Are interventions to prevent housing insecurity by promoting housing affordability and stability associated with improved health outcomes?
This systematic review of 26 randomized trials and observational studies found mixed and mostly low-certainty evidence that interventions to prevent housing insecurity were associated with improved health outcomes, with the highest-certainty evidence suggesting that eviction moratoriums were associated with improved COVID-19 outcomes.
This study suggests that because current data provide only limited-certainty evidence that preventing housing insecurity is associated with measureable health gains, payers and policy makers should consider pairing housing insecurity interventions with other efforts to improve the structural factors associated with improved health.
Housing insecurity—that is, difficulty with housing affordability and stability—is prevalent and results in increased risk for both homelessness and poor health. However, whether interventions that prevent housing insecurity upstream of homelessness improve health remains uncertain.
To review evidence characterizing associations of primary prevention strategies for housing insecurity with adult physical health, mental health, health-related behaviors, health care use, and health care access.
Pairs of independent reviewers systematically searched PubMed, Web of Science, EconLit, and the Social Interventions Research and Evaluation Network for quantitative studies published from 2005 to 2021 that evaluated interventions intended to directly improve housing affordability and/or stability either by supporting at-risk households (targeted primary prevention) or by enhancing community-level housing supply and affordability in partnership with the health sector (structural primary prevention). Risk of bias was appraised using validated tools, and the evidence was synthesized using modified Grading of Recommendations Assessment, Development, and Evaluation criteria.
A total of 26 articles describing 3 randomized trials and 20 observational studies (16 longitudinal designs and 4 cross-sectional quasi–waiting list control designs) were included. Existing interventions have focused primarily on mitigating housing insecurity for the most vulnerable individuals rather than preventing housing insecurity outright. Moderate-certainty evidence was found that eviction moratoriums were associated with reduced COVID-19 cases and deaths. Certainty of evidence was low or very low for health associations of other targeted primary prevention interventions, including emergency rent assistance, legal assistance with waiting list priority for public housing, long-term rent subsidies, and homeownership assistance. No studies evaluated health system–partnered structural primary prevention strategies.
Conclusions and Relevance
This systematic review found mixed and mostly low-certainty evidence that interventions that promote housing affordability and stability were associated with improved adult health outcomes. Existing interventions may need to be paired with other efforts to address the structural determinants of health. As health care systems and insurers respond to increasing opportunities to invest in housing as a determinant of health, further research is needed to clarify where along the housing insecurity pathway interventions should focus for the most effective and equitable health impact.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: September 18, 2022.
Published: November 2, 2022. doi:10.1001/jamanetworkopen.2022.39860
Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2022 Chen KL et al. JAMA Network Open.
Corresponding Author: Katherine L. Chen, MD, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, 1100 Glendon Ave, Ste 900, Los Angeles, CA 90024 (firstname.lastname@example.org).
Author Contributions: Drs Chen and Shekelle had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chen, Miake-Lye, Zimmerman, McGrath, Shekelle.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Chen, Miake-Lye, Begashaw, Larkin, Shekelle.
Critical revision of the manuscript for important intellectual content: Chen, Miake-Lye, Begashaw, Zimmerman, McGrath, Shekelle.
Statistical analysis: Chen.
Obtained funding: Shekelle.
Administrative, technical, or material support: Chen, Miake-Lye, Begashaw, Zimmerman.
Conflict of Interest Disclosures: Drs Shekelle and Miake-Lye and Mss Begshaw and Larkin were supported in part by a grant from Humana to University of California, Los Angeles (UCLA). Dr Chen reported receiving support from the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) via the National Research Services Award T32 Primary Care Research Fellowship at UCLA. Ms. McGrath is a Humana employee. No other disclosures were reported.
Funding/Support: This study was sponsored by Humana Inc (award 1529619).
Role of the Funder/Sponsor: The funder participated in design and conduct of the study (specifically, in setting the scope of the review) and in interpretation of the data via author Ms McGrath. The funder had no role in collection, management, or analysis of the data.
Disclaimer: The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, the HRSA, HHS or the US government.
Additional Contributions: The authors wish to thank Kathryn Leifheit, PhD, MSPH, UCLA, Lillian Gelberg, MD, UCLA, Teryl Nuckols, MD, MSHS, Cedars Sinai Medical Center, and Paul Ong, PhD, UCLA, for their feedback on the conceptual framework. They were not compensated for their contributions.
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