Building the case for housing policy: Understanding public beliefs about housing affordability as a key social determinant of health

Housing inequalities and health outcomes among migrant and refugee populations in high-income countries: a mixed-methods systematic review

BACKGROUND

Migrant and refugee populations are disproportionately affected by the housing crises reportedly impacting high-income countries around the globe. However, the health implications of housing inequalities within these communities and contexts remain relatively understudied. This review aimed to synthesise the evidence on housing and health inequalities prevalent among migrant and refugee populations in high-income countries, and to identify the pathways linking housing inequalities and health outcomes.

METHODS

This systematic review employed the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews using a convergent integrated approach to synthesis and integration. Electronic database searches were conducted using Medline (OVID), Web of Science (ISI), Embase (OVID), PsycInfo (OVID), Scopus, and CINAHL (EBSCO), supplemented by grey literature searches on Google Scholar, MedNar, and WHOLIS. Eligible studies included quantitative, qualitative, and mixed methods designs focused on understanding how housing inequalities are associated with physical and mental health outcomes.

RESULTS

A total of 65 studies published between 1995 and 2024 were included in this review, comprising 38 quantitative and 27 qualitative studies. Substandard housing conditions, such as overcrowding and poor ventilation, were consistently associated with adverse physical and mental health outcomes, including respiratory illnesses and experiences of anxiety and depression. The type of housing tenure also impacted both physical and mental health, specifically living in inadequate rental housing as opposed to self-owned homes, was linked with poorer physical health and increased risk of mental health issues. Similarly, housing insecurity stemming from unstable housing situations and insecure tenancy, as well as neighbourhood conditions such as safety concerns and living in deprived neighbourhoods, led to the exacerbation of both physical and mental health issues. Furthermore, housing affordability challenges and decreased housing satisfaction were linked with poor mental health outcomes such as experiences of depression and psychological distress.

CONCLUSIONS

This review highlights the critical role of housing as a social determinant of health and wellbeing for migrant and refugee populations in high-income countries, along with highlighting the potential pathways through which housing inequalities impact physical and mental health outcomes. Ensuring access to adequate, affordable, and secure housing, while also improving neighbourhood conditions, is essential for improving the health and wellbeing of migrant and refugee populations.

Mental Health and U.S. Attitudes Toward Social Determinants of Health Policies

INTRODUCTION

Research has suggested that individual health may influence policy attitudes, yet the relationship between mental health and policy support is understudied. Clarifying this relationship may help inform policies that can improve the population mental health. To address this gap, this study measures national support for 5 social determinants of health policy priorities and their relation to mental health and political affiliation.

METHODS

This study assessed support for 5 policy priorities related to the social determinants of health using a nationally representative survey of US adults (n=2,430) conducted in March-April 2023. Logistic regression was used to estimate the predicted probability of identifying each priority as important, test differences in support by self-rated mental health, and evaluate whether partisanship modified these relationships. Analyses were conducted in 2023.

RESULTS

The majority of US adults, across partisan identities, supported 5 policy priorities related to improving the economy (84%), healthcare affordability (77%), improving K-12 education (76%), housing affordability (68%), and childcare affordability (61%). Worse mental health predicted significantly greater support for addressing housing affordability (73.9% vs 66.2%), and partisanship modified the relationship between mental health and support for improving the economy, improving K-12 education, and housing affordability.

CONCLUSIONS

In 2023, there was substantial bipartisan support for federal policy action to address the social determinants of health, and worse mental health was related to greater policy support, particularly among Democrats. Federal policymakers have a broad consensus to take action to address the social determinants of health, which may improve the population mental health.

Integrating developmental neuroscience with community-engaged approaches to address mental health outcomes for housing-insecure youth: Implications for research, practice, and policy

One in three children in the United States is exposed to insecure housing conditions, including unaffordable, inconsistent, and unsafe housing. These exposures have detrimental impacts on youth mental health. Delineating the neurobehavioral pathways linking exposure to housing insecurity with children's mental health has the potential to inform interventions and policy. However, in approaching this work, carefully considering the lived experiences of youth and families is essential to translating scientific discovery to improve health outcomes in an equitable and representative way. In the current paper, we provide an introduction to the range of stressful experiences that children may face when exposed to insecure housing conditions. Next, we highlight findings from the early-life stress literature regarding the potential neurobehavioral consequences of insecure housing, focusing on how unpredictability is associated with the neural circuitry supporting cognitive and emotional development. We then delineate how community-engaged research (CEnR) approaches have been leveraged to understand the effects of housing insecurity on mental health, and we propose future research directions that integrate developmental neuroscience research and CEnR approaches to maximize the impact of this work. We conclude by outlining practice and policy recommendations that aim to improve the mental health of children exposed to insecure housing.

Does Subsidized Housing Prevent Health Decline and 2-Year Mortality Among Low-Income Older Renters?

BACKGROUND AND OBJECTIVES

A growing number of older adults in the United States need subsidized housing, but only 36% of eligible households receive assistance. The purpose of this study is to examine if older renters living in subsidized housing are less likely to experience health decline and mortality over 2 years compared to low-income older renters who are likely eligible, but do not receive assistance.

RESEARCH DESIGN AND METHODS

Baseline data include 671 subsidized and unsubsidized low-income older renters from the 2015 National Health and Aging Trends Study. Outcomes of interest include self-rated health decline, developing a new activity limitation, or 2-year mortality between 2015 and 2017. Weighted stepwise logistic regression models test (a) if subsidized older renters were less likely to experience health decline or 2-year mortality compared to unsubsidized older renters, and (b) if housing quality and neighborhood factors mediate the association between subsidized housing and health decline/mortality.

RESULTS

Subsidized older renters were less likely to develop a new activity limitation compared to unsubsidized older renters, but there was not a statistically significant difference in experiencing self-rated health decline or 2-year mortality by subsidized housing status. Housing quality and neighborhood factors did not significantly mediate this association.

DISCUSSION AND IMPLICATIONS

The results provide some support that improving access to subsidized housing for low-income older renters may have additional health benefits, even in the short term. To inform program improvements and maximize potential health benefits, more research is needed to understand the specific health-promoting features of subsidized housing.

Exposing Pittsburgh Landlords To Asset-Framing Narratives: An Experiment To Increase Housing Voucher Participation

Landlords are essential actors within the rental housing market, and there is much to be learned about their willingness to participate in rental assistance programs that improve access to stable housing. Because the success of these programs, such as the Mobility (Location-Based) Voucher program in Pittsburgh, Pennsylvania, can be derailed by landlord opposition, it is important to test strategies that increase landlords' participation. Using data from a unique survey of Pittsburgh landlords, we found that exposing landlords to an asset-framing narrative that highlighted the social, economic, and health benefits of receiving a mobility voucher increased landlords' reported willingness to rent to a mobility voucher recipient by 21 percentage points. Reported willingness was also higher among landlords who believed that housing affordability was connected to health. Our findings offer insight into how to increase landlords' participation in affordable housing programs that require their engagement to succeed.

Financial Behavioral Health and Investment Risk Willingness: Implications for the Racial Wealth Gap

Financial behavioral health (FBH) influences numerous socio-ecological domains, affecting investment risk willingness and consequent wealth levels. The experience of FBH by racial group is unknown, and findings of differences between Black and White investors' risk willingness are mixed. The study's aims are to establish an FBH measure and explore its application to risk willingness by racial group. The study used a subset of data from FINRA's 2018 National Financial Capability Study, including Black (n = 2835) and White (n = 21,289) respondents. Through factor analysis, 19 items were confirmed for the FBH measure; the measure was then applied to investment risk willingness using structural equation modeling (SEM). Invariance analyses showed that the FBH model had an excellent fit for White respondents but not Black respondents. The SEM analysis determined that FBH accounted for 37% of the variance in risk willingness (R² = 0.368; β = 0.256, p < 0.001). Racial group affiliation was a negligible predictor of risk willingness (β = -0.084, p < 0.001). This project contributes an empirical basis for FBH, emphasizes the importance of FBH for investment risk willingness, and elucidates that racial group differences in risk willingness could be an unlikely contributor to the wealth gap.

Rent Burden and Depression Among Mothers: an Analysis of Primary Caregiver Outcomes

Using national longitudinal survey data from the Fragile Families & Child Wellbeing Study (FFCWS), this study builds on existing knowledge about housing insecurity, female caregivers, and well-being. The study analyzed the relationship between housing cost burdens (HCB) and depression among a sample (N = 399) of predominantly (67.6%) Black non-Hispanic mothers and other female primary caregivers. A generalized estimating equation (GEE) model yielded results that indicate housing cost burden among mothers and other female primary caregivers has a statistically significant association with meeting symptoms of depression and liberal criteria for depression as measured by the CIDI-SF survey instrument. This study contributes to the knowledge base of health outcomes related to housing cost burden by providing a unique analysis of the association of depression and housing cost burden at an unprecedented scale by using data from several consecutive waves of survey responses of a large, multi-city, longitudinal study. The findings hold implications that may inform future policy and research concerning the affordable housing crisis, which disproportionately affects mothers and other female heads of household. Considering the prevalence of housing cost burden in the USA and the disproportionate indications of depression found among housing burdened mothers/female caregivers, the findings of this study may hold implications for housing and health policies that address U.S. communities as diverse as the wide range of communities from which the FFCWS respondents were drawn.

“So Glad to Be Home”: Money Follows the Person Participants’ Experiences After Transitioning Out of an Institution

This study examined qualitative data from participants who transitioned from institutional to community living through the Money Follows the Person (MFP) Rebalancing Demonstration in Connecticut. As part of the MFP quality of life survey, 1,566 participants provided qualitative feedback about their experiences at 6-, 12-, and 24-month time points after transition. Maslow’s Hierarchy of Needs serves as a thematic framework to analyze the data. In their open-ended comments, many participants underscored the efficacy of the program and offered constructive feedback; some people also reported barriers and challenges to community living. While MFP participants generally report high satisfaction with the program, both in Connecticut and nationally, some participants identified areas of unmet need, including housing, transportation, and workforce issues. Findings have the potential to expand stakeholders’ understanding of participants’ needs and facilitate policies to improve services and supports for older adults and people living with disabilities who return to community living following institutionalization.

Housing Is Mental Health Care: A Call for Medicaid Demonstration Waivers Covering Housing

Housing is critical to enabling people with serious mental illnesses to live successfully in their communities. Yet unlike other essential community-based services, housing cannot be covered under the Medicaid program, which guarantees states federal reimbursement for between 50% and 83% of the cost of services. Instead, service systems rely on federal housing assistance programs and, where available, on state or local housing subsidy programs. Mental health service systems could make housing more widely available if they could use federal Medicaid funds for housing. The federal government has not provided Medicaid reimbursement for housing because of Medicaid's exclusion of "room and board," but it has recently granted Medicaid demonstration waivers that lift a similar statutory prohibition: the institutions for mental disease (IMD) exclusion rule, which bars Medicaid payments for services to individuals ages 21 to 64 in psychiatric institutions. If the government approves demonstration waivers of the IMD exclusion, it should similarly approve demonstrations covering housing for people with serious mental illnesses. If these demonstrations show that providing Medicaid financing for housing improves mental health outcomes and reduces use of more costly services, those results should spur a conversation about modifying Medicaid to allow reimbursement for housing in appropriate circumstances.

Studying Healthcare Affordability during an Economic Recession: The Case of Greece

The significant deterioration of economic prosperity in Greece during the economic crisis decreased patients’ ability to pay. Thus, the objective of this study is to determine the factors affecting healthcare affordability in Greece during an economic recession. This study used data from the European Union Statistics on Income and Living Conditions (EU-SILC) 2016. The sample consisted of 18,255 households. Healthcare affordability was regressed on geographic characteristics as well as several variables that refer to the households’ financial condition. Region of residence, ability to make ends meet, and capacity to cope with unexpected financial expenses were found to be statistically significant. Using sample sizes of 1000 and 1096 adults, respectively, the European Quality of Life Surveys (EQLS) of 2007 and 2016 were also used as data sources. Economic crisis was expressed with a dummy variable: (1) 0: 2007, and (2) 1: 2016. Difficulty in responding to healthcare costs was regressed on survey year and several demographic, socioeconomic, and health characteristics, revealing that individuals were more likely to face difficulties in responding to healthcare costs during the economic crisis. These results confirm the mechanism on the basis of which economic crises affect healthcare access: primarily through the effects of demand-side barriers.

Mothers' homeownership and children's economic success 20 years later among a sample of US citizens

Familial economic hardship, an adverse childhood experience (ACE) that increases children's risk for exposure to additional ACEs, can derail optimal child development. A compelling area with potential for reducing economic hardship and promoting healthy child development is housing. In the US, the largest contributor to family wealth is homeownership, which may contribute to a family's ability to provide their children opportunities to do better than previous generations. The objective of the current study was to examine the influence of homeownership on children's economic outcomes in adulthood. This study used data from two surveys conducted in the US, the National Longitudinal Survey of Youth 1979 (NLSY79) and the NLSY79 Young Adult survey, to examine the association between mothers' homeownership in 1994 and children's economic outcomes 20 years later. Adults whose mothers owned homes in 1994 were over 1.5 times more likely to own homes, attained higher education, and were moderately less likely to receive public assistance in 2014 compared to adults whose mothers did not own homes. This paper highlights the potential of homeownership to break the intergenerational continuity of poverty. Programs that help families purchase affordable housing hold promise in helping ensure children reach their full potential and improving economic outcomes in future generations.