Association Between Rental Assistance Programs and Hemoglobin A_1c Levels Among US Adults

Abstract

IMPORTANCE Programs that provide affordable and stable housing, such as federal rental assistance, may be associated with improved mean blood glucose levels and related diabetes outcomes.OBJECTIVE To assess whether 2 different types of federal rental assistance programs are associated with glycated hemoglobin A 1c (HbA 1c ) levels among middle-aged and older US adults. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used data from the National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development records of rental assistance participation. Adults aged 45 years or older who were receiving 2 types of rental assistance (project-based housing or housing vouchers) at the time of the NHANES interview and those who would receive rental assistance within the subsequent 2 years (waitlist group) were included. Data were collected from January 1999 to December 2016 and analyzed in October 2021. EXPOSURES Rental assistance participation, including project-based housing (subsidized housing developments including public housing) and housing vouchers (tenant-based subsidies for private market housing). MAIN OUTCOMES AND MEASURESThe primary outcome was continuous HbA 1c level, a common measure of blood glucose reflecting diabetes control. Linear regression was used to estimate the association between the 2 rental assistance programs and HbA 1c level. Logistic regression was used to assess the association between rental assistance programs and HbA 1c cut points (prediabetes: 5.7% to Յ6.5%; diabetes: >6.5%; uncontrolled diabetes: Ն9% [to convert to proportion of total Hb, multiply by 0.01]). Analyses used weights created by the National Center for Health Statistics that adjust for linkage eligibility. RESULTS Among 1050 adults in the study (41.6% aged Ն65 years; 70.1% female), 795 were receiving rental assistance at time of the NHANES interview (450 lived in project-based housing, and 345 had housing vouchers), and 255 received rental assistance within 2 years after the interview.Participants in project-based housing had lower HbA 1c levels compared with individuals in the waitlist group (β, −0.290; 95% CI, −0.599 to 0.020), but the difference was not significant. No significant differences in HbA 1c levels were found between those receiving housing vouchers and those in the waitlist group (β, 0.051; 95% CI, −0.182 to 0.284). Receiving project-based housing was associated with a reduced likelihood of uncontrolled diabetes (−3.7 percentage points; 95% CI, −7.0 to −0.0 percentage points) compared with being in the waitlist group. CONCLUSIONS AND RELEVANCEIn this cohort study of a nationally representative sample of US adults, living in project-based, federally subsidized housing was associated with a reduced likelihood (continued) Key Points Question Is receiving housing rental assistance associated with glycated hemoglobin A 1c (HbA 1c ) levels among middle-aged and older US adults? Findings In this cohort study of 1050 US adults aged 45 years or older, participants who were ...

Housing instability and cardiometabolic health in the United States: a narrative review of the literature

“…A study using the National Health and Nutrition Examination Survey (NHANES) survey data from 1999–2016 comparing 795 adults receiving either project-based housing ( n = 450) or housing vouchers ( n = 345) to 255 adults not yet receiving assistance but remained on the waitlist, found that those receiving project-based housing had lower HbA1c levels compared to the waitlist group, but the differences were not statistically significant. The authors did find, however, that residence in project-based housing was associated with a lower prevalence (− 3.7%, 95% CI − 7.0, 0.0%) of uncontrolled diabetes, defined as HbA1c ≥ 9.0% (74.9 mmol/mol), compared to the waitlist group [ 61 ]. A longitudinal cohort study by Lim et al found that residence in New York City public housing was associated with higher prevalence of stable housing pattern (PR 1.16, 95% CI 1.07, 1.25), based on number of address changes over the 12-year follow-up period, but not with reduced diabetes risk (relative risk [RR] 1.11, 95% CI 0.83, 1.48).…”

“…8 vouchers CVD CVD-related outcomes: history of heart attack or stroke (self-reported), hypertension Lower odds of CVD-related outcomes in unassisted housing group (OR 0.394, 95% CI 0.204, 0.761, p ≤ 0.01) and housing voucher group (OR 0.527, 95% CI 0.280, 0.992, p ≤ 0.05) compared to public housing group Chambers et al 2021 [ 59 ] Cross-sectional Bronx, New York 5846 adults with type 2 diabetes receiving care at Bronx, New York-based hospital system Social needs: housing quality, housing instability (worry about eviction/ homelessness), food insecurity, health transportation, cost-related healthcare nonadherence, utility insecurity, conflicts with family, child or elderly care needs, legal needs, and intimate partner violence Diabetes Diabetes control (HbA1c) Presence of ≥ 3 social needs associated with higher likelihood of uncontrolled diabetes defined as HbA1c ≥ 9.0% (74.9 mmol/mol, adjusted OR 1.59, 95% CI 1.26, 2.00. Presence of housing issues (including needs related to housing quality and instability) associated with higher likelihood of uncontrolled diabetes ( p < 0.05) Charkhchi et al 2018 [ 60 ] Cross-sectional Nationwide survey (BRFSS) 84,353 US adults Housing insecurity: worry about paying rent/mortgage CVD CVD: myocardial infarction, angina, coronary heart disease (self-reported) CVD associated with increased odds of housing insecurity (OR 1.69, 95% CI 1.07, 2.66) Fenelon et al 2022 [ 61 ] Cohort Nationally representative survey (NHANES) 1050 adults receiving rental assistance or on a waitlist at time of NHANES survey Rental assistance: project-based housing, housing vouchers Diabetes HbA1c Project-based housing associated with decreased prevalence of HbA1c ≥ 9.0% (74.9 mmol/mol; prevalence − 3.7%, 95% CI − 7.0, 0.0%) compared to waitlist (prevalence 6.9%); no significant differences in HbA1c between voucher and waitlist groups Fertig & Reingold, 2007 [ 62 ] Cohort Nationally representative survey (FFCWS) 3 subsamples: 1) 422 mothers living in public housing at baseline vs. 2055 in comparison group; 2) 323 mothers who moved into public housing between baseline and year 1 vs. 199...…”

Federal Housing Assistance and Blood Lead Levels in a Nationally Representative US Sample Age 6 and Older: NHANES, 1999–2018

“…This pseudo-waitlist approach has been used in prior studies to assess HUD housing assistance. 35 – 38 , 50 , 51 In addition, we selected a 2-y waiting list duration to reflect the national average wait time for HUD housing assistance at the time of our analysis. 32 Sensitivity analyses conducted in prior studies confirmed that over 70% of adults in the pseudo-waitlist group were on the actual waiting list and had sociodemographic characteristics similar to those on the actual waiting list.…”

Federal Housing Assistance and Chronic Disease Among US Adults, 2005–2018

“…Descriptive statistics published by HUD underscore that adults receiving HUD assistance have a high prevalence of chronic disease (18). However, analyses that use nationally representative data to assess associations between receiving housing assistance and the prevalence of chronic health conditions have been limited to specific populations (19,20) or self-reported outcomes of overall health status (7), physical activity (21), unmet medical need (5), or comparison groups not representing HUD-assistance-eligible people (22). Understanding the relationship between housing assistance and obesity, diabetes, and hypertension is important because these conditions disproportionately affect people who are at greater risk for housing insecurity, including people with low income (especially women) (23), people from racial and ethnic minority groups, and people with disabilities (13,16,17).…”