US Housing Insecurity and the Health of Very Young Children

Abstract

In the United States, as in other countries, housing is considered a strong social determinant of health.¹ Poor housing conditions have been linked to multiple negative health outcomes in both children and adults. The Department of Health and Human Services has defined housing insecurity as high housing costs in proportion to income, poor housing quality, unstable neighborhoods, overcrowding, or homelessness.² Crowding in the home and multiple moves from home to home have clear negative associations for children. Crowding is negatively associated with mental health status,³ ability to cope with stress,⁴ child and parent interaction,⁵ social relationships,³ and sleep.³ It also increases the risk for childhood injuries,⁶ elevated blood pressure,⁵ respiratory conditions,⁷ and exposure to infectious disease.⁷ Adults⁸ and children⁹ living in crowded households are less likely to access health care services than are those in noncrowded households, and families with multiple moves are less likely to establish a medical home and seek out preventive health services for their children than are securely housed families.¹⁰

In older children and adolescents, a history of multiple moves has been associated with mental health concerns,¹¹ substance abuse,¹² increased behavior problems,¹³ poor school performance,^13,14 and increased risk of teen pregnancy.¹⁵ Multiple moves in childhood can have lifelong impact, as evidenced by higher rates of adverse childhood events,¹⁶ lower global health ratings in adulthood,¹⁷ and increased mental health and behavior concerns lasting through adolescence and into adulthood.¹⁶ Grade-school children with more than 2 school moves are 2.5 times more likely to repeat a grade,¹⁸ and adolescents who experience school moves are 50% more likely not to graduate from high school.¹⁹

Access to affordable housing is likely to reduce the chances that a family will live in crowded conditions or make multiple moves within a short period of time. Since the Housing Act of 1937 was passed,²⁰ 30% of monthly adjusted income has been used as the threshold for affordable housing costs. But affordability by this definition is becoming increasingly less common. In 2008, half of renter households paid more than 30% of their income in rent, and nearly a quarter paid more than 50%.²¹ Increases in unemployment and the poverty rate since 2008 have likely increased the number of families living in housing that they are hard pressed to afford. Although poverty is higher among young children than among any other age group,²² little is known about the effects of housing insecurity on very young children who are considered housed, albeit precariously. We examined the health, developmental, and anthropometric correlates of housing insecurity among children younger than 3 years, using crowding and multiple moves as indicators.

METHODS

Between June 1998 and December 2007, researchers with the ongoing Children's HealthWatch study approached 36 618 adult caregivers of children younger than 3 years at Children's HealthWatch sites in 7 central-city medical centers serving diverse, low-income populations in Baltimore, MD; Boston, MA; Little Rock, AR; Los Angeles, CA; Minneapolis, MN; Philadelphia, PA; and Washington, DC. Institutional review board approval was obtained at each site prior to data collection and has been renewed annually since then.

The study design was cross-sectional. At each study site, trained interviewers surveyed caregivers accompanying children younger than 3 years who were seeking care at acute or primary care clinics or hospital emergency departments during peak patient flow times. Interviewers did not approach caregivers of critically ill or injured children. Potential respondents were excluded if they did not speak English or Spanish (or, in Minneapolis only, Somali), were not knowledgeable about the child's household, had been interviewed previously, lived out of state, or did not consent to participate. The caregivers were approached in private settings.

Of the 36 618 caregivers who were approached, 3419 (9.3%) were ineligible, and 3343 (10.9%) refused to participate or were not able to complete the interview (Figure 1). To ensure that sample participants had relatively similar economic backgrounds, participants with private insurance were excluded (n = 3358). Because our study interest concerned housing insecurity distinct from homelessness, we also excluded families who were homeless or living in shelters, residential treatment centers, or military facilities (n = 780) (Figure 1). Also eliminated were 3649 (14.2%) interviews that had missing data. This process yielded a final analysis sample of 22 069 caregiver/child dyads. Those with complete data were similar to those with incomplete data in terms of child's gender, birth weight, household employment, and number of children in the household. Caregivers with incomplete data were more likely to be Hispanic, foreign born, interviewed in Minneapolis, married, older, have less education, have breastfed their child, and not report depressive symptoms.

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FIGURE 1

Description of analytic sample selection: 7 US cities, 1998–2007.

Note. PEDS = Parents’ Evaluation of Developmental Status survey.

^aRespondents who did not complete interview process.

^bi.e., military housing.

RESULTS

Housing insecurity affected 46% of the study sample, with 41% of households experiencing crowding, and 5% of households experiencing multiple moves. As indicated in Table 1, housing insecurity was significantly associated with research site and more children in the home. Maternal older age, minority race/ethnicity, foreign place of birth, single marital status, lower education, depressive symptoms, and breastfeeding were also significantly associated with housing insecurity. Older child age was significantly associated with multiple moves.

Household food insecurity (HFI) was found in 9% of families with secure housing, 12% of families with crowding, and 16% of families with multiple moves (P < .001). Child food insecurity (CFI) was found in 7% of families with secure housing, 17% of families with crowding, and 19% of families with multiple moves (P < .001). Multivariate analysis showed that, compared with the referent of secure housing, crowding was significantly associated with HFI (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43; P < .001) and with CFI (AOR = 1.47; 95% CI = 1.34, 1.63; P < .001) (Table 2). Multiple moves were also significantly associated with HFI (AOR = 1.91; 95% CI = 1.59, 2.28; P < .001) and CFI (AOR = 2.56; 95% CI = 2.13, 3.08; P < .001), with higher AORs than crowding and nonoverlapping confidence intervals. In addition, multiple moves were significantly associated with caregivers reporting their child's health as fair or poor (18% vs 11% of the securely housed, AOR = 1.48; 95% CI = 1.25, 1.76; P < .001) and reporting developmental risk as measured by the PEDS (22% vs 14% of the securely housed, AOR = 1.71; 95% CI = 1.33, 2.21; P < .001). Children in the multiple-moves group had significantly lower weight-for-age z scores than the secure-housing group (–0.082 vs −0.013; P = .02) (Figure 2).

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FIGURE 2

Adjusted mean weight-for-age z scores by housing group: children younger than 3 years, 7 US cities, 1998–2007.

Note. Least squares mean weight-for-age z scores by levels of housing insecurity were adjusted for site, race/ethnicity, US-born mother versus immigrant mother, maternal age, marital status, caregiver education, mean child's age, mean number of children in the home, household employment, breastfeeding, and low birth weight.* P = .02.

When we added maternal depressive symptoms to the models as a covariate, the associations of housing insecurity with fair/poor child health and developmental risk were somewhat attenuated but remained significant. The AOR between multiple moves and fair/poor child health diminished only slightly, from 1.48 (95% CI = 1.25, 1.76) to 1.40 (95% CI = 1.16, 1.70; P < .001), whereas the AOR between multiple moves and developmental risk diminished from 1.71 (95% CI = 1.33, 2.21) to 1.53 (95% CI = 1.18, 1.99; P = .001), remaining significant but showing partial attenuation. Maternal depressive symptoms were significantly associated with HFI, CFI, fair/poor child health, and developmental risk (P < .001) but not with weight-for-age z score. CFI was also tested as a mediator of the association between housing insecurity and child weight for age, but results did not differ from our primary analysis.

DISCUSSION

Homeless children are recognized as being vulnerable to multiple health risks, but there are millions of less visible children whose health, development, and growth may be compromised by living in insecure housing. Nearly half of our sample (46%) had experienced housing insecurity within the past year. We found housing insecurity to be associated with measures of poor health, growth, and development in young children, which is consistent with findings of research on samples of adults and older children. Housing insecurity is also an important marker for food insecurity. Multiple moves had a stronger relation with food insecurity and fair/poor child health than crowding, suggesting that multiple moves are a more severe form of housing insecurity. Whereas crowding may be used as a coping strategy to avoid outright homelessness, housing transiency as reflected by multiple moves may indicate a lack of social ties⁴⁰ to assist families during household crises.

We found that, compared with the rest of our sample, very young children in households with multiple moves had worse caregiver-reported health status, increased developmental risk, and average weight for age that was lower than expected. Although the magnitude of the weight-for-age z-score differences between the groups was not large, the negative growth differences in this group of very young children are cause for concern. Similar to multiple moves, crowding was associated with HFI and CFI, but to a lesser degree. Children living in households with both housing insecurity and food insecurity experience dual threats because food insecurity has been independently associated with children's risk for hospitalization,⁴¹ poor health,⁴¹ developmental delays,⁴² anemia,^43,44 and the mother's risk for depressive symptoms.^45,46

The potential life-course effects of housing insecurity during early childhood are important. Shonkoff et al. made a case that stress or disruption during childhood is a precursor to chronic disease in adulthood.⁴⁷ The relationship between housing insecurity and outcomes of poor child health, diminished weight, increased developmental risk, and greater likelihood of food insecurity suggest that policies promoting stable housing may have latent positive long-term health impacts.

Young children may be particularly vulnerable to the lack of a stable environment or to the stress of their families going through periods of housing insecurity. Social disorganization theory suggests that environmental factors such as housing insecurity influence parenting and child behavior.⁴⁸ Housing insecurity impedes the development of role models, informal neighborhood social supports, connections to resources such as child care, family participation in the social environment, and establishment of a medical home for consistent health care. All of these social factors are important to families with young children. Other social models discuss a competition process whereby neighbors compete for scarce community resources and services, impairing parental mental and physical health and influencing parental behaviors in ways that negatively affect the health of their children. Neighborhoods where families know and trust each other and community-level interventions that ensure adequate, safe, and affordable housing can positively affect the physical and mental health of parents and children.⁴⁹

Programs offering housing subsidies or energy assistance have been shown to protect against child health concerns, including hospitalizations⁵⁰ and poor growth,⁵¹ as well as anemia.⁵² Mills et al. found that families receiving housing subsidies moved less frequently and were less crowded than families that did not receive a subsidy.⁵³ Despite the benefits of subsidized housing, only 1 out of 4 eligible households receives housing assistance.⁵⁴ Meyers et al. found that children younger than 3 years who lived in food-insecure households that were eligible for housing subsidies but did not receive them were more than twice as likely to have growth delays as measured by weight for age compared with those receiving housing subsidies.⁵¹ Frank et al. showed that children in families receiving energy assistance had lower odds of acute hospitalizations and diminished risk of having weight-for-age z scores that were more than 2 standard deviations below the mean.⁵⁰

Recent increases in unemployment, housing foreclosures (including those related to subprime lending), and the continued demand for low-income housing all contribute to an environment of housing insecurity.²¹ Although all socioeconomic groups are affected by housing insecurity, low-income households are particularly at risk because of their already constrained financial resources and lack of reserve funds. Low-income families often pay a larger proportion of their income for housing than do higher-income households, which decreases the resources available for other necessities such as food, transportation, heat, and medical care.²¹

There are several methodological limitations that should be considered when interpreting these data. First, because of the cross-sectional design of this study, it is not possible to determine cause-and-effect relationships on the basis of our findings. Furthermore, although we controlled for important confounding variables, other unmeasured confounders may exist. We further acknowledge that, despite our use of previously independently validated questions whenever possible, respondents may have over- or underreported negative child outcomes. Because this study assesses families from low-income backgrounds in emergency rooms and hospital-based clinics, their children are already at elevated risk for developmental and health concerns and may not be representative of all low-income children. However, we excluded urgently ill or injured children, so some of the highest-risk children may not have been included in this study.

In addition, families that were excluded from the analyses because of incomplete data represent a high-risk segment of the study population, judged on the basis of demographic variables of caregiver education, maternal race/ethnicity, and maternal country of birth. Therefore, it is possible that excluding these families from the analyses contributes to underestimating the impact of housing insecurity. Finally, our measurement of housing insecurity does not incorporate measures of housing safety or quality of neighborhood conditions; nor does it consider affordability.

Nevertheless, the association between housing insecurity and measures of children's health and development provide evidence of the vulnerability of children who have insecure housing but who are not homeless. Low-income children often bear the burden of multiple risk factors for adverse outcomes, some of which (such as housing insecurity) can be addressed through public policies. Governmental action and community investment in expanding the supply of affordable housing, increasing funding for housing assistance programs, and stabilizing families in uncrowded housing they can afford can alleviate housing insecurity. Protecting families with young children from being economically forced into crowded conditions and frequent moves should be a policy priority.

Acknowledgments

Human Participant Protection

References