This survey study analyzes data from the 2022 National Survey of Children’s Health to estimate the prevalence of unstable housing among US children and examine differences by sociodemographic characteristics and health and associations with other hardships.
Key Points
Question
What is the prevalence of unstable housing among US children younger than 18 years?
Findings
This survey study found that in 2022, 17.1% of children currently residing in households experienced 1 or more forms of unstable housing: living in households that were unable to pay mortgage/rent on time in the past 12 months, moving frequently in the past 12 months, or being homeless at some point during their lifetime. Variations in the prevalence of any form of unstable housing were observed by state, child race and ethnicity, and special health care needs status.
Meaning
This study likely underestimates the prevalence of unstable housing because it excludes children who are currently institutionalized or experiencing homelessness.
Abstract
Importance
Housing instability is an important public health issue, particularly for children. This study provides nationally representative estimates of unstable housing among US children.
Objective
To examine unstable housing prevalence; differences by sociodemographic characteristics, health, and state of residence; and associations with other hardships.
Design, Setting, and Participants
This survey study examined data from the 2022 National Survey of Children’s Health, a population-based, nationally representative survey of randomly selected children whose parent or caregiver responded to an address-based mail or web-based survey. Participants were children aged 0 to 17 years living in households in the 50 US states and District of Columbia (N = 54 103). Bivariate analyses tested for observed differences in unstable housing between groups; logistic regression models tested for significant disparities. Associations between unstable housing and health care and food-related hardships, neighborhood conditions, and adverse childhood experiences were examined.
Exposure
Unstable housing experiences.
Main Outcomes and Measures
Unstable housing, comprising 3 indicators: inability to pay mortgage or rent on time in the past 12 months, 2 or more moves in the past 12 months, and homelessness in the child’s lifetime. Analyses were adjusted for child age and family poverty ratio. Secondary analyses examine caregiver-reported stress or worry about eviction, foreclosure, or condemned housing in the past 12 months. Weighted prevalence estimates accounted for probability of selection and nonresponse.
Results
In 2022, 17.1% (95% CI, 16.4%-17.8%) of children living in US households, representing more than 12.1 million children, experienced 1 or more forms of unstable housing: 14.1% (95% CI, 13.4%-14.7%) lived in households that were unable to pay mortgage/rent, 2.9% (95% CI, 2.6%-3.3%) moved frequently, and 2.5% (95% CI, 2.2%-2.8%) experienced lifetime homelessness. Additionally, 9.0% (95% CI, 8.5%-9.5%) of children had caregivers who reported stress/worry over housing. Prevalence of unstable housing varied across states (range, 12.0%-26.6%). Unstable housing was highest among American Indian or Alaska Native children (27.9%; 95% CI, 21.3%-35.6%), Black or African American children (30.4%; 95% CI, 27.8%-33.1%), and Native Hawaiian or Pacific Islander children (27.6%; 95% CI, 16.6%-42.1%) and also differed by special health care needs, family poverty ratio, caregiver education and unemployment status, and whether the family rented or owned their home. Unstable housing was associated with all other types of hardships examined.
Conclusions and Relevance
This study found that 1 in 6 US children experienced unstable housing, varying by state and sociodemographic factors. The prevalence is likely underestimated because the sample excluded children who are currently institutionalized or experiencing homelessness. Results may help move the field toward a unified national definition of unstable housing for families with children and lead to clinically appropriate and evidence-based screening and interventions to support housing stability and improve children’s health.
Introduction
Housing is a critically important social determinant of health, and children are particularly at risk of experiencing housing-related problems and concomitant negative effects on health and health care.1,2,3,4,5,6,7 Six in 10 people experiencing homelessness in the US are children younger than 18 years, and on any given night, about 58 000 families (including more than 100 000 children) experience homelessness.8 In addition, 1 in 3 households with children experience housing cost burdens (spending more than 30% of household income on housing), leaving insufficient resources for other basic needs.9 The COVID-19 pandemic exacerbated housing unaffordability, especially among low-income households, and increased the risk of housing displacement among millions of renters and homeowners.10 In 2023, the Biden-Harris Administration released the US Playbook to Address Social Determinants of Health, highlighting the importance of housing as a key driver of health outcomes and the need to advance data collection and interoperability among health care, public health, social services, and other systems to better address social determinants of health.11
While there is no universally accepted definition of unstable housing,12 numerous studies have established associations between adverse housing circumstances (eg, eviction, frequent moves, homelessness, housing cost burden) and poor health outcomes among children and their caregivers.13,14,15,16,17 Specifically, being behind on paying the rent or mortgage, moving frequently, or experiencing homelessness (henceforth defined as “unstable housing” for the current analysis) have been associated with poor physical and oral health among children, developmental delays, hospitalizations, unmet needs for health care, and health insurance coverage gaps.13,14,15 Children and youth with special health care needs are also at increased risk for unstable housing.18 Furthermore, unstable housing has been linked with poor physical health and depressive symptoms among parents and caregivers.13 Avoidable costs to the health care and educational systems attributable to unstable housing are estimated at $111 billion over 10 years.19,20 In addition to the effects of unstable housing on health status, prior research also suggests strong associations with other material hardships, which each carry their own health risks, including food and energy insecurity, forgone health care, and health care cost burden.21
Unstable housing measures have historically not been included in national health surveys, leaving a gap in federal data collection. To address this gap, the Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB) included a short measure of unstable housing, originally developed by Children’s HealthWatch, in the 2022 National Survey of Children’s Health.22 To our knowledge, findings from the current study provide the first nationally representative estimates of the prevalence of unstable housing affecting currently housed, noninstitutionalized US children and their families, including estimates for subpopulations of interest and by geographical region. Specifically, we sought to address the following research questions: (1) What is the overall prevalence of unstable housing among US children, as well as its specific forms? (2) How does the prevalence of unstable housing differ by various sociodemographic factors? (3) How does the prevalence of unstable housing differ by state of residence? (4) How is unstable housing associated with other selected forms of material hardships?
Methods
Data Source
Data came from the 2022 National Survey of Children’s Health (NSCH), which is funded and directed by HRSA MCHB and administered by the US Census Bureau using an address-based sampling frame. The NSCH is fielded annually via web- and paper-based questionnaires; respondents are parents or caregivers of children in the 50 states and the District of Columbia. The interview completion rate, or the proportion of households confirmed as occupied with children that completed the survey, was 78.5%.23 The sample included noninstitutionalized children aged 0 to 17 years living in US households (N = 54 103, representing more than 73 million children) (eTable 1 in Supplement 1). Detailed survey procedures are described elsewhere.24 Institutional review board approval was not required because the data are publicly available and deidentified.25 American Association for Public Opinion Research (AAPOR) Best Practices for Survey Research were followed in the design and fielding of the NSCH.
Measures
The primary outcome was a dichotomous measure for unstable housing, comprising 3 indicators: caregiver-reported inability to pay mortgage or rent on time in the past 12 months, child experienced frequent moves (≥2 times) in the past 12 months, and child experienced homelessness in their lifetime (eTable 2 in Supplement 1 includes all measure details). Secondary analyses also examined caregiver-reported stress or worry about eviction, foreclosure, or condemned housing in the past 12 months, adapted from the American Housing Survey’s Housing Insecurity Module.26 Observations with missing data on all 3 indicators were excluded from analysis (n = 1232). Observations with missing data on some indicators were included to preserve sample size, reduce potential bias, and align with HRSA MCHB’s coding approach for the Title V Services Block Grant Program national performance measures.27
Covariates of interest were as follows: child sex, age, race and ethnicity, special health care needs status, household poverty status, highest parent/caregiver education in household, parental/caregiver unemployment status, family immigration status, home occupancy type, and state of residence. Race and ethnicity were self-reported by the parent or caregiver and included Hispanic or Latino, non-Hispanic American Indian or Alaska Native (hereafter American Indian or Alaska Native), non-Hispanic Asian (hereafter Asian), non-Hispanic Black or African American (hereafter Black or African American), non-Hispanic individuals reporting multiple races (hereafter multiple races), non-Hispanic Native Hawaiian or Pacific Islander (hereafter Native Hawaiian or Pacific Islander), and non-Hispanic White (hereafter White). Special health care needs were identified based on responses to questions that assessed 5 domains of qualifying health needs.28 Other hardships examined were unmet health care needs, problems paying medical bills, food insufficiency, unsafe neighborhood, detracting neighborhood elements, and adverse childhood experiences (eTable 2 in Supplement 1).
Statistical Analysis
We analyzed the 3 unstable housing experiences as individual items and as a summary measure. We conducted sensitivity analyses using an alternative summary measure that included a fourth item (housing stress/worry) to determine the impact of including this element on estimates of unstable housing. We calculated frequencies, unadjusted proportions, and 95% CIs for unstable housing-related measures, overall and among subpopulations of interest. Bivariate analyses assessed significant associations between covariates of interest and unstable housing using χ2 tests of independence. State-level estimates were compared with national estimates using t tests for overlapping groups. We used multivariable logistic regression models to produce adjusted prevalence ratios (aPRs) to examine statistically significant differences between subpopulations. A parsimonious set of covariates (child age, family poverty ratio) was selected to based on clinical and theoretical relevance to account for the association between increasing age and cumulative lifetime events (eg, homelessness, adverse childhood experiences) as well as the associations between income and the other independent and dependent measures. We did not include all covariates of interest in the models because of the challenges of interpretation of subgroup differences. For example, socioeconomic factors such as unemployment or household education are likely mediators in the relationship between race and unstable housing, so including them in the model would likely underestimate the magnitude of racial inequities. For all variables, the subpopulation with the lowest observed (and reliable) prevalence of the unstable housing indicators was selected as the reference group. In addition, we calculated prevalence estimates and aPRs to assess the association between unstable housing and other hardships.
Analyses were performed using Stata MP version 15 (StataCorp) using survey weights developed by the US Census Bureau. We used a 2-sided P value threshold of .05 to assess statistical significance, with no adjustments made for multiple comparisons because of the exploratory nature of the analysis. Sex (0.1% missing), race (1.7% missing), and ethnicity (0.3% missing) were imputed using hot-deck imputation, and family poverty ratio (19.5% missing) was multiply imputed using regression methods.23
Results
Prevalence and Correlates of Unstable Housing Among US Children
Overall in 2022, 14.1% (95% CI, 13.4%-14.7%) of children living in households had caregivers who were unable to pay the mortgage/rent on time in the previous 12 months, 2.9% (95% CI, 2.6%-3.3%) children experienced frequent moves (2 or more) in the previous 12 months, and 2.5% (95% CI, 2.2%-2.8%) children were homeless during their lifetime (Table 1). Among children who experienced any unstable housing, the most common type of housing difficulty was inability to pay mortgage/rent (70.8%), followed by frequent moves (11.5%) and lifetime homelessness (6.9%) (eFigure in Supplement 1). Smaller proportions of children experienced more than 1 unstable housing indicator (range, 0.7%-5.4%).
Table 1. Inability to Pay Mortgage/Rent, Frequent Moves, and Homelessness Among US Children Aged 0 to 17 Years: Prevalence Estimates and Associations by Sociodemographic and Family Characteristics, 2022 National Survey of Children’s Health.
| Characteristic | Inability to pay mortgage/rent on time, past 12 mo | Frequent moves, past 12 mo | Homelessness, lifetime | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Weighted % (95% CI) | P value | aPR (95% CI)a | Weighted % (95% CI) | P value | aPR (95% CI)a | Weighted % (95% CI) | P value | aPR (95% CI)a | |
| Overall | 14.1 (13.4-14.7) | NA | NA | 2.9 (2.6-3.3) | NA | NA | 2.5 (2.2-2.8) | NA | NA |
| Sex | |||||||||
| Male | 14.1 (13.3-15.1) | .82 | 1 [Reference] | 2.7 (2.3-3.2) | .17 | 1 [Reference] | 2.4 (2.0-2.8) | .46 | 1 [Reference] |
| Female | 14.0 (13.1-15.0) | 0.99 (0.89-1.09) | 3.2 (2.7-3.7) | 1.15 (0.90-1.40) | 2.6 (2.2-3.0) | 1.07 (0.81-1.34) | |||
| Age category, y | |||||||||
| 0-3 | 13.5 (12.0-15.1) | .83 | 1 [Reference] | 1.8 (1.4-2.4) | .001 | 1 [Reference] | 0.9 (0.6-1.4) | <.001 | 1 [Reference] |
| 4-5 | 14.1 (12.4-16.1) | 1.02 (0.83-1.21) | 2.7 (1.9-3.9) | 1.48 (0.82-2.13) | 1.5 (0.9-2.4) | 1.53 (0.59-2.46) | |||
| 6-11 | 14.2 (13.1-15.3) | 1.03 (0.88-1.18) | 3.6 (3.0-4.4) | 1.98 (1.33-2.63) | 2.7 (2.2-3.4) | 2.89 (1.63-4.15) | |||
| 12-17 | 14.3 (13.2-15.4) | 1.03 (0.88-1.18) | 3.0 (2.5-3.5) | 1.61 (1.11-2.11) | 3.4 (2.9-3.9) | 3.57 (2.10-5.03) | |||
| Race and ethnicity | |||||||||
| Hispanic/Latino | 18.5 (16.9-20.3) | <.001 | 1.39 (1.22-1.56) | 3.7 (2.9-4.6) | <.001 | 1.48 (1.09-1.88 | 3.0 (2.3-3.8) | <.001 | 1.44 (0.99-1.89) |
| Non-Hispanic | |||||||||
| American Indian or Alaska Native | 17.8 (12.7-24.2) | 1.33 (0.85-1.80) | 8.2 (4.3-15.1)b | 3.25 (1.01-5.48 | 7.4 (4.3-12.3) | 3.75 (1.55-5.95) | |||
| Asian | 4.8 (3.7-6.2) | 0.49 (0.35-0.62) | 2.7 (2.0-3.7) | 1.32 (0.86-1.79 | 0.9 (0.4-2.2)b | 0.64 (0.09-1.19) | |||
| Black or African American | 25.7 (23.2-28.3) | 1.96 (1.69-2.22) | 5.1 (3.8-6.6) | 1.93 (1.29-2.57 | 6.0 (4.8-7.4) | 2.70 (1.83-3.56) | |||
| Native Hawaiian or Pacific Islander | 19.9 (12.2-30.6) | 1.43 (0.67-2.19) | -c | -c | -c | -c | |||
| Multiple races | 13.2 (11.4-15.1) | 1.30 (1.09-1.52) | 2.6 (1.9-3.5) | 1.26 (0.85-1.67) | 2.5 (1.8-3.4) | 1.71 (1.07-2.35 | |||
| White | 9.7 (9.1-10.3) | 1 [Reference] | 2.0 (1.7-2.3) | 1 [Reference] | 1.4 (1.2-1.6) | 1 [Reference] | |||
| Special health care needs | |||||||||
| Yes | 18.6 (17.2-20.1) | <.001 | 1.40 (1.25-1.55) | 4.9 (4.0-5.9) | <.001 | 1.85 (1.42-2.29) | 5.4 (4.6-6.5) | <.001 | 2.74 (2.06-3.41) |
| No | 12.9 (12.2-13.6) | 1 [Reference] | 2.4 (2.1-2.7) | 1 [Reference] | 1.7 (1.4-2.0) | 1 [Reference] | |||
| Household poverty status | |||||||||
| <100% FPR | 27.2 (25.0-29.4) | <.001 | 6.51 (5.38-7.64) | 5.8 (4.5-7.1) | <.001 | 3.38 (2.35-4.40) | 6.5 (5.3-7.8) | <.001 | 8.28 (5.05-11.51) |
| 100%-199% FPR | 22.8 (20.9-24.8) | 5.46 (4.49-6.43) | 3.4 (2.7-4.2) | 1.98 (1.34-2.62) | 3.1 (2.5-3.7) | 3.88 (2.32-5.44) | |||
| 200%-399% FPR | 11.8 (10.7-12.9) | 2.83 (2.34-3.32) | 2.2 (1.7-2.8) | 1.29 (0.86-1.73) | 1.4 (1.0-1.9) | 1.78 (0.94-2.62) | |||
| ≥400% FPR | 4.2 (3.5-4.8) | 1 [Reference] | 1.7 (1.3-2.1) | 1 [Reference] | 0.8 (0.5-1.1) | 1 [Reference] | |||
| Highest caregiver education | |||||||||
| Less than high school | 21.7 (18.1-25.7) | <.001 | 1.60 (1.24-1.97) | 5.0 (3.7-6.6) | <.001 | 1.67 (1.04-2.31) | 4.2 (3.0-5.9) | <.001 | 1.71 (0.91-2.52) |
| High school | 22.3 (20.5-24.1) | 1.88 (1.61-2.14) | 5.4 (4.3-6.7) | 2.09 (1.47-2.70) | 4.5 (3.6-5.7) | 2.39 (1.56-3.21) | |||
| Some college | 23.3 (21.6-25.0) | 2.26 (1.99-2.53) | 2.8 (2.3-3.5) | 1.23 (0.89-1.57) | 3.9 (3.3-4.7) | 2.55 (1.77-3.33) | |||
| College degree or higher | 6.8 (6.2-7.3) | 1 [Reference] | 1.8 (1.6-2.1) | 1 [Reference] | 0.9 (0.7-1.2) | 1 [Reference] | |||
| Caregiver unemployment | |||||||||
| Yes, ≥1 caregiver unemployed | 26.9 (24.3-29.7) | <.001 | 1.49 (1.29-1.70) | 4.6 (3.1-6.7) | .01 | 1.19 (0.72-1.66) | 5.9 (4.3-8.0) | <.001 | 1.76 (1.15-2.36) |
| No caregivers unemployed | 12.9 (12.2-13.6) | 1 [Reference] | 2.8 (2.5-3.1) | 1 [Reference] | 2.1 (1.9-2.4) | 1 [Reference] | |||
| Family immigration status | |||||||||
| First generation | 15.6 (12.0-19.9) | .46 | 0.96 (0.67-1.26) | 6.0 (4.1-8.7) | <.001 | 2.40 (1.32-3.47) | 2.6 (1.2-5.6)b | .06 | 1.20 (0.20-2.20) |
| Second generation | 14.3 (12.7-16.1) | 1 [Reference] | 2.2 (1.8-2.7) | 1 [Reference] | 1.7 (1.2-2.3) | 1 [Reference] | |||
| Third generation | 13.6 (12.9-14.3) | 1.09 (0.94-1.24) | 2.8 (2.4-3.2 | 1.39 (1.02-1.76) | 2.5 (2.2-2.9) | 1.85 (1.15-2.56) | |||
| Home occupancy type | |||||||||
| Rent | 28.8 (27.0-30.7) | <.001 | 2.28 (2.04-2.52) | 6.2 (5.3-7.3) | <.001 | 2.76 (2.07-3.46) | 5.6 (4.8-6.5) | <.001 | 2.60 (1.86-3.35) |
| Own | 9.3 (8.7-9.9) | 1 [Reference] | 1.9 (1.6-2.1) | 1 [Reference] | 1.4 (1.2-1.7) | 1 [Reference] | |||
| Occupy without payment | 14.1 (8.8-21.8) | 0.94 (0.47-1.42) | 2.8 (1.3-5.8)b | 1.14 (0.24-2.04) | 4.7 (2.0-10.9)b | 1.92 (0.13-3.71) | |||
Abbreviations: aPR, adjusted prevalence ratio; FPR, federal poverty ratio; NA, not applicable.
Covariates were age and income.
Interpret estimate with caution (relative standard error >30%).
Estimate suppressed because of unreliability (relative standard error >50%).
After adjusting for age and income, inability to make mortgage/rent payments was significantly associated with child race and ethnicity (Table 1). (There was increased prevalence among Black or African American children, Hispanic or Latino children, and children with multiple races, and decreased prevalence among Asian children relative to White children.) Special health care needs, lower income, lower caregiver education, caregiver unemployment, and renting were also associated with increased prevalence of inability to make mortgage/rent payments. Frequent moves were associated with older age; American Indian or Alaska Native, Black or African American, and Hispanic or Latino race and ethnicity; special health care needs; lower household income; lower caregiver educational attainment; first- and third-generation immigrant families; and renting. Lifetime homelessness among children was significantly associated with older age; American Indian or Alaska Native, Black or African American, and multiple races; special health care needs; lower household income; lower caregiver educational attainment; caregiver unemployment; third-generation families; and renting.
Regarding the composite measure, 17.1% of currently housed US children aged 0 to 17 years were estimated to have experienced unstable housing (Table 2), representing more than 12.1 million children. The prevalence of unstable housing was highest among American Indian or Alaska Native children (27.9%), Black or African American children (30.4%), and Native Hawaiian or Pacific Islander children (27.6%); children with special health care needs (24.1%); children in families with income less than 100% of the federal poverty ratio (31.5%); children whose caregivers had less than a college degree (25.0%-26.9%), children with an unemployed caregiver (30.3%), and children living in renting households (33.5%). After adjusting for child age and family poverty ratio, unstable housing was significantly associated with child race and ethnicity. (There was increased prevalence among American Indian or Alaska Native children, Black or African American children, Hispanic or Latino children, and children with multiple races, and decreased prevalence among Asian children relative to White children.) Unstable housing was also significantly associated with older child age, having special health care needs, lower household income, lower caregiver education attainment, caregiver unemployment, third-generation immigration status, and renting.
Table 2. Unstable Housing Among US Children Aged 0 to 17 Years: Prevalence Estimates and Associations by Sociodemographic and Family Characteristics, 2022 National Survey of Children’s Health.
| Characteristic | Unstable housing summary measure (≥1 of 3 indicators) | ||||
|---|---|---|---|---|---|
| Unweighted No. | Estimated population frequency, No. | Weighted % (95% CI) | P value | aPR (95% CI)a | |
| Overall | 7149 | 12 191 317 | 17.1 (16.4-17.8) | NA | NA |
| Sex | |||||
| Male | 3753 | 6 187 810 | 16.9 (16.0-17.9) | .67 | 1 [Reference] |
| Female | 3396 | 6 003 507 | 17.3 (16.3-18.3) | 1.02 (0.93-1.11) | |
| Age category, y | |||||
| 0-3 | 1328 | 2 110 588 | 14.9 (13.4-16.5) | .01 | 1 [Reference] |
| 4-5 | 855 | 1 251 078 | 16.5 (14.6-18.5) | 1.10 (0.91-1.28) | |
| 6-11 | 2204 | 4 245 261 | 17.8 (16.6-19.1) | 1.19 (1.03-1.35) | |
| 12-17 | 2762 | 4 584 390 | 17.9 (16.7-19.0) | 1.19 (1.03-1.35) | |
| Race and ethnicity | |||||
| Hispanic or Latino | 1619 | 4 160 948 | 21.7 (19.9-23.5) | <.001 | 1.35 (1.20-1.49) |
| Non-Hispanic | |||||
| American Indian or Alaska Native | 77 | 116 322 | 27.9 (21.3-35.6) | 1.79 (1.27-2.32) | |
| Asian | 279 | 259 734 | 7.6 (6.2-9.3) | 0.62 (0.48-0.76) | |
| Black or African American | 918 | 2 660 028 | 30.4 (27.8-33.1) | 1.92 (1.69-2.16) | |
| Native Hawaiian or Pacific Islander | 34 | 35 384 | 27.6 (16.6-42.1) | 1.68 (0.82-2.54) | |
| Multiple races | 596 | 829 989 | 16.3 (14.4-18.4) | 1.31 (1.13-1.49) | |
| White | 3626 | 4 128 912 | 12.0 (11.4-12.7) | 1 [Reference] | |
| Special health care needs | |||||
| Yes | 2481 | 3 596 420 | 24.1 (22.5-25.7) | <.001 | 1.53 (1.39-1.67) |
| No | 4668 | 8 594 898 | 15.2 (14.5-16.0) | 1 [Reference] | |
| Household poverty status | |||||
| <100% FPR | 1874 | 4 017 607 | 31.5 (29.2-33.8) | <.001 | 5.02 (4.33-5.71) |
| 100%-199% FPR | 2042 | 3 628 656 | 26.1 (24.0-28.2) | 4.14 (3.54-4.74) | |
| 200%-399% FPR | 2083 | 3 012 440 | 14.4 (13.2-15.7) | 2.29 (1.96-2.62) | |
| ≥400% FPR | 1150 | 1 532 614 | 6.3 (5.5-7.0) | 1 [Reference] | |
| Highest caregiver education | |||||
| <High school | 357 | 1 508 776 | 25.0 (21.4-29.0) | <.001 | 1.49 (1.20-1.79) |
| High school | 1702 | 3 516 669 | 26.9 (25.0-28.9) | 1.84 (1.62-2.07) | |
| Some college | 2521 | 3 787 882 | 26.5 (24.9-28.3) | 2.06 (1.85-2.27) | |
| College degree or higher | 2569 | 3 377 991 | 8.9 (8.3-9.5) | 1 [Reference] | |
| Caregiver unemployment | |||||
| Yes, ≥1 caregiver unemployed | 993 | 1 876 242 | 30.3 (27.5-33.2) | <.001 | 1.40 (1.23-1.58) |
| No caregivers unemployed | 6156 | 10 315 075 | 15.8 (15.2-16.6) | 1 [Reference] | |
| Family immigration status | |||||
| First generation | 179 | 397 754 | 19.7 (15.7-24.3) | .34 | 1.06 (0.76-1.35) |
| Second generation | 1180 | 2 739 219 | 16.2 (14.6-18.0) | 1 [Reference] | |
| Third generation | 5160 | 7 892 252 | 16.6 (15.8-17.4) | 1.18 (1.03-1.32) | |
| Home occupancy type | |||||
| Rent | 2998 | 5 881 833 | 33.5 (31.6-35.4) | <.001 | 2.21 (2.01-2.41) |
| Own | 4091 | 6 206 218 | 11.7 (11.0-12.3) | 1 [Reference] | |
| Occupy without payment | 60 | 103 266 | 17.6 (11.9-25.3) | 0.99 (0.57-1.41) | |
Abbreviations: aPR, adjusted prevalence ratio; FPR, federal poverty ratio; NA, not applicable.
Prevalence and Correlates of Caregiver Stress/Worry About Unstable Housing
Overall, 9.0% of children had caregivers who reported stress or worry over eviction, foreclosure, or condemned housing in the past 12 months (Table 3). The prevalence of housing-related worry/stress was highest among American Indian or Alaska Native children (15.4%), Black or African American children (18.0%), and Native Hawaiian or Pacific Islander children (22.9%). One in 5 children from families with income less than 100% of the federal poverty ratio (20.4%), children with unemployed caregivers (22.2%), and children from renting families (19.0%) had caregiver-reported housing worry/stress. After adjusting, caregiver housing-related worry/stress was significantly associated with race and ethnicity (increased prevalence among all groups except Asian children relative to White children), special health care needs, lower household income, lower caregiver educational attainment, caregiver unemployment, and renting.
Table 3. Stress/Worry About Eviction, Foreclosure, or Condemned Housing and an Alternate Unstable Housing Measure: Prevalence Estimates and Associations, 2022 National Survey of Children’s Health.
| Stress/worry about eviction, foreclosure, or condemned housing, past 12 mo | Unstable housing summary measure (alternate version: ≥1 of 4 indicators, including stress/worry) | |||||
|---|---|---|---|---|---|---|
| Weighted % (95% CI) | P value | aPR (95% CI)a | Weighted % (95% CI) | P value | aPR (95% CI)a | |
| Overall | 9.0 (8.5-9.5) | NA | NA | 19.5 (18.8-20.3) | NA | NA |
| Sex | ||||||
| Male | 8.7 (8.1-9.4) | .35 | 1 [Reference] | 19.2 (18.2-20.2) | .30 | 1 [Reference] |
| Female | 9.2 (8.5-10.0) | 1.06 (0.93-1.20) | 19.9 (18.9-21.0) | 1.05 (0.96-1.13) | ||
| Age category, y | ||||||
| 0-3 | 7.9 (6.9-9.1) | .05 | 1 [Reference] | 17.0 (15.5-18.7) | .003 | 1 [Reference] |
| 4-5 | 7.9 (6.7-9.3) | 0.97 (0.74-1.20) | 18.4 (16.5-20.5) | 1.07 (0.90-1.23) | ||
| 6-11 | 9.7 (8.7-10.8) | 1.22 (0.99-1.44) | 20.6 (19.3-22.0) | 1.21 (1.06-1.36) | ||
| 12-17 | 9.1 (8.4-10.0) | 1.13 (0.93-1.33) | 20.3 (19.1-21.5) | 1.18 (1.04-1.32) | ||
| Race and ethnicity | ||||||
| Hispanic or Latino | 11.5 (10.2-12.9) | <.001 | 1.41 (1.18-1.64) | 24.9 (23.1-26.9) | <.001 | 1.39 (1.25-1.53) |
| Non-Hispanic | ||||||
| American Indian or Alaska Native | 15.4 (10.3-22.2) | 1.93 (1.08- 2.78) | 30.2 (23.5-38.0) | 1.73 (1.24-2.22) | ||
| Asian | 6.8 (5.3-8.7) | 1.28 (0.90-1.65) | 12.2 (10.3-14.4) | 0.90 (0.72-1.07) | ||
| Black or African American | 18.0 (15.9-20.2) | 2.22 (1.84-2.60) | 34.3 (31.6-37.1) | 1.95 (1.73-2.18) | ||
| Native Hawaiian or Pacific Islander | 22.9 (14.7-33.9) | 2.93 (1.38-4.47) | 32.2 (20.7-46.3) | 1.77 (0.97-2.57) | ||
| Multiple races | 8.7 (7.2-10.5) | 1.54 (1.21-1.87) | 18.6 (16.5-20.8) | 1.34 (1.17-1.51) | ||
| White | 5.4 (4.9-5.9) | 1 [Reference] | 13.5 (12.8-14.2) | 1 [Reference] | ||
| Special health care needs | ||||||
| Yes | 13.2 (12.0-14.5) | <.001 | 1.61 (1.39-1.83) | 27.2 (25.6-28.9) | <.001 | 1.52 (1.39-1.65) |
| No | 7.8 (7.3-8.4) | 1 [Reference] | 17.5 (16.7-18.3) | 1 [Reference] | ||
| Household poverty status | ||||||
| <100% FPR | 20.4 (18.6-22.3) | <.001 | 12.33 (9.03-15.64) | 36.5 (34.1-38.9) | <.001 | 5.26 (4.60-5.92) |
| 100%-199% FPR | 14.6 (13.1-16.0) | 8.79 (6.41-11.16) | 29.4 (27.3-31.6) | 4.23 (3.66-4.81) | ||
| 200%-399% FPR | 6.4 (5.6-7.3) | 3.87 (2.80-4.95) | 16.7 (15.4-18.1) | 2.41 (2.09-2.72) | ||
| ≥400% FPR | 1.7 (1.2-2.1) | 1 [Reference] | 6.9 (6.2-7.7) | 1 [Reference] | ||
| Highest caregiver education | ||||||
| <High school | 14.5 (11.8-17.7) | <.001 | 1.43 (1.05-1.80) | 29.5 (25.6-33.7) | <.001 | 1.52 (1.24-1.80) |
| High school | 14.8 (13.4-16.4) | 1.76 (1.44-2.09) | 30.6 (28.6-32.7) | 1.82 (1.61-2.02) | ||
| Some college | 14.8 (13.5-16.3) | 2.14 (1.80-2.49) | 30.0 (28.2-31.8) | 2.02 (1.83-2.22) | ||
| College degree or higher | 3.9 (3.5-4.3) | 1 [Reference] | 10.2 (9.6-10.9) | 1 [Reference] | ||
| Caregiver unemployment | ||||||
| Yes, ≥1 caregiver unemployed | 22.2 (19.8-24.8) | <.001 | 1.95 (1.64-2.27) | 35.9 (33.0-38.9) | <.001 | 1.49 (1.32-1.66) |
| No caregivers unemployed | 7.7 (7.2-8.2) | 1 [Reference] | 18.0 (17.3-18.7) | 1 [Reference] | ||
| Family immigration status | ||||||
| First generation | 13.2 (10.0-17.2) | .002 | 1.21 (0.79-1.63) | 24.7 (20.3-29.8) | .009 | 1.09 (0.82-1.37) |
| Second generation | 9.2 (8.1-10.5) | 1 [Reference] | 19.8 (18.1-21.6) | 1 [Reference] | ||
| Third generation | 8.1 (7.5-8.7) | 1.04 (0.87-1.21) | 18.3 (17.5-19.1) | 1.04 (0.93-1.16) | ||
| Home occupancy type | ||||||
| Rent | 19.0 (17.6-20.4) | <.001 | 2.18 (1.88-2.49) | 37.2 (35.3-39.2) | <.001 | 2.08 (1.90-2.26) |
| Own | 5.6 (5.2-6.2) | 1 [Reference] | 13.7 (13.0-14.4) | 1 [Reference] | ||
| Occupy without payment | 11.2 (6.8-17.8) | 1.09 (0.50-1.68) | 20.8 (14.5-28.9) | 0.97 (0.58-1.36) | ||
Abbreviations: aPR, adjusted prevalence ratio; FPR, federal poverty ratio; NA, not applicable.
Covariates were age and income.
In sensitivity analyses examining an alternate composite measure of unstable housing that added a fourth indicator for caregiver worry/stress about housing, the overall prevalence was 19.5% among US children, slightly higher than the original estimate using the first 3 indicators (17.1%). After adjustment, the same sociodemographic characteristics were significantly associated with this alternate measure as with the original composite measure. There were 2 notable differences between the 2 measures: using the original measure, unstable housing was significantly lower among Asian children (relative to White children) and significantly higher among children from third-generation families (relative to those from second-generation families), but the alternate measure including caregiver worry/stress found no statistically significant differences.
State-Level Variation in Unstable Housing Among US Children
There were differences in the prevalence of any form of unstable housing based on state of residence (Figure and eTable 3 in Supplement 1). Five states and the District of Columbia had statistically significantly higher unstable housing estimates than the national average of 17.1% (New Mexico 26.6%, Louisiana 23.8%, District of Columbia 22.8%, Oklahoma 21.9%, Kentucky 21.4%, and New York 20.7%). Seven states had statistically significantly lower unstable housing estimates than the national average (North Dakota 12.0%, Virginia 12.4%, Utah 12.6%, Washington 13.2%, Idaho 13.4%, Colorado 13.8%, and California 14.7%).
Figure. Prevalence of Unstable Housing by State of Residence, 2022 National Survey of Children’s Health.
Associations Between Unstable Housing and Other Hardships
Among children who experienced unstable housing, 7.4% experienced unmet health care needs in the past 12 months, 16.7% experienced problems paying medical bills, and 17.9% experienced food insufficiency (Table 4). More than one-third (35.6%) of children experiencing unstable housing lived in neighborhoods with 1 or more detracting elements (litter/garbage, vandalism, poorly kept or rundown housing). More than half had experienced 1 or more adverse childhood experiences (1 adverse childhood experience, 24.8%; ≥2 adverse childhood experiences, 30.2%). After controlling for child age and income, relative to children with no unstable housing experiences, children with any unstable housing experiences were more than twice as likely to experience unmet health care needs (aPR, 2.79; 95% CI, 2.24-3.34), have problems paying medical bills (aPR, 2.33; 95% CI, 2.02-2.64), and live in unsafe neighborhoods (aPR, 2.62; 95% CI, 2.17-3.08), and 5 times more likely to experience food insufficiency (aPR, 5.12; 95% CI, 4.15-6.09). Unstable housing was significantly associated with all adverse childhood experiences except parental death (aPR range, 1.61-3.55), and children who experienced unstable housing were twice as likely to experience 2 or more adverse childhood experiences (aPR, 2.43; 95% CI, 2.19-2.67).
Table 4. Observed Prevalence of Other Hardships and Associations by Unstable Housing Status, 2022 National Survey of Children’s Health.
| Other hardship | Unstable housing experiences reported, weighted % (95% CI) | P value | aPR (95% CI)a | |
|---|---|---|---|---|
| ≥1 | None | |||
| Unmet health care needs, past 12 mo | 7.4 (6.4-8.6) | 2.4 (2.1-2.6) | <.001 | 2.79 (2.24-3.34) |
| Problems paying medical bills, past 12 mo | 16.7 (15.1-18.5) | 7.4 (6.9-7.9) | <.001 | 2.33 (2.02-2.64) |
| Food insufficiency, past 12 mo | 17.9 (16.2-19.8) | 2.4 (2.1-2.8) | <.001 | 5.12 (4.15-6.09) |
| Unsafe neighborhood | 12.5 (11.0-14.1) | 3.6 (3.3-4.0) | <.001 | 2.62 (2.17-3.08) |
| Detracting elements in neighborhoodb | 35.6 (33.5-37.8) | 21.1 (20.4-21.9) | <.001 | 1.47 (1.36-1.59) |
| Adverse childhood experiences (lifetime) | ||||
| Parent/guardian divorced or separated | 40.7 (38.5-42.9) | 18.4 (17.6-19.1) | <.001 | 2.01 (1.85-2.18) |
| Parent/guardian died | 4.0 (3.4-4.8) | 2.7 (2.4-3.1) | <.001 | 1.17 (0.90-1.45) |
| Parent/guardian served time in jail/prison | 14.7 (13.2-16.3) | 4.5 (4.1-5.0) | <.001 | 2.41 (2.02-2.80) |
| Witness of household interpersonal violence | 13.6 (12.1-15.2) | 3.8 (3.4-4.2) | <.001 | 2.83 (2.32-3.34) |
| Victim or witness of neighborhood violence | 10.7 (9.3-12.3) | 2.4 (2.1-2.7) | <.001 | 3.55 (2.81-4.29) |
| Household mental illness | 18.8 (17.0-20.7) | 6.8 (6.3-7.3) | <.001 | 2.53 (2.20-2.86) |
| Household substance use problem | 16.9 (15.3-18.7) | 6.7 (6.2-7.2) | <.001 | 2.24 (1.93-2.54) |
| Treated/judged unfairly due to race or ethnicity | 8.1 (7.0-9.3) | 3.4 (3.1-3.8) | <.001 | 2.34 (1.90-2.77) |
| Treated/judged unfairly due to sexual orientation/gender identity | 2.7 (2.1-3.5) | 1.7 (1.5-2.0) | .004 | 1.61 (1.09-2.13) |
| Treated/judged unfairly due to health condition/disability | 5.8 (5.0-6.8) | 2.2 (1.9-2.5) | <.001 | 2.43 (1.90-2.96) |
| No. of adverse childhood experiences | ||||
| 0 | 44.9 (42.7-47.2) | 70.9 (70.0-71.7) | <.001 | 0.70 (0.66-0.74) |
| 1 | 24.8 (22.8-26.9) | 17.9 (17.1-18.6) | 1.24 (1.11-1.36) | |
| ≥2 | 30.2 (28.3-32.3) | 11.3 (10.7-11.9) | 2.43 (2.19-2.67) | |
Abbreviation: aPR, adjusted prevalence ratio.
The reference category was no unstable housing experiences. Covariates were age and income.
At least 1 of the following: litter/garbage on sidewalks and streets, vandalism, poorly kept or rundown housing.
Discussion
To our knowledge, this study provides the first nationally representative estimates of unstable housing among US children who are currently housed and noninstitutionalized. Among the 17.1% of children aged 0 to 17 years who experienced unstable housing in 2022, inability to pay mortgage/rent on time was the most common indicator (70.8%). There were higher prevalences of unstable housing among racial and ethnic minority groups and populations experiencing greater societal adversity, including poverty and unemployment. In addition, lack of financial assets (ie, home ownership) was associated with greater unstable housing. Similarly, unstable housing was associated with higher prevalences of household-level hardships, including difficulty accessing and paying for medical care, insufficient food, and perception of unsafe neighborhoods. These findings demonstrate the complex realities faced by families with children in unstable housing circumstances.
Variations in the prevalence of unstable housing by state were expected but with some surprising results. Areas with well-known high housing costs (eg, California, Washington) had lower rates than the national average. However, state policy environments (such as investments in and implementation and availability of housing supports) were not taken into account in the present analysis, which may partially explain the differences. For example, a state may have high costs and great housing pressures but may also invest significant resources in addressing housing needs.
Past studies have shown the relationship between housing instability and structural racism.29,30 Historical practices and policies throughout the US have served to perpetuate structural racism, including more than a century of disinvestment and harmful policies related to housing.29 In particular, “redlining” made mortgages and homeownership less accessible for people in racial and ethnic minority groups, especially Black households, while also impacting neighborhood infrastructure. Although the Fair Housing Act officially banned redlining in 1968, the impact is ongoing with historically redlined neighborhoods receiving less investment, discriminatory zoning laws, and poor access to homeownership, capital, educational and career opportunities, and political power.31,32,33 These and other factors may have lasting current-day impacts on residents’ ability to maintain stable housing as well as their short- and long-term health and well-being, and limit opportunities for economic mobility to break intergenerational cycles of poverty.29,34 This history may provide some important context for this study’s findings regarding differences by race and ethnicity, although it does not provide a full accounting of all the root causes, for example, challenges faced by Native American individuals.35
Housing stability is essential for health and well-being, but there is no consensus or regulatory requirement on how to best screen for and assess it. The most commonly used measures to date have been the questions included in the Centers for Medicare & Medicaid Services Accountable Health Communities Model screening tool,36 and the questions analyzed in this study, which are also included in the Epic electronic health record company’s screening tool.37 However, these measures were designed with primarily adult populations in mind, and there are additional nuances to consider when screening children, such as how to account for split-custody arrangements. Thus, more research is needed to validate standardized screening instruments among pediatric populations. Previous research suggests that screening should include questions that identify experiences of homelessness as well as less severe forms of housing instability that nevertheless pose a risk to health and well-being.1,13,16,38 Thus, the results presented here underscore that efforts to improve children’s health should consider children’s housing-related problems beyond homelessness.
Strengths and Limitations
This study has many strengths, including the nationally representative data set, large sample size, and breadth of questions allowing for nuanced analyses. Despite its strengths, there are several limitations to consider when interpreting the findings. While the housing-related measures captured by the NSCH were based on existing evidence and practice, the individual indicators are not exhaustive and do not address other important domains, such as housing quality, substandard living conditions, or overcrowding. This limits our ability to examine the exacerbating effects of overlapping housing problems. In addition, because the NSCH is an address-based survey of noninstitutionalized children, the estimates may underestimate the prevalence of unstable housing by missing children currently residing in institutional settings (eg, homeless shelters, transitional housing), temporarily staying in hotels/motels, unsheltered, or “doubling up” at someone else’s home. Disaggregated race and ethnicity data were not available, which may mask differences in unstable housing prevalence among subgroups (eg, Asian vs Chinese, Japanese, or Vietnamese). Finally, the cross-sectional design precludes the inference of causal relationships between unstable housing and other types of hardships.
Conclusions
This study found that 1 in 6 US children experiences unstable housing, with variations by state and by sociodemographic factors, including child race and ethnicity and special health care needs, household income, caregiver educational attainment and unemployment, and renting. Efforts to improve children’s health must consider children’s housing-related problems beyond homelessness to reflect the true extent of risk to health and future stability faced by children and their families. Results from these nationally representative analyses may help move the field toward a unified definition of unstable housing for families with children, which would in turn inform clinically appropriate and evidence-based screening and interventions to support housing stability. To that end, HRSA MCHB’s Title V Maternal and Child Health Services Block Grant Program is in the process of adopting the unstable housing measure described in this study as a new national performance measure, to track state-level trends on this social determinant of health among aged children 0 to 11 years beginning in 2024.39 Such data can increase understanding of the size of the problem over time as well as the success of housing instability solutions. Additionally, in November 2023, the US Department of Health and Human Services announced a new Medicaid and Children’s Health Insurance Program Health-Related Social Needs Framework, which will help states support clinically appropriate and evidence-based interventions to address housing and other social needs for certain Medicaid enrollees, including housing navigation services, transition and moving costs, and tenancy-sustaining services.40 Addressing the spectrum of housing-related challenges faced by children and their families is crucial for enhancing their well-being and future prospects.
eTable 1. Characteristics of US Children, 0-17 Years, 2022 National Survey of Children's Health (N=54,103)
eTable 2. Survey Items Used in Measures of Unstable Housing, Other Hardships, and Sociodemographic Characteristics, 2022 National Survey of Children’s Health
eTable 3. Observed Prevalence of Unstable Housing by State of Residence, 2022 National Survey of Children's Health
eFigure. Prevalence of Inability to Pay Mortgage/Rent, Frequent Moves, and Homelessness among U.S. Children Experiencing Unstable Housing
Data sharing statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Characteristics of US Children, 0-17 Years, 2022 National Survey of Children's Health (N=54,103)
eTable 2. Survey Items Used in Measures of Unstable Housing, Other Hardships, and Sociodemographic Characteristics, 2022 National Survey of Children’s Health
eTable 3. Observed Prevalence of Unstable Housing by State of Residence, 2022 National Survey of Children's Health
eFigure. Prevalence of Inability to Pay Mortgage/Rent, Frequent Moves, and Homelessness among U.S. Children Experiencing Unstable Housing
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