About This Literature Summary

This summary of the literature on Housing Instability as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Incarceration, Poverty, and Quality of Housing literature summaries.

Literature Summary

Housing instability encompasses a number of challenges, such as having trouble paying rent, overcrowding, moving frequently, 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, such as children who move frequently and people who have spent time in prison, may be more affected by housing instability.

Households are considered to be cost burdened if they spend more than 30 percent of their income on housing and severely cost burdened if they spend more than 50 percent of their income on housing.5Cost-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 

In 2019:8 

  • 37.1 million households, including renters and owners, were cost burdened — of these, 17.6 million households were severely cost burdened. 
  • 83.5 percent 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 United States 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 580,000 people experienced homelessness in the United States on a single night in 2020.8 A study of newly homeless people in the New York City shelter system found that 6 percent had diabetes, 17 percent had hypertension, 17 percent had asthma, 35 percent had major depression, and 53 percent 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 percent 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. 

Citations

1.

Kushel, M. B., Gupta, R., Gee, L., & Haas, J. S. (2006). Housing instability and food insecurity as barriers to health care among low-income Americans. Journal of General Internal Medicine, 21(1), 71–77. doi: 10.1111/j.1525-1497.2005.00278.x

2.

Frederick, T.J., Chwalek, M., Hughes, J., Karabanow, J., & Kidd, S. (2014). How stable is stable? Defining and measuring housing stability. Journal of Community Psychology, 42(8), 964–979. doi: 10.1002/jcop.21665

3.

Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., ... & Frank, D. A. (2011). US housing insecurity and the health of very young children. American Journal of Public Health, 101(8), 1508–1514. doi: 10.2105/AJPH.2011.300139

4.

Meltzer, R., & Schwartz, A. (2016). Housing affordability and health: Evidence from New York City. Housing Policy Debate, 26(1), 80–104. doi: 10.1080/10511482.2015.1020321

5.

Bailey, K. T., Cook, J. T., Ettinger de Cuba, S., Casey, P. H., Chilton, M., Coleman, S. M., ... & Frank, D. A. (2016). Development of an index of subsidized housing availability and its relationship to housing insecurity. Housing Policy Debate, 26(1), 172–187. doi: 10.1080/10511482.2015.1015042

6.

Hernández, D. (2016). Affording housing at the expense of health: Exploring the housing and neighborhood strategies of poor families. Journal of Family Issues, 37(7), 921–946. doi: 10.1177/0192513X14530970

7.

Joint Center for Housing Studies. (2014). The state of the nation’s housing 2014. Harvard University. http://www.jchs.harvard.edu/sites/default/files/sonhr14-color-full_0.pdf

8.

Joint Center for Housing Studies. (2020). The state of the nation’s housing 2020. Harvard University. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_The_State_of_the_Nations_Housing_2020_Report_Revised_120720.pdf

9.

Crowley, S. (2003). The affordable housing crisis: Residential mobility of poor families and school mobility of poor children. Journal of Negro Education, 72(1), 22–38. doi: 10.2307/3211288

10.

Blake, K. S., Kellerson, R. L., & Simic, A. (2007). Measuring overcrowding in housing. U.S. Department of Housing and Urban Development, Office of Policy Development and Research.

11.

Gove, W. R., Hughes, M., & Galle, O. R. (1979). Overcrowding in the home: An empirical investigation of its possible pathological consequences. American Sociological Review, 44(1), 59–80. doi: 10.2307/2094818

12.

Lepore, S. J., Evans, G. W., & Palsane, M. N. (1991). Social hassles and psychological health in the context of chronic crowding. Journal of Health and Social Behavior, 32(4), 357–367. doi: 10.2307/2137103

13.

Cardoso, M. R. A., Cousens, S. N., de Góes Siqueira, L. F., Alves, F. M., & D’Angelo, L. A. V. (2004). Crowding: Risk factor or protective factor for lower respiratory disease in young children?. BMC Public Health, 4(1), 1–8. doi: 10.1186/1471-2458-4-19

14.

Been, V., & Glashausser, A. (2009). Tenants: Innocent victims of the nation’s foreclosure crisis. Albany Government Law Review, 2, 1.

15.

Saegert, S., Fields, D., & Libman, K. (2011). Mortgage foreclosure and health disparities: Serial displacement as asset extraction in African American populations. Journal of Urban Health, 88(3), 390–402. doi: 10.1007/s11524-011-9584-3

16.

Desmond, M. (2012). Eviction and the reproduction of urban poverty. American Journal of Sociology, 118(1), 88–133.

17.

Desmond, M., & Shollenberger, T. (2015). Forced displacement from rental housing: Prevalence and neighborhood consequences. Demography, 52(5), 1751–1772. doi: 10.1007/s13524-015-0419-9

18.

DeLuca, S., Garboden, P. M., & Rosenblatt, P. (2013). Segregating shelter: How housing policies shape the residential locations of low-income minority families. Annals of American Academy of Political and Social Science, 647(1), 268–99. doi: 10.1177/0002716213479310

19.

Fowler, K. A., Gladden, R. M., Vagi, K. J., Barnes, J., & Frazier, L. (2015). 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. American Journal of Public Health, 105(2), 311–316. doi: 10.2105/AJPH.2014.301945

20.

Manglik S. (2012). Renters in foreclosure: A fresh look at an ongoing problem. National Low Income Housing Coalition. http://nlihc.org/sites/default/files/Renters_in_Foreclosure_2012.pdf [PDF – 428 KB]

21.

Busacker, A., & Kasehagen, L. (2012). Association of residential mobility with child health: An analysis of the 2007 National Survey of Children’s Health. Maternal and Child Health Journal, 16(1), 78–87. doi: 10.1007/s10995-012-0997-8

22.

Herbert, C. W., Morenoff, J. D., & Harding, D. J. (2015). Homelessness and housing insecurity among former prisoners. RSF: The Russell Sage Foundation Journal of the Social Sciences, 1(2), 44–79. doi: 10.7758/RSF.2015.1.2.04

23.

Geller, A., & Curtis, M. A. (2011). A sort of homecoming: Incarceration and the housing security of urban men. Social Science Research, 40(4), 1196–1213. doi: 10.1016/j.ssresearch.2011.03.008

24.

H.R.558 - 100th Congress (1987–1988): Stewart B. McKinney Homeless Assistance Act. (1987, July 22). https://www.congress.gov/bill/100th-congress/house-bill/558

25.

Schanzer, B., Dominguez, B., Shrout, P. E., & Caton, C. L. (2007). Homelessness, health status, and health care use. American Journal of Public Health, 97(3), 464–469. doi: 10.2105/AJPH.2005.076190

26.

Baggett, T. P., Hwang, S. W., O’Connell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., ... & Rigotti, N. A. (2013). Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Internal Medicine, 173(3), 189–195. doi: 10.1001/jamainternmed.2013.1604

27.

Cutts, D. B., Coleman, S., Black, M. M., Chilton, M. M., Cook, J. T., de Cuba, S. E., ... & Frank, D. A. (2015). Homelessness during pregnancy: A unique, time-dependent risk factor of birth outcomes. Maternal and Child Health Journal, 19(6), 1276–1283. doi: 10.1007/s10995-014-1633-6

28.

Do, D. P., & Finch, B. K. (2008). The link between neighborhood poverty and health: Context or composition?. American Journal of Epidemiology, 168(6), 611–619. doi: 10.1093/aje/kwn182

29.

National Bureau of Economic Research. (2011). Moving to Opportunity (MTO) for Fair Housing Demonstration Program. U.S. Department of Housing and Urban Development. http://www.nber.org/mtopublic

30.

U.S. Department of Housing and Urban Development. (n.d.). Moving to Opportunity for Fair Housing. https://www.hud.gov/programdescription/mto

31.

Chetty, R., Hendren, N., & Katz, L. F. (2016). The effects of exposure to better neighborhoods on children: New evidence from the Moving to Opportunity experiment. American Economic Review, 106(4), 855–902. doi: 10.1257/aer.20150572

32.

Ludwig, J., Sanbonmatsu, L., Gennetian, L., Adam, E., Duncan, G. J., Katz, L. F., … & McDade, T. W. (2011). Neighborhoods, obesity, and diabetes — a randomized social experiment. New England Journal of Medicine, 365(16), 1509–1519. doi: 10.1056/NEJMsa1103216

33.

Aratani, Y., Chau, M. M., Wight, V., & Addy, S. D. (2011). Rent burden, housing subsidies and the well-being of children and youth. National Center for Children in Poverty, Columbia University. doi: 10.7916/D8Z89MMD

34.

U.S. Department of Housing and Urban Development. (n.d.) Rental assistance. https://www.hud.gov/topics/rental_assistance

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