Affording Housing at the Expense of Health: Exploring the Housing and Neighborhood Strategies of Poor Families

Abstract

Low-income families often simultaneously encounter housing and neighborhood problems pertaining to safety, affordability, and quality issues that necessitate strategies to maximize limited budgets and ensure safety. Such constrained decisions regarding inadequate housing and poor neighborhood conditions, however, may themselves create or exacerbate health risks. Building on the survival strategies literature, this article offers rich and detailed accounts of coping and management strategies on the part of vulnerable families facing housing and neighborhood hardships. The findings are based on in-depth interviews with 72 respondents and ethnographic observations in an urban community. The results illustrate how low-income women avoid neighborhood danger by relegating family life to the home environment, thereby increasing exposure to health risks such as stress, depression, and asthma. The discussion focuses on public health literature linking housing and health and proposes the use of legal strategies and community engagement as resources to complement current approaches to housing and neighborhood problems.

The survival strategies of low-income householders have long been of interest to sociologists and others (Dominguez & Watkins, 2003; Du Bois, 2011; Edin & Lein, 1997; Heflin, London, & Scott, 2011; Jarrett & Jefferson, 2004; Roberts, 1994; Stack, 1975; Zekeri, 2007). More recently, the documentation of material hardship and corresponding strategies gained attention as families transitioned from welfare to work under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Heflin et al., 2011). Scholars noted the many challenges associated with negotiating poverty and documented complex approaches to making ends meet (Edin & Lein, 1997), intricate tactics to avoid neighborhood danger (Jarrett & Jefferson, 2004), and resource mobilization through social networks and institutional ties (Dominguez & Watkins, 2003; Small, 2009). The strategies of the poor remain relevant for several reasons, namely (a) the long-term impacts of welfare reform, (b) recent economic challenges at the national level that have disproportionately affected vulnerable populations and/or subjected previously unaffected individuals to the harsh realities of financial hardship, and (c) the recognition of associations between socioeconomic disadvantage and health risks (Adler & Rehkopf, 2008; Marmot & Wilkinson, 2009) with housing and neighborhoods cited as prime social determinants of health that spawn various health disparities (Acevedo-Garcia & Osypuk, 2008; Evans & Kantrowitz, 2002; Hood, 2005; Kawachi & Berkman, 2003; Kawachi, Subramanian, & Kim, 2008; Morello-Frosch & Shenassa, 2006; Morello-Frosch, Zuk, Jerrett, Shamasunder, & Kyle, 2011).

Housing and neighborhoods represent rich and underexplored areas to examine strategies employed by low-income householders who must make the most of limited budgets while also protecting the family from safety hazards and other dangers. Despite their commonplace nature and salience, we know relatively little about how families simultaneously negotiate these contexts and the unintended consequences of their approaches. Housing problems, in the various forms they may take, constitute a point of flux and frustration that affects a fundamental aspect of family life. When other aspects of the social and environmental surrounding are simultaneously compromised (i.e., the quality of neighborhoods and local institutions) by elements such as concentrated poverty, pollution, and violence, families are faced with layers of decision making and coping. Still, the survival strategies literature to date has not fully accounted for the complexity of housing and neighborhood strategies on the part of indigent inner-city residents whose choices are complicated by material hardship, layers of constrained decision-making, and competing priorities. This article builds on the survival strategies literature to further explore the management and coping strategies employed by low-income families when confronting various housing and neighborhood hardships. This article fills a critical gap in the literature on how low-income parents house their families. Specifically, it offers a unique view into the mechanisms underlying how housing and neighborhood problems are perceived, endured, and approached by low-income families with particular attention to the health implications of their strategic approaches.

Survival Strategies

Extant literature has established that economic hardship and the need to make ends meet lead to complicated juggling acts that combine both formal and informal approaches to addressing household budget deficits among the poor (Edin & Lein, 1997; Dill, 1998; Roberts, 1994; Venkatesh, 2006). In their seminal study about income and expenditures among low-income working and welfare recipient mothers, Edin and Lein (1997) found that earnings from work and welfare allotments did not fully cover household expenses. To bridge the gap, single mothers used several strategies to supplement their income, including network and agency-based strategies and in high-rent markets, “doubling-up” to pool resources and distribute housing costs among multiple household members. At the neighborhood level, Jarrett and Jefferson (2004) describe strategies employed by women living in an inner-city housing project to manage danger. The authors documented four nonconfrontational and family-centered tactics used: (a) monitoring the environment and identifying potential sources of danger, (b) carefully managing social connections, (c) self-imposing curfews to avoid danger at night, and (d) cloistering in the home. Although using these home-based strategies helped ensure personal and family safety, it also restricted opportunities for socializing and broader community engagement. Moreover, under substandard housing conditions, this approach increases exposures and health consequences related to poor housing quality, an issue that is further eluciated in this article.

Recent work on economic hardships has emphasized the role of housing and utilities as principal elements in the complicated survival scheme traversed by low-income householders. Heflin et al. (2011) used in-depth interviews to describe how poor mothers relied on safety net benefits, social networks, and individual strategies to handle material hardship in the realms of household bills including rent and utilities, food, clothing, and medical expenses. The authors found that families facing housing hardship doubled-up, applied for subsidies, made self-repairs, and moved. Likewise, when dealing with utilities hardship, mothers made partial payments, applied for state and utilities-based home energy assistance programs, used their Earned Income Tax Credits to pay down arrearages, or otherwise received help with family, friends, and romantic partners. In a recent Journal of Family Issues article, Heflin and Butler (2013) demonstrate that maternal health indicators significantly predicted patterns in entering and exiting housing, food and energy insecurity, as well as unmet medical needs. In fact, “maternal health is associated with entry into all four forms of material hardship” (p. 651), though, by comparison, the reasons for exit varied and were not as consistently related to health. In combining the work of Heflin and her colleagues, this article addresses a vital void in the survival strategies literature: the links between housing and neighborhood strategies and health among low-income householders.

Based on in-depth interviews and ethnographic observations, this qualitative study investigates the links between housing, neighborhoods, and health for 72 low-income families recruited at community health centers in Dorchester, Massachusetts. Rich and detailed narrative accounts illustrate how low-income parents navigate complicated situations and employ various problem-solving tactics. Such in-depth understanding of housing-related strategies contribute new insights into the process and implications of constrained decision making, particularly as they relate to health. Specifically, this article explores how factors at the neighborhood level induce fear and safety strategies that render the home environment central to family life. It also shows how the quality and affordability strategies specific to housing carry unintended consequences on health, at times alluded to directly by participants and also substantiated by existing research in public health. Along with a demonstration of passive and proactive problem solving repertoires, the discussion section presents alternative strategies to expand capacity to resolve problems including reinforcing network-based strategies through community engagement and promoting the use of legal strategies.

Data and Method

This study examines housing and neighborhood strategies from an ecological perspective to understand how a group of low-income parents navigate the interrelated facets of the built and social environments that surround them. Specifically, it addresses the following research questions:

Research Question 1: What housing and neighborhood challenges do families living in low-income communities face?

Research Question 2: What strategies do families use to cope with adverse living conditions in their home and neighborhood environments?

Research Question 3: What implications do these strategies have on the health and well-being of at risk families?

This study was approved by several institutional review boards including those at Cornell University, Boston University Medical Center, and Beth Israel Deaconess Medical Center. It also followed internal review procedures at participating community health centers not affiliated with academic institutions.

Sample

Study participants were recruited through community health centers, where I approached families in the waiting areas, informed parents about the study, and asked interested parties to fill out a 10-question screen to determine their eligibility for a study on housing, neighborhoods, and health. Eligible study participants included those with at least one self-reported housing hardship ranging from affordability to frequent moves and hazardous housing conditions, an income at or below 150% of the 2008 poverty level ($21,000 for a household of four), and residence in Dorchester, Massachusetts. This study primarily draws on 72 in-depth interviews with a parent or legal guardian of pediatric patients residing in Dorchester (see Table 1). The study sample consists of 70 female and 2 male heads of household ranging from 18 to 59 years of age. Most were single mothers of Black or Hispanic descent, native English or Spanish speakers, and though the majority of the sample was born in the United States, a sizable number were foreign-born and undocumented immigrants. Most of the respondents held a high school education, earned less than $30,000 per year, and many had housing subsidies.

Table 1.

Descriptive Statistics of Sample Characteristics (N = 72).

Demographic characteristics	n
Gender
Female	70
Male	2
Age (in years)
18-24	17
25-44	45
45-59	10
Education
Less than high school	11
GED/high school diploma	34
Any college	27
Income
Less than $10,000	36
$10,000-$29,999	26
$30,000 or above	10
Housing subsidy
Yes	44
No	28
Marital status
Single, never married	34
Cohabiting	12
Married	15
Separated/divorced/widowed	11
Race/ethnicity
Black	34
White	15
Hispanic	21
Asian	2
Immigration status
Native-born	45
Foreign-born	27
Undocumented	13
Primary language
English	52
Spanish	18
Vietnamese	2

Interviews and Observations

On screening in, participants were invited to schedule a home-based interview using a semistructured interview guide that focused on the following domains: housing conditions, neighborhood perceptions, child and parent health, coping strategies, and the use of various resources including medical and legal services. Questions included the following: “What is it like living in your neighborhood?” “How safe do you feel in your neighborhood?” “What are some of the things that you do to keep yourself and your children safe in this neighborhood?” “Please tell me about your home.” “Now, I'm going to ask you about your housing expenses including the rent and utilities.” “Please describe any problems you've had with respect to your housing” “What have you done to deal with/fix this problem? “How do these circumstances make you feel?” In addition, I asked respondents to show me around their apartments to document the housing conditions that they described in the interview including mold, poor lighting, electrical hazards, outdated appliances, and evidence of pest infestation. From these home-walkthroughs, I noted coping strategies firsthand including, for example, a lamp plugged into a long extension cord in another room to supply light to the bathroom due to a broken fixture. I also documented kitchen cupboards filled with cans from the food pantry, mouse traps, space heaters, and bedrooms housing entire families. The home observations were documented in field notes written within 48 hours of the interview. The interviews and home walkthroughs lasted 90 minutes on average. I personally conducted the interviews in English and Spanish and also in Vietnamese with the assistance of a translator. All interviews were digitally recorded and transcribed. Respondents were compensated $25 in cash and given a brochure with information on local service providers rendering housing, utilities and legal assistance, shelter placements, and domestic violence resources as incentives to participate in the study. Pseudonyms are used throughout the article to refer to respondents and other identifiable information such as street names to protect the anonymity of study participants.

Supplemental data in the forms of census data, crime statistics, local newspaper articles, and archives as well as ethnographic observations were gathered to provide additional contextual information at the neighborhood level. Over the course of 18 months, I regularly attended community meetings and events throughout Dorchester to get a sense of neighborhood life and understand elements associated with being a local resident (as described in the results section). I was present at over 30 area neighborhood, civic and tenant association meetings, and crime watch groups, visiting most at least twice during my time in the field. I also interacted with community residents at local institutions such as the public library, parks, restaurants, church services, area festivals, and events. Observations of community events and activities were captured in detailed field notes written within 48 hours of the encounter and later organized into a single document. The notes described the nature of the events, detailed the actors involved (and those notably absent), and linked the experience to my understanding of the neighborhood or given phenomenon (i.e., safety and violence). A “zigzag” approach was used throughout the study to collect and analyze both interview and ethnographic data in an iterative way. This allowed for the refinement of the interview guide and observational protocol in order to build on new knowledge and better understand recurring themes (Creswell, 2007).

Analysis

Interview transcripts and field notes were systematically coded for emergent themes using a grounded theory analytical approach to understand meanings attributed to everyday experiences with housing, neighborhoods, and poverty (Charmaz & Belgrave, 2003). Two coders (the principal investigator and a graduate-level research assistant) reviewed the transcripts and field notes several times to become deeply familiar with the data and consider its overall meaning. Continuing this inductive analytic strategy, the research team initiated the interpretation process by summarizing the data and organizing and integrating observations into separate sections. In the coding process, we organized small segments of data into meaningful categories, labeled them as discrete topic areas using concise descriptions or in vivo codes (respondent's language), and grouped similarly themed categories to identify instances where participants described their problems, associated strategies, and the overall tone of the participant accounts. This process was enabled by Atlast. ti (Version 6), a qualitative software program that facilitates the systematic analysis of data and assists in the process of categorization and coding, developing themes, and organizing data segments (Creswell, 2007). The analysis yielded emergent themes that surfaced from the data to uncover frequently occurring topics and rich narratives of housing and neighborhood experiences, opinions about living conditions, and perceptions of the consequences of housing and neighborhood hardship particularly as they pertained to health. The emergent themes that surfaced made apparent the layers of risk encountered by participants in their neighborhoods and homes and the complicated schema of strategic action they reported. Several validation procedures were employed. First, we engaged in interrater reliability activities throughout the coding process in which the two coders verified that the application of codes in each transcript was done consistently; any discrepancies were discussed and modified as necessary. Second, results were verified, contextualized and triangulated by referring back to full transcripts, interview summaries, and field notes of the home walkthroughs. Last, two study participants were consulted about preliminary and final study results to ensure that we “got the story right” (Creswell, 2007).

What follows is an in-depth description of the housing and neighborhood strategies employed by study participants as well as an overview of the approaches used by participants to contend with housing and neighborhood problems. Findings are presented using direct quotes and summaries to convey salient lessons learned from the data and to draw connections between events, processes, outcomes, and themes. The subsequent section begins with a description of neighborhood life based on my observations of community meetings and personal experiences. The remainder of the section explores neighborhood and housing strategies and approaches to problems as described by participants.

Findings

Life in Dorchester

Participant observations over the course of 18 months allowed me to appreciate life as a Dorchester resident. Immersion as a neighborhood resident helped situate issues of crime and safety, the lack of adequate recreational options and institutional services as well as the perception of discrimination and challenges associated with acquiring decent housing. During my observations at locally held meetings, I noted that the most civically active community members were often homeowners and older residents who planned local development, celebrated milestones, clamored for greater police presence, and networked with politicians, local leaders, and other neighbors. I summarized the experience of attending local meetings in analytical field notes written toward the end of my time in the field:

On any given weekday evening community members, police officers and politicians convene at neighborhood association meetings throughout Dorchester. In the “Dot,” there seems to be a correlation between how organized a community is and how much crime, especially serious crime, is reported. Interestingly, in areas where there is less severe crime, there also tends to be larger, well-established neighborhood civic associations and crime watch groups that garner firm attendance at monthly meetings. Local politicians almost always appear at the well-attended meetings; meanwhile their staffers are more likely to be found at lower profile meetings. As one civic association president explained to me, “We are proactive and we work together with the police.” In neighborhoods with high crime rates, the groups tend to be smaller and involve local organizations rather than a strong resident base. In all, these meetings are a direct venue to enforce accountability among law enforcement officials and local politicians, yet there are vast differences depending upon where in Dorchester one lives. . . . I'm curious why so few of the participants at these events resemble the women in my study who struggle with the everyday challenges of raising a family, working and living in poverty.

Personally, the experience of living in Dorchester was particularly telling given that as a single female and then-graduate student, I had greater flexibility and wider access to a broader array of housing options—or so it seemed. In fact, I too confronted issues of housing instability that resulted from repeated vandalism and targeting while living in, arguably, the most desirable section of Dorchester. Over the course of 9 months I came to feel unwelcomed in the exclusive section of the neighborhood in which I resided. On three separate occasions, my car's windshield was intentionally broken, someone left a threatening note about parking, and spit phlegm on my windows, and last, feces were smeared on my car's driver's side door panel and keyhole—all for no apparent reason. When I reported the latter incident to Boston police, the officer was perplexed by the situation and noted “but you're a good Puerto Rican.” By this time, I had forged a close relationship with the president of the local neighborhood association, and he was convinced that these acts were likely racially motivated since the area was plagued by a legacy of territoriality and tension between Irish Catholics and Blacks and other minorities. Displaced by these menacing acts, I turned to friends for shelter and stayed “between places” until returning from the field to my home institution. In consequence, I personally encountered housing and neighborhood challenges that, by comparison, could only be further complicated by extreme poverty and parental responsibilities. Ultimately, this experience exposed me to the housing and neighborhood dynamics that present formidable challenges for low-income families residing in inner-city communities.

Neighborhood Strategies

At the time of the study, Dorchester had higher poverty and unemployment rates, more single-parent households, a higher concentration of Blacks, Latinos, and Asian immigrants, more housing density in a largely rental market along with more violent crimes compared to the city of Boston and the State of Massachusetts (Boston Redevelopment Authority, 2013). In many ways, Dorchester resembled a typical inner-city neighborhood peppered with public housing projects and grocery stores and lit up by police sirens at night. When I asked a standard question on the interview protocol, “Is there anything that you do to stay safe in this neighborhood?” study participants described what it took to avoid crime, drugs, and idle street customs that accompanied life in certain parts of Dorchester. Most families described implementing an intricate set of strategies such as (a) limiting outside interactions, (b) restricting family activities to the home environment, and (c) selectively socializing with neighbors. The following quotes are illustrative of maintaining safety in Dorchester:

We avoid the areas that are known for violence, or known for troublesome people—especially in the summertime, we really don't stay down here [in Dorchester] as often. We try to be everywhere but here. (Quanique)

Safety's an issue in every neighborhood but we just try to live, try to stay out of trouble and mind our business. (Kandree)

So far so good. Thank God nothing's happened. If you mind your business and always be alert you'll be okay. But sometimes that doesn't always happen. (Joanna)

Quanique, Kandree, and Joanna all acknowledged safety issues as a fact of life in Dorchester. Quanique responded by fleeing to relatives’ homes in other parts of the state during the summer months. Kandree went about leading a trouble-free life by minding her business, and Joanna did the same and added staying alert but cautioned that this approach was not fail proof. Other respondents avoided the streets particularly at night.

I don't be outside late at night and that's about it. I've been here a long time so I know everyone and everyone knows me. What they would do to a newcomer, they wouldn't do it to me. I don't have the kids out late ‘cause a lot of things can happen at nighttime. (Tasha)

Basically what I do is I try to do everything early and be home at a certain time and just stay home, even though at home you don't feel safe anyways. (Robert)

Tasha and Robert were aware of additional dangers present at night and managed to get things done during the day and stay indoors at night. Robert also duly noted that home is not always safe either. Still, many respondents concurred and reported staying home for extended periods of time in response to negative perceptions of neighborhood safety.

Home is a safer place for me to be. I don't really like going in the streets because I've seen so many people get killed in the last couple weeks that I've known. I'd just rather be in my house. (Leesha)

I try to keep my son in the house as much as possible and I never would go outside too much either myself. (Veronica)

I feel safest when me and my kids are in the house and as long as they are with me. . . . I just don't feel safe with them walking the streets around here. (Sabrina)

We don't go outside. If we don't need to be we don't go outside. I don't socialize with people. I don't sit on the porch. I just stay in here. . . . I stay in the house with my baby. (Katherine)

Leesha, Veronica, Sabrina, and Katherine along with many other respondents described spending significant amounts of time at home to keep safe from harm. Katherine added that she also didn't “socialize with people.” In fact, in addition to staying home, the safety strategies of the parents in this study also entailed carefully managing associations with others. Some mothers chose to (a) limit personal networks by hedging relationships with neighbors and other community members, (b) avoid interactions with strangers, and (c) employ keen discretion regarding children associating with unknown adults. Jackie and Mirta described having superficial interactions with neighbors and practicing vigilance in social interactions. The mothers said,

Even though I say, “hi” and my goodbyes to some neighbors, you know, I stay to myself because I don't really socialize too much. I figure if you're too in people's business you're just gonna get, you know, problems. So I'm to myself. I don't have time to go around with people here. (Jackie)

I try not to bring anyone to the house. If someone comes to the house I must have known them for some time. I really try to monitor who the children speak with, always trying to ensure that they don't just befriend everyone. I'm always aware. I don't know. It's the only way that I can feel safe with the children. (Mirta)

Limited engagement with the neighborhood environment due to safety concerns frequently equated to more time spent at home and less opportunities for socializing with others. Unfortunately, home was often no respite from peril. As evidenced from respondent accounts and home-based observations, study participants also coped with a wide range of housing problems that involved material hardship and poor housing conditions.

Housing Strategies

Affordability

At the time of the study, the average gross rent as a percentage of household income was 35% or greater for 60% to 75% for households in Dorchester earning less than $35,000 (Boston Redevelopment Authority, 2013). According to Stone (2006), these households are “shelter poor.” Those fortunate to have a housing subsidy were often responsible for a third of the rent and, at times, utilities. Others reportedly waited on a subsidized housing list anywhere from 3 to 5 years, which is consistent with recent estimates at the national level (Aratani, Chau, Wight, & Addy, 2011). Household budgets rarely balanced out as parents purchased food, rent, utilities, clothing, diapers, and other basic necessities. The disparities in household income and commonplace expenditures led families to a series of elaborate housing affordability strategies including (a) prioritizing household budget items and employing tradeoffs, (b) applying for benefits and subsidies, and (c) pooling resources and sharing financial responsibilities with family members and/or nonrelatives. They explained,

The thing is no matter how much we try to get ahead we just can't. It's either we pay for food or we pay for the bills so I told my boyfriend, the reality is I have no other choice but to let the bills go, the food's more important. (Elaine) Really, I'm not making ends meet at this moment. At this point they might shut off my light in the next two weeks if I don't pay the bill, and I honestly don't have money to pay the bill. I thought I was going to this week but I can't. (Quanique)

I decided to live in a shelter ‘cause your case comes up quick when you're in a shelter [because] you're considered homeless automatically. . . . With a kid you go, “yeah, I'm a teen parent too.” So you're priority. you're automatically first-priority to them. (Kelly)

So we found this place and rent is 1,000 dollars. My husband is a construction worker, so sometimes he works, sometimes he doesn't. Since I don't work, my husband brought a friend to live in our apartment. It's hard for us because the four of us have to live in a room. We pay our part of the rent and the rest he pays. . . . He sometimes helps us with the kids. (Wanda)

The challenges of scrounging together sufficient financial resources to meet household expenses produced an atmosphere of instability for families as they feared hunger, utility shut-offs, and evictions. Elaine pondered over essential household needs and prioritized food over other basic bills. Meanwhile, Quanique was cornered by poverty and uncertain about the impending darkness borne from utilities hardships. Kelly attempted to circumvent long delays in accessing housing benefits by “going homeless” in order to be given priority on the rolls for subsidized housing. Finally, Wanda and her husband relied heavily on family and close friends to share financial responsibilities and pool resources. As undocumented immigrants, their options for work and eligibility for social benefits were restricted and thus reliance on networks compensated for institutional forms of support available to other participants.

Quality Control

Along with material hardships, many participants also encountered challenges with managing subpar housing environments and other housing quality issues. The most commonly reported housing problems were related to pest infestation (63%), cracks, holes, mold, and leaks (46%) as well as heating/cooling or ventilation system deficiencies (39%). These findings mirror national level statistics that report that the poor, people of color, and the elderly are more likely to contend with housing problems (U.S. Department of Housing and Urban Development, 2011). In response to these housing perils, study participants reasoned,

I've had Section-8 for three years now and I've moved every year since. My last landlord was a slumlord that didn't take care of the property. (Leesha) Yeah, there's too many of them [holes]. I tried patching it myself. I tried getting my own hands in there with compound and my spatula . . . (Joanna)

Leesha and Joanna used two distinct approaches to handle the housing conditions they encountered: residential mobility and self-repairs. On the one hand, Leesha used her housing choice voucher to move on an annual basis though this option increased exposure to the liabilities of frequent moves including loss of continuity in schooling and detachment from social support (Kawachi & Berkman, 2003; Kawachi et al., 2008). On the other hand, Joanna literally took matters into her own hands by patching up holes to halt the intrusion of rats emanating from the ground-level restaurant in her four-story walk-up. In fact, insect and rodent infestations were extremely common problems for families living in older and poorly maintained dwellings where extermination occurred infrequently, and the infestation had proliferated to the point that containing or eliminating rodents was nearly impossible. In lieu of an integrated pest management approach, many study participants reported using toxic chemicals or incorporated household pets to deter the roaches and mice from roaming about in their homes. The participants explained,

I ended up having to get a cat because of the mice. I had the mice come to the stove, on top of the stove, come from under the stove. So the cat had to get the mice. (Faith)

I don't really have a lot of problems that would make me really, really angry. Just the roaches and what I do is just put it under my control. I just buy Raid and I buy the sticky things. The mice traps are something I learned . . . the gluey thing will catch roaches. So when the roaches are running by, they gonna stick to it. (Tasha)

Later in the interview I saw another one of Tasha's methods in action as she sprayed the wall behind the sofa where she was sitting while conducting the interview. After spraying the roach with an oversized bottle of Raid, she noted, “We might get asthma from the spray but not from the roaches.” In contrast, Mariah took a different approach. She noted,

The mice were all across the floor. Plus, I have a little baby. He's crawling now and you never know what he's going to pick up, what types of germs he's picking up off the floor. She [the landlord] said she was going to exterminate but she hasn't yet so I'm gonna have to take that to a higher authority if she don't hurry up.

When you talk about a higher authority, which higher authority would that be? (DH)

Um . . . probably gonna take it to Metropolitan ’cause they're the ones paying the housing and I'm pretty sure they're not gonna pay a landlord $1,100 a month if the conditions aren't right. So I figure if I take it to them they can take it to her. Or, I'm the type of person who would call the health inspection really quick. I don't care. I'll call the inspection people ‘cause I'm a stand up for my rights type of person. (Mariah)

Most of the respondents attempted to do something in response to common problems such as structural deficiencies and pest infestation. Joanna, Leesha, Faith, Tasha, and Mariah described measures such as performing home repairs including patching up holes, placing rodent traps, or moving to evade the conditions altogether, albeit without guarantees that the subsequent place would bear better results. Regardless of the outcome, the approaches described in this section are largely proactive. Nevertheless, approaches to problems varied by respondent and problem type as discussed below.

Approaches to Problems

The process of navigating complicated housing systems yielded findings about the various problem-solving tactics that ranged from passive ones, in which problems were endured or temporarily evaded, to more proactive measures that attempted to eradicate or repair housing problems through the mobilization of resources. Whereas passive approaches involved patience, hope, and faith, proactive measures entailed seeking institutional resources, demanding improvements, and using tactical techniques to garner necessary attention.

Passive Approaches

It has been acknowledged in the literature that negotiating the circumstances of poverty is taxing and time-consuming (Edin & Kefalas, 2011). Seeking help often involves long lines, administrative delays, and internal gumption to withstand the process. For some study respondents, the latter involved spiritual wherewithal and patience.

I'm hoping and I'm praying. Every day I get down on my knees and I just pray. I just hope that, you know, this housing comes through for me because I'm just greatly affected by it. (Shirley)

The bills, it's like I try to stay on them but if I miss one month, then the next thing I know, it's like $200 or you know, and then I'm playing catch-up again. That stresses me out and sometimes I just don't do anything about it. I get overwhelmed and I start shutting down. (Angelina)

I'm definitely interested in getting help. . . . I've heard of a low-income discount for the gas and electric. . . . I left a message on this number my cousin gave me for ABCD. No one ever called me back and I just said, “oh, whatever.” I never called back. . . . See, I don't have that in me. I'm like, okay, I'm not gonna bother them no more. I'm not gonna call no more. I feel bad. I'm that kind of person. I feel like if I was more aggressive maybe more things would be getting done. But I don't have it in me. I really don't. (Lisa)

As Lisa described it, not being “more aggressive” meant that she was ultimately unable to obtain fuel assistance. The consequences of this passive approach included higher utility bills and a lack of shut-off protections in addition to further worry and stress. Shirley also recognized how her wait for a housing placement affected her but resorted to “hoping” and “praying” that a timely resolution would surface. Under similar circumstances, Kelly (from previous section) voluntarily moved into a shelter to expedite the wait. Save for a miracle, the difference between Shirley and Kelly's approaches can be measured in years as homeless families are deemed priority cases and wait less time than others on waiting lists for subsidized housing (Aratani et al., 2011). In addition to it being more efficacious, Kelly's approach was also more proactive.

Proactive Approaches

Along with tenacity, many respondents leveraged institutional resources, were persistent in their requests, and used special tactics to glean desired results from the housing and neighborhood circumstances they faced. We saw this above with several of the participants especially in the housing quality strategies involving do-it-yourself repairs (Joanna) and residential mobility (Leesha). In general, parents employed proactive measures when they were empowered with information through previous experiences or network and organizational ties as well as a clear understanding of tenant rights and the bureaucratic process. For instance, Katherine lived in several apartments with housing code violations and learned that by calling inspectional services she could get the landlord make necessary repairs. She explains,

The inspectors came because of the stove problem and plus, the closet things were all broken and they didn't want to fix it. So I called inspectional services and they came. They made me buy the stove out of the rent, and gave them a set amount [of time] to make the other repairs. Fourteen, I think it was fourteen days to fix it. They didn't do it real well but they fixed everything that needed to be fixed. (Katherine)

Leesha, on the other hand, described how she coaxes the management company to fix things by “nagging”:

Anything that has to do with this apartment-wise, I nag them until they do it. I'll keep calling ‘til they do it. If you call them once, like, I used to call one time and left it alone, and I'd be sitting here forever waiting for them to do it. When the refrigerator in there ain't work, I called them and told them that all the food in the refrigerator had gone bad. They never did nothin’ about it. Then when I kept calling . . . that's when they finally sent the guy out here to fix it. (Leesha)

Tasha, who above demonstrated two strategies to deal with cockroaches— glue traps and roach spray—articulates here a technique she would use if facing an unsafe situation in her neighborhood that required a response from the police. She says:

I thank God I haven't needed the police but if I did and I thought my life was in threat, I would say, “Officer down,” and I would deal with the judge when I get there. . . . When I was young, my mother told me to say they're beating up a white woman in the hallway. Now see, what has really changed? Just the technique. You know what it's gonna take to get the police out here? If there was a white woman up here back in the 70s or the 60s getting beat up in the hallway, please, this whole place would be surrounded. Everybody would be under arrest, everybody. But now, if you say a police down, they'll come. If someone gets shot, you say a police down. You say somebody got shot they're gonna take twenty, twenty-five minutes, the man be done died or something. Unfortunately it's sad, but it's true. (Tasha)

Tasha's approach to problems involved planning and deliberate action. Initially trained by her mother, Tasha revised the tale of “valuable victim” from White woman to police officer. Tasha's tactic exploited notions of social hierarchies to more effectively attract the attention of authorities should an emergency arise in her public housing building complex. From cockroaches to crises, Tasha developed a proactive schema of strategies to contend with housing and neighborhood hardship notwithstanding the stress and health triggers that could not be curtailed by her efforts.

Affording Housing at the Expense of Health

Breaking away from the dichotomization of housing as simply being homeless or stably housed, this article demonstrates that the constant negotiation of housing and neighborhood problems is a consuming process with important implications for health. References to health were alluded to above by Angelina who described feeling “stressed,” “overwhelmed,” and “shutting down” while having to juggle bills. Meanwhile, Tasha mentioned getting asthma from the roaches and/or the roach spray. Most often respondents cited stress, depression, and asthma as the primary health conditions they encountered as a result of housing and neighborhood hardship. Carmen, for example, described the impacts of her housing situation on her health:

How does this whole situation, that right now you're not sure about where you're living, make you feel? (DH)

I start to get stressed out. I have high blood pressure. I have to be taking depression pills as well. (Carmen)

Like Angelina, other parents described coping with depression as they contended with not having enough resources to cover it all. Sylvia elaborated on how her “money situation” triggered her depression:

So what about, if you don't mind, talking about your depression. When does it come on? (DH)

It comes when I'm dealing with some money situation and I know I don't have it. The way I see it, as long as we have a roof over our head and we have food in the house, I don't really try to worry about it. . . . As you see, I've got so much stuff I gotta deal with that I let everything else go for a while . . . for a long time before I even get to it. But I get to that stage where I don't want to see anybody, don't wanna be around nobody. I just wanna sit here not having to deal with anything. I know it's hard. I have kids. But my kids are fine. They know mommy sometimes is upset. (Sylvia)

At times, the conditions at home triggered asthma symptoms as well as further trade-offs. Annette explains her situation with mold, cold, and asthma:

Is mold an issue? (DH)

Um . . . I feel it is in my daughter's room—mildew. When it rains her room smells like mildew. What I found out, these floors under the carpet are cement so my carpet used to stay wet around my window and my daughter's carpet around her bed. So I pulled the carpet up and there's a crack in the floor from one end of my bedroom which goes all the way across to my daughter's bedroom, down the wall into her closet. Prime management came and they patched it up. They cemented it but the guy told me, “They're gonna have to pull these floors up and do them over.” He said, “Because this will last you like a band-aid for about five years.” He was right. It lasted about five years but now her room smells like mildew again, that moldy mildew smell. (Annette)

And you said she has asthma. (DH)

Yeah, and it triggers her asthma. . . . It triggers it but I don't want them to give us the hardwood floors because it's so cold in here. It would just keep the floors freezing cold just to fix it. (Annette)

In effect, respondents such as Carmen, Sylvia, and Annette embodied their housing problems by absorbing stress, coping with depression, and living with one asthma trigger to avoid another. The connections to health were not always explicitly made by participants, but a broader literature on chronic stress demonstrates how poverty “gets under the skin” in the process of cumulative corrosion of physical and mental health where housing plays a significant part (Lupien, King, Meaney, & McEwen, 2001). The following section links study findings on housing and neighborhood risks with the broader social determinants of health literature and proposes the expansion of strategies in two areas: legal strategies and community engagement.

Discussion

Drawing on 18 months of ethnographic observations and in-depth interviews with 72 residents of an urban community, this article demonstrates the interaction between housing and neighborhood hardships as experienced by low-income inner-city residents. Findings suggest that the ecological interface of housing and neighborhoods represent multiple layers of risk and paradox in the living conditions of poor families. In response to eminent risks of violence and fear at the neighborhood level, parents devised safety strategies that included avoiding the streets, particularly at night, carefully managing relationships with neighbors, and relegating family life to the home environment. These tactics used to ensure family safety from neighborhood elements demonstrate how and why the home environment is extremely important to understand, particularly because it relates to associations between health and the built environment as these strategies carry unintended consequences known to compromise health.

For inner-city residents, health hazards are paralleled in the home and neighborhood environments as they experience disproportionate exposure to environmental risks (Morello-Frosch et al., 2011; Morello-Frosch & Shenassa, 2006) and health disparities (Adler & Rehkopf, 2008; Marmot & Wilkinson, 2009). These disparities remain perplexing even as we recognize the need to take the social context of disease more seriously (Williams, Sternthal, & Wright, 2009). The neighborhoods and housing units that individuals and families of limited economic means can access are rooted in the restrictions of poverty, discrimination and segregation. This article shows that while effectively managing one problem by avoiding neighborhood danger, risks in the home also jeopardize the health and well-being of household members. In essence, they are affording housing at the expense of health.

The participant accounts presented above delineate avoiding and carefully managing neighborhood contexts marked by high crime and interpersonal violence and low social cohesion. This limited engagement with the neighborhood environment often resulted in more time spent at home and thus more contact with facets within the context of the home that might endanger the health, safety, or well-being of householders. While at home, overcrowding, poor maintenance, and rodents contribute to illness and stress and affect parent and child health (Bashir, 2002; Evans & Kantrowitz, 2002). Lack of affordability, instability, and poor quality conditions in housing have been linked to health risks including developmental delays, depression, and stress in children, parents, and other household members (Evans, 2004; Krieger & Higgins, 2002). Prolonged exposure to health risks under unsafe or subpar housing conditions increases likelihood of injury and illness associated with conditions such as mold, lead exposure, extreme temperatures, allergens, and pest infestation (Evans & Kantrowitz, 2002; Sahlberg, Mi, & Norbäck, 2009). Roaches and mice are themselves asthma triggers (Krieger, Takaro, Song, & Weaver, 2005), but the strategies employed, including the use of pesticides as demonstrated by Tasha, may further exacerbate asthma and other respiratory illnesses. Indeed, as Tasha asserted in her quote about getting asthma from the roach spray rather than the roaches, many of the chemicals used to deter infestation are toxic and have been found to contribute to or exacerbate health conditions such as asthma, other respiratory disorders, and allergies, and some chemicals, if ingested, are poisonous (Hernández, Parrón, & Alarcón, 2011). Other common strategies hazardous to health included unconventional heating methods such as space heaters or ovens or just uncomfortable home temperatures that increase risk of carbon monoxide, nitric oxide, and black carbon emissions as well as heat or cold stress. These exposures can also lead to injuries, death, fires, and asthma among other health risks (Evans & Kantrowitz, 2002). Moreover, restricting family activities to the home environment reduces opportunities for physical activity and restricts the development of social support through connections with neighbors and other community members (Cleland et al., 2010; Franzini et al., 2009; Gordon-Larsen, Nelson, Page, & Popkin, 2006; Willey et al., 2010).

Expanding the Strategies Toolkit

The set of strategies employed by study participants were primarily directed toward internal resources that, at best, were restricted in their reach. There remains a need to consider additional approaches that can more effectively address the housing, neighborhood, and health concerns affecting vulnerable groups. In light of this need, I offer two distinct recommendations for expanding strategies for low-income households: legal strategies and community engagement. These suggestions are rooted in the data, set at the housing unit and neighborhood levels respectively, and informed by participant accounts and my observations in the field.

Legal Strategies

Legal strategies may present a viable option for securing adequate housing, promoting housing stability, and protecting child and family health and well-being by addressing factors that threaten the basic tenets of housing rights. Legal strategies specifically entail the use of a lawyer to advocate for the protection of civil rights including, for example, entitlements to social benefits and housing violations. In the case of low-income tenants, legal advocacy may be more effective than challenging powerful institutions pro se (on their own) to more fully support and protect their interests. Lawyers may function as a “higher authority” of the type alluded to by Monique above. For instance, lawyers can place demands on landlords and property managers to remediate unfavorable housing conditions or negotiate payments to protect against evictions or utility shut-offs. Legal representation in court (i.e., housing or family court) or other institutional proceedings (i.e., social services and school) may prove beneficial in addressing clients’ specific needs and balancing power differentials between clients and court personnel or institutional representatives. Moreover, by focusing on the home and problems therein, families may benefit from immediate results concerning housing as well be empowered to tackle other civil legal infractions they may face (Hernández, 2010).

Legal aid is among the very limited options available to indigent clients; however, the demand far outweighs the supply. It is estimated that 80 percent of the poor have unaddressed civil legal needs, with housing constituting a critical but untended need (American Bar Association, 2008). This “justice gap” has been shown to reproduce social inequality and further disenfranchise less privileged groups (Sandefur, 2008). The expansion of legal strategies can be facilitated through established legal channels such as legal aid or in innovative ways as with the Medical Legal Partnership (MLP) model, which seeks to simultaneously address health and legal disparities in clinical settings (Sandel et al., 2010; Williams, Costa, Odunlami, & Mohammed, 2008). The MLP model described in detail elsewhere (Sandel et al., 2010) began at Boston Medical Center and has been serving Dorchester residents at local community health centers since 1993 with housing as one of its main areas of legal advocacy. In a recent study, MLP participants experienced significantly better housing resolution outcomes when compared to non-MLP participants (Hernández, forthcoming). In general, more needs to be done to increase opportunities for low-income householders to mobilize the law and benefit from legal strategies to address housing problems, reduce health risks, facilitate greater access to justice, and ensure a better quality of life.

Community Engagement

From my fieldwork, I observed that many Dorchester community members, particularly low-income residents, did not regularly participate in local forms of governance such as neighborhood watch groups, tenant association meetings, and other community gatherings. Despite experiencing many challenges at the neighborhood level, study respondents resorted to restricting social network ties and limiting time outdoors rather than building strong associations with neighbors and making connections with local leaders. This approach constitutes a short-term solution to the problems of neighborhood crime and safety issues that will likely not lead to scalable changes as the politicians, law enforcement officials, and others are not confronted with the concerns of local citizens and are thereby less compelled to address these issues with responsive policy and action. An alternative approach involving greater community engagement garners an opportunity for collective action, developing interpersonal and institutional ties, mobilizing members around pertinent issues, and calling for action and policy change (Portney & Berry, 1997). The voices and perspectives of all residents, especially the socioeconomically disadvantaged groups, ought to be more present in this process of local governance. The challenge of organizing a community has no easy solution, but efforts that seek to increase capacity for community engagement are necessary in order to motivate policy change, increase accountability, and advance opportunities for health, social and economic well-being, particularly in low-income inner-city communities.

From a social capital perspective, the lack of community engagement can itself be detrimental to health (Carpiano, 2006; Kawachi et al., 2008). For families like the ones in this study, a concerted effort is needed to trust again and invest in personal relationships that materialize into enhanced social and health opportunities. Social Capital Inc. (SCI), a Dorchester-based nonprofit organization, was formed in 2002 with a mission to increase civic engagement for health, youth empowerment, and economic development. The premise of the organization is to mobilize community members to motivate positive changes by connecting local residents to each other and to pertinent information. Through active civic engagement and fostering an opportunity to get to know one another, SCI seeks to dispel myths, reduce fear of socializing, and promote the idea that health is fundamentally a social process. During my time in the field, I personally witnessed and benefited from SCI's efforts to organize volunteer activities that provided opportunities for neighbors to get to know one another and work toward a common good. SCI is just one example of a broader effort that ought to be made to encourage community engagement and strengthen social network ties in order to reap social, economic, and health benefits at the individual, household, and community levels.

Conclusion

This study helps fill a crucial void in the survival strategies literature by detailing the contextual demands of low-income families and strategies used to keep them safe and housed. Rich and nuanced narratives illustrate how complicated housing and neighborhood situations are navigated and the ways in which various problem-solving tactics are employed to tackle poor housing, unsafe neighborhoods, and the complexity that poverty imposes including its unintended consequences on health. Participants in this study were shown to employ carefully crafted neighborhood and housing strategies to avoid danger, afford housing, and control housing quality through a combination of passive and proactive approaches. They also noted its connection to health citing stress, depression, and asthma triggers as common ailments associated with housing and neighborhood hardship. In response to study findings, two recommendations were put forward—legal strategies and community engagement—to expand the present scope of available strategies and enhance prospects for improved health and social change.