Association of Promoting Housing Affordability and Stability With Improved Health Outcomes

Abstract

ImportanceHousing insecurity—that is, difficulty with housing affordability and stability—is prevalent and results in increased risk for both homelessness and poor health. However, whether interventions that prevent housing insecurity upstream of homelessness improve health remains uncertain.ObjectiveTo review evidence characterizing associations of primary prevention strategies for housing insecurity with adult physical health, mental health, health-related behaviors, health care use, and health care access.Evidence ReviewPairs of independent reviewers systematically searched PubMed, Web of Science, EconLit, and the Social Interventions Research and Evaluation Network for quantitative studies published from 2005 to 2021 that evaluated interventions intended to directly improve housing affordability and/or stability either by supporting at-risk households (targeted primary prevention) or by enhancing community-level housing supply and affordability in partnership with the health sector (structural primary prevention). Risk of bias was appraised using validated tools, and the evidence was synthesized using modified Grading of Recommendations Assessment, Development, and Evaluation criteria.FindingsA total of 26 articles describing 3 randomized trials and 20 observational studies (16 longitudinal designs and 4 cross-sectional quasi–waiting list control designs) were included. Existing interventions have focused primarily on mitigating housing insecurity for the most vulnerable individuals rather than preventing housing insecurity outright. Moderate-certainty evidence was found that eviction moratoriums were associated with reduced COVID-19 cases and deaths. Certainty of evidence was low or very low for health associations of other targeted primary prevention interventions, including emergency rent assistance, legal assistance with waiting list priority for public housing, long-term rent subsidies, and homeownership assistance. No studies evaluated health system–partnered structural primary prevention strategies.Conclusions and RelevanceThis systematic review found mixed and mostly low-certainty evidence that interventions that promote housing affordability and stability were associated with improved adult health outcomes. Existing interventions may need to be paired with other efforts to address the structural determinants of health. As health care systems and insurers respond to increasing opportunities to invest in housing as a determinant of health, further research is needed to clarify where along the housing insecurity pathway interventions should focus for the most effective and equitable health impact.

Evictions and Infant and Child Health Outcomes

“…Furthermore, housing voucher funding remains inadequate to meet the nation’s housing need . Whereas traditional methods of supporting housing security have modest associations with health outcomes, decisive, drastic, tenant-friendly housing policies have been associated with significant health outcomes in the COVID-19 pandemic. Specifically, eviction moratoria have been found to be associated with decreasing SARS-CoV-2 transmission, reducing COVID-19 mortality, and supporting adult mental health .…”

“…Furthermore, housing voucher funding remains inadequate to meet the nation's housing need. 70 Whereas traditional methods of supporting housing security have modest associations with health outcomes, 61,71 decisive, drastic, tenant-friendly housing policies have been associated with significant health outcomes in the COVID-19 pandemic.…”

Social Determinants of Health Needs and Health-Related Quality of Life Among Surgical Patients

“…Specifically, programs that target unmet food, housing, and transportation needs have been demonstrated to improve health outcomes. 22,25,29 For example, a retrospective cohort study found that 54 low-income patients enrolled in a healthy food incentive program had a mean reduction of 0.74 kg/m 2 in body mass index, compared with age-matched, ethnicitymatched, and comorbidity status-matched control patients who had a mean increase of 0.35 kg/m 2 . 30 In addition, by conducting a randomized controlled trial, Wolitski et al 31 found that patients with housing instability who were provided immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance had significant improvements in patient-reported physical and mental health, compared with patients who were not provided housing assistance.…”

“…Assessment of SDOH needs provides targets for interventions that can be implemented on an individual level to address unmet social needs with potential improvement in health status. Specifically, programs that target unmet food, housing, and transportation needs have been demonstrated to improve health outcomes 22,25,29 . For example, a retrospective cohort study found that 54 low-income patients enrolled in a healthy food incentive program had a mean reduction of 0.74 kg/m 2 in body mass index, compared with age-matched, ethnicity-matched, and comorbidity status-matched control patients who had a mean increase of 0.35 kg/m 2 30 .…”

The social determinants of mental health and disorder: evidence, prevention and recommendations

“…One exception is a cluster randomized trial in Philadel phia 380 , which reported lower depressive symptoms and improved selfworth amongst residents in intervention settings where a green ing initiative focused on improving the physical quality of the built environment by planting trees, removing litter, and landscaping vacant land in urban settings. A recent review of interventions to promote housing affordability and stability found no evidence of improved mental health outcomes in selective populations (par ticularly homeless and Veteran groups) 381 .…”