Subsidized Housing and Health: Time for a Multidisciplinary Approach

The structural and social features of housing affect health in multiple ways. Structural features of the home, such as presence of mold, peeling paint, or pest infestations can have a direct impact on health. Affordability and stability can affect perceptions of stress and distress, impair social connectedness, and alter health behaviors. In addition, location, which determines accessibility to services, recreational opportunities, and food establishments, also has an impact on health. Federal programs, such as rental assistance programs and public housing are designed to address issues of housing affordability. These features require a multidisciplinary approach.

The expectation that addressing each issue of housing affordability separately would confer some health benefits to those aided by these programs has not been fully met. Public housing facilities are often of poor quality, exposing residents to environmental toxins (e.g., lead, mold, air pollutants) and structural deficiencies that worsen health. In addition, public housing is often located in lower-income neighborhoods, which often have higher crime rates and lower access to services and facilities. Federal rental assistance programs were developed to partly address these issues enabling families to live in mixed-income housing and mixed-income neighborhoods; however, the evidence supporting the health benefits of rental assistance programs is mixed.

BOSTON PUBLIC HOUSING

In an article in this issue of AJPH, Mehta et al. (p. 1059) used the 2010–2015 Boston Behavioral Risk Factor Surveillance System (BRFSS) to examine the association between subsidized housing types, specifically public housing and rental assistance, and asthma among adults living in Boston, Massachusetts. In comparison with home owners in Boston, the study noted that residents receiving public housing or rental assistance (e.g., Section 8 housing) had more than twice the odds of reporting current asthma. This association persisted after they accounted for potential confounders, such as smoking, obesity, secondhand smoke exposure, and access to health care. Interestingly, smoking modified this association in that associations between public-housing residents and rental-assistance renters and asthma were only evident among ever smokers. As details on housing quality were not collected, the mechanisms that may explain this interaction are unknown. However, it is plausible that the increased odds among ever smokers reflects the joint impact of smoking and other environmental toxins (e.g., dust or pest allergens, mold) or the joint impact of smoking and social stressors attributable to housing conditions, which have also been shown to exacerbate asthma symptoms.

Although the study is a cross-sectional analysis and cannot establish temporality, it brings light to the health conditions of populations living in public housing and those receiving rental assistance. Previous studies have noted similar associations noting public-housing residents being more likely to report worse health status, depression symptoms, and hypertension.¹ A previous study conducted among Boston-area residents utilizing the 2001 and 2003 Boston BRFSS, the same one used in the Mehta study, noted similarly worse health status and chronic health conditions among Boston public-housing residents. Associations noting greater odds of asthma suggest that the health of public-housing residents and those receiving rental assistance may not have improved over the past 10 years.

HOUSING TYPE AND CHRONIC HEALTH CONDITIONS

Mehta et al. also noted similar associations between housing type and asthma when considering public-housing residents and residents receiving rental assistance. Other studies have noted health benefits among residents who were using rental assistance programs compared with those living in public housing.² The Moving to Opportunity program demonstrated that residents moving from distressed public housing to housing areas with lower rates of poverty through the use of housing vouchers reported less mental distress and greater health benefits.² By contrast, the Affordable Housing as an Obesity Mediating Environment study found similar associations between public housing residents and those receiving rental assistance and depressive symptomatology.³ The Affordable Housing as an Obesity Mediating Environment study did not examine prevalence of asthma, but in the Moving to Opportunity study, adult asthma was not affected by moving to lower-poverty neighborhoods. This could reflect differential mechanisms between chronic health conditions that may be impacted by housing and neighborhood characteristics differently. In addition, quality of housing as well as location (neighborhood) may be the most relevant factors affecting asthma and other health outcomes. It is plausible that housing quality and neighborhood environment did not differ between Boston residents receiving public housing and those receiving rental assistance, thus negating any potential health benefit that may have been conferred through the use of rental assistance.

The observed association between subsidized housing and adult asthma can be attributable to several reasons. Environmental factors such as mold, pest infestation, secondhand smoke, and air pollutants, which can exacerbate asthma symptoms, are often prevalent in deteriorated housing, and have been shown to be more prevalent in public housing.⁴ Other factors such as crowding, disarray, and noise have been associated with both depression and anxiety⁵ and may affect asthma though indirect pathways. For example, previous studies have shown that emotional stress and mental illness can worsen asthma symptoms.^6,7 Concerns related to stability and control of one’s own environment, which can contribute to perceptions of stress and stress response and are also associated with asthma, are likely to be more prevalent among populations receiving housing assistance.^6,7 As noted, housing conditions are tied to economic factors, and, thus, racial/ethnic minorities, low-income households, and other vulnerable populations are most likely to receive housing assistance and suffer the health consequences related to poor housing conditions.⁴ To address this issue, Mehta et al. also conducted analyses among lower-income households, restricting analyses to only those who met family income requirements for most public-housing and rental-assistance programs offered by the Boston Housing Authority. Among Boston residents earning the qualifying amount for public housing or rental assistance, the association between housing type and asthma persisted; as the authors suggest, other vulnerabilities in addition to economic hardship may contribute to worse asthma outcomes.

MULTIDISCIPLINARY APPROACH

The health of public-housing residents as well as those receiving rental assistance warrants the development of strategies and interventions that can address the health needs of these vulnerable populations. A multidisciplinary approach is necessary to address the complexity of environmental, social, and economic issues surrounding housing. Such an approach would allow us to further understand how structural, geographical, and social housing characteristics affect health, how to remediate and improve current housing conditions, and how to plan for future affordable and quality housing that would promote, not hinder, the health of its residents.