The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Housing Instability is a key issue in the Economic Stability domain.
Housing instability has no standard definition.1, 2 It encompasses a number of challenges, such as having trouble paying rent, overcrowding, moving frequently, staying with relatives, or spending the bulk of household income on housing.1, 2 These experiences may negatively affect physical health and make it harder to access health care.1, 3, 4 This summary will discuss the cost of housing as well as the health effects of substandard housing and forced evictions. Certain populations may be more affected by housing instability, such as children who move frequently and people who have spent time in prison.
Households are considered to be cost burdened if they spend more than 30% of their income on housing and severely cost burdened if they spend more than 50% of their income on housing.5 Cost-burdened households have little left over each month to spend on other necessities such as food, clothing, utilities, and health care.1, 6 Black and Hispanic households are almost twice as likely as white households to be cost burdened.7
- 21.3 million households were cost burdened—of these, 11.4 million households were severely cost burdened.
- 83% of households earning less than $15,000 a year were cost burdened.
Due to a limited rental market with few affordable vacancies, people with the lowest incomes may be forced to rent substandard housing that exposes them to health and safety risks such as vermin, mold, water leaks, and inadequate heating or cooling systems.6, 8 They may also be forced to move in with others, potentially resulting in overcrowding.9 Overcrowding is defined as more than 2 people living in the same bedroom or multiple families living in 1 residence.3, 10 Overcrowding may affect mental health, stress levels, relationships, and sleep, and it may increase the risk of infectious disease.11, 12, 13
Housing costs that are more than a household can reasonably afford can lead to foreclosure or eviction (a forced move).9 Forced moves may also happen if a landlord is in foreclosure or the property is deemed unsafe for living.14 Foreclosures cause loss of money and possessions and can damage the social fabric of neighborhoods.15 Evictions that go through the court system result in a permanent record, which can cause potential landlords to refuse to rent to evictees in the future.16 Research has shown that renters who are forced to move are more likely to relocate to poorer and higher-crime neighborhoods compared to those who move voluntarily.17 Evictions may be especially traumatizing to residents due to short relocation notices.17, 18 Suicide rates linked to stress doubled between 2005 and 2010,19 when the U.S. experienced historically high rates of foreclosures, including foreclosures on rental properties.8, 20
Housing instability may impact some populations more than others. Moving 3 or more times in 1 year, often called “multiple moves,” has been associated with negative health outcomes in children.3, 21 Children who move frequently are more likely to have chronic conditions and poor physical health.21 They may also be less likely to have consistent health insurance coverage.21
People who have spent time in prison may be discriminated against by potential landlords, lose eligibility for public housing, and struggle to maintain stable housing.22, 23 People are often released from prison with minimal income, and those who find employment face reduced earnings and may have difficulty paying for housing.22, 23 One study found that 5 years after release, black individuals who have spent time in prison were more likely to experience housing instability than white individuals who have spent time in prison, even after controlling for earnings.23
Homelessness is housing deprivation in its most severe form.9 Homelessness is defined as “lacking a regular nighttime residence or having a primary nighttime residence that is a temporary shelter or other place not designed for sleeping.”24 About 565,000 people were homeless in the U.S. in 2015.8 A study of newly homeless people in the New York City shelter system found that 6% had diabetes, 17% had hypertension, 17% had asthma, 35% had major depression, and 53% had a substance use disorder—indicating that chronic disease is more common among people who are newly homeless than among the general population.25 People who are homeless also have an increased risk of premature death.26 A study in Boston found that for 25- to 44-year-olds, the mortality rate was 9 times higher for men who are homeless and 10 times higher for women who are homeless compared to the general population of Massachusetts—and the mortality rate for 45- to 65-year-olds was 5 times higher for people who are homeless.26 The health effects of homelessness can begin early in life, as pregnant women who are homeless are more likely to deliver preterm and low birthweight babies.27
In addition to the direct health effects of housing instability, frequent moves may prevent individuals and families from building long-lasting attachments to neighborhoods. Neighborhood characteristics can strongly influence health. For example, people living in lower-income areas rate their own health lower than those living in higher-income neighborhoods.28 The Moving to Opportunity (MTO) program provided very low-income families with rental assistance and housing counseling to move from high-poverty to low-poverty neighborhoods.29, 30 Research on the effects of the MTO program showed that people who moved from high-poverty to low-poverty neighborhoods before the age of 13 were more likely to attend college, had higher incomes, were less likely to be single parents, and lived in better neighborhoods as adults.31 Adult women given vouchers through MTO had a lower prevalence of extreme obesity and diabetes after 10 to 16 years compared to those not given vouchers.32
Housing subsidies administered by the federal government provide financial assistance to help low-income people pay rent.6, 33, 34 However, households may be on waitlists for several years before receiving assistance.6, 18, 33 Due to limited funds and the large number of households in need, only 26% of eligible households received federal housing subsidies in 2013.8 Further work is needed to explore potential strategies to reduce housing instability. More research is also needed to identify how to reduce the negative effects of housing instability on health outcomes and health disparities. This additional evidence will facilitate public health efforts to address housing instability as a social determinant of health.
Disclaimer: This summary of the literature on housing instability as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21(1):71-7. doi: 10.1111/j.1525-1497.2005.00278.x.
2 Frederick TJ, Chwalek M, Hughes J, Karabanow J, Kidd S. How stable is stable? Defining and measuring housing stability. J Community Psychol. 2014;42(8):964-79.
3 Cutts DB, Meyers AF, Black MM, Casey PH, Chilton M, Cook JT, et al. US housing insecurity and the health of very young children. Am J Public Health. 2011;101(8):1508-14. doi: 10.2105/AJPH.2011.300139.
4 Meltzer R, Schwartz A. Housing affordability and health: Evidence from New York City. Hous Policy Debate. 2016;26(1):80-104.
5 Bailey KT, Cook JT, Ettinger de Cuba S, Casey PH, Chilton M, Coleman SM, et al. Development of an index of subsidized housing availability and its relationship to housing insecurity. Hous Policy Debate. 2015;26(1):172-87. doi: 10.1080/10511482.2015.1015042.
6 Hernandez D. Affording housing at the expense of health: Exploring the housing and neighborhood strategies of poor families. J Fam Hist. 2016;37(7):921-46.
7 Joint Center for Housing Studies. The state of the nation’s housing 2014 [Internet]. Boston: Harvard University; 2014 Jun 26 [cited 2017 Nov 27]. Available from: http://www.jchs.harvard.edu/sites/default/files/sonhr14-color-full_0.pdf [PDF – 6.7 MB]
8 Joint Center for Housing Studies. The state of the nation’s housing 2016 [Internet]. Boston: Harvard University; 2016 Jun 22 [cited 2017 Nov 27]. Available from: http://www.jchs.harvard.edu/sites/default/files/jchs_2016_state_of_the_nations_housing_lowres_0.pdf [PDF – 3.5 MB]
9 Crowley S. The affordable housing crisis: Residential mobility of poor families and school mobility of poor children. J Negro Educ. 2003;72(1):22–38. doi: 10.2307/3211288.
10 Blake KS, Kellerson RL, Simic A. Measuring overcrowding in housing. Washington, DC: US Department of Housing and Urban Development, Office of Policy Development and Research; 2007.
11 Gove WR, Hughes M, Galle OR. Overcrowding in the home: An empirical investigation of its possible pathological consequences. Am Sociol Rev. 1979;44(1):59-80.
12 Lepore SJ, Evans GW, Palsane MN. Social hassles and psychological health in the context of chronic crowding. J Health Soc Behav. 1991;32(4):357-67.
13 Cardoso MRA, Cousens SN, de Góes Siqueira LF, Alves FM, D'Angelo LAV. Crowding: Risk factor or protective factor for lower respiratory disease in young children? BMC Public Health. 2004;4(1):1.
14 Been V, Glashausser A. Tenants: Innocent victims of the nation's foreclosure crisis. Alb Govt L Rev. 2009;2(1).
15 Saegert S, Fields D, Libman K. Mortgage foreclosure and health disparities: Serial displacement as asset extraction in African American populations. J Urban Health. 2011;88(3):390-402. doi: 10.1007/s11524-011-9584-3.
16 Desmond M. Eviction and the reproduction of urban poverty. Am J Sociol. 2012;118(1):88-133.
17 Desmond M, Shollenberger T. Forced displacement from rental housing: Prevalence and neighborhood consequences. Demography. 2015;52(5):1751-72.
18 DeLuca S, Garboden PM, Rosenblatt P. Segregating shelter: How housing policies shape the residential locations of low-income minority families. Ann Am Acad Pol Socl Sci. 2013;647(1):268-99.
19 Fowler KA, Gladden M, Vagi KJ, Barnes J, Frazier L. Increase in suicides associated with home eviction and foreclosure during the US housing crisis: Findings from 16 National Violent Death Reporting System states, 2005–2010. Am J Public Health. 2015;105(2):311-16. doi: 10.2105/AJPH.2014.301945.
20 Manglik S. Renters in foreclosure: A fresh look at an ongoing problem [Internet]. Washington: National Low Income Housing Coalition; 2012 Sep [cited 2017 Nov 27]. Available from: http://nlihc.org/sites/default/files/Renters_in_Foreclosure_2012.pdf [PDF – 428 KB]
21 Busacker A, Kasehagen L. Association of residential mobility with child health: An analysis of the 2007 National Survey of Children's Health. Matern Child Health J. 2012;16(1):78-87. doi: 10.1007/s10995-012-0997-8.
22 Herbert CW, Morenoff JD, Harding DJ. Homelessness and housing insecurity among former prisoners. RSF. 2015;1(2):44–79.
23 Geller A, Curtis MA. A sort of homecoming: Incarceration and the housing security of urban men. Soc Sci Res. 2011;40(4):1196-213.
24 Stewart B. McKinney Homeless Assistance Act of 1987, Pub. L. No. 100-77, 101 Stat. 482, (Jul. 22, 1987).
25 Schanzer B, Dominguez B, Shrout PE, Caton CLM. Homelessness, health status and health care access. Am J Public Health. 2007;97(3):464-9. doi: 10.2105/AJPH.2005.076190.
26 Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al. Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95.
27 Cutts D, Coleman S, Black M, Chilton M, Cook J, Cuba S, Frank D. Homelessness during pregnancy: A unique, time-dependent risk factor of birth outcomes. Matern Child Health J. 2015;19(6):1276-83. doi: 10.1007/s10995-014-1633-6.
28 Phuong DD, Finch BK. The link between poverty and health: Context or composition. Am J Epidemiol. 2008;168(6):611-9.
29 National Bureau of Economic Research [Internet]. Cambridge: National Bureau of Economic Research. Moving to Opportunity (MTO) for Fair Housing Demonstration Program; [cited 2017 Nov 27]. Available from: http://www.nber.org/mtopublic
30 Housing and Urban Development [Internet]. Washington: U.S. Department of Housing and Urban Development. Moving to Opportunity for Fair Housing; [cited 2017 Nov 27]. Available from: https://www.hud.gov/programdescription/mto
31 Chetty R, Hendren N, Katz LF. The effects of exposure to better neighborhoods on children: New evidence from the Moving to Opportunity experiment. Am Econ Rev. 2016;106(4):855-902.
32 Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, Katz LF, et al. Neighborhoods, obesity, and diabetes—a randomized social experiment. N Engl J Med. 2011;365(16):1509-19.
33 Aratani Y, Chau MM, Wight V, Addy SD. Rent burden, housing subsidies and the well-being of children and youth [Internet]. New York: Columbia University; 2011 [cited 2017 Nov 27]. Available from: https://doi.org/10.7916/D8Z89MMD
34 Housing and Urban Development [Internet]. Washington: U.S. Department of Housing and Urban Development. Rental Assistance; [cited 2017 Nov 27]. Available from: https://www.hud.gov/topics/rental_assistance