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Assisted Housing as a Platform to Improve Quality of Life

Image of a three story multi-family apartment building with a brick façade. A recent HUD report examined the health of HUD-assisted adults, including those residing in public housing, in comparison to unassisted low-income renting adults and the general adult population.

To increase policy attention towards the social determinants of health, the U.S. Department of Housing and Urban Development’s (HUD) “health in all policies” approach fosters interagency collaboration to examine health alongside housing with the aim of improving overall quality of life. A recent HUD report, “A Health Picture of HUD-Assisted Adults, 2006–2012,” uses an array of health indicators to study HUD-assisted adults as well as unassisted low-income renting adults and the general adult population. The report serves as a critical first step to better understand the health challenges of HUD-assisted adults.

Examined alongside unassisted low-income renters and the general adult population, HUD-assisted renters have a high incidence of chronic conditions such as asthma, heart disease, and diabetes. More than 30 percent of HUD-assisted adults self-describe their current general health as fair or poor. Despite having access to medical care through public health insurance, HUD-assisted tenants face a housing cost burden that poses a barrier to improved health outcomes. HUD considers housing costs that fall between 30 and 50 percent of a tenant’s income as moderate cost burdens, and data show that the share of those experiencing cost burdens is increasing. In exchange for more affordable rent, families might settle for inadequate or poor-quality housing with problems such as substandard ventilation, mold, lead or asbestos contamination, and pests that can trigger asthma and transmit disease.

Investigative Approach

Researchers at HUD used descriptive statistics on health indicators gathered from the National Health Interview Survey (NHIS). Each year, researchers use the NHIS to interview about 90,000 individuals to understand the current health status of people in noninstitutionalized settings, focusing on demographic information, health care access, the use of medical facilities, and personal injuries. With the consent of linkage-eligible adults, the National Center for Health Statistics (NCHS) matched NHIS descriptive statistics to individuals within HUD administrative data. The aforementioned report concentrates on NHIS survey years 2006 to 2012.

The researchers examined data from three categories of adults: HUD-assisted renters, unassisted low-income renting adults, and the general adult population. HUD-assisted renters consisted of those residing in public housing, subsidized multifamily housing, or units that accept housing choice vouchers at the time of their health interview. Members of the unassisted low-income renter group lacked HUD assistance even though they might qualify for it. The general adult population group represented the broader U.S. population regardless of housing status, income, or tenure. Participants from all three groups had to agree to answer all questions pertaining to housing status and personal information, and they granted permission for NCHS to link their NHIS responses to other sources.

Demographics

During the study period, 73.8 percent of HUD-assisted adults, 56.0 percent of unassisted low-income renters, and 51.7 percent of the general adult population were women . Most HUD-assisted adults were either non-Hispanic black (38.7%) or non-Hispanic white (38.3%). HUD-assisted adults had low levels of education, with 35.2 percent lacking a high school diploma or general education development certification.

A large proportion of HUD-assisted adults reported having a disability. The study found that 56.5 percent of the HUD-assisted renter group reported difficulty performing basic tasks and participating in social activities (an indicator of disability), and 44.7 percent reported that they were more restricted in their ability to keep a job, participate in recreational activities, and support the needs of a household. These findings were well above the disability prevalence for the other two groups.

Chronic Conditions

HUD-assisted adults faced high prevalence rates of chronic conditions. In fact, 37.9 percent of HUD-assisted adults reported having high blood pressure; 19.8 percent had a history of heart conditions; 17.6 percent indicated that they had diabetes; and 16.3 percent dealt with chronic asthma. HUD-assisted adults were also overweight (29.7%) or obese (41%) at rates exceeding those of the unassisted low-income renter and general adult population groups. Less than 30 percent of HUD-assisted renters indicated that they were in excellent or good health, whereas 48.2 percent of unassisted low-income renters and 59.6 percent of the general adult population reported being in good or excellent health.

Mental Health

The NHIS measures psychological distress through a series of questions about the respondent’s mental state using the Kessler 6 (K6) scale. The survey results showed that 11.6 percent of HUD-assisted renters reported experiencing psychological distress, relative to 8.7 percent of unassisted low-income renters and 3.7 percent of the general adult population. When asked whether their feelings cause mental hardship and interfere with their daily activities, HUD-assisted adults and unassisted low-income renters responded similarly at 39.3 percent and 35.4 percent, respectively. The general adult population dealt with mental hardship less frequently than the other two groups, with only 21.4 percent responding affirmatively.

Nearly 19 percent of HUD-assisted adults sought help from a mental health professional for psychological distress and mental hardship, while 14.3 percent of unassisted low-income renters and 8.7 percent of the general adult population sought help.

Healthcare Use and Access

About 75.0 percent of HUD-assisted adults reported having some form of public health insurance. More than 70.0 percent of HUD-assisted adults reported having access to a primary care physician, a rate exceeding that of the other two groups. 34.3 percent of HUD-assisted adults and 37.5 percent of unassisted low-income renters reported unmet care because they could not afford medication or doctor’s visits.

Only about 4.0 percent of HUD-assisted adults used the emergency room as their usual source of care. Approximately half reported using their doctor’s office or health maintenance organization, and 30.1 percent reported using a clinic or medical center. Only 41.1 percent of HUD-assisted adults reported using dental services within the previous 12 months.

Health Behaviors

The NHIS defines current smokers as those who smoke daily or occasionally and have smoked more than 100 cigarettes in their lifetime. Slightly more unassisted low-income renters than HUD-assisted renters were current smokers, at 34.9 percent and 33.5 percent, respectively. Only 22 percent of the general adult population group were current smokers. Heavy alcohol use was highest among unassisted low-income renters at nearly 7.0 percent, whereas only 4.1 percent of HUD-assisted tenants reported heavy consumption of alcohol.

Nearly 54.0 percent of HUD-assisted adults and approximately 41.0 percent of unassisted low-income renters reported not engaging in light or moderately vigorous exercise. Regular exercise was much higher among the general adult population at 34.7 percent, and only about 30.0 percent of unassisted low-income renters and about 20.0 percent of HUD-assisted adults indicated that they got regular exercise.

Conclusion

Although data are purely descriptive, the report used linked NHIS-HUD data to examine the health status of tenants in HUD-assisted housing using a nationally representative sample. The report shows that most HUD-assisted adults receive public health insurance and visit their primary care physicians more often than the other two groups; however, the use of dental care facilities is lower among HUD-assisted adults when examined alongside the general adult population. The data also indicate that visits for mental health care are rising among HUD-assisted adults. HUD-assisted adults and unassisted low-income renters exhibited similarly high rates of unmet care, in contrast to the general adult population which had a lower rate. As the researchers suggest, the high rates of obesity among HUD-assisted adults, combined with their tendency to get little to no exercise, indicate the need for more fitness and/or nutrition programming with HUD housing as a key intervention point. The descriptive data in this report is accessible to housing officials and community leaders, and it also paves the way for more analytical research on the connections between housing and health.