Poor Living Conditions Affecting Health

[Torie Crivello]

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

In addition, low-income families may be more likely to live in older homes and homes with greater risks that can impact health outcomes.1 For example, these homes may be under-insulated, lack air conditioning, and cost more to heat, leaving homes too hot or too cold, which has been linked to poorer health outcomes.3,4,16 Additionally, limited finances may result in a lack of housing maintenance, which can lead to poor housing conditions inside the home (e.g., damaged appliances, exposed nails, or peeling paint) as well as outside the home (e.g., damage to stairs and windows).6

This microsite is coordinated by the Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services.

Louise Morales-Brown is a social researcher within the civil service, collecting evidence of social issues to inform and evaluate policy decisions. She has an undergraduate degree in applied psychology and criminology from the University of Brighton, in the U.K. She is currently undertaking her Ph.D. part-time at Lancaster University, where she is researching into patient experiences of diabetes distress.

Dr. Adam Bernstein is an ABMS board certified internal medicine physician specializing in lifestyle medicine. He received his doctor of medicine from Boston University and his doctor of science (nutrition) from Harvard University. Dr. Bernstein is also a diplomate of the American College of Lifestyle Medicine.

Anna Smith Haghighi lives in Bangor, Northern Ireland, with her husband and their greyhounds Django and Zola. She found a passion for writing when creating content for various clients as part of an SEO company. Along the way, Anna has been a film and television extra, half of a singing duo, and a team member of the Belfast Eye. These days, Anna is more likely to be walking her dogs or playing a Zelda game for the millionth time.

If people live in unsuitable housing, they may be at risk of exposure to a number of potential health hazards. As a result, poor housing may cause or contribute to many preventable injuries and conditions, such as respiratory, nervous system, and cardiovascular diseases, as well as cancer.

Typically, people from low income households are more likely to live in poorer quality housing, which can negatively impact their health. For instance, if a person lives in an overcrowded place, they may be at an increased risk of poorer mental health, food insecurity, and infectious diseases.

In addition, some people may not have the means to improve the safety and quality of certain systems and appliances. Consequently, they may not be able to adequately heat their home, which may lead to higher levels of blood pressure and result in a heart attack.

Moreover, homes of people from lower income households may be more susceptible to various types of damage that can affect health if not repaired. For example, water leaks may lead to mold growth, which can cause damage to respiratory health.

This can negatively affect health outcomes. For example, a 2020 article reports that during the COVID-19 pandemic, people living in lower income neighborhoods faced barriers that prevented them from staying safe. This then led to higher rates of complications due to COVID-19 in people from low income communities.

Quality, safety, affordability, and neighborhood can all influence housing stability. Without good housing and adequate support, people may risk experiencing housing instability and even becoming homeless.

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Living with housing problems increases the risk of mental ill health. Housing problems tend to persist over time but little is known about the mental health consequences of living with persistent housing problems. We investigated if persistence of poor housing affects mental health over and above the effect of current housing conditions. We used data from 13 annual waves of the British Household Panel Survey (1996 to 2008) (81,745 person/year observations from 16,234 individuals) and measured the persistence of housing problems by the number of years in the previous four that a household experienced housing problems. OLS regression models and lagged-change regression models were used to estimate the effects of past and current housing conditions on mental health, as measured by the General Health Questionnaire. Interaction terms tested if tenure type modified the impact of persistent poor housing on mental health. In fully adjusted models, mental health worsened as the persistence of housing problems increased. Adjustment for current housing conditions attenuated, but did not explain, the findings. Tenure type moderated the effects of persistent poor housing on mental health, suggesting that those who own their homes outright and those who live in social housing are most negatively affected. Persistence of poor housing was predictive of worse mental health, irrespective of current housing conditions, which added to the weight of evidence that demonstrates that living in poor quality housing for extended periods of time has negative consequences for mental health.

Poverty occurs when an individual or family lacks the resources to provide life necessities, such as food, clean water, shelter, and clothing. It also includes a lack of access to such resources as health care, education, and transportation.5 In the United States, federal poverty is expressed as an annual pre-tax income level indexed by the size of household and age of household members. For example, in 2020, the federal poverty income level was $12,760 for an individual younger than 65 years and $26,200 for a family of four.6 In 2019, approximately 10.5% of Americans were living below the poverty line. While overall poverty rates had been declining in the past several years, inequalities remain by SDoH, including race and racism, ethnicity, educational attainment, and disability status.7

Location matters, and there are often dramatic differences in health care delivery and health outcomes between communities that are only a few miles apart. For example, the Robert Wood Johnson Foundation (RWJF) found a 25-year difference in average life expectancy in New Orleans, LA, between inner city and suburban neighborhoods. Similarly, there is a 14-year difference in average life expectancy between two Kansas City, MO, neighborhoods that are roughly three miles apart.15

SDoH are the conditions under which people are born, grow, live, work, and age, and include factors such as socioeconomic status, education, employment, social support networks, and neighborhood characteristics.4 These social factors have a more significant collective impact on health and health outcomes than health behavior, health care, and the physical environment.17,18 SDoH, especially poverty, structural racism, and discrimination, are the primary drivers of health inequities.19,20

Because they intersect with so many SDoH, poverty and low-income status dramatically affects life expectancy.26 Education and its socioeconomic status correlate to income and wealth. These have powerful associations with life expectancy for both sexes and all races at all ages. Students from families with low income are five times more likely to drop out of high school than students from families with high income.27 In 2008, the life expectancy among U.S. adult men and women with fewer than 12 years of education was not much better than the life expectancy among all adults in the 1950s and 1960s.28

However, the effects of poverty are not predictably uniform. Longitudinal studies of health behavior describe positive (e.g., tobacco use cessation) and negative (e.g., decrease in physical activity) health behavior trends in populations with lower and higher socioeconomic status. However, there is a socioeconomic gradient in health improvement. In other words, populations with lower socioeconomic status lag behind populations with higher socioeconomic status in positive gains from health behavior trends. Health behaviors are important in that they account for differences in mortality.34 The fact that positive changes in health behaviors are possible despite the challenges of poverty points to the importance of developing and implementing interventions that promote healthy behaviors in populations with low income.

Thinking of poverty as a risk regulator rather than a rigid determinant of health allows family physicians to relinquish the feeling of helplessness when providing medical care to families and individuals with low income.

Strong primary care teams are critical in the care of patients with low income. These populations often have higher rates of chronic disease and difficulty navigating health care systems. They benefit from care coordination and team-based care that addresses medical and socioeconomic needs.

Care team members can positively affect the health of patients with low income by creating a welcoming, nonjudgmental environment that supports a long-standing therapeutic relationship built on trust. Familiarity with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care can prepare practices and institutions to provide care in a manner that promotes health equity.37

Patients with low socioeconomic status and other marginalized populations rarely respond well to dictation from health care professionals. Instead, interventions that rely on peer-to-peer storytelling or coaching are more effective in overcoming cognitive resistance to positive health behavior changes.38 Physicians and care team members can identify local groups that provide peer-to-peer support. Such activities are typically hosted by local hospitals, faith-based organizations, health departments, or senior centers.

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