters, policy makers should focus on primary prevention of evictions.

Parental relationship status and age at autism spectrum disorder diagnosis of their child

LAY ABSTRACT

Autism spectrum disorder (ASD) can be diagnosed as early as 18 months of age. However, the average age at diagnosis in the United States is over 2 years later. A lot has been written about the many barriers families face when seeking a diagnosis for their child. One area of research that has received no attention is whether separation between a child's biological parents affects the age at which a child is diagnosed with ASD. This study was conducted among 561 children who were receiving an ASD diagnosis for the first time. On average, these children were 5 years of age. The study took place in an urban, outpatient specialty autism clinic in the United States. Biological parents self-reported their relationship status during the evaluation. This was categorized as either "together" (married or living together but not married) or "not together" (separated, divorced, or never married). At the time of diagnosis, most children's biological parents were together (69%). We found children of parents who were together were diagnosed 1.4 years earlier than those who were not together. These findings have important implications for providing support to families that separate early in a child's life, with the goal of reducing the age at ASD evaluation among single parents and those who have been separated from their child's other biological parent. Providing support to these families is important since earlier age at diagnosis leads to earlier intervention, which can improve long-term outcomes for the child, family, and community as a whole.

Housing, Living Arrangements and Mental Health of Young Adults in Independent Living

Young adults are prone to psychological stress and anxiety induced by major transitions to adulthood. While employment has predominated in previous research on the social determinants of young people’s mental health, this study examines the association between young people’s housing problems and mental health in the context of an unaffordable housing market. Using the Survey on the Living Conditions and Welfare Needs of Youths (n = 1308) in Korea, the study found that perceived poor housing quality and material hardship are negatively associated with the mental health of young adults living independently. Specifically, while poor housing quality and material hardship induced by housing cost burden were negatively associated with single-person households’ mental health, only poor housing quality was associated with non-single-person households’ mental health. This study is one of the few studies examining the linkage between housing problems and mental health of young adults and informs the interventions aimed at promoting the psychological well-being of young adults in the transition from parents’ homes to independent living.

Unhealthy behaviours in urban Illinois communities affected by eviction: A descriptive analysis

Eviction of renter-occupied homes is an emerging public health crisis adversely impacting populations already at risk. Although housing quality and home-owner foreclosures have been linked to health outcomes, the relationship between eviction of renter-occupied homes and health has not been well established. The demographics and socioeconomic status of renters differs from homeowners, as such any relationship with health outcomes should be distinguished between the two. The aim of this study is to provide a descriptive analysis of the relationship between renter-specific eviction and unhealthy behaviours at the census tract level. Using data from the Centers for Disease Control and Prevention 500 Cities Project, the Eviction Lab and the U.S. Census Bureau, this study assesses the relationship between eviction rates and health indicators for 1,267 urban census tracts in Illinois in 2016. Binge drinking, current smoking, no leisure-time physical activity, obesity and sleeping <7 hr were used as indicators of unhealthy behaviour as categorised by the Centers for Disease Control and Prevention500 Cities Project. Unadjusted and adjusted linear regression models were used to assess and describe the relationship between each of the dependent variables and each of the independent variables. All five of the unhealthy behaviour indicators were found to be significantly associated with eviction rates and eviction filing rates after adjustment for confounding variables. This study contributes to the understudied area of research focused on how eviction rates contribute to the social determinants of health for already at-risk populations.

The effect of eviction moratoria on the transmission of SARS-CoV-2

Massive unemployment during the COVID-19 pandemic could result in an eviction crisis in US cities. Here we model the effect of evictions on SARS-CoV-2 epidemics, simulating viral transmission within and among households in a theoretical metropolitan area. We recreate a range of urban epidemic trajectories and project the course of the epidemic under two counterfactual scenarios, one in which a strict moratorium on evictions is in place and enforced, and another in which evictions are allowed to resume at baseline or increased rates. We find, across scenarios, that evictions lead to significant increases in infections. Applying our model to Philadelphia using locally-specific parameters shows that the increase is especially profound in models that consider realistically heterogenous cities in which both evictions and contacts occur more frequently in poorer neighborhoods. Our results provide a basis to assess eviction moratoria and show that policies to stem evictions are a warranted and important component of COVID-19 control.

The effect of eviction moratoria on the transmission of SARS-CoV-2

Massive unemployment during the COVID-19 pandemic could result in an eviction crisis in US cities. Here we model the effect of evictions on SARS-CoV-2 epidemics, simulating viral transmission within and among households in a theoretical metropolitan area. We recreate a range of urban epidemic trajectories and project the course of the epidemic under two counterfactual scenarios, one in which a strict moratorium on evictions is in place and enforced, and another in which evictions are allowed to resume at baseline or increased rates. We find, across scenarios, that evictions lead to significant increases in infections. Applying our model to Philadelphia using locally-specific parameters shows that the increase is especially profound in models that consider realistically heterogenous cities in which both evictions and contacts occur more frequently in poorer neighborhoods. Our results provide a basis to assess municipal eviction moratoria and show that policies to stem evictions are a warranted and important component of COVID-19 control.