Empirical evidence has shown that inequitable housing conditions produce health disparities.1 More specifically, a robust body of evidence confirms that poor housing and inequitable neighborhood conditions adversely affect mental health outcomes.2 For example, empirical evidence shows that multi-dwelling housing, compared with single dwellings, is associated with poor psychological health generally, but low-income children and children of color experience these disparities disproportionately.
This essay summarizes the research that confirms the persistent association between three adverse housing conditions and mental health inequity. The lack of affordable housing, substandard housing conditions, and residential segregation are all associated with mental health disparities. With respect to segregated housing, the focus here is placed on racial rather than economic segregation, notwithstanding the important but distinctive concerns raised by concentrated poverty. The reasons for disrupting both forms of housing isolation are similar and compelling; however, this essay zeroes in on racial segregation to address the misconception that improved mental health outcomes community-wide can be achieved without express attention to the impacts of racial injustices specifically. The second part of this essay explores the theoretical grounding that supports intervening to disrupt the relationship between poor housing and poor mental health. The essay concludes with a few examples of how community development can contribute to mental health equity.3
The Goal: Mental Health Equity
Health disparities are differences in which social groups that have systematically and structurally experienced social disadvantages consequently suffer worse health or greater health risks than other, more advantaged groups. In contrast, “health equity” is the ethical concept that describes the absence of unfair and unjust health disparities. Mental health equity would mean that no population group would be forced to bear a disproportionate burden of disability and illness, or the hopelessness of being excluded from receiving the benefit of medical and scientific advances available to others to treat mental illness.4 Thus, a goal of community development is to achieve health equity by eliminating systematic disparities in access to community-level social determinants between more and less advantaged groups.5 Decent, stable housing, both at the individual and community level, is a social determinant of health that research indicates is key to eliminating mental health disparities.6 Moreover, the association between mental health disparities and the community conditions in which people live are also the subject of robust and compelling empirical literature.
Evidence That Housing Inequity Is Associated with Mental Health Disparities
A range of housing and neighborhood characteristics are associated with negative affect, psychological distress, and psychiatric disorders. Three of those characteristics occur more frequently in low-income communities and communities of color, thus contributing to inequitable disparities.
Housing Affordability Affects Mental Health
The lack of affordable housing in the United States has been described as a public health crisis.7 Housing is considered “affordable” when a household spends no more than 30 percent of its income on housing. A household that spends more than this is considered “burdened,” and when a family spends more than 50 percent of its income on housing, the household is “severely burdened.”8 The evidence that unaffordability is an important housing risk factor for poor mental health suggests at least three pathways linking unaffordable housing to mental health disparities.9 First, the prevalence of mental illness among those experiencing homelessness is well-documented, as is the overrepresentation of African Americans within this community.10 Second, the pressure on household finances that unaffordable housing imposes can adversely impact even adults and children who are housed, but it especially harms those who live at or near poverty levels. Low-income families who find housing unaffordable must make tradeoffs to make ends meet. Studies show these families are hardest hit when they include elderly members and children; these households can spend as much as 70 percent less on health care than families with affordable housing.11 Beyond the obvious negative impact this tradeoff may have on mental health, cost-burdened households may make other tradeoffs that potentially harm mental health. A recent study has identified an important relationship between housing affordability and children’s cognitive achievement.12 Cost-burdened households also spend less on enrichment, such as toys, musical instruments, sports, and recreational equipment. As a result, researchers found that children’s math and reading scores suffered in families with very high housing cost burdens, as well as in families with very low housing cost burdens. The latter group likely represents families that are living in neighborhoods with poor-quality housing and schools.13
A third mechanism by which poor housing may contribute to mental health disparities is stress. The stress associated with unaffordable housing goes beyond general financial hardship. Chronic stress related to housing unaffordability not only can cause anxiety individually, but the effects may reverberate through households when stress contributes to child neglect, abuse, or poor health behaviors, such as smoking. Affordable housing can have mental health benefits by offering stability and control over a family’s environment, limiting the stress related to frequent moves.
Notably, the data that show the impact that a lack of affordable housing has on mental health is not limited to low-income households; an increasing number of moderate- or modest-income families are being forced to pay a disproportionate burden of their income on housing or alternatively must accept substandard conditions that are affordable. For this reason, the racialized income gaps14 in the United States further exacerbate the mental health disparities that African Americans and Latinos are experiencing in today’s housing affordability crisis.
Housing Conditions Affect Mental Health
Studies show that substandard housing conditions are positively associated with poor mental health. Studies have shown that pest infestation, mold, and dampness are associated with poor health generally and that housing quality is positively correlated with psychological well-being more specifically. The mediators for this association range from low self-esteem and stigma to anxiety about structural hazards, fear of crime, and lack of control.15 Of course, the fact that substandard housing is often found in low-income neighborhoods also means that these harms are disproportionately visited on the most underrepresented and disadvantaged populations.
Housing Segregation Affects Mental Health
Residential segregation—both economic and racial—has been linked to community health disparities.16 Indeed, racial residential segregation has been identified as a “fundamental cause” of inequitable health outcomes that affect populations of color.17 A fundamental cause is a basic, underlying factor that is so deeply entrenched broadly throughout systems and structures that changing upstream mechanisms that flow from it will ultimately fail to change the differential outcomes it causes. For example, racial discrimination is such a fundamental cause of segregation that even passage of the 1968 Fair Housing Act, which prohibits explicit exclusionary racial covenants, has not erased the segregation that persists in America today.18
When individuals perceive they have been discriminated against, research shows they experience adverse physiological responses. For example, in a study of over 4,000 older adults in Chicago, researchers found that their experiences with discrimination were associated with increased mortality risk.19 In another study of over 3,500 African American, Mexican American, Puerto Rican, and other Latino youths, researchers found that perceived discrimination is associated with increased odds of asthma and poorer asthma control among black youths.20 Racial discrimination is a stressor that can broadly impact mental health, producing psychological distress,21 vulnerability to poor blood pressure control, exaggerated cardiovascular responses, chronic changes in immune and endocrine systems, and reduced protective resources.22 Research has shown that the stress associated with the stigma of living in a segregated neighborhood can adversely affect mental health.23 Therefore, the evidence shows that populations of color living in cities with higher rates of residential segregation experience poorer mental health outcomes.24
Neighborhood Conditions Affect Mental Health
Using a geographic information system (GIS), a spatial analysis tool, researchers have shown that disadvantaged neighborhoods are likely to have more retail outlets that sell alcohol, as well as more residents who are heavy drinkers.25 Policymakers in North Carolina also use spatial analysis to identify disadvantaged communities that put children at high risk for lead contamination, a known risk factor for delayed cognitive and behavioral development.26 Violence, another risk factor for poor mental health outcomes, is a prevalent risk factor in cities where poor and predominantly African American populations live. For example, Chicago has the highest number of homicides nationally. The Third National Survey of Children’s Exposure to Violence found that over half of the 4,000 children surveyed had been exposed to one or more types of violence. This exposure to toxic stressors has been shown to have long-term adverse mental health impacts on children over their life course.
Equitable Community Development
The Theory
Ecosocial theory explains that populations biologically embody adverse exposures from ecological and societal influences.27 That means that the physical conditions of a neighborhood or community environment influence residents’ mental health outcomes. Thus, the result of economically and socially skewed environmental influences is a disparate distribution of poor mental health.28 The good news is that ecosocial theory also suggests that community development can affect the level of justice and equity that disadvantaged families experience.
One application of ecosocial theory explains how built environments, which are socially constructed, can be thoughtfully and intentionally reconstructed to reconfigure access to resources and opportunities so that all community residents can enjoy the advantages of access. Sociologist George Lipsitz has called the geographic congruence of race, place, and power in America “the racialization of space and the spatialization of race.”29 That is to say, racially disparate mental health outcomes are related to the extent to which cities, towns, and counties are segregated by race. This is because opportunities for good mental health are spatialized. Community spaces that are relatively wealthy and white have greater health resources, such as recreational facilities, green open spaces, mental health care providers, and lower crime rates, while those communities that are predominantly black have fewer of these resources.
Another important application of ecosocial theory describes the practice of “community-driven design.” This is a way of designing and constructing built spaces in response to social needs, but through collaboration with local residents and stakeholders and guided by local knowledge.30 Community-driven design can focus on both building capacity within a community, as well as on building the physical environment for community members. It is a practice, moreover, that approaches development by combining local and technical expertise in the decision-making. The result is an approach to community development that focuses on equity in both process and outcome. Thus, the upshot of these theoretical approaches teaches that equalizing access to the social determinants of mental health31 should be the priority of all equitable community development.
The Practice
Effective solutions to improve mental health for all and narrow unfair and unjust mental health disparities will require investment in the social determinants of health. Collaborations among community developers and behavioral health specialists provide a particularly promising approach to these problems. Community partnerships that incorporate trauma-informed strategies can reduce social isolation, especially for seniors and children, by leveraging technology and supportive housing environments.32 Mercy Housing California partners with a school district and housing authority administrators to provide mental and behavioral health services for children, youth, and their families onsite in public housing settings (for more information, see the article by Hurst and Shoemaker in this issue). A student and family community center also provides enrichment activities that this population of children would otherwise lack. The National Housing Partnership Foundation of nonprofit developers is addressing the cumulative effects of poor physical health, memory loss, and loneliness among seniors by leveraging technology to mitigate the effects of social isolation in Washington, DC, and Baltimore. The creative use of technology through multiple senior residential apartment complexes gives seniors access to music, medical reminders, and other voice-assisted services. Multifamily housing projects on the South Side of Chicago are affecting the lives of underserved residents through a neighborhood redevelopment process that includes services to address the impact of toxic stress due to poverty and violence throughout the Woodlawn Neighborhood. There, residents collaborate with partners to run a faith-based center for family development called “I AM ABLE.” The center is located in a central neighborhood where residents meet regularly and have access to a broad network of services that address the impacts of trauma and violence by screening for and supporting needs—“from finance to romance”—through an intervention called “TR4IM” (the Trauma Response, Recovery, Reduction, and Removal Intervention Movement).33 In all three of these examples, community development means much more than expanding buildings and spaces; it serves as an indispensable tool for addressing complex urban problems through meaningful collaboration. More examples may be found in Barbara Brown Wilson’s book, Resilience for All: Striving for Equity Through Community-Driven Design.
Conclusion
The data, theory, and practical examples discussed in this essay all point to the role that innovative community development could play in addressing mental health inequity. In particular, the community development sector has the opportunity to more intentionally promote mental health equity through its existing activities, which could be strengthened by pursuing partnerships with the mental and behavioral health sector. With a targeted focus on increasing accessibility to social resources, affordability, and the quality of housing available to low- and modest-income populations and populations of color, community development could significantly reduce the nation’s mental health disparities.
Dayna Bowen Matthew,
1. J. Krieger and D. L. Higgins, “Housing and Health: Time Again for Public Health Action,” American Journal of Public Health 92 (5) (2002): 758‒68.
2. G. Evans, N. M. Wells, and A. Moch, “Housing and Mental Health: A Review of the Evidence and a Methodological and Conceptual Critique,” Journal of Social Issues 59 (3) (2003): 475‒500. (Dr. Gary Evans et al. provide one of the best available resources to survey the literature that documents the association between housing and mental health, though this resource should be updated.)
3. Cf.: N. Cytron, “Ties That Bind: Income Inequality and Income Segregation,” Community Investments 23 (2) (2011).
4. “Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General” (Chapter 1. Introduction).
5. P. Braveman and S. Gruskin, “Defining Equity in health,” Journal of Epidemiology and Community Health 57 (4) (2003): 254‒58.
6. T. G. McGuire and J. Miranda, “New Evidence Regarding Racial and Ethnic Disparities in Mental Health: Policy Implications,” Health Affairs 27 (2) (2017): 393‒403; J. Ng et al., “Racial and Ethnic Disparities in Mental Health Among Diverse Groups of Medicare Advantage Beneficiaries” (CMS Data Highlight No. 11, 2017).
7. S. A. Bashir, “Home Is Where the Harm Is: Inadequate Housing as a Public Health Crisis,” American Journal of Public Health 92 (5) (2002): 733‒38.
8. M. Schwartz and E. Wilson, “Who Can Afford to Live in a Home?: A Look at Data from the 2006 American Community Survey” (Suitland, MD: U.S. Census Bureau, 2006).
9. K. E. Mason et al., “Housing Affordability and Mental Health: Does the Relationship Differ for Renters and Home Purchasers?” Social Science & Medicine 94 (2013): 91‒97.
10. M. M. Jones, “Does Race Matter in Addressing Homelessness? A Review of the Literature” World Medical & Health Policy 8 (2) (2016): 139‒56.
11. Joint Center for Housing Studies of Harvard University, “The State of the Nation’s Housing 2018” (Cambridge, MA: Joint Center for Housing Studies of Harvard University), p. 31.
12. S. Newman and C. S. Holupka, “Housing Affordability and Children’s Cognitive Achievement,” Health Affairs 35 (11) (2016): 2092‒99.
13. Ibid., 2096.
14. The U.S. Census Bureau reported the following 2016 real median income data by race: non-Hispanic white ($65,041); black ($39,490); Hispanic ($47,675); see Evans, Wells, and Moch, 2003.
15. Ibid.
16. J. Weinstein et al., eds., “Communities in Action: Pathways to Health Equity” (Washington, DC: National Academies of Sciences, Engineering, and Medicine, 2017).
17. D. R. Williams and C. Collins, “Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health,” Public Health Reports 116 (5) (2001): 404.
18. William H. Frey, “Census Shows Modest Declines in Black-White Segregation” (Washington, DC: Brookings Institution, 2015); D. S. Massey and J. Tannen, “A Research Note on Trends in Black Hypersegregation,” Demography 52 (3) (2015): 1025‒34, doi:10.1007/s13524-015-0381-6.
19. L. L. Barnes et al., “Perceived Discrimination and Mortality in a Population-Based Study of Older Adults,” American Journal of Public Health 98 (7) (2008): 1241‒47.
20. Neeta Thakur et al., “Perceived Discrimination Associated with Asthma and Related Outcomes in Minority Youth Chest,” Journal 151 (4) (2017): 804‒12.
21. Tiffany Yip et al., “Racial Discrimination and Psychological Distress: The Impact of Ethnic Identity and Age Among Immigrant and United States–Born Asian Adults,” Developmental Psychology 44 (3) (2008):787‒800.
22. Elizabeth A. Pascoe and Laura Smart Richman, “Perceived Discrimination and Health: A Meta-Analytic Review,” Psychological Bulletin 135 (4) (2009): 531‒54.
23. M. L. Hatzenbuehler, J. C. Phelan, and B. G. Link, “Stigma as a Fundamental Cause of Population Health Inequalities,” American Journal of Public Health 103 (5) (2013): 813‒21, doi:10.2105/AJPH.2012.301069.
24. C. S. Aneshensel and C. A. Sucoff, “The Neighborhood Context of Adolescent Mental Health,” Journal of Health and Social Behavior 37 (4) (1996): 293‒310.
25. E. Hood, “Dwelling Disparities: How Poor Housing Leads to Poor Health,” Environmental Health Perspectives 113 (5) (2005): A310‒17.
26. Ibid.
27. N. Krieger, “Theories for Social Epidemiology in the 21st Century: An Ecosocial Perspective,” International Journal of Epidemiology 30 (4) (2001): 668‒77.
28. N. Krieger, “Methods for the Scientific Study of Discrimination and Health: An Ecosocial Approach,” American Journal of Public Health 102 (5) (2012): 936‒44.
29. G. Lipsitz, “The Racialization of Space and the Spatialization of Race: Theorizing the Hidden Architecture of Landscape,” Landscape Journal 26 (1) (2007): 10‒23.
30. B. B. Wilson Resilience for All: Striving for Equity Through Community-Driven Design (New York: Island Press, 2018).
31. World Health Organization (WHO) and Calouste Gulbenkian Foundation, “Social Determinants of Mental Health” (Geneva, Switzerland: WHO; Lisbon, Portugal: Calouste Gulbenkian Foundation, 2014).
32. See Stewards of Affordable Housing for the Future, SAHF Mental and Behavioral Health Profiles.